Schizophrenia - The Psychological Explanations for Schizophrenia and therapy treatments

Question 1

What are the psychological explanations for schizophrenia?

Answer 1

1. Family dysfunction explanations suggest that schizophrenia is due to family experiences of interpersonal conflict, communication problems, criticism and control:
   - Schizophrenogenic mother
   - Double-bind theory
   - Expressed emotion
2. Cognitive explanations:
   Dysfunctional thought processing (produces hallucinations and delusion)

Question 2

1) Family dysfunction theories - Schizophrenogenic mother

Answer 2

Tienari (2004) / Fromm-Reichmann (1948):
- Mother is cold, controlling and rejecting; father is often passive
- Leads to excessive stress and distrust as the family climate is characterised by tension and secrecy.
- This triggers psychotic thinking and paranoid delusions, and ultimately schizophrenia

Question 3

1) Family dysfunction theories - Double-bind theory

Answer 3

Bateson et al (1956):
- The child receives mixed messages and cannot do the right thing - when they get it wrong, they are punished with a withdrawal of love.
- Leads to understanding the world as confusing and dangerous.
- This triggers disorganised thinking and paranoid delusions, and ultimately schizophrenia

Question 4

1) Family dysfunction - Expressed emotion

Answer 4

Kavanagh (1992):
- The family shows exaggerated involvement in the life of the patient (including needless self-sacrifice) control, verbal criticism of the patient (occasionally including violence) and hostility towards the patient (including anger and rejection)
- Leads to excessive stress beyond impaired coping mechanisms.
- This triggers relapse in patients with schizophrenia and may trigger the onset in a person who is already vulnerable due to their genetic make-up (diathesis-stress model)

Question 5

2) Cognitive approach to explaining schizophrenia - Dysfunctional thought processing

Answer 5

• A cognitive explanation of schizophrenia suggests that it is due to abnormal information processing.
• Dysfunctional thought processing = cognitive habits or beliefs that cause the individual to evaluate information inappropriately and produces undesirable consequences
• Frith et al. (1992) identified two kinds of dysfunctional thought processing that could underlie some symptoms of schizophrenia - central control and metarepresentation

Question 6

2) Dysfunctional thought processing - Frith on meta-representation

Answer 6

Metarepresentation – is the cognitive ability to reflect on thoughts and behaviour which allows us insight into our own intentions and goals.
- Dysfunction in this would disrupt our ability to recognise our own actions and thoughts as being carried out by ourselves rather than someone else. This explains auditory hallucinations and delusions like ‘thought insertion’.

Question 7

2) Dysfunctional thought processing - Central Control

Answer 7

Central control – is the cognitive ability to suppress automatic responses while we perform deliberate actions instead.
- Dysfunction in this would lead to disorganised speech and thought disorder as we are unable to suppress automatic thoughts and speech triggered by other thoughts.
- For example, schizophrenics tend to experience derailment of thoughts and spoken sentences, because each word triggers associations and the patient can’t suppress automatic responses to them.

Question 8

Evaluation of the psychological explanations of schizophrenia - supporting evidence

Answer 8

1) Stirling et al (2006) compared 30 patients with a diagnosis of schizophrenia with 18 non-patient controls on a range of cognitive tasks, including the Stroop test. Patients took over twice as long to name the ink colours in the schizophrenic group
- This provides external validity for the cognitive explanations, in particular the central control aspect.

2) Garety et al (2008) estimated that relapse rates for individuals who receive family therapy as 25% compared to 50% for those who receive standard care alone
- Provides external validity for family dysfunction theories as it suggests the targeted area of the therapy has an influence on relapse

3) CBTp (cognitive behavioural therapy for psychosis) has been demonstrated to be effective in the NICE review for treatments of schizophrenia (2014) when compared to antipsychotic medication, CBTp as more effective in reducing symptoms severity and improving levels of social functioning
- Real-world applications and external validity for the explanations as therapy is effective, so what it is targeting is likely the cause or one of them (cognitive)

Question 8

Evaluation of the psychological explanations of schizophrenia - Weaknesses

Answer 8

1) Historically, family-based explanations have led to parent-blaming; parents who have already suffered seeing their child descend into schizophrenia and who bear lifelong responsibility of their care, feel responsible for their child’s illness which can cause stress and anxiety - out-dated views that were once accepted are no longer tolerated by families and are now seen as destructive rather than productive
- Social sensitivity of the theory makes it unethical as a theory as without suitable causative evidence it is unfair to blame family dysfunction

2) Altorfer et al (1998) found that 1/4 of the patients they studied showed no physiological responses to stressful comments from relatives
- This is undermining evidence for the family dysfunction theories, showing a lack external validity for these theories - in particular the expressed emotion theory

Question 9

Evaluation of the psychological explanation of schizophrenia - weakness and strength

Answer 9

1) Although there is plenty of evidence to support the broad principle that poor childhood experiences in the family are associated with adult schizophrenia, there is almost none to support the importance of the schizophrenogenic mother or double-bind. Berger (1965) found that schizophrenics reported a higher recall of double bind statements by their mothers than non-schizophrenics. Other research is less supportive, Liem (1974) found no difference in parental communication in families with a schizophrenic child and ‘normal’ families
- There is external validity for the schizophrenogenic mother theory but there is also contradicting evidence, suggesting an intersection of causes for schizophrenia and the family dysfunction theory cannot fully explain schizophrenia

Question 10

Psychological treatments for schizophrenia - targeting dysfunctional thought patterns with CBTp

Answer 10

• CBTp aims to help patients to identify irrational thoughts and challenge them (including the origin of ‘voices’) and reality testing them to reduce distress.
• It usually takes place for 5-20 sessions, with NICE recommending at least 16 sessions.
• CBTp uses the ABCDE model. It involves identifying activating events (A) and the resulting beliefs (B) from these events that appear to cause their emotional and behavioural consequences (C). These beliefs can then be rationalised, disputed (D) and changed through critical collaborative analysis, leading to the effect (E) of restructured beliefs.
• Critical collaborative analysis – the therapist uses gentle questioning to help the patient to understand and challenge illogical deductions and conclusions e.g. ‘if your voices are real, why can no one else hear them?’
• Rather than ‘getting rid’ of schizophrenia, CBTp helps patients to cope better with their symptoms because it reduces distress.
• CBTp also uses normalisation. The therapist shares with the patient that many people have unusual experiences such as hallucinations and delusions in many different circumstances. This reduces anxiety and the sense of isolation by making the patient feel less alienated and stigmatised. This makes the possibility of recovery seem more likely.
• Patients may also be set behavioural assignments to improve their general level of functioning, such as to shower everyday or to go out and socialise with friends once between now and the next session.

Question 11

Evidence for CBTp’s use in treating schizophrenia

Answer 11

1) A recent NICE (2014) review o treatments for schizophrenia found consistent evidence that it was an effective form of therapy - CBT was effective in reducing symptom severity with some improvements in social functioning
- However, most studies have included patients who were taking antipsychotics at the same time as undergoing CBTp, making it hard to assess effectiveness

2) Juni et al (2001) concluded that there was clear evidence that trials with weak methodologies lead to biased findings regarding the effectiveness of CBTp - meta analyses for example don’t take into account the quality of each study. Some don’t randomly allocate participants to control and test groups, for example.
- Problems such as these are overlooked in meta-analysis, which is concerning as Wykes et al (2008) found that the more rigorous the study, the weaker the effect of CBTp

Question 12

Evaluation of CBTp as a treatment of schizophrenia - Strengths

Answer 12

1) Evidence to support the benefits of CBTp for schizophrenia - The NICE review found consistent evidence that when compared with standard care (antipsychotics alone), CBTp was effective in reduction rehospitalization rates up to 18 months following the end of treatment - CBTp was also shown to be effective in reducing symptom severity and improving social functioning
- However, most studies on the effectiveness of CBTp have been conducted with patients treated at the same time with anti-psychotic medication, and so it is therefore difficult to assess it’s effectiveness independent of antipsychotics - there is modest support for it but it may be more effective as a long-term therapy as it provides strategies for patients they can use to manage systems beyond therapy

2) CBTp only aims to make schizophrenia more manageable and improve patients’ quality of life as it allows patients to make sense of and challenge some of their symptoms through critical collaborative analysis
- Whilst it is worth doing, it does not cure schizophrenia - it provides patients with strategies to manage their symptoms and improves quality of life

Question 13

Evaluation of CBTp as a treatment for schizophrenia - Weaknesses

Answer 13

1) CBTp is difficult to assess - Despite being recommended by NICE as a treatment for people with schizophrenia, it is estimated only 1 in 10 people in the UK who could benefit from CBTp can get access to it - Haddock et al (2013) found that in NW England, only 6.9% of patients had been offered CBTp
- This limits the effectiveness of the treatment as patients are unable to participate in the therapy - of those who are offered CBTp, a significant number either refuse or fail to attend the therapy sessions, thus limiting its effectiveness even more

2) CBTp requires motivation that patients may not have - the length of the therapy means that patients have to be motivated and committed to multiple sessions - the therapy itself also requires self-awareness and a willingness to engage with the process
- However, the positive symptoms of schizophrenia lead to a lack of awareness and negative symptoms cause a reluctance or inability to engage - the length of the therapy also leads patients to drop out at times of severe episodes - overall, this suggests that CBTp may not be an appropriate treatment for all schizophrenics

Question 14

Evaluation of CBTp as a treatment for schizophrenia - Weaknesses cont.

Answer 14

3) CBTp raises ethical issues - CBTp may involve, for example, challenging a person’s paranoia, which can be seen as interfering with freedom of thought
- If for example, CBTp challenged a patient’s belief in a highly controlling government, this could easily stray into modifying their political beliefs and this is a weakness of CBTp as a treatment for schizophrenia

4) CBTp may be more effective at certain stages of the disorder - Addington and Addington (2005) claim that self-reflection is not particularly appropriate during the initial acute phase of schizophrenia - following stabilisation of psychotic symptoms with antipsychotics, individuals may then benefit more from group based CBTp.
- This can help to normalise their experience by meeting others with similar issues, as research has found those with more experience of schizophrenia and a greater realisation of their symptoms benefit more from individual CBTp - this suggests that CBTp is more effective but may be more appropriate in the latter stages of treatment rather than initially

Question 15

Family therapy as a treatment for family dysfunction - what is it?

Answer 15

• Family therapy is a range of interventions aimed at the family (e.g. parents, siblings, partners) of someone with schizophrenia. It should also involve the person with schizophrenia, if practical
• It aims to improve the quality of communication and interaction between family members, and reduce the stress of living as a family and so reduce rehospitalization.
• It is commonly used in conjunction with drug therapy and outpatient clinical care

Question 16

When is family therapy offered and what are its aims?

Answer 16

• Offered for 3-12 months with 10 sessions
• Interventions aimed at reducing levels of expressed emotion and relapse
• Garety - those receiving therapy had relapse of 25% compared to 50% of those without the therapy
• Offered to everyone with SZ - priority those of a high relapse risk and for those who have expressed emotion family dysfunction
• Aims to provide support for parents and carers to make family life less stressful and reduce rehospitalisation
• The basis of the therapy is research that has shown schizophrenia in families that expressed high levels of criticism, hostility or over-involvement had more frequent relapse

Question 17

How does family therapy work?

Answer 17

• Reduces incidents of relapse by reducing expressed emotion and stress, increasing the capacity of relatives to solve related problems

Strategies used -
- Psychoeducation - helping the person and carers understood the illness better and how to deal with it
- Forming an alliance with relatives who care for the SZ person
- Reducing emotional climate within the family and burden of care
- Enhancing ability of relatives to anticipate and solve problems
- Reducing expressions of anger and guilt
- Maintaining reasonable expectations for patient performance
- Encourage relatives to set appropriate limits whilst maintaining a degree of separation
- During sessions, the individual with schizophrenia is encouraged to talk to their family and explain what sort of support they do and do not find helpful. It improves relationships within the household because the therapist encourages family members to listen to each other, discuss problems and negotiate potential solutions together.
- Pharoah et al. (2010) suggest that these strategies reduce stress and expressed emotion, whilst increasing the chances of patients complying with medication. This tends to result in a reduced likelihood of relapse and readmission to hospital.

Question 18

Pharoah et al (2010)

Answer 18

• Pharoah et al. (2010) reviewed the evidence for the effectiveness of family therapy (compared to antipsychotics alone). They found that:
• There was a reduction in the risk of relapse and a reduction in hospital readmission during treatment and in the 24 months after.
• Some studies reported an improvement in the overall mental state of patients whereas others didn’t.
• There was an increased compliance with medication.
• Family therapy did not appear to have much of an effect on more concrete outcomes such as living independently or employment.

Question 19

Evaluation of family therapy - strengths

Answer 19

1) An advantage of this therapy is the economic benefits - the NICE review of family therapy studies demonstrated that it was associated with significant costs savings when offered to patients alongside standard care and the extra cost of family therapy is offset by a reduction in costs of hospitalisation because of lower relapse rates
- There is also evidence that relapse rates are lower after the completion of the intervention, and so the savings could be even higher

2) Family therapy is also advantageous for family members - Lobban et al (2013) analysed the results of 50 family therapy studies that had included an intervention to help relatives. 60% of these studies reported a significant positive impact on at least one outcome category for relatives such as coping, relationship quality or problem-solving skills.
- However, the researchers also concluded that the methodological quality of the studies was poor, making it difficult to distinguish effective interventions in terms of family members

Question 20

Evaluation of family therapy - Strengths cont.

Answer 20

3) Research evidence suggests that family therapy can be effective in improving clinical outcomes - Pharoah et al (2010) review of 53 studies published and found that patients showed some improvement in social functioning and mental state and patients are also less likely to relapse
- However, the authors suggest that the main reason for its effectiveness may have less to do with the interventions themselves and more to do with that fact that it increases medication compliance
- As such, this undermines the evidence and it suggests that the beneficial effects are not the result of family therapy itself, but because family therapy means that patients are more likely to take their drugs (which are effective)

Question 21

Evaluation of the family therapy - Weaknesses

Answer 21

1) There are a number of methodological issues in research into family therapy - Pharoah et al’s meta-analysis identified the problem of random allocation with a large number of studies being from China; evidence has emerged that in many studies, random allocation had been stated as being used when it had not been (Wu, 2006)
- In some studies the observers were not ‘blinded’ to the condition (family therapy or standard care) which increases the possibility of observer bias

2) Some of the evidence questions the worthiness and value of family therapy; Garety et al (2008) failed to show any better outcomes for patients given family therapy compared to those that simply had carers
- Individuals in both groups were found to have low relapse rates compared to the control group, and researchers also found that the carers had low rates of expressed emotion
- This suggests that family intervention may not improve outcomes further than a good standard (carers with low expressed emotion) of treatment as usual