Psychotherapy for schizophrenia evidence-based and medically necessary?

October 5, 2011
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In the hazy, but not so distant past, schizophrenia was considered one of “functional” psychoses. It did not have an obvious and definitive organic etiology and psychodynamic psychotherapy was the course de rigueur. With advances in psychopharmacology and the neurosciences, the organic perspective prevailed and dynamic psychotherapy as a treatment modality for schizophrenia fell into disrepute.

In his influential book Surviving Schizophrenia, psychiatrist E. Fuller Torrey describes all the potential benefits of supportive therapies, while noting that that "insight-oriented psychotherapy” was of no value for schizophrenia. Of course talk therapy also evolved over this same time period.

Aaron Beck’s Cognitive Behavioral Therapy (CBT) and Albert Ellis Rational Emotive Therapy (RET) put cognitive restructuring in the forefront of talk therapy, replacing dubious constructs such as insight, abreaction, and transference resolution. Gradually CBT was seen as perhaps having some benefit for people with schizophrenia, especially since it intervened at a cognitive level, hopefully helping people change self-defeating or beliefs. Other psychotherapies also evolved for this population such as Personal Therapy, Acceptance and Commitment Therapy, Supportive Psychotherapy, and Compliance Therapy.

In a 2011 Cochrane review abstract, the authors report analyzing 20 randomized controlled trails that compared CBT with other such psychosocial therapies. They concluded that for people with schizophrenia, CBT offered no advantage or disadvantage as a supplemental treatment to medication, when compared to other psychosocial therapies. (Jones C, Hacker D, Meaden A, Cormac I, Irving CB. Cognitive behaviour therapy versus other psychosocial treatments for schizophrenia. Cochrane Database of Systematic Reviews 2011, Issue 4. Art. No.: CD000524. DOI: 10.1002/14651858.CD000524.pub3).

However, there seems to be other opinions. In an August review article of psychotherapeutic treatments for schizophrenia, published in the Journal of Nervous & Mental Disease, Faith Dickerson and Anthony Lehman, from the Sheppard Pratt Health System and University of Maryland School of Medicine concluded that CBT, “ has the strongest evidence base and has shown benefit for symptom reduction in outpatients with residual symptoms.”

Just in the last month Paul M. Grant and his colleagues at the University of Pennsylvania and the Veterans Affairs San Diego Healthcare System published a study in The Archives of General Psychiatry that showed after 18 months of treatment, patients who received a special manualized version of CBT, in addition to medication and case management services, gained an average 10-point improvement on the Global Assessment Scale over a control group that only received medication and case management. One of Grant’ s coauthors was the aforementioned Aaron Beck.

The researcher reported that participants had improved motivation, as therapists worked to restructure destructive self-talk, like “taking even a small risk is foolish because the loss is likely to be a disaster,” and “making new friends isn’t worth the energy it takes.” Although others may disagree Beck is quoted as saying, “You have to understand that this is not like therapy for depressives, who usually get better sooner or later anyhow.

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