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,
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
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,
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 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.
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.
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' 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) .
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,
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.
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
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) .
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
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 (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) .
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.
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) . Biofeedback/Neurotherapy
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) .
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.
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 ,
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 ,
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 ,
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 ,
Hogarty, GE and Flesher, S (1999b). Practice Principles of
Cognitive Enhancement Therapy for Schizophrenia. Schizophr Bull , 25 ,
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 ,
Kingdon, D and Hansen, L (2004). Cognitive therapy for psychosis. Psychiatry , 3 ,
Krabbendam, L and Aleman, A (2003). Cognitive rehabilitation
in schizophrenia: a quantitative analysis of controlled studies. Psychopharmacology , 169 ,
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 ,
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 ,
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 ,
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 ,
Silverstein, SM and Wilkniss, SM (2004). At Issue: The Future
of Cognitive Rehabilitation of Schizophrenia. Schizophr Bull , 30 ,
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 ,
Thatcher, RW (2000). EEG operant conditioning (biofeedback)
and traumatic brain injury. Clin Electroencephalogr , 31 ,
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 ,
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 ,
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.
Zimmermann, G, Favrod, J, Trieu, VH, and Pomini, V (2005). The effect of
cognitive behavioral treatment on the positive symptoms of schizophrenia spectrum
disorders: A meta-analysis. Schizophr Res , 77 ,