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Developed by Beck in the 1960s, Cognitive Behavioural Therapy (CBT) is a form of psychological therapy that focuses on teaching patients to recognise their dysfunctional thoughts and behaviours, how to rationalise these thoughts using logic, and how to avoid acting on these thoughts. CBT is a lengthy process, normally lasting around 6 to 12 weeks depending on the patient’s needs. It requires a therapist to work closely with the patient to build trust and a sense of rapport.
Although this will not necessarily cure schizophrenia, it can help patients cope with the symptoms of the disorder. An accredited cognitive-behavioural-therapy trained therapist will help assess patients.
CBT aims to identify and alter irrational thoughts and behaviours, such as:
General, irrational beliefs e.g. hearing people who are not there talking about you or hearing a voice narrate your daily life.
Self-image issues.
Beliefs about people’s perception of the patient.
Expectations of how those around the patient will act.
Methods of coping with their problems.
When issues with these areas are identified and worked through, a patient with psychosis can then work on clearing up misunderstandings and improving their emotional state.
CBT has multiple stages to help identify the issues and offer solutions to a patient with schizophrenia.
Normally, CBT would follow this process:
Assessment: therapists work with patients and encourage them to explain their concerns, and why they believe certain things. This provides an insight into the issues they’re suffering from, and in the case of schizophrenia, can help identify where positive symptoms such as delusions are stemming from. Patients are encouraged to reflect on their personal lives and relationships and are then asked what they hope to achieve by going through CBT.
The stages of CBT, Tyler Smith - StudySmarter Originals.
Two different approaches to this process can be used.
A clinician may use the ‘ABC’ method, conceived by Ellis in the 1950s before he later expanded on it in the 1990s to the ‘ABC(DE)’ model. Alternatively, they may opt for the ‘CSE’ method.
The ABC(DE) model, conceived and expanded by Ellis (1991) to include ‘DE’, encourages patients to try and understand what is happening in their lives. It finds the source of the faulty condition and then goes on to work towards providing a process to restructure the irrational beliefs.
Activating event: what is causing the problem?
Behaviour and beliefs: how does the patient react in these situations?
Consequences: what impact does this have on the patient’s life and their relationships with others?
Disputing irrational beliefs: working with the therapist to logically dispute and deconstruct these irrational beliefs.
Effect restructuring: working with the therapist to establish the true reality of the situation, rather than believing the irrational thoughts.
We still refer to the model as the ABC model, despite the 'DE' addition.
A diagram of the ABC(DE) model by Ellis, Tyler Smith - StudySmarter Originals.
If a patient with schizophrenia has a delusion that someone is trying to hurt them, say, a doctor, they may then believe that the advice/prescriptions given by the doctor are going to kill them. Consequently, they refuse treatment.
It is then up to the clinician and the patient to challenge and dispute these irrational beliefs using logic: why would a doctor try to kill them when they are there to help them? They have no reason to kill the patient. Once a patient can see this, they then will restructure the consequences and ultimately, the goal will be to resume treatment.
When disputing the beliefs with a schizophrenic patient, it can be done in the following ways.
Reality testing is where a patient is encouraged to evaluate and recognise that their irrational thoughts are not real.
If a patient believes that a family member is breaking into their things and stealing them (activation event and belief stemming from this), they may lose trust and begin displaying distressing emotions and delusions as a result (consequences). A clinician would then show the patient that the family member is not doing this by either finding the ‘stolen’ items or encouraging them to discuss other reasons for the missing items, such as they are misplaced somewhere in the house (disputing irrational beliefs). Then, trust is regained and the consequences dismantled (effect restructuring).
Normalisation is when a clinician works towards helping a patient understand that negative thoughts are normal in certain, appropriate situations. Everyone can at times feel paranoid, for example, if they misinterpret a friend’s actions. The experiences of patients are explained to be on a continuum with normal human experiences, this way the patient feels less stigmatised.
Some patients struggle with normalising their behaviours and thoughts. Their internal thought processes are demonised by their self-persecution, worsened by delusions. This is where a clinician will dispute the ideas and help a patient accept them. The patient will then understand there is no need to feel stress or shame.
A clinician and patient should work together, logically discussing ideas that the patient has, why they are wrong, and why they came about. This is critically analysing ideas together.
Systems are put in place so the patient can recognise these negative thoughts and implement their own tests for these faulty beliefs.
Ideally, the patient can eventually independently challenge and rethink their faulty beliefs. The patient can then develop their own alternative explanations by using these coping strategies, rather than resorting to delusional thinking.
Coping Strategy Enhancement (CSE) encourages patients to develop and apply their own coping strategies. It teaches them how to do so in the hopes of reducing the frequency and intensity of the psychotic symptoms of schizophrenia.
It has two components:
Education and rapport training: developing a good relationship and shared understanding between therapist and patient. This is crucial to allow patients to open up and feel comfortable with the therapist. Therapist and patient can then work together effectively.
Symptom targeting: clinicians will target a patient’s specific symptoms and work towards coping strategies, helping a client through any problems they may have when applying them. Homework is often given, as well as asking patients to record how the coping strategies work when outside of sessions.
Through both of these strategies, a patient with schizophrenia can find out what coping strategies work best for them, what exacerbates their symptoms, and how to deal with these flare-ups. If a coping strategy is not working, they can develop better coping strategies, and if necessary they can target symptoms specifically.
If a patient has issues with delusions, clinicians can work with them to develop coping strategies to logically reason out of these delusions.
Therapy for schizophrenia, flaticon.com.
When using CBT to treat schizophrenia, it’s important to understand whether it’s effective and appropriate, and why this may be the case. The advantages and disadvantages of using CBT are detailed below.
Rector and Beck (2012) found that, when reviewing studies of the use of CBT in treating those with schizophrenia, CBT had large clinical effects on positive and negative symptoms. Those receiving routine care and CBT achieved additional benefits. Overall, this suggests that CBT is a promising therapy style for patients with schizophrenia, being both effective and appropriate.
Turkington et al. (2006) reviewed the efficacy of CBT in patients with schizophrenia in the UK, intending to advise American people of the results. It was found that CBT is highly effective and should have more attention and support in America. These promising results suggest CBT seems to be reliable and consistent.
Rathod et al. (2008) found that, when combined with antipsychotic medication, CBT acted as an effective facilitator to the treatment of positive and negative symptoms of schizophrenia.
CBT has been shown to reduce relapse rates and readmissions to hospitals. It encourages patient independence and offers patients the option of taking control of their treatment, being actively involved in their disorder management.
A major problem with CBT is that it’s a lengthy process. It requires commitment from the patient and the clinician, a suitable setting, and 6 to 12 weeks or more. It’s expensive compared to simply using antipsychotic drugs. Patients often end treatment early.
It requires self-awareness and the willingness of the patient to engage. This in itself has issues, as schizophrenic patients have symptoms of delusions and hallucinations, which can cause problems with self-awareness and their level of trust with the clinician. Symptoms can hold a patient back, and ineffective treatment will likely lead to further disengagement.
Some patients' symptoms are severe. Therefore, for some, the idea of confronting these symptoms (a core aspect of CBT) is too traumatic. Antipsychotic drugs can be used in cases like this to ease the symptoms of schizophrenia first.
Many reviews of CBT treatment for schizophrenia are based on a meta-analysis of studies, the findings of which can be influenced by the failure of considering potential biases, such as not using masking or publication bias. Masking is where potentially influencing information is withheld from investigators, such as what treatment a patient is assigned to. Publication bias is the fact that only studies with positive or confirming results tend to be published.
Jauhar et al. (2014) found that, when including the examination of potential biases in their meta-analysis of CBT effects on schizophrenic symptoms, CBT has a therapeutic effect in the ‘small’ range, diminishing further when biases are taken into account. Masking of outcome assessments had a moderated effect size on overall symptoms.
Kingdon and Kirschen (2006) found that CBT is not suitable for all types of patients. Like antipsychotics, it depends on the tolerance and, as mentioned above, the willingness of patients to engage. Those disorientated, agitated, paranoid, or refusing medications will not find the treatment as effective or appropriate.
As seen in the issues created by expressed emotion affecting schizophrenic patients, it may be worth using CBT with family therapy, as focusing entirely on the patient puts a lot of pressure on them. This may not be fair considering the implications of family dysfunctions on patients with schizophrenia.
An example of CBT is the ABC model.
Cognitive behavioural therapy is a type of therapy used to logically work through patients' symptoms and disorders, addressing dysfunctional thought processes and reconstructing them. It focuses on cognitive functions and how these affect behaviour.
The three main components are identifying the problematic or dysfunctional thought processes and behaviours, recognising they are dysfunctional and problematic, and employing techniques the patient can use to manage these issues (disputing irrational beliefs, for instance).
It involves a therapist sitting with a patient and working through their issues and dysfunctional thoughts, disputing these irrational beliefs, and developing plans for the patient to restructure their thought processes.
It can be used for a multitude of disorders, such as depression, schizophrenia, anxiety, and many more. It helps treat symptoms of these disorders.
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