L5 - Psychological Therapies For SZ

Question 1

3 main psychological therapies for SZ

Answer 1

1. Cognitive behaviour therapy (CBT)
2. Family Therapy
3. Token Economies

Question 2

CBT

Answer 2

• main psychological treatment used with SZ
• idea is beliefs, expectations and cognitive assessments of self, the environment and the nature of personal problems affect how individuals perceive themselves and others, how problems are approached, and how successful people are in coping and reaching goals.
• CBT usually takes place over a period of 5 – 20 sessions either in groups or individually.
• Antipsychotics usually given first to reduce thought process, so CBT can be more effective.
• CBT is then undertaken around once every 10 days for about 12 sessions to identify and alter irrational thinking. Understanding symptoms origins can be useful in reducing sufferers’ anxiety levels.
• One CBT approach is personal therapy (PT), involving detailed evaluation of problems and
  experiences, their triggers and consequences, and strategies being used to cope.

Question 3

Cognitive techniques used

Answer 3

1) Helping understand and make sense of how their irrational cognitions e.g. delusions and hallucinations impact on their feelings and behaviour.
- Understanding where symptoms come from can be hugely helpful for those who experience auditory hallucinations. If a patient hears demonic voices, they will naturally be afraid but if the therapist explains to them that this is due to a malfunction in their speech centre in their own brain and that it cannot hurt them – they just need to ignore it. This can help them to cope.
2) Distractions from intrusive thoughts – tell them to put the volume of the TV up when this happens
3) Challenging the meaning of intrusive thoughts – this can be done through reality testing
4) Increasing/decreasing social activity to distract from low mood
5) Normalisation – conveying to patients that many people have unusual experiences such as hallucinations and delusions under many circumstances reduces anxiety and the sense of isolation. By doing this the patient feels less alienated and stigmatised, and the possibility of recovery seems likely.
6) Using relaxation techniques e.g. breathing, muscle relaxation techniques
7) Positive self-talk e.g. ‘I can do this – I’m not crazy, I am in control’

Question 4

What is PT also used for?

Answer 4

• tackle problems faced by schizophrenics discharged from hospital, taking place in small groups or as one-to-one therapy.
• Patients are taught to recognise small signs of relapse, which can build up to produce cognitive distortions and unsuitable social behaviour

Question 5

CBT evaluation

Answer 5

strengths
- supporting evidence
- effectiveness depends on stage of disorder
weaknesses
- lack of availability/attendence
- meta-analysis
- range of symptoms/techniques

Question 6

Supporting evidence

Answer 6

• Jauhar et al (2014) reviewed 34 studies of using CBT with SZ, concluding that there is clear evidence for small but significant effects on both positive and negative symptoms.
• Other studies have focussed on symptoms for example Pontillo et al (2016) found reductions in frequency and severity of auditory hallucinations.
• clinical advice from NICE (2019) (National Institute for Health and Care Excellence) recommends CBT for SZ.
• This means that both research and clinical experience support the benefits of CBT.

Question 7

Depends on stage of disorder

Answer 7

• CBT appears to be more effective when it is made available at certain stages of the disorder and when the delivery of CBT is adjusted to the stage the individual is currently at.
• Addington and Addington (2005) claim that, in the initial acute phased of SZ, self reflection is not particularly appropriate.
• but following stabilisation of the psychotic symptoms with medication, patients can benefit from group based CBT –which can normalise their experience by meeting similar individuals.
• so research has shown that it is individuals with more experience of the SZ and a greater realisation of their problems are most likely to benefit from CBT.

Question 8

Lack of availability/attendence

Answer 8

• Despite being recommended by NICE as treatment for SZ, it is estimated that in the UK only one in
  ten individuals with SZ actually have access to CBT.
• This figure is even lower in some areas of the UK - Haddock et al (2013), they found that in the North West of England out of 187 SZ patients, only 13 (7%) had been offered CBT.
• However, of those who are offered CBT as a treatment for SZ, a significant number either refuse or fail to attend the therapy sessions (Freeman et al., 2013) thus limiting its effectiveness even more.

Question 9

Meta-analysis

Answer 9

• problems with meta- analysis in this area which can reach unreliable conclusions about CBT is the failure to take into account the quality of the studies.
  E.g. some studies fail to randomly allocate participants to CBT or a control condition; other studies fail to assess the patients subsequent assessment of symptoms and general functioning after they have
  been treated with CBT.
• 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 CBT.
• In fact, Wykes et al. (2008) actually found that the more rigorous the study, the weaker the effect of CBT

Question 10

Range of symptoms/techniques

Answer 10

• Another problem with CBT for SZ is the wide range of techniques and symptoms included in the studies.
• SZ symptoms and CBT techniques vary widely from one case to another.
• Thomas (2015) points out that different studies have involved the use of different CBT techniques and people with different combinations of positive and negative symptoms.
• Thus it becomes difficult to assess what technique works best for what symptom.
• This makes it hard to see how effective CBT will be for a person with SZ

Question 11

Family therapy (FT)

Answer 11

Family Therapy (FT) takes place with families as well as the identified patient (a term used in family therapy which describes one member of the dysfunctional family who expresses the family’s conflicts). The therapy aims to:
- Improve the quality of communication and interaction between family members.
- Increase tolerance levels and decreases criticism levels between family members
- Decrease feelings of guilt and responsibility for causing the illness among family members

Question 12

How long does FT last?

Answer 12

• Like CBT it is given a set amount of time, usually between nine months and a year.
• Thus there is a range of approaches to family therapy for SZ, keeping with psychological theories like the double-bind and the schizophrenogenic mother.

Question 13

FT strategies

Answer 13

Pharoah et al (2010) identified a range of strategies that family therapists use to try to improve the functioning of a family that has a member with SZ:
1) Reduces negative emotions – FT aims to reduce levels of expressed emotions – more so the negative emotions such as anger and guilt which create stress. Reducing stress is important to reduce the likelihood of relapse.
2) Improves the family’s ability to help – the therapist encourages family members to form a therapeutic alliance whereby they all agree on the aims of therapy. The therapist also tries to improve families’ beliefs about and behaviour towards SZ. A further aim is to ensure that family members achieve a balance between caring for the individual and having their own lives too

Question 14

FT model

Answer 14

Burbach (2018) has proposed a model for working with families dealing with SZ:
Phrase 1: sharing basic information and providing emotional and practical support
Phrase 2: involves identifying resources including what different family members can and cannot offer – for example one family member may be able to offer emotional support whereas another may be able to help make the schizophrenic more independent
Phase 3 – this aims to encourage mutual understanding, creating a safe place for all family members to express their feelings
Phase 4 – this involves identifying unhelpful patterns of interaction such as the negative emotions like anger which could make things difficult for everyone in the family
Phase 5 -is about skills training such as learning stress management techniques e.g. relaxation
Phase 6 – focuses on relapse prevention.
Phase 7 – is about maintenance for the future - after they leave therapy, make sure anger doesn’t come back

Question 15

FT evaluation

Answer 15

strengths
- effectiveness
- benefits all family members
- economical benefits
weaknesses
- active participation
- reductionist
- depends on therapist

Question 16

Effectiveness

Answer 16

• One strength of FT for SZ is its effectiveness. A review of studies by McFarlane (2016) concluded that FT was one of the most consistently effective treatments available for SZ
• relapse rates were found to be reduced by about 50-60%.
• McFarlane also concluded that using family therapy as mental health initially starts to decline is particularly promising.
• Clinical advice from NICE (National Institute for Health and Care Excellence) recommends family therapy for everyone with a diagnosis of SZ.
• This means that FT is likely to be beneficial to people who have just started having symptoms of SZ to those who have developed full blown SZ.

Question 17

Benefit for all family members

Answer 17

• Another strength of FT for SZ is the benefits for all family members.
• Therapy is not just for the patient but also for the families that provide the bulk of the care.
• A review of evidence by Lobban and Barrowclough (2016) concluded that these effects are important because the family provide most of the care for the person with SZ.
• By strengthening the functioning of a whole family, FT lessens the negative impact on other family members and strengthens the ability of the family to support the person with SZ.
• This means that FT has wider benefits beyond the obvious positive impact on the identified patient.

Question 18

Economical benefits

Answer 18

• economical benefits to family therapy.
  E.g. the NICE review of family therapy studies (NCCMH, 2009) demonstrated that family therapy is associated with significant cost savings when offered to people with SZ in addition to standard care.
• The extra cost of family therapy is offset by a reduction in costs of hospitalisation (e.g. extra beds)
  because of the lower relapse rates associated with this form of intervention.
• also evidence that family therapy reduces relapse rates for a significant period after completion of the intervention.
• This means that the cost savings associated with family therapy would be even higher (due to less chances of rehospitalisation & family members working)

Question 19

Weaknesses of FT

Answer 19

• generally positive therapy
• but needs active participation from all to be effective
• reductionist - focus SZ on family dysfunction & not genes - could be predisposed to get SZ
• depends on therapist - needs to be good/skilled for therapy to be effective

Question 20

Token economies

Answer 20

• Token economies are reward systems used to manage (rather than treat) the behaviour of patients with schizophrenia in hospital settings, in particular to those who have developed maladaptive behaviours by spending too long in hospital
• Under these circumstances, it is common for patients who are institutionalised (spent too long in hospital) to develop bad hygiene or perhaps remain in pyjamas all day.
• Changing these bad habits does not cure SZ but it improves the patient’s quality of life and makes it more likely that they can live outside a hospital setting.
• Matson et al (2016) identify three categories of institutional behaviour commonly tackled by means of token economies; personal care, condition-related behaviours (e.g. apathy) and social behaviour.

Question 21

What does modifying patients behaviour do?

Answer 21

does not cure SZ but it does have two major benefits:
1) Improves the person’s quality of life within the hospital setting, for example make-up for someone who takes pride in their appearance or social interaction for a usually sociable person
2) ‘Normalises’ behaviour and this makes it easier for people who have spent some time in hospital to adapt back into life in the community, for example getting dressed in the morning or making their bed

Question 22

Tokens

Answer 22

• tokens – e.g. in the form of coloured discs – are given immediately to patients when they have carried out a desirable behaviour e.g.had a shower etc. that has been targeted for reinforcement.
• each individual patient will be assessed and given token for them showing certain behaviours
• Tokens are given immediately to the patients so that the patient can associate that positive behaviour with a reward as opposed to delayed rewards.
• Although the tokens have no value in themselves they can be swapped later for more tangible rewards.
• Tokens are secondary reinforcers because they only have value once the patient has learned that they can be used to obtain rewards

Question 23

Rewards

Answer 23

• tokens have no value in themselves they can be swapped later for more tangible rewards.
• Tokens are secondary reinforcers because they only have value once the patient has learned that they can be used to obtain rewards.
• The rewards in a hospital setting might include objects like sweets, magazines, or access to activities like a film or a walk outside, or perhaps an appointment with a social worker to plan for life after hospitalisation.

Question 24

Theoretical understanding of token economies

Answer 24

• Token Economies are an example of behaviour modification – which is a behavioural therapy based on operant conditioning.
• Tokens are secondary reinforcers because they only have value once the person receiving them has learned that they can be used to obtain meaningful rewards, such as sweets or a walk outside.
• These meaningful rewards are primary reinforcers.
• Those tokens that can be exchanged for a range of different primary reinforcers are particularly powerful secondary reinforcers - also called generalised reinforcers.
• In order for the tokens to become secondary reinforcers they are paired with primary reinforcers, so that at the start of a TE programme token and primary reinforcers are administered together.
  E.g. the token and a packet of sweets will be given together for the patient to understand the connection.

Question 25

Evaluation of token economies

Answer 25

strengths
- evidence
- further research support
weaknesses
- ethical issues
- ecological issues
- alternatives

Question 26

Evidence

Answer 26

• Glowacki et al (2016) identified seven high quality studies published between 1999 and 2013 that examined the effectiveness of token economies for people with chronic mental health issues such as SZ and involved patients living in a hospital setting.
• All the studies showed a reduction in negative symptoms and a decline in the frequency of unwanted behaviours.
• This supports the value of token economies.

Question 27

Research support

Answer 27

• Dickerson et al. (2005) reviewed 13 studies in the use of token economies in the treating SZ.
• 11 of these studies had reported beneficial effects that were directly attributable to the use of
  token economies.
• Dickerson et al. concluded that, overall, these studies provide evidence of the token economy’s effectiveness in increasing the adaptive behaviours of patients with SZ.
• However, Dickerson et al. did caution that many of these studies had methodological issues which could have then effected the overall impact of token economies i.e. whether they were indeed successful

Question 28

Ethical issues

Answer 28

• in order to make reinforcement effective, clinicians may exercise control over important primary reinforcers such as food, privacy or access to activities that stop patients from being bored.
• Patients may then exchange tokens if they display the target behaviours (e.g. domestic duties or personal hygiene).
• However, it is generally accepted that all human beings have certain basic rights that should not be violated regardless of the positive consequences that might be achieved through the token economy programme.

Question 29

Ecological validity

Answer 29

• token economy programme has been shown to be effective in reducing negative symptoms for people with SZ, it has only been shown to work in a hospital setting.
  E.g. Corrigan (1991) argues that there are problems administrating the token economy method with outpatients who live in the community.
• In a hospital, patients receive 24 hour care and can be given tokens straight away.
• In the real world, when people with SZ are living in the community, who will give them the tokens straightaway and how will they exchange them for a tangible item?
• Thus token economies lack ecological validity because they cannot be used in the real world community

Question 30

Alternatives

Answer 30

• Chiang et al (2019) concluded that art therapy might be a good alternative.
• The evidence base for this may be small and have some methodological limitations but it appears that art therapy is a high-gain low-risk approach to managing SZ.
• Even if the benefits of art therapy are modest – this is also true for all approaches to treatment and management of SZ.
• In fact NICE (National Institute for Health and Care Excellence) guidelines recommend art therapy for SZ.
• This means that art therapy may be a good alternative to token economies.