CBT for Psychosis. Does it only help 5% of people?

Yesterday I went to a very interesting debate at the Institute of Psychiatry, with the motion:

This house believes that CBT for psychosis has been oversold.

CBT-for-Psychosis-Final-Poster399x282 (1)

I’m glad to say that it was a well mannered and reasonable debate, with those on both sides presenting interesting cases.  Although the actual question is perhaps not that interesting, the myriad of underlying issues are. Things like:

  • Does CBT for psychosis actually work?
  • If so, for what does it work best?
  • Which version of CBT for psychosis is most effective?
  • Which outcomes should we be measuring?
  • How do we match clients to therapies?
  • Does CBT for psychosis have to change the topology of positive or negative symptoms of psychosis to be useful?  Or might it be enough to change a person’s relationship with their experience?
  • Are there other interventions that we would be better focussing on instead?

In the end, the motion was defeated resoundingly, with a large shift from the first vote at the beginning of the debate.  Those for the motion, put this down to a triumph of anecdote over statistics.  Of course, as psychologists and philosophers may say, it’s not events that matter, but what we believe about them and how we respond.  An alternative belief is that perhaps the audience actually don’t think CBT for psychosis has been sold very strongly at all, regardless of its effectiveness. Or, perhaps people thought that the issues of CBT for psychosis are too complex to be encapsulated in the particular meta-analyses that were the primary focus of the speakers for the motion.   There are many reasons why the vote could have gone this way, and without doing a survey, I could not tell you!

Response to Keith Laws.
One reason I’m writing this, is that I rashly described (over twitter) one of Keith Laws’s assertions as intellectually dishonest, when perhaps I should have said he was loose with his wording.  He understandably challenged me to defend this claim.   So I will do so here on my blog (as I’m not a very familiar with twitter, and don’t think 140 characters is useful for discussion).  Before I go any further, I should declare a conflict of interest, I’m a clinical psychologist and much of my workload involves CBT for psychosis.

Unfortunately I don’t have a recording of the debate yet, so I don’t have his exact words, thus I’m going to address what I thought his point was!  I remember Laws saying that the evidence says that CBT for psychosis only helps 5% of people treated.  For the moment, you can find a reference to this on Alex Langford’s live take on what was said here at storify, and the tweet of the claim in question here.

Laws, I believe, bases this claim on a meta-analysis on which he is last author.  This paper concludes that based on the meta-analysis:

Cognitive-behavioural therapy has a therapeutic effect on schizophrenic symptoms in the ‘small’ range. This reduces further when sources of bias, particularly masking, are controlled for.

And finds that (for example), the effect size on overall symptoms falls from -0.62 to -0.15 (95% CI –0.27 to –0.03), when studies with insufficient and sufficient masking are compared.   (Always note the confidence interval.  Even here, at this significance level, the true effect size might be as low as -0.03 or as high as -0.27).

My claim is that even if we take no issue with the way in which the meta-analysis has been carried out (and of course we might), and even if we temporarily accept the figure of 5% (I’ll confess I’m not sure exactly where this came from, some NNT calculation?), Law’s conclusion that CBT only helps 5% of people seems flawed.

One key reason for this, is that the meta analysis includes both treatment as usual and control interventions as comparators.  Thus a more valid conclusion would be that CBTp helps only 5% more people than a mixture of treatment as usual (TAU) and control interventions such as befriending.  To me, this is a quite different thing.   For instance, it is possible that the control interventions were also very effective and thus CBT had a hard job getting significantly better results.  As an example, let’s say in a study, befriending had a 40% impact on symptoms and CBT had a 45% impact.  This would not mean that CBT helped only 5%, but 5% more, although the difference between interventions was only 5%.

A second reason not to accept this interpretation is that our clients’ wellbeing can be quite independent of the number and frequency of their positive symptoms.  A person can for instance, continue having auditory hallucinations, but completely change their relationship to them, and thus reduce depression and anxiety, and increase quality of life.  Thus CBT may help clients in the absence of a change in positive symptoms (the meta analysis that Laws was an author on, did not consider other outcomes such as depression and anxiety – key issues for our clients).   Equally, if a client asks us first to help them with their panic attacks, that is generally what we do, yet progress here will not necessarily show in a measure of psychosis symptoms.

I’m  in agreement with Laws in some senses. The literature can certainly be improved upon.  Clinically, we often seem to see remarkable change, yet the literature at large, does not necessarily reflect this.  This may be because CBT is not adding much to treatment as usual, or other interventions, but that we wrongly interpret change as related to CBT.  Or, it may be because there are many different types of CBT, some better than others.  Or it may be because we are measuring the wrong things.  Or it may be that we are looking at the evidence too simplistically.

Incidentally, it was argued in the debate that it would take a huge number of extra significant trials to improve the effect size of CBTp in meta-analyses.  This to me, shows a misunderstanding of CBTp.  CBTp is not quetiapine, which is always the same.  CBT is evolving over time and comes in many forms (from individual to group, from classic CBT to taste the difference Mindfulness Based CBT, from CBT for general psychosis to CBT for command hallucinations).  Lumping all studies together as if it were the same, is thus not necessarily a good idea.

Whatever the explanation, it behoves us to rethink the way we have run our trials to date, in order to capture those outcomes that are most useful to service users.  (I suspect Laws may not appreciate how difficult it is to get funding to run sufficiently powered studies, which may also explain how many studies are at the right side of his forest plot, yet non-significant).  We also clearly need to continue to refine our treatment protocols.  We are beginning to do this, with targeted interventions such as the COMMAND trial (among  others).  It’s a hard slog, but I for one, think the future is bright.

Psychosis Is Nothing Like A Badger

An interesting (but perhaps divisive) animation from Henry Gale.

Psychosis is Nothing Like a Badger from Henry Gale on Vimeo.

The badger of the animation is pretty menacing, with a definite streak of dark humour, and definitely not a badger who’d give up easily.   But Henry is clear:

 psychosis is nothing like a badger… and tends to let go after a while.

Henry  says made this animation……

to raise awareness concerning the signs and symptoms of Psychosis, in the hope that sufferers (and those around them) can seek help without fear, judgment, or hesitation.

Having walked away from two episodes of psychosis myself, I felt that the beginning stages of the illness brought me the most fear and confusion. It was a hazy, in many ways unhelpful diagnosis, that was difficult to talk about – both for its stigma and lack of clarity. I’m hoping that this video might help bridge that gap, giving sufferers, as well as their friends and relatives, a simple insight into how and why Psychosis affects people the way it does.

I know little more about Henry Gale, other than the fact that he’s a clearly talented filmmaker, has a few other videos on Vimeo, and has a tumblr page henrysgale.tumblr.com, which has among other things, info about the making of the film.  Anyway, I’ve little insightful to say tonight… so, if you’re still reading, go watch the film.

An interesting article about asylums and overlooked friendships.

Friern Barnet from wikipedia.
Friern Barnet from wikipedia commons.

In this short article introducing her forthcoming book: The Last Asylum: A Memoir of Madness in our Times, Barbara Taylor describes her experiences of living in Friern Barnet mental asylum.   If the article is any indication, the book should be fascinating.  The piece focusses on the friendships developed in psychiatric wards, something that Taylor feels has been totally neglected by researchers.  As Taylor describes:

Magda suffered terribly from black depression yet nearly always she would pull herself together to be with me. Usually I did the same for her. The obligations of friendship trumped madness – and this in itself could be a form of healing.

it may be that the friendships developed on psychiatric wards can be an essential part of patients’ recoveries.  Yet as mental health professionals we often seem confused as to whether to encourage such relationships, and indeed are sometimes very ambivalent.  We may often fail to capitalise on the potential healing ability of our patients’ relationships.  To my knowledge, we know little about whether these relationships are sustained out of hospital and what they mean to our clients.   Yet we know that having good social support is a key factor that mediates recovery (for instance in bipolar disorder), and we know that serious mental illness commonly wreaks havoc on a person’s social networks (e.g. this study looking at the impact of psychosis on social support), so we really should know…



Even more cartoons… this time about anxiety.

Thanks Maria for sending me this link to a buzzfeed page, with loads of great cartoons about anxiety.  I’ll not copy them here, as the buzzfeed page has already done the hard work.

One of them led me to a blog:

sad girl scribbles

by a girl called Gaby at virtualgirlfriend.tumblr.com, which contains a plethora of drawings touching different issues including anxiety and depression.

One of many that I particularly liked was this one, which deals nicely with the tension between wanting to abolish difficult feelings and needing emotions to be human:sadgirlscribbles-plantsPlants may not have feelings… but I think I’ve made a few plants look pretty sad.  They definitely look happier when they’ve had a little love and affection – or at the very least least sun, clean water and good food; all of which I can relate to.

More pictures, less words…

Following from my last post, a few friends have recommended some other videos and pictures and comics.

The first, sent to me by various friends, deserves a whole post to itself.  It’s the wonderful Hyperbole and a Half.  A selection of brilliant comics on a variety of topics including depression.  Both funny, sad, true and uplifting, they are a work of genius.  Some of them are short and sweet, others, like ‘Depression part Two’ are seriously long (by internet attention standards), but deserve a proper read.  The author, who describes him/herself as “heroic, caring, alert and flammable”, brings a dark humour to serious experiences:

Screen Shot 2013-12-12 at 17.14.02

Another friend, Ben, recommended this animation on depression, which uses Churchill’s ‘Black dog’ to illustrate the experience of depression, and how, perhaps using imagery, a person can learn to live with their experiences.  The animation is by the illustrator and author, Matthew Johnstone (in conjunction with the WHO) although I’m not clear if he’s talking of his own experiences.  Worth a watch..

Susanne sent me this cartoon, which speaks for itself.



And then Julia reminded us that depression is  actually often actually misdiagnosed IED (Inappropriate Environment Disorder), a new diagnosis that I’m hoping to get to replace almost all other diagnoses in the DSM-VI.


Empathy and how to help a friend who’s down…. in pictures and words.

A few things popped up on my various feeds this week, all on the same kind of topic.
The first was this cartoon (thanks Catherine)…


Which comes from a blog called www.robot-hugs.com.  Below the line on the facebook page where the cartoon had been posted, was the old story about empathy:

So there’s this guy walking down the street and he falls into a great big hole. A doctor walks by and the guy yells up to the doctor ‘hey, I fell in this hole, can you help me out?’ The doctor writes a prescription, throws it into the hole, and walks on. 

A priest then walks by and the guy yells up to the priest ‘father, can you help me? I fell into this hole and I can’t get out’. The priest says a prayer, throws down a Bible and walks on. 

And then a friend of the guy walks by and the guy yells up ‘hey, buddy, I’m stuck in this hole and -‘ and before he can finish the friend jumps down into the hole. 

‘What the hell are you doing?’ the guy says, ‘Now we’re both down here!’ 

‘Yup’, says the friend, ‘But I’ve been down here before and I know the way out.’

This story is exactly what happened to a client of mine this week.  Someone he cared about jumped into his hole and helped him find the way out.  These are the people we need in our lives.

And then I came across much the same thing from the brilliant RSA shorts series.  This from a lecture about sympathy vs empathy.

Oh, and I nearly forgot the first one, again from Robot Hugs!  Full of useful advice.

2013-11-21-Helpful Advice

Anyone care to recommend any other cartoons they really like about psychological health?


Youtube Channel Review: Time to Change

Type: YouTube Channel: Time to Change
Highly Recommended Resource.

Time to Change is a campaign which sets out to end mental health stigma.   That’s a tough, but laudable goal (especially tough given the continuing level of irresponsible reporting by media such as the Sun newspaper) .

The campaign started in 2007 and is supported by the mental health charities Mind and Rethink.  In terms of online resources, Time to Change has both a webpage and a YouTube channel.   More broadly, Time to Change seeks to engage the general public through all forms of media, whether it be TV, radio, internet, magazines or poster campaigns.  I’m going to briefly discuss the YouTube channel today.

In short, it’s a brilliant resource.  Useful to everyone from mental health service users, through to teachers, families and indeed anyone who wants to know wants to understand more about mental health difficulties, be it their own or other peoples’.

The videos cover a large range of formats/styles and topics.   To take just a few examples:

  • Animations such as the one above, beautifully illustrating a young person’s experience of depression and recovery.
  • A mock horror film trailor, ‘Schizo’, which seeks to undermine traditional associations between mental health and violence).
  • Short, poignant and powerful mini-dramas, such as ‘The Stand Up Kid’, which explores the unseen impact of stigma in schools.
  • A silent film, ‘The 5th Date… time to talk’, complete with speech bubbles, which considers the sometimes scary experience of disclosing one’s mental health diagnosis to a date.
  • Endorsements and discussions from famous people who have been open about their difficulties such as Stephen Fry and Frank Bruno (who discusses mental health with his daughter, Rachel Bruno) .

Many of the videos are sorted into particular topics, for instance there is a section with five videos, all of which feature a different person’s experience of mental health and the workplace.  In total there are over 80 videos, and so far, every one that I’ve watched is excellent.   I’m going to try and work my way through the other videos,  there’s a lot of them, but they are generally very short, and all inspirational, so not a chore.


Video resource: 5 young people’s experiences of mental illness.

Publisher:  Time to change.
Type:  Short Videos Collection

This very brief video (3.25) includes the experiences of 5 young people.   It’s short and concise and thus does not provide much detailed information.  However, each of the young people in this video are featured in their own longer videos, where they discuss their experiences in more detail.  This video thus provides a great opener for for any discussion about mental illness, especially with young people.   The related videos then provide additional material for further, more specific discussion.

These are just some of over 80 videos provided by ‘Time to Change’ on YouTube.   I’ve also provided a brief review of the channel here.



Youtube Bipolar Video – brief review.

Youtube Video Review: ‘Cutiepieforeverc’
Highly Recommended Resource.
Main topic: Bipolar.

Another brave testimony by a young US American lady.  In 16 minutes, ‘Cutiepieforeverc’ describes her experience of bipolar disorder.  Her first clear problems came when she went to college (away from home).  In common with many people who receive a bipolar diagnosis,  her first symptoms were lack of sleep (something it appears that she had always faced to some extent).  This led to a period of 2-3 weeks where she hardly slept and indeed felt very little need to sleep*.  During this period she engaged in a variety of ‘reckless’ behaviour including shopping sprees and late night runs (from which she was regularly picked up by the police).  It appears that she did not seek help at this point, this had to wait until the ensuing depression, which lasted around 6 months, led to her getting to ‘breaking point’ and contacting her mother, leading to her hospitalisation.    Although I don’t have research evidence to support this more generally, many of the young people I have worked with (or done research with) have experienced their first serious problems at college/university, and often in the first year.

‘Cutiepie’  details her hospitalisation as ‘the most horrific experience of my entire life’,  which is not an uncommon description, even from those who believed that they needed to go to hospital.  She worked out that in order to get out of hospital, she could lie and cover up her  depressive symptoms (that hospital may have made worse), which worked.  Again many people will recognise this catch 22 situation, of being stuck in a hospital that does not seem to be working for them, and needing to pretend that all is fine to leave the hospital.   She then goes on to discuss her journey to find a medication treatment that worked for her.  At the point the video was made, she describes feeling very settled and content with her life and medication.  She ends the video with some advice for people going through similar experiences:

  • Don’t ever settle for a medication that does not feel right and does not make you feel right.
  • Don’t ever settle for a doctor that does not want the absolute best for you.

Excellent Advice!  In my opinion, health professions should absolutely encourage their clients/patients to take control of their own treatment and encourage them to seek out (with guidance), what works best for them.

Overall, this video was a very clear and concise description of one young person’s experience of bipolar disorder.  ‘Cutiepie’, describes experiences that many people with a diagnosis of bipolar disorder or similar will be able to relate to, and as such this video would make an excellent resource for therapy groups or interested individuals.

*Sleep abnormalities are becoming one of the most convincing traits linked to bipolar disorder diagnoses, and emerging evidence suggests that early sleep problems may be a risk factor for the development of later mood disorder symptoms.  When I get time, I will try and provide some links to the latest research.