Paper 2: Clinical (AJW) 2017

Evaluating One Psychological Treatment for Schizophrenia: CBTUnlike typical anti-psychotics such as chlorpromazine which sometimes only improve positive symptoms, CBT has been shown to have a beneficial effect on both positive and negative symptoms. Additionally, psychosocial functioning is improved and relapse and rehospitalisation are can be prevented through implementing strategies for stress management whilst educating the person about their disorder and improving self-esteem. This is supported by a meta-analysis by NICE (2009) which concluded that CBT was effective in reducing rates of readmission to hospital and duration of admission. It was also judged to be effective in reducing overall symptom severity, both at the end of treatment and after up to 12 months’ follow-up.

The evidence appears a little contradictory with regard to the extent to which positive symptoms are treatable with CBT and the NICE study suggests that CBT may be less effective for positive symptoms. This said Kuipers et al (1997) who completed the first randomised controlled trial of CBT for psychosis found that drug resistant patients improved when given a form of cognitive therapy adapted to target delusions and hallucinations, two of the core “positive” symptoms of schizophrenia. This finding is further supported by a number of smaller scale studies that have also provided positive results relating to particular symptoms, for example Chadwick and Lowe (1994) found that 83% of people with schizophrenia who attended CBT showed a decrease in the extent of their deluded convictions while 42% actually rejected their delusions altogether. This can be achieved through developing skills which help clients to identify the difference between “confirmable” and “perceived” reality and verbally challenging and confronting them about their beliefs but in a supportive and secure environment.

A further example of this was demonstrated by Combs et al (2007) who successfully used behavioural experiments with a hospitalised client named LN who had behaved aggressively towards her landlord and had persecutory delusions that social services agents were stealing her possessions. The experiments were used to gather and present evidence against her beliefs, e.g. a trusted family member went to her apartment and found some of the lost items which were then photographed as evidence, thus reducing the level of convictions in her deluded beliefs.

Despite some positive research evidence, there is much controversy about the actual usefulness of CBT with many arguing that the effects are not that convincing. A large meta-analysis by Lynch et al suggests that overall CBT

Paper 2: Clinical (AJW) 2017

is ineffective for reducing symptoms and preventing relapse and this is supported by Jauhar et al (2014) who say that the effect size of CBT for schizophrenic symptoms is ‘small’. Similarly, The Cochrane Collaboration (2012) compared cognitive therapy with other psychological therapies and “no clear and convincing evidence of benefits for relapse, readmission to hospital, or a range of mental state measures”. Furthermore, McKenna (2014) cites 9 moderately sized or large (35-257 participants in the cognitive therapy group), blind trials comparing CBT with usual treatment or a control psychological intervention (trials of psychotherapy are invariably carried out under single blind rather than double-blind conditions) where it was found that only 2/9 methodologically rigorous trials had positive results on their primary outcomes of reducing overall symptoms, positive symptoms, or relapse at the end of the treatment period and apparently in one of these studies the “blinding” procedure lapsed as the study unfolded suggesting the results may not have been valid.

Leading from this, critics of CBT such as McKenna have argued that that positive findings result from poorly controlled studies where there is a lack of control over the delivery of other treatments in addition to CBT in inpatient settings, failure to maintain a “double blind” situation, meaning researchers have gradually come to realise which Pps have received CBT and which have not potentially leading to researcher bias and poorly standardised outcome measures. It has also been argued that many studies do not track clients long enough to determine whether CBT is useful long term for staving off relapse in people with schizophrenia.

However, this argument is contested by the findings of Bradshaw (1998) who found that his client Carol, who received 3 years of CBT, showed very positive outcomes in terms of psychosocial functioning, attainment of treatment goals, reduction of symptomatology and no further hospitalisation despite having been hospitalised 12 times prior to treatment. Bradshaw followed Carol up one year on and found that her progress had been maintained.

From a practical point of view it would appear that CBT may have a number of advantages in terms of its ability to help support people returning from hospital and actively reducing readmission rates whereas patients may rely on drug treatments for the rest of their lives. Practically, drug treatments are less expensive but if they do not help diminish readmission and medium to long term hospital stays than CBT could be seen as more cost –effective, even though initially the outlay is higher as CBT for schizophrenia requires a consistent one-to-one approach over many months. Presently the option of computerised CBT for schizophrenia has not really been investigated and it

Paper 2: Clinical (AJW) 2017

is likely that this may not work as the support provided by the therapist may be critical in helping them the person re-integrate into their community. CBT also has less noxious side effects than drug treatments although it is possible that it does not make an especially large difference with regard to the actual experience of symptoms as opposed to reducing stress which can trigger a relapse. From an ethical standpoint, it could certainly be argued that CBT protects clients from side effects of drug treatments, which can be seriously deleterious to health e.g. weight gain can lead to diabetes. Likewise, with CBT this could be seen as a more ethical form of treatments as power is shared between the therapist and the client, in that they work collaboratively towards recovery whereas in drug treatment power and ultimately control lie with the prescribing doctor. CBT is clearly also important in terms of keeping people out of hospital as the NICE report demonstrated that readmissions were reduced by 24% and this shows that CBT may be more effective in terms of helping people with psycho-social “skills for living”,i.e. that is skills that allow a degree of independence and the ability to function in society. This shows that CBT is capable in assisting people to live in their communities where they arguably belong rather than being confide to life in hospital and thus is an ethical form of treatment which enriches their lives longer term compared with drug treatments which have been recently said to potentially lock people into a life of psychosis, (Murray, 2017). This said there are ethical downsides to CBT; challenging the person's delusions can be distressing for them and needs to be managed with sensitivity, starting with weaker evidence to challenge their beliefs at first and moving gradually to the strongest as this will be the most challenging for them to deal with. Also behavioural experiments in the real world need to be handled with care as these could lead to situations which could be dangerous for the client or members of the public if they are poorly managed; role play can sometimes overcome such situations.

Ultimately, both drug treatments and CBT together may present the most beneficial treatment package, however, Burns (2014) argues that “For patients who continue to exhibit symptoms of psychosis despite adequate trials of medication, CBT can confer beneficial effects above and beyond the effects of medication”. At best CBT can be seen to provide a long term solution which empowers people to combat both positive and negative symptoms of their conditions and avoid relapse, however, the literature is contradictory and controversy rages still. Some would argue however, that decades of investment in the pharmacological industry may underpin the reluctance to truly embrace psychological therapies for schizophrenia.