The treatment of schizophrenia is typically confinded to pharmacological treatments alone. However, a number of nonpharmacological treatments can also be used to assist in the recovery and management of schizophrenia and associated symptoms. These techniques have a significant amount of empirical support, particulalry in the United Kingdom and the United States but are rarely used in Australia. The approach is a challenge but significant improvements in the well being and level of functioning in patients can be obtained.

BPG offers an innovative approach to the treatment of schizophrenia by addressing arousal abnormalities, cognitive (thinking) abnormalities and attention - discrimination abnormalities.

The first step in this process is a comprehensive brain function and cognitive assessment. Once the patients profile of strengths, weaknesses and deficits have been obtained, specific remediation techniques are then selected and carried out. Further details of some of the techniques used by BPG are discussed below.

The National Institute for Clinical Excellence has issued clinical guidelines for schizophrenia (NICE, 2002) , which specify that cognitive behavioural therapy (CBT) should be offered to all patients, especially those with persistent positive and negative symptoms (Kuipers, 2005) . At least 10 therapy sessions should be offered, over a minimum of 6 months.

Meta-analyses have demonstrated the efficacy of CBT in schizophrenia and its usefulness in conjunction with medication and other standard treatments (Dickerson, 2000; Kingdon & Hansen, 2004; Kuipers, 2005; Tarrier & Wykes, 2004; Warman & Beck, 2003; Zimmermann et al., 2005) . This is particularly the case for patients who remain asymptomatic despite medication or are noncompliant with medications (Butler et al., 2006; Haddock et al., 1997; Kingdon & Hansen, 2004; Zimmermann et al., 2005) . Although cognitive behavioural therapy for schizophrenia has become popular in the United Kingdom, it has received relatively little attention in the United States (Warman & Beck, 2003) .Therefore, there is also a relative unfamiliarity of this technique for schizophrenia amongst clinicians in Australia.

Randomized controlled clinical trials of CBT have demonstrated that schizophrenic patients who receive CBT as an adjunctive treatment to medication do significantly better than those who receive routine care only (Warman & Beck, 2003) . This is particularly the case for providing immediate relief from positive symptoms (Warman & Beck, 2003) .

Recent meta-analyses of CBT for schizophrenia determined that effect sizes for CBT were large, and that these gains were maintained over follow-up periods; improvements were found for both positive and negative symptoms, both at posttreatment and at follow-up (Butler et al., 2006; Dickerson, 2000; Warman & Beck, 2003) .

Gould et al. (2001) using results from seven controlled trials (340 subjects) of CBT for schizophrenia, performed a meta-analysis on the effects of CBT on psychotic symptoms. The intervention consisted of targeted CBT strategies for modifying patients' distorted beliefs about delusions and hallucinations so as to decrease the negative consequences of these symptoms on their daily functioning. They found a large effect size for reduction in psychotic symptoms between pre- and post-treatment (mean ES = 0.65). Follow-up analyses in four studies indicated that patients receiving CBT continued to make gains over time (ES=0.93). Of the seven studies, five reported relatively large effect sizes (ES=0.48 to 1.26) for relief in psychotic symptoms between the control and treatment conditions at post-treatment. The remaining two studies found relatively smaller effect sizes of 0.2 to 0.37. The mean number of treatment sessions was fourteen with a range of five to twenty. All studies focused on modifying beliefs about delusions and hallucinations in order to decrease the impact that these phenomena had on patients' lives. Interestingly, the study with the largest effect size used combined individual and group therapy.

In the studies examined, therapists used a collaborative process in which they worked closely with a patient to understand the delusions or hallucinations from his/her perspective. They often employed specific strategies such as identifying cognitive errors, Socratic questioning, acting on beliefs to test their validity, and seeking the assistance of others in collecting disconfirming evidence for their beliefs. Therapists also frequently used a hierarchical approach to change delusions by starting with the least strongly held beliefs and then progressing to more firmly held beliefs.

Conventional wisdom has held that patients with schizophrenia are not amenable to CBT because of psychosis, cognitive impairment, and the lack of insight that often accompanies it. Clearly, this is not the case (Gould et al., 2001) . However, it remains to be determined which patients are most able to benefit from CBT.

The following sections provide an overview of the therapeutic strategies for cognitive behavioural therapy for schizophrenia as described in references (Goldberg et al., 2007; Morrison & Renton, 2001; Warman & Beck, 2003) .

Therapeutic Alliance and Empathy

Generally, the difficulty therapists face with schizophrenia patients is the building of a therapeutic alliance with an individual who is generally paranoid and distrustful.

Identification of Hallucinations and Stressors

Identification of situations or stressors that may induce hallucinations is a critical part of cognitive behavioural therapy. Once both internal (thoughts) and external triggers are identified the therapist can begin teaching the patient skills and techniques to address the problematic thoughts and behaviours.

Normalising

The technique of normalising addresses the cognitive distortion of all-or-nothing thinking, or the view of experiences as being a categorical “normal” or “abnormal”. Hallucinations are challenged by teaching the patients that they are a relatively common experience that falls on a continuum, rather than a categorical dimension. In addition, the route to experiencing the hallucination such as stressors (e.g., sleep deprivation) are identified and highlighted. This is aimed at normalising the experience and reducing the typical frightful and anxious reaction. This framework can help the patient deal with such symptoms in a noncatastrophizing manner, by viewing voices as a symptom that may be related to stress or some other trigger rather than a psychotic abnormality.

Another aspect of normalising is to teach the patient to make a hypothesis regarding their interpretation of a situation. Generally, due to the confusing and ambiguous nature of hallucinations this can be particularly difficult. However, patients are taught to consider why a certain situation or environment may be leading to their experience. For example, stating, “It must be strange to have a lot of people you don't know entering your room. That would make me nervous, too.”

Thus, using a normalizing rather than a pathologizing framework can both facilitate therapeutic work with patients and help patients gain perspective on their symptoms.

Collaboration and Hypothesis Testing

Confrontational techniques with schizophrenic symptoms have not been demonstrated as useful. However, careful collaboration with the patient regarding their hypotheses about a situation and careful consideration of alternatives is found to be more successful. Patients are taught how to examine which of the hypotheses fits as the best explanation. For example, if a patient stated that he believed his voices to be the voices of spirits. Rather than telling him that was not the case, the therapist discusses this as one plausible hypothesis. After which, the alternative hypothesis of voices being hallucinations is presented.

Reality Testing for Delusions

‘Reality testing' involves making links between the thoughts, feelings, actions and relevant factors with the patient exploring their understanding of their beliefs and beginning to reason with them. This can assist in modifying some beliefs held with limited conviction, but often this process simply involves a development of the assessment and engagement with the individual (Kingdon & Hansen, 2004) .

Hallucinations

Work with hallucinations – usually voices or visions – involves:

•  Identifying and agreeing about the individual's experience: e.g. ‘is it like me speaking, or shouting at you?'

•  Reviewing beliefs about the origin of the voices or visions: ‘why do you think other people don't share your experience?' ‘Where do you think the visions/voices come from?'

•  Introducing normalizing information about situations which can induce hallucinations, e.g. sleep deprivation, traumatic events: ‘is it like dreaming – a nightmare?'

•  aiming to assist in appropriate attribution of voices – i.e. they are generated by the mind

•  working with the content of the voices/visions; linking to initial experience and to formulation; discussing statements made and debating how true or not they are and reasons to act on them or not: e.g. ‘you're useless', ‘take an overdose'

•  Exploring current coping mechanisms and developing these further.

Working with Negative Symptoms

The evidence for the effectiveness of cognitive therapy for negative symptoms is well supported in the literature and clinical experience (Beck, 2005) . The cognitive model conceptualizes negative symptoms as having a variety of causes. Secondary negative symptoms from depression and medication side-effects (especially sedation and bradykinesia) require attention; primary symptoms need understanding (Kingdon & Hansen, 2004) .

Work with negative symptoms involves the following.

•  The patient and carers should aim first at ‘rest and relaxation', ‘convalescing' or ‘taking a year out' so that anxiety decreases, mood improves and motivation begins to return.

•  Once the person feels more comfortable and is beginning to rediscover some motivation, goals are set which are simple and achievable: e.g. getting up to make a cup of tea in the morning, going to the shop for cigarettes.

•  Long-term goals (in 5 or 10 years' time) may be needed to provide hope for the future and targets to aim for (e.g. being back at college or university, having a partner), but the emphasis is on doing simple, achievable things now. Paradoxically, patients and carers may be encouraged to do less, on the basis that feeling relaxed and comfortable is the first goal.

Behavioural Experiments

The purpose of behavioural experiments is to design a task which tests a patient's belief and are designed to answer a patient's questions. In such tasks patients generally gather evidence to support or disconfirm a question.

Understanding the Meaning of Patients' Delusions

If is often useful to look for the underlying theme or cause of a patients' delusions or beliefs. This may relate back to early experiences that lead to the development of a dysfunctional schema or core belief. Often if these early developmental dysfunctions can be addressed the severity of the delusion can be reduced and the resulting discomfort mediated (Kingdon & Hansen, 2004; Warman & Beck, 2003) .

Role-Plays and Imagery

As with many other psychiatric conditions, role plays or imaginary techniques can be helpful with formulating behavioural experiments and hypothesis testing. This is aimed at building skills that the patient can then apply “in situ”.

Imagery may also be used to help a patient learn to cope with a delusional or hallucinatory experience that he or she may experience.

Cognitive Remediation Therapy

Cognitive Remediation Therapy (CRT) or cognitive enhancement therapy (CET) is a promising new treatment designed to improve neurocognitive abilities such as attention, memory and executive functioning (Bellack et al., 1999; Hogarty et al., 2004; Krabbendam & Aleman, 2003; Penades et al., 2006; Silverstein & Wilkniss, 2004; Twamley et al., 2003) . Its development has partly arisen from cognitive remediation work in the area of traumatic brain injury (Hogarty et al., 2004) . It's use in patients with schizophrenia has followed a reduction in the use of psychotropic medications by as much as 42% (Hogarty et al., 2004) . Two meta-analyses have recently been conducted (Krabbendam and Aleman, 2003 and Twanley et al., 2003) showing that the effect sizes of the trials are approximately intermediate and that they differed slightly over the different studies (Penades et al., 2006) .

In the study by Penades et al. (2006) a total of 40 chronic patients with schizophrenia were randomly assigned for 4 months to one of two treatment groups: CRT or CBT. Results showed that CRT produced an overall improvement on neurocognition (Mean effect size = 0.5), particularly in verbal and nonverbal memory, and executive function. CBT showed the expected treatment effect on general psychopathology (anxiety and depression) but produced only a slight non-specific improvement in neurocognition (Working Memory). Furthermore, patients receiving CRT showed improvement in social functioning, demonstrating that cognitive improvements are clinically meaningful. These gains were still present at the 6 month follow-up.

CRT can be implemented using paper and pencil tasks and is described in a frontal/executive program by Delahunty and Morice (1996) , the cognitive enhancement program by Hogarty and Flesher (1999a; 1999b) and a cognitive remediation program by van der Gaag et al. (2002) . CET also often combines approximately 75 hours of progressive software training exercises in attention, memory, and problem solving with 1.5 hours per week of social cognitive group exercises (Hogarty et al., 2004) . Other CET techniques utilise a number of computer aided cognitive learning tasks (Kurtz et al., 2007; Wykes & van der Gaag, 2001) .

In general, an errorless learning approach is adopted in tasks of progressive complexity set at the subject's own pace. The main instructional technique uses scaffolding. This involves an instructor extending a learner's ability by providing support in those aspects of a task which the learner cannot accomplish, while removing assistance in those areas where competence has been achieved. Patients receive 40 sessions; 1-h sessions two or three times a week over 4 months. The “Cognitive Shift Module” aims to address flexibility in thinking and information-set maintenance both of which presumably require the capacity to effectively engage and disengage activated neural network processing. The “Working Memory Module” aims to target the executive processes central to memory control, and has patients work with as many as two to five information sets at a time. The primary target of the “Planning Module” is self-ordered, goal-oriented, set/schema formation and manipulation, that is, the application of the practiced processes, such as Working Memory, to tasks requiring planning (Penades et al., 2006) .

Attention Training plus CBT

Attentional and discrimination abnormalities are common in schizophrenia and are thought to reflect important vulnerabilities that need to be addressed.

As described above a number of remedial techniques have been devised to improve attention processing and stimulus discrimination in schizophrenia. A more recent method ATT is described below.

Attention Training (ATT) aims to correct attentional biases by enhancing the meta-cognitive control of attention. Patients are asked to practice auditory attentional exercises (selective attention, attention switching, and divided attention), not for the purpose of distraction but to enable them to stop the self-focusing process proposed by the Self-Regulatory Executive Function model (S-REF) model. Self-regulatory processing plays a crucial role in the formation of cognitions and beliefs as it is involved in appraising the personal significance of external events, body signals, and thoughts. ATT therefore intervenes in the attentional syndromes underlying the maintenance of positive symptoms in schizophrenia (Valmaggia et al., 2007; Wells, 2007) .

In each session patients are asked to focus and maintain their attention on up to five different auditory stimuli in the room (such as ticking of a clock, clicking of a pen, the noise of the computer). Next, they are asked to focus on noises outside the room that are more remote and therefore harder to keep focused on (such as cars on the street or footsteps in the corridor). Once patients have learned to focus their attention on one noise at a time, they are asked to switch their attention to different noises. After that they practice dividing their attention—attending to different noises at the same time. When a certain level of mastery over attention is achieved after practicing with neutral auditory stimuli, the therapist asks the patients to approach their specific problematic stimuli (such as worrying, ruminations, bodily sensations, or, as in the present case, voices) as they would do with any other sound. In the case of voices, patients are instructed to focus on the auditory hallucinations first, to then switch their attention between the voices and other noises and to divide their attention between the voices and other sounds. This type of exercises is assumed to modify the self-regulatory processes and to create new processing configurations that lead to the formation of new beliefs about the symptoms (Valmaggia et al., 2007) .

Currently there are growing applications of neurofeedback (NF) that show that patients have benefited by learned self-control of EEG parameters, particularly in the case of attention deficit disorders (Fuchs et al., 2003; Johnstone et al., 2005; Lubar et al., 1995; Lubar, 1997; Rossiter, 2004) . These patients have experienced a normalisation of their attentional deficits and improvement in their global cognitive function and impulsive behaviours. Other areas of application include substance abuse, depression, anxiety, PTSD, irritability, stroke and traumatic brain injury (Bearden et al., 2003; Gruzelier & Egner, 2005; Johnstone et al., 2005; Raymond et al., 2005; Rozelle & Budzynski, 1995; Thatcher, 2000; Thornton, 2000) .

NF techniques have also been found facilitate cognitive performance and enhance attention in healthy subjects (Egner & Gruzelier, 2001; Egner & Gruzelier, 2004; Vernon et al., 2003) .

The use of NF in schizophrenia is still in its relative infancy with few studies (Gruzelier et al., 1999) . However, the efficacy of this method in significant number of clinical and healthy subjects for improving cognition and normalising attentional deficits suggests it may present as a potential method for many schizophrenic patients and deserves further study and trial.

	Read an overview about our treatment options.
	Read about our personalized medicine approach for brain injury.
	Read some of our case examples on schizophrenia.
	Look at some of our scientific publications on schizophrenia.

Bearden, TS, Cassisi, JE, and Pineda, M (2003). Neurofeedback Training for a Patient with Thalamic and Cortical Infarctions. [Article]. Applied Psychophysiology & Biofeedback , 28 , 241-253.

Beck, AT (2005). The Current State of Cognitive Therapy: A 40-Year Retrospective. Arch Gen Psychiatry , 62 , 953-959.

Bellack, AS, Gold, JM, and Buchanan, RW (1999). Cognitive Rehabilitation for Schizophrenia: Problems, Prospects, and Strategies. Schizophr Bull , 25 , 257-274.

Butler, AC, Chapman, JE, Forman, EM, and Beck, AT (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review , 26 , 17-31.

Delahunty, A and Morice, R (1996). Rehabilitation of frontal/executive impairments in schizophrenia. Australian and New Zealand Journal of Psychiatry , 30 , 760-767.

Dickerson, FB (2000). Cognitive behavioral psychotherapy for schizophrenia: a review of recent empirical studies. Schizophr Res , 43 , 71-90.

Egner, T and Gruzelier, JH (2001). Learned self-regulation of EEG frequency components affects attention and event-related brain potentials in humans. Neuroreport , 12 , 4155-4159.

Egner, T and Gruzelier, JH (2004). EEG Biofeedback of low beta band components: frequency-specific effects on variables of attention and event-related brain potentials. Clinical Neurophysiology , 115 , 131-139.

Fuchs, T, Birbaumer, N, Lutzenberger, W, Gruzelier, JH, and Kaiser, J (2003). Neurofeedback Treatment for Attention-Deficit/Hyperactivity Disorder in Children: A Comparison with Methylphenidate. Applied Psychophysiology and Biofeedback , 28 , 1-12.

Goldberg, JO, Wheeler, H, Lubinsky, T, and Van Exan, J (2007). Cognitive Coping Tool Kit for Psychosis: Development of a Group-Based Curriculum. Cognitive and Behavioral Practice , 14 , 98-106.

Gould, RA, Mueser, KT, Bolton, E, Mays, V, and Goff, D (2001). Cognitive therapy for psychosis in schizophrenia: an effect size analysis. Schizophr Res , 48 , 335-342.

Gruzelier, J and Egner, T (2005). Critical validation studies of neurofeedback. Child & Adolescent Psychiatric Clinics of North America , 14 , 83-104.

Gruzelier, J, Hardman, E, Wild, J, and Zaman, R (1999). Learned control of slow potential interhemispheric asymmetry in schizophrenia. Int J Psychophysiol , 34 , 341-348.

Haddock, G, Hopkins, R, Tarrier, N, Morrison, T, and Lewis, S (1997). Intensive cognitive-behavioural therapy for recent onset schizophrenia: a pilot study. Schizophr Res , 24 , 223.

Hogarty, GE and Flesher, S (1999a). Developmental Theory for a Cognitive Enhancement Therapy of Schizophrenia. Schizophr Bull , 25 , 677-692.

Hogarty, GE and Flesher, S (1999b). Practice Principles of Cognitive Enhancement Therapy for Schizophrenia. Schizophr Bull , 25 , 693-708.

Hogarty, GE, Flesher, S, Ulrich, R, Carter, M, Greenwald, D, Pogue-Geile, M, Kechavan, M, Cooley, S, DiBarry, AL, Garrett, A, Parepally, H, and Zoretich, R (2004). Cognitive Enhancement Therapy for Schizophrenia: Effects of a 2-Year Randomized Trial on Cognition and Behavior. Arch Gen Psychiatry , 61 , 866-876.

Johnstone, J, Gunkelman, J, and Lunt, J (2005). Clinical database development: characterization of EEG phenotypes. Clinical EEG & Neuroscience , 36 , 99-107.

Kingdon, D and Hansen, L (2004). Cognitive therapy for psychosis. Psychiatry , 3 , 45-48.

Krabbendam, L and Aleman, A (2003). Cognitive rehabilitation in schizophrenia: a quantitative analysis of controlled studies. Psychopharmacology , 169 , 376-382.

Kuipers, E (2005). Pathways to psychological treatments for psychosis. Psychiatry , 4 , 40-42.

Kurtz, MM, Seltzer, JC, Shagan, DS, Thime, WR, and Wexler, BE (2007). Computer-assisted cognitive remediation in schizophrenia: What is the active ingredient? Schizophr Res , 89 , 251-260.

Lubar, JF (1997). Neocortical Dynamics: Implications for Understanding the Role of Neurofeedback and Related Techniques for the Enhancement of Attention. [Article]. Applied Psychophysiology & Biofeedback , 22 , 111-126.

Lubar, JF, Swartwood, MO, Swartwood, JN, and O'Donnell, PH (1995). Evaluation of the effectiveness of EEG neurofeedback training for ADHD in a clinical setting as measured by changes in T.O.V.A. scores, behavioral ratings, and WISC--R performance. Biofeedback & Self Regulation , 20 , 83-99.

Morrison, AP and Renton, JC (2001). Cognitive therapy for auditory hallucinations: A theory-based approach. Cognitive and Behavioral Practice , 8 , 147-160.

NICE. National Institute for Clinical Excellence., Guidance on the Use of Newer (Atypical) Antipsychotic Drugs for the Treatment of Schizophrenia. Technology Appraisal 43. 2002. London, NICE.
Ref Type: Electronic Citation

Penades, R, Catalan, R, Salamero, M, Boget, T, Puig, O, Guarch, J, and Gasto, C (2006). Cognitive Remediation Therapy for outpatients with chronic schizophrenia: A controlled and randomized study. Schizophr Res , 87 , 323-331.

Raymond, J, Varney, C, Parkinson, LA, and Gruzelier, JH (2005). The effects of alpha/theta neurofeedback on personality and mood. Cognitive Brain Research , 23 , 287-292.

Rossiter, T (2004). The Effectiveness of Neurofeedback and Stimulant Drugs in Treating AD/HD: Part II. Replication. Applied Psychophysiology and Biofeedback , 29 , 233-243.

Rozelle, GR and Budzynski, TH (1995). Neurotherapy for stroke rehabilitation: a single case study. Biofeedback & Self Regulation , 20 , 211-228.

Silverstein, SM and Wilkniss, SM (2004). At Issue: The Future of Cognitive Rehabilitation of Schizophrenia. Schizophr Bull , 30 , 679-692.

Tarrier, N and Wykes, T (2004). Is there evidence that cognitive behaviour therapy is an effective treatment for schizophrenia? A cautious or cautionary tale? Behaviour Research and Therapy , 42 , 1377-1401.

Thatcher, RW (2000). EEG operant conditioning (biofeedback) and traumatic brain injury. Clin Electroencephalogr , 31 , 38-44.

Thornton, KP (2000). Improvement/Rehabilitation of Memory Functioning with Neurotherapy/QEEG Biofeedback. Journal of Head Trauma Rehabilitation , 15 , 1285-1296.

Twamley, EW, Jeste, DV, and Bellack, AS (2003). A Review of Cognitive Training in Schizophrenia. Schizophr Bull , 29 , 359-382.

Valmaggia, LR, Bouman, TK, and Schuurman, L (2007). Attention Training With Auditory Hallucinations: A Case Study. Cognitive and Behavioral Practice , In Press .

van der Gaag, M, Kern, RS, van den Bosch, RJ, and Liberman, RP (2002). A Controlled Trial of Cognitive Remediation in Schizophrenia. Schizophr Bull , 28 , 167-176.

Vernon, D, Egner, T, Cooper, N, Compton, T, Neilands, C, Sheri, A, and Gruzelier, J (2003). The effect of training distinct neurofeedback protocols on aspects of cognitive performance. Int J Psychophysiol , 47 , 75-85.

Warman, DM and Beck, AT (2003). Cognitive behavioral therapy for schizophrenia: An overview of treatment. Cognitive and Behavioral Practice , 10 , 248-254.

Wells, A (2007). The Attention Training Technique: Theory, Effects, and a Metacognitive Hypothesis on Auditory Hallucinations. Cognitive and Behavioral Practice , In Press .

Wykes, T and van der Gaag, M (2001). Is it time to develop a new cognitive therapy for psychosis - cognitive remediation therapy (CRT)? Clinical Psychology Review , 21 , 1227-1256.