Schizophrenia Daily News Blog

Cognitive Behavioral Therapy (CBT) for Schizophrenia - An Indepth Interview with Experts

During the past year we've covered the increasing number of positive research reports on the use of cognitive behavioral therapy (CBT) as a new complementary treatment for schizophrenia (see recent stories here and this List of US Cognitive Behavioral Therapy for Schizophrenia Providers). Because of the significant potential for this therapy and many reader questions, we've asked some of the top psychiatry researchers and practitioners of CBT for schizophrenia to answer our questions so that we may better understand it. We thank Dr. Gottlieb and Dr. Cather of the Massachusetts General Hospital / Harvard Medical School schizophrenia CBT program for their time and effort in responding to our questions.

CBT for psychosis and schizophrenia

From Drs. Gottlieb and Cather: Please note that these responses are based on our interpretation of current research findings and clinical experience. This information in no way constitutes an absolute answer to any individual clinical problem discussed nor do these responses constitute any type of professional or psychotherapeutic relationship with any member of this site or any person who has posted a question or comment. Thank you.

Schizophrenia.com – Personal Background Questions:
Can you briefly tell us about your educational background and the educational path that has led to your current career including how and when you first became interested in schizophrenia?

How did you get your start in schizophrenia (or neuroscience) research?

What do you enjoy most about working in your field?

How is your professional time spent – ie what proportion of your time is spent on research, clinical, academic, volunteer etc?

Response from Jennifer Gottlieb, Ph.D.:

I obtained a B.A. degree in Psychology at American University in Washington, D.C., then a Master’s degree and Ph.D. in Clinical Psychology at the University of Montana. I completed my predoctoral clinical internship at the University of California, San Diego Medical School Department of Psychology and San Diego Veterans Administration Hospital. I currently work as a CBT Psychologist at the Massachusetts General Hospital/Harvard Medical School Department of Psychiatry in the Schizophrenia Clinical and Research Program (housed at the Freedom Trail Clinic) in Boston, Massachusetts.

I have worked with people with schizophrenia for 12 years. Initially, I worked as a volunteer on the inpatient unit while in college at St. Elizabeth’s Hospital in Washington, D.C. Between undergraduate and graduate school, I worked as a case manager and residential counselor in a group home for adults with schizophrenia. In graduate school, I developed a social skills training program in rural Montana for adults with schizophrenia, and conducted related research. During my internship at UCSD, I received advanced specialized clinical training in CBT for people with schizophrenia.

Currently, I spend approximately half of my time engaged in direct clinical work with people with schizophrenia and about half the time developing and conducting research in CBT for schizophrenia. In addition, I periodically give educational seminars about CBT for schizophrenia to other healthcare professionals, psychiatry and psychology trainees, and to consumer-based groups, such as NAMI.

There are so many things that I enjoy about my job and this field. I love helping the people I work with try out new things and make positive changes through CBT. I think it is so important to work on dispelling the myth that schizophrenia is untreatable and that people diagnosed with schizophrenia can’t get better or reach their goals.

Response from Corinne Cather, Ph.D.:

I received my undergraduate degree in biopsychology at Hamilton College in Clinton, NY and my doctorate in clinical psychology from Rutgers University where I received specialized training in CBT and health psychology. I completed internship at the University of Medicine and Dentistry of New Jersey and have remained in the schizophrenia program of the Massachusetts General Hospital (MGH) since doing my post-doctoral fellowship at MGH in the Schizophrenia Clinical and Research Program with Donald Goff, MD in 1999.

Currently, I spend about a third of my time providing CBT to individuals with first-episode or early psychosis, a third of my time teaching and writing about these approaches, and a third of my time conducting research.

My research interests include the development and implementation of CBT with patients with residual symptoms, first episode and early psychosis, medication adherence, and substance use disorders in individuals diagnosed with schizophrenia spectrum disorders.

It was not until my post-doctoral fellowship that I received specialty training in CBT as applied to schizophrenia. My experience to that point had focused on general CBT and on providing CBT to individuals adjusting to chronic medication conditions, such as cardiovascular disease or chronic pain. I remember one of my professors from graduate school telling us that the only patient for whom CBT was not useful was the patient diagnosed with schizophrenia. Around the time of my fellowship, however, there were promising studies from United Kingdom researchers being published on the efficacy of CBT in schizophrenia. Because of my work with medical conditions, it made sense to me that CBT could be helpful in schizophrenia. What I enjoy most about my work is the privilege of working directly with patients and the opportunity to teach other mental healthcare professionals about the value of a CBT.

Schizophrenia.com Questions Requesting an Overview of MGH CBT Program:
Can you tell us more about MGH's CBT program? For example, how long has it been going on, how many patients are generally seen? How long is the treatment? From where are these patients referred? Is this part of the standard of care at MassGen (i.e., MGH)? Do the patients receive it outpatient/inpatient, or both? Does it continue after they leave the program (e.g., does a 6-week intensive program become a 1 day a week program for 6 months and then taper-off to nothing)? Is there evidence that the gains are lasting and that the patients continue to use the skills learned?

Jennifer Gottlieb, Ph.D. and Corinne Cather, Ph.D. Respond:

The Massachusetts General Hospital's CBT program started approximately 9 years ago, around 1998. At present, we have two CBT psychologists on staff (Dr. Cori Cather and Dr. Jennifer Gottlieb), and we offer CBT as a special service to patients who are in our First-Episode and Early Psychosis Program (FEPP). Because of limited staff, we are currently able to provide CBT to 10-15 first episode patients, and are unfortunately generally not able to provide CBT for people who have longer histories of illness. We are however able to accept some patients into our CBT research program. We have plans to expand our program in Fall 2007, as we will have supervised psychiatry residents and psychology doctoral interns on board to provide CBT. We do not offer inpatient CBT for schizophrenia at this time.

We generally begin with a consultation to decide if CBT seems like a reasonable treatment for the person based on the nature of his or her difficulties (and it also helps the patient decide if CBT is something that seems like a good fit and something they want to try). On average, CBT lasts approximately 3 months (12 one-hour sessions weekly). We do tend to taper off sessions toward the end of therapy (e.g. move from weekly to every other week, to once a month, etc) to help people work on using the skills they learned during CBT independently, and we offer “booster sessions” after the CBT has ended in some cases (such as checking back in for a review session 3 months after CBT has ended). We strongly encourage family involvement in the treatment.

The people we see here tend to be referred by either their outpatient psychiatrists, following an ER evaluation, or following an inpatient stay. Some people self-refer from our website on occasion, or after hearing us speak about CBT at a consumer run group or at our annual Schizophrenia Education Day, which is open to the public.

Depending on the patient’s needs, we will provide CBT at the same time that the person is involved in supportive therapy with another provider, or sometimes the person will take a break from their regular therapy to do a course of CBT and then will return to their original therapist, as long as that is okay with the patient and the other clinician. Once CBT has ended, we often refer the patient on to supportive therapy with another therapist if they still want or need support.

We as a program are now starting to track our own patients as far as how they are doing following a course of CBT, but we currently don’t have hard data right now. However, we have found that people seem to like our program, we have good rates of people sticking with CBT (approximately 75%) and they report later that they feel they have learned good skills that they still use.

In general, there actually is some good evidence that gains made from CBT continue once CBT has ended. A research study published in 2000 by Sensky and colleagues found that 9 months after CBT was over, the effects of CBT were even greater than they had been during the treatment. Other studies have not found quite as strong results (Tarrier et al., 2000); however, there is general support for the idea that CBT helps build skills that the person carries with them after the therapy ends.

Schizophrenia.com Questions on Active CBT Research Studies:
Are there are ongoing (major) CBT for psychosis/schizophrenia studies being conducted and can people enroll in them?

Jennifer Gottlieb, Ph.D. and Corinne Cather, Ph.D. Respond:

We do have ongoing CBT-based research for psychosis/schizophrenia here in addition to our regular clinical programs, but we do not have approval from the MGH Institutional Review Board to advertise these studies on this website. People who live in the Boston, Massachusetts area and are interested in finding out more about these studies can contact our department at the following telephone number: 617.912.7833.

Schizophrenia.com Questions on CBT and Schizophrenia:

Briefly, what is Cognitive Behavioral Therapy (CBT) and when used for psychosis and schizophrenia what does it generally entail?
What is the theory behind how CBT might work?

Jennifer Gottlieb, Ph.D. and Corinne Cather, Ph.D. Respond:

The Theory Behind CBT: Cognitive Behavioral Therapy, or CBT model assumes that unhelpful or negative ways of thinking are related to distress that people experience, and are therefore related to the maintenance of certain symptoms or behaviors (like depression, amotivation, social isolation, or even paranoia). There is a strong relationship between how you perceive a situation (thoughts or cognitions), how you feel about it (emotions) and how you react (behaviors). For example:

If someone is invited to a party and thinks, “it won’t be fun and no one will talk to me at the party” (thought), she will likely decide not to go to the party at all (behavior), and will maybe feel more depressed (emotion) than she did before. Instead, however, if she receives the party invitation and thinks, “I was invited because the host wants to spend time with me” (thought), she will likely decide to go to the party (behavior), and will probably feel content (emotion). As you can see, a person’s feelings and behaviors can greatly depend on how one interprets an event that happens in life.

Another example, related to paranoia, is the following: A person is leaving his neighborhood convenience store and notices some men in suits and sunglasses walking past the store. He has the thought, “those men are with the government and are probably following me”. This perception leads him to feel threatened (emotion), and as a result, he decides not to go to that store anymore (behavior). Following this incident, he starts to avoid other places because of increased paranoia, and therefore becomes more isolated. As you can see from these examples, having certain thoughts or beliefs dictates how a person feels and what they decide to do or not do. These thoughts can create a vicious cycle of avoidance, depression, paranoia, social isolation or distress, which unfortunately can keep a person from achieving personal goals or things that they want from life (such as a job, friends, their own apartment, a family, etc).

In addition, CBT presumes that one's symptoms are not random, or fully “biological” in nature, but that they are related to one’s “psychology” and that they are personally meaningful. For instance, CBT theory suggests that someone hearing voices telling him that he is a terrible person is not a random occurrence; it is likely that this person was told that at some point in his life and/or is struggling with his own feelings of worthlessness.

Another theory behind CBT for schizophrenia is that stress makes symptoms considerably worse. So, if a person can learn skills to handle stress more effectively, it is also likely that the person’s symptoms (such as voices or negative symptoms) will also decrease.

What Occurs in CBT: The CBT therapist uses specialized techniques to help the client identify his or her unhelpful thoughts (or cognitions) and teaches skills to aid the client in modifying “maladaptive” cognitions over time. The therapist may help the person explore, for example, “How likely is it that the party will be no fun at all and that no one will talk to you the entire time?” In addition, the therapist helps the client identify which coping strategies he or she currently uses to deal with stress, paranoia, voices, depression or anxiety, and evaluates with the client what is working and what is not working. Through trial and error, the therapist and client strive to optimize coping strategies.

CBT also highlights the importance of developing skills to increase a person’s rational evaluation of their own thoughts and beliefs, to start to examine situations that come up in life in a more “flexible” way (like working on not jumping to conclusions about why something negative happened). This is a helpful technique when working with people who have delusions or paranoia. The “B” or behavioral part of CBT is very important as well -- gradually developing more meaningful activities while working on one’s thinking styles can make a tremendous difference.

In general, CBT is different from other psychotherapies in that it is very structured and collaborative and tends to be fairly short-term (approximately 10-24 sessions, depending on the client). The therapist and client together decide what they will work on, and they are really studying the symptoms and problems together, in order to learn what triggers the symptoms and what makes the symptoms better. There is always a session agenda, created by the client and the therapist at the beginning of the session to determine what will get discussed at the session. And each week, an out-of-session homework assignment is decided upon together, so that the client can have the opportunity to practice a skill learned in session that week. CBT is also very present-oriented in that the majority of the time is spent on what the person is currently experiencing. While we acknowledge that what happened in one’s past and in one’s family is very important to how we became who we are, CBT stays focused more in current situations. We feel that is the best way to help a person move forward and work towards his/her own individual goals.

Schizophrenia.com Questions Regarding Goals of CBT: What, exactly, are the CBT therapists targeting? What is their focus and prime goal? And how do they plan on achieving it? What methods do they use?

Jennifer Gottlieb, Ph.D. and Corinne Cather, Ph.D. Respond:

Treatment Targets and Techniques in CBT: The decision about which problems to target are based on what is causing the person the most distress and impairment. For some, that might be paranoid beliefs or delusions, for others negative symptoms like amotivation or social isolation. Other frequent CBT targets are depression, anxiety, difficulty with medication adherence, problematic drug or alcohol use, problems interacting with others, or not having meaningful daily activities. CBT also targets beliefs that people have about the recovery process from schizophrenia or stigma (“I’ll never make any progress” “I will lead a miserable life because I have schizophrenia,” etc).

Across the board, CBT usually aims to enhance a person's coping skills to be able to deal effectively with what problems and challenges come up in life (whether those are symptoms, family stress, job, etc). In addition, preventing symptom relapse and rehospitalization are important parts of CBT for schizophrenia.

In order to achieve these treatment targets, the therapist and client create a plan together about what will be addressed and how. The client works on exercises such as examining thoughts during and after certain difficult situations, evaluating the helpfulness or accuracy of those thoughts and how those beliefs might affect the person’s problems or goals. Skills around helping clients to make more accurate assumptions or more accurate perceptions about events in their lives are practiced. Examples of weekly homework assignments are: practicing these thinking skills outside of session, trying a new activity, or practicing a skill or “data collection” about the frequency of voices. CBT involves consistent checking-in between therapist and client regarding these techniques and how treatment is going. CBT involves a great deal of collaboration, and modification of homework as needed to best benefit each individual client.

Schizophrenia.com Question Regarding the Role of CBT in the Patient's Treatment Plan: Is CBT used as a primary or exclusive treatment for schizophrenia – or as a complimentary treatment or therapy?

Jennifer Gottlieb, Ph.D. and Corinne Cather, Ph.D. Respond:

It is important to understand that CBT is ALWAYS recommended as adjunctive (in addition) to antipsychotic medication in the treatment of psychosis or schizophrenia, never instead of. As far as being a primary psychotherapy, for some people, it works well as their only psychological therapy, for others it can be used as a “course” during a break from supportive therapy. For some, it is most helpful when used in conjunction with supportive therapy (so the person would, for a period of time, see the CBT therapist and see the supportive therapist, each at different times in the week). CBT tends to address some different types of things and teach a different set of skills than many supportive therapies do, so there is often not too much overlap between the two. It depends on what the client and his/her therapist(s) decide together makes the most sense.

Of note is that CBT has not been suggested to be very helpful without the use of medication. The effects of the antipsychotic medication tend to make CBT more productive. This is because the medications generally provide at least some relief from voices or having confused thinking (which can naturally be very distracting to a person). Therefore, a person will likely be able to concentrate more on the skills and strategies discussed in CBT.

However, with "prodromal" clients (these are young people who may have had some psychotic symptoms recently, but not for a long period of time and not very severely, so they have not been diagnosed with schizophrenia), one study by Morrison and colleagues (2004) found that CBT for psychotic symptoms can be used in place of medication to stave off additional psychotic symptoms.

Schizophrenia.com Questions Regarding the History of CBT: At schizophrenia.com we’ve reported in the past that CBT for psychosis and schizophrenia seems to be quite a common treatment in the UK for people suffering from schizophrenia. Do you know anything about the history of the use of CBT for schizophrenia – and its track record for success? What also is the broader history of CBT for use in depression and anxiety?

Jennifer Gottlieb, Ph.D. and Corinne Cather, Ph.D. Respond:

CBT has been recognized as a treatment for schizophrenia in the U.K. longer than it has in the US. And it has been better integrated into their mental health system as a result of mandates for its use, and the way their health care system is structured. However, clinicians specializing in CBT for schizophrenia in the U.K. have also mentioned that there is unfortunately a shortage of CBT therapists for schizophrenia in the U.K.

In the US, CBT has been the first-line psychotherapy for depression and anxiety for many years, but in practice, CBT is not widely available, and this is especially true for schizophrenia. Nowadays, we’re finding that CBT for schizophrenia is gaining more ground (as more and more research is coming out showing it is helpful), but in general there aren’t many psychologists available to work with individuals with serious mental illness. We developed a list of available USA-based CBT services for schizophrenia that was posted on schizophrenia.com a few months ago. This is a good reference for those across the country interested in finding these resources.

In general, some CBT therapists focus more on “behavioral interventions” (like helping people try out things they have been anxious about, work on social skills in their daily life, experiment with new strategies to decrease distress about voices, etc.), while other therapists focus more on “cognitive interventions” (emphasis on evaluating one’s ‘core beliefs’ about themselves, reworking unhelpful thoughts, etc). We wouldn’t really say that this is a U.K. versus U.S. difference, but more of a CBT therapy style difference.

Schizophrenia.com Questions Regarding Schizophenia State and Success of CBT:

Is CBT possible with someone who is having acute positive symptoms? How do you get someone to be involved in CBT therapy if they're in an acute state? Does this work with someone who is still somewhat delusional and has no insight?

Jennifer Gottlieb, Ph.D. and Corinne Cather, Ph.D. Respond:

There were some encouraging early results for CBT in this regard (Drury and colleagues, 1996) with a group of adults with acute psychosis who were on an inpatient unit. However, these results haven’t really been replicated (Haddock and colleagues (2002)). Therefore, if someone is experiencing severe psychotic symptoms (so much so that they are in the hospital), then that is generally not the best time for CBT for a few reasons. One is that the person might not be in the place where he or she can commit to CBT or feel organized enough to engage in therapy. In addition, as previously mentioned, it is usually helpful to wait for a stable dose of antipsychotic medication before starting CBT.

This is not to say that a person needs to be free of psychotic symptoms in order to have CBT. In fact, this is quite the contrary. CBT for schizophrenia was originally developed as a non-pharmacological way to help people with distressing hallucinations and delusions. And, as mentioned before, these are often the targets of treatment. It is the case, though, that it is important for medication to be used in order to get someone to a place where he/she can feel able to engage in CBT.

Schizophrenia.com Questions Regarding Whether CBT is Helpful for Voices: Do CBT therapists believe there is a cognitive and behavioral approach to either lessen voices or make dealing with them more bearable? I know that CBT works for depression and anxiety, but is it really possible to help with schizophrenia?


Jennifer Gottlieb, Ph.D. and Corinne Cather, Ph.D. Respond:

As this seems to be a topic of interest to people who posted, here are some examples of specific CBT techniques for voices:

It’s important to understand that working with voices involves collaborative trial and error between the therapist and the client. The first step is generally to help the client identify coping strategies that are currently in use, and then figure out if these are helpful or unhelpful strategies. The next step is to help the person eliminate some of the more maladaptive responses (e.g., yelling back at the voices, drinking alcohol, doing everything that the voices say, staying home all day) and then increasing positive, helpful coping responses (e.g., increase activities in spite of what the voices say, challenge some of the negative things the voices are saying). Also useful in CBT is to help people address some of the beliefs that they have about their voices, such as, “there’s nothing I can do to decrease the distress they cause” or “what they are saying about me is true” or “if I don’t do what they say, bad things will happen to me”. Then the therapist can help the client experiment with testing these thoughts, and hopefully come to realize that some of the beliefs they have been holding on to about the voices may not be accurate. This often helps to reduce the distress that is associated with hearing voices.

Schizophrenia.com Question Regarding How it is Quantified: Once someone is not psychotic and delusional how can CBT help someone with schizophrenia develop their social skills and has it shown to help with increasing maturity levels. If so, how do the therapist or researchers quantify it?

Jennifer Gottlieb, Ph.D. and Corinne Cather, Ph.D. Respond:

If psychotic symptoms are no longer much of an issue, CBT can help in several ways. Often CBT therapists and their clients work on the following: the process of recovery from a recent episode (“putting the pieces back together and moving forward”), social skills training and practice, goal-setting, interpersonal relationship building, or getting back to work, This is accomplished by several of the techniques described above, such as evaluating what kinds of thoughts are getting in the way of accomplishing important things (common thoughts are: “I won’t enjoy this activity” “I won’t have anything interesting to say” “I’ll fail” “Schizophrenia has robbed me of all of my work skills”). In addition, the therapist helps the client try out new behaviors for homework (e.g., fill out a job application, practice starting a conversation at the coffee shop, etc). As we all know, just because voices and delusions may have decreased it doesn’t mean that schizophrenia isn’t difficult in other ways. There are usually other symptoms that people have that tend to cause life difficulties.

Schizophrenia.com Questions on CBT Research Findings
What aspects of schizophrenia or psychosis does CBT seem to be most effective in treating?
What is the evidence for effectiveness of CBT in schizophrenia? What are the key research studies that have demonstrated the effectiveness of CBT in psychosis and schizophrenia?

Jennifer Gottlieb, Ph.D. and Corinne Cather, Ph.D. Respond:

There are more randomized controlled trials for CBT than for any other individual psychotherapeutic intervention for psychosis, and so we tend to know more about what CBT does compared to other treatments. However, results from these studies are somewhat mixed. Two summary studies (called “meta-analyses”) have found some common effects for CBT (If interested in these, see the following papers:

Cognitive therapy for psychosis in schizophrenia: an effect size analysis, by Gould, Mueser, Bolton, Mays, & Goff, 2001

The effect of cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum disorders: a meta-analysis, by Zimmerman, Favrod, Trieu, & Pomini, 2005.

Overall, CBT tends to have the largest effect on helping with psychotic symptoms (like voices and delusions) at the end of treatment, and also helps to maintain those gains when treatment is over. In particular, CBT has been found to reduce the severity of these symptoms and also the distress that these symptoms cause in people who have them. There has been some effectiveness in treating negative symptoms and social functioning-related problems, but these results have not been as consistent (or as studied as much as has CBT’s effect on voices and delusions).

Schizophrenia.com Questions Regarding the Possibility of Prevention of Psychosis with CBT.

If CBT works as a treatment for schizophrenia (which the evidence suggests it does) – then doesn't that also suggest that CBT might also be a potential tool for prevention of schizophrenia (by using it on children and teens who are at high risk due to family history)? Do you know what the state of the research in this area shows or suggests?

Also, to follow on from the previous question, given that CBT works – it seems to suggest that how people think about the events in their lives can affect their brain chemistry, and potential risk for schizophrenia. This suggests that parents can teach their children how to think about the problems they encounter and the stresses in their lives – in a manner which may be more healthy (less stressful) and that may result in lower risk for mental illness. For example, Dr. Martin Seligman, a well known psychologist that specializes in CBT at the University of Pennsylvania has written books that propose that teaching children an optimistic interpretation of the world results in children that have greater resiliency in the face of challenges and stress – and lower rates of mental illness (especially depression and anxiety). Dr. Seligman has written books titled “Learned Optimism” and "The Optimistic Child" – see these links for more information:

The Optimistic Child: Raise Your Children To Be Optimists
Learned Optimism - Book Overview & Summary
University of Pennsylvania Positive Psychology Center

Do you think that similar approaches to child-raising that may lower risk of schizophrenia in children?

In the past decade we’ve seen an increasing amount of schizophrenia research that suggests that schizophrenia is a result of a biological predisposition (either genetic, or early prenatal environment) and that the risk of getting the disorder later in life may be increased through other environmental factors – from such things as childhood stress, etc. See this web page: A Healthy Family Social Environment May Reduce Schizophrenia Risk by 86% in High Risk Groups.

Is it reasonable for families to work on creating a positive, supportive, nurturing, and low-stress family environment as a strategy to reduce the incidence of mental illness in their family?

Jennifer Gottlieb, Ph.D. and Corinne Cather, Ph.D. Respond:

These are certainly very interesting, important questions. However, they are a bit difficult to answer, given the current state of research in these areas. While there would likely be a feasible way to implement a type of family therapy aimed at prevention of the development of schizophrenia in those who may be at risk that could be helpful, there is no evidence to date (to our knowledge) for the use of family therapy as a prevention strategy. Unfortunately, we don’t really know much about specific things that can be done in childhood that can lower one’s risk of developing schizophrenia. The ideas that you present certainly make intuitive sense. However, the majority of the research that we are aware of at this point regarding families has to do more with helping people who are already diagnosed with schizophrenia, rather than those who are children and not yet ill.

What we do know is that once an adolescent or young adult is beginning to develop schizophrenia symptoms, or already has schizophrenia, the family plays a very important role in helping people with the disorder to cope with stress and continue working towards their life goals. This helps with the outcome of their illness (e.g., how well they end up doing in certain aspects of life and with dealing with schizophrenia). One of the best available books is called, "The Complete Family Guide to Schizophrenia" by Dr. Kim Mueser and Susan Gingerich, MSW. It is easy to read, practical, comprehensive, and very reasonably priced. I would recommend that anyone with a relative with this disorder pick up this book.

A few things that seem important to emphasize are as follows:

1. It is important to understand that parenting (good or bad) is not the only psychosocial or environmental factor playing a role in whether or not a given individual develops schizophrenia. A variety of other non-biological factors are likely to be important, such as peer relationships, drug or alcohol use, or stressful life events. This means that even if more comprehensive family interventions were instituted during childhood, that would most likely not buffer the child from developing the disorder unfortunately, due to the other types of environmental triggers that exist.

2. We want to be clear that the idea that parents are to blame for schizophrenia has very much fallen out of favor with researchers and clinicians who study schizophrenia. It is an illness that does have a very strong biological component. Unfortunately, some people will develop schizophrenia no matter what kind of parenting occurs or what kinds of skills are taught or not taught. The main thing at this point that we can focus on is how to help someone who develops schizophrenia make the most of their life. What researchers are discovering, fortunately, is that there are many ways to help people achieve these more positive outcomes.

CBT and Client Motivation as Factors in CBT Success

Schizophrenia.com Question Is a clients attitude important in CBT?:

Jennifer Gottlieb, Ph.D. and Corinne Cather, Ph.D. Respond:

Certainly it is very important that the client be motivated to at least give CBT a try. This can’t be something that parents or other family members or therapists can force -- the individual has to be willing to commit to treatment.

Of note is that the research studies that have been done for CBT have been based on a certain type of client: a person who was willing to give an unknown treatment a try, and who volunteered to be part of such a study. This of course is not the case for every client in the real world.

A person’s ability to identify some area of distress, and, with the therapist’s assistance, some treatment targets, is helpful. Engaging someone in CBT who has a lot of paranoia can of course be a challenge. This is because the person is often likely paranoid about the intentions of the therapist, or sometimes it is difficult for the person to leave the house because of paranoia (or negative symptoms or anxiety), but the CBT therapist does what he or she can do to work with the client and surmount some of these challenges. Given the nature of some of these symptoms in schizophrenia, these kinds of obstacles are common and expected. As a result, they are embedded into the types of techniques used in CBT.

A consultation meeting is usually scheduled initially, which addresses a lot of these areas or concern. Then, there is an agreement made between the therapist and client to determine how many sessions to try. Usually, we start with four sessions dedicated to a particular problem, and then the client and therapist together re-evaluate after that time to see what makes the most sense. Sometimes we decide to keep working on the same problem for another few sessions, and sometimes we agree that progress has been made and we can move on to another goal.

Whether or not someone has insight into his or her symptoms (like voices or delusions) is not per se a necessity for being able to engage in CBT. It’s the therapist’s job to work with the client to identify motivations for engaging in CBT (such as reducing distress, improving functioning, getting a job, making more friends, etc.) and these things may have nothing to do with targeting the truth or falsity of a delusion. This work can usually be done independent of insight.

CBT and Causal Factors in Schizophrenia

Schizophrenia.com Question: How is it possible that the talk therapy used in CBT for schizophrenia can help treat schizophrenia if it is (as some people claim) purely a biological brain disorder or disease?

How are the physical causes of schizophrenia related to behaviors, thoughts and emotions that are thought to be causal factors in schizophrenia?

Jennifer Gottlieb, Ph.D. and Corinne Cather, Ph.D. Respond:

There are many common misconceptions about the cause (and treatment) of schizophrenia. Due to historical trends and other attitudes about mental illness, there has been a tendency to dichotomize mental illnesses, such as schizophrenia, as either “purely environmental” (such as a difficult family upbringing or “bad mother”) or “purely biological” (such as a “brain disease”). That is really an oversimplification of such a complicated disorder. The majority of psychiatrists and psychologists who do research and therapy in this area agree that schizophrenia is a combination of both biological and environmental factors that cause, maintain, worsen, and improve this disorder.

An important assumption of CBT is that schizophrenia symptoms, at least in part, are caused or maintained by psychological processes, not just biological ones, and that symptoms are made worse by negative emotion. Therefore, the idea behind CBT is that it exerts its effects on negative emotion, which in turn creates positive change in symptoms. Relatedly, several studies of CBT for schizophrenia have found that, overall, CBT has an effect on symptoms above and beyond medication alone. This is an encouraging finding, and really demonstrates the interaction between the biological and psychological nature of schizophrenia.

Also interesting to note is that just because something is genetic or biologically caused may not mean that it is unchangeable by psychological factors or psychological interventions. For instance, it is now well-known that depression is a “biologically-based” disorder, in that it can be carried from generation to generation due to genetic loadings, and that it is at least partially related to impaired neurotransmitter function in the brain. But, we also know that exercise and CBT and social support can make a big difference in how much a person with depression can improve, as well has whether or not they will have a relapse in the future. Schizophrenia is similar, and this is an important point to keep in mind.

The current “state of the art” is not to dichotomize the causes of schizophrenia, but to understand that there is an integration of causes and therefore there should be an integration of treatments. Most schizophrenia researchers and clinicians these days tend to not believe that schizophrenia is wholly a biological/brain disease. We would not put it in the same category as say, a seizure disorder, where no matter how much therapy a person had, most likely the disorder would not be affected in any substantial way. In addition, studies have found that CBT actually is also helpful for more “biologically-caused diseases” such as chronic pain or migraines.

Another really important point for us to share is that all of the psychiatrists with whom we work in the Mass General Schizophrenia Program are incredibly supportive of CBT for this disorder. These psychiatrists are people who have dedicated their life’s work to understanding and treating schizophrenia, and find a great deal of value in CBT, recommend it to their clients, and support our work.

Schizophrenia.com Question: Schizophrenia has been described by many schizophrenia researchers in the U.S. as a disease of the brain, or a chemical imbalance in the brain (i.e., physical disorder). We’ve also heard in this Robin Murray, Ph.D. Interview, (professor of psychiatry at the Institute of Psychiatry at Maudsley Hospital, Kings College, and University of London) that in Europe the schizophrenia researchers don’t necessarily view schizophrenia as a brain disease – but rather as a psychological disorder. Why do they view schizophrenia so differently in the U.S. vs. Europe – and what is the implication of this different perspective? Is there a growing consensus with regard to how to describe schizophrenia – as a disease or a psychological disorder?

Jennifer Gottlieb, Ph.D. and Corinne Cather, Ph.D. Respond:

There has been a very interesting recent correspondence (September 2006) between Dr. Kontos, from the U.S., and Dr. Turkington, from the U.K., regarding how to describe and treat schizophrenia, and what CBT might address. We will point you to these brief articles, because it addresses your question much better than we could! See the following articles:

Using a Medical Model With Psychotic Patients - American Journal of Psychiatry

Dr. Turkington Replies - American Journal of Psychiatry