read each of the statements and select the one which discribes how you feel / discribe
psychosocial therapies are part of the standard management of schizophrenic illnesses, but have not been subjected to systematic evaluation and are therefore not included in this guideline. This does not imply that they are not essential components of good practice.
The remainder of this section describes the evidence for the effectiveness of Education Programmes, Family Interventions, and Cognitive Behaviour Therapy in the management of schizophrenia. Section 3 provides recommendations for the application of these interventions in clinical practice, according to the phase of the illness.
Education programmes
Education Programmes are directed at either patients or carers/family members and have several aims. Improvement in knowledge of schizophrenia and its course and in compliance with treatment has been shown. There is also evidence of greater satisfaction with services provided. Some programmes go beyond the provision of information and take an educational approach to skills training or problem solving.
Education Programmes for patients may be undertaken in individual or in group settings. Simple information-giving is less effective than interactive sessions. The focus includes giving information about the course and management of the illness, including the importance of compliance with medication and the management of stress.
Providing carers and family members with information on the likely course of the illness, the treatments available, the importance of compliance and the services available is an essential element of good practice It may be undertaken as part of a Family Intervention programme
Specific techniques, e.g. use of homework or video, have not been shown to improve the assimilation of information, but a group setting has advantages
Family interventions
The aims of ‘Family Intervention’ include reduction of frequency of relapse into illness and reduction of hospital admissions, reduction in the burden of care on families and carers, and improvement in compliance with medication.
Some Family Intervention Programmes have targeted families where there are high levels of criticism, hostility and over-involvement. ‘High expressed emotion’ is a measure of these features and programmes which reduce this or reduce the amount of ‘face to face’ contact between the patient and family members have been shown to reduce the frequency of relapse. However, the measurement of expressed emotion is a research technique which is not practical for everyday use. Family Intervention Programmes which are not derived from this theoretical background have been shown to be effective.
Most intervention strategies contain more than one technique. Separating and defining the effects of the components of an intervention strategy is not possible at present as few studies examine the effect of a single technique and only a general description of interventions used in research studies is usually given. However, a number of practice guides have been published which give detailed descriptions of the techniques employed in some studies. Family Intervention has been shown to be effective with some variation in the components of the programme, but family sessions to address the problems identified in the analysis may not be effective if the patient is not included. Social skills training and vocational rehabilitation were included in some studies. These are not covered as separate interventions in the guideline.
Cognitive behaviour therapy
Cognitive Behaviour Therapy for psychosis is a modification of standard cognitive behavioural therapy. The aim is to modify symptoms (e.g. delusions, hallucinations) or the consequences of the symptoms which may be cognitive, emotional, physiological or behavioural. The treatment programme is intensive (involving about 20 hours of individual treatment) and based on an individually tailored formulation which provides an explanation of the development, maintenance and exacerbation of symptoms and of pre-morbid mood, interpersonal and behavioural difficulties.
There is now good evidence that treatment resistant symptoms (delusions, hallucinations) can be substantially reduced in a significant proportion of those who complete therapy. It is not yet clear who is most likely to benefit from treatment and many patients may be unwilling to participate. The treatment is well tolerated. However, reduction of symptoms has not been shown to lead to significant social or lifestyle improvements.
A combination of the following techniques has been shown to be most effective in lessening symptoms of psychosis resistant to other forms of treatment:
◦enhancement of cognitive behavioural coping strategies5
◦developing a rationale to explain symptoms28◦realistic goal setting
◦modification of delusional beliefs29◦modification of dysfunctional assumptions.
A number of these techniques are a refinement of normal good practice using a systematic approach.
‘Early Intervention Studies’ have aimed to identify prodromal symptoms or the ‘signature’ preceding relapse. The approach is not a form of cognitive therapy, but early intervention with medication or Cognitive Behaviour Therapy may be facilitated
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