CBT and Family Therapy

• what is CBT based on?

  the assumption that people with schizophrenia can be helped by identifying and changing their faulty cognitions.
• what is the process of CBT for schizophrenia? (1)

  1. CBTp usually takes place once every ten days for 12-16 sessions.
  2. CBTp It can be delivered in groups, but is typically delivered on a one-to-one basis.
  3. The aim of CBTp is to establish links between the sufferer’s thoughts, feelings, actions and their symptoms and general level of functioning. By monitoring their thoughts, feelings and actions in relation to their symptoms, patients can consider alternative ways of explaining why they feel and behave the way they do.
• what is the process of CBT for schizophrenia? (2)

  • Cognitive techniques are developed between patient and therapist such as:
  • Distractions from intrusive thoughts
  • Challenging the intrusive/irrational thought
  • increasing/decreasing social activity to distract them from the thoughts
  • using relaxation techniques
• evaluation of CBT (1)

  • Research has indicated that those patients who have had CBTp suffer from fewer hallucinations and delusions and recover to a greater degree than those who receive antipsychotic drugs alone. Drury et al. (1996) found a 25-50% reduction in recovery time for patients given a combination of antipsychotic medication and CBT, demonstrating that patients being given CBTp alongside drugs make more rapid improvements.
• evaluation of CBT (2)

  • CBTp in conjunction with drugs has many benefits. For example, Tarrier et al. (2000) found that people with schizophrenia receiving 20 sessions of CBT on a one to-one basis with drug therapy, followed by four booster sessions during the year, made more significant improvements than sufferers receiving drug therapy alone or supportive counselling alone. A
• evaluation of CBT (3)

  • A strength of CBT is that it appears to work for those that are not responding to other treatments. Sensky et al. (2000) found that CBT was effective in treating schizophrenic patients who had not responded to drug treatments. They also found that they continued to improve nine months after treatment had ended. This research shows that CBTs is effective for drug-resistant patients and that the positive effect was long-lasting.
• evaluation of CBT (4)

  • CBTp has fewer side effects in comparison to drug therapy. However, CBTp is a more expensive treatment and this might explain why it is not always readily available. Estimates argue that only 1 in 10 are offered this treatment in the UK and this figure is even lower in some areas of the country. This has economic implications because whilst CBTp is initially more expensive, the lack of negative side effects can help organisations such as the NHS save money due to patients not needing a further intervention like they would with antipsychotics.
• what is family therapy?

  • based on the idea that as family dysfunction plays a role in the development of schizophrenia, and that altering relationship and communication patterns within families should help people with schizophrenia to recover.
• what are the main aims of family therapy?

  • Improve positive and decrease negative forms of communication (such as decreasing criticism and increasing praise).
  • Increase tolerance levels and decrease criticism levels between family members.
  • Decrease feelings of guilt and responsibility for causing the illness among family members.
  • Reduce the burden/stress of care for family members.
  • Enhance relatives’ ability to anticipate and solve problems.
• how does family therapy work? (1)

  • The therapist meets regularly with the patient and close family members, who are encouraged to talk openly about the patient’s symptoms, behaviour and progress.
  • They are taught to support each other and be caregivers, with each person given a specific role in the rehabilitation process.
  • There is an emphasis on openness, with no details remaining confidential, although boundaries of what is and is not acceptable are drawn up in advance.
  • Like CBTp it is given for a set amount of time, usually between 3 months to a year, and at least ten sessions.
• how does family therapy work? (2)

  • This type of treatment is aimed at reducing the level of expressed emotion (EE) within the family, as EE has been demonstrated to increase the likelihood of relapse.
  • It typically involves providing family members with information about schizophrenia, finding ways to support the individual and resolving any practical problems, like ensuring the sufferer keeps medical appointments and takes their medication.
• evaluation of family therapy (1)

  • Pharoah et al. (2010) conducted a meta-analysis of 53 studies from Europe, Asia and the USA, to investigate the effectiveness of family therapy. The studies compared the outcomes from family therapy to ‘standard’ care (e.g. drugs alone). It was found that family therapy increased a patient’s compliance with medication and there was a reduction in the risk of relapse and hospital admission during treatment and for 24 months after. This suggests that the treatment is effective in reducing relapse and for a long time.
• evaluation of family therapy (2)

  • Family therapy can be useful for patients who lack awareness into their illness or cannot speak coherently, as family members can often assist the therapist by giving the information needed to help. Family members have valuable insight into a patient’s behaviour and moods, something the patient doesn’t always have.
• evaluation of family therapy (3)

  • cost-effective. As well as decreasing relapse rates and lowering the need for hospitalisation, family therapy can educate family members to help manage a patient’s medication regime. This can decrease the need for medical help and therefore makes the treatment cost-effective. The Schizophrenia Commission (2012) estimates that family therapy is cheaper than standard care suggesting that it can save money. Furthermore, the extra cost of family therapy is offset by a reduction in costs of hospitalisation because of the lower relapse rates
• what are token economies?

  behaviourist approach to the management of schizophrenia, where tokens are awarded for desired behavioural change.
• how do token economies work?

  1. clinicians set target behaviours that they believe will improve the patient's engagement in their daily activities
  2. tokens are then awarded whenever the patient engages in one of the target behaviours
  3. patient will engage more often with desirable behaviours because the behaviours become associated with these rewards and privileges.
  4. With the token economy, the tokens in themselves are neutral. However, to give the neutral token value it needs to be repeatedly presented alongside or immediately before the reinforcing stimuli
• evaluation of token economy (1)

  • Some research indicates that token economy is effective in managing schizophrenia. Ayllon and Azrin (1968) used a token economy on a ward of female patients with schizophrenia. They were given plastic tokens, each embossed with the words ‘one gift’ for behaviours such as making their beds. These tokens were then later exchanged for rewards such as being able to watch a film. The researchers found that the use of a tokeneconomy with these patients increased dramatically the number of desirable behaviours the patients performed each day.
• evaluation of token economy (2)

  • There are problems with how research is carried out. Comer (2013) suggests that a major problem in assessing the effectiveness of token economies is that studies of their use tend to be uncontrolled. Typically all patients are brought into the programme rather than having an experimental group and a control group that does not. Patients’ improvements can only be compared with their past behaviours. This comparison may be misleading as other factors, like increased staff attention, could be causing patients’ improvement rather than the token economy.
• evaluation of token economy (3)

  • patients becoming more independent and active, which has the knock-on effect of nurses’ increased respect for the patients, leading to the patients becoming even more motivated and developing positive self-esteem. This indicates that token economies are an effective way of helping with institutionalisation which occurs when a patient has been in the hospital for a long time. Also, where token economies have been used on hospital wards they have helped to create a more healthy, safe and stable environment.
• evaluation of token economy (4)

  • any positive effects of the treatment are short-lived. The treatment does not appear to work long-term as the desirable behaviour becomes dependent on reinforcement. Upon release into the community, reinforcement ends leading to high re-admittance rates. It appears that without the professionals there to constantly reinforce the behaviour of people with schizophrenia, they are not able to engage in the target behaviours outside of the hospital setting. Therefore, token economies do not work outside of the hospital.
• evaluation of token economy (5)

  • Some question the ethics behind this treatment, arguing it is humiliating for people with schizophrenia. For example, to make reinforcement effective, clinicians exercise control over important primary reinforcers such as food or privacy. Patients may then exchange tokens if they display the target behaviours. However, it is accepted that all human beings have certain basic rights that cannot be violated regardless of the positive consequences that might be achieved by manipulating them.