Attachment-based CBT for psychosis: a single case experimental design

Best practice guidelines recommend CBT for everyone with psychosis, yet high rates of non-engagement and early drop-out result in many not receiving 'full dose' therapy. For those who do engage, effect sizes are typically modest. Most people with psychosis have an insecure attachment style, characterised by predictable and problematic patterns of beliefs, emotion regulation and interpersonal behaviours, including help-seeking. Attachment-congruent adaptations to CBT could improve retention and recovery outcomes for people who are also insecurely attached.

This is the first evaluation of attachment-congruent adaptations to CBT for psychosis. We assessed impact of therapy for the first five people (aged 30-50) to complete therapy and measures.

We used a single case ABC design and measured paranoia, voices, help-seeking, coping, and personal goals over baseline, intervention, and follow-up phases. We predicted that adapted CBT would lead to improved outcomes which would be maintained at follow-up. Trait measures of voices, paranoia, attachment, and recovery are used to describe the sample.

Participants presented with complex needs, including paranoia, voices, and attachment insecurity. Baseline phases showed high and variable levels of psychosis. All showed improvements in paranoia, voices, willingness to seek help, ability to cope, and/or personal recovery goals over the intervention phase. Gains were largely maintained or improved further at follow-up.

Attachment-congruent adaptations to CBT are likely to benefit people with psychosis who present with the additional cognitive, affective and behavioural complexities characteristic of insecure attachment, which threaten access and impact of recommended treatments if not addressed.