Theory and practice analysis of psychotherapy for patients with schizophrenia

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Theory and practice analysis of psychotherapy for patients with schizophrenia

Tetiana Riakhovska

PhD student of the Department of Clinical Psychology,

Kyiv Institute of Modern Psychology and Psychotherapy,

Abstract

psychotherapy schizophrenia patient

The article is devoted to the theory and practice analysis of psychotherapy for patients with schizophrenia. The article studies characteristic features and main trends of its modern development and provides a brief analysis of the history of psychotherapy for schizophrenia.

Although the role and relative popularity of psychotherapy in the treatment of schizophrenia have varied over time, analysis of the history of psychotherapy for schizophrenia that focused on results uncovers recent trends, including the development of the Cognitive Behavior Therapy (CBT) approach. The article identifies features of CBT as the most promising area of psychotherapy in this endogenous disorder. The article describes the goal, structure, and main focus of the CBT, aimed at assimilating patients' skills in mastering symptoms.

It should also be noted that CBT has recently been used to prevent the development of psychosis and can be effective in preventing or delaying the manifestation of mental disorder in people who are likely to develop psychosis. The basic principles and criteria of CBT implementation were analysed and highlighted in order to enhance the ability of patients to adapt to the illness, increase their social functioning and improve their quality of life. Attention is paid to the study and definition of foundations on which CBT treatment protocols and forms of psychotherapeutic intervention are formed.

The article describes the development of therapeutic approaches combining different theories and philosophical influence. The article provides examples of therapeutic approaches forming techniques and protocols of the third wave psychotherapy development that expand their goals.

It was concluded that despite significant changes in approaches to the treatment of mental patients, individual psychotherapy for schizophrenia has not lost its significance today.

Keywords: schizophrenia, adaptation, Cognitive Behavior Therapy,

psychotherapy

Problem definition

The development and introduction of new methods of treatment and rehabilitation is one of the key functions of psychotherapeutic practice and priority of all its forms and directions. One of the special tasks of the new treatment methods should be how to overcome some historical barriers between evidence-based approach and less evidence based approach, aiming to integrate their basic concepts into the general practice of psychotherapy. Particular attention to these new approaches should be focused on the treatment of patients with psychiatric diagnoses, such as schizophrenia, considering the irreversibility of their condition and the additional problems regarding the possible aggravation, inevitable disability and social stigma.

The present stage of the development of psychological assistance to mental patients is characterized by the rapid development of psychotherapy as a means of auxiliary treatment for psychiatric practice, which, due to the course and consequences of the illness experience additional complications in adaptation to society, and this is a reason to revise existing practices and their effectiveness.

In general, psychotherapy for patients with schizophrenia can be defined as an urgent need for the treatment system of such patients, which is growing rapidly and requires attention and focus on its quality, evidence of effectiveness and solving accessibility problems of its use, both inpatient and outpatient treatment. This is a strategic goal, and it obviously requires the study of existing protocols and the development of new forms of psychotherapy.

The abovementioned is extremely important for Ukraine, because according to the definitions of specialists and experts, the modern system of psychotherapeutic assistance of our state is in the state of development and formation. That is why the new approaches to the analysis of psychotherapeutic practice experience of leading countries are relevant for the development and strategy of introducing new means and methods of the relevant sphere, its transformation into a comprehensive system of alternative and innovative solutions for implementing functions and ensuring optimal support in the treatment of mental patients in Ukraine.

Analysis of recent research and publications. The problem of psychotherapy for patients with schizophrenia is the subject of scientific interest of a wide range of foreign researchers, in particular, only in the last few years a great number of works has been devoted to uncovering various aspects of schizophrenia treatment by groups of scientists and individual scientists. Considering scientific approaches, current problems and development prospects of this issue, these researchers not only set goals in dealing with patients with schizophrenia and described the principles, methods and its forms, but also revealed the evidence base for the psychotherapeutic methods used in high-income countries and discussed whether and how they could be extrapolated to low- and middle-income countries. The study and systematization of this experience will allow Ukrainian scientists to use these achievements for testing and introducing modern and new approaches to the treatment of patients with schizophrenia into psychotherapeutic practice.

At the same time, in our view, a systematic review of existing studies in this area still requires consideration in order to summarize what is known and derives directions for further studies, which may contribute to solving the problem of psychotherapeutic programs implementation in the clinic of endogenous mental illness that forms the goal of this scientific research.

Statement of basic materials

Based on the theory and practice analysis of psychotherapy for patients with schizophrenia, it is possible to identify the characteristic features and main trends of its modern development:

general humanization of the approach to the patient as a suffering person, who is able to fight the illness and cooperate with the person, and not as a passive object of psychotherapeutic influence;

increased attention to the patient's social environment;

integration of different approaches to the patient's treatment, adaptation and rehabilitation;

development of experimental and psychological basis of psychotherapy.

Historically, the development of psychotherapy forms of persons with schizophrenia can be presented as a movement from individual to family therapy and group therapy. Disruption of social contact is a central cause of disadaptation and disability in schizophrenia. Therefore, all known methods of psychotherapy are focused on their recovery.

The problems of patients are not identical and this excludes the possibility of the main way of solving them. Individual psychotherapy is needed in order to capture a unique life story.

Psychoanalysts were the founders of psychotherapy for schizophrenia, so by the 1950s of the twentieth century the concept of psychotherapy was synonymous with psychoanalysis, although there were other approaches. Behavioral therapy originated in the 1950s of the twentieth century and appeared as a radical deviation from the dominant psychoanalytic tradition at that time. It spread and intensified in the 1960s of the twentieth century and included psychotherapeutic influence methods, combined with one theoretical platform, such as learning theory.

In the framework of behaviorism, unlike psychoanalysis, the cause of the illness is not specifically considered. Proponents of the behavioral approach (rejecting the psychogenetic concepts of psychoanalysts) most often accept the biological hypothesis. Behavioral-oriented psychotherapy is understood as a process of aimed formation of desirable, adaptive forms of behavior based on the principles of the learning theory. Psychological factors are considered only in terms of their influence on the course of illness and patients' adaptation.

At the same time in the United States, West Germany and Switzerland, the cognitive psychotherapy for schizophrenia started to develop rapidly. The cognitive psychotherapy is developed on the basis of modern multi-factor models of schizophrenia. While these models differ, there is a common theoretical basis for considering the causes and development of schizophrenia. The researchers of these theories assume that there is a certain prone to illness, which is influenced by genetic, biochemical, social, family and other factors. It consists in the vulnerability of individuals to a certain type of external effects, namely stressors, which are most often serious life situations. If the number of adverse effects reaches a critical value, the disease is manifested. A significant number of studies have focused on the identification of deficient cognitive processes in schizophrenia.

In 1952, A. T. Beck [1] first described the use of CBT in the treatment for schizophrenia on the example of individual patient therapy. A. T. Beck used the narrative method to facilitate the patient's perception of the appearance and maintenance concept of its current life problems. He also suggested a method of Socratic dialogue to test the rationality, truth, and benefit of cognition: for example, a patient with stalking ideas was encouraged to find rational arguments to confirm these views.

Classic psychoanalysis in dealing with patients with schizophrenia did not show high effectiveness. Modern modifications of the psychodynamic direction look more successful. At the same time, many researchers consider that the CBT methods are most promising in working with endogenous mental disorders and psychological learning of patients is an important stage in its structure [2]. Psychological learning should be considered as a prerequisite for the following psychotherapeutic treatment strategies so the patients can choose the treatment form that is optimal for their appropriate phase of the illness.

In the process of CBT, there is a study of the history of the appearance and specifics of disorders and psychotherapeutic case formulation in the form of structured conceptualization [3].

The CBT for psychosis acknowledges the importance of focusing on each single symptom, thus providing a basis for better treatment results. The patient's understanding of this concept has a therapeutic effect and organizes the work.

While in the past researchers have focused primarily on CBT for anxiety and depressive disorders, currently, the study of the use of psychotherapy in the comprehensive treatment of patients with schizophrenia spectrum disorders is being enhanced: many studies are being carried out and new methods and techniques are being developed and applied. In general, it can be noted that studies have confirmed the effectiveness of combining pharmacotherapy and cognitive behavioral psychotherapy in endogenous disorders [2]. In 2003, the CBT was chosen as the primary psychotherapy method for schizophrenia spectrum disorders by the National Institute of Health (Great Britain).

The CBT effectively complements pharmacotherapy. The structure of therapy for patients with schizophrenia spectrum disorders includes basic cognitive and behavioral techniques:

behavioral activation,

skills training,

developing an understanding of cognitive processes and thinking

skills,

cognitive restructuring of dysfunctional beliefs and finding

alternative (adaptive) opinions,

behavioral experiments.

During the therapy of patients with psychotic level, the work aimed at assimilating patients' skills in learning positive symptoms (thought disorder, delusional states, hallucinations). The goal is not to eliminate the symptoms, but to restructure the old evaluation of voices and insane ideas and generate new alternatives that do not cause such distress as previous cognitive interpretations of the patient. Instead of just focusing on reducing symptoms, the treatment should be seen as effective if there is a reduction in emotional distress of the patient as a result of therapy [4] with mandatory social engagement and progress [5].

Current studies and randomized controlled trials show that CBT should be introduced in a way that is acceptable to patients and that will enhance their ability to adapt to the illness and work to improve their quality of life [6]. The CBT in psychosis should be built on the fundamental “classical” principles:

The importance of cooperation is based on the joint development of a common and understandable to the patient concept of formulation that forms his/her understanding of the sources and mechanisms provoking disease and supporting adverse psychotic symptoms.

Normalization through support and acceptance without condemnation to reduce the experience of shame or stigma that are often associated with psychosis.

The patient's orientation to accept psychotic symptoms by refusing to feel that the symptoms of psychosis must be completely absent in order to

live a quality and productive life, and it helps to reduce distress due to

psychopathological symptoms.

The CBT for psychosis has now been adapted and tested for use in many countries and cultures. Meta-analyses of studies indicate that the use of CBT for psychotic symptoms has the right to exist, is practical and effective in the complex of treatment and rehabilitation measures conducted with these patients, resulting in a reduction in the severity of positive symptoms and general improvement in the patients' condition [7, 8].

Even though the primary goal of CBT is to reduce distress and prevent further disability (rather than treating positive symptoms of psychosis), there is still an indirect effect on the clinical characteristics of CBT. Studies have shown that the use of Coping Strategy Enhancement (CSE) as a targeted and short-term form of CBT is effective in treating auditory hallucinations and delusional experiences of patients [9, 10].

This approach was based on a functional and analytical model in which triggers and reactions to psychotic experiences influenced the probability of their reappearance. Patients were expected to have a list of useful coping strategies aimed at triggers and reactions, but the effectiveness was limited by their inconsistent and non-strategic use. The CSE was developed as 10-session therapy for a wide range of psychotic symptoms and its participants as part of case studies reported a decrease in the severity of symptoms. The results of a randomized controlled study also showed improvements in the number and severity of psychotic symptoms.

In addition to distress and establishing a “therapeutic alliance” in psychotic states, researchers as a target for the CBT indicate that these patients have significant instability of negative emotions and maladaptive strategies for its regulation (due to the development of mental disorders), which from the authors' point of view is related to the development of paranoid superstructures [11].

For people with psychosis, social support is an important component of therapy, which is related to the positive dynamics of certain cognitive characteristics, that is, the influence of social support on cognitive mechanism, which as an undeniable component of CBT improves the social functioning of patients.

It should also be noted that CBT has recently been used to prevent the development of psychosis and can be effective in preventing or delaying the manifestation of mental disorder in people who are likely to develop psychosis. Studies suggest that individual CBT may be the most recommended treatment for people at high risk [12].

Currently, different treatment protocols and forms of CBT have been formed. Some researchers suggest adapting modern CBT protocols in both duration and complexity to make them more clinically applicable. The issue of whether CBT can also be conducted in a shorter format than the minimum of 16 sessions (recommended in the NICE guidelines) has prompted hot discussions among researchers and practitioners. Empirically founded knowledge of the minimum and optimal duration of CBT is important with regard to the therapy introduction and cost-effectiveness.

A study, which was conducted in 2016 at the outpatient clinic of the psychological department in Germany and funded by German insurance companies, examined the reasonable minimum duration of CBT in psychosis. The number of sessions usually includes health insurance for cognitive behavior interventions and varies between 25 (short-term therapy) and 45 sessions (long-term therapy). Thereby, 45 therapy sessions were announced and provided to all patients participating in the study. The sample consisted of 58 patients and 36 of them completed a full course of 45 sessions. The study results confirmed the recommendations to provide CBT for a minimum of 16 sessions and indicate that these recommendations can be summarized for clinical practice. However, the results also show that 25 sessions are the most appropriate duration of therapy [13].

Long-term therapy is not available to all patients and entails significant economic costs. In this regard, extensive testing of reduced options for Cognitive Behavior Therapy (less than 16 sessions) is under way. In order to do that the clinical practice of CBT should be developed and new approaches should be included in its program that can be adapted to specific patients, increasing the flexibility of CBT method by modifying therapy (subordinate to primary-formulated psychotherapeutic goals) emanating from a specific combination of the patient's psychopathological symptoms. Another way to reduce the number of sessions is to combine separate techniques that increase the patient's willingness to learn CBT by improving the patient's neuropsychological activity.

These studies contribute to an empirically founded discussion about the minimum and optimal duration of the CBT. It also lays the foundation for planning randomized studies, comparing shorter and longer versions of the CBT.

The protocols of symptom-oriented approaches of the CBT in psychosis, focusing on secondary distress reduction, have worked well and can be used both individually and in a more comprehensive way in the CBT structure [14]. The implementation of symptom-oriented forms of the CBT does not require the involvement of highly qualified cognitive behavior psychotherapists. In general, the following forms can be identified:

- “Cognitive Behavior Therapy for psychosis based Guided Selfhelp” (CBTp-GSH). 17 units and eight worksheets that can be flexibly used by a health professional during 12-16 sessions. CBT-oriented self-help is acceptable and useful to participants and can improve psychological characteristics and reduce disability levels. However, it should be noted that patients with a moderate degree of psychopathology and relatively low level of disability participated in this study. Therefore, caution should be exercised when interpreting the results of these studies without extrapolating them to patients with significant psychopathological symptoms and high levels of disability [15].

“Coping With Voices” (CWV) is a 10-session, interactive, web- based CBT skills program. Participants in the “Coping With Voices” program, compared to the control group, showed significantly greater increases in social functioning. The results of this program have found that the use of “Coping With Voices” technique improves patient's condition by including them in the extensive CBT program and can have a favorable impact on the anxiety relief associated with psychotic symptoms, and can also improve the social functioning of patients [16].

“Intervention for VoicEs” (GiVE) is a technique focused on single psychotic symptoms (such as auditory hallucinations) rather than holistic syndromic manifestations of psychosis. Study findings show significant impact on self-esteem rates, negative self-belief and omnipotence of voice [17].

“Cognitive Adaptation Training” (CAT) is a training of patient environment organization and its technical means include cards, sound reminders, checklists (a special lists of case management established during weekly visits to the patient at home), which are used to compensate cognitive impairment and improve everyday functional results that at the evidence level improved the social functioning of patients. In addition, during the CAT, the severity of auditory hallucinations and the distress caused by this circumstance decreased [18].

“Worry Intervention” is focused on anxiety in delirium. The study results were fully aligned with the conclusion that treating anxiety in patients with persecuted delirium leads to a decrease in delirium. Through psychological treatment, patients also had other important results, such as decrease in the general level of psychiatric symptoms and general levels of paranoid thoughts and improvement in mental well-being [19].

“Individual Resiliency Training” is early intervention treatment programs that have begun to play an increasingly important role in improving long-term results for people with psychosis. The focus of these programs is to help people recover by reducing the risk of relapse, improving self-care skills and making progress in a full life.

There has also been a general development of therapeutic approaches over the past 10 years that are moving around the initial cognitive theory and expanding, including a combination of different theories and philosophical influences. Examples of third wave approaches include mindfulness therapy, therapy and sequences, and metacognitive therapy. These methods are called the “third wave of CBT”, but they bring many new things to the therapeutic approach.

Mindfulness therapy. Mindfulness, as a way of life, is the ability, skill and habit to accompany with consciousness actual conditions, actions, activities, throughout the life. Mindfulness is the result of the activation of consciousness on the event, the attention that we direct willingly, knowingly and impartially to the existing situation. Mindfulness-based approaches use “mind training” to free yourself from interfering automatic thought patterns. All Mindfulness approaches are unique due to their own theoretical focus and techniques. Their commonality is an element of contemplation, reflection, direction of attention and concentration when using techniques based on Eastern meditation practices, but without any religious content. When working with endogenous mental disorders, the group format of work is more commonly used. Mindfulness therapy for psychosis develops slowly, particularly due to the fear and stigma surrounding psychosis. Current studies, showing how to adapt the Mindfulness group to people suffering from psychosis, has contributed to the growth of scientific base and it is now becoming clear that adapted mindfulness therapy for psychosis is safe and therapeutic [20].

Acceptance and Commitment Therapy (ACT) teaches people to notice and accept internal events, unlike traditional CBT when one of the goals is to identify maladaptive thought and change it into a more appropriate context. Encouraging patients to identify individual values and personal meanings is an important element of acceptance and commitment therapy. One of the most significant works on the application of acceptance and commitment therapy to patients suffering from psychosis is based on the idea of helping people use their strategy of learning psychotic experience. An example of such a sequence can be cognitive distancing (learning the skill to perceive your beliefs as unproven statements contrary to facts), acceptance and act of evaluation.

Current studies base indicates that ACT can be considered an effective treatment for psychosis even in short-term forms, such as 4 sessions for hospital patients, and for people with severe symptoms or complex concurrent diseases. There is growing evidence that ACT is a useful intervention for people suffering from psychosis, both in and outside of hospital. The ACT can be used in group therapy formats because it indicates a time saving and cost-effectiveness (including more people). Studies show that ACT can help reduce the hospitalization rates, affect the psychological inflexibility of people experiencing psychosis, and is useful for people suffering from the first episode of psychosis or long-lasting psychosis [21].

Meta-cognitive therapy. In this concept, mental disorder is seen as a result of the way of thinking and the way of controlling one's thoughts (metacognition). Meta-cognitive psychotherapy specifies that it is about verbal thinking (anxiety and “over-focus”), focusing

on threat and negative information, as well as metacognitive actions to suppress thoughts that lead to mental disorder. There are few works on the use of meta-cognitive therapy during endogenous disorders, but they show promising results [22].

Conclusion

Thus, we proposed a summary of the history of psychotherapy for schizophrenia. We assumed that study findings have identified limitations in traditional approaches to psychotherapy, and also we provided opportunities for new approaches to become a mechanism for promoting recovery of people with schizophrenia.

This review has limitations. As in any historical discussion, the emphasis is on certain trends and aspects of the history of some directions at the expense of others. In this regard, we acknowledge that the history is not as clear as we have presented it, and our discussion of recent trends in psychotherapy for schizophrenia has focused on the appearance of CBT, perhaps excluding more detailed consideration of others.

Finally, the third wave psychotherapy methods presented by us offer a promising beginning, but they need to be tested in future trials.

Looking at the broader picture, we suspect that this article creates a space between cognitive behavioral and psychodynamic approaches of psychotherapy, which may encourage integrated work. We consider it possible that parallel integration attempts (rather than competing with each other for advantage) can exist in harmony with each other and ensure further improvement and integration efforts. The developments described here have critical implications for future studies.

In summary it can be said that the CBT has developed dynamically at the present stage, which is useful to solve the complex problems of helping people with schizophrenia spectrum disorders. This direction in psychotherapy can be introduced if both positive and negative symptoms prevail in the clinical picture.

The large number and variety of literature regarding psychotherapy for patients with schizophrenia demonstrates the hard work performed by specialists in this area. Close attention should be paid to the further study of new approaches and their practical implementation in order to increase the effectiveness of the treatment and rehabilitation of patients with schizophrenia and to form a humanistic attitude towards them by modern society.

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