Psychological Therapies for Schizophrenia

Psychological Treatments for Schizophrenia

In the case of schizophrenia, there are three main psychological therapies we like to consider. Each therapy offers a

different avenue of treatment whilst aiming to address the disorder itself, purely from a psychological perspective.

Different therapies use different techniques to treat the underlying cause of schizophrenia. Psychological therapies in schizophrenia address the symptoms as well as try to discern potential causes by exploring patients mind states, emotions, and personal backgrounds and situations. They tend to be much more person-centred approaches.

There are three main types of psychological therapies that we will cover:

1. Cognitive behavioural therapy (CBT)
2. Family Therapy
3. Token Economy

Cognitive Behavioural Therapy (CBT) for Schizophrenia: Cognitive Schizophrenia Treatment

Cognitive behavioural therapy (CBT) is one of the most used therapies out there currently. Curated by Aaron Beck in the 1960s, the main aim of CBT is to identify and then attempt to correct (or at least alter positively) dysfunctional thoughts. Dysfunctional thoughts in schizophrenia are the irrational beliefs schizophrenic patients have, and can manifest in a number of ways.

Typically, CBT heeds the following format (Kingdon & Turkington, 2006):

Step 1: Assessment

Patients explain their situation to their therapist, identifying problematic thoughts and the potential causes for these thoughts. Reflection is a core aspect of the assessment stage, requiring the patient to truly think back on themselves and understand where their symptoms are coming from and what makes them better/worse. Rating scales are used to monitor progress.

Step 2: Engagement

Once the above issues have been identified, the therapist can set out a cognitive framework to address these issues and logically work through them (so, if a schizophrenic patient is having delusions of grandeur, a therapist would identify this with them and logically work through it to show it is a delusion). Socratic questioning is employed, alongside a vulnerability-stress model. Empathy is heavily emphasized between patient and therapist.

The ABC Model of CBT

CBT adopts the ABC model, established by Ellis and Harper (1961). The ABC model attempts to cognitively restructure a schizophrenic patient's thought patterns through identifying activating events, behaviours and beliefs, and any subsequent consequences.

• (A) - Activating event: what is the cause?
• (B) - Behaviour and beliefs: how is the patient reacting?
• (C) - Consequences: what are the consequences of these reactions? How do we recognise the consequences?

CBT then works on disputing these irrational beliefs through reality testing, normalisation, and critical analysis. Overall, CBT usually lasts anywhere from 12 to 20 sessions and aims to help reduce the uncomfortable symptoms of schizophrenia.

Fig. 2 - CBT is a psychological therapy used to treat mental health disorders, including schizophrenia.

Family Therapy for Schizophrenia

Family therapy focuses on the people around the patient, involving them in the treatment process. Research has shown that many relapses in schizophrenia tend to occur after a patient has returned to their family environment. There are multiple reasons why this is the case.

Families are not perfectly attuned to every possible mental health disorder out there, so until it directly affects them, no one will truly know about these issues (and even then, it requires a lot of time, patience, and effort to understand mental health). Family members, especially the main support provider, often report feeling guilty and shameful. It is important, then, that therapy provides help to all those affected.

Family therapy usually involves an interview process, observation of the family, and then frank discussions about the situation and disorder.

The goal of family therapy is to provide or offer (Caqueo-Urízar et al., 2015):

• Psychoeducational.
• Opportunities for stress reduction.
• Avenues for emotional processing.
• Cognitive reappraisal.
• Structured problem-solving solutions to improve situations inside and outside of the home.

Token Economy Systems for Schizophrenia

In schizophrenic patients, token economies focus on maladaptive behaviours that prevent a patient from adapting to new situations, treating both positive and negative symptoms of schizophrenia. Although this treatment method has fallen out of fashion (with the fall in institutionalisation), it does employ some well-established psychological theories.

TES usually involves the following process:

• TES is introduced as soon as a patient enters the setting: rewards and good behaviours are established.
• They use physical tokens or tally systems: they can be earned and easily understood/quantified by introducing physical tokens or tally systems. These are the secondary reinforcers.
• They then trade these tokens in: Rewards can be given based on how many tokens a person has earned with good behaviour (such as bathing, getting up on time, socialising and addressing symptoms through treatment etc.). These are the primary reinforcers.

Overall, primary reinforcers give power to the secondary reinforcers.

TES is catered specifically to the patient (so their wants and needs can be directly addressed and influence their behaviour).

Fig. 3 - Tokens can be exchanged for rewards.

Assess the Effectiveness of Psychological Therapies for Schizophrenia

As with all treatment plans, psychological therapies have their strengths and weaknesses. Let's assess the effectiveness of psychological therapies for schizophrenia. The following can be considered strong points of psychological therapies:

Strengths

Let's explore the strengths of psychological therapies for schizophrenia.

• Concerning CBT, Kuipers et al. (1997) investigated the effects CBT had on psychosis (as it had positive effects on those with depression). 60 participants with at least one positive symptom (who also had issues with medication) were randomly allocated to either a CBT and standard care condition (n = 28), or a control group with standard care only condition (n = 32).Over nine months, they found significant improvement for those receiving treatment compared to standard care only. There was a low dropout rate and high satisfaction, and CBT had a 50% treatment response compared to 31% of the control group. They concluded that CBT for psychosis could improve symptoms.

• Concerning family therapy, Pharoah et al. (2010) found that from data (randomised and quasi-randomised) on families with members affected by schizophrenia, family therapy reduces the rate of relapsing in those with schizophrenia, including the rate of hospitalisation.

• Concerning token economies, McMonagle and Sultana (2000) found that, when comparing a token economy system to standard care, it has an effect on the negative symptoms of schizophrenia, although had little to no effect on other areas. They did, however, state that whether this is reproducible and long-term is up for debate and requires more research.

Weaknesses

Let's explore the weaknesses of psychological therapies for schizophrenia.

• CBT is mostly used alongside drug therapy for schizophrenia in psychology, suggesting that it is not a cure-all, robust therapy. It needs help, and implying CBT is enough alone is ignoring the biological basis of schizophrenia. It also has been shown to have a short-term effectiveness rate, as when studies analysed the rate of relapse compared to standard care, CBT had a similar or the same rate of relapse. CBT also relies on self-reports from patients, which is not the most reliable method of data collection, especially considering a schizophrenic patient's history with hallucinations and delusions.

• Family therapy, similar to CBT, does not address the biological aspect of the disorder, and instead focuses mostly on the nurture side of the debate. Blame can be placed on the family environment, which may incite more feelings of guilt and stress.
• Token economies have ethical issues, as they are essentially withholding freedoms from patients and demanding they are earned back purely through a reward system. Is it ethically acceptable to restrict this right from patients? They also lack ecological validity and struggle to provide consistent, long-term results outside of clinical environments. As well as this, it is only applicable to those willing to work for their rewards. If a patient doesn't want to or is too ill to engage in the behaviours, token economies would be useless or even cruel to them.