Psychotherapy for Persons with Schizophrenia?
By Xavier Amador, PhD
Schizophrenia Magazine
As I have written before in this column, about 50 percent of persons with schizophrenia have difficulty seeing that they have a mental illness (i.e. they have anosognosia) and this lack of awareness is linked to frontal lobe dysfunction. As such, it does not change—insight does not increase—easily over time. The data supporting this statement are so well replicated that ten years ago the diagnostic manual all North American doctors and mental health professionals use, The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, APA Press, 2000) reported these facts. In addition, many persons with schizophrenia either refuse to take their prescribed medication or take only a small portion of it (estimates are 50-75 percent). And for those persons with schizophrenia who understand that they have an illness and take medication, some don’t respond to the treatment and others respond only partially (e.g. the voices are diminished but the delusions persist). So if many people refuse medication, or take only sub-therapeutic doses, and medication does not always work for those who do take it as prescribed, what can be done?
Although I pose the title as a question, I have no doubt that as a field we need to offer psychotherapy to most, if not all, persons with schizophrenia. In this column I will highlight some of the research on Cognitive Behavioral Therapy (CBT) in schizophrenia. I will also briefly discuss Motivational Interviewing, which I consider a “close cousin” of CBT, and argue that strong support exists for their effectiveness in increasing adherence to medication, improving some aspects of insight into illness, lowering the severity of some symptoms, and as importantly, encouraging patients to become active consumers engaged in trying to find the treatments and resources that help them best.
Learning about psychotherapy in schizophrenia
The first lesson I learned was in college, in the classroom in 1978: Long term, intensive psychoanalysis cures schizophrenia. It does not merely reduce the severity of symptoms, it cures the illness itself! Most often the focus of treatment was to undo the damage done by the “schizophrenigenic mother” whose style of communicating emotion produced schizophrenia. I learned the second lesson years later from the doctor who first diagnosed my brother, Henry with schizophrenia: The only treatment for schizophrenia was antipsychotic medication and “supportive therapy.” At the time, supportive therapy appeared to consist of individual meetings and group therapy aimed at “reality testing” which, to my brother’s ears, sounded a lot like people telling him he was wrong to think the things he did and was “crazy”.
Why the change from psychoanalysis to drugs and reality testing? A 1984 landmark study conducted by Yale psychiatrist Tom McGlashan, MD, and his colleagues at the Chestnut Lodge Research Institute, Rockville, Maryland, a nationally renowned treatment center for schizophrenia at the time, showed that psychoanalysis by no means cured schizophrenia and in most instances offered very little help. Then, in the 1990s, with the National Institute of Mental Health’s (NIMH) announcement of the “Decade of the Brain” research initiative for schizophrenia, inspired in large part by family members working with the National Alliance on Mental Illness (NAMI) together with clinicians and scientists, the pendulum swung the other way. Psychotherapy was bad and pharmacotherapy, or drugs, were good. Obviously this is a gross over simplification, but for many of us that was the view.
Although I was trained in psychoanalytic psychotherapy and used it with many patients, I saw how antipsychotic medicines were lowering—and even eliminating—symptoms of schizophrenia in my brother and others with schizophrenia. I gladly joined the chorus of well-intentioned family members, doctors, and researchers who preached that antipsychotic drugs were the key to stabilization and recovery and that there was little or no room for psychotherapy, which promised more harm than good. In retrospect, we threw the baby out with the bath water.
Fortunately, a group of researchers in the United Kingdom came to the attention of Aaron T. Beck, MD, the father of cognitive therapy, from the University of Pennsylvania, and together they began a yearly meeting of scientists studying cognitive therapy in patients with schizophrenia. In June, 2009, I attended their 10th anniversary meeting at the University of Pennsylvania School of Medicine. Although one of my colleagues and I had written a review paper some years before concluding that CBT had many positive applications for persons with schizophrenia, the conference helped to cement and expand this view. Here are some of the lessons I have learned from the conference and the research literature.
The good thing about psychotherapy
First the bad news: The consensus from the conference seemed to be that CBT was not particularly effective in treating negative symptoms (which include blank looks, monotone and monosyllabic speech, few gestures, lack of interest in events or people, and lack of joy or spontaneity). Also, in the United States it is rarely offered, whereas in the United Kingdom it is commonplace. The good news is that research conducted since our last review of the literature in 2001 indicates that CBT is effective in treating some positive symptoms of schizophrenia (positive symptoms include hallucinations, delusions, and thought disorder). Hallucinations, in particular, appear to be helped with CBT.
In our 2001 review of the literature, Anna Seckinger, PhD, and I found that poor insight and nonadherence to medication were common and problematic areas that present major stumbling blocks in the treatment of patients suffering from schizophrenia and that CBT and interventions derived from approaches such as Motivational Interviewing improve some aspects of insight into illness, increase adherence to medication, ameliorate the severity of hallucinations and sometimes delusions, and help with other negative consequences of schizophrenia. The papers presented in 2009 at the 10th Anniversary Conference on CBT in Schizophrenia reaffirmed the main findings of our earlier review.
Also in a 2009 study published in The British Journal of Psychiatry, the authors found that compared to a control therapy, CBT was superior at reducing incidents of aggression in patients with a history of aggression and violence and was superior at reducing delusion severity and decreasing risk management. Furthermore, the treatment was acceptable to the majority of individuals; dropout rates from CBT therapy were much lower than dropout rates from the control therapy.
Finally, a review of 20 years of psychosocial research aimed at improving medication adherence, published in The American Journal of Psychiatry in 2002 (to view the article visit Contact LEAP Institute and click on ‘Review Paper’) found that only those programs that included elements of Motivational Interviewing were effective in helping motivate persons with schizophrenia to accept treatment and stick with it.
Why psychotherapy is rarely offered
Despite all the evidence—and even more data for the effectiveness of CBT for treating other disorders common in schizophrenia like mood and anxiety disorders—the overwhelming majority of persons with schizophrenia in North America have never been offered a course of treatment with CBT or related therapies (such as LEAP: Listen-Empathize-Agree-Partner).
I think this is for two reasons. First, there is no schizophrenigenic mother. Unfortunately most clinicians still feel guilt for believing, or being part of a field that once believed, that bad parenting caused schizophrenia. To them I say: “Get over it, none of us meant to do any harm, we were simply ignorant and stuck in a particular theory that had never been tested.” Second, schizophrenia is indeed a brain disorder. The research conducted during the “Decade of the Brain” and after revealed that fact unequivocally. Consequently consumers, relatives, mental health professionals, and policy makers, tend to focus on the brain forgetting that the brain resides in a human being. Meanwhile, we have never had a multibillion dollar industry promoting consumer and professional education about psychotherapy for schizophrenia. But we have had such deep pockets educating us about the benefits of antipsychotic medicines. This is not a criticism—it is a simple incontrovertible truth.
So it is up to us to become educated about psychotherapies that have been studied and shown to be effective, and up to us to see that both private and public funds are directed toward training the professionals needed to deliver these therapies and make them available in our communities. I don’t find this task daunting or impossible because I have already seen much progress made since I opened my first book about schizophrenia and since my brother’s first episode of illness.
For more information on CBT for persons with schizophrenia see:
www.BeckInstitute.org - Home and LEAP Institute
Xavier Amador, PhD, (Dr. Xavier Amador) an adjunct professor at Columbia University and the author of numerous scholarly and trade publications, including the national bestseller I am Not Sick, I Don’t Need Help (Vida, 2000) is a regular columnist for SZ Magazine.
By Xavier Amador, PhD
Schizophrenia Magazine
As I have written before in this column, about 50 percent of persons with schizophrenia have difficulty seeing that they have a mental illness (i.e. they have anosognosia) and this lack of awareness is linked to frontal lobe dysfunction. As such, it does not change—insight does not increase—easily over time. The data supporting this statement are so well replicated that ten years ago the diagnostic manual all North American doctors and mental health professionals use, The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR, APA Press, 2000) reported these facts. In addition, many persons with schizophrenia either refuse to take their prescribed medication or take only a small portion of it (estimates are 50-75 percent). And for those persons with schizophrenia who understand that they have an illness and take medication, some don’t respond to the treatment and others respond only partially (e.g. the voices are diminished but the delusions persist). So if many people refuse medication, or take only sub-therapeutic doses, and medication does not always work for those who do take it as prescribed, what can be done?
Although I pose the title as a question, I have no doubt that as a field we need to offer psychotherapy to most, if not all, persons with schizophrenia. In this column I will highlight some of the research on Cognitive Behavioral Therapy (CBT) in schizophrenia. I will also briefly discuss Motivational Interviewing, which I consider a “close cousin” of CBT, and argue that strong support exists for their effectiveness in increasing adherence to medication, improving some aspects of insight into illness, lowering the severity of some symptoms, and as importantly, encouraging patients to become active consumers engaged in trying to find the treatments and resources that help them best.
Learning about psychotherapy in schizophrenia
The first lesson I learned was in college, in the classroom in 1978: Long term, intensive psychoanalysis cures schizophrenia. It does not merely reduce the severity of symptoms, it cures the illness itself! Most often the focus of treatment was to undo the damage done by the “schizophrenigenic mother” whose style of communicating emotion produced schizophrenia. I learned the second lesson years later from the doctor who first diagnosed my brother, Henry with schizophrenia: The only treatment for schizophrenia was antipsychotic medication and “supportive therapy.” At the time, supportive therapy appeared to consist of individual meetings and group therapy aimed at “reality testing” which, to my brother’s ears, sounded a lot like people telling him he was wrong to think the things he did and was “crazy”.
Why the change from psychoanalysis to drugs and reality testing? A 1984 landmark study conducted by Yale psychiatrist Tom McGlashan, MD, and his colleagues at the Chestnut Lodge Research Institute, Rockville, Maryland, a nationally renowned treatment center for schizophrenia at the time, showed that psychoanalysis by no means cured schizophrenia and in most instances offered very little help. Then, in the 1990s, with the National Institute of Mental Health’s (NIMH) announcement of the “Decade of the Brain” research initiative for schizophrenia, inspired in large part by family members working with the National Alliance on Mental Illness (NAMI) together with clinicians and scientists, the pendulum swung the other way. Psychotherapy was bad and pharmacotherapy, or drugs, were good. Obviously this is a gross over simplification, but for many of us that was the view.
Although I was trained in psychoanalytic psychotherapy and used it with many patients, I saw how antipsychotic medicines were lowering—and even eliminating—symptoms of schizophrenia in my brother and others with schizophrenia. I gladly joined the chorus of well-intentioned family members, doctors, and researchers who preached that antipsychotic drugs were the key to stabilization and recovery and that there was little or no room for psychotherapy, which promised more harm than good. In retrospect, we threw the baby out with the bath water.
Fortunately, a group of researchers in the United Kingdom came to the attention of Aaron T. Beck, MD, the father of cognitive therapy, from the University of Pennsylvania, and together they began a yearly meeting of scientists studying cognitive therapy in patients with schizophrenia. In June, 2009, I attended their 10th anniversary meeting at the University of Pennsylvania School of Medicine. Although one of my colleagues and I had written a review paper some years before concluding that CBT had many positive applications for persons with schizophrenia, the conference helped to cement and expand this view. Here are some of the lessons I have learned from the conference and the research literature.
The good thing about psychotherapy
First the bad news: The consensus from the conference seemed to be that CBT was not particularly effective in treating negative symptoms (which include blank looks, monotone and monosyllabic speech, few gestures, lack of interest in events or people, and lack of joy or spontaneity). Also, in the United States it is rarely offered, whereas in the United Kingdom it is commonplace. The good news is that research conducted since our last review of the literature in 2001 indicates that CBT is effective in treating some positive symptoms of schizophrenia (positive symptoms include hallucinations, delusions, and thought disorder). Hallucinations, in particular, appear to be helped with CBT.
In our 2001 review of the literature, Anna Seckinger, PhD, and I found that poor insight and nonadherence to medication were common and problematic areas that present major stumbling blocks in the treatment of patients suffering from schizophrenia and that CBT and interventions derived from approaches such as Motivational Interviewing improve some aspects of insight into illness, increase adherence to medication, ameliorate the severity of hallucinations and sometimes delusions, and help with other negative consequences of schizophrenia. The papers presented in 2009 at the 10th Anniversary Conference on CBT in Schizophrenia reaffirmed the main findings of our earlier review.
Also in a 2009 study published in The British Journal of Psychiatry, the authors found that compared to a control therapy, CBT was superior at reducing incidents of aggression in patients with a history of aggression and violence and was superior at reducing delusion severity and decreasing risk management. Furthermore, the treatment was acceptable to the majority of individuals; dropout rates from CBT therapy were much lower than dropout rates from the control therapy.
Finally, a review of 20 years of psychosocial research aimed at improving medication adherence, published in The American Journal of Psychiatry in 2002 (to view the article visit Contact LEAP Institute and click on ‘Review Paper’) found that only those programs that included elements of Motivational Interviewing were effective in helping motivate persons with schizophrenia to accept treatment and stick with it.
Why psychotherapy is rarely offered
Despite all the evidence—and even more data for the effectiveness of CBT for treating other disorders common in schizophrenia like mood and anxiety disorders—the overwhelming majority of persons with schizophrenia in North America have never been offered a course of treatment with CBT or related therapies (such as LEAP: Listen-Empathize-Agree-Partner).
I think this is for two reasons. First, there is no schizophrenigenic mother. Unfortunately most clinicians still feel guilt for believing, or being part of a field that once believed, that bad parenting caused schizophrenia. To them I say: “Get over it, none of us meant to do any harm, we were simply ignorant and stuck in a particular theory that had never been tested.” Second, schizophrenia is indeed a brain disorder. The research conducted during the “Decade of the Brain” and after revealed that fact unequivocally. Consequently consumers, relatives, mental health professionals, and policy makers, tend to focus on the brain forgetting that the brain resides in a human being. Meanwhile, we have never had a multibillion dollar industry promoting consumer and professional education about psychotherapy for schizophrenia. But we have had such deep pockets educating us about the benefits of antipsychotic medicines. This is not a criticism—it is a simple incontrovertible truth.
So it is up to us to become educated about psychotherapies that have been studied and shown to be effective, and up to us to see that both private and public funds are directed toward training the professionals needed to deliver these therapies and make them available in our communities. I don’t find this task daunting or impossible because I have already seen much progress made since I opened my first book about schizophrenia and since my brother’s first episode of illness.
For more information on CBT for persons with schizophrenia see:
www.BeckInstitute.org - Home and LEAP Institute
Xavier Amador, PhD, (Dr. Xavier Amador) an adjunct professor at Columbia University and the author of numerous scholarly and trade publications, including the national bestseller I am Not Sick, I Don’t Need Help (Vida, 2000) is a regular columnist for SZ Magazine.
Last edited:
