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Cognitive Behavioral Therapy for Schizophrenia INTRODUCTION Schizophrenia is a persistent and often unrelenting psychiatric disorder. Twenty-five to fifty percent of patients who are compliant with medication still experience significant symptomatology (Weinberger, 1995). Unfortunately, as many as 50 % of patients are not fully compliant with prescribed medications (Hale, 1995). Thus, practitioners treating patients with schizophrenia can become frustrated by the patient's lack of complete response to medications, problems with medication compliance and the patient's staunch conviction in the content of their delusions and auditory hallucinations.
Cognitive and behavioral interventions have demonstrated effectiveness with depression, panic, eating disorders and phobias (Rayburn & Otto, 2003) The theoretical model for the therapy posits that the patient's assessments of the self, the world and the future are distorted and influence emotions and behavior, which results in maladaptive behavior patterns. The cognitive model is the theoretical basis for cognitive therapy. Thus, all of the therapeutic techniques used in cognitive therapy are directly linked to the theory. Cognitive Therapy helps the patient evaluate problematic thoughts and cultivate more adaptive responses (Beck, 1995). It is reasonable to suspect that cognitive therapy would be effective for schizophrenia due to the cognitive processing biases associated with delusions and hallucinations. That is, patients with schizophrenia have distorted beliefs, which influence their behavior in maladaptive ways.
Although cognitive therapy for schizophrenia teaches the patient to evaluate the validity of psychotic symptoms and develop more adaptive alternatives as in other forms of CT -- in order for cognitive therapy to be optimally effective with schizophrenia, the cognitive model and cognitive therapy has been adapted to meet the special needs of this population. EMPIRICAL SUPPORT FOR COGNITIVE THERAPY FOR SCHIZOPHRENIA The literature regarding psychological treatments of refractory symptoms of schizophrenia as adjunctive to standard antipsychotic and supportive therapies has produced several studies designed to ascertain the efficacy of specific approaches. Cognitive Behavioral Therapy (CBT) is one such approach. In addition to many anecdotal papers, there have now been controlled studies evaluating the efficacy of CBT in different settings. One of the most rigorous reviews (Rector et al. 2003) counted one controlled study assessing the impact of CBT during the acute phase of schizophrenia and five studies assessing it in the chronic phase of the illness. There are more studies evaluating the efficacy of CBT in the chronic phase of schizophrenia than in the acute setting.
These generally evaluate the efficacy using scales evaluating the change in symptoms. Sensky et al. (2000) randomized 90 patients to CBT plus Routine Care or "befriending" therapy plus Routine Care conditions. Treatment occurred over a nine-month period with 20 sessions per patient and raters were blinded as to treatment condition post treatment and at a 9 month follow-up assessment. Immediately post treatment, both groups showed equivalent improvement but at the 9 month follow-up, the CBT group had better sustained outcomes on all measures than did the control group.
Although more research is needed to assess the efficacy of cognitive behavioral therapies in the treatment of schizophrenia, the studies just outlined have shown promising effects. Cognitive behavioral therapy, as a specific treatment in addition to routine pharmacological and supportive care, impacts acute and chronic positive and negative symptoms of schizophrenia. This effect has been found, in some studies, to persist several months post-treatment (Rector et al. 2003). Further trials with patients randomized and matched for type of routine treatment including medication effects and changes and with blinded raters doing assessments should clarify the effect size of these therapies and specific ways to incorporate them into care for patients with schizophrenia.
THE COGNITIVE MODEL OF SCHIZOPHRENIA The Cognitive Model for all presenting problems suggests that thoughts influence emotion and behavior. Thus, one's interpretation of experience is key to understanding the concomitant emotions and behavior. For instance, say Jane sees a friend of hers, Frank, walking down the street. Frank fails to say hello to her.
If Jane thinks "he didn't see me, " she is likely to feel fine and perhaps try to get his attention. However, if Jane thinks, "He saw me and ignored me, everyone ignores me, I will never have any friends, " she is likely to feel sad and lonely and go home. In cognitive therapy, the therapist assists the patient in evaluating the veracity of the patient's beliefs. Beliefs are framed as possibilities or hypotheses that are open to evaluation and restructuring rather than being viewed as facts (Beck, 1995). Like the basic cognitive model, the cognitive model of schizophrenia emphasizes fundamental discontinuities with normal thought and psychological processes. Delusions, voices and paranoia are believed to lie on a continuum of differences in thought and behavior, and do not arise from fundamentally different psychological processes.
This is strikingly different to the clinical stance of some that trying to conduct logical evaluation of delusions is useless because delusions are viewed as fixed false beliefs (Rector & Beck, 2002). Accordingly, recent studies in the cognitive processing of patients with schizophrenia suggest that they make several consistent attribution errors. Patients engage in an egocentric bias wherein they interpret innocuous or irrelevant stimuli as being directed towards them (Rector & Beck, 2002). For instance, the patient who believes that the presence of baby care commercials on television contain a highly personal meaning, just for them, in this case to blame the patient for the abortion she had when she was sixteen. Additionally, patients with schizophrenia also use an externalizing bias where they attribute internal physical symptoms to outside sources (Rector & Beck, 2002). They also report an internationalizing bias where patients assume negative and harmful intentions to other's behaviors.
For instance, a man coughing on the subway is seen as intentionally attempting to make the patient ill. The cognitive model for schizophrenia is based on the assumption of a diathesis-stress model (Rector & Beck, 2002; Kingdon and Turkington 1994). Delusions, especially, are thought to result from faulty interpretations of environmental stimuli. Kingdon and Turkington (1994) suggest that patients are more likely to engage in the cognitive biases mentioned above when they are under significant psycho-social stress, when they experience a loss or when the outcome of the event is important to them, carrying negative personal meaning for the patient. However, since the conviction in faulty attribution is strong, the role of the environmental stressor is minimized in the mind of the patient. The role of historical antecedents and the emphasis on interpretations based in real life problems is a particular contribution of Kingdon and Turkington (1994) to the cognitive therapy for schizophrenia.
This stance places delusions on a continuum of normal thought and allows the therapist the opportunity to normalize the patient's experience, by showing them that their delusional interpretation is actually anchored in historically stressful events. The content of delusions is thought to reflect underlying belief systems that are typical to other psychiatric disturbances. Thus, the beliefs that influence symptoms in panic and depression are also present in psychosis. The cognitive model for hallucinations is similar to the cognitive model for delusions.
Hallucinations in this model are due to problems in discriminating self-generated from environmental stimuli. Additionally, patients with schizophrenia tend to misinterpret the sources of the voices as being omnipotent, omniscient, and controlling (Weinberger, 1995). The more that the patient believes that the voices are powerful, the more likely the patient is to act on what the voices tell the patient to do (Rector & Beck, 2002). One can see how an appropriate goal for treatment in this case would be to help the patient evaluate whether the voices actually know best. This may be accomplished by conducting behavioral experiments about what would happen if he did not follow the voices demands of him. Thus, the goal of the treatment is to help the patient evaluate the content of their delusions and hallucinations, and undermine the rigidly held convictions about the content of the delusions or the power of the voices in order to functionally adjust their behavior.
COGNITIVE THERAPY FOR SCHIZOPHRENIA The general model of Cognitive Therapy is a structured, active, shorter-term therapy focused on the here and now problems of the patient's life. CT is also a collaborative approach that strongly values the therapeutic alliance and helps the patient evaluate his or her beliefs using multiple cognitive and behavioral tools (Beck, 1995). Generally, the patient is seen in individual sessions lasting 50 - 60 minutes. The patient is socialized into the cognitive model in the early stages of therapy through gentle Socratic questioning and guided discovery.
The therapist and patient collaboratively develops a list of problems the patient is experiencing and behavioral goals linked to the problems. An agenda is set for sessions. Thoughts that distress the patient are solicited and evaluated. The therapist "bridges" from the previous session, reviewing homework, checking on the patient's mood since the last session and setting the agenda for the current session (Beck, 1995).
One or two mutually agreed upon main issues are addressed each session. The therapist and patient work collaboratively to address these issues using behavioral techniques along with cognitive restructuring techniques. During the session, the therapist assesses the patient's understanding and agreement with the rationale for treatment. Feedback is solicited about the patient's experience of the therapy, their understanding of the procedures, thoughts about the therapeutic alliance. Finally, both the patient and therapist work to develop homework assignments that are manageable, relevant to the current problems and consistent with the agreed upon treatment goals (Beck, 1995). In cognitive therapy for schizophrenia, several adaptations to the model need to be made, but the course of treatment follows the same basic structure as traditional cognitive therapy.
Therapy is usually delivered in individual sessions, lasting 50 - 60 minutes. However, it can be delivered in shorter duration or the patient can be offered breaks depending on the patient's level of agitation or acute distress. Unlike traditional cognitive therapy, there is a lengthier process for engaging the patient (Kingdon & Turkington, 1994). Stages of Cognitive Therapy for Schizophrenia are the following: Engage; Assess; Trace Origins of beliefs / hallucinations ; Elicit beliefs about the mechanisms underlying delusions / hallucinations ; Normalize symptoms and discuss alternative mechanisms; Re attribute hallucinations and discuss content; Treat Negative symptoms. CONCLUSION Cognitive Therapy is a promising adjunctive treatment for schizophrenia.
Cognitive therapy assists the patient in not only normalizing their symptoms as an extreme reaction to stress, but also helps them evaluate the veracity and utility of their symptoms through cognitive and behavioral interventions. Future directions for cognitive therapy may include better training and dissemination of this efficacious treatment. References Beck, J. (1995). Cognitive therapy: Basics and beyond. New York: The Guilford Press. Hale, A. (1995).
Atypical antipsychotic and compliance in schizophrenia. Nordic Journal of Psychiatry, 49, 31 - 39. Kingdon, D. , Turkington, D. (1994). Cognitive Behavioral therapy of Schizophrenia. New York: Guilford Press Rayburn, N. , Otto, M. (2003). Cognitive-behavioral therapy for panic disorder: a review of treatment elements, strategies, and outcomes.
CNS Sector, 8 (5), 356 - 62. Rector, N. , Beck, A. (2002). A Clinical Review of Cognitive Therapy for Schizophrenia. Current Psychiatry Reports, 4 (4), 284 - 292. Rector, N. , Seen, M. , Segal, Z. (2003). Cognitive therapy for schizophrenia: a preliminary randomized controlled trial.
Schizophrenia Research, 63 (1 - 2), 1 - 11. Sensky, T, Turkington, D, Kingdon, D. (2000). A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Arch Gen Psychiatry, 57, 165 - 172. Weinberger, D. (1995).
Schizophrenia as a Nuerodevelopmental Disorder. Schizophrenia, 16, 293 - 323.
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Research essay sample on Cognitive Behavioral Therapy For Schizophrenia
