Skip to content
Raising the bar for excellence in CBT. Enroll in Beck Institute CBT Certification today!

A Revolutionary Idea: The Pathway to Low-Functioning in Schizophrenia

By Aaron Beck, MD

For many years, Paul Grant, Ph.D., our colleagues, and I have worked to develop a recovery-oriented cognitive therapy treatment for individuals with schizophrenia. Early on, we observed that there was a lack of coherence between neurocognitive impairment and functioning in these individuals, although there was a moderate correlation. We posited that the two were only indirectly correlated and began our search for mediating constructs. We hoped to discover psychosocial factors that could become targets for treatment interventions. This led us to examine the role of defeatist attitudes, which correlated with both neurocognitive impairment and functioning (Grant & Beck, 2009).

We conducted a number of cross-sectional and longitudinal studies, in which we established the primacy of the defeatist and asocial attitudes (Grant & Beck, 2009; Grant et al, 2017). Targeting these negative attitudes was shown to produce a favorable outcome, both in a randomized controlled clinical trial and in an experimental analog (Grant et al, 2012; Grant et al, 2018). Expanding on our work, Thomas et al (2017) established a longitudinal pathway from defeatist attitudes to decreased motivation to low functioning.

Our review of the literature which was recently published (Beck et al, 2018) explores the influence of non-neurocognitive factors on neurocognitive performance, as measured by test batteries. We examined the influence of avolition, effort, dysfunctional attitudes, stress, asociality and disorganized symptoms on neurocognitive test performance. All were found to play a role. Thus, we believe there is sufficient evidence that psychological and environmental factors not only impact performance on neurocognitive tests, but may also be a primary rather than secondary detriment to functioning in schizophrenia. We now believe that much of the poor performance on neurocognitive tests seen in schizophrenia can be attributed to low motivation, which in turn, results from defeatist performance beliefs. By targeting defeatist attitudes in treatment, not only can we improve motivation, but we can thereby shape the pathway between neurocognition and real-world functioning.

The take-home message: do not be distracted by the apparent neurocognitive impairment in treatment; rather focus on engagement, proximal goal setting, meaningful aspirations, and activity. This formulation will activate the individual.


Beck, A. T., Himelstein, R., Bredemeier, K., Silverstein, S. M., & Grant, P. (2018). What accounts for poor functioning in people with schizophrenia: a re-evaluation of the contributions of neurocognitive v. attitudinal and motivational factors. Psychological medicine, 1-10.

Grant, P. M., & Beck, A. T. (2009). Defeatist beliefs as a mediator of cognitive impairment, negative symptoms, and functioning in schizophrenia. Schizophrenia bulletin, 35(4), 798-806.

Grant, P. M., Huh, G. A., Perivoliotis, D., Stolar, N. M., & Beck, A. T. (2012). Randomized trial to evaluate the efficacy of cognitive therapy for low-functioning patients with schizophrenia. Archives of general psychiatry, 69(2), 121-127.

Grant, P.M., Bredemeier, K. & Beck, A.T. (2017) A Longitudinal Study of Defeatist Beliefs, Neurocognition, & Functional Outcomes. (ed. U. r. data): Unpublished raw data. Philadelphia, Pennsylvania, USA.

Grant, P. M., Perivoliotis, D., Luther, L., Bredemeier, K., & Beck, A. T. (2018). Rapid improvement in beliefs, mood, and performance following an experimental success experience in an analogue test of recovery-oriented cognitive therapy. Psychological medicine, 48(2), 261-268.

Thomas, E., Luther, L., Zullo, L., Beck, A., & Grant, P. (2017). From neurocognition to community participation in serious mental illness: The intermediary role of dysfunctional attitudes and motivation. Psychological Medicine, 47(5), 822-836.