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Cognitive behavioral therapy for psychosis (CBTp) and CBT based interventions, such as Metacognitive Training for psychosis (MCT), have been found to be effective in symptom reduction, relapse prevention and, increased quality of life (Moritz et al., 2014). A number of reviews (Tarrier et al., 2002) and meta-analyses (Wykes et al., 2008) have confirmed that group CBT (including MCT) is effective for psychosis (Lecomte et al., 2012), but there is significant heterogeneity in outcome (Zimmermann et al., 2005), with some patients able to gain significantly from participating in psychotherapy, whereas others gain minimally. Given the limited resources available for psychotherapy in psychosis, an important endeavor is the identification of factors that may optimize the allocation of those resources (Zimmermann et al., 2005; Freeman, 2011). While there is a growing body of literature on factors influencing outcome in psychotherapy (Luborsky et al., 1971), that has examined patient, therapist and treatment factors, there is a relative paucity of research focussed on outcomes in group psychotherapy for psychosis. In this opinion paper, we highlight a number of patient factors (including aspects of symptomatology, cognition and personality) that might play a role in outcome in group psychotherapy for psychosis. These factors are based on research of psychotherapeutic outcomes (in psychosis and other disorders), with additional observations based on our clinical experience.  Symptom related factors Paranoia, lack of insight and their effects on treatment alliance There is a large body of literature that has focussed on the non-specific factors associated with outcomes in other psychiatric disorders, and synthesizing it is beyond the scope of the current paper. The bulk of this research has looked at the importance of the therapeutic alliance (Martin et al., 2000), as perceived by the therapist and the client, and suggests that client perceptions of alliance are better predictors of outcome (Krupnick et al., 1996). Crucial to the alliance is the client's belief that they can trust the therapist, and feel understood by them (Frank and Gunderson, 1990). In the context of groups, an additional factor is the ability to trust the other group members. These critical components are negatively impacted by paranoia, and therapists working with clients with psychosis need to grapple with therapeutic ruptures and to avoid being integrated into the client's delusional framework.  CBT based interventions also require ways to discuss specifics of the delusional beliefs (such as the nature of evidence used to maintain the belief), as well as finding shared goals, even when clients have poor insight into their symptoms. This can be a delicate process, with a lot of potential for damaging the alliance. Goldsmith et al. (2015) found that the duration of therapy was associated with symptomatic improvement in those with good treatment alliance, but was actually detrimental for those clients with poor treatment alliance.  Skilled therapists find creative solutions to negotiate these processes. For some clients, particularly those with paranoia, relatively poor insight and an unwillingness to discuss the specifics of their delusional system, a more indirect approach (such as the one provided by MCT) (Kumar et al., 2015) may provide a more fruitful avenue of engagement (Menon et al., 2015). This is because MCT involves a group discussion of cognitive biases commonly associated with psychosis, and opportunities to examine the impacts of these biases in session, using non-delusion specific, and thus less threatening, material (Woodward et al., 2014).

Individual factors predicted to influence outcome in group CBT for psychosis (CBTp) and related therapies