Focusing on social abilities through CBT

CBT can improve social function in schizophrenics. By Lawrence Conway and Professor Douglas Turkington

Schizophrenia is characterised by symptoms such as hallucinations, delusions and thought disorder
Schizophrenia is characterised by symptoms such as hallucinations, delusions and thought disorder

Schizophrenia is a severe mental illness, with 1 per cent lifetime prevalence, which occurs in all cultures. At any time, three or four people in 1,000 show symptoms of the disorder and its treatment.

Although one quarter of first-episode patients make a full recovery, two thirds will experience a fluctuating course with significant disability. Ten per cent face long-term incapacity.

Little is known about the aetiology of schizophrenia, and no single factor, whether genetic, environmental or psychological, has been convincingly shown to be necessary for the disorder to arise.


Schizophrenia is traditionally characterised by positive symptoms (hallucinations, delusions and thought disorder) and a negative syndrome (self-neglect, loss of drive and blunted emotion).

The course of schizophrenia tends to chronic incapacity; typical onset begins in adolescence and effective treatment is difficult.

A diagnosis of schizophrenia can considerably increase the risk of suicide. Patients might also find themselves socially marginalised and developing problems such as drug and alcohol misuse.

Social performance

Clinician-led efforts in the treatment of schizophrenia have focused on social outcomes, which are in turn associated with intact social skills.

However, social functioning has rarely been the primary outcome measure of any randomised controlled treatment trial in schizophrenia. This was due to the lack of a brief, valid and sensitive measure.

The PSP (personal and social performance scale) has been designed to overcome the weaknesses inherent in previous social functioning scales. The scale covers the four principle domains of social outcome: friendliness (lack of aggression), self care, socially useful activities (work) and relationships. The scale does not require specific training, is quick to administer (5–10 minutes) and is sensitive to change.

The PSP is a viable measure of progress for patients with schizophrenia being treated within primary care.


Cognitive behavioural therapy (CBT) for the treatment of schizophrenia is evidence-based, personalised and popular with patients.

It is structured and empowering, enabling the patient and clinician to work together.

CBT destigmatises schizophrenia, improves insight and adherence, and equips patients with the relevant skills to cope with residual difficulties, including the challenges of social rehabilitation.

Some problems experienced by patients with schizophrenia are often common in others; for example, social anxiety and self-defeating behaviours. CBT strategies are therefore already available for such problems.

CBT is differentiated from other psychotherapy approaches in that it addresses symptoms (rather than presumed underlying causes), using techniques that allow patient difficulties to be formulated in testable terms.

Emotional problems in patients with schizophrenia arise from their appraisal of events rather than from the actual events themselves.

Therefore, attending to the personal meaning of events for a person experiencing symptoms of schizophrenia is essential.

Catastrophic misinterpretations of experiences can lock patients into assumptions and beliefs about those experiences, thereby maintaining cycles of emotional disturbance and unhelpful patterns of behaviour.

These misinterpretations are likely to have arisen from formative experiences, for example adversity, marginalisation and trauma.

The goal is to reduce distress associated with symptoms. This is not necessarily done by challenging the patient’s disordered thinking.

It is done by helping the patient to recognise when a thought process is triggering distress so that they can be helped to modify it.

CBT enables a patient to work through the links between his or her cognitions, emotions, behaviour and sensation in order to achieve the desired change.

Therapeutic collaboration that focuses on the symptoms most important to the patient is essential.

CBT by itself will not result in sustained improvements unless the patient’s underlying dysfunctional beliefs are eventually changed.

Transferable skills

Engagement, and empowerment as a result of the patient acquiring transferable skills, may itself reduce symptoms or improve adherence to other aspects of their management.

CBT for schizophrenia is not intrinsically against medication, nor does it deny neurological aspects of the disorder.

However, ultimately improvements in patients’ symptoms may result in less medication, fewer side-effects and increased compliance. 

Mr Conway is a nurse therapist, and Professor Turkington is professor of psychosocial psychiatry at Northumberland, Tyne and Wear NHS Trust


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Case study Alternative treatment for schizophrenic patients

Malcolm presented with paranoid beliefs — he felt both important and at risk. He acted as if people should recognise and respect his ‘specialness’ but at other times he experienced extreme anxiety. His mother often wondered if he was autistic, but he had coped with school and family life.

This changed when he heard voices telling him he was ‘bad’ for secretly smoking. Innocent bodily functions (bowel sounds and constipation sensations) were misunderstood and made meaningful. Frightening images from dreams, together with normal worry about global political instability were recruited into ideas about ‘Armageddon’ and his own role in preventing it.

He avoided all threatening situations and relied on prescription medication to suppress anxiety. He denied aspects of normality that conflicted with his ideas and jumped to unhelpful conclusions on inadequate evidence.

Treatment began by engaging his curiosity about what amplified or attenuated the voices he heard. By wearing a ‘Bluetooth’ headset he found he could challenge the voices without attracting attention.

Learning that alternative interpretations were available (and testable) allowed small shifts in beliefs about the intentions of others. From such insights we worked retrospectively on attributions of past experiences.

Improved stability allowed Malcolm’s social rehabilitation to advance. Positive feedback encouraged lowering of defences and more risk-taking instead of impulsiveness.

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