What Are the Primary Goals of Cognitive Behavior Therapy for ...

Journal of Cognitive Psychotherapy: An International QuarterlyVolume 29, Number 1 • 2015

© 2015 Springer Publishing Company 45

http://dx.doi.org/10.1891/0889-8391.29.1.45

What Are the Primary Goals of Cognitive Behavior Therapy for Psychosis?

A Theoretical and Empirical Review

Robert Brockman, DPsych (Clin)Charles Sturt University, New South Wales, Australia

University of Western Sydney, Australia

Elizabeth Murrell, BSc Psych (Hons), MPsych (Clin)Charles Sturt University, New South Wales, Australia

Despite a rise in the popularity of cognitive behavior therapy for psychosis (CBTp) over the past 15 years, recent systematic reviews and meta-analyses have concluded that CBTp has only modest effects on psychotic syndrome outcomes and that empirical evidence of its superiority over other psychosocial treatments is poor (Jones, Hacker, Meaden, Cormac, & Irving, 2012; Wykes, Steel, Everitt, & Tarrier, 2008). However, for some time now, some authors prominent in the development of CBTp have argued the primary goals of CBTp not to be global syndrome reduction but the amelioration of emotional distress and behavioral disturbance in relation to individual psychotic symptoms (Birchwood & Trower, 2006). A review of the theoretical and empirical literature related to CBTp reveals broad support for this position. Implications and recommendations for research into the efficacy of CBTp are discussed.

Keywords: cognitive behavior therapy; psychosis; CBT; schizophrenia; CBT for psychosis

Cognitive behavior therapy for psychosis (CBTp) has enjoyed endorsement by the United Kingdom’s National Health Service as an evidence-based psychosocial treatment for schizo-phrenia since publishing its National Institute for Health and Clinical Excellence Guidelines

approximately a decade ago (National Institute for Health and Care Excellence, 2002). The latest ver-sion of this guidance states that CBTp should be offered as an adjunct treatment to medication for “all people with schizophrenia. This can be started either during the acute phase or later, including in inpatient settings” (National Institute for Health and Care Excellence, 2009, p. 9). However, a recent Cochrane Review of CBTp versus other psychosocial treatments for schizophrenia has con-cluded that there is no evidence that CBTp is superior to any other psychosocial treatment on illness outcomes such as relapse rates, rehospitalization, or global measures of psychosis (Jones et al., 2012).

The Cochrane Review followed the earlier publication of a comprehensive meta-analysis of 32 CBTp studies by Wykes and colleagues in 2008. A notable part of the trial inclusion criteria for the meta-analysis was that all patients in the studies must have received CBTp as an adjunct to standard psychiatric care including appropriate medication. This meta-analytic study reported finding a modest effect size for CBTp on primary outcome of 0.372, an effect size that decreased

46 Brockman and Murrell

to 0.223 when studies judged to be low in methodological rigor were excluded. These effect sizes might be called modest when compared to those reported elsewhere in the cognitive behavioral therapy (CBT) treatment outcome literature for other disorders. For example, a similar meta-analysis comparing exposure and ritual prevention and CBT for obsessive-compulsive disorder found mean effect sizes for both interventions in the range of 1.0 (Rosa-Alcázar, Sánchez-Meca, Gómez-Conesa, & Marín-Martínez, 2008). Similar results have been found in a meta-analysis of psychological interventions for posttraumatic stress disorder which found a mean effect size for behavior therapy of 1.27 (Van Etten & Taylor, 1998).

Of the 27 studies included in the Wykes et al. (2008) meta-analysis of CBTp interventions delivered in an individual format, 24 used syndrome-focused instruments as the primary measure of outcome, with the positive subscale of the Positive and Negative Syndrome Scale (PANSS; Kay, Fiszbein, & Opler, 1987) the most widely used along with the Brief Psychiatric Rating Scale (BPRS; Overall & Donald, 1962), and Scale for the Assessment of Positive Symptoms (SAPS; Andreasen, 1984). However, an important issue was raised but not addressed by Wykes et al. which may have implications for CBTp research. They point out that when we ask the question “Is CBTp effective?” we also need to ask “for what outcome?” This indicates an understanding that the effects of CBTp may vary depending on the outcome being explored. Wykes et al. go on to explain that CBTp was designed to treat the “positive symptoms” of psychosis, and therefore, they have reported on the relevant outcome of positive symptom reduction, concluding that CBTp has “modest effects” in this area.

The view of Wykes et al. (2008) that positive symptom reduction is the goal of CBTp how-ever appears to be at odds with some authors prominent in the development of CBTp who hold the view that the therapy was not designed primarily to treat positive psychotic symptoms per se. Birchwood and Trower (2006) argue that the approach to the evaluation of CBTp has automati-cally followed that of neuroleptic medication. They point out that the goals of a neuroleptic med-ication intervention are to decrease the symptoms of psychosis, and thus, the outcomes examined included measures of the psychotic syndrome such as the PANSS. According to Birchwood and Trower, the impact of treating CBTp as another neuroleptic medication has been that the goals and outcome measures used for one type of intervention (i.e., medication) have been applied, perhaps inappropriately, to CBTp research trials for almost two decades. They assert that CBTp researchers have pragmatically applied an intervention that has been found to be successful in the treatment of affective disorders (CBT for depression and anxiety disorders) to psychosis, applying the same criteria for success that has been used with neuroleptic medication (i.e., the same goals and outcome measures). Birchwood and Trower question the validity of using CBT to treat non-affective “disorders” because in their view the primary goals of CBTp are the reduction of emo-tional distress and behavioral disturbance related to the experience of psychotic symptoms rather than decreases in severity of psychotic symptoms themselves. In the aftermath of the Wykes et al. meta-analysis, a similar position was taken by Steel (2008) who speculated that the wide-scale use of the P-PANSS as primary outcome in these trials may be partially responsible for the mod-est effect sizes reported in meta-analyses. Steel (2008) cited results of his own earlier research, which found the P-PANSS measure was poorly related to the psychological distress associated with psychotic symptoms (Steel et al., 2007).

Birchwood and Trower (2006) may be highlighting a tension in the CBTp literature where some researchers hold the view that CBTp is designed to treat positive symptoms (e.g., Wykes et al., 2008), whereas other researchers argue that the goals of CBTp are not the amelioration of psychotic symptoms per se but the distress and behavioral disturbance associated with them. It is argued that to answer the question of the efficacy of CBTp “for what outcome” posed by Wykes et al. (2008), another further question must first be posed: “for what goals?” Psychometric theory dictates that to validly measure the outcome of interventions, one must first and foremost

47Review of Cognitive Behavior Therapy for Psychosis

consider the goals of that intervention (Garety, Dunn, Fowler, & Kuipers, 1998), with the construct validity of outcome studies being dependent on their outcome measures having clear relevance to the goals of the treatment (Shapiro, 1996).

This issue is particularly pertinent in the current context because despite the outlined concerns, several rigorous randomized controlled trials of CBTp have emerged since the Wykes et al. (2008) meta-analysis, which have continued to use syndrome-focused measures such as the P-PANSS (Farhall, Freeman, Shawyer, & Trauer, 2009; Lincoln et al., 2012; Peters et al., 2010; Rathod et al., 2013) as the primary indicator of outcome, in addition to relapse rates of psychosis (Garety et al., 2008). The results of these trials have also been generally modest, likely contrib-uting to the conclusions of the latest Cochrane review that the evidence base for CBTp over non-specific therapies is poor (Jones et al., 2012).

The purpose of this article is to review the theoretical and empirical literature relating to cog-nitive models of psychosis so as to (a) clarify the goals of CBTp according to the various models that have been proposed and (b) evaluate the empirical evidence to date for these goals.

The SympTom VerSuS Syndrome ApproAch To pSychoTic experienceS

It can be argued that the dominant scientific and clinical approach to psychotic experiences within the CBT tradition and indeed psychology more generally has been an “individual symptom” approach since at least the late 1980s. Up until that time, the scientific and clinical advancement of psychological models and treatments of psychotic experiences had been sparse to nonexistent. Despite an early successful case study applying cognitive therapy to a delusional psychotic patient (Beck, 1952), the field was dominated by the medical psychiatric model of clinical “syndromes” and the view that psychological approaches had little to offer in furthering the understanding and treatment of psychotic disorders (Bentall, Haddock, & Slade, 1995). The syndrome approach to psychosis assumes a “disease” model of psychosis where a cluster of signs and symptoms are thought to correlate to an underlying pathophysiology and common etiology, as had been demonstrated in physical medicine. The medical model of physical disease was thus applied to psychiatric problems and served as the underlying model from which the diagnostic classification of mental disorders ensued (e.g., the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders or DSM). Although there have been changes in the medical model of psychosis over time, the construct of schizophrenia has remained and largely dominated scientific approaches to psychosis. Although the concepts of psychiatric syndrome and psychiatric disorder are not equivalent, it can be argued that they are functionally equivalent to the degree that they support the construct of schizophrenia as an illness entity that can be observed and studied and which has dominated scientific endeavor in the area. A related but distinct model of schizophrenia that emerged later was the stress-vulnerability model of schizophrenia (Zubin & Spring, 1977). This model proposed that the “psychiatric disorder” of schizophrenia was not just a biological dis-ease entity with a biologically determined course but that critical psychosocial stressors interacted with a biological vulnerability to account for the emergence of schizophrenia in any individual. This opened the door for exploration of psychosocial factors that could explain disease onset and relapse, but the model still did so clearly within a disorder or “illness” framework. This position of “psychosis as illness” saw the development of measurement approaches that focused on the psy-chotic syndrome, the most popular of which has been the PANSS (Kay et al., 1987).

In the 1980s, a movement began within psychology against the validity and use of psychotic syndromes in favor of an individual symptom approach to the understanding of psychotic expe-riences (Bentall, Jackson, & Pilgrim, 1988; Persons, 1986). Bentall et al. (1988) argued for the abandonment of the construct of psychotic syndromes in psychology in favor of an individual


symptom approach to psychotic experiences mainly on the grounds that the construct of a schizophrenic syndrome is too heterogeneous (i.e., too many symptoms and no characteristic symptom), and lacks clinical and scientific use (Bentall, 1993). In particular, it was argued that the construct of schizophrenia had outlasted its usefulness and was in fact constraining scientific progress in the psychological understanding of psychotic phenomena. In light of these theoretical developments, considerable progress ensued in psychology, leading to the development of a clin-ical approach to psychotic experiences grounded in the CBT tradition.

reView of cBTp mAinTenAnce modelS for primAry GoAl And ouTcome emphASeS

Following the theoretical developments of Bentall et al. (1988, 1993) and others (Boyle, 1990; Persons, 1986), Bentall (1996) proposed two early CBTp models that seek to account for the maintenance of delusions and hallucinations as individual symptoms. Both models hold appraisal and emotional processes to be core maintenance mechanisms for these symptoms in line with the movement towards an individual symptom approach to psychotic experiences. Although earlier models existed (e.g., Tarrier, Harwood, Yusopoff, Beckett, & Baker, 1990), these were openly prag-matic and were designed to guide therapy as it emerged rather than being proposed as accurate theoretical explanations of the origins or maintenance of psychotic experiences (Yusupoff & Tarrier, 1996). Despite the usefulness of the two Bentall (1996) models in proposing two early CBTp maintenance models, these early theoretical accounts were not accompanied by a compre-hensive treatment strategy.

The first model of CBTp to be accompanied by a thorough treatment strategy was that of Chadwick and colleagues (Chadwick & Birchwood, 1994; Chadwick, Birchwood, & Trower, 1996). Chadwick et al. (1996) begin their treatment manual and description of a model of CBTp by outlining clearly their philosophical position that CBTp is designed to treat individual symptoms rather than syndromes. Citing Bentall et al. (1988), they argued that psychological approaches to psychotic phenomena are best progressed by abandoning the concept of schizophrenia and syn-dromes and instead developing theoretical and therapeutic approaches to individual symptoms (Chadwick & Birchwood, 1996).

Chadwick and Birchwood’s (1996) model of CBTp applies an ABC framework (Ellis & Dryden, 1987) to individual psychotic, affective, and behavioral symptoms in persons suffer-ing psychosis. Within the ABC framework, the emotional and behavioral consequences (C) of an activating event (A) are mediated by appraisals or beliefs (B) in relation to activating event. The model seeks to account for and address the individual symptoms of hallucinations, delu-sions, and paranoia. The application of the ABC framework was a major contribution to the literature because it for the first time approached hallucinations as triggering situations (As) rather than maintained psychological problems/consequences (Cs) as other models had done (Bentall, 1996). Chadwick and Birchwood’s ABC model views hallucinations as problems only to the degree that they result in negative interpretations (Bs) and are accompanied by emotional dis-tress and behavioral disturbance consequences (Cs). Therefore, according to this model, the core goals of CBTp are to decrease emotional distress and behavioral disturbance through cognitive change. From this position, instead of directly targeting the hallucinations as such, the targets for intervention become the personal meaning attached to the hallucinations, the associated distress, and the behavioral disturbance that can follow. Delusions were conceptualized in Chadwick and Birchwood’s model as the Bs (appraisals or beliefs), which may be targeted directly by cognitive interventions, to the degree that they were associated with distress and disturbance. Lastly, the ABC framework of Chadwick and Birchwood’s model outlined an approach to a third individual


symptom, paranoia, as being the result of negative (often to a delusional conviction) appraisals of self and others.

Chadwick and Birchwood’s (1996) model of CBTp thus relates to three individual psychotic symptoms: hallucinations, delusions, and paranoia. The ABC framework of Chadwick and Birchwood will be used throughout this review as a point of comparison with the goal emphases of the various CBTp models.

Morrison’s (2001) model of hallucinations and delusions is largely commensurate with that of Chadwick and Birchwood (1996). It generally proposes similar maintenance processes, but unlike previous models, Morrison’s (2001) model hypothesizes that hallucinations can be both triggers (As) and outcomes or consequences (C), that are maintained by appraisal and emotional pro-cesses. For Morrison (2001), the development of psychotic hallucinations occurs when “normal intrusions” such as intrusive thoughts, images, and hallucinations, which are triggering situa-tions (As), result in culturally inappropriate and threatening appraisals of these intrusions (Bs). This leads to the maintenance of faulty beliefs about the self and social world (faulty appraisal processes such as delusional beliefs or negative self-schema; Bs), changes in emotional (such as anxiety, sadness, or guilt) and physiological responses (Cs), and the prevalence of cognitive and behavioral responses such as safety behaviors and thought control strategies (also Cs), some of which may provide further reinforcement for the negative/delusional appraisal of the intrusion. Morrison (2001) further posits that appraisal processes do not impact directly on the generation of further intrusions but that such increases in the experience of intrusions are mediated by emo-tional, physiological, cognitive, and behavioral changes. This model thus diverges slightly from the earlier Chadwick and Birchwood (1996) model by leaving open a role for cognitive and be-havioral processes to be “maintenance” processes, which may lead to further hallucinations (albeit mediated through several other processes). An important point made within this model is that hallucinations are in fact normal phenomena but only become problematic when appraised in a culturally unacceptable and threatening way. However, despite this stance on the mediated gen-eration of hallucinations through cognitive processes, Morrison (1998) clearly argues, “The goals of therapy should be to reduce distress and disability associated with hallucinations (by targeting patient’s interpretations of voices) rather than a reduction in hallucinations themselves” (p. 297). The Morrison (2001) model is thus a model of the maintenance of individual symptoms of hal-lucinations and delusions, in the context of emotional distress and behavioral disturbance, and is thus largely consistent with previous models in goal emphasis. A conceptualization of Morrison’s (2001) CBTp model is shown in Figure 1.

A CBTp model with some subtle differences from Morrison (2001) is that of Garety, Kuipers, Fowler, Freeman, and Bebbington (2001). Garety et al. (2001) propose that a biological vulner-ability to psychosis and adverse life events combine in some individuals to produce both cogni-tive dysfunction (e.g., anomalous conscious experiences, heightened perceptions) and emotional changes (As), which combine to feed directly into moment-by-moment appraisal processing (B), which in turn leads to the generation of positive symptoms (Cs). For Garety et al. (2001), negative appraisal (B) is the key mediator between emotional changes, anomalous experiences, aversive environments, and resulting positive symptoms. This model is largely consistent with Morrison (2001); however, their view is that the “normal” intrusions in some individuals are in fact the “anomalous experiences” of people with a biological vulnerability to psychotic experiences. On the role of emotional distress and behavioral disturbance, Garety et al. (1998) write that the goals of CBTp in their view are

(a) To reduce the subjective distress and interference with a person’s life which arises from the experience of psychotic symptoms, particularly hallucinations and delusions; (b) to increase the understanding of psychotic illness, and foster motivation to engage in self-regulatory or coping behaviors; and (c) to reduce depression, low self-esteem, and hopelessness. (pp. 109–110)


Garety et al. (2001, p. 192) also state however that intervening in the CBTp maintenance pro-cesses is for the purpose of reducing positive symptoms and risk of relapse. Gartey et al. (2001) also give an explicit role in their model to stress-vulnerability processes, which is somewhat in line with a syndrome approach because the stress-vulnerability approach implies vulnerability to disorder. Although Gartey et al. (2001) indicate primary goals that are more or less in line with those of previous models (i.e.,, that CBTp targets individual positive symptoms, associated dis-tress, and impact), it is argued that the secondary focus on preventing relapse, and the explicit focus in their model on the role of stress-vulnerability processes, reveals a possible secondary goal in their view to be a reduction in the symptoms and risk of relapse of the psychotic syndrome more globally. This differs markedly from earlier key models (Chadwick & Birchwood, 1996; Morrison, 2001) which make no explicit mention of stress-vulnerability processes in the descrip-tion of their models. A figural depiction of Garety et al.’s (2001) model of positive symptoms is shown in Figure 2.

Beck and colleagues (Beck & Rector, 2003; Beck, Rector, Stolar, & Grant, 2008) have also proposed cognitive models of psychosis which include approaches to individual symptoms of auditory hallucinations, delusions, and negative symptoms. Consistent with earlier models (Chadwick & Birchwood, 1996; Morrison, 2001), Beck and colleagues (2008) view hallucina-tions as situations/events (As) to be interpreted (Bs) which may lead to emotional distress con-sequences (Cs). Beck et al. (2008) state that “although the ultimate elimination of voice activity may not be an achievable goal for patients, the principle goal of cognitive therapy is to reduce the

fiGure 1. Morrison’s (2001) cognitive model of hallucinations and delusions. From “The Interpretation of Intrusions in Psychosis: An Integrative Cognitive Approach to Hallucinations and Delusions,” by A. P. Morrison, 2001, Behavioural and Cognitive Psychotherapy, 29(3), p. 267. Copyright 2001 by Cambridge University Press. Reprinted with permission.

intrusion from low level processing units(cognitive, body state, emotional or external information)

cognitive and behavioural responses(including safety behaviours, selective

attention and thought control strategies)

mood & physiology

experience

faulty self & social knowledge(procedural and declarative beliefs)

interpretation of intrusion(culturally unacceptable)


patient’s experience of distress around the voices and improve his or her quality of life” (p. 234). It appears that the reduction of emotional distress is primary for Beck and colleagues (2008), with changes in some positive symptoms themselves being viewed as secondary and possibly unattainable goals. Beck et al. (2008, pp. 28–29) do however also express the view that emotional distress may be a further contributing factor to the psychosis syndrome, feeding back into stress-vulnerability processes, and may thus be with some caution, a secondary outcome. This is similar to Morrison’s (2001) position; however, Beck et al. (2008) propose that a secondary effect on the positive syndrome could be mediated by the impact of negative beliefs and emotional distress on stress-vulnerability processes. Therefore, although Beck and colleagues’ (2008) approach to CBTp is largely an approach to individual symptoms, emphasizing the reduction of emotional distress as primary, they do posit secondary outcomes of syndrome reduction or prevention through stress-vulnerability processes in line with Garety et al. (2001).

Freeman, Garety, Kuipers, Fowler, and Bebbington (2002) present a cognitive model of perse-cutory delusions which conceptualizes delusions as “threat beliefs” much in the same way that modern CBT is applied to most anxiety disorders (Clark & Beck, 2011). Central to their model is the idea that persecutory delusions (Cs) result from a process where contextual variables (As)

fiGure 2. Conceptualization of Garety et al.’s (2001) model of positive psychotic symptoms. From “Cognitive, emotional, and social processes in psychosis: Refining cognitive behavioral therapy for persistent positive symptoms,” by E. Kuipers, P. Garety, D. Fowler, G. Dunn, and P. Bebbington, 2006, Schizophrenia Bulletin, 32(Suppl. 1), p. S25. Copyright 2006 by Oxford University Press. Reprinted with permission.

Bio-psycho-social vulnerability Trigger Emotional

changes

BasicCognitive dysfunction Anomalous experience

Positive Symptoms

Appraisal influenced by• Reasoning & attributional biases• Dysfunctional schemas of self & world• Isolation & adverse environments

Maintaining factors• reasoning & attributions• dysfunctional schemas• emotional processes• appraisal of psychosis

Appraisal of experience as external


such as stressful life events, emotional changes, and anomalous experiences trigger a search for meaning (Bs; see Figure 3). Freeman et al.’s (2002) model is thus a “single symptom” model of the formation and maintenance of persecutory delusions, which gives a central role to the interaction between negative appraisal processes and anxiety as a maintaining factor for the single symptom of persecutory delusions.

The final CBTp model to be discussed is the cognitive therapy for command hallucinations (CTCH) model (Byrne, Birchwood, Trower, & Meaden, 2006), which might be considered an extension of Chadwick and Birchwood’s (1996) model applied to the specific single symptom of command hallucinations. Combining the ABC analysis of Birchwood and Chadwick (1997) and social rank theory (Gilbert, 1992), the model asserts that social schemas of dominance and sub-ordination are core maintenance factors for the behavior of compliance with command halluci-nations. Beliefs and safety behaviors related to the power and dominance of the voice experience therefore become the treatment targets for CTCH. Like the model of Chadwick and Birchwood, the CTCH model proposes that changes in emotional distress and behavioral disturbance are the core goals of intervention, rather than changes in positive symptoms. They also make no refer-ence to the goal of syndrome reduction.

In summary, this review has found broad similarities in the maintenance processes proposed by six CBTp models. However, there is also some divergence in relation to primary goal em-phasis and/or the degree to which positive psychotic symptoms (either individually or globally)

fiGure 3. Freeman et al.’s (2002) Model of Persecutory Delusions. From “Testing the Continuum of Delusional Beliefs: An Experimental Study Using Virtual Reality,” by D. Freeman, K. Pugh, N. Vorontsova, A. Antley, and M. Slater, 2010, Journal of Abnormal Psychology, 119(1), p. 84. Copyright 2010 by American Psychological Association. Reprinted with permission.

TRIGGERMajor life events, on-going stress, sleep

disturbance, trauma, illicit drugs.

EMOTIONAnxiety, Worry, Interpersonal sensitivity (negative beliefs

about self and others).

INTERNAL AND EXTERNAL EVENTS

Internal: arousal, anomalous experiences, core cognitive dysfunctionExternal: Discrepant, negative, socially

significant, or ambiguous events.

REASONINGJumping to conclusions,

confirmation bias, failure to consider alternatives.

SEARCH FOR MEANINGSearch for understanding/meaning

Not wanting to talk to others/having nobody to provide feedback on ideas.

THE PERSECUTORY (THREAT) BELIEF


are thought to be maintained by cognitive appraisal processes. The primary theoretical orienta-tion of most CBTp models in relation to psychotic experiences appears to include an approach to the maintenance of individual symptom dimensions in sufferers of psychosis rather than global symptoms of a syndrome or illness. Some models emphasize reduction in emotional distress and behavioral disturbance as the core goal of CBTp, with positive symptoms being targeted only for these ends (e.g., Byrne et al., 2006; Chadwick & Birchwood, 1996). Others appear to regard individual symptoms such as hallucinations and delusions to be the direct targets of CBTp, al-beit alongside emotional and behavioral outcomes (e.g., Beck et al., 2008; Freeman et al., 2002; Garety et al., 2001; Morrison, 2001). However, other models seem to consider reduced vulner-ability to psychotic disorder to be a possible mediated secondary goal (e.g., Beck et al., 2008; Garety et al., 2001). Although most theoretical literature behind CBTp takes a single-symptom approach to psychosis (Bentall, 1996; Byrne et al., 2006; Chadwick & Birchwood, 1996; Freeman et al., 2002; Morrison, 2001), some models seem to give a secondary role to cognitive processes in the maintenance of psychosis more globally, perhaps influenced by a syndrome approach to psychosis (Beck et al., 2008; Garety et al., 2001). The difference in goal emphasis thus appears to depend on the degree to which the theoretical position of the model is based on a single-symptom approach, or a stress-vulnerability approach (i.e., to syndrome). The goals of CBTp thus appear to fall into four categories according to this review: reduction of emotional distress, reduction of behavioral disturbance, reduction of individual psychotic symptoms, and reduction in the global psychotic syndrome.

empiricAl eVidence for The coGniTiVe model of pSychoSiS in relATion To VAriouS ouTcomeS

The “cognitive model” in its simplest form is the proposition that negative appraisals (negative automatic thoughts, beliefs, and attitudes) mediate the relationship between contextual stressors and psychological problems or outcomes (Beck, 1976; Brewin, 1989). This is sometimes referred to as the cognitive mediational model. This model has been extended in CBTp to include apprais-als-related dimensions of positive symptoms such as appraisals of threat, cultural inappropri-ateness, power, and dominance of symptoms (Byrne et al., 2006; Chadwick, Lees, & Birchwood, 2000; Freeman et al., 2002). Following is a review of the empirical literature which supports the basic cognitive model of psychosis in relation to various measures and outcomes. Relevant studies were included if they investigated the role of negative appraisal content on measures of well-being in persons suffering psychosis, as per the basic cognitive mediational model. This means other psychological processes potentially relevant to CBTp were not included in the review, including processes such as safety behaviors, meta-cognitive processes, and cognitive biases.

Early Single-Case Studies

Among the first empirical studies to test the cognitive model of psychosis were two case series published by Chadwick and colleagues (Chadwick & Lowe, 1994; Chadwick, Lowe, Horne, & Higson, 1994). The first of these publications, presenting a case series of six patients with delu-sion, reported that cognitive interventions could result in decreased delusional conviction. The second case series (Chadwick & Lowe, 1994) presented the cases of 12 patients with psychosis and reported that reductions in delusional conviction and delusional preoccupation tended to be followed by decreases in self-reported anxiety. A similar trend appeared for depression with the 10 individuals who experienced a decrease in delusional conviction also having decreased scores on the Beck Depression Inventory (BDI; Beck & Steer, 1987). A similar case series of 12 long-term


sufferers of psychosis (Bentall et al., 1994) reported reductions in hallucinatory preoccupation and distress in six of these patients after challenging the personal negative meaning of hallucina-tory experiences.

Basic Experimental and Correlational Studies

A literature search was conducted to find experimental and correlational clinical studies relating to the cognitive meditational model of psychosis. A total of 20 relevant studies were identi-fied through a search of the PsycINFO database and by examination of the reference lists of papers already identified as relevant. A summary of these studies is displayed in Table 1. Eleven (55%) of these studies used some version of the Beliefs About Voices Questionnaire (BAVQ; Chadwick et al., 2000) as a measure of negative appraisal processes. Thirteen of these studies (65%) used some measure of emotional distress as an outcome variable to investigate its rela-tionship to negative appraisal processes. All studies reported finding evidence in support of a link between negative appraisal processes and emotional distress outcomes in this population. Four of these studies (20%) provide evidence of the same links with behavioral focused outcomes such as compliance behavior in relation to voices.

A further nine studies (45%) were identified which provide evidence in support of a link be-tween negative appraisals and several “individual psychotic symptom” dimensions such as hallu-cinations (five studies), paranoia (two studies), and delusions (two studies). Evidence was found of links between negative appraisals and individual symptoms of both paranoia and delusions. Outcomes for hallucinations were less clear, with some studies reporting a significant relationship between measures, whereas others do not. For example, Soppitt and Birchwood (1997) reported a significant relationship between malevolent voice appraisals and voice loudness but not voice clarity, frequency, or intrusiveness. Peters et al. (2012) reported that omnipotent and malevolent voice appraisals were related to PANSS hallucinatory behavior, but that voice severity, frequency, and intensity were not related to emotional distress once negative beliefs were accounted for.

Of the 20 studies, only 1 study reported on the relationship between global psychotic syndrome measures and negative appraisal processes (Smith et al., 2006). This study found that global positive symptoms as measured by the P-PANSS and SAPS were significantly pos-itively correlated to negative schema beliefs about others but not to negative schema beliefs about the self. In the same study, both types of negative beliefs had significant positive rela-tionships with depression. This study further suggests that although negative beliefs in suffer-ers of psychosis appear to have a clear relationship with depression in line with the cognitive model, their relationship with global positive symptoms is less predictable, occurring in some contexts but not others.

One other study was found which linked negative appraisal processes to a more global measure of psychosis (Birchwood & Chadwick, 1997). As a part of a larger study, this study reported on the link between beliefs about voices and two created subscales from items on the Psychiatric Assessment Scale (PAS; Krawiecka, Goldberg, & Vaughan, 1977). They combined two items to produce a measure of positive symptoms (hallucinations and delusions) and three items to pro-duce a measure of negative symptoms. This study reported that in general no differences emerged between different appraisal groups on measures of positive or negative symptoms as they defined them. The one exception was a significant finding in relation to the “malevolent” appraisal group which scored higher on positive symptoms than the “benign’ appraisal group. Although this study provides some further evidence that negative appraisal processes may have a complicated rela-tionship to global symptoms, the way in which positive symptoms were measured in this study (combining two items) could be argued to be unrepresentative of a global measure.


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onn

aire

(B

AVQ

),

mal

evol

ence

, om

nip

oten

ce,

ben

evol

ence

app

rais

als

Com

plia

nce

beh

avio

r (B

AVQ

)C

ompl

ian

ce b

ehav

ior

wit

h c

omm

and

hal

luci

nat

ion

s si

gnif

ican

tly

asso

ciat

ed w

ith

be

liefs

of

omn

ipot

ence

reg

ardi

ng

voic

es.

(Bir

chw

ood

&

Ch

adw

ick,

199

7)E

xper

imen

tal

BAV

Q, m

alev

olen

ce,

omn

ipot

ence

, ben

evol

ence

ap

prai

sals

Cop

ing

beha

vior

(B

AVQ

),

dist

ress

an

d vo

ice

topo

grap

hy (

Hu

stig

&

Haf

ner

, 199

0), p

osit

ive

sym

ptom

s (c

ombi

nin

g ha

lluci

nat

ion

s an

d de

lusi

ons)

, neg

ativ

e sy

mpt

oms

(PA

S)

Mal

evol

ence

bel

iefs

reg

ardi

ng

voic

es a

ssoc

iate

d w

ith

fear

an

d an

ger,

poo

r co

pin

g, a

nd

ben

evol

ence

bel

iefs

ass

ocia

ted

wit

h p

osit

ive

affe

ct a

nd

pos

itiv

e co

pin

g be

hav

ior.

Aff

ect

and

beh

avio

r sh

owed

no

links

to v

oice

ac

tivi

ty (

freq

uen

cy, l

oudn

ess,

cla

rity

, or

form

). I

n g

ener

al, n

o di

ffer

ence

s em

erge

d be

twee

n a

ppra

isal

gro

ups

on

mea

sure

s of

pos

itiv

e or

neg

ativ

e sy

mpt

oms.

On

e ex

cept

ion

: Sig

nif

ican

t fi

ndi

ng

in r

elat

ion

to

mal

evol

ent

grou

p sc

ore

hig

her

on

pos

itiv

e sy

mpt

oms

than

ben

ign

gro

up.

(Sop

pitt

&

Bir

chw

ood,

199

7)C

orre

lati

onal

an

d ex

peri

men

tal

BAV

Q, m

alev

olen

ce,

omn

ipot

ence

, ben

evol

ence

ap

prai

sals

App

rais

al g

roup

m

embe

rshi

p, d

epre

ssio

n

(Bec

k D

epre

ssio

n

Inve

ntor

y [B

DI]

; Bec

k,

War

d, &

Men

dels

on,

1961

), di

stre

ss a

nd v

oice

to

pogr

aphy

Mal

evol

ent

appr

aisa

l gro

up

has

sig

nif

ican

tly

hig

her

dep

ress

ion

th

an b

enev

olen

t ap

prai

sal

grou

p. S

ign

ific

ant

rela

tion

ship

bet

wee

n

mal

evol

ence

an

d di

stre

ss, l

oudn

ess,

bu

t n

ot

for

clar

ity,

freq

uen

cy, o

r in

tru

sive

nes

s of

vo

ices

(ot

her

top

ogra

phy

dom

ain

s). C

onti

nued

56 Brockman and MurrellTA

BlE

1.

Sum

mA

ry

of

co

rr

elA

Tio

nA

l A

nd

ex

pe

rim

en

TAl

STu

die

S Su

pp

or

Tin

G T

he

BA

Sic

co

Gn

iTiV

e m

od

el

of

pSy

ch

oSi

S (C

onti

nu

ed)

Pu

blic

atio

nD

esig

nA

ppra

isal

Pro

cess

/Pre

dict

orO

utc

ome

Var

iabl

eK

ey F

indi

ngs

(Ch

adw

ick

et a

l.,

2000

)C

orre

lati

onal

Rev

ised

Bel

iefs

Abo

ut

Voi

ces

Qu

esti

onn

aire

(B

AVQ

-R),

mal

evol

ence

, om

nip

oten

ce, b

enev

olen

ce

appr

aisa

ls

Dep

ress

ion

an

d an

xiet

y (H

ospi

tal A

nxi

ety

and

Dep

ress

ion

Sca

le

[HA

DS]

; Zig

mon

d &

Sn

aith

, 198

3)

Sign

ific

ant

corr

elat

ion

s be

twee

n m

alev

olen

ce

appr

aisa

ls a

nd

depr

essi

on, a

nxi

ety,

an

d ap

prai

sals

of

omn

ipot

ence

an

d de

pres

sion

, an

xiet

y

(van

der

Gaa

g,

Hag

eman

, &

Bir

chw

ood,

200

3)

Cor

rela

tion

al

and

expe

rim

enta

l

BAV

Q-R

, app

rais

als

of

mal

evol

ence

, ben

evol

ence

, an

d om

nip

oten

ce o

f vo

ices

An

xiet

y (S

piel

berg

er

& G

orsu

ch, 1

983)

, de

pres

sion

(B

DI)

Hig

h-m

alev

olen

t app

rais

al g

roup

has

si

gnif

ican

tly

high

er o

n a

nxi

ety

and

depr

essi

on

than

oth

er th

ree

con

diti

ons,

whe

reas

pos

itiv

e or

neg

ativ

e n

atur

e of

voi

ce c

onte

nt w

as fo

und

to b

e un

rela

ted

to a

nxi

ety

and

depr

essi

on.

(Fav

rod,

Gra

sset

, Sp

ren

g,

Gro

ssen

bach

er,

& H

odé,

200

4)

Cor

rela

tion

al

and

expe

rim

enta

l

BAV

Q, a

ppra

isal

s of

m

alev

olen

ce, b

enev

olen

ce,

and

omn

ipot

ence

of

voic

es

Soci

al fu

nct

ion

ing,

Lif

e Sk

ills

Pro

file

(R

osen

, H

adzi

-Pav

lovi

c, &

Pa

rker

, 198

9)

Ben

evol

ent

voic

e ap

prai

sal a

ssoc

iate

d w

ith

po

or c

omm

un

icat

ion

fun

ctio

nin

g (2

.62)

. B

enev

olen

t vo

ice

hea

rers

fun

ctio

nin

g si

gnif

ican

tly

poo

rly

on c

omm

un

icat

ion

co

mpa

red

to m

alev

olen

t vo

ice

hea

rers

.

(Bir

chw

ood

et a

l.,

2004

)St

ruct

ura

l eq

uat

ion

m

odel

ing

Voi

ce P

ower

Dif

fere

nti

al

Scal

e (V

PD

) an

d So

cial

Po

wer

Dif

fere

nti

al

Scal

e (S

PD

; Bir

chw

ood,

M

eade

n, T

row

er, G

ilber

t, &

Pla

isto

w, 2

000)

Dep

ress

ion

(B

DI)

, di

stre

ss (

Hu

stig

&

Haf

ner

, 199

0)

Test

ed th

ree

mod

els

and

foun

d su

ppor

t for

a

mod

el o

f int

erpe

rson

al s

ubor

dina

tion

sch

ema

(neg

ativ

e be

liefs

abo

ut th

e se

lf a

nd o

ther

s) in

pr

edic

ting

dep

ress

ion

and

dist

ress

in a

gro

up o

f vo

ice

hear

ers

diag

nose

d w

ith

schi

zoph

reni

a.

(Mor

riso

n,

Not

har

d, B

owe,

&

Wel

ls, 2

004)

Cor

rela

tion

al

and

expe

rim

enta

l

Inte

rpre

tati

on o

f Voi

ce

Inve

nto

ry (

IVI;

Mor

riso

n,

et a

l., 2

004)

Em

otio

nal,

phys

ical

, and

co

gnit

ive

char

acte

rist

ics

of v

oice

s (P

sych

otic

Sy

mpt

om R

atin

g Sc

ales

[P

SYR

AT

S]; H

addo

ck,

McC

arro

n, T

arri

er, &

Fa

ragh

er, 1

999)

Clin

ical

voi

ce h

eare

rs d

ispl

ayed

sig

nif

ican

tly

hig

her

leve

ls o

f p

osit

ive

and

neg

ativ

e be

liefs

th

an n

onpa

tien

ts. N

egat

ive

inte

rpre

tati

ons

sign

ific

antl

y pr

edic

ted

emot

ion

al, p

hysi

cal,

and

cogn

itiv

e ch

arac

teri

stic

s of

voi

ces.

P

hysi

cal c

har

acte

rist

ics

and

met

aphy

sica

l be

liefs

wer

e si

gnif

ican

t pr

edic

tors

of

emot

ion

al c

har

acte

rist

ics

of v

oice

s.


(Sm

ith

et

al.,

2006

)C

orre

lati

onal

Bri

ef C

ore

Sch

ema

Scal

es

(Fow

ler

et a

l., 2

006)

P-PA

NSS

, Sca

le fo

r th

e A

sses

smen

t of

Po

siti

ve S

ympt

oms

(SA

PS;

Glo

bal

Posi

tive

Sym

ptom

s),

BD

I, a

nd

indi

vidu

al

posi

tive

sym

ptom

s on

Po

siti

ve a

nd

Neg

ativ

e Sy

ndr

ome

Scal

e (P

AN

SS)

and

SAP

S

Rel

atio

nshi

p be

twee

n P-

PAN

SS a

nd n

egat

ive

othe

rs b

elie

fs (

.38)

and

SA

PS a

nd n

egat

ive

othe

rs b

elie

fs (

.34)

but

not

for

nega

tive

self-

belie

fs. S

igni

fican

t rel

atio

nshi

p be

twee

n

nega

tive

self-

belie

fs a

nd in

divi

dual

sym

ptom

s of

pers

ecut

ory

delu

sion

s (.4

1), g

rand

iose

del

usio

ns

(2.3

3), a

nd d

epre

ssio

n (.

62)

but n

ot fo

r au

dito

ry h

allu

cina

tions

. Sig

nific

ant r

elat

ions

hip

betw

een

nega

tive

othe

rs b

elie

fs a

nd p

erse

cuto

ry

delu

sion

s (.2

2), d

elus

iona

l dis

tres

s (.2

2), a

nd

depr

essi

on (

.42)

but

not

for

gran

dios

e de

lusi

ons

and

for

audi

tory

hal

luci

natio

ns

(Csi

pke

&

Kin

derm

an,

2006

)

Exp

erim

enta

lB

AVQ

, app

rais

als

of

mal

evol

ence

an

d om

nip

oten

ce o

f vo

ices

PAN

SS G

ener

al

Psyc

hop

ath

olog

y su

bsca

le a

nd

hal

luci

nat

ory

beh

avio

r it

em, a

nxi

ety

and

depr

essi

on—

HA

DS

Follo

wed

46

voic

e h

eare

rs lo

ngi

tudi

nal

ly

over

6 m

onth

s an

d fo

un

d th

at g

ener

al

psyc

hop

ath

olog

y an

d h

allu

cin

ator

y be

hav

ior

both

dec

reas

ed s

ign

ific

antl

y ov

er t

ime

but

that

neg

ativ

e be

liefs

abo

ut

voic

es a

nd

dist

ress

di

d n

ot (

no

spec

ific

tre

atm

ent

was

ou

tlin

ed).

(Wat

son

et

al.,

2006

)C

orre

lati

onal

Illn

ess

Perc

epti

on

Qu

esti

onn

aire

(IP

Q;

Wei

nm

an, P

etri

e, M

oss-

Mor

ris,

& H

orn

e, 1

996)

Dep

ress

ion

(B

DI)

, an

xiet

y (B

eck

An

xiet

y In

ven

tory

[B

AI]

; Bec

k &

Ste

er, 1

990)

A s

ampl

e of

su

bjec

ts w

ith

pri

mar

y di

agn

osis

of

sch

izop

hre

nia

an

d co

mor

bid

anxi

ety

and/

or

depr

essi

ve d

isor

der

was

use

d w

ith

a c

ross

-se

ctio

nal

des

ign

. Res

ult

s in

dica

ted

neg

ativ

e ill

nes

s p

erce

ptio

ns

abou

t ps

ych

osis

exp

lain

ed

46%

an

d 36

% o

f th

e va

rian

ce o

f de

pres

sion

an

d an

xiet

y re

spec

tive

ly.

(Kar

atzi

as, G

um

ley,

Po

wer

, &

O’G

rady

, 200

7)

Cor

rela

tion

alPe

rson

al B

elie

fs A

bou

t Il

lnes

s Q

ues

tion

nai

re

(PB

IQ; B

irch

woo

d,

Mas

on, M

acM

illan

, &

Hea

ly, 1

993)

Gro

up

mem

bers

hip

, de

pres

sion

/an

xiet

y ve

rsu

s n

o de

pres

sion

an

xiet

y st

atu

s

Logi

stic

regr

essi

on re

veal

ed th

at c

omor

bid

anxi

ety/

depr

essi

on st

atus

pre

dict

ive

of n

egat

ive

illne

ss

belie

fs a

nd lo

w se

lf-es

teem

. Con

clud

ed th

at

nega

tive

illne

ss a

ppra

isal

s and

low

self-

este

em

are

sign

ifica

nt p

redi

ctor

s of c

o-m

orbi

d an

xiet

y an

d de

pres

sion

in su

bjec

ts w

ith sc

hizo

phre

nia.

Con

tinu

ed


TAB

lE 1

. Su

mm

Ar

y o

f c

or

re

lAT

ion

Al A

nd

ex

pe

rim

en

TAl

STu

die

S Su

pp

or

Tin

G T

he

BA

Sic

co

Gn

iTiV

e m

od

el

of

pSy

ch

oSi

S (C

onti

nu

ed)

Pu

blic

atio

nD

esig

nA

ppra

isal

Pro

cess

/Pre

dict

orO

utc

ome

Var

iabl

eK

ey F

indi

ngs

(Fan

non

et

al.,

2009

)C

orre

lati

onal

BAV

Q, a

ppra

isal

s of

m

alev

olen

ce a

nd

omn

ipot

ence

of

voic

es

Self

-est

eem

(R

osen

berg

Se

lf-e

stee

m S

cale

; R

osen

berg

, 196

5),

depr

essi

on s

ubs

cale

of

PAN

SS

Fou

nd

sign

ific

ant

rela

tion

ship

bet

wee

n s

pec

ific

om

nip

oten

ce it

ems

and

depr

essi

on: “

I ca

nn

ot c

ontr

ol m

y vo

ice”

an

d “M

y vo

ice

rule

s m

y lif

e.”

Self

-est

eem

doe

s n

ot m

edia

te

rela

tion

ship

bet

wee

n b

elie

fs a

bou

t vo

ices

an

d de

pres

sion

.

(Lu

ng,

Shu

, &

Ch

en, 2

009)

Cro

ss-

sect

ion

al,

med

itat

ion

al

BAV

Q-R

, app

rais

als

of m

alev

olen

ce a

nd

omn

ipot

ence

of

voic

es.

Dep

ress

ion

, an

xiet

y (H

AD

S), E

ysen

ck

Pers

onal

ity

Qu

esti

onn

aire

(C

hin

ese

vers

ion

; Ya

oxia

o, 1

984)

Neg

ativ

e be

liefs

bou

t vo

ices

sig

nif

ican

tly

med

iate

rel

atio

nsh

ip b

etw

een

per

son

alit

y an

d em

otio

nal

dis

tres

s (d

epre

ssio

n a

nd

anxi

ety)

. Hal

luci

nat

ion

s ex

per

ien

ce n

o lo

nge

r pr

edic

ts e

mot

ion

al d

istr

ess

once

be

liefs

abo

ut

voic

es, a

nd

per

son

alit

y en

tere

d in

to t

he

mod

el.

(Ben

tall

et a

l.,

2009

)C

orre

lati

onal

Pess

imis

tic

thin

kin

g, t

he

Att

ribu

tion

al S

tyle

Q

ues

tion

nai

re (

ASQ

; Pe

ters

on e

t al

., 19

82)

Para

noi

d id

eati

on,

Pete

rs e

t al

. Del

usi

ons

Inve

nto

ry (

PD

I;

Pete

rs, J

osep

h, &

G

aret

y, 1

999)

Pess

imis

tic

thin

kin

g co

rrel

ates

hig

hly

wit

h

para

noi

a.

(Sor

rell,

Hay

war

d,

& M

eddi

ngs

, 20

09)

Cor

rela

tion

al

and

expe

rim

enta

l

BAV

Q-R

, app

rais

als

of m

alev

olen

ce a

nd

omn

ipot

ence

of

voic

es

Voi

ce d

istr

ess

(PSY

RA

TS)

, de

pres

sion

(B

DI)

Fou

nd

that

“p

erce

ived

rel

atio

nsh

ip w

ith

voi

ce”

pred

icte

d di

stre

ss b

ut

not

inde

pen

den

t of

bel

iefs

reg

ardi

ng

omn

ipot

ence

an

d m

alev

olen

ce. N

oncl

inic

al v

oice

hea

rers

si

gnif

ican

tly

less

dis

tres

s an

d le

ss li

kely

to

hol

d om

nip

oten

ce a

nd

mal

evol

ence

ap

prai

sals

wh

en c

ompa

red

to c

linic

al v

oice

h

eare

rs.


(Joh

nso

n,

Goo

din

g, W

ood,

&

Tar

rier

, 201

0)

Cor

rela

tion

alR

esili

ence

App

rais

als

Scal

e (R

AS;

Joh

nso

n e

t al

., 20

10)

Bec

k Sc

ale

for

Suic

idal

Id

eati

on (

BSS

; Bec

k,

Kov

acs,

& W

eiss

man

, 19

79)

Fou

nd

that

pos

itiv

e ap

prai

sals

sig

nif

ican

tly

mod

erat

e th

e re

lati

onsh

ip b

etw

een

h

opel

essn

ess

and

suic

idal

idea

tion

.

(Pet

ers,

Will

iam

s,

Coo

ke, &

K

uip

ers,

201

2)

Cor

rela

tion

alB

AVQ

-R, a

ppra

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Randomized Controlled Trials

The results of CBTp randomized controlled trials (RCTs) up until 2008 are well summarized by the Wykes et al. (2008) meta-analysis, which found a modest effect on the primary outcome across 18 studies of individual CBTp (mean effect size 5 .372). When methodologically rigorous studies were analyzed alone, the effect size fell to .223. Furthermore, all but 3 of the 27 studies included in the meta-analysis used syndrome-focused global outcome measures for primary outcome. One of these studies stands out among those studies for several reasons (Trower et al., 2004). This study defined a behavioral measure, “compliance with command hallucinations” as the primary outcome, which was linked directly to the specific goals of their CBTp intervention called cogni-tive therapy for command hallucinations (CTCH). This study established clear links between the goals of their intervention and the primary outcome measure and represents an approach to a single symptom (command hallucinations and associated disturbance of behavior) in line with the single-symptom approach to working with psychosis. The resultant effect size reported from this approach was larger (ES 5 1.1). An examination of the methodology reveals that establishing well-defined goals resulted in the selection of a clearly valid sample on which to test the inter-vention. The sample consisted of 38 patients with current symptoms of command hallucinations with which they had recently complied, resulting in serious consequences. This differs from other studies included in the Wykes et al. meta-analysis, which tended to use global syndrome severity cut-off scores for trial recruitment.

Garety and colleagues (2008) have published the results of an RCT subsequent to the pub-lication of the Wykes et al. (2008) meta-analysis. Their study appears to have high rigor; it was a double blind RCT with intention to treat analysis on a sample of 301 patients with an ICD-10 diagnosis of nonaffective psychosis that had recently relapsed. Results of this study found no significant effect for CBT on primary outcomes of relapse rates or remission time at 12- and 24-month follow-up. Furthermore, no significant effects were found on psychotic symptoms as measured by the PANSS total, positive, negative, or general psychopathology subscales. However, although no effects were found for primary outcomes related to the global syndrome (i.e., relapse rates), significant effects were found at 24 months for the CBTp group on depression, delusional distress, and social functioning. Another more recent RCT of efficacy was found in a small trial of worry-focused CBTp in 24 patients suffering persecutory delusions and high levels of worry (Foster, Startup, Potts, & Freeman, 2010). This study found significant effects of worry-focused CBTp on primary outcomes of worry and also delusional distress but not to total positive symp-toms or the individual symptom of paranoia.

An RCT which has recently emerged with a key difference from those reviewed thus far is that of Morrison et al. (2014) who for the first time conducted an RCT into the efficacy of CBTp for patients with diagnosis of psychosis who had chosen not to take antipsychotic medication. The authors randomized 74 patients to receive either cognitive therapy plus treatment as usual (active group) or treatment as usual alone and reported an estimated between group effect size of 26.52 in favor of the active treatment group, an effect size some 17 times larger than the mean effect size reported by Wykes et al. (2008) across some 32 studies, which had used CBTp as an adjunct to medication. Taken in conjunction with the results of Trower et al. (2004), it seems possible that evaluating CBTp in a less medicalized context seems to be associated with larger effect sizes for the treatment.

Three randomized controlled effectiveness trials of CBTp have since emerged, evaluating the degree to which CBTp is effective in routine clinical practice, with all three of these trials using the PANSS syndrome scale as primary outcome (Farhall et al., 2009; Lincoln et al., 2012; Peters et al., 2010). Peters et al. (2010) found no significant effect of CBTp over wait list control on P-PANSS, whereas Farhall et al. (2009) similarly found no advantage for CBTp over usual


psychiatric care on P-PANSS scores. Interestingly, however, Farhall et al. also found no effect for CBTp on their secondary outcome of depression, whereas Peters et al. (2010) found that the only robust findings for CBTp were with depression. Contrary to these two effectiveness trials, Lincoln et al. (2012) found CBTp to be superior to wait list control with effect sizes of .61 and .65 at the end of treatment and 1 year follow-up respectively for the global PANSS. This trial also found similarly moderate effect sizes for depression (ES 5 .50–.63).

Similar results appear in the “ultra-high risk” for psychosis CBT intervention literature. A review by Preti and Cella (2010) focused on the outcome of transition to psychotic syndrome using mostly PANSS cutoff scores and found that overall rates of transition to psychotic syn-drome in CBT conditions was 11% compared to 31.6% for the “no focused treatment” conditions but that this effect was not found at 2–3-year follow-up. The authors concluded that CBTp for this population may only delay onset of psychotic disorder (Preti & Cella, 2010). Consistent with these results, a recent large-scale early intervention RCT found no significant effect of CBT on transition rates to psychosis syndrome (Morrison, French, et al., 2012). The authors concluded,

The results are consistent with findings from clinical trials on people in an at risk mental state. Most trials found that severity of psychotic experiences could be reduced over a moderate time-frame, such as 12 months, whereas some found that it was not possible to reduce transition to psychosis over such a period. (Morrison, French, et al., 2012, p. 1–14)

Although the RCT research to date for CBTp and CBT for “at risk” populations has tended to evaluate CBT regarding outcomes related to psychotic syndrome, there is generally only evidence of poor to modest effects of CBT on these outcomes. In contrast, there is a small degree of emerg-ing evidence which suggests that CBTp may have a larger impact on single-symptom outcomes, particularly those related to affective distress, in line with CBTp models which have their roots in a single-symptom approach to psychosis.

SummAry And concluSionS

The aim of this review was to attempt to clarify the primary goals of CBTp. This review of the theoretical CBTp literature suggests that CBTp models primarily take a single-symptom approach to psychosis and associated emotional distress and behavioral disturbance. However, some models maintain secondary goals of global syndrome reduction and/or relapse preven-tion (Beck et al., 2008; Garety et al., 2001) somewhat consistent with a syndrome approach to psychosis. The goals of CBTp, according to the models reviewed, appear to fall into four catego-ries: reduction of emotional distress, reduction of behavioral disturbance, reduction of individual psychotic symptoms, and reduction in the global psychotic syndrome.

This article then reviewed the empirical literature to ascertain the degree of empirical support for these four goal emphases. It was found that studies of negative appraisal processes in sufferers of psychosis have strongly established their relation to emotional distress and, to a lesser degree, behavioral disturbance and single psychotic symptoms, although largely neglecting to establish a link with global positive symptoms. This provides broad evidence in support of the argument made by Birchwood and Trower (2006) that CBTp is not in the business of treating the psychotic syndrome but is in fact designed to treat the emotional distress related to individual positive symptoms. Furthermore, the lack of attempts in the empirical literature to link these cognitive processes with syndrome measures may indicate that other CBTp researchers in general do not view these outcomes to be of primary relevance. This is further supported by the CBTp RCT data, which to date can only claim modest effects on global syndrome outcomes, a result that stands for both established psychotic and at risk populations in both studies of efficacy and effectiveness.


The weight of empirical evidence from experimental, correlational, single-case, and RCT data thus converge with CBTp theory in support of the argument that the primary goals of CBTp for sufferers of psychosis should be the amelioration of emotional distress and behavioral distur-bance within a single-symptom framework. The CBTp theoretical and empirical literature is sup-portive of the use of CBTp to target single symptoms of hallucinations, delusions, and paranoia, particularly in the context of associated emotional distress and behavioral disturbance. There is a smaller degree of evidence from some CBTp models that CBTp may have as secondary goals, the reduction of global symptoms of a psychosis syndrome; however, the empirical evidence for these goals is thus far poorly established outside of the modest treatment effect findings of RCT data. This review highlights that although most CBTp RCTs use measures of global positive symptom change as the primary indicator of treatment outcome, there is little theoretical or empirical sup-port for this treatment outcome emphasis.

If the primary goal of CBTp is not global syndrome reduction, then the use of syndrome-focused measures to evaluate treatment outcome must substantially reduce the likelihood of finding evidence in support of efficacy. Furthermore, if the primary goals of CBTp are the amelio-ration of single psychotic symptom and associated emotional distress and behavioral disturbance, then the outcome measures used in research trials need to reflect these goals. Another implication of these findings is that CBTp may have been evaluated using largely inappropriate patient sam-ples. Rather than selecting samples that relate directly to the primary goals of CBTp (i.e., those who experience high levels of distress, and behavioral disturbance, associated with specific psy-chotic symptoms), many CBTp treatment outcome studies have tended to include participants that meet global symptom cutoff scores, regardless of whether subjective distress in relation to symptoms was present. This can be argued to be reflective of the syndrome-focused emphasis highlighted as problematic by Trower and Birchwood (2006). The issue of sample characteristics needs to be considered in CBTp treatment outcome trials because it too has the potential to have a deleterious effect on obtained effect sizes. CBTp treatment outcome studies that seek to decrease emotional distress in psychotic populations need to target populations of psychosis sufferers who are, in fact, distressed by their symptoms. It is argued that not doing so is analogous to including people who do not have cancer, in a study evaluating the effectiveness of a cancer treatment.

One way forward for CBTp outcome evaluation could be to study CBTp separately in relation to different outcomes that will vary depending on individualized assessment. This would lead to an empirical evidence base for CBTp applied to samples of patients per single symptoms of psychosis such as hallucinations, delusions, paranoia, and their associated distress and distur-bance of behavior, more closely reflecting CBTp as it is practiced (i.e., formulation-based treat-ment). This appears to have been a strength of the Trower et al., (2004) RCT and one possible reason for the comparably larger effect size observed in that study. Indeed in their CTCH treat-ment manual, Byrne et al. (2006, p. 12) argue that larger effect sizes could be expected in CBTp treatment outcome studies that focus on distress and dysfunctional behavior outcomes within a single-symptom framework. Despite the relative success of the Trower et al. (2004) RCT, only one other study could be found which resembles their approach to primary outcome selection within a single-symptom framework (Foster et al., 2010). This study found significant effects on primary outcomes of worry and also delusional distress but not total positive symptoms or the individual symptom of paranoia. These findings are supportive of taking a single-symptom approach to the selection of outcome measures and relevant participant samples.

The movement within CBTp away from a syndrome emphasis in treatment toward a pri-mary emphasis on emotional distress and behavioral functioning outcomes also places CBTp as being somewhat commensurate with the emerging literature on Acceptance and Commitment Therapy for Psychosis (Morris, Johns, & Oliver, 2013) and other third wave approaches to psy-chosis (e.g., Chadwick, 2006). In this way, this article also highlights a convergence between


second and third wave behavioral and cognitive approaches to psychosis, at least in terms of the target outcomes of treatment. What remains to be seen, however, is the degree to which the dif-fering treatment elements of these approaches (e.g., acceptance, belief modification) might be complementary and/or distinct processes and the contexts in which any such approaches might be more predictive of emotional well-being in people experiencing psychosis.

Future studies focusing on the mechanisms of change in CBTp are needed to ascertain the degree to which CBTp processes relate to a range outcome measures relevant to CBTp. Given the sparse empirical literature linking negative appraisal processes to psychotic symptoms measured globally or individually, further empirical research is required to test the primary argument of this review. Although this review has demonstrated that little empirical evidence exists to suggest that CBTp mechanisms of change relate strongly to syndrome outcomes, there is also sparse evidence to suggest that they do not. Therefore, studies which examine the relationships between CBTp mechanisms of change and the different classes outcome measures examined in this review (e.g., syndrome, single symptom, emotional distress, behavioral functioning) represent a logical next step in the literature.

It can be argued that the development of CBTp and its evidence base has likely benefited from initially being established in comparison to medication and outcomes related to the goals of pharmacology. However, this review suggests that this medicalized approach to evaluating CBTp is poorly supported by CBTp theory and research but also appears to be associated with the reporting of lower effect sizes for CBTp trials. This calls into question the findings of clinical trials thus far, which have tended to evaluate CBTp as although it were a “quasi-neuroleptic” (Birchwood & Trower, 2006). There is a need to be clear about the goals of CBTp in its own right, allowing for the use of outcome measures and participant samples that are more relevant to CBTp and the way it is practiced. The CBTp treatment outcome literature is at a stage where it can be argued with some confidence that CBTp has modest efficacy for the treatment of schizophrenia and related disorders. What remains to be seen is whether CBTp can demonstrate stronger effi-cacy when evaluated in relation to relevant patient samples and with outcome measures that are more in line with its theoretical goals.

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Correspondence regarding this article should be directed to Robert Brockman, DPsych (Clin), School of Social

Sciences and Psychology, University of Western Sydney, Locked Bag 1797, Penrith NSW 2751, Australia.

E-mail: [email protected]

Reproduced with permission of the copyright owner. Further reproduction prohibited withoutpermission.

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