The effectiveness of Cognitive Behavioral Therapy (CBT) for schizophrenia is often questioned. CBT is a form of goal-oriented therapy used to improve mental health issues. CBT is also a type of ‘talking therapy’ because it is usually practised in a conversation session. Engagement with CBT is usually on a one-on-one basis or within a group with a professional.

You may have seen some CBT exercises on social media, teaching you how to overcome your fear or anxiety. That is a peek into what CBT is all about. In actual fact, CBT comprises diverse treatment components.

In this post, we will break down everything you need to know about CBT. We will also look through how it can be a part of a holistic schizophrenia treatment plan. But, what’s the history of CBT? Is this some kind of hocus pocus?

Who Developed CBT?

This type of therapy is not new. It was first documented by a psychiatrist, Aaron Beck in the 1960s. While working with his patients, Dr Beck realised the patients often had random negative thoughts.

These negative thoughts which are unreal usually lead to worsening bleakness as they begin to believe in them. The below cognitive triad depicts Dr Beck’s view on how negative emotions build-up:

Uninvited thoughts and beliefs are spontaneous and not real. Through the cycle of thoughts, these beliefs become real. You can’t help it as it becomes a self-fulfilling cycle as the emotions spiral down. That’s when it becomes a strong belief.

This is where CBT steps in to avoid that from happening.

What Is CBT?

CBT is a form of therapy but what does Cognitive Behavioral Therapy really mean? This therapy involves conscious intellectual activity that includes the act of thinking, reasoning, or the constant need to remember to change your behaviour.

According to Dr Beck, CBT relies on the theory that “the way individuals perceive a situation is more closely connected to their reaction than the situation itself”. CBT is there to change the perception so our actions can be positive.

3 Basic Principles Concepts Of CBT

As explained by Dr Alina Gogorian, there are 3 principles or stages which underlie CBT. The example explains how it relates to someone experiencing schizophrenia.

• Core Beliefs/ Schema: These are ideas one have about self or others. These ideas usually stem from young. Eg. “I’m always unlucky.” or “The world is unfair.”
• Intermediate Belief: Attitudes, rules and assumptions usually develop from Core Beliefs. Eg. “Crying is weak.” or “If the voices continue attacking me, I will be crazy.”
• Automatic Negative Thoughts: Random thoughts that appear, when faced with a situation. Eg. When hearing chattering: “They know I have schizophrenia and are laughing at me .”

Dr Beck’s cognitive triad interrelates with the principles or level of cognition.

The last row shows how a negative automatic thought can appear when triggered by a situation. Then, the respective emotion will take place.

How Does CBT Work?

In essence, CBT aims to change the behaviour or emotion. CBT assists in giving a different perception to the thoughts and beliefs one has. It catches the negativity to avoid spiralling down. The focus is on the present and how we can view a situation differently, instead of being trapped in a cycle.

CBT is structured through three pillars – identification, recognition, and management. With CBT sessions, emotions adapt to a more positive tone.

How CBT Works Step-By-Step For A Schizophrenic?

In the first few sessions, a therapist will try to identify and recognize behaviour patterns. The therapist will ask questions related to a negative emotion or behaviour. Diagrams like the cognitive model are also there to aid the conversations.

The basic goal of these therapy sessions is to gradually progress to make behavioural changes. It takes many sessions before you can see the results.

In my recent session with my therapist, I shared that I hear laughter that morphs into actual my neighbour’s dogs barking. These sounds make me nervous and I get agitated. That’s because, in my opinion, the dogs bark with the purpose to irritate me.

My therapist took time to understand the situation with me. She explained that dogs bark if they are hungry. It’s normal for dogs to bark. There shouldn’t be any association between dogs barking and me. My neighbour has never once purposefully attacked me with their dogs. There is also no proof that the dogs bark to communicate with me. Thus, I will need to tell myself that the dogs bark for a purpose that is unrelated to me.

Of course, I don’t change my opinions immediately. This is a thought I keep in mind to remind myself when the agitation starts.

The 3 Pillars Of CBT

If you notice, the steps taken during a CBT session include the 3 pillars of CBT – identify, recognize and manage. As documented in the CBT Guide by the Center of Addition and Mental Health, CBT helps you to dissect your emotions and behaviours for a positive outcome.

• Identify: Capturing distortion of thoughts such as delusions or hallucinations.
• Recognize: Seeing what is actually happening instead of accepting it as a fact.
• Manage: Observing the situation or emotion from a different perspective. 

CBT Benefits for Schizophrenia

There are so many therapies out there. You might be thinking, why should you try CBT? First of all, it is non-invasive and you can do it on your own too. The cost of entry is also low. More on that below: CBT Self-help.

Those who are non-defensive and focused on identifying thoughts and feelings benefit most from CBT, as documented in a 2014 study. CBT does assist in anger management, reduced irritation and improved communication with others.

At the end of the day, how you feel does affect your actions and your communication with others. Your self-esteem will naturally improve too!

The biggest takeaway is the ability to learn skills on ways to better manage a situation. I also got to build problem-solving methods for coping with emotions. These were very useful as I dealt with other day-to-day stress, besides my schizophrenic symptoms.

Why Is CBT Effective for Schizophrenia?

CBT does not cure schizophrenia but it’s an additional therapy in your treatment plan, CBT proves to be effective for schizophrenia. It also helps other mental health issues like depression.

Schizophrenics usually find their minds in a mess. That’s why simple and direct communication is important. CBT offer exactly that, a structured method which can be easily executed at your own comfort.

A research study performed in 2000, by the Imperial College School of Medicine, documented CBT success with schizophrenia. It helped in treating symptoms of schizophrenia. Its efficacy was sustained over 9 months of follow-up. These patients have continuously improved!

Another study by Dr Faith Dickerson, a clinical psychologist, shows that CBT helps to reduce the severity of symptoms. Patients who are able to identify symptoms and are clear with their issues benefited the most from CBT. This is also reflected in the 2014 study mentioned earlier.

These are a few studies reflecting the success of CBT with schizophrenia. It proves that CBT can help schizophrenia, even for those who are resistant to medicine.

Disadvantages and Limitations of CBT

CBT is not a one-size-fits-all solution. Like most therapies or actions, there are pros and cons to them.

• Compliance: Schizophrenics may have difficulty committing to CBT, especially when experiencing symptoms. A therapist here would be helpful instead of self-help CBT.
• Learning difficulties: Focusing and learning something new can be challenging for schizophrenics. So, it is tough to engage in CBT and progress in it.
• Symptom severity: When struggling with hallucinations or delusions, schizophrenics have a strong belief system that will be hard for CBT to be effective. It’s important to approach CBT with an open mind or at least, the willingness to give it a try.
• Medication: Although research shows this therapy’s effectiveness for those who aren’t medicated, CBT works optimally with medicine. It offers the best result.

Understand the cons of CBT and prepare to overcome them. Take small steps to be open towards a different perspective.

How Long Does a CBT Session Last?

Most mental health institutions and therapist I’ve approached or researched recommend a weekly or fortnightly session. Each session will take about 30 to 60 minutes, for 6 to 20 sessions. These days, you have the option to conduct these sessions online.

My sessions usually last for an hour too. Recently, my sessions are through Zoom. Online sessions work just as well and it’s fitting since I’m still anxious about going out.

CBT Self-Help

Today, CBT is very accessible. I first started CBT through an app called ‘Bloom’ during my relapse when Covid hit. It was an interactive CBT app that features licensed therapists.

I checked in almost daily to learn ways I can work towards better emotions. The CBT exercises are generally simple and you can do them in the comfort of your home.

You can practise CBT any time of the day. Just like any other exercise, it is important to practise by repetition. CBT therapy helped me to give a better insight into how to manage my brain health issues. It suggests ways to ease the symptoms.

On the other hand, talking therapy sessions help me to dig deeper into my thought process. This could be more challenging at times but I often leave every session on a more positive note.

For schizophrenics, the belief can be so strong due to delusions and hallucinations. It is therefore better to work with a therapist on a regular basis.

When Should I Practice CBT?

Perform self-help CBT at home at any time. The best way is to practice incorporating the exercises as a lifestyle. Try to make it a routine. Do it before you start your day and/or before you go to bed.

Have a few CBT exercises that are easily executed for difficult times. Breathing exercises are my favourites. They help in reducing my agitation and are the easiest to execute.

I do have to admit that practising CBT during those times isn’t easy at all. When I’m in a negative mood, I don’t feel like doing anything. Sometimes I do it, sometimes I don’t. But, whenever I do, it made my feelings much lighter. I can concentrate much more on my daily tasks.

Looking back, I do notice an overall improvement. Lately, I catch myself saying certain words which are shaping my thoughts. I’m more self-aware. My loved ones have been noticing a more positive person. That’s a win!

How to Start With CBT for Schizophrenia?

Now that you understand CBT better, give it a try. Start with some specific CBT exercises I’ve tried and tested here.

These are the other ways which I can recommend. I’ve tried them all and they are all useful.

• Psychologist: In-person or online. There are also those who specialize in only CBT. Also, look for one who is also familiar with schizophrenia. I recommend looking for a psychologist or therapist if you want a personalized CBT.
• App/ Video Guided CBT: Guided interactive exercises through prerecorded videos within apps (eg. Bloom) or online video platforms (eg. YouTube). A small cost or for free.
• Paper/Web-based: CBT exercises are broken into smaller chunks in books or websites. You can practice in your own space for almost zero cost. Begin with video-guided CBT or simple CBT exercises.

Conclusion

Treatment for schizophrenia is a process. Everyone has different needs. No doubt, CBT is worth a try. It helps to improve cognitive and social functioning, reduce symptoms such as hallucinations and delusions, and improve the overall quality of life.

It will benefit schizophrenics as they learn to alleviate and manage the situation. Caregivers can also learn some CBT exercises to aid their loved ones.

Speak to a therapist or your current mental health professional if you have more concerns.