How can we treat schizophrenia from a psychological perspective? Are there therapies available for schizophrenia? Psychological therapies explore the mental and emotional side of disorders in an attempt to treat mental health issues, delving into a person's past and future experiences to help with current symptoms. One form of therapy is Cognitive Behavioural Therapy (CBT).

Developed by Aaron Beck in the 1960s, CBT is a form of psychological therapy that focuses on teaching patients to recognise their dysfunctional thoughts and behaviours, how to rationalise these thoughts using logic, and how to avoid acting on these thoughts. CBT is a lengthy process and varies depending on the patient’s needs. It requires a therapist to work closely with the patient to build trust and a sense of rapport.

• We are going to explore the psychological treatment of schizophrenia using cognitive behavioural therapy (CBT).
• First, we will delve into the world of cognitive behavioural therapy, exploring the various cognitive behavioural therapy examples.
• We will define cognitive behavioural therapy and what it entails, and discuss how it applies to schizophrenia.
• Following this, we will discuss cognitive behavioural therapy's strengths and weaknesses.
• Throughout the explanation, we will explore cognitive behaviour therapy's impact factor in relation to schizophrenia.

Fig. 1 - Cognitive behavioural therapy (CBT) is a form of psychological treatment for Schizophrenia and other disorders.

What is the Purpose of Cognitive Behavioral Therapy (CBT)?

As we discussed above, cognitive behavioural therapy is a psychological treatment of mental health disorders. We can define CBT as:

CBT aims to identify and alter irrational thoughts and behaviours, and when we look at it through the lens of schizophrenia, examples include:

• General, irrational beliefs e.g. hearing people who are not there talking about you or hearing a voice narrate your daily life.

• Issues with how the patient views themself, such as delusions of grandeur.

• Issues with paranoia, in which the patient believes someone is watching them.

Cognitive Behavioural Therapy Examples

CBT is not reserved only for schizophrenia. It can also be used to treat other mental health issues, as dysfunctional and maladaptive thoughts are somewhat common symptoms.

Examples of disorders that use cognitive behavioural therapy include:

• Depression.
• Anxiety.
• Bipolar Disorder.
• Obsessive Compulsive Disorder.
• Sleep Disorders (e.g., insomnia, narcolepsy).
• Phobias
• Addiction Issues.

CBT attempts to instil behaviours that help alleviate symptoms in disorders through talking with an accredited therapist.

Key Concepts of Cognitive Behavioural Therapy (CBT)

CBT has multiple stages to help identify the issues and offer solutions to a patient with schizophrenia. Typically, a patient undergoes anywhere from 5 to 20 sessions over multiple weeks (NHS, 2021).

Normally, CBT undergoes a specific process that addresses dysfunctional and maladaptive thoughts to treat symptoms of a disorder, from a psychological perspective. Patients are first assessed to identify areas of concern. The therapist will then work with the patient to break down maladaptive and dysfunctional thoughts and behaviours.

Essentially, we can boil CBT for schizophrenia down to an Assessment and Engagement phase (Kingdon & Turkington, 2006).

1. Assessment: The therapist and patient discuss the patient's symptoms and experiences thoroughly, allowing the patient to explore their emotional and mental state and how this may link to schizophrenia. Rating scales are used. Problematic behaviours are identified alongside dysfunctional, maladaptivce thoughts. Progress is monitored in multiple ways and links between behaviours, emotions, and thoughts are established to help combat them.
2. Engagement: Socratic questioning (a way of engaging in dialogue that is logical, thoughtful, disciplined, and controlled) is encouraged, and the therapy is discussed with the patient to establish the intentions going forwards. Therapists use a vulnerability-stress model, aiding the understanding of the process and how it integrates daily life and the disorder. Empathy is heavily emphasized, and the goal is to help the patient understand the situation and establish coping mechanisms.

We can summarise the process of CBT as:

• Behaviours that are problematic are identified.
• Illogical, dysfunctional thoughts are highlighted and analysed, before being deconstructed logically.
• Behaviours and habits are recommended and implemented to help combat the conditions that led up to or exacerbate symptoms.
• Homework is assigned, in a sense. Behaviours and thought processes are recommended for a patient to practice outside of the sessions in their daily lives to combat their disorder.

A clinician may use the ‘ABC’ method.

The overall goal of CBT is to establish the links between thoughts, feelings, and actions.

Fig. 2 - CBT adopts the ABC method, developed by Ellis and Harper, in some cases.

What is the ABC Model in Cognitive Behavioural Therapy?

The ABC model, developed by Ellis and Harper (1961), encourages patients to try and understand what is happening in their lives. It finds the source of the faulty condition and then goes on to work towards providing a process to restructure the irrational beliefs.

• Activating event: what is causing the problem? Patients often give their own estimation of what they think activating events are.

• Behaviour and beliefs: how does the patient react in these situations? The patient's own beliefs are linked intrinsically to the activating and events and consequences, bridging the missing gaps in the patient's knowledge of their behaviours.

• Consequences: what impact does this have on the patient’s life and their relationships with others? What are the emotional and behavioural consequences?

Overall, links between each stage are made and the therapist helps the patient to see these links.

Socratic questioning is used to move patients through the ABC model, using various scales to monitor the progress of the therapy (such as using a scale of 0 to 10). Patients are encouraged to identify what activating events trigger consequences, and this will ultimately aid them in their daily lives, as they will be able to identify potential triggers outside of a professional environment, and then engage in rationalisation and behavioural restructuring.

Fig. 3 - The ABC model was later expanded on, but typically it is still referred to as the ABC model.

Challenging Beliefs in Schizophrenia: Cognitive Behavioural Therapy

When disputing the beliefs of a schizophrenic patient, it can be done through goal setting, reality testing, normalisation, critical collaborative analysis and the development of alternative explanations (Kingdon & Turkington, 2006).

Goal setting involves identifying goals early in therapy. Alternative explanations are developed towards the end of therapy which allows patients to develop their own alternatives to dysfunctional thoughts and behaviours.

Reality Testing

Reality testing helps a patient identify irrational or illogical events. If patients struggle to differentiate between their internal reality (such as hearing voices and hallucinating), and external reality (what is actually occurring), they may engage in beliefs and behaviours that do not reflect reality and hurt themselves and others around them.

If a patient hears voices telling them a family member is breaking into their house and stealing items (activation event), they may lose trust and begin displaying distressing emotions (beliefs and behaviours) and delusions as a result. They no longer trust their family, and may even isolate themselves (consequences).

A clinician would then show the patient that the family member is not doing this by either finding the ‘stolen’ items, disputing and establishing reality by identifying the whereabouts of family members during these times or encouraging them to discuss other reasons for the missing items, such as they are misplaced somewhere in the house (disputing irrational beliefs). Then, trust is regained and the consequences are dismantled (effect restructuring).

Normalisation

Normalisation establishes that events can occur on a scale or continuum, rather than being a catastrophic psychotic experience that only occurs in disorders such as schizophrenia.

Some patients struggle with normalising their behaviours and thoughts. Their internal thought processes are demonised by their self-persecution, worsened by delusions. A clinician will dispute the ideas and help a patient accept them. The patient will then understand there is no need to feel stress or shame, and reduce feelings of isolation and distress.

Critical Collaborative Analysis

Critical collaborative analysis bridges conversations between patient and therapist so they can explore illogical beliefs together, and identify logical conclusions.

Systems are put in place so the patient can recognise these negative thoughts and implement their own tests for these faulty beliefs. Reality testing is used throughout to continually establish the irrational parts of a patient's thinking, and the therapist remains empathetic and non-judgemental as they coach patients through critical analysis.

Ideally, the patient can eventually independently challenge and rethink their faulty beliefs. The patient can then develop their own alternative explanations by using these coping strategies, rather than resorting to delusional thinking.

Cognitive Behavioural Therapy Strengths and Weaknesses

When using CBT to treat schizophrenia, it’s important to understand whether it’s effective and appropriate, and why this may be the case. The advantages and disadvantages of using CBT are detailed below.

Strengths of Cognitive Behavioural Therapy

Let's explore the strengths of CBT.

• Gould et al. (2001) conducted a meta-analysis investigating cognitive therapy for psychosis in schizophrenia. Over 340 subjects, they found a mean effect size of 0.65 for reducing positive symptoms in schizophrenia, supporting the use of CBT in treating psychotic symptoms of schizophrenia.
• Sensky et al. (2000) investigated CBT use in those with schizophrenia who were resistant to medication. They used a randomised controlled design. They found that CBT is effective in treating both positive and negative symptoms in schizophrenic patients, and this result was sustained when they followed up with patients nine months later, supporting the use of CBT in treating schizophrenia and demonstrating its efficacy.
• Rector and Beck (2012) conducted an empirical review of CBT use in schizophrenia. They found that, when reviewing studies of the use of CBT in treating those with schizophrenia, CBT had large clinical effects on positive and negative symptoms. Those receiving routine care and CBT achieved additional benefits. Overall, the review suggests that CBT is a promising therapy style for patients with schizophrenia, being both effective and appropriate.
• Turkington et al. (2006) reviewed the efficacy of CBT in patients with schizophrenia in the UK, intending to advise the American people of the results. It was found that CBT is highly effective and should have more attention and support in America. These promising results suggest CBT seems to be reliable and consistent.
• Rathod et al. (2010) found that, when combined with antipsychotic medication, CBT acted as an effective facilitator to the treatment of symptoms of schizophrenia.
• CBT has been shown to reduce relapse rates and readmissions to hospitals. It encourages patient independence and offers patients the option of taking control of their treatment and being actively involved in their disorder management.

Weaknesses of Cognitive Behavioural Therapy

Let's explore the weaknesses of CBT.

• A problem with CBT is that it’s a lengthy process. It requires commitment from the patient and the clinician, a suitable setting, and 6 to 12 weeks or more. It’s expensive compared to simply using antipsychotic drugs. Patients often end treatment early.
• It requires self-awareness and patient engagement. This in itself has issues, as schizophrenic patients have symptoms of delusions and hallucinations, which can cause problems with self-awareness and their level of trust with the clinician. Symptoms can hold a patient back, and ineffective treatment will likely lead to further disengagement.
• Some patient's symptoms are severe. Therefore, for some, the idea of confronting these symptoms (a core aspect of CBT) is too traumatic. Antipsychotic drugs can be used in cases like this to ease the symptoms of schizophrenia first.
• Many reviews of CBT treatment for schizophrenia are based on a meta-analysis of studies, the findings of which can be influenced by the failure of considering potential biases, such as not using masking or publication bias. Masking is where potentially influencing information is withheld from investigators, such as what treatment a patient is assigned. Publication bias is the fact that only studies with positive or confirming results tend to be published.
• Jauhar et al. (2014) found that, when including the examination of potential biases in their meta-analysis of CBT effects on schizophrenic symptoms, CBT has a therapeutic effect in the ‘small’ range, diminishing further when biases are taken into account. Masking of outcome assessments had a moderated effect size on overall symptoms.
• Kingdon and Kirschen (2006) attempted to identify who gets CBT when therapy is available. 142 patients were identified, and 69 had been referred for CBT, whereas 73 had not. Those not referred were suggested to have been doing well and did not need therapy, or they were not likely to engage well with the treatment. Only half were deemed suitable. Quite a few were deemed too difficult to engage with, and CBT is not appropriate for them as a result.

Cognitive Behaviour Therapy Impact Factor

The impact factor or score refers to how many research articles cite the content published in a journal within the last year. Impact factors are valuable scores to consider for researchers identifying where to publish their content.

Scopus produces an impact score, and Cognitive Behaviour Therapy currently has an impact factor score of 3.928 (2021), and 5.672 over a five-year period leading up to 2021 (Journal Metrics for Cognitive Behaviour Therapy, n.d.).