Psychological Treatments for SZ

• Cognitive Behavioural Therapy (CBT)

  5-20 sessions (NICE recommends 16)

  group or individual basis

  initial assessment helps establish goals for therapy

  aims to help patients identify irrational thoughts and try to change them using the ABC model

  may involve an argument/discussion of how likely these thoughts are to be true and consider less threatening alternatives

  critical collaborative analysis is a technique involving questioning to help the patient understand illogical conclusions

  doesn't get rid of symptoms but helps SZ patients to cope
• how does CBT help?

  patients can make sense of how delusions + hallucinations impact their feelings and behaviour

  understanding where symptoms come from can be beneficial

  e.g. auditory hallucinations they think are demons would be scary but if they understand what auditory hallucinations actually are, this will help reduce anxiety
• Family Therapy


  with families rather than SZ individuals

  tries to improve communication and interactions of family members

  different approaches: double bind and schizophrenogenic mother think family causes SZ OR focus on reducing stress in family to lower relapse risk (EE)

  typically lasts 3-12 months goes on for 10 sessions
• Pharoah et al


  identified a range of strategies used in family therapy to improve functioning:

  - form therapeutic alliance with all members

  - reduce stress of caring for a SZ

  - improve family ability to anticipate and solve problems

  - reduce anger and guilt

  -help achieve balance between caring for SZ and getting on with own lives

  - improve family beliefs and behaviour towards SZ

  These work by reducing stress and expressed emotion (EE) and increase SZ compliance with taking medication -> combination reduces relapse
• Does family therapy work?

  Pharoah et al

  Procedure - reviewed 53 studies published between 2002-2010 to investigate the effectiveness of family intervention. researchers concentrated on studies that were randomised controlled trials. studies compared outcomes from family therapy to 'standard' care

  Findings:

  Mental state - overall impression was mixed. some studies reported improvement whereas others didn't - compared to standard care.

  Compliance with medication - use of family intervention increase compliance

  Social functioning - appeared to show some improvement, but family intervention didn't have much of an effect on more concrete outcomes e.g. living independently or employment

  Reduction in relapse and readmission - reduction in risk of relapse and a reduction in hospital admissions during treatment + 24 months after.
• Token Economies


  reward systems used to manage behaviour of SZs.

  particularly used for those who have been institutionalised and developed maladaptive behaviours e.g. spending all day in pjs or poor hygiene

  doesn't cure SZ but improve quality of life and increases chances of living outside hospital
• How do token economies work?

  Tokens:

  e.g. coloured discs

  given immediately to patient when they do a desired behaviour, this is reinforcement

  must be immediate to prevent 'delay discounting' where something is less rewarding after a delay

  Rewards:

  tokens can be swapped later on for a reward

  based on principle of operant conditioning

  tokens are secondary reinforcers as they only gain when patient learns they can be swapped for a reward e.g. sweets, trips, cigarettes etc
• Strength for family therapies - considerable economic benefits associated with treating SZ

  NICE review of family therapy studies (NCCMH) showed that family therapies is associated with significant cost savings when offered to people with SZ in addition to 'standard' care. the loss of family therapies of offset by a reduction in costs of hospitalisation and lower relapse rates associated with this interventioon.

  Additionally, there's evidence family therapy reduces relapse rates for a period of time after intervention

  Strength - means cost savings associated with family therapy would be even higher
• Strength for family therapies - shown to improve outcomes for individual with SZ but there may be an additional advantage

  additional advantage - they can have a positive impact on family members to

  Lobban et al analysed the resulted of 50 family therapy studies including intervention to support relatives. 60% of these studies reported a significant positive impact on the intervention on at least 1 outcome category for relatives e.g. coping and problem-solving skills, family functioning and relationship quality.

  The researchers also concluded that the methodological quality of the studies was generally poor, making it difficult to distinguish effective form ineffective interventions.
• Weakness for family therapies - studies aren't worthwhile

  Study by Garety et al failed to show any better outcomes for patients given sessions of family therapy compared to those who had carers but no family therapy.

  Individuals in both groups were found to have unexpectedly low rates of relapse, contrasting with rates found in 'no carer' group.

  Researchers found most of the carers in this study displayed relatively low rates of expressed emotion, which may reflect widespread cultural changes in carers' knowledge and attitudes towards SZ.

  Garety concluded that for many people, family intervention may not improve outcomes further than a good standard of treatments as usual.
• Strength of CBT - advantage over standard care

  NICE review of treatments for SZ found consistent evidence that when compared with standard care. CBT was effective in reducing rehospitalisation rates up to 18months following the end of treatment.

  CBT was also shown to be effective in reducing symptoms severity when compared with patients receiving standard care.

  However, most studies of effectiveness of CBT have been conducted with patients at the same time with antipsychotic medication. Therefore, it's difficult to assess the effectiveness of CBT independent of antipsychotic medication.
• Weakness of CBT - lack of availability

  Despite being recommend by NICE as a treatment for people with SZ, it's estimated that in the UK only 1/10 could benefit to get access to this form of therapy. A survey carried out by Haddock et al in Northwest England found that of 187 randomly selected diagnosed with SZ, only 6.9% were offered CBT.

  However, of those who are offered CBT as a treatment for SZ, a significant number either refuse or fail to attend the therapy sessions (Freeman et al) limiting its effectiveness even more.
• Weakness of CBT - problems with meta-analyses of CBT as a treatment for SZ

  Why meta-analyses in the area can catch unreliable conclusions about CBT effectiveness is failure to consider study quality. Some studies fail to randomly allocate ppts to either CBT or control condition, others fail to mask the treatment condition for interviewers carrying out subsequent assessments of symptoms and general functioning. Despite such differences and failings, all such studies are groups together for a meta-analysis.

  Juni et al concluded there was clear evidence the problems associated with methodologically weak trials translated into biased findings about the effectiveness of CBT. Wykes et al found the more rigorous the study, the weaker the effect of CBT.
• Weakness of token economies - Difficulties assessing the success of a token economy

  Comer suggests a major problem in assessing the effectiveness of token economies is that studies tend to be controlled when a token economy system is introduced into a psychiatric ward, typically all patients are brought into the programme rather than having an experimental groups that goes through the programme and a control group that doesn't

  Results - patients' improvements can only be compared with past behaviours rather than a control group.

  This comparison claims Comer, may be misleading as other factors e.g. an increase in staff attention, could be causing patient's improvement rather than the token economy.
• Strength of token economies - research support for the effectivness of token economies in a psychiatric setting

  Dickerson et al reviewed 13 studies using token economy in the treatment of SZ. 11 of these studies reported beneficial effects that were directly attributable to the use of token economies. Dickerson et al concluded these studies provide evidence of token economy's effectiveness in increasing the adaptive behaviours of patients with SZ.

  However, they did caution that many of the studies reviewed had significant methodological shortcomings that limited their impact in the overall assessment of token economies in this context.
• Weakness of token economies - researchers are yet to conclusively provide an answer to this question

  Very few randomised trials have been carried out to support the claims made for the effectiveness of token economies in manging SZ.

  In an era of evidence-based medicine, this lack of support is considered unacceptable, so token economy programmes have fallen out of use in much of the developed countries.

  McMonagle and Sultana suggests that the token economy may still be a potentially important treatment if such randomised trials could be carried out.

  They suggest it's only likely to be possible in those developing countries where same form of token economy is still practised. This could provide an opportunity to answer questions about the effects of the token economy in the management of people with SZ.