A
Critical Discussion Of The Use Of Psychological Interventions For Psychosis
With Reference To An Individual Patient.
Abul Hussain (UK) © June 2001
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.
Conclusion
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”
Abul
Hussain (UK) June 2001
abulh@dsl.pipex.com
Community Mental Health and Social Work
References:
Adams
R, Dominelli L & Payne M (1998), Social Work: Theme, Issues and
critical debates, Macmillan, UK
Badri M (2000), Contemplation:
An Islamic Psychospiritual Study, The International Institute of
Islamic Thought, Cambridge University Press, UK
Birchwood
M & Tarrier N (1992), Innovations in the Psychological
Management of Schizophrenia, John Wiley & Sons Ltd, UK
Bradshaw
T (1995), Psychological Interventions with psychotic symptoms: a
review, Mental Health Nursing, Vol 15, No.4
Cochrane
Database Review (2000), The Cochrane database of Systematic Reviews,
Cognitive behaviour therapy for schizophrenia, (issue 4).
Effective
Health Care Bulletin (2000), Psychological Intervention for Schizophrenia,
Vol.6 No.3
Enright
S (1997), Cognitive behaviour therapy-clinical applications,
BMJ Vol. 314
Fernando
S (1995), Mental Health in a
Multi-Ethnic Society, Routledge, London
Gamble
C & Brennan G (2000), Working with serious mental illness: A
manual for clinical practice, Harcout Publishers, London.
Gregory
R (1987), The Oxford Companion to the Mind, Oxford University Press.
Oxford
Haddock
G & Slade P (1996), Cognitive-Behavioural Interventions with
Psychotic Disorders, Routledge, UK
Hussain,
A (2001). Islamic beliefs and mental health. Mental Health
Nursing, 21, pp. 6-9
Kareem
J & Littlewood R (1992), Intercultural Therapy: Themes, Interpretations and Practice,
Blackwell Science, London
Kinderman
P & Cooke A (2000), Understanding Mental illness, Recent
advances in understanding mental illness and psychotic experiences,
The British Psychological Society, UK
Kingdon
D & Turkingdon D (1994), Cognitive-Behavioural Therapy for
Schizophrenia, Hove: Lawrence Erlbaum, UK.
Krawieka
M, Goldberg D and Vaughn M (1977), A Standardised psychiatric
assessment scale for rating chronic psychotic patients, Acta
Psychiatrica Scandinavica 1977;55: 299-308
Kuipers
L, Leff J, Lam D (1992) Family work for schizophrenia: a practical
guide, London
Lam
D & Gale J (2000), Cognitive behavioural therapy: teaching a
client the ABC model – the first step towards the process of change,
Journal of Advance Nursing, 31(2)
Nelson
H (1997), Cognitive Behavioral Therapy with Schizophrenia,
Stanely Thornes, UK
Robinson
L (1995), Psychology for Social
Workers - Black Perspectives, Routledge,
London
Romme
M & Escher S (1989), Accepting Voices, Mind
Publications, London.
Sandford T & Gournay
K (1996), Perspectives in Mental Health Nursing, Bailliere
Tindall, London.
Thompson
N (1996), People Skills, A Guide to Effective Practice in the Human
Services, Macmillan.
Wykes
T, Tarrier N & Shon L (1998), Outcome and Innovation in
Psychological Treatment of Schizophrenia, Wiley, UK
|
