Psychological therapies of SZ

Research in the 1970's discovered that the family environment had a potential role in influencing the course of SZ. SZ's in families that expressed high levels of criticism, hostility, or over involvement had more frequent relapses than SZ's who had the same problems with families that weren't as expressive in their emotions. The main aim of family intervention therefore is to make family life less stressfuland to reduce re-hospitalisation.

• Forming an alliance with relatives who care for the person woith SZ.
• Reducing the emotional climate within the family and the burden of care for family members.
• Enhancing relatives' ability to anticipate and solve problems.
• Reducing expressions of anger and guilt by family members.
• Maintaining reasonable expectations among family members for patient behaviour.
• Encouraging relatives to set appropriate limits whilst maintaining some degree of separation when needed.

Supporting Research

A meta-analysis of 32 studies (nearly 2500 pp's) found significant evidence for the effectiveness of Family Intervention in the treatment of SZ. When compared with patients recieveing standard care alone, there was a reduction in hospital admissions during treatment and the severity of symptoms both during and upto 24 months following the intervention. The relapse rate in the family intervention condition was 26%and 50%in the control (standard care) condition.

Why is it effective?

The Pharoah et al meta-analysis established that family intervention may be effective in improving clinical outcomes such as mental stateand social functioning. However, the authors suggest tha tthe main reason for its effectiveness may have less to do with any improvements in these clinical markers and more to do with the fact that it increases medication compliance. Patients are more likely to reap the benefits of medication because they are more likely to comply with their medication regime.

Economic Benefits

The NICE review of Family intervention studies demonstrated that family intervention is associated with significant cost savings when offered to people with SZ in addition to standard care. The extra cost of family intervention is offset by a reduction in costs of hospitalisation because of the lower relapse rates associated with family intervention. There is also evidence that family intervention reduces relapse rates for a significant period after completion of the intervention. This means that the cost savings associated with family intervention would be even higher.

Cultural Limitations

Research evidence has begun to show the effectiveness of family interventions as an addition to antipsychotic medication. However, most of this evidence comes from studies conducted outside of the UK, prinicpally in China. The NICE study expressed the view that hospitalisation levels may differ significantly across the countries, depending on clinical practice within those countries. Therefore, hospitalisation data from Non-Uk countries may not be applicable to the UK setting.

In CBT, Patients are encouraged to trace back the origins of their symptoms in order to get a better idea of how the symptoms might have developped. They are also encouraged to evaluate the content of their delusions or of any internal voices that they might hear, and to consider the ways in which they might test the validity of their faulty beliefs. Patients might also be set behavioural assignments to improve their general level of functioning. The learning of maladaptive responses to lifes problems is often the result of disordered thinking by the schizophrenic. During CBT, the therapist lets the patient develop their own alternatives to these previous maladaptive beliefs, by looking for alternative explanations and coping strategies that are already present in the patients mind. 

Outcome studies measure how well a patient does after a particular treatment, compared with the accepted form of treatment for that condition.

Outcome studies of CBT suggest that patients who receive cognitive therapy experience fewer hallucinations and delusions and recover their functioning to a greater extent than those who receive antipsychotic medication alone. Drury et al found benefits in terms of a reduction of positive symptoms and a 25-50% reduction in recovery time for patients given a combination of both. 

Supporting Research

Research has tended to show that CBT has a significant effect on improving the symptoms of patients with SZ. Gould et al found that all 7 studies from their meta-analysis reported a statistically significant decrease in the positive symptoms of SZ after treatment.

How much is due to the effects of CBT alone?

Most studies of the effectiveness of CBT have been conducted with patients treated at the same time with antipsychotic medication. It has been difficult to assess the effectiveness of CBT independent of antipsychotic medication.

Negative Symptoms

CBT for SZ works by trying to generate less distressing explanations for psychotic experiences, rather than trying to eliminate them completely. Negative symptoms may well serve a useful function for the person and so can be understood as 'safety behaviours.' For example, within a psychiatric setting, the strong expression of emotions might be seen as a way of avoiding making positive symptoms worse. CBT, therefore offers some hope of alleviating these maladaptive thought processes.

Who Benefits?

The use of CBT in conjunction with medications seems to have benefits, but it is commonly believed within psychiatry that not everyone with SZ may benefit from from CBT. For example, in a study of 142 SZ patients in Hampshire, Kingdon, and Kirschen believed they would not fully engage with the therapy. In particular, they found that older patients were deemed less sitable than younger patients.