PRESENTASI JOURNAL READING KE II

Group Cognitive Behavioural Therapy for Psychosis in The Asian

Context: a Review of The Recent Studies

Oleh:
Ika Agitra Ningrum
S572108004

Pembimbing:
Dr. dr. Adriesti Herdaetha, Sp.KJ, M.H.

PPDS-I PSIKIATRI FAKULTAS KEDOKTERAN

UNIVERSITAS SEBELAS MARET/ RSUD. dr. MOEWARDI
SURAKARTA
2022
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Group Cognitive Behavioural Therapy for Psychosis in The Asian

Context: a Review of The Recent Studies

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Tanggal ______Bulan_______2022

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Dr. dr. Adriesti Herdaetha, Sp.KJ, M.H. ..................................................

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dr. Rahaju Budhi Muljanto, Sp.KJ ....................................................

dr. Wahyu Nur Ambarwati, Sp. KJ ....................................................

Sie Ilmiah
 HALAMAN PENGESAHAN

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 International Review of Psychiatry

ISSN: 0954-0261 (Print) 1369-1627 (Online) Journal homepage: https://www.tandfonline.com/loi/iirp20

Group cognitive behavioural therapy for psychosis

in the Asian context: a review of the recent studies

Jade P. S. Wong, Ka Tsun Ting & Agatha W. S. Wong

To cite this article: Jade P. S. Wong, Ka Tsun Ting & Agatha W. S. Wong (2019): Group cognitive
behavioural therapy for psychosis in the Asian context: a review of the recent studies, International
Review of Psychiatry, DOI: 10.1080/09540261.2019.1634012

To link to this article: https://doi.org/10.1080/09540261.2019.1634012

Published online: 24 Jul 2019.

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INTERNATIONAL REVIEW OF PSYCHIATRY
https://doi.org/10.1080/09540261.2019.1634012

REVIEW ARTICLE

Group cognitive behavioural therapy for psychosis in the Asian context: a

review of the recent studies
Jade P. S. Wonga, Ka Tsun Tingb and Agatha W. S. Wongb
a
Department of Psychiatry, The University of Hong Kong, HKSAR, Hong Kong, PR China; bClinical Psychology Service,
Kowloon Hospital, HKSAR, Hong Kong, PR China

ABSTRACT ARTICLE HISTORY

The cardinal symptoms of psychosis include hallucination and delusion, which can be both dis- Received 4 March 2019
tressing and disabling. International guidelines recommend cognitive behavioural therapy for Accepted 13 June 2019
psychosis (CBTp) as an adjunctive intervention to medication management. Considering the dif-
KEYWORDS
ficulty in the widespread dissemination of the individual CBTp, group CBTp is an alternative in
Group therapy; CBT;
improving patients’ access to psychological intervention. Although it has been found feasible psychosis; schizophrenia;
and effective in various studies, systematic review on group CBTp, particularly in Asia, was not group CBT
identified. Hence, this systematic review tried to examine the recent evidence of group CBTp in
Asia in order to shed light on its implementation in routine psychiatric care. A relevant literature
search was conducted in three databases (Pubmed, Web of Knowledge, and PsycINFO) during
the period from January 2000 to December 2018. A total of 114 journal articles were identified.
After a full-text review, four studies met our inclusion and exclusion criteria. Despite methodo-
logical shortcomings, positive results were found in terms of improvements on psychotic symp-
toms, functioning, and quality-of-life. These encouraging results indicate the need for future
research studies with more rigorous methodology, leading to a better understanding on the
applicability and effectiveness of group CBTp in the Asian context.

Introduction suggested as one of the possibilities to bridge the gap

Hallucinations and delusions are considered as the
key defining features of schizophrenia and other
psychotic disorders, associated with patients’ distress
level and functional impairments (APA, 2013).
Pharmacotherapy which targets on regulating dysre-
gulated neurotransmitters in the brain is considered
as the first line treatment for schizophrenia; however,
adjunctive treatments are still needed because of the
inadequate effects of anti-psychotic medication (Stahl,
1999). For example, some studies have shown that
medication-resistant psychosis is not uncommon.
Approximately 20–45% of patients with schizophrenia
remained symptomatic despite adequate trials of
pharmacological treatment (Curson et al., 1985; Kane,
1996, 1999). Around 5–10% of psychotic patients
were non-responsive to any form of medication
(Pantelis & Barnes, 1996). Besides the high rates of
medical non-compliance, relapse, and social disability
arose concerns on the use of monotherapy for schizo-
phrenia (Lieberman et al., 2005; Sarti & Cournos,
1990). Psychosocial intervention was, therefore,
(Pantelis & Lambert, 2003; Warman & Beck, 2003).
Different forms of psychosocial intervention were rec-
ommended such as social skills training, family inter-
vention, cognitive rehabilitation, and coping with
residual positive symptoms to improve the illness
course of psychosis (Penn & Mueser, 1996). Among
these diverse psychological interventions, cognitive
behavioural therapy for psychosis (CBTp) has demon-
strated more promising results in reducing distress
and enhancing patients’ coping on positive symptoms
in several meta-analyses (Burns, Erickson, & Brenner,
2014; Gould, Mueser, Bolton, Mays, & Goff, 2001;
Jauhar et al., 2014; Wykes, Steel, Everitt, & Tarrier,
2008). Clinical guidelines published by the British
National Institute for Health and Clinical Excellence
(NICE, 2009, 2014) (now known as the National
Institute for Health and Care Excellence) and the US
Schizophrenia Patients Outcomes Research Team
(Dixon et al., 2010) also recommend that individual-
based CBTp should be provided as an adjunctive
treatment to all people with schizophrenia.

CONTACT Agatha W. S. Wong agathaws@hotmail.com Clinical Psychology Service, Kowloon Hospital, 147A Argyle Street, Kowloon, HKSAR, Hong
Kong, PR China
ß 2019 Institute of Psychiatry and Johns Hopkins University
2 J. P. S. WONG ET AL.
CBTp was originated in western countries.
Evidence is emerging to support the effectiveness of
culturally adapted CBTp for people with psychosis in
Asian countries. In Hong Kong, there were a case
report and a pilot study suggesting that CBTp might
be helpful in reducing psychotic symptoms and
related distress in hospital and community settings
(Ng, Cheung, & Suen, 2003; Ng, Hui, & Pau, 2008).
In Pakistan, CBTp was found to be effective in
improving positive symptoms, negative symptoms and
insight (Habib, Dawood, Kingdon, & Naeem, 2015;
Naeem et al., 2015). In China, results of a large scale
randomized controlled trial suggested that CBTp
could help to improve positive symptoms, insight,
and social functioning compared to supportive ther-
apy in hospital setting (Li et al., 2015). Another large
scale randomized controlled trial found that patients
who had received brief CBTp had greater improve-
ment in overall symptoms, general psychopathology,
insight, and social functioning compared to the
treat-as-usual group in community setting (Guo
et al., 2017).
Although CBTp appeared to be effective after it
was culturally adapted to Asian countries, to the best
of our knowledge, no systematic review was available
to investigate its effectiveness and efficacy. Besides,
the availability of CBTp in routine clinical setting was
still limited. Li et al. (2017) conducted a qualitative
study with patients, carers, and mental health profes-
sionals on their views of mental health service for
psychosis in China. Only a few patients or carers had
heard of psychotherapy, and none of them had
received CBTp. Naeem et al. (2016) and Li et al.
(2017) mentioned that a lack of training for mental
health professionals in offering CBTp and a lack
of awareness of therapy among patients or carers
were barriers to the availability of CBTp in
Asian countries.
To successfully implement CBTp in routine clinical
setting demands a large number of CBTp therapists.
However, the complexity of the psychopathology of
psychosis requires therapists to have advanced clinical
skills and sensitivity. CBTp is commonly delivered by
well-trained cognitive behavioural therapists and it
makes the broad dissemination of individual CBTp
relatively difficult (Thomas et al., 2014). Therefore,
the delivery of CBTp in a group format could be a
viable option to improve patients’ access to evidence-
based psychotherapy.
Over the years, group CBTp has already been
found to be feasible and effective (Bechdolf, Kohn,
Knost, Pukrop, & Klosterkotter, 2005; Chadwick,
Sambrooke, Rasch, & Davies, 2000; Lecomte et al.,
2008). Apart from the potential to improve access to
psychological intervention, group CBTp appears to be
more effective for people with early psychosis, as it
can help address the uncertainty about illness (Saksa,
Cohen, Srihari & Woods, 2009).
Although research evidence supports the effective-
ness of CBTp, the dissemination and implementation
of CBTp remains a challenge (Sarin, Wallin, &
Widerl€ov, 2011; Wykes et al., 2008). As reviewed
above, CBTp is even not well-developed in Asian
countries. Given group treatment format might help
improve the accessibility of CBTp, it would be inter-
esting and worthwhile to understand the applicability
and effectiveness of group CBTp in Asian countries.
The present review attempts to systematically evaluate
the effectiveness of the recent development of group
CBTp in the Asian context.
Methodology
Search strategy
Following the PRISMA guidelines (Moher, Liberati,
Tetzlaff, & Altman, 2009), a systematic literature
search on the chosen topic was conducted. Papers
that met the selection criteria were included in this
review and analysis. We included the literature pub-
lished from January 2000 to the third week of
December 2018. There were three key concepts under
the search questions: group, cognitive behavioural ther-
apy, and psychosis. They were keyword-based using
standardized searchable subject headings in order to
facilitate a proper and comprehensive search among
journal articles. Those relevant terms were then used
as keywords in the following database searches:
Pubmed, PsycINFO, and Web of Knowledge. Various
combinations of keywords using the Boolean logic
were employed. The following key-word-string was
adapted as the final search parameters. Some modifi-
cations were made in order to suit the search charac-
teristics of different databases.
[Group psychotherapy] OR [Group therapy]
AND
[Cognitive behavioural therapy] OR [Cognitive behav-
iour therapy] OR [Cognitive psychotherapy] OR
[Cognitive Therapy]
AND
[Psychosis] OR [Psychotic disorders] OR
[Schizophrenia]

Table 1. Search inclusion and exclusion criteria.
Inclusion criteria
Studies must be randomized controlled trials or controlled clinical trials
Outcome measures were original quantitative data and analysis
Study subjects were adults (aged 18–64)
Subjects with known diagnoses of psychotic disorders
Studies using structured psychological interventions in group format
Exclusion criteria
Qualitative studies or case studies (n < 3)
Meta-analyses, systematic review, or other review papers
Studies focusing on medical diagnoses other than psychiatric ones
Studies involved pharmacotherapy only
Studies not done in Asia
Studies not published in English
Selection criteria
To be eligible for this review, studies should be ori-
ginal CBT research studies involving adults with
known diagnoses of schizophrenia or psychotic disor-
ders. The intervention protocols should be standar-
dized and delivered in a group format. Originally, we
would like to include only those randomized con-
trolled trials (RCTs) in order to ensure the highest
research quality. However, due to the very limited
search results, we broadened the selection criteria to
include those CBTp being tested under controlled
studies. Qualitative studies, case studies, and system-
atic review papers were excluded. Only English-lan-
guage journals were selected for easy referencing.
Finally, in order to ensure the identified studies were
conducted in Asia, we included ‘location’ as add-
itional filters. Table 1 presents the inclusion and
exclusion criteria.
Screening and eligibility assessment
All records identified through database searches and
any additional records from other sources were
imported into Endnote, a commercial reference man-
agement software, which removed duplicated records,
if any. Initial inspection of journal titles and abstracts
was done manually according to the inclusion and
exclusion criteria. Papers that did not meet selection
criteria were screened out. The full texts of the
remaining articles were assessed for eligibility. The
authors of this review read all the full texts for eligi-
bility assessment and established inter-reviewer
reliability.
Data extraction and analysis
A data extraction form using Excel was developed
with reference to the checklist of the Critical
Appraisal Skills Programme (CASP, 2018) for the
evaluation of randomized controlled trials (RCT).
INTERNATIONAL REVIEW OF PSYCHIATRY 3
Since only two papers employed RCT, some appraisal
criteria (e.g. randomization procedure, baseline char-
acteristics of different groups, blinding to treatment
conditions) could not be compared. Due to the het-
erogeneity of the target participants, primary outcome
measures, and statistical methodologies of the papers
involved (see the Results section), a statistical meta-
analysis of the data might not be appropriated
(Snilstveit, Oliver, & Vojtkova, 2012). Instead, a nar-
rative approach was used in this review.
Results
With reference to our selection criteria and search
strategy, 114 journal articles were identified in the
three databases. No duplication was found. Initial
screening excluded 106 studies for their irrelevancy or
not being conducted in Asia. Out of the remaining
eight papers, four symposium posters (Kang et al.,
2012; Kim, 2016; Kim et al., 2014, 2016) were
excluded as details of the studies were not available.
Surprisingly, only four studies fully met our inclusion
and exclusion criteria, and were regarded as eligible
for this review. Figure 1 shows the database search
flow diagram of this review. Overview and character-
istics of the four studies are summarized as below
and in Table 2.
Summary of the studies
Guo et al. (2010) conducted a study in China to
evaluate the effectiveness of medication treatment
alone against a combined treatment group which
included medication, group CBTp, psychoeducation,
family intervention, and skills training. It was a large-
scale RCT involving 1268 Chinese patients
(16–50 years old) with early-stage (<5 years) schizo-
phrenia or schizophreniform disorder among 10 clin-
ical sites in China. The combined treatment group
received 48 1-h sessions, of which group CBTp was
offered one session a month, over a 1-year period.
Their team of psychiatrists and one research assistant
assessed all the participants at baseline, 6 months, and
12 months. The main outcome measures were the
rate of treatment discontinuation and time-to-discon-
tinuation due to any causes. The levels of psychotic
symptoms, insight, treatment adherence, quality-of-
life, and social functioning were obtained as second-
ary outcomes. They found that comparing with the
control group, i.e. patients only with anti-psychotic
medication, the combined treatment group showed a
significantly lower rate of treatment discontinuation
4 J. P. S. WONG ET AL.
Figure 1. Database search flowchart.
(32.8% vs 46.8%), risk of any-cause treatment discon-
tinuation (hazard ratio ¼ 0.62; p < 0.001), and risk of
relapse (hazard ratio ¼ 0.57; p < 0.001). Patients in the
combined treatment group also demonstrated greater
improvement in their insight, social functioning,
activities of daily living, and quality-of-life.
Chung, Yoon, Park, Yang, and Oh (2013) carried
out a study in Korea to measure the treatment effect
of group CBTp among 24 young adults (18–35 years
old) with first episode or recent-onset (<5 years)
psychosis. Their treatment protocol consisted of 12
weekly sessions of 90 min each, focusing on enhanc-
ing emotional flexibility, thought flexibility, and per-
sonality flexibility, as well as changing life’s direction.
The intervention’s effectiveness was evaluated through
pre–post treatment comparison using both objective
assessments by blinded raters and self-reported meas-
ures. Their outcome measures were primarily on
psychotic symptoms. The secondary outcome meas-
ures covered multi-dimensionalities of mood, negative
symptoms, functioning, schema, and insight. Paired t-
tests revealed that most of the outcome measures,
except insight, showed significant improvement after
the intervention, with effect size ranging
from 0.38–1.21.
Kim et al. (2017) did a retrospective study to
evaluate the effect of a group CBTp intervention
among 34 youth and young Korean adults
(15–35 years old) with recent-onset (<5 years) psych-
otic disorders. The treatment protocol involved 14
sessions and consisted of three components: meta-
cognitive training, cognitive restructuring, and stress
management. Participants first received five sessions
of meta-cognitive training that focused on the dys-
functional coping styles and cognitive biases involved
in the formation and maintenance of psychotic symp-
toms. After the meta-cognitive training, participants
would receive three sessions of cognitive restructuring
based on the Beck’s cognitive therapy model. Then,
three-to-four sessions on lifestyle management includ-
ing stress management, self-esteem enhancement,
time management, and goal-setting would be pro-
vided. Each group had five-to-nine patients. They
were asked to complete self-rated outcome measures
on their subjective well-being, drug attitude, depres-
sive symptoms, perceived stress, and social cognition
at baseline and following the intervention. The assess-
ments on illness severity and treatment responses
were administered by the case managers. Similar to
the abovementioned studies, no follow-up assessments
on the maintenance treatment effects were arranged.
The researchers divided the participants according to
the median duration of the untreated psychosis
(DUP) (i.e. 4 months) and further analysed the
Table 2. Articles included in the review.
Intervention
Number of format & Amount of contact Follow-up
Paper Country Type of study Sampling method Subject Subject age subjects duration for CBT content period Outcome measures Main results
Guo et al. China Randomized Convenience Recent onset 16–50 (mean ¼ 1268 Combined treatment 12 h (1 h  12 Nil Primary: treatment Significantly lower risk of
(2010) controlled sampling from 6 (<5 years) 26.1 ± 7.6 consisting monthly sessions) dis-continuation; treatment
trials university clinics schizophrenia or vs 26.3 ± 8.0) of a 6-people group time to treatment discontinuation and
and 4 province schizophreniform CBTp, psychoeducation, discontinuation relapse in the combined
mental disorder family intervention, and Secondary: treatment group;
health agencies skills training (4 topics PANSS; ITAQ; SF- greater improvement in
 1 h  12 months), 36; GAS; ADL ITAQ, GAS, ADL, and SF-
plus medications 36 for combined
(n ¼ 580) vs Medication treatment, but no
treatment significant changes in
only (n ¼ 604) PANSS scores
Chung et al. Korea Controlled Convenience 1st episode or recent 18–35 (mean 24 Group CBT with four 18 h (1.5 h  12 Nil Primary: AIHQ; Significant decrease in
(2013) clinical trials sampling from onset (<5 ¼ 25.7 ± 4.8) themes: emotional weekly sessions) PANSS; PSYRATS AIHQ ambiguous
Chonbuk National years) psychosis flexibility, thought Secondary: SANS; situations, all PANSS
University flexibility, personality SOFAS; BCSS; scores, and PSYRATS for
Hospital flexibility, and TAS-20; TMMS-30; delusion; positive
life’s direction BCIS; SUMD changes in some 2nd
measures including
BCSS, SANS, SOFAS,
TAS-20, and TMMS
Kim et al. Korea Controlled Convenience Recent onset (<5 15–35 (mean 34 (DUP  4 m, Group CBT of five-to-nine 14 h (1 h  14 Nil SWN-K; AIHQ; DAI; Significant increase in
(2017) clinical trials sampling from years) psychosis ¼ 23.2 ± 4.7) n ¼ 18; DUP patients with three weekly sessions) BDI; PSS; CGI SWN-K & DAI scores
(retrospective Gwangju Bukgu- >4 m, components: meta- and decrease in AIHQ
chart review) Community n ¼ 16) cognitive training, hostility sub-scale, PSS,
Mental cognitive restructuring, & CGI scores; significant
Health Center and time  DUP interaction
lifestyle management effects in SWN-K, DAI,
and BDI scores with
improvement in the
short DUP group
Li et al. China Randomized Stratified cluster Schizophrenia 18–50 (mean ¼ 327 Comprehensive 8 h (2 h  4 Nil ISMI; DISC-12; GAF; No significant reduction in
(2018) controlled random sampling 40.2 ± 7.57 intervention with four monthly sessions) SQLS; SES; BPRS; ISMI on both groups;
trials in 12 regions vs 39.7 ± 7.8) components PANSS-N significant reduction on
of Guangzhou (psychoeducation, social anticipated
skills training, CBT, and discrimination, BPRS, &
strategies against PANSS-N, and increase
stigma & discrimination) in overcoming stigma &
in a 15–20 people GAF in the
group (3 modules  8 intervention group
phases  2 h over 9
months) (n ¼ 169) vs
Control receiving
monthly face-to-face
interviews (n ¼ 158)
ADL: Activities of Daily Living Scale; AIHQ: Ambiguous Intention Hostility Questionnaire; BCIS: Beck Cognitive Insight Scale; BCSS: Brief Core Schema Scale; BDI: Beck Depression Inventory; BPRS: Brief Psychiatric Rating Scale; CGI:
Clinical Global Impression; DAI: Drug Attitude Inventory; DISC-12: Discrimination and Stigma Scale; GAF: Global Assessment of Functioning; GAS: Global Assessment Scale; ISMI: Internalized Stigma of Mental Illness scale; ITAQ:
Insight and Treatment Attitudes Questionnaire; PANSS: Positive and Negative Syndrome Scale; PSS: Perceived Stress Scale; PSYRATS: Psychotic Symptom Rating Scales; SANS: Scale for the Assessment of Negative Symptoms;
SES: Self-Esteem Scale; SOFAS: Social and Occupational Functioning Assessment; SF-36: 36-Item Short Form Health Survey; SQLS: Schizophrenia Quality-of-Life Scale; SUMD: Scale to Assess Unawareness of Mental Disorder; SWN-
K: Subjective Well-being Under Neuroleptics short form; TAS-20: Toronto Alexithymia Scale; TMMS-30: Trait Meta-Mood Scale.
6 J. P. S. WONG ET AL.
time  DUP interaction effect. Almost all outcome
measures showed a significant treatment effect
(Cohen’s d ¼ 0.25–0.95). Significant positive
time  DUP interactions were observed for the well-
being, drug attitude, and depressive symptoms in the
short DUP group (4 months) with a medium-to-
large effect.
Li et al. (2018) conducted a RCT for a community-
based intervention for 327 people with schizophrenia
(18–50 years old) in China. They employed a strati-
fied cluster random sampling method to recruit par-
ticipants in 12 administrative regions in Guangzhou
city. Participants in the experimental condition
(n ¼ 169) received comprehensive intervention with a
group size of 15–20 people. The intervention con-
sisted of 24 modules covering: (1) strategies against
stigma and discrimination, (2) psycho-education, (3)
social skills training, and (4) CBT. Participants com-
pleted the 24 modules in eight phases; each phase
involved three modules and lasted for 120 min.
Patients completed the eight phases in a 9-month
period, with monthly sessions in the first 6 months
and the two remaining sessions in the last 3 months.
Participants in the control group (n ¼ 158) received a
monthly face-to-face interview by community psy-
chiatrists or general practitioners. All participants
were asked to complete self-reported measures on
internalized stigma, experiences of stigma and dis-
crimination, quality-of-life and self-esteem at pre-
intervention, mid-intervention (6th month), and post-
intervention; their levels of psychotic symptoms, glo-
bal functioning, insight and medication compliance
were evaluated by experienced psychiatrists at the
same time-points. Statistical analyses found significant
interaction effect on overcoming stigma (p ¼ 0.001)
and anticipated discrimination (p ¼ 0.046). Significant
positive changes were also obtained in functioning,
positive, and negative symptoms (all p < 0.001).
However, no significant effects on internalized stigma,
quality-of-life, self-esteem, insight, and medication
compliance were found.
Discussion
Study design and quality of evidence
Among the studies included in this review, only two
adopted the design of RCT with large-scale sampling
to ensure better research quality in testing the efficacy
of group CBTp (Guo et al., 2010; Li et al., 2018).
However, in revisiting the design of these two RCTs,
their controlled intervention was either medication
(Guo et al., 2010) or apparently closer to the
treatment-as-usual trajectory, such as involving medi-
cation and regular interview by community psychia-
trists and general practitioners (Li et al., 2018).
Moreover, their intervention consisted of different
treatment components, for instance, Guo et al. (2010)
included psychoeducation, family intervention, skills
training, and CBT, whereas Li et al. (2018) involved
four treatment components in their comprehensive
treatment protocols, namely, strategies against stigma
and discrimination, psycho-education, social skills
training, and CBT. In such cases, the treatment effect
of CBTp could not be teased out. The positive results
could also be attributed to other confounding varia-
bles such as the amount of therapist attention and
level of social support in the intervention group. In
the other two studies (Chung et al., 2013; Kim et al.,
2017), only pre–post treatment effects were examined.
Given their relatively small sample size (i.e. 24 and 34
participants, respectively) and without a controlled
group, possible confounding factors, including regres-
sion to the mean due to passage of time, spontaneous
recovery, etc. could not be eliminated. The lack of
methodological rigor limited the quality of clinical
evidence. Hence, it seemed difficult to have a reliable
picture about the effectiveness and efficacy of group
CBTp (J€ uni, Altman, & Egger, 2001).
Methodological heterogeneity hindering
comparability
These four studies differed in several aspects includ-
ing treatment components, study population, treat-
ment interval, and outcome parameters, which make
direct comparison difficult.
Treatment components
CBTp is a manualized treatment targeting dysfunc-
tional thoughts and maladaptive behaviours. Among
the reviewed studies, Chung et al. (2013) followed
closer to the traditional CBTp protocols (Beck,
Rector, Stolar, & Grant, 2011; Chadwick, Birchwood,
& Trower, 1996; Kingdon & Turkington, 1994) which
covered emotional and cognitive flexibility, and learn-
ing for patients to free themselves from negative crys-
tallized thought patterns. The protocol employed by
Kim et al. (2017) included meta-cognitive training
elements; and 30% of their content were indeed life-
style management (such as self-esteem enhancement
and time management). On the other hand, the two
studies conducted in China only included CBTp as
part of their multicomponent integrated intervention.
For instance, Guo’s et al. (2010) combined group

CBTp with psychoeducation, family intervention, and
skills training with equal weighting for all modules. Li
et al. (2018) also provided a comprehensive interven-
tion programme which consisted of group CBTp,
strategies against stigma and discrimination, psycho-
education, and social skills training. In their protocol,
CBTp only contributed to 8 h of contact. Given the
vast disparity in the treatment elements among the
four studies as well as the discrepancy in the defini-
tions of CBTp, it would be difficult to have a mean-
ingful comparison of their findings.
Study population
The key determining factors in the prognosis of
psychotic patients include the duration of untreated
illness (DUI) (Birchwood, Todd, & Jackson, 1998;
Crumlish et al., 2009) and diagnosis (Harrow,
Grossman, Herbener, & Davies, 2000). These group
CBTp studies targeted different populations: three
studies (except Li et al., 2018) recruited patients with
early psychosis (i.e. first episode or those under 5
years of illness onset), two studies (Guo et al., 2010;
Li et al., 2018) included a diagnosis of schizophrenia
or schizophreniform and excluded other psychotic
disorders (e.g. delusional disorder). The differences in
the client portfolios (i.e. diagnosis, DUI) among the
studies would make the comparison of treatment
effectiveness challenging. However, the favourable
effects of group CBTp on patients with shorter DUP
(Li et al., 2018) is noteworthy. It encourages further
investigation on providing psychological intervention
to patients with early psychosis or even to people
with an at-risk mental state.
Three out of the four studies (Chung et al., 2013;
Guo et al., 2010; Kim et al., 2017) used convenience
sampling only; as sample selection bias was not
addressed it may be difficult to generalize their posi-
tive outcomes to the study population.
Outcome parameters
Most of the CBTp models were developed with a
focus on fostering adaptive coping with and reducing
distress from positive psychotic symptoms (Chadwick
et al., 1996; Garety, Kuipers, Fowler, Freeman, &
Bebbington, 2001; Morrison, 2001). Interestingly, only
Chung et al. (2013) focused on positive psychotic
symptoms as the primary outcome measures. They
used Psychiatric Symptom Rating Scales to assess the
participants’ severity of psychotic symptom, and also
used blind raters to avoid potential subjective assess-
ment bias. The other three studies only measured the
INTERNATIONAL REVIEW OF PSYCHIATRY 7
impact of CBTp on dimensions other than the allevi-
ation of psychotic symptoms. Guo et al. (2010) high-
lighted the rate of medication discontinuation or
change and time to discontinuation. The research
conducted by Kim et al. (2017) was a retrospective
study focused outcome related to subjective well-
being, drug attitude, and depressive symptoms. Li
et al.’s (2018) study targeted stigma and discrimin-
ation, self-esteem, psychotic symptoms, functioning,
insight, and medication compliance. Given the wide
selection of outcome measures, it is difficult to com-
pare the results obtained in different studies and
arrive at a definite conclusion of the impact of group
CBTp. It is suggested that developing and utilizing a
standardized set of core outcome measures in future
group CBTp studies may facilitate comparison or
pooling of data, which can further enhance our
understanding on the real impact of group CBTp.
Apart from the heterogeneity in outcome measures,
none of the studies involved follow-up assessment to
evaluate the maintenance treatment effect. Therefore,
it is not sure whether the positive effect of group
CBTp can be maintained. Particularly, the statistically
significant results could be short-lived and less gener-
alizable, especially when the intervention period lasted
only a few months (Chung et al., 2013; Kim
et al., 2017).
Treatment interval
The duration of group CBTp varied among the stud-
ies. Considering the geographical and travelling con-
straints of the participants, the two teams in China
arranged monthly sessions in a relatively long inter-
vention period (9 and 12 months) (Guo et al., 2010;
Li et al., 2018). The two Korean teams (Chung et al.,
2013; Kim et al., 2017) followed closer to the NICE
(2014) guidelines and scheduled weekly CBTp ses-
sions, although the number of sessions was still less
than recommended. It should be noted that, despite
the heterogeneity in treatment intervals which compli-
cated the direct comparison of results, the four stud-
ies did obtain positive treatment effects. This poses an
interesting question about the adequate amount of
treatment dosage for CBTp, which is worth further
investigation.
To the best of our knowledge, this is the first
endeavour to conduct a systematic review on group
CBTp in Asia. It is surprising that only four group
CBTp trials have been published between 2010 and
2018. We highly appreciated these predecessors’ pio-
neering efforts in exploring the use of group CBTp in
8 J. P. S. WONG ET AL.
the Asian context. Unfortunately, all of these studies
have their own methodological limitations that under-
mine the rigour of their reported positive effects,
including the lack of a well-controlled group
(Rothwell, 2006; Wykes et al., 2008) and the absence
of unblinded raters (Jadad et al., 1996; Kuipers et al.,
1997). Large-scale RCTs are needed to establish the
efficacy and generalizability of group CBTp.
Moreover, the existing studies involve different treat-
ment focuses, sample characteristics, and outcome
parameters. Such heterogeneity makes it difficult and
challenging to compare and evaluate the effectiveness
of the group CBTp among different studies. The
development of CBTp is still budding in Asia.
Therefore, developing and utilizing a standardized set
of core outcome measures such as distress reduction
from positive psychotic symptoms and/or relapse pre-
vention (Chadwick et al., 2000; Lecomte et al., 2008)
is recommended.
Moreover, the present review reflects an important
issue about the underdevelopment of group CBTp in
Asia. Health Quality Ontario (2018) examined several
systematic reviews on CBTp; it was found that there
was only a small volume of literature on group CBTp.
The shortfall of research might possibly be due to dif-
ferences in service structures in different countries
and skepticism about the non-medical treatment of
schizophrenia (Wykes et al., 2008). Another possible
postulation is related to the therapists’ assumptions
and competency in conducting group CBT for psych-
otic patients. Morrison and Barratt (2010) obtained a
consensus in a Delphi study that therapists’ assump-
tions on patients’ psychotic experiences are crucial to
clinical practices. Previous studies found that thera-
pists can have their own intense anxiety at times
when delivering psychological intervention to people
with psychosis, particularly those with paranoia
(Jackson, 1955; Luborsky, Auerbach, Chandler,
Cohen, & Bachrach, 1971). Chadwick (2006) also sug-
gested that beliefs of therapists would trigger their
discomforts or anxiety, and the collaborative working
relationship in CBTp would be threatened. For
example, therapists think they would reinforce
patients’ delusional beliefs if they were not skillful or
careful enough in carrying the conversation with
patients. Thus, it is understood that therapists may be
even less willing to provide group CBTp which
involves group dynamics and social interaction, lead-
ing to the underdevelopment of group CBTp.
Apart from therapists’ attitudes, existing trainings
on CBTp mainly focus on individual-based treatment
which also affects therapists’ level of competency in
providing group CBTp. Different kinds of core skill
sets are required in facilitating the group processes.
For instance, CBTp therapists should also possess
extra skills beside basic empathy and warmth when
conducting a group session, such as agenda setting,
time management, flexibility, creativity, and be tactful
in managing group dynamics (Lecomte, Leclerc, &
Wykes, 2016). As such, the lack of training opportu-
nities may be another possible obstacle to the devel-
opment of group CBTp.
There are undoubtedly some limitations in this sys-
tematic review. First, only three search databases were
used in the process; this could affect the comprehen-
siveness of the review. Second, when selecting
research articles, ‘cognitive behavioural therapy’ or its
equivalent was a MUST in the paper title/abstract.
Besides, our scope of review was limited to research
conducted in Asia and published in English only. Our
limited data (four papers) would have impaired the
reliability of our assessment on the effect of group
CBTp. Loosening the inclusion criteria to include
papers in Chinese or other languages and expanding
search databases could widen the scope of review in
the future.
Despite the limitations of the present review, the
favourable effects of group CBTp in Asian countries
serve a good foundation for its future development.
This is particularly important because group CBTp is
still in its infancy in Asia. To facilitate its further
development, the barriers to conduct group CBTp in
research and clinic settings should be addressed. The
feasibility and the impact of group CBTp should also
be further examined by using a more rigorous
research design. If proven efficacious and effective,
group CBTp may help improve the accessibility of
CBTp in Asian countries.
Disclosure statement
No potential conflict of interest was reported by
the authors.
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 PRESENTASI JOURNAL READING

Group Cognitive Behavioural Therapy for Psychosis in The Asian Context: a Review of The Recent
Studies

Oleh:
Ika Agitra Ningrum
S572108004

Pembimbing:
Dr. dr. Adriesti Herdaetha, Sp.KJ, M.H.

PPDS-I PSIKIATRI FAKULTAS KEDOKTERAN

UNIVERSITAS SEBELAS MARET/ RSUD. dr. MOEWARDI
SURAKARTA 2022
 Latar Belakang

➢ Terapi perilaku kognitif untuk psikosis (CBTp) menunjukkan hasil menjanjikan

dalam mengurangi kesulitan dan meningkatkan koping pasien pada gejala
positif dalam beberapa penelitian meta analisis.

➢ National Institute for Health and Clinical Excellence (NICE)

merokemendasikan (CBTp) per individu harus diberikan sebagai pengobatan
tambahan untuk semua orang dengan skizofrenia.

Dixon, L. B., Dickerson, F., Bellack, A. S., Bennett, M., Dickinson, D., Goldberg, R. W., … Peer, J. (2010).
Schizophrenia Patient Outcomes Research Team (PORT). The 2009 schizophrenia PORT psychosocial treatment
recommendations and summary statements.
 Metodologi
 Strategi Pencarian : Pedoman PRISMA, database Pubmed, PsyINFO dan Web of Knowledge
Alur Penelitian
Hasil
 Diskusi

● CBTp adalah intervensi yang menargetkan pikiran disfungsional dan

perilaku maladaptive diantara studi yang di jabarkan protocol CBTp
meliputi fleksibilitas emosional kognitif dan pembelajaran bagi pasien
untuk membebaskan diri dari pola piker negative yang mendominasi.

● Studi yang dilakukan di Cina mengembangkan CBTp sebagai bagian

dari intervensi terintegrasi multikomponen.
KETERBATASAN ULASAN

• Hanya 3 database digunakan dalam pencarian sehingga mempengaruhi kelengkapan

tinjauan.
• Artikel penelitian “terapi perilaku kognitif” harus dalam abstrak sangat terbatas
mengingat ruang lingkup penelitian dilakukan di Asia dan diterbitkan dalam Bahasa
inggris.

KESIMPULAN

▪ CBTp mengalami pertumbuhan di negara-negara Asia yang menjadikan dasar terbaik

untuk pengembangannya di masa depan.
▪ Kelayakan dan dampak kelompok CBTp harus di periksa lebih lanjut dengan
menggunakan desain penelitian yang lebih ketat sehingga keefktifannya membantu
meningkatkan aksessibilitas CBTp di negara-negara Asia
Critical Appraisal
 VALIDITY
Apakah penulis mencari jenis penelitian Apakah ulasan membahas pertanyaan
yang tepat? Y yang fokus dan jelas? Y
Systematic review ini mencari database dalam Peneliti menjelaskan pertanyaan yang fokus dan
sumber yang tepat. jelas

10
 VALIDITY
Apakah penulis cukup melakukan
Apakah Anda pikir semua studi penting
dan relevan dimasukkan? Y penilaian kualitas studi yang
disertakan?
Y
Peneliti memasukkan semua penelitian yang Peneliti melakukan kualitas studi.
sesuai dengan kriteria inklusi dan eksklusi

11
 Applicability

Apakah manfaatnya sepadan Ya, berdasarkan hasil penelitian ini menunjukkan

dengan bahaya dan biayanya? Y bahwa terdapat hasil signifikan pada kelompok
intervensi.

Bisakah hasilnya diterapkan Ya, secara teknis penelitian ini dapat diterapkan
populasi lokal? Y pada populasi lokal

valid

applicable important

12