psychological explanations and therapies for schizophrenia

7/31/2019 Psychological Explanations and Therapies for Schizophrenia

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Psychological explanations of schizophrenia

Psychological theories

Psychodynamic

Freud (1924) believed that schizophrenia was the result of two related processes, regression to a pre-

ego state and attempts to re-establish ego control.

If the world of the schizophrenic has been particularly harsh, for example if his or her parents were cold

and uncaring, an individual may regress to this early stage in their development before the ego

properly formed and before he or she had developed a realistic awareness of the external world.

Schizophrenia was thus seen by Freud as an infantile state, with some symptoms (e.g. delusions and

grandeur) reflecting this primitive condition, and other symptoms (e.g. auditory hallucinations) reflecting

the persons attempts to re-establish ego control.

Cognitive

This explanation of schizophrenia acknowledges the role of biological factors in causing the initial

sensory experiences of schizophrenia, but claims that further features of the disorder appear asindividuals attempt to understand those experiences.

When schizophrenics first experience voices and other worrying sensory experiences, they turn to

others to confirm the validity of what they are experiencing. Other people fail to confirm the reality of

these experiences, so the schizophrenic comes to believe that others must be hiding the truth. They

begin to reject feedback from those around them and develop delusional beliefs that they are

being manipulated and persecuted by others.

Socio-cultural factors

Life events and schizophrenia

A major stress factor that has been associated with a higher risk of schizophrenic episodes is the

occurrence of stressful life events. These are discrete stresses, such as the death of a close relative tothe break-up of a relationship.

A study by Brown and Birley (1968) found that, prior to a schizophrenic episode; patients who had

previously experienced schizophrenia reported twice as many stressful life events compared to a

health control group.

Family Relationships

Double-bind theory

Bateson et al. (1956) suggest that children who frequently receive contradictory messages from their

parents are more likely to develop schizophrenia. For example, if a mother tells her son that she loves

him while turning her head away in disgust; the child receives two conflicting messages about their

relationship on different communicative levels, one of affection on the vernal level, and one of animosity

on the non-verbal level.

The childs ability to respond to the mothers incapacitated by such contradictions because one message

invalidates the other. These interactions prevent the development of an internally coherent

construction of reality, and in the long run, this manifests i tself as schizophrenic symptoms (e.g.

flattened affect and withdrawal). These ideas were echoed in the work of psychiatrist R.D. Laing, who

argues that what we call schizophrenia is actually a reasonable response to an insane world.

Expressed emotion

Another family variable associated with schizophrenia is a negative emotional climate, or more

specifically, a high degree of expressed emotions. Expressed emotion (EE) is a family

communication style that involves criticism, hostility and emotional over-involvement. Highlevels of EE are most likely to influence a relapse rates. A patient returning to a family with high EE is


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about four times more likely to relapse than a patient returning to a family with low EE (Linszen et al.,

1997).

In a study of the relapse rates among schizophrenics In Iran, Kalafi and Torabi (1996) found that the

high prevalence of EE in Iranian culture (overprotective mothers and rejective fathers) was one of the

main causes of schizophrenic relapses. It appears that the negative emotional climate in these

families arouses the patient and leads to stress beyond his or her already impaired coping mechanisms,

thus triggering a schizophrenic episode.

Labelling theory

The labelling theory of schizophrenia, popularised by Scheff (1999), states that social groups construct

rules for members of their group to follow. The symptoms of schizophrenia (e.g. hallucinations and

delusions, and bizarre behaviour) are seen as deviant from the rules we ascribe to normal experience.

If a person displays these unusual forms of behaviour, they are considered deviant, and the label of

schizophrenic may be applied. Once this diagnostic label is applied it becomes a self-fulfilling

prophecy that promotes the development of other symptoms of schizophrenia (Comer, 2003)

Retrospective studiesBrown and Birley (1968) reported that life events play an important role in

precipitating episodes of schizophrenia. They found that about 50% of people experience stressful life events

in the 3 weeks prior to a schizophrenic episode, while only 12% reported one in the weeks prior to that. A

control sample reported a low and unchanging level of stressful life events over the same period, suggesting that

it was the life events that triggered the relapse.

Prospective studies- unlike retrospective studies, which study events in the past, prospective studies monitorthe presence or absence of stressful life events prospectively (i.e. in the future). Hirsch et al. (1996)

followed 71 schizophrenic patients over a 48 week period. it was clear that life events made a significant

cumulative contribution in the 12 months preceding relapse rather than having a more concentrated effect in

the period just prior to the schizophrenic episode (as suggested by the retrospective studies).

Commentary

Psychotherapeutic explanations

There is no research evidenceto support Freuds specific ideas concerning schizophrenia, except that

subsequent psychoanalysis have claimed, like him, that disordered family patterns are the cause of this

disorder. For example, Fromm-Reichmann (1948)described schizophrenegenic mothers or families

who are rejecting, overprotective, dominant and moralistic, as important contributory influences in the

development of schizophrenia.

Studies have shown that parents of schizophrenic patients do behave differently from parents of

other kinds of patients, particularly in the presence of disturbed offspring (Oltmanns et al., 1999) but

this is as likely to be a consequence of their childrens problems as a cause.

Cognitive explanations

There is much evidence of a physical basis for the cognitive deficits associated with schizophrenia, forexample, research by Meyer-Lindenberg et al. (2002), which found a link between excess dopamine in

the prefrontal cortex, and working memory. The suggestion that madness is a consequence of

disbelieving others receives curious support from a recent suggestion for treatment.

Yollowlees et al. (2002) have developed a machine that produces virtual hallucinations, such as

hearing the TV tell you to kill yourself, or one persons face morphing into another. The intention is to

show schizophrenics that their hallucinations are not real. As yet there is no evidence that this will

provide a successful treatment.

Life events and schizophrenia

Not all evidence supports the role of life events. For example, van Os et al. (1994) reported no link

between life events and the onset of schizophrenia. Patients were not more likely to have had a majorstressful life event in the 3 months preceding the onset of their illness. In a prospective part of the


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study, those patients who had experienced a major life event went on to have a lower likelihood of

relapse.

Evidence that does suggest a link between life events and the onset of schizophrenia is only

correlational. It could be that the beginnings of the disorder (e.g. erratic behaviour) were the cause of

the major life events. Furthermore, life events after the onset of the disorder (e.g. losing ones job,

divorce) may be a consequence rather than a cause of mental illness.

Family relationships

The importance of family relationships in the development of schizophrenia can be seen in an adoption

study by Tienari et al. (1994). In this study those adopted children who had schizophrenic biological

parents were more likely to become ill themselves than those children with non-schizophrenic biological

parents.

However, this difference only emerged in situations where the adopted family was rated as disturbed.

In other words the illness only manifested itself under appropriate environmental conditions. Genetic

vulnerability alone was not sufficient.

Double-bind theory

There is some evidence to support this particular account of how family relationships may lead to

schizophrenia. Berger (1965) found that schizophrenics reported a higher recall of double-bind

statements by their mothers than non-schizophrenics. However, this evidence may not be

reliable, as patients recall may be affected by theirschizophrenia.

Liem (1974) measured patterns of parental communication in families with a schizophrenic child and

found no difference compared to normal families.

Hall and Levin (1980) analysed data from various previous studies and found no difference between

families with and without a schizophrenic member in the degree to which verbal and non-verbal

communication were in agreement.

Expressed emotion

The effects of expressed emotion have received much more universal empirical support than double-bind theory. However, there is the issue of whether EE is a cause or an effect of schizophrenia.

Either way it has led to an effective form of therapy where high EE relatives are shown how to reduce

levels of expressed emotion.

Hogarty et al. (1991) found that such therapy can significantly reduce relapse rates. However, with all

therapies, it is not clear whether the EE intervention was the key element of the therapy or whether

other aspects of family intervention may have helped.

Expressed emotion and cultureAlthough findings on expressed emotion have been replicated cross-

culturally, expressed emotion is much less common in families of people with schizophrenia outside the west

(Jenkins and Karno, 1992). One possible explanation for this is that non-western cultures are less individualist

and less committed to concepts of personal responsibility than western societies such as the US and UK. Thus,

they are less likely to blame someone with schizophrenia for their actions.

Labelling theory

In a review of the evidence, Scheff (1974) evaluated 18 studies explicitly related to labelling theory. He

judged 13 to be consistent with the theory and 5 to be inconsistent, thus concluding that the theory

was supported by the evidence.

A study which he assessed as supporting labelling theory was the Rosenhan study. Rosenhan found

that once the label of schizophrenia had been applied, the diagnosis continued to influence the

behaviour of staff toward the patient, even when it was no longer warranted.


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Psychological therapies for schizophrenia

Cognitive behavioural therapyThe basic assumption of CBT is that people often have distorted beliefs, which influence their behaviour in

maladaptive ways. For example, someone with schizophrenia may believe that their behaviour is being controlled

by someone or something else. Delusions are thought to result from faulty interpretations of events, and cognitivetherapy is used to help the patient to identify and correct these.

CBT techniques

In CBT, patients are encouraged to trace back the origins of their symptoms in order to get a better idea

of how the symptoms might have developed. They are also encouraged to evaluate the content of their

delusions or of any internal voices they hear, and to consider ways in which they might test the validity

of their faulty beliefs. Patients might also be set behavioural assignments with the aim of improving their

general level of functioning.

The learning of maladaptive responses to lifes problems is often the result of distorted thinking by the

schizophrenic, or mistakes in assessing cause and effect (for example assuming that something terrible

has happened because they wished it).

During CBT the therapist lets the patient develop their own alternatives to these previous maladaptive

beliefs, ideally by looking for alternative explanations and coping strategies that are already present in

the patients mind.

Outcome studies

Outcome studies measure how well a patient does after a particular treatment, compared with the

accepted form of treatment for that condition. Outcome studies of CBT suggest that patients who

receive cognitive therapy experience fewer hallucinations and delusions and recover their functioning to

a greater extent than those who receive antipsychotic medication alone.

Drury et al. (1996) found benefits in terms of reduction of positive symptoms and a 25-50% reduction in

recovery time for patients given a combination of antipsychotic medication and CBT.

A subsequent study by Kuipers et al. (1997) confirmed these advantages, but also noted that there were

lower patient drop-out rates and greater patient satisfaction when CBT was used in addition to

antipsychotic medication.

Effectiveness of CBT

Supporting researchResearch has tended to show that CBT has a significant effect on improving the

symptoms of patients with schizophrenia. For example Gould et al. found hat all seven studies in their meta -

analysis reported a statistically significant decrease in the positive symptoms of schizophrenia after treatment.

How much is due to the effects of CBT alone?Most studies of the effectiveness of CBT have been

conducted with patients treated at the same time with antipsychotic medication. It has been difficult, therefore to

assess the effectiveness of CBT independent of antipsychotic medication.


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Effectiveness of psychodynamic therapy

Supporting researchMalmberg and Fenton (2001) argue that it is impossible to draw definite conclusions

for or against the effectiveness of psychodynamic therapy. In fact the Schizophrenia Patient Outcome Research

Team (PORT) has even argued that some forms of psychodynamic therapy are harmful for patients with

schizophrenia. Despite this, a Meta analysis of 37 studies (Gottdiener, 2000) concluded that psychodynamic

therapy was an effective treatment for schizophrenia.

Contradictory findingsresearch on the effectiveness of psychodynamic therapy for schizophrenia has

produced contradictory findings. For example, May (1968) found that patients treated with this therapy together

with antipsychotic medication, had significantly better outcomes than those treated with the therapy alone. What

was even more damning was that antipsychotic medication alone was superior to psychodynamic therapy.

However, Karon and VandenBos (1981) found the opposite, with patients treated with therapy improving more

than those receiving medication alone.

Appropriateness of psychodynamic therapy

Combination therapydespite the fact that evidence for the effectiveness of psychodynamic therapy in

schizophrenia is not entirely convincing, the treatment guidelines of the APA (American Psychiatric Association)

recommend that supportive interviewers such as psychodynamic therapy are appropriate when combined with

antipsychotic medication.

Costs and benefitsone argument against using psychodynamic therapy is that it is expensive

(psychodynamic therapists are expensive and the treatment is usually long term) prevents it being adopted on a

large scale. Some critics argue that because it does not appear more effective than antipsychotic medication,

psychodynamic therapy is not worth the extra expense. However, there is evidence to suggest that the overall

cost of treating schizophrenics decreases with the use of therapy because they are less likely to seek inpatient

treatment and are more likely to gain employment (Karon and VandenBos, 1981).

Methodical limitations of psychodynamic outcome studies

In the Gottdiener study there were a number of methodical issues that prevented firm conclusions being drawn

about the effectiveness of psychotherapy as a treatment for schizophrenia.

1. Number of studiesthe relatively small number if studies meant that it was difficult to assess the

impact of variables such as therapist training or experience.

2. Random allocationabout half of the studies reviewed did not allocate patients randomly to treatment

conditions, thus introducing a treatment bias that may possibly have affected the results.

Ethical issues in schizophrenia research

Research on therapies for schizophrenia must be carried out in a way that doesnt place vulnerable individuals at

unreasonable risk. The BPS advice that when participants take part in a psychological investigation they should

not, in doing so, be increasing the probability that they would come to any form of harm. The possibility for harm

is heightened when dealing with vulnerable groups such as patients with schizophrenia. The potential for harm in

outcome studies of schizophrenia include those associated with medication discontinuation, the use of placebo

conditions and capacity for informed consent.


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psychological explanations and therapies for schizophrenia

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