Psychological Therapies for Schizophrenia: Family and Cognitive Interventions

What does the treatment consist of?
Several manuals have been written for the kinds of CBT approaches that can be helpful.^50-52 There is more than one type of CBT for psychosis, but the differences are probably less evident than the similarities, and different client groups—for instance, those with early onset or those with persistent symptoms—are likely to have shaped most of the variations. Some therapists have emphasized enhancement of problem solving and coping,^30,34 along with normalizing of symptoms (such as the fact that hearing voices is not restricted to clinical groups alone),⁵³ while others have focused on the contribution of emotional states and on formulation and schema work. This can include the effects of long-standing schemas such as “I am useless” to ongoing depressive delusions or to distressing voices. Formulation work is likely to refer back to the way that previous experience in childhood, such as abuse, can relate to current symptoms. This type of CBT is similar to that offered to patients with persistant depression or anxiety states. ^11,54 Trower and associates⁴¹ have shown that tackling beliefs about voices, such as their perceived power, is more important than trying to directly reduce their frequency.

However, all groups have adapted CBT for depression and anxiety to the particular needs of patients with psychosis. For instance, the time needed to engage individuals who are psychotic in therapy—and more crucially, to forge a productive therapeutic alliance—is likely to be longer with this group and needs to be done more frequently, both in later and in earlier sessions (R. Rollinson et al, personal communication, 2006). Part of the skill of the therapist is to engage individuals who may be perceived as suspicious and isolated and who may not have had any successful relationships since the start of psychotic episodes.⁵⁵

Virtually all therapies emphasize the importance of individually tailored and formulated treatment plans designed in collaboration with the patient so that both the patient and the therapist can see the rationale behind suggested homework and interventions. Given that patients, particularly in the persistent-symptom groups, may be both unmotivated and paranoid, transparency in sessions is particularly important. Therapists may have to be more than usually alert to the mental state of a patient during a session and be prepared to be flexible about timing or venue. It may be helpful to cut a session short or see the patient outside of a clinic, such as at home or in a cafe. It can also be useful for the therapist to take responsibility for a session in a way that would not always be indicated in other conditions, such as apologizing for inadvertently upsetting the patient.

In addition, it must be kept in mind that this population may have problems with working memory and attention⁵⁶ and that many patients have problems with information processing and contextual integration.^57,58 These patients may have problems with self-monitoring,⁵⁹ attribution biases,⁶⁰ and reasoning biases such as jumping to conclusions.⁶¹ Difficulties with these cognitive processes can make therapy more difficult and should be assessed and compensated for during sessions.

Other research has made it clear that symptoms such as hallucinations relate to depressed mood and negative schema⁶² and that anxiety and depression relate to paranoia.⁶³ We now know that high levels of conviction in delusions relate to reasoning biases, poor cognitive flexibility,⁶¹ and a lack of alternative explanations.⁶⁴ Thus, in terms of interventions, things such as activity scheduling, anxiety management, and some schema work may be indicated. For those with high conviction, use of disconfirmation strategies and discussion of alternative possible explanations can be helpful. Prior discussion of reality testing and provision of a range of explanations may help dismantle safety behavior—such as social avoidance—which can lead to more isolation, reduced social opportunities, and a tendency to find out that difficulties can be overcome. For example, if a person does go out and no one follows, does that mean that it is an unusual day, that they have been “mad” to have worried about this, or that perhaps it is possible to go out because not all of their fears may be justified?⁶⁵

We also know that a range of adverse environments, from social adversity to criticism from family members, may make outcomes worse for individuals,^66-69 probably via their effects on patient anxiety⁷⁰ and poor self-esteem.⁷¹ Furthermore, support may also be needed to reduce isolation and to improve relationships with caregivers.^17-21

Issues for clinical practice in the community
At present, the emerging evidence seems to support a judicious awareness that talking about distress and symptoms of psychosis can be helpful. Taking patients' views seriously about the difficulties that voices or delusions cause, while trying to improve their understanding of the issues, is indicated. For many, particularly those who hear voices, difficulties will be rooted in the past, and relating them to previous memories or events might be of use. For others, taking a view that emotional issues can make these symptoms worse suggests that straightforward help with reducing anxiety, depression, and obsessional ways can all be attempted and will likely reduce distress. This can be combined with a sympathetic discussion of the difficulties of taking long-term medication and an understanding of how this can be optimized. Finally, reducing social isolation and improving community support, either directly via concerned family members or via supported housing or employment, would also be indicated to reduce emotional distress and improve self-esteem and effectiveness where possible.

Conclusion
Psychological interventions for psychosis are beginning to have an evidence base. The reasonably robust evidence for FI has been around for approximately 20 years, and evidence for CBT has been emerging over the past 10 years. However, there is room for improved effectiveness in both therapies. Neither FI nor CBT for psychosis are widely available, and both are relatively time intensive and require highly trained and supervised staff.

At present, the emphasis needs to be on improving our understanding of the psychological processes that underlie symptoms of psychosis, so that interventions can be better targeted for greater effectiveness. It seems likely that such interventions are best aimed at specific groups of patients, perhaps those in the prodromal phase or those with persistent symptoms and distress, rather than being used for all patients with these problems.

It is possible to offer structured, specific ways of talking to people with psychosis about delusions and hallucinations. This does not seem to make them worse, and for some it can be helpful. The challenge for the future is to improve these therapies and their persistence and then to make them more available.

Dr Kuipers is professor of clinical psychology and head of the department of psychology at the Institute of Psychiatry at King's College, London. She reports that she has no conflicts of interest concerning the subject matter of this article.

Acknowledgments: Some of the research quoted in this article was supported by Programme Grant 062452 from the Wellcome Trust, UK, held by Garety P, Kuipers E, Fowler D, Bebbington P, Dunn G.

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Evidence-Based References

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• Pilling S, Bebbington P, Kuipers E, et al. Psychological treatments in schizophrenia, I: meta-analysis of family intervention and CBT. Psychol Med. 2002;32:763-782.