Cognitive therapy, a well-established treatment for mood and anxiety disorders, appears to be effective in schizophrenia as well. This begs the question of why and how this approach works for this primarily biological disorder. In this book, Aaron Beck, the originator of cognitive therapy, and colleagues systematically address the origin, development and treatment of the symptoms of schizophrenia from the cognitive perspective, and present an integrative cognitive model. The authors build upon the knowledge developed over the last 100 years, referencing Eugen Bleuler who postulated loose associations as a primary cognitive impairment. They allude to the works of Meyer, Sullivan and Arieti who incorporated cognitive impairments as mediators, within their psychodynamic approach to schizophrenia. Biological and stress-diatheses models are reviewed with reference to the cognitive approach. Throughout, they emphasize that ultimately cognitive theory is grounded in a more basic biological theory. Thus, in its 14 chapters, the reader is treated to not only a detailed presentation of cognitive theory and practice in schizophrenia, but also a rich overview of the disorder and current biological models that conceive of cognitive deficits as the central core of schizophrenic psychopathology.

Writing in a style that keeps in mind both professional and lay readers, the authors describe the basic techniques of breaking down each pathological experience to its component parts with emphasis on the chronology of the experience. They note that this method allows for the reinterpretation of symptoms as understandable outcomes of repetitive misperceptions and misevaluations, with high emotional value (salience) attached to them. It paves the way for ‘normalizing’ the pathological conclusions and behaviors. It is noted that in cognitive therapy, rather than tackle delusions and hallucinations head-on, the contributing factors are examined, while empathizing with the patient and suggesting alternate explanations and detours around the impaired process. This technique is particularly beneficial in understanding and dealing with delusions. The larger framework of a stress-diathesis model is often applied to derive individual-specific treatment interventions. Interestingly, cognitive therapy may be effective in well-entrenched delusions, a target not effectively addressed by antipsychotic medicines. On the other hand, this therapy has typically only been studied in medication-compliant persons and it remains unknown how it might or might not benefit those that refuse to take medications. The authors duly note this limitation.

Chapters 3–6 present the primary symptom domains of schizophrenia. Supported by clinical vignettes and experimental data, it is explained how each symptom comes to be, for example ‘hearing voices’, and implausible beliefs. Negative symptoms are conceptualized as compensatory and/or protective, and this opens up treatment techniques to reduce them. This is especially important, as none of the available medications with the possible exception of clozapine are able to make a dent in these behaviors. Likewise the concepts of normalizing and socializing (learning the cognitive model) are very consistent with the psychoeducational, client-centered recovery model and give respectability to the person and depathologize many schizophrenia behaviors. The cognitive conceptualization of formal thought disorders is most contemporary and well integrated with the findings from the Matrix program sponsored by NIH.

Chapters 7–12 deal with assessment and specific therapeutic approaches to each symptom complex. The richness and specificity of available tools, which are also presented in the appendix, are of value to clinicians in their daily work. Many utilitarian tips are provided throughout, such as do not directly negate grandiose ideation but target the underlying thoughts of inadequacy; focus on the distress from consequences of delusional and negative behaviors, etc. Asking the patient to quantify symptoms and behaviors is a hallmark of cognitive therapy and serves as a simple technique to incorporate in clinical practice. Clinical vignettes, succinct tables and simple schematics throughout the book enrich the presentation, and make it easier for the average reader to digest the concepts. A separate chapter is devoted to integration of medication management with cognitive therapy. The last chapter presents an integrative cognitive model explaining the deficits/impairments in schizophrenia on a whole brain level, rather than one or two narrow brain regions.

There are some limitations to this book. There is hardly any reference to psychoanalytic concepts of psychotic cognitions. For example, concepts such as permeable mind and the perceived external origin of sexual feelings, etc. are presented with no reference to their analytic counterparts such as poor ego boundaries, projection, etc. While the role of early trauma in creating ‘hot perceptions’ and ‘hyperrelevant’ experiences is acknowledged, there is no mention of the psychodynamic models that are essentially built around similar concepts. The same goes for the role of self-inadequacy and low self-esteem as the foundations for later delusions and hallucinations. Secondly, while discussing the formation of delusions, and their dimensions, no reference is made to the work of German authors such as Jaspers, Conrad, Fish, Schneider, etc.

Although there are many books on cognitive therapy of various psychiatric disorders, this is the first book dedicated to schizophrenia. Without the clout of industry promotion enjoyed by medications, or the fancy attached to imaging and genetics, psychological approaches are vulnerable to neglect by clinicians. The studies and advances in cognitive therapy, however, have managed to create a silent revolution for the betterment of the field, and this book tells you how and why. The authors make a persuasive case that, when used in conjunction with pharmacotherapy, cognitive therapy could become a key ingredient in offering hope and recovery to many patients with schizophrenia.