Dr. Turkington Replies

To the Editor: We would like to thank Dr. Kontos and colleagues for sharing their concern about what they felt was an exaggerated distinction between cognitive behavior therapy and “biomedical” approaches in working with individuals with schizophrenia. They pointed out the irony of using the word “schizophrenia” in our review of cognitive behavior therapy, even though the cognitive behavior therapy technique may bypass a discussion of the schizophrenia diagnosis. We certainly agree that clinicians can effectively treat their patients without sharing the same explanatory model of the illness. We did in fact oversimplify the contrasts of a medical model and the cognitive behavior therapy approaches covered in this review to emphasize the differences rather than the shared elements between cognitive behavior therapy and psychoeducation as practiced in the United States. We agree that these approaches are not always incompatible, in particular, when the patients’ perspective matches a medical explanatory model.

However, we feel that there are real differences between a cognitive behavior therapy approach and a standard biomedical model approach; for example, NIMH might be considered to be representative of currently accepted clinical perspectives on the diagnosis of schizophrenia. The current NIMH website for clinical trials information for schizophrenia states, “Schizophrenia is a devastating brain disorder—the most chronic and disabling of the severe mental illnesses.” (http://www.nimh.nih.gov/studies/studies_ct.cfm?id=12). We believe that many individuals with schizophrenia would experience this statement as counterproductive to their own treatment, and displaying such information would not be compatible with a cognitive behavior therapy treatment approach. Also on the NIMH website is a hypertext link to the educational information on schizophrenia, where the reader is introduced to a more detailed medical perspective of the disorder, which also notes that “[t]here are a variety of reasons why people with schizophrenia do not adhere to treatment. If they don"t believe they are ill, they may not think they need medication at all” (http://www.nimh.nih.gov/healthinformation/schizophreniamenu.cfm).

Our position is that a cognitive behavior therapy model is not always compatible with a psychoeducation approach. The late Gerald Hogarty, one of the founders of psychoeducation for schizophrenia, would probably agree. Professor Hogarty felt strongly that it was not appropriate to be interested in the personal meaning of psychotic symptoms. His wrote that, “For those that do see the content of a bizarre delusion or hallucination as holding imperative ‘clinical meaning,’ we feel that there is a professional, if not moral, obligation to conduct an experiment on the healing methods that would follow upon this belief” ( 1, p. 10). We strongly believe that these differences in technique and approach can lead to clinically measurable differences in outcome. As stated in the review, we do not fully understand all of the factors that may contribute to the best approach for an individual patient, but these differences do in fact exist.