Modifying Behaviour 2: Cognitive Behavioural Therapy

• The cognitive approach sees mental illness as being caused by problems with the internal mental processes that usually help us to make sense of the world. In schizophrenics, these processes are not working as they should, and the results is delusions or maladaptive thinking typical of the illness.

• CBT aims therefore to alter the way in which schizophrenics think, to help theme manage and organise their disordered thinking. CBT may not be able to prevent a schizophrenic from experiencing delusions or hallucinations, but it may be able to help them deal with and cope with the symptoms when they arise. This can be done in a number of ways.

• For schizophrenics who hear voices, CBT may help the patient attribute these voices as originating in their own mind, rather than from an external source. For those who experience delusions, these can be tested and challenged in a controlled environment so that the schizophrenic may see them for the false beliefs that they are.

• The main aim of CBT is to challenge maladaptive thoughts and replace them with constructive thinking that will lead to healthy behaviour.

• Schizophrenics are often unaware that they are subject to cognitive errors or that there are problems with their thinking.

• The therapist will try to make these maladaptive thoughts conscious, and then by challenging them, the patient will see that there is no basis for these thoughts.

• CBT is produced from both the cognitive and behavioural fields of psychology. The cognitive aspects include altering the way that the patient thinks about the world, and the behavioural side comes about by altering the patient’s behaviour through learning.

• CBT is mainly used to reduce positive symptoms of schizophrenia. However, when the schizophrenic learns these cognitive skills, they may become more independent and confident. Which may have a knock-on effect that negative symptoms may also be reduced.

• CBT usually takes place either weekly or fortnightly and can last for up to 20 sessions. Patients are encouraged to find the origins of their symptom, which in turn, will help them understand how they have developed. Offering different explanations for their delusions and hallucinations can be vital for some patients. This could help reduce the stress and anxiety that come with the illness.

• Smith (2003) identified the key components of using CBT for schizophrenics.

  • Engagement Strategies: Firstly, it is important for schizophrenics to fully engage with the therapist and to ensure they are committed to the therapy. This is because they will need to talk at length to gain a rapport with the therapist. This will include any negative experiences with previous therapists as this can elevate their levels of paranoia.

  • Psychoeducation: The schizophrenic learns about their illness and to learn that their behaviour is a symptom of the illness and can be managed. This normalises the symptoms such as delusions and hallucinations. Once this understanding has been obtained, the therapist and patient can investigate the specific symptoms of the patient. This can be done by identifying the context of their symptoms and their possible psychosis “trigger” factors.

  • Cognitive Strategies: These are the methods taught to the patient to help them deal with the cognitive symptoms of the illness.

• The cognitive side of CBT involves strategies that aim to alter the cognitive errors that are symptoms of schizophrenia. The therapist cannot directly tell the patient that they are thinking wrong and how to do it properly. The job of the therapist is to assist the patient in evaluating their own thoughts, and come to their own conclusions about their thinking patterns. Once the patient is conscious of this, they can address these thoughts, and with the help of the therapist, develop more productive thinking styles.

  • Socratic questioning: This is a series of curiosity driven questions asked by the therapist during the sessions. The aim of these is to help the patient identify the errors in their thinking. It also challenges the patient to find evidence that supports their delusions. The aim is that the lack of evidence should start to undermine the patient's belief in the delusion.

  • Dysfunctional Thought Diary: The patient notes down each time they have a thought that may be classed as dysfunctional or encounter a situation that they feel happy about. This is then challenged by asked to think differently about the situation and by exploring different outcomes or by supplying evidence which supports that the thoughts were appropriate. These are discussed with the therapist.

  • Behavioural Experiments: A patient may be given a behavioural “homework” task, such as testing out an irrational belief. They may be asked to do a behavioural experiment and then report back their findings. This can be done both within or outside of therapy. By testing these beliefs and finding them not to be true, hopefully the patient will change their maladaptive thinking, and realise that their delusions are not based on reality.

• Frith (1992) argues that schizophrenics fail to monitor their own thoughts, misattributing them to the outside world. When a person hear voices, it is actually their own thoughts being misinterpreted. Therefore, part of CBT will be getting the patient to recognise these voices as being part of their own mind.

• Some practitioners believe that schizophrenics who hear voices can be helped to bring the voices under control using cognitive behavioural techniques. The process begins by asking the patient to focus on the nature of the voices they hear i.e. tone and gender.

• They might also find external ways of focusing, by drawing pictures of the different voices. The therapist therefore helps the patient to recognise that the voices represent part of who they are. Patients are also taught strategies to protect them against the wishes of the voices i.e. by using relaxation and distraction techniques or by choosing to only pay attention to the voices at particular times of day. These strategies can make the voices manageable.

Cole et al. (1964) Found that 75% were considered to be ‘much improved’. Therefore, it is more effective than CBT.

CBT is rarely used as the sole treatment of schizophrenia. Most of the time it is paired up with antipsychotic medicine. This is a problem because there is evidence of an imbalance of neurotransmitters which wouldn’t be corrected by CBT. Which means it could be the medicine that is effective.

• Another issue with assessing the effectiveness of CBT is that the treatment is not suitable for all schizophrenics. Patients who have severe symptoms that are resistant to drug treatment may not be able to access the therapy. Likewise, schizophrenics who are in denial about their illness will not be able to fully engage with and commit to the cognitive exercises and behavioural tasks required of CBT.

• The patients that get the most out of CBT are those who are able to acknowledge that their behaviour and thoughts need change, and who are eager to control their symptoms.

• Therefore, if we find that CBT has a high level of effectiveness, this may be artificially enhanced by the fact that the sample used in CBT studies are already biased towards having less severe symptoms and an increased willingness to work to overcome their illness.      

One ethical strength of using CBT rather than antipsychotics is that unlike drug treatments, CBT does not have any side effects. Which is a huge ethical advantage over antipsychotics which may have many side effects such as weight gain, and parkinsonism.

Kingdon and Kirschen (2006) They found that out of 142 individuals that had been diagnosed with schizophrenia, only 49% of these had been referred for CBT. Psychiatric prejudice may be limiting the access to CBT in individuals who could benefit from it.

Kuipers et al (1997) Reported that clients were generally satisfied with their experience of CBT and that they thought it was an appropriate way to deal with their problems. Reviewing the sustainability of a therapy from a client’s perspective is an important aspect in assessing the value of such therapy.

• CBT plays an important role in the treatment of schizophrenia. Without access to psychological treatments, schizophrenics are left to rely on biological treatments, particularly antipsychotic drugs. This is an ethical issue as without being able to learn effective coping strategies, schizophrenics will always be at the mercy of their symptoms and reliant on drugs for the rest of their lives.

• While CBT cannot provide a cure for the illness, it can allow schizophrenics to develop the skills needed to cope with the symptoms. However, there is a big issue that CBT is not readily available for schizophrenics in some parts of the UK. There exists a “postcode lottery” where an individual’s access to psychological treatment is determined by the area in which they live

• Is CBT being offered to everyone? The NHS in England and Wales is organised into various “trusts” which provide services to people living within a particular geographic catchment and manage their own budgets. Royal College of Psychiatrists (2014) Found that CBT was being offered to schizophrenics and ranged between 67% and 14% with 50% not being offered CBT.