Lesson 5 Psychological Therapies For SZ Flashcards
Three main psychological therapies for SZ
- Cognitive Behaviour Therapy (CBT)
- Family Therapy
- Token Economies
Cognitive Behaviour Therapy (CBT)
Cognitive Behaviour Therapy (CBT) is the main psychological treatment used with SZ. The idea is that 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.
Antipsychotic drugs are usually given first to reduce thought process, so that CBT can be more effective. CBT is then undertaken around once every 10 days for about 12 sessions to identify and alter irrational thinking. Drawings are often used to display links
between sufferers’ thoughts, actions and emotions. Understanding where e symptoms originate from 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.
PT is also used to 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
Cognitive techniques between patients and therapists
1) Helping understand and make sense of how their irrational cognitions (such as 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 perhaps 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
7) Positive self-talk e.g. ‘I can do this – I’m not crazy, I am in control’
Advantages of CBT
One strength of CBT is that there is evidence to support that it is effective in treating SZ. 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. In fact 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.
The effectiveness of CBT is dependent on the stage of the disorder – 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. However following stabilisation of the
psychotic symptoms with medication, patients can benefit from group based CBT –which can normalise their experience by meeting similar individuals. Thus 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.
Disadvantages of CBT
Lack of availability of CBT and patients refusal to attend sessions– 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. In a survey by 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.
Problems with meta-analysis of CBT as treatment for SZ – The 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. For example, 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.
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.
Family therapy
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).
Family Therapy like CBT 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. In keeping with psychological theories like the double-bind and the schizophrenogenic mother.
Family Therapy aims
1) Improve the quality of communication and interaction between family members.
2) Increase tolerance levels and decreases criticism levels between family members
3) Decrease feelings of guilt and responsibility for causing the illness among family members
Family therapists strategies
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.
Model for working with families dealing with SZ
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
Phase 6 – focuses on relapse prevention.
Phase 7 – is about maintenance for the future.
Advantages of Family Therapy
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. In particular 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.
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.
A final strength is that there are economical benefits to family therapy. For example 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 because of the lower relapse rates associated with this form of intervention. There is 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)
Token Economy (TE)
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 through spending too long in hospital and developed maladaptive behaviours. 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.
Major benefits of modifying these behaviours
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.
Tokens
The idea that tokens – e.g. in the form of coloured discs – are given immediately to patients when they have carried out a desirable behaviour e.g. made their bed, combed their hair, had a shower etc. that has been targeted for reinforcement. Of course each
individual patient will be assessed and given token for them showing certain behaviours (for example a patient who is unhygienic will be given a token if they have a bath but a patient who is pretty hygienic will perhaps not be given a token for having a bath – because they already have a bath as part of their daily routine). 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.
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. 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.
Theoretical understanding of token economies
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. Such secondary reinforcers are 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. For example, the token and a packet of sweets will be given together for the patient to understand the connection.
