Improving psychological therapies for psychosis: exploring the utility and benefit of using metacognitive training within standard psychological care: a case series
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Date
14/07/2022Author
Eliasson, Emma
Metadata
Abstract
Cognitive Behavioural Therapy for Psychosis (CBTp) is currently recommended by National
Guidelines (NICE) as an adjunct to antipsychotic medication. However, access to CBTp
remains generally poor. Moreover, its effectiveness on positive symptoms and other
outcomes including stigma remains modest, highlighting the importance of continuously
improving “gold standard” therapies for psychosis further.
For this project, first a meta-analysis on the correlates of personal stigma in psychosis
was conducted. Stigma was associated with a range of symptoms including positive
symptoms, depression, hopelessness and suicidality. Moreover, stigma was inversely related
to a range of well-being outcomes including recovery, self-esteem and quality of life;
highlighting the importance of routinely offered psychotherapeutic interventions to not only
target symptoms, but to also address feelings of stigmatisation.
One recently developed intervention, with a focus on the cognitive infrastructure
implicated in the formation and maintenance of delusions, whilst also targeting issues of
stigma and self-esteem is Metacognitive Training (MCT). Whereas studies are still emerging,
individualised MCT (MCT+) appears particularly effective in targeting delusional symptoms,
with studies showing both short and long term effects. The second, and empirical part of the
project was therefore to evaluate the benefit of utilising MCT+ within standard treatment
across NHS Lothian, Scotland, in order to evaluate whether MCT can be used to improve
psychological therapies for psychosis further. To do this, a quasi-randomised case series was
conducted, where individuals currently receiving non-structured psychological support or
were on the waitlist to receive CBTp, were invited to take part, and allocated to receive up to
20 sessions of standard CBTp or MCT+.
Study one sought to evaluate whether MCT+ would lead to additional improvements
in delusions compared to CBTp, and to explore potentially differential mechanisms of action
between the two treatment modalities. Data on delusions and self-reported cognitive biases
were collected weekly during a four week baseline period, on a session-by-session basis
throughout therapy, weekly for four weeks after therapy as well as at a follow up session 12
weeks after therapy. Graphical representations of change before, during and after therapy and
multilevel modelling (MLM) was used to analyse data. Out of 19 individuals allocated to
treatment 16 participants completed 4 or more sessions of CBTp or MCT+ and were included
in the analysis. Results indicated comparable reductions in delusions and the jumping to
conclusions bias across both treatment modalities. However, individuals receiving MCT+
also showed reductions in self-reported belief inflexibility as well as the external attribution
bias, the latter of which predicted delusion reduction across sessions. Both treatment
modalities were also associated with improved functioning and reduced general
psychopathology, whereas no significant change in self-stigma was seen.
Study two sought to build on Study one, and utilised thematic analysis to evaluate
qualitative feedback given by patients on their experience of therapy, as well as interviewing
clinicians about the experience of using MCT+ within standard care. Feedback from both
patients and clinicians indicated that MCT+ may be a useful resource that can be feasibly
implemented and effectively utilised in order to maximise access and choice to psychological
treatments for psychosis. Moreover, reflecting the findings of study one, both patients and
clinicians found the material on attribution particularly useful.
Based on the outcomes of this project, it was concluded that whilst MCT+ did not
enhance delusions reduction above standard CBTp, it may be an effective complement to
standard therapy for delusions through its focus on cognitive biases, where MCT elements
focussing on attribution appeared to be particularly useful. Due to its modular structure and
ease of administration, the finding that MCT+ performed similarly to standard CBTp is
encouraging. To build on the current project, future studies should therefore evaluate the
feasibility and utility of implementing MCT within practices where psychotherapy is not
routinely offered such as in psychiatric nursing settings. This is particularly important in
order to increase access to effective psychological support for individuals with psychosis,
who may otherwise not have access to CBTp.