Health Essay Sample: The Cognitive-Behavioural Model

Using the Cognitive-Behavioural Model in Assessing and Managing Patients with Schizophrenia: An Occupational Therapy Intervention

Introduction

Persons suffering from schizophrenia are often stigmatised in society (Harvey et al, 2004; Green et al, 2004). However, recent advances in medicine and psychology has allowed people suffering from this condition to return to mainstream society as well as control the signs and symptoms associated with the disorder (Heinssen et al, 2000). Schizophrenia is a mental disorder that affects the way the individual thinks, feels and interacts socially (Wallace et al, 1992; Liberman et al, 1998). Treatments ranging from pharmacotherapies to psychosocial have been widely utilised by doctors, psychiatrists and occupational therapists to treat the different phases of the disorder. Researchers have acknowledged that the disorder cannot be cured, however, “it is widely recognized that medical and psychosocial therapies can contribute to symptomatic and functional recovery” (Heinssen et al 2000, p. 21). While medications used during pharmacotherapy are effective in treating symptoms such as delusions and hallucinations, they cannot effectively treat symptoms such as inability to interact socially (Tauber et al, 2000; Kopelowicz et al, 2006). As cited by a number of authors, reliance only on pharmacotherapy would result to individuals suffering from a poor quality of life, distress and long-term unemployment (Stoudemire, 1998; Harvey et al, 2004; Green et al, 2004). As such, a combination of pharmacotherapy and psychosocial therapy is recommended in helping patients with schizophrenia (France & Robson, 1997). Lehman et al (2004) has outlined the different psychosocial treatments available to individuals with this condition. These treatment were found out be effective and include intervention using one’s own family; lending support to the individual to find and maintain employment; community treatment; training of the individual to gain skills in order to enter or re-enter the job market; psychotherapy that utilises the cognitive behavioural intervention model and the economy social learning model (Lehman et al, 2004).

The aim of this paper is to choose an intervention model that would best support and treat a patient named John who is suffering from schizophrenia. An assessment of the different models used in occupational therapy lead to the identification of the cognitive behavioural model as the most appropriate intervention model for individuals like John. An intervention model, such as the cognitive behavioural model, needs to be tailored fit to an individual in order for it to be effective (Beck, 1989; France & Robson, 1997). This paper will explore and present how this model can individualized and used to treat John. The succeeding section will explain the key principles associated with the cognitive behavioural model, assess its strengths and weaknesses and relevant evidences proving its efficacy in treating patients with schizophrenia. The next section will be devoted to expounding on why the intervention model would be used on John. At the same time an assessment of John’s case would be provided together with the interventions. The last section of this paper will capture the main points of the model and its relevance to John’s case.

Assessment of the Cognitive-Behavioural Model Key Concepts or Features

The main feature of cognitive-behavioural therapy is that there is emphasis on the relationship between how one thinks to how one feels and what he does (Gelder et al, 1994; Finaly, 1997). While attempting to be a form of treatment, cognitive behavioural therapy or CBT is in reality a unified version of many kinds of therapies that share similar features. For example, there are many approaches used in CBT that include the following: Cognitive Therapy; Rational Behaviour Therapy; Rational Emotive Behaviour Therapy and Dialectic Behaviour Therapy (Gelder et al, 1994; Pfammatter et al, 2006; Lehman et al, 2004; Heinssen et al, 2000).

Key concepts espoused by the cognitive-behavioural model include the idea that one’s thoughts or thought processes influences one’s behaviour and feelings (Curtis, 2000). External events such as circumstances, happenings or situations do not influence one’s feelings or behaviour (Hagedorn, 2001). Employing this type of therapy only involves limited amount of time as compared to other form of therapy such as psychoanalysis (Finlay, 1997). At the onset of the therapy, there is a mutual understanding between therapists and clients that the formal therapy would end and the entire therapy would heavily rely on ‘homework assignments’ (Stoudemire, 1998). Next, while there might be an assumption that a positive client-therapist relationship would lead to the client’s improvement, in CBT, teaching the client to control one’s thoughts is believed to be the main reason why clients change (Malim & Birch, 1998). Therapists and clients identify goals with the former helping the clients achieve these goals. Additionally, CBT utilises the stoic philosophy (Creek, 2002) wherein clients are taught the practice of being ‘calm’ when faced with distressing situations (Reed and Sanderson, 1999). CBT also uses the education model where clients are taught to ‘unlearn’ (Banyard and Hayes, 1994) emotional reactions and even behavioural reactions. At the same time, this form of therapy also uses the inductive method (Reed and Sanderson, 1999) where the client is encouraged to evaluate his thoughts and compare it with relevant or new information. One of the most prominent features of cognitive-behaviour therapy is the ‘homework’ (Spaulding, 1999) method where clients practice what they learn during therapy sessions and practice them in real life. Lastly, this form of therapy emphasizes the positives and do not focus on the negatives (Granholm, 2009). It accomplished this by encouraging the client to alter one’s negative thoughts and change it to positive ones.

Application of the Model

A number of research studies have utilised cognitive-behaviour therapy in various medical settings and found it successful in their application. A study by Garety et al (2000) used cognitive behaviour therapy in treating psychosis. The cognitive models for psychotic symptoms together with stress models of schizophrenia and the cognitive therapy approach used by Beck were all utilised under the cognitive behaviour model. Evidences have shown that symptoms associated with psychoses diminished along with a reduction in the occurrence of a relapse. Another study (Rofey et al, 2008) evaluated the usefulness and effectivity of CBT on controlling depression and obesity. The trial was done on adolescents with polycystic ovary syndrome (PCOS) who were experiencing emotional disturbances and suffering from obesity. Results of the trial showed a significant decrease of average weight and the Children’s Depression Inventory also showed a significant decrease of the mean scores on depression.

Meanwhile a computerized cognitive behavioural therapy was evaluated by Grime (2004) and results showed that cognitive-behaviour therapy could be recommended for decreasing employee absenteeism caused by stress. The program ran for 8 weeks using randomized trial among 48 workers with stress-related absenteeism record. A questionnaire measuring anxiety and depression was conducted before and after the 8 weeks therapy. Results showed a significant decrease in the mean scores on anxiety and depression. Aside from the promising result of using CBT in treating stress-related absenteeism, it can also be used to treat chronic fatigue syndrome (CFS) (Lange et al, 2008). Combining rehabilitative approach with addressing thought process, CBT is seen as an effective method of treating chronic fatigue syndrome (Lange et al, 2008). Study by Lange, F. et al (2008) also show that “cerebral atrophy associated with CFS is partially reversed after effective CBT.” Meanwhile, CBT might also be used as a potential treatment for VVS or vasovagal syncope (Newton et al, 2003). Vasovagal syncope is a medical term for fainting (Newton et al, 2003) which hampers one’s ability to work or go to school. While the authors concluded that the therapy was effective in all of their nine patients, a randomized controlled trial was recommended.

Cognitive-behavioural therapy delivered through the internet as intervention for children with anxiety disorders was also seen to be promising. A study by March et al (2008) has shown that post treatment assessment among children aged 7-12 years old who were suffering from anxiety disorders revealed a decrease in anxiety symptoms. While more research was recommended by the authors of this study, this research adds to the growing evidence that CBT can be used to treat patients with anxiety disorder. Aside from using the internet as a medium for CBT, a web-based CBT program geared towards management of adolescent chronic pain is also seen to be effective. The study done by Long and Palermo (2008) has shown that the usability of this online CBT program is high and users rated it to be effective. In addition, other authors (Curtis, 2000; Gelder, et al, 1994; Finlay, 1997 and Hagedorn, 2001) also explained that CBT can be used in clients challenged with alcoholism; patients suffering from eating disorders such as anorexia nervosa and bullimia; for clients suffering from chronic pain; and in management of psychotic symptoms such as hallucinations.

Finally, CBT along with pharmacotherapy is used to treat patients with schizophrenia as exhibited in a number of studies (Kern et al, 2009; Spaulding et al, 1999; Heinssen et al, 2000; Lehman et al, 2004; Pfammatter et al, 2006; Reeder et al, 2004). While these studies emphasize one on one therapy with clients, a study by Granholm et al (2009) has shown that there is also a promising result in utilizing group CBT to treat schizophrenia symptoms such as social disinterest and ‘defeatist performance beliefs’ (Granholm et al, 2009, p. 874).

Limitations of the Model

One of the primary concerns in the application of this model is when therapists fail to correctly apply this model (Stoudemire, 1998). This would not only have deleterious effects but might also do more harm than good. As such, it is necessary that therapists are well trained in the application of this model as well as in the introduction and implementation of the procedures (Hagedorn, 2001). A second concern with the cognitive-behavioural methods is its subjectivity (Gelder et al, 1994 and Malim and Birch, 1998). While CBT is already well established and applied in numerous clinical settings, the techniques used in its application might be subjective. Its subjectivity and ethical issues need to be addressed prior in attempting to apply its principles in therapy sessions (Curtis, 2000).

Meanwhile, CBT is not applicable in treating patients or clients with severe learning disability since this limits the client’s response and understanding to the therapy process and in the application of key principles espoused by CBT (France & Robson, 1997). Second, patients in advanced stages of psychosis cannot also actively participate in CBT since this might result to mixed or negative outcomes (Beck, 1989). Third, patients far removed from reality and suffering from severe personality disorders might not also be successfully treated with CBT (France & Robson, 1997).

Use of the Cognitive Behavioural Model in Treating John

An analysis of John’s case would reveal that he is undergoing pharmacotherapy (i.e. he is treated with clozapine). In cases of schizophrenic patients receiving pharmacotherapy, there is a need to supplement this with cognitive behaviourally oriented therapy. Lehman (2004) explained, “The key elements of this intervention include a shared understanding of the illness between the patient and therapist, the identification of target symptoms, and the development of specific cognitive and behavioural strategies with these symptoms.” (p. 203). The range of psychotherapies under the category of CBT includes “a range of therapeutic approaches that vary in their specific treatment elements” (p. 204). These psychotherapies (falling under CBT) will be utilised in assessing and intervening for John’s case. The reasons why these forms would be used will be explained in detail in the succeeding sections.

Areas where John needs Intervention:

Affective

Social Skills

John has limited contact with his neighbours. When he is in the community, he has no problem interacting with people. He often chats with them comfortably. However, he has a tendency to ask personal and often intrusive questions to strangers or fellow passengers on the bus.

Mood

No signs of depressed or elevated mood. John presents as somewhat anxious and reports the increase in anxiety symptoms when he is showing signs of relapse in his psychotic symptoms including auditory hallucinations.

Behaviour

John displays obsessional behaviours with regard to cleaning his flat, repetitive checking and shopping. Whilst he recognizes this as a problem, he states that it is “not as bad as it used to be”.

A number of researchers (Wallace et al, 1992; Liberman et al, 1998; Glynn et al, 2002) expressed that individuals living with schizophrenia can benefit from behavioural training, which is structured, in order to learn social skills along with independent living skills. Lehman, A. et al (2003) explained that “the key elements of this intervention include behaviourally based instruction, modeling, corrective feedback, and contingent social reinforcement.” (p. 203). He also remarked that this skills training should be supported with practice of the new skill acquired in the day to day life of the individual with schizophrenia.

For example, in dealing with John’s lack of social skills when interacting with people, the therapist and John can begin by setting a goal on being able to interact with others appropriately. The other steps in behavioural training and social skills training such as role playing, positive and corrective feedback, social modeling, behavioural practice, positive social reinforcement and homework assignments follow (see Learning-Based Procedures Used in Social Skills Training, Kopelowicz et al, 2006, p. S13). In practice, John can learn how to interact with others in a number of situations in increments. He can also benefit from role playing and modeling in order to lessen his anxiety (Kopelowicz et al, 2006).

The same procedure could also be utilised in dealing with the obsessive compulsive behaviour of John and in dealing with his anxiety. However, it should be noted that skills training, while recommended as part of cognitive behavioural training, its impact on relapse is moderate (Heinssen et al, 2000).

Cognitive

Insight

John has some insight into his illness and an awareness of the obsessional component to his life style. His learning disability has some impact on his understanding and occupational functioning.

Concentration/Attention Span

John is easily distracted by his obsessions and needs to be prompted to complete tasks and conversations.

Memory

John report difficulty with his short term memory.

Problem Solving

John is able to solve problem to some degree but requires support.

John’s cognitive aspect can be corrected by using the cognitive-behavioural model and psychosocial skills training (Heinssen et al, 2000) which is designed to overcome “cognitive deficits” (Kopelowicz et al, 2006, p. S12). In overcoming his cognitive deficits, John can apply social skills training through working with his therapist who can teach him social-problem solving skills. These skills would be taught step by step and practiced in John’s day to day living. For example, in correcting John’s obsessions, he will be taught how to train his thoughts to focus only on the task at hand or conversation he is at. Next, he will be taught how to eliminate thoughts of obsessions. Finally, he will be asked to practice this new skill in real life.

Productivity

Paid/Unpaid Work

John has never worked and has no desire to look for employment. He also has no current care giving or volunteering roles. During his long period of residential care, he was reluctant to engage in work related activities.

Education

John attended mainstream education until age 16 and found school to be difficult. He did not continue into further education and has not considered returning since. While there is an IT course at the local college where John is interested and support is offered to mental health service users, John does not know how to access the facility

Using the cognitive-behavioural model along with social skills training and supported employment, John can find employment through learning job-finding skills (Tauber et al, 2000). As evidenced in his case, he has no desire to work since he is not equipped to land a job. He only attended mainstream education until the age of 16. He has no skills but expressed interest in an IT course at the local college. Through therapy and intervention, John can be taught life skills through training with an IT course and later, job-finding skills once he finishes his IT course (Green et al, 2004).

Leisure

John is not engaged in sports but would like to visit certain locations although he is reluctant to attend day trips. John makes telephone calls only when required but does not answer his phone making it difficult for people to contact him.

John is experiencing social avoidance by refusing to answer his phone. The therapist can correct this problem through modeling and role playing (Green, et al, 2004; Harvey et al, 2004) in order to lessen his anxiety when answering his phone. Next, while John wants to visit places, he is reluctant to do so. This problem can be solved through role playing and modeling. He would be taught coping skills to enable him to engage in day trips and have the physical stamina to carry out such trips.

Physical

John has a tendency to walk out into the road rather than walking to a crossing place or traffic light. John’s speech is pressured at times when he becomes anxious.

John could be taught to control his anxiety in order to make his speech calm and not pressured. The CBT could teach him this method by allowing him to control his thoughts through techniques such as thought-stopping and relaxation techniques. Meanwhile, John’s problem with inability to follow pedestrian rules could also be corrected through teaching him how to follow street rules and role-playing.

Conclusion

Cognitive-behavioural therapy, as presented by a number of research studies, is effective in treating cases such as John’s. It allows the therapist and the patient to work together in order to achieve goals set at the beginning of the therapy. Relying on a number of interventions that fall under the category of CBT, this model can be used in a variety of clinical setting from overcoming cognitive deficits to learning job-seeking skills.