Psychological Therapies

Question 1

How many psychological therapies are there for SZ?

Answer 1

2

Question 2

What are the 2 psychological therapies for SZ?

Answer 2

1) Cognitive-behavioural therapy (CBT)

2) Family intervention

Question 3

Give an example of a delusional belief and how it comes about

Answer 3

Event: see a man outside the house
Interpretation: he is following me
Feeling: scared and paranoid
Behaviour: take evasive action and avoid going out

Question 4

Outline CBT for SZ

Answer 4

Basic assumption is that people often have distorted beliefs which influence their behaviour in maladaptive ways like someone with SZ may believe their behaviour is being controlled by someone or something else - delusions thought to result from faulty interpretations of events and CBT is used to help patient identify and correct these

Question 5

Explain the 5 techniques of CBT for SZ

Answer 5

1) Patients encouraged to trace back origins of symptoms to get a better idea of how they might have developed
2) Encouraged evaluate content of delusions or of any internal voices - they hear and consider ways in which they might test the validity of their faulty beliefs
3) Might be set behavioural assignments with aim of improving their general level of functioning
4) Learning of maladaptive responses to problems is often the result of disordered thinking by SZ of mistakes in assessing cause and effect
5) During CBT, therapist lets the patient develop own alternatives to these previous maladaptive beliefs, ideally by looking for alternative explanations and coping strategies that are already present in patient’s mind

Question 6

What are outcome studies?

Answer 6

Measure of how well a patient does after a particular treatment compared with an accepted form of treatment for that condition

Question 7

What do outcome studies suggest for CBT?

Answer 7

Patients experience fewer hallucinations and delusions and recover their functioning to a greater extent than those who receive antipsychotic drugs alone

Question 8

Name 2 outcome studies for CBT for SZ

Answer 8

1) Drury (96)

2) Kuipers (97)

Question 9

Outline Drury (96)

Answer 9

Found benefits of CBT in terms of reduced negative symptoms and a 25-50% reduction in recovery time for patients given combination of antipsychotic drugs and CBT

Question 10

Outline Kuipers (97)

Answer 10

Confirmed these advantages but also noted there were lower patient drop-out rates and greater patient satisfaction when CBT used in addition to antipsychotic drugs

Question 11

Outline family intervention for SZ

Answer 11

Research has discovered family environment has potential role in influencing course of SZ - main aim is to attempt to make family life less stressful and so decreasing re-hospitalisation

Question 12

What is the main study regarding the origins of family intervention for SZ?

Answer 12

Brown (72)

Question 13

Outline Brown (72)

Answer 13

SZs in families that expressed high levels of hostility, criticism or over involvement had more frequent relapses than people with the same problems who lived in families that were less expressive in their emotions

Question 14

Name the 7 strategies of family intervention for SZ

Answer 14

1) By reducing levels of EE and stress, and by increasing the capacity of relatives to solve related problems, FI attempts to reduce incidence of relapse
2) Forming an alliance with relatives who care for SZ
3) Reducing emotional climate within family and burden of care for family members
4) Enhancing relatives’ ability to anticipate and solve problems
5) Reducing expressions of anger and guilt by family members
6) Maintaining reasonable expectations among family members for patient behaviour
7) Encouraging relatives to set appropriate limits whilst maintaining some degree of separation when needed

Question 15

Name 2 positive points about CBT for SZ

Answer 15

1) Supporting research - found has a significant effect

2) Appropriateness in terms of negative symptoms

Question 16

Name a study supporting the significance of CBT for SZ

Answer 16

Gould (01)

Question 17

Outline Gould (01)

Answer 17

Found all 7 studies in a meta-analysis reported statistically significant reduction in positive symptoms after CBT treatment

Question 18

Name 2 negative points about CBT for SZ

Answer 18

1) How much is due to the effects of CBT alone - often antipsychotic at the same time so difficult to assess
2) Appropriateness in terms of who benefits?

Question 19

Outline the appropriateness of CBT for SZ in terms of negative symptoms

Answer 19

CBT works by trying to generate less distressing explanations for psychotic experiences rather than trying to eliminate them completely - negative symptoms may serve useful function for person and so can be understood as ‘safety behaviours’ - e.g. within psychiatric setting, strong expression of emotions might lead to increase in medication or hospital admission - similarly inactivity and withdrawal might be seen as a way of avoiding making positive symptoms worse - therefore CBT offers some hope of alleviating these maladaptive thought processes

Question 20

Outline the appropriateness of CBT for SZ in terms of who benefits

Answer 20

Use CBT in conjunction with medication seems to have benefits but believed not everyone with SZ may benefit from CBT - study of 142 SZs and Kingdon & Kirschen (06) found many patients not deemed suitable for CBT because thought they would not fully engage with therapy - in particular, found older patients deemed less suitable than younger

Question 21

What is the main study looking into the effectiveness of FI for SZ?

Answer 21

Pharoah (12)

Question 22

Outline Pharoah (12)

Answer 22

Reviewed 53 studies 2002-10 investigating effectiveness of FI - conducted in Europe, Asia & North America - compared outcomes from FI to ‘standard’ care alone

Question 23

What did Pharoah (12) find?

Answer 23

1) Mental state - mixed overall - some reported improvement compared to standard care and others not
2) Compliance with medication - compared to standard, the use of FI increases patients’ compliance with medication
3) Social functioning - although appearing to show some improvement in general functioning, did not appear to have an effect on more concrete outcomes like living independently or employment

Question 24

What does Pharoah (12) suggest?

Answer 24

FI effective in improving clinical outcomes like mental state and social functioning but suggest due to increased medication compliance, patients are more likely to reap benefits of medication as more likely to comply with their medication regime

Question 25

Name 2 negative points about FI for SZ

Answer 25

1) Methodological limitations

2) Cultural limitations

Question 26

Outline the methodological limitations of FI

Answer 26

Pharoah (12) also identified methodological issues with studies randomisation and lack of blinding

Question 27

Outline the problem with randomisation for FI

Answer 27

All 53 studies claimed randomly allocated ppts to treatment conditions, but researchers note that a large number of these studies are from the People’s Republic of China - there is evidence in many Chinese studies, randomisation had been stated as having been used, yet was not

Question 28

Outline the problem of lack of blinding for FI

Answer 28

There is possible observer bias where raters were not blinded to condition in which ppts allocated - 10 studies reported no form of blinding used and 16 did not mention whether blinding had been used

Question 29

Name 2 positive points about FI for SZ

Answer 29

1) Supporting evidence - NICE (09)

2) Economic benefits

Question 30

Outline NICE (09)

Answer 30

Meta-analysis of 32 studies and nearly 2500 patients - found significant evidence for effectiveness of FI - when compared with patients receiving standard care alone, was a reduction in hospital admissions during treatment and in severity of symptoms during and up to 24 months following - relapse rate in FI 26% and control 50%

Question 31

Outline the economic benefits of FI for SZ

Answer 31

NICE (09) demonstrated FI associated with significant cost savings when offered to SZs in addition to standard care - the extra cost of FI is offset by the reduced costs of hospitalisation as reduced relapse rates - also evidence FI reduces relapse rates for significant period after completion - means cost savings of FI are even higher

Question 32

Outline the cultural limitations of FI

Answer 32

Evidence has begun to show effectiveness of FI as an addition to antipsychotic drugs but most of this comes from studies conducted outside UK, principally China - NICE (09) expressed view that hospitalisation levels may differ significantly across countries depending on clinical practise within countries, therefore data on hospitalisation rates from non-UK countries might not be applicable to the UK setting

Question 33

Outline ethical issues regarding research into these psychological therapies in general

Answer 33

Research must be carried out in a way that does not place any vulnerable individuals at risk - BPs advise when take part in psychological investigation, there should not be an increased probability that they would come to any harm - possibility for harm is heightened when dealing with vulnerable groups - potential for harm include those associated with medication discontinuation, use of placebo conditions and capacity for informed consent