4.6. Psychological Treatments of Sz

Question 1

What did NICE recommend?

Answer 1

Everyone with sz should be offered CBT to help patients deal with residual symptoms which persist despite antipsychotic drugs.

Question 2

What do distorted beliefs and delusions do?

Answer 2

Distorted beliefs negatively influence feelings and behaviour.
Delusions result from faulty interpretations of events.

Question 3

How many sessions is CBT?

Answer 3

Between 5-20 sessions, one to one or a group

Question 4

What happens in CBT?

Answer 4

• patients are encouraged to evaluate the content of their delusion/ voices to test validity of beliefs, then change them
• patients helped to make sense of how their delusions/ hallucinations impact on their feelings and behaviour
• distorted thinking and maladaptive beliefs are identified with the help of the therapists, looking for alternative explanations and coping strategies

Question 5

What are the features of CBT?

Answer 5

• Assessment
• Engagement
• Normalisation
• Critical collaborative analysis
• Developing alternative explanations

Question 6

What is assessment in CBT?

Answer 6

Patient expresses their thoughts/ goals using their distress as motivation for change

Question 7

What is engagement in CBT?

Answer 7

• The therapist empathises with the patient’s perspectives and distress.
• The ABC model: activating events (voices), beliefs (voices are mean and hostile) and emotional consequences (sorrow, depression) are discussed.
• Irrational beliefs are disputed.

Question 8

What is normalisation in CBT?

Answer 8

• Patients are reassured that many people have hallucinations and delusions when they’re stressed.
• This helps patients to feel less anxious about their symptoms and to believe in the possibility of recovery.

Question 9

What is critical collaborative analysis in CBT?

Answer 9

The therapist uses gentle questioning to challenge the patient’s beliefs in an atmosphere of trust and non-judgemental acceptance.

Question 10

What is developing alternative explanations in CBT?

Answer 10

The patient develops their own alternative explanations for previously unhealthy assumptions, with the support of a therapist

Question 11

What was Turkington et al’s study?

Answer 11

• Treated a paranoid client who believed the Mafia were plotting to kill him
• The therapist acknowledged the client’s anxiety and explained that there were other, less frightening possibilities and gently asked the client for his evidence for his belief in the Mafia explanation

Question 12

Strength: evidence for effectiveness of CBT

Answer 12

+ Jauhar et al (2014): reviewed 34 studies of CBT for sz and found CBT had a significant but small effect on +ve and -ve symptoms

+ Pontillo et al found reductions in auditory hallucinations

+ NICE recommends CBT for people with sz

+ This means both research and clinical experience support CBT for sz

Question 13

Weakness: quality of evidence

Answer 13

• Thomas: different studies have focused on different CBT techniques and people with different symptoms
• Modest benefits of CBT for sz may conceal a range of effects of different techniques on different symptoms
• Some studies fail to randomly allocate patients to conditions, others fail to mask conditions for assessors.
• This weakens the validity of conclusions of meta-analyses.
• This means it’s hard to say how effective CBT will be for treating a particular person for sz.

Question 14

Weakness: lack of availability for CBT

Answer 14

Only 1 in 10 patients who could benefit are able to access CBT in the UK but some refuse treatments or fail to attend.

Question 15

Weakness: CBT isn’t suitable for all patients

Answer 15

People with extreme agitation will not be able to rationalise or empathise with a therapist.

Question 16

Weakness: CBT as a sole treatment only has a small effect

Answer 16

• More recent meta-analyses of CBT as a sole treatment show only a small effect on +ve symptoms.
• These effects disappeared when symptoms were assessed blind which has led to conflicting treatment advice in different regions of the UK.
• CBT is generally combined with drug treatments

Question 17

Extra evaluation: effectiveness is dependent on the stage of the disorder

Answer 17

• CBT isn’t appropriate in the initial acute phase of psychosis, but when symptoms have been stabilised with drugs, it can be more effective.
• Group based CBT can help to normalise patient’s experience.
• Individuals with more experience and self awareness benefit more from individual CBT

Question 18

Weakness: CBT doesn’t cure

Answer 18

• Helps patients make sense of their symptoms but doesn’t cure.
• Biological therapies don’t cure sz but do reduce severity of symptoms and therefore may be more desirable.

Question 19

What does family therapy aim to do?

Answer 19

• Attempts to help family find more +ve ways of dealing with the stress of life with a family member with sz
• This should reduce relapse rate
• Aims to reduce levels of expressed emotion

Question 20

How many sessions of family therapy are offered?

Answer 20

Around 10 sessions over 3-12 months

Question 21

How does family therapy work?

Answer 21

• Psychoeducation: helping the person and their carers better understand the illness
• Reducing expressions of anger and guilt by family members
• Enabling the patient to explain to their family what support they find helpful and what makes things worse for them.
• Helps the person with the illness move forward and stay as normal as possible
• Gets everyone’s voice heard to reduce tensions

Question 22

What is Burbach’s model?

Answer 22

• Phases 1+2 -> share info and identity resources family can offer
• Phases 3+4 -> learn mutual understanding and look at unhelpful patterns of interaction
• Phases 6,7&8 -> skills training, relapse prevention and maintenance

Question 23

Strength: evidence for effectiveness of family therapy

Answer 23

+ McFarlane concluded family therapy is effective for sz, relapse rates were reduced by 50-60%

+ Family therapy is particularly promising during time when mental health initially starts to decline

+ NICE recommends family therapy

Question 24

Strength: family therapy is beneficial for whole family

Answer 24

+ Lobban and Barrowclough: therapy isn’t just for benefit of patient but also the families that provide the majority of the care for the person with sz

+ Family therapy lessens the -ve impact of sz on the family and strengthens the ability of the family to give appropriate support

Question 25

Strength: Pharoah

Answer 25

+ Compared outcomes from family therapy to treatment involving medication alone. There were mixed results in mental state of the patients.

+ Some improvements in general functioning but no effect on independent living or employment

+ Increased compliance with medication

+ Reduction in risk of relapse and hospital admission during family therapy and for 24 months after. This supports the view that treating the whole family is beneficial.

Question 26

Strength: Bird

Answer 26

Showed that family intervention in early psychosis significantly reduced relapse and readmission rates.

Question 27

Strength: family studies can improve clinical outcomes

Answer 27

Family studied can improve clinical outcomes and social functioning and increase medical compliance

Question 28

Weakness: random allocation

Answer 28

In Pharoah’s meta analysis, many of the Chinese studies may not have used random allocation of ppts to treat conditions

Question 29

Strength: Cost of family therapy

Answer 29

A NICE review of family therapy studies showed that the extra cost of family therapy is offset by a reduction in the costs of hospitalisation because of lower relapse rates.

Question 30

Weakness: good standard of care

Answer 30

If a patient has a good standard of care in a family with relatively low EE, then family therapy may give no further advantage.