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Talking therapy for psychosis

Our researchers pioneered the development of cognitive behavioural therapy for psychosis, now a recommended treatment for people who have schizophrenia.

Two women conversing in cognitive behaviour therapy session
For many years, medication was the only treatment option for people with psychosis. However, our researchers helped prove that a ‘talking therapy’ could make a real difference to people’s symptoms – and were instrumental in shaping UK guidelines that now recommend cognitive behaviour therapy (CBT) for all people who have schizophrenia, alongside appropriate medication.

Professors Philippa Garety and Elizabeth Kuipers were among the psychologists who pioneered CBT for psychosis. They developed and successfully piloted a form of CBT that aims to help people with schizophrenia and schizo-affective disorder try to understand and make sense of their hallucinations and delusions, and find better ways of coping with these unpleasant experiences. Their treatment was published as a manual, Cognitive Behaviour Therapy for Psychosis, in 1995 – and they then went on to stage a major trial to test its success.

The results of the London-East Anglia Randomised Controlled Trial of CBT for Psychosis showed that the targeted therapy helped the symptoms of half the people who had one-to-one sessions over a period of nine months, on top of the treatment and care they were already receiving.

The people who benefited all had a long history of psychosis, and had persistent and medication-resistant symptoms. The effect of CBT on improving symptoms was similar to that of trials testing the effectiveness of clozapine, an antipsychotic drug often prescribed when others have failed.

Very few people dropped out of the CBT programme, and the majority said they were extremely satisfied with the treatment. What’s more, people who had received specialist CBT showed a ‘significant and continuing’ improvement nine months after the treatment had finished.

An economic evaluation showed that the cost of providing CBT was offset by money that would otherwise have been spent on other mental health services.

Meanwhile, research teams from elsewhere were similarly demonstrating that CBT could help to alleviate the symptoms of psychosis, and the talking treatment was first recommended by NICE in 2002. The updated 2009 NICE guideline recommended that CBT for psychosis should be offered to all people with schizophrenia for at least 16 one-to-one sessions, and NHS trusts are now required to put in place plans to implement this recommendation.

The London-East Anglia trial showed that 50 per cent of people benefited CBT for psychosis, so the research team went on to analyse whether it was possible to predict who would respond well to CBT. They concluded the most important predictor was an individual’s readiness to consider an alternative explanation for the delusions they were experiencing.

Following the trial, a CBT for psychosis clinic was opened at the South London and Maudsley NHS Foundation Trust (SLaM). Referrals have continued to increase over the last decade, and the team continues to offer supervision to therapists who want to acquire specialist skills in CBT for psychosis.

Meanwhile, our researchers continue to develop different types of CBT that target specific symptoms of psychosis. For example, by testing a new version of CBT designed to challenge the power of voices that tell people to act in a harmful way.

Research led by Professors Philippa Garety & Elizabeth Kuipers

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• Garety PA et al. CBT for drug-resistant psychosis. British Journal of Medical Psychology 1994; 67: 259 71

• Fowler D et al. (1995) CBT for Psychosis: Theory and Practice (Wiley Series in Clinical Psychology). John Wiley & Sons. Chichester

• Kuipers E et al. London-East Anglia randomised controlled trial of CBT for psychosis. I: Effects of the treatment phase. British Journal of Psychiatry 1997; 171: 319 27

• Kuipers E et al. London-East Anglia randomised controlled trial of CBT for psychosis. III: Follow-up and economic evaluation at 18 months. British Journal of Psychiatry 1998; 173: 61 8

• Garety PA et al. CBT and family intervention for relapse prevention and symptom reduction in psychosis: randomised controlled trial. British Journal of Psychiatry 2008; 192(6): 412 23

• Wykes T et al. CBT for schizophrenia: effect sizes, clinical models, and methodological rigor. Schizophrenia Bulletin 2008; 34(3): 523 37

• Greenwood KE et al. CHoice of Outcome In Cbt for psychosEs (CHOICE): The Development of a New Service User-Led Outcome Measure of CBT for Psychosis. Schizophrenia Bulletin 2010; 36(1): 126 35

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