An Overview of the Evidence for Psychological Interventions for Psychosis: Results From Meta-Analyses

Description

Cognitive behavioural interventions for psychosis (CBTp) build on the assumption that psychotic symptoms lie on a continuum with normal experiences. They are also informed by research suggesting that psychotic experiences result from normal, though exaggerated, mechanisms of perception and reasoning. This understanding has formed the basis for cognitive models of psychosis. As one of the most influential of these models, Garety, Kuipers, Fowler, Freeman, & Bebbington (2001) postulate that psychotic symptoms develop when stressors overload a person, causing them to have unusual experiences. According to this model, not the unusual experience itself is crucial but its appraisal. A variety of approaches within the CBTp-framework have been described (Fowler, Garety, & Kuipers, 1995; Morrison, Renton, Dunn, Williams, & Bentall, 2004). Most descriptions converge in stressing the importance of building a stable therapeutic relationship through the process of listening and validating, of taking a collaborative approach and of working with an individual case formulation. The use of cognitive and behavioural interventions for working with psychotic symptoms as well as for changing dysfunctional beliefs and interventions to prevent relapse are also essential elements.

Evidence Base

Beyond the NICE-Meta-Analysis conducted in 2009 our review is based on seven further meta-analyses (Burns, Erickson, & Brenner, 2014; Jauhar et al., 2014; Jones, Hacker, Cormac, Meaden, & Irving, 2012; Lutgens, Gariepy, & Malla, 2017; Turner, van der Gaag, Karyotaki, & Cuijpers, 2014; van der Gaag, Valmaggia, & Smit, 2014; Velthorst et al., 2015) selected from a larger pool of 13 meta-analyses.

As can be seen in Table 1, with the exception of the Cochrane-analysis by Jones et al., (2012), the meta-analyses consistently detected small effects on overall symptoms at post-treatment and at various follow-up periods favouring CBTp over TAU. The findings were less consistent, however, when CBTp was compared to active control. The picture is similar for positive symptoms, with Jones et al. (2012) reporting mixed findings, while the other meta-analyses consistently revealed effects in favour of CBTp compared to TAU, both at post-treatment and at follow-ups. Again, the comparisons to active control groups were less consistent. For negative symptoms there were small post-therapy effects (Jauhar et al., 2014; Lutgens et al., 2017) and small follow-up effects (NCCMH, 2014), overall, however, the non-significant findings outweighed the significant ones. Relapse rates, rehospitalisations and functioning were only investigated in two meta-analyses (Jones et al., 2012; NCCMH, 2014), and are based on a smaller number of studies. Neither meta-analysis showed an effect on relapse and the effects for rehospitalisations and functioning were mixed.

Description

Third-wave-approaches are new developments in CBT which emphasise the relevance of acceptance, mindfulness and emotions, the relationship, values, goals, and meta‐cognition (Hayes & Hofmann, 2017). In psychosis, adaptations of mindfulness-based therapy, acceptance and commitment therapy (ACT) and compassion focused therapy (CFT) have been studied most. In order to ease distress and achieve acceptance as well as to support the regaining of control, mindfulness-based interventions for psychosis guide patients to notice sensations and their own emotional and cognitive reactions to them with awareness (Chadwick, 2014). In meditation-based practices, patients learn to observe their thoughts, feelings and symptoms in an accepting and non-judgmental way. Mindfulness interventions for psychosis have been implemented as single treatments (e.g. Chadwick, 2014) or combined with CBT (e.g. Wright et al., 2014).

In ACT (Hayes, Strosahl, & Wilson, 1999) experiential avoidance and cognitive fusion are suggested to be the core processes of suffering. In order to increase psychological flexibility and reduce distress associated with psychotic symptoms, patients are guided to develop a balance between committed value-guided action when solving actual problems and acceptance when control of thoughts and feelings is limited (e.g. in the case of hallucinations). ACT has been adapted for the treatment of psychosis (O’Donoghue, Morris, Oliver, Johns, & Hayes, 2018; combined with CBT, Wright et al., 2014).

Compassion-focused therapy (CFT, Gilbert & Procter, 2006) encourages patients to be more compassionate towards themselves and others while reducing shame and self-criticism. Compassionate mind training includes appreciation and imagery exercises as well as aspects of mindfulness and aids the patient to experience different aspects of compassion in order to promote mental wellbeing. CFT has been adapted for the treatment of psychosis (Brähler, Harper, & Gilbert, 2013).

Evidence Base

We selected two (Cramer, Lauche, Haller, Langhorst, & Dobos, 2016; Louise, Fitzpatrick, Strauss, Rossell, & Thomas, 2018) from an identified pool of four meta-analyses. No meta-analysis reported effects-sizes for CFT based on more than one original study, hence, only mindfulness-based interventions and ACT are reviewed.

Both meta-analyses revealed no significant effect of ACT, but a significant small effect of mindfulness-based interventions on overall symptoms at post-treatment (Cramer et al., 2016; Louise et al., 2018). One meta-analysis analysed the effect at follow-up and reported an even increased effect (Cramer et al., 2016).

ACT showed a significant moderate effect on positive symptoms, but not on negative symptoms at post-treatment ( Cramer et al., 2016).

The number of rehospitalisations was only investigated for ACT, revealing a significant small effect (based on two studies; Cramer et al., 2016). Relapse and functioning were not analysed.

Description

Early psychoanalytic conceptions of psychosis understand psychotic symptoms as a manifestation of the mind being invaded by the unconscious and by dreams ( Federn, 1928/1952). More contemporary approaches underline the importance of early relationship patterns (e.g. Bion, 1962; Winnicott, 1991). Internal representations of experiences with significant others and current relationships are assumed to result in tension and psychotic symptoms are considered as a “constructive” way of dealing with this tension (von Haebler & Freyberger, 2013). Psychodynamic therapy focuses on these processes and helps the patient to gain self-awareness and understanding of the influence of the past on present behaviour and it fosters new positive relationship experiences. An empathic, respectful and supportive attitude allows re-enactment of internalised relational patterns in the therapist-patient interaction (Lempa, Montag, & von Haebler, 2013).

Evidence Base

We identified two meta-analyses. However, both the meta-analysis conducted for the NICE-guidelines (NCCMH, 2014) and the one of the Cochrane Collaboration (Malmberg, Fenton, & Rathbone, 2001) were based on four original studies only. The aggregated data of the two analyses did not indicate significant improvement in overall symptoms, functioning (NCCMH, 2014) or rehospitalisations (Malmberg et al., 2001) in patients treated with psychodynamic therapy compared to any control. The inclusion criteria for the present review were not fulfilled as none of the relevant outcome measures were covered by more than one original study; hence, psychodynamic therapies are not included in Table 1.

Description

In client-centred or humanistic therapy, unconditional positive regard, accurate empathy and genuineness are assumed to help a patient to increase the congruence between the real self and the ideal self (Rogers, Gendlin, Kiesler, & Truax, 1967). Rogers and colleagues’ concept of “actualizing tendency” points to an inherent tendency to achieve personal growth and reach one’s full potential. In this framework psychotic symptoms are understood as a distortion of this actualising tendency. Client-centred therapy focuses on personal experiences, whereas relieving specific symptoms is secondary. Thus, no specific therapeutic strategies have been established for psychosis. However, therapists are recommended to pay particular attention to understanding the client’s perspective, ensuring that the patient is being heard and emphasising the personal relationship (Gendlin, 1962).

Evidence Base

Client-centred or humanistic therapy for psychosis has not been covered in a meta-analysis and the only known RCT dates back to 1967 (Rogers) and did not reveal convincing effects.

Description

To enhance knowledge and understanding of psychosis and to improve coping skills psycho-educational interventions are routinely offered in the treatment of psychosis. Mainly in group format, patients receive systematic and structured information on psychosis and its consequences, early warning signs, triggering and maintaining factors, relapse prevention, and modalities of treatment. Psychoeducation aims to help patients to increasingly take personal responsibility and improve coping skills.

Evidence Base

Two comprehensive meta–analyses (NCCMH, 2014; Turner et al., 2014) that provided sub-analyses on the effect of psychoeducation for patients without involving family members did not show any significant effect of psychoeducation on overall symptoms, positive or negative symptoms (Turner et al., 2014), relapse rates or rehospitalisations (NCCMH, 2014).

Description

From the range of different training-based approaches that cannot be fully covered within the scope of this review, we exemplarily focus on two widely used training-based interventions – one targeting positive symptoms (Metacognitive training) and one primarily addressing negative symptoms (Social skills training).

Metacognitive training (MCT; Moritz & Woodward, 2007) was designed to address positive symptoms in patients with schizophrenia. As cognitive biases have been related to positive symptoms (e.g. jumping to conclusions or externalizing attributional bias, see Garety & Freeman, 1999), MCT aims to extent patient’s knowledge of cognitive biases and to provide corrective experiences. Implementing a wide range of examples and exercises, patients participating in a MCT group training are encouraged to identify and gain insight into these cognitive biases and reduce conviction in delusional ideas. MCT is mainly administered in group format.

Social skills trainings (SST) build on the observation that patients with psychotic disorders tend to show impaired social skills. SST involve therapist modelling and instructing socially confident behaviour in specific situations combined with role-plays. Patients receive supportive feedback from the therapist and video feedback can also be used. During the end of the training that usually takes place in group-format patients are encouraged to practice the newly learnt skills in daily life. A frequently used treatment manual was published by Bellack, Mueser, Gingerich, and Agresta (2013).

Evidence Base for MCT

A significant small effect on positive symptoms was reported in two of three identified meta-analyses on the effect of MCT in psychosis (Eichner & Berna, 2016; Jiang, Zhang, Zhu, Li, & Li, 2015), whereas one did not reveal a significant effect at post-treatment (van Oosterhout et al., 2016). Regarding overall and negative symptoms, relapse / rehospitalisations and functioning no aggregated effect sizes were reported.

Evidence Base for Social Skill Trainings

We identified and included three meta-analyses: the NICE meta-analysis (NCCMH, 2014), the Cochrane meta-analysis (Almerie et al., 2015) and the meta-analysis by Turner et al. (2014). There was no effect of SST on overall symptoms compared to control conditions at post-therapy in any of the meta-analyses, follow-up effects were not reported. There was also no effect in favour of SST for positive symptoms (Turner et al., 2014). For negative symptoms there were significant post-therapy effects (NCCMH, 2014; Turner et al., 2014). A significant follow-up effect for SST versus TAU was found in one meta-analysis (Almerie et al., 2015). For relapse and rehospitalisation, the findings were mixed. There was no significant effect for functioning, neither at post-assessment nor at follow-up.

Description

Interventions that include the family are subsumed under the term “family intervention”. The patient may be included in all, some, or – in some programmes – no sessions. Depending on the approach, a family intervention will involve 12 to 25 treatment sessions during the course of a year or longer and accompany the family through the remission phase. The diverse approaches can be broadly subdivided into psycho-educative family interventions, comprehensive interventions that combine information with problem-solving, social and communication skills, and systemic family interventions.

The psychoeducational approach builds on the observation that patients with psychosis often rely on relatives for support ( Dixon, Adams, & Lucksted, 2000) and the assumption that involved family members thus require information and assistance to cope with the challenges posed to the family system. It thus conveys basic knowledge about psychosis, building on the vulnerability-stress models. It sees psychosis as mental illness and enlists family members as therapeutic agents, taking care not to make the relatives feel blamed (Lucksted, McFarlane, Downing, & Dixon, 2012). It aims to convey the relevance of medical and psychosocial treatment, reduce misconceptions and provide a basis on which to promote the self-management skills, improve family coping and reduce relapse.

The skill-training approach builds on findings showing higher rates of relapse if a patient’s family displays a communication style characterised by high levels of criticism, hostility, or emotional over-involvement (“high expressed emotion”, Butzlaff & Hooley, 1998). It builds on the assumption that problems that arise from caring for a mentally ill family member can be solved if the family develops good problem solving strategies and a supportive way of communicating. The therapist models the verbal and non-verbal communication rules and assists the family to use the communication skills in a series of role-plays. The improved skills are then used to solve practical problems within the family context, using a problem solving approach. A well-established program of this type is described by Falloon, Boyd, and McGill, (1984).

Systemic approaches assume that relationships within the family (or other relevant social systems) influence the feelings, beliefs and behaviour of the “index patient” and vice versa and therefore, that psychotic symptoms may have arisen from specific interaction patterns within the family. The therapy aims to identify and change these patterns in order to reduce symptoms. If, for example, family members have stopped communicating about relevant issues with the patient, the therapist would attempt to re-include the patient in the communication processes. Changes in interactions are promoted by specific systemic questioning and reframing (e.g. Retzer, 2004).

Evidence Base for Family Interventions in General

We selected three meta-analyses (Claxton, Onwumere, & Fornells-Ambrojo, 2017; NCCMH, 2014; Pharoah, Mari, Rathbone, & Wong, 2010) from a pool of four available ones. These did not differentiate between different types of family interventions and thus report omnibus effects, with the bulk of the interventions covered in these analyses being psychoeducational in nature, with or without additional skill training.

As can be seen in Table 1, short-term benefits were mixed, but family interventions demonstrated significant long-term benefits over any control conditions on overall symptoms in any of the three meta-analyses. The effects on positive and negative symptoms were short-term in nature (NCCMH, 2014). For relapse and rehospitalisation the majority of the effects were significant and in the moderate to large range, both at post therapy and at follow-ups, although the long-term effects were non-consistent. Small to moderate effects were also found for short- (Claxton et al., 2017; NCCMH, 2014) and long-term functioning (NCCMH, 2014; Pharoah et al., 2010).

In order to provide a picture on differential effectiveness, we reviewed three additional meta-analyses each focusing on one of the three specific subtypes, psychoeducative family interventions (Lincoln, Wilhelm, & Nestoriuc, 2007), comprehensive programs including skilltraining ( Pfammatter, Junghan, & Brenner, 2006) and systemic approaches (Pinquart, Oslejsek, & Teubert, 2016). Moreover, the NICE meta-analysis (NCCMH, 2014) provided a sub-analysis for psychoeducative interventions that included the family.

As can be seen in Table 1, psychoeducative family interventions demonstrated no significant effect on any of the symptom measures (Lincoln et al., 2007; NCCMH, 2014), but a significant small follow-up effect on relapse and rehospitalisation (combined) in one meta-analysis (ES = 0.48; Lincoln et al., 2007) but not in the other (NCCMH, 2014).

For comprehensive programmes including skill-trainings, one meta-analysis (Pfammatter et al., 2006) demonstrated a small follow-up effect on general psychopathology, relapse and rehospitalisation and a short-term benefit on functioning.

For systemic family approaches there was an overall significant effect on all outcome measures combined, without differentiating between the different outcomes (Pinquart et al., 2016).