CBT Modification Promising in Treating Schizophrenia

Cognitive-behavioral therapy (CBT) is being used as an adjunct to pharmacotherapy to treat the core symptoms of schizophrenia, but it differs in important ways from CBT as it is typically used with affective disorders.

A substantial literature, mostly from the United Kingdom, now supports the efficacy of CBT for psychosis, and the treatment is considered standard for antipsychotic-resistant schizophrenia there.

But at APA's 2008 Institute on Psychiatric Services last month in Chicago, U.S. psychiatrists who are successfully using CBT said that treatment of psychosis requires modifications of traditional CBT—as well as a departure from some long-accepted tenets about the treatment of severe mental illness.

Page Burkholder, M.D., said that adapting CBT to the treatment of psychosis requires clinicians and patients to collaboratively seek alternative ways of understanding and managing the hallucinations and delusions of psychosis. Burkholder is with the Schizophrenia Research Program at SUNY Downstate Medical Center in Brooklyn, N.Y.

These fundamentals include “radical collaboration” with the patient and normalization of psychotic experiences.

“Radical collaboration really means being curious with the person you are speaking to, coming from where he or she is, and trying to find out what is distressing to the individual,” she said. “This is different from the medical model because you try to make the differences between yourself and the patient not so hierarchical.

“Normalizing means looking at the fact that many people have strange events in their thinking and perceptions, not just people who are labeled psychotic,” Burkholder said. “You don't have to use the word 'schizophrenia' or [the term] 'severe mental illness.' You can use the stress-vulnerability model because that is a good way to offer an alternative explanatory rationale. Everyone understands stress; with enough stress, anyone can have a psychotic experience. Some people don't take very much stress for that to happen.”

Examples of normalizing can include exploring with the patient anomalous experiences common to many people, such as hearing one's name called in a crowd; sensing a loved one's presence after his or her death; hallucinations that can occur with sleep deprivation; as well as certain religious, spiritual, or philosophic beliefs.

“Everything is a continuum,” she said. “There is a continuum of beliefs and a continuum of options. We don't have to start at the point where [the patient] is ill and has a biological brain disorder. But we also don't have to say that the patient isn't having any problems. So we normalize [those symptoms] and introduce possible alternative explanations.”

Burkholder said there is a body of literature reporting randomized, controlled trials of CBT for psychosis. “Most of the research comes out of the United Kingdom, finding that it is most helpful for people with chronic refractory psychosis. Whether and how it is useful for first episode is still being studied. The literature is not definitive, but it is robust.”