This is Psych boost, and in this video we are going to be looking at a range of psychological
treatments used to manage schizophrenia, these are CBT, family therapy and token economy.
Let's get started CBT
Cognitive behavioural therapy takes the assumption that disorders such as schizophrenia
come from dysfunctional thought processes. The role of CBT then is to identify faulty cognitions,
such as delusions and change them. The therapist actually challenges
irrational beliefs, using logic to dispute delusions and work towards an alternative.
You may be familiar with Ellis’s ABCDE framework to identify, challenge and ultimately restructure
faulty cognitions, in the case of schizophrenia we are referring to delusions.
Let’s go over the framework. Firstly A, the activating event, so let's
say the patient has severe side effects to one of the drugs that they have been prescribed.
An irrational belief B, could be that the hospital staff are trying to kill them.
Leading to the consequence, C of the patient refusing to continue with their treatment.
Well the therapist would attempt to dispute D, the irrational belief trying to logically convince the
patient that the staff have no reason to want to kill them. Hopefully leading to an effect
E, of a restructured belief that the staff are working in the patient's best interest,
don't want to kill them and the drugs are necessary for their recovery.
The therapist may use a technique called reality testing,
this is where in a safe environment the patient can demonstrate to themselves that their beliefs
are irrational. So for example if a patient thinks they are psychic and can predict the future
the therapist may use a deck of cards and ask the patient to predict what they draw.
There is research evidence that CBT is an effective treatment, Senskey studied patients
who were resistant to drug treatment. After an average of 19 sessions of CBT the patients
showed improvements in both positive and negative symptoms. Senskey also followed up these patients
9 months after treatment, finding the patients were continuing to improve.
This is highly suggestive not just that CBT can be effective when the drugs are not,
but CBT may be effective in the long term, while drugs are only reducing symptoms during treatment.
A criticism however of CBT is the long length of the treatment,
during this time symptoms may become severe leading the patient not engaging in the process.
As we have seen it’s a difficult process, the therapist has to challenge beliefs.
Negative symptoms can lead to a lack of motivation, and positive symptoms can
lead to a lack of awareness, or even delusions about the process of CBT.
If symptoms become so severe that the patient can't cope with the process there is the
option of using antipsychotic medication, reducing the symptoms so CBT can resume.
However on its own CBT does not produce the side effects of drug therapies,
but ultimately one of the reasons drug therapy is usually prescribed first is the cost of CBT, that
is working with a trained therapist is expensive. We could
FAMILY THERAPY Secondly let's consider family therapy,
this is an attempt to improve the relationships within the family of people who are suffering
from schizophrenia, hoping to stop relapse because of family dysfunction.
So on that point family therapy is not just trying to change the behaviour of the person
with schizophrenia, but the entire family. So we would call this therapy family centered.
An important part of this process is to educate the family on the symptoms of schizophrenia.
This is designed to help the family be more understanding of unusual behaviours
and is termed psychoeducation. There are also a range of other
priorities of family therapy and they are, to reduce conflict, lowering anger within the family.
Reducing the levels of stress felt by being a carer. Dealing with self sacrifice in the
family by getting the carers to focus on their own needs. Improve communication,
especially by reducing expressed emotion. And finally by helping the family with problem solving
skills,helping them predict problems in advance. When considering evaluations of the effectiveness
of family therapy we can consider Left (1985) who found after 9 months only 8% of patients relapsed
who had received family therapy, compared to 50% of those who only had standard outpatient care,
There was still a difference after two years, with 50% of those who had family therapy relapsing,
compared to 75% who had standard outpatient care. These figures suggest that family is effective,
although families may not be able to maintain their
new communication styles over the longer term. One criticism of family therapy is the length of
treatment, it can take up to a year and in that time symptoms can cause patients to drop out,
or there may be a family incidendent with family members refusing to continue.
Also family therapy may be effective in improving symptoms and improving
the situation at home with the family. However family therapy is about management, not curing.
The final treatment we need to discuss is token economies, this technique uses behaviourist
principles. It is operant conditioning, desired behaviours are reinforced so they are repeated.
How it works is that tokens are used for positive reinforcement, they can be given as an immediate
reward for positive behaviour. This target behaviour will be predefined by the therapist,
for example washing independently. The tokens can be later traded in for something else
that the patient wants, treats like chocolate or being able to take part in certain activities.
The therapist will start giving tokens for small behavioural changes, then only giving
tokens for larger changes in behaviour. This leads over time to behaviour shaping.
TOKEN ECONOMY Token economy is not
designed to reduce symptoms, but to help manage patient behaviour in psychiatric institutions,
often in the hope of changing behaviour enough to eventually move the patient into the community
and for them to be able to cope. Token economy of course is only
used with patients with mild symptoms, patients with severe symptoms are not
able or willing to engage with the process. There is evidence that token economies are
effective, Dickerson reviewed 13 studies on the use of token economies in managing
people with schizophrenia finding that it did improve their adaptive behaviour.
But it should be considered that token economies only have limited value as the treatment does not
directly treat the symptoms of schizophrenia, only addressing issues like poor motivation.
Also if it is used on a range of patients some of which have very severe symptoms,
those with the less severe symptoms will be treated better with more treats and activities,
this could be seen as unethical as we would effectively be punishing people for being unwell.
And another ethical point, using skinnerian operant
conditioning principles to manipulate patients could be seen as degrading.