Improving psychological therapies for psychosis: exploring the utility and benefit of using metacognitive training within standard psychological care: a case series

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.