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Psychological Treatments for Schizophrenia Spectrum Disorder: What Is Around the Corner?† Douglas Turkington & Latoyah Lebert

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Psychological Treatments for Schizophrenia Spectrum Disorder: What Is Around the Corner?† Douglas Turkington & Latoyah Lebert BJPsych Advances (2017), vol. 23, 16–23 doi: 10.1192/apt.bp.115.014787 ARTICLE Psychological treatments for schizophrenia spectrum disorder: what is around the corner?† Douglas Turkington & Latoyah Lebert Douglas Turkington is an transference was opined to make psychoanalysis SUMMARY Honorary Professor of Psychosocial non-viable, and the likelihood of further regression Psychiatry at Newcastle University. The evidence base for cognitive–behavioural ther- within free association to lead to a high probability His research interests include apy (CBT), family therapy, psychoeducation and cognitive–behavioural therapy of relapse. Thus, psychoanalysis in its pure form cognitive remediation as adjuncts to antipsychotic (CBT) for schizophrenia, suicide was simply non-viable. Jung (1911/1912), however, medication in the treatment of schizophrenia is prevention and liaison psychiatry. viewed the experience of psychotic symptoms as a Latoyah Lebert is a researcher well established. It is, however, clear that the currently working on a randomised moderate effect size of the best researched of necessary phase of individuation and as a crucial controlled trial investigating CBT for these treatments (CBT) compared with treatment driver for psychological development, including clozapine-resistant schizophrenia. as usual reduces to small when compared with an creativity and spirituality. For Freud the ‘sticking Her research interests include active psychological treatment. It would seem that plaster’ was a form of self-defence; for Jung the developing CBT techniques for carers of those with schizophrenia. many different psychosocial interventions deliver emergence of psychosis was a sign of psychological Correspondence Professor benefit in schizophrenia. We are now at a stage in development to be understood and integrated. Douglas Turkington, Academic their development when new treatments are being Psychiatry, Wolfson Unit, Newcastle energetically piloted and combination treatments Cognitive therapies General Hospital, Westgate Road, tested. This article outlines the most promising of Newcastle-upon-Tyne NE4 6BE, UK. these new interventions and attempts to answer As in so many areas, Beck did not accept the Email: Douglas.Turkington@ntw. psychoanalytical orthodoxy. In 1952 he treated and nhs.uk the crucial question as to their differential effects on different psychotic presentations. markedly improved the distress and functioning of Copyright and usage a patient with a substantial persecutory delusional © The Royal College of Psychiatrists LEARNING OBJECTIVES system using collaborative questioning and reality 2017. • Be aware of the most promising new psychosocial testing. He was also able to generate a cognitive treatments for schizophrenia formulation and use schema-level techniques to † • Learn the key elements of each intervention For a commentary on this article work with unbearable protected affect. In this see pp. 24–26, this issue. • Understand which of these approaches might case the delusional system protected against guilt. be best suited to particular presentations of Having described this approach (Beck 1952), schizophrenia spectrum disorder he moved on from schizophrenia to work with DECLARATION OF INTEREST anxiety and depression. D. T. delivers lectures and training courses on the By the early 1990s, groups of UK psychologists subject of CBT for psychosis and psychiatrists were developing pioneering new cognitive–behavioural techniques for schizo- phrenia. The breakthroughs began in Sheffield/ Introduction North Nottinghamshire, Manchester, London/ Psychoanalytical views of psychoses East Anglia, Birmingham, Glasgow and Liverpool. In his analysis of the Schreber delusional system, In Sheffield/North Nottinghamshire, Kingdon Freud (1911) set the tone for psychological & Turkington (D. T.) showed the safety and treatments for schizophrenia and allied psychoses acceptability of Beckian cognitive therapy for for a generation. First, he argued that Schreber’s out-patients with chronic schizophrenia (Kingdon grandiose and persecutory system was meaningful, 1991). Recognising that direct engagement and we have much to be grateful for in that. This with the psychotic patient in working on voices, was not simply the aberrant firing of misplaced delusions, thought disorder and negative symptoms neurons, but a delusional system that was was crucial for progress, the old approach of understandable in terms of both form and content. avoiding all such discussion was abandoned. The delusional system was seen as a ‘sticking They described a crucial component of cognitive– plaster’ over the unconscious, and the content behavioural therapy (CBT) in reducing stigma, the related to repressed libidinal desire. Psychotic concept of normalising (Kingdon 1991). Patients 16 Downloaded from https://www.cambridge.org/core. 25 Sep 2021 at 01:56:33, subject to the Cambridge Core terms of use. Psychological treatments for schizophrenia spectrum disorder with schizophrenia are now informed that, although (National Collaborating Centre for Mental Health their voices and delusions are certainly troublesome, 2014). Psychoeducation, in terms of relapse delay, such symptoms are quite common in the general and cognitive remediation, in terms of attentional population (meta-analysis reveals approximately and memory improvement, were not supported 5% prevalence and 3% incidence; van Os 2009). by the same quality of evidence and the National Their voices and paranoid thoughts are described Institute for Health and Care Excellence (NICE as a common human experience with the potential 2014) did not recommend routine implementation. to improve over time. Similarly, they are informed There is preliminary evidence from RCTs for that these psychotic symptoms usually have a clear eye movement desensitisation and reprocessing ‘down to earth’ cause such as sleep deprivation, (EMDR), acceptance and commitment therapy hallucinogen use, unresolved bereavement or (ACT) and cognitive adaptation training. The childhood adversity and other traumas. Also, other new treatments are supported only by an accurate prognosis is given for schizophrenia cohort-level evidence. As regards positive showing that by 25-year follow-up the majority psychology, a systematic review looking at the of patients are no longer troubled by voices or well-being of people with psychosis reported a delusions (Harrison 2001). This increase in hope ‘small and methodologically weak’ evidence base is enhanced by reference to famous voice hearers (Schrank 2013). such as Anthony Hopkins (actor) John Frusciante (guitarist) and Vinnie Jones (footballer and actor). What is the state of the current evidence Following on from Bleuler, Kingdon & Turkington base? (2005) have described subgroups of schizophrenia Current meta-analyses are fairly consistent in with different aetiological components and different their findings. CBT v. treatment as usual (TAU) trajectories towards recovery. delivers a moderate effect size benefit on overall Meanwhile in Manchester, inspired by the symptoms, positive symptoms, negative symptoms work of David Clark in anxiety disorders, and functioning (Jauhar 2014). However, other Tony Morrison described a model of psychotic psychological treatments are also beneficial: for symptom maintenance that was to become hugely example, befriending and supportive psychotherapy influential (Morrison 1998). He placed appraisal both tend to have a detectable but small effect size. of anomalous experiences such as hallucinations, The effectiveness of these interventions (which were paranoid thoughts, intrusions and delusional not specifically designed for schizophrenia) most mood right at the heart of psychosis. Such probably relates to the extreme social isolation appraisals (e.g. ‘the Devil has possessed me’, ‘a of people with schizophrenia in Western society. computer is controlling my thoughts’ or ‘aliens Interestingly, befriending has a differential effect are trying to hack into my mind’) correlate with on different psychotic symptoms. It is ineffective for insomnia and powerful affects such as anxiety, hallucinations, but a viable adjunctive treatment shame and anger. In line with such appraisals, for persecutory paranoia (Samarasekara 2007). safety behaviours are activated such as avoidance In head-to-head comparisons of CBT v. another of social interaction, thought suppression, psychological treatment with patients already repeated checking and hypervigilance. All of these stabilised on antipsychotic medication, CBT has perpetuate the experience of psychosis in a vicious a small but statistically significant benefit over cycle of maintenance acting together to prevent all head-to-head comparators (Jauhar 2014). recovery. Cognitive therapy therefore became CBT has also been shown to be acceptable and a viable and model-based treatment option. In safe in patients with schizophrenia who refuse London/East Anglia, an integrated cognitive antipsychotic medication: one RCT recorded an model was described (Garety 2001) and a therapy effect size of 0.43 (similar to that of antipsychotic developed that stressed the crucial importance of medication) (Morrison 2015). engagement, collaboration and individualised case conceptualisation (Fowler 1995). New directions There are numerous exciting new directions in Other new therapies the psychosocial treatment of schizophrenia to Family therapy also has a robust evidence base. supplement ongoing efforts to improve the side- Meta-analysis of 32 randomised
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