Psychological Therapy, Treatment and Management of SZ

• What is the purpose of Cognitive Behavioural Therapy for psychosis (CBTp)?

  To treat residual symptoms despite medication
• What is a basic assumption of CBTp?

  Distorted beliefs influence feelings and behaviors
• What is the main aim of CBTp?

  To understand the impact of delusions and hallucinations
• What are the key components of the nature of CBTp?

  • Trace origins of symptoms
  • Evaluate content of delusions and voices
  • Test validity of faulty beliefs
  • Set behavioral assignments for improvement
• How does the ABC Model work in CBTp?

  It links activating events to emotional and behavioral consequences
• In the ABC Model, what does 'A' stand for?

  Activating events
• In the ABC Model, what does 'C' represent?

  Emotional and behavioral consequences
• How can a patient's beliefs be changed in CBTp?

  By rationalizing, disputing, and changing them
• What is an example of changing a belief in CBTp?

  Changing 'people won’t like me' to 'some may, some may not'
• What is critical collaborative analysis in CBTp?

  Gentle questioning to understand illogical conclusions
• How can questioning be conducted in CBTp?

  Without causing distress in a trusting atmosphere
• What is essential for effective questioning in CBTp?

  Trust between patient and therapist
• CBTp AO3 - Advantages over standard care


  • NICE review - when compared with antipsychotics medication alone, CBTp was effective in reducing rehospitalisation rates up to 18 months following the end of treatment
  • CBTp was also shown to be effective in reducing symptom severity and there was some evidence for improvements in social functioning
  • However, most of the studies in effectiveness of CBTp have been conducted with patients treated at the same time with antipsychotic medication - therefore difficult to assess effectiveness of CBTp independent of antipsychotic medication
• CBTp AO3 - Effectiveness dependent on the stage 


  • CBTp appears to be more effective when it is made available at specific stages of the disorder and when the delivery of the treatment is adjusted to the stage that the individual is currently at
  • Addington and Addington - claim that in the initial acute phase of SZ self-reflection is not particular appropriating
  • Following stabilisation of the psychotic symptoms with antipsychotic medication individuals can benefit more from group based CBTp
  • This can help normalise their experience by meeting other individuals with similar issues
• CBTp AO3 - Benefits overstated


  • Jauhar et al - recent large scale meta analysis revealed only a small therapeutic effect on the key symptoms of SZ such as hallucinations and delusions
  • Even these small effects disappeared when symptoms were assessed ‘blind’
  • Many studies seem to have similar design problems and in their meta-analysis the uncertainty over whether non-drug therapies such as CBTp really do offer superior outcomes to antipsychotic medication has led to conflicting recommendations even within the UK (Taylor and Perera)
• What is the main aim of family therapy?

  To support carers and reduce rehospitalisation
• Why is family therapy used?

  To improve poor relationships and outcomes
• How does family therapy work?

  By reducing expressed emotion and stress
• How does family therapy aim to reduce relapse for individuals with SZ?

  By enhancing relatives' problem-solving capacity
• What is the typical duration of family therapy?

  Between 3 and 12 months
• How many sessions are typically involved in family therapy?

  At least 10 sessions
• What does Garety et al estimate the relapse rate for individuals receiving family therapy to be?

  25%
• What is the relapse rate for those receiving standard care alone according to Garety et al?

  50%
• How does family therapy improve household relationships?

  By encouraging open discussion and negotiation
• What is encouraged for the SZ patient during family therapy?

  To explain their support needs to family
• With what is family therapy used in conjunction?

  Routine drug treatment and outpatient care
• What strategies are used in family therapy?

  • Psychoeducation for understanding the illness
  • Reducing expressions of anger and guilt
  • Maintaining reasonable expectations for patient performance
• What is the purpose of psychoeducation in family therapy?

  To help understand and manage the illness
• Why is it important to reduce expressions of anger and guilt among family members?

  To create a supportive environment for the patient
• What is the significance of maintaining reasonable expectations among family members?

  To foster a realistic understanding of patient performance
• Family Therapy AO3 - Cost effective


  • Despite the high costs of family therapy, many argue it can reduce the 'revolving door syndrome'
  • Anderson et al - found a relapse rate of almost 40% when patients had drugs only, compared to only 20% when FT was used and the relapse rate was less than 5% when both were used together with the medication
  • With a drastically reduced relapse rate with FT, will reduce the amount of times patients are hospitalised and therefore reduce the cost to the NHS, and therefore the economy
• Family Therapy AO3 - Less effective by itself


  • Family therapy seems to be most effective when used in conjunction with powerful antipsychotics to treat SZ
  • Vaughn and Leff looked at schizophrenic patients returning to either a high or low EE family
  • The effect of no medication on low EE was insignificant
  • In the high EE household, relapse of SZ symptoms increased with more face-to face contact, and with no medication relapse rate rose to 92%
  • This implies that focusing on both family dynamics and biochemistry is best for patients with schizophrenia and their families.
• Family Therapy AO3 - Evidence of effectiveness


  • Leff - programme that involved educational sessions dealing with the nature of SZ, group meetings between families and family sessions
  • Found that families involved in the intervention showed a significant decrease in critical comments directed towards the patient and reduced over-involvement (EE)
  • 78% of patients in control group were readmitted to hospital compared to only 14% of the experimental group with schizophrenia
  • This implies that family intervention made a significant difference to the interactions within the families
• What is a token economy?

  Form of behaviour therapy
• How do clinicians use token economies?

  They set target behaviours to improve engagement
• What is the purpose of a token economy?

  To improve quality of life in hospitals
• How does a token economy help patients adapt?

  Normalises behaviour for community reintegration
• How are tokens awarded in a token economy for schizophrenia (SZ)?

  Tokens are awarded for achieving target behaviours
• Why are tokens considered secondary reinforcers?

  They gain value through learned associations
• What happens when tokens are exchanged for rewards?

  They become primary reinforcers that reinforce behaviour