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Cognitive behavioural therapy for psychosis

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Article in British journal of nursing (Mark Allen Publishing) · October 2013

DOI: 10.12968/bjon.2013.22.18.1061 · Source: PubMed

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Cognitive behavioural therapy
for psychosis and anxiety
Alison Welfare-Wilson and Rebecca Newman
T
he study took place within an early intervention for
psychosis service, which at the time of writing held
a caseload of approximately 350 clients aged 14–35
years. Such services have been developed nationally
in line with the Department of Health’s (DH) (2000) NHS
Plan: A plan for investment, a plan for reform, the Mental Health
Policy Implementation Guide (DH, 2001) and the National
Institute for Health and Care Excellence’s (NICE) (2009)
Schizophrenia: Guideline on Core Interventions. Before the
establishment of these services, there were concerns that
existing mental health services were unable to meet the needs
of individuals during the ‘critical period’ following the onset
of their illness (Lester et al, 2009). The overarching aim of
early intervention services is to provide early detection and
evidence-based treatment of psychosis during this critical
period (Birchwood et al, 1990). Relapse prevention and the
reduction of long-term secondary disabilities are also key in
early intervention service provision.
Use of cognitive behavioural therapy
A key component of early intervention service delivery is
cognitive behavioural therapy (CBT). Psychotic symptoms
are targeted by means of a range of cognitive behavioural
techniques, including the identification of ‘thinking errors’
and ‘hot thoughts’ (Gould et al, 2001) and ‘the reality testing’
of delusional beliefs (Landa et al, 2006). The early symptoms,
or prodrome, of psychosis are often low mood and anxiety
(Schultze-Lutter et al, 2007), making CBT an important
intervention for people at risk of developing psychosis.
However, reductions in relapse rates and hospital admissions
due to CBT have not yet been shown (Craig et al, 2004;
Tarrier et al, 2004). Despite being treated as two separate
disorders, clients with first-episode psychosis often also present
with anxiety, whose symptoms are frequently overlooked
(Montreuil et al, 2013). Dernovsek and Sprah (2009) suggest
that up to 60% of clients with chronic psychotic disorder also
experience anxiety symptoms. Braga et al (2004) cautions
that there is an overlapping of anxiety and psychosis, meaning
clinicians need to be aware that anxiety may be overshadowed
by more dominant psychotic symptoms.
Alison Welfare-Wilson is Mental Health Nurse/Specialist Care
Coordinator and Rebecca Newman is Assistant Psychologist,
© 2013 MA Healthcare Ltd
West Kent Early Intervention for Psychosis Service, Canada House,
Barnsole Road, Gillingham, Kent
Accepted for publication: June 2013
British Journal of Nursing, 2013, Vol 22, No 18
MENTAL Health
Abstract
This article discusses the effectiveness of a cognitive behavioural
therapy (CBT) group for clients with a first episode of psychosis, who
were also experiencing comorbid symptoms of anxiety. Clients of
18–35 years of age who reported anxiety symptoms, either as a direct
or indirect result of psychotic symptoms, were invited to attend a
12-week CBT-based group. The effectiveness of the intervention was
evaluated at screening and 3-month follow-up with the Depression,
Anxiety and Stress Scale (DASS-21) (Lovibond and Lovibond,
2004). The results showed a statistically significant improvement
in symptoms (depression, p=0.06; anxiety, p=0.05; stress, p=.014),
sustainable at 3-month follow-up. The authors concluded that a CBT
group for people with a first episode of psychosis that focuses on
the management of anxiety can be an effective and viable means of
reducing levels of anxiety and associated stress and depression. This
model is recommended for use by community mental health teams.
Key words: Anxiety ■ Cognitive behavioural therapy
■Early intervention ■ First-episode psychosis ■ Group treatment
Naeem et al (2008), in their examination of factors
affecting responses to CBT for psychosis, did not find that
anxiety was predictive of outcome. Conversely, Gaynor et al
(2011) showed that following completion of a 12-week CBT
group with 25 clients experiencing their first episode of
psychosis, and 12 clients whose psychosis was curently stable,
there was a notable reduction in symptoms of depression
and anxiety. The issue of completion and adherence to CBT
in psychosis has been discussed by Alverez-Jiménez et al
(2009) in a longitudinal randomised control trial of CBT in
first episode psychosis versus treatment as usual. They found
that reducing the duration of untreated psychosis and the
promotion of insight were effective in adherence to CBT.
Fanning et al (2012) found that lack of education, presence
of negative symptoms and limited insight were barriers to the
completion of CBT in psychosis.
In the early intervention service in which the current study
took place, clinicians had observed that the clinical symptoms
of anxiety seemed to be a trigger for the development of
psychosis, as well as a maintaining factor and relapse indicator.
Consequently, there were a number of clients for whom
anxiety affected their social and occupational functioning,
requiring medication and psychological intervention. Romm
et al (2012) highlighted the fact that high levels of anxiety,
particularly social anxiety, in clients with first episode
psychosis, were associated with reduced social functioning
and increased clinical symptoms.
1061
 As clinicians, the authors decided that part of the group
programme would also address social functioning and social
anxiety, specifically through the interactions that occurred
during set breaks. The group design also addressed the
identified need to offer skill development by means of
evidence-based interventions for comorbid anxiety. In
addition, the group was offered the chance to support clinical
care coordinators who had expressed a lack of confidence in
treating clients who had debilitating symptoms of anxiety.
Study design
This repeated measures feasibility study was a single-centre
project with participants being recruited over a 3-month
period through individual care coordinators across four
catchment areas. Before recruitment, care coordinators were
given targeted education around potential benefits of group
work and encouraged to discuss referrals with clients who
had disclosed difficulties with anxiety, and with clients they
perceived as having difficulties with anxiety. This process led
to 11 referrals being made. All participants gave informed
consent to attend the group and agreed to complete ratings
at set intervals using the Depression Anxiety and Stress Scale
(DASS-21) to measure progress and effectiveness (Lovibond
and Lovibond, 2004). Individual participants’ scores were
shared with them on request.
Inclusion and exclusion criteria
Clients were aged 18–35 years, whose care was provided by
the early intervention service, who had difficulties with anxiety
and were willing to participate in a group. Although the service
is provided to 14–35 year olds, clients under the age of 18 or
with current acute and severe psychotic experiences were
excluded because of issues of consent and capacity to take
part. Clients were also excluded if they were misusing drugs
or alcohol, had more than a mild learning disability, or were
currently taking large doses of benzodiazepines, as these would
have affected the treatment intervention.
Following referral, clients were invited to participate in
a 30-minute face-to-face interview or telephone screening
assessment by one of the facilitators for the purposes of
inclusion. This allowed for further discussion around their
experience of anxiety; their perceptions of group work;
perceived potential benefits; motivation to attend; and the
emphasis on the completion of homework tasks. Cognitive
ability was assessed by clients evaluating the impact of their
anxiety on their thoughts, feelings and behaviour, through the
creation of individual problem and goal statements devised in
collaboration with the group facilitators.
The group intervention
The group ran for 2 hours once a week at the service team
base and was facilitated by a cognitive behavioural therapist
and a mental health nurse, both of whom were experienced in
group facilitation. The group used an approach documented
in the book Mind over Mood: Change the Way You Feel by
Changing the Way You Think (Greenberger and Padesky, 1995),
which emphasises links between a person’s thoughts, feelings
and behaviour. The group was structured through the use of
a weekly agenda, with each session beginning with a review
1062
of homework tasks from the previous week, moving on to a
theoretical presentation of a rationale for a set skill, followed
by the practising of the skill through individual work, as well
as through small and larger group work.
Topics covered over the course of the 12 weeks were:
socialisation to the CBT model; identification of coping
strategies; mindfulness; relaxation techniques; behavioural
experiments; and completion of thought diaries (encompassing
identification of thinking errors, techniques for identification
of hot thoughts and developing balanced thinking). Later
sessions focused on the identification of early warning signs.
Participants were encouraged to practise skills learned with
their care coordinators. Care coordinators’ learning was
addressed directly in session four, when they were invited to
attend to learn from participants about the model and how
to use thought diaries.
Outcome measures
Ratings were taken at screening and 3-month follow-up by
using the DASS-21 (Lovibond and Lovibond, 2004), which has
been shown to have adequate construct validity (Henry and
Crawford, 2005) with high reliability based on normative data.
This rating scale was not designed specifically for individuals
with psychosis, but allowed the authors to capture difficulties
relating to the three domains identified within the scale.
Results
Client characteristics
The group comprised 57% (n=4) males and 43% (n=3)
females with a mean age of 25 years (range 18–33 years). Four
participants dropped out of the group (missed more than
three treatment sessions). Data from the three participants
who missed more than three treatment sessions were removed
from the study. No significant demographic differences were
found between those who dropped out versus those who
completed the group. Although it was a naturalistic sample,
participants were representative of the service as a whole, in
terms of race (predominantly white British), employment/
education and receipt of benefits.
DASS-21 results
The data from the DASS-21 at baseline and 3-month follow-
up are given in Table 1. Comparisons of the group at screening
and at 3-month follow-up indicated statistically significant
improved outcomes in the three domains of depression,
anxiety and stress, as measured by the DASS-21 scale. To
determine this, both a t-test and Wilcoxon paired signed rank
test were used for each of the three domains. However, due to
the small sample size, results should be interpreted with care.
Depression
Pre-group depression scores as measured by the DASS-
21 (mean(m)=24, standard deviation(SD)=12.27) and at
3-month follow-up (M=6.29, SD=6.68) showed statistical
significance at t(7)=4.091, two-tailed p=.006. The Wilcoxon
© 2013 MA Healthcare Ltd
paired signed rank test showed there was a significant
difference in depression as recorded by the DASS-21 before
and after the formation of the group,Wilcoxon z(n=7)=2.205,
two-tailed p=.027.
British Journal of Nursing, 2013, Vol 22, No 18

Anxiety
Anxiety scores measured by the DASS-21 before the formation
of the group (M=22, SD=11.14) and at 3-month follow-
up (M=7.43, SD=4.58) were again statistically significant,
t(7)=4.285, two-tailed p=.005, Wilcoxon z(n=7)=-2.371,
two-tailed p=.018.
Stress
After a paired samples repeated measure t-test, the difference
between the stress scores measured by the DASS-21 before
the formation of the group (M=27.29, SD=11.15) and at
3-month follow-up (M=10.14, SD=3.58) were statistically
significant, t(7)=3.430, two-tailed p=.014. The Wilcoxon
paired signed rank test showed z(n=7)=-2.197, two-tailed
p=0.28.
Total score
Overall, the differences between the total DASS-21 scores
before the formation of the group (M=73.29, SD=29.07)
and after the group (M=23.86, SD=12.28) were statistically
significant, t(7)=4.409, two-tailed p=.005. The Wilcoxon
showed that, overall, there was a statistically significant
improvement in pre-group and post-group scores, Wilcoxon,
z(n=21)=-2.207, two-tailed p=.027.
Summary of DASS-21 assessments at baseline
and 3-month follow-up
Participant evaluation of treatment
In the final group, session participants completed a qualitative
questionnaire as part of the evaluation, exploring the
usefulness of the group and its design and structure. All
participants reported that they had participated in discussions
about referral to the group and 85% (n=6) considered
that attending the group had helped them to meet the
individual goals they had identified during the screening
process. With regard to the delivery of the group, all
participants felt that they had enough time to express their
concerns and appreciated the time they spent practising skills.
Comments from participants via the questionnaire regarding
the usefulness of the group included:
‘I learnt to recognise when I was in a depressive
state and learnt ways of managing when
problems arose’
‘It helped knowing that others felt the same as
me, that I was not the only one’
With regard to the completion of individual goals, one
participant stated:
‘I feel that I have come away with some good
Table 1. Data from the DASS-21 at baseline and 3-month follow-up
Values n Baseline mean (SD) 3 months (SD)
© 2013 MA Healthcare Ltd
Depression 7 24 (12.27) 6.29 (6.68)
Anxiety 7 22 (11.14) 7.43 (4.58)
Stress 7 27.29 (11.15) 10.14 (3.58)
TOTAL 21 73.29 (29.07) 23.86 (12.28)
British Journal of Nursing, 2013, Vol 22, No 18
MENTAL Health
coping techniques and would recommend the
course to anyone suffering from anxiety’
A further comment highlighted the potential longer-term
benefits of attendance:
‘With the skills I have learnt, I can now plan
longer-term goals as I now know that I can do
things that before I found too hard’
Fifty-seven per cent (n=4) stated that they regularly completed
homework tasks. One participant identified the following
barrier to completion:
‘I found homework hard to complete to start
with because I was scared that I would have to
share it with the group’
One participant who regularly completed homework said she
did so because:
‘I knew that homework tasks were helping me
towards getting better’
In CBT, homework is considered crucial to the
implementation of techniques and skills in everyday situations.
Despite participants’ initial concerns, they did engage in
homework tasks. Facilitators explained to participants from the
outset how important the homework tasks were and dedicated
time at the start of each session to discuss their completion.
Overall, participants’ feedback indicated that they found
the group beneficial, partly, perhaps, because of its simplicity.
It appeared important to participants that the group was
positive, well-structured and fostered a safe, non-judgmental
atmosphere. At the 3-month follow-up, 71% (n=5) re-entered
education or engaged in voluntary work (see Table 2).Although
it cannot be claimed that the progress of these individuals was
due exclusively to group participation, subjective feedback
suggests that the group helped participants develop skills and
gain the confidence to engage in new activities, or return to
previous levels of functioning.
Discussion
Initially, this study was not developed with publication
in mind. It was only after the results proved positive that
publication was considered. Due to its success, the authors
believe that the model could be replicated within community
services. From their study of group CBT in inpatient settings
for individuals with a diagnosis of schizophrenia or schizo-
affective disorder, Haddock et al (1999) concluded that group
treatment is a viable option for inpatient settings.
Our findings suggest that a group-based CBT programme
could be offered in both inpatient and outpatient community
settings. Lecomte et al (2003) developed a 24-session CBT
t values z scores
t(7)= 4.091, two-tailed p=.006 z(n=7)=-2.205, two-tailed p=.027
t(7)=4.285, two-tailed p=.005 z(n=7)= -2.371, two-tailed p=.018
t(7)=3.430, two-tailed p=.014 z(n=7)=-2.197, two-tailed p=0.28
t(7)=4.409, two-tailed p=.005 z(n=21)=-2.207, two-tailed p=.027
1063
Table 2. Participant characteristics at 3-month follow-up it would be advantageous to recruit participants randomly as
Participant Age at start Sex Return to paid or Return to Ethnicity
well as use a control group (active or treatment as usual). In
of group voluntary work education addition, subjective feedback from participants indicated an
improvement in areas of social functioning and self-esteem.
1 24 Male Yes No White British
These were areas not captured by the DASS-21. Lecomte et al
2 33 Female Yes No White British
(2003) and Halperin et al (2000) highlighted that it would be
3 18 Female No Yes Asian beneficial to administer a scale capable of assessing functioning,
4 32 Female No No Asian Other such as the Social Functioning Scale (Birchwood, 1990), the
5 34 Male No Yes White British Global Assessment of Functioning (Caldecott-Hazard and Hall,
6 19 Male No No White British 1995), the Rosenberg Self-Esteem Scale (Rosenberg, 1965), as
7 20 Female Yes No White British well as a specific scale to rate psychotic symptoms to capture
salient changes and give a greater indication of the benefits of
the group for individual participants.
group for individuals who have experienced a first episode Yet despite being a small-scale study, the authors were
of psychosis. Their results were promising, with the areas of able to demonstrate the efficacy of a CBT-based group for
anxiety, self-esteem, stress, depression and substance abuse participants with first-episode psychosis who suffered with
being targeted as effects of a psychotic illness. The results anxiety. It could also be argued that by running a small
showed the need to look at the wider clinical effects of group, the authors were able to get to know participants and
psychosis on individuals, which could be incorporated into encourage them to take part in group activities, which may
the development of future groups. have contributed to their feeling of being listened to.
In addition, Halperin et al (2000) discussed the treatment
of anxiety within a group setting. Although their focus Conclusion
was more on social anxiety as identified through The Brief This was a single-site feasibility study designed to reduce
Social Phobia Scale, they too focused on the measurement of the often debilitating symptoms of anxiety routinely seen
depression, quality of life and psychological symptoms. Their in clients with a first episode of psychosis. The authors have
results indicate significant improvement from baseline scores been able to demonstrate that a CBT group for people with
with gains maintained at 6-week follow-up. It is the authors’ a first episode of psychosis that focuses on the management
view that the involvement of care coordinators in the delivery of anxiety is an effective and viable means of reducing anxiety
of the programme contributed to the group’s positive impact. and associated stress and depression, with gains maintained at
This potential finding would benefit from further study. 3-month follow-up. The authors believe that such a group
could be replicated across the spectrum of community teams,
Study limitations with the flexibility to be facilitated by staff from a range of
An important limitation of the study is that only three clinical professional backgrounds.  BJN

areas were rated by one rating scale. The authors can see that
the use of a range of rating scales would allow more detailed
evaluation. Furthermore, psychotic symptoms were not rated
before group attendance, so the authors were not able to
establish a link between treatment interventions and their direct
impact on psychosis. If the presence of psychotic symptoms had
been measured and then followed up for an extended period,
the authors might have seen a direct improvement in psychotic
symptoms due to patients’ improved coping and CBT skills.
This was an uncontrolled study, so the improvements cannot
be definitively attributed to the intervention. There was
also recruitment bias, as the facilitators were active in client
recruitment and assessment. Should this study be replicated,
Key points
Cognitive
n behavioural therapy (CBT) is a key treatment for individuals with a
first episode of psychosis
CBT
n for anxiety can be delivered effectively in a group setting
As
n well as sustainable gains such as reduced stress, anxiety and depression,
Conflict of interest: none
Acknowledgements: The authors would like to extend their gratitude
to Janet Wood in her expertise in cofacilitation of the group, to Dr
Amanda Scrivener for her unwavering support and encouragement
throughout the entirety of this project, Beth Coleman, and to the
clients who helped make the group a success.
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