Cognitive Therapy of Schizophrenia

Cognitive Therapy of Schizophrenia is an easily accessible, clinically oriented book that provides valuable conceptual organization, techniques, and clinical examples to those who work on the front lines in the provision of schizophrenia services. The authors give us an optimistic counterpoint to the narrow focus on medication that was common during the decade of the brain. Their approach is an empowering one for both patients and therapists, and for this reason alone it is worthwhile.

Although I strongly feel that the book is very useful, I would argue that it is not accurately titled, since it is only partially about cognitive behavior therapy and a great deal about the necessity of employing an eclectic approach to the treatment of schizophrenia. Furthermore, the foundation upon which any technique rests is the establishment of the patient/therapist trust, a concept that transcends all forms of intervention, be it in the form of drug treatment or inference-linking.

As a graduate student some 30 years ago, I had the good fortune of being able to observe regularly Aaron Beck and John Paul Brady as they honed their cognitive and behavioral techniques, respectively. Among my student peers, there was unanimous opinion that both Beck and Brady could have employed any technique effectively. Beck himself wondered how much of his successful treatment of a patient with schizophrenia was because of cognitive techniques and how much was because of the therapeutic relationship (1) .

Consider the following language from the book: “exploratory and nonjudgmental” (p. 15); “negotiating the language we use” (p.19); “being available when they are having or have just experienced a short-lived episode seems very important” (p.39); “reduce the pressure” (p. 40); “befriending” (p. 46); “holistic approach” (p. 77); “psychoeducation” (p. 83); “Interventions need to be administered as part of a broad comprehensive package of care addressing social needs and issues having to do with relationships.” (p. 116); “convalescence” model for negative symptoms (p. 144); and “case management” (p. 150). In reading Cognitive Therapy of Schizophrenia, I had the same reaction that I had when I watched Beck and Brady, namely that while technique is important, the therapeutic relationship is of paramount importance and that the whole package is critical to the establishment of this relationship. To label the package “cognitive therapy” misrepresents the complexity of the process and confounds the study of general and specific factors.

This presents a challenge when facing the new mantra of evidence-based treatment. I am definitely in favor of the empirical validation of therapies. However, I do not believe that we should simplify the study of therapy in order to achieve “evidence-baseness” (see Westen and Bradley [2] .) In addition, the samples upon which cognitive therapy has achieved a “strong evidence base in psychosis” (p. 79) are highly selective, which was also revealed in a previous report (3) . These samples often exclude patients who 1) are secondary to medication noncompliance; 2) fail to describe symptoms; 3) refuse to participate in treatment; 4) have histories of substance misuse/abuse, confusion, and inattention; and 5) are subject to high attrition rates (especially fist-episode). To this limitation, I would add the impossibility of a genuine in vivo double-blind, placebo controlled evaluation of cognitive therapy or any other psychosocial intervention in which the therapist is the “pill.”

The therapist who has been trained to reproduce cognitive techniques with fidelity is not necessarily a good therapist, which is clarified in the book. I wonder what we would know about therapy today if Beck had chosen to explore the therapeutic relationship rather than cognitive technique.