David Kingdon, MD, FRCPsych

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• Strategies used in cognitive-behavioral therapy (CBT) for the treatment of severe mental illness
• Treatment approaches
• The benefits and challenges of using CBT



Who will benefit from reading this article?


Psychiatrists, psychologists, primary care physicians, nurse practitioners, and other health care professionals. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing and certification boards.

Psychotropic treatment can often prevent the relapse of psychotic and mood symptoms. However, many patients take medication intermittently or not at all; or the symptoms may be only partially responsive to medication. Therefore, there is a need for interventions that can supplement the effect of medication and improve treatment outcomes.

Cognitive-behavioral therapy (CBT) has been found to be effective for those with severe mental illness.

 Recent meta-analyses have concluded that CBT has a definite effect on positive and negative symptoms in schizophrenia and there is evidence that it can have a sustained effect on attitudes about medication.

 The American Psychiatric Association practice guideline on schizophrenia refers to CBT as an evidence-based treatment, especially for persistent symptoms.

 Many other guidelines recommend CBT as well.

Evidence of the effectiveness of CBT for bipolar and severe depression is more limited, but there are promising results for family work and social rhythm therapy.


CBT involves working with specific symptoms: techniques to help manage delusions, hallucinations, and negative symptoms are based on the development of a good therapeutic relationship between patient and therapist and formulation of the experiences, competencies, thoughts, feelings, and actions of the patient.

Engaging people who experience psychotic symptoms can be difficult: paranoia diminishes trust, and cognitive impairment and catatonia affect communication. Developing a relationship is a process that requires skill, attention to detail, and adaptation to the patient’s particular concerns.

A good clinical assessment is essential because it provides a wealth of valuable information to inform conceptualization and subsequent intervention and, in itself, can be therapeutic. Details gathered about the first episode of psychosis can be particularly informative. Analysis of the period preceding a psychotic episode can enable the patient to reconsider the conclusions he or she formed at the time, especially if the conclusions evolve into delusional beliefs.

Making sense of the experiences that led to psychosis involves assembling relevant information about predisposing, precipitating, perpetuating, and protective factors with key thoughts, feelings, and behaviors. Connections can be made between precipitating causes and symptoms (eg, stimulant/hallucinogenic drugs and initial psychotic experiences, often viewed as “bad trips”) that further evolved into persistent psychotic symptoms.

Formulation and process Once the precipitating causes are understood, work on delusional beliefs follows. Initially, the process of listening to the patient’s story of how his beliefs developed can improve the therapeutic relationship, allowing discussion and gentle probing about symptoms to begin. It is important for the therapist to begin by “suspending judgment” regarding beliefs. Beliefs may appear to be persecutory (“white vans are following me with intent to destroy me”) or grandiose in nature (“I can influence the weather”). They may include thought broadcast (“the world can hear me thinking”), thought insertion (“you put these ugly thoughts in my head”), or delusions of reference (“the TV show is referring to me”). All beliefs have meaning and function and must be broached with respect and compassion.

It is challenging for any of us to begin considering alternative explanations and ways of being when beliefs are deeply entrenched. A collaborative examination of the evidence offered in support of beliefs can be followed by inquisitive planning of simple experiments. A sample dialogue between the therapist and patient follows.

 It sounds like you feel very distressed by the belief that your family is monitoring your phone calls. This is an understandable reaction to this belief.

 It’s horrible; I can’t trust anyone. My own family is doing this to me!

 I’m wondering how much of you believes that your family is doing this, from 0% to 100%?

I am 95% convinced that they are. All the evidence is there!

 Okay, so you are pretty convinced. However, there is 5% of you that isn’t convinced. Because of the high cost (distress) of your belief, it may be a good idea for us to check out the evidence for this belief. How does this sound to you?

 The most significant piece of evidence I have is that there is a recording device inside the phone. So perhaps we can plan some simple checks with it? I also saw my mom studying the phone bill last month, but at the time I was too scared to ask her why.

 So the recording device and your mother studying the phone bill are 2 things we could potentially explore further…?

Alternative explanations can be explored. For example, a patient who believes he is being electrocuted because his fingers tingle is given information about anxiety and a controlled experiment is undertaken to reproduce the symptoms. By modifying the misinterpretation of events that served to reinforce the delusional belief, the cognitive cycles that maintained the delusion are broken. Exercises that use Socratic questioning to examine beliefs and to foster discussion are very useful in assessment and relationship building. Gentle probing by the therapist can provide additional information and build trust on the part of the patient.

When a patient lacks an absolute conviction in his beliefs, the process of gentle questioning can begin to evoke alternative explanations. When beliefs are very strong and a “chink of insight” cannot be found to build on, such discussion eventually begins to become repetitive and it may be necessary to agree to disagree. Frequently, the patient is open to moving on to other, more important topics about underlying concerns and life goals. Once these are addressed, the beliefs may change. By focusing on why the beliefs are important to the individual and empowering him by teaching him what he can do if beliefs are causing distress (eg, through coping strategy enhancement), the therapist can improve collaboration and begin constructive behavioral change.


Hallucinations are frequently but not always distressing. Some patients describe positive aspects, such as companionship or guidance; nevertheless, hallucinations are disturbing and negative in content and effect for most patients. A structured approach to assessing, understanding, and reattributing voices or other hallucinations is used.

This involves establishing the nature of the perception (“like me speaking to you?”) and then the uniqueness of the experience (“just you, nobody else can hear them?”). Inquiry into beliefs about the origin of the perceptions follows (“why do you think no one else hears them?”); followed by discussing the reasons (“It’s God”; “But would you expect God to say such unpleasant things to you?”).

Alternatively, especially if the patient is uncertain of the origin of the voices, psychoeducation and normalization about the nature of voices can be helpful. For example, explaining the role that the Broca area of the brain plays in inner speech and the similarity to “dreaming awake” can help patients reattribute voices to internal phenomena (“my mind is playing tricks on me”) rather than from external sources (“the neighbors are talking about me”). It then becomes more relevant to use personal ways of coping with them (eg, relaxation, distraction, and taking medication). Coping strategies that involve direct engagement with the voices have been used successfully in patients who have developed insight into the voices but in whom they persist and continue to cause distress. These include the development of an assertive dialogue or use of mindfulness techniques.


There is accumulating evidence that CBT can have an enduring effect on negative symptoms, including amotivation and social withdrawal.

 Rehabilitation methods-such as social skills training, target setting, and behavioral experiments, supported by cognitive interventions-are used for negative symptoms. For example, a patient may set himself a task but be unable to complete it. Through inquiry, the patient’s belief that when he goes outside he is being talked about in the street is uncovered. Work on this belief involves reasoning, ie, reality testing. The emphasis is on ascertaining precisely who is talking about him, what they are saying, and why they may be saying it. Diaries or detailed recall of circumstances can help unblock resistance. Assessing expectations and pressures with families can also be useful. Remember, you cannot push patients out of negative symptoms. It is essential that they are allowed to reestablish control.

Readily achievable and collaboratively developed short-term goals establish momentum. The goals are often initially very simple (eg, go downstairs for coffee in the late afternoon). When the initial goals are achieved, further steps are built on that foundation. Consider suggesting that the person take time off when he has been trying but repeatedly failing to achieve a goal: he may feel less pressured.

Improved concentration and cognitive ability enables work on positive symptoms that interfere with progress. When negative symptoms have emerged during periods of institutionalization, the identification of motivating factors-often long forgotten-can begin the process of reengagement in conversation and social interaction and subsequently set the stage for specifically therapeutic work. CBT techniques for behavioral activation that involve activity scheduling, mastery and pleasure rating (gauges how well the patient has mastered the task and how much he has enjoyed it), and graded task assignment can provide structured support.

Implementation of CBT in severe mental illness


Although sessional CBT is generally provided by clinical psychologists or nurse therapists, it is important for psychiatrists to be involved in the initial work with patients to develop agreement with them to be referred for psychological work. Work on attribution can be fundamental to this process: if the patient does not agree that there is anything wrong, why should he see a therapist to discuss anything?

Focused work on hearing voices, delusions, and negative symptoms can be successful in brief sessions with patients. This may be all that can be offered where availability of skilled therapists is limited. Psychiatrists can take the lead in alleviating the dearth of trained providers by advocating for improved availability through training and education.

After the patient has had sessions with therapists, psychiatrists often continue medication management and provide brief booster sessions with discussion and reinforcement of lessons learned and gains made.


Strong beliefs take time to change and CBT is rarely a quick fix. The major changes seen initially are usually behavioral (eg, increased social involvement rather than cognitive improvement and ability to cope with distressing symptoms). Most therapy courses involve 16 to 20 sessions over 6 to 9 months, and change often continues after completion of therapy. For acutely psychotic patients, CBT can improve engagement; combined with the effects of medication, CBT can allow work on symptoms to commence as agitation and thought disorder are reduced.

Patients with profoundly negative symptoms can be challenging to engage and often a “befriending” approach is helpful. Seeking out areas of interest with appropriate self-disclosure may be a necessary first step for the success of the work on formulation and symptoms, which will follow. Cultural issues are also important to consider and require adjustments to therapy.

Ellie, 50 years old, was housebound and lived alone. She had a long history of mental illness and had been abused as a child. She stated she had an “unhappy childhood.” Also, she had had a “lost year” of drinking and isolation. As a teenager she had 2 hospital admissions related to drugs, alcohol, and depression, and 4 years ago she was hospitalized for alcohol-related hallucinations. Since then, despite a history of overdosing, self-harming, depression, and disengagement, she has managed to stay out of the hospital. A violent incident with her ex-partner coincided with the onset of auditory hallucinations.

Rapport with Ellie was established using a nondirective conversational style: befriending was quite successful in reducing her initial anxiety. Ellie and the psychiatrist worked to normalize and decatastrophize experiences using the stress vulnerability model and psychoeducation. The cognitive model was explained early in therapy: links between the thoughts (perceived as voices), feelings (distress and anger), and behavior (drinking and withdrawal) were creating a self-perpetuating cycle. A history and time line were established, and symptom assessment was completed using a standardized rating scale.

Ellie was highly anxious and depressed, with suicidal thoughts and behaviors. She said, “My life as a whole is black and gray. I’d love some respite from myself.”

Ellie experienced one voice but minimal delusional belief. She was assessed as relatively independent (moderate competence and performance on the Social Functioning Scale) but very socially withdrawn, with a lack of relationships, no social and recreational activities, and unemployment.10 She viewed the voice she heard as malevolent, omnipotent with no benevolence, using the Beliefs About Voices Questionnaire.


Based on the available information and further discussion with Ellie, a list of problems was formulated and agreed on (Table). Most problematic was the experience of hearing voices. Analysis of the last experience clarified that hearing the voice was an activating event. An emotional reaction to its content (anger, shame, anxiety, and guilt) was the consequence, and avoidance, isolation, and obeying the voice was the behavioral response.

The underpinning beliefs were, “What the voice says is true; it will never stop; it is in control and I have no control over my actions.”We formed the problem statement, “When I hear the voice it makes me angry, then I’m too terrified to go outside because I am frightened I could hurt someone, which affects my quality of life.” A plan was developed to address her psychotic symptoms.

Negative core beliefs linked to past events were identified. Ellie had developed unhelpful automatic thoughts and assumptions (eg, “I’m not good enough”) to manage the negative beliefs. During therapy, differing levels of belief were evoked using thought records completed during sessions and as homework. This gave her a simple yet powerful demonstration of the way thought influences and maintains feelings.

Ellie’s experience of hearing the voice was further clarified through assessing attributions, focusing on specific beliefs, and maintaining a voice diary to clarify connections with daily events. The voice was reminiscent of her grandfather, “an evil man.” Both he and the voice used her full name (Eileen), while no one else did. Relating to the voice was set within her interpersonal history: once the gap between negative perception of herself and overly positive attitudes to significant others decreased, it was easier to challenge the voice. She and her doctor discussed how voices and beliefs about voices can arise from childhood abuse and other precipitating events. A responsibility pie chart helped Ellie reattribute blame for the abuse from herself to the adults responsible. Focusing on the psychological origins and the relationship with her grandfather helped Ellie deconstruct the power beliefs and develop some boundaries with the voice.

Ellie achieved self-identified short-term goals related to the problem statement. These were rated regularly on a progress scale of 0 to 8 and plotted graphically to aid visualization of change. Avoidance decreased despite hearing the voice. As fears were disconfirmed, Ellie’s world expanded.

Behavioral experiments, properly designed and carried out, can modify beliefs and assumptions more powerfully than verbal techniques in the office. Ellie made regular late-night trips to the supermarket, where she would avoid speaking to anyone except the cashier. For the experiment to expand her contacts, she asked an assistant “where are the tomatoes?” The process of planning (designing the experiment), experiencing (the experiment itself), observing (examining what happened), and reflecting (making sense of the experiment) was used to maximize gains from this successful experience, and it was used as a foundation to increase levels of social contact.

Concentrating on Ellie’s experience of voice hearing positively changed the other problems: not getting out, difficulties in sleeping, and hopelessness. Reassessments at 6 months highlighted progress. Ellie had become more insightful regarding hearing voices, and her mood and selfesteem had increased. Ellie had become “her own therapist,” learning from and initiating new experiences. She felt hopeful about implementing positive change.

Recovery is a unique individual journey that may not mean being completely symptom-free. The ability to cope and reengage may be the most appropriate goal. This is illustrated by Ellie’s reflection that:

Life as a whole is no longer black and gray. I have color. Some days are brighter than others. There are times of love, light, and happiness; I can be lost in the moment. My life may not be anything special compared to other peoples’, but it is now my life, and the dark times make the okay times that much more special.

1. Wright JH, Turkington D, Kingdon D, Basco M. Cognitive Therapy forSevere Mental Illness: An Illustrative Manual. Arlington, VA: AmericanPsychiatric Publishing, Inc; 2008.
2. Wykes T, Steel C, Everitt B, Tarrier N. Cognitive behavior therapy forschizophrenia: effect sizes, clinical models, and methodological rigor.Schizophr Bull. 2008;34:523-537.
3. Rathod S, Kingdon D, Smith P, Turkington D. Insight into schizophrenia:the effects of cognitive behavioural therapy on the componentsof insight and association with sociodemographics-data on a previouslypublished randomised controlled trial. Schizophr Res. 2005;74:211-219.
4. American Psychiatric Association Steering Committee on PracticeGuidelines. American Psychiatric Association Practice Guidelines for theTreatment of Psychiatric Disorders Compendium 2006.Washington, DC:American Psychiatric Association; 2006.
5. National Institute for Clinical Excellence. Clinical Guideline: Schizophrenia(Clinical Guideline 1). London: Department of Health; 2002.
6. Kingdon DG, Turkington D. Cognitive Therapy of Schizophrenia. NewYork: Guilford; 2005.
7. Turkington D, Sensky T, Scott J, et al. A randomized controlled trialof cognitive-behavior therapy for persistent symptoms in schizophrenia:a five-year follow-up. Schizophr Res. 2008;98:1-7.
8. Rathod S. Expansion of psychological therapies. Br J Psychiatry.2008;193:256-257.
9. Lancashire S. Revised Version of the KGV Scale. Manchester, UK: Universityof Manchester; 1994.
10. Birchwood M, Smith J, Cochrane R, et al. The Social FunctioningScale: the development and validation of a new scale of social adjustmentfor use in family intervention programmes with schizophrenic patients.Br J Psychiatry. 1990;157:853-859.
11. Chadwick P, Birchwood M.The omnipotence of voices, II: the BeliefsAbout Voices Questionnaire (BAVQ). Br J Psychiatry. 1995;166:773-776.

Evidence-Based References
Kingdon DG, Turkington D. Cognitive Therapy of Schizophrenia. NewYork: Guilford Press; 2005.
Wright JH, Turkington D, Kingdon DG, Basco M. Cognitive BehaviourTherapy for Severe Mental Illness: An Illustrated Guide. Arlington, VA:American Psychiatric Publishing, Inc; 2008. 


Articles

Cognitive-Behavioral Therapy in Severe Mental Illness

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 Beck

 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.

 Furthermore, medication compliance remains a major problem despite the introduction of modern atypical antipsychotics. 

 treatment discontinuation in an estimated 74% of patients in both outpatient and inpatient settings.

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 acute

 and the chronic end of the schizophrenia spectrum.

 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 States

 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.

 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,

 can be used to give the patient a way of 

. 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 (

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.

“The doctors will not tell me the truth”


Sorrow
Depression
Loneliness
Desperation

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.

 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.

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.

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.

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 

 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.

 The meta-analysis by Gould and associates

 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.

 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.

 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.

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.

 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.

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.

 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.

 Beck AT. Successful outpatient psychotherapy of a chronic schizophrenic with a delusion based on borrowed guilt. Psychiatry. 1952;15:305-312.


 Harrow M, Carone BJ, Westermeyer J. The course of psychosis in early phases of schizophrenia. Am J Psychiatry. 1985;142:702-707.


 Lieberman JA, Stroup TS, McEvoy JP, et al, for the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med. 2005;353:1209-1223.


 Lewis S, Tarrier N, Haddock G, et al. Randomised controlled trial of cognitive-behavioural therapy in early schizophrenia: acute-phase outcomes. Br J Psychiatry Suppl. 2002;43:s91-s97.


 Sensky T, Turkington D, Kingdon D, et al. A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Arch Gen Psychiatry. 2000;57:165-172.


 Tarrier N, Yusupoff L, Kinney C, et al. Randomised controlled trial of intensive cognitive behaviour therapy for patients with chronic schizophrenia. BMJ. 1998;317:303-307.


 Turkington D, Kingdon D, Turner T, for the Insight Into Schizophrenia Research Group. Effectiveness of a brief cognitive-behavioural therapy intervention in the treatment of schizophrenia. Br J Psychiatry. 2002;180:523-527.


 Pilling S, Bebbington P, Kuipers E, et al. Psychological treatment in schizophrenia: I. Metaanalysis of family intervention and cognitive behaviour therapy. Psychol Med. 2002;32:763-782.


 Torrey EF. PORT updated treatment recommendations. Schizophr Bull. 2004;30:617-618.


 National Collaborating Centre for Mental Health. Schizophrenia: Full National Clinical Guideline on Core Interventions in Primary and Secondary Care. NICE. Available at:

http://www.nice.org.uk/page.aspx?o=289559

 Kingdon DG, Kirschen H. Who does not get referred for cognitive behavior therapy for schizophrenia? Experience from an area where availability has not been limited. Psychiatric Serv. In press.


 Ellis A, Harper RA. A Guide to Rational Living. Chatsworth, Calif: Wilshire Book Co; 1961.


 Kingdon DG, Turkington D. The use of cognitive behavior therapy with a normalizing rationale in schizophrenia: preliminary report. J Nerv Ment Dis. 1991; 179:207-211.


 Gould RA, Mueser KT, Bolton E, et al. Cognitive therapy for psychosis in schizophrenia: an effect size analysis. Schizophr Res. 2001;48:335-342.


 Hansen L. The Influence of Cognitive Behaviour Therapy on Suicidality in Schizophrenia [doctoral thesis]. Southampton, UK: University of Southampton; 2004.


 Dickerson FB. Cognitive behavioral psychotherapy for schizophrenia: a review of recent empirical studies. Schizophr Res. 2000;43:71-90.


 Turkington D, Kingdon D, Weiden P. Cognitive behavior therapy for schizophrenia. Am J Psychiatry. 2006;163:365-373.

This article examines the use of cognitive-behavioral therapy for psychosis, the evidence for its use, and the implications for practicing psychiatrists given the short-comings of pharmacologic therapy.

David Kingdon, MD, FRCPsych

Articles

Cognitive-Behavioral Therapy in Severe Mental Illness

The ABCs of Cognitive-Behavioral Therapy for Schizophrenia