Schizophrenia: Psychological Treatments (Token Economies, CBT + Family Therapy) Flashcards
What’s the aim of token economies?
- A token economy is a behavioural therapy technique in which the aim is to manage the negative symptoms of schizophrenia, such as avolation, by encouraging them to engage in desired behaviours.
How are token economies used in hospitals?
In token economies, patients are given tokens when they complete desirable behaviours,
such as washing and exercising. They can then exchange these tokens for rewards, such as
food or watching a film.
Why are token economies effective?
- Token economies are effective because of positive reinforcement, a type of operant conditioning). By rewarding desirable behaviours, these become reinforced in the patients.
- The tokens themselves are a type of secondary reinforcer. This means they only obtain the ability to reinforce behaviours when they become associated with other reinforcers (eg food, which is a primary reinforcer as it is naturally desired by the patient).
- It is important to give tokens immediately after the target behaviour is completed to avoid delay discounting (the reduced affect of a delayed reward).
- If the tokens are given long after the desirable behaviour is completed, the patient will be less likely to associate the token with the behaviour, resulting in delay discounting.
What research support is there for the effectiveness of token economies in the management of negative symptoms?
McMonagle and Sultana (2000) conducted a meta-analysis of studies examining the effectiveness
of token economies and found slight evidence for the benefits of token economies for improving the
negative symptoms. The researchers only analysed three studies, resulting in a combined sample of
110, as these were the only studies they could find that were randomized trials (studies where
participants are randomly allocated to a treatment or control group). E – This finding suggests token economies may have some benefits, albeit slight, for improving the
negative symptoms of schizophrenia. However, this meta-analysis includes only three studies (N =
110), limiting its sample size and requiring caution when generalizing the findings on the
effectiveness of token economies for managing the negative symptoms of schizophrenia to the
broader schizophrenia population. Furthermore, McMonagle and Sultana noted that the analysed
studies did not examine if the improvements in negative symptoms persisted after patients left
hospital, warranting caution about token economy’s long-term effectiveness as a way of managing
the negative symptoms schizophrenia. This is a particular concern for token economies, as if the
completion of the desirable behaviours is dependent on the behaviour being reinforced, then these
behaviours will become extinct once the reinforcement ends when the patient leaves the hospital.
What methodological issues with the studies examining token economies as a way of managing symptoms of schizophrenia are there?
Usually, whenever token economies are introduced to help manage the symptoms of patients
with schizophrenia on a psychiatric ward, all the patients are brought into the programme. This is an issue as it means studies on token economies rarely use randomized trials, the gold
standard for clinical efficacy, as by bringing all patients into the token economy, it’s not possible to
randomly allocate some to a control group. This lack of experimental control makes it unclear if
behavioural improvements in schizophrenia, like increased washing, result from the token economy
or uncontrolled variables, such as increased staff attention. This means that most of the supporting
evidence for the effectiveness of token economies has very weak internal validity, as it’s not possible
to determine whether the token economies are the cause of patient improvement.
Why are there ethical issues?
The major issues is that the use of token economies results in patients best able to manage
their symptoms receiving greater privileges than those who cannot manage as well.
The ethical issue is discrimination. Token economies disadvantage those with severe symptoms
who struggle to complete tasks, receiving fewer rewards than those with milder symptoms. This
unfair treatment may increase patient stress, hindering recovery.
What is the aim of CBT?
The aim of CBT for schizophrenia is to use a combination of cognitive and behavioural techniques to change patterns of dysfunctional thinking and behaving that contributes to the distress caused by the symptoms of schizophrenia.
What are some CBT techniques?
- Psychoeducation — this involves educating the patient about their condition using the stress-vulnerability model. This teaches them the links between their thoughts, feelings and behaviours.
- It helps patients understand their symptoms, making the condition feel more manageable and reducing the distress. It also enhances engagement with CBT by showing how thoughts and behaviours contribute to distress, motivating change.
- Cognitive therapy for delusions/hallucinations — this involves the therapist guiding the patient to explore the rationality of their delusional beliefs and/or beliefs about their voices, with the aim of changing beliefs that cause distress.
- A therapist may use empirical and logical reasoning (eg by challenging the belief that voices are real by asking how often others have heard them).
- They may also conduct an experiment to test the validity of the belief.
- Behavioural skills training — in this technique, the therapist works with the patient to agree on behavioural actions the patient could tale to avoid or reduce the distress caused by the symptoms (positive and negative).
- Examples are controlled breathing, distraction activities and developing to do lists.
What methodological issues are there with the research into CBT as a treatment for schizophrenia?
One issue is that many of the supporting studies fail to blind the
researchers assessing the effectiveness of the treatment conditions. This is a problem as without blinding, assessors will know which
treatment a participant is receiving. This knowledge could affect their assessment and
undermine the validity of the research (i.e., they could be biased and assess CBT as more
effective than it is).
Research has investigated the effectiveness of CBT as a treatment for schizophrenia.
Berendsen et al. (2024) conducted an umbrella review* of 16 meta-analyses, finding CBT
helped with positive symptoms immediately after treatment but there wasn’t clear evidence
that these effects are sustained in follow-up assessments. They found no statistically
significant benefits for negative symptoms. Although this finding suggests that CBT can be an effective treatment for the positive
symptoms of schizophrenia, it also shows that this treatment may only produce short-term
benefits, thereby weakening its effectiveness. Moreover, its ineffectiveness at treating the
negative symptoms means it offers a limited treatment for schizophrenia. This finding is
compelling as it comes from an umbrella review, which aggregates findings from published
meta-analyses, resulting in a vast sample. This strengthens its conclusions on CBT’s
effectiveness, as its findings are likely to be based on a representative sample of patients
with schizophrenia.
What is an issue with CBT as a treatment for schizophrenia?
It may be unsuitable for some types of patients. One group who may not benefit from CBT are those with very severe positive symptoms.
The confusion and paranoia these symptoms create may prevent the patient being able to
work the therapist and reflect on their own beliefs and behaviours. Such patients may
require the treatment of their positive symptoms with drug therapies before they can
engage with CBT treatment. Another group who may not benefit from CBT are patients who lack sufficient insight to
recognise that they have a mental health condition. Those who do not believe they are
unwell are unlikely to engage with a therapy designed to help them improve.
What is family therapy?
It’s a treatment for schizophrenia that involves both the patient and their family.
Why is providing therapy to the family of a person with schizophrenia helpful?
Family therapists believe that families can provide an important source of support to
patients with schizophrenia (e.g., by helping them take their medication), but this support
can actually be harmful in situations of family dysfunction.
What are the aims of family therapy?
- Improve communication within the family.
- Reduce levels of expressed emotion in the family, which is a cause of relapse.
- Helping family members balance their needs with the need to care for the patient.
How is family therapy conducted?
- Preliminary analysis: Through interviews and observation the therapist identifies strengths and
weaknesses of family members and identifies problem behaviours (e.g., lack of understanding
around the condition or poor communication). - Psychoeducation – teaching the patient and the family facts about the illness, such as its causes,
the influence of drug abuse, and the effect of stress and guilt - Communication skills training – teach family constructive communications skills, such as listening, compromising, and requesting a “time out”.
Researchers examined the effectiveness of family therapy as a treatment for schizophrenia.
Pharoah et al. (2010) conducted a meta-analysis of 53 studies comparing antipsychotics alone to
antipsychotics with family therapy for schizophrenia. They found that adding family therapy
improved medication compliance and reduced relapse and hospital readmission rates. The finding that family therapy reduced relapse and hospital readmission suggests that adding
family therapy to the treatment regime for schizophrenia can be an effective treatment as it helps
patients remain well. However, as Pharoah has suggested, this improved clinical outcome may be
the result of the greater medication compliance in the family therapy conditions. This suggests
family therapy offers a limited treatment, as its effectiveness depends on the effectiveness of drug
therapies. Furthermore, this study’s findings on the effectiveness of family therapy as a treatment
for schizophrenia are enhanced by the use of meta-analysis. Since this method involves aggregating
the results of multiple studies - 53 in this case - it has a large overall sample that’s more likely to be
representative of the population of people with schizophrenia.
What methodological issues are there with the research into family therapy as a treatment for schizophrenia?
Pharoah (2010) noted as a concern that many studies investigating the benefits of family
therapy do not use blinding or did not mention whether blinding was used.
This is a problem as without blinding, assessors will know which treatment a participant
is receiving. This knowledge could affect their assessment and undermine the internal
validity of the research (i.e., they could be biased and assess CBT as more effective than it
is).
Research has questioned the effectiveness of family therapy as a treatment for schizophrenia.
Garety (2008) found that schizophrenic patients without carers experienced high relapse rates,
while those with carers had comparatively low relapse rates, regardless of whether they received
family therapy.
This suggests that family therapy may not be an effective treatment for schizophrenia, as
patients who received family therapy did not show better outcomes than those who did not receive
family therapy. Additionally, the study’s control group, which involved patients cared for by their
families, is particularly important. By controlling for the presence of a supportive family, the study
isolates the impact of family therapy. Without this control, the positive effects of having a caring
family could mask the lack of benefit from family therapy itself.
