Tina is a 64-year-old woman who has been hearing voices for 45 years. She has been hospitalized 4 times over the years, often in connection with life events, such as her mother's death and her brother's alcoholism and violence towards her. She has never accepted a diagnosis of schizophrenia but is compliant with medication and happily agreed to CBT, explaining that she would like to talk to a “nice young man” like the therapist. Following the assessment, it was clear that the patient's main problems were lack of confidence, a tendency to isolate herself at home, and a belief that the voices had an external source (the central heating system). She was still working as a caregiver in a rest home, but after her partner's and mother's deaths 15 to 20 years previously had increasingly lost contact with friends and family. As protective factors, Tina was a healthy, likable woman with a good sense of humor. She was also very happy with her job.
Engagement was unproblematic, but the concepts of continuum and the ABC model proved to be difficult for Tina to understand. It helped when examples—such as temperature—were given to explain the concept of a continuum. To illustrate the ABC model to Tina, a book was held up and the therapist read aloud what he could see on the back of the cover, while she read the front of the cover. She subsequently understood that there could be different angles from which to view the same issue. While the therapist critically looked at her understanding, he also made extensive use of normalizing.
The patient's general functioning, mood, and self-confidence improved significantly, but she remained adamant that the voices had an external source. She had also gained a much larger social life. After a couple of relapse-prevention sessions, it was decided to stop the therapy. Tina had had 22 sessions in all, and the voices were now largely benign and seen as conversational partners that conveniently would remind her about duties such as vacuuming and writing cards to her nephews and nieces.
The general finding has been that CBT significantly improves both negative and positive symptoms in different subgroups of patients with schizophrenia.8 The meta-analysis by Gould and associates14 indicated a strong effect size of 0.65 for positive symptoms. In spite of initial concerns, there is no evidence that suicidality develops during CBT; quite the contrary.15 At this stage, the factors mediating treatment success in these interventions are not clearly known and should be researched further. Compared with pharmacologic therapy, the dropout rates are remarkably low at around 12% in the randomized controlled trials.14 This is quite an achievement considering the severely unwell patient group, and it may indeed carry an important message to service providers about service users' preferences. It must, however, be added that all studies so far have been conducted on patients receiving antipsychotic medication. The proven efficacy of CBT for schizophrenia is also cost-effective.10
Patient predictors of response to CBT remain uncertain. Although there is some evidence that a degree of cognitive flexibility and willingness to disclose are auspicious signs, cognitive variables were not found to be related to treatment response.16 Several of the comparison treatments (supportive counseling, befriending) have been shown to have some effect on a number of symptoms, but CBT has shown clear superiority in durability.5
It appears that CBT equips patients with a set of tools they can use to fight back the symptoms long after the therapy has been terminated. The effect in the comparison groups is thought to be a product of nonspecific therapeutic factors and the impact of being the object of caring attention. The studies have the same methodologic limitations as most other research into psychotherapy, including suitable comparison groups, blinding, and inclusion and exclusion criteria. Recent studies have, to a large degree, dealt with these issues, and the outcome generally remains positive.
It would be wrong to believe that CBT can only be used in formal therapy settings. Many aspects of the therapy can readily be implemented in the day-to-day management of patients with schizophrenia, including the ABC model, normalization, and the search for alternative explanations. The use of these approaches does not necessarily require formal training in CBT. On the other hand, the lack of supervision and of fully accredited therapists are major obstacles in the development of a service that lives up to the standard requirements.17 This area will undoubtedly receive further attention over the coming years, especially as patients and caregivers become more vocal about their needs and preferences.
Over the past decade, CBT has emerged as an evidence-based intervention that provides a long-needed integrative approach to schizophrenia. The emergence of CBT for schizophrenia has added new optimism to the treatment of a highly stigmatized condition and may, in the long term, contribute to a change in the way the general public views people with schizophrenia. As the news about an effective talking therapy penetrates a wider audience, schizophrenia may no longer be seen as an essentially untreatable, incomprehensible, biologic condition beyond the reach of reasoning.
All psychiatrists should therefore at least be acquainted with the basic principles of CBT for schizophrenia in order to incorporate this knowledge into the daily management of severely mentally ill patients and to be able to appropriately refer patients for specialist therapy. Although the existing evidence base for CBT in schizophrenia shares some of the same limitations that exist for other psychotherapies, research has firmly established the evidence for reduction of symptomatology, low dropout rates, and cost-effectiveness. Despite this, widespread availability of CBT for psychotic patients is currently lacking, and providing sufficient availability of this method is one of the greatest challenges facing mental health services today.
Dr Hansen is a Danish-born consultant psychiatrist working in the department of psychiatry, University of Southampton, UK. He is an accredited member of the British Association of Behavioural and Cognitive Psychotherapists and holds a medical doctorate from the University of Southampton. He reports that he has no conflicts of interest concerning the subject matter of this article.
Dr Kingdon is professor of mental health care delivery at the University of Southampton and honorary consultant psychiatrist with Hampshire Partnership Trust. He reports that he has no conflicts of interest concerning the subject matter of this article.
Dr Turkington is a senior lecturer of psychiatry at Newcastle University with a special interest in cognitive-behavioral therapy for schizophrenia. He reports that he has no conflicts of interest concerning the subject matter of this article.