CBT for Schizophrenia
It is quite common for one's mental state to vary now and then; but for most of us, this is normally a temporary phenomenon. This is unfortunately not the case for people suffering from mental illness; they experience these changes more enduringly and the resulting symptoms they experience vary greatly in severity from individual to individual (eNotAlone 2009). There is not a clear understanding of what severe mental illness is, for the simple reason, that it presents itself differently from person to person (Rethink 2009). The term 'Severe Mental Illness,' usually refers to these mental conditions where psychosis occurs. Psychosis is the term used to describe a person's symptom state that refers to the presence of reality misinterpretations, disorganized thinking and lack of awareness regarding true or false reality (Antai-Otong 2008) and one of the most common mental conditions associated with psychosis is undoubtedly Schizophrenia (eNotAlone 2009). Schizophrenia refers to a mental condition where there are impaired thought processes or disorganised thoughts during which time the individual has difficulty in organizing thoughts or in connecting them logically (Antai-Otong 2008). This mental condition manifest itself into positive and negative symptoms whereby psychosis presents itself as the positive symptoms of schizophrenia including: hallucinations, delusions, loosening of associations i.e. jumping from one thought to another and certain type of abnormal behaviours explained by an increase in psychomotor activity (Miles & Taylor 1994). Cohen & Sing (2001, cited in Gillam 2002) note that one out of every 100 people in the UK will develop Schizophrenia between the age of 16 and 64 at some point in their life and that a G.P could expect to see one new presentation of schizophrenia every five years in the 1800 patients they see. This mental condition has a serious effect on the physical health and well-being of people and it affects both men and women in equal numbers, but usually develop in men in their late teens or 20's and a little later in women. Gillam (2002) claims that in the UK about 250,000 people suffer from schizophrenia and that about a third of homeless people in the UK also suffer from this mental condition. Thus a broad understanding of schizophrenia and the various ways it can be treated are required by the health care professionals. Over the years, understanding of this condition, its treatment and care have invariably improved, and various forms of treatment have been used to try to 'treat' or to alleviate symptoms associated with this condition. Many contemporary forms of treatment are now available for management of schizophrenia either in the form of drug therapies or psychosocial interventions or a combination of both so that there is a greater prospect of recovery and of having a better quality of life (eNotAlone 2009). In this essay one method of intervention which is commonly used as a therapy in the treatment schizophrenia in mental services will be discussed and this intervention is Cognitive Behavioural Therapy (CBT). CBT has two distinct but related origins where the main ideas come from the work of Beck who in the 70's was treating many depressed patients using methods learnt from his psychoanalytic training. After many unsuccessful attempts to treat his patients, Beck began to study his patients in a different way laying more emphasis on conscious mental processes than on the unconscious processes or as symptoms of biochemical disorder (Fattah 2009). From his findings, Beck developed new techniques for changing first of all the way of thinking of the client and when using these methods as therapy, he found that recovery was better and faster in patients where cognitions were brought under control. Cognitive and behavioural approaches were thus integrated into the understanding and treatment of human psychological problems (Curan et al 2006). The second line of development of CBT can be traced to a group of American psychologists who modify Beck's original method to make it more flexible so that it could also be applied to other disorders (Fattah 2009). From then on, it has been noted that CBT has been increasingly made available in the treatment of schizophrenia over more than a decade and it has been welcomed by patients and carers (Turkington & McKenna 2003). These days, the use of CBT in the treatment of schizophrenia is well recommended in the clinical guidance number 82 (CG82), which is an updated version of the NICE guidelines for schizophrenia (NICE 2002).
CBT's main premise
CBT's main premise is that thinking processes are altered by emotions, physical symptoms and behaviour which means that an individual is not a passive recipient of environmental and physical emotions but will actively build their personal interpretations and meanings (Wells 1997). Central to the CBT approach in the treatment of schizophrenia is the importance of the link between the thoughts and the feelings about the current symptoms and the re-evaluating of these thoughts in relation to these symptoms (Turkington et al 2006). Using CBT as a treatment for schizophrenia involves the formation of a trusting therapeutic alliance where engaging the psychotic patient is always maintained as a focus in every session. At the beginning of the therapy the patient's model of symptoms initiation and maintenance is well explored before any other explanations are considered. Emphasis is laid on the understanding of the onset of the psychotic symptom using a stress vulnerability model (Zubin and Spring 1977, cited in Turkington et al 2006) which focus on the fact that all individuals experience psychotic symptom at one point if we are stimulated by sufficient stress factors but owing to our individual genetic physiological, psychological and social vulnerabilities, our vulnerability to a psychotic breakdown will vary from one individual to the other. CBT for schizophrenia facilitates the engagement of collaborative empiricism, with reality testing based on guided discovery rather than confrontation or collusion (Turkington & McKenna 2003). Confrontation and collusion are both avoided by focusing on the framing questions and the gathering of evidence in a non-judgemental manner as patients often want to understand things better, feel more in control, or be able to use better coping skills. Homework exercises are important in the testing of the possible explanations of the nature and the cause of psychotic symptoms such as hallucinations and delusions and allow the patients, often with the help of key-workers or carers, to begin to make sense of their distressing experiences and to see the effects on avoidance, rational responding or changing coping strategies. Thus through use of guided discovery, the psychotic patient will often give up dysfunctional explanations e.g. if the patient believes his voices come from evils, he will probably feel more relaxed once he starts to consider some less frightening explanations (Turkington et al 2006). CBT in schizophrenia lays emphasis on normalizing psychotic experiences such as voice hearing, in order to eliminate catastrophic interpretations of what having these symptoms mean to the psychotic patients. The normalizing process is re-enforced through homework exercises including reading hand-outs describing various phenomena e.g. relationship between sleep deprivation and hearing voices (Oswald 1974, cited in Turkington et al 2006). The explanations are based on the individualized symptoms of the patient rather than being generalized educational statement about schizophrenia. During the normalizing process, CBT also helps to decatastrophize the distressing beliefs the patients have about what it means to have a diagnosis of schizophrenia by providing valid information and more optimistic views concerning the long-term outcome of the illness. CBT also helps the client to develop a therapeutic relationship with the therapist and which facilitates a better understanding of the origin and persistence of the symptoms and this relationship is the key to the success in targeting hallucinations and delusions in reality testing. When such a "bond" is formed between the client and his therapist, the client will generally see the therapist as a powerful ally who will take their experience seriously and will show interest in what these strange and frightening situations may mean (Turkington et al 2006).Some patients will very often develop underlying thoughts and attitudes relating to the high stress stimuli they go through during their pre-psychotic period and these attitudes or thoughts will often result in disruptive adherence in the treatment of the patient and very often the patients will stop taking his prescribed drugs. These attitudes and thoughts are challenged through analysis of the evidence, positive logging, use of the belief continuum, operationalizing a negative construct and making use of role play (Turkington & Siddle 2000). CBT is now the first choice of the government's plan to help people with mental conditions, mainly schizophrenia (CG82) but it is well-known that any methods of treatment have their strengths and weaknesses; and using CBT as therapy for treatment of schizophrenia is no exception. According to Willis (2006), CBT has the advantage of being brief and time-limited. It usually takes 12 to 20 sessions and each session is aimed at helping the patient to reach explicit goals which are agreed by the patient at the beginning of the therapy. Each session is specific and each of them will vary according to the nature of the problem the patient is experiencing and each session will aim at different goals (Curan et al 2006). Generally the sessions are relatively high frequency, usually up to three times a week and are of moderate duration, 45 minutes to 1 hour and are typically done over 10 to 12 weeks (Buck 2008)
Moreover CBT has become very popular as a therapy for Schizophrenia across the UK over the last 10 years and it has been welcomed by patients and carers for the simple reason that CBT helps both the patient and the carer to be actively involved in the treatment as active participants in the management of psychotic symptoms (Turkington & McKenna 2003). The therapy facilitates the creation of a therapeutic relationship between the client and his therapist which allows for the testing and working through of hypothesis regarding the disappearance and persistence of symptoms. Sensky et al., 2000, cited in Turkington & McKenna 2003) report that hallucinations, delusions, negative symptoms and depression have all been shown to be well responsive to CBT. Another advantage is that CBT, being an individualised intervention based on a case formulation, will help the patient to understand why he/she has changed so much and to begin to see and understand the importance of taking prescribed medication and to be compliant to the treatment (Turkington & McKenna 2003). Improvement in insight and adherence to treatment will thus lead to reductions or preventions of relapse and rehospitalisation and it has been noticed that carers who worked in this way changed their mind to a more hopeful and less alienated position instead of expressing the feeling of frustration and guilt towards the client. Pilling et al 2002, cited in Turkington et al 2008) remark that all the CBT trials to date have proved to have a greater effect on overall severity symptoms; and this is supported by Gumley et al (2003), cited in Turkington et al (2008), who point to evidence suggesting that CBT may delay relapse and reduce days hospitalised. While medication remains central to the treatment of schizophrenia, Gillam (2002) argues that pharmacological treatment alone is not enough to help the client with the psychological and social impact of the illness and suggests that a wild range of psychosocial interventions, including CBT, is the key component in the treatment of schizophrenia. Turkington et al (2006) add that CBT has also proved to be an adjunct to antipsychotic medication and remediative approaches such as social skills training in the management of residual symptoms of chronic Schizophrenia, works well on the positive symptoms, depression and overall symptoms Another advantage of CBT is that it can be available as a self-help therapy (Grant 2009). CBT self-help is available on facilitated guided reading or computerised CBT aka CCBT (NICE 2004). Walker (2006) mentioned that a CCBT was developed in Tayside, Scotland consisting of 22 sessions and which was used by the MDT as a method of therapy for patients suffering from schizophrenia in the high-security state hospital of Carstairs, Scotland. By the end of the therapy, the results showed clearly that compliance with prescribed medication for the treatment of schizophrenia was near to 90% and thus helped the patient to become more stabilised and reduced the risk of relapse. Ferriter et al (2008) confirm that CBT being used as self-help has proved to be an advantage as it helps the patient to promote his self-monitoring role in the course of his treatment. Walker (2006) explains that this approach is advantageous in the sense that patients develop better understanding of their illness and are less likely to self harm or to show violence towards others. Cunningham et al (2001) cited in Walker (2006), mention that a range of educational packages has been developed to improve the outcome of social functioning and medication adherence through increasing understanding of the illness and the potential benefits of medication. However, Merinder (2000, cited in Walker 2006), points out that the results of educational interventions in psychosis are very far from being conclusive and states that there was no clear guidance on the most appropriate format or structure for educational interventions in dealing with psychosis, their optimal duration or what selection criteria can be applied to allow pointing those who will benefit most. The NICE guidelines (2006) backed up the concerns of Merinder's (2000) review in offering specific information on how family interventions should be delivered and made it clear that clinicians should carefully consider when and how to give information about the illness and what information should be given. While proponents of CBT (e.g. Turkington & McKenna, 2003) have emphasised the role of CBT in reducing relapses, there have also been opposing evidence, questioning the effectiveness of CBT in schizophrenia. For instance, Garety et al (2008, cited in Gumley 2009), did not find any evidence of the effectiveness of CBT in reducing relapse, and suggest that this may have been due to too much focus being placed by cognitive behaviour therapists on targeting principally positive psychotic symptoms of schizophrenia while neglecting the emotional distress associated with these symptoms. Willis (2006) suggests that one of the downfalls of CBT is that there is a lack of trained therapists in UK who can effectively deliver CBT. In Britain, services provide to the primary care trust are increasing in line with WHO recommendation (WHO 2001) and there is an urgent need for clinicians to develop services that are more clinically effective, efficient, equitable and accessible (DOH 2004). Lord Layard stated in one of his speech, that mental health is considered to be the biggest social problem in UK and also added that we would need 10,000 additional therapists to deliver 10 sessions of CBT to 1,000,000 individuals each year (Sainsbury Centre for Mental Health 2005). If the proposal of Lord Layard materializes, the lack of trained therapists is going to get worst and there would be a big gap to fill in. O'Hara (2005) states that nurses are the largest group of professionals who can administer CBT, but nursing organisations are very concerned about it and would argue that there is already a lack of psychiatric nurses in UK and do not advise the few psychiatric nurses available to get involved in the delivery of CBT, hence exacerbating current shortages. Cooper (2008) postulates that another disadvantage of CBT is that the therapist is the principal determinant of the orientation of the therapy and Miller et al (2008) would add that a lot depend on the therapist as an individual, on the personality of the therapist, on the openness to critics and feedback and most of all on the professional experience of the therapist. Okiishi et al (2003) stress that research over the years have showed distinctive differences in outcomes across therapies led by different therapists; and patients of the most effective therapists have been observed to improve 10 times more on the average while clients receiving therapies from the least effective therapists got worse. Cooper (2008) also reported that there is a much greater difference in the effectiveness of delivering CBT as a treatment from one CBT practitioner to the other compared to the effectiveness of delivering CBT as a therapy between all CBT practitioners or all therapist of any other orientation. The key contribution to the outcomes of the therapy will depend much more on how therapists relate to their clients
To conclude, any therapy has benefits as well as drawbacks, which need to be taken into account when assessing what will be most appropriate for any given patient. It must also be noted that therapies are continuously evolved, modified and updated through research and practice to increase their effectiveness and minimize their shortcomings. CBT is one of those therapies that has been constantly modified and updated throughout the years after its original creation by Beck in the 70's. CBT has proved through many meta-analyses and original research that it works; its positive effect in the management of psychosis in schizophrenia and also in the prevention of relapse. However, some challenges remain and some of them might be to develop evidence based therapies more focussed on the developmental psychopathology of schizophrenia as well as established CBT treatment principles. A further challenge is to make CBT adaptable and acceptable through different settings such as in-patients and residential settings and also through different modalities such as self-help and web-based. These are some of the most important challenges that the next generation of clinical researchers and clinicians must address.
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