Reviewed by Richard Evans, M.D.
As an indication of how far our understanding has come since I started practicing psychiatry, I want to begin with the authors' premise: "It is possible to ameliorate the major symptoms (in schizophrenia) by activating higher cognitive functions such as distancing from dysfunctional interpretations, evaluating the evidence and exploring alternative explanations."
This bold idea, supported by thirty years of clinical experience in the United States and England, would have been impossible in the 1970s when psychotherapy for treating the psychoses lost credibility. While Beck (the founder of CBT) had written a paper describing the effective use of CBT with a patient with schizophrenia as early as 1952, this had little impact. Schizophrenia was thought to be incurable, even for those discharged from hospitals, and rarely treated successfully in the community.
Even recently, few could have imagined that psychotherapy, or its later manifestation in cognitive behavioral therapy (CBT), could offer a theoretical model accompanied by techniques for treating schizophrenia. This book changes the picture while it fully elaborates the model and techniques for both the beginner and veteran therapist.
Cognitive therapy has been criticized as a set of techniques without a theory. This book belies that criticism while it provides an integrated model of schizophrenia as a neurobiological vulnerability which can lead stress-induced experiences that culminate in psychosis. It also challenges the notion that "the pathogenic beliefs are fixed because of their neural basis. . .[C]ognitive therapy taps into patient's cognitive reserve by activating alternate brain structures or networks that are not ordinarily engaged." In other words, with support, effort and selected techniques people with schizophrenia become able learn new patterns of thinking.
The many pathways leading to cognitive impairments and "biases" that underlie thought disorganization -- referential thinking, delusions and other misappraisals of reality -- are detailed. Given the vast heterogeneity in histories of those who develop psychosis it is wise to consider multiple "pathways" instead of a uniform cause. A psychotic episode may be preceded by heavy drug use in a susceptible, socially anxious or depressed adolescent. Another may have been diagnosed with Asperger's syndrome or experienced childhood trauma. Often there are neurocognitive impairments in attention, working memory and executive functions, as well as episodes of major depression or severe social anxiety. Some, without extraordinary stress beyond a first time away from home at college, develop early symptoms, become suspicious, withdrawn and slip into psychosis. In some is found a history of schizotypal (odd or eccentric)) thinking. And in a few there is a family history of psychosis.
For the vulnerable individual, any of these pathways can lead to the events that are finally expressed as a major neurobiological upheaval. While for the past fifty years there has been focus upon increased dopamine expression in the striatum as the central neurobiological event in psychosis, we now realize that other neurotransmitters (such as glutamate) and brain areas are involved. In fact, current neuroscientific evidence strongly suggests that schizophrenia involves brain-wide disruption of connectivity, explaining why so many areas and functions are involved.
While these complexities are still under investigation, the model Beck, et. al., present attempts to bridge what is known about brain disturbance and the cognitive disabilities (problems with effort, attention, working memory and executive functions such as planning) that underlie symptom formation. Here we meet the CBT working model of thought disorder in schizophrenia. As is stated, "A crucial factor in the progression to psychosis is the development of dysfunctional cognitive schemas that facilitate the onset of aberrant experiences such as hallucinations and delusions."
What are the inner workings of this "progression"? Remaining for a moment on the neurobiological side of the model, we presume that multiple neurotransmitter disturbances (in at least frontal and temporal cortices) give rise to anomalous, often threatening, perceptual events that are interpreted in a manner which seriously challenge the sense of personal agency. The attribution of internally generated voices to external sources ("They are calling me stupid") in one who is already prone to self-criticism moves into a downward spiral. These internal experiences gain strong emotional salience and finally lead to a devastating sense of powerlessness, of being prey to outside forces.
The cognitive therapist encounters a patient whose experiences are considered deviant, whose beliefs are dysfunctional and who carries a sense of profound demoralization. Cognitive therapy meets this challenge with a theoretical model and a set of techniques. Considering these takes us to the heart of the book.
While all positive and negative symptoms are covered, CBT is well elaborated and defined in its approach to delusional thinking. The model suggests a number of complex preconditions for the development of delusions: the underlying biological vulnerability to stress noted above, traumatic or stressful life experiences and most important a set of preexisting cognitive tendencies such as: externalization (believing that all outcomes are determined by factors outside the self); catastrophizing (assuming the worst possible outcome); misattributions (attributing incorrect motives and intents to others); jumping to conclusions; overgeneralization (exemplified by the use of "all" and "never"); and easy suspicion along with a strong tendency to slip automatically into these patterns at times of stress. Into this mix, at the time of upheaval, appear the anomalous perceptual experiences (such as hearing voices) that lead to delusions of external influence. Whether persecutory or grandiose, these beliefs become "hyper-salient" and come to dominate cognition.
A most helpful way of assessing these beliefs is to explore the degree of conviction with which it they are held. This dimension is illuminated in Beck's Cognitive Insight Scale,(found in the appendix). It is a series of fifteen statements reflecting the balance between certainty about beliefs and capacity for self-reflection. Statements such as, "My interpretations of my experiences are always right," or "If someone points out that my beliefs are wrong I am willing to consider it" are scored on a numerical scale. Clinical progress can be seen as an increase of "self reflection" over certainty regarding delusional beliefs. This is a selective process since there are obviously functional beliefs which may be held with conviction.
Modifying psychotic thinking does not come easily and requires a collaborative effort from a therapist and patient that includes mutually endorsed goals, guided discovery, the firm challenging of automatic responses (such as jumping to conclusions or attributions of malevolent intent), offering of alternative perspectives, searching for new evidence and recommending between session behavioral "experiments." Personal history, which plays a role both in the genesis of the content of delusions and their perpetuation, is considered.
Beyond these specifics, and of prime importance, CBT offers a language (of "normalizing explanations") for the therapeutic dialogue that can effect a human reconnection for those who experience themselves as deviant, powerless and excluded. For who among us, at moments of stress, has not jumped to conclusions, imagined the worst, or cast a suspicious eye and then made the effort to overcome these automatic responses? Thus CBT calls upon the "cognitive reserves" of us all.
In summary, this book is a thoughtful, well-documented attempt to provide both a theoretical rationale and a set of useful tools for the therapeutic encounter with a still mysterious and troubling illness. Small wonder that in both the United States (Schizophrenia Patient Outcome Research Team, 2009)) and England (National Institute for Clinical Excellence, 2002) CBT is clearly recommended in the treatment in schizophrenia.
Richard Evans, M.D.
Great Barrington, Mass.
Dr. Richard Evans is the Director of Mental Health Services at Volunteers in Medicine (VIM), Great Barrington, Mass., and a staff psychiatrist at Gould Farm, Monterey, Mass. He has been on the faculties of the departments of psychiatry at Einstein College of Medicine, and Columbia Presbyterian Hospital. He is a recipient of the NAMI Exemplary Psychiatrist award.