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Cognitive-Behavioral Therapy for
Schizophrenia: Applications to Social
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Virgil L. Gregory Jr. MSW
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Published online: 19 Feb 2010.
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ISSN: 1533-2985 print/1533-2993 online
DOI: 10.1080/15332980902791086
WSMH 1533-2985 1533-2993 Social Work in Mental Health, Vol. 8, No. 2, December 2009: pp. 00 Social Work in Mental Health
Cognitive-Behavioral Therapy
for Schizophrenia: Applications
to Social Work Practice
Cognitive-Behavioral Therapy for Schizophrenia V. L. Gregory
VIRGIL L. GREGORY, JR., MSW
School of Social Work, Indiana University-Purdue University, Indianapolis,
Indiana, USA
Schizophrenia is a psychotic disorder that has been considered to
be the epitome of a severe mental illness. The negative psychosocial
consequences of schizophrenia are well documented. Despite the
advent of antipsychotic medication, residual symptoms persist for
many persons diagnosed with schizophrenia. Cognitive-behavioral
therapy (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-analyses
have supported the use of CBT for schizophrenia. This article
describes and synthesizes the literature to articulate precise appli-
cations to social work practice and the congruence between CBT
for schizophrenia and the social work profession. Limitations of
CBT are also discussed.
KEYWORDS Cognitive-behavioral, schizophrenia, randomized
controlled 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 aspects
of idiographic functioning (Hofmann & Tompson, 2002). Schizophrenia is
associated with lack of employment (Rosenheck et al., 2006), increased risk
for 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: vgregory@imail.iu.edu
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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 show
an ability to decrease positive symptoms, treatment of schizophrenia
switched from psychodynamic therapy to biologically based intervention
(Pratt & Mueser, 2002). Currently, the United States views neuroleptic
(antipsychotic) treatment as the fundamental aspect of intervention for
schizophrenia (Turkington, Kingdon, & Weiden, 2006).
Although neuroleptics have had some success in addressing schizo-
phrenic symptoms and reducing relapse, symptoms persist for numerous
persons (Gould, Mueser, Bolton, Mays, & Goff, 2001). Despite the advan-
tages of neuroleptics, individuals diagnosed with schizophrenia have high
relapse rates (Ilott, 2005). One fourth to half of individuals who adhere to
pharmacological 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% to
30% decrease in symptoms relative to the placebo. In contrast, the FDA
requires that antidepressant medications show a 50% decrease in symptoms.
With regard to the outcome of schizophrenia, . . . approximately 20% make
a 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). For
therapy to have maximum effectiveness, pharmacological intervention for
schizophrenia 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 was
believed that clients with schizophrenia could not be treated with CBT, yet
this is not true (Gould et al., 2001). Cognitive-behavioral therapy has
become 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 United
States (Turkington et al., 2006). Although studies (Bradshaw, 1997, 2003;
Bradshaw & Roseborough, 2004) have provided insight regarding CBT for
social work practice with persons who have schizophrenia, the applicability
of CBT for schizophrenia in social work practice can be improved via
reviewing the theory, practice, randomized controlled trials (RCTs), and
effect 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
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142 V. L. Gregory
large enough to generate statistical power, are the designs that best fit for
the purpose (p. 313). Although the implications of CBT for schizophrenia
are 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 interventions
for schizophrenic symptoms, describe the experimental status of CBT for
schizophrenia, synthesize the literature to articulate precise applications to
social work practice and research, and explicate the congruence between
CBT for schizophrenia and the social work profession.
COGNITIVE-BEHAVIORAL THEORIES OF SCHIZOPHRENIA
Vulnerability
Theories of schizophrenia have been used to explain causal factors, identify
targets 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 certain
level of susceptibility to schizophrenia and the individuals response to
stressful situations will mediate the ultimate manifestation of schizophrenic
symptoms. 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 negative
changes (divorce) as life events. Once schizophrenia has developed, the
vulnerability model suggests that individuals try to adapt via accommoda-
tion or assimilation. Accommodation refers to intrapersonal changes the
individual makes to adjust to environmental demands. Assimilation occurs
when individuals seek to change their environmental circumstances to cope
with stressors. These two processes can either enable or impede adaption
(healthy responses to stressors).
The vulnerability model (Zubin & Spring, 1977) has cognitive-behavioral
implications in that it states . . . it must be remembered that the stress value
of various life events depends on the perception of threat by the individual
(p. 114). Likewise, the cognitive-behavioral model of psychopathology
maintains that affective and behavioral responses are determined by the
individuals 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 and
treatment of clients with schizophrenia.
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Cognitive-Behavioral Therapy for Schizophrenia 143
Auditory Hallucinations
The cognitive model of auditory hallucinations maintains that clients mal-
adaptive beliefs about voices cause undesirable emotional and behavioral
consequences (Chadwick & Birchwood, 1994). Believing that the voices
intend to do harm (malevolent) causes the person to feel emotions such as
sadness, angst, fright, and anger. With regard to behavior, malevolent
beliefs about voices lead individuals to argue with voices, yell, and avoid
stimuli that elicit voices. Chadwick and Birchwoods model also implies that
emotive and behavioral outcomes are influenced by beliefs the client has
about whom the voice belongs to and how much power the voice
possesses.
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-voices
questionnaire (BAQV) (Chadwick & Birchwood, 1995) and were classified
as having malevolent, benevolent (believing the voices have good inten-
tions), or benign beliefs about voices. With regard to the level of distress for
the three different belief systems, there were statistically significant differ-
ences. The malevolent and benevolent groups experienced the most and
least amount of distress, respectively. The study demonstrated that persons
who had malevolent beliefs about their voices had a statistically significant
greater 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 than
participants 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 of
voices (Chadwick & Birchwood, 1994). If clients with schizophrenia
believed 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 literature
regarding 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 individuals
attempt to explain unusual perceptual stimuli (hallucinations). According to
Mahers theory, delusions provide comprehensive explanations that account
for the hallucinations occurrence, origin, and idiosyncratic nature. The
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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 as
an ordinary response to atypical stimuli. The theory does not claim to apply
to all persons with delusions. Cognitive-behavioral therapy seeks to aid the
individual in understanding that the delusion is the following: perceptual
rather than actual, an attempt to explain their experience, accompanied by
behavioral 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 and
suggests that negative symptoms in schizophrenia are partially influenced
by beliefs pertaining to social interaction, pleasure, success, and resources
(Rector, Beck, & Stolar, 2005). In describing and justifying their cognitive
model, Rector and associates rely on published studies. Clients with nega-
tive symptoms are theorized as having beliefs that are antithetical to social
interaction. Such clients are also viewed as having pessimistic beliefs about
their intrapersonal and social adequacy. The cognitive model maintains that
negative symptoms are in part facilitated by the client not expecting to
obtain satisfaction or achievement from potentially gratifying activities. The
authors 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 of
negative 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 of
vulnerability, auditory hallucinations, delusions, and negative symptoms are
only four of the theoretical explanations that have been submitted to
explain symptoms of schizophrenia. These theories were described here
because of the frequency with which they are cited in cognitive-behavioral
literature, 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 by
these theories. Given the cognitive-behavioral theoretical underpinnings of
schizophrenic symptoms, case formulation and CBT are logical extensions.
COGNITIVE-BEHAVIORAL INTERVENTIONS FOR SCHIZOPHRENIA
Cognitive-behavioral interventions for schizophrenia are currently available
in several treatment manuals (Beck, Rector, Stolar, & Grant, 2009; Byrne,
Birchwood, Trower, & Meaden, 2006; Chadwick et al., 1996; Fowler et al.,
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Cognitive-Behavioral Therapy for Schizophrenia 145
1995; Kingdon & Turkington, 1994, 2005; Morrison, Renton, Dunn, Williams,
& Bentall, 2004). Social workers who use cognitive-behavioral techniques to
treat other disorders will be familiar with many of the interventions that are
described in these manuals. For example, common cognitive restructuring
interventions like systematically evaluating the evidence for and against
beliefs (Beck et al., 1979) are used in the treatment of schizophrenia.
Conventional behavioral interventions like behavioral experiments and
activity scheduling (Greensberger & Padesky, 1995) are frequently
employed as well. Table 1 provides a list of cognitive-behavioral interven-
tions and treatments manuals that discuss their application. Table 1 is not
meant to be an exhaustive reiteration of the techniques described in the
cited treatment manuals. Instead, the purpose of Table 1 is to provide social
workers 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 techniques
are classified according to whether they are primarily used to identify and
monitor beliefs, alter maladaptive beliefs, or cope with symptoms. The clas-
sification of the interventions are somewhat relative, as the techniques are
not 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 beliefs
ABC Technique
Downward Arrow Technique
Exposure
Thought records
Challenging maladaptive thoughts and beliefs
Alternative explanations for events
Behavioral experiments
Evidence for and against beliefs
Imagery
Pie charts
Pros and cons of beliefs
Psychoeducation
Relaxation
Coping skills
Activity scheduling
Distraction
Flashcards
Normalizing
Pie charts
Prodrome monitoring
Role-plays
CBT Treatment Manuals: Beck et al. (2009); Byrne et al. (2006); Chadwick et al. (1996); Fowler
et al. (1995); Kingdon & Turkington (1994, 2005); Morrison et al. (2004).
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146 V. L. Gregory
engagement (Haddock & Siddle, 2003). Cognitive-behavioral therapy
must include a strong therapeutic relationship between the clinician and
client (Beck, 1976, 1995). Consequently, the development of therapeutic
rapport is highly important (Kingdon & Turkington, 2002) and the initial
goal of CBT (Tarrier, 2005). The therapeutic relationship is essential to
case formulation and the application of cognitive-behavioral interven-
tions to persons with schizophrenia (Hewitt & Coffey, 2005). Failure to
develop 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 to
be a huge barrier, the process may not be as complicated as it initially
looks (Kingdon & Turkington, 2005). Explicit details regarding how to
build therapeutic rapport are beyond the scope of this article; however
Kingdon and Turkington (2005) have provided a chapter length summary
regarding ways to facilitate the therapeutic relationship with clients who
have schizophrenia.
Cognitive-behavioral therapy is used in the treatment of schizophre-
nia to accomplish specific psychosocial outcomes. Objectives of CBT for
schizophrenia 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 the
clients insight (Kingdon & Turkington, 1994). Insight refers to the clients
acknowledgment that he or she has a psychiatric illness, attribution of
hallucinations and delusions to psychiatric illness, and adherence to
treatment (David, 1990). Cognitive-behavioral therapy for auditory halluci-
nations enhances client insight via assisting the client in recognizing that
the 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 in
conjunction with medical intervention (Psychosocial Interventions,
2005). When used simultaneously, the treatments collectively increase
compliance and communal functioning (Pharmacotherapy, 2005). It is
not currently known if CBT can be effective for schizophrenia in the
absence of pharmacotherapy (Kingdon & Turkington, 2005). Evaluating
the effectiveness of CBT, as a stand alone treatment for schizophrenia,
raises ethical issues (Kingdon & Turkington, 2005). The absence of
research examining CBT as a stand alone treatment is attributable to the
severe 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 to
control groups.
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Cognitive-Behavioral Therapy for Schizophrenia 147
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 focuses
exclusively on meta-analytic studies. Meta-analyses are beneficial to summa-
rizing research because they provide structure to synthesizing data coming
from different studies, report effect sizes rather than probabilities regarding
null 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 (November
2008) 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, randomized
controlled trial, and RCT were used to identify pertinent meta-analytic stud-
ies. Reference lists of the included meta-analytic studies and seminal texts
were reviewed to identify relevant meta-analyses that may not have been
published in peer-reviewed journals.
Each of the meta-analytic studies was subject to inclusion and exclusion
criteria. For a meta-analysis to be included in the current review the following
inclusion 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) the
number of studies using a RCT is reported, (5) the average standardized mean
difference 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 represents
a posttest or pretest to posttest comparison, (7) the statistic used to calculate
the effect size is stated, and (8) a systematic literature search strategy is con-
ducted and described. Meta-analytic studies were excluded if a comorbid
DSM-IV axis I or II disorder was the specific focus of evaluation or if the study
was a review of meta-analyses. Of the ten studies that were identified, four
meta-analyses met inclusion criteria for this review. Excluded studies and
their 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 positive
symptoms of schizophrenia show the CBT cohorts as having small to large
treatment effects. The meta-analytic studies included in this review (Gould
et al., 2001; Rector & Beck, 2001; Wykes, Steel, Everitt, & Tarrier, 2008;
Zimmermann, Favrod, Trieu, & Pomini, 2005) provide insight and support
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Cognitive-Behavioral Therapy for Schizophrenia 149
regarding the efficacy of cognitive-behavioral interventions for positive and
negative symptoms of schizophrenia. Additionally, the meta-analyses are
overwhelmingly composed of experimental studies that encompass an inter-
val of over 25 years. Meta-analyses which incorporate RCTs are optimal
because 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 that
on average CBT had a large effect size for positive and negative symp-
toms, while control groups had moderate effect sizes for the two sets of
symptoms. All seven studies in Rector and Becks analysis were RCTs and
the experimental and control cohorts were all receiving pharmacother-
apy. Gould and colleagues meta-analysis included seven RCTs, yielded a
large effect size at post-treatment, and supported CBTs ability to reduce
the intensity of positive symptoms. Of the seven studies, one study
involved 95% of the participants receiving pharmacotherapy, while all of
the participants in the remaining six studies received pharmacological
intervention.
The meta-analysis conducted by Zimmermann and associates showed
CBT as significantly reducing positive symptoms of schizophrenia. The
study found that at post-treatment, the average participant in CBT had
greater reductions in positive symptoms than 64% of persons in control
groups. Of the 14 studies included in the meta-analysis, 13 were RCTs. To
be included in the Zimmermann and associates meta-analysis a supportive
therapy, treatment as usual, or wait-list control was required. However, the
meta-analysis lacked adequate discussion pertaining to the pharmacological
intervention that control groups received.
The most extensive meta-analysis conducted thus far shows CBT as
having favorable effects on positive, negative, and affective symptoms
(Wykes et al., 2008). Functioning was also shown to be favorably influenced
by 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 and
practices 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 some
of the same studies.
CONCLUSIONS
The theoretical, practical, and empirical aspects of CBT for schizophrenia
have many applications to social work practice. Given the current effect
sizes of the CBT cohorts, there is considerable empirical support for the use
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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 demonstrates
or implies the ability of CBT for schizophrenia to be successfully applied by
social workers. Because the empirical evidence supports the effectiveness
of CBT for schizophrenia, social workers will be operating within the ethics
of 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 of
clients. Yet, social workers should be cognizant of the finding that studies
with 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 wish
to effectively integrate the intervention into social work practice. Clinicians
must have a fundamental comprehension of CBT and experience with CBT
in clients without psychosis (Turkington, Dudley, Warman, & Beck, 2004).
In Bradshaw and Roseboroughs study (2004), the therapists were licensed
clinical social workers (LCSWs) who had masters degrees in social work
(MSWs) and an average of five years in mental health experience. Over a
duration 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 supervision
that 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 fundamentals
of CBT for schizophrenia, it takes at least two weeks of rigorous training
and continual supervision by a CBT expert (Turkington et al., 2006). For
social workers who meet the prerequisite criteria, workshops are available
(Turkington et al., 2004). Treatment guidelines (American Psychiatric
Association, 2004; National Institute for Clinical Excellence, 2003) provide
practical insight into the application and status of CBT for schizophrenia.
The availability of CBT for clients with schizophrenia is dependent on the
accessibility of supervision and administrative support (Turkington et al.,
2004). All factors considered, given the empirical support of CBT for
schizophrenia, social work administrators should seriously consider the
practical and fiscal viability of integrating CBT into their agencys treatment
protocol.
There are several aspects of CBT for schizophrenia that make its appli-
cation among social work practitioners less complicated. To reiterate, many
of the techniques described in the aforementioned treatment manuals are used
to treat other axis I disorders in the Diagnostic and Statistical ManualIV
(DSM-IV). For example, cognitive-behavioral techniques used to treat
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Cognitive-Behavioral Therapy for Schizophrenia 151
schizophrenia are also used to treat other SMIs such as bipolar disorder and
endogenous (biologically based) depression. Additionally, CBT is compati-
ble with other treatments for schizophrenia, such as assertive community
treatment (ACT), cognitive remediation, and family intervention (Turkington
et al., 2004).
For social work practitioners who use CBT to treat persons with schizo-
phrenia, perhaps the biggest clinical advantage to clients is the social
workers ability to substantively influence both intrapersonal and environ-
mental factors. Social work is characterized by its emphasis on individual
functioning in the social environment (NASW, 1999). It is this factor that sets
social work apart from other helping professions (Sheafor, Horejsi, & Horejsi,
2000). The accommodation and assimilation processes that are articulated in
the vulnerability model (Zubin & Spring, 1977) could be facilitated by micro
and macro social work interventions, respectively. Adjunctive social work
interventions to CBT (such as case management, class and case advocacy,
policy formulation, etc.) could positively facilitate the assimilation and
accommodation processes which can contribute to the restoration of
adaption.
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 social
environment 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 management
involves 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 clinician
and case manager (Sheafor et al., 2000). Social workers have claimed to be
the most suitable health profession to perform case-management tasks
(Berger, 2002). When therapy and case-management services are provided
by the same person the advantages include the possibility that: case-
management services may aid the therapist in establishing a therapeutic
relationship with the client, the client will relate better to one person
instead 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 schizophrenia
via advocating for national and organizational policies that increase the
funding, dissemination, adoption, and evaluation of the treatment. The lack
of 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 micro
and macro levels (Haynes & Mickelson, 2000). Indeed, bachelors of social
work (BSW) and MSW programs that are accredited by the CSWE (2008) are
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152 V. L. Gregory
required to teach social work students to utilize research to enhance policy
and the delivery of social services. Consequently, it is certainly within the
professional scope of social workers to improve the availability of CBT for
schizophrenia via advocating for policy change that is connected with the
administration of social services. Such advocacy could ultimately improve
the treatment options available to and well-being of clients.
Social workers should be cognizant of limitations that are associated
with 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 at
post-treatment and at the one-year follow-up. The authors stated that these
results were similar to prior findings by other studies. The evident lack of
research and potential lack of external validity that CBT could have for per-
sons with schizophrenia who are not Caucasian, is noteworthy because
social work places specific emphasis on vulnerable and marginalized
groups (NASW, 1999) such as racial minorities (CSWE, 2008). Factors that
may preclude or diminish the effectiveness of CBT for schizophrenia
include cultural incongruence between the practitioner and client, extreme
paranoia, absence of pharmacological intervention, and severe symptoms
(Turkington et al., 2006). Currently it is premature to conclude that CBT
lacks 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 are
still limitations and issues that require further investigation. Meta-analyses
are needed which directly address the possible effects of moderating and
mediating variables. Such variables are important because they could
provide further explanation regarding the relationship between CBT and
relevant outcomes of schizophrenia (see Frazier, Tix, & Barron, 2004 for
discussion 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 can
be evaluated to account for the variance (Huedo-Medina, Schez-Meca,
Marn-Martnez, & Botella, 2006). Heterogeneity was examined in all of
the included meta-analyses. Tests of heterogeneity were not significant for
three of the included meta-analyses (Gould et al., 2001; Rector & Beck,
2001; Zimmermann et al., 2005). Even when heterogeneity tests are not
significant, meta-regression is a viable option to examine variables that
may 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 by
Zimmermann and colleagues. It would be advantageous if meta-regression
was used to determine the potential moderating impact of the patients
age, marital status, employment status, or race. The meta-analyses provide
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Cognitive-Behavioral Therapy for Schizophrenia 153
scant attention to cultural variables that, at least theoretically, may influ-
ence treatment. The lack of attention to culture in the meta-analyses could
be attributable to cultural variables not being reported in the studies
included in the meta-analyses. The potential moderating effects of race
still require further examination.
Meta-regression or other statistical analyses should be conducted that
evaluate 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 regarding
the effectiveness of CBT administered by clinicians with less experience
(Jones, Cormac, Silveira da Mota Neto, & Campbell, 2004). Meta-analyses
included in this review do not substantively address this issue. Meta-analytic
exploration of the aforementioned moderating and mediating variables may
ultimately clarify and improve the delivery of CBT. It is worth reiterating
that to a great extent, meta-analyses are restricted to the data that is
reported in included studies. Before quantitative reviews can provide the
most effective meta-analytic procedures, the relevant variables must first be
collected and articulated.
This review has detailed the theoretical underpinnings, techniques,
and empirical support for CBT of schizophrenia. The compatibility
between 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 empirical
justification for using CBT in the treatment of schizophrenia; (2) While
issues pertaining to external validity require further investigation, CBT for
schizophrenia is consistent with the social work professions mission and
standards; (3) Cognitive-behavioral therapy for schizophrenia could
be complemented by social works person-in-environment perspective;
(4) Given the aforementioned published outcomes, treatment manuals,
and treatment guidelines regarding CBT for schizophrenia, social work
administrators need to thoroughly consider the actual and potential impli-
cations of providing the treatment to clients served by their agency (see
Bradshaw and Roseboroughs, 2004 for similar discussion); (5) Social
workers have the prerequisite skills to use social policy to advance the
availability of cognitive-behavioral interventions for clients with schizo-
phrenia; (6) The current status of CBT for schizophrenia can be improved
by the production and consumption of research that examines factors that
are germane to social works mission and practitioners. The social work
profession has used treatments that have been shown to not help clients
or has failed to use treatments that demonstrate an ability to help clients
(Soydan, 2008). As it pertains to social work practice, cognitive-behavioral
theory, interventions, and experimental research have been described and
synthesized here to change the latter.
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154 V. L. Gregory
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APPENDIX: EXCLUDED STUDIES
Jones, C., Cormac, I., Silveira da Monta Neto, J. K., & Campbell, C. (2004).
Cognitive behaviour therapy for schizophrenia. Cochrane Database of
Systemic 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 of
psychological therapy in schizophrenia: Conclusions from meta-analyses.
Schizophrenia Bulletin, 32(S1), S64S80. doi:10.1093/schbul/sbl030 (Study
provides 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
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Cognitive-Behavioral Therapy for Schizophrenia 159
[Electronic Version]. Psychological Medicine, 32(5), 763782. doi:10.1017/
S0033291702005895 (Study lacks an average standardized mean difference
effect 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 and
Psychosomatics, 74, 131135. (Study is not a meta-analysis)
Tarrier, N. (2005). Cognitive-behaviour therapy for schizophreniaA
review of development, evidence, and implementation. Psychotherapy and
Psychosomatics, 74, 136144. (A systematic literature search strategy is not
conducted 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)
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