Cognitive Behavior Therapy for Psychosis (CBTp) is considered an effective intervention that is recommended for the treatment of schizophrenia (American Psychological Association, 2004). With that said, offering treatment during an acute episode, while in an inpatient facility proves challenging. Even still, group intervention for psychosis has shown to increase outreach and streamline treatment (Owen et al., 2015).
Though there is support for group CBTp, evidence is not definitive. More specifically, the literature indicates mixed results in the effectiveness of group CBTp as compared to other interventions (i.e., social skills training, psychoeducation). Consequently, due to no clear heterogeneity within CBTp models or use of outcome measures, it is difficult to compare results across studies. Furthermore, other limitations emerge when attempting a controlled trial in an inpatient setting. For example, the timing of interventions (individuals are typically in a crisis), uncertainty of the length of stay, and typical medication changes upon admission are noteworthy concerns (Owen et al., 2015).
While considering the limitations, research shows positive findings for group CBTp through improvement in one’s wellbeing and reduced readmission rates (Svensson, Hansson, & Nyman, 2000; as cited in Owen et al., 2015). Furthermore, these positive result are aligned with a recovery model, in that gains are not signified through the reduction of psychotic symptoms, but are more so related to the functional gains made by the individual (e.g., increased confidence, understanding, and improved quality of life; Owen et al., 2014). As noted by Owen et al. (2015), improvements related to recovery are influential in determining discharge; in other words, the ability to cope effectively may be more important than a reduction in symptoms (Owen et al., 2015).
Consistent with a recovery model, Owen et al. (2015) created a quasi-experimental design to assess the effects of CBTp within an inpatient setting. The program attempted to balance the reduction of symptoms and the empowerment of individuals by increasing control and understanding of experiences. Thus, they hypothesized that participants receiving group CBTp would show reductions in distress, improvements in confidence about their mental health, and a reduction in positive symptoms of psychosis compared to Treatment as Usual (TAU).
Briefly, Owen et al. (2015) compared two groups of participants from acute inpatient units, one group received a four-week group on CBTp and the other group received TAU. There were 113 participants (80 men, 33 women) between the ages of 19 and 66, with the majority classified as “White British,” and from an impoverished geographic area. Participants included individuals experiencing psychotic symptoms (e.g., hallucinations, delusions, paranoia). Groups were conducted for 1.5 hours, over four consecutive weeks. CBTp groups were co-facilitated by a clinical psychologist, a “service user,” a person with personal experience of psychosis and recovery, and unit staff. Groups consisted of no more than eight participants and were closed. They collected data over three periods: at baseline, post-intervention, and a one-month follow-up. Individuals discharged during the group were invited back to attend, and if discharged before the one-month follow-up, they were sent the measures for data collection.
The group intervention was based on Clarke and Pragnell’s (2008) inpatient group CBTp program. The program consisted of four sessions with different topics, handouts, and homework (Owen et al., 2015). Session one focused on group rules, psychoeducation of psychotic experiences, normalization, and monitoring skills. Session two addressed the understanding of experiences within a CBT model. Specifically, session two introduced the use of a continuum for shared and personal experiences as related to symptom monitoring, worked on the identification of triggers, and discussed how the interpretation of events influence emotions and behaviors. Session three focused on coping skills, differences in distractions and focusing, and introduced mindfulness and breathing. Finally, session four explored how to make sense of experiences, introduced the stress-vulnerability model, and understanding psychosis.
Findings indicated encouraging results regarding the effects of group CBTp. First, participants in the CBTp group showed greater reductions in distress at follow-up. Though this finding was not consistent overall, the results remain consistent with a recovery model. For individuals in the CBTp group, confidence improved from baseline to post-intervention, and at follow-up. The author’s noted that insufficient data were collected to measure reduction in positive symptoms, but data indicated a trend, in that individuals in the CBTp group showed a decrease in symptoms overtime (Owen et al., 2015).
Qualitative analyses conducted by Owen et al. (2015) further indicated positive gains from the CBTp group. Many participants reported feeling more positive, confident, and hopeful about the future. They reported increased coping strategies and acknowledgment that the group helped some understand their experiences differently. Again, such results are consistent with a recovery model for psychosis, in that the CBTp group demonstrated an increase in confidence more so than a mere reduction in symptoms (Owen et al., 2015). In essence, the group members were learning how to “cope with, and accept, difficult and frightening experiences, rather than attempting to reduce their occurrence” (Owen et al., 2015, p. 83).
Further analyses indicate a positive correlation for this sample between distress and type of admission, noting that individuals first admitted voluntarily, and later adjusted to involuntary status showed the most distress (Owen et al., 2015). Though distress can decrease over time, regardless of intervention, the findings indicate that group intervention during the crisis period helped some maintain improvement in distress after the crisis subsided and possibly during discharge (Owen et al., 2015).
Limitations of a high drop-out rate (62.8%), inability to randomize participants into groups, and unit staff noted to be more interested in helping with the CBTp group than TAU may have mitigated the results of the study (Owen et al., 2015). Furthermore, the authors acknowledged that due to the limitations in design and high attrition rates, the findings should be considered interesting and not definitive (Owen et al., 2015). Overall, Owen et al.’s (2015) results indicate that CBTp may decrease distress and enhance confidence for individuals suffering from psychosis. They note that the intervention used was feasible, acceptable, as well as, valued by the participating staff.
Though limited by design due to constraints of an inpatient facility (e.g., discharge, acute/crisis presentation, medication changes) the results indicate group CBTp to be consistent with a recovery model and particularly focused on hope, normalization, and overall improvement in quality of life.
References
American Psychological Association. (2004). Practice Guidelines for the Treatment of Patients with Schizophrenia (2nd ed.). Retrieved from http://psychiatryonline.org/guidelines
Clarke, I., & Pragnell, K. (2008). The Woodhaven ‘What is real and what is not?’ group programme: A psychosis group in four sessions for an impatient unit. Retrieved from http://www.isabelclarke.org/psychology/index.htm#CBT
Owen, M., Sellwood, W., Kan, S., Murray, J., & Sarsam, M. (2015). Group CBT for psychosis: A longitudinal controlled trial with inpatients. Behaviour Research and Therapy, 65, 76-85. doi: 10.1016/j.brat.2014.12.008
Dannie S. Harris, M.A., M.A., M.A.Ed., Ed.S.
WKPIC Practicum Trainee
