For years in community mental health, I sat across from people the world had already given up on.
The chart said “schizophrenia.” The referral said “non-compliant.” The case manager said “keeps talking to himself.”
But when you actually sit with someone long enough, not in the sterile minutes of an intake but in the long quiet of a Tuesday afternoon, you begin to see something different.
You see a person trying to think.
I have spent much of my career in the trenches. Crisis centers, ACT teams, jails, assisted living facilities, and even the lobbies of hospitals watching my client speaking to God.
In those moments, schizophrenia is not a diagnosis code. It is a daily reality. I have seen men and women pacing the halls, muttering to voices I could not hear. But what struck me most was not the hallucination itself. It was the confusion.
When you talk to them, it is not just that they hear something you do not. It is that they cannot organize what is real and what is imagined. Thoughts drift. Words tangle. You ask a question, and the answer wanders off before it finds its way back.
That is not delusion. That is cognitive breakdown. And it is devastating.
AND WE KNOW IT!!
We have seen the imaging. We know what uncontrolled psychosis looks like over time. We have watched those scans show cortical thinning, neural atrophy, and a brain that slowly disconnects from itself. What happens next? It takes more and more medication to hold the line, which means more and more side effects.
What did CATIE and years of follow-up data tell us? People living with schizophrenia lose an average of about 14 years of life expectancy. Much of that loss comes from the cumulative toll of uncontrolled illness and the metabolic side effects of long-term treatment. Fourteen years gone.
We cannot keep pretending we do not see it.
It turns out the science has finally caught up to what many of us have witnessed all along.
A 2023 review in Molecular Psychiatry described cognitive impairment as the core feature of schizophrenia, present long before the first psychotic episode and largely untouched by our dopamine-blocking medications.
A 2024 targeted review in The Journal of Clinical Psychiatry showed that clients with moderate to severe cognitive impairment had double the rate of relapse-related hospitalizations and emergency room visits compared to those with milder deficits.
Thanks to the MATRICS Consensus Cognitive Battery, we can finally measure these impairments systematically. MATRICS provided a framework to assess seven key cognitive domains including processing speed, attention, working memory, verbal learning, visual learning, reasoning and problem solving, and social cognition. It helped quantify what clinicians have long observed in practice.
In other words, when cognition falters, everything else collapses around it. Adherence, relationships, employment, and independence all suffer.
We keep measuring delusions, but it is the disorganized circuitry of thought that determines who truly recovers.
Early in my career, I thought success meant “no voices.”
Now, I think success means “clarity.”
I have seen clients with persistent hallucinations live meaningful, independent lives because they could still reason, process, and adapt.
I have also seen others, technically “stable” on medication, lost in a fog of disorganized thought that left them isolated and dependent.
That is when it hit me. Cognition should not be sitting in the back of the bus. It should be driving it.
Our treatments, our outcome measures, and our insurance metrics all chase visible symptoms. But cognition determines function, and function determines freedom.
If we truly want to transform lives, we have to move cognition to the front of the conversation. We need to design medications, digital therapeutics, and behavioral interventions that restore thinking itself.
The good news is that we are starting to get there.
New medications are showing early signs of improving cognition in schizophrenia, something no antipsychotic has ever done. These advances are being measured through tools like the MATRICS Consensus Cognitive Battery (MCCB), which for the first time gave us a standardized way to evaluate the cognitive domains that truly matter including processing speed, working memory, attention, reasoning, and social cognition.
Cognitive remediation programs such as CIRCuiTS and SocialVille use neuroplasticity-based training to strengthen attention, memory, and problem-solving.
Even simple combinations of exercise and cognitive training have been shown to increase cortical thickness in the very brain regions tied to executive function.
The future is not just about quieting voices. It is about reconnecting circuits.
After years in this field, I have come to believe that schizophrenia is, at its core, a disorder of thought.
If we can help people think more clearly, we do more than reduce symptoms. We return identity, autonomy, and dignity.
It is time to stop managing the illness and start restoring the mind.
Because when cognition drives the bus, everything else—insight, motivation, independence, and recovery—finally knows where it is going.
Schedule an appointment today to get diagnosed, receive a prescription, and continue your journey towards mental peace.
