Psychological Interventions for People Distressed by Psychotic Experiences: Encouraging Debate

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Today a landmark study has been published on the efficacy of psychological interventions for people distressed by psychotic experiences such as hearing voices or profound fears about their safety. This ‘network meta-analysis’ (NMA), published in World Psychiatry, was prepared by a group of authors more commonly known for their influential Lancet meta-analyses on antipsychotic and antidepressant medication efficacy. NMA represents an important new approach to evidence synthesis. Its principal advantage over more traditional meta-analysis is that it allows for conclusions to be drawn about the relative efficacy of treatments that have yet to be compared directly in randomised controlled trials. The underlying logic is that if intervention A has been compared to intervention B, and intervention B has been compared to intervention C, then we might be able to use this data to make claims about the differences between interventions A and C.

The debate about the effectiveness of psychological interventions for psychosis, in particular cognitive behavioural therapy (CBT) has been heated and fractious. In recent years a group of researchers who are known to be highly vocal in their animosity towards these interventions published three traditional meta-analyses, where they concluded that CBT did not work for psychosis when examined in trials where those assessing participant progress were ‘masked’ to which group they were in. Indeed, one of these authors – Keith Laws, a Professor of Neuropsychology at the University of Hertfordshire – took the unusual step of calling for CBT to no longer be offered to people distressed by their psychotic experiences.

However, the authors of this new NMA are themselves regarded as neutral in this debate. Moreover, their paper represents the largest synthesis of evidence since the NICE guideline on schizophrenia was published in 2008. It included 53 RCTs and data from over 4,000 people with psychosis. Unlike almost all previous researchers, critics and non-critics alike, these authors pre-registered their meta-analysis in the public domain, thus reducing the risk of their own biases influencing their methods or interpretation.

They found that CBT did help to “reduce the positive symptoms of psychosis”, regardless of whether usual care or non-specific ‘supportive therapy’ was the control condition. Most importantly, they did not find that the apparent efficacy of CBTp was simply a consequence of assessor bias or researcher allegiance. Overall, their work means people distressed by psychotic experiences and their clinicians can now be confident that CBT represents an effective and acceptable non-pharmacological approach to helping with distressing experiences such as intrusive voices and persecutory fears.

We suggest there now ought to be an important debate as to why those who have been highly critical of CBT for psychosis found such a different result to the present authors, and whether this has led to people who are distressed by experiences such as hearing voices or other experiences of psychosis being less likely to have been offered an effective intervention for several years as a direct consequence.

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Peter Kinderman is Professor of Clinical Psychology at the University of Liverpool, an honorary Consultant Clinical Psychologist with Mersey Care NHS Foundation Trust, and former President of the British Psychological Society. His research interests are in psychological processes as mediators between biological, social and circumstantial factors in mental health and wellbeing. His most recent book, ‘A Prescription for Psychiatry’, presents his vision for the future of mental health services. You can follow him on Twitter as @peterkinderman.

3 COMMENTS

  1. I suppose the obvious reason why authors might be highly critical of CBT for experiences that get called “psychosis” is that it’s the mainstay of all the “mental disorders” – the quintessential “abnormality”. There are those that believe the survival of psychiatry as a medical discipline depends on there being persuasive arguments for the concepts of “abnormality” and “mental disorder”. If “psychosis” can be treated effectively without drugs, the prize horse is leaving the stable. A lot of individual psychiatrists have been completely de-skilled and only know how to diagnose “mental disorders” and prescribe drugs. So there would potentially be a huge motivation to try and stop people receiving CBT for “psychosis”. I don’t know how meta-analyses are constructed, but I do wonder whether the methods of their study ‘against’ CBT held up to critical analysis?

    I do agree with the comment above that CBT isn’t the way for everyone – also about medicalised language.
    Metaphor and personal meaning can make more sense of things. But that being said, I’ve come out of “psychosis” really quickly just by being around people I could trust. Or by accepting that what I was experiencing wasn’t “real” and then training my brain back on “real” – or more mundane interpretations of the world. So I can see how CBT might bring someone out of a “psychosis” mindstate – but would it help with making sense of why it happened, so those aspects of a persons subjective world can be resolved without having to enter the “psychosis” mindstate again in the future?

  2. Here’s an example of using Personal Construct Psychology in a real world setting. The easily medicalised CBT was not needed…

    https://www.academia.edu/37156309/Personal_Construct_Psychology_for_Hearing_Voices

    Full article in here pages 10-13:

    https://issuu.com/juliecrompton/docs/july_18_mag_webversion

    Using metaphor can be useful…

    https://www.academia.edu/15367587/A_Community_of_Voices

    Why not just not use medicalised language like ‘interventions and treatments’? Just a thought…

  3. Thanks for this and its great we now have the mad in America resource UK specific!

    It would be great to see a much wider debate about talk therapies in general – the quality of the research and appropriateness of RCT’s in trying to assess something as vague and complex as we humans.

    After having worked for many years in the mental (ill) health system I find I constantly question just what it is we think we can do for people in distress? – especially in what is often short term therapy.

    This is highlighted by the forever rising rates of distress/suicide/misery in the face of more and more ‘treatment’s’. Treatments that mostly locate suffering within the person rather than seeing distress as a normal reaction to distressing experiences outside of ourselves.

    Another interesting article on this site by Alec Grant speaks to the huge issue of uncritical acceptance of current paradigms of care – This is also a huge issue in talk therapies most often because staff are suffering from varying degrees of burnout from the relentless pursuit of meaningless targets – eg people ‘scoring below clinical’ on empty measures like the PHQ9 – critical reflection or even basic reflection on current cases is becoming almost impossible beyond the usual monthly one hour of supervision – and this is basically an echo chamber for learning to trust the model rather than question its validity and what it can realistically achieve.

    How do we question self interest not just of our own wants and needs, mortgage repayments etc but also of the competing therapy schools and the all powerful business model slowly taking over earth?

    When do we look outside of ourselves and stop reducing the irreducible down to some trigger for a hypothesized internal fault?

    Its amazing to me that something so obviously limited as talk therapy and or prescribed drugs etc can be dressed up, promoted and sold for so long and so powerfully.

    I wonder Peter what are your thoughts about the critics on the research – this is one https://www.youtube.com/watch?v=Cu5CxJnZqGs&t=1858s