There are numerous psychological approaches to psychosis that differ in focus, specificity and formats. These include psychodynamic, humanistic, cognitive-behavioural and third-wave-approaches, psychoeducation, various types of training-based approaches and family interventions.
We briefly describe the main aims and focus of each of these approaches, followed by a review of their evidence-base in regard to improvement in symptoms, relapse and functioning. We conducted a systematic search for meta-analyses dating to 2017 for each of the approaches reviewed. Where numerous meta-analyses for an approach were available, we selected the most recent, comprehensive and methodologically sound ones.
We found convincing short- and long-term evidence for cognitive behavioural approaches if the main aim is to reduce symptom distress. Evidence is also strong for psychoeducative family interventions that include skills training if the main aim is to reduce relapse and rehospitalisation. Acceptance and commitment therapy, mindfulness-based approaches, meta-cognitive and social skills training, as well as systemic family interventions, were also found to be efficacious, depending on the outcome of interest, but meta-analyses for these approaches were based on a comparatively lower number of outcome studies and a narrower selection of outcome measures. We found no convincing evidence for psychodynamic approaches, humanistic approaches or patient-directed psychoeducation (without including the family).
An array of evidence-based psychological therapies is available for psychotic disorders from which clinicians and patients can choose, guided by the strength of the evidence and depending on the outcome area focused on. Increased effort is needed in terms of dissemination and implementation of these therapies into clinical practice.
Meta-analyses show convincing evidence for CBT if the main target is psychotic symptoms. Meta-analyses show convincing evidence for family interventions if the main target is relapse. Effects are promising for ACT, mindfulness-based and systemic approaches, but more research is needed.
The array of effective approaches allows clinicians and patients to select the most appropriate one.
Patients with psychotic disorders often face a diverse and complex set of problems. One part of these problems are the symptoms as such. These include persecutory delusions, hearing
voices and feeling driven, or negative symptoms, such as the loss of drive. Not only do these symptoms tend to cause severe distress (
Since the discovery of antipsychotic drugs in the early 1950s, this help has been primarily pharmacological in nature. Although medication is valuable in the acute phase, the effect
sizes in randomised trials for medication alone are only small to moderate (
The scope of the present review covers the efficacy of different psychological approaches for psychosis offered in combination with pharmacotherapy as reflected in meta-analyses.
A systematic search for methodologically sound meta-analyses via Web of Science, PsycINFO, PSYNDEX, and Medline was conducted to establish a German guideline for the psychological
treatment of schizophrenia and psychotic disorders (
The outcome measures covered include improvement in symptoms (overall symptoms, positive symptoms and negative symptoms), relapse rates and rehospitalisations as well as psychosocial functioning.
Psychological approaches reviewed covered individual and group interventions conducted within in- and out-patient settings. We report the effectiveness of each approach on the basis of randomised-controlled trials that compared the approach either to the usual treatment (TAU; e.g. pharmacotherapy and consultation) condition alone or to a TAU plus an active control condition (e.g. supportive therapy or psychoeducation) at post-treatment and/or at follow-up (ranging from weeks to years). In order to be able to compare the effectiveness of these approaches we focus on comparisons to “any control”, because meta-analyses on approaches which have not been comprehensively investigated often do not differentiate between comparisons to TAU versus active controls. Only effect sizes based on at least two independent original studies were considered.
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,
Beyond the NICE-Meta-Analysis conducted in 2009 our review is based on seven further meta-analyses (
As can be seen in
Meta-analysis | General psychopathology (ES)
|
Positive symptoms (ES)
|
Negative symptoms (ES)
|
Relapse (RR)
|
Rehospitalisation (RR)
|
Functioning (ES)
|
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---|---|---|---|---|---|---|---|---|---|---|---|---|
Post | Follow-ups | Post | Follow-ups | Post | Follow-ups | Post | Follow-ups | Post | Follow-ups | Post | Follow-ups | |
Cognitive-behavioural therapy (CBTp) | ||||||||||||
0.27* | 0.23* |
0.17* | 0.15* |
n.s. | 0.16* |
n.s. | n.s. | 0.76* |
n.s. |
0.20* |
||
n.s. | n.s. |
n.s. | n.s. |
n.s. | n.s. |
n.s. | n.s. | n.s. | 0.50* | n.s. | ||
n.s. |
* |
n.s. | n.s. |
n.s. |
n.s. |
n.s. | n.s. | n.s. |
* a | n.s |
||
0.52* | 0.40* | 0.47* | 0.41* | |||||||||
0.33* | 0.25* | 0.13* | ||||||||||
0.44* |
||||||||||||
n.s. | n.s. |
|||||||||||
0.16* | 0.16* | n.s. | ||||||||||
0.34* | ||||||||||||
Mindfulness-based interventions | ||||||||||||
0.62* | 1.27* | 1.40* | ||||||||||
0.46* | ||||||||||||
Acceptance and commitment therapy (ACT) | ||||||||||||
n.s. | 0.63* | n.s. | 0.41* | |||||||||
n.s. | ||||||||||||
Psychodynamic therapy | ||||||||||||
– | ||||||||||||
Humanistic approaches | ||||||||||||
– | ||||||||||||
Psychoeducation not involving family members | ||||||||||||
n.s | n.s. | n.s. | ||||||||||
n.s. | n.s. | n.s. | ||||||||||
Metacognitive training | ||||||||||||
* | ||||||||||||
0.34* | ||||||||||||
n.s. | ||||||||||||
Social skills training | ||||||||||||
n.s. | 0.37 | n.s | n.s. | n.s. | n.s. | |||||||
post n.s.; follow-up n.s. b | ||||||||||||
* | 0.52* | |||||||||||
n.s. | n.s. | |||||||||||
n.s. | n.s. | 0.27* | ||||||||||
Family interventions OVERALL | ||||||||||||
0.36* | 0.30* | 0.46* | n.s. | 0.26* | n.s. | 0.55* |
0.62* |
0.53* |
* |
n.s. |
0.38* |
|
* | n.s. |
n.s. | 0.78* |
* |
||||||||
n.s. | 0.85 | Combined analysis of relapse and rehospitalisation: post: *; follow-up: n.s. | 0.74 | |||||||||
Family psychoeducation | ||||||||||||
n.s. | Combined analysis of relapse and rehospitalisation at follow-up: 0.48* | |||||||||||
n.s. | ||||||||||||
Family comprehensive programs | ||||||||||||
0.40* | 0.42* | 0.22* |
0.38* | |||||||||
Systemic family interventions | ||||||||||||
Analysis of different outcome measures combined at post: 0.69* and follow-up: 0.69* |
a“any control” was superior to the treatment. beffect sizes based on studies reporting combined analysis of relapse and rehospitalisation only.
Third-wave-approaches are new developments in CBT which emphasise the relevance of acceptance, mindfulness and emotions, the relationship, values, goals, and meta‐cognition
(
In ACT (
Compassion-focused therapy (CFT,
We selected two (
Both meta-analyses revealed no significant effect of ACT, but a significant small effect of mindfulness-based interventions on
ACT showed a significant moderate effect on
The number of
Early psychoanalytic conceptions of psychosis understand psychotic symptoms as a manifestation of the mind being invaded by the unconscious and by dreams (
We identified two meta-analyses. However, both the meta-analysis conducted for the NICE-guidelines (
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 (
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.
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.
Two comprehensive meta–analyses (
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).
A significant small effect on
We identified and included three meta-analyses: the NICE meta-analysis (
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
The
We selected three meta-analyses (
As can be seen in
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 (
As can be seen in
For comprehensive programmes including skill-trainings, one meta-analysis (
For systemic family approaches there was an overall significant effect on all outcome measures combined, without differentiating between the different outcomes (
As has become apparent from this review, there are now a variety of different psychological interventions available, of which the majority have a good evidence base for the outcomes that they focus on primarily. If the aim is to reduce general psychopathology or positive symptoms, CBT has the strongest evidence-base both in terms of the number of studies conducted and in regard to the robustness of effects over follow-up periods. Other approaches, such as acceptance and commitment therapy, mindfulness-based approaches, and meta-cognitive training are also promising for these outcomes. Negative symptoms, however, appear to respond better to social skills trainings.
Family interventions are also well-researched and appear to be effective for a broader array of outcomes, including relapse and rehospitalisation as well as functioning. Within family interventions, the strongest effects are found for a combination of psychoeducative and skill-training with families, although it needs noting that this specific combination was only the focus in one meta-analysis. Systemic approaches are also promising, but more high-quality randomised controlled trials are necessary to ascertain their effectiveness for different types of outcomes. There was no convincing evidence for patient-directed psychoeducation (without family involvement) despite the fact that this approach is widespread. However, it may be more difficult to construct a fair evaluation of this approach in RCTs because any control condition is likely to involve psychoeducation to a certain extent. Psychodynamic therapies and humanistic approaches were also not found to be effective, but more RCTs are required in order to draw definite conclusions in this regard.
No approach has a consistently good evidence-base for the entire range of outcomes investigated. This may be partly due to the fact that different types of interventions have focused on different types of outcomes. For example, family interventions have a traditional focus on relapse, whereas CBT focusses on the positive symptoms. Thus, studies investigating these approaches did not consistently include a wider spectrum of outcome measures. More RCTs focusing on the full spectrum of outcome areas are required in order to understand whether different approaches are truly differentially effective. Also, with the exception of a few large effect sizes for family interventions, the effect sizes were largely in the small to marginally moderate range – and thus no higher than those found for pharmacotherapy. However, all original studies in the meta-analyses included here are based on designs that compare psychological interventions combined with medication to medication alone or to medication combined with an additional control condition. Thus, the effects need to be interpreted as “add-on” effects to medication and cannot be directly compared with the effect sizes for medication. So far, it is unclear whether psychological therapy would fare better or worse without the combination with medication as this question has not been investigated.
The wide scope of interventions reviewed comes at the price of detail. For reasons of space, we did not include the specific search-terms or provide a full account of each of the
meta-analyses excluded along with the reasons for in- or exclusion. Also, we did not report the evidence available for questions regarding specific subgroups, formats (e.g. group
versus individual, short versus long) or settings (e.g. is family intervention more effective when delivered to individual families versus in groups of families). In
The method as such, a summary of meta-analyses, also has its limitations due to the overlap between meta-analyses. Moreover, the differences in methodological rigour, the inclusion criteria, and the classification of therapy approaches (e.g. inconsistency in what is counted as CBT) result in high levels of heterogeneity in the findings and make it difficult to directly compare different meta-analyses. We attempted to control this bias to a certain extent by disregarding meta-analyses with strong overlap or questionable quality. Another limitation is that the focus on meta-analyses does not provide information on psychological approaches, that are not represented well in the meta-analytic literature. Finally, the continuous accumulation of further evidence renders meta-analyses and reviews outdated at an increasing speed and several new ones have been published since finalizing the selection for this overview.
In this context, it is also worth mentioning a recent meta-analysis that also approached the question of the effectiveness of different psychological approaches to psychosis (
The variety of efficacious interventions available for psychotic disorders is reassuring. Unfortunately, however, efficacy studies and clinical guidelines alone do not guarantee the
implementation of evidence-based interventions, in routine clinical practice (
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