Schizophr Bull 2009 Tai 865 73

The Evolution of Cognitive Behavior Therapy for Schizophrenia: Current Practiceand Recent Developments

Sara Tai1,2 and Douglas Turkington3

2School of Psychological Sciences, University of Manchester,Coupland Building, Manchester M13 9PL, UK; 3School ofNeurology, Neurobiology and Psychiatry, Newcastle University,Newcastle upon Tyne, UK

Cognitive behavior therapy (CBT) evolved from behavioraltheory and developed to focus more on cognitive modelsthat incorporated reappraisal of thinking errors andschema change strategies. This article will describe thekey elements of CBT for schizophrenia and the currentevidence of its efficacy and effectiveness. We concludewith a description of recent concepts that extend the the-oretical basis of practice and expand the range of CBTstrategies for use in schizophrenia. Mindfulness, meta-cognitive approaches, compassionate mind training, andmethod of levels are postulated as useful adjuncts forCBT with psychotic patients.

Key words: cognitive behavior therapy/psychosis/schizophrenia/mindfulness/methodof levels/meta-cognitive

Introduction

Cognitive behavior therapy (CBT) is an evidence-basedtalking therapy that attempts cognitive and behavioralchange based on an individualized formulation of a cli-ents personal history, problems, and world views. CBTas a treatment for schizophrenia can be understoodwithin a wider framework of CBT as applied to a rangeof mental disorders such as anxiety, posttraumatic stressdisorder (PTSD), and depression. The influences andfundamental building blocks upon which theory andpractice are based are varied and far reaching, and in clin-ical practice, CBT sessions do not always look the same.As a result, CBT has been criticized as a set of techniquesand tools. However, CBT is better understood in terms ofa set of core principles that rely on a personalized concep-tualization of an individuals problems to guide the

application of techniques and strategies. CBT continuesto evolve and develop through reciprocal relationshipsamong theory, research, and practice.

Cognitive Behavior Therapy

Cognitive therapy for depression was first described ina clear manualized format by Aaron T. Beck in 1979.1

This manual that emphasized the need to focus on con-scious thinking was a direct challenge to behaviorism andthus became termed the cognitive revolution or secondwave. The theory developed by Beck built on behavioralprinciples in that it not only recognized how behavior wasthe result of learned contingencies between stimuli andevents but also emphasized clear relationships betweencognition, physiology, and emotion.Beck based his early theory upon an assumption fun-

damental to psychoanalytical thinking, ie, that early lifeexperiences and social environment can contribute to thedevelopment of adult emotional problems. He stressedthe salience of early life experiences in forming beliefsor schemas about the self, other people, and the world.These beliefs were then thought to lead to certain cogni-tive distortions and negative styles of thinking. Beck2

postulated that through the examination of thoughtprocesses and by evaluating their accuracy, many nega-tive emotional reactions due to inaccurate or distortedthinking could be reduced or extinguished.The key elements of CBT as described by Beck

included engaging the patient, collaboratively developinga problem list, and deciding on a clear goal for the ther-apy session. Once the goal had been decided on, a CBTtechnique would be used (eg, guided discovery and So-cratic questioning [described below]) to identify distor-tions in thinking style. This would be followed by anagreed task (homework) for the patient to complete bythemselves before the following appointment (eg,attempting to identify these distortions over the nextweek and trying to correct them). Regular feedbackand asking the patient to provide a capsule summary(ie, personal understanding) of the session were also cru-cial elements. This therapy structure relied very much oncollaborative working with the patient within an empir-ical methodology. A formulation (narrative of the per-sons history) was jointly generated to make sense of

1To whom correspondence should be addressed; tel: 44 (0) 1612752595, fax: 44 (0) 161 2752588, e-mail: [email protected].

Schizophrenia Bulletin vol. 35 no. 5 pp. 865873, 2009doi:10.1093/schbul/sbp080Advance Access publication on August 6, 2009

The Author 2009. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center. All rights reserved.For permissions, please email: [email protected].

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the emergence and maintenance of the problem at hand.This psychotherapy revolution placed the patient at theheart of the recovery process and introduced the conceptof rational review of appraisal errors.

CBT Techniques

Beck used narrative formation or the development ofa coherent personal story of ones experience as anexplanatory framework to make hypotheses about thedevelopment, maintenance and links between differentproblems. There is evidence that developing such a narra-tive formation is a therapeutic process in itself and anessential aspect of recovery.3

Beck specified how thoughts and beliefs can be exam-ined for their truth by questioning. He showed theusefulness of the Socratic questioning technique to en-courage the probing of evidence, reason, and rationale.For example, a patient who believed that he was undersurveillance was asked to give a rationale for his belief.The CBT therapist used questions to explore the individ-uals reasoning (eg, How do you know that is happen-ing?, Can you give me an example of that?, What doyou think causes this to happen?, When you think itthrough now, are these reasons good enough?).Another technique commonly employed in CBT is re-

ality testing where a patient will be encouraged toactively find evidence to test the reality base of a beliefor assumption; a process which is done in collaborationwith the therapist. For example, a person who believes inthe existence of giant moths that will eat people might beencouraged to find some evidence-based informationabout moths and discover that these insects tend onlyto live for approximately 12 weeks and would be unableto bite a human as they have no teeth!Behavioral experiments are another method fre-

quently utilized in CBT whereby a scientific experi-ment can be set up to test a specific prediction. Forexample, a person who believes that his next door neigh-bor is communicating threats to him by coughing mightset up an experiment in which he watches a television pro-gram to test alternative predictions that there are otherreasons why people cough. The CBT therapist will facil-itate the patient in developing awareness (guided discov-ery) of how people might cough due to smoking, allergy,or a chest infection. Once the patient can see that the peo-ple on the TV are possibly coughing for other reasons thepatient can, then the local environment can begin to beexplored, and the reality of the patients ideas specificallyabout his or her neighbors coughing can be explored.Somemight argue that behavioral experiments look no

different to exposure or behavior modification, but theyclearly illustrate the way in which the underlying theoryof CBT has evolved from behavior to cognitive theory.Beck et al1 described how For the behaviour therapist,the modification of behaviour is an end in itself; for the

cognitive therapist it is a means to an endnamely cog-nitive change (p119).

CBT for Schizophrenia

CBT for schizophrenia, as first described in a single casestudy by Beck in 1952,4 has subsequently been developedin the last 30 years from the traditional model of CBT fordepression as described above.2,5 However, cognitive the-ory and interventions for anxiety, social phobia, PTSD,and obsessive-compulsive disorder (OCD) also findapplication within the practice of CBT for psychosis.Earlier forms of CBT for schizophrenia relied primar-

ily on behavioral strategies to affect change, with a sec-ondary focus on the cognitive components. These earlierforms of CBT for schizophrenia focused on improvingcoping,6 building social and independent living skills,and increasing compliance using behavioral strategiessuch as linking tablet taking to another activity.7 Simi-larly, negative symptoms were targeted by providinggraded activity programs.8 These approaches have con-tinued to be applied where deficit symptoms of schizo-phrenia and improving functional outcomes are themain focus of intervention.9

For many years, it was assumed that the positive symp-toms associated with schizophrenia lay outside of therealms of normal psychological functioning. Thus, thetransition to incorporating more cognitive theory andtechniques into practice came much later comparedwith CBT for nonpsychotic disorders.Cognitive models outline how hallucinations and delu-

sions can occur when anomalous experiences that arecommon to the majority of the population10 are misat-tributed in a way that has extreme and threatening per-sonal meaning.11,12 These models specify the role offaulty beliefs, increased attention to threat-related stim-uli, biased information processing of confirmatoryevidence, and safety behaviors (ie, avoidance of specificsituations) in the experience of positive symptoms. Theemphasis is on distress resulting not necessarily from dif-ficult experiences but the meaning placed on those veryexperiences. For example, an individual who experiencesphysical sensations of tingling and attributes this to jobstress is likely to have a markedly different outcome topersons who believe that people at work are persecutingthem and have planted microchips under their skin. Cog-nitive theory is based on the notion that the cognitive pro-cesses implicated in mood and anxiety disorders occurtransdiagnostically.13 Research findings support the no-tion that psychotic symptoms can be conceptualized withreference to normal psychological processes, whereby thecontent of symptoms is understandable and amenable toCBT.14 For example, Chadwick et al15 built on the workof Beck in OCD to demonstrate that voices could beconceptualized as intrusive thoughts.

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Kingdon and Turkington16 and Fowler et al17 de-scribed how CBT for disorders such as anxiety anddepression could be applied in schizophrenia. Therewere some key amendments. Stigma was addressedby identifying the negative beliefs and assumptionspeople held about the diagnosis and prognosis ofschizophrenia and then providing evidence that someof these experiences are actually fairly common inthe general population (normalizing). In addition,the therapist provided alternative explanations, suchas the role of stress, that provided more optimisticand hopeful perspectives.18 Compared with CBT forother disorders, the sessions were often shorter inlength and much more flexible, and homework was sim-plified. The role of sleep disturbance, affect, and safetybehaviors (eg, behaviors such as avoidance that main-tained faulty beliefs) was identified to produce mini-formulations of positive symptom maintenance.19

Figure 1 presents an example demonstrating how crit-ical hallucinations, triggered by sleep deprivation, aremaintained by a negative appraisal, emotions of sad-ness and shame, and safety behaviors including socialwithdrawal.Cognitive biases are directly addressed by CBT pre-

dominantly through focusing on the content of thoughtsand styles of thinking. These include the jumping to con-clusions error and biases in styles of judgment found inindividuals with unusual beliefs (delusions) and the biasesin attributional styles and attentional processing associ-ated with hallucinations. In CBT, it is the individualspersonal meaning, understanding, and coping with symp-toms that are the focus of treatment. For example, indi-viduals are facilitated in testing out the location of thehallucinations (internal vs external), carefully examiningthe appearance and behavior of suspected persecutors,

and attempting homework that is pertinent to theirstated goals.

The Evidence Base for CBT in Schizophrenia

There is now a considerable body of evidence that illus-trates the efficacy of CBT for schizophrenia.20 Random-ized controlled trials (RCTs) have shown moderate effectsizes for positive and negative symptoms at the end stagesof therapy with sustained benefits over time.21 There isevidence that these research findings are also sustainedin clinical settings22,23 and are cost effective.24 Virtually,all trials have been on patients with stabilized antipsy-chotic medication regimes; however, case series existshowing that there is a potential benefit of CBT being of-fered to patients who refusemedication treatment.25 Bothhallucinations and delusions respond to CBT.26,27 Notonly negative symptoms respond28 but also there is a du-rable effect at medium term follow-up.23 The cognitivemodels relating to these presentations have all beenrecently described in detail.29 Patients with substancemisuse and other comorbidities are likely to be more dif-ficult to engage and treat, but there are promising signs.30

CBT struggles more where people have difficulty identi-fying that they have mental health problems,31 delusionalsystems,32 or extreme primary negative symptoms.33

Similarly, when comorbidities accumulate, CBT effectsare liable to be significantly less. Meta-analysis ofZimmermann et al34 found that acute presentations dobetter than chronic. However, people in acute episodesusually improve with standard nursing care or supportivecounseling. CBT would seem to be of benefit in treatingpsychotic prodromes of mild/moderate severity and forthose who are at ultrahigh risk of conversion or withsevere symptomatology.35,36

On the basis of such consistent evidence over the last1015 years, in the UK andUS, the National Institute forClinical Excellence37 and The Schizophrenia PatientOutcomes Research Team38 guidelines, respectively,are recommending that CBT be offered routinely to indi-viduals with residual symptoms of schizophrenia. Morerecently, further evidence is being provided that CBTis likely to be of particular benefit to individuals with re-cent onset of schizophrenia.37

Despite a clear message that CBT for psychotic symp-toms appears to be beneficial, questions remain. The ex-tent to which CBT is limited to effecting change onlywithin the peripheral features (consequences) of the dis-order, such as distress and behavioral reactions that con-tribute symptom maintenance or target more centralmechanisms and processes hypothesized to underlie thespecific symptoms of schizophrenia, is unclear. It isnot clear whom CBT works for and when, raising furtherquestions as to how therapeutic change occurs. Overall,what does the impact of CBT inform us about the natureof schizophrenia itself? These questions may partially be

Appraisal The devil is talking

to me

Critical Voices

BehaviorSelf harm

Social withdrawal

EmotionsSadness Shame

Trigger(no sleep for 3 days)

Fig. 1.Mini-formulation of Hallucination Maintenance.

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answered by pre- and post-CBT functional neuroimagingstudies that are currently under way.

CBT and Functional Outcome

The cognitive model predicts improved functioning, andempirical studies support the efficacy of CBT in thisregard. CBT can improve functioning even when symp-toms do not improve, which is one reason it is consistentwith recovery and an important adjunct to antipsychoticmedication. CBT can be seen to be complementary todopaminergic blockade that reduces the salience of envi-ronmental cues.39 Lieberman et al40 argued that atypicalantipsychotic medication improved neurogenesis, andthis would also complement a psychotherapy targetedon the acquisition of new skills.

Developments in CBT for Schizophrenia

Ongoing research and practice of CBT have led to emerg-ing evidence of other important factors in schizophrenia,in addition to thought content and thinking styles. Theseinclude the role of arousal,41 emotion,42 attachment andinterpersonal issues,43,44 loss and trauma,45 self-esteem,46

and acceptance and self-to-self relating.47 These pro-cesses may potentially have a causal role in the develop-ment of the disorder andmay contribute to the symptomsexperienced in schizophrenia, the way in which these areexpressed and the subsequent course of the disorder. Theimportance of these factors has been demonstrated in re-covery approaches to psychosis, where there has beenmarked value in helping individuals to develop personalmeaning and empowerment from their own psychoticexperiences, acquire a sense of inner control and self-regulation, and enable emotional and cognitive changefacilitating the attainment of goals and recovery.48 Ap-preciation of the heterogeneity and complexity ofprocesses operating in schizophrenia beg a broaderapproach to treatment that incorporates evolving cogni-tive theory and practice.Cognitive schema theory underlying CBT has thus

evolved over the years, changing the way in which mentaldisorders are understood. This occurred in part due tocriticisms of earlier theory underlying CBT havingbeen developed on the basis of clinical caveats with noscientifically tested model of concepts such as schemas.This caused difficulties in relating clinical findings to thework of cognitive scientists who had developed theoriesof how the mind worked that were based on experimentalobservations and data. A common problem in CBT wasin accounting for the gap that commonly occurs betweenlogical reasoning and strong emotion (eg, persons canknow rationally that they are not being followed bythe mafia, but simultaneously they still feel that theyare being followed and continue to be distressed). Cog-

nitive science has developed our understanding of howpeople develop beliefs and emotions on the basis of2 types of knowledge. Propositional knowledge isa kind of rational knowledgebased on referentiallyspecific information (eg, facts and figures). The otheris implicational knowledge that is the more abstractknowing with the heartbased on integrated informa-tion drawn through the senses (eg, sight, smell, taste, etc)that is involved in creating more elaborate schematicmodels of the self.49

Thus, there has been a shifting away from linear for-mulations of how irrational thoughts directly lead tomaladaptive behaviors and negative emotions to anincreased understanding of the complex interactingand self-regulating relationships between thoughts, be-havior, feelings, and physical sensations.49 Practicalapplication of theory within cognitive behavioral thera-pies has advocated a shift from predominantly challeng-ing the content of negative thoughts and schemas toinstead altering a persons relationship to both thoughtsand feelings. In this sense, it is not necessarily the thoughtthat is problematic but the way in which an individualthinks about their thoughts! For example, someonewho responds to distressing intrusive thoughts by worry-ing and trying to suppress the intrusions increases hisanxiety and attentional focus on these unwanted experi-ences. He is likely to suffer an exacerbation of the intru-sions and greater distress and emotional disordercompared with someone who does not ruminate and dis-tracts himself by listening to music.There is a growing trend in CBT to focus less on chang-

ing faulty thinking and employ additional therapeuticmethods to emphasize working with different compo-nents of schema, interpersonal relationships, emotionalregulation, information processing (ie, attentionalbiases), and ways of relating to the self. Control ishighlighted as having central importance within mentaldisorder. Interpersonal control can be regarded a devel-opmental factor, loss of control is a consequence, andmental control is an important maintenance process.Control in other forms is also evident, such as the reducedinterpersonal control often reported during therapy(collaborative or client-centered styles of therapy) andcontrol of ones life as a goal or outcome for most peo-ple.50 This evolution in thinking and practice has lead towhat has been increasingly referred to as the third waveafter Hayes used it to describe acceptance and commit-ment therapy (ACT), a mindfulness-based therapy.51

The last 510 years has witnessed a general burgeoningof therapeutic approaches that push beyond original cog-nitive theory and extend to include an eclectic combina-tion of theories and philosophical influences. Examplesof third-wave approaches include mindfulness, meta-cognitive therapy (MCT), compassionate mind training(CMT), and the method of levels (MOL). The extentto which these approaches can be considered third

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wave is debatable as this suggests something new toCBT. These more recent CBTs have made some theoret-ical departures from traditional cognitive and behavioraltheory, but the practical application of these approachesechoes the field. These more recent approaches are still intheir infancy but have potential to influence the applica-tion of CBT for schizophrenia. Each approach will bedescribed briefly.

Mindfulness-Based Approaches

Mindfulness approaches (ie, mindfulness-based stress re-duction52 and mindfulness-based cognitive therapy[MBCT])53,54 have been used for a range of disordersand have a good developing evidence base.55 All involvetraining of the mind to disengage from unhelpful andautomated patterns of thinking (meta-cognition isthe term used to describe thinking about ones thinking).Each mindfulness-based approach is somewhat distinctwith its own individual theoretical orientation and tech-niques. The commonality is an element of contempla-tionthe directing of attention or concentration,influenced by Eastern traditions of meditation such asBuddhism. Approaches might also involve the teachingof behaviors of kindness, compassion and generosity,the advocacy of empathic strategies (ie, being nonjudg-mental and giving and resonating with anothers suffer-ing), and cognitive strategies of developing a mind setasense of self-betterment and personal transformationthrough openness or receptiveness. Instead of becomingpreoccupied with difficult experiences (eg, hallucinations,unwanted memories, or thoughts), individuals are en-couraged to focus attention on their experiences in orderto develop different ways of relating to these thoughtsand feelings, no matter how unpleasant they are. Atten-tion to meta-cognitive processes is not new to traditionalCBT where strategies for identifying cognitive errors andmaladaptive thinking styles are frequently used. How-ever, mindfulness differs in the way it places significantlygreater emphasis on different aspects of meta-cognitivecomponents of therapy. For example, persons who expe-rience distressing critical voices might in traditional CBTbe encouraged to utilize distraction techniques or reap-praise their related thoughts. In mindfulness-basedapproaches, the person would be encouraged to engagewith the voice with an emphasis on altering the emotionalexperiences associated with its presence. A case exampleis of a man who suffered from distressing command hal-lucinations for more than 20 years. Whenever the voicesstarted up, he would respondwith anger, pacing the roomand shouting back at them. A mindful approach taughthim that his unsuccessful attempts to avoid the experi-ence led to him interpreting the voices as taunting himpurposefully, which he would ruminate about and expe-rience anger. He trained in accepting the presence of thevoices and shifting his attention to them while adopting

a nonjudgemental and indifferent attitude, leading to thevoices being less distressing and less intrusive.Chadwick and colleagues have applied MBCT to

working with people with psychotic symptoms with evi-dence that this is a feasible intervention that can be usefuland beneficial for some people.56,57 They have also beenusing mindfulness-based CBT in group format.58

Acceptance and Commitment Therapy

Theory behind ACT59 draws on relational frame theory,behavior analysis, and influences frommindfulness. ACTdoes not encourage people to control intrapersonal activ-ities (thoughts, feelings, etc) as in traditional CBT butteaches them to just notice, accept, and encompass in-ternal events. It emphasizes identifying an individualspersonal values and encouraging them to act on these.In the process of facilitating people to discover personalmeaning and value within their life, ACT strives to in-crease psychological flexibility. Pankey and Hayes60 pro-vided a thorough overview of howACT can be applied toworking with people with psychosis. They advocatedhelping people to use strategies to cope with psychoticexperiences, such as cognitive distancing (getting peopleto treat their beliefs as hypothetical statements as op-posed to facts), acceptance, and valued action. Theyargue that the focus in traditional CBT on reducing spe-cific symptoms might paradoxically make them worse.They emphasized instead intervening on a persons will-ingness to have symptoms and reduce attempts to act onthem. Pankey and Hayes60 also stated that the approachcan be helpful with people who might have limited cog-nitive ability. ACT has been used with a wide range ofpopulations and disorders although evidence of its effi-cacy on the basis of high-quality clinical trials with ade-quate scope and follow-up are limited. Hayes et al61

provided an overview of the literature summarizingthat ACT is so far proving to be applicable and accept-able across a broad range of problems of varying severity,effect sizes appearing greater for more severe problems.For psychosis, Bach and Hayes62 demonstrated thatACT significantly reduced hallucinations and hospitali-zation days. These findings were replicated by Gaudianoand Herbert.63 Application of mindfulness-based techni-ques, such as ACT, is more commonly being augmentedinto CBT as a treatment for psychosis.64

Compassionate Mind Training

CMT is an approach to be delivered within traditionalCBT but with an additional emphasis on increasingawareness of negative self-to-self relating. It draws its the-oretical links from evolutionary social ranking theory.65

CMT specifically targets shame and self-criticism fromthe point of view that this can act as an internal hostilesignal stimulating submissive and negative affective

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responses that can maintain psychiatric disorders.47,66

The key principles of CMT are to facilitate individualscaring for their own well-being, becoming sensitive toand accepting of their own needs and distress, and torespond toward themselves with warmth and compas-sion.67 Techniques are used such as 2-chair techniquewhere the inner bully is interviewed, giving a voice toa persons critical self-talk and facilitating a functionalanalysis of self-attacking. Many traditional CBT techni-ques such as Socratic questioning are also employed withthe aim of reframing self-criticism changing the tone ofthe associated emotional experience and developingmore compassionate beliefs and sensitivity to the self.Working with the patients mental imagery (eg, alteringthe mental image of the inner bully) is also employed asa significant therapeutic aid in CMT.68These strategiesare particularly important when working with psychoticsymptoms. Self-criticism and negative self-to-self relatinghave been demonstrated to be particularly relevant, espe-cially in instances where comorbid anxiety and affectivedisorder are present.6971 Self-attacking is a psychologicalvulnerability factor increasing potential for relapse.71,72

Voices are believed to operate like external social rela-tionships and might often resemble an individuals socialsense of being powerless and controlled by others.43,73

There is a clear theoretical basis for using CMT withinCBT for psychotic symptoms and thus a promising out-look for its inclusion as a therapeutic strategy for symp-toms common in schizophrenia.44,74 Researchestablishing further the application of CMT in psychosisis underway.

Meta-cognitive therapy

MCT75 is theoretically based on the Self-regulatory Ex-ecutive Function model.76 From this perspective, disor-der is considered to occur as a result of thinking styleand the way in which people control their thoughts(meta-cognition). MCT specifies that it is verbal stylesof thinking (worry and rumination), the focus of atten-tion on threat and negative information, and meta-cognitive actions of thought suppression and avoidancethat lead to disorder. It is by targeting these meta-cognitive processes in treatment that MCT aims tochange the way in which people experience and regulatetheir thoughts. In this sense, MCT is a departure fromtraditional CBT insofar as it focuses exclusively on thecognitive with no emphasis on behavioral features oftreatment. MCT involves teaching people alternativeskills to experience their thoughts utilizing techniquessuch as attention training and altering meta-cognitivebeliefs that worrying is necessary or those thoughts can-not be controlled or are dangerous. There have been sev-eral studies evaluating the effectiveness of MCTproviding emerging evidence of positive effects ofMCT for people with generalized anxiety disorder,

PTSD,OCD, and depressionwith stable effects at follow-up.77,78 Further studies are required with follow-up ofmore than 12 months and with larger comparativeRCTs. Valmaggia et al79 recently applied an 8-sessioncourse of attentional training treatment in a single caseto treat auditory hallucinations in the context of a diag-nosis of schizophrenia, resulting in symptom reductionand increased perceived control and mastery of the hal-lucinations. This example demonstrated how someonewho was distressed by repeated abusive hallucinatoryvoices experienced being very much at their beck andcall. He felt that he had no control over them and wasunable to function in social settings due to their presence.He was trained over 6 weeks to practice daily focusing hisattention on different types of auditory stimuli. His abil-ity to focus on the radio, clock, and traffic steadilyimproved. When he began to use this new skill he foundthat he had much more control over the voices andbegan to engage more in social activity. MCT is a prom-ising development with the potential for application toschizophrenia.

The Method of Levels

MOL is a therapy based on the principles of perceptualcontrol theory (PCT),80,81 which provides an account ofthe mechanisms of change within psychotherapy.8284 Itis a significant theoretical departure from CBT. PCTspecifies that people do not seek to control their behaviorbut their perceptual experiences, where the goal is tomake what is perceived from the environment matchwith internal standards (or goals).85 Internal standards(conceptualized as being somewhat analogous to sche-mas in CBT) are organized in hierarchical control sys-tems with higher goals (standards) at the top (eg, tobe close to people) that set a series of lower goals atthe levels below (eg, spend time with others). Emo-tional difficulties and unwanted perceptual experiences(eg, paranoid beliefs) arise as people often have multiplegoals that are prone to conflict with one anothereg, tobe close to other people versus to stay safe by avoidingbeing to close to others.86,87

PCT postulates that the essential feature of successfulchange within CBT (or any other psychotherapy) is theshifting of a persons awareness to higher perceptual lev-els (goals) so that conflict in control systems can be reor-ganized.88 In this sense, MOL does not claim to be a newtherapy but capitalizes on what it considers to be theeffective ingredient of therapythe mobility of mental(meta-cognitive) awareness.81,89

During a session of MOL, the patients choose to talkabout any problem they wanted to discuss. The therapistobserves shifts in their awareness, (identified through dis-ruptions to the flow of conversation such as changes ingesture, tone of voice, or dialogue flow) and directsthe patients attention to these by asking them about

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associated background thoughts, images, or other per-ceptual experiences. This helps them to become awareof the higher goals and standards leading to their prob-lems so that conflict can be reorganized. The redirectingof awareness is similar to the traditional CBT strategiessuch as Socratic questioning. However, in MOL, othertraditional structures of CBT (formulations, advice,homework tasks, formal assessments, etc) are seen tobe less relevant and potentially intrusive to meta-cogni-tive processing81 and the linking of cognition, affect, andemotion in an online experiential way.Outcome studies for MOL indicate that it is an effec-

tive and acceptable psychotherapy with benefits at end oftherapy and in short-term follow-up studies.88,90,91 Thesestudies have been based only in community clinics, andlarger controlled trials are required. However, Careyet al88 advocate that this approach appears to be es-pecially useful for people with unusual perceptualexperiences and complex problemsparticularly whenengagement is difficult, people feel stuck and are un-clear about their problemsand for people who mighthave difficulty with remembering past events. MOLcan be considered an MCT that can be delivered inpure form or within traditional CBT.92 This makes itideal for application within schizophrenia, and prelimi-nary case studies have demonstrated its utility when de-livered within the traditional CBT format.93 Researchspecifically applying MOL to working with psychoticsymptoms is underway.

Conclusion

Cognitive models have much to offer in aiding our under-standing of the maintenance of the core symptoms ofschizophrenia. Cognitive behavioral therapies based onthese models have been demonstrated to be effectiveand valuable treatments for a range of positive and neg-ative symptoms. However, theoretical developments andadvances in cognitive treatments of disorders such as anx-iety and depression have also helped to reveal a morecomplex picture of the transdiagnostic processes operat-ing in schizophrenia. It is becoming clear that it is neces-sary to develop a broader conceptualization andtreatment approach to psychotic symptoms that encom-passes the heterogeneity and multifaceted nature of thedisorder. Recent developments in cognitive treatmentsbranded as third-wave approaches illustrate the advan-tage of not only targeting the content of thoughts andbeliefs but also developing alternative methods of chang-ing the way in which people relate to their thoughts andfeelings. Collectively, they present a positive and encour-aging developing evidence base with promising results.Evidence of the applicability of such approaches toschizophrenia is apparent, and further research isrequired to examine the wider feasibility and potentialas a treatment for psychosis. These developments should

be regarded as evolving cognitive therapies as opposed toa new wave. It is important to view CBT as a range oftherapies and increase our understanding of how theymight be applied to specific problems and circumstances,where efficacy is best understood through multifacetedand individualized formulations of patients.

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