Evaluate Evidence for a Psychological Intervention for Schizophrenia

Clinical Psychology Assignment

Evaluate the evidence for a psychological intervention for schizophrenia. Is there sufficient evidence to justify its use?

There are perhaps two main prongs to the development of Cognitive Behavioural Therapy as an intervention for schizophrenia, the first being based upon the sizable research that centre on family interventions, which have been successful in reducing patient relapse in schizophrenic families (Pilling et al., 2002). Family interventions are important to consider as they became established treatments during a phase where drug treatments were the main focus of attention in this field and so opened the area of non biological treatment for schizophrenia. And as I will touch upon later drug therapies are frequently used to reduce psychotic symptoms and relapse but these treatments rarely provide the answer, with as many as 50% of patients suffering from persistent psychotic symptoms when adhering to pharmacological treatments (Dickerson, 2000).

The other aspect that has seen CBT be considered as a treatment for schizophrenia is that it has been effective in treating a range of non-psychotic disorders both mild and more serious (e.g., Hawton, Salkovskis, Kirk, & Clark, 1989; Clark & Fairburn, 1997). The range of effective CB therapies stem from early studies where depression and anxiety disorders were the subject of interest (Beck et al., 1979; Barlow, 1988) to more serious psychotic disorders, such as bipolar disorder (Basco, Rush, 1995; Perry et al, 1999) and personality disorders (Beck et al, 1990).

While the success of family intervention, a non drug related therapy, and CBT's success in treating various disorders provide evidence for the potential of CBT in treating schizophrenia they have been developed amid a backdrop in which drug therapy has been extensively explored, but has failed to produce a whole solution to the complexities exhibited by schizophrenia sufferers. It is likely then that as an intervention for schizophrenia CBT will provide a part solution rather than an all-encompassing answer. Detailed study of patients' experiences has led to a greater understanding of the stress suffered by patients who go on to develop coping mechanisms, which can be treated using CBT, to deal with the symptoms of their illness (Mcnally, Goldberg, 1997). The fact then that there are so many aspects to this disease means that it would be impossible to provide a comprehensive review in this paper but I will discuss a number of aspects within the field.

Cognitive Behavioural Therapy has largely emerged from the UK where a number of centres have developed CBT conventions and tested them in clinical trials.

In a study by Jackson et al, 1998 in which the therapist engages with the patient shortly after the first psychotic symptoms have subsided. The focus of the therapy is the patient's adaptation to the psychotic illness and secondary symptoms. Patients who received CBT and those who refused CBT were compared with those who did not qualify for CBT on either of the conditions and who lived outside the region. When compared with the control group those who received CBT adapted better to the illness, understood the illness more (the Explanatory model), scored better on the Quality of Life Scale and the Scale for the Assessment of Negative Symptoms (SANS). However the CBT group only outperformed the CBT refusal group on the adaptation to the illness. There was no significant difference in the relapse rates of either group. This particular study is limited by pre-treatment differences. The control group had a mean duration of psychosis of 91 days and the CBT patients 19 days; also the reliability of the study was not reported. Thus this study which focused

on early intervention showed only slight benefit of CBT.

As-well as help the patient to adapt to their illness early on, cognitive interventions can also challenge the patient's long held belief system by verbally challenging the system and reality testing. Pointing out irrationalities and inconsistencies in the belief systems of patients creates a clear dichotomy to the patient who then adapts their belief system to a more rational and positive one. Studies that have done this have received positive outcomes but are limited by the self-report nature of the therapy sessions. Three studies carried out by Chadwick and Lowe with a total number of 12 patients, who had all held delusional beliefs for more than two years showed positive results. 10 out of 12 patients showed a weakening of their delusional beliefs and 5 out of 12 rejected their delusions altogether. (Chadwick and Lowe, 1990, 1994; Lowe and Chadwick, 1990; Chadwick et al., 1994) Patients also reported a 25% reduction in preoccupation and anxiety over the course of their treatment.

Another small related study carried out by Chadwick and Birchwood (1994) but centred on hallucinations also proved successful in reducing the strength of beliefs for 3 of the 4 patients studied, dropping from almost 100% to less than 25% in those cases. Where this change occurred it fostered major life changes.

While providing support for the verbal challenge as a viable intervention for aspects of schizophrenia it is at best preliminary and as mentioned the outcome measures are not objective but self reported. Perhaps more importantly the studies use very narrow patient populations.

This work on delusional symptoms created a bright outlook for CBT as an important adjunct treatment for individuals with residual symptoms of schizophrenia. It demonstrated that the belief systems of patients were robust enough to resist CBT and given the right therapeutic environment the patient would respond to reality testing.

Where Chadwick and Lowe's studies were relatively short term, the last follow up was at 6 months, a long-term trial of CBT is reported by Wiersma et al (2001). This study combined CBT with coping skills training and targeted auditory hallucination. Unlike the previous studies mentioned this used a larger sample of 40 patients and was long term, conducted over four years. The results indicated that there were positive reduction of hallucinations and their burden to the patient. The majority of patients had over five years of contact with psychiatric services. The assessment tools used were the Auditory Hallucinations Rating Scale (Haddock, 1994) and the Positive and Negative Syndrome Scale (Key et al, 1987). The results of the study showed that 7 patients had a complete recession of hallucinations and 24 patients improved with regard to anxiety, loss of control and thought disturbance. Perhaps most encouraging is the fact that daily functioning improved for 26 patients. However specific