PSYCHOLOGICAL TREATMENTS FOR SCHIZOPHRENIA
SCHIZOPHRENIA SPECIFICATION
Cognitive behaviour therapy and family therapy as used in the treatment of schizophrenia. Token economies as used in the management of schizophrenia.
COGNITIVE BEHAVIOUR THERAPY AND FAMILY THERAPY AS USED IN THE TREATMENT OF SCHIZOPHRENIA
Cognitive Behavioural Therapy (CBT)
CBT is an intervention for changing both thoughts and behaviour, representing an umbrella term for many different therapies that share the common aim of changing both cognitions and behaviour. CBT will be discussed generally in this article.
Background
Cognitive psychologists look at how people perceive, anticipate and evaluate events rather than the events themselves. For example how someone perceives exams. It is not the exam itself; it is how someone perceives, anticipates and evaluates taking exams. If they have optimistic or healthy cognitions, their perception of examinations will be realistic and healthy, even if they fail! The main premise of CBT is that cognitions affect behaviour: Healthy cognitions lead to normal behaviour. Faulty cognitions lead to abnormal behaviour, emotions and perceptions. (Self-fulfilling prophecy). You are what you think you are!
The CBT therapist encourages the client to become aware of beliefs contributing to dysfunctional behaviour. This involves direct questioning such as: “Tell me what you think about exams?” “Tell me why you think Madonna wants to marry you. The therapist does not comment upon the client’s beliefs; instead, they are treated as a hypothesis and examined for validity.
“CBT is a form of psychotherapy that attempts to change the patient's unhealthy thoughts and actions. The patient learns to identify distorted thought patterns and beliefs and to replace them with more productive ways of thinking and acting.”
CBT for Schizophrenia (summarised version)
The aims of the therapy are as follows:
To discover that we all have inherent tendencies to certain negative thoughts that evoke unhappiness and disturbance - especially in response to particular trigger situations.
To help the patient to identify delusions.
To challenge and modify delusory beliefs (make irrational thoughts rational). To challenge those delusions by looking at evidence. To help the patient begin testing the reality of the evidence.
Recognise negative thoughts. Once patients accept that fact, they can learn to spot these negative thoughts as they arise and then challenge and re-think them. To trace back the symptoms to get a better idea of how they developed
Evaluate the context of the patient’s delusions and hallucinations by considering ways to test the validity of their faulty beliefs.
Set behavioural assignments to improve general Levels of functioning
Let the patient develop alternatives to their previous maladaptive behaviour by looking at coping strategies and alternative explanations.
Distraction strategies for hallucinations and delusions. They are drowning out voices by shouting or turning up the volume of the TV.
Behavioural strategies include initiating and withdrawing social contact, deep breathing, and other relaxation techniques.
Positive self-talk.
An example of faulty cognition
Another example related to paranoia is when A person leaves his neighbourhood supermarket and notices some men in hoodies and sunglasses walking past the shop. He has the thought, “Those men are a gang and are following me so they can mug me”. This perception makes him feel threatened (emotion), so he decides not to go to that shop anymore (behaviour). Following this incident, he starts to avoid other places because of increased paranoia and, therefore, becomes more isolated. As you can see from these examples, having certain thoughts or beliefs dictates how a person feels and what they decide to do or not do. These thoughts can create a vicious cycle of avoidance, depression, paranoia, social isolation or distress, which unfortunately can keep a person from achieving personal goals or things that they want from life (such as a job, friends, their flat, a family, etc.).
CBT theory in detail
CBT presumes that one's symptoms are not random or fully “biological” in nature but that they are related to one’s “psychology” and that they are personally meaningful. For instance, CBT theory suggests that someone hearing voices telling him that he is a terrible person is not a random occurrence; this person was likely told that at some point in his life and is struggling with his feelings of worthlessness.
Another theory behind CBT for schizophrenia is that stress makes symptoms considerably worse. So, if a person can learn skills to handle stress more effectively, it is also likely that the person’s symptoms (such as voices or negative symptoms) will also decrease.
Therapy in Detail
The CBT therapist uses specialized techniques to help the client identify his or her unhelpful thoughts (or cognitions) and teaches skills to aid the client in modifying “maladaptive” cognitions over time. In addition, the therapist helps the client identify which coping strategies he or she currently uses to deal with stress, paranoia, voices, depression or anxiety and evaluates with the client what is working and what is not working. Through trial and error, the therapist and client strive to optimize coping strategies. The therapist and client decide what they will work on, and they study the symptoms and problems together to learn what triggers the symptoms and what makes the symptoms better. The client and the therapist always create a session agenda at the beginning to determine what will be discussed. Each week, an out-of-session homework assignment is decided upon together so that the client can have the opportunity to practice a skill learned in a session that week. CBT is also very present-oriented in that most of the time is spent on what the person is experiencing. While therapists acknowledge that what happened in one’s past and in one’s family is very important to know how clients became who they are, CBT stays focused more on current situations. Therapists feel that is the best way to help a person move forward and work towards his/her own goals.
Evaluation positive
CBT tends to have well-specified treatment goals and clear guidelines for assessing treatment progress.
It has flexibility in meeting individual needs.
Evaluation negative
In general, CBT is different from other psychotherapies in that it is very structured and mutual and tends to be fairly short-term (approximately 10-24 sessions, depending on the client). Frequently, the treatment is very problem-orientated and prescriptive, and individuals are active collaborators." In most cases, the short duration of 5-20 weeks is appealing to insurance companies.
· Researchers generally perceive CBT to be an evidence-based, cost-effective form of treatment that can be successfully applied to a broad range of psychopathologies, including Schizophrenia.
CBT generally emphasises building self-efficacy (belief in one's ability to perform a task.).
Research on the effectiveness of CBT is very mixed: On the one hand, advocates claim that CBT tends to have the largest effect on helping with psychotic symptoms (like voices and delusions) at the end of treatment and also helps to maintain those gains when treatment is over (relapse). In particular, CBT has been found to reduce the severity of these symptoms and also the distress that these symptoms cause in people who have them. An interesting point is that both anti-psychotics and CBT are effective in treating positive symptoms only, lending more support to the notion that they are different disorders. Other positive research is:
· Drury et al.: when using CBT and drugs, there was a 25-50% reduction in positive symptoms and recovery time
· Kuipers et al: when using CBT, there was increased satisfaction and low dropout rates
· This type of treatment is effective for reducing the positive symptoms of schizophrenia, for reducing relapse and for enhancing recovery when schizophrenia is diagnosed early.
· Chadwick and Lowe (1993) found that CBT reduced delusions in 10/12 of the patients in their study. However, whilst it helps around 70% of patients, it has deteriorated the other 30% (Kingdom and Turkington, 1996).
However, very recently, many psychologists have criticised the previous studies that have endorsed CBT as an effective treatment for Schizophrenia. (See this review of CBT meta-analyses by Butler et al., 2006). They conclude that CBT is no better than non-specific control interventions in the treatment of schizophrenia and does not reduce relapse rates. Butler says, “Lately, we've been treated to a plethora of articles and press releases saying that antidepressants are worthless and no better than placebo. The present meta-analysis by Lynch et al. (2009) came to the same conclusion about CBT in schizophrenia. The press release is quite blunt:” Cognitive Therapy Is of No Value in Schizophrenia, Science Daily (June 26, 2009) — Research co-led by an academic at the University of Hertfordshire concludes that cognitive behavioural therapy (CBT) is of no value in schizophrenia. “
The results of the review suggest that CBT is ineffective in treating schizophrenia. The meta-analysis included studies examining the effectiveness of CBT against symptoms of schizophrenia and in reducing relapse in schizophrenia. Rigorous criteria were used when selecting only well-conducted clinical trials of CBT for inclusion: A major criticism of CBT of previous research in this area has been that the studies have all employed inadequately delivered psychological treatments for comparison and poor controls.
Dickerson (2000) also examined 20 studies of CBT in schizophrenia and concluded that the effects of CBT were less apparent when compared with other psychological treatments that controlled for therapy time. Moreover, CBT for Schizophrenia research encompasses patients who vary considerably in symptom presentation and course, number of hospital admissions, self-esteem, depression, suicidality, social/family support, response to medication, etc. Cognitive–behavioural therapy as a descriptor is similarly imprecise. Therefore, findings were invalid and unreliable.
Does CBT provide added value when compared with other non-specific psychological interventions? E.g. EE therapy? Plus research from non-western countries shows that Schizophrenia has a better prognosis if families are supportive.
CBT has been criticised for only dealing with the present and not examining a patient’s personal and family history. These may be important arrears to discuss, especially as current research is now suggesting abuse may be the stress factor that triggers the disorder.
Is CBT effective for Schizophrenia? Positive symptoms are associated with higher levels of Dopamine. Higher levels of Dopamine activity are observed in persons who take street drugs. One would not expect a person high on crack or cocaine, a Dopamine agonist, to be able to be talked out of being high. Similarly, is it too much to expect that a Schizophrenic experiencing similar effects from their high levels of Dopamine would be lucid enough to respond to CBT? Plus, attention deficits may make it impossible to concentrate. Stabilise patients with drugs for therapy
Many CBT therapists advocate drug therapy in conjunction with CBT; as a result, it is difficult to work out which has been effective or not when assessing CBT.
Do CBT therapists see the world through rose-tinted spectacles? Sometimes life is horrible. Maybe some of a patient's thoughts are not faulty and negative. Maybe they are real reflections of what is happening in their lives.
EFFECTIVENESS OF CBT IN THE TREATMENT OF SCHIZOPHRENIA
Cognitive-behavioural therapy became part of the treatment for schizophrenia in the UK in 2002 (NICE, 2014). Early studies of the efficacy of CBT in the treatment of schizophrenia highlighted positive effects on positive and negative symptoms, mood, anxiety and functioning. A meta-analysis of methodologically rigorous studies (Wykes et al. 2008) concluded that it benefits positive symptoms. In contrast to the earlier research, several recent meta-analyses have found no clear and convincing evidence that CBT is better than other non-pharmacological treatments (Jones et al. 2018, Jauhar et al. 2014). A meta-analysis of the effects of CBT on functioning, distress and quality of life (Laws et al. 2018) found a small therapeutic effect, which was not maintained at follow-up. Future studies using treatments tailored to specific subgroups of patients (organised by level of neurocognitive impairment and severity of the disorder) and manual-based protocols to ensure fidelity of implementation, and delivered by the supervised and more experienced therapist, could be used to examine the different effects of various elements of CBT on specific symptoms and outcomes. This might enable the development of more effective, personalised forms of CBT treatment to become available to a greater number of patients with schizophrenia. Treatment protocols should also incorporate elements of the third wave of CBT (mindfulness-based therapy, acceptance and commitment therapy, compassionate mind training and meta-cognitive therapy), which targets how people relate to their thoughts and feelings and the content of their thoughts and beliefs. Is psychology a science?
Schizophrenia as a diagnosis pulls together a group of people who vary considerably in symptom presentation and course, number of hospital admissions, self-esteem, depression, suicidality, social/family support, response to medication, etc. Cognitive–behavioural therapy as a descriptor is similarly imprecise. At present, the label is applied to a wide range of interventions, ranging from a few sessions of support and psycho-education, through specific interventions for individual symptoms, to therapies that last 20–50 sessions and claim to be weakening not only the full range of positive and negative symptoms but also enduring models of self (schemata). Therapy might be delivered individually or in groups. Then there are therapists themselves: trials are not always using therapists who are accredited cognitive–behavioural therapists, let alone those who are accredited and practised with psychosis. What this points to is that there is no one CBT for schizophrenia. Rather, a range of CBT therapies, some with different underlying theoretical models, are offered to a diverse group of patients by therapists who vary in ability and experience.
What does all this mean about its scientific credibility?
Nature versus Nurture
If the cause is not one thing, e.g. neither just nature (biological) nor nurture (psychological: cognitive, psycho-dynamic, Behavioural, etc.), then should treatment reflect this? For example, treatment should be biological (drugs) and psychological (counselling). CBT reflects a more eclectic approach to treatment as it recognises that the best outcomes involve CBT and Antipsychotics. Presumably, this ensures that the patient is more stable and can be more responsive to CBT.
Determinism? CBT presumes persons have free will and can change their behaviour. This is a refreshing and optimistic view of humanity. On the negative side, people can be blamed for not changing and held responsible for their actions.
Reductionism? Reducing treatment to changing faulty cognitions suggests that cause and treatment are cognitive only, although many CBT therapists advocate drug therapy in conjunction with CBT. However, research shows cause is not just biological nor to do with faulty cognitions and that family dynamics and abuse may play a part in aetiology. Therefore, family therapy should also be considered.
