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CONITIVE BEHAVIORAL THERPAY IN RELATION TO
SCHIZOPHRENIA
What is COGNATIVE BEHAVIORAL THERAPY:-
Cognition” has more than one
meaning. Cognitive–behavioral therapy refers to therapies that work on changing
automatic thoughts and resulting schemas. When effective, cognitive therapy
helps patients:
• Become aware of automatic thoughts
• Appreciate how these lead to
schemas that distort global perception and limit one’s repertoire off responses
• Question and alter thoughts and
schemas and thus achieve cognitive restructuring
A common metaphor for successful
cognitive–behavioral therapy is that a patient comes in seeing the glass as
“half empty” and leaves able to see that even “half–empty” glasses are
simultaneously “half full .In contrast, cognitive remediation, developed by
neuropsychologists who initially used techniques for helping persons with
traumatic brain injury, uses exercises—many computer– based—and other
techniques to help patients with deficits in underlying processes that lead to
disruptions in thinking. Cognitive remediation is focused not on distortions in
global schemas but on neurocognitive processes that need to be either
strengthened or bypassed by auxiliary pathways.
Cognitive-behavioral treatment (CBT) has been widely used and its effectiveness established with numerous patient populations and problems (Beck, 1993). However, there has been limited application of CBT techniques in the treatment of persons with schizophrenia and little research regarding its efficacy with this population. This neglect may be due to the dominance of pharmacological treatment and the decline of psychotherapy, the severity of the disorder, or the inadequacies of previous attempts to understand and manage schizophrenia from a cognitive behavioral framework (Birchwood & Preston, 1991; Goggin, 1993)
Cognitive behavioral therapy (or cognitive
behavioral therapies or CBT) is a psychotherapeutic
approach that aims to solve problems concerning dysfunctional emotions,
behaviors and cognitions through a goal-oriented, systematic procedure. The
title is used in diverse ways to designate behavior therapy, cognitive therapy, and
to refer to therapy based upon a combination of basic behavioral and cognitive
research.
Several
meta-analyses have shown CBT effective in schizophrenia and the American Psychiatric Association includes CBT in its schizophrenia guideline as an evidence-based
treatment. There is also some limited evidence of effectiveness for CBT in bipolar disorder and severe depression
CBT can help patients with severe mental disorders to make sense of experiences that lead to symptoms, and to associate key thoughts and feelings with factors that predispose to or precipitate them. For instance, it can help to make rational connections between precipitating
causes such as stimulants or hallucinogenic drugs and symptoms such as
psychotic episodes. With the help of a therapist, patients may even devise and
carry out behavioral experiments that can help them to learn how to improve
their quality of life.
CBT is a combination of psychotherapy and behavioral therapy. It works by changing people's attitudes and their behavior by focusing on their thoughts, images, beliefs and attitudes and how these relates to the way they behave.
STEPS TO COGNITIVE RESTRUCTURING--Follow these steps to change your own
thinking.
1. Identify FEELINGS/EMOTIONS and other CONSEQUENCES/OUTCOMES.
> Identify both
positive (reinforcing) and negative outcomes
> Identify both
internal (emotional/feedback) and external outcomes.
2. Identify SITUATIONS & STIMULI/CUES initiating the sequence of
events. Also,
identify similar situations where you use similar unproductive ways of dealing
with events. See what these situations have in common and identify how they are
different (a la Kelly)_ from situations where you use more productive means of
dealing with them.
3.. Identify UNPRODUCTIVE BEHAVIORS (eg. Avoidance, aggression, defensiveness,
addictive behaviors, etc)
4. Identify THOUGHTS that preceded the unproductive behaviors and feelings. Also,
search for UNDERLYING BELIEFS or COGNITIVE BIASES which are generating the
unproductive thoughts.
5. Question the "rationality", productiveness, and consistency
with your newer "higher self" belief system.
6. Develop NEW, more constructive UNDERLYING BELIEFS and SPECIFIC
THOUGHTS that can be used in that or similar situations.
MORE POSITIVE
STRATEGIES:
> FOCUS ON MY
THOUGHTS AND ACTIONS. I realize that I can only control my thoughts and
actions--I have no control or responsibility for what others or the world does.
I will learn to focus on my thoughts and actions and "let go" of the
effects of my actions.
> All humans make
lots of mistakes--I am only human.
> An overall goal
is my personal growth and learning. In order to learn I must risk and make
mistakes. I can learn from even the worst of events.
> I am
experimenting with new approaches and will learn through trial and
error--errors are important.
7. PRACTICE using these new beliefs and thoughts. Keep repeating this
process until the new beliefs and thoughts become completely automatic
responses to these types of situations/cues.
1. George Kelly-The Psychology of Personal Constructs
2. RATIONAL EMOTIVE THERAPY--ALBERT ELLIS
SOME COMMON "IRRATIONAL" BELIEFS
* I must be
LOVED/APPROVED OF by ALMOST EVERYONE.
* I must be
THOROUGHLY COMPETENT at ALMOST EVERYTHING.
* Some people are
"BAD" PEOPLE and must be SEVERELY PUNISHED.
* If things aren't
the way they "SHOULD" be or the way that I want them, then it is
CATASTROPHIC. (Eg. "I cannot live without being loved by someone, life
would be too terrible to face.")
* EXTERNAL FORCES
(including other people) largely control human (or my) happiness. There is
little I can do to change my feelings.
* It is EASIER (and
less painful) to AVOID difficult feelings or situations than to face them
directly.
* People (or I) am a
slave to my PAST HISTORY. (Eg. "My parents divorce, rejection, alcoholism,
abuse, etc. has affected me so much that it has ruined my chances for happiness
forever.")
"MUSTERBATION"==>
"SHOULDS" & "MUSTS" that are internalized without
understanding and agreeing with the reasons and consequences are
"irrational". In general it is better to rephrase these
sentences--see below.
3. COGNITIVE THERAPY (or "Cognitive Restructuring")--AARON BECK,
et al.
OUTCOMES
* Best evidence of
any approach for dealing with depression (including persons who are suicidal).
* Strong evidence of
effectiveness in dealing with anxiety and panic disorders.
* Scattered evidence
of success in many other applications.
IMPORTANT TYPES OF COGNITIVE BIASES IN DEPRESSION & OTHER DISORDERS
* NEGATIVE BIAS--a
tendency to look at the more negative side.
> Perception of
Events (past, present, etc) (Eg. See "dark" side.)
> Expectation of
outcomes for self/world (Eg. Pessimistic)
> Self-evaluations
(Eg. Very self-critical)
> Negative
explanations (Eg. Assume worst of peoples motives)
INSTEAD--I will
think:
> I will be
happier and more motivated if I assume the best.
> If I make a
mistake in the direction of being too negative I will have worried and been
negative for nothing. If I make a mistake in the direction of being too
positive, at least I will have been happy and motivated up until the time I
found out the truth. Even then I can deal with the negative events.
> Positive
self-fulfilling prophesies tend to create positive outcomes and self-fulfilling
prophesies tend to create negative outcomes.
> Negative
self-evaluation leads to depression, guilt, anxiety, or frustration. It is
de-motivating and unproductive in meeting my goals and making me happy.
Positive self-motivation creates energy, direction, and happiness.
> Negative
explainations of my own or other peoples "underlying motives" cause
me to intensify my anger or other negative feelings toward that person. It
builds conflict, distance, and animosity in relationships. Assuming the best,
is more often accurate with those we are close to, and builds harmony, trust,
and closeness.
> Assuming the
world is a hostile, unfriendly, negative place creates feelings of fear,
anxiety, and anger toward. Viewing the world as more positive and accepting
even the worst as necessary and out of my control gives me a feeling of peace
and acceptance of the world.
> If I view my
current state as deprived, unfair, and not begin given the opportunties others
have had, then I will be constantly resentful and unhappy. If I view my current
state as being a gift that I was not "owed", and am grateful for all
I have and every minute of my existence, then I will feel happy.
* SELECTIVE ABSTRACTION--Taking
negative features of a situation out of context and exaggerating their
significance while downplaying positive features. Eg. If a Sam gets 4
"A"s and one "C", he focuses on the "C".
> I will list at
least one positive for each negative.
* OVERGENERALIZATION
(or magnification)--assuming far-reaching conclusions from very limited data.
For example, making an "F" on a test and getting thoughts of how you
will flunk the entire course, flunk out of school, and how you are a very stupid
person.
INSTEAD:
> I will put the
negative event into its proper perspective.
> I will step into
the future one or more years and look back and see how important this event
really was.
> I can keep
"blowing" up this event until it becomes ridiculous and I can see how
ridiculous "overgeneralizing" really is.
* THINKING IN
EXTREMES--exaggerating differences. Everything is either good or bad, wonderful
or awful, always or never. A person who thinks this way often uses this radical
categorization of their own and other persons behavior--leading to exaggerated
emotional reactions.
> I will learn to
realize that there are no "NEVER", "ALWAYS", 100% your
fault or my fault events. Instead I will always try to be accurate in balancing
out "causation" or "blame". If I state an absolute, I will
immediately begin LOOKING FOR EXCEPTIONS to that rule, not find more supporting
evidence.
4. "STRESS INOCULATION" -- DONALD MEICHENBAUM
Use of imagery and
cognitive restructuring to prepare yourself for anticipated stressful
events--such as surgery. It works in reducing peoples anxiety level.
5. LINGUISTIC THERAPY METHODS--Example: Rudestam
(Ideas overlap
cognitive therapy ideas above.)
LINGUISTIC HABITS WITH "IRRATIONAL BELIEF" INFERENCES
* "SHOULD",
"MUST"--can imply internal or external "authority" that
cannot be questioned or understood.
OUTCOMES-- give up
your power & deny responsibility
REPLACE WITH--"I
WANT" or give reasons/outcomes why you choose it.
* "CAN'T",
"WON'T"--can imply inability/incompetence.
OUTCOMES-- deny its a
problem of choice or motivation. Lower self-confidence.
REPLACE WITH--"I
CAN, BUT I CHOOSE NOT TO TAKE THE TIME/ENERGY TO.."
* "YOU MAKE ME
[feel, etc]..."-- implies that others control you or your feelings.
OUTCOMES -- deny
responsibility for own feelings. Lowers self-confidence and self-control over
own feelings, etc.
REPLACE WITH --
"WHEN YOU ..., I ALLOW MYSELF (or "choose") TO FEEL ..."
* CONFUSING FEELINGS
WITH THOUGHTS -- implies that you are not really in touch with your feelings
[are "intellectualizing"]. Eg. "I feel that I am not going to
finish this paper on time."
OUTCOMES -- avoids
facing or dealing with, or telling others of threatening or embarrassing
feelings.
REPLACE WITH--
ACCURATE USE OF FEELING WORDS. Eg. "I feel embarrassed and angry with
myself, because I am not going to finish this paper on time."
* UNCLEAR OR MISUSE
OF PRONOUNS or INDEFINITE NOUNS -- Eg. "Lifes a bitch, and then you
die." "The administration makes life miserable for us." "We
(you and I) would never believe such a stupid thing."
OUTCOMES -- can lead
to avoiding responsibility or manipulation of others.
REPLACE WITH-- CLEAR,
HONEST, STATEMENTS USING I, YOU, ETC PROPERLY. "I AM very unhappy with MY
life." "I DON'T UNDERSTAND why MY BOSS asked ME to redo this
report." "I would like for YOU to BELIEVE..."
* INAPPROPRIATE
STATEMENTS OF DEFERENCE TO OTHERS
> "LET
ME"-- can imply seeking permission and approval.
> INAPPROPRIATE
APOLOGIZING-- can imply insecurity and lack of self-confidence.
OUTCOMES -- deference
to other's, lowered self-esteem.
REPLACE WITH --
"I WOULD LIKE TO..." Replace apologies for behavior you are really
glad you did with attempts at helping others deal with THEIR unhappiness or
problem about what you did.
* MIXED MESSAGE
AGREEMENTS [such as "okay" or "all right"] often said in
with reluctant overtones. A form of "passive aggression".
OUTCOMES--"dishonest",
"hidden", "passive" message to self and other that you do
not really want--and possibly do not really intend--to do it. Or negative
messages of your unhappiness to "get even" with the other for
coercing you into doing it.
REPLACE WITH--Deal
DIRECTLY WITH YOUR NEGATIVE FEELINGS/RESERVATIONS until they are resolved.
Either EXTERNALLY deal with them directly with the other person until they are
resolved, or truly INTERNALLY ACCEPT THAT YOU WILL TO WHAT YOU HAVE AGREED and
work at motivating yourself to do it enthusiastically.
6. DIRECT DECISION THERAPY -- HAROLD GREENWALD
DECISIONS-CHOICES ARE
FUNDAMENTALLY IMPORTANT FOR CURRENT ENVIRONMENTS, HABITS, IMPORTANT LIFE
SITUATIONS
* CURRENT COMMITMENTS
made by past decisions.
* PROCESS OF
RE-EXAMINING CURRENT COMMITMENTS
* MAKE NEW DECISIONS 
The ABCs of Cognitive-Behavioral Therapy for
Schizophrenia
Cognitive-behavioral therapy (CBT)
in schizophrenia was originally developed to provide additional treatment for
residual symptoms, drawing on the principles and intervention strategies
previously developed for anxiety and depression. In the 1950s, Aaron Beck1
had already treated a psychotic patient with a cognitive approach, but
thereafter the research in this specific area lay dormant for decades. Only
after cognitive therapy had been firmly established for depression and anxiety,
in the 1990s, did the research into psychological treatments for psychotic conditions
gather force—again, with Beck in the forefront.
Pharmacologic
therapy can leave as many as 60% of psychotic patients with persistent positive
and negative symptoms, even when the patients are compliant with their
medication instructions.Furthermore, medication compliance remains a major
problem despite the introduction of modern atypical antipsychotics. Studies
have shown treatment discontinuation in an estimated 74% of patients in both
outpatient and inpatient settings.
CBT is now recognized as an effective
intervention for schizophrenia in clinical guidelines developed in the United
States and in Europe. In spite of the evidence base and absence of side
effects, however, the general availability of this treatment approach within
community settings is still low. This article will examine the procedure of CBT
for psychosis, the evidence for its use, and the implications for practicing
psychiatrists.
PROCEDURE
The therapeutic techniques used for
patients with schizophrenia are based on the general principles of CBT. Links
are established between thoughts, feelings, and actions in a collaborative and
accepting atmosphere. Agendas are set and used but are generally more flexibly
developed than in traditional CBT. The duration of therapy varies according to
the individual's need, generally between 12 and 20 sessions, but often with an
option of ongoing booster sessions. CBT for psychosis usually proceeds through
the following phases.
Assessment
The assessment begins by allowing
the patient to express his or her own thoughts about his experiences while the
therapist listens actively. The use of rating scales—both specific and
general—is encouraged to monitor progress, and the results are shared with the
patient. Diagrams and written material can be most useful, especially for
patients with chaotic lifestyles. The formulation of symptom causation and
maintenance is also shared with the patient and evolves throughout the therapy
as new information is considered.
Engagement
stage
Initially the therapist will state
clearly what the therapy is about (including a safe and collaborative method of
looking at causes of distress). Throughout the therapy, the use of Socratic
questioning is emphasized. This involves drawing out the person's own
understanding of his situation and ways of coping with it through a process of
guided discovery. Attempts are made to empathize with the patient's unique
perspective and feelings of distress and to show flexibility at all times. A
vulnerability-stress model is used, so that the patient can understand that
vulnerability is a dynamic concept that can be influenced by many factors, such
as life events, coping mechanisms, or physical illness. The therapist stresses
that he or she does not have all the answers but that useful explanations can
be developed in cooperation. The typical nonspecific therapeutic factors of
warmth, genuineness, humor, and empathy are of great value in this type of
therapy, as in all other therapeutic encounters.
ABC
model
The ABC model, which was originally
developed by Ellis and Harper, can be used to give the patient a way of
organizing confusing experiences. It involves slowly and thoroughly moving the
patient through the various steps using Socratic questioning to clarify the
links between the emotional distress the patient is experiencing and the
beliefs he holds .
Goal-setting
Realistic goals for therapy should
be discussed early in the therapy with the patient, using the distressing
consequences (C) to fuel the motivation for change. It is the therapist's job
to ensure that the goals are measurable, realistic, and achievable. The goals
are revisited both during and at the end of therapy.
Normalization
A normalizing rationale is
helpful in decatastrophizing psychotic experiences. Education regarding the
fact that many people can have unusual experiences in a range of different
circumstances (stressful events, hyperventilation, torture, hunger, thirst,
falling asleep, etc) reduces anxiety and the sense of isolation. By having the
psychotic experiences placed on a continuum with normal experiences, the
patient will often feel less alienated and stigmatized. As a consequence, the
possibility of recovery seems less distant.
IMPLICATIONS
It would be wrong to believe that
CBT can only be used in formal therapy settings. Many aspects of the therapy
can readily be implemented in the day-to-day management of patients with
schizophrenia, including the ABC model, normalization, and the search for
alternative explanations. The use of these approaches does not necessarily
require formal training in CBT. On the other hand, the lack of supervision and
of fully accredited therapists are major obstacles in the development of a
service that lives up to the standard requirements.17 This area will
undoubtedly receive further attention over the coming years, especially as
patients and caregivers become more vocal about their needs and preferences.
How to Treat Schizophrenia with CBT
Cognitive-behavioral therapy (CBT) in
adjunction to pharmacotherapy seems to help the basic symptom control in
patients with schizophrenia. However, the success comes from modifying the
traditional form of CBT and applying the modifications as a long term therapy
to treat schizophrenia.
CBT and Schizophrenia
Schizophrenia patients have an aversion to seeking treatment due to the "voices" they hear and the control they feel others have over them. The first step is to control the
aversion to treatment using CBT and prepare the patient to benefit from psychopharmacology.
The CBT treatment is very patient centered and the clinician must accept the patients' goals and also accept the paranoia of the patient. Then this same paranoia should be used to seek the necessary treatment and assess the goals of the treatment.
The command auditory hallucinations (CAH) that make people with schizophrenia behave in destructive ways has to be used to control them. Without detracting from the importance of the message the clinician will use the "voices" to "outrank" them and create another base of control. The base lessens the importance of the CAH and creates a less destructive meaning to it. This works in accordance with regular treatment and medications.
·
Step
4
The CBT treatment must help clinicians control the
negative emotions of the patient. The depression, the low self-esteem and the
control of the "voices" is lessened through an understanding of the
same. The patient is taught to interpret the hallucinations in a more positive
manner and thus to an extent control them.
.
·
Step
5
The CBT treatment cannot treat people with
schizophrenia completely. However, the psychotic episodes may be reduced and
hospitalization terms may also be reduced through use of CBT and drugs.
There is strong evidence supporting the implementation of cognitive
behavior therapy (CBT) for
people with psychosis. However, there are a variety of approaches to the delivery and conceptual underpinnings within
different research groups, and the degree of consensus or
disagreement regarding what are
the intrinsic components has not been explored. This study uses
the Delphi method to try
to establish what a group of
experts in CBT for psychosis view as
important. Experts were invited to participate in 3 rounds of producing and rating
statements that addressed areas such as principles, assessment, models, formulation, change strategies,
homework, and therapists’ assumptions in
order to consolidate
consensus of opinion.
Seventy-seven items were
endorsed
as important or essential for CBT for psychosis by >80%
of the panel. These recommendations should ensure greater fidelity in clinical practice, allow greater evaluation of
adherence within clinical
trials, facilitate the development of competency frameworks, and be
of value in relation to training and
dissemination of CBT
for psychosis.
Difficulties in social skills are addressed by involvement in group treatment and planned group activities that include appropriate behavioral interaction and conversational topics. To be better able to cope with day-to-day living, the patient learns or re-learns more productive, acceptable behavior.
Other aspects of treatment deal with personal care, living skills, managing money and other practical matters. In many areas, people who have schizophrenia are able to receive assistance from local community mental health facilities and possibly qualify for a case manager. A case manager is someone who helps to ensure that the patient can get to appointments and group activities, monitors the progress of the patient and helps him apply for other available assistance.
Cognitive deficits are in the heart of schizophrenia. Because it effects the patients real-life functioning, they have remarkable negative impact on patient’ lives. These deficits hold back patients from their recovery period. Usually it accompanies with a longer hospital stays. It is important to know that Cognitive symptoms of schizophrenia can overlap with negative symptoms.
People with schizophrenia may experience a range of cognitive deficits, including problems with memory, psychomotor skills, and attention. To identify these problems, patients are given psychological tests that help distinguish premorbid traits from changes caused by the disease. The performance of patients on these tests can be broken down into several aspects of learning — such as decision-making, short-term memory, and short-term verbal learning — to help identify specific deficits and their impact on the patient’s life. For example, patients who are deficient in verbal learning (e.g., the ability to store and retrieve words for more than a few minutes) may have problems with learning and decision-making.
Many cognitive deficits may be seen during the first psychotic episode, during remissions, and in unaffected first-degree relatives. Thus, these problems may reflect fundamental features of schizophrenia and may even reveal a vulnerability to schizophrenia. Cognitive deficits are important symptoms because they can impair the person’s activities of daily living and rehabilitation. In fact, the severity of such deficits can predict how well a person will eventually function socially and vocationally.
Significant and widespread cognitive problems appear to exist in schizophrenia in its earliest phase, making it very
hard for people with the disorder to work, study or be social.
Understanding the early and
central role of cognitive problems may help clinicians to more accurately
diagnose incipient schizophrenia by telling it apart from other neuropsychiatric
disorders that also have cognitive problems, such as attention-deficit
hyperactivity disorder (ADHD).
It
could also allow them to provide more appropriate treatment. Combining
schizophrenia’s cognitive warning signs with family history and signs of
worsening daily functioning may also aid early diagnosis. Should improved early
treatments become available, early diagnosis could make it possible to ease or
even prevent these problems.
Cognitive psychotherapy, often incorporating
behavioral therapy techniques, has been found to be more effective than other
types of psychotherapy in treating several specific types of psychological
problems, including depression and panic attacks. Sometimes this treatment
approach is called cognitive-behavioral psychotherapy because of the ease with
which the two approaches combine to effectively treat a variety of
psychological problems. This combination of treatment techniques is also
effective in the treatment of schizophrenia.
The basic premise of cognitive therapy is that
beliefs, expectations, and cognitive assessments of self, the world, and the
nature of personal problems in the world affect how we perceive ourselves and
others, how we approach problems, and ultimately how successful we are in
coping in the world and in achieving our goals. Schizophrenia results in
distorted perceptions of the world, including self, and disordered or
disorganized thinking. It seems reasonable that a cognitive treatment approach
would be helpful in treating schizophrenia, assuming that medication is also
employed to alleviate psychotic thought processes which would interfere with
any psychotherapeutic interventions.
Behavioral therapy has been used in the treatment of
schizophrenia for many years, but usually within a structured psychosocial
rehabilitation program, rather than a part of an individual treatment approach.
There are many reasons for this. First, schizophrenia is seen as a life-long
illness, and few insurance plans were willing to provide coverage for treatment
in the private sector because of the anticipated expense. This continues
to be true, especially with managed care. The psychosocial rehabilitation
programs that incorporated behavioral treatments were usually either hospital
based, or funded by public money or non-profit grants. As such, budget
constraints would encourage group behavioral treatment, offered by treatment
providers with limited training or experience. These approaches demonstrated some
success, but the potential value of behavioral treatment was often lost within
the greater structure of the broad rehabilitation program. In other words, the
program as a whole was evaluated, rather than specific components of the
program. This is further complicated by the variety of rehabiltation programs
that incorporate many different behavioral treatment modalities. If no two
rehabilitation programs are identical, then it is difficult, or impossible, to
evaluate the relative effectiveness of specific components. However, an
assessment of the interpersonal deficits produced by schizophrenia predicts
which behavioral treatments are most likely to be effective.
Cognitive
Therapy with Schizophrenia
The
misinterpretation of events in the world is common in schizophrenia. Using
cognitive therapy with schizophrenia requires the psychologist to accept that
the cognitive distortions and disorganized thinking of schizophrenia are
produced, at least in part, by a biological problem that will not cease simply
because the "correct" interpretation of reality is explained to the
client. Cognitive therapy can only be successful if the psychologist accepts
the client's perception of reality, and determines how to use this
"misperception" to assist the client in correctly managing life
problems. The goal is to help the client use information from the world
(other people, perceptions of events, etc.) to make adaptive coping decisions.
The treatment goal, for the cognitive therapist, is not to "cure"
schizophrenia, but to improve the client's ability to manage life problems, to
function independently, and to be free of extreme distress and other
psychological symptoms.
Behavior
Therapy with Schizophrenia
Behavior
therapy assumes that certain skills increase our ability to function in the
world, and to solve problems as they arise. Many psychosocial skills develop as
a consequence of our experiences in the world. We "learn from our
mistakes" and from our successes in managing different types of problems.
Since people have different life experiences, some people learn skills well,
and others do not learn as many skills. Another individual difference, is our
ability to learn from our experiences. In order to learn from experience, we
must correctly analyze what was effective and what was not effective in solving
a problem. We can also "learn" ineffective or maladaptive responses
to problems, especially if those responses lead to immediate reduction of pain
or embarrassment, despite having no affect on the long term solution to the
problem. The learning of maladaptive responses top problems is often the result
of cognitive distortions or making mistakes in assessing cause and
effect. That is why cognitive therapy and behavioral therapy are often
combined. Individuals with schizophrenia often make incorrect assessments
of cause and effect. Also, they often do not learn as well from experience
because of their disordered and disorganized thinking. Behavior therapy teaches
them the social skills they never learned, and helps them understand when to
apply those skills to problems in the world.
Examples
of Behavioral Skills Training
Cognitive
Family Therapy with Schizophrenia
Cognitive
family treatment usually identifies the expectations of family members and how
those expectations affect their interactions with the person diagnosed with
schizophrenia. Additionally, connections are made between the family
expectations and their emotional response to their ill relative.
Appropriate expectations are explored, and problem solving sessions allow
family members to meet their own emotional needs. Family members frequently
need stress management training as well, and need to learn what their
limits are, and what to do when those limits are reached.
Cognitive behavioral therapy (CBT) is a form of psychotherapy in which the patient is given challenges to certain beliefs they have. Using changes in behavior and changes in the way people process certain ideas, a patient can try and understand the world differently. CBT is very often used to treat depression; patients often perceive the world negatively and put a negative spin on most thoughts. CBT is used to help change those perceptions to a view more based on reality. In this way, people with depression are more able to focus on their problems and solve them rather than letting them build up to insurmountable obstacles.
In
schizophrenia, CBT can be useful for many symptoms. Other studies have shown
benefits in stable outpatients in decreasing re hospitalizations, increased
social skills and decreased distress from symptoms such as voices and other
hallucinations/delusions. It also has shown benefit in treating negative
symptoms (flat affect, decreased pleasure, decreased emotion, etc.) However,
conventional wisdom used to hold that in an acute setting such as the hospital,
patients were too sick to utilize psychotherapy because they were too
symptomatic to concentrate on the ideas of the therapy.
·
Cognitive
approach
A theoretical analysis of schizophrenia based on a cognitive model integrates the complex interaction of predisposing neurobiological, environmental, cognitive, and behavioral factors with the diverse symptomatology. The impaired integrative function of the brain, as well as the domain-specific cognitive deficits, increases the vulnerability to aversive life experiences, which lead to dysfunctional beliefs and behaviors. Symptoms of disorganization result not only from specific neurocognitive deficits but also from the relative paucity of resources available for maintaining a set, adhering to rules of communication, and inhibiting intrusion of inappropriate ideas. Delusions are analyzed in terms of the interplay between active cognitive biases, such as external attributions, and resource-sparing strategies such as jumping to conclusions. Similarly, the content of hallucinations and the delusions regarding their origin and characteristics may be understood in terms of biased information processing. The interaction of neurocognitive deficits, personality, and life events leads to the negative symptoms characterized by negative social and performance beliefs, low expectancies for pleasure and success, and a resource-sparing strategy to conserve limited psychological resources. The comprehensive conceptualization creates the context for targeted psychological treatment.
Patients
with schizophrenia are impaired in both emotion perception and contextual
processing, however these two processes have not been thoroughly assessed
simultaneously in adults with schizophrenia. This study examined the impact of
social contextual information upon the perception of emotional intensity in
schizophrenia. 30 clinically stable outpatients with schizophrenia and 30
demographically matched healthy subjects assessed the intensity of a single
emotion (anger, disgust, happiness, sadness or fear) from images of people
presented under two conditions (context-free and context embedded). During the
first assessment, a single person (face and body) was presented without any background (e.g., contextual)
scenery. The second assessment included the same person but with the original
background of the image. Differences between the first and second ratings
provided an index of the extent to which contextual information was used to
judge emotional intensity. Without contextual cues, patients with schizophrenia
viewed scenes as having greater disgust and anger than healthy subjects.
Furthermore, patients were less impacted by contextual cues as evidenced by the
minute changes in their assessments. These results suggest that patients with
schizophrenia differ from healthy subjects in both their ability to rate
emotional intensity and the influence of contextual adjustment upon such
ratings.
A
clinical review of cognitive therapy for schizophrenia:
Major advances
have been made in the cognitive understanding and treatment of the symptoms of
schizophrenia, including delusions, hallucinations, and emotional withdrawal.
Experimental studies on the psychological aspects of schizophrenia demonstrate
the importance of information processing biases, such as cognitive biases and
distortions, that are functionally related to the maintenance of symptoms.
Understanding the aspects of schizophrenia in cognitive terms provides a
framework for psychotherapeutic intervention with the adaptation of the
cognitive strategies proven effective in the treatment of mood and anxiety
disorders. The authors of this paper first outline the cognitive conceptualization
and strategies employed by cognitive therapists to treat positive and negative
symptoms, and conclude with a summary of the empiric status of cognitive
therapy for schizophrenia. Cognitive therapy has been shown to be an important
adjunct to standard treatments of schizophrenia.
Early case studies and no controlled trial studies focusing on the treatment of delusions and hallucinations have laid the foundation for more recent developments in comprehensive cognitive behavioral therapy (CBT) interventions for schizophrenia. Seven randomized, controlled trial studies testing the efficacy of CBT for schizophrenia were identified by electronic search (MEDLINE and PsychInfo) and by personal correspondence. After a review of these studies, effect size (ES) estimates were computed to determine the statistical magnitude of clinical change in CBT and control treatment conditions. CBT has been shown to produce large clinical effects on measures of positive and negative symptoms of schizophrenia. Patients receiving routine care and adjunctive CBT have experienced additional benefits above and beyond the gains achieved with routine care and adjunctive supportive therapy. These results
reveal promise for the role of CBT in the treatment of schizophrenia although additional research is required to test its efficacy, long-term durability, and impact on relapse rates and quality of life. Clinical refinements are needed also to help those who show only minimal benefit with the intervention. Cognitive behavior therapy (CBT) has been demonstrated to be a useful adjunct to medication and other standard treatments for schizophrenia patients. Although the cognitive approach to schizophrenia has become popular in the United Kingdom, it has received relatively little attention in the United States. The present paper serves as on overview of CBT for schizophrenia, with an emphasis on delusions. We discuss the purpose and enumerate the challenges of conducting CBT with schizophrenia patients, providing specific case examples and strategies — such as normalizing, collaboration, behavioral experiments, understanding the meaning of patients' delusions, role-plays, and imagery exercises — for handling such challenges. It is concluded that CBT can lead to decreased distress associated with patients' symptoms.
Psychiatrists
generally agree that current treatment should offer both medical and
psychological treatment to the patient. Cognitive-behavioral approaches are
showing promise. Support to the family or other caregiver is also important for
the long-term improvement of people with schizophrenia.
Development and
implication:
Insight in schizophrenia is an evolving concept with widespread use
in clinical practice. Results are presented from a multicentre randomized trial
in which patients with schizophrenia and careers received a short
insight-focused Cognitive behavior Therapy (CBT) intervention from trained
nurses in the community. The CBT group demonstrated significantly greater
improvement in insight into compliance with treatment and the ability to
re-label their psychotic symptoms as pathological compared with the control
group at post-therapy assessment. Those participants who demonstrated improved
insight into having a mental illness tended to become depressed. At the end of
therapy and at 1-year follow-up, there was a statistically significantly
increased dropout rate in African-Caribbean and Black African participants. The
Black Caribbean group showed a significantly smaller change in insight compared
to the white group. At 1-year follow-up, the result on total insight and
compliance was durable. The change in insight in the Black African group was
significantly lower compared to the white group. The study emphasizes the role
of a short insight-focused CBT intervention in improving patients' insight into
compliance and its implications. The results confirm previous findings of
difficulties in engaging patients of Afro-Caribbean origin and their poor
response to psychological therapies as currently delivered.
An
expanding literature into cognitive-behavioral therapy (CBT) for psychosis is
broadening the options for serving these individuals in their communities. This
does, however, pose a number of challenges for the community team, to the
extent that some have suggested that this role should be reserved for
specialist services: At the level of individual staff members, training and
supervision needs must be satisfied, while nurturing new attitudes towards the
work they undertake with their clients; on a broader level, organizational
changes are necessary to modify the distribution of cases across team members,
and to re-think the format and timing of intervention. This article seeks to
identify the challenges of developing CBT for psychosis within generic teams,
and considers how these may be met.
CONCLUSIONS
Over the past decade, CBT has
emerged as an evidence-based intervention that provides a long-needed
integrative approach to schizophrenia. The emergence of CBT for schizophrenia
has added new optimism to the treatment of a highly stigmatized condition and
may, in the long term, contribute to a change in the way the general public
views people with schizophrenia. As the news about an effective talking therapy
penetrates a wider audience, schizophrenia may no longer be seen as an
essentially untreatable, incomprehensible, biologic condition beyond the reach
of reasoning.
All psychiatrists should therefore
at least be acquainted with the basic principles of CBT for schizophrenia in
order to incorporate this knowledge into the daily management of severely
mentally ill patients and to be able to appropriately refer patients for
specialist therapy. Although the existing evidence base for CBT in
schizophrenia shares some of the same limitations that exist for other
psychotherapies, research has firmly established the evidence for reduction of
symptomatology, low dropout rates, and cost-effectiveness. Despite this,
widespread availability of CBT for psychotic patients is currently lacking, and
providing sufficient availability of this method is one of the greatest
challenges facing mental health services today.
Schizophrenia is mental illness which
causes the sufferer to have a distorted view of the world because of delusions
and hallucinations. Schizophrenia is a chronic
disease that requires long term treatment, and in that way it is no different
to asthma, high blood pressure or diabetes, except
it is the brain that is involved. This article sum up the literature on
the use of cognitive behavior therapy for the treatment of schizophrenia, and
for enhancing the effectiveness of other treatments and services such as
medication and vocational support. The underlying symptoms of schizophrenia
have reported to remain unaffected by to treatment with medication alone and
can be targeted for the treatment with CBT.
Treating
schizophrenic with CBT is an approach used but Beck to treat the delusional
beliefs held by people with schizophrenia. Studies done but Dury et al showed
that cognitive therapy reduces the positive symptoms of the schizophrenia at a
faster rate. It was also reported that the negative symptoms remained; there
was no difference in the decrease of them. Hence CBT is a technique that could
be used to treat the positive symptoms of the schizophrenia.
There are
certain limitations for the use of CBT for the treatment of schizophrenia as
reported by Tai and Turkington that CBT is not effective when people don’t
regard themselves as having a mental health problem and when people have co
morbid disorders such as substance abuse. However CBT is still effective in
complex clinical situations.
Turkington
et al pointed that it is not necessary that the patient has same view of their
symptoms as the physician has, for the treatment of schizophrenia. The
physician might help the patient minimize his symptoms and don’t insist that
the patient endorse the diagnosis of schizophrenia. For instance, physician may
give explanation for the hallucinations that some people hear voices under
circumstances such as sleep deprivation and grief. They pointed out that there
should be therapeutic alliance based on patient perspective of the disorder or
the symptoms; physician may develop alternative explanations for the symptoms
of schizophrenia and try t reduce the impact of positive and negative symptoms.
In another
study done by Haddoc, it was revealed that CBT could enhance the coping
strategies already being employed by people with schizophrenia. The coping
training given to people with schizophrenia use over learning, simulation and
role playing. Coping skills that often begin with external verbalization which
then diminishes as the procedure becomes internalized are introduced in the
coping training. The cognitive and behavior techniques are attention switching,
attention narrowing, increased activity levels, social engagement and
disengagement, modification of self statement and internal dialogue
The review
by Beck and Rector provided that there are neurocognitive impairments that make
the individual vulnerable to aversive experiences such As schizophrenia. They
noted that people with schizophrenia have impairments in the neurocognition.
They also hypothesized that per morbid attitudes toward social affiliation, low
expectancies for pleasure, success and acceptance can maintain negative
symptoms. With respect to treatment they reported typical techniques of Ct that
included building trust and engagement, working collaboratively, normalizing
the experiences and educating the patient about stress vulnerability model.
In the
treatment of schizophrenia the initial focus is on the initiation of
antipsychotic medication that substantially decrease relapse rates for people
with schizophrenia. However, even with the excellent adherence to antipsychotic
medications, many individuals experience both relapse and residual symptoms.
These persistent symptoms are often target of CBT. Therefore the ability of CBT
to decrease symptoms may have additional benefit of improving medication
adherence. Once people of schizophrenia have recovered from the acute symptoms
they still face the negative symptoms like avolition, anhendonia, amotivation
and affective blunting. These can be addressed directly by the techniques of
CBT. The negative and positive symptoms in schizophrenia can be due to the
secondary assumption that patient makes about themselves. These multiple
failure statements and experiences are obliviously target for CBT as it can
cement the negative beliefs.
People with schizophrenia
have co morbid disorders like substance abuse, depression and anxiety. For some
problems like PTSD and specific phobia clinicians are reluctant to use CBT,
especially in the treatment of trauma. In specific phobia techniques like flooding
and systematic desensitization can be uses to overcome fears. People with
schizophrenia often complain social unease or anxiety. This can be again
treated with CBT.It could be helpful to identify challenging and distorted
thoughts.
People with
schizophrenia frequently find themselves with substance abuse disorder.
Specific CBT techniques like role playing and contingency planning can help
them to overcome the symptoms.
In this
article, CBT has shown promising results in the treatment of the acute or
persistent primary symptoms of schizophrenia and co morbid disorders of
schizophrenia. CBT has been successful in treating the sucidality.CBT has been
adopted as a standard treatment in United Kingdom for the people with
schizophrenia, and is gaining more acceptances in US for the treatment of
schizophrenia. (SADAF)