Psychological explanations and treatment Flashcards
Family dysfunction
Schizophrenic Mother - Mother is cold, controlling and rejecting. Father is often passive, Mother is dominant.
Double Bind theory - Mixed messages, child will never know what to do and will see the World as confusing and dangerous.
Expressed emotion - High EE environment –> Higher relapse rate –> Relapse rate doubled (Butzlaff + Hooley, 1998) –> Emotional over involvement, overbearing, anger, hostility, self - sacrifice, verbal criticism.
Family dysfunction - Schizophrenia is due to family experiences of interpersonal conflict, communication problems, criticism and control.
Interpersonal conflict - Conflict between you and other individuals in the home.
The schizophrenogenic Mother
Fromm Reichmann (1948) - A neo - freudian
Proposed a psychodynamic explanation for schizophrenia. Based on the accounts she heard from her patients about their childhoods.
She noticed that many of her patients spoke about a particular type of parent, which she called the SM.
The schizophrenogenic Mother is cold, rejecting and controlling. She tends to create a family climate characterised by tension and secrecy.
This leads to distrust and later develops into paranoid delusions.
Double - bind theory
Bateson et al (1972) - Agreed that family climate is important in the development of sz, but emphasised the role of communication style within a family. The developing child regularly finds themselves trapped in a situation where they fear doing the wrong thing, but receive mixed messages about what this is and feel unable to comment on the unfairness of the situations or seek clarification.
When they get it wrong, the child is punished by the withdrawal of love.
This leaves them with an understanding of the world as confusing and dangerous. This is reflected in symptoms like disorganised thinking and paranoid delusions.
Expressed Emotion
Brown et al (1972) -
The level of particularly negative emotion expressed towards a patient by their carers.
These high levels of EE –> a source of stress for the patient.
Primarily an explanation for relapse in patients with schizophrenia, but may also be a source of stress that can trigger the onset of sz in a vulnerable person.
Verbal criticism - “They just really frustrate me”
Hostility - anger and rejection - “They cause problems for me everyday”
Emotional over involvement/ Self-sacrifice - “I don’t care about myself anymore, I would rather focus on him getting better.”
A03) Evaluation
Weakness of RM:
P) Although there is a large amount of evidence to support the idea that poor childhood experiences in the family are associated with adult schizophrenia, there is almost none to support the schizophrenogenic Mother or double-bind.
E) Berger (1965) - Found that schizophrenics reported a higher recall of double bind statements by their Mothers than non-schizophrenics.
C) However, other research is less supportive.
Liem (1974) –> Found no difference in parental communication in families with a schizophrenic child compared to normal families.
Whilst Berger’s study supports the association between double bind and sz, this research may not RELIABLE, as patient’ recall may be affected by their sz, or by time.
C) This use of retrospective data, where patients report childhood, lowers the validity, as recall and accuracy may be affected. This may also be subjective, so not scientific data. To combat this, use inter-rater reliability.
A03) Evaluation
Weakness of RM:
P) Weakness of the family based explanations –> led to parent blaming.
E) Parents, who have already suffered at seeing their child’s descent into schizophrenia, are also likely to bear the lifelong responsiblity for their care and feel responsible for their child’s illness, which causes even greater stress and anxiety.
C) The views are outdated –> no longer tolerated by families –> seen as destructive rather than productive. Highly unethical + adds insult to the injury.
C) Therefore, the shift in the 1980’s from hospital to community care (often parental care), may be one of the factors leading to the decline of the schizophrenogenic Mother and double bind theories, as parents no longer tolerated them.
A03) Evaluation
Supports A01:
P) Families where communications are commonly to do with criticism, hostility and disapproval are said to have high EE.
E) Brown (1966): People recovering from SZ and discharged from hospital were followed up over a 9 month period. Interviews with the family members were conducted to determine the level of expressed emotion.
Findings: High EE levels - 58% of people returned to hospital for further treatment.
Low EE levels - 10% returned to hospital.
C) Criticism - The sufferer may be influencing the family behaviour patterns rather than the other way round.
Western Cultures - No consideration of other cultures –> imposed etic —> cultural bias.
C) Supports high EE’s role in schizophrenia, but methodology problems.
A03) Evaluation
Supports A01/ Weakness of RM:
P) Supporting evidence for the effectiveness of family therapy and the role of EE in relapse.
E) Garety et al (2008) –> estimates that relapse rates for individuals who receive family therapy are 25%, compared to 50% for those who receive standard care alone. The effectiveness of family therapy, based on reducing expressed emotion, supports the family dysfunction approach, as by reducing the expressed emotion, the rate of relapse reduces.
C) However, Altorfer et al (1998), found that 1/4 of patients they studied showed NO PHYSIOLOGICAL RESPONSES to stressful comments from their relatives. This suggests that NOT ALL patients who live in high EE families relapse.
L) Therefore, there are individual differences in response to high EE, which lowers the validity, as the explanation may not apply to all schizophrenia sufferers. However, expressed emotion does still play a role in the return of schizophrenia symptoms, but individual differences need to be considered.
Psychological treatments: Family therapy
Family therapy - A range of INTERVENTIONS aimed at the family of someone with schizophrenia.
Improve communication and interaction, reduce stress, reduce re hospitalisation, used with drug therapy and clinical care. The main aim of family therapy is to provide SUPPORT for carers, in an attempt to make family life LESS STRESSFUL and so REDUCE
RE-HOSPITALISATION.
Family intervention - Has developed as a result of STUDIES of the family environment and its potential role in affecting the course of sz.
Research has consistently shown that the long-term outcome for an individual with sz has much to do with the RELATIONSHIP between the individual and carers.
Poor relationships tend to result in poor outcomes eg. a greater chance in relapse.
How does family therapy help?
Pharoah et al (2010) - Identified a range of strategies by which family therapists aim to improve the functioning of the family with a member suffering from schizophrenia.
- Forming a therapeutic ALLIANCE with all family members.
- Reducing the levels of EXPRESSED EMOTION and STRESS of caring for a relative with schizophrenia.
- Reduction of anger + guilt in family members.
- Improving the ABILITY of the family to ANTICIPATE and SOLVE PROBLEMS.
- Helping family members achieve a BALANCE between caring for the individual and MAINTAINING their OWN LIVES.
- Improving families beliefs about behaviour towards schizophrenia.
- Psycho education - Helping the person and their carers to understand and be better able to deal with the illness.
Pharoah –> These strategies work by REDUCING STRESS LEVELS and EXPRESSED EMOTION, while also INCREASING the chances of patients COMPLYING with MEDICATION. This combination tends to result in reduced relapse rates and re- admission to hospital.
Family therapy activity -
- Psycho education - Educate them on sz + how to communicate with patients.
- Talk about triggers to anticipate and solve problems.
- Identify expressed emotion, talk through it, teach communication techniques.
- Helplines and other resources to help stress.
- Deal with double bind (mixed messages).
NICE Guidance
National Institute for Clinical Excellence - An organisation
NICE recommend that family therapy should be offered to ALL individuals with schizophrenia, who are IN CONTACT with or LIVE with family members.
They stress that such interventions should be considered a PRIORITY where there are PERSISTENT symptoms or a HIGH risk of relapse.
Duration of family therapy
- Typically offered for a period of between 3-12 months and at least 10 sessions.
- Garety et al (2008) - Estimated those who received family therapy had 25% relapsed rate, compared to those who received standard care alone had a 50% relapse rate.
A03) Family therapy
Challenges A01)
P) Family therapy aims to improve the patients’ quality of life and make sz more manageable.
E) It helps by reducing stress in the family and the patient themselves.
C) Whilst this is worth doing, it does not cure sz.
C) Therefore, whilst providing coping strategies for patients, which they can use to manage their current and future symptoms is effective, family therapy still isn’t an independent successful cure for sz.
A03) Family therapy
Weakness of RM)
P) Methodological limitations of FT studies was shown by Pharoah et al (2010), who reviewed the evidence for the effectiveness of FT compared to anti-psychotics alone.
E) Findings –> There was a reduction in the risk of relapse and hospital readmission, during treatment and in the 24 months after.
C) However, whilst some studies showed an improvement in the overall mental state of patients, others did not, yet there was an increased compliance with medication. Additionally, FT did not appear to have much of an effect on CONCRETE outcomes, such as living independently or employment.
C) This suggests that FT significantly REDUCES
RE HOSPITALISATION, and somewhat improves the quality of life for patients and their families, but the findings are INCONSISTENT. So, the evidence to support the effectiveness of FT is fairly WEAK.
A03) Family therapy
Challenges A01)
P) Weakness of FT –> Idea proposed by Pharoah et al (2010) –> suggests that it may have less to do with improvements in functioning and more to do with the fact that it increases medical compliance.
E) Patients are more likely to reap the benefits of medication, because they are more likely to COMPLY with their MEDICATION REGIME.
C) Therefore, anti-psychotics may be the more effective treatment for schizophrenia and family therapy may ONLY BE NECESSARY to the extent that it encourages patients to take anti-psychotics.
C) Additionally, Pharoah et al’s META ANALYSIS found METHODOLOGICAL ISSUES.
Although 53 studies claimed to have RANDOMLY ALLOCATED participants to TREATMENT groups, the researchers note that a LARGE NO. of studies used in this review were from the people’s republic of CHINA. Evidence has emerged that there may be some DISCREPANCY as whether there was actually random allocation (Wu et al, 2006). Additionally, this could be seen as CULTURAL BIAS + IMPOSED ETIC, as the majority are in ONE AREA.
A03) Family therapy
Supports A01)
P) Family therapy has ECONOMIC BENEFITS.
E) It is associated with significant cost savings, when offered to people with sz, in addition to standard care. Therapy is expensive, but LESS EXPENSIVE than being constantly re-hospitalised, as there are LOWER RELAPSE rates associated with FT.
Further evidence –> relapse rates down for a significant period after completed intervention –> means that cost savings would be even higher.
E) This suggests that family therapy may be an APPROPRIATE TREATMENT for sz, from the perspective of the NHS.
L) Therefore, FT clearly has significant cost savings, which supports its effectiveness, as relapse rates are lowered.
Contrast point: Is FT used for therapeutic benefit or for financial benefit?
A03) Family therapy
Supports A01)
P) An additional advantage of FT –> it has been shown to improve outcomes for the individual with sz, but it may also have a POSITIVE IMPACT on family members.
E) Lobban et al (2013) –> META ANALYSIS –> analysed the results of 50 family therapy studies that had included an intervention to support RELATIVES.
E) Findings –> 60% of these studies reported a significant positive impact of the intervention on at least ONE OUTCOME category for relatives. For example, coping and problem solving skills.
L) Therefore, FT has evidence to support positive impacts on the family, as well as the patient.
Cognitive Explanation
Keywords:
Cognitive - Thinking processes
Dysfunctional thought processing - Cognitive beliefs that cause the individual to EVALUATE information INAPPROPRIATELY and produces UNDESIRABLE CONSEQUENCES.
Meta representations - DISRUPTS our ability to recognise our OWN ACTIONS and THOUGHTS as being carried out by OURSELVES, rather than SOMEONE ELSE.
Central control - Sufferers with sz tend to experience DERAILMENT of thoughts and spoken sentences, because each word triggers ASSOCIATIONS and the patient CANNOT SUPPRESS AUTOMATIC RESPONSES.
Dysfunctional thought processing
Cognitive explanations emphasise the role of dysfunctional thought processing, especially in those who display the POSITIVE SYMPTOMS of sz, such as delusions and hallucinations.
Cognitive explanations of hallucinations:
- Hallucinating individuals focus EXCESSIVE ATTENTION on AUDITORY stimuli (hypervigilance) and so have a HIGHER EXPECTANCY for the occurrence of a VOICE than normal individuals.
Baker + Morrison, 1998 - Hallucinating patients with sz are significantly more likely to MISATTRIBUTE the source of SELF-GENERATED AUDITORY EXPERIENCE to an EXTERNAL SOURCE, than are NON-HALLUCINATING patients with schizophrenia.
Simon et al, 2015 - REDUCED processing of info in the TEMPORAL and CINGULATE gyri is associated with hallucinations. Additionally, REDUCED THOUGHT PROCESSING in the VENTRAL STRIATUM is associated with NEGATIVE SYMPTOMS.
Frith’s Model (1992)
Proposes that Sz sufferers are NOT ABLE TO DISTINGUISH between actions influenced by EXTERNAL FORCES and those driven by INTERNAL INTENTIONS. He identified 2 types of dysfunctional thought processing, that could underlie symptoms.
Metarepresentation - The cognitive ability to reflect on thoughts and behaviour. Allows us INSIGHT into our OWN INTENTIONS and GOALS, as well as allowing us to INTERPRET the actions of others.
Dysfunction in metarepresentation would DISRUPT our ability to recognise our own actions + thoughts as being carried out by OURSELVES rather than SOMEONE ELSE. This would explain hallucinations of voices and delusions like THOUGHT INSERTION.
Central control - The cognitive ability to SUPPRESS AUTOMATIC RESPONSES while we perform DELIBERATE ACTIONS instead. If someone has the inability to suppress automatic thoughts + speech triggered by other thoughts, this could lead to DISORGANISED SPEECH and THOUGHT DISORDER.
For example, sz sufferers tend to experience DERAILMENT of thoughts and spoken sentences, because each word triggers ASSOCIATIONS and the patient cannot suppress automatic responses to these. Can result in speech poverty + word salad.
Example: Leads to them losing their train of thought and not being able to focus on others.
Hemsley (1993,2005)
Sz involves a breakdown in the relationship between memory and perception.
People with sz have a DISCONNECT between their SCHEMAS and what they actually SEE + HEAR.
When they encounter new situations, their schemas are NOT ACTIVATED.
Therefore, people with sz experience SENSORY OVERLOAD, because they don’t know what to attend to.
A03) Cognitive explanation
Supports A01:
P) Supporting evidence –> For the relationship between central control dysfunction and schizophrenic symptoms.
E) Stirling et al (2006) –> Compared 30 patients with a diagnosis of Sz, with 18 non patient controls, on a range of cognitive tasks eg. the STROOP TEST.
Patients took over TWICE as LONG to name the ink colours as the control group.
C) However, even if the link between faulty cognitions and symptoms is clear, this does not tell us about the ORIGINS of those COGNITIONS and thus the ORIGINS of SCHIZOPHRENIA.
C) This supporting evidence backs up Frith’s suggestion of a relationship between central control dysfunction and sz symptoms. However, the origins are still unclear, lowering the validity.
A03) Cognitive explanation
Supports A01/ RWA:
P) Strength of CBTp –> It has been demonstrated to be effective in the NICE review of treatments for schizophrenia (2014).
E) When compared to anti psychotic medication, CBTp was MORE EFFECTIVE in REDUCING SYMPTOMS SEVERITY and IMPROVING LEVELS of SOCIAL FUNCTIONING.
C) Counter criticism –> CBTp requires more motivation and takes longer.
C) This supports the idea that the origin of sz may be in faulty cognitions, as changing these cognitions has evidence to support it reducing the symptoms of schizophrenia.
Psychological treatments: CBTp
Cognitive Behavioural Therapy is the MAIN psychological treatment for schizophrenia. However, antipsychotics are often used ALONGSIDE CBT to reduce PSYCHOTIC thought processes, ensuring CBT is most effective and to reduce patient dropout rate (Kuipers et al, 1997).
Aims of the therapy:
- To help the patient to identify delusions. To challenge and modify delusory beliefs (make irrational thoughts rational) also by looking at evidence.
- To help the patient begin to test the REALITY of the evidence.
- Recognise negative thoughts.
- Delusions can also be CHALLENGED, so that a patient can come to learn that their beliefs are not based on reality.
- Set BEHAVIOURAL assignments to improve general levels of functioning eg. educating yourself on your delusions.
