Dr Katherine Newman-Taylor

2023

Background

Cognitive Behavioural Therapy for psychosis (CBTp) was developed in the 1990s as a psychological approach to address the limitations of existing treatments. CBTp focuses on focuses on the thoughts, feelings and behaviours that contribute to distressing psychotic experiences, such as hallucinations and paranoia. CBTp aims to help people clarify the meaning they give to their experiences, developing individualised ‘formulations’ (maps) of these processes, and then reconsider some of their beliefs about themselves and others (e.g. “I’m no good”) that may have developed early in life and get in the way of leading the life they’d like to lead. This is done in the context of a trusting relationship. CBTp is the recommended therapy for psychosis in many Western countries. However, recent research raises questions about the overall effectiveness of CBTp and whether other simpler interventions may be just as useful.

Methods

This opinion piece discusses two large scale (‘umbrella’) reviews of the impact of CBTp, and how therapy might be improved for people with psychosis.

Results

Overall findings from numerous studies indicate that CBTp is useful for some people but not others. One study also suggests that CBTp may be harmful if the person has a poor relationship with their therapist, though this relationship has been largely neglected by CBTp researchers. More people may benefit from CBTp if we focus on the therapeutic relationship and target specific processes that cause or maintain psychotic symptoms, for example past trauma and current worry.

Conclusion

It is unlikely everyone with psychosis will respond similarly to CBTp. A more personalised approach should be used, learning from previous research into anxiety and depression which uses ‘machine learning’ to work out who benefits from different treatments. Psychological therapies for psychosis would be improved if these are informed by individual characteristics, ensure a strong therapeutic relationship, and target specific mechanisms (such as trauma and worry). This will require new research strategies and be likely improve outcomes for people with psychosis.

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