Cognitive behavioral psychotherapy for schizophrenia: a review of recent empirical studies

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Abstract

A set of cognitive behavioral psychotherapies (CBT) has been developed for schizophrenia. These interventions have been used for the treatment of both recent onset patients and those with treatment-refractory symptoms. This article reviews clinical trials of CBT for schizophrenia since 1990. The CBT interventions appear to be beneficial in reducing overall symptom levels, especially the severity of delusions. The relative efficacy of CBT is more evident when CBT is compared with routine care than when it is compared with other therapies matched for therapist attention. Further studies are needed to objectively determine the active ingredients of CBT and to better identify the interactions of CBT with concurrent psychosocial and medication treatments.

Introduction

Schizophrenia is a devastating illness marked by hallucinations and delusions, emotional withdrawal, and poor social functioning (Kane and McGlashan, 1995). The mean age of illness onset is in the mid-20s, and fewer than 60% of patients achieve full symptom remission (Shepherd et al., 1989). Many patients with schizophrenia have residual psychotic symptoms and social disability that persist throughout their adult lives (Bustillo et al., 1999).

Schizophrenia treatment has been focused on anti-psychotic medications, which have been available since the mid-1950s. Psychotherapy continues to be practiced to some extent with this population, and surveys indicate that it is perceived to be of value to patients with schizophrenia (Coursey et al., 1995). However, there is no consistent therapy model currently being used, nor has it been established what type of psychotherapy is effective for which type of patient (Fenton and McGlashan, 1997, Fenton, in press, McGlashan, 1994, Scott and Dixon, 1995).

In the United States, psychosocial therapies focus on rehabilitation approaches such as skills training, family education, and case management (Kopelwicz and Liberman, 1995, Mueser et al., 1997, Penn and Mueser, 1996). Psychodynamic individual psychotherapy for schizophrenia fell out of favor by the 1980s after well-designed studies found that it did not lead to better outcomes than more structured and supportive approaches (Gunderson et al., 1984, May, 1968). A structured interpersonal psychotherapy, Personal Therapy, was tested in the mid-1990s and was shown to be effective for some patients (Hogarty et al., 1997).

Within the field of behavior therapy, operant approaches were developed in the 1960s and 1970s to modify the social behavior of patients in long-stay hospital environments. Reinforcement programs, such as the token economy, were found to be effective tools that could be used to improve the functioning of institutionalized patients (Ayllon and Azrin, 1968, Paul and Lentz, 1977). These approaches have been underutilized because of misconceptions about operant behavior therapy (Glynn, 1990). Reductions in the length of stay in inpatient settings have also limited the application of these approaches. The use of operant behavior therapy to modify the psychotic verbalizations of individual patients with schizophrenia has been described in case reports; however, available evidence suggests that clinical gains achieved do not generalize beyond the therapy setting or to patients' delusional convictions (Alford, 1986, Ayllon and Haughton, 1964, Himadi et al., 1991, Patterson and Teigen, 1973).

Over the last two decades, behavior therapy has expanded to include cognitive approaches. Effective cognitive behavioral therapies (CBT) have been developed for depression and anxiety disorders (Barlow, 1988, Beck et al., 1979). Recently there has been renewed interest in cognitive behavior psychotherapy for more serious psychiatric disorders. Specialized cognitive behavioral approaches have been developed for severe depression (Scott, 1996, Scott and Wright, 1997), bipolar disorder (Basco and Rush, 1995, Perry et al., 1999), and personality disorders (Beck and Freeman, 1990, Linehan et al., 1991). Building on earlier case reports (Beck, 1952, Watts et al., 1973), cognitive behavior therapies have also been developed for schizophrenia (Alford and Correia, 1994, Beck and Rector, 1998, Chadwick et al., 1996, Fowler et al., 1995a, Perris, 1989).

A major impetus for the CBT for schizophrenia includes the fact that anti-psychotic medications lead to incomplete clinical improvement for many patients. Detailed investigations about patients' experiences have led to the understanding that many patients are distressed by their symptoms and attempt to deal with them through various coping mechanisms (Brier and Strauss, 1983, McNally and Goldberg, 1997, Strauss, 1989). Additionally, psychological experiments suggest that patients' psychotic symptoms can be modified by structured cognitive interventions (Alford, 1986, James, 1983).

The goal of this review is to summarize the recent empirical literature on the cognitive behavioral psychotherapy of schizophrenia.

Section snippets

Methods

Published articles describing empirical trials of cognitive behavior therapy (CBT) with schizophrenia were identified by Ovid Medline using the following key search words: cognitive, behavior, cognitive-behavior, psychotherapy, schizophrenia. Studies included in this review are those that were published in or since 1990; that include more than one patient; that clearly describe a method of psychotherapy which is cognitive behavioral in nature; that offer a systematic assessment of patients and

Results

A total of 20 citations met the above criteria. In some cases, more than one citation includes data from the same study population. The studies are grouped below according to the particular type and focus of the cognitive behavioral therapy.

Replicated findings

The results of these studies indicate that there are cognitive behavioral strategies that are effective in reducing the severity of psychotic symptoms among some patients with schizophrenia. CBT interventions appear to be the most helpful for patients who have clearly defined symptoms and who identify these symptoms as problematic.

In terms of specific outcomes, the cognitive behavioral therapies appear to be the most beneficial in reducing the conviction about, and distress related to,

References (105)

  • J.M. Kane et al.

    Treatment of schizophrenia

    The Lancet

    (1995)
  • C.F. Lowe et al.

    Verbal control of delusions

    Behav. Ther.

    (1990)
  • J. Scott

    Cognitive therapy of affective disorders: A review

    J. Affect. Dis.

    (1996)
  • T. Sensky et al.

    A randomized controlled trial of cognitive behaviour therapy in the management of treatment-resistant schizophrenia

    Schizophr. Res.

    (1998)
  • T. Ayllon et al.

    The Token Economy: A Motivational System for Therapy and Rehabilitation

    (1968)
  • D.H. Barlow

    Anxiety and Its Disorders: The Nature and Treatment of Anxiety and Panic

    (1988)
  • M. Basco et al.

    Cognitive-behavioral Treatment of Manic-depressive Disorder

    (1995)
  • A.T. Beck

    Successful outpatient psychotherapy of a chronic schizophrenic with a delusion based on borrowed guilt

    Psychiatry

    (1952)
  • A.T. Beck

    Cognitive Therapy and the Emotional Disorders

    (1976)
  • A. Beck et al.

    Cognitive Therapy of Depression

    (1979)
  • A.T. Beck et al.

    Cognitive Therapy of Personality Disorders

    (1990)
  • A.T. Beck et al.

    Cognitive therapy for schizophrenic patients

    Harvard Ment. Hlth Lett.

    (1998)
  • J.J. Blanchard et al.

    The neuropsychological signature of schizophrenia: generalized or differential deficit?

    Am. J. Psychiatry

    (1994)
  • D.L. Braff et al.

    The generalized pattern of neuropsychological deficits in outpatients with chronic schizophrenia and heterogeneous Wisconsin Card Sorting Test results

    Arch. Gen. Psychiatry

    (1991)
  • H.D. Brenner et al.

    Treatment of cognitive dysfunction and behavioral deficits in schizophrenia

    Schizophr. Bull.

    (1992)
  • J.R. Brett-Jones et al.

    Measuring delusional experiences: A method and its application

    Br. J. Clin. Psychol.

    (1987)
  • A. Brier et al.

    Self-control in psychotic disorders

    Arch. Gen. Psychiatry

    (1983)
  • A. Buchanan et al.

    Acting on delusions II: the phenomenological correlates of acting on delusions

    Br. J. Psychiatry

    (1993)
  • G. Buchkremer et al.

    Psychoeducational psychotherapy for schizophrenic patients and their key relatives or care-givers: results of a 2-year follow-up

    Acta Psychiatr. Scand.

    (1997)
  • J.R. Bustillo et al.

    Schizophrenia: Improving outcome

    Harvard Rev. Psychiatry

    (1999)
  • P. Chadwick et al.

    The omnipotence of voices: A cognitive approach to auditory hallucinations

    Br. J. Psychiatry

    (1994)
  • P. Chadwick et al.

    Cognitive Therapy for Delusions, Voices and Paranoia

    (1996)
  • P.D.J. Chadwick et al.

    Measurement and modification of delusional beliefs

    J. Consult. Clinical Psychol.

    (1990)
  • R.D. Coursey et al.

    Individual psychotherapy and persons with serious mental illness: The client's perspective

    Schizophr. Bull.

    (1995)
  • L. Davidson et al.

    The varied outcomes of schizophrenia

    Can. J. Psychiatry

    (1997)
  • F.B. Dickerson et al.

    Lack of insight among outpatients with schizophrenia

    Psychiatr. Serv.

    (1997)
  • V. Drury et al.

    Cognitive therapy and recovery from acute psychosis: a controlled trial. I. Impact on psychotic symptoms

    Br. J. Psychiatry

    (1996)
  • V. Drury et al.

    Cognitive therapy and recovery from acute psychosis: a controlled trial. II. Impact on recovery time

    Br. J. Psychiatry

    (1996)
  • V. Drury

    Follow-up to study of CBT in acute schizophrenia. Schizophrenia Conf., Beck Institute, Philadelphia, PA

    (1999)
  • J. Edwards et al.

    Treatment of enduring positive symptoms in first-episode psychosis: A randomized controlled trial of CBT and clozapine

    Schizophr. Res.

    (1999)
  • A. Ellis

    Reason and Emotion in Psychotherapy

    (1962)
  • W.S. Fenton et al.

    We can talk: Individual psychotherapy for schizophrenia

    Am. J. Psychiatry

    (1997)
  • W.S. Fenton

    Evolving perspectives on individual psychotherapy for schizophrenia

    Schizophr. Bull.

    (1999)
  • D. Fowler et al.

    Cognitive Behaviour Therapy for Psychoses: Theory and Practice

    (1995)
  • D. Fowler et al.

    Vulnerability-stress models of psychotic illness and their clinical implications

  • C.D. Frith

    The Cognitive Neuropsychology of Schizophrenia

    (1992)
  • P.A. Garety et al.

    Cognitive behavioural therapy for drug-resistant psychosis

    Br. Med. J.

    (1994)
  • P. Garety et al.

    London–East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis. II. Predictors of outcome

    Br. J. Psychiatry

    (1997)
  • S. Glynn

    The token economy: Progress and pitfalls over 25 years

    Behav. Mod.

    (1990)
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