Cognitive Therapy of Schizophrenia:

A New Therapy for the New Millennium

AARON T. BECK, M.D.*

NEIL A. R E C T O R , Ph.D.**

Over the past decade, major advances have he en made in extending the
principles and therapeutic strategies of cognitive therapy to the treatment of
schizophrenia. In a number of large-scale outcome studies with cognitive
therapy for schizophrenia, cognitive therapy has been shown to offer
significant gains for those patients who have not been wholly helped with
medications. It may even serve to prevent the consolidation of the illness if
delivered with those in the early stage of the illness. We first outline the
state-of-the-art" conceptualization and strategies employed by cognitive
()

therapists to treat positive and negative symptoms and then review the clinical
trials.

As we enter the New Millennium, a promising new approach to schizophre-

nia is emerging. Accumulating empirical evidence indicates that cognitive
therapy combined with standard treatments provides significant improve-
ment of drug resistant and residual symptoms. In addition, the new
approach offers a more humanistic understanding of the patient with this
devastating disorder. In contrast to the more mechanistic framing of
schizophrenia in terms of abnormal brain scans and deficient responses to
tests of attention, memory and cognitive performance, the cognitive ap-
proach views the patient as a whole person with many troubling, apparently
baffling problems but also with the resources for testing and modifying his
or her more esoteric beliefs.
Specifically, the cognitive therapist views the phenomena, such as
persecutorial delusions and distressing hallucinations as a highly convo-
luted expression of the kind of reaction experienced by anyone who has felt
mistreated, depressed or fearful. When these more bizarre elaborations are
explored, the therapist can discern the more familiar psychological prob-
lems characteristic of depression, social phobia, anxiety disorder, obses-

*Professor of Psychiatry, Dept. of Psychiatry, University of Pennsylvania; Director, The Beck

Institute of Cognitive Therapy. Mailing address: Room 754, Science Center, 3600 Market Street,
Philadelphia, PA 19104-2648.
**Clarke Institute of Psychiatry, 250 College Street, Toronto, Canada.

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sional disorder, and posttraumatic stress disorder and can draw on the
kinds of strategies used in the cognitive therapy of these conditions.
The patients' neuro-developmental vulnerability makes them exquis-
itely sensitive to the kind of life stresses we all encounter, but with fewer
psychological resources to deal with them. Additionally, more unique
stressors, including enforced hospitalization, imposed behavioral controls,
and stigmatization, added to the demoralization produced by a chronic
relapsing disorder, pose therapeutic issues that the cognitive approach aims
to address.

COGNITIVE F O C U S IN SCHIZOPHRENIA

Nearly fifty years ago, Beck (1) described the cognitive treatment of a man
with a seven-year, treatment-resistant delusional system. The patient was a
28-year-old WWII veteran, who, upon returning home from the war, had
come to believe that former members of his military unit were now working
on behalf of the FBI to monitor his activities. The patient also was
experiencing extreme anxiety and dissociative states as a response to the
erroneous beliefs. He was treated for 30 sessions over eight months. The
focus of treatment was on the identification of the antecedents of the
patient's delusional system and the implementation of reality-testing strate-
gies to modify the beliefs; that is ways of questioning and testing alternative
ways of understanding events. By the end of treatment, the patient was able
to stand back, and reason himself out of the erroneous beliefs when he
became suspicious of being watched. Two decades later, this case report
was followed with a report of a cognitive investigation of eight patients with
ongoing delusions (2). Through careful questioning of the evidence that
these patients held in support of the delusions, they began to see their
delusions as hypotheses about the meaning of events rather than as
absolute, rigid "truths." Other clinical researchers began to report similar
benefits using the same cognitive focus (3).
More recent laboratory experiments testing cognitive processes in
persons diagnosed with schizophrenia have extended our understanding of
the biases that may serve to maintain erroneous beliefs and aberrant
perceptions. Studies have shown that paranoid schizophrenics, for ex-
ample, have a selective perceptual bias for threat-related stimuli (4).
Further, they are far more prone than other patients to attribute distressing
occurrences to other people rather than to themselves or the situation (5).
Moreover, despite this compensatory strategy of blaming others for mis-
haps, they show low self-esteem on covert assessments (5). Studies of
hallucinations have shown a similar perceptual bias (6-8). People who hear
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voices are more likely than controls to recall printed words as voices or
misidentify garbled sounds as true words (4,9).
The application of cognitive therapy is based on several observations
about the patient. A psychotic patient is not pervasively irrational but has a
psychosis-free zone that can be utilized in therapy. Contrary to popular
belief, the hallucinations and delusions are not impermeable to psychologi-
cal interventions. Further, these symptoms can be triggered or ameliorated
by environmental factors. Finally, it is possible to make sense of the seeming
bizarreness of the content of the delusions, hallucinations, and thinking
disorder, and these symptoms can be placed in a meaningful context.
The focus of cognitive theory is on the patient as a unique individual
whose psychosis developed in a specific setting. Throughout treatment, a
trusting, collaborative relationship between patient and therapist is crucial.
It often takes much longer and requires more effort to establish rapport,
trust, and collaboration than with other psychiatric patients. The therapist
uses the same kind of gentle questioning, collaboration, and empirical
testing of beliefs intrinsic to the cognitive therapy of depression.
While for the sake of convenience it is useful to discuss the approaches
to hallucinations, delusions, and negative symptoms separately, in actual
practice, these approaches are synchronized (9-12).

VOICES
Careful questioning about the nature of the auditory hallucinations can
provide a number of clues for therapeutic intervention. The therapist
inquires about the frequency, duration, intensity, and variability of the
voices. What circumstances tend to bring them on, and what circumstances
tend to terminate or attenuate them? What events occurred prior to their
initial onset? What agents (God, the devil, dead relatives, etc.) are suppos-
edly talking to the patient? What are or have been the patient's reactions to
the voices: at first, surprised, puzzled, uncertain; then, scared, angry, sad (in
unusual cases, happy or indifferent)?
In most cases, the patients react to the voices as they would to other
people talking to them; that is, they establish an interpersonal relationship
with the voices. The patient may believe that because of their imperative
tone and content, the voices are omnipotent, omniscient, or uncontrollable.
Consequently, the patient often feels helpless, vulnerable, hopeless, or
desperate. These beliefs can be alleviated by a number of strategies. The
uncontrollable belief can be addressed by demonstrating to the patients
that they can initiate, diminish, or stop the voices. Initiating voices is
accomplished by selecting and reproducing a stimulus known to excite
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them; e.g., recalling or imagining a scene, discussing a sensitive event, or

focusing on others' voices or sounds in the next room. Diminishing or
obliterating voices is accomplished by listening to music with a radio
headset, shadowing (repeating what the voice says), or engaging in conver-
sation.
The omnipotence and omniscience are addressed by setting up experi-
ments that will prove that the patients can ignore the commands or "mind
reading" without dire consequences. The devastating threat-filled meaning
of the voices (for example, tortured for eternity) can be alleviated by
demonstrating to the patients that the voices are generated not by a
malevolent entity but by the brain. Socratic questioning is useful: Can
others hear the voices? Why not? The ability to turn them on and off
provides further evidence that they are generated internally. Explanations
regarding how the brain functions to produce thoughts that are vocalized
often helps. Finally, demonstrating that the voices reflect the patients' past
or present thoughts can suggest that the voices simply represent their own
attitudes about themselves or those they think other people have about
them.

DELUSIONS

Delusions, although often bizarre, may be approached in much the same

way that we address beliefs, hypotheses and distortions in nonpsychotic
patients. The major difference is that cognitive distortions are more readily
discounted by nonpsychotic individuals if they do not hold up under
reasoning or reality testing. Patients with psychoses take hypotheses as
facts, imaginings as reality.
The content of psychotic delusions reflects everyday concerns regarding
interpersonal relationships: being attacked, influenced, manipulated, con-
trolled, demeaned. A significant feature of delusions is the "centrality" of
the patients' interpretations. They perceive themselves as the focal point of
a global drama and relate all events to themselves. Once formed, the
delusions shape the interpretation of events and explanations for adversi-
ties.
The therapeutic approach is directed at undermining the tenacity and
centrality of the delusions. By gently questioning the patient about the
nature, origin, and basis of the delusions, it is possible to move the patient
into a questioning mode. The therapist initially deals with the kinds of
interpretations and explanations that are peripheral to the more flagrant
and highly charged beliefs. The therapist, for example, selects one or more
of a series of questions to help the patient to evaluate his or her conclusions.
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Consider a patient who decides the following events are attributable to

the deliberate harassment by a conspiratorial group: his laundry arrived
late, loud noises from a truck woke him up during a nap, and he could not
find his notebook. The questions could take the following form: 1. Does it
follow that this inconvenience is due to a deliberate manipulation rather
than a random event? 2. What is the evidence that it is caused by a group?
3. What alternative explanations are there? The patient may also be
questioned regarding the mechanisms by which he reads other people s
minds. By questioning the inferences, the therapist can help to undermine
the underlying belief structures.
"Focusing" is another therapeutic intervention. The therapist encour-
ages the patient to concentrate on the visible characteristics of the sup-
posed persecutors and formulate criteria by which a trusted outsider (such
as the therapist) could apply these criteria. Generally, the more the patient
concentrates on observing the unique features of the presumed persecutor,
the less they fit the profile and the more likely they are to be discarded.
Using a variety of approaches such as these enables the therapist to break
the deadlock the delusions have on the processing of information.

NEGATIVE SYMPTOMS
The negative symptoms revolve around affective and behavioral defini-
tions: flattening of affect, paucity of speech, anhedonia, withdrawal, apathy,
and abnormality of thinking. Many, but not all, of the negative symptoms
may be attributed to depression (which may be alleviated using standard
cognitive strategies and techniques). Symptoms not responding to antide-
pressant approaches may be attributed to the positive symptoms: hallucina-
tions and delusions. Patients may fold into themselves under the powerful
pressures of the hallucinations and delusions.
The alleviation of delusions and hallucinations may have a favorable
impact on other "deficit" symptoms. The residual symptoms may then be
approached by engaging the patients in real-life tasks: depending on their
level of functioning, the therapist may try to arouse the patients' interest in
various projects, improve his socialization, and reinforce vocational skills.
Even the thinking disorder manifested by highly symbolic, mixed-up
ideas may be alleviated. The therapist attempts to pick out the theme that
appears to be represented in these verbalizations. By translating the
chopped-up and highly symbolic language into the patient s everyday
concerns, the therapist can switch the patient to a higher cognitive level and
begin to focus on the patient's perceived interpersonal problems.
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SESSION-BY-SESSION STRUCTURE
In terms of the delivery of cognitive therapy, sessions are active and
structured: the therapist and patient are working collaboratively toward
mutually agreed-upon goals. Individual sessions follow pretty much the
same format as cognitive therapy for other psychiatric disorders: a struc-
tured agenda is set at the beginning of each session; the therapist and
patient work toward prioritized goals; homework is set at the end of each
session and may include: the monitoring of situational triggers that activate
delusional beliefs and/or hallucinatory activity; the monitoring of mood
states and the important link between negative automatic thoughts and
negative moods with dysfunctional thought records (DTR); the completion
of activity schedules to reinforce participation in pleasurable and task-
based activities; and homework assignments that involve behavioral experi-
ments to test erroneous beliefs and/or control over hallucinations. Sessions
typically run between 15-45 minutes, include frequent breaks, and offer
flexibility in terms of the session-to-session goals. The manual-based
cognitive-therapy interventions were developed for delivery in individual
format, although recent clinical developments have shown the safety and
effectiveness of cognitive therapy in group modality. For instance, Wykes
and colleagues (13) have described a very effective group cognitive therapy
for auditory hallucinations, consisting of six group-sessions.
RESEARCH FINDINGS

Programmatic research testing the effectiveness of cognitive therapy for

schizophrenia has largely taken place in England (14-23) although a more
recent study has been completed in Italy (21). While there are some minor
differences between the cognitive-therapy interventions delivered in these
studies, they all share a common emphasis on the use of cognitive and
behavioral techniques to 1. target and reduce the frequency, severity, and
distress associated with the experience of positive and/or negative symp-
toms, 2. enhance coping skills to better manage both positive and negative
symptoms, and 3. reduce the personal stigma associated with the illness.
I s COGNITIVE THERAPY EFFECTIVE IN COMBINATION WITH MEDICATIONS FOR
MEDICATION-RESISTANT SCHIZOPHRENIA?
Garety and colleagues (14) conducted a nonrandom-allocation controlled
trial pilot study. Patients were assigned to receive either standard care (i.e.,
pharmacotherapy plus case management) or cognitive therapy plus stan-
dard care. Cognitive therapy was delivered weekly or biweekly over a
six-month period for a maximum of 22 sessions. Patients receiving cogni-
tive therapy showed global improvement on psychiatric symptomatology as
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well as lower levels of preoccupation, conviction, and acting on delusional

beliefs. There were modest differences between the two treatment groups
on indices of dysfunctional self-perception, such as self-esteem and depres-
sion.
A more recent, randomized controlled trial by Kuipers and colleagues
(15) has been completed. Patients were randomly allocated to either
cognitive therapy and standard care (n = 28) or standard care only (n = 32).
Following nine months of weekly or biweekly individual therapy, clinical
improvement, as assessed by a general measure of symptomatic distur-
bance, was significant only for patients who received cognitive therapy.
This study also demonstrated that patients have a low drop-out rate (11%)
and express high levels of satisfaction with the CBT intervention (80%). A
subsequent paper on the predictors of outcome in this study showed that
the key predictor of response to cognitive therapy was "a response indicat-
ing cognitive flexibility concerning delusions" whereas this cognitive vari-
able was unrelated to outcome in the control group (16).

Is COGNITIVE THERAPY MORE EFFECTIVE THAN SUPPORTIVE THERAPIES?

Sensky and colleagues (17) conducted a randomized controlled study with
90 patients with medication-resistant schizophrenia. Patients were random-
ized to receive either 20 weeks of cognitive therapy plus standard care or 20
weeks of "befriending" therapy plus standard care. Befriending therapy
was conducted by the same therapist who delivered the cognitive-therapy
intervention and the total amount of time spent in individual face-to-face
therapy was equivalent in both treatment groups. Befriending therapy
encouraged patients to talk about neutral, nonthreatening topics (e.g.,
current events, hobbies, holidays, etc.). Both groups showed significant
improvement on the schizophrenia change scale score at the end of
treatment. However, patients who received cognitive therapy showed more
clinical improvement at nine-month follow-up, whereas the clinical gains
made by the befriending group deteriorated to pretreatment, baseline
levels. Significant gains were also reported in the reduction of depression
severity in this study.
Tarrier and colleagues (18-20) conducted two trial studies on their
comprehensive cognitive-behavioral program termed 'Coping Strategy En-
hancement' (CSE) that resulted in similar findings. The first study assessed
the efficacy of a 10-session CBT intervention compared to a problem-
solving treatment condition, and a control condition. This study pointed to
superior benefits of CSE compared to both the problem-solving, and the
control condition. Differences were most apparent on measures of the
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frequency and severity of delusions and this improvement was still appar-
ent at six-month follow-up.
In a more recent study, Tarrier (19) randomly allocated chronic schizo-
phrenic patients suffering from persistent positive symptoms to: 1. cogni-
tive therapy plus standard care, 2. supportive counselling plus standard
care, or 3. standard care only. Both psychotherapy conditions consisted of
20 sessions within a ten-week period followed by four booster sessions at
monthly intervals. Cognitive therapy was superior on all measures of
clinical outcome: delusions, hallucinations, and general psychopathology.
The routine-care group, moreover, experienced more relapses and spent
more days in hospital. Further, patients who received cognitive therapy
continue to maintain their clinical benefits and have significantly fewer
positive symptoms than patients in the other two groups, at twelve-month
follow-up (20).
Is COGNITIVE THERAPY MORE EFFECTIVE IN COMBINATION WITH ATYPICAL
ANTIPSYCHOTICS?
Pinto and colleagues (21) in Italy completed a randomized controlled study
comparing cognitive therapy (n = 19) versus supportive therapy (n = 18)
in medication-resistant inpatients and outpatients, started on an effective
dose of clozapine. Both treatments were shown to produce statistically
significant improvement on overall psychotic symptoms, positive symp-
toms, and negative symptoms. However, patients receiving cognitive therapy
showed greater reductions on measures of overall psychotic symptoms and
positive symptoms than did patients receiving combination supportive
therapy. An unpublished study at six-month follow-up showed that pa-
tients who received cognitive therapy in combination with clozapine
continued to have significantly better outcomes on measures of total-
symptom and positive-symptom but also on negative-symptom ratings,
compared with patients who received adjunctive supportive therapy. While
the beneficial effects of cognitive therapy were not due to differences in
medication use as daily clozapine use was equivalent between the groups
during the active phase of treatment, the overall effect-size scores in this
study were extremely large and greater than in any other study conducted
to date. These results may point to the superior effects when cognitive
therapy is combined with the novel antipsychotics.
Is COGNITIVE THERAPY EFFECTIVE IN THE ACUTE STAGE OF THE ILLNESS?
Drury and colleagues (22, 23) have tested the effectiveness of cognitive
therapy in acute psychosis. Forty patients were randomized to either a
cognitive therapy or to a control group consisting of structured recreational
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activities and informal support. An equal number of hours were devoted to

each group. At posttreatment, patients in the cognitive therapy group
showed significantly greater reduction in delusional beliefs than did pa-
tients in the control group. The improvement in delusional thinking was
first noticeable at seven weeks. At nine-month follow-up, 95% of the
patients receiving cognitive therapy showed no, or only minor hallucina-
tions or delusions, as compared to 44% of the control group. Depending
on the definition of recovery from the acute phase of the illness, cognitive
therapy was associated with a 25-50% reduction in recovery time. The time
from admission to discharge from the hospital was 49 days on average for
patients receiving cognitive therapy and 108 days on average for patients in
the control group.

CONCLUSION

There is increasing evidence to suggest that patients with psychosis can

benefit from cognitive techniques that identify, reality-test, and correct
distorted conceptualizations underlying the experience of delusions and
hallucinations. There is also evidence to suggest that CBT can help patients
to become more motivated and engaged with social and vocational
events—in this way, reducing some of the negative, deficit features of the
illness. Neuroleptic medications continue to offer tremendous benefit to
patients with psychosis but they appear to be only part of the answer. The
studies reviewed point to clinically significant gains (25-50%) offered by
CBT above and beyond that of medications. These positive gains appear
also to be maintained over time—leading to lower relapse rates, less time
hospitalized, and reduced costs to the health care system. Finally, the
finding that outcomes of cognitive therapy are superior to supportive
therapy suggests that cognitive, and not general therapeutic factors, are the
active ingredients of change.
There are grounds for optimism that cognitive therapy is a safe, feasible,
and effective psychosocial intervention in combination with medication-
based treatments for schizophrenia. Increasing attention is being given to
determine whether early intervention with cognitive therapy can change the
long-term trajectory of the disorder. More attention to clinical refinements
and therapist training in the U.S. and Canada is needed.

REFERENCES

1. Beck AT (1952). Successful outpatient psychotherapy of a chronic schizophrenic with a delusion

based on borrowed guilt. Psychiatry, 15, 305-312.
2. Hole RW, Rush AJ, & Beck AT (1979). A cognitive investigation of schizophrenic delusions.
Psychiatry, 42, 312-319.

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3. Watts F N , Powell G E , & Austin SV (1973). The modification of abnormal beliefs. British Journal of
Medical Psychology, 46, 359-363.
4. Kaney S, Wolfenden M, Dewey M E , & Bentall RP (1991). Persecutory delusions and recall of
threatening and non-threatening propositions. British Journal of Clinical Psychology, 31, 85-87.
5. Bentall RP, Kinderman P, & Kaney S (1994). The self, attribution processes and abnormal beliefs:
Towards a model of persecutory delusions. Behavior Research and Therapy, 32, 331-341.
6. Bentall RP (1990). The illusion of reality: A review and integration of psychological research on
hallucinations. Psychological Bulletin, 107, 82-95.
7. Chadwick P D & Birchwood MJ (1994). Challenging the omnipotence of voices: A cognitive
approach to auditory hallucinations. British Journal of Psychiatry, 164, 190-201.
8. Birchwood M & Chadwick PDJ (1997). The omnipotence of voices: Testing the validity of a
cognitive model. Psychological Medicine, 27, 1345-1353.
9. Kingdon D , & Turkington D (1994). Cognitive behavioral therapy of schizophrenia. New York:
Guilford.
10. Fowler D , Garety P, & Kuipers E (1995). Cognitive behaviour therapy for psychosis: Theory and
practice. New York: Wiley.
11. Chadwick PDJ, Birchwood M, & Trower P (1996). Cognitive therapy for delusions, voices, and
paranoia. New York: Wiley.
12. Tarrier N (1992). Psychological treatment of schizophrenic symptoms. In D Kavanagh (Ed.).
Schizophrenia: An overview and practical handbook. London: Chapman &Hall.
13. Wykes T, Parr A, & Landau S (1999). Group treatment of auditory hallucinations. British Journal of
Psychiatry, 175, 180-185.
14. Garety PA, Kuipers L , Fowler D , et al. (1994). Cognitive behavioural therapy for drug-resistant
psychosis. British Journal of Medical Psychology, 67, 259-271.
15. Kuipers E , Garety P, Fowler D , et al. (1997). London-East Anglia randomized controlled trial of
cognitive-behavioural therapy for psychosis. I: Effects of the treatment phase. British Journal of
Psychiatry, 171,319-327.
16. Garety P, Fowler D, Kuipers E , et al. (1997). London-East Anglia randomized controlled trial of
cognitive-behavioural therapy for psychosis: I I . Predictors of Outcome. British Journal of
Psychiatry, 171,319-327.
17. Sensky T, Turkington D , Kingdon D , et al. (2000). A randomized controlled trial of cognitive-
behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Archives of
General Psychiatry, 57, 165-112.
18. Tarrier N , Beckett R, Harwood S, et al. (1993). A trial of two cognitive-behavioural methods of
treating drug-resistant residual psychotic symptoms in schizophrenic patients: I. Outcome.
British Journal of Psychiatry, 162, 524-532.
19. Tarrier N , Yusupoff L , Kinney C, et al. (1998). Randomised controlled trial of intensive cognitive
behaviour therapy for patients with chronic schizophrenia. British Medical Journal, 317,
303-307.
20. Tarrier N , Wittkowski A, Kinney C, et al. (1999). Durability of the effects of cognitive-behavioural
therapy in the treatment of chronic schizophrenia: 12-month follow-up. British Journal of
Psychiatry, 174, 500-504.
21. Pinto A, L a Pia S, Mannella R, et al. (1999). Cognitive behavioral therapy and clozapine for clients
with treatment-refractory schizophrenia. Psychiatric Services, 50, 901-904.
22. Drury V, Birchwood M, Cochrane R, & MacMillan F (1996). Cognitive therapy and recovery from
acute psychosis: A controlled trial I. Impact on psychotic symptoms. British Journal of
Psychiatry, 169, 593-601.
23. Drury V, Birchwood M, Cochrane R, & MacMillan F (1996). Cognitive therapy and recovery from
acute psychosis: A controlled trial II: Impact on recovery time. British Journal of Psychiatry, 169,
602-607.

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