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Article Excerpt
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A clinical case format was conducted by the author to assess the efficacy of Cognitive Behavioral Therapy and adjunct coping skills with a female diagnosed with a psychotic illness. The treatment outcome after fifteen sessions was positive as assessed by a reduction in presenting psychotic symptoms and an increase in the client's self-awareness and confidence.
Introduction
Current research suggests that the effect of rehabilitation on the myriad of cognitive difficulties in schizophrenia are substantial. Rehabilitation strategies/interventions that combine interpersonal skills training and cognitive methods appear to offer the most generalized results. Clinicians tend to teach Cognitive Behavioral Therapy (CBT) coping strategies to psychotic outpatients in an effort to increase client 'quality of life'--the non-specific improvement of life satisfaction that results from reduction of auditory and visual hallucinations, delusions, and disorganized thought patterns. Learning effective CBT coping strategies to challenge and restructure impaired cognition yields, at the least, increased frequency of patient statements about 'quality of life' and, at the most, generalization of these coping techniques to be utilized on a day-to-day basis. Unfortunately, measuring quantifiable change in personality has been a difficulty with this clientele as attention, concentration, and processing deficiencies have rendered most testing impractical (e.g., MMPI; PAI; MCMI).
Cognitive remediation paradigms (e.g., Corrigan, Schade, & Liberman 1992; Kingdon & Turkington, 1994) have suggested an attempt to moderate patients' levels of physiological arousal. Relaxation strategies that reduce the outpatients' state of arousal may have positive cognitive effects. It has been suggested (Corrigan et al., 1992) that understanding the various forms of cognitive impairment and rehabilitation in schizophrenia requires a superordinate framework model such as the 'Vulnerability-Stress-Model' (Perris, 1989). More specifically, that a Vulnerability-Stress Model may enhance cognitive models of rehabilitation over the course of treatment. For example, relaxation strategies that reduce anxiety for hyper-aroused patients and intervention strategies that stimulate hypo-aroused patients may have positive cognitive effects. When the psychotic outpatient is intensely anxious and available processing capacity is diminished, dysfunction is caused in information processing.
It has also been suggested that, as cognitive remediation strategies continue to develop, clinical investigators need to specify the strength of treatment efficacy. During the past twenty years, the development and use of cognitive behavioral techniques have been adapted for schizophrenic patients (Kingdon & Turkington, 1994). The following study outlines a treatment paradigm of coping strategies taught and successfully utilized by a schizophrenic outpatient to remediate thought disorder, delusions, and auditory and visual hallucinations.
Purpose of Study
"Linda," a 25-year-old female outpatient of Korean origin, was referred to the writer to commence 'treatment of symptoms' as requested by her parents. A standard psychiatric history, mental status examination, and structured clinical interview were used to elicit significant life events as perceived by the client and to obtain a working differential diagnosis (i.e., undifferentiated schizophrenia; rule out schizoaffective disorder). Throughout the interview, Linda described presenting symptoms that had occurred on a daily to weekly basis including auditory and visual hallucinations, delusions of reference, magical thinking, and periodic depression, all of which had been prevalent during the past four years of her life.
Background Information
At age twenty, an initial psychotic episode occurred during Linda's first year at junior college with the aforementioned array of symptoms. This had caused Linda great emotional pain and anguish, loss of friendships, and loss of capacity to finish her post--secondary schooling. She remained at home and watched as her former friends continued on with successful achievements while she "stayed at home to play her violin, paint, and watch TV." The writer established that an overall treatment goal aimed to reduce psychotic symptoms by utilizing a gradually accumulated array of coping strategies and to operate from a cognitive behavioral treatment perspective (i.e., cognitive restructuring).
It was also stated to the family that the treatment emphasis would be in the 'here and now' and would initially require weekly, 90-minute sessions to develop a therapeutic alliance and successfully teach CBT strategies. It was emphasized that the therapeutic alliance developed during the course of treatment was of utmost importance. More specifically, throughout the treatment period, a close relationship would be established not only betweent the therapist and client, but a consensual understanding of the process developed between the client, therapist, significant others, and, if required, the other mental health professionals (e.g., family physician, psychiatrist) previously involved in treating Linda. The writer further reinforced the importance of the overall treatment goal: the improvement of Linda's subjective 'quality of life' via the assimilation of coping strategies to process and reduce her chaotic inner experiences.
Treatment Concepts
One concept of major importance when treating outpatients diagnosed with psychosis is 'expressed emotion' (EE) (Dailey & Moss, 2002, p.91). EE is evaluated by counting the number of critical statements, hostility, and emotionally-loaded behavior within the family unit. A high EE attitude in professionals and the outpatient's support network correlates with a worse treatment outcome (Merlo, Perris, & Brenner, 2002). In the post-acute phase of the illness, reactions to schizophrenic outpatients are often characterized by either extreme criticism (imputing a negative valence) or over-involvement (imputing incapacity). In regards to this, Podvoll (1990) considered a healthy therapeutic atmosphere as possessing a positive relationship with the patient, characterized by empathy, acceptance, and avoidance of unnecessary power over the individual.
The basic premise of cognitive therapy suggests that cognition is responsible for behavior and emotions (Beck, 1976; Ellis, 1979); ostensibly the mind affects emotional interpretation of events. Negative cognitions are influenced more by thought patterns based on a systematic mistake in thinking and less by actual environmental conditions. Hence, therapists utilizing cognitive behavioral therapy believe that an effective treatment paradigm can be achieved only by recognizing and altering basic cognitions about unrealistic schemata and mistaken thinking patterns.
Within the cognitive behavioral paradigm of treatment strategies, various authors have developed therapeutic approaches that emphasize the importance of the interaction between cognitions, emotions, and behavior (e.g., Beck, 1976; D'Zurilla & Goldfried, 1971; Ellis, 1979; Meichenbaum, 1977). EE has been a major predictor for the development and continuation of psychotic behavior (Brown, Monck, Carstairs, & Wing, 1962; Vaughn & Leff, 1976). In this regard, the atmosphere of the family system from which a schizophrenic outpatient resides is paramount for further development of the illness. The risk of relapse is much higher if the outpatient resides in a family with high EE and is compounded by poor medication compliance.
Teaching the family members and schizophrenic outpatient the fundamentals of progressive deep muscle relaxation techniques (Bernstein, Berkovac, 1973)--thought-stopping, counting and visualizing numbers, and diaphragmatic breathing exercises--are all important adjuncts to basic cognitive behavior therapy interventions that reduce unhealthy levels of EE.
A treatment plan was discussed with Linda and her family. The plan included 1) Treatment interventions that would be built upon and expanded; 2) Discussing the nature and subjective understanding of the schizophrenic illness during early sessions to address any/all misperceptions about the treatment challenges; 3) Cognitive training exercises for psychosis regarding coping strategies to counteract the negative effect of auditory and visual hallucinations and delusions; 4) Cognitive restructuring; 5) Self-regulation strategies; 6) Imagination behavior exercises including relaxation training; and lastly, 7) Working with the parents after the treatment session had concluded with their daughter for that particular week.
The interventions were introduced in stages, which were expanded, rehearsed, and reviewed on an ongoing basis. Brenner, Kraemer, Hermanutz, and Hodel (1990) have suggested teaching and applying cognitive methods before behavioral interventions. The rationale being that if cognitive performance is improved through specific cognitive training, individuals would be able to be taught progressively more complex therapy and rehabilitation techniques even if the cognitive skills deteriorate.
Within the therapeutic plan devised for Linda, a flexible and personalized manner of treatment was introduced. The method of training in the respective treatment domains depended on Linda's readiness and mental condition for that particular week of therapy and included, as one criterion, a review of the completed homework assignments.
The frequency of individual sessions was mutually decided upon between the writer, Linda, and her parents. Weekly sessions for an initial period often weeks were conducted with the central feature of the treatment being the actual therapy techniques being assimilated. This took the longest period of time in the overall treatment paradigm. Five additional treatment sessions were mutually decided upon based on Linda's progress during the first ten sessions. The following section illustrates each treatment phase...
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