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Learn about cognitive behavioural therapy, psycodynamic therapy and schizophrenia drug therapy
Drug therapy is very commonly used in the treatment of people with schizophrenia and plays an important role in regulating dopamine levels in the brain and lessening the positive symptoms experienced by these patients. Anti-psychotic medication reduces these symptoms by blocking the effects of dopamine in the synapses of the brain. There are 3 different types of anti-psychotics; typical, less typical and atypical and they all work to block the action of dopamine. Typical antipsychotics e.g. haloperidol are sometimes described as ‘older’ as they were first used in the 1950s and contain phenothiazine, which was found to relieve patients of positive symptoms. Less typical anti-psychotics e.g. pimozide are useful for alleviating particular psychotic symptoms and atypical anti-psychotics e.g. clozapine and risperidone are the most recently developed and appear to be the most effective at treating psychotic symptoms, with less chance of relapse and side-effects.
Anti-psychotics are the most effective treatment option available to people with schizophrenia (May et al., 1981) and not only help to alleviate positive symptoms but can positively improve other aspects of a sufferers life e.g. increased ability to concentrate and process information effectively. However, like other drug treatments they do not treat the cause of the schizophrenia but merely treat the symptoms and thus, are not getting to the root of why schizophrenia developed in the first place.
Despite their effectiveness, anti-psychotics have a number of side-effects. When taking typical anti-psychotics patients could experience stiffness/shakiness (similar to Parkinson’s disease), and slowing down of thinking and when taking atypical anti-psychotics they could experience weight gain and Type 2 diabetes. This is not a definitive list of side-effects and often the drugs will affect people in different ways so a process of ‘trial and error’ will often take place in order to find the correct medication for that individual. Due to the serious implications of these drug therapies relapse becomes an issue, as people choose to cease medication rather than continue experiencing the negative side-effects. In addition, anti-psychotics do not work as effectively at reducing negative symptoms of schizophrenia e.g. lack of motivation and often patients will be required to engage in additional treatment e.g. CBT to improve this aspect of the disorder.
Cognitive Behavioural Therapy (CBT)
Cognitive psychologist Ellis would argue that if a patient’s irrational thoughts can be altered to more rational ones then a more rational “internal dialogue” will occur, resulting in more rational behaviour. REBT therapy, developed by Ellis, uses the ABC model; A is the activating event, B are the beliefs (about event A) and C are the consequences (of B). It works by helping patients to organise confusing experiences and rationalise their beliefs which ultimately are the cause of the behaviours seen in schizophrenia. Beck’s form of CBT also aims to challenge the unreasoned thinking processes in sufferers of schizophrenia and improve their ability to reason logically about their experiences, particularly their psychotic thoughts and feelings.
The therapy might involve identifying the problem e.g. hallucinations and trying to interpret these in a way that is less threatening to the individual. This might involve comparing their unusual experiences with the experiences of others in order to decatastrophize their psychotic episode and help them to feel less isolated. The therapist will also work with the patient to consider alternative explanations for the hallucinations. This is led primarily by the patient to allow autonomy and to base any coping strategies on skills the patient already has. Coping strategy enhancement (CSE) has more recently been developed to help people with schizophrenia to deal with their symptoms more effectively, focussing on the symptoms that cause the most distress.
There are inconsistent results about the effectiveness of CBT as a treatment for schizophrenia. Zimmerman et al. (2005) found the treatment to be effective at alleviating positive symptoms for up to 12 months, compared to receiving no treatment at all. However, he also recognised that the therapy was not helpful for all schizophrenia sufferers to the same extent, and that it was more effective for some symptoms compared to others, particularly reducing the distress experienced as a result of having hallucinations. Sensky et al. (2000) also found that CBT could be effective for a prolonged period (9 months) even after the treatment was finished, demonstrating its long term effects.
However, one of the main symptoms of schizophrenia is disordered thinking, to the extent that some sufferers are unaware they are mentally unwell. This reduces the appropriateness of the treatment option as patients are not able to engage effectively with the process. It may be better to consider the usefulness of CBT in conjunction with other therapies to treat schizophrenia. Drug therapy could be used to alleviate positive symptoms in the patient allowing them to focus and participate more actively in the psychological therapy. Kopelowicz and Liberman (1998) found a reasonable improvement in symptoms when drug therapy was combined with CBT. However, this change was only present in 50-60% of the patients and there was no significant change in symptoms when CBT was used on its own.
Freud’s approach to therapy relied heavily upon a relationship being built between the patient and the analyst. He believed this relationship could not be obtained if the patient was psychotic and not in touch with reality and so had minimal interest in treating psychotic disorders. However, other psychoanalysts, Sullivan and Pratt, adapted his therapy to treat schizophrenia in the 1920s. The aim of the therapy was to allow the sufferer insight into their current emotional state and identify the past experiences that were impacting their mental stability now. The patients were also taught communication skills to aid the process, enabling them to speak fluently and effectively about how the past has affected them. As in all psychotherapy, a non-threatening environment is created in the therapy sessions to allow openness and make the patient feel safe enough to discuss traumatic experiences.
There is minimal research support for the effectiveness of psychodynamic therapy for people with schizophrenia. Sullivan and Pratt reported success with the patients they treated, however these patients may not actually have been suffering with schizophrenia as it would be diagnosed now. This is because the label of schizophrenia was given to a wide range of disorders at this time. In addition, when psychoanalysis is compared with other therapies for schizophrenia is was found that it could actually exacerbate the patient’s symptoms and lead to longer hospitalisation (Drake and Sederer, 1986), rather than improving the symptoms. This could be due to the nature of the therapy being highly emotional and distressing for the patient to recount traumatic childhood experiences. Similarly, Stone (1986) described the absence of any improvement for schizophrenics who were treated with psychoanalysis. He argued that gaining insight into their complex psychotic disorder actually appeared to make the patient’s worse rather than improve their current condition.