Discuss about the Symptoms of Schizophrenia as Primary Target.
Li et al. (2015) aimed to compare the efficacy of cognitive behavioural therapy (CBT) and Supportive therapy (ST) for patient with schizophrenia. The main rational for evaluating CBT therapy was the limitation of pharmacological treatment in achieving long-term recovery of patient. To address the gap found in previous research, the researcher used multi-centered randomized controlled study design to evaluate the efficacy of CBT over other intervention. Research participants were randomly allocated to CBT and the ST group. On assessment of patients regarding severity, insight and social functioning, it was found that CBT intervention was more effective in achieving favourable outcome for patient compared to ST group. CBT increased the chances of symptom reduction in patient and the finding was consistent with many other research studies. The author argues that CBT can be used to improve severity of symptoms and justified that such outcome is possible because of features of therapeutic alliance, behavioural modification and changing dysfunctional cognition of schizophrenia patient.
Haddad, Brain & Scott (2014) discussed regarding the challenges in managing patients with schizophrenia due to non-adherence with antipsychotic medication. As schizophrenia is associated with social isolation, stigma and depression, not adhering with medication increases the risk of relapse and hospital cost. The researcher gave an overview about the efficacy of different types of antipsychotic medications and argued that antipsychotics reduce the rate of relapse and the likelihood of hospital admissions. However, the prevalence of non-adherence with medication has become an issue and with support from research evidence, the author also gave an indication regarding the cost of non-adherence. Non-adherence was found to be associated with violence, victimization, poor satisfaction with life and alcohol related problems. Link between non-adherence and risk of self-harm was also indicated in the study. The article gave idea regarding several interventions to improve adherence with anti-psychotic medications such as psychosocial intervention, electronic reminders and financial incentives. Review of psychosocial intervention gave the insight regarding the use of psychosocial intervention to elicit behavioural change in patients with schizophrenia. Multi-dimensional approach is considered more effective in the management of non-adherence compared to single intervention.
The focus on the health related quality of patients with schizophrenia has become a prominent topic in recent research. Mihanovi? et al. (2015) emphasized that quality of life is important for patients with schizophrenia as the disorder has an impact on all aspects of their life. The study aimed to evaluate the quality of life of schizophrenia patients treated in foster home care where pharmacotherapy, family therapy and psychotherapy is provided to patients. By means of a Health Survey Questionnaire completed for schizophrenia patients in foster home care and standard outpatient treatment, the study showed that patient who entered into foster home care had poor quality of life compared to patients who went to outpatient treatment. However, after 6 months, it was found that the patients in the foster home care group achieved better results compared to patients in the outpatient group. This gives the implication that psychosocial factors play a major role in the functioning of patients and in their quality of life.y. Schizophrenia bulletin, 43(Suppl 1), S257.
Wartelsteiner et al. (2017) investigated about the role of resilience, hopelessness, self-esteem and psychopathology in influencing health related quality of life of patients with schizophrenia. Research in this area was important to predict symptom remission and recovery in patients. A total of 52 patients with schizophrenia were recruited from a cross sectional study and level of self-esteem, resilience, hopeless and psychopathology was measured in patients by different measuring tools. Compared to healthy controls, people with schizophrenia were found to have lower level of self-esteem, resilience, quality of life and hopelessness. Hopelessness was also common in such patients indicating the quality of life is highly dependent on self-esteem, resilience and hopeless. The author suggested that by taking lesson from the research outcomes obtained, health care professionals and psychiatrist can work to promote self-esteem and resilience of schizophrenia patients. Identifying and implementing appropriate intervention to promote self-esteem and resilience may help to provide better quality of life to patients living with schizophrenia.
Klingberg et al. (2011) emphasized that for patients with schizophrenia, cognitive behavioural therapy is effective in addressing negative symptoms. Focus on negative symptom is important as negative symptoms are the reason for poor prognosis, poorer social outcome and quality of life. However, the gap found in last research is that there was lack of studies which had methodological sound clinical trials to assess the efficacy of CBT on schizophrenia patients. The researcher used randomized controlled trial with 2 parallel groups to investigate about the impact of CBT and cognitive remediation on patients with schizophrenia. The uniqueness of this research is that the study used rigorous methodology such as randomized multi-centred research design, systematic recruitment method, data monitoring and considerations related to keeping external statistician to handle missing data. Patients in both CBT and CR group showed improvements in negative symptoms overtime. Hence, there was no signs of special effects of CBT over CR. This limitation suggested the need to conduct further research to identify effect of combining both CBT and CR on patients with schizophrenia.
Armando, Pontillo & Vicari (2015) gave an overview about the impact of various psychosocial interventions for very early and early onset schizophrenia. These two conditions are regarded as the most severe forms of schizophrenia compared to adult onset as schizophrenia at young age is less common and it is more severe and disabling than other conditions. By the use of systematic narrative review method, several interventions like CBT, cognitive remediation, psycho-education and family intervention. The review of all these types of intervention showed lack of efficacy of psychosocial intervention in the treatment of early onset schizophrenia. The main reason for achieving sub-optimal outcome was that individuals with early onset had certain specific developmental issues too which differed significantly from that of adult patients with schizophrenia. Hence, the research emphasize more focus on motivating young patients in taking part in the therapy than engaging in behavioural interventions like CBT. The limitations found in this research suggest need for high quality research in the future to validate the findings.
During one of my mental health nursing placement, Mr. A (hypothetical), a 20 year old patient with schizophrenia came to the clinic. He was brought to the emergency department by his mother and sister after he started acting in a bizarre way and socially isolated himself from social gathering. Although Mr. A was a bright student, however episodes of hallucination and delusion since the past two years have affected his studies. His mother reported experience of frequent delusion and hallucination as Mr. A was found to mumble sentences like ‘ I am useless’ and ‘I am not good for anyone’. He was also suspended two times as he became very aggressive and violent at the college campus. Deterioration in his symptoms were observed one year back when his mother noticed that he was no more interested in his friend. His appearance became shabby and he took no interest in any social pursuits. He baths seldom and wears the same dress for days. Dressing him with the aid of others is also difficult. He spend long hours in his room and is often found to be depressed. Being physically inactive and lack of attention to basic self-care needs has also made him put on weight and increased risk of infection.
Mr. A’s psychosocial functioning has also been affected because of the method he has adopted for coping. Presence of symptoms of hallucination, delusion has significantly impaired Mr. A’s psychosocial functioning and led to increase in negative symptoms like stress, depression, negative cognitions and psychosis. His withdrawal from the outside world is one major risk as without appropriate treatment, he is at increased risk of attempting suicide particularly during psychotic episodes.
On the review of the case scenario of Mr. A, it is evident that experience of hallucination and delusion is one major issue for client as it has increased his tendency to socially withdraw from people and affected his daily life functioning. Inability to complete basis task such as self-care needs has also resulted in feelings of depression in client. According to Shioda, Tadaka, and Okochi (2016). loneliness among people with schizophrenia is a serious problem as it decreased the quality of life of patient and contribute to suicide. To promote self-efficacy for community life of Mr. A., there is a need to apply an intervention that can promote behavioural change and improve psychosocial outcome of client. It was decided to implement cognitive behavioural therapy (CBT) as an intervention to improve psychosocial functioning and address hallucination in Mr. A. This was necessary because CBT has been found to be particularly effective in improving social functioning of schizophrenia patients (Li et al., 2015). Deficit in social functioning is prevalent among schizophrenia patient and CBT reduce hospital admission rate by improvement in positive and negative symptoms, social anxiety and social functioning.
CBT is a goal oriented psychotherapy treatment where the focus is to change patterns of thinking and behaviour of people. As schizophrenia is a disorder where thinking pattern is severely affected and people develop delusions, the use of CBT is considered most appropriate to treat Mr. A. Patients with delusion hold false ideas or beliefs that does not exist in reality and they misinterpret certain sensory experiences too (Frith 2014). Hence, CBT targets impaired thinking pattern of patient and works to change client’s attitude and behaviour. With this rational, it was decided to use CBT as an intervention to treat CBT. 50 minute session each per week was provided to the client for 2 months. As a mental health nurse, implementing CBT required training to develop skills to promote behavioural change in client. Short term training course helped to develop techniques to build rapport with client. With support and supervision from a physiotherapist, CBT intervention was applied to the setting. I used communication skills, listening skills and problem solving skills to achieve the goal of the therapy (Ince, Haddock & Tai, 2016).
The use of CBT to improve quality of life and social functioning in patients with schizophrenia has been covered in many research evidence. Li et al., (2015) gave evidence regarding the role of CBT as a standard treatment for patients with schizophrenia. The session is delivered once or twice a week. The first few session focus on building therapeutic alliance with patient and then it proceeds to psycho-education and normalization of the experience of psychosis. As per problem faced by individual clients, CBT works to address delusion, hallucination, depression and negative symptoms. In case of Mr. A, it was found that he used a negative coping strategy of withdrawal to cope with delusion and hallucination. However, according to Addington and Lecomte, (2012), the advantage of CBT for patients with schizophrenia is that it supports patient to manage their symptoms by improving personal coping strategies and eliminating dysfunctional and self-defeating beliefs. Mr. A was also developing self-defeating beliefs like ‘He is useless’ which reduced his self-esteem. Hence, according to research evidence, it is clear that after implementing CBT, schizophrenia patients can manage daily hassles and negative symptoms in appropriate manner.
After the reviewing the issues faced by Mr. A in the case study, it is evident that experience of social withdrawal, poor self-care skills and poor social relationship has reduced his quality of life. For patients with schizophrenia, poor self-esteem and feelings of hopelessness is a common issue. The research literature by Wartelsteiner et al. (2017) established correlation between quality of life and resilience, self-esteem and hopelessness and recommended the need to promote self-esteem of patients. Mihanovi? et al. (2015) explained that quality of life is essential for patients with schizophrenia because as the disorder negatively affects all areas of life such as work and ability to manage basic daily activity. Antipsychotic treatments can reduce positive symptoms; however cognitive impairment and negative symptoms are not addressed. Assessment of patient’s well-being and quality of life is also essential to increase client’s motivation towards pharmacotherapy adherence and engaging in psychosocial rehabilitation. Evidence exists regarding the success of CBT in treating anxiety and co-morbid mood. Morrison, (2009) argues that depression and anxiety are those symptoms that impair quality of life and lead to impairment. These kind of issues can be successfully managed with CBT. Physiotherapist mainly targets techniques of identifying and challenging distorted thoughts and gradually diminishing negative symptoms. The evidence also showed the potential of CBT in promoting functional capacities of schizophrenia patient. With the presence of these evidences, the decision to use CBT as a treatment option for Mr. A is justified.
Apart from other symptoms, CBT was also chosen because of experience of hallucination and delusion faced by client. Mr. A’s family detected changes in behaviour of patient and delusion was the main problem for him. Candida et al. (2016) supports the use of CBT to address hallucination. A number of techniques are used to target cognitive processing biases and reduce negative symptoms. While implementing CBT session to target hallucination, a therapist focuses on identifying characteristics of voices. After few session of careful assessment, range of techniques is used to reduce distress in patient. For example, techniques like distraction, effective coping skills, normalization techniques are used to treat negative emotions due to hallucinations. Dealing with delusion is specifically challenging during the treatment process. To influence and modify patient’s thought, the therapist need to understand the context and persistence of beliefs. However, this is a time consuming process as many patients resist in disclosing their psychotic experience. Strong therapeutic relationship is needed to identify delusional beliefs and comprehend unique psychotic experience of patients (Joyce, 2018).
The implementation of CBT is associated with many challenges as well as benefits for patients and care providers. The effectiveness of CBT for treatment of patients with schizophrenia has been proved. The advantage of its use for schizophrenia patient is that it is an appropriate replacement of pharmacotherapy. Although anti-psychotic medications are the first line of treatment for patients, however significant side effects in medicine increase the burden for caregivers. Stroup & Marder (2015) shows the efficacy of pharmacotherapy in combination with psychosocial intervention to achieve optimal outcome for patients. However, many barriers have been identified in implementing the intervention. Various clinical practice guidelines like the National Institute for Health and Clinical Excellence (NICE) recommends CBT as a recommended treatment for patients with schizophrenia. Despite this, Thomas (2015) argues that the key limitation of CBT is that several within-trial heterogeneity exist during therapy delivery. As per the problem faced by patient, variety of intervention protocols are implemented to treat patients These therapeutic methods include coping enhancements, relapse prevention and modification of delusions. Another challenges in the use of CBT for patient is the need for skilled therapist. In clinical setting with limited staffs, providing skills training related to CBT in a short duration becomes an issue. Limited availability of CBT practitioners is also an issue which demands the need to train registered nurse to promote behavioural change in patient (Lovell et al. 2017). This evidence indicates that efficacy is not an issue for use of CBT for patients with schizophrenia, however the challenge is the related to wide access of the therapy. There is vague evidence to prove what exactly is working for client. The intervention is less accessible for practitioners who are new to the technique or therapy (Thomas, 2015).
CBT is regarded as a useful intervention particularly to address medication resistant problem in patients with schizophrenia. Haddad, Brain and Scott (2014) states that patient with schizophrenia do not comply with medication regimen. This is seen due to the effect of social isolation and stigma and effect of several other symptom domains. Focussing on addressing medication adherence is also necessary because of risk of relapse, self-harm and poor quality of life. To manage non-adherence issue, interventions must be targeted to patient. () gave evidence regarding the effectiveness of CBT for outpatients with medication resistant psychosis. The main rational for its effectiveness is that it takes present-oriented approach to support patients to identify relationship between thoughts, feeling and behaviour. Collaborative interaction between therapist and patients enables taking a shared approach to the client’s problem and adapt techniques to manage symptoms. Various techniques such as establishing connections between activating agents, psycho-education and normalization and discovering origin of experiences are used to treat patients.
Criticism exist regarding the heterogeneity of CBT approaches, however many randomized controlled trials have proved the benefits of CBT in reducing psychiatric symptoms. The cost-effectiveness of the therapy is seen from the reduction in the duration of hospital stays and improvement in social functioning of patients. For patients with problems related to hallucination and delusions too, CBT has been found to be superior to supportive counselling in addressing symptoms (Burns, Erickson & Brenner 2014). Despite these benefits, Hazell et al. (2017) again argues regarding the limitation of using CBT because of barriers in implementing the intervention. Limited resources have been regarded as a barrier to implementation. Another weakness is that to achieve optimal result, it is necessary that the therapist or the person implementing the therapy commits to the intervention. However, using the intervention for patients with complex mental needs must be difficult. Another disadvantage of the therapy is that it works to address individual problems related to thoughts, feelings and behaviour of patient, but wider problems such as poor social relationship or issues in family cannot be addressed (Ringle et al., 2015). There is a need to engage in critical thinking and make the intervention flexible enough to be applied in individual patient context.
Another evidence that critiques the CBT intervention is the study by Johnsen & Friborg, (2015) which conducted a meta-analysis of studies to show that the usefulness of CBT to treat emotional distress is falling. Modern trial shows less evidence regarding getting relief from depressive symptoms. Therapist related barriers are some major challenges in applying the therapy for schizophrenia patients. The effectiveness of the therapy is highly dependent on the competence of the therapist. For example, meta-analysis of studies has revealed that patients who have received CBT from experienced therapist are more successful in getting positive outcome compared to patients who have receive the therapy from less experience persons like psychology students or nurses. The simple objective of changing maladaptive cognitions to eliminate emotional disorders is often perceived as very easy to learn. However, extensive practice, proper training and supervision is essential to improve the effectiveness of CBT. Researchers have also warned against deviating with guidelines and intervention. This may help to get proper treatment effects.
Degree of experience of therapist also affects treatment outcome significantly. The fidelity of the intervention is highly dependent on experience with the method. This is also essential to realize expected benefits for patient and allocate resource to achieve optimal outcome for patient. Kramer and Burns (2008) assessed the feasibility of CBT and showed that the process is time consuming and strong communication skill is needed to influence in patient and change their maladaptive cognitive thinking. Combination of antipsychotic treatment and CBT is considered effective in making the intervention safe and feasible for patients with psychosis or schizophrenia. Hence, implementation of CBT in the real world is a complex process. Taking the approach to assess clinical environment and multiple barriers that can exist during the implementation process can also help to improve its feasibility.
There are ethical issues and concern in implementing CBT intervention too. For example, confidentiality is an issue while implementing therapy. As the therapist need to take various details of patient to interpret impaired thoughst and behaviour, there is a strict requirement to maintain confidentiality and privacy of client’s information as per ethical code of conduct. Strict measures should be taken to ensure that confidentiality is not broken and it does not threaten engagement with the therapy (Hazell et al., 2017). However, the problem in many health care setting is that complete confidentiality is not maintained. Increasing awareness among mental health care professionals regarding confidentiality is important to foster therapeutic relationship with patient. Balance between scientific rigor and ethical principles related to beneficence or non-maleficence and dignity is necessary. To promote feasibility of the intervention, it is also necessary to follow evidence based guidelines for intervention. While developing CBT portfolio, it is necessary that all ethical aspects related to CBT is essential to ensure transparent techniques are used to treat patients and support them in living a high quality and dignified life. As per the severity of symptoms, the duration of the therapy should also be verified (Haman & Hollon, 2009).
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