CBT and Schizophrenia

This article was downloaded by: [72.252.115.92]On: 03 June 2014, At: 12:10Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954 Registeredoffice: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Social Work in Mental HealthPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/wsmh20

Cognitive-Behavioral Therapy forSchizophrenia: Applications to SocialWork PracticeVirgil L. Gregory Jr. MSW aa School of Social Work, Indiana University-Purdue University ,Indianapolis, Indiana, USAPublished online: 19 Feb 2010.

To cite this article: Virgil L. Gregory Jr. MSW (2010) Cognitive-Behavioral Therapy for Schizophrenia:Applications to Social Work Practice, Social Work in Mental Health, 8:2, 140-159, DOI:10.1080/15332980902791086

To link to this article: http://dx.doi.org/10.1080/15332980902791086

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (theContent) contained in the publications on our platform. However, Taylor & Francis,our agents, and our licensors make no representations or warranties whatsoever as tothe accuracy, completeness, or suitability for any purpose of the Content. Any opinionsand views expressed in this publication are the opinions and views of the authors,and are not the views of or endorsed by Taylor & Francis. The accuracy of the Contentshould not be relied upon and should be independently verified with primary sourcesof information. Taylor and Francis shall not be liable for any losses, actions, claims,proceedings, demands, costs, expenses, damages, and other liabilities whatsoever orhowsoever caused arising directly or indirectly in connection with, in relation to or arisingout of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

140

Social Work in Mental Health, 8:140159, 2010Copyright Taylor & Francis Group, LLC ISSN: 1533-2985 print/1533-2993 onlineDOI: 10.1080/15332980902791086

WSMH1533-29851533-2993Social Work in Mental Health, Vol. 8, No. 2, December 2009: pp. 00Social Work in Mental Health

Cognitive-Behavioral Therapy for Schizophrenia: Applications

to Social Work Practice

Cognitive-Behavioral Therapy for SchizophreniaV. L. Gregory

VIRGIL L. GREGORY, JR., MSWSchool of Social Work, Indiana University-Purdue University, Indianapolis,

Indiana, USA

Schizophrenia is a psychotic disorder that has been considered tobe the epitome of a severe mental illness. The negative psychosocialconsequences of schizophrenia are well documented. Despite theadvent of antipsychotic medication, residual symptoms persist formany persons diagnosed with schizophrenia. Cognitive-behavioraltherapy (CBT) has emerged as an adjunctive treatment to phar-macotherapy. Cognitive-behavioral theories of positive and nega-tive symptoms are described, as are interventions. Meta-analyseshave supported the use of CBT for schizophrenia. This articledescribes and synthesizes the literature to articulate precise appli-cations to social work practice and the congruence between CBTfor schizophrenia and the social work profession. Limitations ofCBT are also discussed.

KEYWORDS Cognitive-behavioral, schizophrenia, randomizedcontrolled trial, social work, meta-analysis

Many consider schizophrenia to be the epitome of a severe mental illness(SMI) (Hofmann & Tompson, 2002). Characterized by hallucinations, delu-sions, and other psychotic symptoms (American Psychiatric Association,2000), schizophrenia frequently has a deleterious influence on various aspectsof idiographic functioning (Hofmann & Tompson, 2002). Schizophrenia isassociated with lack of employment (Rosenheck et al., 2006), increased riskfor homelessness (Folsom & Jeste, 2002), as well as marital discord (Hooley,Richters, Weintraub, & Neale, 1987). Symptoms of schizophrenia are linked

Received August 21, 2008; accepted January 12, 2009.Address correspondence to Virgil L. Gregory, Jr., MSW. E-mail: [email protected]

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14

Cognitive-Behavioral Therapy for Schizophrenia 141

to impairment in academic performance, daily living activities, parenting,and social relationships (Mueser & McGurk, 2004). In the United States,approximately 5 out of 1000 people are diagnosed with schizophrenia (Wu,Shi, Birnbaum, Hudson, & Kessler, 2006). After neuroleptics began to showan ability to decrease positive symptoms, treatment of schizophreniaswitched from psychodynamic therapy to biologically based intervention(Pratt & Mueser, 2002). Currently, the United States views neuroleptic(antipsychotic) treatment as the fundamental aspect of intervention forschizophrenia (Turkington, Kingdon, & Weiden, 2006).

Although neuroleptics have had some success in addressing schizo-phrenic symptoms and reducing relapse, symptoms persist for numerouspersons (Gould, Mueser, Bolton, Mays, & Goff, 2001). Despite the advan-tages of neuroleptics, individuals diagnosed with schizophrenia have highrelapse rates (Ilott, 2005). One fourth to half of individuals who adhere topharmacological treatment still have considerable difficulty (Rector, 2004).The limited symptomatic benefit of neuroleptics for schizophrenia is illus-trated by the Food and Drug Administrations (FDAs) more liberal require-ments for symptom improvement (Patterson, Albala, McCahill, & Edwards,2006). To be approved by the FDA neuroleptics must demonstrate a 20% to30% decrease in symptoms relative to the placebo. In contrast, the FDArequires that antidepressant medications show a 50% decrease in symptoms.With regard to the outcome of schizophrenia, . . . approximately 20% makea full recovery, 20% have relapses with no intervening deterioration, 40%have relapses with some deterioration, and fewer than 20% remain chroni-cally ill and show little recovery (Kingdon & Turkington, 2005, p. 2). Fortherapy to have maximum effectiveness, pharmacological intervention forschizophrenia should be supplemented by psychotherapeutic treatment(Patterson et al., 2006).

Effective psychosocial treatment like cognitive-behavioral therapy(CBT) is needed to complement pharmacological interventions for schizo-phrenic symptoms (Bieling, McCabe, & Antony, 2006). Previously it wasbelieved that clients with schizophrenia could not be treated with CBT, yetthis is not true (Gould et al., 2001). Cognitive-behavioral therapy hasbecome a recognized treatment for psychosis in the United Kingdom(Tarrier & Haddock, 2002). Despite its availability in the United Kingdom,there has been a lack of attention on CBT for schizophrenia in the UnitedStates (Turkington et al., 2006). Although studies (Bradshaw, 1997, 2003;Bradshaw & Roseborough, 2004) have provided insight regarding CBT forsocial work practice with persons who have schizophrenia, the applicabilityof CBT for schizophrenia in social work practice can be improved viareviewing the theory, practice, randomized controlled trials (RCTs), andeffect sizes of CBT for schizophrenia. According to Soydan (2008), . . .when it comes to measure the effects of social work interventions, experi-mental studies, especially when randomized, conducted very carefully, and

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14

142 V. L. Gregory

large enough to generate statistical power, are the designs that best fit forthe purpose (p. 313). Although the implications of CBT for schizophreniaare widely available, explicit applications for social work are less promi-nent. In an effort to increase U.S. social workers awareness, application,and evaluation of CBT for schizophrenia, this review has several purposes.This article seeks to explain cognitive-behavioral theories and interventionsfor schizophrenic symptoms, describe the experimental status of CBT forschizophrenia, synthesize the literature to articulate precise applications tosocial work practice and research, and explicate the congruence betweenCBT for schizophrenia and the social work profession.

COGNITIVE-BEHAVIORAL THEORIES OF SCHIZOPHRENIA

Vulnerability

Theories of schizophrenia have been used to explain causal factors, identifytargets for intervention, and guide the psychosocial treatment process.Acknowledged in cognitive-behavioral treatment for schizophrenia (Fowler,Garety, & Kuipers, 1995; Kingdon & Turkington, 1994, 2005), the vulnerabil-ity model (Zubin & Spring, 1977) maintains that individuals have a certainlevel of susceptibility to schizophrenia and the individuals response tostressful situations will mediate the ultimate manifestation of schizophrenicsymptoms. Intrinsic vulnerability to schizophrenia includes genetic risk fac-tors. Extrinsic vulnerability pertains to life events such as traumatic experi-ences, stressful situations, disease, and familial and social experiences.Zubin and Spring consider positive (career advancement) and negativechanges (divorce) as life events. Once schizophrenia has developed, thevulnerability model suggests that individuals try to adapt via accommoda-tion or assimilation. Accommodation refers to intrapersonal changes theindividual makes to adjust to environmental demands. Assimilation occurswhen individuals seek to change their environmental circumstances to copewith stressors. These two processes can either enable or impede adaption(healthy responses to stressors).

The vulnerability model (Zubin & Spring, 1977) has cognitive-behavioralimplications in that it states . . . it must be remembered that the stress valueof various life events depends on the perception of threat by the individual(p. 114). Likewise, the cognitive-behavioral model of psychopathologymaintains that affective and behavioral responses are determined by theindividuals appraisal of events, rather than the events themselves (Beck,1995). Since Beck first used CBT to treat schizophrenia in 1952, cognitive-behavioral theories of hallucinations (Birchwood & Chadwick, 1997;Chadwick & Birchwood, 1994) and delusions (Garety, Kuipers, Fowler,Freeman, & Bebbington, 2001) have advanced case formulation for andtreatment of clients with schizophrenia.

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14


Auditory Hallucinations

The cognitive model of auditory hallucinations maintains that clients mal-adaptive beliefs about voices cause undesirable emotional and behavioralconsequences (Chadwick & Birchwood, 1994). Believing that the voicesintend to do harm (malevolent) causes the person to feel emotions such assadness, angst, fright, and anger. With regard to behavior, malevolentbeliefs about voices lead individuals to argue with voices, yell, and avoidstimuli that elicit voices. Chadwick and Birchwoods model also implies thatemotive and behavioral outcomes are influenced by beliefs the client hasabout whom the voice belongs to and how much power the voicepossesses.

There is empirical support for the cognitive model of auditory halluci-nations (Birchwood & Chadwick, 1997). Persons diagnosed with schizo-phrenia or schizoaffective disorder completed the beliefs-about-voicesquestionnaire (BAQV) (Chadwick & Birchwood, 1995) and were classifiedas having malevolent, benevolent (believing the voices have good inten-tions), or benign beliefs about voices. With regard to the level of distress forthe three different belief systems, there were statistically significant differ-ences. The malevolent and benevolent groups experienced the most andleast amount of distress, respectively. The study demonstrated that personswho had malevolent beliefs about their voices had a statistically significantgreater chance of having at least moderate depressive symptoms, in com-parison to persons who had benevolent beliefs. Participants with malevo-lent beliefs about voices had significantly more positive symptoms thanparticipants with benign beliefs about voices. The cognitive model of audi-tory hallucinations suggests that distress could me minimized via challeng-ing and replacing core beliefs about the intention, authority, and identity ofvoices (Chadwick & Birchwood, 1994). If clients with schizophreniabelieved that their auditory hallucinations were generated from themselves,the resulting affect and conduct may be substantially different (Chadwick &Birchwood, 1994).

Delusions

Mahers (1974) theory is frequently cited in cognitive-behavioral literatureregarding the explanation for (Bentall, Corcoran, Howard, Blackwood, &Kinderman, 2001; Bentall, Kinderman, & Kaney, 1994; Birchwood & Jackson,2001; Freeman, 2007; Garety et al., 2001) and treatment of delusional beliefs(Chadwick, Birchwood, & Trower, 1996; Chadwick & Lowe, 1990, 1994).Maher maintained that delusional beliefs develop from the individualsattempt to explain unusual perceptual stimuli (hallucinations). According toMahers theory, delusions provide comprehensive explanations that accountfor the hallucinations occurrence, origin, and idiosyncratic nature. The

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14

144 V. L. Gregory

explanatory function of delusions are said to provide a reduction in anxiety.Specific content of the delusion is believed to be a product of the individ-uals previous and current experiences. Mahers theory views delusions asan ordinary response to atypical stimuli. The theory does not claim to applyto all persons with delusions. Cognitive-behavioral therapy seeks to aid theindividual in understanding that the delusion is the following: perceptualrather than actual, an attempt to explain their experience, accompanied bybehavioral and emotive disadvantages, false and inferior to a more reason-able belief (Chadwick et al., 1996).

Negative Symptoms

The cognitive model acknowledges the role of biological vulnerability andsuggests that negative symptoms in schizophrenia are partially influencedby beliefs pertaining to social interaction, pleasure, success, and resources(Rector, Beck, & Stolar, 2005). In describing and justifying their cognitivemodel, Rector and associates rely on published studies. Clients with nega-tive symptoms are theorized as having beliefs that are antithetical to socialinteraction. Such clients are also viewed as having pessimistic beliefs abouttheir intrapersonal and social adequacy. The cognitive model maintains thatnegative symptoms are in part facilitated by the client not expecting toobtain satisfaction or achievement from potentially gratifying activities. Theauthors stated that in reality clients do receive some gratification from activ-ities when they participate in them. The model identifies the clients ten-dency to underestimate resources as a key part in the maintenance ofnegative symptoms. Cognitive-behavioral techniques used (Beck, Rush,Shaw, & Emery, 1979) for depression are also applied to the negative symp-toms of schizophrenia (Rector, 2004). The aforementioned theories ofvulnerability, auditory hallucinations, delusions, and negative symptoms areonly four of the theoretical explanations that have been submitted toexplain symptoms of schizophrenia. These theories were described herebecause of the frequency with which they are cited in cognitive-behavioralliterature, their contribution to the symptomatic understanding of schizo-phrenia, and the practical implications they have for treatment. Cognitive-behavioral therapy for schizophrenia has been substantially influenced bythese theories. Given the cognitive-behavioral theoretical underpinnings ofschizophrenic symptoms, case formulation and CBT are logical extensions.

COGNITIVE-BEHAVIORAL INTERVENTIONS FOR SCHIZOPHRENIA

Cognitive-behavioral interventions for schizophrenia are currently availablein several treatment manuals (Beck, Rector, Stolar, & Grant, 2009; Byrne,Birchwood, Trower, & Meaden, 2006; Chadwick et al., 1996; Fowler et al.,

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14


1995; Kingdon & Turkington, 1994, 2005; Morrison, Renton, Dunn, Williams,& Bentall, 2004). Social workers who use cognitive-behavioral techniques totreat other disorders will be familiar with many of the interventions that aredescribed in these manuals. For example, common cognitive restructuringinterventions like systematically evaluating the evidence for and againstbeliefs (Beck et al., 1979) are used in the treatment of schizophrenia.Conventional behavioral interventions like behavioral experiments andactivity scheduling (Greensberger & Padesky, 1995) are frequentlyemployed as well. Table 1 provides a list of cognitive-behavioral interven-tions and treatments manuals that discuss their application. Table 1 is notmeant to be an exhaustive reiteration of the techniques described in thecited treatment manuals. Instead, the purpose of Table 1 is to provide socialworkers with an overview of cognitive-behavioral techniques that are fre-quently used in the treatment of schizophrenia and a list of treatment manu-als where interventions are explicated. The cognitive-behavioral techniquesare classified according to whether they are primarily used to identify andmonitor beliefs, alter maladaptive beliefs, or cope with symptoms. The clas-sification of the interventions are somewhat relative, as the techniques arenot necessarily mutually exclusive with regard their purposes.

In conjunction with other factors, the applicability of cognitive-behavioral interventions is determined by the extent of the clients

TABLE 1 Cognitive-Behavioral Interventions Used in the Treatment of Schizophrenia

Identifying thoughts and beliefsABC TechniqueDownward Arrow TechniqueExposureThought records

Challenging maladaptive thoughts and beliefsAlternative explanations for eventsBehavioral experimentsEvidence for and against beliefsImageryPie chartsPros and cons of beliefsPsychoeducationRelaxation

Coping skillsActivity schedulingDistractionFlashcardsNormalizingPie chartsProdrome monitoringRole-plays

CBT Treatment Manuals: Beck et al. (2009); Byrne et al. (2006); Chadwick et al. (1996); Fowleret al. (1995); Kingdon & Turkington (1994, 2005); Morrison et al. (2004).

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14

146 V. L. Gregory

engagement (Haddock & Siddle, 2003). Cognitive-behavioral therapymust include a strong therapeutic relationship between the clinician andclient (Beck, 1976, 1995). Consequently, the development of therapeuticrapport is highly important (Kingdon & Turkington, 2002) and the initialgoal of CBT (Tarrier, 2005). The therapeutic relationship is essential tocase formulation and the application of cognitive-behavioral interven-tions to persons with schizophrenia (Hewitt & Coffey, 2005). Failure todevelop a therapeutic relationship will minimize the effectiveness of cog-nitive-behavioral techniques (Beck, Wright, Newman, & Liese, 1993).Fortunately, although engaging a client with schizophrenia can seem tobe a huge barrier, the process may not be as complicated as it initiallylooks (Kingdon & Turkington, 2005). Explicit details regarding how tobuild therapeutic rapport are beyond the scope of this article; howeverKingdon and Turkington (2005) have provided a chapter length summaryregarding ways to facilitate the therapeutic relationship with clients whohave schizophrenia.

Cognitive-behavioral therapy is used in the treatment of schizophre-nia to accomplish specific psychosocial outcomes. Objectives of CBT forschizophrenia include reductions in the frequency and intensity of posi-tive symptoms, stigma, relapse, and co-occurring depression and anxiety(Rector, 2005). An associated objective of CBT is the development of theclients insight (Kingdon & Turkington, 1994). Insight refers to the clientsacknowledgment that he or she has a psychiatric illness, attribution ofhallucinations and delusions to psychiatric illness, and adherence totreatment (David, 1990). Cognitive-behavioral therapy for auditory halluci-nations enhances client insight via assisting the client in recognizing thatthe voices are attributable to herself or himself (Chadwick & Birchwood,1994).

Similar to some of the aforementioned goals of CBT for schizophre-nia, psychotropic medication has been beneficial in decreasing the fre-quency and intensity of symptoms (Kingdon & Turkington, 1994).Psychosocial treatment of schizophrenia is maximized when it is used inconjunction with medical intervention (Psychosocial Interventions,2005). When used simultaneously, the treatments collectively increasecompliance and communal functioning (Pharmacotherapy, 2005). It isnot currently known if CBT can be effective for schizophrenia in theabsence of pharmacotherapy (Kingdon & Turkington, 2005). Evaluatingthe effectiveness of CBT, as a stand alone treatment for schizophrenia,raises ethical issues (Kingdon & Turkington, 2005). The absence ofresearch examining CBT as a stand alone treatment is attributable to thesevere nature of schizophrenia and the effectiveness of neuroleptics(Wright, 2004). To the contrary, numerous RCTs have examined the effec-tiveness of CBT with pharmacotherapy for schizophrenia in comparison tocontrol groups.

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14


METHODS

Given the many experimental trials that have examined CBT for schizophre-nia over the past 30 years and the purpose of this review, this article focusesexclusively on meta-analytic studies. Meta-analyses are beneficial to summa-rizing research because they provide structure to synthesizing data comingfrom different studies, report effect sizes rather than probabilities regardingnull hypothesis significance tests, and have the potential to determine rela-tionships that may be masked by other summary methods (Miller & Salkind,2002). The present study used Medline and PsychInfo databases (November2008) to systematically obtain meta-analyses pertaining to CBT for schizo-phrenia. Keywords such as cognitive behavioral, cognitive behavior, CBT,cognitive therapy, meta-analysis, effect size, schizophrenia, randomizedcontrolled trial, and RCT were used to identify pertinent meta-analytic stud-ies. Reference lists of the included meta-analytic studies and seminal textswere reviewed to identify relevant meta-analyses that may not have beenpublished in peer-reviewed journals.

Each of the meta-analytic studies was subject to inclusion and exclusioncriteria. For a meta-analysis to be included in the current review the followinginclusion criteria must have been met: (1) the study must be a meta-analysis,(2) CBT is identified as the independent variable in the analysis, (3) partici-pants were classified as having a schizophrenic spectrum disorder, (4) thenumber of studies using a RCT is reported, (5) the average standardized meandifference effect size (see Henson, 2006; Rosnow & Rosenthal, 2003 for dis-cussion) of positive (hallucinations, delusions) and/or negative symptoms(anhedonia, avolition, etc.) is explicitly reported, (6) the effect size representsa posttest or pretest to posttest comparison, (7) the statistic used to calculatethe effect size is stated, and (8) a systematic literature search strategy is con-ducted and described. Meta-analytic studies were excluded if a comorbidDSM-IV axis I or II disorder was the specific focus of evaluation or if the studywas a review of meta-analyses. Of the ten studies that were identified, fourmeta-analyses met inclusion criteria for this review. Excluded studies andtheir reason for exclusion can be found in the Appendix.

RESULTS

Research has shown CBT to be effective in challenging and altering mal-adaptive beliefs that contribute to hallucinations and delusions (Rector &Beck, 2002). As can be seen in Table 2, the average effect sizes for positivesymptoms of schizophrenia show the CBT cohorts as having small to largetreatment effects. The meta-analytic studies included in this review (Gouldet al., 2001; Rector & Beck, 2001; Wykes, Steel, Everitt, & Tarrier, 2008;Zimmermann, Favrod, Trieu, & Pomini, 2005) provide insight and support

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14

148

TA

BLE

2Cogn

itive

-Beh

avio

ral Ther

apy

for

Schiz

ophre

nia

M

eta-

Anal

yses

Met

a-an

alys

is

Tota

l num

ber

of

studie

s

Num

ber

of

RCTs

(%)

ES

stat

istic

Mea

n E

S

Typ

es o

f co

ntrol

groups

nAttritio

nA

rtic

le

timef

ram

es

Gould

et al

. (2

001)

77

(100

%)

Gla

sss D

elta

Positiv

e sy

mpto

ms

= 0.

65a

ST, TA

U, W

L34

012

.4%

1978

200

0Rec

tor

& B

eck

(200

1)7

7 (1

00%

)Cohen

s d

Positiv

e sy

mpto

ms

= 1.

31b

Neg

ativ

e sy

mpto

ms

= 1.

08b

ST, TA

U38

3N

/A19

932

000

Wyk

es e

t al

. (2

008)

3430

(88

%)

Gla

sss D

elta

Positiv

e sy

mpto

ms

= 0.

37ad

N

egat

ive

sym

pto

ms

= 0.

43ad

ST, TA

U58

.2c

Seve

n s

tudie

s w

ith a

n a

ttritio

n

rate

above

25%

1978

200

6

Zim

mer

man

n et

al.

(200

5)14

13 (

92%

)H

edge

s g

Positiv

e sy

mpto

ms

= 0.

37ad

ST, TA

U, W

L14

84N

/A19

932

004

a Post

test

effec

t si

ze.

bPre

test

to p

ost

test

effec

t si

ze.

c Ave

rage

.dRan

dom

Effec

ts M

odel

(REM

).A

cronym

s: E

S = E

ffec

t Si

ze;

n =

Sam

ple

Siz

e; N

/A =

Not

Applic

able

, Li

mite

d o

r no i

nfo

rmat

ion r

eported

; RCT =

Ran

dom

ized

Controlle

d T

rial

s; S

T =

Supportiv

eTher

apy;

TA

U =

Tre

atm

ent as

Usu

al; W

L = W

ait-Li

st.

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14


regarding the efficacy of cognitive-behavioral interventions for positive andnegative symptoms of schizophrenia. Additionally, the meta-analyses areoverwhelmingly composed of experimental studies that encompass an inter-val of over 25 years. Meta-analyses which incorporate RCTs are optimalbecause such designs control threats to internal validity (Campbell &Stanley, 1963) and increase the likelihood of a cause-and-effect relationship(Kirk, 1999) between CBT and a reduction in schizophrenic symptoms.

Effect sizes calculated by Rector and Beck (2001) demonstrate thaton average CBT had a large effect size for positive and negative symp-toms, while control groups had moderate effect sizes for the two sets ofsymptoms. All seven studies in Rector and Becks analysis were RCTs andthe experimental and control cohorts were all receiving pharmacother-apy. Gould and colleagues meta-analysis included seven RCTs, yielded alarge effect size at post-treatment, and supported CBTs ability to reducethe intensity of positive symptoms. Of the seven studies, one studyinvolved 95% of the participants receiving pharmacotherapy, while all ofthe participants in the remaining six studies received pharmacologicalintervention.

The meta-analysis conducted by Zimmermann and associates showedCBT as significantly reducing positive symptoms of schizophrenia. Thestudy found that at post-treatment, the average participant in CBT hadgreater reductions in positive symptoms than 64% of persons in controlgroups. Of the 14 studies included in the meta-analysis, 13 were RCTs. Tobe included in the Zimmermann and associates meta-analysis a supportivetherapy, treatment as usual, or wait-list control was required. However, themeta-analysis lacked adequate discussion pertaining to the pharmacologicalintervention that control groups received.

The most extensive meta-analysis conducted thus far shows CBT ashaving favorable effects on positive, negative, and affective symptoms(Wykes et al., 2008). Functioning was also shown to be favorably influencedby CBT. Three of four studies in the meta-analysis did not support the effec-tiveness of CBT for hopelessness. Wykes and associates included 30 RCTs(34 studies in total) and used advantageous meta-analytic methods andpractices that other studies did not. In the Wykes and colleagues meta-anal-ysis, pharmacological intervention of all participants was required for stud-ies to be included. The aforementioned meta-analyses have included someof the same studies.

CONCLUSIONS

The theoretical, practical, and empirical aspects of CBT for schizophreniahave many applications to social work practice. Given the current effectsizes of the CBT cohorts, there is considerable empirical support for the use

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14

150 V. L. Gregory

of CBT in the treatment of schizophrenia. The meta-analyses are comple-mented by non-experimental (Bradshaw, 1997) and experimental studies(Bradshaw, 1996, 2003; Bradshaw & Roseborough, 2004), which demonstratesor implies the ability of CBT for schizophrenia to be successfully applied bysocial workers. Because the empirical evidence supports the effectivenessof CBT for schizophrenia, social workers will be operating within the ethicsof the social work profession (see NASW, 1999) and adhering to the man-dates of the educational policy and accreditation standards (see CSWE,2008), when they competently use the treatment to improve the welfare ofclients. Yet, social workers should be cognizant of the finding that studieswith less scientific rigor are empirically associated with inflated effect sizes(Tarrier & Wykes, 2004).

Therapists must receive training in CBT for schizophrenia (Bradshaw &Roseboroughs, 2004). Such training is essential to social workers who wishto effectively integrate the intervention into social work practice. Cliniciansmust have a fundamental comprehension of CBT and experience with CBTin clients without psychosis (Turkington, Dudley, Warman, & Beck, 2004).In Bradshaw and Roseboroughs study (2004), the therapists were licensedclinical social workers (LCSWs) who had masters degrees in social work(MSWs) and an average of five years in mental health experience. Over aduration of six months, the LCSWs were given 48 hours of training in CBT.Training also involved each of the social workers using CBT with three cli-ents and clinical supervision. To effectively provide CBT for schizophrenia,psychiatric nurses were trained for ten days and participated in supervisionthat occurred on a weekly basis (Turkington, Kingdon, & Turner, 2002).Based on the study conducted by Turkington and others (2002), for counse-lors (who have previously treated schizophrenia) to learn the fundamentalsof CBT for schizophrenia, it takes at least two weeks of rigorous trainingand continual supervision by a CBT expert (Turkington et al., 2006). Forsocial workers who meet the prerequisite criteria, workshops are available(Turkington et al., 2004). Treatment guidelines (American PsychiatricAssociation, 2004; National Institute for Clinical Excellence, 2003) providepractical insight into the application and status of CBT for schizophrenia.The availability of CBT for clients with schizophrenia is dependent on theaccessibility of supervision and administrative support (Turkington et al.,2004). All factors considered, given the empirical support of CBT forschizophrenia, social work administrators should seriously consider thepractical and fiscal viability of integrating CBT into their agencys treatmentprotocol.

There are several aspects of CBT for schizophrenia that make its appli-cation among social work practitioners less complicated. To reiterate, manyof the techniques described in the aforementioned treatment manuals are usedto treat other axis I disorders in the Diagnostic and Statistical ManualIV(DSM-IV). For example, cognitive-behavioral techniques used to treat

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14


schizophrenia are also used to treat other SMIs such as bipolar disorder andendogenous (biologically based) depression. Additionally, CBT is compati-ble with other treatments for schizophrenia, such as assertive communitytreatment (ACT), cognitive remediation, and family intervention (Turkingtonet al., 2004).

For social work practitioners who use CBT to treat persons with schizo-phrenia, perhaps the biggest clinical advantage to clients is the socialworkers ability to substantively influence both intrapersonal and environ-mental factors. Social work is characterized by its emphasis on individualfunctioning in the social environment (NASW, 1999). It is this factor that setssocial work apart from other helping professions (Sheafor, Horejsi, & Horejsi,2000). The accommodation and assimilation processes that are articulated inthe vulnerability model (Zubin & Spring, 1977) could be facilitated by microand macro social work interventions, respectively. Adjunctive social workinterventions to CBT (such as case management, class and case advocacy,policy formulation, etc.) could positively facilitate the assimilation andaccommodation processes which can contribute to the restoration ofadaption.

Clients with schizophrenia may benefit from social workers who simul-taneously provide CBT and case management (see Kingdon & Turkington,2005). Social workers have knowledge regarding ways in which the socialenvironment contributes to the growth or stasis of client development(CSWE, 2008). Problems stemming from the social environment can poten-tially be mitigated via case-management services. Case managementinvolves aiding the client with regard to the applicability, accessibility,advantage, and request of resources (Miley, OMelia, & DuBois, 1998).Social work encompasses a number of professional roles, including clinicianand case manager (Sheafor et al., 2000). Social workers have claimed to bethe most suitable health profession to perform case-management tasks(Berger, 2002). When therapy and case-management services are providedby the same person the advantages include the possibility that: case-management services may aid the therapist in establishing a therapeuticrelationship with the client, the client will relate better to one personinstead of several, or after therapeutic services have ceased, case manage-ment may still be able to continue (Kingdon & Turkington, 2005).

Social workers can influence the availability of CBT for schizophreniavia advocating for national and organizational policies that increase thefunding, dissemination, adoption, and evaluation of the treatment. The lackof attention for CBT of schizophrenia in the United States is partially attrib-utable to . . . the difference in health care research and delivery . . .between the United States and United Kingdom (Turkington et al., 2006, p.371). Social workers are assumed to have been trained to intervene at microand macro levels (Haynes & Mickelson, 2000). Indeed, bachelors of socialwork (BSW) and MSW programs that are accredited by the CSWE (2008) are

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14

152 V. L. Gregory

required to teach social work students to utilize research to enhance policyand the delivery of social services. Consequently, it is certainly within theprofessional scope of social workers to improve the availability of CBT forschizophrenia via advocating for policy change that is connected with theadministration of social services. Such advocacy could ultimately improvethe treatment options available to and well-being of clients.

Social workers should be cognizant of limitations that are associatedwith CBT for schizophrenia. Little is known about the effects of CBT for cli-ents with schizophrenia from diverse cultures (Tarrier, 2005). In one study(Rathod, Kingdon, Smith, & Turkington, 2005), relative to Caucasians, per-sons who were of African descent had a significantly greater attrition rate atpost-treatment and at the one-year follow-up. The authors stated that theseresults were similar to prior findings by other studies. The evident lack ofresearch and potential lack of external validity that CBT could have for per-sons with schizophrenia who are not Caucasian, is noteworthy becausesocial work places specific emphasis on vulnerable and marginalizedgroups (NASW, 1999) such as racial minorities (CSWE, 2008). Factors thatmay preclude or diminish the effectiveness of CBT for schizophreniainclude cultural incongruence between the practitioner and client, extremeparanoia, absence of pharmacological intervention, and severe symptoms(Turkington et al., 2006). Currently it is premature to conclude that CBTlacks external validity for racial minorities.

The meta-analyses included in this review make a substantial contri-bution to the empirical status of CBT for schizophrenia; however there arestill limitations and issues that require further investigation. Meta-analysesare needed which directly address the possible effects of moderating andmediating variables. Such variables are important because they couldprovide further explanation regarding the relationship between CBT andrelevant outcomes of schizophrenia (see Frazier, Tix, & Barron, 2004 fordiscussion regarding moderator and mediator variables). Tests of hetero-geneity allow the meta-analyst to determine if there is significant variabil-ity in the studies; if there is significant variability moderator variables canbe evaluated to account for the variance (Huedo-Medina, Schez-Meca,Marn-Martnez, & Botella, 2006). Heterogeneity was examined in all ofthe included meta-analyses. Tests of heterogeneity were not significant forthree of the included meta-analyses (Gould et al., 2001; Rector & Beck,2001; Zimmermann et al., 2005). Even when heterogeneity tests are notsignificant, meta-regression is a viable option to examine variables thatmay possibly contribute to a lack of homogeneity (Thompson & Higgins,2002). Gould and associates examined the role of gender on effect sizes.The effects of control group types and patients status were explored byZimmermann and colleagues. It would be advantageous if meta-regressionwas used to determine the potential moderating impact of the patientsage, marital status, employment status, or race. The meta-analyses provide

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14


scant attention to cultural variables that, at least theoretically, may influ-ence treatment. The lack of attention to culture in the meta-analyses couldbe attributable to cultural variables not being reported in the studiesincluded in the meta-analyses. The potential moderating effects of racestill require further examination.

Meta-regression or other statistical analyses should be conducted thatevaluate the possible influence of the clinicians years of education, profes-sional affiliation, and years of experience. These variables could substan-tially impact effect sizes. Current research provides little insight regardingthe effectiveness of CBT administered by clinicians with less experience(Jones, Cormac, Silveira da Mota Neto, & Campbell, 2004). Meta-analysesincluded in this review do not substantively address this issue. Meta-analyticexploration of the aforementioned moderating and mediating variables mayultimately clarify and improve the delivery of CBT. It is worth reiteratingthat to a great extent, meta-analyses are restricted to the data that isreported in included studies. Before quantitative reviews can provide themost effective meta-analytic procedures, the relevant variables must first becollected and articulated.

This review has detailed the theoretical underpinnings, techniques,and empirical support for CBT of schizophrenia. The compatibilitybetween CBT for schizophrenia and social work practice has been expli-cated. In summary, there are a number of key points for social work prac-titioners to consider regarding the application of CBT for schizophrenia:(1) Via meta-analyses and RCTs, which they consist of, there is empiricaljustification for using CBT in the treatment of schizophrenia; (2) Whileissues pertaining to external validity require further investigation, CBT forschizophrenia is consistent with the social work professions mission andstandards; (3) Cognitive-behavioral therapy for schizophrenia couldbe complemented by social works person-in-environment perspective;(4) Given the aforementioned published outcomes, treatment manuals,and treatment guidelines regarding CBT for schizophrenia, social workadministrators need to thoroughly consider the actual and potential impli-cations of providing the treatment to clients served by their agency (seeBradshaw and Roseboroughs, 2004 for similar discussion); (5) Socialworkers have the prerequisite skills to use social policy to advance theavailability of cognitive-behavioral interventions for clients with schizo-phrenia; (6) The current status of CBT for schizophrenia can be improvedby the production and consumption of research that examines factors thatare germane to social works mission and practitioners. The social workprofession has used treatments that have been shown to not help clientsor has failed to use treatments that demonstrate an ability to help clients(Soydan, 2008). As it pertains to social work practice, cognitive-behavioraltheory, interventions, and experimental research have been described andsynthesized here to change the latter.

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14

154 V. L. Gregory

REFERENCES

American Psychiatric Association. (2000). Diagnostic and statistical manual of men-tal disordersIVtext revision (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2004). Practice guidelines for the treatment ofpatients with schizophrenia (2nd ed.). Retrieved July 7, 2008 from http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=Schizophrenia2ePG_05-15-06

Beck, A.T. (1952). Successful outpatient psychotherapy of a chronic schizophrenicwith a delusion based on borrowed guilt. Psychiatry, 15, 305312.

Beck, A.T. (1976). Cognitive therapy and the emotional disorders. New York: Inter-national Universities Press.

Beck, A.T., Rector, N.A., Stolar, N., & Grant, P. (2009). Schizophrenia: Cognitive theory,research, and therapy. New York: Guilford Press.

Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy of depres-sion. New York: Guilford Press.

Beck, A.T., Wright, F.D., Newman, C.F., & Liese, B.S. (1993). Cognitive therapy ofsubstance abuse. New York: Guilford Press.

Beck, J.S. (1995). Cognitive therapy: The basics and beyond. New York: GuilfordPress.

Bentall, R.P., Corcoran, R., Howard, R., Blackwood, N., & Kinderman, P. (2001).Persecutory delusions: A review and theoretical integration. Clinical Psychol-ogy Review, 21(8), 11431192. doi:10.1016/S0272-7358(01)00106-4

Bentall, R.P., Kinderman, P., & Kaney, S. (1994). The self, attributional processesand abnormal beliefs: Towards a model of persecutory delusions. BehaviourResearch and Therapy, 22(3), 331341. doi:10.1016/0005-7967(94)90131-7

Berger, C.S. (2002). Social work case-management in medical settings. In A.R. Roberts& G.J. Greene (Eds.), Social workers desk reference (pp. 497501). New York:Oxford University Press.

Bieling, P.J., McCabe, R.E., & Antony, M.M. (2006). Cognitive-behavioral therapy ingroups. New York: Guilford Press.

Birchwood, M., & Chadwick, P. (1997). The omnipotence of voices: Testing thevalidity of a cognitive model. Psychological Medicine, 27, 13451353.doi:10.1017/S0033291797005552

Birchwood, M., & Jackson, C. (2001). Schizophrenia. Philadelphia: Taylor & Francis.Bradshaw, W. (1996). Structured group work for individuals with schizophrenia: A

coping skills approach. Research on Social Work Practice, 6(2), 139155.doi:10.1177/104973159600600201

Bradshaw, W. (1997). Evaluating cognitive-behavioral treatment of schizophrenia:Four single-case studies. Research on Social Work Practice, 7(4), 419445.doi:10.1177/104973159700700401

Bradshaw, W. (2003). Use of single-system research to evaluate the effectiveness ofcognitive-behavioural treatment of schizophrenia. British Journal of SocialWork, 33, 885899. doi:10.1093/bjsw/33.7.885

Bradshaw, W., & Roseborough, D. (2004). Evaluating the effectiveness of cognitive-behavioral treatment of residual symptoms and impairment in schizophrenia.Research on Social Work Practice, 14(2), 112120. doi:10.1177/1049731503257872

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14


Byrne, S., Birchwood, M., Trower, P.E., & Meaden, A. (2006). A casebook of cognitive-behaviour therapy for command hallucinations. New York: Routledge.

Campbell, D.T., & Stanley, J.C. (1963). Experimental and quasi-experimentaldesigns for research. Boston, MA: Houghton Mifflin Company.

Chadwick, P., & Birchwood, M. (1994). The omnipotence of voices: A cognitiveapproach to auditory hallucinations. British Journal of Psychiatry, 164,190201.

Chadwick, P., & Birchwood, M. (1995). The omnipotence of voices II: Thebeliefs about voices questionnaire (BAVQ). British Journal of Psychiatry,166, 773776.

Chadwick, P., Birchwood, M., & Trower, P. (1996). Cognitive therapy for delusions,voices, and paranoia. Chichester, UK: Wiley.

Chadwick, P.D.J., & Lowe, C.F. (1990). Measurement and modification of delusionalbeliefs. Journal of Consulting and Clinical Psychology, 58(2), 225232.doi:10.1037/0022-006X.58.2.225

Chadwick, P.D.J., & Lowe, C.F. (1994). A cognitive approach to measuring andmodifying delusions. Behaviour Research and Therapy, 32(3), 355367.doi:10.1016/0005-7967(94)90133-3

Council on Social Work Education (CSWE). (2008). Educational policy and accredita-tion standards. Retrieved July 5, 2008 from http://www.cswe.org/NR/rdonlyres/2A81732E-1776-4175-AC42-65974E96BE66/0/2008EducationalPolicyandAccreditationStandards.pdf

David, A.S. (1990). Insight and psychosis. British Journal of Psychiatry, 156,798808.

Folsom, D., & Jeste, D.V. (2002). Schizophrenia in homeless persons: A systemicreview of the literature. Acta Psychiatrica Scandinavica, 105, 404413.doi:10.1034/j.1600-0447.2002.02209.x

Fowler, D., Garety, P., & Kuipers, E. (1995). Cognitive behaviour therapy for psycho-sis: Theory and Practice. Chichester, UK: Wiley.

Frazier, P.A., Tix, A.P., & Barron, K.E. (2004). Testing moderator and mediatoreffects in counseling psychology research. Journal of Consulting and ClinicalPsychology, 51(1), 115134.

Freeman, D. (2007). Suspicious minds: The psychology of persecutory delusions.Clinical Psychology Review, 27, 425457. doi:10.1016/j.cpr.2006.10.004

Garety, P.A., Kuipers, E., Fowler, D., Freeman, D., & Bebbington, P.E. (2001). Acognitive model of positive symptoms of psychosis. Psychological Medicine,31, 189195. doi:10.1017/S0033291701003312

Gould, R.A., Mueser, K.T., Bolton, E., Mays, V., & Goff, D. (2001). Cognitive therapyfor psychosis in schizophrenia: An effect size analysis. Schizophrenia Research,48, 335342. doi:10.1016/S0920-9964(00)00145-6

Greensberger, D., & Padesky, C.A. (1995). Mind over mood: Change how you feel bychanging the way you think. New York: Guilford Press.

Haddock, G., & Siddle, R. (2003). Psychosis. In R.L. Leahy (Ed.), Roadblocks incognitive-behavioral therapy: Transforming challenges into opportunities forchange (pp. 135152). New York: Guilford Press.

Haynes, K.S., & Mickelson, J.S. (2000). Affecting change: Social workers in the polit-ical arena (4th ed.). Needham Heights, MA: Allyn & Bacon.

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14

156 V. L. Gregory

Henson, R.K. (2006). Effect-size measures and meta-analytic thinking in counselingpsychology research. The Counseling Psychologist, 34(5), 601629. doi:10.1177/0011000005283558

Hewitt, J., & Coffey, M. (2005). Therapeutic working relationships with people withschizophrenia: Literature review. Journal of Advanced Nursing, 52(5), 561570.doi:10.1111/j.1365-2648.2005.03623.x

Hofmann, S.G., & Tompson, M.C. (Eds.). (2002). Treating chronic and severe men-tal disorders: A handbook of empirically supported interventions. New York:Guilford Press.

Hooley, J.M., Richters, J.E., Weintraub, S., & Neale, J.M. (1987). Psychopathologyand marital distress: The positive side of positive symptoms. Journal of Abnor-mal Psychology, 96(1), 27 33. doi:10.1037/0021-843X.96.1.27

Huedo-Medina, T.B., Schez-Meca, J., Marn-Martnez, F., & Botella, J. (2006).Assessing heterogeneity in meta-analysis: Q statistic or I2 Index? PsychologicalMethods, 11(2), 193 206. doi:10.1037/1082-989X.11.2.193

Ilott, R. (2005). Does compliance therapy improve use of antipsychotic medication?British Journal of Community Nursing, 10(11), 514519.

Jones, C., Cormac, I., Silveira da Monta Neto, J.K., & Campbell, C. (2004). Cognitivebehaviour therapy for schizophrenia. Cochrane Database of Systemic Reviews2004, Issue 4. Art. No.: CD000524. doi:10.1002/14651858.CD000524.pub2

Kingdon, D.G., & Turkington, D. (1994). Cognitive-behavioral therapy of schizo-phrenia. New York: Guilford Press.

Kingdon, D.G., & Turkington, D. (2002). Using cognitive behavioral therapy of schizo-phrenia in a district psychiatric service. In M.C.G. Merlo, C. Perris, & H.D. Brenner(Eds.), Cognitive therapy with schizophrenic patients: The evolution of a new treat-ment approach (pp. 5967). Kirkland, WA: Hogrefe & Huber Publishers.

Kingdon, D.G., & Turkington, D. (2005). Cognitive therapy of schizophrenia. NewYork: Guilford Press.

Kirk, R.E. (1999). Statistics: An introduction (4th ed.). Orlando, FL: Harcourt Brace.Maher, B.A. (1974). Delusional thinking and perceptual disorder. Journal of Indi-

vidual Psychology, 30, 98113.Miley, K.K., OMelia, M., & DuBois, B.L. (1998). Generalist social work practice: An

empowering approach (2nd ed.). Needham Heights, MA: Allyn & Bacon.Miller, D.C., & Salkind, N.J. (2002). Handbook of research design and social mea-

surement (6th ed.). Thousand Oaks, CA: Sage Publications.Morrison, A.P., Renton, J.C., Dunn, H., Williams, S., & Bentall, R.P. (2004). Cognitive

therapy for psychosis: A formulation based approach. New York: Routledge.Mueser, K.T., & McGurk, S.R. (2004). Schizophrenia. The Lancet, 363, 20632072.

doi:10.1016/S0140-6736(04)16458-1National Association of Social Workers (NASW). (1999). Code of ethics of the

national association of social workers. Washington, DC: Author.National Institute for Clinical Excellence. (2003). Schizophrenia: Full national clinical

guideline on core interventions in primary and secondary care. Retrieved July 6,2008 from http://www.nice.org.uk/nicemedia/pdf/cg001fullguideline.pdf

Patterson, J., Albala, A.A., McCahill, M.E., & Edwards, T.M. (2006). The therapistsguide to psychopharmacology: Working with patients, families, and physiciansto optimize care. New York: Guilford Press.

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14


Pharmacotherapy. (2005). Canadian Journal of Psychiatry, 50 (Suppl. 1), 19S28S.Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Orbach, G., &

Morgan, C. (2002). Psychological treatments in schizophrenia: I. Meta-analysisof family intervention and cognitive behaviour therapy [Electronic Version].Psychological Medicine, 32(5), 763782. doi:10.1017/S0033291702005895

Pratt, S.I., & Mueser, K.T. (2002). Schizophrenia. In M.M. Antony & D.H. Barlow(Eds.), Handbook of assessment and treatment planning for psychological dis-orders (pp. 375414). New York: Guilford Press.

Psychosocial interventions. (2005). Canadian Journal of Psychiatry, 50(Suppl. 1),29S36S.

Rathod, S., Kingdon, D., Smith, P., & Turkington, D. (2005). Insight into schizophre-nia: The effects of cognitive behavioural therapy on the components of insightand association with sociodemographics-data on a previously reported ran-domized controlled trial. Schizophrenia Research, 74, 211219.

Rector, N.A. (2004). Cognitive theory and therapy of schizophrenia. In R.L. Leahy(Ed.), Contemporary cognitive therapy: Theory, research, and practice(pp. 244265). New York: Guilford Press.

Rector, N.A. (2005). Cognitive-behavioural therapy for severe mental disorders.Canadian Journal of Psychiatry, 50(4), 245246.

Rector, N.A., & Beck, A.T. (2001). Cognitive behavioral therapy for schizophrenia:An empirical review [Electronic Version]. The Journal of Nervous and MentalDisease, 189(5), 278287. doi:10.1097/00005053-200105000-00002

Rector, N.A., & Beck, A.T. (2002). Cognitive therapy for schizophrenia: Fromconceptualization to intervention. Canadian Journal of Psychiatry, 47(1),3948.

Rector, N.A., Beck, A.T., & Stolar, N. (2005). The negative symptoms of schizo-phrenia: A cognitive perspective. Canadian Journal of Psychiatry, 50(5),247257.

Rosenheck, R., Leslie, D., Keefe, R., McEvoy, J., Swartz, M., Perkins, D., Stroup, S.,Hsiao, J.K., Lieberman, J., & CATIE Study Investigators Group. (2006).Barriers to employment for people with schizophrenia. American Journal ofPsychiatry, 163(3), 411417. doi:10.1176/appi.ajp.163.3.411

Rosnow, R.L., & Rosenthal, R. (2003). Effect sizes for experimenting psychologists.Canadian Journal of Experimental Psychology, 57(3), 221237. doi:10.1037/h0087427

Sheafor, B.W., Horejsi, C.R., & Horejsi, G.A. (2000). Techniques and guidelines forsocial work practice (5th ed.). Needham Heights, MA: Allyn & Bacon.

Soydan, H. (2008). Applying randomized controlled trials and systemic reviews insocial work research. Research on Social Work Practice, 18(4), 311318.doi:10.1177/1049731507307788

Tarrier, N. (2005). Schizophrenia. In M.M. Antony, D.R. Ledley, & R.G. Heimberg(Eds.), Improving outcomes and preventing relapse in cognitive-behavioraltherapy (pp. 306347). New York: Guilford Press.

Tarrier, N., & Haddock, G. (2002). Cognitive-behavioral therapy for schizophrenia:A case formulation approach. In S.G. Hoffman & M.C. Tompson (Eds.), Treat-ing chronic and severe mental disorders: A handbook of empirically supportedinterventions (pp. 6998). New York: Guilford Press.

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14

158 V. L. Gregory

Tarrier, N., & Wykes, T. (2004). Is there evidence that cognitive behaviour therapyis an effective treatment? A cautious or cautionary tale? Behaviour Researchand Therapy, 42, 13771401. doi:10.1016/j.brat.2004.06.020

Thompson, S.G., & Higgins, J.P.T. (2002). How should meta-regression analyses beundertaken and interpreted? Statistics in Medicine, 21, 15591573. doi:10.1002/sim.1187

Turkington, D., Dudley, R., Warman, D.M., & Beck, A.T. (2004). Cognitive-behav-ioral therapy for schizophrenia: A review. Journal of Psychiatric Practice,10(1), 516.

Turkington, D., Kingdon, D., & Trevor, T. (2002). Effectiveness of a brief cognitive-behavioural therapy intervention in the treatment of schizophrenia. BritishJournal of Psychiatry, 180, 523527. doi:10.1192/bjp.180.6.523

Turkington, D., Kingdon, D., & Weiden, P.J. (2006). Cognitive behavior therapy forschizophrenia. American Journal of Psychiatry, 163(3), 365373. doi:10.1176/appi.ajp.163.3.365

Wright, J.H. (2004). Integrating cognitive-behavioral therapy and pharmacotherapy.In R.L. Leahy (Ed.), Contemporary cognitive therapy: Theory, research, andpractice (pp. 341366). New York: Guilford Press.

Wu, E.Q., Shi, L., Birnbaum, H., Hudson, T., & Kessler, R. (2006). Annual preva-lence of diagnosed schizophrenia in the USA: A claims data analysis approach.Psychological Medicine, 36, 15351540. doi:10.1017/S0033291706008191

Wykes, T., Steel, C., Everitt, B., & Tarrier, N. (2008). Cognitive behavior therapy forschizophrenia: Effect sizes, clinical models, and methodological rigor. Schizo-phrenia Bulletin, 34(3), 523537. doi:10.1093/schbul/sbm114

Zimmermann, G., Favrod, J., Trieu, V.H., & Pomini, V. (2005). The effect of cogni-tive behavioral treatment on the positive symptoms of schizophrenia spectrumdisorders: A meta-analysis. Schizophrenia Research, 77, 19. doi:10.1016/j.schres.2005.02.018

Zubin, J., & Spring, B. (1977). VulnerabilityA new view of schizophrenia. Journalof Abnormal Psychology, 86(2), 103126. doi:10.1037/0021-843X.86.2.103

APPENDIX: EXCLUDED STUDIES

Jones, C., Cormac, I., Silveira da Monta Neto, J. K., & Campbell, C. (2004).Cognitive behaviour therapy for schizophrenia. Cochrane Database ofSystemic Reviews 2004, Issue 4. Art. No.: CD000524. doi:10.1002/14651858.CD000524.pub2 (Study lacks an average standardized mean differ-ence effect size for positive and/or negative symptoms)

Pfammatter, M., Junghan, U. M., & Brenner, H. D. (2006). Efficacy ofpsychological therapy in schizophrenia: Conclusions from meta-analyses.Schizophrenia Bulletin, 32(S1), S64S80. doi:10.1093/schbul/sbl030 (Studyprovides a review of meta-analyses)

Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Orbach, G.,& Morgan, C. (2002). Psychological treatments in schizophrenia: I.Meta-analysis of family intervention and cognitive behaviour therapy

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14


[Electronic Version]. Psychological Medicine, 32(5), 763782. doi:10.1017/S0033291702005895 (Study lacks an average standardized mean differenceeffect size for positive and/or negative symptoms)

Sensky, T. (2005). The effectiveness of cognitive therapy for schizo-phrenia: What can we learn from the meta-analyses? Psychotherapy andPsychosomatics, 74, 131135. (Study is not a meta-analysis)

Tarrier, N. (2005). Cognitive-behaviour therapy for schizophreniaAreview of development, evidence, and implementation. Psychotherapy andPsychosomatics, 74, 136144. (A systematic literature search strategy is notconducted or described)

Tarrier, N., & Wykes, T. (2004). Is there evidence that cognitive behav-iour therapy is an effective treatment? A cautious or cautionary tale? Behav-iour Research and Therapy, 42, 13771401. doi:10.1016/j.brat.2004.06.020(A systematic literature search strategy is not conducted or described)

Dow

nloa

ded

by [7

2.252

.115.9

2] at

12:10

03 Ju

ne 20

14

Documents

CBT and Schizophrenia