Outline and evaluate psychological therapies for schizophrenia

The underlying idea of cognitive behaviour therapy (CBT) is that people with mental disordesr have irrational and distorted ways of thinking. The goal of CBT is to provide an alternative to the often bizarre psychotic thoughts and feelings that the person with schizophrenia experiences. Although there are several forms of CBT, all have the aim of modifying hallucinations and delusional beliefs. CBT attempts to challenge (and to reality test) the client’s interpretation of their hallucinations and to propose alternative explanations.

One form of CBT is called Coping Strategy Enhacement (CSE). One of the ideas behind this approach is the finding that the majority of people who experience delusions and/or hallucinations report using coping strategies (Tarrier 1987). Such strategies include drowning-out voices by turning up the television set, use of distraction, withdrawal from social contact and self-talk. CSE aims to develop the client’s coping strategies in order to reduce the frequency, duration and intensity of the psychotic symptoms. The therapist and client work together to improve the effectiveness of the client’s coping strategies, and to identify additional strategies. The strategy is practised during the therapy session and the client is then given homework to ensure continued practise.

Zimmerman et al (2005) found that CBT was more effective in treating the positive symptoms than having no treatment.

Tarrier (2005) reviewed 20 studies and concluded that there was consistent evidence that CBT reduces positive symptoms in the short-term.

In a review of the overall benefits of CBT Kopelowicz & Liberman (1998) found that CBT moderately improved the symptoms of schizophrenia in 50% to 60% of sufferers, but only when it was used in conjunction with drug therapy.

However, other studies have found no benefits for CBT a year after treatment was stopped. It is not clear whether CBT is ...

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Zimmerman et al (2005) found that CBT was more effective in treating the positive symptoms than having no treatment.

Tarrier (2005) reviewed 20 studies and concluded that there was consistent evidence that CBT reduces positive symptoms in the short-term.

However, other studies have found no benefits for CBT a year after treatment was stopped. It is not clear whether CBT is effective in reducing relapse rates. Although CBT reduces positive symptoms of schizophrenia; there isn’t evidence that CBT reduces negative symptoms.

However, although there is reasonably strong evidence that CBT can improve or normalise certain symptoms of schizophrenia – it does not provide a cure.

Two reasons that CBT is appropriate for people with schizophrenia include:

Many symptoms of schizophrenia are cognitive in nature, for example, delusions, hallucinations and disorganised speech, and CBT directly targets cognitive processes.

Many people with schizophrenia use coping strategies to control their delusions and hallucinations, so it makes sense for a therapy to build on these coping strategies.

However, people with schizophrenia generally do not realise they have a problem, and thus lack insight into their condition, a further limitation of CBT’s appropriateness.

CBT does not take into account the biological factors (e.g. biochemistry), thus it is doubtful whether CBT on its own would be effective.

CBT involves the active co-operation of the client – thus is avoids the criticism made against drug therapy, that the client is a passive recipient of treatment.

Family therapy focuses on the social dynamics within the family. The aim is to reduce the level of negative expressed emotion in the family. It requires the involvement of several family members as well as the person with schizophrenia.

Key features of family therapy include:

Educating family members about the disorder; e.g. neurobiological factors and genetic factors, symptoms of schizophrenia, signs of impending relapse
Informing patients and families about antipsychotic medication
Helping families to avoid blaming – either themselves or the person with schizophrenia
Improving communication within the family – by developing their skills in expressing both positive and negative feelings in a constructive and empathetic manner
Encouraging families to widen their social contacts, especially support networks
Instilling hope that things can improve

Falloon et al (1985) compared people with schizophrenia who received family therapy with others who were receiving individual therapy from a therapist. Both groups were on drug therapy. Falloon et al found that the relapse rate was significantly lower among those receiving family therapy than those receiving individual therapy. 50% of those in the individual-therapy group returned to hospital without one year, compared to 11% of those in the family therapy group.

Other studies have investigated relapse rates among people diagnosed with schizophrenia living in families previously identified as having high expressed emotion. Birchwood and Jackson (2001) found that the relapse rate over 12 months was between 25% and 33% for those receiving family therapy, compared to 60% for those receiving routine treatment.

It is unlikely that family therapy can provide a cure for schizophrenia. Although there is convincing evidence that family therapy benefits people with schizophrenia, it does not make their social functioning comparable to that of healthy controls.

65% of patients with schizophrenia return from hospital to their families. Thus the role of the family is crucial. Family therapy is an appropriate way of establishing a secure family environment.

There is evidence that expressed emotion within the family increases the risk of relapse therefore a therapy that focuses on family dynamics has obvious value.

People with schizophrenia are socially isolated – and a therapy that emphasises social functioning addresses this important issue.

However, family therapy probably doesn’t work on its own, but needs to be used in conjunction with drug therapy.

Many patients with schizophrenia do not belong to a functioning family, hence there are limitations to its appropriateness.