Critically discus the strengths and limitations of using Cognitive Behavioural Therapy (CBT) as treatment for psychotic disorders.
The National Institute of Mental Health (NIMH, 2008) declared that psychotic disorders cost one hundred ninety three billion dollars annually due to loss of earning, diagnosis, treatment and other indirect costs. The economic burden is also evident in UK and elsewhere around the world. In England, the cost for care and treatment for psychotic disorders is one hundred and five billion pounds a year (Cyhlarova, McCulloch, McGuffin, & Wykes, 2010). Although the pharmacological approach substantially reduces the economic burden of psychotic disorders, on the other spectrum, cost and benefits analysis of cognitive behaviour therapy indicates that greater access to the therapy would likely result in better treatment of psychotic disorders and reduction in costs of medical care and other economic burden (Myhr, G & Payne, K, 2006). Cognitive behaviour therapies for psychotic disorders are an evidence informed management strategies that help patients and carers to make informed decisions for early intervention, prevention and recovery of psychotic disorder (NICE, 2009). Numerous Meta analytical research suggested that cognitive behaviour therapy are effective in drug resistant symptoms and patient compliance to medication adherence (NICE, 2008; Wykes, Steel, Everitt &Tarrier, 2008). The systematic review of randomized trials revealed that cognitive behaviour therapy significantly reduced patients stay at the hospitals and prevent recurring hospitalization compared with other management therapies (NICE, 2009). However, the issue of whether cognitive behaviour therapy is as effective as claimed by the meta-analytical studies has been the subject for much debate. Research studies which employed proper control measures and methods of blinding reported that cognitive behaviour therapy is ineffective against relapse and reducing negative symptoms in patients suffering from schizophrenia (Scott et al., 2006; Lynch, Laws & McKenna, 2010). Cognitive behaviour therapy is also indicated to be futile in befriending and interpersonal strategies (Sensky et al., 2000; Lewis et al., 2002). However, these arguments do not settle the issue in question. In fact, it is arguable that the strength of cognitive behaviour therapy for psychotic disorder lies in the evident based therapy that is derived from well validated theories, but the lack of validated research evidence limits the scope of therapy application and development of new therapy strategies for psychotic disorder.
This essay will discuss the strengths and limitations of using cognitive behaviour therapy as a treatment of psychotic disorders.
Cognitive behavioural therapy for psychotic disorders evolved from Beck’s (1976, as cited in Tai & Turkington, 2009) behavioural and cognitive strategies. The early cognitive therapies primarily relied on behavioural modification strategies and later the cognitive perspective and stress-vulnerability models of schizophrenia was incorporated (Tai & Turkington, 2009; Turkington et al., 2006). The cognitive mediation attempts to change dysfunctional thoughts to more functional interpretations of events (Butler, Chapman, Forman & Beck, 2006). Formulations are techniques used in cognitive behaviour therapy to precipitate problems and issues that trigger psychosis. The link between emotional disturbances and behavioural responses are tackled through the examination of predisposing elements and factors that have perpetuated the psychological problems (Butler et al., 2006). Hence, formulation in cognitive behaviour therapy is a useful technique for the appraisal of dysfunctional beliefs, hallucinations and delusions in psychosis (Garety et al, 2001). Cognitive behaviour therapy employs a number of techniques to foster change in thoughts and behaviour. Techniques such as Socratic method of questioning are demonstrated to reduce the exacerbation of delusional thoughts (Messari & Hallam, 2003). Coping strategies such as attention redirection, voice diary, methods of distractions and behavioural experiments are found effective in minimizing hallucinations, voices and paranoia symptoms (Tarrier et al., 1993; Tarrier et al., 1990; Sivec & Montesano, 2012). The cognitive behaviour therapy works by dissecting and breaking down the events that activated the psychotic disorder in a meaningful way to the therapy users and this, is achieved through a mutually collaborative effort between therapists and clients. The approach is efficient in treating people with medication-resistant, reducing distress caused by psychological disturbances, prevention of relapse and promotion of social integration (Garety, Fowler & Kuipers, 2000). However, despite having specific dedicated frameworks to assess hallucinations and delusional beliefs, the theoretical link between auditory hallucinations and thoughts of harming self or others remained unclear (Freeman and Garety, 2004). Furthermore, the cognitive behaviour therapy was argued to be effective only for positive symptoms of psychosis and therefore, negative symptoms are not appraised alongside the positive symptom (Freeman and Garety, 2004).
Emotional problems such as anxiety, low mood, self-evaluative thoughts, relapse prevention, hallucinations and delusions are some of the target concerns that are addressed by the cognitive behaviour therapy for psychosis (Kingdon & Turkington, 1991; Kuipers et al., 1997). Reviews of meta-analysis literatures demonstrated that cognitive behaviour therapy is effective in treating symptoms that are resistant to anti-psychotic medications and medication compliance (Butler, Chapman, Forman & Beck, 2006). Based on numerous outcomes of research, which strongly demonstrated the benefits of cognitive-behavioural therapy for psychosis, The National Institute of Clinical Excellence in United Kingdom (NICE, 2004) accepted cognitive behaviour therapy as a compulsory therapy for patients suffering from schizophrenia. Wykes, Steel, Everitt and Tarrier(2008) analyzed thirty-four research from public data domain and found significant effects of cognitive behaviour therapy for studies linked to positive symptoms (thirty two studies), negative symptoms (twenty three studies), functioning(fifteen studies), mood (thirteen studies) and social anxiety (two studies) with effects ranging from 0.35-0.44. Nevertheless, studies on the long-term outcome of cognitive behaviour therapy did not yield any considerable results (Addington & Lecomte, 2012). A randomized controlled study which applied cognitive behaviour therapy for participants diagnosed with schizophrenia was found effective only for a short period of time, but the same finding was not evident after six months (Valmaggia et al., 2005). On the contrary, a comparative study on the therapy efficacy at the Hospitals in Tayside and Fife, Scotland, revealed a moderate improvement for cognitive behaviour therapy on medication resistance psychotic symptoms compared with another supportive psychotherapy or Treatment as Usual (Durhan et al., 2003). The Positive and Negative Syndrome Scale (PANSS) and The Psychotic Symptoms Ratings Scale (PSYRATS) measurement showed twenty-five percent and fifty percent improvement after three months of cognitive behaviour therapy (Durhan et al., 2003). While the results indicated slight improvement compared with other treatment options, questions remain whether cognitive behaviour therapy in clinical protocols demonstrated the same results as found in randomized control trials (Scott, 2008; Rakovshik & McManus, 2010). The lack of evidence-based research in clinical practices has contributed to a polarized view, with some research showing cognitive behaviour therapy as efficacious in the treatment of psychosis (Durhan et al., 2003) and others who argued against the effectiveness of cognitive behaviour therapy in routine clinical practice (Lincoln et al.,2012; Scott, 2008).