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.
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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