The history of CBT and schizophrenia

Initially, Cognitive-Behavioural Therapy (CBT) was seen as a therapy for anxiety and mood disorders and not used as a primary treatment for schizophrenia. However, since people with schizophrenia often lack the necessary coping skills to manage their symptoms this can leave them vulnerable to stress and this can further exacerbate the condition, leaving the person increasingly disabled.

Relapse is often associated with stressful interactions with family members, stressful life events, over-stimulating residential and treatment environments and other general problems with managing and regulating emotions. If prodromal symptoms can be identified, early intervention could prevent relapse. It seems important therefore that the initial stages of recovery are …

  • managed very carefully as overly ambitious treatment expectations could lead to further stress and increase likelihood of relapse
  • focused on helping the client identify stressors and respond more favourably through stress management techniques, in order to limit decompensation

Brown (1998) says that CBT needs to be developed that is tailored for the specific needs of people with schizophrenia including helping the person to develop coping skills to help them to manage stress and to help them to “change perceptions and interpretations of events, reduce physiological arousal and manage affect” in order to improve their overall ability to function successfully and more independently. 

CBT has been used to successfully help clients to learn to control their hallucinations and delusions and also to help destigmatize the experience, enabling clients to manage the symptoms more effectively. Clinical outcomes have included “considerable reduction in symptomatology, rehospitalisations and improvement in psychosocial functioning and attainment of treatment goals that were maintained at 1-year follow-up”, (Bradshaw, 1997).

Some studies have targeted specific delusions and tried to reduce the conviction with which they are held (that is how strongly a person believes their belief is true) and to replace the delusions with more adaptive beliefs. CBT may also be used to reduce the emotional distress associated with the delusions, (Combs, et al.2007).

What does CBT look like when used with people with schizophrenia?

Step 1:

  • establishing the “therapeutic alliance” including discussing the rationale of the treatment
  • helping the client to understand the process of CBT
  • agreeing on treatment goals
  • educating the person about schizophrenia
  • trying to normalize and destigmatize the experience of schizophrenia
  • discussing biological vulnerability to stress of individuals with schizophrenia and the importance of identifying stresses and improving methods of coping with stress

Step 2:

  • teaching strategies to help the person to manage stressful situations in their life
  • For people who have been previously hospitalized this may involve helping to structure the day into blocks (morning, afternoon, evening) that can be then reviewed in therapy to identify events which trigger stress and lead to decompensation.
  • may focus on improving daily living skills (self-care, cooking, cleaning, time management)
  • exploring previous interests to expand the range of activities that the person is involved with
  • the therapist may ask the client to rate their daily activities for “mastery” and “pleasure” to help evaluate the benefits of the activities and to identify cognitive distortions that minimise sense of accomplishment and pleasure.
  • The client will be taught to identify stress triggers (e.g. creating a personal stress thermometer to “take the stress temperature”) and taught coping strategies (e.g. meditation) which can be initiated to counteract relapse

Step 3:

  • continuing the good work and helping the client to identify habitual sources of stress in their lives that can be worked on using the principles of CBT, e.g. social situations, the impact of schizophrenia and fear of relapse.
  • clients may be trained to  “check it out” by identifying automatic thoughts, evaluating evidence, exploring alternative explanations and generating new coping self-statements to replace the automatic thoughts.
  • hallucinations and delusions may not directly challenged, but simply interpreted as reactions to stress meaning the focus is on the context triggering the symptoms rather than their content.
  • this said, clients may be helped to develop skills to identify the difference between “confirmable” and “perceived” reality.
  • focus on social skills training using role-play for example.
  • the therapist may also assist in developing the client’s sense of self (e.g. not just a “a mental patient”) and self esteem.

Step 4:

  • the client will inevitably have anxieties surrounding ending treatment and developing plans to maintain treatment gains is the final part of the process
  • reviewing progress particularly with identifying early warning signs or stressors and how to deal with them
  • agreeing on what to do in an emergency situation
  • transition plan will be created including gradually reducing the number of sessions and continuing to provide support over the phone and through “booster” sessions.

Describing CBT for schizophrenia

Evaluating CBT for Schizophrenia:

Weaknesses of the evidence base for CBT

  • relatively brief periods of experimental treatment with brief follow-up
  • others lack designs that control for the multiple treatments clients received in inpatient settings
  • most lack standardised measures of outcome and provide limited post-treatment data.
  • little comprehensive application of CBT to the multiple problems of clients with schizophrenia over the long-term course of the disorder.

Practical problems with CBT with people with schizophrenia

  • difficulties with self-reflection (introspection) and logical reasoning
  • use of defence mechanisms such as denial and projection
  • behavioral experiments do not always work on people who are having persecutory delusions as they tend to have a strong confirmation bias, that is, they report only the evidence that supports their belief; this means that the person may need to come to therapy with a trusted friend or family member to serve as an additional observer for the experiment as this can provide contradictory evidence to consider
  • Behavioural experiments need to be considered very carefully due to the risk of harm; if the person believes someone is trying to harm them and confronts that person as part of a behavioural experiment this could be dangerous for both the person with schizophrenia and the member of the public and therefore danger and distress need to be carefully assessed; it may be better to use a simulated role play whereby alternative narratives are presented to the person with schizophrenia
  • patients can be anxious about coming to the end of the agreed treatment period and this transition needs to be planned carefully including a plan for emergencies, a gradual reduction in the number of sessions and continued support over the phone and through “booster” sessions.

Ethical/Social and Moral Implications

  • Client collaboration means that the power resides with the client rather than the therapist
  • However, challenging the person’s delusions can be distressing for them and needs to be managed with a good deal of sensitivity, starting with weaker evidence to challenge their beliefs first and then moving gradually to the strongest as this will be the most challenging for them to deal with.

Further reading:

Up to date review paper for evaluation: McKenna vs Kingdon head to head 2014

An essay that evaluates CBT for schizophrenia; long as ever and you would certainly not need to write all of this in the exam but hopefully serves a purpose. In lesson time you will work with the essay and create your own slimline version using the essay planner sheet to ensure you hit the all important criteria:  essay-planner-sheet-8 THERAPY

ao3-cbt-schiz FINAL

Practice Questions

  1. Describe the use of one psychological treatment for schizophrenia (5)
  2. Evaluate the use of one psychological treatment for schizophrenia with reference to research evidence (8)
  3. Compare the use of one biological and one psychological treatment for schizophrenia (4)

4. Harry has recently be discharged from hospital following a two month stay. Whilst he was there, he was diagnosed with schizophrenia. He had been experiencing symptoms including thought insertion and hallucinations. Harry will be seen as an outpatient and will receive psychological treatment.

a. Describe one form of treatment or therapy that might be used with Harry (5)

b. Explain two possible benefits that Harry may experience following one treatment or therapy other than medication (4)

c. Outline one practical and one ethical issue relating to the form of treatment or therapy you explained above (4)

  1. Raza has schizophrenia. His therapist has suggested using a non-biological treatment to aid his recovery.

a. Explain how the therapist might attempt to help Raza. (5)

b. Suggest two ways that the therapist could encourage Raza to give the treatment a try, You must refer to research evidence in your answer. (4)

All materials on this website are for the exclusive use of teachers and pupils of psychology . Any unauthorised copying or posting of material from this site is a copyright infringement and could result in legal action being taken against you.

© Amanda J Wood, 2016-2017