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(p. 329) Research evidence of the effectiveness of cognitive behavioural therapy for persecutory delusions: more work is needed 

(p. 329) Research evidence of the effectiveness of cognitive behavioural therapy for persecutory delusions: more work is needed
Chapter:
(p. 329) Research evidence of the effectiveness of cognitive behavioural therapy for persecutory delusions: more work is needed
Author(s):

Philippa Garety

, Richard P. Bentall

, and Daniel Freeman

DOI:
10.1093/med:psych/9780199206315.003.0016
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Subscriber: null; date: 16 January 2019

Introduction

Elsewhere in this book, we read that the very first report of cognitive behavioural therapy (CBT) by its founder, Aaron Beck, concerned successful work with a persecutory delusion (Beck 1952; see Chapter 20 of this volume). In this section, the other chapters describe the process and main elements of therapy with persecutory delusions, and illustrative case examples are provided, together with a first-person account of the experience of therapy. These accounts indicate that CBT is an increasingly popular and acceptable approach for working with persecutory delusions: but what is the research evidence for its effectiveness? In this chapter, we offer a descriptive summary of the relevant research in CBT, note that the evidence for effectiveness is mixed and modest, and highlight key questions for future development.

The development of CBT for psychosis

Beck’s 1952 case report did not immediately stimulate the development of CBT for psychosis. Instead, Beck turned his gaze on depression and the serendipitous discovery of antipsychotic effects of chlorpromazine in the same year (1952) initiated an era dominated by pharmacological treatments for psychosis. However, in time, the limitations of the antipsychotic medications, in terms of their effectiveness, acceptability and side-effects, came to be recognized and the search for other treatment approaches, to supplement medication, gained ground (Curson et al. 1988; Garety et al. 2000). By the late 1980s/early 1990s, a new generation of largely British psychologists and psychiatrists started (p. 330) to experiment with CBT approaches for delusions and hallucinations, influenced by the evidence supporting CBT for anxiety and depression, the emerging cognitive theories of delusions and hallucinations (e.g. Hemsley and Garety 1986; Bentall 1990) and a number of behavioural and coping-focused case studies targeting psychotic symptoms, published in the preceding decade. Encouraging case reports and small controlled trials of CBT were first published (e.g. Fowler and Morley 1989; Chadwick and Lowe 1990; Kingdon and Turkington 1991; Tarrier et al. 1993; Garety et al. 1994). These were soon to be followed by the development of treatment manuals as the basis for more substantial randomized controlled trials (RCTs) of CBT (Kingdon and Turkington 1994; Chadwick et al. 1996; Fowler et al. 1995).

The evidence from randomized controlled trials

The study populations: do they include people with persecutory delusions?

A major difficulty in reviewing the literature on the effectiveness of CBT for persecutory delusions is that no RCT has yet been published. In this respect, the lack of formal evidence for the evaluation of the psychological treatment of persecutory delusions mirrors the situation in pharmacology (see Chapter 15). The first generation of CBT case studies was focused on people with persistent and generally distressing delusions and hallucinations, since these were the medication-unresponsive symptoms for which new treatment approaches were seen to be needed. The first wave of RCTs therefore also largely selected people meeting the same criterion of positive symptom persistence, all in the context of a diagnosis in the schizophrenia spectrum (Tarrier et al. 1993, 1998; Kuipers et al. 1997; Pinto et al. 1999; Sensky et al. 2000). None of these studies was focused on people with persecutory delusions; although, of course, as persecutory delusions are the second most common positive symptom, after ideas of reference (Freeman 2007), CBT in these studies will frequently have been targeted on persecutory delusions. (Typically persecutory delusions occur in about 50% of those with schizophrenia and in a higher proportion, above 80%, of those with delusions.) Only one trial, that by Kuipers et al. (1997), has reported outcomes for persecutory delusions (combined with ideas of reference). Since 2000, there have been further RCTs for people with persistent positive symptoms and a diagnosis of schizophrenia (Durham et al. 2003; Cather et al. 2005; Valmaggia et al. 2005).

Very soon, however, CBT broadened its scope beyond people with persistent positive symptoms and RCTs were reported with populations selected by a wide variety of new criteria, only some of which used a diagnostic criterion (p. 331) of schizophrenia. These include: acute psychosis (Drury et al. 1996; Bach and Hayes 2002; Startup et al. 2004; Bechdolf et al. 2004; Gaudiano and Herbert 2006; Garety et al. in press); early psychosis (Haddock et al. 1999a; Lewis et al. 2002; Jolley et al. 2003; Jackson et al. 2005); people with co-morbid substance misuse (Barrowclough et al. 2001); people with negative and positive symptoms (Rector et al. 2003); community patients (Turkington et al. 2002) and older community patients (Granholm et al. 2005); people stable in the community and at risk of relapse (Gumley et al. 2003); people with hallucinations (Wykes et al. 1999; Jenner et al. 2004; Trower et al. 2004) and people considered at high risk of developing psychosis (Morrison et al. 2004). Many, but not all, of these populations will include a substantial, but generally unknown, proportion of people with persecutory delusions. It should also be noted that therapies in most of these studies were delivered individually, while a small number used a group format. This review therefore can only offer an overview of outcomes for psychosis and, where measured, positive symptoms; and, with one exception (Kuipers et al. 1997), we need to extrapolate from these studies to make any inferences about outcomes for persecutory delusions. Since studies targeting hallucinations or at-risk mental states explicitly do not directly target persecutory delusions, we will not consider them further in this review.

Study design: choice of control group

The RCTs differ not only in respect of the study populations, and individual or group format, but also in terms of design, a key difference being the choice of control condition. The majority of studies compare CBT added to Routine care or ‘Treatment as usual (TAU, typically drug treatment and case management)’ with TAU alone. Another group of studies compares CBT plus TAU with another psychological intervention (e.g. supportive counselling) plus TAU. Rarely, there are three conditions, with CBT (plus TAU), an active intervention (plus TAU) and a TAU-only condition. Clearly these designs have different strengths and limitations. The CBT comparison with TAU allows investigation of the effects of CBT when added to standard care; however, it does not permit inferences about the specific benefits of CBT rather than any psychological approach. However, the comparison of CBT with an active psychological intervention, in the absence of a TAU-only condition, does not enable us to infer whether CBT is beneficial, only whether it is more or less beneficial than an alternative psychological approach. In this review, we therefore separately examine comparisons of CBT with TAU and with another active treatment. We do not report analyses which combine outcomes from two different psychological interventions (e.g. CBT and supportive therapy) and compare both with TAU.

(p. 332) CBT approach

Most studies have used a generic CBT for psychosis approach, based on the early manuals or variants of these. All of these emphasize the importance of engagement, collaboration, considering the personal meaning and appraisals of psychotic experiences, normalizing and gently exploring alternative explanations, and work with affective symptoms and relapse prevention. It has been suggested that in the studies with generic CBT for psychosis, some CBT therapists and trial research groups have practised a more behavioural style of CBT, in contrast with a more purely cognitive approach (Tarrier and Wykes 2004); however, whether any such differences affect outcome has not been prospectively investigated. There are also some studies which explicitly describe some differences in emphasis of CBT, as delivered. For example, a number of CBT approaches report a particular focus on social functioning (e.g. ‘functional CBT’: Cather et al. 2005; and ‘cognitive behavioural social skills training’: Granholm et al. 2005).

There is also a new variant of CBT for psychosis, with distinctive theory and therapy elements, sometimes called ‘third wave’, Acceptance and Commitment Therapy (ACT) [the first wave being behavioural therapies and the second cognitive therapies (Hayes 2004)].ACT differs from traditional CBT in emphasizing acceptance and mindfulness, aiming for a new relationship to negative thoughts and emotions, in contrast to ‘formal disputation of dysfunctional thought content’ (Gaudiano et al. 2006). Two studies of acute psychosis have used ACT (Bach and Hayes 2002; Gaudiano and Herbert 2006). These will therefore be considered separately.

Outcomes

One important issue for the evaluation of RCT evidence concerns the selection of trial outcomes. There are of course a wide variety of potentially important outcomes from therapy for psychosis, and different trials have had different intended benefits. Initially, trials concentrated particularly on reducing positive symptoms and measured this using standardized scales, such as the Brief Psychiatric Rating Scale (BPRS; Overall and Gorham 1967) and the Positive and Negative Symptom Scales (PANSS; Kay et al. 1989). This approach has been criticized by some authors, notably Birchwood and Trower (2006), who argue that the goals of CBT should not be assumed to be the same as the goals of drug treatment, that is symptom reduction. They propose, instead, that CBT should be focused on emotional dysfunction and reactions to psychotic experiences. Indeed, from early on, many CBT studies have also targeted the distress associated with symptoms, and measured this using multi-dimensional scales (e.g. PSYRATS, Haddock et al. 1999b) as well measures of affective (p. 333) symptoms and social functioning. More recent trials with other specific targets of treatment have measured these other outcomes, such as relapse, appraisals of hallucinations and transition to psychosis. In this overview, we consider the most commonly measured outcomes: positive and negative symptoms, depression, social functioning and relapse.

Methodological requirements

There has been considerable variability in the methodological conduct of trials and a growing awareness that these methodological differences might have had an impact on intervention effects, through contributing to sources of hidden bias (Tarrier and Wykes 2004). Methods to reduce bias include independent randomization in allocation to treatment, blind assessment, and improving rates of follow-up. Recent years have therefore witnessed a greater sophistication in the methodology of trials, influenced both by this awareness and by the requirements set by consensus good practice statements, such as the CONSORT group statement (Altman et al. 2001). We note in particular whether blind assessment has been undertaken, since this has been found to be a particular source of bias (Tarrier and Wykes 2004). It is worth adding that, in general, the methodology of many CBT trials has been superior to that of many pharmacological investigations, for example those comparing first-and second-generation anti-psychotics, which have been compromised by short follow-up periods and high drop-out rates (Geddes et al. 2000).

Summary of outcomes from RCTs for CBT for psychosis

In Tables 16.1, 16.2 and 16.3a and 16.3b we present a summary of the effects of individually delivered CBT for psychosis, at the end of the treatment phase and at follow-up, grouped by treatment population, separately for comparisons with TAU and with an active treatment. Group treatments are shown together in Tables 16.4a and 16.4b.

Table 16.1 Evaluations of individual cognitive-behavioural therapy (CBT) for the positive symptoms of psychosis that compare CBT plus treatment as usual (TAU) and a TAU control

Study

Patients

n

Groups

Assessment points

Blind assessment

Treatment length

End of CBT treatment effects Relapse

over trial

Positive symptoms

Negative symptoms

Depression

Social functioning

Persistent symptoms

Tarrier et al. (1993)

Persistent positive symptoms

39

  1. 1. Coping strategy enhancement

  2. 2. Problem solving

  3. 3. Waiting list control

Pre-waiting period, pre-treatment, post-treatment (6 weeks), 6-month follow-up

No :

6 weeks

Yes

No

No

No

Garety et al. (1994)

Persistent distressing positive symptoms

20

  1. 1. CBT

  2. 2. Waiting list control

Monthly for 6 months

No

6 months

Yes

Yes

No

Kuipers et al. (1997)

Persistent distressing positive symptoms

60

  1. 1. CBT

  2. 2. TAU control

0, 3, 6, 9, 18 months

No

9 months

Yes*

No

No

Tarrier et al. (1998)

Persistent positive symptoms

87

  1. 1. CBT

  2. 2. Supportive counselling

  3. 3. TAU control

Baseline, 3 months, 12 months

Yes

10 weeks

Yes

No

Durham et al. (2003)

Persistent distressing positive symptoms

66

  1. 1. CBT

  2. 2. Supportive therapy

  3. 3. TAU control

0, post-treatment, 3-month follow-up

Yes

9 months

Yes

Rector et al. (2003)

Persistent positive and negative symptoms

42

  1. 1. CBT

  2. 2. TAU control

0, 6 (post-treatment), 12 months

Yes

6 months

No

No

No

Outpatients

Turkington et al. (2002)

Outpatients with a diagnosis of schizophrenia

422

  1. 1. Brief CBT

  2. 2. TAU control

Baseline, post therapy, 12 months

No

6 sessions over an average of 20 weeks

No

No

Yes

Yes

Gumley et al. (2003)

Patients with schizophrenia, vulnerable to relapse and no current severe positive symptoms

144

  1. 1. CBT

  2. 2. TAU control

0, 12, 26, 52 weeks

No

5 sessions in first 12 weeks plus additional sessions at signs of relapse

Yes

Yes

Yes

Yes

Acute psychosis

Lewis et al. (2002)

Acute psychosis (first or second episode)

315

1. CBT

0, 2, 3, 4, 5 weeks.

Yes

5 weeks

Yes

No

2. Supportive counselling

3. TAU control

6-10-week and 18-month follow-ups

Jolley et al. (2003)

Schizophrenia diagnosed in the last 5 years and symptoms present within last 3 months

21

  1. 1. CBT

  2. 2. TAU control

0, 2, 4, 6, months

Yes

6 months

No

No

No

Startup et al. (2004)

Acute psychosis

90

  1. 1. CBT

  2. 2. TAU control

0, 6, 12, 24 months

No

Up to 25 sessions over year

Yes

Yes

Yes

No

Garety et al. (in press)

Acute psychosis

301

  1. 1. CBT

  2. 2. Family intervention

  3. 3. TAU control

0, 3, 6, 12, 24 months

Yes

9 months

No

No

No

No

No

ACT/acute psychosis

Bach and Hayes (2002)

Acute psychosis

80

  1. 1. ACT

  2. 2. TAU control

Baseline, 4-month follow-up

No

4 sessions

No

Gaudiano and Herbert (2006)

Acute psychosis

40

  1. 1. ACT

  2. 2. TAU control

Baseline, discharge, 4-month follow-up

No

Length of inpatient stay

Yes

No

Yes

No

Substance misuse

Barrowclough et al. (2001)

Schizophrenia and substance abuse

36

  1. 1. Motivational interviewing, CBT and family intervention

  2. 2. TAU control

0, 9, 12 months

Yes

9 months

Yes

No

No

Early psychosis

Jackson et al. (2005)

Early psychosis

91

  1. 1. COPE

  2. 2. TAU control

0, 6, 12 months

Yes

12 months

No

No

No

No

No

*Improvement in persecutory ideation.

ACT, Acceptance and Commitment Therapy; COPE, cogntively oriented psychotherapy for early psychosis.

Table 16.2 Trials comparing cognitive-behavioural therapy (CBT) with another active psychological intervention

Study

Patients

n

Groups

Assessment points

Blind assessment

Treatment length

End of CBT treatment effects

Relapse over trial

Positive symptoms

Negative symptoms

Depression

Social functioning

Persistent positive/psychotic symptoms

Pinto et al. (1999)

Persistent psychotic symptoms

41

  1. 1. CBT and social skills training

  2. 2. Supportive therapy

0, 6 (post-treatment) months

No

6 months

Yes

No

No

Sensky et al. (2000)

Persistent distressing psychotic symptoms

90

  1. 1. CBT

  2. 2. Befriending

0, 9 (post-treatment), 18 months

Yes

9 months

No

No

No

Cather et al. (2005)

Persistent psychotic symptoms

30

  1. 1. Functional CBT

  2. 2. Psycho-education

0, 4 (post-treatment)

Yes

4 months

No

No

No

No

Valmaggia et al. (2005)

Persistent positive symptoms in long-term patients

62

  1. 1. CBT

  2. 2. Supportive counselling plus psycho-education

0, 4 (post-treatment) 6 months

Yes

4 months?

  • No

  • Yes (hallucinations, some aspects)

No

No

No

Acute psychosis

Drury et al. (1996)

Acute psychosis

40

  1. 1. Individual and group CBT

  2. 2. Activity control group

Weekly for 6 months. Follow-up at 9 months.

No

8 h per week during inpatient admission

Yes

No

No

Haddock et al (1999)

Acute psychosis (and onset <5 years)

21

  1. 1. CBT

  2. 2. Supporting counselling and Psycho-education

0, 5 weeks (post treatment) 5–6 months, 2 years

Yes

5 weeks

No

Table 16.3a Outcomes at follow-up for comparisons of individual cognitive-behavioural therapy (CBT) plus treatment as usual (TAU) and TAU control

Study

Duration of treatment

Duration of follow-up

Positive symptoms

Negative symptoms

Depression

Social functioning

Relapse or readmission

Kuipers et al. (1997, 1998)

9 months

18 months

Yes

No

Tarrier et al. (1998, 1999, 2000)

10 weeks

12 months

Yes

No

No

24 months

Yes

Yes

Durham et al. (2003)

9 months

3 months

Yes

Rector et al. (2003)

6 months

6 months

No

Yes

No

Turkington et al. (2002, 2006b)

6 sessions over an average of 20 weeks

12 months

No

Yes

No

No

Yes

Lewis et al. (2002);

5 weeks

18 months

No data on CBT vs TAU

No data on CBT vs TAU

No

Tarrier et al. (2004)

Startup et al. (2004, 2005)

Up to 25 sessions over year

24 months

No

Yes

Yes

No

Garety et al. (in press)

9 months

24 months

No

No

Yes

No

No

Bach and Hayes (2002)

4 sessions

4 months

No

Yes

Gaudiano and Herbert (2006)

Length of inpatient stay.

4 months

No

Barrowclough et al. (2001);

9 months

18 months

No

Yes

Yes

No

Haddock et al. (2003)

Jackson et al. (2005)

12 months

4 years

No

Table 16.3b Outcomes at follow-up for comparisons of individual cognitive-behavioural therapy (CBT) and an active psychological intervention

Study

Duration of treatment

Duration of follow-up

Positive symptoms

Negative symptoms

Depression

Social functioning

Relapse or readmission

Persistent positive/psychotic symptoms

Sensky et al. (2000); Turkington et al. (2008)

9 months

18 months

Yes

Yes

Yes

5 years

No

Yes

No

No

Valmaggia et al. (2005)

4 months?

10 months

No

No

No

Drury et al. (1996, 2000)

8 h per week during inpatient admission

5 years

No

No

Table 16.4a Evaluation of group cognitive-behavioural therapy (CBT) trials

Study

Patients

n

Groups

Assessment points

Blind assessment

Treatment length

End of CBT treatment effects

Relapse over trial

Positive symptoms

Negative symptoms

Depression

Social functioning

Group CBT trials (TAU comparison)

Barrowclough et al. (2006)

Persistent positive symptoms of schizophrenia

113

  1. 1. Group

  2. 2. CBT Control

Baseline, 6 (post-treatment), 12 months

Yes

6 months

No

No

  • No

  • Yes (hopelessness/self-esteem)

No

No

Granholm et al. (2005)

Older patients (aged 42–74 years) with schizophrenia in the community

76

  1. 1. CBT and social skills training

  2. 2. Control

0, 3, 6 (post-treatment) months

Yes

6 months

No

No

No

Yes

Group CBT trials (CBT and active psychological intervention comparison)

Bechdolf et al. (2004)

Inpatients with schizophrenia

88

  1. 1. Group CBT

  2. 2. Group psycho-education

Baseline, 2 (post-treatment) 6 months

No

8 weeks

No (6 months)

No (6 months)

  • Yes (rehospitalized at 6 months)

TAU, treatment as usual.

Table 16.4b Outcomes at follow-up for group cognitive-behavioural therapy (CBT) trials

Study

Length of treatment

Length of follow-up

Positive symptoms

Negative symptoms

Depression

Social functioning

Relapse over trial

Group CBT trials (CBT and TAU comparison)

Granholm et al. (2005)

6 months

12 months

No

No

No

Yes

Group CBT trials (active psychological intervention comparison)

Bechdolf et al. (2004, 2005)

8 weeks

24 months

No

No

No

TAU, treatment as usual.

The most consistent evidence for reductions in positive symptoms occurs in trials of individual CBT with people with persistent positive symptoms, where the CBT intervention is compared to a TAU control. One trial in this subgroup (Kuipers et al. 1997) specifically reports a positive effect on persecutory delusions and ideas of reference (BPRS suspiciousness item). This is the largest sub-group of studies and we can conclude that individual CBT is effective for reducing persistent positive symptoms and is, by extrapolation, very likely to have benefits for the treatment of persistent persecutory delusions. To add a note of caution, we note that these studies are generally small, with fewer than 100 participants, and include a number of the earlier, less methodologically robust trials. (p. 334) (p. 335) (p. 336) (p. 337) (p. 338) (p. 339) (p. 340) (p. 341) (p. 342) (p. 343)

(p. 344) The results are less consistent for all the other sub-groups of studies. It is noteworthy that, when CBT for persistent positive symptoms is compared to an active psychological intervention (supportive counselling, befriending or psycho-education), although the number of studies is small, CBT does not show significantly greater effects than other treatment, at the end of treatment, on positive symptoms (see Table 16.2). However, most of these studies suggest that both groups show improvements and that there are trends to greater effects for CBT. In one study (Sensky et al. 2000), effects on ‘schizophrenia change scores’ weresignificantly greater for CBT than the befriending control at follow-up (see Table 16.3b). Some trials report enduring effects, up to two or even five years. However, in general, effects are less often significant at follow-up.

There is also, at present, some more limited and mixed evidence for benefits of CBT for positive symptoms in acute psychosis (Table 16.1). It is perhaps noteworthy that only one trial using blind assessment shows post-treatment improvements in positive symptoms in acute psychosis. Furthermore, this set of studies includes two of the larger and more methodologically robust studies (Lewis et al. 2002; Garety et al. in press). It is acknowledged in these latter studies that patients generally show a positive response to medication in the acute phase and thus demonstrating an additional effect of CBT in the context of this improving course is challenging.

The ACT studies (Bach and Hayes 2002; Gaudiano and Herbert 2006) are intriguing, in that both report some positive results in the context of very brief interventions in acute psychosis, lasting only three or four sessions. This is apparently very different from the effects of the other CBT studies. However, some points might elucidate these differences, before firm conclusions are drawn. Both trials had a very short total duration, including follow-up (four months), which is arguably too early for assessing relapse as a primary outcome, as reported by Bach and Hayes (2002). (Both studies nevertheless reported unusually high and non-significantly different rates of relapse within this short period, of 20% and 28% in the treatment and 40% and 45% in the control arm.) The trials were also less methodologically robust in that neither used blind assessment. The Gaudiano and Herbert (2006) study had an unusually high proportion of participants with major mood disorder (42%) rather than schizophrenia spectrum psychosis, and only eight of these (total n = 40) reported self-rated delusions, although all reported hallucinations. We therefore consider it premature to draw any conclusions from these studies about the effectiveness of ACT with persecutory delusions.

There is only a small number of group CBT treatment studies: Granholm et al. (2005), Barrowclough et al. (2006), and that of Bechdolf et al. (2004) employing an active intervention control (see Table 16.4a). Two of these studies have so far published an analysis of outcomes at follow-up (Bechdolf et al. 2005; (p. 345) Granholm et al. 2005) (see Table 16.4b). There are therefore limited conclusions we can draw; however, the evidence so far does not support significant benefits for positive symptoms for CBT in a group format.

Meta-analyses and reviews

Recent reviews and meta-analyses are consistent with the evidence presented in the tables (Gould et al. 2001; Pilling et al. 2002; Tarrier and Wykes 2004; Zimmerman et al. 2005; Pfammater et al. 2006; Turkington et al. 2006a). They all conclude that there is good evidence that CBT is effective for the reduction in positive symptoms. Effect sizes are generally modest and are most consistent for persistent positive symptoms (for example, an effect size of 0.47 is cited by Pfammater et al. 2006 based on analysis of data from 12 trials for persistent positive symptoms). Zimmerman et al. (2005), in an analysis of 17 studies, report a mean effect size of 0.35 for positive symptoms. In contrast to the general conclusion of the reviews, Zimmerman et al. (2005), also conclude that effect sizes are larger for treatment in the acute episode compared to treatment in the ‘chronic’ condition, although this conclusion is only based on three studies in the acute episodes.

Gaudiano (2006) assessed the clinical significance of symptomatic improvement in response to CBT and also contrasted effects between comparison conditions. He concludes that reliable and clinically significant improvements in psychotic symptoms are demonstrated in RCTs of CBT. As seen in Table 16.2, he also notes that the clear advantage of CBT consistently demonstrated when the comparison condition is TAU is less unequivocal when CBT is compared to a credible alternative intervention. Gaudiano argues that supportive interventions appear also to be efficacious.

In summary, then, meta-analyses support our conclusion that individually delivered CBT is effective for persistent positive symptoms. We can extrapolate from these findings with reasonable confidence to conclude that CBT is effective for persistent persecutory delusions. The size of the effect is generally small–medium. However, although CBT appears to be somewhat more effective than other psychological treatments, the trials do not unequivocally demonstrate that CBT is the most effective approach and supportive approaches are likely also to be of benefit. CBT may also have beneficial effects for persecutory delusions in acute episodes and in other subgroups, but the data so far are not consistent with these populations.

Conclusions

In this descriptive review of CBT for psychosis, we have focused on symptom outcomes, particularly on positive symptoms. We conclude that CBT for (p. 346) psychosis, delivered individually, has small-to-moderate effects in improving positive symptoms, particularly when symptoms are persistent. The trials of CBT in acute psychosis are generally more recent, with larger and well-conducted studies, but demonstrate less positive evidence. Treatment for persecutory delusions in groups has, as yet, little evidential basis. Although we find CBT for psychosis to be effective for persistent positive symptoms, and by extension, for persecutory delusions, little is known about the mechanisms of change. We have used the term ‘generic CBT for psychosis’ since most trials reviewed here have used a broad-based approach to treatment, targeting a wide range of symptoms and potential mechanisms. In this context, it is not clear that CBT is more effective than alternative less structured therapies, such as supportive counselling.

We do consider that CBT is not a ‘quasi-neuroleptic’ with a sole purpose of reducing symptoms (Birchwood and Trower 2006). It has an equally important role to play in working with emotional distress and the reactions of person with psychosis to their experiences of psychosis and of the self. We have not reviewed such outcomes in detail, but note that a number of trials suggest some benefits in depression, emotional distress and social functioning; we support the view that these specific targets of treatment are important and should also be evaluated.

This research literature is new and is developing rapidly. It is less than 15 years since the first trials of CBT for psychosis were published. We are witnessing and recording here the early stages of innovation and development of a new treatment approach. It would have been considered, only two decades ago, to be a radical departure from the assumptions of the time about what works with psychosis. Further experimentation and development of CBT are clearly warranted, to build on the successes demonstrated and to improve on the outcomes. In this volume, many chapters report empirical evidence of psychological processes causally implicated in persecutory delusions. It is now possible to develop new CBT approaches, which use theoretically informed strategies, to attempt to change the hypothesized causal mechanisms and thereby produce beneficial outcomes. It is particularly timely to develop and test new forms of CBT for persecutory delusions.

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