Lesson 5 – Psychological Treatments for Schizophrenia

Question 1

What are the three psychological treatments for schizophrenia

Answer 1

Cognitive Behaviour Therapy (CBT), Family Therapy and Token Economies

Question 2

What is CBTp

Answer 2

NICE (National Institute for Health and Care Excellence) recommend that all people should be offered CBT- this form of therapy is referred to as CBTp (cognitive behavioural therapy for psychosis) when used in the treatment of SZ. CBTp in SZ was originally developed to provide treatment for residual symptoms that persist despite the use of antipsychotic medication.

Question 3

How does CBTp work

Answer 3

Assessment, Engagement, The ABC model, Normalisation, Critical collaborative analysis and Developing alternative explanations

Question 4

What is Assessment in CBTp

Answer 4

The patient expresses his thoughts to the therapist. Realistic goals for therapy are discussed – using the patient’s current distress as motivation for change.

Question 5

What is Engagement in CBTp

Answer 5

The therapist emphasises with the patient’s perspective and their feelings of distress, and stresses that explanations for their distress can be developed together.

Question 6

What is The ABC model in CBTp

Answer 6

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 actually the cause of C, can then be rationalised, disputed and changed. E.g. the belief that ‘people won’t like me if I tell them about my voices’ might be changed to a more healthy belief, e.g. ‘some may, some may not, friends may find it interesting’

Question 7

What is Normalisation in CBTp

Answer 7

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 more likely.

Question 8

What is Critical collaborative analysis in CBTp

Answer 8

The therapist uses gentle questioning to help the patient understand illogical deductions and conclusions. For example, ‘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, who remains empathetic and non-judgemental.

Question 9

What is Developing alternative explanations in CBTp

Answer 9

The patient develops their own alternative explanations for their previously unhealthy assumptions. If the patient is not forthcoming with healthy alternative explanations – new ideas can be constructed in cooperation with the therapist. E.g. Positive self talk – where the therapist encourages the client to repeat things such as ‘I can do this, I don’t need to think like this’

Question 10

How is CBTp delivered

Answer 10

CBTp can be delivered in groups, but it is more usual that it is delivered on a one-to-one basis. NICE recommend at least 16 sessions in treating SZ.

Question 11

What is the aim of CBTp

Answer 11

The aim of CBTp is to help people establish links between their thoughts, feelings or actions and their symptoms and general level of functioning.

Question 12

How are patients encouraged during CBTp

Answer 12

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, and to consider ways in which they might test the validity of their faulty beliefs. 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 patients mind.

Question 13

Strengths of CBT in treating schizophrenia

Answer 13

CBTp seems to be more effective in treating SZ compared to standard care - antipsychotic medication alone – The NICE (2014) review of treatments for SZ found consistent evidence that when compared with standard care (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 the severity of symptoms as well as improvements in social functioning. Although it is difficult to assess the effectiveness of CBTp alone as patients were being treated with both medication and CBTp.

The effectiveness of CBTp is dependent on the stage of the disorder – CBTp appears to be more effective when it is made available at certain stages of the disorder and when the delivery of CBTp 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 CBTp –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 CBTp.

Question 14

Weakness of CBT in treating schizophrenia

Answer 14

Lack of availability of CBTp 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 CBTp. 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 CBTp. However, of those who are offered CBTp 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 CBTp as treatment for SZ – The problems with meta-analysis in this area which can reach unreliable conclusions about CBTp is the failure to take into account the quality of the studies. For example, some studies fail to randomly allocate participants to CBTp or a control condition; other studies fail to assess the patients subsequent assessment of symptoms and general functioning after they have been treated with CBTp. 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. Infact, Wykes et al. (2008) actually found that the more rigorous the study, the weaker the effect of CBTp.

Question 15

What is the aim of family therapy

Answer 15

Families can play an important role in helping a person with SZ to recover and stay well. The main aim of family therapy, therefore, is to provide support for carers in an attempt to make family life less stressful and so reduce rehospitalisation.

Question 16

What is family therapy

Answer 16

Family therapy is the name given to a range of interventions aimed at the family (e.g. parents, siblings, partners) of someone with SZ. In their guidance on treatment and management of SZ, NICE recommend that family therapy should be offered to ‘all individuals diagnosed with SZ who are in contact with or live with family members’. They also stress that such interventions should be considered a priority where there are persistent symptoms of a high risk of relapse

Question 17

How is family therapy delivered

Answer 17

Family therapy is offered for a period of 3 -12 months and at least ten sessions. Family-based interventions are aimed at reducing the level of expressed emotion within the family, as expressed emotion has been demonstrated to increase the likelihood of relapse. Garety et al. (2008) estimate the relapse rate for individuals who receive family therapy as 25% compared to 50% for those who receive standard care alone.

Question 18

How does family therapy work

Answer 18

Family therapy makes use of a number of strategies including:
Psychoeducation, Forming Alliances, Reducing conflict, Enhancing problem solving, Reducing hostile expressions, Maintaining feasible expectations and Setting Boundaries

Question 19

Psychoeducation in family therapy

Answer 19

Helping the person and their carers to understand and be better able to deal with the illness.

Question 20

Forming Alliances in family therapy

Answer 20

Forming an alliance with relatives with care for the person with SZ

Question 21

Reducing conflict in family therapy

Answer 21

Reducing the emotional climate within the family and the burden of care for family members

Question 22

Enhancing problem solving in family therapy

Answer 22

Enhancing relatives’ ability to anticipate and solve problems

Question 23

Reducing hostile expressions in family therapy

Answer 23

Reducing expressions of anger and guilt by family members

Question 24

Maintaining feasible expectations in family therapy

Answer 24

Maintaining reasonable expectations among family members for patient performance

Question 25

Setting Boundaries in family therapy

Answer 25

Encouraging relatives to set appropriate limits whilst maintaining some degree of separation when needed

Question 26

Pharoah et al (2010) study procedure

Answer 26

Pharoah reviewed 53 studies published between 2002 and 2010 to investigate the effectiveness of family intervention. Studies chosen were conducted in Europe, Asia and Noeth America. The studies compared outcomes from family therapy to ‘standard’ care (antipsychotic medication alone). The researchers concentrated on studies that were randomised controlled trials (RCTs).

Question 27

Pharoah et al (2010) study findings

Answer 27

Findings: the main results (individuals receiving family therapy compared to those receiving standard care) were:
* Mental state – the overall impression was mixed, some studies reported an improvement in the overall mental state of patients compared to those receiving standard care, whereas others did not
* Compliance with medication - the use of family therapy increased patients compliance with medication
* Social functioning – although appearing to show some improvement on general functioning, family intervention did not appear to have much of an effect on more concrete outcomes such as living independently or employment
* Reduction in relapse and readmission – there was a reduction in the risk of relapse and a reduction in hospital admission during treatment and in the 24 months after.

Question 28

Strengths of family therapy for treating schizophrenia

Answer 28

According to Pharoah’s study, it increases patient compliance with medication which can then lead to improvements in their mental state and social functioning – this then suggests that family therapy is effective in the sense that it teaches family members about the importance of taking medication rather than other factors. Does this mean that it is the medication or the family therapy that improves patients symptoms? Overall the evidence for family therapy according to Pharoah’s study is mixed.

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)

The impact of family therapy on family members is also advantageous. For example, Lobban et al. (2013) analysed the results of 50 family therapy studies that had included an intervention to support relatives. 60% of these studies reported a significant positive impact of the intervention on at least one outcome category for relatives, e.g. coping and problem-solving skills, family functioning and relationship quality (including expressed emotion) – although the methodological quality of most of these 50 studies was poor, making it difficult to distinguish effective from ineffective interventions.

Question 29

Weaknesses of family therapy for treating schizophrenia

Answer 29

There is an overall problems with a lack of blinding in family therapy studies. For example, in Pharoah’s study 10 of the 53 studies reported in this meta-analysis did not use any form of blinding – this means that the raters were not blinded to the condition to which participants has been allocated – which meant that they knew whether participants were attached to the experimental or control conditions – this would then create rater bias – as the raters would know which conditions participants would be allocated to so they may rate the participants allocated to the family therapy conditions as showing an improvement in their symptoms rather than the participants allocated to the control conditions. This is a problem because it does not really tell us whether family therapy is really effective.

Question 30

What are token economies

Answer 30

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 with other patients who may have showed catatonia.

Question 31

What is the aim of token economies

Answer 31

The principle of token economies are based on the principles of operant conditioning when the patient is given a token (reward) for carrying out a good behaviour (positive reinforcement) – this should then encourage them to repeat that behaviour in hope for another token. These tokens are then accumulated and swapped for a tangible reward e.g. sweets, cigarettes or even a walk outside the hospital.

Question 32

What are tokens

Answer 32

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. Ofcourse 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 hygenic 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

Question 33

What rewards in token economies

Answer 33

Although the tokens have no value in themselves they can be swapped later for more tangible rewards. Token are secondary reinforcers because they only have value once the patient has learned that they can be used to obtain rewards.

Question 34

Strengths of token economies to treat schizophrenia

Answer 34

There is research support for token economies for example 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 35

Weaknesses of token economies to treat schizophrenia

Answer 35

There are ethical concerns concerning the use of token economy programmes in psychiatric settings. For example, 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.

Token Economy programmes lack ecological validity. Although the 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. For example, 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.

Do token economy programmes really work? As yet there is no real conclusive evidence. For example, there are very few randomised trials that have been carried out in token economy research studies. In an era where everything requires research support, token economy programmes are not really used in the developed world but would be very prominent if randomised trials were used so there may be hope for this programme in treating SZ in the future especially in a hospital setting. However, critics would argue that token economies are only used in hospitals to manage and control schizophrenic patients rather than ‘treat’ their symptoms.