Focus

It’s about more than symptoms

Cognitive-behavioural therapy promises to improve functioning

By Patricia Nicholson

Traditional schizophrenia treatment focuses heavily on medication to treat psychosis. But new approaches that incorporate cognitive-behavioural therapy (CBT) suggest that neurobiology may not be destiny when it comes to schizophrenia, and quality of life issues suggest there is more to treat than paranoia and voices.

“There are also negative symptoms that patients sturggle with,” says Dr. Gail Myhr, director of the CBT Unit at the McGill University Health Centre in Montreal, Quebec. “Difficulty doing things, getting out and resuming their lives after a psychotic break; maybe they’ll go home and live with their parents and stay in the basement.”

These are often people whose positive symptoms are under control, but whose functioning remains low. “They’re not actually hallucinating or frightened or anxious or depressed, but they’re not doing a lot,” says Myhr. “This is an aspect of schizophrenia which is troubling, particularly for families. With CBT, we can focus on that [functioning] and gradually get people in a stepwise fashion to resume a life which is satisfactory to them.”

Traditional therapy does not address cognitive deficits, but CBT – which has enough evidence behind it to make it a mandated treatment in the United Kingdom – is growing in popularity in North America as an adjunct treatment.

Widely used in the treatment of anxiety and depression, CBT addresses distorted thoughts and dysfunctional behaviours. It is a client-focused intervention that encourages clients to set and pursue their own goals. “It takes a bit of courage because it’s a very different paradigm than what we’re used to,” says Myhr. “We’re used to dealing with psychosis as a strictly biological difficulty.”

This new paradigm can focus on issues such as employment or personal goals, but Myhr says her overall goal is to reduce suffering and help clients feel better. “There’s the concept of recovery, where people can work towards the most satisfactory, rewarding life that they can have within the limitations of whatever they’re dealing with – just like anyone else,” she says.

Negative symptoms such as apathy, social withdrawal and lack of ambition have often been viewed as outcomes of neurobiological or structural brain abnormalities, says Dr. Neil Rector, director of research in the Psychiatry Department of Sunnybrook Health Sciences Centre in Toronto.

“It may be that there are certain neurocognitive components,” Rector says, “but from a cognitive perspective, we have noted that people with many negative symptoms have a lot of negative expectancies: they don’t expect to do well at the things they try, they expect to fail, they expect to derive very little pleasure. These are the types of appraisals that really get in the way of thinking that making an effort is worthwhile.”

CBT can help address those negative expectancies and the underlying dysfunctional beliefs. “As we were targeting those types of appraisals we found that patients became more engaged,” Rector says.

CBT isn’t entirely new to schizophrenia treatment. Social worker Virginia Lafond of the Schizophrenia Program at the Royal Ottawa Mental Health Centre in Ottawa, Ontario, uses CBT to help clients manage positive symptoms like paranoia and voices.

She begins by helping clients understand that the voices are a symptom of the illness. A careful assessment of the voices, including their nature and the client’s beliefs about them, is followed by an exploration of what types of activities, events or other factors affect the voices. “The goal is for the person, not the voices, to be in charge,” says Lafond.

Paranoid thoughts are an example of distorted thinking that CBT can address. “A common expression of paranoia is that the person will think that if they are in public people are looking at and talking about them, laughing about them,” Lafond says. “In a worst-case scenario, the behaviour is that the person stays home and is not able to attend to their basic needs.”

Using CBT and a tool called meta-thinking (thinking about thoughts), clients learn to assess situations more objectively. “The person can learn to look at that thought and appreciate that that is a narrow, negative take, possibly paranoid,” Lafond says.

Back in Montreal, Myhr uses CBT to treat both positive and negative symptoms, as well as mood shifts, self-esteem and behavioural issues like avoiding social situations. “We find that these tend to improve,” she says. She adds that clients with schizophrenia often have depression. “CBT can help, and there’s some evidence that it may reduce suicidal thoughts in this population,” she says.

While Myhr stresses that medication remains a mainstay of treatment, she also describes CBT as “one of the most hopeful areas of development in the treatment of schizophrenia.” She gives the example of a woman in her 50s who was referred for treatment because the voices she had been hearing for 30 years had become louder and more distressing. The situation forced the woman to abandon her regular activities, and medication was not helping. “She ended up in the emergency department,” Myhr says. “She hadn’t slept for a long time and the voices were insulting and instructing her to do unwise things.”

CBT enabled the woman to trace the escalation to a stressful event in a relationship. Exploring the influence of elements such as sleep and lifestyle factors on the voices helped yield potential ways to control the volume of the voices – playing music, relaxing and distracting herself helped to quiet the voices. By examining the distressing nature of the voices, which were insulting her, the woman was able to understand that what the voices were saying was incorrect.

This process of reflection successfully lowered the disturbance caused by the the voices and pushed them into the background so the woman could resume regular activities. “That’s a small example,” says Myhr. “But in the old days, when you saw someone with a 30-year history of voices, you would significantly increase the medication, but the voices would persist, and the person would still be upset. Cognitive therapy gave this woman another important tool to deal with her voices.”

CBT is beginning to be offered in schizophrenia programs across the country, including the Centre for Addiction and Mental Health in Toronto, but it has yet to be widely adopted in North America. Part of this lag relates to lack of training and resources. But it may also be related to lingering doubts about the usefulness of CBT. “There’s a bit of skepticism, even though we have studies to prove it, and meta-analyses have shown the power of this intervention,” says Helene Racine, director of nursing and director of quality at the Douglas Mental Health University Institute in Montreal.

Racine is training front-line workers such as nurses, social workers and occupational therapists to deliver CBT to clients with schizophrenia. Currently, the intervention is not widely available in Quebec outside of major urban centres; but Racine’s program, which works with the McGill University Health Centre CBT Unit, is trying to broaden accessibility by training throughout the province using teleconferencing. “We’re organizing so eventually each region can have a supervisor for CBT for psychosis, and people will learn the theoretical part through teleconferencing with us,” she says. “Staff will have a supervisor on site helping them with the practical part.”

As trainees begin to treat clients using CBT, the on-site supervisor can provide guidance. “I think we’re able to do things we would not have been able to do in terms of training even a couple of years ago,” Racine says. “Hopefully we can enlarge this model throughout Quebec.”

Racine acknowledges the challenges of changing long-standing treatment approaches and overcoming lingering skepticism. “Wanting to change a practice with people who have been practicing in a certain way for a long time, people have to really want change; we have to put the energy into making changes in practice,” she says. “It takes a lot of energy to do that.”

Beyond training: CBT tips for therapists

Adopting a new treatment modality is always a challenge for mental health professionals. Here, practitioners who are already using CBT for schizophrenia offer tips for success.

Dr. Gail Myhr, director of the McGill University Health Centre CBT Unit in Montreal, acknowledges that while CBT therapists may be comfortable helping clients with anxiety and depression, they may not be as comfortable talking about the kinds of unusual and sometimes alarming thoughts that people with psychosis may have. “When people are telling you things that are surprising to you, or that don’t fit what you know of the world, it can be upsetting at the beginning,” Myhr says. But all those thoughts can be discussed in CBT. “Just remember the underlying message that people with psychosis or schizophrenia are not fundamentally different from anyone else. Then you have the confidence to move ahead and try new forms of treatment.”

For Virginia Lafond of the Royal Ottawa Hospital’s schizophrenia program, acknowledging the grieving of mental illness in CBT work is key. “The person is often restive, discontent, rarely happy with him- or herself,” she says. “Conscious, constructive use of the grieving process can help bring resolution of the practical problems.” Lafond encourages clients to use two key coping questions: How can I help myself cope with a specific problem? Can I put the feeling of anger or fear or sadness etc. to constructive use?

Helene Racine, director of nursing and director of quality at the Douglas University Mental Health Institute in Montreal, says it is important to be confident that clients can learn these skills. “Stay open-minded,” she says. “If you are open-minded that they can achieve things on their own, then they can be successful at achieving what they want and they can learn about their own thought processes.”