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Psychological therapies for schizophrenia aim to reduce the distress caused by symptoms, improve everyday functioning and lower the risk of relapse. They are used alongside antipsychotic medication rather than instead of it, which is itself an expression of the interactionist approach to the disorder. This lesson examines three psychological interventions named on the specification — cognitive-behavioural therapy for psychosis (CBT), family therapy and token economies — and then sets them within the interactionist approach, including the diathesis-stress model (Meehl; Zubin and Spring) and its supporting evidence (Tienari et al.'s adoption study). Throughout, the register is measured and clinical: therapies are described objectively, and people with schizophrenia are treated as active partners in care, not as objects of management.
Key Definition: Psychological therapies for schizophrenia are non-pharmacological treatments that apply psychological principles to help a person manage symptoms, reduce distress, improve coping and lower relapse, usually in combination with medication.
This lesson covers the remaining treatment and explanatory strands of the AQA 7182 Paper 3 option: cognitive-behavioural therapy and family therapy as treatments; token economies as a management technique based on operant conditioning; and the importance of an interactionist approach in explaining and treating schizophrenia (the diathesis-stress model). You must be able to describe how each therapy works and its evidence base, and describe the diathesis-stress model and the interactionist rationale for combined treatment. You must then evaluate these as AO3 — the effectiveness and limits of each therapy, the appropriateness of behavioural control, and the strengths and weaknesses of the interactionist case. The recurring examiner theme is that, because schizophrenia is best explained by an interaction of biological vulnerability and environmental stress, it is best treated by combining biological and psychological methods.
Cognitive-behavioural therapy for psychosis (CBTp) adapts standard CBT for people experiencing psychotic symptoms such as hallucinations and delusions. It is recommended in clinical guidelines (NICE) as a psychological treatment for schizophrenia, delivered alongside medication.
The core aims of CBTp are to help the person:
Crucially, CBTp does not begin by telling the person that their experiences are "not real". The therapist works collaboratively, building a shared understanding (formulation) of how the person's beliefs and experiences arose and are maintained, and then gently helping them to test whether alternative interpretations might fit the evidence better or cause less distress.
| Technique | Description | Illustrative use |
|---|---|---|
| Reality testing / evidence review | Collaboratively weighing evidence for and against a belief | Examining what does and does not support a belief that one is being monitored |
| Normalising | Explaining that unusual experiences are commoner than assumed, reducing alarm and self-stigma | Noting that a meaningful proportion of the general population reports voice-hearing at some point |
| Behavioural experiments | Testing a prediction through a planned, low-risk activity | Planning a brief outing to test a feared prediction and reviewing what actually happened |
| Coping-strategy work | Developing and rehearsing responses to symptoms | Practising ways of responding to a distressing voice |
| Homework | Between-session tasks that consolidate learning | Keeping a simple record of triggers and responses |
CBTp is typically delivered over roughly 16 or more sessions of around an hour, beginning with engagement and assessment, moving through collaborative formulation and active work, and ending with relapse prevention. A trusting therapeutic relationship — warmth, empathy and a non-judgemental stance — is essential, because the work involves discussing beliefs and experiences the person may find frightening or stigmatising.
Exam Tip: Describe CBT for psychosis specifically, not CBT in general. The examinable detail is that it targets the distress and conviction attached to hallucinations and delusions through collaborative reality-testing and normalising — not anxiety or low mood.
Controlled trials and reviews indicate that CBTp produces modest improvements in symptoms, particularly positive symptoms and the distress associated with them, when added to standard care. Tarrier (2005) and others reported greater improvement in positive symptoms for patients receiving CBTp than for those receiving routine care or supportive counselling alone, with benefits persisting at follow-up. The effect sizes reported across meta-analyses are generally small to moderate, and they tend to shrink in the most methodologically stringent analyses (for example, those restricted to trials with blinded outcome assessment) — an important point for evaluation.
Family therapy works with the whole family rather than the individual alone, and its central rationale is to reduce expressed emotion (EE) — the high-criticism, high-hostility or emotionally over-involved climate that, as Lesson 3 established, predicts relapse.
The aims of family therapy include:
In practice, family therapy involves the patient and the relatives they live with, over a series of sessions across several months. Pharoah et al. (2010), in a review of relevant trials, reported that family therapy reduced relapse and readmission rates and improved adherence to medication, with benefits maintained at follow-up. The intervention is one of the better-evidenced psychosocial treatments for schizophrenia.
Key Definition: Family therapy for schizophrenia is a structured, psychoeducational intervention that works with the patient and their family to reduce expressed emotion, improve communication and lower relapse.
Token economies are a behavioural management technique based on operant conditioning (Skinner). They were used extensively in psychiatric institutions in the 1960s and 1970s to support the behaviour of people with chronic schizophrenia, particularly the self-care and engagement deficits associated with negative symptoms and long hospitalisation.
The behaviourist rationale is that institutionalisation can reinforce passivity and "learned helplessness", and that systematic reinforcement of adaptive behaviour can counteract this. Token economies do not claim to treat the disorder itself; they manage behaviour.
Key Definition: A token economy is a behaviour-management system in which target behaviours are reinforced with tokens (secondary reinforcers) that can be exchanged for desired primary reinforcers, based on the principles of operant conditioning.
Ayllon and Azrin (1968) conducted an influential study on a psychiatric ward, rewarding self-care behaviours such as bed-making with tokens. The frequency of the target behaviours increased when tokens were available and decreased when the system was withdrawn, demonstrating that the reinforcement, rather than some incidental factor, was responsible. Later reviews (for example, McMonagle and Sultana, 2000) concluded that token economies could improve targeted behaviours but that the evidence base was limited and consisted largely of older studies with methodological weaknesses, and that effects on the disorder itself were not demonstrated.
The combined use of medication and psychological therapy is not an arbitrary mixture; it follows directly from the interactionist approach, which holds that schizophrenia arises from an interaction of biological and environmental factors and should therefore be treated on both fronts.
The diathesis-stress model proposes that a person develops schizophrenia only when an underlying vulnerability (diathesis) is combined with sufficient environmental stress. Meehl (1962) gave an early, explicitly biological formulation: he proposed an inherited vulnerability — which he termed "schizotypy", arising from a hypothesised single gene ("schizogene") and an associated abnormal "schizotypic" personality organisation — such that only those with the diathesis could develop schizophrenia, and even then only if exposed to appropriate stress (for Meehl, particularly a schizophrenogenic mother). Zubin and Spring (1977) broadened the model: every individual has some level of vulnerability, and whether the disorder develops depends on the balance between that vulnerability and the level of stress experienced. A person with a high diathesis may develop schizophrenia under relatively mild stress, whereas a person with low diathesis would require severe stress.
The model has since become biopsychosocial: the "diathesis" is no longer seen as a single gene but as a polygenic biological vulnerability (Lesson 2) possibly combined with psychological vulnerability, and "stress" is broadened to include not only family environment but also psychological and social stressors such as childhood adversity, cannabis use, migration and urban living.
graph TD
A["Diathesis (vulnerability)<br/>polygenic risk, neural / dopamine"] --> C{"Interaction"}
B["Stress (triggers)<br/>family EE, trauma, drug use, urban living"] --> C
C -->|"Vulnerability + sufficient stress"| D["Schizophrenia develops / relapses"]
C -->|"Low vulnerability or low stress"| E["Disorder does not develop"]
The clearest empirical support for the interactionist position comes from Tienari et al. (2004) (also discussed in Lesson 2). Adopted-away children of biological mothers with schizophrenia (the high-genetic-risk group) and a control group were assessed alongside the quality of their adoptive family environment. The high-risk children were significantly more likely to develop schizophrenia only when raised in a disturbed (high-stress) adoptive family; high-risk children raised in healthy families, and low-risk children in disturbed families, were largely unaffected. This pattern — risk expressed only when genetic vulnerability and environmental stress were both present — is precisely what the diathesis-stress model predicts, and it is difficult to explain on a purely genetic or purely environmental account.
If schizophrenia results from an interaction of vulnerability and stress, treatment should address both. The interactionist approach therefore supports combining antipsychotic medication (which acts on the biological diathesis) with psychological therapies such as CBTp and family therapy (which reduce stress and improve coping). Clinical guidelines reflect exactly this logic, recommending medication together with psychological intervention. Importantly, the combined approach is not merely additive: by reducing stress and improving coping and adherence, the psychological therapies may lower the likelihood that the biological vulnerability is expressed as relapse, so the two kinds of treatment reinforce one another in a way the diathesis-stress model predicts.
| Feature | Drug therapy | CBTp | Family therapy | Token economies |
|---|---|---|---|---|
| Primary target | Biological diathesis (dopamine) | Beliefs and distress | Family stress (expressed emotion) | Specific behaviours |
| Positive symptoms | Effective | Modest benefit | Indirect (via relapse) | Not targeted |
| Negative symptoms | Limited (better with clozapine) | Small | Indirect | May improve self-care |
| Relapse prevention | Effective while taken | Some benefit | Well evidenced | Limited / institutional |
| Role of the patient | Recipient of medication | Active collaborator | Family participant | Recipient of reinforcement |
| Main ethical concern | Side effects, consent | Few | Few; avoids blame | Autonomy / control |
The table makes the interactionist point visible: the therapies target different levels of the disorder, which is precisely why combining them is more powerful than relying on any one alone.
This lesson connects to several wider areas of the specification:
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