schizophrenia is among the most economically costly and severe medical conditions . because onset is in young adulthood and disability
can last a lifetime , this illness creates tremendous distress , pain and impoverished quality of life for the affected individual and their family .
these additional  costs  are not measurable in monetary terms but provide compelling reasons for developing treatments that alleviate such suffering .
even with best practices , there are limitations to the effectiveness of medications in the treatment of schizophrenia .
relapse rates are high and some individuals remain symptomatic and , despite treatment , functional recovery ( i.e. social relationships , making friends , finishing school , or attending work ) remains a major challenge .
all the evidence suggests that individuals with schizophrenia do best with a combination of pharmacological and psychosocial intervention .
thus , it is critical that we have effective psychological treatment approaches to complement pharmacology . in the treatment of psychiatric problems ,
one of the most widely used and effective psychological treatments is cognitive behaviour therapy ( cbt ) .
traditionally , cbt has been used to treat depression and anxiety , but over the last twenty years it has been adapted to treat psychosis and is gaining recognition as a potentially effective treatment in schizophrenia at all stages of the illness , including the pre - psychotic phase .
cbt aims at modifying the person s non - adaptive thoughts and beliefs in the context of a collaborative working alliance by teaching the link between perceptions , beliefs and emotional or behavioral reactions , questioning the apparent evidence supporting abnormal beliefs , encouraging self - monitoring of thoughts and , teaching effective coping strategies for dealing with distressing symptoms .
in fact , most schizophrenia treatment guidelines have specific recommendations about including cbt as an intervention [ 2 - 4 ]
the second is that , since it is unlikely that cbt could be implemented in regular mental health centers , how can it be implemented so that patients can benefit .
most work has been carried out in academic research centers where highly trained therapists are available .
later it was tested in those at their first episode , and current research has a focus on whether cbt may be the treatment to prevent transition from an at - risk state to full blown psychosis .
to date , over 30 randomized controlled trials of cbt for schizophrenia have been published , demonstrating ( on average ) moderate benefits .
some of these trials did have design problems ; however , the main finding by wykes and colleagues was that the more rigorous the study , the weaker the effect of cbt .
though most have used a more general cbt for psychosis model , focusing on all positive symptoms ( delusions , hallucinations , thought disorder , bizarre behaviour ) , some have specifically targeted a single symptom ( e.g. voices , or paranoid delusions ) , whereas others have still focused on modifying other symptoms linked to schizophrenia , namely negative symptoms ( i.e. apathy , avolition , poverty of content and thought , flat affect )   and psychological distress such as depression or anxiety .
several studies in the meta - analysis by wykes et al .   have begun to address functional outcome ( that is the ability to develop and maintain relationships and to work or attend school ) but only as a secondary outcome to symptoms . some excellent work has demonstrated that cbt can be used successfully to prevent relapse   and to reduce command hallucinations ( i.e. hallucinations that command the patient to perform certain acts ) , which are among the most distressing and high - risk symptoms , and may be dangerous to the patient and others .
despite advocating cbt as a valuable treatment for young people experiencing their first episode of psychosis , there are very few published random clinical trials of cbt with a first episode sample .
one of the most methodologically sound and rigorous trials , the socrates trial in the uk [ 11 - 13 ] , demonstrated that both cbt and supportive therapy produced improved symptoms compared with treatment as usual .
unfortunately , this trial attempted to deliver the treatment over a 5-week period during the acute phase of the illness . in the acute phase it is difficult to determine the effectiveness of cbt relative to that of medications .
similarly , the ace trial from australia   demonstrated that although those receiving cbt showed more rapid improvement , this difference was not sustained .
however , a group trial comparing cbt for psychosis with social skills training for symptom management and with a wait - list control for individuals with early psychosis discharged from the hospital did demonstrate superior improvements for cbt on overall symptoms , as well as on self - esteem , coping strategies and social support .
this suggests that , possibly with these young patients , a group format may be more effective .
a large body of recent research has identified individuals who may be at risk for psychosis   based on the presence of attenuated psychotic symptoms that are often accompanied by a significant decline in social functioning .
there are concerns with using medications in this young group , which make a case for cbt as a treatment for emergent psychotic symptoms as a more acceptable , and presumably safer , first step in preventive intervention .
thus , it is possible that cbt might reduce or avoid the need for drug treatment .
although cbt seems a logical treatment for those at clinical high risk of developing psychosis , there are actually very few studies examining its effectiveness .
early studies had the goal of using cbt to prevent conversion to a full - blown psychotic illness , but later studies began to focus on improving the presenting symptoms and poor functional outcome . in all current studies to date , both the cbt and the control treatment groups appeared to demonstrate some improvement in symptoms .
although the control group also improved , the edie trial in manchester did demonstrate that cbt was effective in reducing conversion .
however , the german network study   reported improvement in both groups in terms of social functioning .
the adapt trial in canada was the first to compare two psychological treatments , but the number of conversions was very low   and both groups improved .
overall interpretation of effectiveness of cbt is difficult in these groups as there are some unique issues studying cbt with this population .
firstly , the number of trials is limited and secondly , the numbers converting are low at times and thus many studies are underpowered .
first , in examining current studies , cbt seems to offer better results when it is offered at specific stages of recovery and when the treatment delivery is adjusted to the stage .
for instance , acute psychosis is not ideal for self - reflection , but following stabilization , individuals with early psychosis might benefit more  initially from group cbt that could help normalize their experience by meeting peers with similar issues .
multiple studies have shown that individuals with more experience with the illness , and who have some degree of realization of their goals and problems , will benefit from individual cbt for psychosis .
older individuals with stabilized psychotic symptoms , who are more likely to be socially isolated with few goal - oriented activities , appear to benefit from a group approach integrating cbt principles with social skills training .
the question is no longer whether cbt for psychosis is effective or not , but rather when should it be offered , to who , and which modality . in terms of who should receive cbt for psychosis ,
currently , it seems to be somewhat random for those who have the opportunity . yet to obtain results above and beyond what , for example , supportive therapy could offer , a certain level of cognitive functioning ( memory , attention , problem solving ) and of social cognitive functioning ( insight , emotion recognition ) might be necessary . in terms of modalities , even within the individual and group approaches , several variants exist , making study comparisons at times difficult .
even though most cbt therapists agree on the essential elements that should be included in cbt for psychosis , there are a range of treatment manuals available with a variety of techniques and philosophies .
for instance , some might be more goal - oriented , whereas others might be problem - focused . individual formulation ( i.e. developing a shared comprehension of the person s cognitive biases and problems based on their past experiences ) is the basis for some cbt therapists , but not for all . furthermore , there are no guidelines as to what may be an adequate dose of cbt .
many studies offer over 9 months of weekly sessions , whereas others offer a few months . in some studies
it has been suggested that those in the cbt groups did not receive an adequate dose of cbt .
the majority of the trials have been conducted in controlled settings , using highly trained expert cbt therapists .
there is emerging evidence suggesting the effectiveness of cbt using  non - expert  cbt therapists , for example , psychiatrists , community nurses , or other mental health professionals .
given the paucity of expert cbt therapists in many mental health settings , training and supervising non - experts in delivering the intervention , albeit perhaps using a structured manual , could be a viable option .
there appears to be a need for a typology of cbt approaches and modalities used in studies , in order to ensure replicability of the results by clinicians in real - world settings .
cbt for psychosis is currently being adapted according to recovery stages and treatment needs . as such , studies underway are investigating combining cbt with other evidence - based approaches such as supported employment , family psychoeducation , motivational interviewing , social skills training , and third - wave cognitive behaviour therapies , such as acceptance and commitment therapy .
more studies are warranted in order to better understand the best moment to offer cbt for psychosis , to whom , and using which modality .
researchers are also investigating process issues in real - world settings , and will perhaps help us understand which aspects of the treatment are essential .
overall , little is known about the moderators of cbt for psychosis , i.e. for whom or under which conditions cbt may work or about the mediators , that is , how cbt might achieve its effects .
baseline patient characteristics , such as cognitive functioning , provide valuable information to help identify which patients might be responsive to a given treatment .
understanding the mechanisms through which treatments work is likely to lead to more effective therapies . to date
, there is no single treatment ( including medication ) for schizophrenia that helps 100% of those receiving it . in the meantime ,
 schizophrenia is one of the major and potentially severe mental illnesses . even with best practices , 
 there are limitations to the effectiveness of treatments that include medications for this disorder . 
 relapse rates are high and often those with the illness remain symptomatic and functionally impaired . 
 all the evidence suggests that individuals with schizophrenia do best with a combination of pharmacological and psychosocial intervention . 
 one psychosocial treatment that has received much attention is cognitive behaviour therapy ( cbt ) . 
 this brief review will address what we know about the use and effectiveness of cbt at all phases of schizophrenia and its strengths , weaknesses and its future . 
Introduction
CBT for schizophrenia
CBT for a first episode of psychosis
CBT in the pre-psychotic or prodromal phase of the illness
More questions than answers?
What next?
Competing Interests