PSYCHOLOGICAL THERAPIES FOR SCHIZOPHRENIA
To read up on psychological therapies for schizophrenia, refer to pages 414–423 of
Eysenck’s A2 Level Psychology.
Ask yourself
 How can the behavioural approach be applied to the treatment of
schizophrenia?
 How can the cognitive approach be applied to the treatment of
schizophrenia?
 How can what we know about the interactions within the family of a
schizophrenic be applied to treatment?
What you need to know
BEHAVIOURAL THERAPY COGNITIVEFAMILY THERAPY
BEHAVIOURAL THERAPY
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Token economy
Research, evidence,
and evaluation
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Research, evidence,
and evaluation
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Research, evidence,
and evaluation
Until the 1960s, it was widely believed that schizophrenia was such a serious
disorder that psychological therapies were doomed to failure. Biological therapies
have long been held to be the main form of treatment for schizophrenia, however
the following three therapies show there are alternatives to a purely biological
approach.
Behavioural therapy
Behavioural therapy developed during the 1950s and 1960s and is based on the
assumptions that abnormality is due to maladaptive learning, and so treatment
needs to replace the maladaptive behaviour with more adaptive behaviour. Classical
and operant conditioning are the methods used to change unwanted behaviour into
more desirable behaviour.
Token economy
Token economy is based on the use of selective positive reinforcement or reward.
This tends to be used with institutionalised patients, who are given tokens (e.g.
coloured counters) for behaving in appropriate ways. These tokens can later be
used to obtain various privileges (e.g. cigarettes, watching television).
RESEARCH EVIDENCE FOR TOKEN ECONOMY
 Ayllon and Fzrin (1968, see A2 Level Psychology page 415) reported on the
use of token economy with female patients with schizophrenia, who had
been hospitalised for an average of 16 years. They were rewarded with
plastic tokens for actions such as making their beds or combing their hair.
The tokens were exchanged for pleasant activities, such as seeing a film or an
additional visit to the canteen. The number of chores the patients performed
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each day increased from five to over forty. Thus, token economy was found to
be successful in socialising the patients into taking more responsibility for
themselves.
Dickerson, Tenhula, and Green-Paden (2005, see A2 Level Psychology page
416) reviewed studies of token economy through a meta-analysis and
reported beneficial effects were reported in 11 of 13 studies. They also
concluded that token economy was best used in combination with other
therapies such as psychosocial and/or drug therapy.
EVALUATION OF TOKEN ECONOMY
Effectiveness
 Moderate effectiveness. Token economies have proved moderately
effective with institutionalised patients resistant to other forms of therapy.
 Need continuous reinforcement. Beneficial effects are often greatly
reduced when good behaviour is no longer followed by the rewards the
patients have become used to receiving. This means the therapy only really
works in the structured hospital environment and so lacks external validity
to the patients’ home environment.
 Too specific. Token economies only treat a few of the symptoms of
schizophrenia. Token economies increase certain kinds of behaviour but do
not address cognitive symptoms of schizophrenia, such as hallucinations,
delusions, or disorganised speech.
 Superficial change. It is possible that token economies only effect
superficial change where schizophrenics imitate normal behaviour without
any accompanying changes in their thoughts and beliefs.
Appropriateness
 Appropriate for some symptoms. Token economies are appropriate for
symptoms such as lack of motivation and a general disengagement. The
tokens provide patients with the incentive to behave in desirable ways and
so can have a real effect on these symptoms.
 Ethical issues. Are the “desired behaviours” really desirable for the patient
or is it more the institution that benefits? This can be countered as the
improved social behaviour of the patients, such as not spitting in their food,
is desirable for the patients and their fellow patients.
 Does not treat all symptoms. A number of the more serious symptoms
cannot be treated with a token system, e.g. delusions, hallucinations, and lack
of emotion.
 Reductionism. The behavioural treatment ignores other relevant factors, e.g.
genetic factors, biochemistry, and poor communication within the family,
that play important roles in producing schizophrenia.
 Less effective in less structured settings. The great majority of patients
with schizophrenia nowadays are treated in the community, and token
economies are not appropriate for less structured settings.
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No lasting change. It can be argued that token economies produce rather
short-lasting and even superficial changes in behaviour that fail to generalise
well to the outside world. Therefore, they do not meet the goal of therapy to
provide lasting change.
Cognitive-behavioural therapy
The principle underling cognitive-behavioural therapy (CBT) is the assumption that
patients often have irrational thoughts and beliefs about themselves and about the
world, and these can lead to abnormality. Consequently, changing the patients’
beliefs by challenging them and demonstrating they are wrong is one goal of
cognitive-behavioural therapy. The other is to change behaviour. At one time it was
thought that cognitive-behavioural therapy would not work for the very serious
cognitive disturbances of schizophrenia. In fact it has proven effective and this is
linked to the combined use of drug therapy, which enables patients to be more
responsive to cognitive-behavioural therapy, and the fact that many patients with
schizophrenia actively engage in coping strategies to control their delusions and
hallucinations, and so the therapy adds to these coping strategies (Tarrier, 1987, see
A2 Level Psychology page 417).
Cognitive-behavioural therapy for schizophrenia tends to focus on the positive
symptoms (hallucinations and delusions) rather than the negative symptoms (such
as lack of emotion, lack of motivation, speaking very little). The Coping Strategy
Enhancement works by establishing the context of patients’ delusions and
hallucinations (type and triggers) and the coping strategies they use. The therapist
and the patient work together to improve the patient’s existing coping strategies.
The patient is given the “homework” of applying one or more coping strategies
whenever the target delusion or hallucination is experienced, and the therapist and
patient discuss ways of making the coping strategies more effective.
Other forms of cognitive-behavioural therapy focus on trying to change patients’
delusions and hallucinations. This may begin with asking the patient to think of
alternative explanations for his or her beliefs. After this, there is “reality testing”, in
which the therapist and patient plan an activity that is designed to test the validity
of a delusional belief, e.g. if the patient thought they had a special power the
therapist would ask the patient to demonstrate it.
RESEARCH EVIDENCE FOR COGNITIVE-BEHAVIOURAL THERAPY
 Tarrier et al. (1993, see A2 Level Psychology pages 418–419) tested the
effectiveness of Coping Strategy Enhancement. Patients treated with this
showed significantly more reduction in positive symptoms than patients on a
waiting list for treatment, and the improvement was still there 6 months
after the end of treatment.
 A meta-analysis of several studies found CBT was moderately effective in
reducing positive symptoms and also led to slight improvements in social
functioning (Pfammatter, Junghan, & Brenner, 2006, see A2 Level Psychology
page 419).
EVALUATION OF COGNITIVE-BEHAVIOURAL THERAPY
Effectiveness
 Sample drop-off. The main problem was that almost half of the patients
scheduled to take part in the Tarrier et al. (1993) study refused to participate
or dropped out. This may have exaggerated the apparent effectiveness of the
treatment as those who stayed in the study are likely to be those whose
treatment had better outcomes.
 We don’t know how CBT works. There are many aspects of CBT and we
don’t know which have most effect. This limits effectiveness as the therapy
could be made more effective if we knew which aspects had most benefit.
This also limits appropriateness as is it appropriate to use a treatment we
don’t fully understand?
 Inadequate control treatments. There is another issue concerning the
interpretation of the findings. In many studies CBT was compared against a
control treatment (e.g. routine therapy) and found to be superior. This
difference may be due to the effectiveness of CBT but it may be because the
control treatment is inadequate.
Appropriateness
 Schizophrenia is characterised by cognitive dysfunction. Thus, it seems
appropriate to treat the cognitive dysfunction.
 Draws on existing coping strategies. It is appropriate to develop
therapeutic techniques to improve those coping strategies.
 Can raise self-esteem. The therapy involves the realisation that similar
delusions and hallucinations sometimes occur in healthy individuals and this
can improve their mental state.
 Doesn’t treat negative symptoms. CBT is specifically designed to reduce
only certain positive symptoms of schizophrenia. Thus, it does not treat the
negative symptoms.
 High relapse rate. CBT has very modest beneficial effects on relapse rate.
 Reductionism. Ignores other relevant factors, e.g. biological factors
associated with schizophrenia.
 High drop-out rate. The appropriateness of CBT is reduced because many
patients with schizophrenia drop out of therapy. This can be linked to the
fact that patients need to be highly motivated because the treatment requires
a certain amount of effort and commitment from the patient.
Family therapy
Family therapy has focused on high levels of expressed emotion (e.g. hostility;
excessive criticism) because these have been linked to relapse and negative
outcomes. Falloon et al. (1985, see A2 Level Psychology page 420) devised a form of
family management that teaches everyone in the family how to be constructive,
undemanding, and empathic in their dealings with each other and with their
schizophrenic relative. The family is also encouraged not to have high expectations
of the family member with schizophrenia and to avoid stressful interactions with
him or her. The patient is encouraged to develop his or her communication skills
and social network. This approach is described as family psychoeducation.
Falloon and colleagues have further developed their family-centred therapy through
the Optimal Treatment Project. This involves providing education for caregivers and
patients to allow them to cope with stressors, training in social skills for patients,
effective drug therapy, and monitoring patients’ condition to enhance the
effectiveness of treatment.
RESEARCH EVIDENCE FOR FAMILY THERAPY
 Falloon et al. (1985, see A2 Level Psychology pages 420–421) found that the
relapse rate was markedly lower amongst patients receiving family therapy
than those receiving individual therapy. 50% of those in the individualtherapy group returned to hospital compared with only 11% of those in the
family-therapy group.
 Birchwood and Jackson (2001, see A2 Level Psychology page 420) found that
the relapse rate over 12 months was 60% for patients with schizophrenia
receiving routine treatment, but was between 25% and 33% for those
receiving family therapy.
 McFarlane et al. (2003, see A2 Level Psychology page 421) carried out a metaanalysis on the effects of family psychoeducation on patients with
schizophrenia. They concluded that it was associated with reduced relapse
rates, improved recovery, and improved family well-being.
 The Optimal Treatment Project has been used in over 20 different countries,
and the evidence indicates that it is significantly more effective than
traditional ways of managing schizophrenia (Falloon et al., 2004, see A2 Level
Psychology page 421).
EVALUATION OF FAMILY THERAPY
Effectiveness
 Reduced relapse rate. Family therapy has proved its worth by reducing the
relapse rate of patients with schizophrenia and making it less likely that they
will have to return to hospital.
 Biased trial studies. Hayman-White and Happell (2007, see A2 Level
Psychology page 421) have pointed out trials of the Optimal Treatment
Project have generally taken place at specially selected sites where the
therapists and administrators were highly motivated.
 Effectiveness is limited. Family therapy is not a cure. Patients usually
continue to require drug therapy and their level of social adjustment is
markedly lower than that of healthy individuals.
Appropriateness
 Patients are more likely to be cared for at home. This of course makes
family therapy highly appropriate as a family being taught to better support
their schizophrenic relative is highly positive.
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Evidence for expressed emotion. There is much evidence that high
expressed emotion can increase the relapse rate and so it is highly
appropriate to focus on reducing expressed emotion.
Patients do tend to lack social skills. Many of the symptoms of
schizophrenia (e.g. disorganised speech, speaking very little, lack of emotion)
help to isolate patients with schizophrenia socially, and so therapy that
emphasises social functioning is appropriate.
Reductionism. Family therapy does not consider other relevant factors, such
as genetic or biochemical factors, and so only focuses on one level of
behaviour.
Unlikely to work on its own. Family therapy would probably not be
successful on its own, but needs to be used in conjunction with drug therapy,
which means we cannot be sure how much any improvements are due to the
family therapy as opposed to the drug therapy.
Not a cure. Family therapy does significantly improve functioning and some
of the aspects it tackles, such as poor social skills, may well be the underlying
causes of the disorder but it does not provide a cure for schizophrenia. Even
when social functioning is the focus of therapy it is not possible to increase
social functioning to the level of healthy controls.
So what does this mean?
Any comparisons of the effectiveness of different treatments should be treated with
caution as it is difficult to know if differences are due to the actual therapy or the
individual differences of the patient or therapist. Therapy depends in part on the
skills of the therapist and so differences in improvement may be due to such
differences rather than the treatment itself. The fact that patients usually choose
their own treatment and so are a self-selected sample also complicates comparing
treatments. Moreover, recovery may not be due to the specific nature of the
treatment but to general factors that underpin all treatments, such as the effect of
having someone sensitive to talk to and being able to express all worries and fears,
which is known as the “general therapy effect”.
Assessing the effectiveness of treatments is further complicated by the “hello–
goodbye effect” whereby patients overestimate their symptoms at the start of
treatment and underestimate their symptoms at the end.
Another issue is publication bias whereby significant findings are published more
than non-significant ones. These biases may make therapies appear more effective
than they really are. Imagine if all the findings that a therapy doesn’t work are
suppressed, then of course it’s going to appear effective!
Ethical issues raise further concerns as can the patient really give fully informed
consent? A number of factors can limit this, such as the patient not being provided
with enough information about the treatment, they may not remember the
information accurately, and they may agree just because they respect the therapist
rather than understand the treatment.
However, in spite of all of these issues, it is important to understand as best we can
the effectiveness and appropriateness of therapies because, especially in the case of
schizophrenia, no treatment is not an option. The psychological therapies,
particularly cognitive-behavioural and family therapy, do show there is more to
treatment for schizophrenia than just drugs. However, the optimal approach to
treatment is a multi-dimensional one in which drugs are combined with one or
more other treatments.
Over to you
(a) Outline one or more psychological therapy (ies) for schizophrenia. (9 marks)
(b) Evaluate the therapy(ies) described in (a). (16 marks)