Schizophrenia: CBT Flashcards
What is CBT?
A combination of cognitive therapy (a way of changing maladaptive thoughts and beliefs) and behavioural therapy (a way of changing behaviour in response to these thoughts and beliefs.
What are the assumptions of CBTp?
The basic assumption of CBTp is that people often have distorted beliefs, which influence their feelings and behaviours in maladaptive ways. For example, someone with schizophrenia may believe that their behaviour is being controlled by someone or something else. Delusions are thought to be a result of faulty interpretations of events, and CBTp is used to help the patient identify correctly these faulty interpretations. CBTp can be delivered in groups but is more usually that is delivered on a one-to-one basis. NICE recommend at least 16 sessions when used in the treatment of schizophrenia.
What is the nature of CBT?
Patients are encouraged to trace back the origins of their symptoms in order to get a better idea of how they might have developed. They are also encouraged to evaluate the content of their delusions or of any voices and to consider ways in which they tend to test the validity of their faulty beliefs. Patients might also be set behavioural assignments so that they might improve their general level functioning. The learning of maladaptive responses to life’s problems is often the result of distorted thinking by schizophrenics or mistakes in assessing cause and effect. During CBTp, the therapist lets the patient develop their own alternatives to these previous maladaptive beliefs, ideally by looking for alternative explanations and coping strategies that are already present in the patient’s mind.
How does CBTp work?
CBTp usually proceeds through the following phases:
- Assessment: The patient expresses his or her thoughts about their experiences to the therapist. Realistic goals for therapy are discussed, using the patient’s current distress as motivation for change.
- Engagement: The therapist emphasises the patient’s perspective and their feelings of distress, and stresses that explanations for their distress can be developed together.
- The ABC model: The patient gives the explanation of the activating event that appears to cause their emotional and behavioural consequences. The patient’s own beliefs which are the cause of C can be rationalised, disputed and changed.
- Normalisation: Information that many people have unusual experiences such as hallucinations and delusions and are in many different circumstances reduces anxiety and the sense of isolation. By placing psychotic experiences on a continuum with normal experiences, the patient feels less alienated and stigmatised and recovery seems more possible.
- Critical collaborative analysis: The therapist uses gentle questioning to help the patient understand logical deductions and conclusions. Questions can be carried out without causing distress, provided there is an atmosphere of trust between the patient and the therapist.
- Developing alternative explanations: The patient develops her own alternative explanations for their previous and healthy assumptions. Their healthy exclamations might have been temporarily weakened by their dysfunctional thinking patterns.
A03:
+ Advantages of CBTp over standard care.
+ Effectiveness of CBTp is dependent on the stage of the disorder.
- Lack of availability of CBTp
- The benefits of CBTp may have been overstated
A03: Advantages of CBTp over standard care
The NICE review of treatments for sz found consistent evidence that when compared with standard care, 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 symptom severity and when compared with patients receiving standard care, there was evidence for improvements in social interaction and functioning. However, most studies of the effectiveness of CBTp have been conducted with patients treated at the same time as antipsychotic medication therefore difficult to assess the effectiveness of CBTp independent of antipsychotic medication.
A03: Effectiveness of CBTp is dependent on the stage of the disorder.
CBTp appears more effective when it is made available at specific stages of the disorder and when the delivery of the treatment is adjusted to the stage that they are on currently. Addington and Addington (2005) claimed that in the initial acute phase of schizophrenia, self-reflection is not appropriate. Following stabilisation of the psychotic symptoms with antipsychotic medication, however, individuals can benefit more from group-based CBTp. This can normalise their experience by meeting other individuals with similar issues. If they have more experience with their schizophrenia then they benefit more from individual CBTp.
A03: Lack of availability of CBTp
Despite being recommended by nice as a treatment for people with schizophrenia, it is estimated that only 1 in 10 of those who could benefit get access to this form of therapy. This figure is even lower in some areas of the country. A survey carried out by Haddock et al in the North West of England found that out of 187 randomly selected schizophrenic patients only 13 had been offered CBTp and of those who are offered it as a treatment a significant number refuse or fail to attend therapy sessions, thus limiting its effectiveness even more.
A03: The benefits of CBTp may have been overstated
A more recent and methodological sound meta-analysis of the effectiveness of CBTp as a sole treatment for schizophrenia suggests that its effectiveness may be lower than thought. Jauhar et al revealed only a small therapeutic effect on the key symptoms of schizophrenia. Small effects disappeared when symptoms were assessed as blind. Many studies investigating CBTp have similar design flaws and lack of originality in their meta-analysis. This uncertainty over whether non-drug therapies such as CBTp really offer superior outcomes to antipsychotic medication has led to conflicting recommendations even within the UK.
