Schizophrenia-therapies-psychological

Question 1

CBT- URAP

Answer 1

developed to treat depression due to effectiveness in treating negative symptoms
but also routinely used to treat psychotic symptoms too

USE: NICE recommend it to all patients in combo with drug treatments

RATIONALE/ AIM: sz caused or at least maintained by the beliefs patients have about tier experiences.
deal with symptoms by changing beliefs and leading to less catastrophic symptoms
aim to identify these flaws in rationality which contribute to symptoms and change them

PROCESSES: agenda set between therapist and patient
more flexible than normal CBT
generally 12-20 sessions- reflecting complexity and diversity of disorders

Question 2

Cognitive element

Answer 2

make patient aware of their cognitions and its role and how they impact their functioning

meta-cognition- thinking about thoughts

question challenge and change beleifs

Question 3

behavioural element

Answer 3

test patients beliefs against reality
achieved through experimentation and role play and homework
allow patients to become aware of irrationality of beliefs

but try to treat them as a rational person as much as possible

Question 4

example of CBT

Answer 4

Ellis’s rational emotive behavioural therapy

ABC model is used to allow the patient to organise their confusing experiences

how activation events beliefs and consequences interact

eg
patient pinpoints an activating event and subsequent consequence e.g hearing voices causing looniness/depression, the patient may say the voices control their life, so the therapist tries to get the patient to understand that the beliefs they have are illogical by testing the evidence for and against maladaptive beliefs
e.g pinpoint behaviours that patient has engaged in which they have had full control over

Question 5

other techniques within CBT normalisation

Answer 5

normalisation techniques: being empathetic to the patients irrational beliefs and as much as possible get them to understand that they’re normal but not entirely accurate for example a patient thinking that the police are racist towards him, when they’re just racist generally, enabling them to understand that the delusional fear is somewhat founded and normal. this doesn’t negate their beliefs, it allow them to maintain them but in a more realistic form.

Question 6

other techniques within CBT decatasrophising

Answer 6

decatastrophising
informing the sz patient that lots of people have unusual experiences in circumstances e.g. stressful events, torture, hunger, thirst etc) reducing the anxiety they have around it and the sense of isolation, so the psychotic symptoms are put on a continuum with normal experiences. the possibility of recovery then feels less distant

Question 7

developing trust through non judgemental approach

Answer 7

gentle questioning allows the patient to recognise potentially illogical deductions and conclusions

if your voices are coming from the radiator- why can’t anyone else hear them?

testing evidence for and against maldadptive beliefs

Question 8

effectiveness of CBT- research design

Answer 8

some trials conducted are repeated measures pre-post treatment trials-

less useful than independent design- comparing CBT with a control group or another treatment

because pre-post allows for spontaneous remission (natural regression of symptoms) cannot truthfully detect whether the change is natural or due to the treatment

Question 9

issues in evaluating CBT

Answer 9

only some trials are RCT

in most trials the majority of patients will be on medication as well

would be immoral to justify use of only CBT for some patients as there’s strong evidence that the illness is on a biological premise- could be detrimental to their health

so theres no other way of doing it

but this makes it more difficult to separate the effects of the drugs from that of the CBT

Question 10

effectiveness of CBT

Rector and BEck AND Gould et al

Answer 10

found CBT reduces positive symptoms but effects are smaller in proper RCT rather than pre-post treatment studies

Question 11

effectiveness of CBT wakes et al

Answer 11

found effect size of 0.4 (weak-moderate) between CBT and no treatment
but only an overall effect size of 0.22 in quality trials (those with blinding) which is weak

Question 12

effectiveness of CBT jones et al

Answer 12

meta anlaysis (cochrane review)

review of RCTs found that CBT was no more effective than other psychological therapies on any criteria (functioning, relapse etc).
this is despite NICE recommending it as the front line psyholoigcal treatment for schizophrenia.

although overall number of people leaving the study early was low compared to drug trials— meaning talking therapies may be better at retaining people with sZ in treatment.

the review also suggested there may be some longer term advantage in CBT for dealing with emotions and distressing feelings

Phoroah et al’s cohcrane review found the same (no difference between CBT and other talking therapies)

Question 13

concluding thoughts on effectiveness of cBT

Answer 13

the original enthusiasm for CBT may have been based on inadequate trials including some weak blinding and in the case of NICE the relative cost of CBT (i.e. training therapists) compared to other psychological treatments.

the positive view of CBT is often based on individual trials and sometimes older meta-analyses- jones et al’s cochrane review is more recent and less positive-
which may be particularly reliable as a cochrane review, so should be less biased than reviews conducted by those with their professional reputation as proponents ofCBT at risk

trials that have shown cbt to be very effective, alarm us to the fact that they have methodooligcal flaws- e.g wykes points out that ‘trials make no attempt to mask the group allocation are likely to have inflated effect sizes.’ so when they know which group has the treatment they favour the cbt condition

Question 14

CBT appropriateness

Answer 14

low cost and speed - good for NHS (tax payer consideration)

no side effects! compared to drug treatments!

fewer issues on dependence on therapist because the there isn’t a close relationship between CBT and patient it’s more teaching to improve (collaborative) rather than comforting to encourage independence of patient so an advantage over other talking therapies e.g psychoanalysis

patients tend to like CBT
trials tend to have lower attrition than drug trials and other talking therapies

big advantage! even if it is no more effective than other talking therapies it is better that patients stay in therapy and get these benefits if they would just drop out of psychoanalysis for example

Question 15

issues related to effectiveness of CBT

Answer 15

if the meta analyses are right that CBT is equally as effective as other talking therapies then maybe it should be that others are available not he NHS

but then again it;s the cost that has to be considered which justifies the use of cBT over anything else

Question 16

CBt and drug treatments

Answer 16

cbt is usually used in combination with drug treatments

it could be argued that cbt could be used on its own with patients who are drug resisitant especially if they’re having problems with the side effects

Question 17

family interventions uses:

Answer 17

for szs with family members or other people that live with them i.e. a carer

Question 18

family I Rationale

Answer 18

schizophrenia is maintained (relapses more likely) by communication and emotional problems, particularly high levels of EE, within the family of people with schizophrenia

EE is not seen as the sole cause of the illness but a factor affecting the course of the illness i.e. the chances of a relapse in those at a genetic risk

Question 19

FI- aim

Answer 19

to provide family with practical coping skills that enable them to manage difficulties

to reudce levels of EE within families
to thus reduce the risk of relapse

Question 20

FI- Processes

Answer 20

educate the family about sz e.g causes, course and symptoms
improve communication within families
develop cooperative and trusting relationships
adjust expectations of family members to avoid imposing guilt etc on the patient

reduce levels of EE
recognise early signs of relapse
expand social networks of family to allow communication with other parents of ppl with sz- learn from others real life personal experiences they may share/cna relate to and feel less alone.

Question 21

effectiveness of FI LEFF et al

Answer 21

Leff et al found that after FI treatment there was a significant decrease in EE (especially critical comments and over emotional involvement)

78% of the control group had been readmitted to hospital during this 2 year period while 14% of programme group had
this is evidence for EE being related to relapse since lowered levels reduced need to go to hospital because of the relapses. (support for the rationale)

the programme involved
educational sessions nature of SZ and how to deal with behaviour/ relapse etc
group meetings for those coping well with SZ member
family sessions discuss concerns with a social worker

Question 22

effectiveness of FI NICE review

Answer 22

found relapse rates of 26% in the treatment condition and 50% in the control group

Question 23

effectiveness of FI Pharaoh et al

Answer 23

reviewed 53 randomised studies
with positive results in relation to relapse, hospital admission and compliance of medication but the report emphasized the use of ‘MAY’

however there were major issues about bias due to the lack of random allocation and blind assessments in many of the studies that were conducted in china, likely to exaggerate the effects
researcher bias meant that those who were less severe in symptoms/would respond well to the treatment were put in the treatment group so they came out looking more improved

if these studies implemented the CONSORT guidelines (to reporting of research) we would have more confidence in these findings

Question 24

appropriateness of FI

Answer 24

best used as complementary to drug treatments (as occurs in trials)

a problem is that family members may not want or be able to take part due to guilt or lack of time
(as suggested by McCreadie) who found that only half of relatives of SZ volunteered to take part in FI and only half of them actually turned up
may think that its the patients that need to change and not them- denial that they’re part of the issue/ feel blamed

non applicable for those living alone/woth friends/without a family/aren’t exposed to family

with any therapy there is a generalised placebo effect- just through participating in any treatment can improve a patient’s condition- the want/desire to get better can help improve mind set and therefore the condition.