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date: 23 February 2024

Cognitive Behavior Therapy for Psychosis (CBTp)free

Cognitive Behavior Therapy for Psychosis (CBTp)free

  • Anthony P. MorrisonAnthony P. MorrisonUniversity of Manchester
  •  and Lisa J. WoodLisa J. WoodNorth East London Foundation Trust, National Health Service


Cognitive behavior therapy (CBT) is an evidence-based psychological therapy that has been shown to have small to medium effects in improving outcomes for people experiencing psychosis. CBT’s theoretical model, drawing together cognitive and behavioral theories, outlines that it is the appraisal and response to an event which maintains distress rather than the event itself. CBT for psychosis (CBTp) specifically aims to modify appraisals and responses to psychotic experiences in order to reduce distress. CBTp has a substantial evidence base and is the most frequently offered psychological treatment for psychosis. There have been significant advancements in the field, with process-oriented therapies and digital interventions showing promise; however, more large-scale trials are required. Moreover, service users report positive experiences with CBTp and value the normalizing therapeutic relationship, improved personal understanding, and acquisition of new coping strategies. Improving dissemination and adapting CBTp so that it is appropriate for all populations is an ongoing priority for future research. Moreover, the evidence base requires more user-centered research to ensure CBTp is meeting the needs of service users.


  • Cognitive Psychology/Neuroscience
  • Methods and Approaches in Psychology

Origins and Development of Cognitive Behavioral Models of Psychosis

Psychosis comprises experiences such as hearing voices or seeing things that others do not, strongly held beliefs that others do not share, and difficulty with thinking and concentration (British Psychological Society, 2017). People who experience psychosis are often diagnosed with a psychotic disorder which includes schizophrenia, schizoaffective disorder, schizophreniform disorder, and delusional disorder (National Institute of Clinical Excellence [NICE], 2014). Psychosis has the potential to be an extremely debilitating mental health difficulty, which can significantly impact on a person’s functioning and quality of life (Yi Chong et al., 2016). The typical onset for psychosis is between the age of 14 and 35 years, with a high likelihood of further episodes throughout life (Di Capite et al., 2018).

Cognitive behavior therapy (CBT) is an evidenced-based formulation-driven psychological therapy which aims to reduce emotional distress and improve functioning by targeting underlying cognitions and behaviors (Beck, 1979, 2005). CBT was developed by Aaron Beck, drawing upon existing behavioral and cognitive theories. CBT is based on the premise that it is the way a person makes sense of an event which is important rather than the event itself and that emotional distress occurs when a person’s interpretation of an event is excessively threatening and disproportionate (Mander & Kingdon, 2015). CBT theory states that cognitions, behaviors, emotions, and physiology are interdependent and collectively contribute to the development and maintenance of emotional distress (Beck, 2005).

CBT was first applied to psychosis in 1952 by Beck, who undertook a case study of CBT aiming to treat a veteran’s delusional beliefs (Beck, 1952). However, this early work did not instantly lead to the development of CBT for psychosis (CBTp), as Beck’s initial body of work prioritized developing CBT for depression and anxiety. Manualized CBT approaches for anxiety and depression emerged in the 1970s whereas manualized approaches for psychosis developed later in the 1990s (Beck, 2005). One of the reasons for this delay was due to the medicalized conceptualization of psychotic symptoms and perceptions that they are fixed and less susceptible to change (Mander & Kingdon, 2015). However, evidence was forming to demonstrate that psychosis was not a permanent medical disorder but an experience that was on the continuum of normal experience and modifiable. As a result, the CBTp model evolved and a number of theories were established (Fowler et al., 1995; Freeman & Garety, 1999; Garety et al., 2001; Morrison, 2001). Early forms of CBTp primarily prioritized behavioral strategies to affect change, such as coping strategy enhancement (Tarrier et al., 1990), with cognitive strategies as secondary (Tai & Turkington, 2009). However, as the evidence has progressed, the equal importance of cognitive strategies in CBTp was recognized. Currently, the CBTp model assumes that adverse life events in childhood lead to the development of underlying core beliefs about the self, the world, and others and that psychosis is maintained through threat-based cognitions, behaviors, emotions, and physiological responses (Morrison, 2001). Two influential CBTp models describing this process are discussed in more detail here.

Figure 1. Garety et al. (2007) cognitive model of psychosis.

Garety (2001) developed a model to explain the development and maintenance of psychosis, which is outlined in Figure 1. The model outlines that people who experience psychosis have a vulnerable disposition (a biopsychosocial vulnerability) and develop psychosis within the context of adverse environments, illicit drug use, and stressful life events. Once a triggering event is present, psychosis can develop via two proximal routes: one via cognitive and emotional change and the other through affective disturbances alone. The first route is more common. This leads the individual to appraise experiences as external (i.e., as more threatening and uncontrollable) and develop positive symptoms of psychosis. The model outlines that the development of psychotic symptoms is influenced by underlying reasoning and attribution biases, dysfunctional schemas of the self and world, isolation, and adverse environments. Garety (2001) emphasized that the different types of reasoning and attribution biases impact on the development and maintenance of psychosis. She explained that people with psychosis are likely to jump to conclusions more quickly, believe that internal events have an external cause, and have little flexibility in their beliefs (Garety, 2001).

Another CBTp model was developed by Morrison (2001). This model emphasized that it is the culturally unacceptable interpretations or appraisals of events which are key to the development and maintenance of psychosis. For example, if someone had palpitations and believed they were having a panic attack, they would more likely present with panic disorder, but if they interpreted the palpitations as caused by someone who had attempted to drug and kill them, they would present with psychosis. It is these culturally unacceptable interpretations that distinguish psychosis from other mental health difficulties. The nature of the culturally unacceptable interpretations is determined by a combination of personal experiences, beliefs, and knowledge. These culturally unacceptable (i.e., psychotic) interpretations are then maintained by safety-seeking behaviors and other responses, faulty self-knowledge (including metacognition) and social knowledge, negative mood, and physiology. This model is outlined in Figure 2.

Figure 2. Morrison (2001) cognitive model of psychosis.

Since the development of these models, symptom-specific approaches have also emerged, which focus on particular symptoms of psychosis (Birchwood et al., 2014; Freeman et al., 2015; Palmier-Claus et al., 2017; Thomson et al., 2017). Birchwood and colleagues developed a model which specifically targeted command hallucinations (Birchwood et al., 2014). This model outlines that it is the belief that an auditory hallucination is malevolent and powerful along with compliance behaviors that can cause and maintain command hallucinations. The approach aims to reduce compliance and reevaluate appraisals to reduce distress. A CBT model for visual hallucinations has also been developed (Thomson et al., 2017). This model aims to target the appraisals and safety behaviors maintaining the visual hallucination to reduce the frequency and related distress (Dudley et al., 2012). Freeman and colleagues developed a modularized approach for working with persecutory delusions (Freeman, 2015; Freeman et al., 2021). This approach asserts that there are six key psychological mechanisms that cause and maintain persecutory delusions, which include worry, negative self-belief, anomalous experiences, sleep dysfunction, reasoning biases, and safety behaviors. This modularized approach attempts to reduce these maintenance factors, reduce the frequency and distress of persecutory delusions, and increase an individual’s sense of safety. Other approaches are also emerging for other symptoms such as negative symptoms (Staring et al., 2013) and thought disorder (Palmier-Claus et al., 2017). Therapeutic approaches to treat posttraumatic stress disorder symptoms in psychosis have also been developed (Peters et al., 2020; Steel et al., 2017).

Outlines of Treatment

Although there are many different approaches and intervention protocols that fall under the umbrella of CBTp, there are many commonalities. The treatment begins with a cognitive-behavioral assessment that usually would include a brief history taking as well as a focus on current difficulties, examining relevant thoughts, feelings, and behavior. A problem list would be collaboratively generated, and one or more goals would be identified. This information would commonly be used to develop a formulation, which may focus on maintenance factors for a specific problem, such as hearing distressing voices, or a developmental formulation that focuses on the relationship between past experience, beliefs formed as a result, and current difficulties. The format of the formulation would usually be based on one of the specific development or maintenance models already described; however, some of the treatment protocols are not formulation driven and may apply specific change strategies in a more rigid manner (e.g., coping strategy enhancement). The change strategies in formulation-driven CBTp are selected on the basis of the formulation and include both cognitive and behavioral strategies. Cognitive strategies include consideration of alternative explanations and advantages and disadvantages of appraisals, evidential analysis, schema change strategies, imagery modification, and problem-solving. Behavioral strategies include behavioral experiments (often testing the usefulness of safety-seeking behaviors), activity scheduling, graded exposure, and skills practice. Normalization and psychoeducation regarding psychotic experiences are also commonly involved. The use of specific strategies would be emphasized to a greater or lesser degree, depending on the specific model, treatment targets, and manual. Most approaches to CBTp would also incorporate an element of summarizing progress within therapy, consolidating treatment gains, staying well, and relapse prevention. Most approaches would also emphasize the importance of principles such as collaboration and between session or homework tasks. The duration of CBTp and the frequency and format of sessions is variable, but the National Institute of Clinical Excellence guidelines recommends a minimum of 16 sessions along with individual delivery (rather than group) and use of a manualized treatment. A Delphi study has highlighted consensus among expert CBTp practitioners regarding essential elements and important principles (Morrison & Barratt, 2010). A competency framework distilled from the manuals used within the clinical trials has also been developed in order to specify the skills, knowledge, and experience that are required to deliver CBTp (Roth & Pilling, 2012).

Efficacy and Evidence

The evidence base for CBTp has grown extensively over the past 25 years and there are now over 60 randomized controlled trials (RCTs) which have examined its efficacy (Hardy, 2021). There is consensus that CBTp is an effective treatment on a number of key outcomes and has small to medium effect sizes (Bighelli et al., 2018; Wykes et al., 2008). This was also identified in a recent systematic review which examined individual patient data across 23 RCTs (Turner et al., 2020). Overall, systematic reviews of CBTp have shown small to moderate effects on a number of important outcomes, including a reduction in overall symptoms of psychosis, positive symptoms (auditory hallucinations and delusions), functioning, mood, social anxiety, and negative symptoms at the end of therapy and at follow-up (Bighelli et al., 2018; Health Quality Ontario, 2018; Wykes et al., 2008). However, other systematic reviews have not shown any benefit of CBTp over other active control interventions (Jones et al., 2012). Two reviews found that CBTp was not favorable over other psychosocial therapies on the outcomes of relapse, rehospitalization, quality of life, positive or negative symptoms, or social functioning (Jones et al., 2012; Laws et al., 2018). Jones et al. (2012) also identified only limited evidence for longer-term impacts of CBTp on affective symptoms such as depression. However, one of these reviews has been criticized for a number of methodological flaws, including analyzing incorrect time point data and the arbitrary separation of interventions into small, medium, and long-term (Hutton et al., 2013). As a result, it is generally accepted that CBTp is an effective intervention for psychosis with small to medium effect sizes on psychotic symptomology, particularly positive symptoms (Bighelli et al., 2018).

In terms of presentation, the evidence for CBTp has been demonstrated that it has more effect in high-risk and first episode groups than those with more severe and enduring presentations. For example, van der Gaag et al. (2013) conducted a systematic review and demonstrated that the risk of developing a first episode of psychosis was reduced by 54% when CBTp was offered over usual treatments. Developments in the evidence base have demonstrated that CBTp is a feasible and acceptable treatment in comparison to antipsychotic medication in a first episode sample (Morrison et al., 2020). Previous research has usually offered CBTp to samples already taking antipsychotic medication and a head-to-head comparison had never previously been completed. Thus, this study provides initial evidence that CBTp may be a useful alternative to medication, but further research is required. Most recently, there is evidence that modularized approaches to CBTp are beneficial. The feeling safe program, a modularized approach to persecutory delusions, has demonstrated to have moderate effects on persecutory beliefs compared to an active control (Freeman et al., 2021).

As a result of this extensive body of research, CBTp is recommended as the first line of psychological intervention for psychosis in U.K. and U.S. clinical guidelines (Keepers et al., 2020; NICE, 2014).

Relapse Prevention

Relapse rates are high for people experiencing psychosis. It is estimated that 80%–90% of people who have experienced a first episode of psychosis go on to experience a relapse in their psychosis, leaving a large proportion of people at risk of relapse (Emsley et al., 2013). In a longitudinal observational study following up with people after their first episodes of psychosis, 32.8% had relapsed after 12 months, 53.4% at 24 months, and 63.8% at 36 months (Pereira et al., 2017). CBTp can prevent relapse by using change strategies that specifically target relapse-related appraisals and behavior (Birchwood et al., 2000; Gumley et al., 2003). Psychoeducation, normalizing, and identifying and targeting early warning signs and relapse appraisals have been demonstrated as strategies integral to relapse prevention CBTp (Birchwood et al., 2000; Gleeson et al., 2009; Gumley & Power, 2000).

There are a number of randomized controlled trials (RCTs) examining the efficacy of CBTp interventions on relapse-related outcomes, including relapse in psychotic symptoms, rehospitalization, and readmission (Hutton & Taylor, 2014; Wykes et al., 2008). However, the evidence base for the efficacy of CBTp to reduce relapse is mixed, with some studies demonstrating that CBTp is not indicated for relapse prevention (Garety et al., 2008). For example, Gleeson et al. (2009) undertook an RCT of relapse prevention CBTp with people experiencing their first episode of psychosis (Gleeson et al., 2009, 2013). The intervention significantly reduced relapse rates and prolonged the time to relapse when compared to treatment as usual (TAU) in the short-term (at 7 and 12 months) but not at long-term follow-up (18, 24, or 30 months; Gleeson et al., 2013). Moreover, Gumley and colleagues examined the efficacy of early intervention CBTp for relapse in schizophrenia and found that the CBTp group had significantly reduced levels of relapse compared to TAU at 12-month follow-up, but not rehospitalization (Gumley et al., 2003). Finally, a large RCT (n = 301) of relapse focused CBTp was conducted with people who had recently relapsed (Garety et al., 2008). Findings demonstrated that CBTp had no effects on rates of remission, relapse, or number of days in hospital at 12 or 24 months.

There is a wider evidence base of CBTp RCTs (delivering therapy not specifically focused on relapse) examining efficacy on relapse outcomes. A systematic review conducted by Bird et al. (2010) examined the efficacy of CBTp on relapse and hospital admission. The review identified that CBTp for first episode patients had no effect on relapse or readmission rates 2 years after the receipt of the intervention (Jackson et al., 2019; Lecomte et al., 2009; Lewis et al., 2002). In another large review, CBTp was examined for its efficacy against TAU and an active control on relapse outcomes (Health Quality Ontario, 2008). It was identified that CBTp did not have an effect on relapse or number of days in hospital at the end of treatment compared to TAU (Baandrup et al., 2016). It was also identified that CBTp did not have an effect on relapse (one RCT) or hospitalization (five RCTs) at the end of treatment or at follow-up compared to other psychotherapies (Jones et al., 2012).

Overall, there seems to be limited evidence to support the use of CBTp for relapse prevention in psychosis, even in exclusively early onset populations. If CBTp is to be used for relapse prevention, a specific relapse prevention model should be offered.

Mediating Factors

There are several factors that could influence response to treatment in CBTp, including patient characteristics (e.g., psychological factors, motivation to change, symptom profiles, and current context and life history), therapist factors (e.g., specific skills and competencies and assumptions about psychosis), therapy factors (e.g., number of sessions, use of specific intervention strategies, emphasis on active change and between session tasks, and conceptual model), and interactions of these factors (e.g., a good therapeutic alliance may increase the likelihood of between session task completion).

Some studies have examined patient characteristics by considering baseline variables as predictors of response to CBTp. One study found that, among patients with delusions, the “possibility of being mistaken” (in relation to their delusional belief) was associated with good response to therapy (Garety et al., 1997). Insight at baseline has been shown to be associated with good outcomes in CBTp (Naeem et al., 2008), and another study found that lower levels of conviction at baseline in people with delusional beliefs were associated with good response to CBTp (Brabban et al., 2009). Beck and colleagues conceptualized insight in psychosis as a combination of the ability to reflect on the unusualness of experiences and overconfidence in judgments (Beck & Warman, 2004); higher baseline cognitive insight predicted reduced delusional severity posttreatment (Perivoliotis et al., 2010). Other patient characteristics, including recent hospital admissions (Garety et al., 1997) and severity and type of symptoms (Tarrier et al., 1998), have been shown to be associated with better outcomes, which may relate to motivational issues that could affect engagement in CBTp. Shorter duration of illness has also been shown to be associated with response to CBTp (Drury et al., 1996a,Drury et al., 1996b; Morrison et al., 2004, 2012). Finally, female gender has been shown to be associated with better outcomes (Brabban et al., 2009; Drury et al., 1996a, 1996b).

With regard to therapy and therapist characteristics and their interactions with patient variables, comparatively less research has been conducted. A Delphi study examining expert consensus regarding the essential elements of CBTp found that factors such as homework, an emphasis on active change strategies, and therapist assumptions about psychosis were considered important (Morrison & Barratt, 2010), but there are no studies that systematically relate such factors to treatment response. Studies have shown an incremental beneficial effect of each additional CBTp session (Morrison et al., 2018; Spencer et al., 2018). The therapeutic relationship is also related to treatment response in CBTp (Dunn & Bentall, 2007; Goldsmith et al., 2015). There is also an indication from a meta-analysis of cognitive therapy for psychosis trials that the incorporation of behavioral elements within interventions may be an important predictor of effect size (Wykes et al., 2008); it is important to note that this does not contradict cognitive mediation of change, as it is generally recognized that behavioral methods are often the best way to evaluate cognition within cognitive therapy for psychosis (Chadwick & Lowe, 1990).

Some studies have examined the effects of therapy on specific cognitive processes that are hypothesized to mediate change. A series of causal interventionist studies by Freeman and colleagues have shown that targeting specific maintenance mechanisms (e.g., sleep, worry, and negative beliefs about self) can lead to changes in these mechanisms and also result in changes in paranoid thinking (Freeman et al., 2021). Changes in cognitive insight have also been associated with improvements in positive and negative symptoms (Granholm et al., 2005). Morrison et al. (2012) found that changes in appraisals of voices and paranoid thinking were related to changes in symptomatic outcomes and social recovery.

Turner et al. (2020) conducted individual participant data meta-analyses exploring the role of patient factors as modifiers of treatment outcome but found no robust demographic (e.g., age, gender, ethnicity, education, employment status) or clinical characteristics (e.g., severity of psychosis, illness duration) modifying outcomes for CBTp, although sensitivity analysis suggested the number of sessions attended was important. A larger, more comprehensive individual participant data meta-analysis is currently being conducted in an attempt to identify treatment effect modifiers (Sudell et al., 2021) but has yet to report findings.

Given the majority of factors found to predict outcome have been in small, underpowered studies and are usually not replicated, very little is known about who is most or least likely to benefit from CBTp. Therefore, the current National Institute of Clinical Excellence guidelines, which recommends that CBTp be offered to all patients who meet criteria for schizophrenia or psychosis, would seem appropriate.

Service User Perspectives

Research examining service user experiences of CBTp has become an integral part of the evidence base, with qualitative studies now embedded in the vast majority of CBTp randomized controlled trials (RCTs). The literature examining service user perspectives of CBTp has grown considerably over the past 15 years, giving insight into the service user experience, including research that has been led by user researchers (Berry & Hayward, 2011; Brabban et al., 2016; Wood et al., 2015). Overall, there is evidence that service users find CBTp a useful and acceptable therapy. The qualitative literature has outlined that CBTp was helpful in addressing a wide array of issues, including improvements in psychotic symptoms, emotional distress, anxiety, depression, self-esteem and self-concept, and internalized stigma (Berry & Hayward, 2011; Wood et al., 2015). Service users found that CBTp helped facilitate personal recovery as it was flexible, could be adapted to meet their goals, and did not just focus on psychotic symptom reduction (Kilbride et al., 2013). Service users found that CBTp helped them develop knowledge on managing experiences of psychosis, understand and accept their psychosis, learn new coping strategies, gain hope and independence, and improve their relationships and general functioning (Kilbride et al., 2013).

Service users have also identified the key components of CBTp that they found most helpful. Across the literature, person-centered engagement was prioritized (Berry & Hayward, 2011; Kilbride et al., 2013). A number of studies have found that a strong trusting relationship, based on partnership and collaboration, was key to the delivery of CBTp (Kilbride et al., 2013; Morberg Pain et al., 2008). Without this, it was unlikely that the delivery of CBTp would be successful. In addition to a strong therapeutic relationship, the literature outlined that service users valued the opportunity to develop new skills and strategies through a process of structured learning (Kilbride et al., 2013). In particular, service users valued developing a formulation of their difficulties, reappraising and reevaluating thoughts, monitoring their progress, normalizing, and learning about their experiences of psychosis through psychoeducation (Morberg Pain et al., 2008; Wood et al., 2015).

Service users have also identified some challenges with undertaking CBTp. Kilbride et al. (2013) identified that CBTp was challenging work as it required motivation and personal agency. CBTp was also emotionally demanding due to discussing emotive and potentially traumatic issues. Other studies have identified that service users felt CBTp had limited gains and did not work when it was offered in coercive conditions or when a shared goal could not be identified (Kilbride et al., 2013; Wood et al., 2015). Also, service users identified that CBTp could be difficult on a personal level as it involved being able to acknowledge and discuss personal difficulties, undertake work outside of therapy, and apply new ideas to potentially distressing situations—all of which could be very draining and exhausting (Wood et al., 2015).

Service users have described a number of benefits of CBTp and stressed the importance of a therapeutic relationship. However, it has been acknowledged that there is a gap in the literature from the perspective of those who have dropped out of CBTp or not found therapy helpful (Wood et al., 2015). Further exploration of the adverse effects of CBTp from a service user perspective is also required. There also needs to be more user-led and user-centered design (UCD) in the CBTp field. A study by Hardy et al. (2018) utilized a UCD to adapt a digital CBTp intervention for psychosis, SlowMo, ensuring that service users were central to every stage of the research process. By doing so, they were able to develop an acceptable intervention that met the needs of service users experiencing psychosis. More research utilizing UCDs needs to be undertaken to ensure future CBTp interventions meet the needs of service users.

Process-Oriented Therapies

There has been considerable development in the application of process-oriented therapies, also often referred to as third-wave approaches, to psychosis over the past 15–20 years. All process-oriented therapies incorporate a focus on metacognition which is defined as an awareness of one’s own thought processes and an understanding of the patterns behind them (Hayes, 2004). Rather than focusing on changing psychological events directly, process-oriented interventions seek to change the function of those events and the individual’s relationship to them (Hayes, 2004).

One prominent process-oriented therapy for psychosis is acceptance and commitment therapy (ACT; Hayes et al., 2006). ACT is underpinned by relational frame theory and outlines that psychological distress is caused by cognitive entanglement, experiential avoidance, and belief inflexibility which inhibits an individual from living their life in line with core values (Hayes & Smith, 2005). ACT aims to improve a person’s relationship with their thoughts and feelings rather than changing the content of them. It aims to increase psychological flexibility and support a person to live their life in accordance to their values. ACT has been applied to a wide range of populations, and there is a growing evidence base for its effectiveness; however, its application to psychosis is still developing. A recent systematic review identified 11 randomized controlled trials (RCTs) examining ACT for psychosis (Yildiz, 2020). The review did not undertake a meta-analysis but found that a number of individual RCTs uncovered a small to moderate effect for ACT on emotional distress, negative symptoms, depression, and anxiety. There is less evidence for ACT’s effects on psychotic symptoms, with only a handful of studies finding a small effect on psychotic symptoms and the rest reporting mixed findings (Yildiz, 2020).

Compassion-focused therapy (CFT) is an integrated approach drawing upon evolutionary, social, developmental, and Buddhist psychology (Gilbert, 2010). It asserts that all humans have motivational and emotional systems rooted in mammalian heritage (Heriot-Maitland et al., 2019). These systems serve to ensure survival by having basic needs met, helping to forge relationships, and keeping people safe from harm. However, if people have experienced interpersonal trauma or had difficult attachment relationships, these emotion systems can be more sensitive to threat and lead one to experiencing high levels of shame and self-criticism (Gumley et al., 2010). CFT aims to help people cultivate compassionate attributes and skills in order to influence affect regulation (Gumley et al., 2010). It does this by concurrently targeting shame and self-criticism and increasing warmth and compassion through a variety of therapeutic strategies (Heriot-Maitland et al., 2019). CFT has been utilized with psychosis, and there is some evidence of its use with people who hear voices (Braehler et al., 2013; Laithwaite et al., 2009; Mayhew & Gilbert, 2008). However, the evidence base of CFT for psychosis is still limited despite increasing interest in the approach for psychotic experiences. One feasibility RCT was undertaken to examine the usefulness of CFT for psychosis in a sample of 40 service users (Braehler et al., 2013). They were offered 16 sessions of group CFT, and the trial demonstrated that compared to treatment as usual, the CFT group was associated with greater observed clinical improvement, significant increases in compassion, and significant reductions in depression and social marginalization. It has been postulated that CFT is likely to have good clinical applicability to psychosis, but more research is required (Heriot-Maitland et al., 2019; Tai & Turkington, 2009).

Metacognitive therapy (MCT) draws upon the self-regulatory executive function model and asserts that emotional distress occurs as a result of unhelpful metacognitive processes (Moritz et al., 2011). Therefore, it is not the content of one’s thoughts that causes distress but rather the way the thoughts are controlled (Lysaker et al., 2018). For example, unhelpful metacognitive processes include worry and rumination, an attentional focus on threat and negative information, and thought suppression and avoidance. It is by targeting these processes that emotional distress is reduced (Tai & Turkington, 2009). It has been highlighted that unhelpful metacognitive processes are prevalent in people experiencing psychosis (Sellers et al., 2017), and are key to development and maintenance of psychosis, which is why there has been interest in applying MCT to this presentation (Lysaker et al., 2018). However, similar to other process-oriented therapies, the evidence base for MCT in psychosis is limited but developing. A small feasibility study (n = 10) examined pre-post outcomes following 12 sessions of MCT (Morrison et al., 2014). It found a moderate to large effect on psychotic symptoms at the end of treatment and follow-up (Morrison et al., 2014). It also found that 50% and 40% of participants achieved at least a 25% reduction in psychotic symptoms by the end of therapy and follow-up, respectively. Similar findings were identified in a small (n = 10) pilot study on ultra-high-risk individuals with moderate to large effect sizes on psychotic-like experiences, anxiety, depression, and functioning (Parker et al., 2020). A larger RCT of MCT for psychosis (n = 176) has demonstrated that it can improve positive symptoms, cognitive biases, and theory of mind in people with moderate to severe psychosis (Schneider et al., 2018). Another study has also shown that the effects of MCT on delusions are maintained over a follow-up period (Liu et al., 2018).

Mindfulness is described as the process of being able to intentionally and nonjudgmentally pay attention and be in the present moment (Kabat-Zinn, 2003). This practice stems from the Buddhist religion where mindfulness meditation is a key part of practice (Kabat-Zinn, 2003). Mindfulness-based cognitive therapy (MBCT) is the combination of mindfulness practice and cognitive therapy to help cultivate a present-focused nonjudgmental attitude (MacKenzie & Kocovski, 2016). It aims to train the mind to disengage from negative automatic thoughts by being able to notice thoughts rather than getting preoccupied by them (MacKenzie & Kocovski, 2016). Individuals are encouraged to focus their attention on their internal experiences in order to find better ways of relating to difficult thoughts and feelings (Tai & Turkington, 2009). This mindfulness approach has been found to be helpful within the context of psychosis experiences and can help people better manage voices and delusional beliefs (Khoury et al., 2013). Chadwick and colleagues have been prominent in the application of MBCT in psychosis (Chadwick et al., 2016). They undertook a pragmatic RCT of a 12-week group MBCT intervention with n = 108 participants and found that MBCT significantly improved depression, voice hearing, and behavioral disturbance. However, they did not find significant improvement of psychological distress and disturbance.

The evidence base for process-oriented therapies shows some promise; however, further large-scale research is required to definitively determine its effectiveness for psychosis.

Dissemination and Implementation

Despite National Institute of Clinical Excellence (NICE) guidelines (CG155 and CG178) for treatment of psychosis and schizophrenia recommending that treatment options should include CBTp, it is currently very difficult to access (Schizophrenia Commission, 2012), with recent national audit data from the United Kingdom suggesting that 26% of service users have received it (Royal College of Psychiatrists, 2018). This has been the case in all previous national audits of care for schizophrenia and psychosis despite CBTp having been a NICE-recommended intervention since the first NICE guideline was published in 2002 (CG1). CBTp is also excluded from the curriculum for Improving Access to Psychological Therapies Programme (IAPT) (Clark et al., 2009). The recent Schizophrenia Commission executive summary asks: “Why is it that the integrated therapies that work so well in early intervention are not being offered to people throughout the course of their illness?” In addition, it states: “. . . it is unacceptable that only 1 in 10 of those who could benefit get access to true CBT despite it being recommended by NICE.”

There are many barriers to the implementation of CBTp. Berry and Haddock (2010) identified resource constraints, including lack of funding and workforce problems (e.g., not enough clinical psychologists working in secondary care), structural service-related issues (mental health professionals trained in CBTp returning to generic roles where management of risk issues and high caseloads prevent implementation of CBTp and cause difficulties releasing staff for training, as well as limited availability of supervisors), and service culture issues (prioritization of biomedical approaches over psychosocial approaches, insufficient management support resulting in psychological interventions not being given priority, and resistance to change). It is also clear that perceptions regarding relevance and efficacy of CBTp and pessimistic attitudes held by clinicians also contribute to lack of access (Carter et al., 2017; Prytys et al., 2011).

There has been significant investment in additional posts and training initiatives in recent years in an attempt to address some of these barriers, but a change in service culture and a challenge to the biomedical dominance of mental health services is likely to be required before access to and provision of CBTp is considered to be as important as antipsychotic medication.

Digital Interventions

The evidence base for CBTp continues to evolve and a significant area of advancement is the application of technology to the delivery of CBTp. The main areas of development include the application of virtual reality (VR), apps, and websites. In terms of VR, it has been applied to a variety of different symptoms of psychosis. Freeman et al. (2016) have used VR cognitive therapy to treat both persecutory delusions and social anxiety by exposing people to their feared situation, testing their belief predictions about what would happen in the situation, and asking them to drop their safety behaviors (Freeman et al., 2016). A large multisite trial of VR for social anxiety is currently being undertaken and will provide definitive evidence of its efficacy (Freeman et al., 2019). VR has also been applied to omnipotent voices. AVATAR is a therapeutic approach underpinned by cognitive therapy principles that develops a digital visual representation of the entity to which the omnipotent voice belongs to (Craig et al., 2018). The aim of the therapy is to facilitate a dialogue between the patient and the avatar in order to reduce distress and gain control. Initial evidence demonstrates that AVATAR is feasible and acceptable and can significantly reduce the frequency, intensity, and omnipotence of the voices (Craig et al., 2018). A large multisite trial is currently ongoing in the United Kingdom, which will provide more definitive evidence.

In terms of apps and websites, several novel CBTp-informed interventions have been developed. Actissist, a CBTp-informed self-directed app, draws upon psychoeducation and self-help to target relapse in early psychosis (Bucci, Barrowclough, et al., 2018). Early evidence demonstrates that it is feasible, acceptable, and safe, and a large multisite trial is currently underway (Bucci, Barrowclough, et al., 2018). Another, HelpID, is a self-directed digital intervention that aims to target depression and positive symptoms in psychosis (Moritz et al., 2016). It incorporates belief testing, psychoeducation, strengthening social relationships, attention strategies, and relapse prevention exercises. A small randomized controlled trial (RCT) demonstrated that the intervention helped reduce depressive symptoms posttreatment compared to a wait-list control (Moritz et al., 2016). An app-assisted CBTp intervention has also been developed for negative symptoms in psychosis and examined in a small feasibility RCT, which was found to have high retention and a reduction of experiential negative symptoms (Granholm et al., 2020). Another app-based intervention is SlowMo, a digital intervention delivered by a trained therapist which targets the “fast thinking” reasoning style, often associated with paranoia (Garety et al., 2021). It aims to increase a person’s awareness of their thinking biases and increase belief flexibility. The app includes psychoeducation, vignettes, games, and strategies to increase belief flexibility. A large multisite trial (n = 361) was recently conducted but demonstrated that SlowMo did not reduce paranoid thoughts compared to treatment as usual at 24 weeks (Garety et al., 2021).

Service user perspectives on digital interventions for psychosis have identified key facilitators and barriers to the implementation of digital CBTp interventions. A qualitative study conducted by Bucci, Morris, et al. (2018) (with n = 21 early intervention in psychosis service users) identified that digital interventions were progressive, modern, and largely supportive; however, concerns regarding digital exclusion, privacy, and data security were also identified. Advancements in technology may improve access to CBTp across mental health services in the future; however, the evidence base is still developing and further large-scale trials are required.

Future Directions

It is becoming increasingly acknowledged that further work is required to ensure that CBTp is appropriately adapted to meet the needs of certain populations. It is now widely acknowledged that CBTp needs to be more accessible to those from racialised minorities. Some initial work has been undertaken to examine the usefulness of culturally adapted CBTp models, but more is required to ensure that CBTp is culturally competent (Habib et al., 2015; Rathod et al., 2019). There is also limited evidence for the usefulness of CBTp for older adults and adolescents. Therefore, further trials of CBTp for these populations are required (Mander & Kingdon, 2015).

Considerable work needs to be undertaken to ensure that CBTp is disseminated and accessible to everyone rather than just to a small percentage of people who currently have access. Further research needs to be undertaken to explore structural barriers and implementation challenges and to identify initiatives to overcome these impediments. For example, CBTp could be delivered as a low-intensity intervention using psychology graduates (i.e., assistant psychologists) to those with less complex needs (Hayward et al., 2020).


In summary, CBTp has a robust evidence base demonstrating small to medium effects in improving outcomes for people with psychosis, particularly positive symptoms (Bighelli et al., 2018). Service users have reported that CBTp is a useful intervention that helps them understand and normalize their experiences of psychosis and find ways to cope, but further research is needed to understand the adverse effects of CBTp. The evidence base for digital CBTp interventions is also emerging and may assist with wider dissemination of CBTp, but further large-scale research is needed to determine its effectiveness. CBTp needs to be suitable and accessible to everyone; therefore, future research needs to explore its usefulness with older people, adolescents, and those from racial minorities.


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