Thinking Well: A randomised controlled feasibility study of a new CBT therapy targeting reasoning biases in people with distressing persecutory delusional beliefs
Open accessAbstract
BACKGROUND AND OBJECTIVES: Delusional beliefs with persecutory content are common in psychosis, but difficult to treat. Interventions targeting hypothesised causal and maintaining factors have been proposed as a way of improving therapy. The current study is a feasibility randomised controlled trial of the 'Thinking Well (TW)' intervention: This novel approach combines the recently developed Maudsley Review Training Programme (MRTP), with additional, focussed cognitive-behavioural therapy sessions. METHODS: 31 participants with distressing persecutory delusions and schizophrenia spectrum disorders were randomised to TW or to treatment as usual in a 2:1 ratio. Participants completed outcome assessments at 0 (baseline), 1 (post-MRTP), 6 (post-TW) and 8 (follow-up) weeks. Key outcomes included belief flexibility, paranoia, and delusional conviction and distress. Participants allocated to TW completed the MRTP package and four CBT sessions with a clinical psychologist. RESULTS: Recruitment proved feasible. Participants reported the intervention was relevant and had resulted in positive changes in thinking and mood, which they could use in everyday life. Treatment effects were moderate-large for key outcomes including belief flexibility, paranoia conviction and distress. The additional TW sessions appeared to confer benefits over MRTP alone. LIMITATIONS: Assessments were not carried out blind to treatment condition. Recruitment was opportunistic, from an identified pool of research participants. Finally, a few participants had already completed the MRTP as part of a previous study. CONCLUSIONS: The TW intervention appears to be feasible and acceptable to participants, and the effects of treatment are promising. A fully powered randomised controlled trial of the intervention is warranted.
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“Tatsächlich zeigen viele Studien, dass metakognitives Training [Eichner und Berna, 2016; Moritz et al., 2014a] und «reasoning training» [Waller et al., 2015] Wahnvorstellungen und andere Positivsymptome in der Größenordnung einer kleinen bis mittleren Effektstärke verringern [Eichner und Berna,…”
BackgroundClinical symptoms and social functioning in schizophrenia
Escandell, M. J., Prat, G., García‐Franco, M., Martin-Martínez, J. R., Ochoa, S., Tortadès, I., Vilamala, S., Verdaguer-Rodríguez, M., & Casas-Anguera, E. (2020) · Revista de Psiquiatría y Salud Mental · doi:10.1016/j.rpsm.2020.05.009 · Cited by 4 · see citing works
Jenner, L., Payne, M., Waite, F., Beckwith, H., Diamond, R., Isham, L., Collett, N., Emsley, R., & Freeman, D. H. (2025) · Schizophrenia Bulletin · doi:10.1093/schbul/sbaf083 · Cited by 3 · see citing works
“…and other people (measured by the BCSS 45 ), anomalous experiences (measured by the SPEQ 46 ), jumping to conclusions (measured by the beads task 47 ), possibility of being mistaken (measured on a 0-100% scale 48 ) and safety-seeking behaviours (measured by the Safety Behaviours Questionnaire 49 ).”
Self-citationVarese, F., Sudell, M., Morrison, A. P., Longden, E., & Smith, C. T. (2024) · Health Technology Assessment · doi:10.3310/ncfr5074 · Cited by 3 · see citing works
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“2014) and its extention, the Thinking Well Intervention (Waller et al. 2015), as well as cognitive behavioural therapy for psychosis (CBTp) more generally (Lincoln and Peters 2018) build on the assumption that changes in reasoning biases mediate improvements in symptom severity.”
BackgroundRefining targets for urban remediation in early psychosis
Empson, L. A., Golay, P., Baumann, P. S., Favrod, J., Söderström, D., Codeluppi, Z., & Conus, P. (2025) · Schizophrenia Research · doi:10.1016/j.schres.2025.07.028 · Cited by 2 · see citing works
Poli, S., Ruggeri, M., Bonetto, C., Santi, K. D., Miglietta, E., Petterlini, S., Alpi, A., Bislenghi, L., Bolis, T., Fascendini, S., et al. (2020) · The Cognitive Behaviour Therapist · doi:10.1017/s1754470x20000355 · Cited by 2 · see citing works
Clinical symptoms and social functioning in schizophrenia
Escandell, M. J., Prat, G., García‐Franco, M., Martin-Martínez, J. R., Ochoa, S., Tortadès, I., Vilamala, S., Verdaguer-Rodríguez, M., & Casas-Anguera, E. (2022) · Revista de Psiquiatría y Salud Mental (English Edition) · doi:10.1016/j.rpsmen.2020.05.003 · Cited by 2 · see citing works
Gussmann, E., Lindner, C., Lucae, S., Falkai, P., Padberg, F., Egli, S., & Kopf‐Beck, J. (2023) · European Archives of Psychiatry and Clinical Neuroscience · doi:10.1007/s00406-023-01690-y · Cited by 2 · see citing works
“Our sample size of N = 37 participants exceeded the suggested benchmark of N = 20 participants required to evaluate the feasibility, acceptability and preliminary effectiveness of a group therapy intervention [47], also for studies with PSDs [48–50].”
BackgroundDelusional disorder and its treatment
Ocisková, M., Praško, J. P., Hodný, F., Vaněk, J., Holubová, M., Bundárová, L., Bocek, J., Zaťková, M., & Šlepecký, M. (2021) · Psychiatrie pro praxi · doi:10.36290/psy.2021.024 · Cited by 1 · see citing works
Mehl, S., Hautmann, C., Schlier, B., Dorn, L. M.-L., Ludwig, L., Teismann, T., Franz, M., Rief, W., Stark, R. M., & Lincoln, T. M. (2026) · Schizophrenia · doi:10.1038/s41537-026-00737-y · Cited by 1 · see citing works
“Their approach was superior to routine care in improving delusions and the targeted cognitive factors in two randomized controlled trials (RCTs) 16,17 .”
Massicotte, D., Livet, A., Lahlou, M., Potvin, S., & Lecomte, T. (2026) · Schizophrenia Bulletin · doi:10.1093/schbul/sbag066 · Cited by 1 · see citing works
“34 ,36 ,37 In contrast, a small but statistically significant effect was observed for belief inflexibility using “possibility of being mistaken” measures, 71 ,73 ,94 whereas tasks requiring “alternative expla-nations” showed no consistent change and were examined in only a small number of studies.”
Psychological therapies for psychosis: a view from the hills
Kuipers, E., Onwumere, J., & PETERS, E. R. (2016) · The Lancet Psychiatry · doi:10.1016/s2215-0366(15)00570-2 · Cited by 1 · see citing works
Self-citationMehl, S. (2023) · Springer eBooks · doi:10.1007/978-3-662-64465-2_32 · Cited by 1 · see citing works
Lamster, F., Kiener, J., Wagner, K., Rief, W., Görge, S. C., Iwaniuk, S., Leube, D., Falkenberg, I., Kluge, I., Kircher, T. T. J., et al. (2018) · Verhaltenstherapie · doi:10.1159/000486966 · Cited by 1 · see citing works
“In der Meta-Analyse von Mehl et al. [2015] erwiesen sich Interventionsstudien, die diesen Ansatz verfolgten [Waller et al., 2015; Freeman et al., 2015; Freeman et al., 2014; Foster et al., 2010], als signifikant erfolgreicher in der Reduktion von Wahnerleben im Vergleich zu klassischer CBT-p.”
BackgroundUpdate kognitive Verhaltenstherapie bei Psychosen
Pillny, M., & Lincoln, T. M. (2020) · Psychotherapie · doi:10.30820/2364-1517-2020-1-67 · Cited by 1 · see citing works
Assessing the effectiveness of CBTp across time : a systematic review and meta-analysis
Sitko, K. (2019) · White Rose eTheses Online (University of Leeds, The University of Sheffield, University of York)
Letter to the Editor: Should we focus on quality or quantity in meta-analyses? – a reply
Moritz, S. (2016) · Psychological Medicine · doi:10.1017/s0033291716000192
“Readers are kindly referred to studies written by founders of modern CBTp (Garety, Kuipers, Fowler, and Freeman) who developed a special reasoning training, which partly uses exercises derived from MCT/MCT+ (Waller et al. 2015), and combined it with CBTp.”
Doelgerichte CGT vermindert psychotische klachten
van Loghum, B. S. (2015) · GZ - Psychologie · doi:10.1007/s41480-015-0056-3
Rakitzi, S. (2023) · Springer eBooks · doi:10.1007/978-3-031-27837-2_20
Refining Targets for Urban Remediation in Early PsychosisPreprint
Empson, L. A., Golay, P., Baumann, P., Codeluppi, Z., Favrod, J., Söderström, D., & Conus, P. (2025) · SSRN Electronic Journal · doi:10.2139/ssrn.5173712
Torras, M. G., Pousa, E., Ochoa, S., & Santos, J. M. (2025) · The European Journal of Psychiatry · doi:10.1016/j.ejpsy.2025.100304
Liu, X., Wang, H., Wang, S., Wang, R., Zhao, Q., Tian, S., Guo, X., & Cao, H. (2026) · Psychiatry Research · doi:10.1016/j.psychres.2026.117188
- Authors
- Waller, H., Emsley, R., Freeman, D., Bebbington, P., Dunn, G., Fowler, D., Hardy, A., Kuipers, E., & Garety, P.
- Affiliations
- King's College London (GB)
- Manchester Academic Health Science Centre (GB)
- University of Oxford (GB)
- University College London (GB)
- University of Sussex (GB)
- Corresponding author
- Waller, Helen
- ORCID
- Venue
- Journal of Behavior Therapy and Experimental Psychiatry
- Publisher
- Elsevier BV
- Published
- 2015-09
- Volume
- 48
- Pages
- 82-89
- ISSN
- 0005-7916 (ISSN-L)
- PMC
- PMC4429971
- OpenAlex
- W1986753969
- Cited by
- 77
- References
- 30
- Citations by year
- 2026: 3 · 2025: 4 · 2024: 4 · 2023: 4 · 2022: 6 · 2021: 4 · 2020: 11 · 2019: 6 · 2018: 9 · 2017: 12 · 2016: 11 · 2015: 3
- FWCI
- 9.46
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Journal of Behavior Therapy and Experimental Psychiatry (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research Explorer (The University of Manchester) (publishedVersion)
- Sussex Research Online (University of Sussex) (submittedVersion, cc-by)
- UCL Discovery (University College London) (submittedVersion)
- Figshare (submittedVersion, cc-by)
- Research Portal (King's College London) (submittedVersion, cc-by)
- Funders
- Wellcome Trust (085396)
- NIHR Biomedical Research Centre, Royal Marsden NHS Foundation Trust/Institute of Cancer Research
- National Institute for Health and Care Research (NF-SI-0611-10103)
- King's College London
- Medical Research Council
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Social Sciences › Psychology › Clinical Psychology › Psychological Treatments and Assessments
- Social Sciences › Arts and Humanities › Philosophy › Mental Health and Psychiatry
- Keywords
- persecutory delusions, cognitive behavioral therapy, reasoning biases, schizophrenia spectrum disorders, paranoia, delusional conviction, psychosis treatment, feasibility
- MeSH terms
- Adult, Delusions, Feasibility Studies, Female, Humans, Male, Middle Aged, Paranoid Disorders, Pilot Projects, Psychotic Disorders, Thinking, Cognitive Behavioral Therapy, Outcome Assessment, Health Care
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