Treatments of a psychotic disorder - Schizophrenia

Aim: To compare social learning agianst milieu therapy for treating patients with psychotic disorders.

Background: Paul and Lentz believed that positive reinforcement techniques could selectively reinforce socially acceptable behaviours and reduce unacceptable behaviour based on a token economy program. A therapeutic milieu is a structured group setting in whic positive peer pressure, trust and safety and repitition of behaviours needing to be improved provides the setting for group members to work through their psychological issues.

Sample: 84 chronically institutionalised, psychotic patients from four state hospitalss in Illinois took part.

Method: This was a field experiement with an independant measures design. Patients were put into 3 groups: one was the social learning group, one was the milieu therapy group and the control group, who remained in hospital for the usual therapy. the social learning theory group followed token economy system with rewards over approximately 85% of their available time and this was matched by a similar time spent in milieu therapy by the second group. The social learnign group would be rewarded for behaviours which would increase their ability to function outside the insititution, such as personal care, making conversation and managing other daily tasks. The control condition was varied byt generally spent less time in any kind of structured program of treatment which only occupied approximately 5% of their time.

Results: By the end of the study, 92.5% of the bahviour group, 71% of the milieu group and 48% of the control group were released. This clear difference emerged at every assessment which was done with a battery of psychometric tests. The results support the use of token economies in institutions to help prepare patients for release into the community.

Evaluation: Good internal and external validity ebcause of the design being a field experiment. Good control of amount of time in therapy. Determinism vs. free will - supports the behaviourist view that behaviour is a result of external positive and negative reinforcers. These are very useful findings which can easily be put into effect in many similar institutions and which are easy to train people to implement.

Aim: To compare the effectiveness of fluphenazine against a placebo.

Background: Drug treatments are a big part of the treatment of schizophrenia and the fact that they appear to reduce symptons suggest thsat there is an underlying biological cause or reaction in the brain. Patients with an acute first attack of schizophrenia are thought to have the best chance of remission and there is a debate as to whether using drugs is a good idea or not at the point where patients are no longer experiencing symptoms. This study investigates patients in this phase of the illness.

Sample: 28 patients who had recently recovered from an acute-onset first episode schizophrenic illness took part.

Method: This was a one year double blind comparison of fluhenazine and placebo. Patients were removed if they dropped out, had bad side effects or replapsed.

Results: Of the 17 patients receiving the placebo, 7 replapsed after a mean of 19 weeks and 7/11 drug treated patients dropped out after a mean of 21 weeks. Therefore only three patients compeleted the study. Among the 11 drug treated patients there were no replapses but two dropped out at four weeks and one at 24 weeks due to toxic side effects that meant they had to stop taking the medication. Therefore although drug treatment appears to work, it cannot be tolerated by quite large percentages of patients.

Evaluation: This research suggests that drugs are effective in preventing replapses and the findings come from a strongly controlled double-blind trial which is high in validity and reliablity. Psychology was a science - this is the best kind of well-controlled scientific method. However it is a redutionist explanation of schizophrenia which looks for a chemical explanation of the symptoms. This was a very small sample and the problems with tolerating the drug may limit its usefulness for many patients.

Aim: To compare cognitive behaviour therapy with a befriending control for treatment of schizophrenia.

Background: Research vidence supports the effectiveness for cognitive behavioural therapy in the treatment of schizophrenia where, if the positive symptoms are the result of distorted perceptions, it should be possible to alter those perceptions.

Sample: 90 patients from 5 clinical areas, aged 16-60, who had the symptoms of schizophrenia for at least 6 months and who adhered to their drug medication (chlorpromazine) but who had not shown great improvement.

Method: A randomised controlled design was used. Both treatment were given by two experienced nurses. Patients were assessed at baseline, after treatment over 9 months and at a 9 month follow up with a battery of psychometric tests including the Comprehensive Psychiatric Rating scale (CPRS). The assessments were rated by people who were blind to the conditions. CBT followed the usual pattern of identifying problem behaviours, finding the antecedents and developing a normalising strategy. any depression was also treated. The befriending group controlled the contact time (45 mins per week) and focused on neutral topics such as hobbies and sports with no direct intervention on symptoms.

Results: Both the CBT and befriending groups improved and at the end of the treatment there was no significant difference between them. However, nine months later the CBT group showed significant gains across all the measures, suggesting that it was a superior form of treatment with lasting benefit.

Evaluation: There was a good spread of the sample across different regions. However this group are traditionally the easiest to treat and they were all good adherers to medical advice. A wider sample may not show the same differences. It could be that the drugs are just taking longer to work. Psychology as a science - this study is a good example with its strong methodology and sampling. FRee will vs. determinism - the research suggests that we can take control of  mental illnes with CBT. CBT is helpful in treating both positive and negative symptoms of schizophrenia. This is really important because the negative symptoms are very hard to treat.