Psychological Therapies: CBT, Family Therapy & Token Economics (AQA A-Level Psychology): Revision Notes
Psychological Therapies: CBT, Family Therapy & Token Economics
Cognitive behavioural therapy (CBT)
What is CBT?
Cognitive behavioural therapy (CBT) is the primary psychological treatment used alongside antipsychotic medication for schizophrenia. This approach focuses on modifying distorted thought patterns to bring about changes in both behaviour and emotional responses. The therapy operates on the principle that our beliefs, expectations, and perceptions of ourselves, our environment, and our personal difficulties influence how we view ourselves and others, how we understand problems, and how we cope with challenges.
Definition: Cognitive Behavioural Therapy
CBT is a treatment approach that modifies thought patterns to alter behavioural and emotional states. It targets the maladaptive thinking and distorted perceptions that underpin schizophrenia symptoms, helping patients develop strategies for managing their condition rather than treating symptoms directly.
CBT aims to help patients develop strategies for managing their condition and improving their overall functioning, working alongside medication to provide comprehensive treatment.
How CBT works
CBT is typically delivered in structured sessions, usually once every 10 days over approximately 12 sessions. Antipsychotic medications are generally prescribed first to reduce the intensity of psychotic thoughts, making CBT more manageable and effective for patients.
Key CBT Techniques for Schizophrenia
The therapy employs several essential strategies:
- Challenging intrusive thoughts: Patients learn to question and examine the validity of their distorted thinking patterns
- Distraction techniques: Strategies to redirect attention away from troubling thoughts or experiences
- Activity modification: Increasing or decreasing social activities to help manage mood changes and reduce isolation
- Relaxation strategies: Techniques to manage anxiety and stress that may exacerbate symptoms
Personal therapy (PT) is one specific CBT approach that involves detailed examination of individual problems and experiences, including their triggers and consequences. Therapists work collaboratively with patients to develop coping strategies tailored to their specific needs.
Rational emotive therapy is another component that addresses emotional instability, a common feature of schizophrenia. Patients learn muscle relaxation techniques to detect early signs of anger or agitation and apply relaxation skills to manage their emotional responses.
Research evidence
Multiple studies have investigated CBT's effectiveness for schizophrenia treatment, with varying results that highlight both promise and limitations.
Research Study: Tarrier et al. (2000)
Method: Patients received 20 sessions of personal therapy over 10 weeks, combined with medication, followed by four booster sessions the following year.
Results:
- One-third of patients receiving personal therapy achieved a 50% reduction in psychotic experiences
- 15% became completely free of positive symptoms
- In contrast, the counselling group showed only 15% symptom-free rates
- Medication-only group: 7% achieved complete symptom relief
Conclusion: Personal therapy showed superior outcomes compared to medication alone or supportive counselling.
Research Study: McGorry et al. (2002)
Findings: After six months of treatment:
- 36% of high-risk individuals receiving supportive psychotherapy developed schizophrenia
- Only 10% who received medication and CBT combined developed the condition
Implication: CBT may be more effective than psychotherapy alone in preventing first-onset schizophrenia.
Tarrier (2005) reviewed 20 controlled trials using 739 patients, finding consistent evidence of reduced symptoms, particularly positive symptoms, lower relapse rates, and faster recovery for acutely ill patients. However, these benefits appeared to be short-term, with follow-up studies needed to assess long-term effectiveness.
Zimmerman et al. (2005) conducted a meta-analysis of 14 studies involving 1,484 patients, revealing that CBT did reduce positive symptoms and was particularly beneficial for patients experiencing short-term acute schizophrenic episodes.
Critical Research Finding: Jauhar et al. (2014)
A comprehensive meta-analysis of 50 studies conducted over 20 years found only small therapeutic effects on symptoms, including positive symptoms like delusions and hallucinations that CBT primarily targets.
Crucially: Even these small effects disappeared when only blind studies were considered, raising serious questions about CBT's true effectiveness for schizophrenia.
Evaluation of CBT
Strengths:
Research evidence suggests CBT combined with antipsychotic medication is more effective than either medication or CBT alone, supporting integrated treatment approaches. CBT offers a non-pharmacological option with fewer side effects compared to antipsychotic drugs, though it is more expensive and resource-intensive. The therapy can be particularly beneficial for patients who refuse medication or experience severe side effects from antipsychotics.
Limitations:
Training and Cultural Considerations
Training requirements for CBT practitioners are substantial, with successful treatment depending on developing empathy, respect, unconditional positive regard, and honesty between patient and therapist. Research by Rathod et al. (2005) indicates that therapists from different ethnic backgrounds may have reduced success with patients from other ethnic groups due to difficulties establishing therapeutic rapport.
CBT may not be suitable for all patients, particularly those who are severely disorientated, highly agitated, or too paranoid to form trusting relationships with therapists. Some patients who refuse medication may find it challenging to engage effectively with CBT.
The lack of consistent blind testing in CBT research makes it difficult to assess treatment effectiveness objectively, as highlighted by Jauhar et al.'s findings. While CBT has fewer side effects than medication, it represents a more expensive treatment option, with cost being a consideration during periods of reduced healthcare budgets.
Research by Trower et al. (2004) suggests that CBT may not actually reduce hallucination intensity but rather helps patients perceive them as less threatening by teaching coping strategies for managing these experiences.
Family therapy
What is family therapy?
Family therapy, also known as family-focused therapy, is a psychological intervention based on the understanding that family dysfunction can contribute to the development and maintenance of schizophrenia. This approach recognises that altering relationship patterns and communication systems within dysfunctional families, particularly by reducing levels of expressed emotion, can support recovery and help prevent relapse.
Definition: Family Therapy
Family therapy is a treatment approach that modifies communication systems within families to support schizophrenia recovery. Rather than focusing solely on the individual with schizophrenia, it treats the entire family system as the patient's support network, acknowledging that family dynamics can either hinder or facilitate recovery.
How family therapy works
Family therapy addresses the complex interplay between family dynamics and mental health outcomes through structured interventions.
Three Primary Aims of Family Therapy
- Improve communication patterns: Increasing positive interactions while decreasing negative forms of communication between family members
- Increase tolerance and reduce criticism: Building understanding and patience while reducing critical attitudes that may contribute to stress and symptom exacerbation
- Reduce guilt and blame: Helping family members understand that they are not responsible for causing the illness, which can improve family relationships and reduce emotional burden
Therapists meet regularly with both the patient and family members, encouraging open discussion about the patient's symptoms, behaviour, treatment progress, and how the illness affects the entire family. Family members learn to support each other and take on specific roles in the patient's rehabilitation process.
The therapy emphasises 'openness' in communication, though boundaries are established regarding what information can be shared and what remains confidential. These boundaries are agreed upon in advance as part of informed consent procedures.
Treatment typically lasts between nine months and one year, focusing initially on symptom reduction while helping family members develop skills they can continue using independently after therapy concludes.
Research evidence
Several studies demonstrate family therapy's effectiveness in reducing relapse rates and improving patient outcomes.
Research Study: Leff et al. (1985)
Method: Compared family therapy with routine outpatient care for patients from families with high expressed emotion.
Results:
- First 9 months: 50% relapse rate for routine care vs 8% for family therapy
- After 2 years: 75% relapse rate for routine care vs 50% for family therapy
Conclusion: Family therapy showed particular effectiveness in short-term relapse prevention.
Research Study: Xiong et al. (1994)
Method: 63 Chinese patients randomly allocated to standard medication care vs standard care plus family therapy.
Results after one year:
- Standard care: 61% relapsed (36% required rehospitalisation)
- Family therapy group: 33% relapsed (12% required rehospitalisation)
Conclusion: Family therapy demonstrates effectiveness as an adjunct to medication across different cultural contexts.
Pilling et al. (2002) conducted a meta-analysis of 18 studies involving 1,467 patients, finding that family therapy showed the lowest relapse rates, fewest hospital readmissions, and highest medication compliance rates among psychological treatments, though CBT had the best success with treatment-resistant forms of schizophrenia.
McFarlane et al. (2003) found that family therapy reduces relapse rates and symptoms in patients while improving family relationships and overall patient well-being. Better family relationships appear to be the key mechanism driving therapeutic effectiveness.
Evaluation of family therapy
Strengths:
Family members can provide valuable insights into patient behaviour and mood patterns that patients themselves may be unable to articulate, particularly when patients lack insight into their condition. The therapy can significantly reduce relapse rates and hospitalisation needs while educating family members to help manage medication regimens, making treatment more cost-effective.
Younger patients living at home may particularly benefit from family therapy interventions. The Schizophrenia Commission (2012) estimates family therapy costs £1,004 less per patient over three years compared to standard care, making it relatively cost-effective.
Limitations:
Communication Challenges
The emphasis on open communication can create problems when family members are reluctant to share sensitive information, potentially causing or reopening family tensions and reducing treatment effectiveness. Some family members may be reluctant to discuss their own problems or admit their role in family difficulties, which can limit the therapy's effectiveness.
While combined medication and family therapy approaches are desirable, cost constraints often make it difficult to provide patients with both treatments simultaneously, limiting access to optimal care combinations.
Token economies
What are token economies?
Token economies represent a behaviourist therapeutic approach to schizophrenia management, where tokens are awarded to patients for demonstrations of desired behavioural changes. This technique, introduced in the 1970s, is primarily used in long-term hospitalised patients to enable them to eventually leave hospital and live more independently within the community.
Definition: Token Economies
Token economies are a method of behaviour modification used with schizophrenic patients that reinforces target behaviours by awarding tokens that can be exchanged for material goods. This approach specifically targets negative symptoms of schizophrenia, such as low motivation, poor attention, and social withdrawal, which are often less responsive to medication than positive symptoms.
How token economies work
The system operates on operant conditioning principles, where patients receive reinforcement through tokens immediately after producing desired behaviours. These tokens can later be exchanged for goods, privileges, or activities that patients value.
Key Features of Token Economy Systems
- Target behaviours: Self-care, medication adherence, positive social interaction
- Immediate reinforcement: Tokens given immediately after desired behaviours
- Clear connections: Patients can make direct links between behaviour and consequences
- Individualised approach: Systems tailored to meet specific patient requirements
- Flexible rewards: Tokens exchanged for personally meaningful goods or privileges
The immediate nature of token rewards helps patients make clear connections between their behaviour and consequences, gradually shaping more adaptive functioning. The flexibility of token economies allows them to be tailored to meet individual patient requirements, using consistent principles while targeting different behaviours based on each patient's specific needs and goals.
Research evidence
Research on token economies shows mixed but generally positive results for improving patient behaviour and engagement.
Research Study: Ayllon & Azrin (1968)
Participants: Female schizophrenic patients hospitalised for an average of 16 years
Method: Patients could earn tokens for viewing films or visiting the canteen by engaging in behaviours such as brushing their hair or making their beds
Results: The average number of daily chores completed increased from 5 to 42, demonstrating the technique's success in encouraging patients to take greater responsibility for themselves.
McMonagle & Sultana (2000) conducted a meta-analysis of token economy programmes involving 110 patients with schizophrenia, finding slight evidence for improved mental state, particularly regarding negative symptoms. This provides some degree of support for the treatment approach.
Dickerson et al. (2005) reviewed 13 studies, finding the technique generally useful for increasing adaptive patient behaviour, which supports its classification as an effective treatment. Token economies worked best when combined with psychosocial and medication therapies, though specific benefits when used as combination treatment were not clearly identified.
Research Study: Silverstein et al. (2009)
Finding: Patients with schizophrenia living in the community often struggle with jobs requiring long-term commitment, such as monthly wages, due to difficulties engaging with distant rewards.
However: They engage readily with token economy systems offering hourly or daily rewards, suggesting patients need more frequent, short-term reinforcement when employed.
Implication: Token systems may have applications beyond institutional settings for community-based support.
Evaluation of token economies
Strengths:
Token economies work most effectively alongside antipsychotic medication and other personalised psychotherapeutic treatments, rather than as standalone interventions. An unexpected benefit is that token systems create safer, more stable therapeutic environments with reduced staff and patient injuries, decreasing staff absenteeism and emergency incidents.
Patients often become more independent and active through token programmes, leading to increased motivation and improved self-regard among participants. The approach offers considerable flexibility, allowing adaptation to different patients' needs and various treatment settings using consistent underlying principles.
Limitations:
Dependency and Generalisation Concerns
A major concern is that desired behaviours may become dependent on continued reinforcement, with patients showing high readmission rates when community programmes lack token economy systems. The technique can be tailored to individual needs, but this flexibility means benefits may not generalise effectively to real-life settings outside controlled environments.
Some clinicians view token economies unfavourably, perceiving patient participation as humiliating and questioning whether benefits extend beyond institutional settings to everyday life. Long-term hospitalisation can lead to institutionalisation, where patients lose motivation and become apathetic, making independence more difficult to achieve.
Key Points to Remember:
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CBT focuses on changing distorted thinking patterns and is most effective when combined with antipsychotic medication, though research on its standalone effectiveness remains mixed.
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Family therapy targets communication patterns and expressed emotion within families, showing strong evidence for reducing relapse rates and improving patient outcomes.
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Token economies use operant conditioning principles to reward desired behaviours and are particularly effective for addressing negative symptoms in institutional settings.
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All three therapies work best as part of integrated treatment approaches rather than standalone interventions, with combination treatments showing superior outcomes to single interventions.
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Research evidence varies in quality and consistency across all three approaches, with methodological issues such as lack of blind testing affecting the reliability of some findings.