Cognitive-Behavioural Therapy for Severe Mental Disorders
Rector, Neil A., Canadian Journal of Psychiatry
Over 4 decades, ago Aaron T Beck presented the basic theoretical and treatment approach of cognitive-behavioural therapy (CBT). Since then, hundreds of randomized controlled clinical trials (RCTs) have demonstrated the efficacy of CBT for the broad range of psychiatric conditions, including severe mental disorders such as bipolar disorder, refractory obsessive-compulsive disorder (OCD), substance abuse, suicide, personality disorders, and schizophrenia. Increasingly, we see the integration of CBT with biological psychiatry resulting in optimized treatment outcomes. This may be no better illustrated than in the recent efforts to develop and test cognitive and behavioural interventions for patients experiencing persistent symptoms of psychosis with only partial response to pharmacologic interventions. Although it has been noted that, as late as the 1980s, schizophrenia was the "forgotten child of behaviour therapy" (1), significant developments in the use of CBT for medicationresistant symptoms in schizophrenia have occurred over the past 15 years.
The CBT treatment approach to schizophrenia has been detailed in several step-by-step treatment manuals. Typically, it includes the following therapeutic goals: 1) the establishment of a solid therapeutic alliance; 2) psychoeducation, within a biopsychosocial model, about the nature of psychosis; 3) reducing stigma and normalizing the symptoms of psychosis; 4) delivering cognitive and behavioural interventions to reduce the occurrence and distress associated with delusions and hallucinations; 5) reducing comorbid anxiety and depression; and 6) reducing relapse. Considerable scientific support now exists for the efficacy and effectiveness of CBT in schizophrenia: metaanalyses of RCTs conducted on CBT have concluded that CBT effectively treats the positive symptoms of schizophrenia, reduces relapse, and enhances recovery during the acute phase (2-5). These positive findings have led to the inclusion of CBT in prominent expert treatment guidelines for schizophrenia-among others, the American Psychiatric Association's treatment guidelines for schizophrenia (6) and the core interventions for schizophrenia published by the UK National Institute for Clinical Excellence (7). In the UK, CBT has not only been integrated into routine clinical care in the National Health Service, it has also become a mandated treatment for all patients diagnosed with schizophrenia.
Efforts to date have focused on developing cognitivebehavioural treatments for such perceptual distortions as auditory hallucinations and aberrant thought processes (that is, delusions); however, we need to better understand and develop psychological treatments for the condition's other debilitating and frequently medication-refractory symptoms, such as negative symptoms and poor social functioning. In this issue, 2 papers attempt to address the cognitive conceptualization and treatment of emotional, social, and behavioural disengagement in schizophrenia. In the first paper, my coauthors (Aaron Beck and Neal Stolar) and I offer a cognitive perspective on the psychological components that contribute to persistent and periodic exacerbation of negative symptoms (8). Preliminary experimental evidence and the detailing of patient accounts in cognitive therapy lead us to propose that, in addition to the primary role of neurobiological vulnerabilities in the production of negative symptoms, a patient's chronic mental set, characterized by negative expectancies and dysfunctional performance beliefs, contributes to the particular expression and, in some instances, the persistence of negative symptoms. …