Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
Department of Psychology, University of Melbourne, Melbourne
Correspondence: Dr Jean Addingtion, Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario, M5S 2S1, Canada. Tel: +1 416 535 6936; fax: +1 416 979 693; e-mail: jean_addington{at}camh.net
*Paper presented at the Third International Early Psychosis Conference, Copenhagen, Denmark, September 2002.
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ABSTRACT |
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INTRODUCTION |
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CBT FOR PSYCHOSIS: OUTCOME |
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Very few CBT trials have focused on populations with first-episode psychosis. The SoCRATES trial used a large representative sample (n=315; 83% first episode) to compare a 5-week treatment package of CBT plus routine care with supportive therapy plus routine care and with routine care alone during the acute phase of the psychotic illness. The aim of the SoCRATES trial (Lewis et al, 2002a) was to determine the impact of CBT during the acute phase of the psychotic illness on accelerating remission from acute symptoms. At 70 days there were trends towards faster improvement of positive symptoms in the CBT group compared with supportive therapy and routine care (Lewis et al, 2002a). At 18 months follow-up, CBT demonstrated significant advantages in outcome over routine care and some advantages over supportive therapy (Lewis et al, 2002b).
Cognitively Orientated Psychotherapy for Early Psychosis (COPE; Jackson et al, 1999) aims to facilitate adjustment after a first episode of psychosis. In an open trial those receiving COPE demonstrated improved illness adaptation as assessed by an integration and sealing-over scale (McGlashan et al, 1977) compared with those who had not participated (Jackson et al, 2001). It has been demonstrated (Thompson et al, 2003) that sealing-over/integration is an important factor related to recovery which is malleable over time.
In the RCTs that compared CBT with varied forms of supportive therapy, the positive impact of CBT was inconsistently diminished relative to the supportive therapy, although never outperformed (Lewis et al, 2002a,b; Tarrier et al, 1999; Sensky et al, 2002). In a comprehensive review, Penn et al (2004) consider the potential mechanisms behind this reported effectiveness of supportive therapy and conclude that there is an important role for meaningful social contact with others. The clear implication from the review is that CBT should target social needs and goals, placing a greater emphasis on the interpersonal context and social consequences of relationships, including the therapeutic relationship.
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CBT IN EARLY PSYCHOSIS PSYCHOSIS PROGRAMMES |
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THEORETICAL BASIS OF CBT FOR EARLY PSYCHOSIS |
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Indeed, as Perris & McGorry (1998) suggest, when developing cognitive interventions for psychosis it is clearly an advantage to expand other theoretical ideas to broaden and deepen the approach. In fact, Perris & McGorry go as far as anticipating the challenge as not only integrating different models of CBT but integrating the meta-theories underpinning CBT with theories of cognitive neuropsychology and another neuroscientific aspect of psychosis, such as the neuroimaging paradigms.
What is important for the development of CBT interventions in early psychosis is that this meta-perspective allows the CBT therapist to maintain both a conceptual and theoretical fidelity and yet blend models to maximise flexibility and pragmatism to address a range of problems in a range of cases (Howes & Parrott, 1992; Howes & Vallis, 1996). A further rationale for this broader approach is aptly stated by John Strauss:
What we are dealing with is not some stereo stereo-typed disease process stamped onto some shadowy"every person"but processes of the disorder that interact with a very important and differentiated person a person that is goal directed, a person whose feelings and interpretations influence actions that in turn affect phases of the disorder or recovery (1989, p.185).
Thus, CBT for early psychosis must address functional outcome and not just psychotic symptoms. Adopting only one model of CBT is too narrow and is deficient in addressing both the range of difficulties following the first episode as well as the heterogeneity of psychosis. Alternatively, without this meta-perspective the different models of CBT could become so eclectic as to develop into an amalgam of techniques and strategies that appear cognitive or behavioural in nature and which are adopted and used without any real understanding of their implications. Thus, CBT for early psychosis can and should be based on sound theoretical models of cognitive therapy and psychopathology that lend themselves to further refinement and testing.
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GOALS OF CBT IN EARLY PSYCHOSIS |
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MODULAR APPROACH TO CBT FOR EARLY PSYCHOSIS |
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Three texts offer both a theoretical basis for and a systematic guide to the therapy (Kingdon & Turkington, 1994; Fowler et al, 1995; Chadwick et al, 1996); Nelson offers a detailed description of CBT for symptoms as a practice manual (Nelson, 1997); and others offer a range of useful case studies (Kingdon & Turkington, 2002; Morrison, 2002). Drawing from the work of several of the above texts, Systematic Treatment of Persistent Psychosis (STOPP; Hermann-Doig et al, 2003) is the only manual that has a specific focus on CBT for first-episode psychosis. Additional works address the individualised formulation (Fowler, 2000), adaptation to the illness (Jackson et al, 1999), coping strategy enhancement (Tarrier, 1992), strategies for hallucinations (Haddock & Slade, 1996), relapse prevention strategies (Birchwood & Spencer, 2001; Gumley et al, 2003; Gleeson, 2004) and CBT strategies to enhance adaptive functioning (Penn et al, 2004).
One of the advantages of offering a modular approach is that there is a range of interventions to meet many of the needs of clients with first-episode psychosis and thus there is less need for exclusion criteria. Phases of illness include acute inpatient, acute out-patient, in recovery, in remission and in prolonged recovery. It is recommended that CBT be introduced to patients with first-episode psychosis once medication, stabilisation and symptom remission has begun, in order to enhance the goal and expectation of optimal recovery. Typically, the length of treatment is approximately 20 sessions over 6 months. This allows strategies to be offered to those who may be experiencing a prolonged symptomatic recovery. Only a brief description of the modules is possible.
Engagement, assessment and formulation phase
The engagement phase includes the formation and development of the
therapeutic alliance. Engagement occurs not only between therapist and client
but between client and therapy. The range and extent of assessments can vary
and routine instruments may have already been completed as part of the
service. Instruments specifically relevant to the focus of the therapy can be
used here. Assessment helps these individuals to realise that their
experiences are understood.
Developing an individualised formulation begins at the first session of CBT and through several sessions in order to identify problem areas and to develop a sound understanding of the key elements leading to the psychotic disorder and of the factors that maintain the problem areas. An assessment of the background to psychosis gives the psychotic episode a specific biological, psychological and social context. The therapist outlines his or her understanding of the aetiology, development and maintenance of the problem and supplies a rationale for the intervention and length and frequency of sessions. Developing a consensus about treatment goals facilitates an atmosphere of trust. The ultimate goal of the formulation is to help the individual make sense of the current situation and to establish a specific rationale for the direction the therapy might take. Further elaboration and refinement of the formulation occurs as more information is obtained during the course of therapy as well as in the context of more general psychiatric assessment.
Psychoeducation
There are many aspects of psychosis that patients need to understand. These
include symptoms, diagnoses, theories of psychosis, individual explanatory
models of psychosis, impact of substance misuse, medications, warning signs,
nature of recovery, and agencies and personnel involved in treatment. In an
integrated early psychosis programme such education may occur elsewhere, for
example, as part of a group programme. Regardless, before embarking further
with CBT for psychosis it is important that the individual has some
understanding of the concept of psychosis and what it means for them, rather
than just providing facts and information. This may occur at different times
and even in different contexts depending on the individuals coping
style and readiness to absorb the information.
Adaptation to psychosis
In this model, the approach focuses on the individual and addresses his or
her understanding of the disorder, the disorders impact on the self,
the adaptation to the psychosis and self-esteem. These individuals need to
realise their potential. They can take stock of themselves by
identifying strengths and limitations, expand coping skills, and make
realistic plans for new directions. Learning how to distance oneself from the
negative aspects of the environment and focusing on accomplishments can only
serve to enhance self-esteem. Work at this point can include challenging
social fears, increasing competence and improving self-esteem. Finally,
addressing adaptation can help patients engage in constructive activities to
implement change and improve their functioning. The realisation that the
changes they make reflect their own capabilities and that this contributes to
their own recovery is powerful.
Treatment of secondary morbidity
Secondary morbidity is the result of a failure to adapt and includes
depression, anxiety and substance misuse. In this phase individuals learn
about the nature of the secondary condition. There may be a focus on cognitive
challenging where underlying beliefs and assumptions are examined, challenged
and replaced with more appropriate and rational beliefs and assumptions. This
can be supplemented by group-based interventions for anxiety management or
substance misuse.
Coping strategies
Coping strategies are designed to help with positive and negative symptoms
and with the functional and emotional problems that arise from the symptoms.
Target positive symptoms need to be identified. Available strategies include
coping strategy enhancement (Tarrier,
1992) and distraction and focusing techniques for voices.
Interventions for negative symptoms typically include behavioural
self-monitoring, paced activity scheduling, assertiveness training and diary
recording of mastery and pleasure. Specific behavioural and cognitive
strategies are available to help patients work towards improved functional
outcome despite symptoms.
Relapse prevention
Relapse prevention is experienced by 8095% of patients over the
first 25 years after the commencement of treatment
(Robinson et al,
1999). A range of interventions and general principles, derived
from CBT, have been described to address relapse prevention. These include
monitoring for and intervening with early warning signs of relapse and
cognitive restructuring of enduring self-schema which may be associated with
elevated risk of relapse.
Techniques to address delusions and beliefs about voices
Specific techniques are well described for addressing positive symptoms.
For auditory hallucinations, collaborative critical analysis of beliefs about
the origin and nature of the voice(s) is followed by the use of voice diaries,
reattribution of the cause of the voices and generation of possible coping
strategies. Interventions for delusions can include identifying precipitating
and maintenance factors, modifying distressing appraisal of the symptoms and
generating alternative hypotheses for abnormal beliefs.
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DELIVERY OF AND SUPERVISION IN CBT |
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To enhance the delivery of CBT in an early psychosis programme, there needs to be clarification of the different roles of those providing ongoing treatment as well as communication and agreement among team members about treatment plans. Second, clinicians offering CBT need to have access to quality training and quality ongoing supervision which focus on both general therapist skills as well as skills specific to CBT. Third, the service not only requires adequate resources to support the implementation of CBT but must have a clearly stated philosophy and operational policy consistent with the CBT that is being delivered.
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DISCUSSION |
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There is a risk as early intervention programmes develop that having a CBT component is seen as desirable and may develop atheoretically out of a pragmatic need to offer some of the well-described interventions. First, an early psychosis service needs to carefully consider the nature and philosophy of their programme and how CBT will best fit in terms of treatment delivery, training and supervision. The CBT component then needs to be based on firm theoretical grounds to optimally offer the course of treatment most needed by these individuals.
Considerably more research both conceptual and empirical is required to evaluate the effectiveness of CBT in the treatment of psychotic disorders at this early stage. Despite recent criticism of CBT for psychosis (Turkington & McKenna, 2003), the very few quality RCTs that have been completed (only one with patients with first-episode psychosis) have, in fact, paved the way for future endeavours in CBT. They have demonstrated effectiveness not only for CBT in both chronic and early stages of psychotic disorders but also for intervention in the interpersonal context. The fact that the supportive therapies demonstrated effectiveness, although never outperforming the CBT (Tarrier et al, 1999; Sensky et al, 2000; Lewis et al, 2002a,b), is a valuable addition to our knowledge in attempts to develop the best treatments for these individuals. Schizophrenia and other psychotic disorders remain disorders of interpersonal functioning more so than other psychiatric disorders and it makes sense to add the interpersonal focus as in the development of CBT for other disorders. We have a lot more to learn about the phase of illness at which to intervene most effectively (Lewis et al, 2002a).
Thus, before CBT is consigned....to.. to history (McKenna in Turkington & McKenna, 2003, p. 478) there is a need for future research to determine the effectiveness of CBT in early psychosis services by including an interpersonal component, examining optimal timing of delivering interventions and considering a wider range of clinical and functional outcomes. Our goal is to find the most effective strategies to help these individuals and we need to learn from these early trials to advance and develop our psychological treatments (Penn et al, 2004) and then to test their effectiveness.
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Clinical Implications and Limitations |
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LIMITATIONS
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