Psychological therapy Flashcards
CBT
Cognitive behaviour therapy (CBT) is commonly used to treat people with schizophrenia. It usually takes place over a period of 5-20 sessions (this is longer than for other conditions), either in groups or on an individual basis. CBT aims to deal with both thoughts (cognitions) and behaviour.
How CBT helps
CBT can help a client make sense of how their irrational cognitions (such as delusions and hallucinations) impact on their feelings and behaviour. Just understanding where symptoms come from can be hugely helpful for those with symptoms like auditory hallucinations. If, for example, a client hears voices and believes the voices represent demonic forces, they will naturally be very afraid. If a therapist can convince them that the voice actually comes from the malfunctioning speech centre in their own brain and that it cannot hurt them if they ignore it, this is much less frightening and hence less debilitating. This will not eliminate the symptoms of schizophrenia but it can make people better able to cope with them. This in turn reduces their distress and improves their ability to function adequately.
People hearing voices can also be helped by teaching them that voice-hearing is an extension of the ordinary experience of thinking in words. This is called normalisation.
Delusions can also be challenged, for example by a process of reality testing in which the person with schizophrenia and their therapist jointly examine the likelihood that beliefs are true. In some cases where delusions are resistant to reality testing CBT can still be used to tackle the anxiety and depression that result from living with schizophrenia.
A case example
Douglas Turkington et al. (2004) describe an example of CBT used to challenge where a paranoid client’s delusions come from:
Paranoid client: The Mafia are observing me to decide how to kill me.
Therapist: You are obviously very frightened… there must be a good reason for this.
Paranoid client: Do you think it’s the Mafia?
Therapist: It’s a possibility, but there could be other explanations. How do you know that it’s the Mafia?
Family therapy
Family therapy takes place with families as well as the identified patient (a term used in family therapy which describes one member of a dysfunctional family who expresses the family’s conflicts). The therapy aims to improve the quality of communication and interaction between family members. There is a range of approaches to family therapy for schizophrenia.
In keeping with psychological theories like the double-bind and the schizophrenogenic mother
How family therapy helps
Fiona Pharoah et al. (2010) identified a range of strategies that family therapists use to try to improve the functioning of a family that has a member with schizophrenia.
Reduces negative emotions -Family therapy aims to reduce levels of expressed emotion
(EE), i.e. reduce the level of emotion generally but especially negative emotions such as anger and guilt which create stress. Reducing stress is important to reduce the likelihood of relapse.
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 schizophrenia. A further aim is to ensure that family members achieve a balance between caring for the individual with schizophrenia and maintaining their own lives.
A model of practice
Frank Burbach (2018) has proposed a model for working with families dealing with schizophrenia. This begins with sharing basic information and providing emotional and practical support. Then it develops through progressively deeper levels. Phase 2 involves identifying resources including what different family members can (and cannot) offer. Phase 3 aims to encourage mutual understanding, creating a safe space for all family members to express their feelings. Phase 4 involves identifying unhelpful patterns of interaction. Phase 5 is about skills training such as learning stress management techniques. Phase 6 looks at relapse prevention planning and Phase 7 is maintenance for the future.
S-CBT-evidence for effectiveness
One strength of CBT for schizophrenia is the evidence for its effectiveness.
Sameer Jauhar et al. (2014) reviewed 34 studies of using CBT with schizophrenia, concluding that there is clear evidence for small but significant effects on both positive and negative symptoms. Other studies have focused on symptoms, for example Maria Pontillo et al. (2016) found reductions in frequency and severity of auditory hallucinations. Clinical advice from NICE
(2019), the National Institute for Health and Care Excellence, recommends CBT for schizophrenia.
This means that both research and clinical experience support the benefits of CBT for schizophrenia.
L-CBT-quality of evidence
One limitation of CBT for schizophrenia is the wide range of techniques and symptoms included in studies.
extra eval-CBT may improve the quality of life for people with schizophrenia but not actually ‘cure’ them. As schizophrenia appears to be largely a biological condition we would expect that a psychological therapy like CBT just benefits people by improving their ability to live with schizophrenia.
On the other hand studies report significant reductions in the severity of both positive and negative symptoms. This suggests that CBT does more than enhance coping
CBT techniques and schizophrenia symptoms vary widely from one case to another.
Neil 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. The overall modest benefits of CBT for schizophrenia probably conceal a wide variety of effects of different CBT techniques on different symptoms.
This makes it hard to say how effective CBT will be for a particular person with schizophrenia.
S-family therapy-evidence of effectiveness
One strength of family therapy for schizophrenia is evidence of its effectiveness.
A review of studies by William McFarlane (2016) concluded that family therapy was one of the most consistently effective treatments available for schizophrenia. In particular relapse rates were found to be reduced, typically by 50-60%. McFarlane also concluded that using family therapy as mental health initially starts to decline is particularly promising. Clinical advice from NICE recommends family therapy for everyone with a diagnosis of schizophrenia.
This means that family therapy is likely to be of benefit to people with both early and ‘full-blown’ schizophrenia.
S-family therapy-benefits to whole family
A further strength of family therapy for schizophrenia is the benefits for all family members.
Therapy is not just for the benefit of the identified patient but also for the families that provide the bulk of care. A review of evidence by Fiona Lobban and Christine Barrowclough
(2016) concluded that these effects are important because families provide the bulk of care for people with schizophrenia. By strengthening the functioning of a whole family, family therapy lessens the negative impact of schizophrenia on other family members and strengthens the ability of the family to support the person with schizophrenia.
This means that family therapy has wider benefits beyond the obvious positive impact on the identified patient.
extra eval-Because family therapy reduces relapse rates and makes families better able to provide the bulk of care it has huge economic benefits. The State does not need to pay so much.
On the other hand, family therapy also has very significant therapeutic benefits for people with schizophrenia and their families.
