CBT for schizophrenia: a critical viewpoint


In England and Wales, cognitive behavioral therapy (cognitive therapy, CBT) has been part of official treatment guidelines for schizophrenia since 2002 (NICE, 2009, p. 212). The 2014 NICE guideline (NICE, 2014), which is based on the same meta-analytic evidence as its predecessor in 2009, recommends that it be offered to all people with schizophrenia, including first-episode patients and those with established illness, and to patients who are actively symptomatic and in remission. Similar recommendations are to be found in the Scottish SIGN guideline (SIGN, 2013) as well as those of several other countries (Rathod et al ., 2010).

In 2012, however, the Cochrane collaboration sounded a discordant note, concluding that ‘[t]rial-based evidence suggests no clear and convincing advantage for cognitive behavioural therapy over other–and sometimes much less sophisticated–therapies for people with schizophrenia’ (Jones et al ., 2012). A further challenge came from a 2014 meta-analysis carried out by ourselves (Jauhar et al ., 2014), which found end of treatment effect sizes (ESs) that were uniformly in the small range [overall symptoms: 0.33 (95% CI 0.19–0.47), 34 studies; positive symptoms: 0.25 (95% CI 0.13–0.37), 33 studies; negative symptoms: 0.13 (95% CI 0.01–0.25), 34 studies] ( note these and all further ESs are shown as a positive sign favoring CBT). A 2018 network meta-analysis of various psychological interventions to reduce positive symptoms in schizophrenia (Bighelli et al ., 2018), carried out on a rather different dataset of 27 studies than us, again found pooled ESs for CBT in the small range, though this time at the upper end of this [ v . treatment as usual (TAU): 0.30 (95% CI 0.14–0.45), 18 trials; v . inactive control interventions: 0.29 (95% CI 0.03–0.55), seven trials] (Bighelli et al ., 2018). Most recently, a 2018 update of the 2012 Cochrane meta-analysis has continued to find no clear or convincing evidence of superiority on any measure apart from leaving the study early (Jones et al ., 2018).

In the wake of a ‘viewpoint’ article examining whether it is right to continue to regard CBT as a gold standard for depression and anxiety (Leichsenring and Steinert, 2017), we consider the current status of this form of therapy in schizophrenia and the related psychotic disorders that are typically included in trials (schizoaffective disorder, delusional disorder, and psychosis not otherwise specified). We draw on what can legitimately be regarded as the two best sources of evidence, namely meta-analyses and large, well-conducted individual trials.


There’s a knack to CBT. It’s a skill that the patient may not (or probably won’t) pick up on.

If the patient is too numb or traumatised for CBT then something like EMDR might be more suitable.


Refresh my memory. What is EMDR?


Eye Movement and Desensitisation. Here’s an ABC News 20/20 clip about it, 10 minute clip.