Metacognitive training in Cognitive Behavioural Therapy: A case series
Research type
Research Study
Full title
Metacognitive training in Cognitive Behavioural Therapy for psychosis: A case series
IRAS ID
203489
Contact name
Emma Eliasson
Contact email
Sponsor organisation
University of Edinburgh
Duration of Study in the UK
1 years, 0 months, 1 days
Research summary
Summar of Research
Individuals with psychosis often experience delusions, hallucinations and disorganised thinking. Clinicians call these ‘positive symptoms’ as they are seen as an addition to regular functioning. Psychosis can also lead to loss of some functions such as lower motivation and decreased interest in activities; these are called ‘negative symptoms’. Even though most people receive medication for psychosis, psychological therapies such as Cognitive Behavioural Therapy for psychosis (CBTp) are also important in terms of managing symptoms and increasing well-being. Standard CBTp is made up of different ‘ingredients’, also called treatment components. In therapy, different treatment components can be included or excluded depending on the needs of the individual. In this study we are looking to identify treatment components that are beneficial to CBTp. In particular, we want to test whether adding some newly developed treatment components to CBTp can lead to additional benefits to treatment outcome. This will be done through a double-blind randomized case-series design, where participants will either receive standard CBTp or standard CBTp with added treatment components.
Three weeks before the intervention starts and throughout therapy participants will complete some brief weekly questionnaires to assess symptoms and thinking patterns. This will allow the researcher to measure changes across time. Additional questionnaires and interviews as well as computer tasks will also be completed at baseline, mid-therapy and post-therapy to gain more insight into changes in mood, quality of life, thinking patterns and symptoms. In addition, to study the long-term effect of the intervention, participants will be asked to complete a follow-up assessment session 12 weeks after the therapy is completed.Summary of Results
Some people may believe things that others do not or may be worried that others are out to cause them harm. Such experiences are sometimes referred to as delusions, which someone with psychosis may experience. The National Institute for Health and Care Excellence (NICE) currently recommend that people with psychosis receive a therapy called Cognitive Behavioural Therapy for psychosis (CBTp). However, whilst many people find CBTp helpful, it is important to study ways in which such therapies can be improved further. One recently developed intervention, that mainly focuses on certain thinking styles (so-called cognitive biases) that may be relevant to psychosis, whilst also addressing feelings of stigma and self-esteem, is Metacognitive Training (MCT). This training has been shown to be particularly helpful for individuals who may be experiencing delusions. The aim of this project, therefore, was to test whether MCT might improve current standard CBTp treatments. This was done through a study that included a final sample of 16 individuals with delusions, who either received MCT or standard CBTp. Data on delusions and self-reported 'cognitive biases' that MCT targets was collected at each session of therapy. More specifically this data was collected weekly for four weeks before treatment started, and during treatment at each session, as well as four weeks after treatment finished (this is called an ABA case series design). However, participants were also invited to a follow up session 12 weeks after treatment had ended. Data on feelings of stigma and other outcomes such as for instance functioning, quality of life and mood were also collected, but less frequently, namely at 6 time points through the study (two times before therapy started, one time during therapy, and three times after therapy had finished). For both CBTp and MCT groups, delusions reduced throughout treatment, with no difference in improvement observed between the groups. Participants in both groups also showed improvements in a bias called the "jumping to conclusions bias" which describes decision making, and how much information we may seek before making a decision. Moreover, for the group receiving MCT, improvements were seen on two biases: one called the "belief inflexibility bias" which assesses how flexible we are in our thinking, and another bias called the “external attribution bias” which measures how we interpret different situations. Through statistical analysis, we also found that improvements in the "external attribution bias" predicted improvements in delusions. This means that focusing on attributional style might be particularly important in therapy. Some improvements in both groups were also seen in functioning, but no change was observed in quality of life or mood. Moreover, none of the groups improved regarding feelings of stigma, which means more work needs to be done to investigate how this can be tackled better within therapy.To build on the findings of the first study, a second study sought to conduct interviews with patients and clinicians in order to obtain feedback on what elements patients perceive as useful in therapy. There were elements in both CBTp and MCT that patients found beneficial, which suggests that combining elements from both treatments could be used to optimise outcome. Patients and clinicians particularly found that the therapeutic material in MCT that targeted attributional style was useful, which reflected the findings of the first study.
Based on the outcomes of this project, it was concluded that MCT can be equally effective to CBTp when it comes to helping individuals who experience distressing delusions, and therefore it may be a useful complement to standard therapy. However, it is important to note that this was a small study, and therefore any conclusions drawn should be interpreted with caution. Nevertheless, due to its structured format and its ease of administration, the finding that MCT performed similarly to standard CBTp is encouraging. To build on these findings, future larger studies should test benefits 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 access CBTp.
Please note: for a more comprehensive description of the results, including other secondary outcome measures and details of statistical analyses, please refer to chapter 5 & 6 of the published thesis available online: https://eur03.safelinks.protection.outlook.com/?url=https%3A%2F%2Fu2790089.ct.sendgrid.net%2Fls%2Fclick%3Fupn%3DXv3JSvJ-2B3M71ppf7N9agbeqq8tsdNaCj-2BtIHKqD-2BlkMy4Rea7wfEnT695jSplKaDWELd_E1aO2-2BZlVOSJJV-2FajQqskegTd6IRomHYTi-2Fbt8SH3YI-2FKyPNPj12dTYf-2FwK9LEH5D7Tfjt-2FvZvbqFWnNoq4JBXVl3hSBhrwRpfRMGvYPj89fVrxL8A2W67RtpF1-2FsinPhspXGPes-2BrIxfE2Y12g6rMPrepKltEZyeeSa2oBrOMjC8RGJygAZV6Y3cxAJX9-2BI3fde7xiJZX-2Ftrj0uDbyVcw-3D-3D&data=05%7C01%7Capprovals%40hra.nhs.uk%7C80728813b1de4555e4b608daab952366%7C8e1f0acad87d4f20939e36243d574267%7C0%7C0%7C638010954274518859%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=QGaIpUYtka%2FApdRBy7%2BL%2FLBConTjBGr6bF85eKVHBj8%3D&reserved=0
REC name
South East Scotland REC 01
REC reference
17/SS/0011
Date of REC Opinion
20 Mar 2017
REC opinion
Further Information Favourable Opinion