Heldt, Knapp and Cordioli, 2010). MI is used as a supplement to CBT, according to the above mentioned authors. In contrast to the abovementioned viewpoint ...
Dec 16, 2004 - 2.1 Description of underlying health problem. 1. 2.2 Current Service Provision. 5. 2.3 Description of New Intervention. 8. 2.4 NICE Guidance on CCBT. 12 ..... as a book. CBT- refers to the pragmatic combination of concepts and techniqu
Computerised cognitive behaviour therapy for depression and anxiety update: a systematic review and .... incremental cost-effectiveness of BT Steps over ...... In Stage 7 the participant is shown how to practise the strategies in both imagined and li
Jan 1, 2007 - Department of Psychiatry, University of British Columbia, Vancouver, Canada. Abstract ... item self-report questionnaire (Peterson & ... obsessive compulsive disorder (OCD) and .... report questionnaire designed to assess chil-.
Mar 30, 2007 - ... assessed. Most children reported pulling hair from multiple sites on ... responders at post-treatment and 64% at 6-month follow-up. Key words: ... tension immediately before pulling or when .... TTM were assessed via the Trichotill
Brain regions and networks which support high-level cognitive functions have ... Paes F, Nardi AE, Machado S. Cognitive-behavioral therapy for schizophrenia: an overview on ..... prazo dos sintomas positivos e negativos da esquizofrenia.
2 Greater Manchester West NHS Mental Health Foundation Trust, Manchester, UK ... Key words: Antipsychotic medication, cognitive therapy, psychosis, schizophrenia. Introduction .... our two sites (Manchester and Newcastle/North East).
(CET), on cognitive and functional outcomes in early-course schizo- phrenia. Methods: Early-course .... social exchanges, presenting home- .... (Table 3). A closer inspection of ef- ..... Delis DC, Kramer JH, Kaplan E, et al: Cali- fornia Verbal ...
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theory and practice accordingly, and to modify ... socially acceptable one, which makes immedi- ... into something simpler during psychoanalytic work. The analyst is pushed constantly from ..... To consider now the case of the hypothetical.
Aug 2, 2017 - behavioural therapy (CBT) is the recommended treatment and systematic reviews have reported its efficacy (Higa- ..... 2007) to measure adherence to CBT/coun- selling and the Therapy Process Observational Coding ..... Excluded: Declined
Jul 28, 2015 - made us believe that a pharmacological solution for every psychiatric problem is just around the corner. ... Therapy or Cognitive Behaviour Therapy was a short step because it made even more sense .... Since these two issues reflect th
Spek V, NyklÄ±cËek I, Cuijpers P, Pop V. Alexithymia and cognitive ... depression has often been found (5â9). ... enough symptoms to meet the DSM-IV criteria of.
p.569) has been identified as a core process in the onset and maintenance of depression. Rumination is .... development of âthird waveâ CBT therapies such as Behavioural Activation, Rumination-focused. CBT and ... full flow of rumination, because
(iCBT-MDD) versus a treatment as usual control group .... Emerging technologies and therapeutics ..... Nobis S, Lehr D, Ebert DD, et al. Efficacy of a web-based.
May 1, 2013 - on the PSYRATS, and the GAF symptom score at posttreatment. At 12 months follow-up only the GAF symptom score remained significantly ...
Nov 25, 2015 - Keywords: anxiety; CBT; food allergy; parents; quality of life; worry ... unpleasant symptoms including rash, itching, swelling of mouth and lips, ...
Feb 21, 2012 - tion (ERP), and a relapse prevention programme. (Abramowitz, 2006, 2009) ... text material (about 100 pages) and worksheets div- ided into 10 ...
Jul 15, 2010 - Method: This two-centre (Hampshire and West London) qualitative study consisted of individual ... Keywords: Cognitive therapy, schizophrenia, psychosis, ethnic minority, patient views, ...... implications for East and West.
Simon Wessely, Trudie Chalder. Ã. King's College London, Academic Department of Psychological Medicine, Weston Education Centre, Cutcombe Road, ...
then move on to review the efficacy of CBT for the treatment of PTSD caused by various traumas, including assault, road traffic ... Finally, we will outline the major challenges and future directions of CBT ...... Paper presented at 32 Congress of EA
unconditional and pervasive low self-esteem (âcore low self-esteemâ); the third concerns .... succeeds in helping many patients overcome ongoing interpersonal ...
Jan 16, 2014 - In this randomized controlled study of 60 patients with hyperacusis, CBT was compared with a waiting list control ... There were significant between-group effects in favour of the CBT group on all measures except for the. HADS anxiety
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Special Article Psychother Psychosom 2005;74:136–144 DOI: 10.1159/000083998
Cognitive Behaviour Therapy for Schizophrenia – A Review of Development, Evidence and Implementation Nicholas Tarrier Academic Division of Clinical Psychology, University of Manchester, Manchester, UK
Key Words Cognitive behaviour therapy Cognitive therapy Schizophrenia Psychosis
Abstract Background: Schizophrenia and other psychotic disorders were once thought to be impervious to psychological treatments; however, there is accumulating evidence that cognitive behaviour therapy (CBT) can result in significant clinical benefit to these patients. Aim: This paper aims to describe the development and adaptation of CBT in the treatment of schizophrenia, to summarise the evidence to support CBT as a viable treatment and to outline some of the issues in ‘rolling out’ this treatment into normal clinical settings. Results: A number of clinical models of CBT have been developed and these typically consist of a variety of clinical methods with different models providing differing emphasis. Twenty controlled trials of CBT in schizophrenia in which 739 patients were included are reviewed. These studies have a mean effect size for CBT of 0.37 (SD 0.39). There is consistent evidence that CBT reduces persistent positive symptoms in chronic patients and may have modest effects in speeding recovery in acutely ill patients. The evidence of CBT reducing relapse rates is equivocal, although targeted early intervention is promising. The available evidence suggests that CBT can be utilised effectively in routine clinical practice. However, the dissemination of novel psy-
Schizophrenia and other psychotic disorders were once thought to be biologically determined and impervious to psychological treatment. Traditional forms of psychotherapy appeared to have little or no beneﬁt for those suffering these conditions and may well be harmful to people with schizophrenia . However over the last decade evidence has accrued that cognitive behaviour therapy (CBT), has considerable utility in treating schizophrenia and psychosis when added to standard psychiatric care [2–5]. There has been sufﬁcient evidence for CBT to become a recommended treatment for schizophrenia in the UK National Institute of Clinical Excellence , the government body that recommends which treatments should be used in clinical practice. Furthermore, advances in theoretical understandings of schizophrenia from a psychological perspective [7, 8] can be expected to further inform therapeutic developments in the future. The aim of this descriptive review is to summarise the development and results of CBT studies which have used
Prof. Nicholas Tarrier Academic Division of Clinical Psychology, Education and Research Building (2nd Floor) Wythenshawe Hospital Manchester M23 9LT (UK) Tel. +44 161 291 5883, Fax +44 161 291 5882, E-Mail [email protected]
an individual cognitive-behavioural approach to treat directly the positive symptoms of schizophrenia1. There remain gaps within the evidence , and such a discussion may stimulate ideas for further research and evaluations. Furthermore, this paper aims to discuss issues regarding the potential impact of CBT studies upon standard clinical practice, that is the implementation of CBT in standard care of schizophrenia.
Development of CBT for Schizophrenia
There have been a number of reasons for the increased interest in effective psychological therapies. In spite of improvements in anti-psychotic medication, there are a substantial group of patients (about 40%) who show minimal or only partial improvement . Even with good medication compliance, a signiﬁcant and increasing number of patients will relapse. However, medication compliance is rarely good, resulting in further adverse outcomes . Anti-psychotic medication frequently results in unpleasant and distressing side effects, especially disorders of movement. Some side effects can be permanent, such as tardive dyskinesia, and some, on rare occasions, can be fatal. Furthermore, in recent years there has arisen an increasingly vocal and powerful consumer or user movement in mental health that has sought to increase user choice and preference in available treatments for mental disorders. Lastly, there has been much greater emphasis on evidence-based health care and the implementation of treatment approaches that have been shown to work. CBT, with a commitment to evaluation, has demonstrated a signiﬁcant advantage over other schools of psychotherapy in this regard . CBT for schizophrenia, although following a common theme and set of principles, has developed in a number of centres and been informed by a number of theoretical and conceptual bases. For example, in my own group in Manchester we developed the coping skills approach which originated from a number of sources. Firstly, we were inﬂuenced by the empirical ﬁnding that many patients with schizophrenia acquire coping strategies to deal with their hallucinations and delusions . This observation was found to be in agreement with the ﬁndings of other researchers [13–17]. Secondly, of importance was the work on self-regulation by Karoly and Kanfer  in
1 Compliance therapy has not been included as it does not conform to these criteria.
Cognitive Behaviour Therapy for Schizophrenia
which target behaviour is identiﬁed as problematic and monitored with the purpose of implementing alternative responses through a process of self-regulation. This approach was thought to be especially relevant to schizophrenia as it involved a potential enhancement of executive control through response inhibition, selection and implementation. Lastly, central to the coping approach, although not unique to it, was the process of a detailed individual idiosyncratic assessment or case formulation to understand the individuals experience of psychosis. (For a detailed account of case formulation in CBT generally see Tarrier and Calam , and for a clinical heuristic in psychosis see Haddock and Tarrier  and Tarrier .) This allowed a treatment strategy to be formulated based upon the clinician’s assessment of the determinants of the individual’s psychotic symptoms. The aim of the coping skills approach is in line with a recovery model in which the patient learns cognitive and behavioural strategies with which to reduce psychotic symptoms or the distress they cause. This has the advantage of emphasising coping as a normal reaction to aversive experiences which aids engagement. Other clinical research groups have modiﬁed Beck’s version of cognitive therapy to use with schizophrenic patients , which have given central emphasis to the role of beliefs in causing and maintaining psychopathology. Beck  ﬁrst published a case study of cognitive therapy in the treatment of delusions in 1952. Kingdon and Turkington  have also given prominence to the concept of a normalising rationale in providing the patient with an acceptable understanding of their disorder. This emphasis on beliefs has been taken a logical step further in analysis of schema or underlying assumptions or beliefs held by the patient . Hall and Tarrier  adopted a very speciﬁc CBT approach to improve the patient’s self esteem, which was derived from Beck’s cognitive therapy with depression , in demonstrating that the strength of beliefs about self are inﬂuenced by focus of attention and evaluation of evidence. Bach and Hayes  have developed a version of CBT called Acceptance and Commitment Therapy (ACT) which is based upon mindfulness . ACT also has its origins in radical behavioural approaches of goal attainment. More recently, an approach from the ﬁeld of substance abuse, motivational interviewing , has inﬂuenced CBT approaches to psychosis. Initially, this new method was developed to address the considerable problem of increasing drug and alcohol misuse amongst people suffering from psychosis [31, 32]. Motivational interviewing-inﬂuenced CBT is potentially valuable in itself in bringing
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about positive change in general and in facilitating the patient achieve valued goals which psychotic symptoms may impair . Thus CBT is not, as some claim, merely a set of techniques but it is a clinical approach that is dynamic and developing and has a theoretical basis which continues to stimulate advances in clinical practices. However, in spite of the development of various clinical heuristics on which to base different treatment models there is as yet little direct empirical support to demonstrate the superiority of any one theoretical approach.
Specific Difficulties in Treating Schizophrenia
Schizophrenia, by its nature, poses a number of difﬁculties for the clinician delivering a psychological treatment (see Haddock and Tarrier  and Tarrier  for a more detailed discussion of these). These consist of: (1) psychological factors, such as restricted attention, elevated arousal, stigmatization, co-morbidity and high risk of suicide; (2) psychosocial factors, such as sensitivity to interpersonal and family environments and risk of victimization, and (3) social factors, such as social deprivation, downward social drift, restricted social networks and adverse effects of a psychiatric career. These factors may effect the nature and delivery of CBT. Furthermore, because schizophrenia is a relapsing condition with frequent incomplete recovery, there are phasespeciﬁc aims which will determine the nature and strategy of the CBT intervention. For example, in chronic patients with drug-resistant symptoms the aim will be to achieve further symptom reduction in a relatively clinically stable patient, whereas in acutely ill patients, the aim will be to speed symptom recovery in ﬂoridly ill patients. In remitted patients the aim may be to prevent future relapse. In prodromal stages, the aim may be to achieve early identiﬁcation and implement treatment so as to decrease the duration of untreated psychosis. There are intriguing preliminary results which suggest that CBT can prevent translation into full psychosis in vulnerable individuals who are experiencing prodromal symptoms . How therapy is focussed and delivered will vary depending on these phase-speciﬁc conditions. Lastly, in many patients schizophrenia may be a life-long disorder which will require more than a brief therapeutic intervention of up to 12 months. The literature to date does little to address this issue and whether intervention over long periods is feasible or beneﬁcial nor indicate how different phase-related aspects of CBT could be integrated into long-term care.
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The Evidence for CBT for Schizophrenia
Twenty clinical trials have been identiﬁed that evaluate CBT used directly to reduce positive psychotic symptoms as an adjunct to standard psychiatric care, which includes antipsychotic medication. These studies compare the CBT group with a control group which usually consists of standard psychiatric care. Sixteen of these studies have been carried out within the UK with one each from Canada, The Netherlands, Italy and the USA. Sixteen studies involve chronic outpatients, one chronic inpatients and three patients hospitalised for an acute episode. These 20 trials treated a total of 739 patients with CBT, with a mean of 37 (SD = 48, range = 7–225) treated in each study. Using the method described by Gould et al. , the effect size was calculated from data presented in 19 of these trials2. These studies have a mean effect size for CBT compared to the relevant control condition of 0.37 (SD = 0.39, median = 0.32) with a range between –0.49 and 0.99. Using Cohen’s  convention for categorising effect sizes, 14 (74%) studies achieve at least a small effect size, 6 (32%) at least a moderate effect size and 3 (16%) a large effect size . However, there is variability in methodological rigour within these trials. Investigation of the association of methodological rigour and effect size indicates that trials with methodological weaknesses, especially lack of blind assessment, are associated with elevated effect sizes . These trials are described in table 1, including detail of their methodological strengths. Reduction of Persistent Positive Symptoms in Chronic Schizophrenia There is consistent evidence that CBT in addition to standard psychiatric care can reduce persistent psychotic symptoms when compared to standard psychiatric care alone. This has been demonstrated in small pilot trials and in larger more robust randomised controlled trials (table 1). There are signiﬁcant beneﬁts of CBT over standard care in both positive and negative symptoms, and these appear to be sustained over a follow-up period of up to 2 years after the termination of treatment [56–58]. A number of trials have compared CBT in addition to standard care with a non-speciﬁc control treatment, for example supportive counselling (SC) [45, 51] and befriending . The results with this comparison are equivocal. Tarrier et al.  and Durham et al.  show non-
One trial report did not publish adequate data on positive symptoms and these data were not forthcoming from the authors.
Table 1. Controlled trials of CBT for schizophrenia Study
CBT (n = 72) TAU (n = 72) CBT included EI relapse prevention
CBT > TAU
Hall and Tarrier (2003) 
CBT (n = 12) TAU (n = 13)
CBT > TAU
Cognitive Behaviour Therapy for Schizophrenia
Randomization Blind rating yes
Focusing = –0.29 distraction TAU not analysed –0.37
CBT = SP
not described treatment 10% completers
CBT > SP
all available 0%
CBT = befriending
CBT > TAU
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Table 1 (continued) Study
Randomization Blind rating
Outcomes Drop-out and Analysis attrition
Valmaggia et al. chronic  out-patient
CBT (n = 34) TAU (n = 24)
ITT missing CBT = TAU data estimated
Startup et al. (2004) 
CBT (n = 47) TAU (n = 43)
SAPS SANS BPRS
CBT > TAU
CBT = Cognitive behaviour therapy; PS = problem solving; ATY = activity and recreational therapy; TAU = treatment as usual; SP = supportive psychotherapy; EI = early intervention; BPRS = brief psychiatric rating scale; PQ = personal questionnaire; MADS = Maudsley assessment of delusions scale; PAS = psychiatric assessment scale; PQRST = personal questionnaire
rapid scaling technique; PANSS = positive and negative symptom scale; SAPS = scale for assessment of positive symptoms; SANS = scale for assessment of negative symptoms; CPRS = comprehensive psychiatric rating scale; PSYRATS = psychotic symptom rating scale; REML = residual maximum likelihood; ITT = intention to treat.
signiﬁcant advantages of CBT generally compared to SC that disappear over follow-up . Whereas Sensky et al.  report little difference between CBT and befriending at post-treatment but signiﬁcant advantage for CBT at 18 months of follow-up when the positive effects of befriending decay with time. The performance of these non-speciﬁc treatments was a surprise as they were predicted to perform no better than treatment as usual. However, there is evidence that when the effects of treatment on speciﬁc psychotic symptoms were investigated, SC did signiﬁcantly worse with hallucinations compared with CBT . Thus it may be that unstructured treatments do have a therapeutic effect on delusional thought but speciﬁc structured interventions are necessary to improve hallucinations. This is an area that requires further investigation.
out by an experienced psychiatrist; clearly deﬁned CBT without inclusion of family groups, and a clearly deﬁned SC control group. Although there were differences between the CBT and control group over 2-year follow-up, including a lower percentage of relapses, time to relapse and days spent in hospital, these differences were not statistically signiﬁcant. It is possible that the results reported by Drury et al. [40, 41] were over-optimistic, resulting from an inﬂated effect size due to inadequate methodology. In spite of these potential difﬁculties, the study by Drury et al. [40, 41] established that CBT could be carried out even with those who were most severely ill, a fact conﬁrmed by Haddock et al. . This ﬁnding stimulated the Study of Cognitive Reality Alignment Therapy in Early Schizophrenia (SoCRATES) [49, 61] which tested whether CBT delivered during admission for an acute episode of early (ﬁrst or second episode) schizophrenia would speed recovery and confer resistance to subsequent relapse. CBT in addition to standard in patient care, treatment as usual (TAU), was compared with SC in combination with TAU and TAU alone in 11 mental health units serving three geographically deﬁned catchment areas. Three hundred and nine patients, 80% of whom were ﬁrst episodes, were randomly allocated to one of the three treatment groups. All groups showed a signiﬁcant improvement over the ﬁrst 70 days with faster resolution of symptoms shown in both groups who received the psychological additional treatments. There were signiﬁcant beneﬁts for those who received CBT compared with those who received solely TAU at 4 weeks. These beneﬁts disappeared at 6 weeks. There appeared to be no difference between CBT and SC except in the treatment of hallucinations in which SC did poorly .
Speeding Recovery in Acute Schizophrenia A number of studies have investigated the efﬁcacy of CBT in speeding recovery in acutely ill patients hospitalised for a ﬂorid psychotic episode. Drury et al. [40, 41] reported on a very innovative approach and demonstrated that CBT reduced recovery time by 25–50% and produced signiﬁcant clinical beneﬁts in terms of reduced symptomatology. In a 5-year follow-up of their sample, the CBT group reported less residual symptomatology than the activity control group although there was no difference in positive symptoms as a whole . Haddock et al.  attempted to reproduce the results of Drury et al. [40, 41], with a sample size based upon the reported effect size from the study by Drury et al. [40, 41]. There were a number of methodological improvements in the study by Haddock et al . These included: blind and independent assessment of outcome; assessments carried
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The results at 18 months of follow-up, essentially mirror the earlier treatment phase results. Patients who received TAU only had signiﬁcantly more psychotic symptoms at follow-up than those who received either of the two psychological treatments. Again there was an indication that SC did poorly with hallucinations although there were no other differences between the CBT and SC groups. There were no differences between the three treatment groups in relapse, rehospitalization or time to relapse or rehospitalization . Retrospective analysis of the data from the SoCRATES study suggested that there may be an age effect in response to treatment. The younger group (under 22 years of age) had signiﬁcantly higher symptom scores and lower levels of social functioning and showed a poorer response to TAU than the older group. The younger group were also rated by the therapists as signiﬁcantly more difﬁcult to engage in therapy, either CBT or SC . Relapse Reduction Although there is evidence for symptom reduction with CBT in both chronic and acute phases of schizophrenia, the evidence that CBT signiﬁcantly reduces relapse is less impressive. The ﬁnding for patients treated during an acute episode are disappointing [46, 60, 61]. In the SoCRATES study of acute patients, similar rates for clinical relapse for CBT (33%), SC (29%) and TAU (36%) and rehospitalization CBT (55%), SC (52%) and TAU (51%) were reported . In patients treated during the chronic phase the results are more equivocal. In their chronic sample, Tarrier et al.  reported 14% relapses in TAU compared with none in the CBT or SC groups over the 3 months of treatment period. This changed to relapse rates of 28% for CBT, 19% for SC and 27% for TAU after 15 months . At 27 months, there were 27% relapses in the combined CBT and SC group and 39% in the TAU group . However, none of the follow-up results are signiﬁcant for across-group comparisons. Bach and Hayes  using ACT with inpatients found a subsequent reduction in rehospitalization from 40% in the TAU to 20% in the ACT group over a 4-month follow-up period. Gumley et al.  used a targeted CBT which was implemented on the appearance of early signs of relapse. The CBT group showed signiﬁcantly reduced relapses (14%) compared with the control group (36%) over a 12-month period. The duration of relapse, but not the severity or time to relapse, was also reduced. These results suggest that a dedicated and intensive relapse prevention programme is necessary to impact upon relapse rates.
Cognitive Behaviour Therapy for Schizophrenia
Depression One issue which is often raised by psychiatrists is their fear that CBT in reducing psychotic symptoms may increase depression and possibly also suicide risk. An improvement in insight might be the mechanism by which depression is precipitated. Strangely, this concern is not raised when symptomatic improvement is achieved with anti-psychotic medication, even though there are other disadvantages to medication. To test the hypothesis that alleviation of positive symptoms would result in an increase in depression, the correlations between both patient-rated and observer-rated measures of depression and hopelessness with positive symptoms were investigated retrospectively by Tarrier et al. . If depression increased after successful symptom reduction then a signiﬁcant negative correlation would be predicted. This was not the case, in fact modest but highly signiﬁcant positive correlations were found indicating that depression and hopelessness were reduced with a reduction in positive symptoms . Co-morbid depression, hopelessness and suicidality have not been the direct focus of cognitive-behavioural treatments up to the present time but are urgent clinical problems which will need to be addressed by future studies.
Applicability to Normal Clinical Settings
Well-controlled randomised clinical trials are often criticised in that they do not reﬂect the ‘real world’ of clinical practice. This is for two reasons. Firstly, the therapists in clinical trials are highly trained ‘experts’ working from a university research centre. Secondly, the narrow inclusion criteria operating in clinical trials means that the atypical and frequently difﬁcult and complex cases often seen in clinical practice are excluded. It is probably true that in the early stages of evaluation of any new therapy, the trial therapists will be the ‘experts’ who devised the therapy. But in the later phases of evaluation this is less likely. In the SoCRATES trial [49, 61] the therapist were clinical psychologists and nurse therapists who had worked in normal service settings. In a trial by Turkington et al.  community psychiatric nurses were trained to deliver CBT in a trial that recruited 422 patients suffering from schizophrenia in which 225 completed CBT treatment. Patients treated with CBT by nurses showed signiﬁcant clinical gains compared with control patients who received standard care. In these two trials, experienced therapists were trained and supervised to deliver CBT indicating that it is not
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just a small group of ‘experts’ who can deliver therapy. It may well be that to deliver CBT to these patients, therapists need to be skilled, experienced and well trained; they may become ‘experts’ but this does not mean that the therapy is inaccessible. Sometimes, the argument is advanced that the specialist skills required to deliver CBT makes it too expensive and uneconomical. A well-trained workforce in mental health would appear a positive advantage to society rather than a disadvantage, and the beneﬁts accruing to those suffering severe mental disorders are worth the cost. After all, the same argument is not advanced to terminate heart surgery, which also requires highly trained, experienced and skilled practitioners. A number of studies have been reported on the successful use of CBT to treat psychotic patients in routine clinical practice [63, 64]. Turkington and Kindon  demonstrated that CBT could be administered by general psychiatrists working in the public health services, in spite of their heavy work load, with signiﬁcant beneﬁts to their patients. Lastly, in a study of the effectiveness of the Thorn Training Programme in psychosocial interventions at Manchester, it was reported that patients treated by psychiatric nurses trained in CBT with individuals and families showed signiﬁcant clinical improvements . One of the major challenges of the implementation of evidence-based medicine is that new empirically supported treatments are disseminated into clinical practice as rapidly as possible and that those who would beneﬁt from these treatments have easy access to them. Mental health services, unfortunately, rarely reﬂect research and many commonly used treatments have, at the best, equivocal support for their effectiveness . There are a number of reasons why psychological treatments of proven effectiveness are slow to permeate into routine services. These include: a lack of a partnership between researchers and clinicians; an absence of the appropriate knowledge and skills within the workforce; characteristics of the workplace which impede new developments, and the fact that it takes longer to acquire and implement new skills than is generally thought . Lastly, unlike the heavy marketing by drug companies of their pharmaceutical agents there are few ‘product champions’ that have the same inﬂuence and resources to ‘market’ and promote the implementation of non-drug treatments. One perquisite for increasing the availability of a new psychological treatment is to train the workforce to provide the treatment. This is a more complex issue than was once thought, and it raises questions about the adequacies
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of training, clinical competence, supervision and professional qualiﬁcations. Further questions arise on how training is best delivered and how to maintain therapists’ skills and the quality of treatment delivered. A simple example will sufﬁce, on training psychiatric nurses in psychosocial treatment skills we found that many were enthusiastic and highly competent but after completing their training and returning to their place of work they were frequently either not supported by their management and they became frustrated and left or they were no longer satisﬁed with their routine clinical work and left to seek teaching or research posts. Either way, highly trained clinicians were lost to the clinical workforce. However, dissemination is by no means impossible and can be achieved, although it is a complex process and much more likely to happen if there is support at institutional and policy levels. A further difﬁculty in the effective ‘rolling out’ of CBT into a general service setting is that there is little guidance on the number, frequency or duration of CBT treatment sessions. The frequency or intensity of treatment has shown some variation in the published studies . For example, Tarrier et al.  implementing an intensive twice weekly CBT intervention over 3 months compared with Kuipers et al.  who provided CBT on a weekly or fortnightly basis over 9 months. Both studies report clinical beneﬁts from their interventions. In the published studies, the duration of treatment is determined by the constraints of a clinical trial; however, in a service setting many patients will have long term needs, and CBT of much longer duration may be indicated although the current literature provides no indication as to whether this is either feasible, effective or economically viable. Furthermore, there is little indication as to which techniques are important or necessary in bringing about clinical change. This search for ‘active ingredients’ has yet to be initiated as a research programme although is has been marked up for future research . However, faith in the productive result of such a programme may be misplaced. If CBT is regarded as an approach rather than just a set of techniques, then different conclusion can be drawn. CBT as an approach implies there is a shared ‘world view’ about the nature of therapy and how clinical problems should be addressed which includes shared assumptions about the origins of psychopathology and causality. This can be thought of as an adherence to a general model and, thus, therapy and therapeutic actions will either be within the ‘spirit of CBT’ or not. Thus, it may be that, therapeutically, adherence to the ‘spirit of CBT’ may be more important than which speciﬁc individual or collection of
techniques are included. This has implications for training and implementation as the CBT approach needs to be taught and implemented rather than set of techniques.
There have been considerable advances in recent years at both a theoretical and treatment development level in the psychology of schizophrenia. The evaluations of CBT have shown marked improvements in methodological rigour, and there is promising evidence that CBT will result in clinical beneﬁts for schizophrenic patients. However, the most recent meta-analysis concluded that ‘Cognitive behavioural therapy is a promising but underevaluated intervention. Currently, trial-based data supporting
the wide use of cognitive behavioural therapy for people with schizophrenia or other psychotic illnesses are far from conclusive. More trials are justiﬁed, especially in comparison with a lower grade supportive approach. These trials should be designed to be both clinically meaningful and widely applicable’ . Further research should focus on identifying the characteristics of patients who will beneﬁt from CBT at various phases of the disorder and in understanding the mechanisms by which improvement occurs. There is evidence that these treatment methods can be transferred to routine clinical practice, although the broad dissemination of the required skills and knowledge throughout the workforce may be a complex process. Universal accessibility to effective CBT treatments may be a slower process than was once hoped but it remains an achievable goal.
References 1 Mueser KT, Berenbaum H: Psychodynamic treatment of schizophrenia: Is there a future? Psychol Med 1990;20:253–262. 2 Cormac I, Jones C, Campbell C, Silveira da Mota Neto J: Cognitive Behaviour Therapy for Schizophrenia (Cochrane Review); in The Cochrane Library. Chichester, Wiley, issue 2, 2004. 3 Gould RA, Mueser KT, Bolton E, Mays V, Goff D: Cognitive therapy for psychosis in schizophrenia: An effect size analysis. Schizophr Res 2001;48:335–342. 4 Rector NA, Beck AT: Cognitive behavioral therapy for schizophrenia: An empirical review. J Nerv Ment Dis 2001;189:278–287. 5 Pilling S, Bebbington P, Kuipers E, Garety P, Geddes J, Orbach G, Morgan C: Psychological treatments in schizophrenia. I. Meta-analysis of family interventions and cognitive behaviour therapy. Psychol Med 2002;32:763–782. 6 National Institute for Clinical Excellence: Schizophrenia: Core interventions in the treatment and management of schizophrenia in primary and secondary care. National Institute for Clinical Excellence, 2003. 7 Garety PA, Kuipers E, Fowler D, Freeman D, Bebbington PE: A cognitive model of the positive symptoms of psychosis. Psychol Med 2001;31:189–195. 8 Barrowclough C, Tarrier N, Humphreys L, Ward J, Gregg L, Andrews B: Self esteem in schizophrenia: The relationships between self evaluation, family attitudes and symptomatology. J Abnorm Psychol 2003;112:92–97. 9 Kane J: Treatment resistant schizophrenic patients. J Clin Psychiatry 1996;57(suppl 9):35– 40. 10 Buchanan A: Compliance with Treatment in Schizophrenia. Maudsley Monographs. Hove, Psychology Press, 1996, No. 37. 11 Tarrier N: Yes, cognitive behaviour therapy may well be all you need. BMJ 2002;324:291– 292.
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12 Tarrier N: An investigation of residual psychotic symptoms in discharged schizophrenic patients. Br J Clin Psychol 1987;26:141–143. 13 Falloon IRH, Talbot RE: Persistent auditory hallucinations: Coping mechanisms and implications for management. Psychol Med 1981; 11:329–339. 14 Breier A, Strauss JS: Self-control in psychotic disorders. Arch Gen Psychiatry 1983; 40: 1141–1145. 15 Cohen CI, Berk LA: Personal coping styles of schizophrenic outpatients. Hosp Community Psychiatry 1985;36:407–410. 16 Carr V: Patients’ techniques for coping with schizophrenia: An exploratory study. Br J Med Psychol 1988;61:339–352. 17 Romme MA, Escher AD: Hearing voices. Schizophr Bull 1989;15:209–216. 18 Karoly P, Kanfer FH: Self-Management and Behaviour Change: From Theory to Practice. New York, Pergamon, 1982. 19 Tarrier N, Calam R: New developments in cognitive-behavioural case formulation. Epidemiological, systemic and social context: An integrative approach. Behav Cogn Psychother 2002;30:311–328. 20 Haddock G, Tarrier N: Assessment and formulation in the cognitive behavioural treatment of psychosis; in Tarrier N, Wells A, Haddock G (eds): Treating Complex Cases: The Cognitive Behavioural Therapy Approach. Chichester, Wiley, 1998. 21 Tarrier N: The use of coping strategies and selfregulation in the treatment of psychosis; in Morrison A (ed): A Casebook of Cognitive Therapy for Psychosis. Cambridge, Cambridge University Press, 2001. 22 Kingdon DG, Turkington D: The use of cognitive behaviour therapy with a normalising rationale in schizophrenia. J Nerv Ment Dis 1991;179:207–211.
23 Beck AT: Successful out-patient psychotherapy of a chronic schizophrenic with a delusion based on borrowed guilt. Psychiatry 1952; 15: 305–312. 24 Kingdon DG, Turkington D: Cognitive behavioural therapy of schizophrenia. New York, Guilford Press, 1994. 25 Brabban A, Turkington D: The search for meaning: Detecting congruence between life events, underlying schema and psychotic symptoms; in Morrison A (ed): A Casebook of Cognitive Therapy for Psychosis. Cambridge, Cambridge University Press, 2002. 26 Hall PH, Tarrier N: The cognitive-behavioural treatment of low self-esteem in psychotic patients: A pilot study. Behav Res Ther 2003;41: 317–332. 27 Beck AT, Rush AJ, Shaw BF, Emery G: Cognitive therapy of depression. New York, Guilford Press, 1979. 28 Bach P, Hayes SC: The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. J Consult Clin Psychol 2002; 70:1129–1139. 29 Teasdale JD: The relationship between cognition and emotion: The mind-in-place in mood disorders; in Clark DM, Fairburn CG (eds): The Science and Practice of Cognitive Behaviour Therapy. New York, Oxford University Press, 1997, pp 67–93. 30 Miller WR, Rollnick S: Motivational interviewing: Preparing people for change. New York, Guilford Press, ed 2, 2002. 31 Barrowclough C, Haddock G, Tarrier N, Lewis S, Moring J, O’Brian R, Schoﬁeld N, McGovern J: Randomised controlled trial of motivational interviewing and cognitive behavioural intervention for schizophrenia patients with associated drug or alcohol misuse. Am J Psychiatry 2001;158:1706–1713.
Psychother Psychosom 2005;74:136–144
32 Haddock G, Barrowclough C, Moring J, Tarrier N: Cognitive-behaviour therapy for patients with co-existing psychosis and substance use problems; in Morrison A (ed): A Casebook of Cognitive Therapy for Psychosis. Cambridge, Cambridge University Press, 2001. 33 Barrowclough C, Conrod P, Haddock G, Lowens I, Moring J, Tarrier N, Wykes T: Motivational interviewing plus cognitive behaviour therapy for co-morbid schizophrenia and substance misuse: Treatment manual; unpubl, University of Manchester, 2004. 34 Morrison AP, French P, Walford L, Lewis SW, Kilcommons A, Green J, Parker S, Bentall RP: Cognitive therapy for the prevention of psychosis in people at ultra-high risk: randomised controlled trial. Br J Psychiatry 2004;185:291– 297. 35 Cohen J: Statistical power analysis for the behavioural sciences, rev ed. New York, Academic Press, 1988. 36 Tarrier N, Wykes T: Do we have evidence that cognitive behaviour therapy is an effective treatment for schizophrenia? A cautious or cautionary tale? Behav Res Ther 2004;42: 1377–1401. 37 Milton F, Patwa VK, Hafner RJ: Confrontation vs belief modiﬁcation in persistently deluded patients. Br J Med Psychol 1978; 51: 127–130. 38 Tarrier N, Beckett R, Harwood S, Baker A, Yusupoff L, Ugarteburu I: A controlled trial of two cognitive behavioural methods of treating drug-resistant residual psychotic symptoms in schizophrenic patients. I. Outcome. Br J Psychiatry 1993;162:524–532. 39 Garety PA, Kuipers L, Fowler D, Chamberlain F, Dunn G: Cognitive behavioural therapy for drug resistant psychosis. Br J Psychiatry 1994; 67:259–271. 40 Drury V, Birchwood M, Cochrane R, Manmillan F: Cognitive therapy and recovery from acute psychosis: A controlled trial. I. Impact on psychotic symptoms. Br J Psychiatry 1996; 169:593–601. 41 Drury V, Birchwood M, Cochrane R, Manmillan F: Cognitive therapy and recovery from acute psychosis: A controlled trial. II. Impact on recovery time. Br J Psychiatry 1996; 169: 602–607. 42 Bentall RP, Haddock G, Slade PD: Cognitive behaviour therapy for persistent auditory hallucinations: From theory to therapy. Behav Ther 1994;25:51–66. 43 Haddock G, Slade PD, Bentall RP, Reid D, Faragher EB: A comparison of the long-term effectiveness of distraction and focussing in the treatment of auditory hallucinations. Br J Med Psychol 1998;71:339–349. 44 Kuipers E, Garety P, Fowler D, Dunn G, Bebbington P, Freeman D, Hadley C: London-East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis. I. Effects of the treatment phase. Br J Psychiatry 1997;171:319–327.
45 Tarrier N, Yusupoff L, Kinney C, McCarthy E, Gledhill A, Haddock G, Morris J: A randomised controlled trial of intensive cognitive behaviour therapy for chronic schizophrenia. BMJ 1998;317:303–307. 46 Haddock G, Tarrier N, Morrison AP, Hopkins R, Drake R, Lewis S: A pilot study evaluating the effectiveness of individual inpatient cognitive-behavioural therapy in early psychosis. Soc Psychiatry Psychiatr Epidemiol 1999; 34: 254–258. 47 Pinto A, La Pia S, Mennella R, Giorgio D, DeSimone L: Cognitive-behavioural therapy and clozapine for clients with treatment-refractory schizophrenia. Psychiatr Serv 1999; 50:901–904. 48 Sensky T, Turkington D, Kingdon D, Scott JL, Scott J, Siddle R, O’Carrol M, Barnes TR: A randomised controlled trial of cognitive-behavioural therapy for persistent symptoms in schizophrenia resistant to medication. Arch Gen Psychiatry 2000;57:165–172. 49 Lewis SW, Tarrier N, Haddock G, Bentall R, Kinderman P, Kingdon D, Siddle R, Drake R, Everitt J, Leadley K, Benn A, Glazebrook K, Haley C, Akhtar S, Davies L, Palmer S, Faragher B, Dunn G: Randomised controlled trial of cognitive-behaviour therapy in early schizophrenia: Acute phase outcomes. Br J Psychiatry 2002;181(suppl 43):91–97. 50 Turkington D, Kingdon D, Turner T: Effectiveness of a brief cognitive-behavioural therapy intervention of schizophrenia. Br J Psychiatry 2002;180:523–527. 51 Durham RC, Guthrie M, Morton RV, Reid DA, Treliving LR, Fowler D, MacDonald RR: Tayside-Fife clinical trial of cognitive-behaviour therapy for medication-resistant psychotic symptoms: Results to three months followup. Br J Psychiatry 2003;182:303–311. 52 Rector N, Seeman MV, Segal ZV: Cognitive therapy for schizophrenia: A preliminary randomised trial. Schizophr Res 2003;63:1–11. 53 Gumley A, O’Grady M, McNay L, Reilly J, Power K, Karatzias A, Tait A, Chouliara Z, White C: A randomised trial of targeted cognitive behavioural therapy in schizophrenia: Effects on relapse at 12 months. Psychol Med 2003;33:419–431. 54 Valmaggia L, van der Gaag M, Tarrier N, Pijnenborg GHM, Sloof CJ: A randomized controlled trial of cognitive behavior therapy with treatment refractory positive symptoms of schizophrenia, in press. 55 Startup M, Jackson MC, Bendix S: North Wales randomised controlled trial of cognitive behaviour therapy for acute schizophrenia spectrum disorders: Outcomes at six and twelve months. Psychol Med 2004; 34: 413– 422. 56 Kuipers E, Fowler D, Garety P, Chisholm D, Freeman D, Dunn G, Bebbington P, Hadley C: London-East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis. III. Follow-up and economic evaluation at 18 months. Br J Psychiatry 1998; 173: 61– 68.
Psychother Psychosom 2005;74:136–144
57 Tarrier N, Wittkowski A, Kinney C, McCarthy E, Morris J, Humphreys L: The durability of the effects of cognitive behaviour therapy in the treatment of chronic schizophrenia: Twelve months follow-up. Br J Psychiatry 1999; 174: 500–504. 58 Tarrier N, Kinney C, McCarthy E, Humphreys L, Wittkowski A, Morris J: Two years followup of cognitive-behaviour therapy and supportive counselling in the treatment of persistent positive symptoms in chronic schizophrenia. J Consult Clin Psychol 2000; 68: 917–922. 59 Tarrier N, Kinney C, McCarthy E, Wittkowski A, Yusupoff L, Gledhill A, Morris J: Are some types of psychotic symptoms more responsive to CBT? Behav Cogn Psychother 2001;29:45– 55. 60 Drury V, Birchwood M, Cochrane R: Cognitive therapy and recovery from acute psychosis: A controlled trial. 3. Five-year follow-up. Br J Psychiatry 2000;177:8–14. 61 Tarrier N, Lewis SW, Haddock G, Bentall R, Drake R, Dunn G, Kinderman P, Kingdon D, Siddle R, Everitt J, Leadley K, Benn A, Glazebrook K, Haley C, Akhtar S, Davies L, Palmer S: 18 months follow-up of a randomised, controlled clinical trial of cognitive-behavior therapy in ﬁrst episode and early schizophrenia (The SoCRATES Trial). Br J Psychiatry 2004; 184:231–239. 62 Haddock G, Lewis S, Bentall R, Dunn G, Drake R, Tarrier N: Outcome following psychological treatment for young adults experiencing ﬁrst episode psychosis. Unpubl. paper, University of Manchester, 2005. 63 Jakes S, Rhodes J, Turner T: Effectiveness of cognitive therapy for delusions in routine clinical practice. Br J Psychiatry 1999; 175: 331– 335. 64 Wiersma D, Jenner JA, van de Willige G, Spakman M, Nienhuis FJ: Cognitive behaviour therapy with coping training for persistent auditory hallucinations in schizophrenia: A naturalistic follow-up study of durability of effects. Acta Psychiatr Scand 2001;103:393–399. 65 Turkington D, Kindon D: Cognitive-behavioural techniques for general psychiatrists in the management of patients with psychoses. Br J Psychiatry 2000;177:101–106. 66 Lancashire S, Haddock G, Tarrier N, Baguley I, Butterworth CA, Brooker C: The impact of training community psychiatric nurses to use psychosocial interventions with people who have serious mental health problems: The Thorn Nurse Training Project. Psychiatr Serv 1997;48:39–41. 67 Anderson J, Adams C: Family interventions in schizophrenia: An effective but little used treatment. BMJ 1996;313:505. 68 Tarrier N, Barrowclough C, Haddock G, McGovern J: The dissemination of innovative cognitive-behavioural treatments for schizophrenia. J Ment Health 1999;8:569–582.