Cognitive-Behavioral Therapy for Schizophrenia: A Critical Evaluation of Its Theoretical Framework from a Clinical-Phenomenological Perspective

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1 Original Paper DOI: / Received: July 8, 2011 Accepted after revision: August 9, 2012 Published online: October 3, 2012 Cognitive-Behavioral Therapy for Schizophrenia: A Critical Evaluation of Its Theoretical Framework from a Clinical-Phenomenological Perspective B. Škodlar a c M.G. Henriksen b, c L.A. Sass d B. Nelson e J. Parnas b, c a University Psychiatric Clinic Ljubljana, University of Ljubljana, Ljubljana, Slovenia; b Danish National Research Foundation, Centre for Subjectivity Research, University of Copenhagen, and c Psychiatric Center Hvidovre, University of Copenhagen, Copenhagen, Denmark; d Department of Clinical Psychology, Rutgers University, New Brunswick, N.J., USA; e ORYGEN Research Centre, University of Melbourne, Melbourne, Vic., Australia Key Words Cognitive-behavioral therapy Schizophrenia Phenomenology Negative symptoms Delusions Abstract Background: Cognitive-behavioral therapy (CBT) has played an increasingly important role in psychotherapy for schizophrenia since the 1990s, but it has also encountered many theoretical and practical limitations. For example, methodologically rigorous meta-analyses have recently found only modest overall effect sizes of CBT treatment, and therefore questions have emerged about for what and for whom it actually works. Method: The focus of the present paper is to elucidate the theoretical assumptions underlying CBT for schizophrenia and to examine their consistency with abnormalities of experience and self-awareness frequently reported by schizophrenia patients and systematically studied in phenomenological psychopathology from the beginning of the 20th century. Results: We argue that a strong theoretical emphasis on cognitive appraisals with only subsidiary attention devoted to affective and behavioral processes as is characteristic of many forms of CBT cannot satisfactorily account for the complex subjective experiences of schizophrenia patients. We further argue that certain theoretical strategies widely employed in CBT to explore and explain mental disorders, which involve atomization and, at times, a reification of mental phenomena, can be problematic and may result in a loss of explanatory potential. Finally, we provide a detailed account of how negative symptoms and delusions are conceptualized in CBT and consider the question of how these concepts fit the actual phenomenology of schizophrenia. Conclusion: We suggest that further advancement of CBT theory and practice can benefit from a dialogue with phenomenological psychiatry in the search for effective psychotherapeutic strategies for schizophrenia patients. Copyright 2012 S. Karger AG, Basel Introduction During the last 5 decades, cognitive-behavioral therapy (CBT) has become the most widely used form of psychotherapy. It is now recommended as the first-choice psychological treatment approach for nearly all psychiatric disorders. It has been said to be the fastest growing and most heavily researched orientation on the contemporary scene [1]. Since the 1990s, it has played an increasingly important and influential role in psychotherapy for Fax karger@karger.ch S. Karger AG, Basel /13/ $38.00/0 Accessible online at: Prof. J. Parnas Danish National Research Foundation Centre for Subjectivity Research, University of Copenhagen Njalsgade , DK 2300 Copenhagen (Denmark) hum.ku.dk

2 schizophrenia. This rapid spread happened partly because of CBT s pragmatic orientation, operationalized techniques, systematic research (published in major psychiatric journals), ensuring manageable training, and a simultaneous increasing awareness of the need to complement pharmacological treatments with psychother apy. CBT for schizophrenia started with a pragmatic focus on how to bring relief to patients with medication-resistant delusions and hallucinations. Later, the target was broadened to include patients with acute or early psychosis and people at high risk for psychosis, and eventually CBT was advocated for all phases and clinical manifestations of schizophrenia. Many empirical studies have been conducted to test the effectiveness of the approach. The design of these studies shifted from case studies to randomized controlled trials (RCTs), reaching publication thresholds of major psychiatric journals. However, the initial enthusiasm and overall optimism have lately been confronted by two difficulties. The first concerns dilemmas about for what and for whom CBT really works. The second concerns the recently found, relatively modest overall effect sizes of CBT for schizophrenia (in addition to the effect of antipsychotic medication) treatment as usual or other forms of nonspecific psychotherapies [2]. However, it is crucial to bear in mind that other forms of psychotherapy for schizophrenia have not shown better results and have not been studied as systematically as CBT. Precisely because of this systematic research and positive results, CBT brought about a renaissance of interest in psychotherapy for schizophrenia in the scientific community. The purpose of this article is to offer a balanced scrutiny of the theoretical underpinnings of CBT for schizophrenia with the following, more specific, aims: (1) to outline a theoretical framework in order to examine potential connections with other theoretical approaches (e.g. cognitive neuroscience, phenomenological psychiatry); (2) to examine claims of the validity of CBT in terms of implicative relations between, on the one side, the phenomenological architecture of schizophrenia and, on the other, the techniques and theory of CBT (e.g. are CBT counter-delusional techniques consistent with phenomenological accounts of delusions in schizophrenia?); (3) to explore the contribution of CBT to the general understanding and conceptualization of schizophrenia, and (4) to discuss the limitations of the approach imposed by its theoretical premises, which are potentially important for its future development. Our theoretical point of departure is phenomenological psychopathology in the standard use of the term, i.e. the systematic study of subjective experiences in psychiatric disorders, syndromes and symptoms. Phenomenology has a long tradition in schizophrenia research, from Jaspers to a strong revival in contemporary research (see authors like Cutting and Dunne [3], Fuchs [4, 5], Stanghellini [6], Uhlhaas and Mishara [7], Lysaker and Lysaker [8], Ratcliffe [9], Parnas and Sass [10 12] and Nelson et al. [13] ). It offers, in our view, the most comprehensive study of what it is like to experience schizophrenia [14]. It aims at a detailed description of these experiences and is therefore indispensable in any discussion on the theory and praxis of psychotherapy for schizophrenia. This article is divided into 5 sections, as follows: (1) Historical Sources, Relation to Cognitive Psychology and Neuroscience, (2) General Premises and Models in CBT for Schizophrenia, (3) Empirical Validation of CBT for Schizophrenia and, finally, two concrete examples of how psychiatric symptoms are conceptualized by CBT, namely (4) Negative Symptoms and (5) Delusions. Historical Sources, Relation to Cognitive Psychology compared to Neuroscience The earliest CBT report of psychotherapeutically treating a patient with chronic schizophrenia dates back to the early 1950s [15]. Beck s [16, 17] research and theoretical formulations in the 1960s focused on cognitive processes in depression. These very first CBT approaches belong to what is today described as the beginning of the second wave of CBT. The bulk of the development of CBT for schizophrenia, which belongs to this second phase, started in the early 1990s with a strong British leadership [18]. We are aware that CBT for schizophrenia is not an homogenous approach; it has arisen in a number of centers and there are significant differences in how it is conceived and practiced. Nonetheless, we believe that it is possible to extract a set of common elements. Possibly due to their pragmatic orientation, CBT authors (with some exceptions [19] ) often write little about the theoretical underpinnings of their approach and they rarely relate their approach to broader epistemological positions or to other psychological theories of schizophrenia. This can also be said for other forms of psychotherapy for schizophrenia. The main theoretical source for CBT theory is found in Beck s framework for explaining psychological processes in depression [16, 17]. Beck himself credits two authors for inspiring his theory; he adopted a part of the complex theory of personal constructs from George Kelly [20] and the premises of rational therapy 250 Škodlar /Henriksen /Sass /Nelson /Parnas

3 CBT for Schizophrenia: Phenomenological Perspective (later called rational-emotive behavioral therapy) from Albert Ellis [21]. The main assumption of these theories, and also the contemporary CBT for schizophrenia, is that neither the events nor the experiences per se but rather the individual s appraisal, i.e. the view and anticipation of such events and experiences, are pathogenic and influence the development of mental disturbance. In addition to the mentioned cognitive tradition, CBT theory also draws on and employs insights from the traditions of behaviorism and behavior analysis (the latter based on Skinner s radical behaviorism ). The diachronic development of CBT is, as already mentioned, sometimes described in terms of phases, the so-called three waves of CBT [22]. The first wave focuses on behavioral changes following associative learning theory, e.g. token economy and behavioral activation strategies. The second wave primarily tackles cognitive processes, like dysfunctional beliefs and biased information processing, as means to change behavior and emotions. The third wave covers a variety of theoretically diverse approaches (e.g. acceptance and commitment therapy and mindfulness-based therapies), advocating contextual and experiential change strategies in contrast to challenging, testing and analyzing the content of thoughts (as practiced in the second wave). Even though third-wave approaches might be closer to a phenomenological perspective, we nonetheless primarily investigate the second wave, which is so far the most widely used and researched CBT approach for schizophrenia. As noted above, the second wave awoke interest in and systematic research on the efficacy and effectiveness of CBT and psychotherapy in general. The second wave of CBT for schizophrenia coincides partly with the framework of cognitive psychology. Both operate with concepts such as information processing or mental representations, which are conceived as mediators between stimuli and responses (e.g. maladaptive behavior and symptoms of people with mental disorders). This inner play of representations thus creates the interior, originally ignored as the black box of behaviorism. Although several provisional models combining cognitive neuroscience and CBT have been proposed, the authors often do not address any of the fundamental problems of construing such models, e.g. defining the relation between information processing in the brain and subjective experiences (called by Chalmers [23] the hard problem of consciousness) or the personal-subpersonal distinction [24, 25]. Searching for models and construing hypotheses in accordance with new empirical findings are of course crucial, but the relations between neurocognitive impairments, cognitive dysfunctions and patients experiences (such as social anxiety), for example, must be scientifically grounded, not merely postulated [26, 27]. Again, this criticism could be leveled at other psychotherapeutic theories as well. Furthermore, it is questionable how well the CBT conceptualizations match the findings of psychological research, e.g. concerning the complexities of conscious and unconscious mechanisms of goal pursuit; dynamic intertwinements of beliefs, affects and motivation; intricacies of self-reports; beliefs about oneself; diversity or heterogeneity of rationality, and questions of embodied-embedded cognition, rationality of decisions and judgments and coexistence of rational and irrational assumptions [28 32]. All these vividly researched issues of cognitive psychology are underemphasized in the CBT theories of schizophrenia and corresponding models of psychotic symptoms. Though some, more complex, models have been proposed, e.g. the notion of a mode [33], i.e., a network of cognitive, affective, motivational and behavioral components or interacting cognitive subsystems framework [34] framework with discrimination of qualitatively different kinds of information or mental codes, they have not been incorporated into the general theory of CBT for psychoses. Most explanatory accounts in the CBT approach to psychoses take concepts like beliefs, motives, goals, rationality and reality testing as unequivocal. The validity of these elements is taken for granted and conceived as a solid underpinning of our experiential life. However, to give one example of the problem, the concept of reality testing may not pertain to a modular and specific psychological function but rather to a general reflective capacity of a subject and her anchoring in the intersubjective world. According to CBT, patients build a sort of theory of themselves using these elements, which they then more or less consistently follow. The role of the cognitive-behavioral therapist is thus to identify the elements in patients personal theory causing the distress and to help them become aware of these dysfunctional elements and replace them with more functional ones, e.g. beliefs or goals that do not cause distress. Almost all CBT theories of schizophrenia adopt the stress-vulnerability model of mental disorders [19, 27]. They reject both the disease model in the Kraepelinian sense, and frequently also the label schizophrenia as such. Two theoretical justifications for adopting the stress-vulnerability model seem to be accepted: (1) it should provide a theoretical basis for integrating empirical findings and (2) it should give a rationale for psychotherapeutic 251

4 measures by manipulating environmental precipitating factors and enhancing patients coping skills [35]. The most influential for CBT theories was the stress-vulnerability model developed in the early 1980s by Nuechterlein and Dawson [36], which consisted of (1) enduring vulnerability characteristics, i.e. reduced available processing capacity, autonomic hyperreactivity to aversive stimuli and deficits of coping and social competence, (2) environmental stimuli, i.e. social stressors and a nonsupportive social network, (3) transient intermediate states, i.e. processing capacity overload, autonomic hyperarousal and deficient processing of social stimuli and (4) outcome behaviors, i.e. schizophrenic psychotic symptoms. Zubin and Spring [37] defined their vulnerability-stress perspective as a pragmatic second-order model with numerous contributions to an individual s degree of vulnerability, ranging from his genetic inheritance to his acquired propensities. A prominent characteristic of CBT models of schizophrenia is the wide methodological heterogeneity of empirical data gathered under the umbrella concept of vulnerability or diathesis, which in combination with stressors leads to frank psychosis. The models incorporate information from large-scale epidemiological studies on frequencies of individual symptoms or social factors, from diverse studies on etiological factors and from correlations between symptoms and chosen metacognitive concepts or variables of neuropsychological and neuroscientific studies. Such methodological tolerance is appealing, because it induces hope for an homogenous picture of schizophrenia. However, many connections within these models are, as indicated above, mere speculations, e.g. between reduced cognitive resources and delusions [27] or between reasoning processes and delusions [38]. Furthermore, hardly anything is said to clarify the relations between the models. General Premises and Models in CBT for Schizophrenia The fundamental assumption of CBT is that the information processing of external and internal stimuli is biased in mental disorders, thereby causing systematic distortions of the individual s construction of experience [27]. These distortions consist of cognitive errors (biases), dysfunctional beliefs and enduring maladaptive cognitive structures (schemas), where the latter two are stored constructs (representations) of previous experiences. Schemas are defined as stereotyped or repetitive patterns in screening, coding, classifying and evaluating impinging stimuli. It is the schemas that provide the basis on which particular thought contents are formed, i.e. attitudes, beliefs and assumptions [17]. According to Beck [39], when these three types of distortion (errors, dysfunctional beliefs and schemas) occur, they lead to the typical cognitive content of a specific mental disorder. The aim of CBT is thus to change the cognitive errors, dysfunctional beliefs and negative schemas (e.g. beliefs about self-deficiency and negative expectations) that generate the symptoms. As Beck [33] once put it, we need to demonstrate to a patient that a particular belief is wrong or dysfunctional and that another belief is more accurate and adaptive. The symptoms of schizophrenia thus depend on how the patient relates to his perceptions, attributes causation to them, creates beliefs and interprets these beliefs. Such cognitive appraisals are interpreted as generative for a range of symptoms, emotions and behaviors of the patient. Simultaneously, the role of direct, immediate experiences (such as perceptions, sensations, affects or moods) is either seen as secondary or is not addressed at all. Although some authors refer to studies about contributions of certain immediate experiences (e.g. negative life events, trauma and adverse experiences in the family) [40], they do not empirically investigate these contributions, but rather focus on their impact on the cognitive appraisals (e.g. beliefs, attitudes, expectations) or incorporate them into schemas, i.e. enduring sources of cognitive distortions. We can say that these theories are concerned more with the role of maladaptive cognitions than with their origins [41]. From a phenomenological point of view, the attempts to understand mental phenomena by converting them into an interplay between certain (maladaptive) cognitive appraisals fail to grasp and acknowledge the complexity of a patient s lived experience. For example, if a schizophrenia spectrum patient states that she feels profoundly different from other people, we cannot just conceive her statement as a belief that causes anxiety as well as other affects. Such a statement frequently expresses a pervasive and immediate sense of altered self-presence (e.g. a sense of not really existing) and uneasiness when engaging with others [42 45]. These experiences, we believe, can be addressed directly (and not only through cognitive appraisals). We agree that cognitive appraisals of immediate experiences play a role in the configuration of experience, but we disagree with the view that this role is central to or even exclusive for symptom formation in schizophrenia. 252 Škodlar /Henriksen /Sass /Nelson /Parnas

5 Rather than conceiving such appraisals as simply causing affects and behaviors, the latter have in fact been shown to strongly influence the former [46 48]. Since beliefs and appraisals are influenced and changed by emotional states and moods, they are not as consistent and enduring as assumed by CBT and hence they can hardly form a primary target for the psychotherapy of schizophrenia. CBT theories have a tendency to conceptualize emotions as resulting from appraisals and expectations, as a sort of postcognitive phenomenon (for an autocritical evaluation of this position see Safran [47] ). Beck [17], for example, writes: The affective response is determined by the way an individual structures his experience. Thus, if an individual s conceptualization of a situation has an unpleasant content, then he will experience a corresponding unpleasant affective response. Although such a cognitivist conception of emotions as a sort of evaluative judgment is widespread in the philosophy of emotions [49, 50], it is not unequivocally accepted [45, 51]. From a phenomenological perspective, cognitivism faces many difficulties in explaining emotions [9]. For example, Heidegger [52] denied the possibility of sharply distinguishing between emotions and understanding, arguing that our understanding is always attuned by a background of emotions and moods that anchors us in the world. From this perspective, emotions and moods are neither considered evaluative judgments nor accompanying subjective phenomena that color our otherwise objective experiences. On the contrary, emotions and moods constitute our very belonging to the world, i.e. they determine the way the world is disclosed to us, e.g. as threatening or boring [9, 53]. Two main and intertwined theoretical strategies in CBT for observing and measuring mental processes can be identified as atomization and reification of mental phenomena. The first, atomization, is reflected in the single-symptom approach in CBT, an approach that is said to avoid the conundrums of conventional psychiatric classification and diagnosis [35]. The main idea is therefore to study individual symptoms and to discard the ideas of syndromes or disease entities, especially the almost certainly meaningless concept of schizophrenia [54]. The authors conceive syndromes as mere statistical associations between symptoms and criticize the tendency to believe that they [syndromes] carry greater implications [54]. Such an approach leads, we argue, to an atomistic model of mind with symptoms coexisting side by side and having independent itineraries in a person s mind. Bentall [54] claims that by this strategy it should be possible to identify which kinds of cognitive abnormalities are implicated in which symptoms, and to thereby construct a CBT for Schizophrenia: Phenomenological Perspective kind of cognitive table of psychopathological states analogous to the periodic table in chemistry. Two assumptions, both problematic, are implied in this single-symptom approach: (1) that symptoms are readily definable isolated elements similar to basic chemical elements and (2) that in disordered mental states symptoms are traceable like elements in chemical composites. The first assumption was addressed by a leading researcher in the psychopathology of schizophrenia when he wrote: Symptoms are quite complex and therefore their assessment is not likely to be a straightforward and non-controversial matter [55]. Both assumptions, as thoroughly discussed in the phenomenological psychiatric literature (cf. Parnas and Sass [12] ), lead to an approach lacking organizing principles, meanings or interconnectedness of symptoms. By stripping symptoms of their contexts and embeddedness in the patients experiential world, the essence of the symptoms in question can hardly be captured. For example, the grandiose feelings of a successful sportsman are essentially different from the grandiose feelings of a schizophrenia patient, and to study these feelings as two easily comparable experiences seems highly questionable. The second strategy used by CBT for observing and measuring mental processes is reification, i.e. reduction of mental phenomena to object-like entities that can be defined and understood in isolation. In this sense, mental phenomena are interpreted as independent objects with readily definable properties, akin to physical objects in the world, e.g. a chair or an orange. For example, persecutory delusions are defined as threat beliefs that meet two criteria: firstly, the individual believes both that harm is occurring, or going to occur, to him or her, and the individual believes that the persecutor has the intention to cause harm [56], and secondly, the beliefs have various characteristics (e.g. resistant to change, preoccupying, distressing) [57]. From a phenomenological perspective, it is crucial to go beyond such limited definitions and to consider the larger subjective context in which delusions occur and are experienced; otherwise an essential quality of consciousness its meaningful unity is ignored. When the above-mentioned features of persecutory delusions are treated as features or dimensions that happen to be correlated, for instance, there is a failure to appreciate the essential intertwining of qualities that actually exist in relationships of mutual implication. Persecutory delusions do not simply occur as isolated beliefs within the stream of experiences. Rather, they are experiences of an already altered sense of reality stemming from overwhelming feelings of profound anxiety and uneasiness. 253

6 If we want to get behind these mere external characteristics into the psychological nature of delusion, argued Jaspers [58], we must distinguish the original experience from the judgment based on it. One of our patients, recalling his persecutory delusions, defined them as attempts to explain a very deep restlessness, as an attempt to seek rescue in a story in which you eventually get lost. In contrast to the reification-based definition of persecutory delusions in CBT, our patient s definition brings us closer to the phenomenon of persecutory delusions, since it provides an account of how they are experienced from a first-person perspective. By applying these strategies, i.e. atomization and reification, mental phenomena become easily describable and measurable and thus readily available to be studied quantitatively. However, in this process, mental phenomena are sequestrated into isolated parts and subsequently compared as independent entities, which can lead to superficial and spurious results. For example, some CBT studies of suicidality [59 61] claim that hopelessness, suicidal intent and the index of wish to die versus wish to live are independent key predictors of ultimate suicide, while studies of persecutory delusions claim that high levels of anxiety, worry and catastrophising were associated with high levels of persecutory delusion distress [62]. Neither of these examples seems to offer much explanatory power. Of course, we do not disagree that suicidal intent, index of wish to die versus wish to live and feelings of hopelessness are predictors of ultimate suicide; we just claim that this is what it means to be suicidal, and that the results therefore add little, if anything, to the understanding of suicidality. The two examples illustrate how atomization and reification can lead to questionable correlations between supposedly separate components that, in fact, might better be understood not as independent components but as aspects of the same overall phenomenon. Additionally, treating aspects of the same phenomenon as separate entities leads to an unnecessary expansion of terms and blurs the picture of the studied phenomenon. Another, not unproblematic assumption incorporated in CBT is a normalizing attitude, which is an explicitly recommended strategy in the majority of therapy manuals. The basic idea is that psychotic symptoms are widely distributed in the general population and that the manifest psychosis and its chronic manifestation, schizophrenia, are but exaggerations of experiences and traits that are universally present. However, it is worth remembering that schizophrenia sufferers often report that some of their experiences are not merely exaggerations or variations of normal experiences [63, 64] ; as Schreber [63] once wrote, matters are dealt with that lack all analogies in human experiences. Furthermore, recent empirical studies have found specific alterations of the structure of experiencing in early phases of the illness, and these results show significant differences between schizophrenia spectrum patients and non-spectrum individuals [65]. Although the normalizing attitude can be comforting for patients as well as their families and may have antistigmatizing effects, it should not prevent researchers from seeing the specificity and severity of schizophrenic experiences. Finally, some CBT authors stress the importance of formulation-based [35] and person-based [66] approaches in cognitive therapy for schizophrenia. According to them, a therapist must explore the full range of symptoms and the patient s history, including sources of distress and positive strengths, in order to formulate an individualized treatment plan. This, of course, is a widely accepted view in most psychotherapeutic approaches, cognitivebehavioral and otherwise. However, it does not do much to address the above-mentioned general traits of the CBT approach. Whether the third-wave approaches, like acceptance and commitment therapy [67] or mindfulnessbased [68] approaches for schizophrenia, which in our view seem promising and relevant, will solve some of the above-mentioned dilemmas remains to be seen. Empirical Validation of CBT for Schizophrenia If we leave aside theoretically ambiguous case reports [15], the empirical validation of CBT for schizophrenia started with pilot and feasibility trials and RCTs from 1990 onwards. From the beginning of the 2000s, metaanalyses of rapidly accumulating studies started to provide a systematic overview of the field [2, 69 74]. These meta-analyses found the mean effect sizes of CBT for schizophrenia to range from 0.21 to The only symptoms consistently reported in the studies as reduced were persistent, distressing and medication-resistant positive symptoms [2, 69, 73, 74]. The effects are much lower than reported in earlier trials, which has been explained by the lack of masking of the group allocation [2] and tendentious reporting [75]. Unblinded studies tend to be too optimistic about the effects of CBT, with effect sizes % higher than those found in blinded studies [76]. Lower effect sizes due to improved methodology are found in other psychotherapy studies as well as in other branches of medicine, even if the disorders and treatments studied are less complex than in the case of schizophrenia. 254 Škodlar /Henriksen /Sass /Nelson /Parnas

7 CBT for Schizophrenia: Phenomenological Perspective Almost all studies and meta-analyses conclude that specific mechanisms responsible for the observed therapeutic effects need to be addressed in future studies. Some researchers argue that these effects are due to the specific focus of CBT on dysfunctional beliefs [15]. Meanwhile, studies of CBT treatment of depression suggest that improvement in depression is more likely attributable to the behavioral activation elements of the treatment and not to belief modification techniques [77]. A thorough review of component studies of CBT for depression and anxiety disorders found that the effectiveness of treatment could not be ascribed to cognitive interventions; i.e. cognitive components were found not to provide added value to behavioral components [78]. It has been suggested that the same occurs in CBT for schizophrenia [79]. For example, Tarrier and Wykes [76] in their meta-analysis found a trend in favor of the more behavioral procedures, in contrast to more cognitive ones. However, a meta-analysis by Lincoln et al. [80] focusing on cognitive interventions for schizophrenia found that the amount of cognitive interventions was positively correlated with the before/after effect sizes. Interestingly enough, meta-analyses have shown moderate effects on negative symptoms, functioning, mood and social anxiety [2], despite a lack of theoretical rationale for these effects. One explanation for these unexpected effects may be the more general focus of CBT actually delivered in practice, which is adapted from CBT interventions for depression and anxiety. For example, the authors of a recent well-designed and methodologically rigorous RCT of CBT and family intervention for relapse prevention and symptom reduction stated: It was sometimes difficult, in the absence of symptoms or of distress, to maintain a clear focus on the positive psychotic symptoms for which generic CBT for psychosis is best established. Instead, therapists covered a wide range of self-reported problems and symptoms, adopting a general approach to emotional distress [81]. This finding is consistent with studies comparing CBT for schizophrenia with some other treatment modalities performed in RCTs in order to exclude nonspecific effects of psychotherapy, such as supportive counseling, befriending and problem solving. Though some studies have shown results in favor of CBT [82 84], a thorough meta-analysis concludes that not one study has shown clear and significant overall differences between CBT and the nonspecific control groups [76]. Furthermore, the treatment modalities in control groups were newly designed and theoretically inert, so to date, no quality RCT has compared CBT for psychosis to another theoretically different but empirically supported intervention [85]. Hence, we cannot exclude the possibility that the overall effectiveness of CBT does not depend strongly on specific cognitive interventions but rather on more general therapeutic factors such as a trustful and respectful relationship with the therapist [86]. In contrast to some individual studies [87], a recent meta-analysis found no effect of CBT for reducing either relapse or hopelessness [2]. Indeed, significant correlations were found between improvements (i.e. a decrease) in positive symptoms and a worsening of hopelessness [2]. There is evidence that improvements in positive symptoms and emerging hopelessness related to awareness of illness are associated with increased suicidality [44, 88, 89]. A cautionary therapeutic implication can be drawn from these findings, namely that a primary focus on positive symptoms and corresponding improvement of those same symptoms may not necessarily result in a satisfactory clinical outcome. Clinical research directed toward a more adequate consideration of the affective dimensions of patient recovery is needed and is in fact emerging [90, 91]. An important and to some extent unavoidable dilemma of the research on psychotherapy of schizophrenia, especially in the form of RCTs, is what type of patients are studied. In this illness, in which patients overall motivation, interests, goals and insight are pervasively at stake, additional care and attention to this problem is needed. In early studies of CBT for schizophrenia that showed very positive results, predominantly help-seeking patients with distressing positive symptoms were studied. In the period of RCTs and meta-analyses that have shown more moderate effect sizes, a broader population of patients was recruited. However, even in these RCT studies, researchers obtained informed consent from a low percentage of the recruited patients; in the case of the aforementioned study by Garety et al. [81], it was only 44%. The exclusion criteria were, among others, lack of disclosure of symptoms and refusal to participate in treatment [69]. Hence, the question of how representative these samples are for the whole range of schizophrenia patients remains open. It is therefore not unlikely that the patients who are the most ill may be unable to participate or to benefit from this approach [69]. Consistent with this view, it has been reported that patients with insight, i.e. patients willing to consider that their beliefs may be wrong, are most likely to respond to CBT [92]. Now, we will discuss two concrete examples of how symptoms are conceptualized in CBT. 255

8 Negative Symptoms In the CBT theories, less consideration is devoted to the so-called negative symptoms compared to positive symptoms. As Rector et al. [93] remarked: To date, there has been very little psychological theorizing or experimentation on the negative symptoms of schizophrenia, and there are gaps in the empirical evidence for our proposed perspective. The origin of the distinction between negative and positive symptoms is mixed, but it is at least partly inspired by Hughlings Jackson [94], who distinguished between negative symptoms as direct consequences of brain damage (deficits) and positive symptoms as secondary sequels of dissolution resulting in disinhibition or release phenomena. The primary phenomenological source of the concept of negative symptoms is Eugen and Manfred Bleuler s concept of the fundamental symptoms, especially the concept of schizophrenic autism [95, 96]. Many continental psychiatrists consider autism as a generative, essential core of the psychopathology of schizophrenia. It comprises expressive features (e.g. flat affect, bizarre rapport, isolation, formal thought disorder) and experiential aspects (e.g. unstable first-person perspective, hyperreflexivity, inability to immerse oneself in the intersubjective world) [12, 97]. From DSM-III onwards [98], the negative symptoms comprise assumed deficits, often indicated by the deprivative, i.e. alogia (poverty of speech), avolition, amotivation, anergia, anhedonia and asociality, in addition to a lack of affect (affective flattening) and, sometimes, attentional problems [99, 100]. CBT conceives the negative symptoms rather inclusively, both as emotional and behavioral disorders, resulting in addition to neurocognitive impairments from certain beliefs, appraisals or expectations [93]. It is common, in cognitive science, to distinguish between direct, unmediated experiences, such as perception, sensation, feelings and mood change, and more sophisticated cognitions such as reflective, thematic evaluations. CBT operates here from a sort of anti-jacksonian perspective; the positive symptoms (i.e. delusions and hallucinations) are seen as central, causally primary expressions of schizophrenia, in contrast to the original conceptualizations of Hughlings Jackson [94] : I submit that disease only produces negative mental symptoms, answering to the dissolution, and that all elaborate positive mental symptoms (illusions, hallucinations, delusions, and extravagant conduct) are the outcome of activity of nervous elements untouched by any pathological process. According to the CBT model, the crucial (propositionally structured) cognitive distortions comprise (1) social aversion or disinterest (i.e. negative attitudes toward social engagement), (2) defeatist beliefs regarding performance (i.e. overly generalized negative conclusions about one s own performance) and (3) low or negative expectancies for pleasure and success [27, 93]. The CBT therapeutic strategies for negative symptoms take these as targets, trying to diminish them through psychoeducation, changing of beliefs and expectancies, and instigating activation strategies [27, 35]. Some studies report correlations of medium effect size between these distorted appraisals and the severity of negative symptoms, e.g. between defeatist beliefs regarding performance and negative symptoms [101, 102] or between social disinterest attitudes and functional disability [103]. Although not always explicitly stated, the CBT models of negative symptoms conceive the correlations between distorted appraisals and negative symptoms as evidence of a causality, e.g. the cognitive model of negative symptoms posits that dysfunctional beliefs, including negative beliefs about performance [ ] are key factors in the development and maintenance of negative symptoms [102]. From this perspective, defeatist beliefs cause social avoidance and apathy [27] ; in addition, low expectancies for success cause amotivation [93]. Such causal implications are furthermore clearly reflected in the treatment strategies. Nonetheless, there are also models that endorse circular and not only unidirectional causality [104]. However, an at least equally plausible interpretation of these correlations is that the distorted appraisals are consequences of negative symptoms. From a clinical and phenomenological perspective, this latter interpretation seems more likely. Negative symptoms are temporally anterior to and more stable across time than positive symptoms [105, 106]. They are present in the prodromal and early psychotic phases of the illness [107]. Studies have shown that they are a reliable prognostic factor for social and vocational functioning, independently of positive symptoms, as well as for the quality of life of schizophrenia patients [ ]. Given these empirical findings, it seems more plausible to conceive this enduring and pervasive symptom domain (i.e. negative symptoms) as a cause rather than a consequence of certain appraisals or beliefs. Moreover, there is a rapidly growing body of empirical literature suggesting a temporal and psychopathological primacy of the experiential aspects of negative symptoms, namely anomalies of self-awareness, self- 256 Škodlar /Henriksen /Sass /Nelson /Parnas

9 presence (sense of basic self-coincidence or identity) and correlated problems with immersion in the intersubjective meaningful world [10, 43, 44, 65, ]. In phenomenological studies, negative symptoms of schizophrenia are conceived as manifestations of profound alterations in the patients sense of self, others and the world [10, ]. From such a perspective, the definition of negative symptoms as straightforward deficits or lacks of certain psychological functions or behaviors (cf. Andreasen [99] ) is problematic, because it fails to grasp the quality and the role of the experiences underlying and generating these symptoms. These may involve qualitative alterations of various kinds, which are, in this simple dimensionality, in fact positive ( too much ) phenomena, e.g. instability of the first-person perspective, thought pressure or perceptual disorders [100, 117, 118]. Even more problematic is the reduction of negative symptoms to consequences of certain beliefs or negative expectations. For example, when patients isolate themselves from others, it is not at all obvious that this is due to a privative process of withdrawal or a simple consequence of low expectancies for pleasure or success. Rather, the patients isolation may also grow from the inside, resulting in a solipsistic world, or the patients may isolate themselves due to underlying and overwhelming feelings of anxiety and exposure, which make any interpersonal contact unbearable. Another typical example in the literature is low self-esteem. However, in many schizophrenia patients low self-esteem reflects not merely certain beliefs about one s performance, such as seeing oneself as a failure or having negative expectations for success and pleasure. More frequently, the low self-esteem of these patients reflects a more primary and pervasive experience of being radically different from other persons, typically involving a profound lack of interest, i.e. of vital force of self-presence, that precedes any explicit self-appraisal, interpretation or belief [44, 53, 114]. From this perspective, activation strategies such as participation in daily routines, sports and groups recommended also in CBT may have a strong therapeutic effect on negative symptoms in addition to modifying dysfunctional cognitive appraisals. In summary, CBT appears not to have appreciated the full range of subjective experiences associated with negative symptoms but has focused on propositionally structured negative beliefs and anticipations. Moreover, it seems that many crucial first-person phenomena that are generative of negative symptoms have somehow fallen out of its theoretical and empirical considerations. CBT for Schizophrenia: Phenomenological Perspective Delusions As already indicated, delusions are by far the most investigated symptomatic domain of schizophrenia within the CBT literature. Many studies report a positive effect of the CBT approach for delusions. Obviously, we find this fact crucial. The following paragraphs intend only to shed some additional light on what the mechanisms might be that play a role in the treatment of delusions. In CBT, delusions are primarily conceptualized as false or dysfunctional beliefs, determined by cognitive biases involving distortions of information processing [27, 104, 119]. In other words, delusions are seen as dysfunctional aspects of the so-called theoretical rationality, i.e. inference-based logical and probabilistic reasoning. Three main sources of such distortions have been suggested (not only in CBT but also in mainstream Anglophone psychiatry) as possible pathogenetic mechanisms (and typically considering delusions as a homogenous phenomenon) [27, 38, 120] : (1) jumping-to-conclusions data gathering bias; (2) externalizing attributional (explanatory) style, and (3) theory of mind deficit. Although other contributing factors are recognized (e.g. anxiety, negative schemas, anomalous experiences), they do not play a primary or prominent role in the proposed CBT models. We will now briefly address the three postulated mechanisms. The evidence supporting the role of a jumping-toconclusions bias in delusion formation is inconsistent. Several studies have shown that schizophrenia patients tend to seek less information to reach a decision. This tendency is not considered to be a bias of probabilistic reasoning, since the patients are able to estimate probabilities, but rather as a data gathering bias whereby patients hastily accept hypotheses without collecting a sufficient amount of evidence to support them [ ]. However, other studies have not found a jumping-toconclusions bias to be associated with delusions [124, 125]. Furthermore, a recent meta-analysis of jumpingto-conclusions studies found no support for the hypothesis that this bias plays a role in delusion formation or maintenance [126]. Nonetheless, hasty data gathering or jumping to conclusions has been found in subjects in an at risk mental state, i.e. exhibiting a putative risk for psychosis [127], and in individuals at risk for delusions [128], as well as in schizophrenia patients whose delusions have remitted [129]. However, in our view these results do not imply that jumping to conclusions is a pathogenetic mechanism for 257

10 schizophrenia. Rather, jumping to conclusions is simply constitutive (is a part of) of the clinical judgement of the patient as being delusional or predelusional. In other words, when you interview a patient whom you suspect of harboring a delusional or predelusional ideation, her logical style of jumping to conclusions will amplify or strengthen your diagnostic hunch. An externalizing attributional style, i.e. the tendency to attribute negative events to external causes, also lacks consistent support as a mechanism in delusion formation. While some studies have found an association between such an explanatory style and delusions [ ], other studies have not replicated these findings [125, ]. Moreover, several studies challenge the hypothesis that an externalizing attributional style is a primary mechanism in delusion formation. One study found an externalizing attributional style to be exaggerated in patients with a lower severity of symptoms [138]. Another study found the opposite, namely an internalizing attributional style in some schizophrenia patients [137]. In fact, the opposition between externalization and internalization seems to mirror the basic cognitive epistemic mechanisms of assimilation and accommodations, described by Meissner [139] in paranoid and schizophrenic processes. The overall empirical support for the externalizing hypothesis therefore remains uncertain [57]. We wish to again draw attention to the clinical fact that certain aspects of the externalizing style, the so-called projective aspects, constitutively contribute to the diagnosis of delusional or predelusional states, as was the case with jumping to conclusions [140, 141]. A more complex problem faces the third hypothesis for delusion formation, i.e. the theory of mind deficit. Theory of mind refers to the cognitive capacity to represent one s own and other persons mental states (beliefs, desires, feelings, intentions); it is hypothesized to be deficient in schizophrenia patients and infantile autism [142, 143]. Basically, this hypothesis claims that schizophrenia patients have difficulties in attributing mental states and motives to others and in seeing things from another person s perspective. While some studies show an association between theory of mind deficits and delusions [135, ], others show no such association [148]. Several studies of theory of mind deficit in schizophrenia found associations between theory of mind deficit and negative symptoms or thought disorders, but not with delusions [ ]. Furthermore, a detailed study of schizophrenia patients in real-life clinical interactions showed no theory of mind deficit; the patients speech clearly showed awareness of the existence of other perspectives; the patients were well aware that their beliefs were different from those of others, and they recognized that their justifications were unconvincing and not understandable for their interlocutors, but nonetheless they did not modify their beliefs [152]. Zahavi and Parnas [153] emphasized the fact that the available first-person accounts from patients with schizophrenia and infantile autism contradict a hypothetical sequel from a deficit in the theory of mind. As already noted, other contributing factors for delusion formation are also discussed in the CBT literature. Recent models of delusion formation refer not only to cognitive biases but also to affective disturbances (anxiety, depression, low self-esteem), dysfunctional schemas (core beliefs about oneself, others and the world) and anomalous experiences [119, 154], but these are seen as additions to the main deficits of the theoretical rationality. Though these factors are probably operative in delusion formation, they are neither defined or described in the CBT literature, nor are their positions clearly articulated in the CBT models [27, 38, 57]. For example, a recent CBT model incorporates Maher s well-known hypothesis of delusions as explanations of anomalous experiences (put forward by Wernicke [155] as Erklärungswahn ), but no definition or description of anomalous experiences in schizophrenia is provided, either originally by Maher [156] or by Freeman [57, 119]. The authors cite epidemiological studies concerning the presence of anxiety in different phases of schizophrenia and write that anxiety is given a central role in the model [119]. However, they do not explain either the relation between anxiety and persecutory delusions or why anxiety should be central to the formation of delusions. From a phenomenological perspective, the relationship between delusions and anxiety (distress) is assumed to be complex, given that patients experience overwhelming anxiety before, during and after the delusional phase. Contrary to the majority of CBT theories, which often conceive anxiety as a consequence of delusions, patients frequently report that they found relief in their delusional grasp of their stressful, anomalous experiences. The most comprehensive study along these lines is by Klaus Conrad [157] on 117 cases of beginning schizophrenia. It clearly shows that anxiety is a part of what Conrad dubs the Trema (stage fright), an initial phase of schizophrenia with intense anxiety and perplexity, both receding at the crystallization of delusions (see also Jaspers [58], for a description of delusional mood and delusion formation). Furthermore, when delusions recede, patients often report feeling empty, isolated, frustrated and depressed, 258 Škodlar /Henriksen /Sass /Nelson /Parnas