Cognitive Group Therapy for Paranoid Schizophrenics: Applying Cognitive Dissonance

Article excerpt

Psychotherapy with paranoid schizophrenics is a hard and often unrewarding task. Individual and group therapies are usually supportive only and are not aimed at changing the paranoid mode of thinking. Although cognitive therapy has been applied in schizophrenic patients, it has not gained wide acceptance.

Cognitive dissonance postulates that individuals experience discomfort and tension when holding two dissonant beliefs simultaneously. We here present the group therapy of six schizophrenic paranoids treated by modified cognitive group therapy implementing cognitive dissonance as the vector of change. A control group of six age- and sex-matched paranoid schizophrenics was treated by supportive group therapy. Analysis of the results, using the Positive and Negative Syndrome Scale (PANSS), during therapy and at follow-up of 4 weeks demonstrates statistically significant improvement in total PANSS score as well as in the positive symptoms subscale.

Group therapies have been used widely with schizophrenic patients. Although many approaches underlie the theoretical basis of such groups (behavioral, insightoriented or psychodynamic), standard psychiatric texts maintain that a supportive approach appears to be the most effective for schizophrenic patients (Gabbard, 1994; Yalom, 1983).

Bloch in 1993 reviewed the current state of cognitive strategies in schizophrenia and stated:"... recent studies have suggested that systematic cognitive interventions aimed at reducing the convictions with which these beliefs (delusions) are held, may be more successful than conventional wisdom would suggest." Further support for this unorthodox approach was supplied by Ferris (1989), who stated that: "It must be emphasized that cognitive psychotherapy can, when used in individual format, represent an answer to the search for a known reductionistic psychotherapeutic approach that takes into account the heterogeneity of the schizophrenic disorders and allows therapists to cope with their complexity"

In the last few years several studies have been published describing the use of cognitive approaches to the treatment of delusional patients. Among these, two studies evaluated the efficacy of individual cognitive psychotherapy in reducing the conviction with which delusional beliefs are held (Chadwick & Lowe, 1990; Kingdom & Turkington, 1991). Lately, our team has published a single case study wherein cognitive dissonance was the tool for inducing change in a schizophrenic patient's paranoid system (Levine, Barak, & Caspi, 1994) and a theoretical model, illustrated by a case report and preliminary results of applying such a model to several additional schizophrenic paranoid patients (Levine, Barak, & Caspi, 1995). These cases, although mainly treated by individual therapy, also made use of group pressure which served as a vehicle enabling the inducement of cognitive dissonance. Although nonsupportive group therapy is not recommended as a mode of therapy in paranoid schizophrenics, this technique was well accepted by the patients.

However, all the above mentioned studies have several drawbacks. No controls were used, selection criteria for entering cognitive treatment were not clearly defined, and no standardized, validated instruments were used for measuring changes in the patients' psychiatric status and/or delusional beliefs. The present study was designed as a controlled study measuring the efficacy of inducing cognitive dissonance in order to change psychotic paranoid ideation. In light of the data gathered from our previous work (Levine, Barak, & Caspi, 1994; 1995), demonstrating patient acceptance of group work within the context of their individual therapy, we applied the above technique in a highly structured group setting with supportive group therapy as a control. The PANSS (Kay, Opler, & Fiszbein, 1990) was used to assess baseline status, change during the procedure and outcome at follow-up. …