Book Review
Schizophrenia 
Cognitive Therapy of Schizophrenia David G Kingdon, Douglas Turkington. Jacqueline B Persons, series editor. New York (NY): The Guilford Press; 2005. 219 p. US$35.00.
Reviewer
rating*: Excellent
Review by: Gail Myhr, MD,CM, MSc
Montreal, Quebec
First developed by Aaron T Beck over 40 years ago to treat depression and anxiety, cognitive therapy (CT) uses a reasoning-based approach to the treatment of mental disorders. In the last 15 years, efficacy studies of CT for schizophrenia have demonstrated clear and durable effects on positive and negative symptoms when it is administered as an adjunct to usual treatment involving medications.
Much of the work on CT of schizophrenia originated in the United Kingdom, where psychiatrists David Kingdon and Douglas Turkington have had a great influence on its development. Their first book, Cognitive Behavioural Therapy of Schizophrenia, published in 1994 (1), was a slim but groundbreaking volume describing their approach to a disorder wherein fear of the unknown is a major source of suffering and demoralization. Kingdon and Turkington assume that individuals with schizophrenia are not substantially different from anyone else and that they are struggling with thoughts and experiences that can be understood as being on a continuum with normal thoughts and experiences. This intensely humanizing stance stresses the importance of finding, together with the patient, a joint explanation for psychosis and of collaboratively exploring troubling thoughts, hallucinations, and negative symptoms. In a gentle, nonconfrontational manner, therapists can assist patients to consider alternate explanations for their perceptions, to test them out, and to draw their own conclusions from their experiences.
In “decatastrophizing” the dangers of talking to patients in depth about what preoccupies them, and in offering the hope of making a difference through psychological means, their 1994 book profoundly altered how many of us related to our schizophrenia patients. However, we found that the more we talked to patients about their thinking, the more questions arose. What do we do when we ourselves are incorporated into a patient’s delusions? How do we deal with a grandiose delusion that gives the patient great pleasure and escape from his or her existence? What do we do when we can’t get a word in edgewise or don’t follow any of the connections made by the patient? How do we handle refusal to consider medication? What do we do if we feel that we are getting nowhere?
After over 25 years of working in this area, Kingdon and Turkington offer their latest book, a most welcome arrival that answers these and many other questions. Unlike multiauthored texts, this comprehensive guide shows unity of theme and purpose and provides a framework for administering evidence-based CT of schizophrenia. It begins with a phenomenological exploration of the broad diagnostic category called schizophrenia and summarizes the literature on known biological, social, and psychological vulnerabilities. The evidence for CT as an effective treatment of psychosis is presented, as is the rationale guiding their approach. For example, on the subject of insight, there is evidence that better outcomes are associated with accepting the need for treatment and with recognizing that voices and delusions originate from within oneself. The insight that one has an illness has not been associated with better outcomes but with increased depression and suicidality. The authors have used this literature to support their focus on understanding symptoms and their meaning and their preference for using cognitive-behavioural explanations for psychotic experiences rather than insisting on acceptance of the label schizophrenia.
The book discusses how to set up psychotherapy with individuals suffering from psychosis, beginning with assessment, case formulation, and management of the therapeutic alliance. The vulnerability–stress model is their source for “normalizing explanations” for psychosis—the notion that, given sufficient stress, most individuals could develop the symptoms the patient is experiencing. Normalizing, employed early in therapy, reduces anxiety and enhances engagement. The authors describe strategies for dealing with delusions, hallucinations, negative symptoms, and thought disorders, as well as termination, relapse prevention, and—my own personal favourite—difficulties in therapy. Clinical vignettes and snippets of dialogue illustrate key concepts. For example, one objective in dealing with a patient suffering from paranoid delusions is to reduce generalization. This is done by getting the patient to be specific. One could go to a window and look at passers by and ask about specific people as they pass: “Are they part of the plot?” “How did you decide that?” “Was it something they did?” “Or something they wore or a way they looked?” (p 113). This process of guided discovery can elicit the idea that not everybody is against the patient—that there are probably exceptions. This helps the patient to develop a “critical position” that he or she can use when outdoors.
This reasonably priced book is an excellent—and, I would add, essential—resource for any mental health professionals working with schizophrenia, whether or not they are cognitive therapists. It should embolden therapists accustomed to treating depression or anxiety but apprehensive about working with psychosis. It is methodic, thorough, and clear, with many figures and tables highlighting key points. The appendix includes patient information handouts (for example “Getting Motivated,” and “Understanding Voices”), as well as forms for monitoring voices, thought broadcasting, or referential thinking. Standardized rating scales are included to monitor patient progress.
My reservations about the book are few. The authors describe 4 clinical psychosis subgroups, defined on the basis of their experience and which they are currently validating: sensitivity psychosis, drug-induced psychosis, traumatic psychosis, and anxiety psychosis. (These were not familiar to me.) They give a case example of each, and follow these 4 cases through the book, describing treatment elements pertinent to each case at the end of every chapter. Although this is a pedagogically sound technique in theory, in practice I found it repetititious and hard to follow. To allow integration of various treatment concepts, I would have preferred a single chapter detailing the evolution of the 4 cases.
This, however, is a minor quibble. The gentle, compassionate approach to individuals with schizophrenia espoused by these world-renowned experts is inspiring, and their book ably reflects it. As they write:
It does involve . . . therapists having faith that there is meaning in the depths of conversation—and that can be hard to find in the more profoundly thought-disordered person. However, given time, some order always seems to emerge (p 135).
Reference
1. Kingdon D, Turkington D. Cognitive behavioural therapy of schizophrenia. New York (NY): Guilford Press; 1994.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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