Psychological Therapies for Schizophrenia: Family and Cognitive Interventions
February 2007, Vol. XXIV, No. 2
The present state of research provides sound evidence for the efficacy of psychological therapy in the treatment of schizophrenia.”1
It used to be clear that talking about symptoms to those with delusions and hallucinations was not only unwise but might also make things worse. This view related to old ideas that “madness” was a way of preserving the ego, and if the madness were dismantled by insight, the resulting collapse would lead to depression and suicide. It also related to the newer idea that talking about symptoms would positively reinforce them. Either way, it was something to be avoided. Published evidence confirmed some of this caution. Intensive psychodynamic therapy had been shown to make some symptoms worse2 and a subsequent meta-analysis of psychodynamic treatment for psychosis found no evidence for a positive effect.3
However, other verbal and social interventions have begun to show some promise when used with optimal medication, and this article will focus on these interventions. Specifically, there is good evidence that family intervention (FI) in schizophrenia can reduce relapse rates and improve social functioning.4 There is also evidence that cognitive-behavioral therapy (CBT) can be adapted from its successful treatment of panic disorders,5 posttraumatic stress disorder,6 obsessive-compulsive disorder,7 depression,8,9 and borderline personality disorder10 for treating patients with positive symptoms of psychosis.4,11 In addition, there is some evidence that therapies such as social skills training12 or cognitive remediation aimed at improving memory and attention13 can be helpful for negative symptoms by improving motivation or poor confidence, or by helping to recover work skills. However these are not “psychotherapies” as the term is usually understood.
FI has quite an extensive evidence base, with more than 30 randomized controlled trials. The evidence suggests that a combination of education and improved communication (particularly listening and negotiating skills), problem solving, and processing of emotions such as grief and loss can be helpful both for family members and for affected individuals once there has been an episode of schizophrenia.1,4,14,15 In the United Kingdom, the National Institute for Health and Clinical Excellence guideline for schizophrenia recommends FI when the patient has persistent or relapsing symptoms and has access to a caregiver.16 Although several manuals have been written and disseminated,17-21 one of the problems in trying to apply FI to patients with schizophrenia is that social networks are dramatically reduced22 and, particularly in the inner cities, there may be fewer than 30% of patients who either can or are willing to identify a caregiver.
FI is also rather intensive in time and staff effort. The evidence is currently best for individual family treatment and for it to continue for longer than 6 months, or at least 10 sessions.16 Most manuals suggest that teams of 2 staff members work with the families, and home visits are encouraged to improve engagement; thus, family visits may need to take place outside of normal working hours. Because of these, as well as other logistical reasons, such as lack of support for trained staff, the use of FI has been limited.23 The one exception is the use of teams during early intervention, when families are more likely to be intact and patients may not yet have left home. Involving caregivers in the early stages is reasonable, and there is evidence that it has had some success.24,25
Individual CBT for psychosis
Individual cognitive work for psychosis is most like psychotherapy for other disorders in that outpatients are seen weekly or fortnightly for up to an hour by a therapist. As with FI, CBT should be used in addition to a range of other community, social, and vocational support interventions and in combination with optimal antipsychotic medication. Current evidence shows that low-dose typical antipsychotics can be as effective as atypical medications26,27 but that up to 40% of those with psychosis may still have distressing positive symptoms. Those with distressing, ongoing positive symptoms, despite adequate medication (typical or atypical), are the group to whom considerable psychotherapeutic effort has been targeted and which continues to have the best evidence for outcome so far.1,4,28,29
The evidence base for the use of CBT for psychosis is still developing, with many studies based in the United Kingdom. Given the pessimistic therapeutic climate associated with schizophrenia, early studies concentrated on dealing with distress and ensuring that therapy did not make things worse.30-36 Initial studies showed that supportive therapy was helpful, even if its effects were not usually long-lasting. Other studies looked at intervention in acute conditions,37 in early episodes with brief treatment for acute states,38 in relapsing groups,39 with brief treatment offered by frontline community staff and not by “experts,”40 and specifically for those with auditory hallucinations.41
Effect sizes remained moderate at 0.37 in the meta-analyses by Tarrier and Wykes28 and Zimmermann and colleagues29; and 0.47 in Pfammatter and colleagues' analysis.1 One longer-term follow-up study of 2 trials found that gains did not tend to continue and that as few as 10% maintained symptomatic improvements more than 2 years after treatment.42 Tarrier and Wykes28 have criticized the methodology of early trials and claimed that better results were to be found in poorer-quality trials; other investigators have disagreed.29
Overall, evidence is accumulating that, particularly for those with persistent symptoms, specifically delusions, longer treatment duration may reduce symptoms, at least in the medium term.1,4 For persistent hallucinations, there is some evidence that changing beliefs can reduce distress.41
In trials of CBT with prodromal groups (patients with a relatively high risk of transition to psychosis), the evidence is more tentative. A study by McGorry and colleagues43 has shown no real changes with CBT and medication in reducing transition to psychosis over the longer term. In their study, Morrison and colleagues44,45 offered CBT alone and found early indications that this can be helpful, but the rate of transition to psychosis (around 20%) was not high for either the intervention or control group. Some studies have shown that relapse rates46 and social functioning47 can be improved with early intervention (after one episode of psychosis) and that both intervention and control groups improve over time,48 while others have shown reduced transition rates but no long-term clinical effects.49
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.
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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