LO: To be able to describe and evaluate the Cognitive Treatment for Schizophrenia

CBT Psychological treatments, such as cognitive behavioural therapy (CBT), can help people with schizophrenia to cope better with the symptoms of hallucinations or delusions. Psychological treatments can also help to treat some of the negative symptoms of schizophrenia, such as apathy or a lack of volition, motivation and enjoyment in life. It is not a cure for Sz – it does help improve quality of life though. We need to ask 1. is it an appropriate therapy? 2. is it an effective therapy?

Cognitive behavioural therapy (CBT) is based on the idea that most unwanted thinking patterns, and emotional and behavioural reactions are learnt over a long period of time. What is CBT?

The CBT approach to treatment of schizophrenia differs slightly from conventional CBT methods. The aims of this therapy are as follows: To challenge and modify delusory beliefs To help the patient to identify delusions To challenge those delusions by looking at evidence To help the patient to begin to test the reality of the evidence

An example of a delusional belief Event Overhearing someone saying “I know what’s on your mind” Interpretation Everyone can read my thoughts Feeling Paranoid, scared and believing that others will attack me for my thoughts Behaviour Take evasive action – avoiding situations that will bring me into contact with others

CBT TECHNIQUES trace back to the origins Patients are encouraged to trace back to the origins of their symptoms in order to get a better idea of how they may have developed. rational alternatives Try to help the patient come up with rational alternatives

LONG-TERM HELP their own coping strategies The therapist encourages patient to come up with their own coping strategies for when they experience any symptoms avoid acting on They may then receive help and advice about how they can avoid acting on delusional thoughts. Patients come up with their own solutions using their own thoughts –i.e. alternative explanations already present in their own mind

For example, you may be taught to recognize examples of delusional thinking in yourself. e.g. – thinking that people what to kill you. You may then receive help and advice about how you can avoid acting on these thoughts. e.g. – Rationalizing that people have no reason to want to hurt you. Encouraging you to engage with people in meaningful ways. Allowing opportunities to practice these new skills and share your experiences and reflect on how it felt to engage in positive social interactions.

Normalizing strategies can be used where the patient is taught to understand the nature of schizophrenic symptoms Challenge ‘catastrophizing’ beliefs about schizophrenia Help patient feel that symptoms are understandable and ‘normal’

CBT Course Most people will require between 8 to 20 sessions of CBT over the space of 6 to 12 months. CBT sessions usually last for about an hour.

This type of treatment has been shown to be effective for reducing the positive symptoms of schizophrenia, for reducing relapse and for enhancing recovery when schizophrenia is diagnosed early.

Cognitive Treatment Sensky et al. (2000) To compare cognitive behavioural therapy (CBT) with non-specific befriending interventions for patients with schizophrenia Design A randomized controlled design. Patients were allocated to one of two groups: – a cognitive behavioural therapy group. – a non-specific befriending control group. Aim

Participants 90 patients.  57 from clinics in Newcastle, Cleveland and Durham and 33 from London. They had diagnoses of schizophrenia that had not responded to medication.  Aged 16–60 years. Procedure Patients were allocated to one of two groups. Both interventions were delivered by two experienced nurses who received regular supervision. Patients were assessed by blind raters  at baseline.  after treatment (lasting up to 9 months).  at a 9-month follow-up evaluation. They were assessed on measures including the Comprehensive Psychiatric Rating Scale, the Scale for Assessment of Negative Symptoms, plus a depression rating scale. Patients continued to receive routine care throughout the study. The patients received a mean of 19 individual treatment sessions over 9 months.

Cognitive behavioural therapy condition A normal routine of CBT was used: initially engaging with patient psycho education developing a reason for the behaviour Cognitive and behavioural interventions treatment of other disorders such as depression Reducing relapse by planning ahead

Specific techniques for positive symptoms of schizophrenia were used: – critical analysis of beliefs about auditory hallucinations. – patients were helped to change their beliefs. – patients taught coping strategies to deal with the voices. Delusions and thought disorders were also addressed using cognitive strategies. CBT Strategies Used

Befriending condition The patients had the same time allocation at the same intervals as patients in the CBT condition. The therapists were empathic and non-directive. There was no attempt at therapy: The sessions focused on hobbies, sports and current affairs.

Findings Both interventions resulted in significant reductions in positive and negative symptoms and depression. After treatment there was no significant difference between the two groups. At the nine-month follow-up evaluation, patients who had received CBT therapy showed greater improvements on all measures. – They had improved, while the befriending group had lost some of the benefits.

Conclusions Cognitive behavioural therapy is effective in treating negative as well as positive symptoms in schizophrenia resistant to standard antipsychotic drugs. Its efficacy is sustained for at least nine months. Evaluate the research:

Shown to be effective for some patients Allows people to function more normally with symptoms, preventing learned symptoms from developing. Can be used in conjunction with other therapies Improves symptoms, recovery and relapse rates No side effects Chadwick & Lowe (1993) – found CBT led to significant reductions in delusions in 10 out of 12 patients  Doesn’t work for everybody  Expensive and time consuming  Helps 70% of patients although other 30% may deteriorate (Kingdon & Turkington, 1996) Evaluation of CBT for Schizophrenia

Read the Case study and answer the questions on the worksheet Bradshaw’s – ‘Carol’

Extension Apply your knowledge: You have a friend that you believe has schizophrenia. You have been asked to explain to them why they might have schizophrenia. They also ask you about which treatments you would recommend. Which explanations / treatments would you share with them? Are there any that you would leave out?