Schizophrenia: Does psychological therapy make symptoms worse?

In the field of mental health, schizophrenia is one of the most famous labels out there. It’s often misunderstood, but it’s also relatively common in the general population. Antipsychotics are often criticised for the effects they have on the physical health and mortality of those who take them and emotions on both sides of the argument run rather high.

Psychologists don’t prescribe medication and we often like to think that the treatments we dispense have far fewer side effects. That’s not necessarily the case though – if you’re working with someone who’s traumatised, it’s perfectly possible to retraumatise them through therapy (although we try our absolute best to avoid doing so. But we’re not immune and it would be pompous to pretend that we do nothing but nothing but good.

This paper appearedn recently in The Journal of Nervous and Mental Disease. It was designed to investigate the effect of psychological therapy on symptoms associated with schizophrenia. Schizophrenia symptoms are typically divided into ‘positive’ and ‘negative’ (there is a third category but it simply refers to cognitive functioning). The former are the things we tend to associate with the label: delusions, hallucinations and unusual or disordered thinking. The latter are less flamboyant: they tend to be a certain ‘flatness’ in mood, lack of spontaneous speech and limited pleasure from daily activities. Often, the negative symptoms look very much like depression and they can be the first things you notice.

This study looked the effect of cognitive-behavioural therapy on negative symptoms. It’s an interesting study, because CBT is the recommended intervention fro depression and is one of the recommended interventions for schizophrenia. At the same time, there has been little investigation into the adverse effects of CBT in this population. Psychologists may not be medical doctors, but the old adage of ‘first do no harm’ remains pertinent. CBT was compared to cognitive remediation therapy. For those unfamiliar with either, CBT looks at the patterns between thoughts, feelings and behaviours. It considers how you interpret events and how these interpretations affect the way you respond. CRT is designed to diminish the cognitive decline associated with schizophrenia by providing training in domains such as attention, memory and learning. 198 patients (only 1/3 of those who were eligible) consented to participate and were randomly allocated to receive either CBT or CRT. The effect of random allocation is that you even the sample out – if you knowingly allocate you might skew the groups in terms of age, gender or severity of symptoms. Because we’re all vulnerable to biases, it’s preferable to randomise and to have the randomisation done by machine so that the research team doesn’t know which participants are getting which treatment (this is referred to as ‘blinding’ and the researchers will get the data collected rather than carrying out the treatments as this would obviously mean they knew who was getting what).

So. The results. No one died through suicide during the course of the study, which is good, especially as there is a higher suicide rate associated with schizophrenia. One made an attempt, however, and one had a ‘suicidal crisis’. Those allocated to CBT had slightly elevated scores on a measure of psychotic symptoms compared to those given CRT following treatment, but it was a very light increase; essentially, the risk only increases from a baseline of 1 to 1.1. However, those allocated to CBT were significantly more likely to report elevated depressive (negative) symptoms than their CRT colleagues.

So what do we make of it? Negative symptoms may protect against suicide and some research suggests this is the case. But equally, we don’t want to exacerbate negative symptomatology. In general, CBT had no more ‘side effects’ than CRT: some of those given CBT reported more symptoms at the end of treatment, but their symptoms were no more severe than those of the participants with CRT. Unfortunately, there was no ‘control’ group; a group of people who had similar demographic characteristics to the rest of the sample but who were given no treatment. So although we can state that there is an association between CBT and this increase in symptoms, we can’t attribute one to the other.What this means clinically is that we still don’t know how bad CBT is for your health. What we do know is that it doesn’t prevent those receiving it from going through a crisis (that probably won’t come as a surprise to many) but that, for some people, it may be linked to more negative symptomatology. What clinicians have to do, therefore, is closely monitor the people they see and ensure that crisis and risk plans are both kept updated and implemented as necessary, as well as be prepared to offer more intensive interventions when necessary. Crucially, we need to remember that there are potential risks when engaging in psychological work, just as there are when taking medication.

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