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Objective: A growing body of evidence supports the use of cognitive behavior therapy for the treatment of schizophrenia. A course of cognitive behavior therapy, added to the antipsychotic regimen, is now considered to be an appropriate standard of care in the United Kingdom. The objective of this article is to offer a broad perspective on the subject of cognitive behavior therapy for schizophrenia for the American reader. Method: The authors summarize current practice and data supporting the use of cognitive behavior therapy for schizophrenia. Results: Five aspects of cognitive behavior therapy for schizophrenia are addressed: 1) evidence from randomized clinical trials, 2) currently accepted core techniques, 3) similarities to and differences from other psychosocial interventions for schizophrenia, 4) differences between the United States and United Kingdom in implementation, and 5) current directions of research. Conclusions: The strength of the evidence supporting cognitive behavior therapy for schizophrenia suggests that this technique should have more attention and support in the United States.

Schizophrenia is often explained to patients and their families in terms of complex biological and/or psychological processes thought to underlie the disease. But as researchers have learned more about schizophrenia, it has become apparent that the delusions and hallucinations experienced can also occur in 'normal' subjects under extreme conditions such as sensory deprivation and solitary confinement, and some resemble supernatural phenomena that people in certain cultures believe exist. An attempt to destigmatize psychotic phenomena might include relating them to such culturally acceptable beliefs. It is hypothesized that cognitive-behavioral therapy is one means to accomplish this destigmatization. In an experimental protocol, 64 schizophrenics over a five-year period were offered cognitive-behavioral therapy in addition to their usual treatment. The cognitive-behavioral therapy included a destigmatizing rationale to explain the symptoms that the patient experiences to both the patients and their relatives. The rationale included, for instance, explanations of hallucinations as not external but internal, and related to excessive stress such that normal people undergoing unusual stress might experience them. It was found that patients and families were receptive to the explanations, and their use was correlated with relatively low use of medication and hospitalization. Since the study did not include a control group, it is difficult to assess its significance. (Consumer Summary produced by Reliance Medical Information, Inc.)

Aims and methodIn three localities in a mental health trust in England, an enhanced bed management team was established to improve patient flow and reduce out-of-area placements. Trusted assessments were provided to support risk management and conflict resolution. Two measures of flow were compared before and after the team was established.ResultsThe trusted assessment recommendation was for discharge in 70% of cases. The number of out-of-area placements was significantly reduced (P< 0.05), saving £616 876 over a 12-month period. Patient flow was significantly improved in one of the three localities as measured by patients/bed/6-month period (P< 0.05). In one of the other localities increased use of trusted assessment input and reduced numbers of patients being transferred in are recommended to improve flow.Clinical implicationsMental health trusts should consider the establishment of an enhanced bed management team, including trusted assessment, as a safe and cost-effective approach to improving patient flow and reducing the need for out-of-area placement.

CBT can improve social function in schizophrenics. By Lawrence Conway and Professor Douglas Turkington. Schizophrenia is a severe mental illness, with 1 per cent lifetime prevalence, which occurs in all [...]

Although clozapine is the treatment of choice for treatment-refractory schizophrenia, 30–40% of patients have an insufficient response, and others are unable to tolerate it. Evidence for any augmentation strategies is scarce. We aimed to determine whether cognitive behavioural therapy (CBT) is an effective treatment for clozapine-resistant schizophrenia.

SummaryThe evidence base for cognitive-behavioural therapy (CBT), family therapy, psychoeducation and cognitive remediation as adjuncts to antipsychotic medication in the treatment of schizophrenia is well established. It is, however, clear that the moderate effect size of the best researched of these treatments (CBT) compared with treatment as usual reduces to small when compared with an active psychological treatment. It would seem that many different psychosocial interventions de liver benefit in schizophrenia. We are now at a stage in their development when new treatments are being energetically piloted and combination treatments tested. This article outlines the most promising of these new interventions and attempts to answer the crucial question as to their differential effects on different psychotic presentations.Learning Objectives• Be aware of the most promising new psychosocial treatments for schizophrenia• Learn the key elements of each intervention• Understand which of these approaches might be best suited to particular presentations of schizophrenia spectrum disorder

SummaryAuditory hallucinations (voices) are the most common symptom in schizophrenia, occurring in 70% of those with the diagnosis. A proportion respond to antipsychotic medication, but despite adequate concordance with prescribed medication, voices may still remain. Voice hearers often inadvertently activate coping strategies that maintain the symptoms and linked distress. Assessment can identify ineffective strategies. Effective strategies can then be initiated, starting with distraction to reduce distress in the short term and leading to focusing approaches that give an improved understanding of voice maintenance. This article describes how to recognise voice hearers' ineffective coping strategies and how to teach effective approaches that are a crucial catalyst in the recovery process.

Antipsychotic drugs are usually the first line of treatment for schizophrenia; however, many patients refuse or discontinue their pharmacological treatment. We aimed to establish whether cognitive therapy was effective in reducing psychiatric symptoms in people with schizophrenia spectrum disorders who had chosen not to take antipsychotic drugs.

Case managers spend more time with clients with schizophrenia than any other professional group does in most clinical settings in the United States. Cognitive behavioral therapy (CBT) adapted for individuals with persistent psychotic symptoms, referred to as CBT-p, has proven to be a useful intervention when given by expert therapists in randomized clinical trials. It is currently unknown whether techniques derived from CBT-p could be safely and effectively delivered by case managers in community mental health agencies. Thirteen case managers at a community mental health center took part in a 5-day training course and had weekly supervision. In an open trial, 38 clients with schizophrenia had 12 meetings with their case managers during which high-yield cognitive behavioral techniques for psychosis (HYCBt-p) were used. The primary outcome measure was overall symptom burden as measured by the Comprehensive Psychopathological Rating Scale, which was independently administered at baseline and end of intervention. Secondary outcomes were dimensions of hallucinations and delusions, negative symptoms, depression, anxiety, social functioning, and self-rated recovery. Good and poor clinical outcomes were defined a priori as a 25 improvement or deterioration. t-Tests and Wilcoxon’s signed-ranks tests showed significant improvements in all primary and secondary outcomes by the end of the intervention except for delusions, social functioning, and self-rated recovery. Cohen’s deffect sizes were medium to large for overall symptoms (d= 1.60; 95 confidence interval CI, −2.29 to 5.07), depression (d= 1.12; 95 CI, −0.35 to 1.73), and negative symptoms (d= 0.87; 95 CI, −0.02 to 1.62). There was a weak effect on dimensions of hallucinations but not delusions. Twenty-three (60.5) of 38 patients had a good clinical result. One (2.6) of 38 patients had a poor clinical result. No patients dropped out. This exploratory trial provides evidence supportive of the safety and the benefits of case managers being trained to provide HYCBt-p to their clients with persistent psychosis. The benefits reported here are particularly pertinent to the domains of overall symptom burden, depression, and negative symptoms and implementation of recovery-focused services.

This article discusses several models of Psychosis, research on Cognitive Behavior Therapy for Psychosis (CBTp) and recent developments and new directions in the theory and practice of CBTp. Throughout the article we focus on the evolution of the field of CBTp as well as issues and opportunities for the field. We have highlighted the evolution of a more humanistic and strengths-based approach to recovery in psychosis, which focuses to a greater extent on personal values and goals rather than symptoms, as compared to earlier CBT models for psychosis. We have also consolidated information related to trends and innovations in CBTp. In the spirit of clinical utility, we have emphasized and referenced clinical resources and practical materials on CBTp interventions. Finally, we highlight the need for further research, enhanced consumer involvement, and increased access and resources for those with lived experience of psychosis.

AIMS AND METHOD Health promotion campaigns using current terminology have had limited success in reducing stigma to schizophrenia. Terminology and subgroups based on historical precedent, clinical experience and psychosocial research have been developed to provide an alternative to existing terminology, and the attitudes to schizophrenia and alternative terminology of a sample of medical students (n=241) were compared. RESULTS: Overall attitudes were significantly less negative with the alternatives. The students were less negative about the potential for recovery in relation to all the subgroups than for schizophrenia. Concerns about dangerousness were also less prominent with the exception of the drug-related group. CLINICAL IMPLICATIONS Subgroups and alternative terminology should be further explored in programmes to destigmatise schizophrenia.

Research meta-analyses have found that cognitive-behavioral therapy (CBT) is beneficial for persistent symptoms of schizophrenia. This review describes and updates the evidence base for this statement. A review of the existing literature (Medline, PsychInfo, and Embase) was carried out according to the guidelines for systematic reviews. Based on the findings of this review, the updated conclusion is that CBT has emerged as an effective adjuvant to antipsychotic medication in the treatment of persistent symptoms of schizophrenia. Studies of the use of CBT in the prodromal phase of psychosis and in combination with family therapy are currently underway.

Affective symptoms are often present and under-treated in schizophrenia. This case study reports the effect of treatment of a specific phobia and associated avoidance on the psychotic symptoms of a patient with medication resistant schizophrenia. The treatment of the specific phobia and agoraphobia followed a traditional systematic desensitization procedure. The successful treatment of the phobias led to improvements in psychotic symptoms. Previously, the client had only a limited response to a number of antipsychotic medications including clozapine but responded well to a traditional systematic desensitization program that produced positive consequences for the psychotic symptomatology. The clinical and theoretical aspects of this case are discussed.

Most studies demonstrating the benefits of cognitive–behaviour therapy for schizophrenia were carried out in the 1990s. The majority targeted treatment resistant positive symptoms. Recent research is now focussing on the impact of cognitive–behaviour therapy on prodromal states, acute schizophrenia, negative symptoms, loss of insight and relapse prevention.

This review outlines the role that cognitive behavioral therapy can play in specifically addressing the distress associated with the symptoms of schizophrenia, such as hallucinations and delusions. Some of the features that are given greater emphasis (or are a feature of working with people with psychotic illness), engagement, understanding the onset of the illness and work with hallucinations and delusional beliefs are outlined. The evidence base for the utility of cognitive behavioral therapy is considered, and the development and further application of cognitive behavioral therapy for schizophrenia and related disorders are outlined.

Trauma within psychosis is often undiagnosed or untreated. There is a wide body of literature on the efficacy of cognitive behaviour therapy (CBT) for post-traumatic stress disorder (PTSD), but there has been no report of combining CBT for psychosis and CBT for PTSD in modular form. The authors discuss a combined treatment for two patients with psychosis and a history of trauma. The clinical features, process of therapy, and outcome are all described in relation to cognitive therapy models developed for use in PTSD. The implications for therapy, service development, and training are discussed.

Cognitive-behavioral therapy (CBT) has a proven role as an adjunct to antipsychotic medication and remediative approaches such as social skills training in the management of residual symptoms of chronic schizophrenia. Positive symptoms, depression, and overall symptoms appear to be viable treatment targets for CBT with a less pronounced effect on negative symptoms. The effect size at end of therapy is strong, with durability at short-term follow up. CBT can be used safely in patients with schizophrenia, and caregivers can help with homework exercises. There is also evidence that psychiatric nurses in the community can use CBT effectively with this patient group under supervision. CBT can be combined with family therapy and assertive community treatment programs targeted to reduce relapse. CBT improves the coping of patients with schizophrenia through improved adherence and symptom management. CBT techniques include development of trust, normalizing, coping strategy enhancement, reality testing, and work with dysfunctional affective and behavioral reactions to psychotic symptoms. An enhanced response to CBT would be expected when given with low dose cognitively enhancing atypical antipsychotic medication.

In order to have a chance of coping and developing a reasonable quality of life, the individual suffering from the symptoms of schizophrenia will very often need to change lifelong attitudes towards psychiatric illness and medication. Deeply held personal attitudes towards achievement, approval, and control will often need to be developed to facilitate optimal understanding of the emergence of psychosis, its maintenance, and to optimize symptom control. This paper describes viable approaches to changing attitudes in schizophrenia within a CCOR1 framework, which should facilitate optimal adherence and coping.

Improvement in social functioning is the key to recovery in schizophrenia.Here,the authors discuss how cognitive behavioural therapy (CBT) may help improve social functioning and therefore complement drug treatment in people with schizophrenia. Copyright © 2007 Wiley Interface Ltd

The article focuses on the use of cognitive behavior therapy (CBT) for improving social function in schizophrenics. Schizophrenia, a severe mental illness, is characterized by delusions, thought disorder and self-neglect. CBT for the treatment of schizophrenia is evidence-based, personalized and popular with patients. It destigmatises schizophrenia, improves insight and equips patients with the relevant skills to cope with residual difficulties, including the challenges of social rehabilitation.