Guest Editorial
Cognitive-Behavioural Therapy for Severe
Mental Disorders
Neil A Rector, PhD1
Over 4 decades, ago Aaron T Beck presented the basic theoretical and treatment approach of cognitive-behavioural therapy (CBT). Since then, hundreds of randomized controlled clinical trials (RCTs) have demonstrated the efficacy of CBT for the broad range of psychiatric conditions, including severe mental disorders such as bipolar disorder, refractory obsessive–compulsive disorder (OCD), substance abuse, suicide, personality disorders, and schizophrenia. Increasingly, we see the integration of CBT with biological psychiatry resulting in optimized treatment outcomes. This may be no better illustrated than in the recent efforts to develop and test cognitive and behavioural interventions for patients experiencing persistent symptoms of psychosis with only partial response to pharmacologic interventions. Although it has been noted that, as late as the 1980s, schizophrenia was the “forgotten child of behaviour therapy” (1), significant developments in the use of CBT for medication- resistant symptoms in schizophrenia have occurred over the past 15 years.
The CBT treatment approach to schizophrenia has been detailed in several step-by-step treatment manuals. Typically, it includes the following therapeutic goals: 1) the establishment of a solid therapeutic alliance; 2) psychoeducation, within a biopsychosocial model, about the nature of psychosis; 3) reducing stigma and normalizing the symptoms of psychosis; 4) delivering cognitive and behavioural interventions to reduce the occurrence and distress associated with delusions and hallucinations; 5) reducing comorbid anxiety and depression; and 6) reducing relapse. Considerable scientific support now exists for the efficacy and effectiveness of CBT in schizophrenia: metaanalyses of RCTs conducted on CBT have concluded that CBT effectively treats the positive symptoms of schizophrenia, reduces relapse, and enhances recovery during the acute phase (2–5). These positive findings have led to the inclusion of CBT in prominent expert treatment guidelines for schizophrenia—among others, the American Psychiatric Association’s treatment guidelines for schizophrenia (6) and the core interventions for schizophrenia published by the UK National Institute for Clinical Excellence (7). In the UK, CBT has not only been integrated into routine clinical care in the National Health Service, it has also become a mandated treatment for all patients diagnosed with schizophrenia.
Efforts to date have focused on developing cognitive-behavioural treatments for such perceptual distortions as auditory hallucinations and aberrant thought processes (that is, delusions); however, we need to better understand and develop psychological treatments for the condition’s other debilitating and frequently medication-refractory symptoms, such as negative symptoms and poor social functioning. In this issue, 2 papers attempt to address the cognitive conceptualization and treatment of emotional, social, and behavioural disengagement in schizophrenia. In the first paper, my coauthors (Aaron Beck and Neal Stolar) and I offer a cognitive perspective on the psychological components that contribute to persistent and periodic exacerbation of negative symptoms (8). Preliminary experimental evidence and the detailing of patient accounts in cognitive therapy lead us to propose that, in addition to the primary role of neurobiological vulnerabilities in the production of negative symptoms, a patient’s chronic mental set, characterized by negative expectancies and dysfunctional performance beliefs, contributes to the particular expression and, in some instances, the persistence of negative symptoms. Preliminary evidence suggests that patients’ negative symptoms improve when CBT directly targets these cognitive aspects (9).
Dr Corrine Cather, a leading expert in the CBT treatment of schizophrenia at Harvard Medical School, outlines a novel cognitive-behavioural approach to remediating social functioning deficits (10). In contrast to the prevailing view that the symptoms of psychosis should be targeted first to remove putative barriers to improved social and vocational performance, she outlines a new treatment approach wherein the primary treatment target is to harness patients’ motivation to help them identify, pursue, and achieve important life goals in the face of residual psychotic symptoms. The benefits of helping individuals to develop concrete and achievable goals are nicely illustrated in clinical vignettes.
Taken together, these papers highlight the potential for CBT to contribute not only to reducing personally painful experiences associated with distorted reality perception but also to reducing negative symptoms and to helping the person with schizophrenia become emotionally reengaged with personally relevant life goals.
References
1. Bellack AS. Schizophrenia: behavior therapy’s forgotten child. Behav Ther 1986;17:199–214.
2. Gould RA, Mueser KT, Bolton E, Mays V, Goff D. Cognitive therapy for psychosis in schizophrenia: an effect size analysis Schizopr Res 2001;48:335–42.
3. Pilling S, Bebbington P, Kuipers E, Garety P, Geddes J, Orbach G, and others. Psychological treatments in schizophrenia: I. Meta-analysis of family interventions and cognitive behaviour therapy. Psychol Med 2002;32:763–82.
4. Rector NA, Beck AT. Cognitive behavioral therapy for schizophrenia: an empirical review. J Nerv Ment Dis 2001;189:278–87.
5. Tarrier N, Wykes T. Cognitive-behavioural treatment of psychosis: clinical trial and methodological issues in clinical psychology. In: Day S, Green S, Machin D, editors. Textbook of clinical trials. Chichester (UK): Wiley; 2004.
6. American Psychiatric Association. Treating schizophrenia: a quick reference guide. Arlington (VA): American Psychiatric Association; 2004
7. National Institute for Clinical Excellence. Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care. London: National Institute for Clinical Excellence; 2003.
8. Rector NA, Beck AT, Stolar N. The negative symptoms of schizophrenia: a cognitive perspective. Can J Psychiatry 2005;50:247–57.
9. Rector NA, Seeman MV, Segal ZV. Cognitive therapy of schizophrenia: a preliminary randomized controlled trial. Schizophr Res 2003;63:1–11.
10. Cather C. Functional cognitive behavioral therapy: a brief, individual treatment for functional impairments resulting from psychotic symptoms in schizophrenia. Can J Psychiatry 2005;50:258–63.
Author
1. Psychologist, Centre for Addiction and Mental Health, Toronto, Ontario; Associate Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario.
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