Psychological Therapies For SZ

Question 1

What are the three main psychological therapies for SZ

Answer 1

1. Cognitive behaviour therapy
2. Family therapy
3. Token economies

Question 2

What 6 phases does CBTp work through (cognitive behavioural therapy for psychosis)

Answer 2

1. Assessment
2. Engagement
3. The ABC model
4. Normalisation
5. Critical collaborative analysis
6. Developing alternate explanations

Question 3

Assessment phase of CBTp

Answer 3

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 4

Engagement phase of CBTp

Answer 4

– 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 5

CBTp the ABC model phase

Answer 5

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 6

CBTp normalisation phase

Answer 6

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 7

Critical collaborative analysis phase CBTp

Answer 7

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 8

Developing alternative explanations

Answer 8

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 9

How many recced sessions to treat sz

Answer 9

• at least 16
• can be groups but usually 1 on 1

Question 10

(+) effectiveness of CBT compared to standard care (which is antipsychotic meds alone)

Answer 10

– 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.

Question 11

(-) of CBTp = it’s lack of availability and patients refusal to attend sessions

Answer 11

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.

Question 12

(-) problems with meta analysis of CBTp as a treatment for SZ? (Study quality?)

Answer 12

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 13

What’s ‘family therapy’ (AO1)

Answer 13

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, Research has shown that schizophrenics in families that expressed high levels of criticism, hostility 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

How long is family therapy offered for & how many sessions

Answer 14

3-12 months
At least 10 sessions

Question 15

What does family therapy typically involve

Answer 15

providing family members with information about SZ, finding ways of supporting an individual with SZ and resolving any practical problems.
Interventions to reduce the level of expressed emotion within the family to minimise relapse likelihood

Question 16

What strategies does family therapy use?

Answer 16

a)Psychoeducation – helping the person and their carers to understand and be better able to deal with the illness.
b)Forming an alliance with relatives with care for the person with SZ
c)Reducing the emotional climate within the family and the burden of care for family members
d)Enhancing relatives’ ability to anticipate and solve problems
e)Reducing expressions of anger and guilt by family members
f)Maintaining reasonable expectations among family members for patient performance
g)Encouraging relatives to set appropriate limits whilst maintaining some degree of separation when needed

Question 17

What’s the key study for family therapy?

Answer 17

Pharaoh et al (2010)

Question 18

Pharoah et al (2010) what did he investigate (procedure)

Answer 18

Procedure: 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 19

Pharoah et al (2010) Findings

Answer 19

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 20

(+/-) pharaoh’s study provides mixed evidence for effectiveness of family therapy?

Answer 20

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.

Question 21

(+) economical benefits long term of family therapy

Answer 21

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)

Question 22

(+) how family therapy is important and helpful for both the diagnosed AND their family members

Answer 22

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 23

What’s a token economy

Answer 23

A reward system used to manage rather than treat behaviour (in this case, of patients with SZ in hospital settings)

Question 24

Why is token economy helpful for patients e.g. what habits may they have picked up being institutionalised?

Answer 24

Some may have developed maladaptive behaviours through spending too long in hospital with other patients who may have showed catatonia. 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.

Question 25

What principles are token economies based on

Answer 25

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

Question 26

Are tokens primary or secondary reinforcers

Answer 26

Secondary reinforcers
The primary one = the reward it’s swapped for

Question 27

(-) of token economy: how it lacks ecological validity

Answer 27

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.

Question 28

(-) of token economy: can we be sure it even genuinely works (it doesn’t rly TREAT does it?)

Answer 28

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.

Question 29

(-) why are there ethical concerns to do with token economy programmes in psychiatric settings

Answer 29

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.

Question 30

(+) of token economies = the research support for it?

Answer 30

Someone 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.

overall, these studies provide evidence of the token economy’s effectiveness in increasing the adaptive behaviours of patients with SZ. However, 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 31

How to treat symptoms with cognitive behaviour therapist

Answer 31

• help them identify their irrational thoughts
• help see the link between their thoughts, emotion, and behaviour
• offer alternative interpretations
• give strategies to counter irrational thoughts e.g. self distraction