Understanding Cognitive Behavioral Therapy for Psychosis Through the Predictive Coding Framework.

Psychological treatments for persecutory delusions, particularly cognitive behavioral therapy for psychosis, are efficacious; however, mechanistic theories explaining why they work rarely bridge to the level of cognitive neuroscience. Predictive coding, a general brain processing theory rooted in cognitive and computational neuroscience, has increasing experimental support for explaining symptoms of psychosis, including the formation and maintenance of delusions. Here, we describe recent advances in cognitive behavioral therapy for psychosis-based psychotherapy for persecutory delusions, which targets specific psychological processes at the computational level of information processing. We outline how Bayesian learning models employed in predictive coding are superior to simple associative learning models for understanding the impact of cognitive behavioral interventions at the algorithmic level. We review hierarchical predictive coding as an account of belief updating rooted in prediction error signaling. We examine how this process is abnormal in psychotic disorders, garnering noisy sensory data that is made sense of through the development of overly strong delusional priors. We argue that effective cognitive behavioral therapy for psychosis systematically targets the way sensory data are selected, experienced, and interpreted, thus allowing for the strengthening of alternative beliefs. Finally, future directions based on these arguments are discussed.

Delusions are distressing and disabling psychiatric symptoms. Cognitive behavioral therapy for psychosis (CBTp) is the leading psychotherapeutic approach for treating delusions. Predictive coding is a contemporary cognitive neuroscience framework that is increasingly being used to explain mechanisms of delusions. In this article, we attempt to integrate CBTp within the predictive coding framework, outlining how effective CBTp techniques impact aspects of the predictive coding model to contribute to cutting-edge treatment and cognitive neuroscience research on delusions and inform recommendations for treatment advancement.

Cognitive behavioural therapy for psychosis: The end of the line or time for a new approach?

PURPOSE: Following its introduction in the early 1990s, cognitive behavioural therapy for psychosis (CBTp) has been evaluated in a large number of clinical trials and is now established as a recommended treatment in the UK National Health Service and elsewhere in the world. Meta-analyses, however, indicate modest effects compared to treatment as usual or comparison therapies such as supportive counselling. Here, we seek to identify factors impacting the effectiveness of CBTp, and avenues for future psychotherapy research that may improve outcomes. METHOD: We outline two recent umbrella reviews and discuss factors likely to impact the effectiveness of CBTp. RESULTS: Modest effect sizes from meta-analyses mask heterogeneous outcomes, with some people benefiting and others possibly being harmed by therapy. Common factors such as the therapeutic alliance play an important role in determining outcomes but have been largely neglected by CBTp researchers. There is also the promise of improving outcomes by identifying and targeting the psychological mechanisms that either maintain psychotic symptoms (e.g. worry) or are causally implicated (e.g. trauma). CONCLUSIONS: It is unlikely that everyone with psychosis will be equally responsive to the same therapeutic protocols. We need a new, personalised psychotherapy approach to CBTp research and practice, and can learn from research for anxiety and depression examining predictors of therapeutic response to inform treatment decisions. Precision psychological therapies informed by a combination of individual characteristics, common factors and a focus on specific mechanisms will require new research strategies and are likely to lead to improved outcomes for people with psychosis.

Ethnic differences in receipt of psychological interventions in Early Intervention in Psychosis services in England - a cross-sectional study.

There is some evidence of differences in psychosis care provision by ethnicity. We investigated variations in the receipt of Cognitive Behavioural Therapy for psychosis (CBTp) and family intervention across ethnic groups in Early Intervention in Psychosis (EIP) teams throughout England, where national policy mandates offering these interventions to all. We included data on 29,610 service users from the National Clinical Audit of Psychosis (NCAP), collected between 2018 and 2021. We conducted mixed effects logistic regression analyses to examine odds ratios of receiving an intervention (CBTp, family intervention, either intervention) across 17 ethnic groups while accounting for the effect of years and variance between teams and adjusting for individual- (age, gender, occupational status) and team-level covariates (care-coordinator caseload, inequalities strategies). Compared with White British people, every minoritized ethnic group, except those of mixed Asian-White and mixed Black African-White ethnicities, had significantly lower adjusted odds of receiving CBTp. People of Black African, Black Caribbean, non-African/Caribbean Black, non-British/Irish White, and of "any other" ethnicity also experienced significantly lower adjusted odds of receiving family intervention. Pervasive inequalities in receiving CBTp for first episode psychosis exist for almost all minoritized ethnic groups, and family intervention for many groups. Investigating how these inequalities arise should be a research priority.

Predictors of positive outcomes from 'Early Intervention in Psychosis': protocol for a national retrospective cohort study.

Background: Psychotic disorders are severe and prevalent mental health conditions associated with long-term disability, reduced quality of life, and substantial economic costs. Early Intervention in Psychosis (EIP) services aim to provide timely and comprehensive treatment for psychotic disorders, and EIP service input is associated with improved outcomes. However, there is limited understanding of the specific components of EIP care that contribute to these improvements. There is significant nationwide variability in the commissioning and delivery of EIP, with individuals receiving different packages of components from different services. In this study, we seek to explore associations between EIP components and clinically significant outcomes, in order to understand the mechanisms underlying improved psychosis care. Methods: This national retrospective cohort study will utilize data from the 2019 National Clinical Audit of Psychosis (NCAP), examining the care received by 10,560 individuals treated by EIP services in England. Exposure data from the NCAP, capturing the components of care delivered by EIP services, will be linked with outcome data from routine NHS Digital datasets over a three-year follow-up period. This will be the first study to use this method to examine this population in England. The primary outcomes will be surrogate measures of relapse of psychosis (hospital admission and referral to community-based crisis intervention services). Secondary outcomes include duration of admissions, emergency hospital attendances, episodes of detention under the Mental Health Act, and all-cause mortality. We will use multilevel regression to examine associations between exposures and outcome events. We will handle missing data using appropriate imputation techniques. Discussion: This study aims to provide valuable insights into the long-term effects of variations in EIP service delivery. The study involves a large, diverse cohort including individuals treated by every EIP service in England. While there are limitations inherent in the observational nature of the study, any associations identified will be of great relevance to clinicians, researchers, and policymakers seeking to optimize EIP care. The results will enable more targeted treatment planning, resource allocation, and potential innovations in EIP care, ultimately leading to improved prognoses for people experiencing psychosis.

CBTp for people with treatment refractory schizophrenia on clozapine: a systematic review and meta-analysis.

BACKGROUND: Cognitive behavioural therapy for psychosis (CBTp), an effective treatment for people with schizophrenia, may have a role in clozapine refractory schizophrenia. AIMS: A systematic-review and meta-analysis on the impact of CBTp on psychotic symptoms in people on clozapine. METHODS: We searched PubMed, Embase, PsycInfo, CINAHL and Cochrane for randomised control trials of CBTp as augmentation in people with treatment-refractory schizophrenia on clozapine and conducted pair-wise meta-analyses. RESULTS: Four studies met inclusion criteria. On pairwise meta-analyses, the primary outcome of total psychotic symptoms was not significantly altered by CBTp at either therapy endpoint or six to twelve months follow-up. Secondary outcomes showed that CBT improved positive symptoms at both therapy endpoint (SMD -0.33, 95%CI -0.50 to -0.16, p = 0.002, I2 = 0%) and six to twelve months follow-up (SMD -0.20, 95%CI -0.38 to -0.02, p = 0.03, I2 = 0%) though did not alter negative psychotic symptoms at either timepoint. CONCLUSIONS: CBTp may lead to small benefits for positive symptoms refractory to clozapine. Given the low risks associated with CBTp, and the limited alternative options for clozapine refractory schizophrenia, this approach should be considered in this population.

Crisis-focused Cognitive Behavioural Therapy for psychosis (CBTp) in acute mental health inpatient settings (the CRISIS study): protocol for a pilot randomised controlled trial.

BACKGROUND: Cognitive Behavioural Therapy for psychosis (CBTp) has an established evidence base and is recommended by clinical guidelines to be offered during the acute phases of psychosis. However, few research studies have examined the efficacy of CBTp interventions specifically adapted for the acute mental health inpatient context with most research trials being conducted with white European community populations. AIMS: The aim of this study is to conduct a pilot randomised controlled trial (RCT), which incorporates the examination of feasibility markers, of a crisis-focused CBTp intervention adapted for an ethnically diverse acute mental health inpatient population, in preparation for a large-scale randomised controlled trial. The study will examine the feasibility of undertaking the trial, the acceptability and safety of the intervention and the suitability of chosen outcome measures. This will inform the planning of a future, fully powered RCT. METHODS: A single-site, parallel-group, pilot RCT will be conducted examining the intervention. Drawing on principles of coproduction, the intervention has been adapted in partnership with key stakeholders: service users with lived experience of psychosis and of inpatient care (including those from ethnic minority backgrounds), carers, multi-disciplinary inpatient clinicians and researchers. Sixty participants with experience of psychosis and in current receipt of acute mental health inpatient care will be recruited. Participants will be randomly allocated to either the crisis-focused CBTp intervention or treatment as usual (TAU). DISCUSSION: Findings of this pilot RCT will indicate whether a larger multi-site RCT is needed to investigate the efficacy of the intervention. If the initial results demonstrate that this trial is feasible and the intervention is acceptable, it will provide evidence that a full-scale effectiveness trial may be warranted. TRIAL REGISTRATION: This trial has been prospectively registered on the ISRCTN registry ( ISRCTN59055607 ) on the 18th of February 2021.

Increasing Access to CBT for Psychosis: Development, Feasibility, and Acceptability of a Specialized Outpatient Service.

Despite the increasing demand for cognitive behavioural therapy for psychosis (CBTp), the existing literature is lacking in terms of models for sustainable implementation. The aims of this study were to: (a) describe the development of a specialized CBTp Service; (b) report demographic characteristics and referral patterns over 1 year to examine feasibility; and (c) review feedback from participants in group-based CBTp to examine acceptability. Data were analyzed from 126 referrals (M = 35.52, SD = 13.06, 59.5% men) to an outpatient CBTp Service at the Centre for Addiction and Mental Health (Toronto, Ontario) between January 2019 to January 2020. Anonymous feedback was obtained from 54 individuals who completed group-based CBTp. Positive symptoms and distressing emotions were the main reasons for referral. Over half of eligible referrals scheduled an intake assessment and 70% of individuals who completed this assessment attended further treatment. Primary reasons for service refusal were scheduling conflicts and illness-related barriers. The total service wait-time was two months, with the longest delay between dates of referral and initial contact. Satisfaction with the quality of CBTp and its components was rated high among group members. Although variable wait-times and engagement levels were identified across stages of the referral process, the CBTp Service demonstrates preliminary feasibility and acceptability, and provides a model of service delivery to incorporate within future CBTp implementation efforts in Canada.

Managing emotions in psychosis: Evaluation of a brief DBT-informed skills group for individuals with psychosis in routine community services.

OBJECTIVES: Individuals with psychosis report that emotion regulation (ER) difficulties are treatment priorities, yet little is known about how targeted ER interventions may help. We evaluated a new eight-session Dialectical Behavioural Therapy (DBT)-informed skills group specifically adapted for individuals with psychosis: the Managing Emotions Group (MEG) in diverse, inner-city community services. METHOD: A mixed-method design was utilised to assess the feasibility (acceptability and potential clinical impact) of local delivery of MEG. Uptake, completion (≥50% of sessions), post-session satisfaction ratings, and thematic analysis of qualitative feedback from 12 completers assessed acceptability. Pre-post-intervention changes in psychological distress, self-reported ER difficulties, and adaptive ER skill use assessed potential clinical impact. RESULTS: Forty-eight individuals (81% of attenders) completed the intervention (Mage = 43, 54% female) of whom 39 completed pre- and post-group measures. Participants reported high satisfaction and meaningful improvements in understanding and managing emotions, with positive impact on daily life. Self-reported psychological distress, ER difficulties, and adaptive ER skill use significantly improved, with medium-to-large pre-post effects (d = 0.5-0.7) except lack of emotional clarity (d = 0.3). CONCLUSIONS: MEG was feasible and acceptable, and a future feasibility randomised controlled trial is warranted. PRACTITIONER POINTS: Individuals with psychosis report that support with their emotions is a priority. Brief interventions for emotion regulation difficulties are acceptable to individuals with psychosis and can be feasibly delivered in a local outpatient service. Distress and emotion regulation difficulties and skills improved significantly from pre-post treatment for clients completing the managing emotions group. Further implementation and evaluation are needed to support continued refinement to meet the needs and priorities of individuals with psychosis.

Cognitive Behavioral Therapy for Prodromal Stage of Psychosis-Outcomes for Transition, Functioning, Distress, and Quality of Life: A Systematic Review and Meta-analysis.

OBJECTIVE: This study aimed to provide insight into the efficacy of cognitive-behavioral therapy for psychosis (CBTp) in patients with "clinical high risk of psychosis (CHR-P)". METHODS: Major scientific databases were searched up to April 17, 2020. Randomized controlled trials in CHR-P individuals, comparing CBTp with needs-based interventions (NBI, including treatment as usual or nonspecific control treatment) were included, following PRISMA guidelines. The primary outcome (efficacy) was transition to psychosis by 6 months, 12 months, 24 months, and over 24 months. Secondary outcomes were change in attenuated psychotic symptoms, depression, distress, improvements in functioning, and quality of life. RESULTS: Ten randomized controlled studies met inclusion criteria. The comparisons included 1128 participants. CBTp was significantly more efficacious in reducing rate of transition to psychosis by 6 months (after post-hoc sensitivity analysis) (relative risk [RR] = 0.44, 95% confidence interval [CI]: 0.26, 0.73), 12 months (RR = 0.44, 95% CI: 0.30, 0.64), 12 months (RR = 0.46, 95%CI: 0.30, 0.69), and over 24 months (RR = 0.58, 95% CI: 0.35, 0.95) after treatment, compared with those receiving NBI. CBTp was also associated with more reduced attenuated psychotic symptoms by 12 months (SMD = -0.17, 95% CI: -0.33, -0.02) and by 24 months (SMD = -0.24, 95% CI: -0.43, -0.06). No beneficial effects on functioning, depression, quality of life, or distress were observed favoring CBTp. CONCLUSIONS: CBTp is effective in reducing both psychosis transition rates and attenuated psychotic symptoms for the prodromal stage of psychosis. It is a promising intervention at the preventative stage.

Engagement with online psychosocial interventions for psychosis: A review and synthesis of relevant factors.

BACKGROUND: Little is known about factors associated with engagement with online interventions for psychosis. This review aimed to synthesise existing data from relevant literature to develop a working model of potential variables that may impact on engagement with online interventions for psychosis. METHODS: Online databases were searched for studies relevant to predictors of engagement with online interventions for psychosis; predictors of Internet use amongst individuals with psychosis; and predictors of engagement with traditional psychosocial treatments for psychosis. Data were synthesised into a conceptual model highlighting factors relevant to engagement with online interventions for psychosis. RESULTS: Sixty-one studies were identified. Factors relevant to engagement related directly to the impact of psychosis, response to psychosis, integration of technology into daily lives and intervention aspects. CONCLUSION: While several candidate predictors were identified, there is minimal research specifically investigated predictors of engagement with online interventions for psychosis. Further investigation examining both individual- and intervention-related factors is required to inform effective design and dissemination of online interventions for psychosis.

A systematic review and meta-analysis of cognitive behavioural informed psychological interventions for psychiatric inpatients with psychosis.

Psychological interventions such as Cognitive Behavioural Therapy for psychosis (CBTp) are recommended by the National Institute of Health and Care Excellence (NICE) for delivery in the acute phase of people's mental health difficulties. However, the effectiveness of cognitive behavioural informed psychological therapies for psychiatric inpatients is unknown. The aim of this review is to examine the type, quality and efficacy of cognitive behavioural informed psychological interventions for psychiatric inpatients experiencing psychosis. A systematic review and meta-analysis was conducted of randomised controlled trials examining the efficacy of cognitive behavioural informed psychological interventions offered to acute psychiatric inpatients with psychosis on primary (positive symptoms) and secondary outcomes of interest. A total of 23 studies were identified reporting on 18 trials of interventions such as CBTp, Acceptance and Commitment Therapy (ACT) and Metacognitive Therapy (MCT). Cognitive behavioural informed psychological interventions were found not be effective in reducing positive symptoms (primary outcome) at post-therapy and at follow-up but when a one study removed analysis was conducted a positive effect was found at both time points. In regard to secondary outcomes, cognitive behavioural informed psychological interventions demonstrated a significant favourable effect on negative symptoms (post-therapy), total symptoms (post-therapy and follow-up), functioning (post-therapy and follow-up) and readmission (follow-up). These psychological interventions may have potential to be effective for those admitted to psychiatric inpatient care and in acute crisis. However, findings are equivocal with evidence that these interventions have effect on some symptom measures but not others. Further examination of inpatient adapted cognitive behavioural informed psychological interventions is required.

Do Attitudes Matter? Evaluating the Influence of Training in CBT-p-Informed Strategies on Attitudes About Working with People Who Experience Psychosis.

Attitudes of mental health providers are an important consideration in training and delivering evidence-based practices. Treatment approaches for individuals who experience schizophrenia consistently endorse the importance of a recovery perspective. At the same time, a review of the literature suggests that the attitudes of many providers and many policies of community health care settings serving individuals who experience schizophrenia, may not align with the recovery perspective. This brief report provides a summary of the program evaluation outcomes of a wide range of mental health providers who participated in a 2-day intensive training to learn strategies informed by Cognitive Behavioral Therapy for Psychosis (CBT-p). This intensive training emphasizes engagement strategies and person-centered approaches inherent in the recovery perspective. Consistent with the aims of the training, participants' attitudes about working with people who experience psychosis appeared to be positively influenced by training.

Corrigendum: Does Cognitive Behavior Therapy for psychosis (CBTp) show a sustainable effect on delusions? A meta-analysis.

[This corrects the article DOI: 10.3389/fpsyg.2015.01450.].

Cognitive Behavioural Therapy for schizophrenia - outcomes for functioning, distress and quality of life: a meta-analysis.

BACKGROUND: The effect of cognitive behavioural therapy for psychosis (CBTp) on the core symptoms of schizophrenia has proven contentious, with current meta-analyses finding at most only small effects. However, it has been suggested that the effects of CBTp in areas other than psychotic symptoms are at least as important and potentially benefit from the intervention. METHOD: We meta-analysed RCTs investigating the effectiveness of CBTp for functioning, distress and quality of life in individuals diagnosed with schizophrenia and related disorders. Data from 36 randomised controlled trials (RCTs) met our inclusion criteria- 27 assessing functioning (1579 participants); 8 for distress (465 participants); and 10 for quality of life (592 participants). RESULTS: The pooled effect size for functioning was small but significant for the end-of-trial (0.25: 95% CI: 0.14 to 0.33); however, this became non-significant at follow-up (0.10 [95%CI -0.07 to 0.26]). Although a small benefit of CBT was evident for reducing distress (0.37: 95%CI 0.05 to 0.69), this became nonsignificant when adjusted for possible publication bias (0.18: 95%CI -0.12 to 0.48). Finally, CBTp showed no benefit for improving quality of life (0.04: 95% CI: -0.12 to 0.19). CONCLUSIONS: CBTp has a small therapeutic effect on functioning at end-of-trial, although this benefit is not evident at follow-up. Although CBTp produced a small benefit on distress, this was subject to possible publication bias and became nonsignificant when adjusted. We found no evidence that CBTp increases quality of life post-intervention.

Identifying the "Therapy Targets" for Treating the Negative Symptoms of Psychosis Using Cognitive Behavioral Therapy.

The division of psychotic symptoms into positive and negative categories has largely divided the research on them. While the research on positive symptoms of psychosis has rapidly developed over the last three decades, the literature on negative symptoms has noticeably lagged behind. Negative symptoms have likely been ignored in the treatment literature because they were previously thought to remit following the treatment of positive symptoms. Recent evidence does not consistently support this theory and indicates that the different manifestations of negative symptoms require distinct approaches to treatment. The current review provides a re-evaluation of the theoretical literature on negative symptoms to inform and identify "treatment targets" to reduce them. The "treatment targets" are then translated into intervention strategies using a cognitive behavioral framework. A review of the empirical literature on cognitive behavior therapy for treating negative symptoms is then offered along with a critical discussion of where cognitive behavior therapy stands compared to other interventions and what research is still needed.

Understanding clinician attitudes towards implementation of guided self-help cognitive behaviour therapy for those who hear distressing voices: using factor analysis to test normalisation process theory.

BACKGROUND: The Normalisation Process Theory (NPT) has been used to understand the implementation of physical health care interventions. The current study aims to apply the NPT model to a secondary mental health context, and test the model using exploratory factor analysis. This study will consider the implementation of a brief cognitive behaviour therapy for psychosis (CBTp) intervention. METHODS: Mental health clinicians were asked to complete a NPT-based questionnaire on the implementation of a brief CBTp intervention. All clinicians had experience of either working with the target client group or were able to deliver psychological therapies. In total, 201 clinicians completed the questionnaire. RESULTS: The results of the exploratory factor analysis found partial support for the NPT model, as three of the NPT factors were extracted: (1) coherence, (2) cognitive participation, and (3) reflexive monitoring. We did not find support for the fourth NPT factor (collective action). All scales showed strong internal consistency. Secondary analysis of these factors showed clinicians to generally support the implementation of the brief CBTp intervention. CONCLUSIONS: This study provides strong evidence for the validity of the three NPT factors extracted. Further research is needed to determine whether participants' level of seniority moderates factor extraction, whether this factor structure can be generalised to other healthcare settings, and whether pre-implementation attitudes predict actual implementation outcomes.

Identification of the delivery of cognitive behavioural therapy for psychosis (CBTp) using a cross-sectional sample from electronic health records and open-text information in a large UK-based mental health case register.

OBJECTIVE: Our primary objective was to identify cognitive behavioural therapy (CBT) delivery for people with psychosis (CBTp) using an automated method in a large electronic health record database. We also examined what proportion of service users with a diagnosis of psychosis were recorded as having received CBTp within their episode of care during defined time periods provided by early intervention or promoting recovery community services for people with psychosis, compared with published audits and whether demographic characteristics differentially predicted the receipt of CBTp. METHODS: Both free text using natural language processing (NLP) techniques and structured methods of identifying CBTp were combined and evaluated for positive predictive value (PPV) and sensitivity. Using inclusion criteria from two published audits, we identified anonymised cross-sectional samples of 2579 and 2308 service users respectively with a case note diagnosis of schizophrenia or psychosis for further analysis. RESULTS: The method achieved PPV of 95% and sensitivity of 96%. Using the National Audit of Schizophrenia 2 criteria, 34.6% service users were identified as ever having received at least one session and 26.4% at least two sessions of CBTp; these are higher percentages than previously reported by manual audit of a sample from the same trust that returned 20.0%. In the fully adjusted analysis, CBTp receipt was significantly (p<0.05) more likely in younger patients, in white and other when compared with black ethnic groups and patients with a diagnosis of other schizophrenia spectrum and schizoaffective disorder when compared with schizophrenia. CONCLUSIONS: The methods presented here provided a potential method for evaluating delivery of CBTp on a large scale, providing more scope for routine monitoring, cross-site comparisons and the promotion of equitable access.

Converging effects of diverse treatment modalities on frontal cortex in schizophrenia: A review of longitudinal functional magnetic resonance imaging studies.

OBJECTIVES: A variety of treatment options exist for schizophrenia, but the effects of these treatments on brain function are not clearly understood. To facilitate the development of more effective treatment strategies, it is important to identify how brain function in schizophrenia patients is affected by the diverse therapeutic approaches that are currently available. The aim of the present article is to systematically review the evidence for functional brain changes associated with different treatment modalities for schizophrenia. METHODS: We searched PubMed for longitudinal functional MRI (fMRI) studies reporting on the effects of antipsychotic medications (APM), repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS), cognitive remediation therapy (CRT) and cognitive behavioral therapy for psychosis (CBTp) on brain function in schizophrenia. RESULTS: Thirty six studies fulfilled the inclusion criteria. Functional alterations were observed in diverse brain regions. Across intervention modalities, changes in fMRI parameters were reported most commonly in frontal brain regions including prefrontal cortex, anterior cingulate and inferior frontal cortex. CONCLUSIONS: We conclude that current treatments for schizophrenia commonly induce functional brain alterations in frontal brain regions. However, interpretability is limited by inconsistency in task and region of interest selection, and failures to replicate. Further task independent fMRI studies examining treatment effects with whole brain analysis are needed to deepen our insights.

Cognitive Behavioral Therapy for Psychosis (CBT-p) Delivered in a Community Mental Health Setting: A Case Comparison of Clients Receiving CBT Informed Strategies by Case Managers Prior to Therapy.

This exploratory case comparison examines the influence of case management activities on engagement and progress in psychotherapy for clients with schizophrenia. Six clients were recruited to participate in ten sessions of Cognitive Behavioral Therapy for psychosis (CBT-p). Three clients who had received Cognitive Behavioral techniques for psychosis (CBt-p, a low-intensity case management intervention) prior to receiving therapy were selected from referrals. A comparison group of three clients who had received standard case management services was selected from referrals. Cases within and across groups were compared on outcome measures and observations from case review were offered to inform future research. Delivering CBT-p services on a continuum from low- to high-intensity is discussed.