A critical discussion of the use of psychological
interventions for psychosis with reference to an individual patient.
Community Mental Health and Social Work
This essay is two parts. Firstly, it will look at the wider body of
literature on psychological interventions for psychosis including the
advancement of Cognitive Behavioural Therapy (CBT). It is worthwhile mentioning
that the term ‘psychosis’ will refer to a range of symptoms that are found
within the diagnostic categories of schizophreniform illness (Gregory, 1987). Secondly, it will focus on the use of CBT,
including engagement, assessment and coping enhancement as tools for
psychological intervention. The
application of these tools will be demonstrated by a brief case study with a
patient with psychosis.
Psychological Interventions
Since the development of
anti-psychotic medication and the dominance of biomedical models during the
1950’s, mental health care has been changing and evolving. The dependency on the sole use of medication
was found to have left patients with residual symptoms and social disability,
including difficulty with interpersonal skills and limitation with coping (Sanford
& Gournay, 1996). This prompted
the return of psychological interventions to be used in conjunction with
medication. During the 70’s, the aim was to reduce residual disability and
include in the treatment process social skills training and rehabilitation (Wykes
et al., 1998). This class of
treatment interventions was based on methods and principles derived from social
learning theories to train (or retrain) motor and interpersonal skills and
competencies. During this period, the
psychological management of psychotic symptoms also relied upon theories of
operant leaning in an attempt to modify behaviours by manipulation of rewards
and punishment (Bradshaw, 1995; Haddock & Slade, 1996). In Bradshaw’s (1995) evaluation of the early
works of psychological interventions, many limitations are highlighted. He
notes that, while varying techniques helped to improve the outward functioning
of patients, the benefits were short term and they did not necessarily reduce
psychotic symptoms. Instead, he argues, it may have enabled the patient to
disguise the symptom and avoid talking about them.
Given this shortcoming,
since the pioneering work of US Psychiatrist Aaron Beck on cognitive therapy,
there has now been a real growing interest in including cognitive skill
techniques in traditional social skills training approaches (Haddock &
Slade, 1996). Cognitive therapy is
now accepted as a testable and reliable treatment for depression and anxiety
even though the techniques were primarily used for patients with delusional
beliefs (Bradshaw, 1995). The
concept of this model holds that, the thoughts people have of a situation and
the way they understand it, are largely influenced by their beliefs about
themselves and the world (Nelson, 1997). In recent times, psychological interventions have become better
understood. It is increasingly recognised
that the onset of psychotic experiences can be traumatic and lead to major life
changes, emotional support and the opportunity to talk is then very
important. Also, that intervention
should be based on a trusting, collaborative working relationship or alliance
between the therapists and patient, this process is regarded as the main
‘active ingredient’ (Kinderman & Cooke, 2000).
Cognitive Behavioural Therapy (CBT)
In the 80’s the Cognitive
Therapist joined forces with the Behaviour Therapist to change people’s
inaccurate beliefs. The two therapies
merged to work hand in hand, which led to much research taking place in recent
years, mainly in the UK, advocating the development of cognitive-behavioural
interventions for psychosis (Haddock & Slade, 1996). Psychological techniques developed in CBT to
help modify medication resistant experiences claim to be the most promising
advancement in the treatment of schizophrenia for many years (Kingdon &
Tukington, 1994). The aim was to
move more towards directing therapies for specific symptoms and designed to
help patients normalise or become accepting of their experience, which
otherwise would be disturbing. The main assumption behind CBT is that,
psychological difficulties depend on how people think and interpret events
(cognition), how people respond to these events (behaviour), and how it makes
them feel (emotions) (Kinderman & Cooke, 2000). In other words, links are then made between
the patient’s feelings and the pattern of thinking which underpin the distress. In another words, it can be understood that,
the way people feel about a situation or experience depends on what they think
about it and how they interpret Nelson (1997). In the context of
psychosis, CBT aims to work with those who have difficulties with their
thoughts, making illogical associations and developing false and sometimes
bizarre explanations for their feelings, which may lead to poor social
functioning or withdrawal. The
techniques used with schizophrenia seeks to strengthen the patient’s logical
reasoning ability against their intuitive feelings, for example, it encourage a
split between “I feel/believe/hear”.
Standards to the CBT model include logical reasoning, evidence for and
against distressing beliefs, reality testing and generating alternative
explanations (Kingdon & Tukington, 1994).
Positive symptoms such as
hallucinations are often distressing experiences because of the patient’s
perception of whom or what is responsible.
The use of CBT can encourage patients to challenge commanding voices in
a collaborative manner. For example, to
limit the power of commanding voices, which threaten bodily harm if, say, an
occurrence of obsessive thought was to be stopped intentionally, one may develop
counter thoughts (Kingdon & Turkingdon, 1994). This can be: “Why should I do that? You are
only a voice and powerless: there is no way a voice can bring me physical harm”
and “I have not done what you commanded last night for an hour and there was no
consequence”. This may help empower the
patient to have more control over their symptoms and improve
self-confidence. If, say for example,
critical voices were to accuse the patient of being subnormal, who then
experiences a behavioural consequence of becoming socially withdrawn, the
voices themselves can be challenged to produce evidence to back up this
statement. A failure to produce such evidence may render the voices unworthy
and mute, which may then help to increase the patient’s social
functioning. This type of intervention
to modify delusional beliefs about the origin of voice may help to reduce the
distress they can cause and lead to an evaluation and re-interpretation of
psychotic experiences (Nelson, 1997).
Given that delusional beliefs can be held very firmly, most literature
on CBT warn that, even the most of gentlest challenge need to be proceeded
slowly and cautiously and that the technique is used to challenge the evidence
supporting the distressing belief rather than the belief itself (Gamble
& Brennan, 2000). The therapist
then works with the patient to help them identify thoughts and behaviours that
are relevant to their problem and teaches them to carry out the whole thought
process independently. The idea behind
this is that, when patients learn to challenge their own thoughts, armed with
that knowledge, they can use the skills on their own. They also learn new behaviours and problem solving skills so that
they can interpret their thoughts and behaviours in more rational ways. Educating clients to understand how and what
they think in the moment is therefore an important part of the therapeutic
process (Lam & Gale, 2000). This
has brought about a psychological understanding and aim to help people work out
their own understanding of the nature of illness and what is likely to
help.
Over 400 hundred patients
have entered the trial of CBT and both short and medium term data suggest that
CBT may decrease relapse/readmission (Effective Health Care Bulletin).
Some of the well-known randomised control trial studies on the efficacy of CBT
on psychosis against standard care and supportive counselling, which show
reasonable consistency across studies: see Tarrier (1998); Drury (1996); Garety
(1996) and Kemp (1996). In the
Cochrane’s Database review (2000), these studies are evaluated. The data show that the group who received
cognitive behavioural intervention over a period of 9 months including a follow
up period had significantly greater improvements in measures of both positive
and negative symptoms compared to those in the standard care. Further differences are observed favouring
CBT over standard care. CBT helped to
reduce risk of relapse by 54% and increase interpersonal functioning while the
standard care group were characterised by serious symptomatology and impairment
in functioning requiring medical treatment.
The studies also report the beneficial effects of these interventions in
improving compliance and insight. The recent evidence available strongly
supports the use of CBT in the treatment of psychotic symptoms both in the
early stage of illness and in long-term illness resistance to medication. These studies also show that CBT has
sustainable effect after active treatment has finished. Research has also focused on using CBT in
family interventions and reports show a significant improvements in families’
problem solving skills and reduction in clinical, social and family morbidity (Kuipers
et al., 1992).
While the efficacy of CBT is
unquestionably well documented, the generalisability of the data in the studies,
however, raises some concerns. Often
established controlled studies, lack an adequate breakdown of sample
characteristics in terms of race and culture. Furthermore, discussion is also
lacking on the details as to the way in which symptoms improved or social
functioning enhanced in behavioural terms in relation to social context. As a
result, it is difficult to deduce factors, other than cognitive behavioural
interventions, which may together influence change. In the main, there is often a quantitative presentation of data
rather than qualitative. Given that the
population in the UK is increasingly multi-cultural and diverse, including
people from various cultural, racial and spiritual backgrounds (Fernandos,
1995; Adams et al.,1998), how inclusive are these studies of different
minority ethnic groups? Given that, it
is a well documented fact that many ethnic groups are often not referred to
psychotherapy due to the inherent stereotype view held in psychology that they
are not psychologically minded (Robinson, 1995), has the widely
acknowledged promising usage of CBT shown a difference? Some black communities
are unable to articulate distress adequately in the English language or have no
direct meaning in their own language for anxiety or feelings (Kareem &
Littlewood, 1992; Hussain 2000), how does then one carry out collaborative
work when, say, looking at the link between emotion and thought in an attempt
to ‘strengthen the patient’s logical reasoning’? Can it be argued that CBT is likely to be most effective with the
indigenous population, while it has minimum usage with other groups? Especially so, say, for some parts of the
Muslim community (see Badri, 2000; Hussain, 2000), who may not
culturally view life or conceptualise health and illness in separate bits - as
in CBT’s ‘rational’ or ‘thinking’ terms.
The use of
psychological tools of engagement, assessment and coping enhancement with a
patient with psychosis
Mr. X is a 28-year-old white
male with a history of schizophrenia and numerous admissions. He is being treated with anti-psychotic
medication and lives with his mother in a two-bedroom council flat. Initially
in the engagement stage, the interventions focused on developing rapport by
showing an interest to Mr. X’s experience of living with a psychotic illness (Nelson,
1997). Given the assumption that, I
was likely to be viewed by Mr. X as part of the psychiatric system that is
demeaning, the aim was to demonstrate an openness and honesty about my role and
bring to the session a sense a difference from the ward staff. This was a way in, in an attempt to provide
a rationale for the CBT work and developing trust, which helps to promote a
collaborative partnership between the therapist and patient (Thompson, 1996). A reciprocal discussion with Mr. X on how
the referral came about, what his expectations were, explanation on what I had
to offer and an exploration of his feelings on considering new ways of dealing
with psychotic symptoms (Gamble & Brennan, 2000), was further useful
for the engagement process.
Mr. X’s clinical symptoms
were assessed using the KGV (Krawieka, Goldberg and Vaughn, 1977)
symptom scale, which focuses on five areas including anxiety, depression,
suicidal thoughts and behaviours, elevated moods, hallucinations and delusions. The use of direct and somewhat intrusive
questioning in the KVG, found Mr. X to score significantly between three and
four for anxiety and between two and three for hallucination in comparison to
the other symptoms. It was clear that
Mr. X was hearing critical voices of a debilitating nature a number of times in
a day, which was making him feel confused, frightened and restless. Given this preoccupation, the anticipation
of panic and powerlessness once exposed to any environment different from his
flat had also stopped him from going outside regularly. This was making him
increasingly distressed and house bound.
Assessment is a process that elicits the presence of disease or
vulnerability and level of severity in symptoms (Birchwood & Tarrier,
1992). This gathering of
information provides the basis to develop a plan for suitability of treatment,
identifies problems and strengths and agree upon priorities and goals (Gamble
& Brennan, 2000; Nelson, 1997).
While the assessment helped
to form a picture of Mr. X’s problem and suitability for CBT, it also provided
a scope for further work on his coping skills.
Given the assumption that, a person may feel reluctant to give up a
particular way of coping, as this may be the only means of control (Gamble
& Brennan, 2000), the exploration was collaborative. It was found that Mr. X had a faulty way of
coping with his critical voices. When
the voices start commanding he shouts back at them in an aggressive and loud
manner. While this gives him temporary relief as the voices stop, leaving Mr. X
feeling safe, his neighbours would react either by knocking on his door or
calling the police. This would make him feel that people are against him and
further power and trigger the cycle of critical voices. The adoption of Coping Strategy Enhancement (Birchwood
& Tarrier, 1994) and Romme & Escher’s (1989) ideas on coping
strategies were used. The idea was to
build on Mr. X’s existing coping method and introduce an alternative. We agreed upon distraction as a coping
strategy. The plan was for Mr. X to
listen to music or carryout breathing exercises when the critical voice appear
and to start interacting with them by telling them to go away instead of
shouting at them. This plan used over a period of time seemed to have reduced
the psychological arousal and helped him gain maximum usage of these strategies
in controlling the symptom.
Studies highlighted in this
essay show considerable strength in supporting claims of efficacy that CBT can
work and does help to reduce and control symptoms of psychosis. However, in the light of multi-culturalism
and increasing diversity in work force and population, a quote from Enright
(1997:1815) brings to focus a critical review of CBT that is often
overlooked in the wider literature:
“Some applications of cognitive behaviour therapy remain highly experimental and require considerable more research and more sophisticated theoretical models. Without this increased understanding of what works for whom, and why, we should remain cautious of overenthusiastic claims for efficacy and of the clumsy application of generic cognitive behavioural theory being made to fit increasingly diverse disorders”
Community Mental Health and
Social Work
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