Schizophrenia Research 74 (2005) 201 – 209

www.elsevier.com/locate/schres

A pilot study of functional Cognitive Behavioral Therapy

(fCBT) for schizophrenia
Corinne Cathera,*, David Pennb, Michael W. Ottoa, Iftah Yovela,
Kim T. Mueserc, Donald C. Goff a
a
Schizophrenia Program of the Massachusetts General Hospital, Freedom Trail Clinic, 25 Staniford Street, Boston, MA 02114, USA
b
University of North Carolina at Chapel Hill, USA
c
Dartmouth Psychiatric Research Center/Dartmouth Medical School, USA
Received 13 February 2004; received in revised form 30 April 2004; accepted 11 May 2004
Available online 20 July 2004

Abstract

Background: The feasibility and preliminary efficacy of a novel cognitive behavioral treatment for decreasing psychotic
symptoms and improving social functioning was evaluated in a pilot study. This represents the first treatment outcome study of
CBT for psychosis with a manualized, active comparison condition.
Methods: Thirty outpatients with schizophrenia or schizoaffective disorder, depressed type with residual psychotic symptoms
were randomly assigned to either 16 weekly sessions of functional cognitive behavioral therapy (fCBT) or psychoeducation
(PE) with assessments conducted at baseline and post-treatment by blind evaluators.
Results: Attrition was only 7% and did not differ between fCBT and PE, indicating good tolerability of both treatments. For this
sample with persistent symptoms, between groups effects were not significantly different, but within group effect sizes indicated
greater treatment benefit for fCBT on positive symptoms, particularly for the PSYRATS voices subscale.
Conclusion: The results suggest that fCBT is well tolerated and holds promise for reducing persistent positive symptoms.
D 2004 Elsevier B.V. All rights reserved.

Keywords: Schizophrenia; Therapy; Cognitive-behavioral therapy

1. Introduction symptoms in medication-treated individuals (Kane

and Marder, 1993; Pantelis and Barnes, 1996;
The need for improved treatment of schizophrenia Wiersma et al., 1998), suboptimal medication adher-
is underscored by high rates of residual positive ence in the majority of patients (Fenton et al., 1997),
and the burden to patients and caregivers of subjective
* Corresponding author. Tel.: +1 617 912 7891; fax: +1 617
distress, legal problems, financial costs, and impaired
723 3919. social functioning (Bustillo et al., 1999; Kane and
E-mail address: [email protected] (C. Cather). McGlashan, 1995). Awareness of these issues has led

0920-9964/$ - see front matter D 2004 Elsevier B.V. All rights reserved.
doi:10.1016/j.schres.2004.05.002
202 C. Cather et al. / Schizophrenia Research 74 (2005) 201–209

to a surge of interest in cognitive-behavioral inter- and thereby minimizing the effects of individual
ventions for schizophrenia in Europe, and more therapist factors on outcome (Cris-Christoph et al.,
recently in North America (Cather et al., in press). 1991).
Typically, these interventions have been tested as an For the present study we examined the efficacy of
adjunct to pharmacotherapy and case management. CBT compared to a manual-based psychoeducational
To date, at least eight randomized, controlled trials program. As noted by Penn et al. (in press), active,
of cognitive behavioral therapy for treatment refrac- supportive comparison conditions have shown to have
tory psychotic symptoms in schizophrenia outpatients a modest benefit for individuals with schizophrenia,
have been published, excluding studies with patients perhaps by providing a comfortable situation for
early in the course of illness as well as those which discussing problems with a concerned, helpful person.
combine cognitive behavioral therapy with other The psychoeducational (PE) program studied here
stand-alone interventions such as motivational inter- incorporated supportive elements of therapy in a
viewing or social skills training (Durham et al., 2003; manualized intervention delivered by experienced
Gumley et al., 2003; Kuipers et al., 1997; Rector et cognitive-behavioral therapists who spent an equiv-
al., 2003; Sensky et al., 2000; Tarrier et al., 1993, alent amount of time with participants. Accordingly,
1998; Turkington et al., 2002). Most of these studies this study provides a preliminary test of whether the
have demonstrated advantages of CBT over control specific elements of fCBT offer additional benefits
conditions for symptom reduction with treatment other than a structured format, psychoeducation, and
gains maintained up to 18-months post-treatment supportive interactions.
(Gould et al., 2001; Pilling et al., 2002). Impaired functioning is a hallmark of schizophre-
Although a meta-analysis of early studies of CBT nia and there is a growing recognition of the need to
for psychosis found large treatment effect sizes measure the effect of interventions not only on
(Gould et al., 2001), many of these studies were symptoms, but also on functional outcomes. Existing
characterized by one or more of the following approaches have modified CBT interventions for
limitations, including the absence of blind evalua- anxiety and depressive disorders for psychosis and
tions, relatively high attrition rates, selection biases have sought to increase insight or recognition by the
that may have prohibited the generalizability of patient of psychotic symptoms (Chadwick et al.,
findings to more severely ill individuals, a failure to 1996; Fowler et al., 1995; Nelson, 1997; Perris,
control for time with the therapist in the comparison 1989). The treatment employed in this study, func-
condition, and a lack of standardization of pharmaco- tional cognitive-behavioral therapy (fCBT), represents
therapy treatments (Drury et al., 1996a,b; Garety et a novel, manualized approach to CBT for residual
al., 1994; Milton et al., 1978). Recent studies have psychotic symptoms in two important ways (Cather et
addressed some of these methodological issues, al., unpublished manuscript; Cather et al., in press).1
including the role of non-specific effects of therapy First, fCBT was developed to target only symptoms
by employing supportive therapy as the control that interfere with progress toward functional goals.
condition (Durham et al., 2003; Gumley et al., 2003; This approach was designed to enhance client
Lewis et al., 2002; Rector et al., 2003; Sensky et al., motivation to work on symptom reduction. Further-
2000; Tarrier et al., 1998). more, because fCBT does not rely on improving
Meta-analyses suggest CBT is effective at reducing insight as a mediator of change in psychotic symp-
symptoms, although there has been wide variation in toms, it was anticipated that it would have broader
the reported effect sizes. One reason for this is that the applicability than traditional cognitive-behavioral
strength of the control conditions has varied across approaches to psychosis. Secondly, fCBT was
studies. Although supportive therapy has been used as designed to target improved functioning as an explicit
a control intervention in several CBT studies, it has outcome of treatment. Specifically, fCBT incorporates
not been structured and guided by a manual. Manual- goal-setting and problem-solving in the areas of
based control interventions provide a more rigorous
and valid comparison treatment than non-manualized
1
control interventions by standardizing the material The fCBT manual is available from the lead author.
 C. Cather et al. / Schizophrenia Research 74 (2005) 201–209 203

social, personal care, or occupational functioning into dmoderateT or higher, or previous exposure to the
treatment with the explicit aim of improving function- study treatments.
ing in these areas. Eligible patients were identified by staff psychia-
In summary, the current pilot study sought to trists and referred to one of the principal investigators
accomplish two goals. The primary aim of the study for consent. After providing informed consent, study
was to assess the feasibility of a new method of CBT staff confirmed eligibility criteria with the Structured
for psychotic symptoms, fCBT. The second goal was Clinical Interview for DSM-IV (SCID-IV; First et al.,
to assess whether fCBT confers greater benefit than a 1996), chart review, and consultation with the treating
structured psychoeducational intervention for both psychiatrist. Following the baseline interview, partic-
psychotic symptoms and social functioning. ipants were randomly assigned to fCBT or PE.

2.3. Assessment measures

2. Methods
2.3.1. Schizophrenia symptom severity
2.1. Design The PANSS is a structured clinical interview
consisting of 30 items designed to assess severity of
We used a randomized controlled design to symptoms over the past week on a 7-point scale (Kay
compare the efficacy of fCBT to a structured psycho- et al., 1987). Raters were trained to an inter-rater
educational (PE) program for treating residual psy- agreement of 80% on a series of videotapes for which
chotic symptoms. Participants were stratified by bgold standardQ consensus ratings had been deter-
severity of symptoms (PANSS cut off score of b63) mined by a group of experienced raters. PANSS
and gender and randomized to receive either fCBT or subscales corresponding to the factor structure
PE by an independent member of the research team. described by (White et al., 1997) were used to
Both treatments consisted of weekly 1-h individual measure negative symptoms (i.e., blunted affect, lack
sessions for a total of 16 weeks. Assessments were of spontaneity, emotional withdrawal, poor rapport,
conducted at baseline and post-treatment (week 16) by passive/apathetic social withdrawal, motor retarda-
interviewers who were blind to treatment condition. tion, mannerisms and posturing), positive symptoms
(i.e., delusions, hallucinations, unusual thought con-
2.2. Participants tent, grandiosity), and dysphoric mood (i.e., depres-
sion, tension, anxiety, guilt, somatic concern).
A total of 30 individuals with schizophrenia or More detailed information on hallucinations and
schizoaffective disorder, depressed type were enrolled delusions was collected with the Psychotic Rating
in the study. Participants were recruited from two sites Scales (PSYRATS; Haddock et al., 1999). The
in Boston, the Massachusetts General Hospital Schiz- PSYRATS consists of 17 items that focus on auditory
ophrenia Program outpatient clinic and the Boston hallucinations and delusions experienced over the past
Veterans Administration outpatient clinic (n=18), and week. This scale rates features such as frequency,
the Schizophrenia Treatment and Evaluation Program intensity, and interference of hallucinations and
at the University of North Carolina at Chapel Hill delusions on a 4-point scale, and yields a total score,
(n=12). Inclusion criteria were: 18–65 years of age, and scores on hallucination and delusion subscales.
English speaking, treated with olanzapine for at least Higher scores on the PSYRATS are indicative of more
6 months and at a stable dose for at least 30 days, and severe and less controllable symptoms.
exhibiting residual psychotic symptoms as defined by
two ratings of dmildT or one rating of dmoderateT on 2.3.2. Social functioning
bpsychosisQ items of the Positive and Negative The Social Functioning Scale (SFS; Birchwood et
Syndrome Scale (PANSS; Kay et al., 1987). Exclu- al., 1990) measures social and occupational function-
sion criteria were known or suspected organic brain ing of individuals with schizophrenia. The SFS is
disorder, substance use disorder in the past 3 months, comprised of 74 items that are rated by the respondent
a conceptual disorganization rating on the PANSS of on likert and frequency scales with higher scores
204 C. Cather et al. / Schizophrenia Research 74 (2005) 201–209

indicating better functioning. Although the scale was the focus on the connection between thoughts,
designed to assess functioning over the past 3 months, behaviors, and present difficulties, the development
for this study the past week was used as the timeframe of written materials during the session, and the
of assessment in order to be consistent with the other assignment of homework are each exemplified in the
outcomes. There are seven subscales of the SFS: (1) videotape.
social engagement/withdrawal; (2) interpersonal Beginning in the second session, and continuing
communication; (3) independence-performance, fre- through session five, the client is engaged in
quency of performing activities of daily living (ADLs) developing a list of functional goals and the
without help; (4) independence-competence, ability to symptoms that interfere with attaining them. The
perform ADLs; (5) recreation, frequency of engage- content of sessions 6–16 is determined by the
ment in nonsocial leisure activities; (6) prosocial, selection of particular treatment targets based on
frequency of participation in social activities; and (7) the therapist’s case formulation. Each module
employment. The subscale and total scores on the SFS involves targeting a symptom or behavior believed
were used as indices of social functioning. to be interfering with functionality. The specific
interventions (e.g., coping skill training, behavioral
2.4. Treatments experiments, cognitive restructuring, increasing activ-
ity level, etc.) include those typically used in current
2.4.1. Functional Cognitive Behavioral Therapy CBT interventions (Chadwick et al., 1996; Fowler et
(fCBT) al., 1995; Kingdon and Turkington, 1994; Nelson,
fCBT is a 16-session, weekly individual treatment 1997).
for residual psychotic symptoms in schizophrenia.
FCBT comprises several modules, including educa- 2.4.2. Psychoeducation (PE)
tion, coping skills, cognitive restructuring, behavioral Team Solutions is a psychoeducational interven-
experiments and goal-setting. Early in treatment, the tion developed and sponsored by Eli Lilly and
therapist seeks to identify ways in which symptoms Company to teach patients about schizophrenia and
are interfering with functioning or causing distress. the principles of its management. The program,
Patients are taught skills for managing persistent which is not medication-specific, includes a video,
positive symptoms that interfere with accomplishing patient workbook and instructor’s manual and was
certain activities or goals; only symptoms that delivered in an individual format. The program is
interfere with goal attainment or role functioning are organized into 10 modules including, promoting
targeted. This approach allows the therapist to understanding of the illness and of symptoms of
maintain a consistent focus on improving the patient’s schizophrenia, identifying members of the treatment
sense of well-being and achievement of meaningful team and their roles, learning about medication and
personal goals, while narrowing treatment targets. For side effects, preventing relapse, and coping with
example, rather than discussing hallucinations or symptoms. The philosophy of Team Solutions is
delusions as breal or unrealQ or brational or distorted,Q rooted in promoting dreintegrationT, which corre-
fCBT focuses on whether psychotic symptoms and sponds largely to improved functioning through
responses to these symptoms block attainment of education about symptoms and strategies for symp-
specific goals. This approach helps ensure that tom management. One of the investigators (CC) was
therapists always have a context for challenging formally trained in the implementation of Team
maladaptive responses to symptoms. Solutions and authorized to train therapists in its
To acquaint patients with the style and content of use. For the purposes of this study, the videotape
therapy, an introductory videotape is used in the first was reviewed in session one and each of the 10
session. The videotape presents general information modules were taught over 1–2 sessions. In the event
on schizophrenia and its treatment with fCBT, and that all of the material was covered prior to session
provides brief, simulated therapy vignettes. For 16, the patient and therapist collaboratively decided
example, the active role of the therapist, the on modules for review over the remaining sessions.
collaborative nature of the therapeutic relationship, Sessions involved an introduction to the material in
 C. Cather et al. / Schizophrenia Research 74 (2005) 201–209 205

the module, review, and in-session completion of the of patients who achieved a clinically significant
corresponding patient workbook. reduction of positive symptoms, which was defined
as a 20% reduction in PANSS positive factor score
2.5. Therapists from pre- to post-treatment.

Treatment was delivered by nine therapists with an

average of 7.8 years (SD=4.77) of experience 3. Results
conducting cognitive-behavioral therapy. Weekly
supervision meetings were held to discuss cases and 3.1. Sample characteristics
ensure protocol adherence.
Demographic characteristics and baseline measures
2.6. Statistical analyses are presented in Table 1. Sixty-one percent of the
participants had a diagnosis of schizophrenia and 39%
Due to the preliminary nature of the study and had a diagnosis of schizoaffective disorder, depressive
small sample size, we examined the magnitude of type. Participants had a mean age of 40.4 years
effect sizes for between- and within-group compar- (SD=11.96) and were ill for an average of 18 years
isons, and complemented these analyses with tradi- (SD=13.1). Participants were more likely to be male
tional significance testing. Consistent with previous (57.1%), Caucasian (67.9%), and had a mean educa-
research in the area (Kuipers et al., 1997), we also tion level of 13.7 years (SD=1.89). Participants from
compared, using a Fisher’s exact test, the proportion the Boston sites were older, less educated, had a

Table 1
Sample characteristics, total sample
Variable MGH (n=16) UNC (n=12) Total sample
(n=28)
Age, M (SD)** 45.88 (10.20) 33.08 (10.34) 40.4 (11.96)
Gender, % female (n)* 25 (4) 66.7 (8) 42.9 (12)
Ethnicity, % (n)
White, non-Hispanic 68.7 (11) 66.7 (8) 67.9 (19)
Hispanic 6.3 (1) 0 (0) 3.6 (1)
Black 25 (4) 33.3 (4) 28.5 (8)
Education, M (SD)** 13.07 (1.49) 14.58 (2.07) 13.7 (1.9)
Years of illness, M (SD)*** 24.88 (11.48) 8.83 (9.12) 18 (13.1)
Diagnosis, % (n)
Schizophrenia 62.5 (10) 58.3 (7) 60.7 (17)
Schizoaffective disorder 37.5 (6) 41.7 (5) 39.3 (11)
Olanzapine dose, M (SD) 21.67 (7.72) 16.39 (9.45) 19.69 (8.61)
Additional neuroleptic, % (n) 31.3 (5) 37.5 (3) 33.3 (8)
Number of Sessions, M (SD) 14.33 (2.55) 15.83 (0.58) 15 (2.06)
PANSS negative factor, M (SD)* 15.94 (4.97) 12.17 (3.86) 14.3 (4.8)
PANSS positive factor, M (SD) 13.88 (4.43) 13.08 (3.03) 13.5 (3.8)
PANSS dysphoric factor, M (SD) 14.44 (4.99) 13.33 (2.77) 14 (4.2)
PANSS total, M (SD) 55.25 (14.09) 45.49 (7.83) 51.1 (12.6)
PSYRATS-voices, M (SD) 25.19 (11.34) 16.33 (12.62) 21.4 (12.5)
PSYRATS-delusions, M (SD) 12.56 (6.48) 10.92 (5.00) 11.9 (5.9)
PSYRATS-total, M (SD) 37.69 (12.21) 24.42 (13.87) 33.3 (13.7)
Auditory hallucinations, % Yes (n) 87.5 (14) 83.3 (10) 85.7 (24)
Social functioning scale, M (SD) 115.61 (24.58) 131.64 (18.86) 118.5 (21.5)
* pb0.05.
** pb0.01.
*** pb0.001.
206 C. Cather et al. / Schizophrenia Research 74 (2005) 201–209

longer history of illness and more severe negative measures from pre- to post-treatment. Although the
symptoms than the North Carolina participants (see interaction terms did not reach the pb0.05 significance
Table 1). However, there were no site differences on level in this small study, differential effects of treat-
any of the symptom measures for which there were ment, favoring fCBT, were suggested for the PSY-
significant within group effects. RATS-total, PSYRATS-Voices, and the SFS by effect
Doses of olanzapine ranged from 5 to 40 mg, with sizes in the small to medium range according to
a mean daily dose of 19.7 (8.6) mg; 33% of the Cohen’s (1988) standards (0.3bdb0.5). Examination
sample was taking another antipsychotic in addition to of within group t-tests indicated a significant reduc-
olanzapine. There were no differences between treat- tion in PSYRATS total score (t(13)=2.64, pb0.05),
ment groups at baseline in any of the symptom and PSYRATS voices (t(13)=2.87, pb0.05) for the
measures. fCBT condition. There were no significant pre-post
differences in the PE condition on any of the symptom
3.2. Treatment participation measures and no significant within treatment effects
were observed for either condition on either the SFS
The number of sessions received over the 16-week total or subscale scores. Differential treatment effects
period of treatment ranged from 9 to 16, with a mean on the SFS appeared to be driven by a worsening in
completion rate of 75% for all 16 sessions. Of the social functioning in the PE group (reflecting an effect
participants who completed the baseline assessment, size of d=0.36), whereas no substantial change was
two participants (1 in fCBT and 1 in PE) received evident in the fCBT group. Both treatment groups
fewer than four sessions and were considered drop- improved on the PANSS positive factor, with only
outs and excluded from the analyses. Attrition rates a slight advantage indicated for fCBT relative to
did not differ significantly between the fCBT (6%) PE, reflecting an effect size in the small range
and PE (7%) groups. (d=0.16). According to within group t-tests, signifi-
cant improvement in PANSS positive scores occurred
3.3. Evaluation of treatment efficacy only in the fCBT group (t(14)=3.33, pb0.01). In a
further test of the CBT model, we examined whether
Table 2 provides a summary of mean differences improvements in positive symptoms were associated
and effect sizes associated with the primary outcome with improvements in social functioning by looking at

Table 2
Means (standard deviations) and effect sizes for outcome variables for each treatment group before and after intervention
Variables fCBT PE Interaction
a effect size
Pre-tx (n=15) Post-tx (n=15) t-value fCBT effect Pre-tx (n=13) Post-tx (n=13) t-value PE effect
size size
PANSS positive 13.80 (4.26) 10.93 (2.55) 3.33** 0.67 13.23 (3.44) 11.08 (3.73) 1.42 0.63 0.16
factor
PANSS negative 14.33 (5.34) 14.87 (4.97) 0.64 0.10 14.31 (4.40) 14.92 (5.72) 0.58 0.14 0.02
factor
PANSS dysphoric 14.27 (3.86) 13.13 (4.47) 0.24 0.29 13.62 (4.61) 12.38 (4.23) 0.62 0.27 0.02
factor
PSYRATS-total 33.22 (10.90) 28.58 (14.18) 2.64* 0.43 31.08 (14.68) 31.34 (17.13) 0.05 0.02 0.36
PSYRATS-voices 21.79 (10.59) 18.11 (11.36) 2.87* 0.35 19.46 (13.91) 20.52 (12.57) 0.23 0.08 0.41
PSYRATS-del 11.54 (4.75) 10.69 (6.49) 0.77 0.18 11.46 (6.74) 10.15 (7.48) 0.60 0.19 0.08
SFS 132.07 (17.99) 129.88 (24.91) 0.47 0.12 114.27 (25.18) 105.21 (25.57) 1.27 0.36 0.32
t-values associated with within subject comparisons.
a
ns vary somewhat because some scales are only applicable to individuals who endorse particular symptoms (e.g., hallucinations).
* pb0.05.
** pb0.01.
 C. Cather et al. / Schizophrenia Research 74 (2005) 201–209 207

associations between change scores on the PSYRATS with increased engagement in ADLs and recreational
voices subscale and change scores on the subscales of activities from pre- to post-treatment, suggesting
the SFS. We found that reductions in voices as functional benefits of symptom reduction in the fCBT
measured by the PSYRATS from baseline to post- group. Prior studies of cognitive behavioral treatment
treatment was associated with increased functioning of persistent positive symptoms have found that
on the independence-performance (r= 0.61, pb0.05) significant improvements often occur following ter-
and recreation subscales of the SFS (r= 0.56, mination of the treatment (Gould et al., 2001; Gumley
pb0.05) from baseline to post-treatment for the fCBT et al., 2003; Pilling et al., 2002; Sensky et al., 2000),
condition only. suggesting that core skills taught in treatment may be
consolidated over time in the absence of ongoing
3.4. Clinical significance of symptom changes therapy. It is possible that differences between fCBT
and PE in social functioning would emerge after
Sixty percent of subjects who received fCBT treatment termination. Second, social functioning was
showed a clinically significant reduction in positive assessed over the past week, rather than the past 3
symptoms (i.e., a 20% reduction in PANSS positive months as recommended by the developers of the
factor), compared to only 31% of subjects who instrument (Birchwood et al., 1990). This briefer time
received PE (Fisher’s Exact Test p=0.12, ns). This interval may have introduced error into the measure of
corresponds to a large effect size (d=0.74). social functioning, making it more difficult to detect
treatment effects. Third, it is possible that fCBT needs
to be strengthened in order to improve social
4. Discussion functioning, perhaps by addressing either general
neurocognitive deficits or deficits in social cognition
This pilot study had two aims: (1) to evaluate the (Penn et al., in press; Pinkham et al., 2003).
feasibility of a new cognitive-behavioral approach for This study has a number of strengths, which
persistent psychotic symptoms in schizophrenia include a randomized design, a stringent manualized
(fCBT) and (2) to evaluate whether fCBT had a comparison condition, standardization of pharmaco-
greater impact on symptoms and social functioning therapy, and evaluations that were blind to treatment
than psychoeducation (PE). The high rate of retention assignment. Limitations of the study included the
in therapy by fCBT (94%) supports the feasibility of small sample size and the lack of long-term follow-up
the program in this population. We did not find assessments. These limitations notwithstanding, the
significant between-group differences on symptom results of this study support the feasibility of the fCBT
reduction, indicating no significant benefit of fCBT treatment, and suggest possible benefits for positive
over PE. Within-group effect sizes, however, suggest symptoms. Further research on fCBT is warranted to
an advantage for fCBT relative to PE for reducing evaluate its long-term effects on psychotic symptoms
positive symptoms, particularly auditory hallucina- and functioning.
tions. Our study was the first investigation of
cognitive-behavioral treatment of persistent psychotic
symptoms to employ an active, manualized treatment Acknowledgments
control group. The use of an active rather than passive
control intervention created a more stringent compar- Supported by an unrestricted educational grant
ison for fCBT, which may have further reduced power from Eli Lilly and Company awarded to Donald C.
to detect the hypothesized changes. Goff, M.D.
Contrary to expectations, fCBT did not signifi-
cantly improve social functioning, although there was
a relationship between decreased auditory hallucina- References
tions and improvement in functioning for recipients of
fCBT. Specifically, decreased PSYRATS voices Birchwood, M., Smith, J., Cochrane, R., Wetton, S., Copestake, S.,
scores from baseline to post-treatment were associated 1990. The social functioning scale: the development and
208 C. Cather et al. / Schizophrenia Research 74 (2005) 201–209

validation of a new scale of social adjustment for use in family Kane, J.M., Marder, S.R., 1993. Psychopharmacologic treatment of
intervention programmes with schizophrenic patients. Br. J. schizophrenia. Schizophr. Bull. 19, 287 – 302.
Psychiatry 157, 853 – 859. Kane, J.M., McGlashan, T.H., 1995. Treatment of schizophrenia.
Bustillo, J.R., Lauriello, J., Keith, S.J., 1999. Schizophrenia: The Lancet 346, 820 – 825.
improving outcome. Harv. Rev. Psychiatry 6, 229 – 240. Kay, S., Fiszbein, A., Opler, L., 1987. The positive and negative
Cather, C., Penn, D., Otto, M.W., Goff, D.C., in press. Advances in syndrome scale (PANSS) for schizophrenia. Schizophr. Bull. 13,
the cognitive-behavioral treatment of schizophrenia: a focus on 261 – 274.
delusions. J. of Cog. Psychotherapy: An Intl. Qrtly. Kingdon, D., Turkington, D., 1994. Cognitive-Behavioral Therapy
Cather, C., Penn, D., Mueser, K.T., Otto, M.W., unpublished for Schizophrenia. Lawrence Erlbaum, Hove, England.
manuscript. Functional Cognitive Behavioral Therapy (fCBT) Kuipers, E., Garety, P., Fowler, D., Dunn, G., Bebbington, P.,
for Schizophrenia. In. Freeman, D., 1997. London-East Anglia randomized controlled
Chadwick, P., Birchwood, M., Trower, P., 1996. Cognitive Therapy trial of cognitive-behavioral therapy for psychosis: I. Effects of
of Delusions, Voices and Paranoia. John Wiley and Sons, the treatment phase. Br. J. Psychiatry 171, 319 – 327.
Chichester, England. Lewis, S., Tarrier, N., Haddock, G., Bentall, R., Kinderman, P.,
Cohen, J., 1988. Statistical Power Analysis for the Behavioral Kingdon, D., Siddle, R., Drake, R., Everitt, J., Leadley, K.,
Sciences, 2nd ed. Lawrence Earlbaum Associates, Hillsdale, et al., 2002. Randomised controlled trial of cognitive-behav-
NJ. ioural therapy in early schizophrenia: acute-phase outcomes.
Cris-Christoph, P., Baranackie, K., Kurcias, J.S., Beck, A.T., Br. J. Psychiatry 181 (Suppl. 43), s91 – s97.
Carroll, K., Perry, K., Luborsky, L., McLenllan, A.T., Woody, Milton, F., Patwa, V.K., Hafner, R.J., 1978. Confrontation vs. belief
G.E., Thompson, L., et al., 1991. Meta-analysis of therapist modification in persistently deluded patients. Br. J. Med.
effects in psychotherapy outcome studies. Psychother. Res. 1, Psychol. 51, 127 – 130.
81 – 91. Nelson, H.E., 1997. Cognitive Behavioural Therapy with Schizo-
Drury, V., Birchwood, M., Cochrane, R., MacMillan, F., 1996a. phrenia. A Practice Manual. Stanley Thornes Publishers,
Cognitive therapy and recovery from acute psychosis: a Cheltenham, England.
controlled trial. Br. J. Psychiatry 169, 593 – 601. Pantelis, C., Barnes, T.R., 1996. Drug strategies and treatment
Drury, V., Birchwood, M., Cochrane, R., MacMillan, F., 1996b. resistant schizophrenia. Aust. N. Z. J. Psychiatry 30, 20 – 37.
Cognitive therapy and recovery from acute psychosis: a Penn, D.L., Mueser, K.T., Tarrier, N., Gloege, A., Cather, C., Serrano,
controlled trial: II. Impact on recovery time. Br. J. Psychiatry D., Otto, M.W., in press. Supportive therapy for schizophrenia:
169, 602 – 607. possible mechanisms and implications for adjunctive psychoso-
Durham, R.C., Guthrie, M., Morton, V., Reid, D.A., Treliving, L.R., cial treatment for schizophrenia. Schiz. Res.
Fowler, D., Macdonald, R.R., 2003. Tayside-Fife clinical trial of Perris, C., 1989. Cognitive Therapy with Schizophrenic Patients.
cognitive-behavioural therapy for medication-resistant psychotic Guilford, New York.
symptoms. Br. J. Psychiatry, 182. Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J.,
Fenton, W.S., Blyler, C.R., Heinssen, R.K., 1997. Determinants of Orbach, G., Morgan, C., 2002. Psychological treatments in
medication compliance in schizophrenia: empirical and clinical schizophrenia: I. Meta-analysis of family intervention and
findings. Schizophr. Bull. 23, 637 – 651. cognitive behavioral therapy. Psychol. Med. 32, 763 – 782.
First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.B.W., 1996. Pinkham, A.E., Penn, D.L., Perkins, D.O., Lieberman, J., 2003.
Structured Clinical Interview for DSM-IV Axis I Disorders— Implications for the neural basis of social cognition for the study
Patient Edition (SCID-I/P, Version 2.0). Biometrics Research of schizophrenia. Amer. J. of Psychiatry 160, 815 – 824.
Department, New York. Rector, N.A., Seeman, M.V., Segan, Z.V., 2003. Cognitive therapy
Fowler, D., Garety, P., Kuipers, E., 1995. Cognitive Behaviour for schizophrenia: a preliminary randomized controlled trial.
Therapy for Psychosis Theory and Practice. John Wiley and Schizophr. Res. 63, 1 – 11.
Sons, Chichester, England. Sensky, R., Turkington, D., Kingdon, D., Scott, J.L., Scott, J.,
Garety, P., Kuipers, L., Fowler, D., Chamberlain, F., Dunn, G., Siddle, R., O’Carroll, M., Barnes, T.R., 2000. A randomized
1994. Cognitive behavioral therapy for drug resistant psychosis. controlled trial of cognitive-behavioral therapy for persistent
Br. J. Med. Psychol. 67, 259 – 271. symptoms in schizophrenia resistant to medication. Arch. Gen.
Gould, R.A., Mueser, K.T., Bolton, M.A., Mays, V.K., Goff, D.C., Psychiatry 57, 165 – 172.
2001. Cognitive therapy for psychosis in schizophrenia: an Tarrier, N., Sharpe, L., Beckett, R., Harwood, S., Baker, A.,
effect size analysis. Schizophr. Res. 48, 335 – 342. Yusupoff, L., 1993. A controlled trial of two cognitive
Gumley, A., O’Grady, M., McNay, L., Reilly, J., Power, K., Norrie, behavioural methods of treating drug-resistant residual psy-
J., 2003. Early intervention for relapse in schizophrenia. Results chotic symptoms in schizophrenic patients: II. Treatment
of a 12-month randomized controlled trial of cognitive specific changes in coping and problem solving. Soc. Psychiatry
behavioral therapy. Psychol. Med. 33, 419 – 431. Psychiatr. Epidemiol. 28, 5 – 10.
Haddock, G., McCarron, J., Tarrier, N., Faragher, E.B., 1999. Tarrier, N., Yusupoff, L., Kinney, C., McCarthy, E., Gledhill, A.,
Scales to measure dimensions of hallucinations and delusions: Haddock, G., 1998. A randomized controlled trial of intensive
the psychotic rating scales (PSYRATS). Psychol. Med. 29, cognitive behavior therapy for patients with chronic schizo-
879 – 889. phrenia. Br. Med. J. 317, 303 – 307.
 C. Cather et al. / Schizophrenia Research 74 (2005) 201–209 209

Turkington, D., Kingdon, D., Turner, T., 2002. Effectiveness of a of the factorial structure of the Positive and Negative Syndrome
brief cognitive-behavioural therapy intervention in the treatment Scale. Psychopathology 30, 263 – 274.
of schizophrenia. Br. J. Psychiatry 180, 523 – 527. Wiersma, D., Nienhuis, F.J., Slooff, C.J., 1998. Natural course of
White, L., Harvey, P.D., Opler, L., Lindemayer, J.P., 1997. schizophrenic disorders: 15 year follow-up of a Dutch incidence
Empirical assessment of the factorial structure of clinical cohort. Schizophr. Bull. 24, 75 – 85.
symptoms in schizophrenia. A multisite, multimodel evaluation