Multimodal cognitive therapy: combining treatments that bypass cognitive deficits and deal with reasoning and appraisal biases.

The process of recovery in schizophrenia involves resolving persistent symptoms, addressing cognitive impairments, and improving functional outcomes. Our research group has demonstrated the efficacy of cognitive adaptation training (CAT)--a home-based psychosocial treatment utilizing environmental supports such as medication containers, signs, checklists, and the organization of belongings to bypass deficits in cognitive functioning and cue and sequence adaptive behavior) for improving adherence to medications and functional outcomes in schizophrenia. Early CAT pilot studies utilizing some therapists with training in cognitive behavior therapy (CBT) techniques for psychosis found significant improvements in positive symptoms. More recent larger scale randomized clinical trials failed to replicate this finding with CAT therapists not trained in CBT techniques. Persistent psychotic symptoms substantially impair patients' ability to adapt to life in the community. Cognitive behavior therapy for psychosis (CBTp) is an evidence-based practice for addressing persistent positive symptoms and the distress associated with them. CBTp decreases symptomatology and minimizes the negative effect of persisting symptoms upon individuals with this disorder. We now describe a home-delivered, multimodal cognitive treatment targeting functional outcomes and persistent positive symptoms for individuals with schizophrenia by utilizing both CAT and CBT techniques. We discuss the advantages and challenges of combining these 2 interventions, present a small retrospective data analysis to support their combination into a multimodal treatment, and describe the design of an ongoing randomized trial to investigate efficacy.