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

Schizophrenia

DSM-5: schizophrenia spectrum is characterized according to the following five areas:

delusions,

hallucinations,

disorganized thinking,

abnormal motor behavior and

negative symptoms.

Negative symptoms include:

a diminished emotional expression,

avolition,

alogia,

anhedonia and

asociality

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,

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).

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

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

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)

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).

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).”

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.

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).

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).

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.

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.

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

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”