Customer Reviews

Schizophrenia: Cognitive Theory, Research, and Therapy

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Beck et al. not only provide an excellent, clinically oriented assessment of CBT, but they also provide an incredible discussion on the pathology, etiology, & neuropsychiatry of schizophrenia that I've never before seen. It is clear, concise, and very easy to understand. Other authors tend to get wrapped up in the minutia of neuropsychiatry, but not these! I was amazed at how much better I understood schizophrenia after reading just the first few opening chapters.

This book goes into depth about the psychological aspects of the problems that get diagnosed as "schizophrenia," while integrating that with the latest research, so there's a lot to recommend it. It contains some interesting perspectives and original thinking, and I learned a lot from it, even though I was already pretty well read on the subject. Most of the thinking appears to be top-notch, including both depth and coherence.

But that's not why I'm writing this review. While I was struck by the quality of the thinking in most areas, I found that when it came to discussing the possibility of doing therapy without medications, it suddenly seemed that dogma was taking the place of thinking.

At one point (page 317 to be exact) it is stated categorically that "cognitive therapy alone cannot treat the symptoms of schizophrenia...." On page 305 it is stated that "The use of cognitive and other forms of therapy may lessen the amount of medication needed but not eliminate the need completely." The problem is, this contention flies in the face of actual outcome data in many cases. For example, it's well known that all of the long term outcome studies on schizophrenia show that large percentages of people, 25% or more, manage to get off medication completely and do well. In one of the earlier studies of CBT for psychosis (Kuipers et al. (1997)), at the end of the study 25% of those in the CBT group, but none of those in the control group, were off medication. Many case reports show successful outcomes using CBT with clients who decline to use medication, and having good results. A number of studies using psychosocial only approaches had outcomes at least as good as those achieved by medication treatment (such as the Soteria project.)

To add insult to injury, on page 305 a statement is made implying that the only reason a practitioner might want to treat a person with therapy only, and not medication, is because of a "personal preference." Given that medications cause innumerable negative effects on health, some of which are potentially fatal, and given they often both subjectively and objectively have many negative effects on mental and emotional functioning, it would seem that there really are other reasons a practitioner might want to try therapy without medications in cases where it seems that might work.

So, why do the authors of an otherwise thoughtful book make a claim so at odds with the facts, and then imply that anyone who disagrees with them is somehow morally defective and operating out of simple "personal preference"? I think I detect the heavy hand of politics here - it seems that the authors must have caved in to pressure to not present CBT as a possible alternative to the medical model, but only as a "supplement." Certainly, in many circles, CBT is likely to face easier sailing if it is presented that way. But really, people deserve the truth, even when it makes the establishment uncomfortable, and that's why it is sad that the truth got left out here.

Certainly it is true that we don't have a psychological treatment that in all cases can treat the symptoms that get labeled schizophrenia without the use of medications. But the evidence seems clear, from a huge number of studies (not just the ones I mentioned above) that in many cases, psychological or psychosocial treatment alone can be adequate, and comes without the serious hazards of treatment with medications. These facts argue for a more individualized approach, open to the possibility that some will be able to make it without the medications. It's too bad that the authors of this book did not accept those facts and argue for an individualized approach as well, or discuss the unknowns and conclude that that more research is needed, rather than making a blanket & untrue statement that medications are always necessary.

This is a well researched/written book, which keeps in perspectivet past literature and reseaarch, but forges new ground that could be helpful to the many who suffer from this disorder.