Just as with cognitive-behavioral therapies (CBT) used to treat psychosis, specialized and scientifically validated psychotherapies have a role to play in supporting people with schizophrenia, in addition to other forms of care. CBT emphasizes quality of life, independence, and personal goals, going beyond mere clinical stabilization.

When Frank Bellivier, the ministerial delegate for mental health and psychiatry, warned on March 26, 2025, about the shortcomings in the care of severe psychiatric disorders in France, his remarks must be viewed in the context of current knowledge.

A review of the available scientific data on the effectiveness of psychotherapies provides a better understanding of clinical issues and evidence-based recommendations, particularly for schizophrenia spectrum disorders.

What do we know today about schizophrenia?

Schizophrenia is one of the top ten causes of disability worldwide. It affects approximately 1% of the global population—nearly 600,000 people in France—and typically begins during adolescence or early adulthood.

Symptoms include delusions and hallucinations (so-called “psychotic” symptoms), reduced emotional expression, impoverished speech, and a lack of initiative (known as “negative symptoms”), as well as incoherent speech and disorganized behavior (so-called “disorganized” symptoms).

The causes of schizophrenia remain poorly understood, but researchers agree that this disorder arises from a combination of genetic and environmental factors. Its presentation varies widely, which is why a personalized approach—based on an understanding of its biological, psychological, and social mechanisms—is so important.

Specialized psychotherapies—but that's not all…

As a clinical psychologist and researcher, I devote part of my career to elucidating the psychological mechanisms of schizophrenia and improving the lives of those affected. In this context, I am pleased to see the growing recognition of the role of psychotherapy.

However, these must be empirically grounded—that is, validated by research—and based on a detailed understanding of the psychological processes at play, such as self-confidence, rumination (recurring and repetitive thoughts that are difficult to control, centered on evaluating the reasons, causes, consequences, and implications of a situation—the “why?”), etc.

Of course, these psychotherapies should be considered in conjunction with other treatment modalities, whether medication, cognitive remediation (a form of therapy that involves training to improve certain functions, ed.), peer support (receiving support from peers with similar experiences, editor’s note), or other interventions aimed at psychosocial rehabilitation, when necessary.

Effective programs… but not very accessible

For a long time, the treatment of schizophrenia has focused on reducing symptoms, most often through medication alone.

Today, a more comprehensive approach focused on psychosocial rehabilitation is emerging. This approach emphasizes quality of life, independence, and personal goals, going beyond mere clinical stabilization.

Among the available tools, cognitive-behavioral therapies (CBT) play an important role. They are based on the idea that our interpretations of events—shaped over the course of our lives—can cause or perpetuate psychological distress.

CBT is part of a collaborative approach that aims to help people develop a more flexible way of understanding their environment and their emotions, adjust their behaviors, and, in this way, support them in achieving their life goals.

When it comes to psychosis, contrary to popular belief, these therapies do not seek to deny psychotic experiences, but rather to help the person make sense of them, respond to them differently, and regain control over their life. However, access to these therapies remains very limited, even in France.

Data are lacking, but in better-resourced countries (such as the United States, Canada, and the United Kingdom), the results regarding access to CBT for psychosis—whether in terms of professional training, program implementation, or actual access to care—remain discouraging.

Are cognitive and behavioral therapies appropriate for schizophrenia?

CBT was first applied to psychosis (CBT-P) in 1952 by Aaron Beck. However, it was not until the 1990s that more systematic and theory-based approaches to psychosis emerged. For a long time, psychotic symptoms were considered unchangeable.

However, research has shown that these experiences fall on a continuum with ordinary human experiences and that they can be modified. Today, models derived from CBT applied to psychosis posits, for example, that negative early-life events can contribute to the formation of rigid beliefs about oneself and the world, which, under stress, can manifest as psychotic symptoms.

Robust research shows that CBTs are effective, particularly in reducing psychotic and negative symptoms. These effects are more pronounced with long-term follow-up, but some brief interventions may also be beneficial.

Most importantly, the severity of symptoms does not appear to diminish the therapy’s effectiveness, suggesting that even the most severely affected individuals can benefit from it. Some approaches have even proven effective in patients with severe cognitive impairments.

Beyond symptoms, CBT also improves quality of life and social functioning. Interventions targeting families have also shown positive effects. However, these effects are often short-lived, which has led to the development of new approaches that address emotional regulation, sleep disorders, and trauma.

Some international guidelines, such as those from the National Institute for Clinical Excellence (NICE) in the United Kingdom, now consider CBT to be the first-line treatment for schizophrenia.

It should be noted that, to date, France does not have guidelines equivalent to those published in the United Kingdom regarding psychotherapies and other non-pharmacological treatments for schizophrenia.

Abroad, a few programs have proven successful

While this list is by no means exhaustive, here are a few recent programs that have proven effective and could be integrated into the healthcare system.

In 2021, Daniel Freeman and his colleagues at the University of Oxford demonstrated that the “Feeling Safe” program is effective in treating delusions of persecution (which affect approximately 80 percent of people with schizophrenia).

This program addresses ruminative thoughts, sleep difficulties, self-esteem, and coping with hallucinations, and promotes new learning. It has achieved a recovery rate ofapproximately 50 percent.

Mark Hayward and his colleagues at the University of Sussex have developed a specific program to support people who experience verbal auditory hallucinations (voices), which is used in “Voices Clinics.” This program aims to develop coping strategies, challenge certain beliefs (“the voices are mean”), promote cognitive flexibility, and strengthen assertiveness skills. It should be noted that there are two voice clinics in France.

Finally, Aaron Beck’s 18-month recovery-focused CBT program has shown improvements in functioning and symptoms among people with schizophrenia who have cognitive deficits. It aims to support participants in achieving their personal goals using CBT tools.

What's the current situation in France?

We lack precise data on access to cognitive-behavioral therapies for psychosis (CBT-P) in France, but the available evidence suggests that access is very limited.

Several obstacles can be identified: training in CBT remains unevenly distributed among universities; there are too few psychologists trained in these approaches in public institutions; and access to private practice is often hindered by financial constraints, particularly for people with mental disabilities.

For specialized and scientifically validated approaches

The treatment of schizophrenia is complex and involves many factors. The political will to invest in psychotherapy is a welcome step forward.

However, for it to have a real impact, it is essential that the proposed approaches be specialized, scientifically validated, and grounded in a psychosocial rehabilitation framework.