Lack of awareness of a mental disorder is a prevalent feature of schizophrenia and is associated with poor outcome. Cognitive therapy (CT) is a promising adjunctive treatment for schizophrenia but is believed to be less efficacious for patients with poor insight. This article describes a goal-oriented CT approach that was innovated to circumvent limited insight in a young woman with severe paranoid delusions and auditory hallucinations. The treatment facilitated recovery by targeting avoidance, inactivity, and social withdrawal, and by promoting detachment from psychotic experiences without directly challenging delusional beliefs. The case study demonstrates the involvement of family in CT and the use of behavioral exercises to modify dysfunctional beliefs and behaviors. Results are consistent with recently advanced cognitive conceptualizations of schizophrenia and suggest that when appropriately tailored and focused on functional goals, CT can promote recovery in the absence of insight.
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