Cognitive Behavioural Therapy Flashcards
define cognitive behavioural therapy
1
a combination of cognitive therapy (which involves changing maladaptive thoughts and beliefs) and behavioural therapy (which involves changing behaviour in response to these thoughts and beliefs)
development of CBT
4
NICE (the National Institute for Health and Care Excellence) recommend that all people with schizophrenia should be offered cognitive behavioural therapy
this form of therapy is referred to as CBTp (cognitive behavioural therapy for psychosis) when used in the treatment of schizophrenia
CBTp in schizophrenia was originally developed to provide treatment for residual symptoms that persist despite the use of antipsychotic medication
it aims to deal with the remaining symptoms and improve the patient’s functioning generally
what is CBTp?
8
the basic assumption of CBTp is that people often have distorted beliefs, which influence their feelings and behaviours in maladaptive ways
for example, someone with schizophrenia may believe that their behaviour is being controlled by someone or something else
delusions result from faulty interpretations of events and CBTp is used to help the patient identify and correct these faulty interpretations
it can be delivered in groups, but it is more commonly delivered on a one-to-one basis
NICE recommend at least 16 sessions when used in the treatment of schizophrenia
the aim of CBTp when used in this context is to help people establish links between their thoughts, feelings or actions and their symptoms and general level of functioning
by monitoring their thoughts, feelings or behaviours with respect to their symptoms, patients are better able to consider alternative ways of explaining why they feel and behave in the way that they do
this reduces distress and so improves functioning
what is involved in CBTp?
5
in CBTp, patients are encouraged to trace back the origins of their symptoms in order to get a better idea of how they might have developed
they are also encouraged to evaluate the content of their delusions or of any voices they hear and consider ways in which they might test the validity of their faulty beliefs
patients might also be set behavioural assignments so that they can improve their general level of functioning
the learning of maladaptive responses to life problems is often the result of distorted thinking by the schizophrenic or mistakes in assessing cause and effect — for example, assuming that something terrible has happened because they wished it
during CBTp, the therapist lets the patient develop their own alternatives to these previous maladaptive beliefs, ideally by looking for alternative explanations and coping strategies that are already present in the patient’s mind
how does CBTp work?
3
CBTp proceeds through a series of phases, which include…
1) assessment
2) engagement
3) the ABC model
4) normalisation
5) critical collaborative analysis
6) developing alternative explanations
these phases lead to the development of alternative explanations to replace previously unhealthy assumptions
stages of CBTp: assessment
2
the patient expresses their thoughts about their experiences to the therapist
realistic goals for therapy are discussed using the patient’s current distress as motivation for change
stages of CBTp: engagement
2
the therapist empathises with the patient’s perspective and their feelings of distress
they emphasise that explanations for the patient’s distress can be developed together
stages of CBTp: the ABC model
3
the patient gives their explanation of the activating events (A) that appear to cause their emotional and behavioural (B) consequences (C)
the patient’s own beliefs, which are usually the cause of the consequences, can then be rationalised, disputed and changed
for example, the belief that “people won’t like me if I tell them about my voices” might be changed to a more healthy belief such as “some may, some may not, friends may find it interesting“
stages of CBTp: normalisation
4
the therapist may present the patient with the information that many people have unusual experiences such as hallucinations and delusions under many different circumstances
for example, in situations of extreme stress
this reduces anxiety and the sense of isolation they feel
by placing psychotic experiences on a continuum with normal experiences, the patient feels less alienated and stigmatised and the possibility of recovery seems more likely
stages of CBTp: critical collaborative analysis
4
the therapist uses gentle questioning to help the patient understand illogical deductions and conclusions
for example, they may ask “if your voices are real, why can’t other people hear them?”
questioning can be carried out without causing distress, provided there is an atmosphere of trust between the patient and the therapist
the therapist must remain empathetic and non-judgemental
stages of CBTp: developing alternative explanations
3
the patient develops their own alternative explanations for their previously unhealthy assumptions
these healthier explanations might have been temporarily weakened by their dysfunctional thinking patterns
if the patient is not forthcoming with alternative explanations, new ideas can be constructed in cooperation with the therapist
x4 evaluation points for CBT
support for the effectiveness of CBTp over standard care
limits to the effectiveness of CBTp
problems with meta analyses of CBTp
the benefits of CBTp may have been overstated
EVALUATION
support for the effectiveness of CBTp over standard care
6
the NICE review of treatments for schizophrenia in 2014 found consistent evidence that, when compared with standard care which involves antipsychotic medication alone, CBTp was effective in reducing rehospitalisation rates up to 18 months following the end of treatment
CBTp was also shown to be effective in reducing symptom severity
also, when compared with patients receiving standard care, there was some evidence for improvements in social functioning for CBTp patients
however, most studies of the effectiveness of CBTp have been conducted with patients that are treated with therapy and medication at the same time
therefore, it is difficult to assess the effectiveness of CBTp independent of antipsychotic medication
but even these studies suggest that CBTp, when used in conjunction with medication, is more effective that drug therapy alone
EVALUATION
limits to the effectiveness of CBTp
10
effectiveness of CBTp is dependent on the stage of the disorder — it appears to be more effective when it is made available at specific stages and when the delivery of the treatment is adjusted to the stage the individual is currently at
Addington and Addington (2005) claim that in the initial acute phase of schizophrenia, self reflection is not particularly appropriate
however, following stabilisation of the psychotic symptoms using antipsychotic medication, individuals can benefit more from group based CBTp
which can help normalise their experiences by meeting other individuals with similar issues
research has consistently shown that it is individuals with more experience of their schizophrenia and a greater realisation of their problems that benefit more from individual CBTp
this suggests that CBTp cannot be equally applied to everyone as it’s effectiveness and how it is administered depends on the stage of the patient’s schizophrenia, limiting its general effectiveness
another thing that limits its effectiveness is the lack of availability
despite being recommended by NICE as a treatment for schizophrenia, it is estimated that in the UK only 1 in 10 of those who could benefit from CBTp actually get access it
this figure is even lower in some areas of the country — a survey carried out by Haddock et al (2013) in the North West of England found that of 187 randomly selected schizophrenic patients, only 6.9% had been offered CBTp
of those who are offered CBTp as a treatment, a significant number either refuse or fail to attend therapy sessions, thus limiting its effectiveness even more
EVALUATION
problems with meta analyses of CBTp
5
one reason why meta analyses of CBTp as a treatment for schizophrenia can reach unreliable conclusions about its effectiveness is failure to take into account study quality
some studies fail to randomly allocate participants to either a CBTp or controlled condition while others fail to mask the treatment condition for interviewers carrying out subsequent assessments of symptoms and general functioning
nevertheless, these low quality studies are still grouped together for meta analyses
Juni et al (2001) concluded that there was clear evidence that the problems associated with methodologically weak trials translated into biased findings about the effectiveness of CBTp
in fact, Wykes et al (2008) actually found that the more rigourous the study, the weaker the effect of CBTp
