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The use of psychotherapy in the treatment of schizophrenic patients has gone into a long decline. Nearly 50 years ago, discouraging results of controlled psychotherapy studies began to come in while apparently effective antipsychotic medications were being introduced. By now, schizophrenia is generally understood to be a brain disorder with biological, partly genetic, origins. But this knowledge has not yet borne fruit in the form of radically better treatments.
Meanwhile, we've learned that drugs have serious limitations -- including the second generation of slightly improved drugs (see Harvard Mental Health Letter, September 2002). They are only partially effective at best, and they do little to relieve some of the most serious schizophrenic symptoms, including limited speech, slowed thinking, constricted emotional expression, passivity, and apathy. Up to 40% of patients do not respond to drugs at all or quit because of side effects. So the interest in psychosocial treatments is reviving.
One treatment attracting special renewed attention is cognitive behavioral therapy. Cognitive behavioral therapists are concerned with how patients perceive and think about themselves and the world in everyday situations. To change behavior, the therapist tries to identify and correct misdirected attention, distorted recall, misinterpretations, false assumptions, fixed ideas, unjustified generalizations, oversimplification, the habit of thinking in extremes and absolutes, and the tendency to jump to conclusions. The patient learns and practices more effective habits of thought and action. The therapist works by asking questions and suggesting hypotheses to be confirmed or refuted. One of the aims is to make complaints and conditions that seem general and vague more concrete and specific, so that they become problems to be solved. For example, if the patient says, "I feel terrible," a cognitive therapist may ask, "What are you thinking about?" The action takes place outside as well as inside the therapist's office. Patients are often asked to keep records of their daily activities and perform assigned tasks while recording the associated thoughts. They may rehearse the assignments in the office with the therapist serving as an instructor and model.
Schizophrenic patients were once regarded as too badly damaged for this kind of correction and persuasion. Their minds, the argument went, were too fogged; they lacked sufficient capacity to keep track of their thoughts and behavior. Cognitive behavioral therapists do not share that opinion. They hope to help people with schizophrenia test the reality of their thoughts and perceptions, reduce the influence of hallucinations and delusions, and sometimes even shake off apathy and emotional constriction.
The therapist tries to identify the source of psychotic experiences and explore their function in the patient's life. If a paranoid patient says, "They are poisoning me with these drugs," the therapist may help him understand the side effects of medications. A woman who insists that she is a member of the royal family may be conveying the thought that if she were a queen her husband would treat her better. If a patient says that his thoughts are being broadcast to the world or inserted into his mind by an outside power, the therapist might ask about the evidence for this belief and suggest alternative explanations.
One of the most common symptoms of schizophrenia is hallucinatory voices, usually threatening or abusive. The therapist asks the patient to record when and where the voices occur, who is speaking, what they are saying, what makes the voices come and go, and what feelings they inspire. The aim is to convince the patient that his or her own mind is generating these perceptions of being attacked and humiliated.
Sometimes a patient can be persuaded to move from verbal questioning to experiment: "If you really think that so-and-so is out to get you, what do you suppose would happen if you did X or Y?" Patients may learn to still the voices by repeating what they say, listening to music, humming, or engaging in conversation. The aim is to transform psychotic symptoms, as much as possible, into testable beliefs and perceptions. In that way the therapy can reduce the influence of hallucinations and delusions and help relieve the resulting anxiety, depression, and confusion.
To compensate for negative symptoms -- passivity, social withdrawal, emotional unresponsiveness -- a cognitive behavioral therapist may try to help patients plan their days and put more structure into their lives. They may be asked to establish a daily schedule and discuss the thoughts that account for their lack of initiative -- why bother, I don't have time, everything is too difficult. Social skills training may also help patients emerge from isolation and passivity.
Some good results of cognitive behavioral therapy have been reported.
Not all results are so promising. Cognitive behavioral therapy has now been compared with routine care, supportive therapy, social skills training, and family intervention in at least three meta-analyses (analyses of pooled data from many studies). Statistically, it is more effective as a treatment for both positive (psychotic) and negative (non-psychotic) symptoms of schizophrenia, but it does not have an advantage in improving social functioning, reducing relapse rates, or enhancing the overall quality of life. Some studies may not have corrected for the effects of extra attention from cognitive behavioral therapists.
Still, the British National Health Service regards the evidence as strong enough to make cognitive behavioral therapy for schizophrenia a reimbursable treatment. In the United States, the 1999 Expert Consensus Treatment Guidelines for Schizophrenia also included an endorsement of cognitive behavioral therapy. More definitive results will require longer-term studies with larger numbers of patients and more accurate descriptions of the treatments involved. Cognitive behavioral therapy is a complicated technique with assorted components and variants that may be helpful for different patients. Other questions are how treatment can be combined with medications and other treatments, and how best to measure outcomes.
Psychotherapists who treat schizophrenic patients are often discouraged by their seemingly intractable symptoms. With its focus on solving specific problems and reaching definite goals, cognitive behavioral therapy can help both the patients and their therapists resist the feeling of being overwhelmed by a sea of troubles. But engaging these patients can be difficult because of the many interfering circumstances, including severe psychotic symptoms, homelessness, and substance abuse. Like many other psychosocial treatments, the cognitive behavioral approach to schizophrenia may always be more admired than practiced. The model programs used in controlled trials are expensive and time-consuming, and require specialized training along with a strong commitment from both patients and therapists. Still, even a therapeutic technique that most schizophrenic patients will never encounter in its standard forms can be an effective alternative for some, as well as a source of ideas on how to cope with the symptoms of this devastating disorder.
Practice Guideline for the Treatment of Patients with Schizophrenia
- Lehman, A. F., Lieberman, J. A., Dixon, L. B., McGlashan, T. H., Miller, A. I., Perkins, D. O., and Kreyenbuhl, J. (2004). American Psychiatric Association.
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