Cognitive therapy outcome for the treatment of schizophrenia

1. J O H N G . K U N A , P S Y . D . & A S S O C I A T E S
D R J O H N G K U N A . C O M
5 7 0 - 9 6 1 - 3 3 6 1
Outcomes of Cognitive Therapy for
the Treatment of Schizophrenia

2. Schizophrenia
 DSM-5: schizophrenia spectrum is characterized
according to the following five areas:
 delusions,
 hallucinations,
 disorganized thinking,
 abnormal motor behavior and
 negative symptoms.

3.  Negative symptoms include:
 a diminished emotional expression,
 avolition,
 alogia,
 anhedonia and
 asociality

4. Diagnostic criteria
 1) in a one month period, two or more of the following
symptoms are present for significant portion of time:
 delusions, hallucinations, disorganized speech, grossly disorganized
catatonic behavior, and negative symptoms,
 2) there is marked clinical impairment due to
symptomatology in one or more major life area (work,
interpersonal relationships, or self-care),
 3) symptoms persist continuously for at least a 6 month
period,
 4) a diagnosis of schizoaffective disorder and depressive
or bipolar disorder with psychotic features can be ruled
out based on the lack of presence of mood disorder
episodes,

5. Diagnostic criteria, cont.
 5) a medical condition or the effects of a substance
can be ruled out, and
 6) if a history of autism spectrum disorder (or
communication disorder) as a child is present,
prominent delusions or hallucinations must be
present to qualify for a schizophrenia diagnosis
(American Psychiatric Association, 2013).

6. Treatment
 Medication management--treatment as usual (TAU)
 Growing clinical interest in developing a cognitive
behavioral approach.
 25-50% of schizophrenic individuals who are medication
compliant still report clinically distressing hallucinations and
delusions (Harrow, Carone, & Westermeyer, 1985).
 Typical antipsychotics frequently prescribed to schizophrenic
patients are often accompanied by a host of side effects
 Profiteering of Big Pharma

7. Treatment
 Therapeutic techniques involved in a CBT approach
to schizophrenia differ slightly from one author to
the next, the general principles remain consistent.
 typically adhere to the general CBT guidelines as
applied to anxiety or depression

8. Treatment
 Following variables are essential to the successful
application of CBT to a schizophrenic population:
 a strong therapeutic alliance;
 therapy as problem-focused,
 time-limited and directive;
 a process of collaborative empiricism and guided discovery;
 employment of normalization techniques**
 development of alternative explanations, and
 goal setting.
 (Turkington, Kingdon & Weiden, 2006)

9. Treatment
 Process of normalization as a key component for
therapeutic change in this population
 (Kingdon & Turkington, 1991).
 Hallucinatory experiences seen as continuum, rather
than an extreme and abnormal occurrence,
 Universalizing approach enables the client to feel less
stigmatized and isolated, more open to disclose.
 Psycho-education provided to the client to explain that
many people have reported strange experience due to
diverse situations, such as hunger, lack of sleep, stress, or
even falling asleep
 (Kingdon & Turkington, 1991).

10. Treatment
 Beck: “Hallucinatory experiences are seen to lie at
the extreme end of a belief continuum rather than lo
represent categorical abnormalities (Rector & Beck,
2002, p. 42).”

11. Treatment
 Beck
 1952--successful treatment of an individual with paranoid
delusions by the use of a cognitive psychotherapeutic
approach.
 Beck recalls that the therapeutic intervention he used involved
 the use of building rapport,
 a detailed exploration of the individual’s life events preceding the
onset of paranoid delusions.
 The therapy appeared successful, with no reoccurrence of
delusions upon follow up.

12. Treatment
 Beck
 individual (not group format),
 structured, and time-limited (6-9 months, with up to 3 booster
sessions post-treatment for relapse prevention purposes).
 As with CBT in general, in the initial sessions of exploratory
phase, the therapist should focus on fostering the therapeutic
relationship, and validating the client.
 collaborative empiricism will drive the mutually agreed upon
goals for the continuation of therapy (Rector & Beck, 2002).

13. Treatment
 Beck
 the therapist gently guides the client to recognize the
relationship between cognitions, emotions, and behaviors.
 Core values and beliefs are identified by way of the downward
arrow technique, and
 the client’s hypotheses about the self (“I’m unlovable”), others,
and the world are identified (Rector & Beck, 2002).
 typical therapy sessions may last from 25-45 minutes, and
follow a semi-structured format that Beck provides (Rector &
Beck, 2002).

16. Treatment
 Schizophrenia co-morbidities
 Mood disorders (bi-polar)
 Substance Abuse
 Depression
 Trauma
 Use CBT approach to target co-morbidities first, then
use cognitive techniques to challenge delusions,
hallucinations, etc.

17. Treatment
 Therapist qualities
 cannot be assumed to be able to employ the cognitive
behavioral techniques to treat individuals with schizophrenia
without advanced training, supervision, and experience in
both cognitive therapy as well as extensive experience working
with individuals with psychosis.

18. Treatment
 Delusions
 several cognitive and behavioral strategies aimed at
undermining the rigid conviction and centrality of the
delusion(s).
 Before attempting to shift the patient to a questioning
mode, the therapist first attempts to understand the
patient's life context, including important past life events
and their appraisal.
 The approach is collaborative and Socratic.
 aims to change delusional thinking by setting up
behavioral experiments that test the accuracy of different
interpretations

19. Delusions, cont.
 Example: Delusion of Reference:
 “She believed that when people spat on the ground they
were actually spitting to communicate to her that she was
not welcome there. After several sessions considering
alternative explanations for this behavior, 2 hypotheses
were entertained for testing: either people truly were
spitting to communicate a message to her, or people
sometimes spat, and this was not meant to communicate
a specific message to her. Her experiment was to go to the
busy downtown street where this happened often and to
observe the frequency of this behavior, first while away
from the sidewalk and then while walking on the
sidewalk. The data generated by the behavioral
experiment were reviewed”