Psychological Therapies for Schizophrenia

Psychological therapies for schizophrenia aim to reduce the distress caused by symptoms, improve social functioning, and reduce the risk of relapse. They are typically used alongside antipsychotic medication rather than as a standalone treatment. This lesson examines Cognitive Behavioural Therapy (CBT), family therapy, and token economies, evaluating their effectiveness and comparing them with drug therapy.

Key Definition: Psychological therapies for schizophrenia are non-pharmacological treatments that use psychological principles to help patients manage symptoms, improve coping, and enhance quality of life.

---

CBT for Psychosis (CBTp)

Cognitive Behavioural Therapy for psychosis (CBTp) is an adaptation of standard CBT designed specifically for individuals experiencing psychotic symptoms such as hallucinations and delusions. It is recommended by NICE (2014) as a first-line psychological treatment for schizophrenia.

Aims and Principles

The core aims of CBTp are to:

1. Help patients identify and evaluate the evidence for their delusional beliefs
2. Develop alternative explanations for psychotic experiences
3. Reduce the distress associated with hallucinations and delusions (even if the experiences themselves do not entirely cease)
4. Improve coping strategies and everyday functioning

CBTp does not assume that the patient's experiences are "not real." Instead, the therapist works collaboratively with the patient to explore the beliefs underlying their symptoms and to test whether alternative interpretations might be more accurate or helpful.

Key Techniques

Technique	Description	Example
Reality testing	Collaboratively examining evidence for and against a belief	"What evidence supports the idea that your neighbours are spying on you? What evidence contradicts it?"
Thought records	Monitoring automatic thoughts and identifying cognitive distortions	Patient records thoughts, situations, emotions, and alternative interpretations in a structured diary
Behavioural experiments	Testing beliefs through planned activities	If the patient believes they will be harmed if they leave the house, they plan a brief trip and record what actually happens
Normalising	Explaining that unusual experiences are more common than patients realise	"Research shows that about 10% of the general population hear voices at some point in their lives"
Homework assignments	Tasks completed between sessions to reinforce learning	Practising alternative responses to auditory hallucinations

Typical Course of Treatment

• 16–20 sessions delivered over at least 4 months
• Sessions last approximately 50–60 minutes
• Treatment begins with engagement and assessment, followed by collaborative formulation, active intervention, and relapse prevention
• The therapeutic relationship is crucial — the therapist must demonstrate empathy, warmth, and unconditional positive regard while gently challenging delusional thinking

Exam Tip: A common exam mistake is to describe CBT in general terms. For full marks, you must describe CBTp specifically as applied to psychosis. This means discussing how it targets hallucinations and delusions rather than anxiety or depression.

Effectiveness of CBTp

Tarrier et al. (2004) conducted a randomised controlled trial (RCT) comparing CBTp with supportive counselling and routine care. Patients receiving CBTp showed significantly greater improvements in positive symptoms than those receiving supportive counselling alone. Benefits were maintained at 12-month follow-up.

Wykes et al. (2008) conducted a meta-analysis of 34 RCTs and found that CBTp produced moderate effect sizes for positive symptoms (d = 0.37). However, effects on negative symptoms were smaller and less consistent.

Jauhar et al. (2014) conducted a more stringent meta-analysis, including only studies with blind assessors. They found that the effect of CBTp was small (d = 0.25 for positive symptoms, d = 0.13 for overall symptoms). This raised questions about whether the benefits of CBTp are clinically meaningful or merely statistically significant.

Evaluation of CBTp

Strengths:

• Recommended by NICE (2014) as a first-line treatment — strong evidence base
• Empowers patients by giving them an active role in managing their symptoms
• Can be used alongside medication — no pharmacological interactions
• Addresses the psychological distress caused by symptoms, which medication alone may not resolve

Limitations:

• Requires patients to have sufficient cognitive functioning and insight to engage in therapy — some severely ill patients may not be suitable candidates
• Not all patients benefit — response rates vary, and some meta-analyses show only small effects
• CBTp is time-intensive and requires skilled therapists — access can be limited, especially in underfunded NHS services
• It does not treat the underlying neurochemical causes of schizophrenia — it manages symptoms rather than curing the disorder

---

Family Therapy

Family therapy for schizophrenia aims to improve the functioning of the family unit and, in particular, to reduce levels of expressed emotion (EE) that have been shown to predict relapse.

Aims of Family Therapy

1. Psychoeducation — educating family members about schizophrenia, its symptoms, and its course, to reduce blame and increase understanding
2. Reducing expressed emotion — helping families move from high-EE (critical, hostile, over-involved) to low-EE communication patterns
3. Improving communication — teaching family members to express their needs and concerns constructively
4. Problem-solving — developing strategies for managing difficult situations and reducing conflict
5. Reducing relapse — by creating a supportive home environment that minimises stress

How Family Therapy Works

Family therapy typically involves: