Psychological: Cognitive Explanation & Cognitive Treatment

Psychological Explanations: Cognitive Impairments

Frith et al (1992) identified 2 Dysfunctional Thought Processes that could be linked to schizophrenia

Central control:

Central control is the ability to suppress automatic responses while we perform deliberate actions. For example, if I say the word polar bear during the lesson you might think of ice and global warming, but you can easily get back to the task in the lesson, because you are able to suppress any other information about polar bears because it is not useful to you. 

Disorganised speech and thought disorder could result from the inability to suppress automatic thoughts and speech triggered by other thoughts. As schizophrenics are thought to have an impaired central control, they will see a word, and each word triggers associations and the patient cannot suppress automatic responses to these, this leads to a mass of information swirling around in their minds! For example say polar bear to someone with schizophrenia, and anything related to a polar bear would come up, this would then be connected as a flow of other words like a game of categories e.g. ice, cold, winter, jumper, wool, sheep, field, grass, cow. They get from ice to cow! Very confusing.

Metarepresentation:

Metarepresentation is the cognitive ability to reflect on our own thoughts and behaviour. It allows us insight into our own intentions and goals and to understand that our own thoughts are separate to other peoples thoughts. People with schizophrenia fail to meta-represent. It is really important to emphasise this when describing the explanation in your exams.  

According to Frith, failure to meta-represent can lead to symptoms such as auditory hallucinations and thought broadcasting. This is because people with schizophrenia fail to recognise that their thoughts are their own. Instead they might believe that they are someone else’s thoughts or someone else talking. This is where the auditory hallucinations maybe linked, because they think that someone else is talking to them, but in fact, it is their own internal voice. Failing to meta-represent can also lead to the belief that someone else is accessing their thoughts and trying to change the way they think (thought broadcasting – a type of delusion). Many schizophrenics display paranoia about people accessing their thoughts and controlling their mind and this could be having an impaired ability in metarepresentation.

Evaluation: Cognitive Explanation 

  • Research to support: Frith’s idea that people with Schizophrenia have problems with meta-representation. Bentall (1991) 2 groups: Schizophrenics and non schizophrenics asked to read out category words e.g. plants beginning with the letter C. Some were provided for them, some they had to think of themselves. A week later, they were asked to identify which words they had read, which words were new and which words they thought up themselves. Schizophrenics struggled to distinguish between words they have come up with themselves and those they had heard. 
  • Research to support: Stroop test – research has found that people with schizophrenia find it difficult to perform the Stroop test. This test involves naming the colour that the word that is written is, rather than the colour that is spelt out. This research suggests that people with schizophrenia struggle to have central control, as they can’t suppress automatic responses, and therefore, they tend to quickly read the word by mistake.
  • Issues with Research to support: One weakness is the research used to support lacks ecological validity. Bentall found that when recalling a word category task, schizophrenics struggled to distinguish between words that they have come up with themselves, and those that they had heard from the researchers. This is an artificial task, and may not be effective in supporting the idea of schizophrenics failing to metarepresent in everyday settings.
  • Useful Applications: The cognitive explanation has led to the development of Cognitive Behavioural Therapies. Tarrier et al. (2000) found that people with schizophrenia receiving 20 sessions of CBT in 10 weeks, coupled with drug therapy, followed by four booster sessions during the next year, had a better reduction in symptoms than sufferers receiving drug therapy alone. 
  • Usefulness: The cognitive approach does not provide treatments that can cure schizophrenia, but instead it helps to make schizophrenia more manageable. For example, Trower et al (2004) found that CBT did not actually reduce or get rid of hallucinations, but helped patients to be feel less threatened by them. This means that treatments that are based on cognitive explanations will not provide an extensive treatment that address all symptoms.
  • Reductionist: The cognitive approach is reductionist as it tries to explain a complex disorder at the level of individual cognitive symptoms. Schizophrenia includes auditory hallucinations, and it would difficult to assume that this positive symptom is solely cognitive. The physical brain and cognitive neuroscience would provide a superior explanation because it sees the mind and brain holistically.
  • Alternate explanations: Gottesman (2010) found that the risk of mental illness was much greater for children who had two parents with a diagnosis of bipolar or schizophrenia: 67.5% of offspring who had both parents diagnosed with schizophrenia, had developed a mental health issue by the age of 52. The family dysfunction explanation and the cognitive explanation ignores the impact of the biological causes. This suggests that the psychological explanations are too simplistic. It is also difficult to assume that cognitive faults or family dysfunction leads to hallucinations, especially when there is a lot more biological support for the positive symptoms. Therefore, an interactionist approach is needed in order to provide the most credible explanation for schizophrenia. 

Psychological treatments for schizophrenia: CBT 

We cover two main treatments for Schizophrenia which include CBT, and Family Therapy. We then look at Token Economy , which is NOT classed as a treatment. Token Economy is used as a way to manage schizophrenic patients within mental health hospitals and institutions. 

Cognitive Behavioural Therapy 

Cognitive behavioural therapy assumes that schizophrenia is the result of dysfunctional thought processes. For example faulty cognitions such as delusions are identified with CBT and ultimately changed. The therapists role is to challenge irrational beliefs, this could be by logically disputing the reality of the delusions and helping to develop alternatives. CBT can take between 5 and 20 sessions. 

Identify: ABC (DE) model by Ellis is used to understand the source of the faulty cognition, and provide a process to cognitively restructure irrational beliefs (delusions). The therapist will firstly use the ABC model to identify the irrational beliefs. See the example below:

A – Activating event – Drug treatment causes side effects

B- Beliefs – Hospital staff are trying to kill them

C-Consequences – Refusing treatment

Educate: Once the irrational belief is identified, the irrational belief is challenged by the therapist through a process called Disputing (we have covered this before in the cognitive treatments for depression). 

D – Disputing irrational beliefs

Logical Dispute – (does it make sense?) Could there be other reasons for having side effects to the drugs? This line of questioning would help the patient to see that the staff have no reason to kill them.

Empirical Dispute – Within a CBT session the therapist will encourage the use of Reality Testing in order to challenge the irrational beliefs. For example, the therapist may ask the patient to think of examples when the staff have protected you? Maybe focusing on the idea that they are still alive. This is an example of empirical dispute, as the therapist is encouraging the patient to look for evidence.

This line of questioning can be carried out without causing distress, provided there is an atmosphere of trust between the patient and the therapist, who remains empathetic and non-judgmental.

E – restructured belief (Effect) – This is the outcome in response to the cognitive therapy. The patient develops a new belief that is a more accurate reflection of reality – The drugs are necessary for me to get better. 

Watch this video so you can see how CBT looks like and how it works

Evaluation of Psychological Therapies – CBT 

  • Research to support the effectiveness of CBT: Tarrier et al. (2000) found that people with schizophrenia receiving 20 sessions of CBT in 10 weeks, coupled with drug therapy, followed by four booster sessions during the next year, had a better reduction in symptoms than sufferers receiving drug therapy alone. 
  • Research to oppose the effectiveness of CBT: Tarrier et al (2000) and many other researchers which investigate the effectiveness of CBT, use participants that are also taking ant-psychotics or some from of drug treatment. Therefore, we must be cautious in drawing the conclusion that CBT is effective in treating schizophrenia as it is difficult to conclude the extent to which CBT plays in treating schizophrenia in comparison to the drugs.
  • Freewill is encouraged in CBT – CBT works with the individual and allows them an element of freewill within their treatment. Drugs are sometimes felt by the patients as something that is done to them, and it may also mean that underlying issues are not addressed. CBT allows individuals to feel empowered and take control. Trower et al (2004) found that CBT did not actually reduce or get rid of the hallucinations, but helped patients to be feel less threatened by them. Therefore, because the patients are being taught how to identify and manage their delusions, it may mean that they can tackle these independently and therefore could improve the effectiveness of the treatment over time.
  • Free will issues in CBT – The fact that both therapies encourage a sense a freewill and works on the basis that the patient has to make a conscious choice to be committed to the treatment causes some issues. In relation to CBT, the patient is required to have willingness for it to be effective. The negative symptoms such as avolition and emotional flattening can lead to a reluctance to participate and an inability to engage and therefore act as a deterministic factor.
  • Usefulness of CBT – CBT could be deemed more useful in the sense that it doesn’t cause any physical side effects in comparison to anti-psychotic drugs. Use evidence from studies in biological treatments for schizophrenia.
  • Practical Issues – Usefulness of CBT – However, could be deemed less useful because therapies are expensive and can be very time consuming. This means that it can be difficult to offer therapy on a mass scale (especially when it is the most common psychotic disorder), and it could lead to drop out rates, especially when a patient in going through a severe episode. The individual must be committed and attend regular sessions in order for it to be successful. In addition, CBT requires self-awareness to engage with process. Positive symptoms lead to lack of awareness which can make CBT very difficult to implement. 
  • Idiographic approach/Individual differences –CBT allows for the therapy to target and improve the unique deficits of each individual. Unlike drug therapies that provide a one fits all approach. However, not all clients are suited to vigorous confrontation.