Department of Psychiatry, University of Dundee, Scotland
School of Health Policy & Practice, University of East Anglia, Norwich
Department of Psychology, University of Stirling, Scotland
Correspondence: Rob Durham, Department of Psychiatry, Ninewells Hospital & Medical School, Dundee DDI 9SY, Scotland, UK. E-mail: r.c.durham{at}dundee.ac.uk
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To test the effectiveness of cognitivebehavioural therapy delivered by clinical nurse specialists in routine practice.
Method Of 274 referrals, 66 were allocated randomly to 9 months of treatment as usual (TAU), cognitivebehavioural therapy plus TAU (CBT) or supportive psychotherapy plus TAU (SPT) and followed up for 3 months.
Results Treatment effects were modest but the CBT condition gave significantly greater improvement in overall symptom severity than the SPT or TAU conditions combined (F (1,53)=4.14; P=0.05). Both the CBT and SPT conditions combined gave significantly greater improvement in severity of delusions than did the TAU condition (F (1,53)=4.83; P=0.03). Clinically significant improvements were achieved by 7/21 in the CBT condition (33%), 3/19 in the SPT condition (16%) and 2/17 in the TAU condition (12%).
Conclusions Cognitivebehavioural therapy delivered by clinical nurse specialists is a helpful adjunct to routine care for some people with chronic psychosis.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
All referrals were offered an appointment for a screening interview to establish diagnosis (using both ICD10 (World Health Organization, 1992) and DSM-IV (American Psychiatric Association, 1994) criteria), to determine if selection criteria were met and to obtain consent. Suitable patients who consented were given further structured assessments as detailed below and included in the baseline phase of the study. They were then offered a further assessment interview 3 months later to reassess selection criteria and willingness to participate. The second screening interview was included in order to ensure stability of symptoms and as an added check on suitability for inclusion in the trial. Participants who met the criteria on both occasions were then randomised to one of three treatment conditions (cognitivebehavioural therapy plus treatment as usual CBT; supportive psychotherapy plus treatment as usual SPT; treatment as usual TAU) and entered a 9-month treatment phase. They were then reassessed at the end of treatment and at a 3-month follow-up.
The randomisation procedure (sealed envelope technique) was devised by the project statistician (Cathy Hau) and administered centrally by the non-clinical project coordinator (Jen Petrie). It was carried out separately within each treatment centre using randomised permuted blocking (Johnson, 1992). Power calculations were based on the expectation of a reasonably large effect size as found at post-treatment in a clinical trial comparing a coping skills enhancement condition and a problem-solving control (Tarrier et al, 1993). This was the closest example of relevant research when the project was planned. Cohen (1992) states that having 21 patients in each group gives an 80% power of detecting a large effect size with a two-tailed significance level of 0.05. In retrospect this power calculation was not well founded because large treatment effects have not been reported generally in subsequent clinical trials. On the assumption that about two-thirds of screened patients would consent and be suitable and that about two-thirds of this number would complete, it was calculated that about 150 patients would need to be screened. In fact, these assumptions proved to be unrealistic and only about one-fifth of referrals ended up completing treatment.
Assessments
A broad range of measures were administered as part of structured
interviews at initial screening, second screening, post-treatment and 3-month
follow-up. Organisation and administration of the work of the independent
assessors and therapists were kept strictly separate in order to maintain the
blindness of the assessor. Patients also were asked not to mention any details
of their treatment during post-treatment assessments, but three patients did.
The primary outcome measures were chosen following perusal of the literature
on assessment of psychosis (e.g. Barnes
& Nelson, 1994) and consultation with clinical research teams
experienced in the field. They consisted of standardised assessments of the
severity of psychotic symptomatology in general, and delusions and
hallucinations in particular. The former was assessed with the Positive and
Negative Syndrome Scale (PANSS; Kay et
al, 1987), which has been used frequently in clinical trials
with psychosis and is recommended in reviews (e.g.
Drake et al, 1998).
There are three sub-scales (positive symptoms, negative symptoms and general
psychopathology) and a total score. The Psychotic Symptom Rating Scale
(PSYRATS; Haddock et al,
1999) was used to assess specific dimensions of hallucinations and
delusions. The hallucination sub-scale consists of items such as frequency,
duration, loudness, negative content, intensity of distress and degree of
disruption. The delusion sub-scale consists of items such as amount of
pre-occupation, degree of conviction, intensity of distress and disruption.
Both of these instruments have good internal reliability and validity and
provide a comprehensive and clinically useful picture of current mental state
that should be sensitive to treatment effects. At the end of the structured
interview the assessor completed the Global Assessment Scale (GAS;
Endicott et al, 1976) and also Clinical Global Improvement (Guy,
1976) in terms of seven categories (marked, moderate or mild
deterioration, no change, mild, moderate or marked improvement). Other
self-report measures were administered to assess symptom severity, self-esteem
and attitude to illness, but these are not central to the main research
question and are omitted from this report.
Attitude to treatment was assessed at two time points. At the beginning and
middle of therapy patients receiving either of the two psychological therapies
were asked to rate the quality of the therapeutic alliance, using the Penn
Helping Alliance Questionnaire (Luborsky
et al, 1996), to assess their degree of improvement in
terms of seven categories (much worse, moderately worse, a bit worse,
unchanged, a bit better, moderately better and a lot better) and to rate the
suitability of treatment and the degree to which they were learning new ways
of coping. These last two measures were on 0-8 Likert scales. These data were
collected on those patients receiving therapy who were given the forms to
complete and managed to return them (68% in CBT, 63% in SPT). Some bias in the
sample may be present. Finally, at the end of the follow-up interview, once
all assessments had been completed, patients from all three treatment
conditions were administered a brief semi-structured interview to assess the
perceived helpfulness of treatment over the course of the trial and the
quality of their relationship with their therapist/key worker. The blindness
of the independent assessor was broken at this point. As a check on blindness
the assessor was asked to guess treatment allocation after the final outcome
assessments were completed. Analysis of these guesses found that they were no
better than chance (2=5.63, d.f.=2, NS).
Treatment conditions
Overview
Participants in all three conditions received the usual care provided by
the psychiatric services in Tayside and Fife. Services are well developed in
these two areas, with a focus on community care delivered by community mental
health teams. Services include regular psychiatric consultation and contact
with a key worker (typically a trained community psychiatric nurse), with
emergency assessment and hospital admission available as required. Facilities
in the community include day care, sheltered work, supported accommodation and
volunteer befriending. Specialist psychological intervention for psychosis
within a cognitivebehavioural framework, although a limited resource,
is offered through clinical psychology and clinical nurse specialists.
All but one of the therapists in the trial saw patients as part of their routine clinical work and it was not possible to follow a rigid protocol in respect of the duration, frequency and location of individual sessions. These aspects of the protocol were kept flexible so as to accommodate the varied needs of individual patients and therapists. The overall aim was to give each patient a maximum of 20 therapy sessions of approximately half an hour in length over a 9-month period. This level of intensity of therapy was the best that could be managed within the constraints of patient concentration and therapist workload.
Therapists
The CBT arm of the trial was delivered by five clinical nurse specialists
with extensive professional experience of severe mental disorder. All had
completed a recognised post-registration training in Dundee that mainly
focuses on standard cognitivebehavioural therapy for common mental
disorders but includes a module on psychosis. All were registered as
therapists with the British Association of Behavioural and Cognitive
Psychotherapy. One of these five (R.V.M.) had developed a specialist interest
in cognitivebehavioural therapy for psychosis over several years and
took the lead role in developing the treatment protocol, training and
supervising the other therapists and treating the majority of patients. He was
employed part-time on the research grant. None of the CBT therapists saw
patients in the supportive psychotherapy arm of the trial, which was delivered
by 16 mental health professionals (mainly nursing but also psychiatry and
occupational therapy) who were attached to the clinical teams responsible for
the patients referred to the trial and each saw one or two patients as part of
their routine clinical work. All had expressed an interest in developing
clinical skills in psychotherapy for patients with psychosis and none had
received any formal training in cognitivebehavioural therapy. They were
given training and supervision by a consultant psychotherapist (L.R.T.), who
has consultant responsibility for one of the day hospitals in Dundee and is
director of psychotherapy training in Tayside. She took responsibility for
developing the supportive psychotherapy protocol and for training and
supervising the therapists. All therapists in both treatment conditions were
offered bi-weekly supervision for the duration of their contact with patients
in the trial, and most participated on a regular basis.
Cognitivebehavioural therapy
The treatment protocol in the CBT condition drew on best practice as
exemplified by the treatment manuals of Tarrier
(1992) and Kingdon &
Turkington (1994). It was
strongly influenced by training workshops in cognitivebehavioural
therapy for psychosis delivered in Dundee by Tarrier & Turkington. The
essential elements were as follows: initial emphasis on engagement, education
and building a therapeutic alliance; functional analysis of key symptoms,
leading to a formulation and problem list; development of a normalising
rationale for the patient's psychotic experiences; exploration and enhancement
of current coping strategies; acquisition of additional coping strategies for
hallucinations and delusions; and focus on accompanying affective
symptomatology using relaxation training, personal effectiveness training and
problem-solving as appropriate. The overall aims were: to enhance knowledge
and acceptance of illness; to encourage the acquisition of specific coping
skills for managing hallucinations and delusions; and to develop an
understanding of personal vulnerability and how to mitigate its effects.
Supportive psychotherapy
The treatment protocol in the SPT condition was developed by L.R.T. using
the framework described by Garfield in his book Unbearable Affect: A Guide
to the Psychotherapy of Psychosis
(Garfield, 1995). This book
provides therapists with vivid case histories and concrete illustrations of
therapeutic strategies that give a sense of understanding the nature of
psychotic experience and the ways in which talking through these experiences
can bring some measure of relief and perspective. The approach is
psychodynamic in orientation (cf. De
Jonghe, 1993) and seeks to understand psychotic experience as a
function of being overwhelmed and unable to bear intensely charged emotional
experiences. The essential elements of therapy were as follows: provision of a
safe and supportive atmosphere in which to raise issues of emotional
importance to the patients, with an emphasis on the non-specific factors of
warmth, empathy and genuineness; opportunity for the patients to describe the
narrative of their lives, including the impact of the illness, so that they
can be helped to make sense of the timing of the illness and its nature and
content with reference to strong and unbearable affect regarding
past aspects of personal history; and description and working through of the
transference as a process through which an individual transfers onto the
analyst and others, past experiences, attitudes and feelings that he or she
used to experience in relation to important figures earlier in life
(Bateman & Holmes,
1995).
Treatment adherence and quality
Treatment protocols in the CBT and SPT conditions required audiotaping of a
random selection of early, middle and late sessions. Sessions to be taped were
indicated in advance and therapists were encouraged to seek consent for
recording at the beginning of treatment. In practice, tapes were not obtained
from a sizeable minority of participants (38% in CBT and 35% in SPT), because
either consent was refused or the therapist did not feel comfortable asking
for consent from a particular patient (e.g. owing to intense paranoia), or
because the quality of the recording was too poor to be usable. In total, 65
audiotapes were obtained and coded so as to conceal the therapist's identity.
Transcripts of these tapes were made and a representative sample of 45
transcripts of sessions from 23 patients were sent to an independent assessor,
D.F., who used the Cognitive Therapy Scale
(Vallis et al, 1986) and the Cognitive Therapy for Psychosis Adherence Scale
(Startup et al, 2002)
to examine treatment integrity and quality. Items that were core to both
treatments were identified and additional items were included to measure key
components of supportive psychotherapy. The same assessment scales were used
for all transcripts and tapes.
Transcripts were necessary in order to take account of the different therapists providing treatment in the two conditions. Once the transcripts were assessed for integrity, tapes were provided to assist in the assessment of quality. It was concluded that: the two psychological therapy conditions were clearly distinct, with correct identification of therapy allocation made in 22/23 cases; adequate levels of nonspecific therapy ingredients were present in both conditions, with frequently good levels of interpersonal skill; CBT sessions all involved specific, cognitivebehavioural techniques and received competent ratings on the Cognitive Therapy Scale (Vallis et al, 1986). It was also noted that only half of the SPT sessions were rated as having involved a specific psychodynamic approach. Four of thirteen CBT sessions were rated as adherent using the Cognitive Therapy for Psychosis Adherence Scale (Startup et al, 2002). This suggests that relatively few sessions included specific cognitivebehavioural therapy for psychosis techniques of the kind advocated in the Fowler et al (1995) treatment manual. This analysis represents one of the first investigations of the nature and quality of cognitivebehavioural therapy delivered in a clinical trial with psychosis patients and points to the existence of different approaches to providing such therapy for this population.
Patient characteristics
Basic demographic characteristics of the participants are presented in
Table 1. In common with other
trials of this kind (e.g. Kuipers et
al, 1997) the sample consisted mainly of middle-aged, single,
unemployed men with a long history of illness. There were no significant
differences in these characteristics across the three treatment groups. The
participants as a whole were poorly educated, with 90% having left school at
age 16 years or less. At the time of initial referral 85% were living in the
community and 15% were in-patients in a psychiatric hospital. Of the 56
participants living in the community, 30 (54%) lived with friends or
relatives, 17 (30%) lived alone and the remainder were in supported
accommodation. A summary of the diagnostic and clinical status of participants
is presented in Table 2.
|
|
Recruitment and attrition
A total of 274 people were referred for possible inclusion in the trial, of
whom 95 (35% of initial referrals) fulfilled the initial criteria, entered the
baseline assessment phase and were offered a further screening interview 3
months later. Of these, 66 (24% of initial referrals, 38% of 171 potentially
suitable referrals) entered the study and were randomised to treatment
conditions. Progress through these stages is shown in a CONSORT diagram (see
Fig. 1).
|
Medication
Antipsychotic drug dosages over the course of the trial were available for
22 patients in CBT (100%), 19 in SPT (83%) and 18 in the TAU condition (86%).
They were converted to mean daily equivalents of chlorpromazine using standard
guidelines (Atkins et al,
1997) and are summarised in
Table 3. The very broad
confidence intervals reflect the wide variation in dosages within and between
treatment conditions and none of the differences is significant. The increases
in dosage post-treatment were a result of increasing use of atypical
antipsychotics. Four of the fifteen patients who were started on an atypical
were prescribed clozapine. No relationship was found between outcome and
commencement of atypical antipsychotics. In order to assess whether or not
outcome could be attributed to changes in medication, following randomisation
the sample was grouped according to dose change (increased, unchanged,
decreased) and an analysis of variance was conducted on difference scores on
the primary outcome measure (total PANSS score) from baseline to
post-treatment and baseline to follow-up. No significant differences were
found at either post-treatment (F (2,55)=0.63, P=0.54) or
follow-up (F (2,52)=1.51, P=0.23). The largest decreases in
symptom severity were associated with reductions in medication dose.
|
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Changes in severity from baseline
Mean scores across treatment conditions for the four main outcome measures
are shown in Table 4. It can be
seen that baseline scores are very stable for all measures across all three
treatment conditions. An average of the baseline scores was used as the
pre-treatment measure. Repeated measures analyses of variance were first
conducted with three levels of treatment (CBT v. SPT v. TAU)
and three time points (baseline, post-treatment, follow-up). There were
significant effects for time for all variables except the GAS but no
significant time x treatment interaction effects or contrasts for any of
the measures. The analyses were repeated with two levels of treatment, first
to provide a more powerful test of CBT effects against an aggregate of the two
control conditions (CBT v. SPT and TAU) and, second, to test for the
effects of receiving psychological therapy (CBT and SPT v. TAU). The
first set of analyses replicated the initial analysis with the exception of
the total PANSS score, where there was a significant time x treatment
within-subject effect (F(2,106)=3.15, P=0.047). The linear
effect of the time x treatment interaction was also significant
(F(1,53)=4.14, P=0.047). The degree of overall improvement
was greater in the CBT condition than in the other two conditions combined.
The second set of analyses again replicated the initial analysis with the
exception of the PSYRATS delusions score, where there was a non-significant
effect of time (F(2,106)=2.79, P=0.06) but a significant
time x treatment within-subject effect (F(2,106)=3.25,
P=0.043). The linear effect of time x treatment interaction was
also significant (F(1,53)=4.83, P=0.032). The degree of
overall improvement in severity of delusions was significantly greater for
those patients receiving psychological therapy (either CBT or SPT) than
TAU.
|
In order to test for the location and magnitude of change in the two outcome measures with significant time x treatment interactions (PANSS total score and PSYRATS delusions), difference scores were calculated between average baseline scores and post-treatment and follow-up scores. The significance of these differences was examined with paired t-tests and the results are summarised in Table 5. It can be seen that the one significant change on the PANSS total score occurs in the CBT condition at follow-up. The changes at post-treatment are generally much smaller and none is significant. Changes on the PSYRATS delusions sub-scale are of a similar magnitude in the CBT and SPT conditions, with small non-significant changes at post-treatment and larger, significant changes at follow-up. Corresponding changes in TAU are very small and non-significant at post-treatment and follow-up.
|
Clinically significant improvement
Table 6 summarises the
proportion of patients in each treatment condition who showed 25% and 50%
improvements on PANSS total scores. The right-hand part of the table shows the
difference in these proportions for patients treated with CBT relative to
those with either SPT or TAU, from which the number needed to
treat statistic can be calculated. At post-treatment it can be seen
that no patients showed a 50% reduction and relatively small proportions
(10-20%) showed a 25% reduction. Although twice as many patients in the CBT
condition achieved a 25% improvement, the absolute numbers are small and the
differences are not significant. Thus, the number of patients that would need
to be treated with CBT in order to achieve a difference of this kind, relative
to SPT and TAU, is 13, which is a relatively large number. At follow-up it can
be seen that one-third of patients in CBT achieved a 25% reduction, which is
more than twice the proportion for SPT and TAU combined, and the number of
patients that would need to be treated with CBT in order to achieve a
difference of this kind, relative to SPT and TAU, is now six and five,
respectively. Only four patients in the study achieved a 50% decrease in
overall symptomatology, three of whom were in the CBT condition.
|
Patient and assessor ratings of overall improvement
Judgements of overall improvement over the course of the trial were made by
the independent assessor at the 3-month follow-up. For the patients as a
whole, 10% were rated as having some degree of deterioration, 40% as being
unchanged and 50% as having improved to some degree. When broken down by
treatment condition there was a trend for a greater proportion of patients in
the CBT condition being rated as improved to some degree (63%) compared with
SPT (36%) and TAU (50%), and also for a larger proportion of CBT patients
(15%) to be rated as having deteriorated to some degree in comparison with SPT
(6%) and TAU (6%) patients. Judgements of overall improvement made by patients
at the 3-month follow-up were broadly similar, although a rather greater
proportion rated themselves as being worse (18%), a rather smaller proportion
as unchanged (19%) and a rather larger proportion as being better to some
degree (64%). None of the differences between treatment conditions was
significant.
Patient attitudes to treatment
Table 7 summarises patient
responses to two questions that were put to them by the independent assessor
at the end of the 3-month follow-up interview. There was a broadly positive
attitude to treatment across all three conditions but a significant tendency
for patients receiving CBT to rate their experience as definitely positive and
helpful in comparison with the other two groups (70% CBT, 37% SPT, 30% TAU;
2=6.93, d.f.=2, P=0.031; CBT v. combined SPT
and TAU,
2=6.72, d.f.=1, P=0.01). This difference is
not simply a result of patients in CBT getting on better with their therapist,
as indicated by the responses to the second question, which asks about the
therapeutic relationship. Responses to this question were broadly positive and
almost identical across treatment conditions. It is worth noting in this
context that virtually identical ratings were made of the quality of the
therapeutic relationship when measured by a sub-scale of the Penn Helping
Alliance during the early stage of therapy. This rating was completed by 15
patients in CBT and 12 patients in SPT on a 25-point scale with a minimum of 5
and a maximum of 30 (mean score CBT=25.1, s.d.=3.0, mean score SPT=25.7,
s.d.=3.0).
|
Difference in perceived helpfulness of therapy may have been due to differences in ratings of perceived suitability of treatment made by patients in CBT (n=13) in comparison with patients in SPT (n=12). At the first administration of this rating (0-8 scale: 0, not at all suitable; 8, very suitable) there were no significant differences between treatments (mean score CBT=5.5, s.d.=2.1; mean score SPT=5.0, s.d.=2.0), but at the second administration, during the middle stage of therapy, mean ratings of suitability of treatment by patients in CBT were significantly higher than those by patients in SPT (CBT=6.6, s.d.=1.6; SPT=4.9, s.d.=2.1; t=2.27, d.f.=23, P=0.033). There was a similar (although non-significant) trend with regard to ratings of learning new ways of coping with problems and difficulties.
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Methodological issues
This clinical trial is one of the first investigations of the efficacy of
cognitivebehavioural therapy for psychosis in which treatment was
delivered as part of routine clinical practice. The following features have
helped to ensure methodological rigour: a 3-month pre-treatment baseline, to
ensure the stability of the presenting symptomatology; outcome evaluation with
standardised measures by an independent assessor, an experienced psychiatrist,
blind to treatment allocation at post-treatment and 3-month follow-up; a
credible supportive psychotherapy condition carried out by separate therapists
to control for the non-specific effects of CBT; a TAU condition to control for
changes over time; an independent evaluation of adherence to psychological
treatment protocols and of the quality of therapy delivered; and a research
team drawn from nursing, psychiatry and clinical psychology with varying
professional commitments to cognitivebehavioural therapy, psychodynamic
therapy and biological psychiatry.
Methodological limitations include: lower than expected numbers in each treatment condition as a consequence of a higher than expected proportion of patients refusing to participate at the initial screening (44% of 171 suitable referrals); variable medication regimes between and within treatment conditions following baseline assessment, producing potential biases with the small sample sizes; and a potential confound of treatment condition with differences in therapist experience and expertise in delivering psychological therapy for patients with chronic psychosis. The advantage of CBT over SPT may be a function of the considerable experience and expertise in delivering psychological therapy with this population developed by clinical nurse specialists in cognitivebehavioural therapy over several years. In particular, the construction and presentation of a formulation a potentially powerful intervention with this population takes considerable practice. Therapists in the SPT arm were, on the whole, less experienced and found the role of therapist more challenging.
Comparison with other trials
Three other randomised controlled trials have been published that
specifically test the efficacy of cognitivebehavioural therapy for
chronic psychosis: the LondonEast Anglia study (Kuipers et al,
1997,
1998), the Manchester Wellcome
study (Tarrier et al,
1998) and the LondonNewcastle Wellcome study
(Sensky et al, 2000).
In common with the present investigation, all three trials found evidence that
cognitivebehavioural therapy was more effective than alternatives and
associated with low drop-out rates and high patient satisfaction. However, the
proportion of patients in cognitivebehavioural therapy judged to be
treatment responders at follow-up was found to be 65% in the LondonEast
Anglia study (based on 25% reductions in symptom severity), 33% in the
Manchester Wellcome study (based on 50% reductions in symptom severity) and
63% in the LondonNewcastle Wellcome study (also based on 50% reductions
in symptom severity). Varying operational definitions of a clinically
significant treatment response, as well as different measures, timescales and
selection procedures, make direct comparisons across studies problematic but
it would appear that all three of these trials found higher rates of treatment
responders than the 33% found in the present study (based on 25% reductions in
symptom severity).
Variable nature of cognitivebehavioural therapy for
psychosis
One possible explanation for this apparent difference in outcome may lie in
the type of treatment delivered. The analysis of treatment integrity and
quality completed by D.F. found that the style of cognitivebehavioural
therapy delivered was competent with respect to the standard treatment
approach used but included few of the specific adaptations for psychosis
advocated in the Fowler et al
(1995) treatment manual. The
variations in practice within cognitivebehavioural therapy for
psychosis raise the possibility that some approaches may be more effective
than others, and this is an important area for future research.
Cognitivebehavioural therapy is a demanding therapy with complex
presentations (Durham et al,
2000) and there is much scope for better models and illustrations
of good practice. Clinicians working with cognitivebehavioural therapy
and psychosis do not have the benefit of a range of videotape material
demonstrating therapeutic styles and techniques but instead have to work from
treatment manuals containing general guidelines and brief transcripts. It is
not an easy task to apply this knowledge to the wide variety of clinical
presentations of psychosis and it is often hard to know how an
expert in the field might handle the difficulties that arise. On
the other hand, the present study demonstrates that significant benefits in
routine clinical practice can result from using standard approaches to
cognitivebehavioural therapy for psychotic disorder and that the
therapy can be of value even with therapists given relatively brief training
(Turkington et al,
2002).
Whatever the explanation for the apparent discrepancy in outcomes between the present study and previous clinical trials, it will be important to conduct further studies in the field to clarify the relationship between the nature and quality of therapy delivered and clinically significant outcomes. The current debate on this issue tends to be polarised between those who believe that cognitivebehavioural therapy is clearly efficacious and those who seem sceptical of any incorporation of specialised psychological intervention into routine care. Our own view of the evidence is that people with chronic psychosis should be given the opportunity to engage in systematic psychological therapy on the grounds that most will find this of some value and a few will be able to use the opportunity to make a significantly better adjustment for the future.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Atkins, M., Burgess, A., Bottomley, C., et al (1997) Chlorpromazine equivalents: a consensus of opinion for both clinical and research applications. Psychiatric Bulletin, 21, 224-226.
Barnes, T. & Nelson, H. (1994) The Assessment of Psychoses: A Practical Handbook. London: Chapman and Hall Medical.
Bateman, A. & Holmes, J. (1995) Introduction to Psychoanalysis. London: Routledge.
Cohen, J. (1992) A power primer. Psychological Bulletin, 112, 155-159.[CrossRef]
Cormac, I., Jones, C., Campbell, C., et al (2002) Cognitive behaviour therapy for schizophrenia. Cochrane Library, issue 4. Oxford: Update Software.
De Jonghe, F. (1993) Psychoanalytic supportive psychotherapy. Journal of the American Psychoanalytic Association, 42, 421-425.
Drake, R., Haddock, G., Hopkins, R., et al (1998) The measurement of outcome in schizophrenia. In Outcome and Innovation in Psychological Treatment of Schizophrenia (eds T. Wykes, N. Tarrier & S. Lewis), pp. 43-57. Chichester: John Wiley & Sons.
Durham, R., Swan, J. & Fisher, P. (2000) Complexity and collaboration in routine practice of CBT: what doesn't work with whom and how might it work better? Journal of Mental Health, 9, 429-444.
Endicott, J., Spitzer, R., Fleiss, J., et al (1976) Global Assessment Scale: a procedure for measuring overall severity of psychiatric disturbance. Archives of General Psychiatry, 33, 766-771.[Abstract]
Fowler, D., Garety, P. A. & Kuipers, L. (1995) Cognitive Behaviour Therapy for People with Psychosis: A Clinical Handbook. Chichester: John Wiley & Sons.
Garfield, D. (1995) Unbearable Affect: A Guide to the Psychotherapy of Psychosis. Chichester: John Wiley & Sons.
Guy, W. (1976) Assessment Manual for Psychopharmacology. Washington, DC: US Government Printing Office.
Haddock, G., McCarron, J., Tarrier, N., et al (1999) Scales to measure dimensions of hallucinations and delusions: the psychotic symptom rating scales (PSYRATS). Psychological Medicine, 29, 879-889.[CrossRef][Medline]
Johnson, T. (1992) Statistical methods in clinical trials. In Research Methods in Psychiatry (eds C. J. Freeman & P. Tyrer), pp. 24-61. London: Gaskell.
Kane, J. M. (1996) Treatment-resistant schizophrenic patients. Journal of Clinical Psychiatry, 57 (suppl. 9), 35-40.
Kay, S., Fiszbein, A. & Opler, L. (1987) The Positive and Negative Syndrome Scale (PANSS). Schizophrenia Bulletin, 13, 261-273.[Medline]
Kingdon, D. G. & Turkington, D. (1994) CognitiveBehavioural Therapy of Schizophrenia. Hove: Lawrence Erlbaum.
Kuipers, E., Garety, P., Fowler, D., et al (1997) LondonEast Anglia randomised controlled trial of cognitivebehavioural therapy for psychosis. I: effects of the treatment phase. British Journal of Psychiatry. 171, 319-327.[Abstract]
Kuipers, E., Fowler, D., Garety, P., et al (1998) LondonEast Anglia randomised controlled trial of cognitive behavioural therapy for psychosis III: follow-up and economic evaluation at 18 months. British Journal of Psychiatry, 173, 61-68.[Abstract]
Luborsky, L., Barber, J. P., Siqueland, L., et al (1996) The revised Helping Alliance Questionnaire (HAQII). Journal of Psychotherapy Practice and Research, 5, 260-271.
Pilling, S., Bebbington, P., Kuipers, E., et al (2002) Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychological Medicine, 32, 763-782.[CrossRef][Medline]
Sensky, T., Turkington, D., Kingdon, D., et al
(2000) A randomized controlled trial of
cognitivebehavioural therapy for persistent symptoms in schizophrenia
resistant to medication. Archives of General
Psychiatry, 57,
165-172.
Startup, M., Jackson, M. & Pearce, E. (2002) Assessing therapist adherence to cognitivebehaviour therapy for psychosis. Behavioural and Cognitive Psychotherapy, 30, 329-339.[CrossRef]
Tarrier, N. (1992) Management and modification of residual psychotic symptoms. In Innovations in the Psychological Management of Schizophrenia (eds M. Birchwood & N. Tarrier), pp. 147-170. Chichester: John Wiley & Sons.
Tarrier, N., Beckett, R., Harwood, S., et al (1993) A trial of two cognitivebehavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients: I. Outcome. British Journal of Psychiatry, 162, 524-532.[Abstract]
Tarrier, N., Yusupoff, L., Kinney, C., et al
(1998) Randomised controlled trial of intensive cognitive
behaviour therapy for patients with chronic schizophrenia.
BMJ, 317,
303-307.
Turkington, D., Kingdon, D. & Turner, T.
(2002) Effectiveness of a brief cognitivebehavioural
therapy intervention in the treatment of schizophrenia. British
Journal of Psychiatry, 180,
523-527.
Vallis, T. M., Show, B. F. & Dobson, K. S. (1986) The Cognitive Therapy Rating Scale: psychometric properties. Journal of Consulting and Clinical Psychology, 54, 381-385.[CrossRef][Medline]
Volavka, J., Czobor, P., Sheitman, B., et al
(2002) Clozapine, olanzapine, risperidone, and haloperidol in
the treatment of patients with chronic schizophrenia and schizoaffective
disorder. American Journal of Psychiatry,
159,
255-262.
World Health Organization (1992) The ICD10 Classification of Mental and Behavioural Disorders. Geneva: WHO.
Received for publication July 1, 2002. Revision received November 7, 2002. Accepted for publication December 3, 2002.
Related articles in BJP: