The efficacy of CBT for severe mental illness and the challenge of dissemination in routine care.

CBTp did not perform significantly better than a control treatment of supportive counselling, although both did better than routine care, in the treatment of delusions. However, supportive counselling appeared to worsen auditory hallucinations , whilst CBTp resulted in their reduction (4). Accepting that CBTp has a beneficial effect, how then to increase availability? The apparently simple solution to this is to train the workforce in these treatment techniques, thus an increasingly skilled workforce will increase access and availability of CBTp. This is based upon a number of assumptions which may not be accurate. First, it assumes that training is available. This is not always true. In the US there is a lack of training opportunities (5). In the UK, where training may be available, it is not clear to what level of training, experience or skills clinicians need to be able to deliver CBTp. With the heterogeneity and variation in CBTp, it is not clear what should be taught. What are the necessary techniques and competencies, assuming it is possible to try and define these, a difficult task at the best. Given that psychotic disorders are notoriously difficult to treat, it might be expected that the most qualified and experienced practitioners would provide treatment, as would be the case, say, with complex heart surgery. But this is rarely the case in mental health services, where costs are the main driver. Thus, there is frequently a move to employ the cheapest staff and provide the minimum training necessary when rolling out new treatments , which could dilute treatment effects and be poor value for money. Once trained staff return to their work place, they do not necessarily receive the management support and have the time to implement their training. Furthermore, having received training , staff may no longer be willing to work on the front line and, having become more qualified, they may prefer to take up teaching or research posts. Thus, training has the unanticipated effect of depleting the skilled workforce rather than enhancing it. Lastly, what of the future? I would like to raise a few possibilities. First, an integration with neuroscience, so that investigations on brain plasticity effects of cognitive, behavioral and social interventions can be undertak-en. Second, a greater focus on positive emotions and clinical methods which elicit and encourage these as part of a treatment strategy, from both a theoretical and clinical perspective. For example, broaden-and-build …