Cognitive-behavioral therapy (CBT) in schizophrenia was originally developed to provide additional treatment for residual symptoms, drawing on the principles and intervention strategies previously developed for anxiety and depression. In the 1950s, Aaron Beck1 had already treated a psychotic patient with a cognitive approach, but thereafter the research in this specific area lay dormant for decades. Only after cognitive therapy had been firmly established for depression and anxiety, in the 1990s, did the research into psychological treatments for psychotic conditions gather force—again, with Beck in the forefront.
Pharmacologic therapy can leave as many as 60% of psychotic patients with persistent positive and negative symptoms, even when the patients are compliant with their medication instructions.2 Furthermore, medication compliance remains a major problem despite the introduction of modern atypical antipsychotics. Studies have shown treatment discontinuation in an estimated 74% of patients in both outpatient and inpatient settings.3
The evidence for the efficacy of CBT in treating patients with persistent symptoms of schizophrenia has progressed from case studies, case series, and uncontrolled trials to methodologically rigorous, randomized, controlled trials that include patients from both the acute4 and the chronic end of the schizophrenia spectrum.5-7 Subsequent meta-analysis8 and systematic reviews have further strengthened the evidence base.
CBT is now recognized as an effective intervention for schizophrenia in clinical guidelines developed in the United States9 and in Europe.10 In spite of the evidence base and absence of side effects, however, the general availability of this treatment approach within community settings is still low.11 This article will examine the procedure of CBT for psychosis, the evidence for its use, and the implications for practicing psychiatrists.
The therapeutic techniques used for patients with schizophrenia are based on the general principles of CBT. Links are established between thoughts, feelings, and actions in a collaborative and accepting atmosphere. Agendas are set and used but are generally more flexibly developed than in traditional CBT. The duration of therapy varies according to the individual's need, generally between 12 and 20 sessions, but often with an option of ongoing booster sessions. CBT for psychosis usually proceeds through the following phases.
The assessment begins by allowing the patient to express his or her own thoughts about his experiences while the therapist listens actively. The use of rating scales—both specific and general—is encouraged to monitor progress, and the results are shared with the patient. Diagrams and written material can be most useful, especially for patients with chaotic lifestyles. The formulation of symptom causation and maintenance is also shared with the patient and evolves throughout the therapy as new information is considered.
Initially the therapist will state clearly what the therapy is about (including a safe and collaborative method of looking at causes of distress). Throughout the therapy, the use of Socratic questioning is emphasized. This involves drawing out the person's own understanding of his situation and ways of coping with it through a process of guided discovery. Attempts are made to empathize with the patient's unique perspective and feelings of distress and to show flexibility at all times. A vulnerability-stress model is used, so that the patient can understand that vulnerability is a dynamic concept that can be influenced by many factors, such as life events, coping mechanisms, or physical illness. The therapist stresses that he or she does not have all the answers but that useful explanations can be developed in cooperation. The typical nonspecific therapeutic factors of warmth, genuineness, humor, and empathy are of great value in this type of therapy, as in all other therapeutic encounters.
The ABC model, which was originally developed by Ellis and Harper,12 can be used to give the patient a way of organizing confusing experiences. It involves slowly and thoroughly moving the patient through the various steps using Socratic questioning to clarify the links between the emotional distress the patient is experiencing and the beliefs he holds (Table). It includes the following steps:
- Based on a scale of 0 to 10, the patient rates the intensity of distress.
- The consequence (C) is assessed and divided into emotional and behavioral Cs.
- The patient gives his own explanation as to what activating events (As) seemed to cause C; and the therapist ensures that the factual events are not “contaminated” by judgments and interpretations.
- The therapist provides feedback to the patient to acknowledge the A-C connection.
- The therapist assesses the patient's belief, evaluations, and images and communicates to the patient that a personal meaning is lacking in the A-C model; simple examples can be provided to facilitate understanding.
- The patient's own belief (B), which is actually the cause of C, is then discussed; often, this can be rationalized, and a B such as “nobody will like me if I tell them about my voices” can be disputed and changed to “I can't demand that everyone likes me. Some people will and some won't...Maybe some friends might find it interesting.” This may lead to a change in C, ie, less sadness and isolation.
Clinical illustration of the ABC model (see Case study)12
“Voices are driving me mad”
“I’ll never find the truth”
“The doctors will not tell me the truth”
“I’ll never be normal”
“Voices are in control of my life”
Realistic goals for therapy should be discussed early in the therapy with the patient, using the distressing consequences (C) to fuel the motivation for change. It is the therapist's job to ensure that the goals are measurable, realistic, and achievable. The goals are revisited both during and at the end of therapy.
A normalizing rationale11,13 is helpful in decatastrophizing psychotic experiences. Education regarding the fact that many people can have unusual experiences in a range of different circumstances (stressful events, hyperventilation, torture, hunger, thirst, falling asleep, etc) reduces anxiety and the sense of isolation. By having the psychotic experiences placed on a continuum with normal experiences, the patient will often feel less alienated and stigmatized. As a consequence, the possibility of recovery seems less distant.
Critical collaborative analysis
To proceed to this stage, the therapeutic relationship must have developed a degree of trust. The therapist uses gentle Socratic questioning to help the patient appreciate potentially illogical deductions and conclusions:
- “If your voices came from the radiator, why can't anyone else hear them?” or
- “Hold on for a moment, this puzzles me. How do you explain your rape by this famous actor, since we know for a fact that he has never been to this country?”
Testing the evidence for and against maladaptive beliefs can safely be carried out without causing distress as long as the therapist remains nonjudgmental, empathic, and open-minded. An assessment is made of how the beliefs occurred—through inferences or cognitive distortions (eg, dichotomous thinking, selective inference, emotional reasoning, jumping to conclusions). Reviewing antecedents (stress, trauma, loss) that prepare the ground for psychotic change can be an eye-opening exercise for both patient and therapist. Identification of misattributions and attempts to reattribute are as productive as homework tasks.
Developing alternative explanations
It is of crucial importance to let the patient develop his own alternatives to previous maladaptive assumptions, preferably by looking for alternative explanations and coping strategies already present in the patient's mind. It can be dangerously tempting to force the therapist's readymade explanations onto the patient. The patient's own healthier explanations might just be temporarily weakened by either external factors or dysfunctional thinking patterns. If the patient is not forthcoming with alternative explanations, new ideas can be constructed in cooperation with the therapist. Certain seeds might have been sown earlier in the therapy (from leaflets and previous discussions) that can now be used as building blocks.