CONITIVE BEHAVIORAL THERPAY IN RELATION TO
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.
* 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.
> 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.
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.
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.
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.
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 .
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.
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.
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.
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)