“A Literature Review of Previous Research on Schizophrenia: CBT, Ecotherapy, and
Others as Treatment”

An Honors Thesis

by

Brittney M. Roberts

California, Pennsylvania
2022

A Literature Review of Previous Research on Schizophrenia: CBT, Ecotherapy, and
Others as Treatment

Brittney Roberts
California University of Pennsylvania
Honors Thesis
Dr. Justin Hackett
May 6, 2022
Keywords: Schizophrenia, Cognitive Behavioral Therapy (CBT), Ecotherapy, Nature
Therapy, Shinrin-yoku

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Abstract
Schizophrenia is a mental disorder that does not have any specific cause but can have a
profound impact on one’s life. Symptoms can include delusions, paranoia, and
inappropriate actions. Many individuals with Schizophrenia can live their lives with
proper treatment and care. Cognitive Behavioral Therapy (CBT) is an evidence-based
treatment for Schizophrenia. CBT is used for treatment in many other situations such as
anxiety, depression, and much more. It deals with replacing unwanted thoughts with
more rational thinking and includes many ways to make this replacement happen
(American Psychological Association, 2017). However, what if there was another
possible treatment for Schizophrenia? A more natural approach would be Ecotherapy
which involves getting out into nature with Mindfulness playing a large part of its
existence.

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A Literature Review of Previous Research on Schizophrenia: CBT, Ecotherapy, and
Others as Treatment
Through several years of research, Schizophrenia is still a subject that researchers
do not know much about. One of these reasons being the simple fact that there is no
known cause of this disease. Without cause, it is difficult to determine prevention
strategies and treatment plans. However, Cognitive Behavioral Therapy (CBT) has been
known to improve patients’ quality of life through focusing on thoughts and emotions.
CBT is somewhat of a long-term treatment plan that asks the individual to attend therapy
sessions over longer periods of time – even sometimes taking years (Castelnovo et al.,
2020). Could there be something better – a prevention strategy even? Ecotherapy is an
ever-growing field in which the individual connects with nature through sessions led by a
therapist who must have a greater connection with nature themselves (Ganguly et al.,
2018).
The recognition of mental health issues has been increasing in recent years
because of the growing number of suicides in people from ages 15-29 years old (WHO,
n.d.). In fact, twenty percent of all children under the age of 18, are living with a mental
health condition (WHO, n.d.). This effects their ability to effectively communicate with
family and friends, actively participate in school or work, and just simply live a normal,
everyday life (WHO, n.d.). Treatment for mental health conditions is very costly. Two of
the most common mental health conditions would include anxiety and depression which
cost around one trillion dollars per year globally (WHO, n.d.). Not as common,

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schizophrenia effects nearly 1 in every 300 people according to the World Health
Organization (n.d.). Many are not receiving appropriate treatment. Only approximately
one-third of all individuals with schizophrenia are receiving health care from a specialist
(WHO, n.d.).
Schizophrenia
A background on schizophrenia should provide a historical overview and include
the information that is known at this point in time. Eugen Bleuler was a Swiss
psychiatrist that first coined the term after his work suggesting that the splitting of the
psychic functioning was crucial for a schizophrenia diagnosis (Ashok et al., 2012).
Before this, schizophrenia was called dementia praecox and Bleuler argued that it had
nothing to do with dementia or precociousness. He knew this by studying individuals in a
clinical observation instead of only looking at individual’s records like those before him.
Schizophrenia is a difficult mental health condition to treat simply because there
is not one known cause (DeLisi, 2021). It is unclear if schizophrenia involves one single
disease with different causes or if it is one single cause of several different diseases
(DeLisi, 2021). A question that is always at hand involves nature vs. nurture. There is
strong evidence that Schizophrenia is a genetic disease (DeLisi, 2021). There has been
research done with biological children vs. children who were adopted. In these studies,
children who were adopted still develop schizophrenic symptoms when their biological
parents had schizophrenia. This occurred even if the adoptive parents did not show signs
of schizophrenia. According to Matsumoto et al. in 2017, if the parent suffers from
schizophrenia, the child will have a 10% chance of having it as well (Ganguly et al.,
2018).

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In addition to schizophrenia being hereditary, males are more likely to develop
schizophrenia than females (Aleman, 2003). This could be because men are less likely to
seek out help for psychiatric symptoms. When individuals are at risk, stressful events can
sometimes trigger schizophrenia to present itself according to Hwang and Nasrallah (as
cited in Ganguly et al., 2018). Stressful events would include abuse, both physical and
mental, having a social disadvantage, and living in environments that would be
considered urban or more densely populated areas (Ganguly et al., 2018). Rates of
Schizophrenia are higher in racial minorities compared to the majorities (Cowan et al.,
2011). These differences may be impacted by socio-economic status. According to
Pogue-Geile, obsessive alcohol and drug use such as cannabis and amphetamine could
cause schizophrenic symptoms in people who are at risk (as cited in Ganguly et al.,
2018). Alcohol and drug use are also linked to symptoms of schizophrenia reoccurring
(Ganguly et al., 2018). Substances affect the dopaminergic and glutaminergic systems in
the individual’s brain (NCCMH, 1970). These parts of the brain are associated with
delusions and hallucinations which are common symptoms of schizophrenia. Along with
this finding, individuals with schizophrenia use alcohol and drugs more than others in the
general population.
Signs of schizophrenia usually start to appear in the late teenage years or early
adulthood but can still appear in the middle age (Kirkbride, 2016). Some early signs of
schizophrenia in adolescents are usually associated with lower academic achievement,
especially mathematic achievement (Oswalt, 2020). Childhood adverse experiences are
sometimes linked to higher rates of substance abuse (Youseff et al., 2022). In a study
done by Youseff and colleagues (2022), they found that there is a significant relationship

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between childhood adverse experiences, substance abuse, and schizophrenia.
Researchers have found that genetically, the same variant that is associated with cannabis
use is also associated with schizophrenia (Hunt, 2017). This causes researchers to
question whether cannabis use is somehow the cause of schizophrenia.
Daniel Paul Scheber had a psychotic episode in his early forties and experienced
symptoms of schizophrenia at an older age than typically seen (Lipski, 2018). He was a
German judge and wrote down most, if not all of what he was experiencing as it was
happening. It gave insight to what individuals with schizophrenia are seeing, hearing, and
feeling. Scheber had several delusions, including that he was transformed into a woman
and would often compare himself to Christ because he was going to save the world. The
information that Scheber was able to give psychologists was very beneficial as they were
able to get into the mind of an individual with the disease.
The circumstances of the Galvin family are another set of cases of interest to
schizophrenia researchers. Out of twelve biological children, six males grew up to have
schizophrenia in the 1960s (Kolker, 2020). During this time, schizophrenia was blamed
on the mother for being too overbearing (Burnfield, 2021). Researchers of schizophrenia
are particularly interested in this case because of the genetics of the disease. Researchers
found that there was a mutation in the SHANK-2 gene in all affected individuals (Kolker,
2020). However, the mutation was also present and transmitted by the unaffected mother,
Mimi, and present in one of the unaffected female siblings and her female offspring.
Although not affected and not experiencing any psychosis, the females with the mutation
in their SHANK-2 gene had a history of major depression (Kolker, 2020).

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Symptoms of schizophrenia include delusions, hallucinations (both auditory and
visual), and paranoia (Spencer et al., 2020). According to Coid et al in 2013, 70% of
individuals with schizophrenia report persecutory delusions (as cited in Spencer et al.,
2020). Hugdaul (2015) said that 70-80% of these individuals report hearing voices (as
cited in Spencer et al., 2020). Other symptoms of schizophrenia include disorganized
thinking, highly disorganized behavior, inability to experience interest or pleasure, and
extreme agitation (WHO, n.d.). To receive a diagnosis of schizophrenia, psychiatrists use
the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
The DSM-5 states that “the diagnostic criteria include the persistence of two or more of
the following active-phase symptoms, each lasting for a significant portion of at least a
one-month period: delusions, hallucinations, disorganized speech, grossly disorganized or
catatonic behavior, and negative symptoms” (DSM-5, 2013).
There are several other disorders that may accompany schizophrenia including
anxiety, depression, social phobia, post-traumatic stress disorder (PTSD), obsessivecompulsive disorder OCD, generalized anxiety disorder, and/or panic disorder (Howells,
2017). Twin studies have frequently found anxiety and schizophrenia to be related.
Howells (2017) found that while one identical twin had schizophrenia and the other did
not, but the twin with schizophrenia also had higher levels of anxiety. It is common to use
Cognitive Behavioral Therapy (CBT) as treatment for most of these mental health
conditions, but according to works by Steel and colleagues (2016), CBT does not help
PTSD.
The end result for individuals with schizophrenia can sometimes be a good one.
According to a fifteen-year study longitudinal study, 27% of the individuals in their study

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accomplished complete remission (Wiersma et al., 1998). However, not all individuals
fared as well with 11% experiencing chronic psychosis, 43% with negative syndrome
after one or more episodes, and about 66% with at least one relapse after the initial
psychosis was discovered. Alarmingly, 11% of the individuals committed suicide.
If first attempts of treatment with CBT are unsuccessful, most schizophrenia cases
are treated with a combination of medication and therapy. When an antipsychotic
treatment is used, it usually reduces positive symptoms by blocking dopamine receptors
according to Gallety and colleagues (2016) (as cited in Ganguly, 2018). Haloperidol,
fluphenazine, and chlorpromazine have been used to treat schizophrenia for the last
several years (Medication for Schizophrenia, n.d.). Some side effects of these
medications include tremors and dystonia and if not taken care of in a long-term sense,
the possibility of tardive dyskinesia comes into play. In more recent years, different
medications such as quetiapine, risperidone, and aripiprazole are prescribed for
schizophrenia because their side effects are less than the latter. With these medications,
negative side effects are lessened, but not completely eliminated. Individuals prescribed
this medication have an increased risk of diabetes and high cholesterol (Medication for
Schizophrenia, n.d.). They must be monitored in order to ensure their physical health is
thriving as well. Along with the worry of side effects from the medication, health
professionals have the additional worry of keeping individuals with schizophrenia away
from drugs and alcohol. As mentioned previously, 1) drugs and alcohol are more likely to
produce a psychotic episode and 2) individuals diagnosed with schizophrenia are more
likely to use drugs and alcohol as a coping mechanism (Ganguly et al., 2018).

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CBT
Cognitive Behavioral Therapy (CBT) is one of the most recommended therapy
plans for individuals with schizophrenia (Howells, 2017). It is used for anxiety and the
intentions are to minimize disastrous ideas along with stress. CBT can involve therapy
with family members in order to remove disapproval from family members whose
opinion matters to the individual. Individuals with schizophrenia often have difficulty
deciphering between what is real and what is not. Cognitive restructuring is a part of CBT
that challenges the individual to provide evidence to prove that their beliefs are real
(Ganguly, 2018). This helps the individual to realize that they do have delusions and it
challenges their negative and irrational thoughts. During the therapy session and after the
realization that delusions are occurring happens, the individual will be asked to replace
the irrational or negative thoughts with rational or positive ones.
CBT is usually used along with medication but is also a safe alternative for
individuals that refuse drugs according to Morrison and colleagues (2014) (as cited in
Castelnovo et al., 2020). While medication works for some people, it is not fully
compatible for some individuals with schizophrenia. Around 20% of the schizophrenia
population is not responsive to the medication mentioned previously and some others are
only partially response to it (Bellack, 2004). CBT usually works best with medication,
however, as mentioned, it can be a safe substitute as well (Castelnovo et al., 2020).
CBT includes several body-mind techniques. These can include of number of
things including exercise, mindfulness practice, and yoga therapy which seems to be
superior to all physical practices (Howells et al., 2017). Exercise for schizophrenia
patients may consist of a wide variety of activities including taking a short walk daily,

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riding a stationary bike, or simply following instructions from an exercise video. Of
course, they are not limited to any number of activities. Mindfulness is the ability to be
aware of one’s surrounding without being overly reactive or overwhelmed by what is
going on (Bayes-Fleming et al., 2022). Practicing mindfulness could include meditation,
living in the moment, focusing on breathing, along with a long list of other mindfulness
techniques (Hall-Flavin, 2020). Finally, yoga therapy practically combines physical and
mental exercises. It involves stretching while staying present in the moment.
Along with the previously listed instruments, CBT also involves rational problem
solving, modifying distorted thinking, and reducing dysfunctional behavior (Howells et
al., 2017). Individuals with schizophrenia will oftentimes have irrational thoughts such
as, “That person wants to hurt me,” or “I am being followed.” CBT challenges those
irrational thoughts and works to replace them with something more rational.
Schizophrenic individuals will also have distorted thoughts that might include something
like, “I need to be perfect so that everyone will like me.” Socratic dialogue and
collaborative empiricism challenges the distorted thoughts (Bellack, 2004). Along with
these things comes dysfunctional behavior which does not fit into the everyday norms of
society. By challenging the irrational thoughts and distorted thinking, CBT hopes to
eliminate or lessen the episodes of dysfunctional behavior.
Lastly, CBT involves receiving homework from the instructor. It is believed that
this will help to foster generalization (Bellack, 2004). Homework helps the individual to
continually think about what they have learned in the therapy session and practice the
things they have learned. It usually involves practice of coping strategies that they might
have learned or practicing more adaptive ways of thinking (Bellack, 2004).

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Ecotherapy
Ecotherapy is a combination of Ecology and Psychology. The main idea of it is to
remind humans that they are a part of Ecology rather than separate from it (Jones, 2010).
It is shown to reduce pain, PTSD, mood swings, and stress, and is used for ADHD and
dementia patients (Summers & Vivian, 2018). Kellert (as cited in Summers & Vivian,
2018) determined that exposing children to nature and ecotherapy helped them to become
better developed both cognitively and morally. Previously, it has been used to treat
schizophrenia during adventure- and recreation- based programming to promote weight
loss. This of course is after the onset of schizophrenia has already begun.
Shinrin-yoku is a form of Ecotherapy and translates to “forest bathing” (Kotera et
al., 2020). This form of Ecotherapy consists of yoga, meditation, walking, and other
recreational activities that could include basically any type of exercising outdoors. The
main idea of forest bathing is to be mindful of all senses while immersing oneself in these
activities. This is where CBT and Ecotherapy can overlap because mindfulness can be a
large part of both of them. When engaging in Forest Bathing, there are many physical
changes to one’s body. Intracellular anti-cancer proteins increase, blood pressure is
lowered, and there is a decrease in stress hormones (Macháčková et al., 2021). It is said
that spending only a few hours in a forest being mindful and meditating while walking
will decrease the stress hormones and increase the immune system’s activity. Along with
that, Forest Bathing helps with cardiovascular and respiratory systems (Kotera & Rhodes,
2020).
Not only is there a physical improvement, but also mental. As mentioned before,
Forest Bathing can be used for mood disorders, stress, and mental relaxation (Kotera et

12
al., 2020). Agreeing with previous research, Bratman et al. (2015) agrees that taking just
a 90-minute walk in nature will also help to lessen a patient’s rumination and activities of
subgenual prefrontal cortex. Forest bathing is helpful and good for treating anxiety,
depression, and anger. However, it is especially helpful with treating anxiety (Kotera et
al., 2020). It enhances relaxation, gratitude, and selflessness (Kotera & Rhodes, 2020).
For many people, Forest Bathing is accessible, free to use, and effective for a wide
variety of health outcomes. While it does not cost money to use, one must take into
consideration the environmental preservation that must take place as well.
Nature therapy is another version of Ecotherapy. With this concept, the mindbody connection is highlighted (Berger & Tiry, 2012). Escaping feelings of alienation,
fragmentation, and isolation is the main hope for therapists using nature therapy.
Individuals will gain personal knowledge by mirroring the therapist’s ideas, reflecting on
past experiences, and attuning through external reflection (Naor & Mayseless, 2021).
When using nature therapy, there are three participants: the patient or individual, the
therapist, and nature itself. The possibility for nature therapy to work depends on the
therapist’s relationship with nature themselves. If the therapist does not have a good
relationship with nature, the session will not be as likely to be successful for the patient.
According to Naor and Mayseless (2021), there are five methods to nature
therapy. First, one must create basic trust and safety/ethical boundaries. Creating these
boundaries will help ensure the therapist and individual to be safe throughout the
experience. Sticking with the boundaries that are set into place will establish trust.
Second, both the therapist and the patient must be aware of both internal and external
nature. Internal nature would include present feelings, thoughts, and body movements.

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External nature would include what they could smell, hear, and see. Third, the therapist
should work with the individual to develop new ways of knowing. This would involve
sensory, emotional, and symbolic ways that the individual could use to gain knowledge
about their irrational thoughts. Fourth, role modeling is an important aspect of nature
therapy. The therapist should be setting a clear example of what is expected of the
individual. For example, the therapist may suffer from anxiety themselves. In an anxiety
causing situation, the therapist could show the patient how to react. Finally, it is
important for the individual to understand the symbolic meaning of the exercises that are
being done.
During a nature therapy session, there is an importance of using metaphors and
hands-on experiences. In an example given by Naor and Mayseless (2021), the therapist
asked the individuals to build a fire. However, they came back with wet leaves because it
was the closest thing. The therapist then switched gears and asked them how this might
be like their own lives. It opens up opportunities for therapists to apply things in nature to
an individual’s own personal life. It is thought that the metaphor along with the hands-on
experience is what helps the individual to make a solid connection. Along with this,
nature therapy can be paired with art and drama therapy for the same reasons (Berger &
Tiry, 2012). There are many opportunities for metaphors to be used in drama therapy as
well.
For nature therapy to work properly, there are several skills that are needed from
both the individual/patient and the therapist (Naor & Mayseless, 2021). Body awareness,
deep listening, mindfulness, symbolic interactionism, experimental ways of knowing, and
learning from a role model. Although some of these skills are repeated from before, they

14
are all important aids in allowing the experience for both the individual and the therapist
to go smoothly. However, there are certain skills that are specifically needed from the
therapist. The first of these would include flexibility of boundaries. Setting clear and
concise boundaries for the individual is important but knowing when to be flexible with
those boundaries is an important factor as well. Second, the therapist must loosen control
of both themselves and the individual. Lastly, the therapist must work on being open to
the various adaptable situations that could occur within nature.
Discussion
With Cognitive Behavioral Therapy and medication being tested as treatment for
schizophrenia time and time again, it would be ridiculous to suggest instead using
Ecotherapy as treatment. However, there may be a way to assist in prevention of the
disease from occurring or progressing. There are several signs to watch for along with
genetic factors that one must take into consideration when looking at children of those
with schizophrenia. A suggestion would be to use Ecotherapy specifically for children
who have a higher likelihood of developing it later in life. For example, children of
schizophrenics, alcoholics, or addicts.
Previous research has shown that schizophrenia begins showing itself during
one’s late teens or early twenties (Ganguly et al., 2018). It is also known that the
prefrontal cortex of the brain will usually be fully developed by the age of twenty-five
(Arain et al., 2013). Could schizophrenia be caused by a malfunction in the frontal lobe
during maturation? Is there a way to stop the malfunction from occurring? It has also
been found that the use of drugs and alcohol heighten the possibility of schizophrenia

15
occurring (Ganguly et al., 2018). The use of drugs and alcohol including nicotine and
cannabis, inhibit the maturation of the frontal lobe as well (Arain et al., 2013).
Ecotherapy is already being used for children with some mental health concerns
including behavioral and emotional problems (Macháčková et al., 2021). Wilderness
therapy, another branch of Ecotherapy, is sometimes useful for helping children with
anxiety, depression, substance abuse and dependency, along with disruptive behavioral
issues, interpersonal relationships, and a long list of others. Several of these listed would
go right along with schizophrenia and its symptoms.
Another prevention technique that researchers have used is mapping the mutations
in families whose members share a complex genetic disorder like schizophrenia. This
allows therapists and psychiatrists to see where the mutations had led the brain astray
(DeLisi, 2021). This is another way that researchers are finding that helped to stop the
development and progression of the illness. Tailoring the treatment directly to the
individuals and involving their families are very important parts of the process.
Conclusion
Overall, without knowing the cause of schizophrenia, it is difficult to come up
with a solution to the problem. CBT has been in place for many years, but that is
treatment after schizophrenia symptoms have already set in. The suggestion being
presented here is that therapists implement Ecotherapy in its variety of forms as treatment
for children whose parents or other close relative have schizophrenia. Using Ecotherapy
as a prevention technique along with informing young teens of the dangers and potential
threats from drugs and alcohol could help many individuals in the long run.

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