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This paper describes functional cognitive-behavioural therapy (FCBT) for persons with schizophrenia and other psychotic disorders. This approach was developed to extend the effects of cognitive-behavioural therapy (CBT) beyond symptom reduction. FCBT uses many elements of treatment found in other forms of CBT for psychosis but delivers them to different targets and with a different philosophy. Psychotic symptoms are addressed to the extent that they interfere with goal setting or achievement. Rather than discussing hallucinations or delusions as “real or unreal” or “rational or distorted,” FCBT focuses on whether psychotic symptoms and responses to these symptoms interfere with attainment of specific social functioning goals. This motivational interviewing approach helps ensure that therapists always have a context for challenging maladaptive responses to symptoms by evaluating whether these beliefs and actions help or hinder psychosocial goal attainment. Moreover, interventions tend not to focus on symptom reduction per se but, rather, on persisting toward goals in the face of symptoms. This paper provides a rationale for devising a therapy with a focus on functional impairment, describes FCBT, furnishes case examples illustrating the approach, and discusses preliminary research findings on FCBT. Why Develop a CBT Focused on Social Functioning?Our interest in modifying existing CBT therapies for psychosis was based on several factors. First, persons with psychotic disorders identify social isolation and lack of employment or other meaningful activity as areas of dissatisfaction in their lives (1–4). From a motivational perspective, it is critical to have treatment models that address these concerns. We reasoned that linking CBT symptom-reduction interventions to life goals might enhance the therapeutic alliance, as well as patients’ motivation and skill development. Second, evidence is lacking for the effects of CBT on the social impairments characteristic of psychotic disorders. Although research suggests that CBT can reduce residual positive symptoms in both inpatients and outpatients with schizophrenia (5–9), there is little evidence that CBT improves social functioning in persons with psychotic disorders (10–12). Given the centrality of social impairments and other functional deficits in schizophrenia and the suggestion that functional improvement results in a modest improvement in symptoms (13), we viewed this as an important limitation of extant CBT approaches to schizophrenia (14). Third, we reasoned that an intervention focused on making goals concrete, breaking goals into smaller steps, and translating intention into behavioural action might be necessary to compensate for cognitive and goal-setting deficits typical of schizophrenia (15). Goal setting is not typically featured as a key intervention strategy in existing CBT interventions for psychosis, and grounding treatment in social functioning goals provides a template for this in FCBT. Fourth, we hypothesized that the positive effects of CBT on psychosis are more a function of reducing distress rather than symptom frequency, which suggests that patients need to develop a goal of “living with the illness” rather than a focus on eliminating symptoms and then moving on with life. We based the design of this intervention on the premise that patients can achieve improvements in social functioning without developing insight into psychotic symptoms. In this, we were influenced by models of treatment whose central goals include tolerance of negative affective states (16) and by interventions proposed by Fowler and colleagues (17), who describe “working within the delusion.” Overview of FCBTFCBT is designed for individuals suffering from schizophrenia spectrum disorders with residual psychotic symptoms that interfere with social functioning. FCBT is delivered in 16 weekly outpatient sessions. Elements of this approach are described elsewhere (18), and a treatment manual is available from the author. FCBT uses a flexible, modular approach that delivers the first 5 sessions in a similar way across patients. The first session is devoted to presenting an instructional videotape that orients the patient to the FCBT model. In the second session, and continuing through session 5, the patient is engaged in 2 primary activities: 1) developing a list of functional goals and the symptoms that interfere with goal attainment and 2) scheduling pleasant activities. Goals typically focus on improving occupational functioning (for example, working, attending classes, volunteering, or managing a household) or social activities (for example, joining a social club, having friends, and dating). From our perspective, these functional goals serve to decrease stress, increase feelings of productivity, and promote social connectedness—all of which are protective factors against relapse (19). Sessions 6 and 7 entail a discussion of the case formulation with the patient and the development of a treatment plan. Specific cognitive-behavioural interventions are applied in sessions 8 to 15, and the final session is devoted to a consolidation of gains made in treatment, along with termination. In the following sections, we amplify the discussion of each treatment phase and provide case illustrations in which information that might identify the patients and details of the case have been altered to protect patient confidentiality. Videotape To acquaint patients with the style and content of therapy, an introductory videotape is used in the first session. The videotape presents general information on psychotic symptoms and their treatment with FCBT and provides brief, simulated therapy vignettes. For example, the traditional structure of CBT sessions; the active role of the therapist; the collaborative nature of the therapeutic relationship; the focus on the connection between thoughts, behaviours, and present difficulties; the development of written materials during the session; the assignment of homework; and the solicitation of patient feedback at the end of the session are each exemplified in the videotape. Not only does the videotape demonstrate the treatment, it also establishes therapist expertise in the treatment of psychotic symptoms, models a strong therapeutic alliance, and instills hope that the treatment will work. We have observed that using the videotape rather than probing questions is extremely helpful in mitigating the anxiety typical of a first therapy session. Identifying Pleasurable Activities and Functional Goals The primary purpose of sessions 2 to 5 is to lay the groundwork for the case conceptualization, which is later shared with the patient. A secondary aim is to increase participation in pleasant events. Patients often have few pleasurable activities, a situation that may maintain negative affective states and contribute to the persistence of negative symptoms. Also, because pleasant activities are by definition inherently rewarding, these events are a good starting point for goal setting and implementation. This orientation to treatment provides an alternative to patients who are consumed with ideas about what they “should” accomplish rather than what they “want to” accomplish. Patients with prominent negative symptoms may find it extremely difficult to identify current sources of pleasure, requiring the clinician to facilitate activities enjoyed in the past. For example, one of our patients was unable to identify anything pleasurable apart from smoking cigarettes in his room. When asked where he used to spend time, he said that he used to feed peanuts to the squirrels in the public park but that he did not do that any longer. This line of inquiry (“Where did you used to hang out?”) revealed that there had been places where he experienced some degree of comfort. Although he was unable to say that he enjoyed these activities at baseline and he did not predict that he would find them enjoyable, he did report enjoying them, once engaged. This clinical example is relevant to experimental findings of diminished emotional response in daily life among schizophrenia patients (20). Because FCBT is based on a case formulation that addresses symptoms only to the extent that they interfere with functional goals, goal identification is more complex than soliciting a “problem list” from the patient. Apart from psychotic symptoms, many factors, including skill deficits, educational deficits, low self-esteem, and negative symptoms, can impede skill development in patients suffering from psychosis. The interventions central to FCBT, however, have been articulated by researcher-clinicians in the field of CBT for psychotic symptoms (5,17,21–24); thus the case formulation and the focus of treatment prioritize social functioning deficits that are conceptualized as primarily related to psychotic symptoms. There are several avenues to identifying functional goals. For example, a patient may indicate a wish to eliminate voices as a goal, in which case the clinician should explore how voices interfere with the patient’s life, how the patient’s daily life and current life situation would be different in the absence of the voices, and whether the patient would miss anything about the voices if they were gone. Alternatively, a patient may indirectly suggest a goal of increasing social connection by stating, for example, that “loneliness” is a problem. Again, the clinician should work to uncover how psychotic symptoms interfere with that goal. It is also possible that a patient may furnish a delusional goal (“I want to reunite with the starship that is converting me to an android, so that I will have eternal life, be with others like me, and work 24 hours a day.”). Exploring such a goal may uncover nondelusional goals or problem areas, such as social isolation or lack of activities that encourage feelings of productivity. During goal setting, it is important that clinicians steer patients away from too modest goals, because such goals may not sufficiently motivate patients to mobilize their resources and work on their goal. Case FormulationThe purpose of case formulation is to direct the clinician’s selection of interventions and to offer the patient an understandable rationale for these interventions. After establishing that psychotic symptoms impede progress toward a goal, the clinician must identify how cognitive and behavioural patterns specifically interfere with particular functional domains. The process of case formulation is perhaps best illustrated through a case example. Case Example A young African-American woman with auditory hallucinations, paranoid delusions, delusions of reference, and a history of childhood verbal and physical abuse and adult sexual assault felt extremely hopeless about her prospects for developing social ties. She believed that her persecutors had informed others of her socially undesirable activities (for example, screaming for voices to stop while in her apartment). The belief that others wanted nothing to do with her was reinforced by threats of eviction from her landlord and by unfriendly exchanges, related to her disruptive and odd behaviour, with other members of her apartment complex. Not surprisingly, she was socially isolated. When she did leave her home, she often covered her head with a black kerchief and wore dark sunglasses, partly in an effort to disguise herself from her persecutors and thereby to limit monitoring of her activities and the probability that berating voices and messages would be directed at her. During periods when the voices diminished, she reported increased depression and thoughts that even they “had abandoned her.” The case formulation shared with the patient was that, like other victims of abuse, she had erroneously internalized beliefs that she was somehow responsible for the abuse and had reasoned that only a bad person would be the victim of abuse. Because, as a child, she was powerless in the face of her abusers and because, as an adult, she was overwhelmed and constantly besieged by voices, she developed the belief that she was ineffective and not in control of her own life. Viewing herself as helpless contributed to her anxiety and depression, which depleted her energy to pursue relationships and increased the frequency of voices and messages. To feel more control, she developed a strategy of decoding messages in the behaviour and speech of others. Although this strategy initially reduced her anxiety (“I’ve figured it out—they are telling me to do x!”), the implications of the messages typically resulted in overall increased distress. Other safety behaviours that she relied on (for example, wearing sunglasses) were identified and labelled as being at cross purposes to her wish to feel more socially connected. In the absence of true social connections, she had come to rely on the companionship of the voices, finding that, even though this relationship was unsatisfying, it was better than none at all. For this patient, the goal of social connection was broken down into subgoals, each of which focused on a particular domain of her life (for example, the outpatient clinic, the family, the apartment complex, and her neighborhood). The treatment plan therefore focused on identifying and remedying cognitive distortions, safety behaviours, and other behaviours that were conceptualized as exacerbating paranoia and hypervigilance in ways that undermined her goal of social connection. InterventionsThe cognitive-behavioural strategies that comprise the bulk of the intervention include coping skills enhancement and cognitive restructuring. Cognitive restructuring primarily targets how patients view themselves in relation to the illness, to its symptoms, to others, and to the utility of particular safety behaviours. In FCBT, cognitive restructuring tends not to target the truth or falsity of a particular delusional belief, except among patients who themselves report the “possibility of being mistaken,” an established positive predictor of response to approaches that have routinely incorporated this type of intervention (10). The following section provides excerpts of case examples that typify these interventions. One of our patients reported to us that she was unable to work because her response to having auditory and visual hallucinations was to rest for 4 hours in a darkened room. She described hallucinations as triggering panic symptoms and the belief that she was in danger of fainting and embarrassing herself in public. Therapy in this case focused on developing alternative coping responses (for example, she found making a fist to combat a vasovagal response particularly useful) and using evidence of more effective coping strategies to combat her view of herself as helpless and functionally limited by the hallucinations. A young man we saw in FCBT wanted to date but believed (with 70% conviction) that his peers were making fun of him for having a mental illness, a belief reinforced by his hearing voices saying he was “just a paranoid schizophrenic.” To challenge his self-stigmatizing beliefs, we conducted behavioural experiments that focused on the belief that he could identify others who suffered from mental illness. In the experiments, we showed him pictures of famous people with or without known mental illness to see how accurate he was. Another patient was tormented by voices and messages that he interpreted as consistent with his persecutors’ ordering him not to work. For example, he believed that a security guard who was counting money while shaking his head was doing this to warn him that, if he began to work, he would be jailed for fraud by social security. Self-monitoring of his command hallucinations revealed that this patient received many instructions during the day and complied with all of them in an effort to ward off feared consequences. In this case, treatment interventions focused on behavioural experiments designed to uncover whether noncompliance was in fact followed by the feared consequences. It began with instructions wherein disobedience was viewed as having potentially minor consequences (for example, failing to make his bed when ordered) and proceeded through instructions that were viewed as having more severe potential consequences (for example, attending an information meeting about possible transitional employment options, despite hearing voices saying that he would be burned for working and ordering him not to work). He was able to recount that the voices’ instructions did not always make sense but that he complied with them anyway. In his case, the clinician introduced the idea that the voices were like a group of 6-year-olds in a candy store, each of whom wanted a different type of candy, and that his job was analogous to an adult with the authority to decide which single type of candy he would buy for the group. Similarly, the clinician suggested that the patient view himself as president of a company with many underlings advising him to make various decisions. He, however, was the final decision maker, which at times might involve rejecting everyone else’s opinions. To foster skill generalization and to promote progress toward the functional goal, FCBT therapists attempt to assign skills practice in real settings. For example, an intermediate goal for a socially isolated college student whose ultimate goal is to develop friends might be to tolerate sitting near other people, despite feeling that others can hear his or her thoughts and despite fearing that they might be talking about him or her. Before carrying out this exercise, the student would have been equipped with skills for managing distress (perhaps in the form of a coping card with statements like “You can get through this” or “Remember that you do not need to act on every thought or feeling that you might have.”) Treatment Consolidation and Termination Although the final session is dedicated to relapse prevention and termination, reviews of functional gains and novel skills to manage or tolerate symptoms are interwoven throughout the entire treatment course. A method of ending treatment that we have found particularly useful is to provide patients with a typed letter that summarizes the therapy and praises them for their progress in CBT. The letter’s stated purpose is to remind patients of how they and their clinician conceptualized the relation between their particular psychotic symptoms and their functional limitations, the skills they learned, the progress made toward their goals during treatment, and how they might continue to use these skills to reach their ultimate goals. Preliminary ResultsA pilot study by Cather and others evaluated the feasibility and preliminary efficacy of FCBT for decreasing psychotic symptoms and improving social functioning (25). In this study, 30 outpatients with schizophrenia or schizoaffective disorder, depressed type with residual psychotic symptoms, were randomly assigned to a manualized treatment, either FCBT or a psychoeducational program (PE). Participants were stratified by severity of psychotic symptoms and by sex and were randomized to receive either FCBT or PE by an independent member of the research team. Both treatments consisted of weekly 1-hour individual sessions for a total of 16 weeks. Assessments were conducted at baseline and posttreatment (week 16) by interviewers who were blind to treatment condition. It was predicted that FCBT would be superior to PE in improving social functioning, as assessed by Birchwood’s Social Functioning Scale (SFS, 26), and in decreasing positive symptoms, as measured by the Psychotic Symptoms Rating Scales (PSYRATS, 27) and the Positive and Negative Syndrome Scale (PANSS, 28). Attrition was only 7% and did not differ between FCBT and PE, indicating good tolerability for both treatments. Within-group analyses indicated that the FCBT group showed a significant reduction in voices from pre- to posttreatment, as measured by the PSYRATS. Of subjects who received FCBT, 60% showed a clinically significant reduction in positive symptoms (that is, a 20% reduction in the PANSS positive factor), compared with only 31% of subjects who received PE. We found that reductions in voices from baseline to posttreatment, as measured by the PSYRATS, were significantly correlated with increased functioning from baseline to posttreatment, as measured by the Independence-Performance and Recreation subscales of the SFS, for the FCBT condition only. The study’s limitations included a small sample size and the low sensitivity of the social functioning measure; however, the results suggest that FCBT is well tolerated and holds promise for reducing persistent positive symptoms, particularly voices. Moreover, in the FCBT group, decreases in psychotic symptoms were associated with improved functioning in activities of daily living and greater involvement in leisure activities, suggesting that FCBT had some success in targeting symptoms with the goal of improving functioning. Future DirectionsWe observed that, although patients enrolled in FCBT were often able to make progress toward intermediate goals (for example, creating a resume, making an effort to be more friendly in daily interactions, and attending a fair to learn about volunteering options), they were often unable to attain their ultimate goal (for example, working, making a friend, dating, or volunteering) during the course of the 16-week treatment. It is possible that intensifying the treatment, perhaps by increasing its frequency or duration, might improve goal acquisition and social functioning outcomes. To date, there have been no large randomized controlled trials (RCTs) of CBT in schizophrenia patients in the US. Relatively little is known about either the factors that predict who will benefit from treatment or what the mechanism of change is for those who do benefit. Positive results from an RCT could generate broader recognition of CBT as a treatment empirically validated by patients, families, and mental health professionals; such results could transform the current situation, in which relatively few US mental health professionals are trained in CBT for schizophrenia. The impact of empirical investigation will be much greater if it can demonstrate benefits in terms of functional improvement, reduced relapse, and cost-effectiveness than if demonstrated effects are limited to symptoms alone. References1. Corin E, Lauzon G. From symptoms to phenomena: the articulation of experience in schizophrenia. J Phenomen Psychol 1994;25:3–50. 2. Davidson L, Stayner D, Haglund KE. Phenomenological perspectives on the social functioning of people with schizophrenia. In: Mueser KT, Tarrier N, editors. Handbook of social functioning in schizophrenia. Boston: Allyn & Bacon; 1998. 3. Mueser KT, Becker DR, Wolfe R. Supported employment, job preferences, job tenure and satisfaction. J Ment Health 2001;10:411–7. 4. Mueser KT, Salyers MP, Muser PR. A prospective analysis of work in schizophrenia. Schizophr Bull 2001;27:281–96. 5. Beck AT, Rector NA. Cognitive therapy of schizophrenia: a new therapy for the new millennium. Am J Psychother 2000;54:291–300. 6. Rector NA, Beck AT. Cognitive behavioral therapy for schizophrenia: an empirical review. J Nerv Ment Dis 2001;189:278–87. 7. Gould RA, Mueser KT, Bolton MA, Mays VK, Goff DC. Cognitive therapy for psychosis in schizophrenia: an effect size analysis. Schizophr Res 2001;48:335–42. 8. Pilling S, Bebbington PE, Kuipers E, Garety PA, Geddes J, Orbach G. Psychological treatment in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychol Med 2002;32:763–82. 9. Tarrier N, Wykes T. Is there evidence that cognitive behaviour therapy is an effective treatment of schizophrenia? A cautious or cautionary tale? Behav Res The 2004;42:1377–401. 10. Garety P, Fowler D, Kuipers E, Freeman D, Dunn G, Bebbington P. London-East Anglia randomized controlled trial of cognitive-behavioural therapy for psychosis. II: predictors of outcome. Br J Psychiatry 1997;162:524–32. 11. Kuipers E, Fowler D, Garety P, Chisholm D, Freeman D, Dunn G, and others. London-East Anglia randomized controlled trial of cognitive-behavioral therapy for psychosis. III: follow-up and economic evaluation at 18 months. Br J Psychiatry 1998;37:415–30. 12. Gumley A, O’Grady M, McNay L, Reilly J, Power K, Norrie J. Early intervention for relapse in schizophrenia: results of a 12-month randomized controlled trial of cognitive behavioral therapy. Psychol Med 2003;33:419–33. 13. Bond GR, Resnick SG, Drake RE, Xie H, McHugo GJ, Bebout RR. Does competitive employment improve nonvocational outcomes for people with severe mental illness? J Consult Clin Psychol 2001;69:489–501. 14. Roberts DL, Penn D L, Cather C, Otto M, Goff DC. Should CBT target the social impairments associated with schizophrenia? J Cog Psychother: An Int Q 2004;18:255–64. 15. Morris RG, Rushe T, Woodruffe PWR, Murray RM. Problem solving in schizophrenia: a specific deficit in planning ability. Schizophr Res 1995;14:235–46. 16. Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy: an experiential approach to behavior change. New York: Guilford Press; 1999. 17. Fowler D, Garety P, Kuipers E. Cognitive behaviour therapy for psychosis theory and practice. Chichester (UK): John Wiley & Sons; 1995. 18. Cather C, Penn DL, Otto M, Goff DC. Cognitive therapy for delusions in schizophrenia: models, benefits, and new approaches. J Cog Psychother: An Int Q 2004;18:207–21. 19. Zubin J, Spring B. Vulnerability: a new view of schizophrenia. J Abnorm Psychol 1977;86:103–26. 20. Kring A. Emotion in schizophrenia: old mystery, new understanding. Cur Dir Psychol Sci 1999;8:160–3. 21. Chadwick P, Birchwood M, Trower P. Cognitive therapy of delusions, voices and paranoia. Chichester (UK): John Wiley & Sons; 1996. 22. Kingdon D, Turkington D. Cognitive-behavioral therapy for schizophrenia. Hove (UK): Lawrence Erlbaum; 1994. 23. Morrison AP. A casebook of cognitive therapy for psychosis. New York: Taylor & Francis In; 2002. 24. Nelson HE. Cognitive behavioural therapy with schizophrenia. A practice manual. Cheltenham (UK): Stanley Thornes Publishers Limited; 1997. 25. Cather C, Penn D, Otto MW, Yovel I, Mueser KT, Goff DC. A pilot study of functional cognitive behavioral therapy (FCBT) for schizophrenia. Schizophr Res 2005;74:201–9. 26. Birchwood M, Smith J, Cochrane R, Wetton S, Copestake S. The social functioning scale: the development and validation of a new scale of social adjustment for use in family intervention programmes with schizophrenic clients. Br J Psychiatry 1990;57:853–9. 27. Haddock G, McCarron J, Tarrier N, Faragher EB. Scales to measure dimensions of hallucinations and delusions: the psychotic rating scales (PSYRATS). Psychol Med 1999;29:879–89. 28. Kay S, Fiszbein A, Opler L. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizopr Bull 1987;13:261–74. Author(s)Manuscript received and accepted January 2005 1. Clinical Assistant in Psychology, Massachusetts General Hospital, Boston, Massachusetts; Instructor, Department of Psychiatry, Harvard Medical School, Boston, Massachusetts. Address for correspondence: Dr C Cather, Schizophrenia Program of the MGH, Freedom Trail Clinic, 25 Staniford Street, Boston, MA 02114 e-mail: ccather@partners.org
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