Psychological Therapies

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Coping Strategy Enhancement - AO1

1. Therapist asks detailed questions to establish the content of the patients delusions and hallucinations - the trigger for these thoughts and the coping strategies they use.

2. The patients rates these coping strategies in terms of their effectiveness.

3. One of the patients delusions or hallucinations is selected for treatment, often as this is the one the patient already uses as a moderate coping strategy. May identify additional strategies.

4. Patient given 'homework' of applying these coping strategies whenever the target delusion or hallucination occurs.

5. At the next meeting, the therapist and patient discuss ways to make the strategy more effective.

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CSE - Effectiveness - Tarrier (1993)

Patients with schizophrenia showed significantly more reduction in positive symptoms than patients on a waiting list for treatment.. The improvement was still there 6 months after treatment. Showed improvement in coping skills and this improvement was associated with decreased hallucinations and delusions.

However, almost half the participants scheduled to take part - refused to participate or dropped out.

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CSE - Effectiveness - Tarrier (2005)

Came to conclusion after reviewing 20 studies that there is consistent evidence that CBT reduces persistant positive symptoms in chronic patients, and may have modest effects in speeding recovery in acutely ill patients.

However, it was not clear whether CBT was effective in reducing relapse rates.

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CSE - Effectiveness - Pfammatter (2006)

Meta-analysis found that CBT was moderately effective in reducing positive symptoms and led to slight improvement in social functioning.

However, we don't know why CBT is effective. There are several different aspects of treatment for CBT, and it has not been found which is the most important.

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CSE - Effectiveness - Interpretation

Issues of interpreting the findings. In most studies, CBT has been compared against some control treatment (e.g. routine therapy) and found to be superior. This difference could occur either because CBT is especially effective, or because the control treatment is inadequate. Control treatments are sometimes given by non-experts. Therefore, the use of inadequate control treatments might explain some of the findings.

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CSE - Appropriateness

  • Several symptoms of schizophrenia (delusions, hallucinations) are mainly cognitive and this is a cognitive therapy.
     
  • As many patients with schizophrenia use coping strategies, it is reasonable to develop therapeutic techniques to improve these coping strategies.
     
  • Patients with schizophrenia are often concerned about their bizarre delusions and hallucinations. Their realisation in therapy that similar hallucinations and delusions sometimes occur in healthy people is useful in helping them improve their mental state.
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CSE - Inappropriateness

  • Only designed to reduce positive symptoms of schizophrenia.
     
  • CBT has only modest beneficial effects on relapse rate. This is not as good as it is usually important to patients with schizophrenia to their well being of avoiding relapse.
     
  • Does not take into acount biological factors - such as neurochemistry - the underlying cause of schizophrenia - reductionist.
     
  • Appropriateness reduced as usually a very high drop out rate.
     
  • Appropriateness and effectiveness would be increased if we knew which aspects of the therapy were most beneficial in producing changes.
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Token Economy - AO1

  • Behavioural therapy.
  • Based on asumptions that abnormality is due to maladaptive learning, and so treatment needs to replace the maladaptive behaviour with more adaptive behaviour. 
  • Classical and operant conditioning are the methods used to change unwanted behaviour into more desirable behaviour.
  • Based on positive reinforcement and rewards.
  • Recieve tokens as a reward, to reinforce target behaviours. They can be exchanged for more food, trips out, film nights.
  • The coloured dics can be given when brushing teeth, making bed, saying goodmorning, for example.
  • Tends to be more effective at reducing negative symptoms - related to hygiene issues, social withdrawal, personal care, etc.
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Token Economy - Effectiveness - Azrin (1968)

Female patients with schizophrenia, hospitalised for an average of 16 years. Rewarded with tokens for actions such as making bed or combing hair. Tokens exchanged for activities - seeing a film, additional visit for canteen. Very successful.No. of chores increased each day from 5 - over 40 chores when behaviour rewarded with tokens.

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Token Economy - Effectiveness - Paul and Lentz (19

Used token economy with hospitalised patients with long term schizophrenia. Patients developed social and work-related skills, became able to look after themselves and their sympytoms reduced. These results achieved at same time as reduction in the number of drugs that were given to patients. After 41 years, 98% of patients in token economy had been released, compared with only 45% who recieved no specific treatment.

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Token Economy - Effectiveness - Dickerson (2005)

Reviewed 13 studies of token economies being used with schizophrenia patients. Beneficial effects reported in 11 of these. Concluded that they are especially effective when used in combination with psychosocial and/or drug therapy.

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Token Economy - Effectiveness - Negatives

  • Needs continous reinforcement. Beneficial effects reduced when good behaviour is no longer followed by rewards the patients have been recieving. Meaning the therapy only works in structured hospital environment and so lacks external validity to the patients home environment.
  • Too specific. Only treat a few symptoms of schizophrenia (e.g. social withdrawal). Does not address cognitive symptoms of schizophrenia such as hallucinations etc.
  • Superficial change. Schizophrenics may only imitate normal behaviour without any changes in their thoughts or beliefs.
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Token Economy - Appropriateness

  • Symptoms of schizophrenia include catatonic behaviour - patients remain rigid, and negative symptoms such as lack of motivation and general disengagement may occur. Providing patients with schizophrenia, with the incentive to behave in desirable ways can have direct effects on these symptoms.
     
  • Dickerson (2005) stated that token economies are probably most appropriate when used in combination with other forms of therapy designed to address other symptoms of schizophrenia.
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Token Economy - Inappropriateness

  • Ethical issues - the goals are designed by the institution not by the individual. May not be acceptable to patient if they had a free choice.
  • Don't tackle positive symptoms.
  • Use token economy within various institutional settings as therapists may exert the environmental control in such settings. However, nowadays it is done more in the community and it is much less effective in such settings.
  • A goal of therapy is producing long lasting effects. Token economies often short lasting and only superficial changes in behaviour that don't generalise well to the outside world.
  • Reductionism - this treatment ignores other relevant factors. E.g. genetics, biochemistry, poor communication with the family - which play an important role in producing schizophrenia.
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