COGNITIVE GROUP THERAPY FOR PARANOID SCHIZOPHRENICS:

APPLYING COGNITIVE DISSONANCE

Joseph Levine Yoram Barak Ilana Granek

JOSEPH LEVINE Associate professor (BGU)

EDUCATION 1957 -1969 Elementary School (Beit Yehezkel), and high school (Tager

High School), both in Ashkelon, Isreal. Tel-Aviv University, MD,

Tel-Aviv University, M.A. Sci in Physiology– Pharmacology (Cum Laude)

Tel-Aviv University school of psychotherapy (3 years of studies and training in psychotherapy)

Tel-Aviv University school of psychotherapy (2 more years of advanced studies in family therapy)

Tel-Aviv University Senior Medical Administrative Certificate administered by

Post Graduate Institute of Education of Kupat Holim

WHAT IS THE MOTO OF COGNITIVE THERAPY ?

Aaron T. Beck, M.D.You feel the way you think

THOUGHTS FEELINGS

Leon Festinger

Cognitive dissonance is a condition first proposed by the psychologist Leon Festinger in 1956, relating to his hypothesis of cognitive consistency.

COGNITIVE DISSONANCECOGNITIVE DISSONANCE

• Cognitive dissonance is a state of opposition between cognitions. Cognitive dissonance is a perceived inconsistency between two congnitions in which the person believes one thing but then acts in a different way from what they believed. For the purpose of cognitive dissonance theory, cognitions are defined as being an any element of knowlege attitude,emotion, beleif or value, as well as a goal, plan, or an interest. In brief, the theory of cognitive dissonance holds that contradicting cognitions serve as a driving force that compels the human mind to acquire or invent new thoughts or beliefs, or to modify existing beliefs, so as to minimize the amount of dissonance (conflict) between cognitions.

Further propositions by Festinger

• Festinger proposed that cognitive dissonance is a "negative drive state", a similar psychological tension to hunger and thirst and that people will seek to resolve this tension.

• Reduction of cognitive dissonance may be good because one feels better, and because one can come closer to consonance by eliminating contradictions. On the other hand some of the ways of reduction of cognitive dissonance involve a distortion of the truth, which may cause wrong decisions. The harder way of changing favourable cognitions may in the longer run be better

• When confronted with two beleif cognitions that contradict each other, Festinger suggests the dissonance can be resolved by finding and adding a third piece of information relevant to the two beliefs. For example, if Sam believes that elected officials are trustworthy, but also believes that elected officials have broken his trust, then the cognitive dissonance can be resolved by discovering that all elected officials lie. This enables Sam to (it is to be hoped)to still hold that elected officials are still largely trustworthy, but that they also all lie.

• If dissonance is experienced as an unpleasant drive state,the individual is motivated to reduce it. Now that the factors that affect the magnitude of this unpleasantness have been identified, it should be possible to predict what we can do to reduce it:

• Changing Cognitions • If two cognitions ar discrepant, we can simply change one to make it

consistent with the other. Or we can change each cognition in the direction of the other.

• Adding Cognitions • If two cognitions cause a certain magnitude of dissonance, that magnitude

can be reduced by adding one or more consonant cognitions. • Altering importance • Since the discrepant and consonant cognitions must be weighed by

importance, it may be advantageous to alter the importance of the various cognitions.

• The material above is the background reading for the Cognitive Dissonance Lab. These are excerpts from Frederick M. Rudolph¹s page on Social Psychology. For a more detailed discussion on cognitive dissonance and related theories, visit

• The main criticism of the cognitive consistency hypothesis is that it is impossible to verify or falsify by experiment. Even so, experiments have attempted to quantify this hypothetical drive. Opponents of this hypothesis cite the apparent ability of many human beings to reconcile mutually exclusive or contradictory beliefs with no apparent stress, though the original theory would suggest that such beliefs were not psychologically important.

Cognitive Therapy with Schizophrenia

• The misinterpretation of events in the world is common in schizophrenia. Using cognitive therapy with schizophrenia requires the psychologist to accept that the cognitive distortions and disorganized thinking of schizophrenia are produced, at least in part, by a biological problem that will not cease simply because the "correct" interpretation of reality is explained to the client.

• Cognitive therapy can only be successful if the psychologist accepts the client's perception of reality, and determines how to use this "misperception" to assist the client in correctly managing life problems.  The goal is to help the client use information from the world (other people, perceptions of events, etc.) to make adaptive coping decisions.

• The treatment goal, for the cognitive therapist, is not to "cure" schizophrenia, but to improve the client's ability to manage life problems, to function independently, and to be free of extreme distress and other psychological symptoms

• Over the past 10 years, CBT for schizophrenia has received considerable attention.

• In this treatment, patients are encouraged to identify beliefs and their impact and to engage in experiments to test their beliefs. Treatment focuses on thought patterns that cause distress and also on developing more adaptive, realistic interpretations of events.

• Delusions are treated by developing an understanding of the kind of evidence the person uses to support the belief and encouraging the patient to recognize evidence that may have been overlooked that does not support the belief.

• Furthermore, the assumed omnipotence of "voices" is tested, and patients are encouraged to utilize various coping mechanisms to test the controllability of auditory hallucinations

Schizophrenia- paranoid type

COGNITIVE GROUP THERAPY FOR PARANOID SCHIZOPHRENICS: APPLYING COGNITIVE DISSONANCE

Joseph Levine M.D. M.Sc1,

Yoram Barak M.D.2 Ilana Granek M.A.2

• Bloch in 1993, reviewed the current state of cognitive strategies in schizophrenia and stated: "... recent studies have suggested that systematic cognitive interventions aimed at reducing the convictions with which these beliefs, (delusions), are held, may be more successful than conventional wisdom would suggest". (3).

• Further support for this unorthodox approach was supplied by Perris in his 1989 book entitled: "Cognitive therapy with Schizophrenic Patients". (4). Perris stated that: "It must be emphasized that cognitive psychotherapy can, when used in individual format, represent an answer to the search for a known reductionstic psychotherapeutic approach that takes into account the heterogeneity of the schizophrenic disorders and allows therapists to cope with their complexity". (4).

• In the last few years several studies have been published describing the use of cognitive approaches in the treatment of delusional patients. Among these, two studies evaluated the efficacy of individual cognitive psychotherapy in reducing the conviction with which delusional beliefs are held (5,6).

• Lately, our team has published a single case study wherein cognitive dissonance was the tool for inducing change in a schizophrenic patients' paranoid system (7). and a theoretical model, illustrated by a case report and preliminary results of applying such a model in several additional schizophrenic paranoid patients (8). These cases (7,8) althought mainly treated by individual therapy made use of structured pressure, induced by a group serving as a vehicle enabling the inducement of cognitive dissonance. Although non ‑ supportive group therapy is not recommended as a mode of therapy in paranoid schizophrenics. This technique was well accepted by the patients.

• However, all the above mentioned studies, (5‑8), have several drawbacks. No controls were used, selection criteria for entering cognitive treatment were not clearly defined and no standardized, validated instrument was used for measuring changes in the patients' psychiatric status and / or delusional beliefs.

• The present study was designed as a controlled study measuring the efficacy of inducing cognitive dissonance in order to change psychotic paranoid ideation. Taking into consideration data gathered from our previous work (7,8) demonstrating patient acceptance of group work within the frame of their individual therapy, we applied the above technique in a highly structured group setting with supportive group therapy as a control. The PANSS (9) was used to assess baseline status, change during the procedure and outcome at follow‑up.

• METHODS AND SUBJECTS

• SUBJECTS: The present study encompassed 12 paranoid schizophrenic patients. Inclusion criteria were: a) diagnosis according to DSM ‑ III ‑ R criteria (10). b) age: 20 ‑ 45 years. c) documented disease duration: 5 years at least d) education: 8 years of schooling and more. e) active delusional system, and f) no change of antipsychotic drugs in the last 3 months.

• Exclusion criteria were: a) alcohol and / or drug abuse. b) chronic physical conditions and, c) orthodox religious convictions. [These patients were found as relatively less responding to cognitive therapy inducement (8)]

• Subjects were randomly assigned either to group cognitive therapy or to a supportive group. Table 1 presents the clinical and demographic data for both groups.

• METHODS: a) cognitive ‑ dissonance group therapy: all researchers taking part in the present study were previously trained in inducing cognitive dissonance in paranoid patients. For further details of such training see reference 8.

• Recruitment: staff members and each patient met for 30 minutes. One of the staff presented to the other staff members several questions for which alternative answers may be given. For example, "What may cause a traffic jam?". Questions were carefully prepared beforehand in order to be neutral and free of paranoid content, as much as possible. Following the staff's "demonstration" of giving several alternative answers the patient was presented with questions similarly constructed and encouraged to provide alternative answers. This was repeated with the patient becoming proficient in the procedure. At the end of each individual meeting, the staff followed by the patient agreed to the formulation of the following statement: "It is axiomatic that any event has several alternative explanations perceived by the keen observer". This was put in writing and signed, first by all staff members and than by the patient. It is important to note that social influence and group pressure applied by figures perceived as more knowledgeable or of higher status has been shown to be an effective method of inducing conformity with group norms (11).

• The first group session began by introducing the co ‑ therapists (male and female) and the patients to each other. Each participant again announced his / her acceptance of the axiom. The therapists than defined the group as a "working group" enquiring into the various possibilities of understanding life ‑ events. Patients were informed that following each session, home assignments will be given to be returned and discussed in the next session. The first session than moved on to rehearse generating alternatives to neutral occurrences. The assignment was to write 2 alternative explanations to typed pre ‑ prepared situations. If at any time during this session a patient raised a delusional alternative the therapist acknowledged that it is only one of many possible explanations and immediately encouraged generation of further answers. In no may was the delusion contradicted by the therapist.

• The second session was opened by reviewing the home assignment, with each patient. Than, patients were trained to generate 3 alternatives to neutral stimuli. Patients were encouraged to give their own questions for the group to answer. Group cohesiveness was increased by mutual aid in alternatives generation by the patients when one found it difficult to do so on his own.

•The third session was opened by going over the home assignment with each patient. Group members were than presented and encouraged to contribute their own examples of impersonal elements capable of arousing paranoid ideation. The elements were ones which could give rise to paranoid alternatives in a general sense.

• Home assignment requested alternatives to paranoid provoking occurrences. For example, "What may explain a scene where two people force a pedestrian into a car and drive off".

• The fourth session again opened with review of home assignments. The session was than devoted to explaining (via alternatives) issues of insanity and eccentricity. For example, patients were asked to give several alternatives to thought insertion, the reasons for involuntary hospitalization etc. Again, individuals who presented specific delusions derived from their inner experience were treated as though these are just one of many other possible alternatives. Home assignments were still restricted to general issues of psychoses

• The fifth session again begun by reviewing the assigments. The patients were encouraged to present their own delusions, to give alternative explanations to them, and to receive alternative explanations offered by the other members. This sessions was characterized by a highly affect leaden participation of all members. The home assignment was individually tailored to each patients delusions ‑ requiring him to generate 3 alternative explanations for each component of the delusional system.

• The sixth session was along similar lines described previously. The focus was on the central private delusion of each patient. All members were encouraged to present several reason for their hospitalizations and psychiatric treatment. The session ended by the therapists summarizing that now patients are in control of a powerful method by which to evaluate their inner experience in light of the basic axiom that they have all rehearsed.

• It should be stressed that the therapists acted within an atmosphere of a joint effort with the patients to try and understand the dilemmas, ideas and notions raised in the sessions. In addition during the sessions, the therapists channeled the patients to use "true" alternatives and not "pseudo" alternates. Positive verbal reinforcement was the tool for channeling. "Pseudo" alternatives were defined as either variants of the same answer, answers that are completely opposite to each other (black and white thinking; dichotomic thinking) or a certain answer and one or more of it's generalizations.

• VIGNETTE (SESSION 3): One of the patients asked the group for explanations regarding his inability to sell his appartment. The therapists rephrased the question in a general manner: "Why would an apartment not sell?" This type of question touches on the periphery of paranoid thinking in patients who may have had delusions in relation to neighbours, planting of microphones etc. Each group member than generated at least 2 alternatives; for example: Patient A: "The price may be too high. However, it may be that one of the neighbours moves furniture around, bangs with a hammer. There may be ghosts".... Patient B: "Ownership may not be legal. The place may be booby ‑ trapped, or one could be a poor salesman".

• Therapist: "Patients C, What alternatives can you add?"...

• VIGNETTE (SESSION 6):

• Patients D declares that the source of his troubles is an unjust persecution by psychiatrists, leading to involuntary hospitalization. Therapist: "Could there be an even more central issue causing your problems". Patient D: ""No. This is my burden". Therapist: "Are there alternative explanations to your experience?" Patients D: "No". Therapist (addressing the group): "Is there any event with only one explanation?" Group: Laughter. Patient D: "It may be that there is an alternative view", for example... Therapist: "What are the alternatives?". Patients D: "I could be responsible to certain of the happenings ... but I am not sure". Therapist: "If you are responsible, what does it imply?". Patients D: "That I am sick ... insane". The patient than looks around the group, assessing the members reactions,

• and than states "I may have acted out of madness...."

• SUPPROTIVE GROUP

• Patients of the supportive group (controls) first met, individually with their therapists, (a male and a female) for a brief introduction and explanation regarding the procedure. They than met for 50 minutes, once weekly, for six weeks. The content of the group sessions focused on difficulties patients presented with coping in everyday life. Four weeks after the sixth session a single follow ‑up meeting took place. The group's therapists avoided relating to delusional material and focused on strengthening existing defenses.

• The PANSS, (9), (positive and negative symptoms scale), and it's positive, negative and general subscales, was used to asses the patients status (both groups) at: baseline, 2 weeks, 4 weeks, 6 weeks (study's completion) and at follow ‑ up, 4 weeks later (week 10). The PANSS scale was scored by an independent, board ‑ certified, psychiatrist.

• STATISTICAL ANALYSIS:• results are presents as mean, and S.D.

Comparison between groups and within ‑ group ‑ evaluations were undertaken using the two ‑ tailed student ‑ t ‑ test. Significance was defined as P<0.05.

• RESULTS• There were 12 subjects in the present study. Table "1" presents

demographic and clinical variables regarding these patients. It should be noted that all subjects were males diagnosed as suffering from paranoid schizophrenia.

• The PANSS results are presented in tables "2" and "3". Table "2" presents the results of the cognitive (dissonance) therapy and table "3" of the supportive therapy.

• Statistically significant differences in total PANSS score were found between CD and control groups baseline versus end of treatment (6 wks), (t=4.93, df = 10, P<0.001), and between baseline versus follow ‑ up (t = 4.92, df = 10, P<0.001). In addition these were also significant differences for the positive symptoms sub ‑ scale for baseline to end of treatment and to follow ‑ up, (t = 3.92, df = 10, P<0.01. t = 5.61, df = 10, P<0.001 = respectively). The general psychopathology and the negative symptoms sub ‑ scales demonstrated a trend towards better effect of the CD treatment which did not reach statistical significance, (P<0.08).

•

• In accordance with Melnick and Woods' salient generalization that homogenous groups appear to coalesce more quickly, offer more immediate support to members, have better attendance, less conflict and provide rapid relief (19); we have designed the present research so as to create a highly homogenous group. All participants were relatively young adult males, of the same diangosis and pharmacological treatment.

• DISCUSSION• Cognitive dissonance (CD) was first described by L.

Festinger in 1975 (11) who postulated that an individual experiences discomfort and tension when holding two dissonant beliefs simultaneously. Cognitive dissonance has been used to explain a variety of psychiatric phenomena, such as: smoking (12), alcohol abuse (13), prediction of violence (14) and suicide (15). It has also been used to explain phobias (16), and psychogenic pain (17). However research focusing on cognitive dissonance has not evolved into the therapeutic arena.

• Recently our group published two articles describing the application of CD in the treatment of paranoid schizophrenic patients (7,8). Our results demonstrate that CD has a potentially positive outcome as a tool for changing paranoid ideation. However in order to establish these preliminary limited cases we felt the need for a larger, controlled study.

• Group psychotherapy as a mode of change for paranoid schizophrenics with active delusions is not an obvious choice. Although some authors have argued that paranoid, acutely psychotic individuals are poor candidates for group treatment, others have taken the opposite stance (18). This position is based, for example, on the assumption that homogenous groups could be designed to work effectively with such patients.

• The positive change among the CD group in our study may be related to several factors. Public declaration and group pressure have been shown by Asch (20) to be effective tools in causing attitude changes. These strategies were used by our group during the recruitment phase. The recruitment phase is a part of the role preparation procedure, described by Orlinsky and Howard (21) as a significant factor in better outcome of treatment. In addition, group pressure and adherence to the original axiom continued to exert influence throughout the therapy sessions. Various authors recommend encouragement of intellectual criticism on the part of the paranoid patients (22,23). The patients presented here, (CD ‑ group), cooperated willingly and with great interest in investigating their inner worlds, feeling that their therapists and fellow group members have become their partners in an effort to understand their view of the world.

• The literature demonstrates that it is not therapist activity per se, that is critical in causing improvement, but rather interventions that define the nature of the task (24,25). Our co ‑ therapists, (see methods), specifically foucused on such interventions. Defining the task as alternatives generation. More than that, this was the only task requested, thus maintaning a clear focus rehearsed again and again.

• The question of the specifity of CD in the treatment of paranoid patients is a central one in discussing the present study. In our opinion, (7,8), one can perceive the paranoid system as an end ‑ product of a series of CD states that may arise in persons that become paranoid. It is possible that the diathesis for such a process is a low tolerance for CD. It might be that the treatment using induction of CD, in a step by step manner, enabled a gradual exposure of patients who accepted the axiom, to deal with neutral, than low to high emotion leaden paranoid occurences, until questioning the very existence of the paranoid system. One might also speculate that the axiom offered may act as a center for crytalizations of a new expanding system relatively more normal, gradually displacing the old paranoid system. Such an explanation has of course to be proven and we are engaged nowadays in a clinical trial trying to test this hypothesis.

• We see our results as preliminary. Further research in needed to substantiate our data, to focus and clarify indications and contraindications for patient's selection and finally to assess this technique amongst larger numbers of patients

Table "1"

DEMOGRAPHIC AND CLINICAL DATA

patient age (yrs)

marital status

schooling (yrs)

dis. duration (hospitalization)

treatment other

AB 30 single 8 10 (5)

fluphenazine 25mg X 1/2 wks

RV 41 single 7 12 (6)

halidol - Dec. 100mg / month

mother; brother; p. schiz

CY 35 single 11 14 (4)

fluphenazine 12.5mg X 1/2 wks

brother; p. schiz

MD 38 M + 2 13 20 (2)

halidol - Dec. 200mg / month

CYo 30 divorced 10 10 (3)

halidol - Dec. 100mg / month

mother; p. schiz

KM 39 M + 3 12 16 (7)

halidol - Dec. 100mg / month

adopted

GY 41 M + 2 10 10 (2)

clopixol 200 mg / 2 wks

WI 28 single 12 9 (3)

halidol - Dec. 200mg / month

BY 42 single 16 10 (2)

fluphenazine 12.5mg X 1/2 wks

JY 24 single 10 7 (4)

fluphenazine 25mg / 2 wks

SK 25 single 12 7 (2)

modal 800mg/d mother; p. schiz

AE 41 divorced 8 6 (2)

modal 600 mg/d

patient

AB

RV

CY

MD

CYo

KM

GY

WI

BY

JY

SK

AE

PANSS baseline 2 wks 4 wks completion 6 wks

follow-up (4 wks later)

Positive mean 15.7 10.8 9.0 7.8 7.0

sub-scale SD 7.2 4.2 4.4 4.1 4.6

Negative mean 10.3 9.7 7.2 7.2 7.8

sub-scale SD 3.8 3.7 3.5 3.8 4.0

General mean 23.2 20.5 18.7 16.2 14.7

sub-scale Sd 6.4 5.5 4.9 3.5 3.1

PANSS

Positive

sub‑scale

Negative

sub‑scale

General

sub‑scale

PANSS

Table "2"COGNITIVE GROUP THERAPY

PANSS baseline 2 wks 4 wks completion 6 wks

follow-up (4 wks later)

Positive mean 15.2 15.0 13.8 13.7 13.7

sub-scale SD 2.3 2.5 2.5 2.5 3.0

Negative mean 16.3 16.3 15.8 15.2 15.0

sub-scale SD 2.3 2.3 1.9 1.7 1.5

General mean 35.2 35.2 34 32.7 31.8

sub-scale Sd 3.0 3.0 3.0 3.6 2.8

PANSS

Positive

sub‑scale

Negative

sub‑scale

General

sub‑scale

PANSS

Table "3SUPPORTIVE GROUP THERAPY

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