Schizophrenia: Treatment Approaches
Schizophrenia or dementia praecox is a chronic mental health disorder that is characterized by the presence of delusions, hallucinations, erratic behavior, and the impairment of cognitive abilities (Patel, Cherian, Gohil, & Atkinson, 2014). According to the description of the disorder in the DSM-5, it is associated with the following diagnostic criteria: disorganized speech, delusion, hallucinations, grossly disorganized behavior, social or occupational dysfunction, duration of six months, schizoaffective exclusion, and substance exclusion (Tandon et al., 2013). The onset of the mental disorder usually occurs in the first half of life; however, many episodes of schizophrenia have been registered beyond the age of 60 years (Hafner, Maurer, & Heiden, 2013). The prevalence of the debilitating disorder in the US population falls in the range between 0.6 percent and 1.9 percent (Patel et al., 2014). There is no variation in the prevalence of schizophrenia between sexes. The condition is treated with the help of a large number of both non-pharmacological and pharmacological therapies.
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Non-pharmacological therapies are used in conjunction with pharmacological approaches and target residual symptoms (Patel et al., 2014). Furthermore, non-pharmacological therapies such as psychotherapy are necessary to ensure that patients adhere to their pharmacological treatments. It is extremely important since the condition is characterized by high non-adherence rates. Psychotherapeutic approaches to the treatment of schizophrenia fall into three categories: individual, group, and cognitive-behavioral (Patel et al., 2014). Cognitive-behavioral approaches consist of cognitive-behavioral therapy and compliance therapy (Patel et al., 2014). Individual approaches are comprised of the following therapies: supportive, personal, social skill, and employment rehabilitation (Chien, Leung, Yeung, & Wong, 2013).
This paper aims to review, as well as to compare and contrast, two peer-reviewed articles on psychotherapeutic treatment approaches to schizophrenia. The paper will also discuss theories associated with treatment interventions outlined in the articles.
An article by Grant, Huh, Perivoliotis, Stolar, and Beck (2012) describe the results of a randomized control trial on the efficacy of the application of cognitive therapy (CT) for treatment of “neurocognitively impaired, poorly functioning patients with chronic schizophrenia” (p. 122). The trial was approved by the University of Pennsylvania and was conducted at a single institution in Philadelphia (Grant et al., 2012). The researchers enrolled 60 patients with schizophrenia in the study (Grant et al., 2012). The following eligibility criteria were used for the enrollment: DSM-IV diagnosis of schizophrenia, severe negative symptoms, aged between 18 and 65 years, and mental ability to consent (Grant et al., 2012). The diagnostic assessment of the patients was conducted by the research personnel holding PhD and MD degrees. A single-blind design helped to ensure that therapies were not known to outcome assessors.
The CT Intervention
The CT was used as an intervention in the study. Specifically, all patients received on average 18 months of CT treatment (Grant et al., 2012). Throughout the treatment, the participants were involved in 50 minutes’ sessions in outpatient settings (Grant et al., 2012). The duration of the sessions and their frequency varied based on patients’ needs and states; however, each secession was scheduled once a week. The most salient elements of the CT were goal orientation and personalized treatment planning (Grant et al., 2012). Strong therapeutic relationships were established during initial sessions, which helped to promote adherence to the therapy.
During early sessions, the patients were encouraged to recognize dysfunctional beliefs and other impediments to their short-term, intermediate, and long-term goals. Independent housing and improvement in social and occupational functioning were established as long-term goals of the treatment. Therapists participating in the intervention used a wide range of cognitive and behavioral techniques and practices during sessions. The most commonly used activities were exercises, role-playing, and community outings (Grant et al., 2012). Strategies outlined in Beck and associates’ book Schizophrenia: Cognitive Theory, Research, and Therapy were used to overcome other obstacles to reaching the goals such as delusions and disorganized thinking (Grant et al., 2012).
In addition to targeting common symptoms of the disease, the therapy was designed to address “deficits in attention, executive function, and social skills” (Grant et al., 2012, p. 123). During later stages of the treatment, functional gains were consolidated to prevent symptom reversions. Furthermore, therapists used visual aids to improve understanding of take-home materials and provided patients with colorful reminders of therapy assignments (Grant et al., 2012). All sessions were tailored to participants’ levels of cognitive functioning and insight.
The intervention described in the study is based on a confluence of theories underlying modern CT or cognitive behavioral therapy (CBT). The key theoretical underpinning of the therapy can be found in the works of Beck who attempted to explain individual psychological processes associated with depression (Skodlar, Henriksen, Sass, Nelson, & Parnas, 2013). Beck’s theoretical foundation of CBT has been constructed with the help of the theory of personal constructs and rational-emotive behavioral therapy (Skodlar et al., 2013). The modern CBT approach to the treatment of schizophrenia is based on theoretical assumptions of these two theories according to which only people’s appraisals of events play a role in “the development of mental disturbance” (Skodlar et al., 2013, p. 251).
The CBT presupposes that mental disorders prevent individuals from the normal interpretation of external stimuli; therefore, their mental states are affected by a range of cognitive distortions (Leahy, 2015). These distortions in information processing can be categorized as biases, schemas, and representations. The role of a therapist is to change the client’s cognitive distortions, thereby eliminating symptoms.
When it comes to the treatment of schizophrenia, patients’ symptoms depend on their relation to cognitive perceptions, causation attribution, belief creation, and belief interpretation (Leahy, 2015). CBT therapists regard cognitive appraisals as generative for both negative and positive symptoms of the disorder. It means that the immediate experiences of patients are either considered as secondary or not addressed during interventions. Therefore, two key theoretical strategies used in the CBT for the recognition of mental processes do not take into consideration the immediate experiences of patients. The first strategy is atomization, which presupposes a single-symptom approach (Leahy, 2015). The second theoretical strategy is reification, which interprets mental phenomena in isolation.
The CBT theories have several explanations for the mechanisms underlying delusion formation in schizophrenia. The most common sources of dysfunctional beliefs are “jumping-to-conclusions data-gathering bias, externalizing attributional (explanatory) style, and theory of mind deficit” (Skodlar et al., 2013, p. 257). Jumping-to-conclusions bias is a mechanism of delusion formation is a tendency for hasty data gathering (Skodlar et al., 2013). The second mechanism is a “tendency to attribute negative events to external causes,” which is targeted during CBT sessions (Skodlar et al., 2013, p. 257). The theory of mind deficit is based on the hypothesis that schizophrenic patients have difficulties in recognizing other people’s perspectives. It has to be borne in mind, however, that validity of these mechanisms is widely contested by acclaimed scholars (Skodlar et al., 2013). Therefore, one has to be careful when informing their practice by some theories underlying the CBT.
The intervention group showed a marked improvement on the global functioning score from baseline when compared to the control group subjected to standard treatment (ST)—1.36 and 0.06, respectively (Grant et al., 2012). Another difference in the outcomes of the two groups is a reduction of avolition-apathy—1.66 for the CT group and 2.81 for the ST group (Grant et al., 2012). Hallucinations, delusions, and disorganization also subsided significantly in the intervention group (Grant et al., 2012). The researchers argue that the CT helped to move patients “out of their withdrawn state” (Grant et al., 2012, p. 126). The findings of the study are consistent with the theoretical underpinnings of the CT. It follows that the CT can be effectively used to treat patients with schizophrenia who are on the low end of the spectrum of social functioning.
Unfortunately, the results of the study are not confirmed by other clinical trials that do not show a significant difference in the improvement of positive schizophrenia symptoms (Jones, Hacker, Cormac, Meaden, & Irving, 2012). It means that even though findings of the study conducted by Gran and associates convincingly favor the CT as a schizophrenia intervention, it is necessary to critically compare it to other psychotherapeutic approaches. It is extremely important, since the assessment of the reliability of research, is a key element of the introduction of evidence-based intervention in advanced clinical practice.
Cognitive Enhancement Therapy
A study conducted by Eack, Mesholam-Gaterly, Greenwald, Hogarty, and Keshavan (2013) explores the effects of cognitive enhancement therapy (CET) on schizophrenia outpatients. The researchers selected 58 patients with the early course of the disorder for participation in a randomized control trial (Eack et al., 2013). The following inclusion criteria were used for the trial: schizophrenia diagnosis, an IQ over 80, no history of substance abuse, and substantial impairment of social or cognitive functioning (Eack et al., 2013). The diagnostic assessment of the patients was conducted by the research personnel. Unlike the participants in the study conducted by Grant and associates who were mostly African American, the majority of participants in the study under discussion were male and Caucasian (Eack et al., 2013).
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The intervention used in the study was longer than that in the randomized control study conducted by Grant and associates and lasted for two years (Eack et al., 2013). Eligible participants underwent 60 hours of computer-based training on average (Eack et al., 2013). The training targeted attention, memory, and problem-solving skills of the participants of the study. Also, all individuals with schizophrenia diagnosis attended 45 social-cognitive group sessions the aim of which was to improve their ability to “take the perspective of others, accurately appraise spontaneous social contexts, be foresightful, and understand the social ‘gist’ from novel interpersonal encounters” (Eack et al., 2013, p. 23). Furthermore, the sessions were designed to help the participants to better manage stress and develop effective coping mechanisms. The emphasis on the development of the ability to recognize the perspective of others is informed by CBT’s theory of mind, which is a point of overlap between the two therapeutic approaches.
The interventions focused on both illness management and social function recovery. During the early stages of the treatment, patients were taught effective stress management techniques such as passive distraction and avoidance of stressful environments (Eack et al., 2013). During the intermediate stage of recovery, the patients were presented with more complex stress management methods such as criticism management and diaphragmatic breathing (Eack et al., 2013). Similarly to the CT intervention, sessions were held every week during the early stages of the treatment. However, as the patients progressed in their recovery, both the frequency and the length of sessions changed to facilitated biweekly encounters with mental health practitioners.
The therapy has been developed to improve the neurocognitive and thinking abilities of individuals with schizophrenia (Singh, Barber, & Sant, 2016). The therapy falls into the category of cognitive remediation and is based on a neurodevelopmental theory of cognitive development (Roberts & Penn, 2013). The basis of a theoretical framework for the therapy is the “recognition of the developmental nature of the brain and cognition” (Roberts & Penn, 2013, p. 336). Methods adopted for CET rely on “the sociological principles of secondary socialization” and other theories of social development (Roberts & Penn, 2013, p. 337). Therefore, CET relies on small-group sessions to facilitate recovery.
CET draws heavily on the modern understanding of neurodevelopmental disorders. By analyzing the cognitive impairments of patients with schizophrenia, Hogarty and associates have developed a method for addressing the developmental interruption in cognitive functioning, thereby creating the therapy (Roberts & Penn, 2013). Furthermore, CET relies on the ever-increasing body of evidence on brain plasticity.
Unlike the study conducted by Grant and associates, the CET research focused on the assessment of the therapy’s impact on negative symptoms of schizophrenia and the social-cognitive domains of patients’ functioning. Eack et al. (2013) argue that the intervention resulted in the improvement of negative symptoms. The researchers report “specific differential improvements in social withdrawal, motor retardation, and affective flattening, with the largest effects observed in the domain of social withdrawal” (Eack et al., 2013, p. 24).
The intervention was also effective in improving the cognitive scores of the participants. Furthermore, the researchers discovered the link between changes in neurocognition and amelioration of negative symptoms (Eack et al., 2013). However, the therapy did not help to improve the emotional procession of the participants. The results of the study are congruent with modern theories on cognitive processes. Given that cognitive processes are interdependent, the treatment of schizophrenia has to focus on “both neurocognitive and social-cognitive functioning” (Roberts & Penn, 2013, p. 337). The intervention described in the study is based on the integrated approach, which is fairly effective in addressing the disorder. Even though the two studies target different symptoms of schizophrenia, it can be argued that CET is a more effective treatment approach. It has to do with the fact that the intervention has been specifically developed to address cognitive processes associated with the disease. Also, the treatment is based on modern studies on brain plasticity and helps patients with schizophrenia to improve their social cognition.
The paper has critically reviewed two professional articles on psychotherapeutic approaches to the treatment of schizophrenia—the CT and CET. The paper has outlined interventions presented in the articles and discussed theories underlying the treatments. It has been argued that CET should be used in advanced clinical practice because it is extremely effective in improving multiple patients’ outcomes associated with schizophrenia.
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