John J. Miller, MD: Dr [Nev] Jones, what is the role of cognitive behavioral therapy [CBT] in managing the range of symptoms in patients with schizophrenia?

Nev Jones, PhD: To zoom out a little bit and just kind of reference back, I think of best practice models; they’re really comprehensive. You have people struggling with different things and are going to benefit to varying degrees, whether that’s medications, therapy, supportive education, employment, more intensive case management, or social skill training, which is more on the multiepisode side.... And an individual is going to need different things in different doses and potentially at different times in their life. Therapies are one piece of that. Again, the therapy and medications alone are rarely enough; I just want to emphasize this. I think one of the challenges when it comes to financing and thinking about the managed care role here is figuring out how and what services beyond therapy and medications to be investing in and based on what kind of criteria. I do think a lot of work is happening in this part, in part inspired by what’s happened with coordinated specialty care. CBT has been adapted for psychosis; actually, Aaron Beck was instrumental in that, the father of CBT. A lot of them were subsequent developments focused on psychosis that have happened in the United Kingdom and other countries. Specialized CBT for psychosis adapts basic CBT principles and techniques for symptoms like distressing voices, paranoia, etc. It is most effective in positive symptoms, what we’ve been referring to as positive symptoms. There have been some adaptations, including coming out of the back institute to explicitly try to focus on negative symptoms and some progress there, certainly not in a way that we see has been scaled out into the community. There are other second and third ways of CBTs, many of which now have a fairly robust evidence base, including mindfulness-based approaches, acceptance and commitment therapies specialized for psychosis, narrative CBTP, cognitive behavioral therapy for psychosis. Then in the United States, I think it’s extremely difficult to access training in CBTP; in many cities it would be nonexistent. The bulk of the workforce, social workers, [and] counselors are getting no training whatsoever while they’re in school, and then it’s difficult to access afterward. It’s often sort of cognitive behaviorally informed, what one could call cognitive behaviorally informed interventions and therapies, and that’s mostly what we actually see in coordinated specialty care. It’s not the full-fidelity CBTP that has been tested in clinical trials, but it’s an adapted version meant to be more easily scalable and implementable in real-world settings. In terms of domains like cognition, sometimes it’s important to keep in mind that what manifests as a cognitive problem, challenging concentration is really due to, for example, hearing distressing voices. In many cases the reality is that you improve things in one area and then that can carry over when we’re talking pragmatically and functionally about what people are experiencing. Some cognitive problems may be due to what’s going on in people’s heads and how difficult it’s making to navigate the world. So CBT and other therapies can be really helpful and ways that end up trickling down across all these other areas when it comes to motivation as a domain with negative symptoms. In a sense, anything that is helping bolster and strengthen motivation is going to be helpful in CBT. In the hands of a skilled therapist, certainly, it can help a lot. I would just conclude by going back to the importance of moving beyond psychotherapy and medication management for this array of other interventions. In public managed care on the Medicaid side, that’s really the core of a lot of the services that we see in terms of case management, various forms of community treatment teams, and then culminating in a sort of community treatment at the top. They don’t necessarily do a lot of CBTP in the formal sense because it’s more driven by people’s needs across a spectrum of domains and areas.

John J. Miller, MD: Thank you. So important to all of us, to become more familiar with experienced CBTP.

Transcript edited for clarity.