Psychological Therapies for Schizophrenia: CBTp, Family therapy & Token economy

What does CBTp stand for?

Cognitive Behavioural Therapy for psychosis

Describe CBTp

• Usually takes place for between 5-20 sessions

  • Can either be in groups or individually

• The therapist begins by developing a trusting relationship with the Sz patient

  • They help them see that many of their symptoms (paranoid thoughts, hallucinations etc.) are more common than they think - normalisation

  • This helps to reduce anxiety levels

Describe the assumptions of CBTp

• Ellis’ ABC model - Activating event, Belief, Consequence

  • Beliefs about events cause problems rather than the activating event

  • Distorted beliefs have a negative effect on feelings

    • E.g., a person with Sz may believe their behaviour is being controlled by someone else - CBTp will help the patient identity and correct these faulty interpretations and beliefs

Describe how the therapist tackles irrational beliefs

• The therapist will discuss with the patient how likely these irrational beliefs are to be true and consider more rational beliefs

  • This allows the patient to make sense of how their delusions impact their feelings

    • E.g., if a patient hears voices and they believe they are demons, they are naturally very afraid

    • By considering how likely they are to be true, the client should feel the effect and become less anxious

Describe coping strategies

• People with auditory hallucinations would be encouraged to limit the time they actively listen to voices - e.g., 30 minutes a day

• Patients may also be encouraged to listen to music whenever they start to hear voices

There is some support showing the benefits of CBTp when treating Sz. Describe how this is a strength of CBTp in treatment of Sz

• Tarrier (2005): reviewed 20 studies using CBTp and found persistent evidence of the following…

  • Reduced positive symptoms

  • Lower relapse rates

  • Faster recovery rate in ill patients

• Jauhar et al (2014): reviewed 34 studies and concluded that CBTp has a significant but fairly small effect on both positive & negative symptoms

• This is a strength as it suggests that CBTp is an effective therapy for helping people with Sz control their symptoms

Patients with severe symptoms drop out of CBTp. Describe how this a weakness of CBTp as a treatment of Sz

• Tarrier (1993): 45% of the sample refused to cooperate or dropped out during the trial

  • Patients need to be highly motivated and have the ability to put in the time and effort for the therapy to be a success

  • Some patients suffer with avolition so engaging in a lengthy therapeutic process will be problematic for them in particular

• This is a strength as it suggests that CBTp may not be a suitable treatment for all patients with Sz and alternative treatments such as drug therapy may be more appropriate

A combination of CBTp and drug therapy may be the best approach to treating Sz. Describe how this a weakness of CBTp as a treatment of Sz.

• Addington and Addington (2005): they claim that self-reflection on symptoms is not particularly appropriate when the patient is in the initial phase of Sz

  • Individuals can benefit from group-based CBT following stabilisation of their symptoms with antipsychotic medication

    • This helps to normalise their experience by meeting other individuals with similar issues

  • This suggests that CBTp may only be useful for specific stages of treatment and may need to be constantly adapted

• This is a strength as it means CBT may not be effective for all patients with Sz and alternative treatments may be necessary

Describe family therapy as a treatment of Sz

• Form of psychotherapy which is based on the idea that communications and interactions amongst the family of patients with Sz are dysfunctional

  • The therapy involves the patient’s whole family and aims to improve the quality of communication & interaction and to reduce levels of (EE)

• Usually offered for a period of between 3-12 months and at least 10 sessions

• Should be offered to all individuals diagnosed with Sz who are in contact with or live with family members

Describe the strategies proposed by Pharoah (2010)

• Aims to improve functioning of a family - this can done by….

  • Forming a therapeutic alliance with all family members

  • Problem solving

  • Reduction of anger and guilt

  • Helping family members achieve a balance between caring for the individual and maintaining their own lives

Family therapy has been found to be effective. Describe how this is a strength of family therapy as a treatment of Sz

• Pharoah et al (2010): conducted a meta-analysis on 53 studies to compare the effectiveness of family therapy for the treatment of Sz with antipsychotic medication

  • They found a reduction in the risk of relapse and reduction in hospital admission during treatment and in 24 months after

  • It also increased patient’s compliance with medication

• This is a strength as it suggests family therapy is an effective treatment which could hint that better family relationships are the key element in helping a patient recover

Family therapy is useful for patients who lack insight into their Sz. Describe how this is a strength of family therapy as a treatment of S

• Family members are able to assist with providing lots of useful info about the patient’s Sz in a coherent way

  • They have insight into the patient’s moods and are able to speak for them when they cannot speak for themselves

    • This helps them receive therapy immediately

• Lobban et al (2013): analysed the results of 50 family therapy studies that had included an intervention to support relatives

  • 60% of these studies showed a positive impact on at least one outcome for the relative e.g., coping or problem solving

• This is a strength as it demonstrates that family therapy can have positive consequences for many family members which in the long-term can be cost-effective in reducing relapse & re-hospitalisation

Not all evidence suggests that family therapy is effective. Describe how this is a weakness of family therapy as a treatment of Sz.

• Garety et al (2008): found little difference in the improvement of symptoms of Sz in patients that received family therapy compared to patients that received no family therapy but had carers

  • Patients in both groups had low incidences on relapse

  • Researchers found that the carers had low levels of EE and this could explain why there was little difference between the 2 groups

• This is a strength as it shows that low levels of EE are important for improving symptoms of Sz and that family therapy may not necessarily be anymore effective than carers

Describe token economy

• Form of behavioural therapy - based on the principles of operant conditioning

  • Aim = changing maladaptive behaviours (social withdrawal & poor motivation) into more desirable behaviours through the use of tokens

Describe the use of tokens in token economy

• A token (a coloured disk) is given IMMEDIATELY on completion of a desired behaviour, e.g., getting dressed in the morning

  • The immediacy of the reward is important as it prevents delayed discounting (the depreciation of a value of a reward related to the time takes to be given)

  • They can later be swapped for material treats such as sweet or magazines

    • Tokens are secondary reinforcers of desirable behaviour - this helps in the management of schizophrenia

Token economy is effective in managing the symptoms of schizophrenia. Describe how this is a strength of token economy in the management of schizophrenia.

• Glowacki (2016): identified 7 studies published between 1999 and 2013

  • Reported that all studies had shown a reduction in negative symptoms and decline in the frequency of unwanted behaviours

• This is a strength as the findings demonstrate support for the view that token economies are effective in managing schizophrenia in hospitalised patients - they can be tailored to the individual patient’s requirements

  • This is because it is possible to control the environment and ensure that patients are rewarded consistently for desirable behaviours

Token economies are not effective in managing all symptoms of schizophrenia. Describe how this is a weakness of token economies in the management of schizophrenia

• Token economies are only really effective in treating the negative symptoms which involve social withdrawal but not positive symptoms such as hallucinations and delusions

  • It has been argued that they only produce token (minimal) learning

    • E.g., it is possible that patients learn to merely imitate normal behaviour without any deeper changes in their thoughts and beliefs

• This is a weakness as it suggests the therapy may be limited in terms of its effectiveness in that it may be very superficial and temporary

  • It may only be useful within an institution and may not provide the patient with skills for living in the outside world

There are ethical issues surrounding the use of token economies. Describe how this is a weakness of the use of token economies in the management of schizophrenia

• Privileges and services become more accessible for patients with milder symptoms and less available for patients with severe symptoms

• It also has the potential for abuse

  • Corrigan (1995) claimed that token economy can be abusive and humiliating and has the potential for taking away power from the patient and allowing others to have power over them

• This is a weakness as it suggests token economies may not always be appropriate when they are used for reasons other than treatment of patients