CBT for Schizophrenia (CBT-P):
An Introduction

 

What is Cognitive Behavioral Therapy (CBT-P) for Schizophrenia?

CBT for Schizophrenia is an evidence-based treatment which directly addresses key symptoms of schizophrenia including delusions, hallucinations and negative symptoms (lack of motivation, lack of interest, lack of pleasure). It seeks to develop a strong therapeutic alliance based on understanding the person's perspective and experience; uses gentle questioning techniques to test out strongly held beliefs (delusions), cope with voices (auditory hallucinations,); and, alleviates distress and psychological pain (Kingdon & Turkington, 2005). Contrary to common clinical wisdom, direct discussion of delusions and hallucinations does not lead to worsening of symptoms. Often, people feel relieved that someone is listening and trying to make sense of their distressing and confusing experiences. This approach can greatly assist in engaging people in treatment specially when our focus is on important aspirations and goals.

What is Recovery-Oriented Cognitive Therapy? (CT-R)

CT-R focuses on the individuals' most important goals and aspirations as a way of engaging people in therapy and helping them move toward personal goals in a step-by-step manner.

Download the NAMI Marin Presentation for more on this topic.

What is the evidence that CBT is effective for people with Schizophrenia?

A recent systematic review of more than 35 clinical trials of CBT for schizophrenia (CBTp) concluded that  "CBTp was superior for hallucinations (g = 0.34, P < .01) and delusions (g = 0.37, P < .01) when compared with any control. Compared with TAU, CBTp demonstrated superiority for hallucinations (g = 0.34, P < .01) and delusions (g = 0.37, P < .01). Compared with AC, CBT was superior for hallucinations (g = 0.34, P < .01), but not for delusions although this comparison was underpowered." (Turner et al., 2020). [Note AC= Active Controls, TAU= Treatment as Usual.]

What is the 'right dose' of cognitive therapy for people with psychosis or schizophrenia.

The 'right' amount of therapy may vary considerably. One study suggested that a minimum of 16 sessions of individual CBT with more improvements showing up at an average of 25 sessions. (Lincoln et al., 2016)

A second study suggest that even lower intensity doses of cognitive therapy might have benefit (Hazel et al., 2016)

Who can benefit from this type of therapy?

This type of therapy can be used with people who have schizophrenia, schizoaffective disorder, and delusional disorders. It is mainly useful for people who are distressed by their symptoms. It can be effective even if the person does not appear to have insight into his/her illness, as long as we can be engage in a helping relationship focused on your goals and aspirations.

SOME IMPORTANT PRINCIPLES

First develop the therapeutic alliance:
Instill hope and try to help the person understand their experience. The main goal is to instill hope by developing a respectful, compassionate and honest relationship with the person. It is best to start by trying to understand the person’s experience even if it seems frightening, bizarre or confusing.  Check out the person's level of understanding frequently using open-ended questions. Do not make assumptions about what the person thinks or believes.   Give simple explanations of what you want to do or learn and why.  Provide a rationale- allow the person to understand what you are doing. Use a clear and understandable session structure.  Be collaborative and try to establish common goals. For example, “help” might be more specifically helping the person deal with their distress over hearing voices.  (Kingdon and Turkington, 2005, p. 45)

Focus on important aspirations and goals

It's important to begin therapy by focusing on important personal goals and aspirations.  In a recovery oriented therapy we make aspirations the driving force behind the work of therapy.

Psychoeducation and Normalization: 
Introducing the stress-vulnerability model can be a very useful starting point. While recogizing the biological aspects of the illness (vulnerability), this model underlines the value of helping the person discover coping strategies to help reduce stress. Reassure the person that, from their perspective, there may be good reasons for thinking and feeling the way they do.

  • “Given what you’ve told me, I can understand why you might have these thoughts. Many people would!”
  • “The key to the client’s being able to understand the distressing and confusing experiences that occur in schizophrenia is psychoeducation based on the case formulation” (Kingdon and Turkington, 2005, p. 83).
  • “How long do you think others have been talking about you?”
  • “Do you think think this happens all the time?"
  • “Education that normalizes effectively can be highly valued” (Kingdon and Turkington, 2005, p. 85). This means avoiding the use of jargon and technical terms that can be confusing to a client.
  • “Normalization is the process by which thoughts, behaviors, moods, and experiences are compared and understood in terms of similar thoughts, behaviors, moods, and experiences attributed to other individuals who are not diagnosed as ill” (Kingdon and Turkington, 2005, p. 87).

Take time to show the person the relationships between thoughts, feelings and behaviors as outlined below.

It should be noted that Kingdon and Turkington (2005) recognize the risks of normalizing are minimization of the person's problems and not dealing with actual consequences. It is not useful to avoid or minimize significant problems that may have a very negative impact on the person. It is best to take a direct, matter-of-fact approach.

Use of Guided Discovery Techniques:

Typically, guided discovery involves gentle questioning about problems designed to help people uncover relevant patterns in thoughts feelings and behavior that might contribute to ongoing problems or make existing problems worse.
Client: “I keep thinking about the stalker.”
Therapist: “When did these thoughts first start to bother you?”
Client: “When I began working at that first job I told you about. It was awful- people hated me.”
Therapist: “So when you first started work in the new office, that was when you began to worry that someone was watching you”
Client: “Yes.”
Therapist: “It must have been a very uncomfortable time for you. Do you get nervous around people a lot?”

 

Using the ‘ABC’ Model to find connections between:

(A) Activating Events

(B) Beliefs

(C) Consequences

 

Often people feel confused, frightened and overwhelmed by their disturbing symptoms (voices, frightening beliefs, etc). Therapy can help  develop an understandable narrative (“what this all means”) about the problems that they are experiencing, their internal experiences and their responses. Explaining this all in an understandable way can be very reassuring and lead to useful solutions and possibly new and more effective coping strategies.

When did start thinking that the people might be talking about you or bugging your phone?”  What was happening when the client first became upset or distressed?  What were they thinking?  What were they feeling?

Did you notice that after you heard those voices you got scared and went up to your room right away?  What did they do?  What was the outcome?

What happened after that? Did you feel better or worse?  If the person gets distressed, it’s often a good idea to talk about something else for the rest of the session. Keep discomfort and anxiety low!

Intervening with delusions

The goal here is to generate alternative explanations for delusions and further explore how they developed without being directly challenging. Some possible questions you might use:

  • “Are there any other possible explanations for what happened?”
  • “What about this as a possibility…?”
  • “Do you think just possibly…?”
  • Are you 100% certain that this is true?”

(Kingdon and Turkington, 2005, p. 105)

First work on establishing any evidence for the delusion. This won’t worsen the delusion or become part of it. This will likely strengthen the bond between therapist and client.
Discussing and gently debating delusions:

  • Establish engagement- this is where the client is interested in and attentive to the conversation with the therapist.
  • Trace the origins of the delusion.
  • Build a picture of the prodromal period (just before the person became ill).
  • Identify significant life events and circumstances.
  • Identify relevant perceptions and thoughts.
  • Review negative thoughts and dysfunctional (maladaptive) assumptions, especially ‘taking things personally’ and ‘getting things out of context’ or ‘jumping to conclusions’.  (Kingdon and Turkington, 2005, p. 103)
Intervening with Auditory Hallucinations (Voices)

Auditory hallucinations or voices are viewed as automatic thoughts that are misperceived as originating from the outside. For some, externalizing distressing thoughts may help them cope with severe distress. People may benefit from several basic cognitive behavioral strategies including reattribution, debating the content of the hallucination (evidence for and against what the voice is saying), understanding how the hallucination might reflect some underlying beliefs, and developing coping strategies.

Why do you think others can’t hear the voices?”  Re-attribution (changing the client’s assumptions and beliefs about the voices being ‘out there’). The aim is to allow the person to see that the voices may be his/her own thoughts.

- Discuss the client’s specific experience with voices
- Is it only the client who can hear the voices?
- Discover beliefs about the origin of the voices
- Look for possible alternative explanations and discuss with client
- Create more helpful alternative explanations.

Have people begin to monitor experiences; keep a 'Voices Diary' to record triggers and fluctuations in the voice-hearing experience.

Work on helping with coping strategies. (“What has worked in the past with the voices?”)

Reduce safety behaviors (coping strategies that make the symptoms worse) if they are maintaining symptoms. Safety behaviors are problematic ways of responding or efforts that people use to reduce distress or anxiety that actually reinforce the problem. For example, think of the socially anxious person who attends a party but immediately exits when they start to feel nervous. This tends to increase their anxiety and make them more likely to escape the next time.

Help the person use cognitive behavioral strategies that apply to handling automatic thoughts such a rational responding, challenging, and examining the evidence.

Help the person understand how the voices might reflect problematic beliefs.
(Kingdon and Turkington, 2005, p. 120)

References

Grant PM, Beck AT. (2009). Defeatist Beliefs as a Mediator of Cognitive Impairment, Negative Symptoms, and Functioning in Schizophrenia. Schizophrenia Bulletin, 35(4), 798–806.

Grant PM, Beck AT. (2010). Asocial Beliefs as Predictors of Asocial Behavior in Schizophrenia. Psychiatry Research, 177, 65-70.

Grant PM, Huh GA, Perivoliotis D, Stolar NM, Beck AT. Randomized Trial to Evaluate the Efficacy of Cognitive Therapy for Low-Functioning Patients with Schizophrenia. Archives of General Psychiatry, 69(2), 121-127.

Grant PM, Bredemeier K, and Beck AT. (2017). Six-Month Follow-Up of Recovery-Oriented Cognitive Therapy for Low-Functioning Individuals with Schizophrenia. Psychiatric Services, 68(10), 997-1002.

Beck, J.S. (1995). Cognitive therapy: Basics and Beyond. New York: Guilford Press.

Kingdon, D., & Turkington, D. (2006). Cognitive-Behavioral Therapy of Schizophrenia.  New York: Guilford Press.

Wright, N. P., Turkington, D., Kelly, O. P., Davies, D., Jacobs, A. M., & Hopton, J. (2014). Treating psychosis: A clinician's guide to integrating acceptance and commitment therapy, compassion-focused therapy, and mindfulness approaches within the cognitive behavioral therapy tradition. New Harbinger Publications.

(c) Robert Reiser, PhD and Andrea Feit, All Rights Reserved 2013