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