February 23, 2007

Cognitive Therapy and Schizophrenia

Kate mentioned that she was interested in Cognitive Behavioral Therapy (CBT) and wondered what it was all about. I wrote in the comments section that from my hospital stays, at Dr O's hospital, where all patients are expected to attend the CBT group -- and patients by and large are mostly schizophrenic or bipolar with a number of sufferers from depression as well -- I have learned a little about the subject. Though I did not attend often, being frequently on one to one and unable to, when I did we often watched a video about someone who has a problem and is essentially giving himself the message that he isn't good enough, or smart enough, or whatever, to handle it and take care of it. He goes to see a counselor who, through the magic of CBT has him learn to think about things and himself differently, which leads to a change in his feelings about himself and about the problem, which he then can go out and solve. The essence of CBT is, I believe, that what you think influences how you feel and hence how you behave, so if you can change how you think, consciously, you will then change unconsciously how you feel and as a result how you behave.

But don't take my word for it. Here is what the National Association of Cognitive Behavioral Therapists - NACBT - has to say on its web page:

Cognitive-Behavioral Therapy...

is a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do. Cognitive-behavioral therapist teach that when our brains are healthy, it is our thinking that causes us to feel and act the way we do. Therefore, if we are experiencing unwanted feelings and behaviors, it is important to identify the thinking that is causing the feelings / behaviors and to learn how to replace this thinking with thoughts that lead to more desirable reactions.

There are several approaches to cognitive-behavioral therapy, including Rational Emotive Behavior Therapy, Rational Behavior Therapy, Rational Living Therapy, Cognitive Therapy, and Dialectic Behavior Therapy.

However, most cognitive-behavioral therapies have the following characteristics:

1. CBT is based on the Cognitive Model of Emotional Response.
Cognitive-behavioral therapy is based on the scientific fact that our thoughts
cause our feelings and behaviors, not external things, like people, situations,
and events. The benefit of this fact is that we can change the way we think to
feel / act better even if the situation does not change.

2. CBT is Briefer and Time-Limited.
Cognitive-behavioral therapy is considered among the "fastest" in terms of
results obtained. The average number of sessions clients receive (across all
types of problems) is only 16. Other forms of therapy, like psychoanalysis,
can take years. What enables CBT to be briefer is its highly instructional
nature and the fact that it makes use of homework assignments.

3. A sound therapeutic relationship is necessary for effective therapy, but
not the focus.
Some forms of therapy assume that the main reason people get better in
therapy is because of the positive relationship between the therapist and
client. Cognitive-behavioral therapists believe it is important to have a good,
trusting relationship, but that is not enough. CBT therapists believe that the
clients change when they learn to think differently; therefore, CBT therapists
focus on teaching rational self-counseling skills.

4. CBT is a collaborative effort between the therapist and the client.
Cognitive-behavioral therapists seek to learn what their clients want out of life
(their goals) and then help their clients achieve those goals. The therapist's
role is to listen, teach, and encourage, while the client's roles is to express
concerns, learn, and implement that learning.

5. CBT is based on stoic philosophy.
Cognitive-behavioral therapy does not tell people how they should feel.
However, most people seeking therapy do not want to feel they way they do.
CBT teaches the benefits of feeling, at worst, calm when confronted with
undesirable situations. It also emphasizes the fact that we have our
undesirable situations whether we are upset about them or not. If we are
upset about our problems, we have two problems -- the problem, and our
upset about it. Most sane people want to have the fewest number of problems

6. CBT uses the Socratic Method.
Cognitive-behavioral therapists want to gain a very good understanding of
their clients' concerns. That's why they often ask questions. They also
encourage their clients to ask questions of themselves, like, "How do I
really know that those people are laughing at me?" "Could they be laughing
about something else?"

7. CBT is structured and directive.
Cognitive-behavioral therapists have a specific agenda for each session.
Specific techniques / concepts are taught during each session. CBT
focuses on helping the client achieve the goals they have set. CBT is
directive in that respect. However, CBT therapists do not tell their clients
what to do -- rather, they teach their clients how to do.

8. CBT is based on an educational model.
CBT is based on the scientifically supported assumption that most emotional
and behavioral reactions are learned. Therefore, the goal of therapy is to
help clients unlearn their unwanted reactions and to learn a new way of
reacting. While CBT therapists do not present themselves as "know-it-alls",
the assumption is that if clients knew what the therapist had to teach them,
clients would not have the emotional / behavioral problems they are

Therefore, CBT has nothing to do with "just talking". People can "just talk"
with anyone.

The educational emphasis of CBT has an additional benefit -- it leads to
long term results. When people understand how and why they are doing
well, they can continue doing what they are doing to make themselves well.

9. CBT theory and techniques rely on the Inductive Method.
A central aspect of Rational thinking is that it is based on fact, not simply
our assumptions made. Often, we upset ourselves about things when, in
fact, the situation isn't like we think it is. If we knew that, we would
not waste our time upsetting ourselves.

Therefore, the inductive method encourages us to look at our thoughts as
being hypotheses that can be questioned and tested. If we find that our
hypotheses are incorrect (because we have new information), then we can
change our thinking to be in line with how the situation really is.

There are over 25 very common mental mistakes that people make that cause
them to not have the facts straight.

10. Homework is a central feature of CBT.
If when you attempted to learn your multiplication tables you spent only one
hour per week studying them, you might still be wondering what 5 X 5
equals. You very likely spent a great deal of time at home studying your
multiplication tables, maybe with flashcards.

The same is the case with psychotherapy. Goal achievement (if obtained)
could take a very long time if all a person were only to think about the
techniques and topics taught for one hour per week. That's why CBT
therapists assign reading assignments and encourage their clients to
practice the techniques learned.

Finally, research is beginning to prove that schizopohrenia is amenable to CBT and other cognitive therapies as the book review below suggests. The review, and the book, are written for psychiatric professionals, so it might be somewhat obscure and difficult to read. Doctors not only can't handwrite, they can't write write, not so anyone else can understand them! BD Anyhow, the essential point is that therapy has been ruled out for schizophrenics for most of the past century on rather shaky grounds, since there were no real studies PROVING that it didn't work or was actually harmful. Now that research is being done, it looks like cognitive therapeutic approaches are not only harmless but very helpful...

All I can say is that I have been "in therapy" that is, I have had someone to talk to, a psychiatric professional, ever since I was diagnosed. Somehow I managed this, despite being in the "system" for many years, when I could so easily have been shunted into a medication group and told that therapy was bad for me so the state wouldn't pay for it. Instead, I had either clinic therapists -- a psychiatrist when they were still the practicing therapist norm, then nurses -- or a private psychiatrist who saw me for free. And I would never have survived without them. I don't think we did any "in depth" therapy particularly, but we did talk about day to day problems and my favorite public mental health system therapist, a nurse, discussed my illness with me a lot, telling me facts about it, what it was, what my symptoms were, why I had this or that and so forth. And I found every single one of them, even the worst of them, essential to my survival. Now I can talk about anything I want to and though it tends to be my daily encounters with various problems of paranoia it isn't always, not by a long shot. I haven't tried CBT though, not formally, as set out by the NACBT. I wonder if it would actually make Dr O unnecessary. It would be good to feel like I could survive on my own, not drown without someone to shore me up every week or so. Of course, I'd still need medications, would still have the visiting nurses to give them to me, I guess...I dunno. Kate, if you try it, I hope you'll keep us all posted, here or on your own blog! Below is the book review and the site I stole it from (here's the link to it

Psychiatr Serv 58:277-278, February 2007
doi: 10.1176/
© 2007 American Psychiatric Association

Book Review
Cognitive Therapy of Schizophrenia
by David G. Kingdon and Douglas Turkington; New York, Guilford Press, 2004, 219 pages, $37

Timothy B. Sullivan, M.D.

It's hard to say how bad ideas, misinformed or misguided clinical saws, originate. One of the most enduring in psychiatry is the notion that talking to patients with schizophrenia about their symptoms or about their subjective experiences is potentially harmful. It is little wonder that so few medical students or psychiatric residents wish to specialize in work with patients who have seriously mental illness.

There have been studies and reviews, most famously the Patient Outcomes Research Team recommendations (1), which have directed our attention to the lack of efficacy (2), obvious paucity of controlled observation, and insufficiently documented putative harm associated with "uncovering therapies," by which is meant psychoanalytic therapy and its congeners. Kingdon and Turkington lament the effect these proscriptions have unintentionally had on creative engagement of persons suffering from disorders such as schizophrenia. They note that "many practitioners continue to believe that the content of psychotic symptoms should be ignored and that any psychological work ... is liable to lead to increased distress and exacerbation of symptoms, as a result of having opened up disturbing areas."

Of course the problem with past, well-intentioned, and compassionate efforts by a legion of gifted therapists is that the therapeutic model, and the theory of mind supporting it, did not accurately reflect the nature of the disorder. It was not the effort to be empathic that was flawed but the various notions about how symptoms were produced or could be ameliorated. If you don't understand what you're treating, you will misdirect, misinform, and inevitably disappoint.

Kingdon and Turkington set out to provide clinicians with a treatment model that will make the uncertain knowable and that which is alienating comfortable. They successfully present a cogent, approachable, and flexible model for psychotherapeutic engagement of persons suffering from serious psychotic illness. This is not a "manualized" treatment, and the authors explain why that approach is not appropriate. A careful exposition of the nature of the illness processes, and the theory of cognitive-behavioral therapy and its particular adaptation to this setting, is explicated. There are many clinical examples, guidelines, forms to use, and even patient handouts that can be copied and distributed are included. The succinct review of the psychology of schizophrenia is particularly useful, such as the discussion of "externalizing bias" and the central role of stigmatization in symptom development.

The fourth chapter, on therapeutic engagement, and later chapters on work with delusions and hallucinations, are not only brilliantly executed but come as close as one can, in print, to detailed individual case supervision. Even experienced practitioners will find these presentations extremely helpful, because they reflect the careful thought of talented clinicians who have immersed themselves in their subject and achieved valuable insights.

I do have one brief quibble. As a heuristic device, Kingdon and Turkington use four clinical subgroups to differentiate "types" of schizophrenia. In the context of the book, these subgroups are useful and unify their presentation. I am not sure I can agree that the subgroups encompass the range of patients I see.

Reviewers will often say that the book they are reviewing belongs on everyone's shelf. I urge you to please buy and read this book. Our patients deserve our attention to these issues. Those of you who are talented clinicians but who avoid this population out of confusion or lack of confidence in your ability to help will, I assure you, find this book crucial. You will find yourself able to approach a person with schizophrenia with confidence, and it will change how you think about your work.


Dr. Sullivan is chief of services for the seriously mentally ill at Saint Vincent's Catholic Medical Center, Westchester, New York, and assistant professor of psychiatry at New York Medical College, Valhalla.


1. Lehman AF, Steinwachs DM: Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophrenia Bulletin 24:1-10,1998[Medline]
2. Gunderson JG: Effects of psychotherapy in schizophrenia: II. comparative outcome of two forms of treatment. Schizophrenia Bulletin 10:564-598,1984[Medline]

Posted by pamwagg at February 23, 2007 09:33 PM


Pammy love,
I know you will do anything to help a friend, but I'm afraid that you are draining an awful lot of energy writing these very long and technical blogs. I have gleaned from Kate's comments that she is very well informed on psychiatry in general and schizophrenia in particular. I think that if you simply give her the sources that she needs, she is very well equipped to find and read and digest and understand EVERYTHING YOU FIND FOR HER on her own. My Scorpion intuition is certain that she will agree with me. You are caring for Joe, trying to make sure that you are eating adequately,dealing with the Karen issue,and polishing your manuscript in hope of finding a publisher, to list just a few of your activities(and how could I forget your perfect or nothing artwork?). You are very close, but you are not Superwoman. Please give yourself some time to smell the roses. My issues are far from resolved, but I had to get my concern for you out in the open.
Lovingly, Paula

Posted by: Paula Kirkpatrick at February 26, 2007 09:51 PM

Dear Pam, it amazes me that it is only just now that it is considered okay, even very good, to treat serious mental illnesses like schizophrenia with therapy. I shudder to think what it would have been like for us even fifty years ago. At least now the world of therapy is opening up to us. At least now we're getting treated with a certain humanity which calls for interaction. One of the reasons I, too, have made it this far is because of having therapy. It's not a cure-all (is anything?) but it addresses a major liability of having schizophrnenia: the sense of isolation from others.

CBT sounds like an excellent approach. Of course, work with your thoughts and change the emphasis towards the positive. I think the 12 step programs work with a form of CBT, especially changing the negative into the positive in thought and then action. Focusing on the practical. The importance of practice. I think I'll ask my therapist about whether she's studied any CBT techniques. Maybe she could include some in our sessions.

Posted by: Kate K. at February 25, 2007 04:20 PM

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