factors in outcome of cognitive-behavioural therapy for psychosis: users' and clinicians'...

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Factors in outcome of cognitive-behavioural

therapy for psychosis: Users’ and clinicians’ views

John F. McGowan1*, Tony Lavender2 and Philippa A. Garety3

1 East Sussex County Healthcare NHS Trust, Eastbourne, UK2 Centre for Applied Social and Psychological Development, Salomons, Canterbury

Christ Church University College, UK3 Guy’s, King’s and St. Thomas’ School of Medicine and Institute of Psychiatry, Kings

College, London, UK

Objectives. Despite increasing evidence to suggest that cognitive-behavioural

therapy (CBT) is helpful for a significant proportion of people with psychosis, only

limited information is available regarding factors implicated in outcome. The present

study investigated factors differentiating outcomes on the basis of accounts from

participants in the therapeutic process.

Method. Four therapists and eight of their clients were interviewed about their

experiences of CBT. Clients were defined as having progressed or not progressed

during therapy. Interview data were analysed using a qualitative ‘grounded theory’

methodology.

Results. A number of major categories differentiated the two client groups, including

ability to let go of distressing beliefs, logical thought, holding therapy, and presence of a

shared goal. Overall, clients who progressed were better able to move into the

therapist’s frame of reference. Therapists and clients also felt that non-specific benefits

accrued from the therapy for both groups.

Conclusion. The results were consistent with previous studies suggesting that ability

to disengage from distressing beliefs is important in therapeutic progression. Reasons

considered for the inability to progress include emotional investment in psychotic

beliefs and cognitive processing. Further research is required to clarify the role of logical

thought and therapeutic alliance in progress and in predicting outcome.

* Correspondence should be addressed to Dr John McGowan, Department of Psychiatry, Eastbourne District General Hospital,

Kings Drive, Eastbourne, East Sussex, BN21 2UD, UK (e-mail: [email protected]).

TheBritishPsychologicalSociety

513

Psychology and Psychotherapy: Theory, Research and Practice (2005), 78, 513–529

q 2005 The British Psychological Society

www.bpsjournals.co.uk

DOI:10.1348/147608305X52559


There is now an accumulating body of evidence to suggest that cognitive-behavioural

therapy (CBT) techniques may be effective in ameliorating the distress of positive

psychotic symptomatology for some individuals (e.g. Drury et al., 1996a, 1996b;

Kuipers et al., 1997; Sensky et al., 2000; Tarrier et al., 1998). However, there is still a

limited amount of data on the factors involved in a successful outcome. All the trials

quoted above have shown a substantial portion of people who failed to respond

significantly (between 27% and 67%). Consideration of why some individuals do not

progress is important for two reasons. Firstly, it is central to the improvement of success

rates, and secondly, considering both successful and unsuccessful therapies may provide

information as to how this kind of therapy actually produces change.

Several studies have attempted to address the issue of failure to progress. Employing

a single case methodology, Chadwick and Lowe (1990) observed that the ability to

question delusions in the face of hypothetical contradiction may be a predictor of

treatment success. A related finding in a case analysis conducted by Sharp et al. (1996)

suggested that improvement in their study was positively associated with the Belief

maintenance factors subscale of the Maudsley Assessment of Delusions Scale (MADS;

Wessely et al., 1993). This measures an individual’s ability to identify internal and

external factors that maintain his or her belief and the ability to hold alternative views. In

a controlled trial of CBT for psychosis, Garety et al. (1997) found the key predictors of a

good outcome were firstly (similar to the observations of Chadwick and Lowe, 1994), a

willingness to admit possibly being mistaken about psychotic beliefs (again based on the

MADS), and secondly, a greater number of recent hospital admissions. Garety et al.

hypothesized that increased hospital admissions might signal increased instability of

psychosis, resulting perhaps in greater opportunity to modify beliefs. This finding,

however, seems atypical, as it is at odds with the results of Tarrier et al. (1998) who

found that a short duration of illness and fewer hospital admissions were significant in

good outcome. It appears therefore that the one consistent factor emerging in positive

outcomes is a willingness to consider alternative explanations for psychotic

phenomena.

The primary goal of the present study was to expand understanding of the

differences in good and poor outcomes in CBT with psychotic symptoms. Studies such

as those of Garety et al. (1997) have been reliant on anticipating which factors might

affect outcome and rating their influence on them at completion of therapy. This study

took the different approach of asking individuals who had already participated in CBT

(with differing outcomes) for their reflections on the process in an interview. The aim of

using this method was to generate new ideas about factors that may be implicated in

outcome.

A secondary goal of the study was to record some of the experiences of service users

who have received this kind of therapy. To date there has been limited consideration of

these types of data for CBT with psychotic symptoms. User perspectives offer another

important element in the evidence-base for these types of therapies (Thornicroft, Rose,

Huxley, Dale, & Wykes, 2002).

John F. McGowan et al.514


As well as the different kinds of information this interview methodology can

produce, it is complementary to other methodologies in that it may provide further

hypotheses on which to base more controlled investigations. Encouragement in the use

of such interview methods comes from the increasing recognition of the usefulness of

qualitative analysis (see Hayes, 1997, for further discussion), which provides rigorous

and systematic means of analysing the content of interview-based data.

Method

Design

The data in this study were collected from participants in eight therapeutic dyads who

had been involved in using CBT methods to treat psychotic symptoms. Accounts of the

experience of such therapy were collected through individual interviews with

therapists and two of each therapist’s clients: one who had progressed in therapy and

one who had failed to progress.

The data generated by the interviews were analysed using a grounded theory

methodology (Charmaz, 1995; Strauss & Corbin, 1998). This provides strategies for

developing categories and theories ‘grounded’ on a fine-grained consideration and

coding of small units of data, such as lines, and then building these into higher-order

categories to describe the main themes emerging from the data. This process leads to

the development of a central thematic framework to describe the data.

Participants

Four therapists who used CBT to treat psychosis and eight of their clients were the

participants in the study. The study employed purposive systematic, non-probabilistic

sampling (Mayes & Pope, 1995). The purpose of this was to identify potential

participants who possessed characteristics relevant to the purposes of the investigation,

rather than to select a random or representative sample.

Selection criteria

Therapists who had conducted CBT for psychotic problems were selected on the basis

that:

(1) they had completed formal training in CBT and received further training and/or

supervision in using CBT for psychosis;

(2) they were able to suggest two clients they had seen in therapy who conformed to

the client selection criteria (see below);

(3) they were willing to have their interviews and interviews with their selected

clients audiotaped.

Clients who were willing to participate were selected according to four criteria:

(1) they had at least one positive symptom of schizophrenia according to DSM-IV

(American Psychiatric Association, 1994);

Cognitive-behavioural therapy for psychosis 515


(2) they had received treatment for their psychotic symptoms using CBT methods

with an appropriately qualified therapist;

(3) their outcome in therapy was defined as having either ‘made significant progress’

or ‘failed to progress or worsened’;1

(4) they had either completed therapy within 3 months of the interview or, if the

therapy was not over, they had (in the opinion of the therapist) completed

‘substantive work’.2

All four therapists (designated T1, T2, T3, and T4) were clinical psychologists. Three

therapists were employed in community rehabilitation services and one therapist was

employed in an acute psychiatric ward setting. To verify that the therapy given

conformed to a recognized CBT framework, each therapist confirmed that they based

their treatment on the practice manuals of either Chadwick, Birchwood, and Trower

(1997) or Fowler, Garety, and Kuipers (1995).3

The details of clients in the progressor (P) and non-progressor (NP) groups are

provided in Table 1. All were taking antipsychotic medication which had been varied

during the period of treatment. All participants had received therapy as out-patients with

the exception of P4 and NP4 who were seen in a ward setting. No information was

collected on clients previous experiences of psychological therapies as clear records

were not available for all and systematic consideration of this variable was unlikely to be

possible.

Procedure

The client participants were informed that the study was an investigation into

experiences of psychological therapy. They were not informed that the purpose of the

study was to consider CBT for psychosis as the intention was to elicit individuals’

interpretations of their experiences rather than imposing concepts on them.

All interviews were conducted by the first author. Interviews with clients took

between 40 and 50 minutes and interviews with therapists (during which they

discussed both clients), took between 60 and 75 minutes. Interviews were audiotaped

and literal transcription of the recordings was undertaken by the first author.

1Originally it was intended that the judgment of progress in therapy would be made on the basis of questionnaire outcome

measures. However, in practice no such measures were available for any of the clients considered. The assessment of outcome

was therefore made in the judgment of the therapist concerned.2Outcome implies a finished therapy. However, in practice, as a number of such clients are seen on a long-term basis,

stipulation of finished therapies proved impractical. Judgment of ‘substantive work’ was again a matter for the therapist.

Because of the highly variable nature of therapies on offer in clinical settings no minimum or maximum length of therapeutic

contact was stipulated for those who had progressed. Those who had failed to progress were required to have had a minimum

of 12 sessions.3 As a retrospective study it was clearly difficult to exercise further quality control measures relating to the therapies

(which were clinically rather than research driven). Accounts of the therapies provided in the Results section do offer some

insight into the kinds of techniques and interventions employed which did conform to a number of recognized CBT standards.



The interview timetable

The interviews were based on semi-structured schedules with parallel questions for the

therapists and clients. Items in the interview schedule were intended to elicit reflections

from therapists and clients in the following areas:

. the circumstances which led to the therapy;

. expectations of the therapy and what took actually place;

. what the client found helpful and less helpful about the therapy;

. the therapeutic alliance between therapists and clients (including prompts on

trust, confidence, and a sense of shared goals);

. understanding of the therapeutic techniques employed;

. current well-being.

Table 1. Client characteristics

Client Therapist Age Sex Therapy complete Background

P1 T1 42 M Y Weekly therapy for 18 months. Primary

symptoms: auditory hallucinations

experienced over an unknown period.

P2 T2 37 M Y Weekly therapy for 1 year. Primary symptoms:

auditory hallucinations for 15 years.

P3 T3 44 F N Weekly therapy for 8 months. Primary

symptoms: persecutory delusions

for 3 years.

P4 T4 36 F Y Six sessions over 4 months. Primary

symptoms: persecutory delusions over a

10-year period.

NP1 T1 40 M Y Weekly therapy for 1 year. Primary symptoms:

auditory hallucinations for an unknown

period.

NP2 T2 38 M N Weekly and fortnightly therapy for 18 months.

Primary symptoms: auditory hallucinations

and disturbing memories over

approximately 12 years.

NP3 T3 37 F N Weekly and fortnightly therapy for 1 year.

Primary symptoms: grandiose delusions and

auditory hallucinations for approximately

20 years.

NP4 T4 26 F Y 12 therapy sessions over 5 months. Primary

symptoms: persecutory and grandiose

delusions for approximately 6 years.



Methodological quality controls

Papers addressing this area (e.g. Elliott, Fischer, & Rennie, 1999; Mayes & Pope, 1995;

Stiles, 1993) have suggested that verifying the reliability of observations and the validity

of interpretations are of central importance in conducting rigorous qualitative research.

The present study employed a number of recognized measures to control subjectivity

and enhance transparency in these areas. These included: using several data sources, the

‘grounding’ of ideas in a fine-grained analysis of the data, inter-rater reliability and

respondent validity studies of the final analysis (both of which are reported in the

Results); and auditability of the analysis via regular peer review during the study, and via

illustrative quotations reproduced below.

Results

In view of the large volume of data, the analysis reported here concentrates on

categories that clearly distinguished between the P and NP.

Main categories emerging from the data

Six main category headings were developed to capture the major observable areas of

difference between the two groups. Subcategories are also described.

Category 1: Definitions of progress

A central concern was to consider the criteria by which the therapists had selected

people for these groups. Examples of subcategories identified from descriptions are

provided in Table 2.

It is clear that therapists’ accounts indicating progress in CBT terms (i.e. referring to

areas specifically targeted by CBT for psychosis such as changed beliefs about symptoms

and reduced distress) was applied only to the P group, whereas descriptions indicating

failure to progress was applied to the NP group. The interviews with clients supported

Table 2. Category 1: descriptions of progress or failure to progress in CBT terms

Subcategories P Group NP Group Sample quotations

Changed interpretation

of symptom

4 – T2 on P2: ‘a shift in P2’s understanding of his

difficulties to an explanation that seemed less

distressing for him.’

P4: ‘She was helping me to perceive things in

a different way’

Reduced distress relative

to symptom

2 – T2 on P2: ‘He seems to have more of an under -

standing of these experiences : : : that is less

frightening to him.’

No changed interpretation

of symptoms

– 3 T2 on NP2: ‘We haven’t managed to change how he

sees it.’



what the therapists said, as three of the clients from the P group described their success

in terms of changed understandings.

It is important to note that descriptions from both therapists and clients also indicated

non-model-specific benefits of therapy for both groups. Among the factors mentioned

most frequently was the importance of having difficult experiences listened to and taken

seriously. It is also important to emphasize that the picture of the experience of therapeutic

contact that emerged from clients’ descriptions was broadly extremely positive.

Category 2: Moving to new and disregarding old understanding

Quotations relating to this issue suggested that the changed interpretations described

above had two components. The first of these was a new understanding. However, three

members of the NP group did appear to have a new understanding in the sense

(following therapy) that they were already able to describe an illness model of their

symptoms that they had not been able to describe before (as opposed to, for example, a

supernatural model). This suggests that the second component of a changed

interpretation is the ability to move on from an old understanding (Table 3).

All four of the P group included instances of one explanation supplanting another

(in each case lowering distress). No such evidence was found in the therapists’

Table 3. Category 2: descriptions on ability to move on from a distressing understanding.


One explanation

superseding another

2 – T2 on P2: ‘when I first started to see him

[he had] a vaguely supernatural

explanation. He’s ended up with more of

an illness model.’

Eliminating other

explanations

1 – P1: ‘by a process of : : : elimination: : : I

eliminated Satan and said it was

telepathy and: : : I thought it was a trick

of the mind.’

Holding two

explanations

simultaneously

– 2 T1 on NP1: ‘he’s quite happy with this twin

track explanation that what the problem

is that he has a mental illness and there

are evil spirits attacking him.’

Sliding into other

multiple explanations

– 2 T2 on NP2: ‘he didn’t have one kind of, or

even two, definitive explanations for his

experiences: : : There’s this kind of

whole range of possible explanations and

any attempt to sort of pin them down

was really completely unsuccessful. He’d

slide off into another explanation.’



descriptions of the NP group. On the contrary, therapists’ understanding of the NP group

suggested that these clients were failing to move beyond distressing explanations.

The accounts suggested that this happened in a number of different ways. For example,

the therapist’s description of NP1 implied that this client was capable of holding

views that appeared contradictory without feeling they were contradictory

(e.g. a supernatural model and an illness model). The therapist’s account of NP2

suggested a fluid movement between different sets of psychotic beliefs or views of

reality that were not controllable.

Category 3: Ability to engage in clear, logical thinking

This category referred to material in accounts (predominantly from therapists),

concerned with the importance of the clarity of clients’ thinking in making progress in

therapy. The views of therapists are supported by illustrations of clear and unclear

thinking in the clients (see Table 4).

All accounts suggesting reflective or logical thinking applied to clients in the P group

and no descriptions of equivalent clarity of thinking were provided in descriptions of

the NP group. As well as the value of clarity of thought, two of the therapists talked

about the value of them being able to help the client in the P group think more clearly.

Table 4. Category 3: discourse on ability to think reflectively


Using therapist to aid clarity of thought 2 – T1 on P1: ‘And yet there was a

sense in which the way I was

there was almost as a kind of

cognitive prosthesis. That I was

doing the thinking for him and he

could attach my thinking to his

thinking’

Clear thinking aiding understanding 1 – T2 on P2: ‘at times when his

thinking is clearer he can also

understand it in terms of a kind

of stress/vulnerability interaction.’

Inability to think logically enough – 1 T2 on NP2: ‘Reflecting on your

experiences for cognitive therapy

requires some capacity to kind of

think through things at kind of

semi-logical level anyway: : : And

I just really didn’t think NP2 could

do that.’



Category 4: Continuity in therapy

This category provides an understanding of the language used (again predominantly by

therapists) concerning the ability of clients to work with a measure of continuity from

session to session (Table 5).

Three of the clients in the P group showed an ability to work on themes over a period

of weeks in therapy. Two of the clients in the NP group were described in completely

opposite terms as being unable or unwilling to work in this way. A more severe difficulty

emerged from T2’s account of NP2, which suggested that such continuity was initially

extremely difficult because the client could notmaintain the idea that she (the therapist),

was a permanent object who would return.

Category 5: Remembering and understanding therapy

The previous category ‘continuity in therapy’ was supported by Category 5, which

emerged from the accounts given by clients relating to their ability to elaborate on

elements of their therapy (Table 6).

It can be seen that three of the clients in both groups were able to identify particular

suggestions made by the therapist. However, a clear distinction between groups was

observed when it came to the understanding of how they had been helped. Three

clients in the P group were able to operationalize the change clearly (i.e. say what it was

and how it worked, rather than just saying that the therapy or elements of it were

helpful in an unspecified way). Failures to provide evidence of meaningful of change

were a feature of the language used by two of the NP group.

Table 5. Category 4: descriptions on continuity in therapy


Continuity in therapy 3 – T1 on P1: ‘He remembered things I was

saying and considered them between

times.’

Absence of continuity – 2 T1 on NP1: ‘It was always my experience

that he would change his tune. Simply

forgetting something that was blatantly

obvious in the previous session. And it’s

almost as if every session is new ground.’

Discontinuity in client’s

experiential world

– 1 T2 on NP2: ‘It’s only relatively recently after

a year and a half of working with him

that he thinks I might come back.

Previously he thought that a missed

session was me gone. And he would be

really quite shocked when I returned.’



Category 6: Therapeutic alliance-shared goal

There was some suggestion (in therapists’ accounts particularly) that there was a

difference between the two groups of clients in terms of sense of a shared task or shared

goal in therapy (Table 7).

Table 6. Category 5: descriptions illustrating remembering and understanding therapy


Operationalizing a change 3 – P3: ‘I feel I have a terrible

problem with not being able to

motivate myself to get things done.

And she suggested to me that

maybe it was because my standards

for myself were too high and

that had never occurred to me.’

Failing to operationalize

the idea of helpful

– 3 NP1: ‘NP1: [A book on voices] was

a in certain way beneficial

I: Could you tell me how it helped?

NP1: It was helpful, helpful.’

Table 7. Category 6: descriptions on shared task in therapy

Subcategories

P

Group

NP

Group

Sample

Quotations

Clear description of

shared task

3 1 T1 on P1: ‘He walked the walk. It was clear

that he was thinking things in between

times and he knew why I was there and

roughly the focus of what we were doing

and why I was asking those questions.’

No sense of shared task – 2 T1 on NP1: ‘Despite my continued asking

of him of what he wanted, I felt that he

was talking the talk: : : it wasn’t

necessarily an alliance in that sort of

mutual sense that both of us knew that

there was work to do.’

T4 on NP4: ‘I think she did things because

she felt they were the polite thing to do.’

Difficulty of sharing task

with client

– 1 T2 on NP2: ‘I think with NP2 it’s more

difficult because the: : : task is really

rebuilding him, his sense of himself and

therefore other people. And if someone

already has fundamental difficulties in

those areas its pretty hard to actually say

explicitly that that’s what you think the

work is.’



It can be seen from Table 6 that with three of the P group and one of the NP group

therapists understood that there was a clear shared task. However, there also appeared

to be circumstances where therapists felt that there was less sense of a shared task with

clients (all of whom were from the NP group) and, in the case of NP2, the impossibility

of truly sharing the real work of therapy with a client with a complex psychotic

experience.

The suggestion that a shared task was not always present in the NP group was borne

out by the accounts given by the clients from that group. It can be seen that NP2

signalled that he had a different agenda in therapy, which perhaps was not being

addressed. A further difficulty was signalled by NP4who, at points, had incorporated the

therapist into her delusional system (as an agent of the IRA whom she felt were

persecuting her). Such an incorporation implies a fundamental breakdown in having a

shared task or agenda.

Central theme: understanding, holding and engaging with the therapist’s model

of reality

A feature of the grounded theory methodology is the focus on a central theme emerging

from the categories. The clearest theme emerging from the six categories was a

pronounced difference between the two groups in understanding, holding, and

engaging with the model of reality offered by the therapist. Engaging with the therapist’s

model of reality appears to be contingent on leaving more distressing explanations

behind. Progression also appeared to be related to a clarity and logic in thought

processes required by the therapy and actually sharing the same goal in the work.

A number of these elements of sustained holding, engaging, and ultimately, change are

encapsulated in the description given by T1 of P1 shifting towards a different

(and ultimately less distressing) view of his difficulties:

Table 7. (Continued)

Subcategories P

Group

NP

Group

Sample

Quotations

Client has different agenda – 1 NP2: ‘I: Are you focused on the same stuff

or is she going different ways from you?

NP2: Well this is where I feel that my

therapy could take a new direction: : : I

feel. It could be that my therapy needs to

be taken much more seriously.’

Therapist becoming incorporated

into the delusional system of

the client

– 3 NP4: ‘But then I thought that maybe she

was only pretending to phone the police

and that maybe she was involved in the

IRA as well.’



T1 on P1: we were able, during the 5 months that I saw him, to construct an experiment

which was good enough: : :We figured out what it would mean to him if it went either way,

in which he attempted to communicate something to the deputy manager of the house by

telepathy who reported back to P1 that he’d heard nothing, didn’t know what P1 was

thinking. And then P1 was instantly convinced that telepathy was not happening.

Inter-rater reliability (IRR)

An independent rater was asked to classify 15 sample quotations into the six main

category headings without knowledge of the categories assigned by the investigators

(main-category IRR). Then the rater was asked to classify a body of 110 quotations into

the subcategories listed in the tables above, again without prior knowledge

(subcategory IRR). Inter-rater reliability was calculated using Cohen’s kappa (k). Values

were interpreted according to the classification of strength of agreement provided by

Landis and Koch (1977). The k value for the main category IRR task was .68 (equalling

‘substantial’ strength of agreement). Kappa values for the subcategory IRR task are

reproduced in Table 7. As can be seen, k values ranged from substantial to perfect

(Table 8).

Respondent validity

Three of the original participants were interviewed again between 6 and 8 weeks after

the original interviews, and asked to give their views on the category scheme.

One participant was drawn from each of the three groups (T2, P3, and NP3). They were

asked to rate the six main categories produced as either distinguishing between people

who progress and do not progress in CBT for psychosis (in the therapist interview), or as

important in their own experience (in the client interviews), using a 5-point Likert scale

(from 1 strongly disagree to 5, strongly agree). The ratings produced a high level of

agreement with the categories produced in the analysis with all three respondents rating

agreement with each category as either 4 or 5.

Table 8. Kappa values signalling inter-rater reliability in subcategory IRR task

Main Categories

k and strength of agreement for

Subcategory IRR)

Definitions of progress .85 (almost perfect)

Being able to move clearly to

new interpretations while disregarding old ones.

.67 (substantial)

Ability to engage in thinking logically

or reflectively

1 (perfect)

Continuity in therapy 1 (perfect)

Remembering and understanding therapy 1 (perfect)

Therapeutic alliance-shared goal 1 (perfect)



Discussion

The central question posed in this research related to observable differences in accounts

of the therapies of individuals who progressed or failed to progress in CBT for psychosis.

The categories described in Results suggest that there were indeed such differences in

several areas: in terms of outcomes, in terms of ability to disregard psychotic

understandings of symptoms, in terms of clear reflective thinking, in the continuity in

therapy and remembering and understanding the work, and in developing a shared goal

in the therapy. Overall, the results suggested that failure to progress was related to a

difficulty in entering the therapist’s frame of reference.

Four points appear important when considering the first category of the results,

definitions of progress of success. Firstly, the study contributes on a small scale to the

increasing evidence base for CBT for psychosis, helping to confirm that, for some

individuals at least, CBT is clearly useful. Secondly, all therapists defined progress in CBT

in relatively homogeneous terms. Thirdly, both therapists and clients described benefits

of therapeutic contact outside strictly CBT criteria for both groups. Fourthly, as

consideration of the perspective of clients on CBT for psychosis has been limited, it was

also of importance in the present study that these judgments of success and benefits

made by therapists were not one-sided.

Turning to the second category of the results, moving on from distressing

understandings, the results of the present study relate closely to the published literature

on factors that appear to predict progress in therapy. As discussed above, earlier

investigations (e.g. Chadwick & Lowe, 1990; Garety et al., 1997) observed that the

ability to entertain alternative explanations that contradict psychotic understandings

was the most effective predictor of treatment success. While retrospective rather than

predictive, the observation that those classed as non-progressors in the present study

had difficulty disregarding distressing psychotic beliefs (rather than just entertaining

other potentially less distressing beliefs) may be related to this predictive variable.

However, the present study indicates that a slightly different emphasis is important:

namely that in CBT it is the realization of being mistaken and a concomitant letting go of

the distressing belief that is important, as well as contemplating alternatives.

The category clear, logical thinking may also relate to the predictive variables

suggested by Chadwick and Lowe (1994) and by Garety et al. (1997). One way to define

clarity of thinking is to suggest that someone is able to perceive the contradictory nature

of two apparently opposed beliefs. By this standard the NP group were less logical in

terms of their thinking. However, it is also important to note that none of the outcome

studies have found any measures of logical thinking to predict outcome.

If measures of logical thinking do not predict outcome this contrasts with the

apparent importance of logical or reflective thinking in the present study. The issue of

how logical thought relates to progress signals two important limitations of the present

findings. Firstly, within this study the definitions given of logical or reflective thought

were far from precise and it is possible that therapists were talking about something



different from the kinds of factors measured by previous controlled trials. Secondly, the

retrospective methodology raises the issue that the development of logical thought may

be something that actually emerges during therapy rather than being a capacity present

at the beginning. Predicting who will be able to think clearly enough to progress at the

beginning of therapy may require experimentation with a range of pre-treatment

measures.

The issue of holding of therapy (i.e. remembering from session to session) does not

find any reference in the CBT psychosis literature. It is logical, however, that those who

are able to hold the themes of therapy over the weeks may be more likely to progress

(or perhaps that progression may lead to greater understanding). The remembering, and

particularly the understanding, of therapy also appeared to distinguish between the

P and NP group. As with the previous categories, it is not possible to ascertain whether a

capacity to understand and remember was something that distinguished the groups at

the beginning of therapy or whether this was something that emerged during the

therapy.

The finding that there may not always be a shared goal in the case of the

NP participants is a novel one in this field. The development of a shared goal is an

important feature of therapeutic alliance (e.g. Agnew-Davies, Stiles, Hardy, Barkham, &

Shapiro, 1998). None of the main outcome studies in this area have investigated the

association between therapeutic alliance and outcome. However, a meta-analysis of the

research literature on therapeutic alliance and outcome in a range of therapies by

Hovarth and Symonds (1991), suggested that up to 30% of variability in outcomes for

psychological therapies could be accounted for by quality of therapeutic alliance. It is

unsurprising therefore that this factor emerged from the present study.

The results of the present study suggest a number of areas of relevance to the clinical

practice of CBT with psychosis. These apply to two areas in particular: how change is

achieved and how success rates might be improved. In terms of how change is achieved

(or not), the accounts of the therapeutic process in this study provide an enhanced

picture of what occurs in this kind of therapy. Considering the issue of moving on from

distressing understandings as an example, the implication of the literature to this point

has been that new understandings are central to success. However, the present study

emphasises the need for work in understanding and changing existing distressing

understandings as distinct from providing new understandings (i.e. recognizing that

acquisition of the latter does not necessarily lead to the former).

Other issues emerging from the study included the value of aiding logical thinking

and developing a shared goal. On this point it is important note that the CBT literature

emphasises flexibility in maintaining therapeutic alliance and developing shared goals

and joint understandings (e.g. sharing a focus on distress and making suggestions of

reinterpretation from ‘within’ some of the realities assumed in a delusional system).

The NP participants in the sample do highlight, however, that these kinds

of presentations may present particular difficulties in developing shared goals (e.g. the

therapist being incorporated into a delusional system). Related to this point are



the possible non-CBT-specific benefits of therapeutic contact mentioned in the study. In

the absence of clear shifts in interpretations from clients, the importance of such

non-specific elements may be easily underrated.

While the present provides some possible understanding of how change is achieved,

asking how success rates might be improved raises two further questions: why do some

people find it so difficult to shift and how is change achieved with such individuals?

The therapists interviewed described various issues that they felt were relevant to

helping clients who appear unable to move. For example, T3 suggested that NP3 might

have a powerful emotional investment in his beliefs and that this impeded progress. This

argument is related to the views put forward by Bentall, Kinderman, and Kaney (1994)

and by Trower and Chadwick (1995) that delusions (particularly of a persecutory type)

may be constructed to defend aspects of the self from a sense of insecurity or alienation.

It is possible that this kind of ‘delusions as defence’ model, rather than being implicated

in all persecutory delusions per se, may be more relevant for a subset of people. It may

be that individuals who are in a position of needing to defend themselves in this way

may find it far more difficult to move away from problematic beliefs in therapy.

Other possible explanations for failure to progress in CBT may concern the role of

cognitive or neurological factors leading to flawed information-processing in psychosis.

Authors such as Frith (1992) and Hemsley (1994) have proposed explanations relating

to poor assessment or regulation of incoming stimuli by attentional processes. There is a

large body of evidence relating such theories to psychosis, which cannot be reviewed

here. However, these types of explanations may also offer a way forward in thinking

specifically about individuals who find it difficult to progress using CBT.

It is clear that considering how to tackle apparent difficulties in making therapeutic

shifts is beyond the scopeof this investigation.However,CBTwouldbenefit fromaclearer

understanding of the reasons why such shifts are difficult. Clearly there does not have to

be a single reason. A combination of the kinds of explanations outlined above is possible.

As discussed in the introduction, one of the central purposes of a qualitative

methodology is to provide ideas for further investigation and this study suggested several.

Firstly, it would be desirable to replicate the main distinguishing categories themselves,

particularly as this study sacrificed breadth for depth and employed a small sample.

Secondly, the possible roles of emotional and information-processing factors may be

worth consideration. Thirdly, while the monitoring of antipsychotic medication was

beyond the scope of this investigation, it is clearly possible that changes in medication

may interact with changes emerging in CBT. Systematic investigation of this interaction

may prove fruitful. A final areawhere results such as thesemay be particularly useful is via

investigations into the possibility that some of the distinguishing features of the groups

(such as capability for logical thinking and ability to develop a shared goal)mayhave some

predictive power in terms of outcome of CBT. This last point is particularly salient given

the retrospective nature of the study and the concomitant lack of information it provides

about capacities thatmay predict progress. However, investigation of such factorsmay be

of great value, especially in controlled studies.



Conclusions

The picture that emerges of people with different outcomes in CBT signals a number of

important issues for clinical practitioners. The results provided a broadened

understanding of failure to progress in CBT for psychosis and a positive picture of

user views of psychological therapies with these difficulties. The differences observed,

in particular, the possible predictive power of some of the dimensions considered do,

however, require further investigation.

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Received 12 March 2002; revised version received 19 December 2004


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