Schizophrenia 2 Flashcards
What is Family Therapy?
. Involves the identified patients and their families
. The therapy aims to improve the quality of communication and interaction between family members, in line with psychological explanations such as the schizophrenogenic mother
. Pharoah et.al (2010) Identified a range of strategies used by therapists to improve family functioning:
- Reduces negative emotions - Family therapy aims to reduce levels of expressed emotion - reducing general levels of emotions, but in particular negative levels of emotion, such as anger and guilt which create stress (reducing stress helps reduce the likelihood of relapse)
- Improve the family’s ability to help - The therapist encourages the family to form a therapeutic alliance. In this, they all agree on the aims of therapy, the therapist attempts to improve the families beliefs about schizophrenia, and they aim to ensure a balance between the family members caring for the individual and maintaining their own lives
What is another difference between the ICD-10 and DSM-5?
The ICD-10 includes 5 subtypes of schizophrenia due to the wide variety of symptoms. The latest edition of the DSM-5 has removed this. Subtypes include:
. Disorganised schizophrenia - includes disorganised behaviour like not washing, disorganised speech, hallucinations and delusions
. Catatonic schizophrenia
. Paranoid schizophrenia - includes delusions of persecution, angry, suspicious, agitated
. Residual schizophrenia - mild symptoms
. Undifferentiated schizophrenia - Broad category, ‘leftover’, people who don’t fit the rest
What is meant by a ‘model of practice’?
Burbach (2018) proposed a model for working with families dealing with schizophrenia.
Phase 1 - sharing basic information and providing emotional and practical support. It then develops progressively through deeper levels.
Phase 2 - involves identifying recourses, including what 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 eg. learning stress management techniques.
Phase 6 - looks at relapse prevention planning.
Phase 7 - maintenance for the future.
What are some strengths of Family Therapy?
+ Evidence for the effectiveness of family therapy as a treatment for schizophrenia - In a review of studies, McFarlane (2016) concluded that family therapy was one of the most consistently effective treatments for schizophrenia. Relapse rates were found to be reduced by 50-60% in most cases. McFarlane also concluded that using family therapy as mental health initially starts to decline is especially effective. Anderson et.al (1991) found a relapse rate of almost 40% when patients used drugs only, compared to 20$ when family therapy or social skills training were used. NICE recommends family therapy for everyone with a diagnosis of schizophrenia. Family therapy appears to be an effective treatment, with practical benefits to people with both early and ‘full-blown’ or long term schizophrenia
+ Has benefits for all family members, not just the sufferer - Lobban and Barrowclough (2016) concluded that the effects of family therapy on the family of the identified patient are vital as they provide the bulk of care. By strengthening the functioning of the family, the negative impacts of schizophrenia are lessened, and their ability to support the patient is strengthened. This can also help reduce the likelihood of a relapse.
Not only is family therapy a beneficial treatment for the immediate sufferer, but it also has wider benefits for the family.
+ Economic benefits - Strengthening family functioning enables the family to provide the bulk of care for the patient. This means the state does not have to contribute as much to treatment as in CBT or drug therapy.
What are Token economies?
A form of behavioural modification, where desirable behaviours are encouraged by the use of selective reinforcement.
In terms of schizophrenia, it is commonly used in the case of institutionalised patients (especially those who have developed patterns of maladaptive behaviours from spending long periods in psychiatric hospitals), in order to manage their behaviours.
Token economies were used extensively in the 1960’s and 1970’s when the norm for treating schizophrenia was long-term hospitalisation. In the UK, use has now declined, partially because of a growth in community-based care, and partially because of complex ethical issues raised by restricting pleasures and rights for patients.
What did Ayllon and Azrin (1968) find about token economies?
Ayllon and Azrin trialled a token economy system in a ward of female schizophrenia patients. Every time patients carried out a task, such as making their beds or cleaning up, they were given a plastic token. These tokens could then be swapped for ward privileges eg. being able to watch a film. The number of desirable tasks being carried out increased significantly.
What is Institutionalisation?
Develops following periods of prolonged hospitalisation. It can lead to the development of bad habits, such as poor hygiene and inability to socialise.
Matson et.al (2016) identified 3 categories of institutional behaviour commonly tackled by token economies: personal care, condition-related behaviours eg. apathy, and social behaviour
What is the rationale behind token economies?
Modifying institutional behaviour does not cure schizophrenia, but has two major benefits:
. Improves the individuals quality of life within the hospital setting eg. makeup for someone who normally takes pride in their appearance
. ‘Normalises’ behaviour, making it easier for patients to adapt back into everyday life and their communities
How do token economies work?
The idea is that tokens are given immediately to individuals who have carried out a desirable behaviour. They can then be swapped out for a real, tangible reward. Having an immediate reward is important as delayed rewards are less effective.
Target/desirable behaviours are decided on an individual basis, and it is important to know the patient personally to decide on the most appropriate behaviours for them (Cooper et.al 2007)
Token economies are an example of behaviour modification (behavioural therapy based on operant conditioning). Tokens act as secondary reinforcers because they only have value once the individual exchanges them for rewards, which are primary reinforcers.
Tokens can also be exchanged for a range of different primary reinforcers. These are particularly powerful secondary reinforces, known as generalised reinforcers.
In order for the tokens to become secondary reinforcers, they are paired with primary reinforcers - at the start of a token economy programme, they are administered together.
What are some strengths of token economies?
+ Research support for the effectiveness of token economies - Glowacki et.al (2016) identified 7 high quality studies published between 1999 and 2013 that examined the effectiveness of token economies for people with chronic mental health issues. All studies showed a reduction in negative symptoms, and a decline in the frequency of unwanted behaviours. This supports the value of token economies.
—- COUNTER —- Limited evidence base due to the small size of the sample, so problems with generalisability. Also, the small sample size could reflect the file drawer problem (where studies with undesirable findings are ‘filed away’), which leads to a bias towards positive published findings.
What are some limitations of token economies?
- Ethical issues - The use of token economies gives professionals considerable power to control the behaviour of patients. It involves imposing one individuals or one institutions norms onto others, which can result personal freedoms being restricted unnecessarily. Also, restricting the availability of pleasures, so that they are only used as a form of reward, worsens the quality of life of patients who are already experiencing a distressing situation. This has even resulted in legal action by family members of institutionalised patients, showing the severity of this concern. Additionally, the use of token economies could result in discrimination, as severely ill patients may be less able to engage in desirable behaviours, so do not receive rewards, while more moderately ill patients can perform desirable behaviours so are rewarded. The benefits of token economies may be outweighed by their impact on personal freedoms and quality of life.
- Other, more ethical alternatives - Chiang et.al (2019) concluded that art therapy may be a good alternative to token economies, as it appears to be a high-gain, low-risk substitute. It is a pleasant experience, without the major risks of ethical abuses. NICE guidelines recommend art therapy for schizophrenia. As such, token economies may not be the best treatment for schizophrenia.
What is the interactionist approach to explaining schizophrenia?
An approach which acknowledges that there a biological, psychological and social factors involved in the development of schizophrenia. Biological factors can include genetic vulnerability and neurochemical and neurological abnormalities. Psychological factors include stress eg. from life events and social factors eg. poor quality interactions within the family.
A key aspect of the approach is the diathesis-stress model
What is the diathesis-stress model?
. Diathesis - vulnerability
. Stress - negative experience
. The diathesis-stress model suggests that both an existing vulnerability to schizophrenia and a stress-trigger are necessary to develop the disorder.
. Underlying factors make the individual vulnerable to developing schizophrenia, but the onset of the condition is triggered by stress
What was Meehl’s (1962) original diathesis-stress model?
Meehl’s original diathesis-stress model (1962) - suggests that the diathesis aspect is entirely genetic, the result of a particular ‘schizogene’.
This led to the idea of a biologically based schizotypic personality - one characteristic of which is sensitivity to stress. According to Meehl, if someone doesn’t have the schizogene then no amount of stress will result in schizophrenia.
However in carriers of the gene, chronic childhood/adolescent stress, such as having a schizophrenogenic mother, can result in the development of the disorder
What is the modern understanding of diathesis?
. Diathesis:
. Many genes each appear to increase genetic vulnerability slightly, rather than one single ‘schizogene’ (Ripke et.al 2014)
. The modern view also considers a range of factors as the diathesis (vulnerability) beyond genetic, including psychological trauma (Ingram and Luxton 2005).
. Read et.al (2001) proposed a neurodevelopmental model, in which early trauma affects the developing brain. Severe, early trauma (such as child abuse) can affect several areas of brain development, such as hypothalamic-pituitary-adrenal (HPA) system (which controls how the body responds to a chronic stressor). This can become overactive, making a person more vulnerable to later stress
