Specification: Cognitive behaviour therapy and family therapy as used in the treatment of schizophrenia. 

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is based on the assumption that schizophrenic patients can be helped by identifying and changing their faulty cognitions. It is the main psychological treatment used with schizophrenia, and the NICE (2014) recommends that all patients with schizophrenia are offered this treatment. 

The basic assumption is that people with schizophrenia have distorted beliefs which influence their behaviour. A person with schizophrenia may believe that they are being controlled by someone or something else. These delusions are thought to result from faulty interpretations of events, and CBT is used to help the sufferer identify and correct these distorted irrational beliefs. Therefore, CBT aims to help people with schizophrenia by changing the maladaptive thinking, and distorted perceptions which are thought to underpin the disorder, to modify and ultimately improve their symptoms (e.g. hallucinations and delusional beliefs). 

The type of CBT offered to people with schizophrenia is often referred to as Cognitive Behavioural Therapy for Psychosis (CBTp) and was originally designed to help with the residual symptoms (long-term) that persist with antipsychotic medication. 

What is the process of CBTp? 

Note: Antipsychotic drugs are usually given first to reduce psychotic thoughts; this is to make the CBT more effective. 

1. CBTp usually takes place once every ten days for 12-16 sessions. The NICE organisation recommends 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. Patients are also taught to recognise the signs of relapse. 

4. Drawings are often used to display links between the sufferer’s thoughts, actions and emotions. 

5. Cognitive techniques are developed between patient and therapist such as: 

   • Distractions from intrusive thoughts. 

   • Challenging the intrusive/irrational thought thoughts (for example, looking for evidence that disproves the thought so they can identify they are not based on reality). 

   • Increasing/decreasing social activity to distract them from the thoughts. 

   • Using relaxation techniques (for example, meditation or muscle relaxation). 

6. This therapy relies on the patient taking an active part, and they are given 'homework' between sessions, like keeping a diary of the contents of their delusions. Later on, their homework might be to try out ways of coping which they have learned during therapy. 

7. During the therapy the therapist lets the patient develop alternatives to any previous maladaptive explanations, ideally looking for alternative explanations and coping strategies that are already present in the patient’s mind. 

Evaluation of CBT

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. 

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 oneto-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. Also, Kuipers et al. (1997) found that patients had lower drop-out rates and higher satisfaction when CBTp was used with antipsychotic medication. This illustrates that when CBTp and drugs are used together, both treatments become more effective. However, it must be noted that CBTp was being used in conjunction with drug treatment. Therefore it is hard to distinguish whether it is the combination of both treatments or just CBT alone which is being effective and therefore no firm conclusions about the effectiveness of CBTp can be drawn from these studies. 

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. 

CBTp has fewer side effects in comparison to drug therapy, for example, sufferers are not at risk of other physical problems like tardive dyskinesia or diabetes. However, CBTp is a more expensive treatment, and with cost being a key factor at a time of reduced health-care budgets, 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. Haddock et al. (2013) found that only 6.9% of their sample of 187 sufferers were offered CBTp. 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. 

Many psychiatrists state that people with schizophrenia do not benefit from CBT and that is not appropriate for everyone with schizophrenia. Kingdon et al. (2006) state that in a study of 142 patients in Hampshire, there were many patients that were not deemed suitable for CBT. This was because they would not fully engage with the therapy. Interestingly, they found that older patients were less suitable than younger ones. It might be that CBT is not suitable and therefore appropriate for all patients, especially those who are too disorientated, agitated or paranoid to form trusting relationships with therapists. It may be more appropriate for those refusing drug treatments. However, such patients are often so highly disturbed, that it is difficult to undertake CBTp effectively. 

Research into the effectiveness of CBT has been criticised. For example, Jauhar et al. (2014) performed a meta-analysis of 50 studies of CBT for schizophrenia conducted over the last 20 years, finding only a small therapeutic effect on symptoms, including positive ones like delusions and hallucinations, which apparently CBT targets specifically. Even this small effect disappeared when only studies using blind testing were considered. Blind testing is where the researchers are not aware which patients have been given CBT. Meta-analysis is regularly used to assess the effectiveness of treatment. However, blind testing is not routinely used in the research into CBT’s effectiveness, which calls into question the research’s validity. Also, some studies fail to randomly allocate participants to either CBTp or a control group; others fail to mask the treatment condition for interviewers carrying out the assessments. Wykes et al. (2008) found that the more rigorous the study, the weaker the effect of CBT on schizophrenia. 

Family therapy

Also known as family-focused therapy, this is a form of psychotherapy. It is 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. Therefore, this treatment involves the whole family, not just the sufferer. NICE (2014) recommends that family therapy should be offered to all individuals diagnosed with schizophrenia, who are in contact with or live with family members. It should be a priority where there are persistent symptoms or a high risk of relapse. 

The main aims of family therapy are to:  

• 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. 

Family therapy forms a part of an overall treatment package and is commonly used alongside drugs and outpatient clinical care. 

How does it 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. 

2. They are taught to support each other and be caregivers, with each person given a specific role in the rehabilitation process.

3. 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. 

4. Like CBTp it is given for a set amount of time, usually between 3 months to a year, and at least ten sessions.

5. 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. 

6. 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

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 (that is they took their medication more easily and willingly) 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. However, critics argue that the findings are less to do with any improvements and more to do with the fact that it increases medication compliance - the patients are more likely to benefit from the drugs because they are more likely to comply with their drug routine. Therefore, the results may not be due to the family therapy. Nevertheless, McFarlane et al. (2003) also conducted a metaanalysis and confirmed that family therapy reduces relapse rates, leads to symptom reduction and improved relationships among family members, which leads to increased well-being for patients. This further suggests that family therapy is an effective treatment. 

Some critics of the therapy argue that the nature of the therapy causes problems. With the emphasis on ‘openness’, there can be an issue with family members being reluctant to share information, as it may cause or reopen family tensions. Some might not even want to face up to the issues, which lowers the effectiveness of the treatment as without family members being honest and engaging fully, the treatment cannot tackle the faulty family communication. 

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. 

Family therapy appears to be 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. Although a combination of drug and family treatments is desirable, due to cost constraints, it is often not possible of offer a combination. However, the Schizophrenia Commission (2012) estimates that family therapy is cheaper than standard care (drugs alone) by £1,004 a patient over three years, 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 associated with the therapy. 

Possible exam questions

1. Outline and briefly evaluate one study in which a form of psychological therapy was used to treat schizophrenia. (4 marks)

2. Evaluate the use of family therapy to treat schizophrenia. (8 marks)

3. Nigel has gone to see a psychologist because he is suffering from schizophrenia. He has delusions that he has superpowers and he says that he knows what people are going to say before they speak.
   Suggest how a cognitive psychologist could use CBT to treat Nigel and briefly discuss the effectiveness of using CBT in this case. (8 marks)

4. Describe and discuss the effectiveness of psychological therapies for schizophrenia. In your answer, refer to evidence. (16 marks)

5. Discuss the view that schizophrenia should be treated using psychological therapies view. (16 marks)

6. Patients with schizophrenia are mostly treated with anti-psychotic drugs. Describe and discuss at least two other ways in which schizophrenia might be treated. Refer to empirical evidence in your answer. (16 marks)

7. Outline and evaluate two treatments for schizophrenia. (16 marks)

8. Outline and evaluate one psychological therapy for schizophrenia. (8 marks)