Book review of CBT for Psychosis: Process-Orientated Therapies and the Third Wave

Book Review of: CBT for Psychosis: Process-Orientated Therapies and the Third Wave (2019)

Edited by Caroline Cupitt (Published for ISPS by Routledge)

Third wave approaches to psychosis have been around for at least 10 years alongside burgeoning interest in the role childhood adversities and later trauma play in the emergence of psychosis.  Broadly-speaking, third wave cognitive behavioural therapies focus on emotions, compassion and de-centring from distressing experiences and process rather than content is emphasised. Such relational emphasis contrasts with second wave Cognitive Behavioural Therapy such as ‘traditional’ CBT for Psychosis (CBTp) recommended in current UK national guidance which emphasises the centrality of cognitions. Though offering potential for benefitting people living with psychosis, the sheer range of third wave approaches can seem overwhelming to experts by experience and practitioners alike. As a seasoned CBTp practitioner with training in several mindfulness-based approaches, I’m pleasantly surprised how this publication tackles this complexity in an accessible and meaningful way whilst remaining true to the unique aspects of each therapy.

The book is a collective work from eminent contributors all national or international experts within their fields with extensive lived and/or professional experience of therapeutic delivery of, or researching, third wave CBTp interventions and models. It skilfully collates the main developments and controversies regarding the applicability of third wave CBT, and process – orientated, approaches to psychosis. Starting with robust overviews of current and emerging theoretical perspectives regarding metacognitive, attachment-based, and, dissociative factors in the development and maintenance of psychosis, Part 1 sets the scene. An excellent chapter on attachment proposes future research priorities to develop clinical interventions for those with psychosis and complex traumatic relational histories. The pervasiveness of disorganised attachment patterns in relation to therapy and to people’s social and familial relationships is also considered.

Part 2 identifies the key features of the main third wave perspectives on CBTp, many of which seem trans-diagnostic. This whets readers’ appetites for discovering more about particular approaches whilst steadfastly focusing on person-centred collaboration, prioritising shared meaning-building and alleviating suffering. This part also stimulates interest in the delivery and evaluation of third wave CBTp and highlights lived experiences of those undergoing such therapies. These third wave ways of sense-making are presented not as devaluing traditional CBT which is acknowledged as providing firm foundations for these newer but equally valid interventions. However, this work definitively shifts away from the predominantly symptom-focused approach advocated in traditional CBTp to instead questioning how we relate to difficult (or unusual) experiences. All chapters (implicitly or explicitly) encourage this new stance for people living through psychosis and their supporters be they family members, friends or mental health staff. The publication also emphasises ‘getting alongside’ people arguably much more so that traditional CBTp (the Method Of Levels approach for instance advocates patient-led apt scheduling).

The final part of the book (Part 3) insightfully critiques earlier parts by considering some potential (though not necessarily insurmountable) disadvantages of ‘third wave CBTp’ including deconstructing the concept itself. It also elucidates similarities, differences and overlap between the various therapies. This is done in a grounded and accessible way which celebrates the complexity and diversity of CBTp and the fact   that ‘one size doesn’t fit all’. This part also imaginatively and succinctly sets out future challenges for CBTp – including adopting a more social view of psychological distress- and reiterates the value of supporting alternative therapies (i.e. ‘alternative’ in that they are not currently in national guidance for Psychosis) as well as alternatives to therapy. This proposed direction of travel which prioritises social justice and advocates a shift towards more integrative and pluralistic refinements of CBTp is described as a possible ‘fourth wave’ of CBTp.

One minor criticism is not all the chapters on specific therapeutic perspective include case vignettes. Also, scant reference is made to supervision and training requirments but in fairness this book never sets out to be a treatment manual.

This book will be extremely useful for clinicians unfamiliar with some or any of the therapies and for people living with psychosis and their supporters looking to better understand the pros and cons of different third wave CBTp approaches. I also recommend this eminently readable and thought-provoking publication to psychologists, therapists (of all modalities not just CBT), psychiatrists and mental health nurses; trainees in all those and similar professions as well as early career psychosis researchers, and, managers and commissioners of therapy services. In recognition of the empowering and potentially radical spirit of much of the volume’s content, maybe not only therapeutic teams but also co-constructed special interest groups or joint EBE/staff forums should aspire to read and discuss it together. Doing so will undoubtedly inform future developments in local delivery of CBTp to enhance people’s recovery journeys and meaningfully challenge social factors implicated in psychosis.

Reviewer: Jenny Droughton (Consultant Cognitive Therapist/Trainee Counselling Psychologist) 27/01/19