psychological treatments of sz

Question 1

what are the 3 different psychological treatments for SZ?

Answer 1

• CBTp
• family therapy
• token economy

Question 2

how does CBTp help SZ?

Answer 2

Schizophrenia, as a whole, is a distortion or breaking from reality.

Cognitive Behaviour Therapy may therefore be effective in grounding these individuals’ beliefs.

CBT aims to change the maladaptive thinking of schizophrenic individuals.

• It is a teaching and active therapy
• Identification and adaptation of irrational thinking
• Teaching of the origins of symptoms
• The patient provides evidence for their irrational thoughts-this challenges their thoughts
• Teaching of relaxation techniques
• Homework is often set, usually involving a diary to record thoughts

They do this by using CBT- Integrated Psychological Therapy and Coping Strategy Enhancement

Question 3

how does CBT- Integrated Psychological Therapy help SZ?

Answer 3

• To improve attention and refine concept formation - identifies specific cognitive deficits and remedy them in a non-confrontational manner.
• can improve the flat/ inappropriate effect and avolition and alogia clients are taught to recognize and respond appropriately to social cues to combat avolition and inappropriate effect and to understand verbal statements more accurately to combat alogia and disorganized thoughts.
• This could take place in engaging group excersizes that emphasize repetitive training that allows sz patients to refine new behavioral tactics.
• another step would be to challenge the faulty interpretations using reality tests to remove some false beliefs

Question 4

how does the Coping Strategy Enhancement??

Answer 4

• This technique tries to teach patients with schizophrenia better ways to manage the severity and frequency of their psychotic symptoms to reduce distress and their impact on day-to-day functioning.
• teaches coping skills to patients and CSE is based on a thorough behavior analysis of each symptom and the assessment of any coping strategy the subject may ready employ. the patient is then trained in the use of appropriate coping strategies in response to the occurrence of the
  psychotic symptoms
• cognitive strategies can include distractive thoughts and positive self talk whereas behavioral techniques will use relaxation techniques and ways of drowning out hallucinatory voices and Tarrier et al found that 73% of their sample reported that they were successful in managing their symptoms

Question 5

what are the positive evaluations of CBTp?

Answer 5

• Cognitive treatments such as CBT can be praised due to having research to support the theory. STARTUP et al (2004) investigated the effectiveness of CBT, by recruiting 90 patients who had been admitted to hospital with an acute episode. 43 were given standard care i.e. antipsychotics and nursing care, whilst the other 47 were given standard care plus up to 25, 90 minute sessions of CBT. They found that 60% of CBT group showed reliable and clinical improvement, with fewer positive AND negative symptoms, compared to 40% of the control group. More importantly, these benefits stood the test of time and remained at 6 and 12 month follow ups, compared to just 17% of the control group.This supports CBT as a treatment for schizophrenia because the results were highest when patients had CBT. However, they also received drug treatments in both conditions so a combination approach may be the most effective.
• Moreover, CBT may be criticised for not tackling the root cause of schizophrenia but there are other areas CBT can help patients.
  GARRETT (2008) proposed peripheral benefits of CBT.
  Garrett suggested that CBT can help to change a patient’s mind about taking the antipsychotic and therefore reducing symptoms in that way. This can help give patients a combined treatment plan, increasing the likelihood of managing their symptoms.
  This shows that CBT can be appropriate for schizophrenic patients.

Question 6

what are the negative evaluations of CBTp?

Answer 6

• Many clinicians have criticised the use of CBTp with schizophrenic patients as they characteristically do not have coherent thinking and insight into their condition to actually gain therapeutic benefit.
  For example, many delusionary patients may not accept they are ill and need help in the first place.
  Kingdon & Kirschen (2006) found that clinicians significantly judged older schizophrenic patients as being far less suitable/appropriate than younger patients to benefit from CBTp.
  Therefore, CBTp may not suitable for all patients – some may be too old to benefit from CBTp as cognitions are set.
• Furthermore, the appropriateness of CBTp is also called into question when considering patients may suffer from different schizophrenic symptoms.
  Zimmerman et al. (2005) found that there does seem to be a place for CBTp helping with the auditory and visual hallucinations that sufferers experience; and it particularly helps in reducing the distress and negative emotions experienced by individuals who suffer these hallucinations.
  However, it may be less helpful in treating some of the negative symptoms of schizophrenia, like flat affect and avolition.
  This could suggest… CBTp is of limited usefulness as it can reduce the distress of schizophrenic patients who suffer more from hallucinations, but is less useful for those struggling with their negative symptoms.

Question 7

how does family therapy help SZ?

Answer 7

• Family therapy is an attempt to fix the faulty and dysfunctional dynamic of a family that may have caused schizophrenia.
  It tries to alter communication practices within a family and trains people to express emotion in a more beneficial way.
• The main aims of the therapy are:

Improve positive and decrease negative forms of communication

Increase tolerance levels and decrease criticism within the family dynamic

Decrease feelings of guilt and responsibility for causing the illness.

Therapists aim to hold an open forum about the effects the illness has had on the family.

Question 8

explain the process of family interventions/ therapy?

Answer 8

1) Co-operative and trusting relationships

Both the patient and family meet in a supportive environment, where all family members are valued. This process usually lasts around 6 months, with a minimum of 10 sessions recommended to patients and families.

2) Educate

Therapist educates the group about the symptoms, causes and prognosis of SZ whilst family members bring together their experiences of the disorder. E.g., the patients will be encouraged to open up to their family about what is helpful and what makes their symptoms worse.

3) Practical coping skills

The patients and family are provided with a set of practical coping skills that enable then to manage the everyday difficulties involved with SZ. These are behavioural and cognitive techniques. E.g., setting targets so the patient isn’t dependent on their family (i.e., responsibility over household chores).

4) How to express concern without resorting to high EE

It is accepted that the family may occasionally feel anger and impatience, but they are taught how to express concern without resorting to high EE. E.g., using relaxation techniques to calm yourself down before discussing concerns.

5) Recognising the early signs of potential relapse

Learning how to detect the early signs of relapse means they can respond rapidly and reduce its severity. E.g., insomnia, social withdrawal, difficulty concentrating, loss of interest, increasing paranoia, and hallucinations.

Question 9

what are the positive evaluations of family therapy?

Answer 9

• There is research to support family therapy as a treatment for schizophrenia.
  Leff et al (1982) tested the effectiveness of family therapy. He had a sample of 24 Pt’s, and looked at 3 different types of treatments. The 3 programmes involved (i) educational sessions dealing with the nature of schiz, its symptoms and the best way to deal difficult behaviour. (ii) group meetings took place between families to discuss how they dealt with schiz family members (iii)family sessions took place where social workers and other professionals were present. The effects of the programme were evaluated after a two year follow up. Families who did not take part in the study acted as a natural control group. Patients in both conditions were on also on anti-psychotics. The results showed families involved in the intervention showed a significant decrease in critical comments directed towards the patient and reduced over –involvement (characteristics of high EE). Plus, 78% of patients in control group were readmitted to hospital compared to only 14% of the experimental group.
  This supports family therapy as a treatment for schizophrenia as it had the lowest relapse rate, supporting its effectiveness.
• Family therapy seems to be most effective when used in conjunction with powerful antipsychotics to treat schizophrenia.
  Vaughn and Leff (1976) looked at schizophrenic patients returning to either high or low EE in the household.
  The effect of no medication on low EE was insignificant.
  In the high EE household, relapse of schizophrenic symptoms increased with more face-to face contact, and with no medication relapse rate rose to 92%, showing the importance of effective treatment.
  This implies that focusing on both family dynamics and biochemistry is best for patients with schizophrenia and their families.
• Family therapy seems to be most effective when used in conjunction with powerful antipsychotics.
  For example, A study by Anderson et al. (1991) found a relapse rate of almost 40% when patients had drugs only, compared to only 20% when Family Therapy was used and the relapse rate was less than 5% when both were used together with the medication.
  With a drastically reduced relapse rate with FT, will reduce the amount of times patients are hospitalised and therefore reduce the cost to the NHS, and therefore the economy.
  This implies that focusing on both family dynamics and biochemistry is best for patients and their families.
• Despite the high costs of family therapy, many argue it can reduce the ‘revolving door syndrome’ often seen with schizophrenic patients.
  Reduces revolving door syndrome refers to being in and out of hospital, due to unmanaged symptoms. By treating more of the cause of schizophrenia, patients can manage their disorder long term, therefore reducing the “revolving door syndrome”.
  This could save money overall on the NHS, as it will reduce how often someone is in clinical care.
  This means that many psychologists would state that family therapy is a cost effective mechanism for dealing with schizophrenia.

Question 10

what are the negative evaluations for family therapy?

Answer 10

• However, research like Leff’s has many methodological flaws that limit the credibility of the support.
  For example, the families were already on the waiting list, so no manipulation of the IV. This means that the family would be open to this type of therapy, whereas not all families would be happy to take part in family therapy. Leff’s results need to be used carefully as it may not be family therapy itself that aided the low relapse rate, but rather the type of family that took part and how open they are to changing they way they all communicate that led to the low relapse rates.
  This implies that family therapy lacks rigorous experimental support which questions how effective it real is for schizophrenia. Methodological issues-natural experiment.

Question 11

how doe token economies help SZ?

Answer 11

• based on operant conditioning techniques such as positive reinforcement
• ‘normal’ behaviours that are desired are postiely rewarded which means this behaviour wll be repeated again in the future.
• the desirable behaviours are reinforced by the use of plastic tokens which are secondary reinforces
• the tokens have no intrinsic value but can be exchanged for primary reinforces
• a primary reinforce can meet a basic need like TV time, cigarettes and time out or chocolate
• critically the primary reinforces must be viewed as highly desirable by the patients
• may also use negative reinforcement where privileges or tokens are taken away until patient performs desirable behavior.

Question 12

what is the three behaviors that can be addressed within a token economy?

Answer 12

Matson et al. (2016) identified three categories of problematic behaviours that develop in a hospital and can be addressed through the use of token economies:

• Personal hygiene issues (problems with hygiene such as showering, changing clothes, and brushing teeth)
• Illness-related behaviours (problems with positive and negative symptoms)
• Social behaviours (problems in dealing with other people)

Question 13

hoe could negative symptoms of sz be treated by token economies?

Answer 13

Speech poverty (Alogia):

• Not replying when someone speaks to them
• Receiving a token for when they do give a reasonable length, coherent reply to someone

Flat affect:

• Have dulled emotional expression
• A token is taken away

Avolition

• Not engaging in activities in the hospital like playing a sports activity
• Receiving a token when they do engage in activities

Question 14

what are the positive evaluations of token economies?

Answer 14

• Originally, Token Economy was classed as one of the first humane therapies to treat schizophrenia.
  In the past schizophrenics would be isolated and confined in order to exercise control. Early use of Token economies allowed patients to be treated more humanely with more freedom and independence, which probably contributed to the therapeutic effect.
  This suggests that Token economies should be praised for the ethical treatment of schizophrenia
• There is evidence that Token economies are very effective in the management of schizophrenia.
  For example, Allyon and Azrin (1968) researched patients in ward of a psychiatric hospital, comprised of 45 female chronic schizophrenic patients, with an average of 16 years of hospitalization. They screamed for long periods, were mute, assaultive, many were incontinent, and they no longer ate with cutlery. Following a system of TE they were carefully reinforced with tokens for their ward work and self-care behaviours which were later exchanged for chosen privileges (e.g. listening to music, renting a private room, seeing a social worker). This regime led to a dramatic improvement in self-care behaviours, however, When the system was removed these behaviours disappeared.
  This implies that Token economies are a cost effective strategy to use with institutionalised patients suffering from schizophrenia
• There is evidence that token economies are very effective in the management of schizophrenia.
  Allyon and Azrin (1968) studied 45 female chronic schizophrenic patients, with an average of 16 years of hospitalisation. They screamed for long periods, were mute, assaultive, many were incontinent, and they no longer ate with cutlery. Following a system of TE they were carefully reinforced with tokens for their ward work and self-care behaviours which were later exchanged for chosen privileges (e.g. listening to music, renting a private room, seeing a social worker). This regime led to a dramatic improvement in self-care behaviours, however, When the system was removed these behaviours disappeared.
  This implies that TEs are a cost effective strategy to use with institutionalised patients suffering from schizophrenia.

Question 14

what are the negative evaluations of token economies?

Answer 14

• There can also ethical issues with using a token economy approach.
  First and foremost, it gives staff significant control over the behaviour of the patients. It imposes a ‘norm’ that, whilst it may be appropriate in societal settings, it is not fair to expect this perfection off of patients (for example, a patient may not want to dress a certain way for the day, or may prefer to bathe every two days). This is a restriction of personal freedoms.
  Also, if they are having a few ‘off-days’ and are therefore not earning tokens, it has a significant impact on the patient’s daily life. It would be unfair to deprive a patient of their favourite things because you were having a bad day. This has led to legal action in the past, as families are not okay with personal liberties being taken away from the patient.
  This reduces the reputation of the treatment and could put hospitals off the idea of implementing it in their institution to avoid complaints.
• Many psychologists believe that token economies do nothing to attempt to cure schizophrenia and in fact provide nothing but ‘token learning’.
  It is difficult to keep this treatment going once the patients are back at home in the community.
  Kazdin et al. Found that changes in behavior achieved through token economies do not remain when tokens are withdrawn, suggesting that such treatments address effects of schizophrenia rather than causes. It is not a cure.
  This could imply that the benefits of TEs for schizophrenia are institutionally bound and disappear when patients rejoin the real world.
• However, it is argued that a token economy is only partially effective as it only reduces certain symptoms.
  Gholipour et al (2012) found that a token economy approach reduced negative symptom scores by 46% from scores of 77 to 41.
  Furthermore, McMonagle & Sultana (2000) also found that token economies were more effective at reducing negative symptoms, rather than positive. They also highlighted potential issues with the permanence of the token regime as well. This refers to token learning - the term for when behaviour is only shown during a token regime (e.g. prisons).
  This suggests that token economies are not as useful as they are not fully addressing the symptoms displayed by patients, with positive symptoms like hallucinations and delusions going unchecked.