Psychotherapy treatment for schizophrenia

• 'Psychotherapy' is a generic term that covers a range of therpies such as psychodynamic and cognitive therapies. 
• Psychotherapy is not always effective for individuals with severe schizophrenic symptoms, as the therapies often rely on talking and listening

• Cognitive-behavioural therapies have focused on individual symptoms, such as hallucinations and delusions. 
• Patients experience distress with some of the more troublesome psychotic symptoms of schiz, and many engage in a variety of coping strategies.

Aim: To investigate the use of coping strategies during psychotic episodes.

Meth: 25 patients with schiz who suffered hallucinations and/or delusions following a psychotic episode were interviewed. Details of psychotic experiences were elicted, including when and where these occurred, the patients' emotional reaction and their use of coping strategies. 

Results:1/3 identified 'triggers' to the symptoms, such s traffic noise or feeling anxious, 75% reported major distress and 1/3 reported distruption to thinking and behaviour. 75% disclosed the use of coping strategies such as distraction, postive self-talk, withdrawl or relaxation.

Conc: The use of coping strategies helped patients cope with their symptoms

Eval: This type of study relies on the client being able to recall and communicate effectivley, which is not possible in many cases involvin people suffering from schiz.

The study by Tarrier (1987) was groundbreaking and led to the development of a new therapeutic approach ; it involves teaching patients new coping strategies based on their own preffered strategy, and is known as coping strategy enhancement (CSE).

The aim of CSE is to teach the individual how to use coping strategies to reduce the frequency and intensity of psychotic symptoms. Useful strategies already present in the individual are built on and new strategies are encouraged. The therapy involves a number of intial steps:

• Assess the form and the content of the psychotic experience (eg, is there one voice?)
• Assess the emotional response (eg, how do the voices make you feel?)
• Assess the person's thought that accompany the emotion (eg, do you think you're in danger?)
• Assess any prior warning, or antecedent (eg, Do you know when the voice will appear?)
• Assess the individual's coping strategies (eg, how do you cope with this?)
• The individual then rates each strategy in terms of it's effectiveness

The therapy then progresses using two components:

• Education and rapport training: this involves creating an ambience and shared understanding so that the therapist and client can work together.

• Symptom targeting: A symptoms is targeted, usually one for which a coping strategy is already in use, and this strategy is then enchanced and practised during the session. For 'homework' the client is asked to assess the use and effectiveness of the strategy and may a record.

• Tarrier et al (1993) carried out a study investigating the effectiveness of CSE over problem solving therapy in 49 patients taking anti-psychotic medication but who continued to experience hallucinations and delusions. Patients were randomly allocated to treatment conditions which involved 10 one hour sessions. Both groups reported 50% improvement on positive symptoms compared with a control and this significant gain was still found after the six month follow-up. Patients recieving CSE,  however, also showed significant improvement in coping skills.
• One of the issues associated with treatment research with patients with schiz is that there is usually a high drop out rate, in the Tarrier et al study 47% dropped out.
• CBT has been shown to be effective when combined with other drugs, and patients experience fewer hallucinations and delusions, and recover to a greater extent than those with soley medication. Drury et al found a reduction of positive symptoms and a 25-50% reduction in recovery time for patients given this combination.
• Kuipers et al (1997) who also note lower patient drop out rates and greater patient satisfaction when CBT was used in addition to medication.
• Research has tended to show that CBT has a significant effect on improving the symptoms of patients with schiz. Gould et al found a statistically significant decrease in positive symptoms after treatment in all 7 studies in their metaanalysis.
• For people with additional learning difficulties it may not work and many would not engage fully in the process (Kirschen, 2006)

• Supporters of cognitive therapy argue it is beliefs of the self and apprisials of events that are responsible for the negative affect (emotion.)
• The therapy requires thoughts and their associated affects to be elicited and challenged - this may involve  putting such thoughts to 'reality testing'.
•  Up until quite recently, it was thought this approach would not work with schiz patients as attempting to modify beliefs could end up strengthening them. Two principles underpinning the present approach are:
• start with the least important belief 
• work with evidence for that belief, not the belief itself (Watts et al, 1973.)

Cognitive therapy usually involves the following symptoms:

• A verbal challenge of the evidence for the least significant belief is made, where the therapist questions the client's delusional interpretation and puts forward a more reasonable one.
• By challangeing the evidence for the belief,a reduction in conviction can occur. Also, the client becomes aware of the link between events, belief, affect and behaviour
• Reality testing involves planning and performing an activity to invalidate a belief. Chadwick et al (1996) reported the case of Nigel, who claimed to have the special power of knowing what people were going to say before they said it. To test this, a number of video recorders were put on pause, and Nigel had to say what was coming next. Over 50 attempts, Nigel did not get one correct, and he concluded he did not have the power at all.

• Research trials using cognitive therapy for delusions have demonstrated a 40% reduction in the severity of psychotic symptoms (Kuipers et al, 1997).
• During a period of acute psychosis, cognitive therapy led to a faster response to treatment in a group of patients with schiz compared with drugs alone, and to improved recovery (Drury et al, 1996).

Aims to increase tolerance, decrease criticism, reduce guilt and improve communication in families of schizophrenic patients.

As remission rates are higher in families with high expressed emotion, family therapy attempts to lower EE exhibited within a family group by:-

• Getting family members to be more tolerant and less critical
• Helping family members to feel less guilty and less reponsibility for causing the illness
• Improving positive communication and decreasing negative communication between family members

Support groups are also considered helpful, where family members can go and talk to other people in the same situation as themselves for support and guidance.

This helps to reduce the feelings of isolation for families, who feel they have to change their behaviours and thinking, in order to improve relapse rates for the family member diagnosed with schizophrenia (Chien et al, 2004).

• Reserach evidence shows that family therapy is useful to prevent relapse in schizophrenic patients when combined with social skills training.
• Hogarty et al (1986) conducted a study into the effectiveness of family therapy. There were 4 groups of patients: those who recieved medication only, those who recieved medication and social skills training, those who recieved medication and family therapy, and those who recieved medication, social skills, training and family therapy. Patients were followed up over a 1 year period and the frequency of relapse measured: the medication only group had a 40% relapse rate, and all the therapies had a 0% relapse rate. Medication and family therapy had a 20% relapse rate.
• Patients can relapse if therapy ceases - Hogarty's study was followed for a second year, when therapies had ceased, and found higher relapse rates. The treatment needs to be maintained, even when the person may be in the recovery phase.
• Reducing EE in families helps reduce relapse rates - research has found that sucessful treatments focused on reducing EE in families resulted in reduced relapse rates (Doane)
• Each psychotherapy addresses a different aspect of the disorder
• Family therapy is very sucessful when combined with drugs (Goldstien and Falloon)
• Only focuses on stress in families which acts as a trigger - does not deal with the underlying cause of the disorder. Most schizophrenic patients will need drug treatment to stabilise them as well as a form of psychotherapy.