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Psychological Therapies for Schizophrenia

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Psychological Therapies for Schizophrenia

When people think of a psychologist, most would imagine a person sitting across from a patient in an armchair, with a notepad ready to dissect every word that comes out of a patient's mouth. While not as simplified as this, psychological therapies certainly offer therapies that are similar to the stereotype.

In the case of schizophrenia, there are three main psychological therapies we like to consider (specifically for your exam). Each treatment offers a different avenue of treatment whilst aiming to treat the disorder itself, purely from a psychological perspective. Unlike the biological approach, most psychological therapies focus on addressing and altering the mind state through addressing a patient’s thought patterns and behaviours.

Let's now outline and evaluate psychological therapies for schizophrenia.

Psychological Therapies Head Flower Schizophrenia StudySmarterPsychological therapy, Flaticon

An outline of psychological therapies in schizophrenia

Different therapies use different techniques to treat the underlying cause of schizophrenia. Psychological therapies in schizophrenia also address the symptoms as well as try to address the cause.

There are three main types of psychological therapies that we will cover:

  1. Cognitive behavioural therapy (CBT)
  2. Family Therapy
  3. Token Economy

Cognitive behavioural therapy (CBT) for schizophrenia in psychology

Cognitive behavioural therapy (CBT) is likely one of the most used therapies out there currently. Curated by Becks in the 1960s, the main aim of CBT is to identify and then attempt to correct (or at least alter positively) dysfunctional thoughts.

We mean by dysfunctional thoughts in schizophrenia by the irrational beliefs schizophrenia patients suffer from more than others.

CBT, for instance, would work by addressing these irrational beliefs and working through them logically, which also works for other positive symptoms such as hallucinations and delusions.

Typically, CBT follows the following format:

  1. Assessment: patients explain their situation to their therapist, identifying problematic thoughts and the potential causes for these thoughts. Reflection is a core aspect of this stage, requiring the patient to truly think back on themselves and understand where their symptoms are coming from and what makes them better/worse.
  2. Engagement: once the above issues have been identified, the therapist can set out a cognitive framework to address these issues and logically work through them (so, if a schizophrenic patient is having delusions of grandeur, a therapist would identify this with them and logically work through it to show it is a delusion).

CBT adopts the ABC model:

  • Activating event: what is the cause?
  • Behaviour and beliefs: how is the patient reacting?
  • Consequences: what are the consequences of these reactions?

CBT then works on disputing these irrational beliefs through reality testing, normalisation, and critical analysis.

The coping strategy enhancement (CSE) model is an alternative and focuses on the patient developing coping strategies. This is seen through education and rapport training and symptom targeting.

Overall, CBT usually lasts anywhere from 6 to 12 weeks.

Psychological Therapies for Schizophrenia behaviour therapy for schizophrenia psychology CBT StudySmarterCBT, Flaticon

Family therapy

Family therapy focuses on the people around the patient, involving them in the treatment process. Research has shown that many relapses in schizophrenia tend to occur after a patient has returned to their family environment. There are multiple reasons why this is the case.

This is typically due to expressed emotions (EE), stress, guilt, and an overall lack of education or ignorance about the disorder. Families are not perfectly attuned to every possible mental health disorder out there, so until it directly affects them, no one will truly know about these issues (and even then, it requires a lot of time, patience, and effort to understand mental health).

Family therapy usually involves the following format:

  1. Preliminary analysis: the patient is interviewed, and observations in the family environment are made.
  2. Information transfer: the therapist then speaks with family members and educates them about schizophrenia, aiming to reduce feelings of guilt, stress, and the occurrence of EE.

Education typically involves:

  • Compromise and negotiation

  • Communication skills training

  • Being family-centred focused, not just focused on the patient.

Psychological Therapies for Schizophrenia Family Therapy Family Tree StudySmarterFamily tree, Flaticon

Token economies

Token economies (TES), also developed in the 1960s, involve a behavioural based reward system that encourages 'good behaviours' and discourages 'bad behaviours'. It is primarily based on the concept of operant conditioning.

In schizophrenic patients, it focuses on maladaptive behaviours that prevent a patient from adapting to new situations, treating both positive and negative symptoms of schizophrenia. Although TES has fallen out of fashion (with the fall in institutionalisation), it does employ some well established psychological theories.

TES usually involves the following process:

  1. TES is introduced as soon as a patient enters the setting: rewards and good behaviours are established.
  2. They use physical tokens or tally systems: they can be earned and easily understood/quantified by introducing physical tokens or tally systems. These are the secondary reinforcers.
  3. They then trade these tokens in: Rewards can be given based on how many tokens a person has earned with good behaviour (such as bathing, getting up on time, socialising and addressing symptoms through treatment etc.). These are the primary reinforcers.

Overall, primary reinforcers give power to the secondary reinforcers.

TES is catered specifically to the patient (so their wants and needs can be directly addressed and influence their behaviour).

Psychological Therapies for Schizophrenia Token Economy StudySmarterToken economy, Flaticon

Evaluation of psychological therapies in schizophrenia

As with all treatment plans, psychological therapies have their strengths and weaknesses. Let's assess the effectiveness of psychological therapies for schizophrenia.

Strengths

The following can be considered strong points of psychological therapies:

  • Concerning CBT, Kuipers et al. (1997) investigated the effects CBT had on psychosis (as it had positive effects on those with depression). 60 participants with at least one positive symptom (who also had issues with medication) were randomly allocated to either a CBT and standard care condition (n = 28), and a control group with a standard care only condition (n = 32).

    Over nine months, they found significant improvement for those receiving treatment compared to standard care only. There was a low dropout rate and high satisfaction, and CBT had a 50% treatment response compared to 31% of the control group.

    They concluded CBT for psychosis could improve symptoms.

  • Concerning family therapy, Pharoah et al. (2010) found that from data (randomised and quasi-randomised) on families with members affected by schizophrenia, family therapy reduces the rate of relapsing in those with schizophrenia, including the rate of hospitalisation.

  • Concerning token economies, McMonagle and Sultana (2000) found that, when comparing a token economy system to standard care, it has an effect on the negative symptoms of schizophrenia, although had little to no effect on other areas. They did, however, state that whether this is reproducible and long-term is up for debate and requires more research.

Weaknesses

The following can be considered the weak aspects of psychological therapies:

  • CBT is mostly used alongside drug therapy for schizophrenia in psychology, suggesting that it is not a cure-all, robust therapy. It needs help, and implying CBT is enough alone is ignoring the biological basis of schizophrenia. It also has been shown to have a short-term effectiveness rate, as when studies analysed the rate of relapse compared to the standard care, CBT had a similar or the same rate of relapse.

  • Family therapy, similar to CBT, does not address the biological aspect of the disorder, and instead focuses mostly on the nurture side of the debate. Blame can be placed on the family environment, which may incite more feelings of guilt and stress.

  • Token economies have ethical issues, as they are essentially withholding freedoms from patients and demanding they are earned back purely through a reward system. Is it ethically acceptable to restrict this right from patients? As well as this, it is only applicable to those willing to work for their rewards. If a patient doesn't want to or is too ill to engage in the behaviours, token economies would be useless or even cruel for them.

What type of therapy works best for schizophrenia?

This is up for debate, as both biological therapies for schizophrenia in psychology and psychological therapies have their strengths and weaknesses. We cannot conclusively say one is perfect for schizophrenia. However, cognitive behavioural therapy combined with drug therapy has shown promising results.


Psychological Therapies for Schizophrenia - Key takeaways

  • Where schizophrenia is concerned, there are three main psychological therapies.
  • This includes cognitive behavioural therapy (CBT), family therapy, and token economies.
  • CBT involves addressing dysfunctional thoughts and symptoms and working through these issues logically, implementing new thought processes. It employs the ABC model (and can use the CSE model).
  • Family therapy involves incorporating the immediate members of a patient's everyday life (usually close family members) into the treatment plan, focusing on educating them and aiding the patient's recovery, whilst also assisting them in feelings of stress and guilt.
  • Token economies, whilst they have fallen out of fashion with the decline of institutionalisation, focus on rewarding good behaviours and reinforcing them. They use a token system that can be exchanged for rewards.
  • All therapies have research evidence to back them, although implying one therapy alone is best can have issues with ignoring the proven biological aspect of the disorder (and the success of drug therapy treatment), as well as raising its own ethical issues.

Frequently Asked Questions about Psychological Therapies for Schizophrenia

This is up for debate, as both biological and psychological therapies have their strengths and weaknesses, so we cannot conclusively say one is perfect for schizophrenia. However, cognitive behavioural therapy combined with drug therapy has shown promising results.

Psychological therapies help schizophrenia by addressing dysfunctional thoughts and helping a patient logically work through them, which is also transferrable to everyday life (it can be practised outside of a therapy session). It also allows patients to reflect on their behaviours and potentially address their social circle and family life. 

In terms of the psychological factors of schizophrenia, this could be referring to the imbalance in dopamine and serotonin (the neurotransmitters affecting the person's brain with the disorder). Ultimately, this results in positive symptoms (hallucinations, delusions of grandeur) and negative symptoms (alogia, depression, lack of motivation). 

Interventions can come in the form of family therapy, group therapies, and general counselling sessions. 

Yes, primarily when used in combination with drug therapies. Although, whether it has long-term effects is still up for debate.

Final Psychological Therapies for Schizophrenia Quiz

Question

What is cognitive behavioural therapy (CBT)?

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Answer

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.

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Question

How long does CBT usually take?

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Answer

Around 6 to 12 weeks depending on the patient’s needs.

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Question

What are the stages of CBT?

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Answer

Assessment and engagement.

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Question

What are the two different methods a clinician can use to work through CBT with a patient? 


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Answer

The ABC and CSE methods.

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Question

What is the ABC method?

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Answer

The ABC method includes finding out the patient's Activating event, Behaviours and beliefs, and the Consequences of these beliefs. ABC was expanded in the 1990s to include Disputing the beliefs (D) and restructuring the Events (E).

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Question

How does the ABC method dispute a patient with schizophrenia’s belief systems?

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Answer

By reality testing, normalisation, and critically analysing ideas together, developing new explanations as a result. This helps patients see past their delusions and hallucinations using logic and encouraging independence.

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Question

What is the CSE method?

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Answer

Coping Strategy Enhancement (CSE) encourages patients to develop and apply their coping strategies, teaching them how to do so in the hopes of reducing the frequency and intensity of their psychotic symptoms.

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Question

How does the CSE method work through a patient's schizophrenia?

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Answer

By education and rapport training, building trust between the clinician and the patient to find out what the current coping strategies are and developing them/new ones. CSE also targets specific symptoms to develop coping strategies for and normally assigns homework/a monitoring system for the patient. 

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Question

Name two strengths of using CBT to treat schizophrenia. 


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Answer

CBT has been proven to be effective in treating positive and negative symptoms in studies (Turkington et al., 2006). It has also been shown to reduce relapse rates and readmissions to hospitals.

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Question

Name two weaknesses of using CBT for schizophrenia treatment.

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Answer

It’s a lengthy process, so it has issues with being more expensive than drug treatments and patients often drop out early. Most meta-analysis reviews fail to consider potential biases, and 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, reducing further when biases (masking, publication bias) are taken into account.

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Question

What did Rathod et al. (2008) find in their study?

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Answer

They found that CBT had large clinical effects on positive and negative symptoms.

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Question

When something is being masked in a study, what does that entail?

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Answer

If something is being masked, it means it is being kept hidden from the individual being studied and/or the investigators to avoid potential bias occurring.

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Question

Name another form of bias that can occur in research, that was found to be a problem in some meta-analysis reviews. 


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Answer

Publication bias.

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Question

What does the term ‘normalisation’ mean when conducting CBT on patients with schizophrenia? 


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Answer

It is when patients are taught that their negative thoughts are not always inappropriate or bad, and can be normal in certain situations.

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Question

What did Kingdon and Kirschen (2006) find in their study? 


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Answer

They found that CBT is not appropriate for every patient with schizophrenia. It depends on the individual and how they respond to treatment, and how severe their symptoms are.

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Question

Define family therapy.

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Answer

Family therapy, also known as systemic therapy, is a form of psychological treatment used for patients with schizophrenia, involving a therapist and group sessions.

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Question

What is the average length of family therapy?

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Answer

Usually, family therapy lasts for up to a year.

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Question

What are the goals of family therapy?

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Answer

Family therapy intends to improve patient and family relationships and communication styles. This should address issues such as stress in the household, reducing levels of expressed emotion (EE) and relapse rate in schizophrenia. 

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Question

What are the processes of family therapy?

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Answer

Preliminary analysis, information transfer, and communication training.

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Question

What is preliminary analysis in family therapy?

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Answer

This is where families and households undergo interviews and observations with a therapist to identify the problem areas and strengths of the family.

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Question

What is information transfer in family therapy? 

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Answer

This is where the therapist encourages patients and the family to learn about the facts and causes of schizophrenia. This includes the influence of drugs and the effects issues such as additional stress and unwarranted guilt can cause for the patient AND the caregiver/family members. 

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Question

What is psychoeducation in family therapy?

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Answer

It is the process of educating the family involved about the disorder and the effects of outside influences on it.

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Question

What is communication training in family therapy?

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Answer

Communication training is the process of teaching family members how to communicate with each other without relying on negative behaviours and exacerbating symptoms/feelings of stress and guilt. This is for the patient and the family members.

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Question

What do we mean by being family-centred in family therapy?

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Answer

Family therapy intends to change the whole family’s behaviour, not just the patient. This removes a lot of pressure from the patient and justifiably addresses issues outside their control. It reduces levels of EE, self-sacrifice in family members, and conflicts within the household.

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Question

What is the strength of family therapy?

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Answer

It reduces levels of relapse rates in patients with schizophrenia.

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What is a weakness of family therapy?

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Answer

It is a lengthy process, and families can drop out due to the severity of symptoms or unresolved conflicts.

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Question

What did Leff (1985) find?

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Answer

In patients with schizophrenia, those with standard outpatient care had a relapse rate of 50% within nine months. However, those who had family therapy had a relapse rate of only 8% within nine months. After two years, 50% of patients with family therapy relapsed, and 75% without family therapy.

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Question

What do the results of Leff (1985) suggest?

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Answer

Family therapy is an effective treatment when reducing rates of relapse. However, it may only be a short-term solution.

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Question

What did Claxton et al. (2017) find in their study?

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Answer

When looking at family therapies reduction effect on relapse rates, after around six months, this effect reduces dramatically, and evidence of improvement was not sustained past six months.

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Question

What did Lobban (2013) find?

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Answer

Lobban (2013) found that family members felt they were coping better thanks to family therapy. Thus, family therapy reduces the pressures and resulting negative systems that develop due to poor support systems at home.

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Question

What are token economy systems?

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Answer

Token economy systems (TES) are a form of psychological therapy in which a reward system is used to manage maladaptive behaviours; patients earn tokens through good behaviour and then exchange them for rewards.

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Question

What theory does TES rely on?

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Answer

The theory of operant conditioning.

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Question

What are maladaptive behaviours? 

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Answer

Maladaptive behaviours are behaviours that prevent patients from adapting to new or difficult situations – most often they result in negative/difficult behaviours.

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Question

What are some examples of ‘incorrect’ behaviours?

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Answer

Issues with bad hygiene, disruptive behaviours, and lower socialisation with other patients/members of staff.

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Question

What are primary reinforcers in token economy systems?

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Answer

The reward acts as the primary reinforcer.

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Question

Give an example of a reward a patient with schizophrenia can earn.

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Answer

Examples include: 

  • A day out walking in a park.
  • Sweets and treats.
  • Access to films.
  • Access to magazines.

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Question

What are secondary reinforcers in token economy systems?

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Answer

The tokens act as the secondary reinforcers.

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Question

What three categories did Matson et al. (2016) establish of institutional behaviour affected by token economies?

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Answer

Personal care, condition related behaviour, and social behaviour.

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Question

 What did Allyon and Azrin (1968) find in their study?

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Answer

Patients have to want to do certain behaviours for TES to be applicable.

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Question

Give an example of a negative symptom of schizophrenia that TES affects.

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Answer

Avolition.

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Question

What is TES effective in?

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Answer

It is effective in reducing negative symptoms, increasing adaptive behaviours, reducing maladaptive behaviours, and causing a decline in undesirable behaviours.

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Question

What are the weaknesses in TES?

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Answer

It gives professionals/medical staff significant power of control over the behaviour of the patients. It also has methodological issues in the studies that were reviewed and is not maintained outside of a hospital setting.

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Question

Describe the Glowacki et al. (2016) study.

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Answer

Glowacki et al. (2016), in a meta-analysis of seven high-quality studies of the effectiveness of TES in hospitals, found that all studies showed decreased negative symptoms and a decrease in the frequency of undesirable behaviours (violence and aggression).

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Question

What did Kazdin (1982) say about TES? 

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Answer

Kazdin (1982) found that changes that were developed during a patient’s time in hospital using TES did not remain once they were discharged. Although TES is a way to alleviate symptoms, it is not a cure. 

Show question

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