Schizophrenia - cognitive therapies

One more schizophrenia post after this one - diagnosis, reliability & validity. This post will cover Cognitive Behavioural Therapy and Cognitive Behavioural Family therapy, two psychological treatments for schizophrenia. There's probably more here than you can expect to write in half an hour, so pick your favourite studies and relevant evaluative points and use those. The only one I would recommend to definitely use would be be Falloon et al (1985), as it is some strong supporting evidence for the efficiency of CBFT compared to CBT.

Black: AO1 - Description
Blue: AO2 - Evaluation - studies
Red: AO2 - Evaluation - evaluative points

Cognitive Behavioural Therapy

CBT is not a "cure" for schizophrenia, as the cognitive distortions and disorganised thinking associated with schizophrenia are a result of biological processes that will not right themselves when the correct interpretation of reality is explained to the patient. The patient is not in control of their thought processes. The goal of CBT is to help the patient use information from the world to make adaptive coping decisions - improving their ability to manage problems, to function independently and to be free of extreme distress and other psychological symptoms. CBT teaches them the social skills that they never learned, as well as how to learn from experience and better assess cause and effect. Skills taught often address negative symptoms, such as alogia, social withdrawal and avolition, and can include social communication skills, the importance of taking antipsychotics routinely, and managing paranoia and delusions of persecution by challenging the evidence for these irrational beliefs.

Cognitive Behavioural Family Therapy (CBFT) is designed to delay relapse by helping the family of the schizophrenic to support the patient, by methods such as stress management training, relaxation techniques, communication and social skills, emphasis on the importance of antipsychotic drugs, and assessment of expressed emotion. High levels of expressed emotion on scales of hostility, emotional over-involvement and critical comments have been linked to rehospitalisation, so CBFT uses cognitive and behavioural methods to lower the emotional intensity of the patient’s home life. It has two general goals: To educate family members about schizophrenia, and to restructure family relationships to facilitate a healthier emotional environment.

Laing suggested the most important factor in the progression of schizophrenia is the family and how they treat the patient. A study by Brown (1972) supports this - he studied family communication patterns in schizophrenics returning home after hospitalisation.  Results showed that communication was a critical variable in whether patients would relapse into a psychotic state – patients returning to homes with a high level of expressed emotion were much more likely to relapse than those returning to homes with a low level. This supports the role of expressed emotion in determining long-term outcomes for schizophrenics.

Vaughn + Leff (1976) studied 128 schizophrenics discharged from hospital and returned to their families. Communication patterns between family members were rated for EE. The crucial finding was that families showing high levels of negative expressed emotion (Hostility, over-involvement, criticism) were more likely to have their patient relapse than families showing low levels of negative EE. Relatives with high levels of negative EE responded fearfully to the patient, characterised by lacking insight into and understanding of the condition. 

Leff + Vaughn (1985) found that a high level of positive EE with communication patterns showing warmth and positive comments is associated with prevention of relapse. They concluded that not all expressed emotion is detrimental to the relapse prospects of the patient. 

Sarason + Sarason (1998) summarised key findings from research into EE and schizophrenia: 

• Rates of EE in a family may change over time – during periods of lower symptom severity, rates of negative EE drop and vice versa. High rates of EE may only reflect periods of high symptoms severity, and not be an overall reflection of the family dynamic. 
• Cultural factors may play a role in EE. The association between high EE rates and relapse has been replicated in many cultures, but cultural factors may influence rate of EE and the way it is communicated. Cross-cultural studies have shown that Indian and Mexican-American families show lower levels of negative EE than Anglo-American families. 
• EE is not limited to families. The association between EE and relapse has been demonstrated with patients living in community care - the significant factor could be communication patterns between patient and those they live with, rather than with family. 

Falloon et al (1985) found a markedly lower relapse rate among schizophrenic patients receiving CBFT than in those just receiving individual CBT. FT sessions took place in the patients’ homes, with family and patient participating. Importance of medication was emphasised, and the family was instructed in ways in which to express both positive and negative emotions in a constructive, empathetic manner. Symptoms were explained to the family, and both family and patient were instructed in adaptive coping mechanisms. Large differences in effectiveness were found - 50% of those in the individual-therapy group returned to hospital over the course of the study compared with only 11% of those in the family-therapy group. 

However, investigators were mindful that patients undergoing CBFT may have improved more than the controls due to taking their medication more routinely – family therapy subjects complied better with their with their medication regimens.

However, these results were challenged by a study by the University of Hertfordshire, carrying out a meta-analysis of over 50 studies on the use of CBT from around the world. They only found a small therapeutic effect on schizophrenic symptoms such as delusions and hallucinations, which disappeared when blind studies were used, suggesting that CBT has a negligible effect in treating schizophrenia, if any at all.

Jauhar et al (2014) conducted a systematic review and meta-analysis of the effectiveness of CBT for schizophrenia, examining potential sources of bias. They found that overall, CBT has a small therapeutic effect on schizophrenic symptoms in the "small" range, but this effect reduces further when sources of bias are controlled for.

Sarason and Sarason suggested two ways in which findings have been misinterpreted. “Expressed emotion” has been misinterpreted to mean that the expression of any emotion is harmful, rather than just negative emotions – in fact, the expression of warmth and positive emotions can play a role in reducing relapse rates.

Secondly, some family members feel guilty for their emotional expression – it is important to emphasise to them that it does not play a direct causal role, but rather, is a factor that may influence relapse. Allowing them to feel guilt can actually increase the family's levels of negative expressed emotion, harming the patient's long-term prospects.

Global cultural differences mean that in some cultures, high levels of expressed emotion is not a social norm. Results from research suggest that cultures with lower levels of expressed emotion should have lower schizophrenia rates, but they do not, challenging the role of EE in the development and maintenance of schizophrenia.

There are ethical issues with comparing a therapy group with a control. If the therapy group improves and the control group doesn't, the researcher has knowingly denied the control group an effective method of treatment.

Schizophrenics do tend to lack social skills, and many of the negative symptoms (disorganised speech, speaking very little, lack of emotion) do help isolate them socially, so therapy that emphasises social functioning is appropriate and important in helping treat this specific aspect of the disorder.

Research into CBFT has not shown a causal role for the family in schizophrenia development, as Bateson once thought, but has shown that the family can be a powerful factor in determining the patient’s risk of relapsing to a psychotic state. CBFT used to restructure family relationships and reduce levels of negative EE is a crucial tool in both increasing the patient’s quality of life, and helping the family detect early warning signs of a relapse.

Studies that compare effectiveness between different therapies often do not measure outcomes in the same way - some look at attrition rates, some look at symptom severity before and after, and some look at relapse rates. Also, the "hello-goodbye effect" refers to the bias caused by patients who tend to exaggerate their symptoms before therapy, and exaggerate their progress after therapy, leading to inaccurate conclusions being drawn. This makes holistic comparisons of effectiveness between therapies difficult, and results must be handled with care.

CBT/CBFT does significantly improve functioning and reducing the suffering of schizophrenic patient, but it is not a cure, and is unlikely to work on its own. When used in conjunction with appropriate drugs, it tackles symptoms such as poor social skills, alogia and avolition, but is often unsuccessful at treating the more serious positive symptoms. Even when social function is the focus of therapy, it is not possible to increase social functioning to the level of non-schizophrenics.