[PSYCHOTHERAPY ROUNDS] SERIES EDITOR: PAULETTE M.

GILLIG, MD, PhD

Professor of Psychiatry, Department of Psychiatry,
Boonshoft School of Medicine, Wright State University, Dayton, Ohio

COGNITIVE BEHAVIOR THERAPY FOR

PEOPLE WITH SCHIZOPHRENIA
by ANN K. MORRISON, MD
Associate Professor, Department of Psychiatry, Wright State University Boonshoft School of Medicine, Dayton, Ohio

Psychiatry (Edgemont) 2009;6(12):32–39

ABSTRACT
This article summarizes the
current literature on the use of
cognitive behavioral therapy for
people with schizophrenia for the
primary symptoms of illness, the
secondary social impairments,
comorbid disorders, and for
enhancing the effectiveness of other
treatments and services, such as
medication and vocational support.
Ways in which cognitive behavioral
therapy techniques can be
incorporated into the current
mental health system is suggested.
It should be acknowledged that a
few recent reviews and studies have
called into question the quality of
the evidence or the true
effectiveness of cognitive behavioral
therapy in schizophrenia and other
severe mental disorders and
comorbid conditions.

INTRODUCTION
There has been renewed interest
in psychosocial interventions, FUNDING: There was no funding for the development and writing of this article.
including psychotherapy, in the
treatment of schizophrenia. In FINANCIAL DISCLOSURE: The authors have no conflicts of interest relevant to the content of
recent years, this has included this article.
adapting cognitive behavioral
therapy (CBT) techniques EDITOR’S NOTE: The authors have no conflicts of interest relevant to the content of this article.
previously used mainly in the
treatment of mood and anxiety ADDRESS CORRESPONDENCE TO: Ann Morrison, Department of Psychiatry, Boonshoft School
disorders for use with individuals of Medicine, Wright State University, 627 S. Edwin C. Moses Blvd., Dayton, OH 45408-1461;
with more severe mental disorders.1 E-mail: [email protected]
The core symptoms of
schizophrenia in many people have KEY WORDS: Cognitive behavioral therapy, CBT for schizophrenia, psychotherapy for
proven to be resistant to treatment schizophrenia, inference chaining, schizophrenia plus comorbid conditions

32 Psychiatry 2009 [VOLUME 6, NUMBER 12, DECEMBER]

with medication alone and can be positive symptoms at a faster rate Tai and Turkington18 acknowledge
targeted for treatment with CBT.2 during the initial 12-week period that 1) CBT is not as effective when
Impairments in major role function following hospital admission, and people do not view themselves as
due to negative symptoms,3 some of the overall amount of positive having a mental health problem,
which have proved especially symptoms were reduced during this have delusional systems, or have
recalcitrant to pharmacologic time compared to those patients extreme primary negative systems;
agents,4 can be addressed with CBT that received an equal amount of and 2) when people have comorbid
to improve relationships with family activity therapy and support. There disorders, such as substance
and friends and success at work. was no difference in the decrease in misuse, because they are more
People with schizophrenia often negative symptoms between the difficult to engage and treat.
struggle with comorbid mood and groups during the initial 12-week However, CBT does show promise
anxiety disorders, including past period. At nine-month follow up, even in these more complex clinical
traumas,5 which can be successfully the group that received cognitive situations.
treated with CBT.6–8 Disseminating therapy continued to have Factors that have seemed to
and implementing these treatments significantly fewer positive predict improvement with CBT have
into a system of care that has, for symptoms than the control group. been identified in several studies. In
more than a decade, focused on At this follow up, there was no Drury et al,14,15 early work with
pharmacologic treatments and difference in negative symptoms. In acutely psychotic inpatients, female
community support services has addition, Drury et al15 found more gender, shorter duration of illness,
proven challenging especially in the rapid improvement in clinical and shorter duration of untreated
United States.9 recovery as measured by increased illness predicted better outcomes.
This article will summarize the insight, less dysphoria and “low Tarrier et al,19 in a stable, outpatient
current literature on the use of CBT level” psychotic thinking, and less population with persistent
for people with schizophrenia for disinhibition. symptoms, also found shorter
the primary symptoms of illness, the The majority of the studies duration of illness and less severe
secondary social impairments, following Drury’s group work with symptoms predicted the greatest
comorbid disorders, and enhancing acutely ill patients focused primarily improvement. More recently,
the effectiveness of other on treating the chronic and Brabban et al20 cited female gender
treatments and services, such as persistent symptoms of and low level of conviction in
medication and vocational support. schizophrenia. Approximately half delusions as predicting positive
Ways in which CBT techniques can of people (47%) with schizophrenia response to CBT.
be incorporated into the current exhibit clear psychotic features and
mental health system will be 22 percent experience weak or CBT: THEORY AND TECHNIQUES
suggested. It should be sporadic psychotic features.16 These Several leaders in the field of
acknowledged, however, that a few studies have been primarily done in CBT for treatment of schizophrenia
recent reviews and studies have the United Kingdom where there have provided summaries of the
called into question the quality of has been broader dissemination of theorectical background and
the evidence or the true the approach, likely at least in part therapeutic techniques.21–23 Tarrier
effectiveness for CBT in due to formal endorsement by the and Haddock21 note the recognition
schizophrenia and other severe National Institute for Clinical of coping strategies as a buffer
mental disorders and comorbid Excellence.17 Tai and Turkington18 against psychotic decompensation
conditions.1,10–12 summarize the results of the CBT and that CBT could enhance these
studies and reviews of these studies coping strategies already being
CBT: A REVIEW OF THE with the following points: employed by people with
LITERATURE schizophrenia. They describe the
Treating people with 1. Randomized controlled trials following characteristics of coping
schizophrenia using CBT is not an (RCTs) have shown moderate training:
entirely new approach. Beck,13 in effect sizes for positive and
1952, described successfully negative symptoms at the end of 1. Emphasis on the normal and
treating a delusional belief held by a therapy and with sustained general process of dealing with
patient with schizophrenia using effects. adversity (psychosis is an
CBT. Initial systematic efforts to use 2. CBT has been effective in clinical example of adversity)
CBT for the treatment of as well as research settings. 2. Use of overlearning, simulation,
schizophrenia focused on the 3. Hallucinations and delusions and role playing
treatment of acute symptoms respond to CBT. 3. Addition of coping strategies
experienced by inpatients.14 4. Negative symptoms respond together to progress toward in-
Studies by Drury et al14 showed initially, and improvement remains vivo implementation
that cognitive therapy reduced at medium-term follow up. 4. Provision of a new response set

[VOLUME 6, NUMBER 12, DECEMBER] Psychiatry 2009 33

 to ongoing problems under certain circumstances, such additional aversive experiences that
5. Coping skills that often begin as sleep deprivation or grief. subsequently increase
with external verbalization, which Turkington et al23 summarize the psychophysiological stress. They
then diminishes as the procedure main techniques as follows: note that people at risk for
becomes internalized schizophrenia have impairments in
6. Behavioral coping skills that are 1. Develop a therapeutic alliance neurocognition (attention problems,
learned through graded practice based on the patient’s impaired working memory, and
or rehearsal. perspective executive function), which they
2. Develop alternative explanations lump together as “cognitive
Specific cognitive and behavioral of schizophrenia symptoms insuffiency.” This insufficiency can
techniques Tarrier and Haddock21 3. Reduce the impact of positive result in inadequate performance,
advocate are attention switching, and negative symptoms which leads to increased stress.
attention narrowing, increased 4. Offer alternatives to the medical They hypothesize that the increased
activity levels, social engagement model to address medication stress and the resulting increase in
and disengagement, modification of adherence. corticosteroids contributes to the
self-statements, and internal development of delusions and
dialogue. To reduce the impact of positive hallucinations. They propose that
Other types of interventions symptoms, “peripheral questioning,” loss on integrative functions impairs
described by this group are de- a technique in which the person is other functions, such as self-
arousing techniques, increasing queried about the specifics of his or reflection, self-monitoring, and
reality or source monitoring, and her delusional beliefs in order to correction of misinterpretations,
belief and attribution modification. understand how he or she arrived at which lead to delusional beliefs,
Turkington et al23 emphasize that his or her conclusions, may be used. impaired insight, and reality testing.
the establishment of therapeutic This is then linked with graded Beck and Rector22 review
alliance, common to all successful reality testing to introduce doubt particular symptoms of
therapies but developed in an and postulate other explanations. schizophrenia and the way in which
overtly collaborative manner For example, a patient with the a cognitive assessment may be used
emphasizing the patients belief that he or she has invented to help diminish symptoms. For
perspective, is a hallmark of CBT in machines that will solve many of the instance, delusions they note can be
general. However, they emphasize world’s problems might be asked characterized by the cognitive
that patients with schizophrenia about how and when the idea came patterns of externalizing,
may be less amenable to any to him or her, what the early phases internalizing, and intellectualizing
attempts by the physician to view of design entailed, whether he or biases; categorical thinking;
their problems as biomedical in she has taken any steps to file for emotion-based and somatic-based
origin. For instance, if the patient patents, and whether others have reasoning; and inadequate cognitive
describes his or her problem as helped him or her in the endeavors. processing, such as jumping to
“depression,” “stress,” a The idea is to look for any gaps in conclusions. The self-centered
“misunderstanding” with family his delusional system that might focus, external locus of causation,
members, or even an “odd provide the therapist in-roads into and tendency to relate irrelevant
sensation” in his or her head, it is freeing up the conviction the events to themselves lead the
better to use these as openings into patient has in his beliefs. “Inference individual to arrive at false
how the physician might help the chaining,” in which the personalized conclusions.22 In the review, the
patient minimize these symptoms meaning of a systematized delusion, authors describe how hallucinations
rather than insist that the patient is explored to decrease the distress and negative symptoms can be
endorse a diagnosis of engendered by the delusion. understood and treated in a
schizophrenia. They point out that The review by Beck and Rector22 cognitive context. Premorbid
it is not necessary that the patient provides theoretical underpinnings attitudes toward social affiliation
share the physician’s view about the in the use of CBT for schizophrenia. coupled with low expectancies for
origin of his or her symptoms to They describe a neurocognitive pleasure, success, acceptance, and
work together to diminish the impairment in the premorbid state perception of limited resources
symptoms’ impact on the person. that makes the individual vulnerable produce and maintain negative
One technique, normalizing to aversive experiences (such as symptoms.22 Patients with
psychotic symptoms such as school failure). These lead to schizophrenia often have long
auditory hallucinations, is somewhat dysfunctional beliefs (such as “I’m established habits of looking for
discordant with the biomedical inferior”) and the dysfunctional slights, believing that others do not
model. For instance, to help engage cognitive appraisals and like them, and anxiety about dealing
the patient, the physician may point maladaptive behaviors (such as with conflict with friends and family,
out that many people hear voices social withdrawal). These lead to which may lead to worsening of

34 Psychiatry 2009 [VOLUME 6, NUMBER 12, DECEMBER]

psychotic symptoms. People with
schizophrenia may need to be TABLE 1. Targets and techniques of cognitive behavioral therapy for schizophrenia
coached through even simple tasks,
such as sharing chores with
roommates, setting limits on the TARGET TECHNIQUE
access that sexual partners of
roommates have to common living
areas, and agreeing to rules about Positive symptoms Alternate explanations to patient
appropriate behavior in these share
areas. Individuals with schizophrenia Normalizing
Hallucinations
may be particularly sensitive to off- Enhancing coping strategies
hand comments made by roommates,
such as mentioning plans to spend Inference chaining
Delusions
time with others, as being evidence Peripheral questioning
that the roommates do not care for
them or want them out of the
Negative symptoms Behavioral interventions
apartment.
With respect to treatment, Beck
and Rector22 describe using typical Avolition Behavioral self monitoring
CBT techniques: building trust and Amotivation Activity scheduling
engagement; working collaboratively Anhedonia Mastery and pleasure ratings
to understand the meaning of Affective blunting Social skills training
symptoms; understanding the
patient’s interpretation of past and
present events, especially those that comfort. For instance, a patient with develops acutely or more
the patient feels are related to the schizophrenia may need to be insidiously, the initial focus of
development and persistence of his coached on how to approach an treatment will be the initiation of
or her current problems; normalizing office staff person, whom he or she antipsychotic medication, usually a
these experiences and educating the has known for years, with a request second-generation agent. For most
patient about the stress-vulnerability that will keep him or her engaged in individuals, adhering regularly to
model; and socializing the patient to more than minimal conversation. medication for a long-term illness
the cognitive model, including the Some patients have so long ago proves daunting. The Clinical
relationship between thoughts, abandoned hobbies and interests Antipsychotic Trials of Intervention
feelings, and behaviors. Elucidating that the therapist and patient may be Effectiveness (CATIE) study24
the emotional and behavioral hard pressed to find something in reported discontinuation rates
consequences when a delusion is their current repertoire from which ranging from 68 to 82 percent over
activated leads to exploration of the to choose for developing an activity an 18-month period. Working with
evidence, initially with more schedule to enhance mastery and patients on both their automatic
peripheral interpretations. Beck and pleasure. Still, patients will often thoughts and beliefs about the
Rector22 advocate addressing agree to experiment with reengaging meaning of taking psychotropic
negative symptoms, such as their interests in music, gardening, medication and developing
amotivation, anergia, anhedonia, and or painting, for example, with behavioral routines and cues may be
social withdrawal, with behavioral enough support and practical help in helpful in improving adherence;
self monitoring, activity scheduling, overcoming obstacles, such as however, the earlier promise of
mastery and pleasure ratings, graded budgeting for supplies. Advocacy compliance therapy (a brief,
task assignments, and assertiveness groups, drop-in centers, clubhouses, cognitively based intervention using
training. Again, for patients whose and other nonclinical services can motivational interviewing
lives may have been severely limited provide less threatening and more techniques) has not been replicated
for many years, these behavioral accepting environments for patients recently.25 Behavioral management
schemes may have to be undertaken to explore these activities. Table 1 of some side effects, such as weight
at a more modest pace than the summarizes some of the target gain and the accompanying
clinician is used to when working symptoms and CBT techniques used metabolic sequelae or sedation and
with less impaired patients. Patients to ameliorate these problems. inactivity, may also prove useful.26
with schizophrenia may have to be Antipsychotics substantially
instructed to spend extremely small FIRST PSYCHOTIC EPISODE decrease relapse rates for people
amounts of time in a social situation AND CBT with schizophrenia. In one multisite
and the situation may have to be one Following a person’s first collaborative study, which included
with which they still have some experience of psychosis, whether it groups receiving placebo alone,

[VOLUME 6, NUMBER 12, DECEMBER] Psychiatry 2009 35

placebo and major role therapy, significant social impairments, steady job to provide for themselves,
antipsychotic alone, and especially from negative symptoms, form lasting relationships including
antipsychotic and major role therapy, such as avolition, anhedonia, sexual intimacy, and have fractured
the placebo-alone group had a 72.5- amotivation, and affective blunting. relationships with their families
percent relapse rate at one year The prevalence of the deficit through years of struggle with the
compared to a 32.6-percent relapse syndrome (primary and enduring disorder. These multiple experiences
rate for drug alone.27 Cumulative negative symptoms that are not of failure and loss, not surprisingly,
relapse rates for all placebo-group secondary to positive symptoms or can cement negative core beliefs, an
patients versus all drug-group treatments) is estimated to be 15 to obvious target for CBT. The same
patients were 67.48 percent versus 20 percent of people with techniques that one would use to
32.91 percent.27 Therefore, schizophrenia.30 The prevalence of all combat these core beliefs and the
maximizing adherence is an persistent negative symptoms automatic thoughts that arise from
important step in improving clinical (primary and secondary) is probably them in depression can be used to
outcomes. While adherence remains higher.30 These can be addressed help the person with schizophrenia.
a vexing problem, review of the directly by well-established CBT Patients themselves will often
adherence literature indicates that techniques, such as activation spontaneously express these
those interventions that go beyond strategies. Teaming an exploration of expectations of failure ironically,
education are likely to be more distorted cognitions with behavioral often when they are doing well, in
effective.25 activation may be especially helpful the form of “I know this cannot last,”
However, even with excellent in improving anhedonia and the lack or “something bad is going to
adherence to antipsychotic of social interaction secondary to happen.” These can be reasons for
medications, many individuals this, as it has been shown that not taking additional steps toward
experience both relapse and residual people with schizophrenia have independence, such as pursuing
symptoms. Cannon and Jones28 difficulty predicting, but not work, with people reporting, “I tried
estimate the general outcomes at five experiencing, enjoyment of that before and I could not handle
years for people with schizophrenia activities.22,31 Exploring automatic it.” Since these fears are often based,
to be 35 percent poor, 29 percent thoughts can be particularly helpful at least in part, on an accurate
intermediate, and 36 percent good. in uncovering a residual positive assessment of the past, one must be
They note that 14 to 19 percent symptom, such as paranoia, careful not to trivialize or dismiss
develop chronic, unremitting, masquerading as a negative them. However, the physician can
psychotic symptoms. A more recent symptom. Patients may deny a look for positive experiences to
first-episode psychosis study superficial inquiry into whether they discuss with the patient to
reported a similar 15.1 percent of were “paranoid or suspicious” but counteract those negative ones, such
people had persistent psychosis at eliciting more detail about the last as recent success with volunteer
two years.29 These persistent time they passed on a social work, having people with whom the
symptoms are often the target of opportunity may reveal residual patient can discuss challenges, and
CBT. Patients often cite beliefs that they will be mistreated or finding a medication that had helped
ineffectiveness as a reason for plotted against by family members or the individual concentrate better and
discontinuation of antipsychotic that others are only pretending to feel less anxious. These positive
medication at higher rates in most accept them temporarily so that they experiences can help diminish the
cases than side effects.24 Therefore, can reject or harm them more in the degree to which individuals with
the ability of CBT to decrease these future. Not venturing onto one’s schizophrenia hold to the negative
symptoms may have the additional porch may be a reflection of living in expectations. Dissecting these past
benefit of improving medication a bad neighborhood, reliving a past experiences might provide further
adherence. assault when taking a walk, or information that specifically can be
concern that one is under used to contradict current negative
MIDCOURSE TREATMENT OF surveillance from the streetlights. thoughts and beliefs.
SCHIZOPHRENIA AND CBT In addition to the positive and
Treatment of residual symptoms negative symptoms attributable to COMORBID CONDITIONS
of schizophrenia of both positive and schizophrenia itself, impairment in AND CBT
negative types remains a focus for role function can be due to the People with schizophrenia often
treatment with CBT through the secondary assumptions that patients have comorbid disorders, such as
midcourse of illness. Once people make about themselves, their future, substance use, depression, and
with schizophrenia have had and the reaction of others to them anxiety.5 The impact that anxiety
resolution of initial, acute symptoms, based on their experience of illness. symptoms have on quality of life and
which are typically the most Many individuals with schizophrenia interaction with psychotic
responsive to antipsychotic have been unable to complete their symptoms, including contributing to
medication, they often still suffer educational plans, hold down a distress and impairment, for people

36 Psychiatry 2009 [VOLUME 6, NUMBER 12, DECEMBER]

with schizophrenia has been
TABLE 2. Strategies for comorbid conditions of schizophrenia
described.32 These problems may
also be successfully managed with
CBT. For some problems, such as
COMORBIDITY STRATEGIES
posttraumatic stress disorder
(PTSD) or specific phobias, CBT
may be the treatment of choice. Substance use disorders CBT/motivational interviewing
However, there is evidence that
clinicians who treat people with
schizophrenia are reluctant to use Depression CBT
CBT, especially in the treatment of
trauma.33 This is unfortunate,
especially as the high prevalence of Panic disorder CBT
trauma and PTSD in patients with
schizophrenia and related disorders
is increasingly recognized.25 Two Specific phobia Exposure/systematic desensitization
recent studies, one open and one
randomized and controlled, have
PTSD CBT/exposure
shown improvement in PTSD
symptoms in patients with severe
mental illness.7,8 OCD CBT/exposure-response prevention
Specific phobias may be
overlooked as an obstacle in people
with schizophrenia because the Key: CBT—cognitive behavioral therapy; PTSD—posttraumatic stress disorder;
individuals may describe their OCD—obsessive compulsive disorder
problems as “paranoia” (e.g., they
are fearful of going to the dentist or health centers, such as group social skills training, target
doctor, traveling to see family, therapies and community support substance abuse by teaching
driving, or visiting friends who have services, can be utilized for these patients skills to decrease
birds). By using either systematic exposure experiences, but one substance use, including practicing
desensitization or, in some cases, needs to identify the individual’s refusal.35,36 These programs utilize
flooding (if the patient will tolerate specific thoughts and fears to some of the same techniques used
this), these fears can be overcome. address them effectively. For in more specific CBT, such as role
Patients with schizophrenia, instance, if one simply accompanies playing and contingency planning. A
however, may require significant an individual to the grocery store more formal study of CBT in
support and assistance with without identifying that the anxiety patients with schizophrenia and
implementing the behavioral plan. the individual feels is caused by substance use disorders has shown
Community support specialists or fear of scrutiny when scanning a promise.37 Table 2 summarizes some
behavioral therapists (if available) debit card or having to ask where of the comorbid conditions that
may need to assist the patient with an item is shelved, then an might be addressed with specific
exposure experiences. opportunity to transition the person CBT techniques.
People with schizophrenia often to independent shopping may be
complain of social unease or anxiety lost. Symptoms of social anxiety PROMOTING FURTHER
in absence of frankly psychotic may inhibit people with RECOVERY AND RESILIENCY
beliefs about people. These also can schizophrenia not just from basic The earlier discussion focused on
be addressed with CBT. Again, day-to-day tasks, such as grocery the use of CBT for acute or
working with the usual techniques shopping, but may prevent them persistent primary symptoms of
of identifying and challenging from taking more advanced schizophrenia or targeting co-
distorted thoughts, such as challenges, such as pursuing school occurring conditions, such as PTSD
“everyone is looking at me,” “I’ll or work. or substance use. An additional
make a mistake and everyone will People with schizophrenia target for CBT has been to help
notice,” or “they’ll think I’m stupid,” frequently find themselves with the disabilities that arise from
and developing a hierarchical struggling with substance use peoples’ experience of
method of exposure to gradually disorders. Schizophrenia has the demoralization and failure,
more anxiety-provoking situations highest comorbidity rate with especially in the area of major role
can diminish these symptoms. The substance abuse (47%) than any function. Earlier hopes that the
conventional treatment and services other mental disorder.34 Many newer antipsychotics would not
available in community mental psychosocial interventions, such as only have fewer side effects but

[VOLUME 6, NUMBER 12, DECEMBER] Psychiatry 2009 37

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