June 29, 2006

Evidence-Based Psychotherapy for Schizophrenia

Typically treatment for schizophrenia focuses on the use of antipsychotic medications, and case management, accompanied by little to no psychotherapy. Previous reviews on psychotherapy have shown promising results for a multitude of psychiatric illnesses. A 1994 meta-analysis of over 320 studies, spanning from 1895 to 1992, found that only an estimated 1/3 of patients suffering from schizophrenia have a favorable outcome with medication alone (Harvard Medical School, Hegarty 1994). (though a skeptical person would say that there were no effective treatments for schizophrenia prior to Chlorpromazine in the 1950s, so why have the study authors included such old data in their meta-analysis?). More recent studies suggest that approximately 50% of people will find any one medication helpful - but which medication works for any one person, and for how long, is an open issue.

Whatever the issues with that particular study, research does support the idea that some form of psychotherapy may be beneficial. The purpose of this article is to summarize different forms of psychotherapy used for treating schizophrenia, and their ability to effectively eliminate or decrease symptoms.

Cognitive Behavioral Therapy (CBT):

CBT, usually one-on-one therapy based, has the strongest evidence supporting its ability to alleviate symptoms in schizophrenia. CBT is conducted in an environment where the patient feels safe, the therapist avoids challenging delusions, and instead helps implement natural coping strategies. The main goal is not to “cure” the patient, but to help them develop rational thoughts and perspectives about their delusions and hallucinations . This is in hopes of giving the patient the tools to help themselves maintain reality in their illness.

But there are many variations of CBT for schizophrenia, and the differences between these variations have not been thoroughly studied. Therefore which variation or style is best suited for treatment is unknown at this time.

Reviews and meta-analyses on CBT and schizophrenia have shown significant improvements in positive symptoms, and overall symptoms. But no significant improvements were found with negative symptoms, depression, or social functioning. But the lack of improvement for all areas does not conclude CBT to be unsuccessful. Many studies showed that the improvements that do occur are long standing and remain after completion of treatment.

CBT is not suited for all patients and drop out rates for these programs are very high in acute sufferers. The best candidates for CBT are those with long-standing suffering and resistance to medications or typical treatments.

Personal Therapy (PT):

PT utilizes many of the same elements as CBT. Its one-on-one sessions, customized to the individuals disorder and symptoms. The main focus of PT is affective dysregulation, and the ability to adapt to stressors of the illness. PT differs from CBT in its utilization of phases. These phases correspond with the patients’ recovery, and to advance is dependant on the degree to which the patient improves. Because of this, PT is a long-term treatment plan, spanning several years.

One study compared PT with family therapy, and supportive psychotherapy on patients recently released from hospitals. The therapies were administered over a 3 year time period. Though no significant differences were shown in the patients’ relapse rates (returning to hospitals), significant improvement was found in psycho social functioning for those treated with PT.

Compliance Therapy:

Compliance therapy is administered during the acute phase of schizophrenia for a short period of time (4-6 sessions in hospital, and a few more after discharge). The main goal is medication adherence, getting the patient to take their medication following discharge from a hospital setting. Studies examining the ability of Compliance Therapy to effectively accomplish this goal have shown inconsistent results. One study found it to be more effective than traditional counseling, while another found no significant difference at all.

Acceptance and Commitment Therapy (ACT):

ACT varies from CBT in its approach to alleviating symptoms. ACT focuses on the patients association to their thoughts. ACT attempts to eliminate stress associated with delusions or hallucinations by asking the patient to simply take note of them. Because they are no longer attempting to suppress, control, or judge these delusions and hallucinations, and instead just be aware of them, they are eliminating a major stressor. In schizophrenia stress can not only be a result of symptoms, but also a trigger for more/new symptoms.

Very little research has been done on ACT and schizophrenia, but the two pilot studies conducted concluded lower rates for relapse into hospitals, and decreased stress associated with hallucinations.

Supportive Psychotherapy:

There is no standard of supportive therapy, but is frequently administered to those suffering from schizophrenia. Supportive therapy counsels the patient while they deal with life issues raised by their disorder with reassurance, clarifications, and general assistance. When compared to CBT, supportive therapy provided results.


Reviewing the literature on treatment of schizophrenia with psychotherapy provides one clear conclusion; no single method can address all the issues and needs of the patients. A combination of “illness education, cognitive remediation, and social skills training” accompanied with medication would provide the best treatment.

Dr. Faith Dickerson, and Dr. Anthony Lehman highlight “emotional support in dealing with a disabling illness, enhancement of coping strategies to promote functional recovery, and alteration of underlying pathophysiology and processes of illness” as the three elements future psychotherapy interventions for schizophrenia should focus on.

Original Article:
“Evidence-Based Psychotherapy for Schizophrenia.”
Journal of Nervous and Mental Disease. (http://www.jonmd.com). January 2006, vol. 194, No. 1

More Information on CBT and Schizophrenia:

One hundred years of schizophrenia: a meta-analysis of the outcome literature

Treatment of Schizophrenia via Cognitive Behavioral Therapy

Review of CBT for psychosis - Harvard University Presentation/video


Many of the statements in this article are very questionable, such as the figure for 'favorable out come with medication alone', which is rated far higher in many other studies. Other studies have backed up the idea that therapy can help, but not the suggestion that only 30 per cent see improvement with medication alone.

Other studies say that the highest reduction in relapses results from a combined approach, but all the studies i have read have shown conclusively that without medication, psychotherapy and other methods have very poor results. Statistically, the main protection against relapses is medication, that achieves something like a 60-80 per cent improvement in relapse rate in other studies, and then start improving even over that by using supportive therapies.

Again, consider looking for juried, reviewed studies in legitimate journals, and please present a balanced view and give the other legit studies a chance. There is nothing out there to back such an abysmal performance of medication, nothing. Much of the actual number a study comes up with depends on how the study is designed, and other study designs come up with vastly different numbers.

Posted by: slc2 at June 30, 2006 08:08 AM


I agree that this is only one statistic on the outcome of medications in the use for schizophrenia. When I return home I will add the citation to that specific study. We must also remember, their definition of favorable could very well be different than we are interpreting it. Thank you for pointing this out.

The purpose of this article was not to promote the use of psychotherapy over medication, but rather to evaluate the different methods being used, accompanied with traditional treatments (like case management, and pharmacotherapy).

I believe the goal of this review is to encourage further research on implementing a CBT model to the already successful treatments for schizophrenia.

Posted by: Michelle Roberts at June 30, 2006 10:42 AM

Here is a link to the article that the statistic was obtained from.

Reviewing the abstract has shed some more light on the validity of the statistic. It came from an extensive meta-analysis by researchers at Harvard Medical School, and in the past decade the favorability report has been 36.4% (3% higher than 1/3), though overall they found it to be 40%.

Article (see link below):

One hundred years of schizophrenia: a meta-analysis of the outcome literature

Posted by: Michelle Roberts at June 30, 2006 03:26 PM

does anyone have any idea on psychoanalytically oriented psychotherapy for schizophrenia patients ?

Posted by: ilker at July 10, 2006 04:33 AM

i'm not in favor of it and there have been a number of studies done over the years that have contributed to that view, but my most compelling experience was watching someone with schiz and bipolar disorder go thru this treatment and seeing what it did to him. i do know bert karon, who treats schizophrenics with this model. he is a very sincere person and really believes in what he's doing. i don't. to explain why would take far more space than is available here.

Posted by: slc2 at July 11, 2006 10:12 AM

I agree completely with Susan here - I've seen no studies that support the idea that "psychoanalytically oriented psychotherapy" is of any value to people who have schizophrenia - in fact quite the opposite.

CBT is very different from psycho-analytical psychotherapy - and does have more of a track record of success from everything I've read.

Posted by: Sz Administrator at July 11, 2006 12:39 PM

How do I find a psychiatrist who actually uses CBT with their patients? The doctor that my 23 year old son has seen over the past five years usually only spends about 10 minutes with him and generally asks him the same questions every time. (This is my son's opinion. Since I'm not in the room at the time, I don't know what is discussed.) My son hates going to see a doctor and he gets very annoyed and upset with them. He often refuses to go to appointments. We live in Orange County, CA. Can you point me to a referral list of pyschiatrists/psychologists/or other therapists who accept MEDI/MEDI and who specialize in various models of CBT?? CBT sounds GREAT on paper......but it's of no benefit to the average patient, such as my son, if we can't find anyone who uses it in their practice.

Posted by: Valerie at July 16, 2006 11:58 AM


My 25 yr old brother has the exact same experience with his psychiatrist (10 min sessions focusing on suicide risk and medication side effects only).

I am trying to search for some therapists who specialize in CBT for psychotic disoders....but the problem is, its not a standard of treatment in the US.

Very few people/centers specialize in this type of treatment, and regular CBT from a therapist who is only trained to work with people who don't suffer from psychosis may not be helpful at all.

If anyone has info please let us know.

Posted by: Michelle Roberts at July 16, 2006 09:31 PM


We're going to pull together a list of the centers that provide CBT as add-on therapy for schizophrenia.

I know that one is Harvard University/McLean Hospital in Boston. I also know that the Early Treatment Program (PIER) in Portland, Maine also has it. Other than that - I don't know off the top of my head. We'll check on it and get back to you.

Posted by: Sz Administrator at July 18, 2006 09:36 PM

You'd be best off discontinuing your search for 'psychiatrists' that practice psychotherapy, at all. You need to look for a Ph.D., clinical psychologist that has been trained in a more academic (major state U. and not a Psy.D.) instituation if you want 'good' CBT for anything. This is my opnion and I'm a more psychoanalytic Ph.d., Clinical Psychologist. My .02 cents.

Posted by: Mark at May 24, 2007 12:05 AM

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