• Life history, critical incidents, current environment, congruence with symptoms
• Standardised measures
– PSYRATS
– BAVQ, IVI, BAPQ
– Mood, Safety behaviour interview, TCQ etc.
– PTCI, DES, CTQ, THQ
• SMART goals, belief ratings etc.

4 levels:
• basic / horizontal
• maintenance
• internal generation
• historical / developmental / vertical

EVENT
THOUGHT FEELING BEHAVIOUR hear voice it’s the devil scared pray & visit church see ceefax I’m the devil scared p666 burn self

Triggers (cannabis, paranoid thoughts, arousal, religious )
Hear Voices scared, increased arousal no sleep pray, hide in church, attend to relevant stimuli
It is the devil trying to possess make me harm people

Early Experiences mental and sexual abuse from religious mother physical abuse from father to both told to harm father; told she was evil catholicism
Beliefs Formed
I am evil and the devil is in me
I might harm other people
Must think good thoughts
Thinking something evil is as bad as doing it
Critical Incident
Raped
Hear voices saying bad things

Intrusions / event
Social situations / reminders
Flashbacks / dissociation
Critical voices
Making sense of things
They are talking about me / want to hurt me
I’m mad / not normal
It’s a Bully from beyond the grave
Cog. & Beh. responses
Safety behaviours
Dissociation
Thought supression
Avoid situations
Run away
Look out for danger
Don’t express self
Beliefs / strategies / rules
I am vulnerable / useless
I am mad / not normal
People will hurt you & can’t be trusted
‘Paranoia’ keeps me safe
Bullying was my fault
If I keep busy or spaced out then I won’t have time to think / feel bad
Experience
Bullying
Physical Abuse
Emotional abuse
Mood & physiology
Anxious
Hyperarousal
Paranoid
Depressed
Sleep problems

Experiences that worry me
Hear whispering and laughing
See bodies
See people staring
What I make of it
They might be ghosts
I must be going mad
They might harm me
What I do
Try to stay in control of thoughts
Hide from ghosts
Look out for things happening to me
What I make of the self / world
I should be in total control
I am bad
Need to be alert for danger
Other people cannot be trusted
Early experiences
Baby brother died, mum blamed me
Sexually abused aged 14
Dad horrible to me
How I feel scared agitated angry sad

• Role play assessment of patient and formulation

• Developing case formulation

• Suggest intervention strategies based on formulation

• Trauma (assault, bullying, kidnap, combat)
• Drug abuse
• Isolation / Sensory deprivation
• Bereavement
• Sleep deprivation

• Philosophers and thinkers:
Socrates
Plato
Aristotle
Descartes
Mahatma Gandhi
Spiritual and religious figures:
Moses
Jesus
Mohammed
Joan d'Arc
George Fox (Founder of the Quakers)
Leaders and rulers
Alexander the Great
Caesar
Oliver Cromwell
Napoleon
Churchill
• Authors, musicians and creative artists:
Jonathan Swift
Beethoven
Mozart
Byron
Edgar Allen Poe
Charles Dickens
Philip K Dick
Anthony Hopkins
Zoe Wanamaker
Paul McCartney
Brian Wilson
Scientists,Discoverers & Explorers
Christopher Columbus
Galileo
Isaac Newton
John Nash
Footballers
Tony Cascarino
Paul Gascoigne

• “I’ve learnt a lot...erm I guess about mental health it happens to a lot of people and things like... I thought I was abnormal, especially when I was down I thought what is wrong with me erm and [therapist] would always say well would you think somebody was normal if they had green eyes, and you’d be like yeah, and she’d say like... well more people have mental health problems than have green eyes” (8)
• “…all these thoughts, I was thinking when I felt fine, oh my god they’re crazy but
[therapist] helped me to see that the thoughts weren’t crazy, after looking at what happened” (1)

• Advantages and disadvantages
• Normalisation and formulation
• Evidence for and against
• Explore meaning / downward arrows
• Modify environment
• Belief restructuring:
– Historical review
– Meaning of event
– Continuum
– Evidence, data log
• List alternative explanations
– Conviction ratings
– Pie chart
– Refer to feelings and behaviour

• Behavioural experiments:
– Drop safety behaviours
– Exaggerate and drop
– Attentional focus
– Test reality
– Practical stuff
– Test alternatives
– Monitoring
– Symptom induction
– Surveys
• Metacognitive
– beliefs (e.g. positive/negative beliefs about paranoia/rumination/worry)
– strategies (e.g. postponing perseverative processing)
– attentional strategies (e.g. external focus)

• “We could test out our predictions, and like look for other explanations like, there was some exercises in the CBT that I could do...so eventually I’d feel, like I’d get a de-escalating feeling of anxiety” (1)
• “I think the evidence thing’s kind of good, sort of it is real and you have to sort of work out well, is it likely to be real. Like if you think, say, people taking thoughts out of my head, and erm, it’s sort of well what’s the proof that they are” (2)

• Identify thoughts, feelings & behaviour
• Evaluate advantages and disadvantages
• Evaluate thoughts:
– evidence for and against
– generate alternative explanations
– advantages & disadvantages
• Education
– anxiety, intrusions, metacognition,
– reasoning biases, thinking errors, selective attention
• Behavioural experiments

Advantages
Makes me feel special
Keeps my belief in a soulmate
Makes life feel special
Disadvantages
Frustration when Richard and I do not meet.
Causes difficulties with present partner
Has got me into trouble with the police in the past
My psychiatrist thinks this is a problem
It upsets my daughter a lot
I’m distraught when Richard tells me he is not in love with me
Anger towards Richards wife
Unable to go away for the weekend as need to stay near house in case Richard decides to come and see me

Evidence for
“The neighbours are going to attack me”
Evidence against
“The neighbours are going to attack me”
There are rowdy noises from next door
I have been assaulted by other people in the past
They can read my mind
I have seen them 3 times this week and they haven’t attacked me
I have never been assaulted by anyone from my street
I have never seen the neighbours be violent to anyone
I don’t think they are going to attack me when I am drunk or when I am with other people

The rowdy noises from next door are due to:
Initial belief: The neighbours want to attack me
The neighbours are having a party
The neighbours are having an argument
The neighbours are making noises to wind me up
I am imagining the noises
The noises are being beamed into the house from outer space
10%
0%
Stress, lack of sleep & beliefs are making me misinterpret noises 25%
80%
25%
50%
50%

• mediate distress
• identify
• use modified DTR
• use questionnaires
• use interviewing
• use downward arrows to access personal meaning
• use content
• use qualities of voice

• evaluate by
• use of list of interpretations
• generate alternative interpretations
• relate to normalising information
• rate & rerate belief each session
• use diaries / monitoring
» include how related were the voices to your thoughts or worries or yourself

• Evaluating...
• examine evidence for and against
» including content
» use shadowing
» compatibility of modulators
• behavioural experiments
» drop/modify safety behaviours
» manipulate attentional biases
» control

• encourage one to be internally generated
• provide information re: research
• behavioural experiments using subvocalisation
• analysis of voice content in relation to thoughts
• education re: intrusive thoughts
• identify metacognitive beliefs
• challenge metacognitive beliefs

• Can mediate distress
• Identify using:
– modified DTR
– shadowing
– role play
– diaries

• Challenge using:
– link between thoughts and voices
– evidence for and against
– alternative explanations
– role play
– flashcards

• Content of voices often related to experience
• bullying
• sexual abuse / rape
• worthlessness
• evil
• guilty
• threat

• Challenge using Padesky’s (1994) techniques:
– continuum methods
– surveys
– historical test
– positive data logs

The rationale for homework
• The idea that homework enhances therapy should be replaced by the idea that therapy enhances homework .
Secondary gains of homework
• active
• achievement
• collaborative nature of the therapeutic relationship
• empowerment

• Decide work to be done jointly.
• Clearly identify the rationale for doing the homework.
• Check out obstacles.
• Make the homework meaningful but achievable.
• Establish prompts.
• Begin the use of homework from the first session.

• “I feel if I hadn’t done the homework that I had, then, and showed up to the sessions as well, I think it would have taken me a lot longer” (1)
• “…when I first like you know got told I was gonna have CBT you just expect you get better but it doesn’t, there’s a lot of like, you got a put a lot in yourself to get a lot out really” (7)
• “So once we had worked out that I was actually doing it right I could do it by myself”
(1)

• A powerful way to test alternative belief derived from verbal testing
• Facilitates ‘gut’ level change
• Links behaviour with personal meaning
• Specifically targeted - increases efficiency and effect
• Wider range of uses

Behavioural experiments
• Can include:
– Observations
– Surveys
– Acting ‘as if’
– Hypothesis testing (A/B)
– Increasing / Decreasing responses
– Symptom induction
– Role plays

• Be collaborative
• Motivation to complete them
• Practical implementation

• Behavioural experiments
– Drop safety behaviours
– Suppression vs. counter-suppression
– Recording
– Deliberate broadcasting to provoke responses
– Surveys


A cognitive model is required from which to empirically derive effective treatments:
FORMULATE USING MODEL
• What are you concerned about?
SHARE A GOAL
• You are not mad, you are normal:
NORMALISE
• Either it is real or you believe it to be real:
SIT ON A COLLABORATIVE FENCE
• How you appraise events contributes to distress:
EVALUATE USING E-T-F-B
• It’s not always what you think, sometimes it’s how you think
MODIFY CONTROL STRATEGIES
• Test it out – drop your safety behaviours:
EXPERIMENT IN & OUT OF SESSION

• Important to relate to goals (usually emotional change or changing ‘what I do’ to improve QoL)
• Use match between appraisal and emotion, and emotion and behaviour
• Only draw in arrows with agreement – otherwise investigate relationships
• Normalise the ‘story’
• Use arrows to plan treatment

• Agree a shared goal first and foremost
• Explicit structure and labels
• Focus on specifics, not general
• Leave plenty of time for ‘between session tasks’

• NICE guidelines say at least 16 sessions over at least 9 months
• Numerous meta-analyses in support (BUT as adjunct to antipsychotics in most participants)
• Aims to reduce distress and improve quality of life

• 1) either meet ICD-10 criteria for schizophrenia, schizoaffective disorder or delusional disorder or meet entry criteria for an Early Intervention for Psychosis service (operationally defined using PANSS) in order to allow for diagnostic uncertainty in early phases of psychosis
• 2) either have at least 6 months without antipsychotic medication and experiencing continuing symptoms OR never have received antipsychotics and be currently refusing
• 3) score at least 4 on PANSS delusions or hallucinations or at least 5 on suspiciousness/persecution, conceptual disorganisation or grandiosity

• Symptoms:
– PANSS
– Psychotic Symptom Rating Scales
(PSYRATS; Haddock, McCarron, Tarrier and
Faragher, 1999).
• Recovery
– A user-defined measure of recovery (QPR;
Neil et al., 2009)
• Functioning
– PSP

Allocation
Follow-Up
Analysis
Referred (n = 43)
Assessed for eligibility (n=
26)
Enrollment
Allocated to intervention
(n= 20)
Received allocated intervention
(n= 19, 1 withdrew after 1 session)
Assessed n =17 declined n = 1 withdrew n = 2
Analysed (n= 20)
Excluded from analysis
(n=0)
Last observation carried forward (LOCF) at end of treatment analysis (n = 3)
LOCF at follow up analysis
(n = 5)
Excluded (n= 6)
Not meeting inclusion criteria
(n= 5)
Refused to participate
(n= 1)

• Gender
– Male N = 10
– Female N = 10
• Age
– Mean = 26
– Range 16 - 56
• Ethnicity
– White British N = 16
– Black African N = 1
– Black Caribbean N = 1
– Other N = 2

• Schizophrenia N = 15
• Schizoaffective Disorder N = 4
• Delusional Disorder N = 1
• Disabling hallucinations N = 13
• Disabling delusions N = 17
• Both delusions and hallucinations N = 10

• 8 therapists contributed to the delivery of
CT within the trial.
• The number of participants treated by each ranged between 1 and 10.
• participants received a mean of 16.7 sessions (S.D. = 7.26; range 1 to 26)
• Acceptability: no participant not attending any sessions, and 19/20 receiving 6 or more sessions

Variable Baseline to end of treatment
0.87
PANSS positive
PANSS negative
PANSS general
PANSS total
1.00
0.51
0.85
PSYRATS delusions 0.98
PSYRATS voices 0.56
Baseline to 6 month follow up
1.05
0.77
1.06
1.23
0.99
0.79
PSYRATS total 0.90
1.07

PANSS total – mean scores at baseline, end of treatment and follow up
A significant difference from baseline to end of treatment was identified
(p = 0.001)
A significant difference from baseline to follow up was identified (p =
.0001)
45
39.55
40
35
29.05
30
25 21.88
20
15
10
5
0 baseline (SD=11.9) end of treatment
(SD=19.1)
6 month follow up
(SD=17.1)

Secondary outcomes
PANSS positive – mean scores at baseline, end of treatment and follow up
A significant difference from baseline to end of treatment was identified
(p = 0.01)
A significant difference from baseline to follow up was identified (p =
.001)
14
12
10
8
2
0
6
4
11.75
7.65
5.94
baseline (SD = 4.74) end of treatment (SD =
7.37)
6 month follow up (SD =
5.99)

Secondary outcomes
PSYRATS delusions – mean scores at baseline, end of treatment and follow up
A significant difference from baseline to end of treatment was identified
(p = 0.0001)
A significant difference from baseline to follow up was identified (p =
.001)
16
14
12
10
8
6
4
2
0
14.7
6.45
5.23
baseline (SD=6.66) end of treatment
(SD=7.07)
6 month follow up
(SD=6.3)

Secondary outcomes
PSYRATS voices – mean scores at baseline, end of treatment and follow up
A significant difference from baseline to end of treatment was identified
(p = 0.02)
A significant difference from baseline to follow up was identified (p =
.003)
25
19.35
20
15
10
5
0
10.81
9.48
baseline (SD=15.02) end of treatment (13.55) 6 month follow up
(12.34)

Variable
QPR total
PSP total
Pre treatment:
Mean (SD)
Post
Treatment:
Mean (SD)
Follow up:
Mean
(SD)
Pre- treatment to posttreatment t p d 95% CI t
Pre-treatment to follow-up p d 95% CI
48.83
(15.69)
57.22
(18.59)
60.96
(18.80)
-1.69
.110
.41
0.09,
0.90
-2.50
.024
0.65
0.08,
1.11
47.4
(13.80)
56.45
(18.37)
66.05
(18.31)
-2.44
.025
0.54
0.07,
1.01
-3.99
.001
0.87
0.34,
1.37

25%+ Decrease on PANSS = Good clinical outcome
25% +Increase on PANSS = Poor clinical outcome
Table 2. % decrease on PANSS total scores at end of therapy and follow up
Total N 0 – 24% increase
0% - 24% reduction
25% - 49%
Reduction
End of therapy
20 3 7 3
50% - 74% reduction
75% -
100% reduction
5 2
6 month follow up
20 2 7 1 6 4

18
16
14
12
10
8
6
4
2
0
0
Started on anti psychotic medication during therapy
3
17
Started on anti psychotic medication post therapy
Not started on anti psychotic medication

BAPS: negative change
PANSS total change
.465*
IVI: metaphysical change
IVI: control change
Age
DI
DUP
Number of sessions
Gender
-.187
.255
.443
-.774**
-.307
-.096
.000
PSYRATS delusions change
PSYRATS voices change
.426
-.078
.038
.277
.388
-.295
-.817**
-.476
-.026
-.018
.707**
-.529*
-.017
.127
-.083
-.152

BAPS: negative change
PANSS total change
.647**
IVI: metaphysical change
IVI: control change
Age
DI
DUP
Number of sessions
Gender
-.314
.088
-.318
-751**
-.377
0.22
-.038
PSYRATS delusions change
PSYRATS voices change
.468* -.280
-.096
.318
.260
-.348
-717**
-.368
.002
-.024
.470*
-.385
.036
.089
-.007
-.149

• Pilot study
– Small (N = 20)
– No control group
– No randomisation
– Rater bias?
– LOCF (but only one condition)

• Two site single blind RCT with two conditions
(CT plus TAU vs. TAU) for people with psychosis not taking antipsychotic medication
(due to refusal or discontinuation)
• Assessments are 3 monthly following the initial baseline assessment (i.e. at baseline, 3, 6, and 9 months)
• Follow-up assessments are at 12, 15 and 18 months
• n=74

PANSS subscale
PANSS positive total
PANSS negative total
PANSS general total
PANSS total
Mean
(S.D)
20.89
(4.91)
14.31
(4.61)
36.18
(7.70)
71.55
(13.76)

Antipsychotic naïve: discontinued ratio
Reasons for not taking anti-psychotic medication
Side effects
Philosophical view on psychosis – disagrees with the medical model/ preference for psychological treatment
Health reasons including pregnancy
Symptoms are unresponsive to anti-psychotic medication
Disagrees with diagnosis
Other
Data unable to be captured
34:40
23 (31.08)
15 (20.27)
5 (6.76)
4 (5.41)
6 (8.11)
16 (21.62)
5 (6.76)

• Treatment options for first episode psychosis
– If the child or young person and their parents or carers wish to try psychological interventions
(family intervention with individual CBT) alone without antipsychotic medication, advise that psychological interventions are more effective when delivered in conjunction with antipsychotic medication. If the child or young person and their parents or carers still wish to try psychological interventions alone, then offer family intervention with individual CBT. Agree a time limit(1 month or less) for reviewing treatment options, including introducing antipsychotic medication. Continue to monitor symptoms, level of distress, impairment and level of functioning, including educational engagement and achievement, regularly.

1.3.27 CBT should be delivered on a one-to-one basis over at least 16 planned sessions (although longer may be required) and: follow a treatment manual* so that
- children and young people can establish links between their thoughts, feelings or actions and their current or past symptoms, and/or functioning
- the reevaluation of the child or young person’s perceptions, beliefs or reasoning relates to the target symptoms also include at least one of the following components:
- normalising, leading to understanding and acceptability of their experience
- children and young people monitoring their own thoughts, feelings or behaviours with respect to their symptoms or recurrence of symptoms
- promoting alternative ways of coping with the target symptom
- reducing distress
- improving functioning.

• 1-8
– Problems and goals (confidence, self-esteem, low mood and self-harm, voices, low motivation)
– Formulation
– Continuum for low self-esteem
– Evidential analysis of self-critical thoughts
– Positive imagery
– Survey / results (judged, relationship, employ)

Experiences that worry me
Social situations
Voices
What I make of it
I am not good enough
I must harm myself
Voices are bullies
Others will harm me
What I do
Try to stay in control of thoughts
Isolate self and withdraw
Negative comparisons
Rituals
Daydreaming / dissociation
What I make of the self / world
I am different
I am unimportant and worthless
Need to be alert for danger
Other people cannot be trusted
Others will leave and reject me
Early experiences
Family criticism
Never fit in
Severe bullying at school and work
Wrongful arrest and harassment
How I feel
Low mood
Hopeless
Anxiety
Anger

• 9-11
– Revisit goals
– Negative comparisons
– I’m a failure
– Activity for mood
• 12-15
– Daydreaming and dissociation (normalising; pros/cons; diary; modified GAD model)
– Voices

• 16-18
– PTSD (grounding, attentional focus, reconsider meaning)
• 19-22
– Social anxiety (stop post-mortems, anticipation > event, stop safety behaviours, external focus, update image)

What I do
Arrive late
Avoid eye contact
Only speak to people I know
Speak with hand over mouth
Doodle/fidget
Hunch up and try to disappear trigger
Social situations
Negative thought
Others will judge me
Others will reject me
Image of self
Weak
Vulnerable
Hunched
Ugly
Very skinny
Unconfident
Shaky
How I feel
Anxiety
Tense
Palpitations
Sweaty
Shaky

• Progress:
– I am good enough 0% 80%
– Social confidence
– I am different
10% 70%
100% 50% (neutral)
– I’m as important as others 0% 80%
– No flashbacks, no self-harm, no suicidal thoughts
– Voices only at night and managable
– Getting married
– Doing postgraduate course

Study or Subgroup
ADDINGTON2011A
MORRISON2004
MORRISON2011
PHILLIPS2009
VAN DER GAAG2012
CBT SC
Events Total Events Total Weight
Risk Ratio
M-H, Random, 95% CI
7
7
9
0
2
16
26
95
29
75
10
6
20
3
5
15
16
93
19
86
2.5%
9.0%
24.4%
24.3%
39.7%
0.13 [0.01, 2.40]
0.25 [0.05, 1.12]
0.69 [0.27, 1.72]
0.76 [0.30, 1.93]
0.52 [0.25, 1.06]
Total (95% CI) 241 229 100.0%
Total events 25 44
Heterogeneity: Tau² = 0.00; Chi² = 2.77, df = 4 (P = 0.60); I² = 0%
Test for overall effect: Z = 2.57 (P = 0.01)
0.55 [0.35, 0.87]
Risk Ratio
M-H, Random, 95% CI
0.5
0.7
1 1.5
2
Favours CBT Favours SC

Study or Subgroup
CBT + risperidone SC
Events Total Events Total Weight
Risk Ratio
M-H, Random, 95% CI
MCGORRY2002
PHILLIPS2009 7
6 24
27
10
6
17 56.2%
19 43.8%
0.42 [0.19, 0.94]
0.82 [0.33, 2.06]
Risk Ratio
M-H, Random, 95% CI
Total (95% CI) 51 36 100.0%
Total events 13 16
Heterogeneity: Tau² = 0.02; Chi² = 1.13, df = 1 (P = 0.29); I² = 11%
Test for overall effect: Z = 1.73 (P = 0.08)
0.57 [0.30, 1.08]
0.5
0.7
1 1.5
2
Favours CBT + risperidone Favours SC

Study or Subgroup
PHILLIPS2009
ADDINGTON2011A
MORRISON2004
MORRISON2011
CBT
Mean SD Total
2.8
5.2
2.9
5.6
10.5417
3.05001
14.88
15.54
Mean
SC
SD Total Weight
Std. Mean Difference
IV, Random, 95% CI
27
27
3.1
6.6
3
4.7
35 10.9286
2.99908
95 20.84
17.75
18
24
23
93
12.9%
15.1%
16.6%
55.4%
-0.10 [-0.70, 0.50]
-0.27 [-0.82, 0.29]
-0.13 [-0.65, 0.40]
-0.36 [-0.64, -0.07]
Std. Mean Difference
IV, Random, 95% CI
Total (95% CI) 184
Heterogeneity: Tau² = 0.00; Chi² = 0.94, df = 3 (P = 0.82); I² = 0%
Test for overall effect: Z = 2.48 (P = 0.01)
158 100.0% -0.27 [-0.49, -0.06]
-1 -0.5
0 0.5
1
Favours CBT Favours SC

60
50
40
30
20
10
0
PACE
McGorry et al. 2002
[CBT plus risperidone]
EDIE
Morrison et al. 2004
[CT]
PRIME
McGlashan et al. 2006
[Olanzapine]
EDIE-2
Morrison et al. 2012
[CT]

NICE draft guideline:
Psychosis and schizophrenia in children and young people: recognition and management
• Treatment options for symptoms not sufficient for a diagnosis of psychosis or schizophrenia
• When transient or attenuated psychotic symptoms or other mental state changes are not sufficient for a diagnosis of psychosis or schizophrenia, consider:
– treatments recommended in NICE guidance for any recognised conditions such as anxiety, depression, emerging personality disorder or substance misuse, or
– individual or family cognitive behavioural therapy (CBT) to decrease distress (delivered as set out in recommendation
1.3.27). [1.2.5]
• Do not offer antipsychotic medication for psychotic symptoms or mental state changes that are not sufficient for a diagnosis of psychosis or schizophrenia, or with the aim of decreasing the risk of psychosis. [1.2.6]

t ARMS
Mean (SD)
Psychosis
Mean (SD)
P 95% CI
Self as abnormal 13.56 (2.53)
Expectations 10.43 (2.70)
Shame
Depression
Social anxiety
5.69 (1.36)
9.73 (4.48)
41.18
(16.98)
13.56 (3.33)
10.95 (2.64)
5.88 (1.42)
9.61 (4.73)
40.77 (18.03)
-.001
.999
-.760 - .759
-1.531
.127
-1.20 - .150
-.979
.187
.172
.328
.851
.864
-.562 - .189
-1.09 - 1.32
-4.33 - 5.16

BDI SIAS
ARMS Psychosis ARMS Psychosis
Self as abnormal
Expectations
Shame
.471**
.452**
.332**
.375**
.543**
.486**
.405**
.422**
.325**
.376**
.426**
.442**

30
25
20
15
10
5
0 baseline 6 12 24
CT
Monitoring

• “I never expected it to be a wondercure, and that Edie 2 at the end of it I was going to feel normal again, but in terms of looking at the horrible side of mental health, I feel as though they’ve confirmed that I’m not going down that road, and that’s helped me feel better inside I guess”
(m2)

• Minimise harm from medication, especially if no benefits
• Promote choice and alternatives
• Normalise / understand psychosis from a psychosocial perspective
• Reduce distress with CBT
• Promote recovery
• Promising for preventing first episodes of psychosis and reducing symptoms in UHR
• Work in genuine partnership with young people

• More research required
– Who benefits from antipsychotics
– Who benefits from CBT
– Alternatives evaluated in comparison to antipsychotics
– Other alternatives
• Reasons for optimism
– CBT reduces transition and symptoms in ARMS
– CBT is encouraging as an alternative to antipsychotics for established psychosis
– CBT without antipsychotics seems to work well for early phases of psychosis / young people

• “I feel if I hadn’t done the homework that I had, then, and showed up to the sessions as well, I think it would have taken me a lot longer” (1)
• “…when I first like you know got told I was gonna have CBT you just expect you get better but it doesn’t, there’s a lot of like, you got a put a lot in yourself to get a lot out really” (7)
• “I think what I struggled with was the fact that I was having to look at myself and em, and then there was like homework that came with it you know, and I struggled with that for a while purely and simply because I was having to look at myself” (t8)
• “To be honest there would have been times where there was no way I would have engaged with it or benefited from it…think you’ve got to be ready and motivated for it cos there is quite a lot of thinking and you need to be fairly open minded.” (3)