An Updated Systematic Review and Meta-Synthesis of Service User's Experiences of Cognitive Behavioural Therapy for Psychosis (CBTp).

Abstract

Over the past 20 years, cognitive behavioural therapy for psychosis (CBTp) has seen worldwide implementation in mental health services. Systematic reviews and meta-syntheses have identified common and specific therapeutic factors in CBTp, yet its efficacy remains modest. Since its global implementation, a myriad of qualitative studies have explored service users' experiences of CBTp but have yet to be comprehensively integrated in one meta-synthesis to identify paths forward. A thematic meta-synthesis of qualitative studies examining service users' experiences of CBTp was conducted according to a pre-registered protocol. Systematic searches of CINAHL, Embase, PsycInfo, PubMed and MEDLINE databases were conducted in May 2026. Independent raters screened results for eligible papers and assessed their quality using the Critical Appraisal Skills Programme. Results are reported in accordance with PRISMA guidelines. Twenty-four studies were included in the analysis, with a pooled sample of 334 participants. Three interconnected themes were generated: active collaboration empowers me; promoting safety makes me feel more trusting; developing shared understandings helps me accept or challenge upsetting experiences. They show that CBTp techniques promote acceptance and new meanings if sensitively and collaboratively used and collaboration in CBTp facilitates therapeutic outcomes via empowerment. Both relationships occur only when participants feel safe. In the largest review to date, these themes indicate the pivotal importance of collaboratively building safety and acceptance in facilitating therapeutic gains in CBTp. The development of scalable talking therapies should not compromise idiosyncrasy and digitisation of CBTp should carefully avoid compromising the therapeutic relationship for the sake of challenging appraisals.