Evidence-Based Practice in Cognitive-Behavioural Therapy for Schizophrenia - Essay Example

?Evidence-Based Practice in Cognitive-Behavioural Therapy for Schizophrenia Introduction As component of a transition in clinical practice from dependence on established professionals and theory to dependence on empirical findings from clinical studies, evidence-based practice has currently turned out to be the rationale of treatment choices for schizophrenia. The Institute of Medicine defines evidence-based practice (EBP) as the combination of leading empirical findings/evidence with patient inputs and scientific/clinical knowledge, which means that individual treatment choices must be derived from clinical evidence regarding the costs and effectiveness of other treatments (Hersen & Sturmey 2012, 3). Thus far, there is no legitimate group assigned to give definition to formal EBP for mental disorder. Therefore, a broader understanding of EBP necessitates up to date and unbroken knowledge of clinical evidence associated with the treatment of mental illnesses. This essay discusses evidence-based practice for cognitive-behavioural therapy (CBT) in schizophrenia. This is an important issue to discuss in the field of EBP because there are still a lot of unsettled problems that need a certain extent of care in the implementation of CBT methods. Empirical support for CBT has been fairly substantial to justify application for the treatment of schizophrenia in the United Kingdom. Nevertheless, the empirical support concerning CBT has critical weaknesses. There are still problems in understanding CBT’s specificity and the stability of any positive outcome beyond the duration of the treatment itself (Gaudiano 2006, 3). The explanation for the conflicting results is not identified and thus is uncertain. Such unsettled issues suggest the importance of further controlled, randomised studies placing emphasis on the stability and specificity of any supposed positive effects of CBT. Empirical Support for EBP in Schizophrenia A primary motivator for studies on psychological treatments for individuals with schizophrenia is the reality that a large number of people still develop signs of psychosis—possibly 40 percent—in spite of intervention with antipsychotics (Roth & Fonagy 2005, 281). CBT administered to clients individually has been examined for community-based samples of individuals with mental illness, for severe current-onset mental disorder, and for relapse avoidance. More currently, research has also started to consider administering CBT to individuals who are highly susceptible to mental illness (Whitfield & Davidson 2007, 47). Even though there are proofs that CBT can have numerous positive outcomes, these proofs are not definite. A major question is which benefits should be considered vital. The study of Rector and Beck (2001) focusing on CBT for delusions discovered positive outcomes for CBT combined with less detailed psychosocial treatments. Likewise, several individual investigations have discovered evident benefits of controlled CBT-based models such as with regard to relapse rates. But on the contrary, other studies that have focused on rates of relapse, such as the study of Pilling and associates (2002), have discovered that CBT does not improve them. CBT for schizophrenia is intended to be a supplementary therapy to pharmacotherapy; hence, controlled, randomised studies before usually used supplement research paradigms, evaluating usual treatment against usual treatment in addition to CBT. After a number of trials discovered definite gains for CBT outside usual treatment, accurately designed trials started to surface evaluation CBT against nonspecific treatments (Gaudiano 2006, 2). As expected, findings evaluating CBT against another treatment were less notable. A number of metal-analyses have been made public in the past summing up the results of treatment demonstrated in investigations of CBT for mental illness. Tarrier and Wykes (2004), derived from a current review of 19 clinical studies, discovered an “effect-size difference between CBT and comparison conditions of .37 at post-treatment on positive symptom measures, which represents a modest treatment effect” (Gaudiano 2006, 2). Almost all of the trials that Tarrier and Wykes looked at were administered to patients with chronic illness whose syndrome had not been sufficiently affected by medication therapy. Moreover, these researchers integrated trials employing additive paradigms alongside those evaluating CBT against another treatment. Such variables probably led to the less encouraging outcomes discovered in their meta-analysis. Furthermore, the researchers reviewed the features of the methodology of the 19 studies. Results indicated that methodological accuracy was oppositely associated with the result (Gaudiano 2006, 2-3). Basically speaking, the more accurate studies demonstrated more modest treatment impacts for CBT. Startup and associates (2005), Lewis and colleagues (2002), and Drury and colleagues (1996), conducted three experiments for CBT for ‘acute-onset schizophrenia’ (Whitfield & Davidson 2007, 48). The first experiment produced highly valuable gains from the CBT-designed treatment in comparison to a control treatment. These consist of more rapid recuperation from positive symptoms and briefer hospital confinement. Nevertheless, the therapy administered involved a certain form of family, group, and individual effort. Roth and Fonagy (2005) emphasise that this implies that the research does not confirm efficacy of personalised CBT because the family component could have been the dynamic component. In addition, as reported by Drury and colleagues (2000), ‘relapse rates were also no different’ (Whitfield & Davidson 2007, 48) between the control and CBT trials. Lewis and colleagues’ (2002) research evaluated usual treatment, supportive therapy, and CBT. Their findings confirmed no advantage of CBT over supportive therapy. Findings like these have pushed a number of scholars to examine whether CBT’s specificity is required in the treatment of mental disorder, or whether the more common human interaction component is mainly dynamic. Ultimately, Startup and colleagues’ (2004) research on severe mental disorder demonstrated greater positive effects in symptoms (e.g. delusions and hallucinations) with CBT. A particular issue that emerges from the less positive outcomes and high level of inconsistency located in publicised studies is the medical value of the treatment outcomes. Jacobson and Truax (1991) described medical value as a recovery from abnormal functioning after therapy. Even though this result is not probable for most chronically ill patients, medical value measures can still offer a valuable instrument for interpreting the impacts of CBT for schizophrenia. Primarily, effects linked to the treatment should be proven to go above the error linked to the instrument itself (Gaudiano 2006, 3). In addition, this consistent level of change must be significant enough to classify individuals outside the array of the pathological group, and ideally, within the array of the normal population. In studies confirming consistent outcomes, a medically substantial reduction in symptoms was approximated to be attained in roughly 14 percent in the comparison settings and 16 percent of individuals under CBT (Gaudiano 2006, 4). Even though inconsistency was once more an issue in the medical experiments analysed, outcomes indicated that a number of patients gained considerably from CBT. It is crucial to stress that, since CBT for schizophrenia is applied as a supplement to other effective intervention the outcomes, such as antipsychotic medication, will probably be minor in several instances. Nevertheless, even a minor positive effect can be medically valuable in groups with high levels of disorder and modest benefits from common treatment. The guidelines of the National Institute of Clinical Excellence (NICE 2003) for schizophrenia emphasise that psychological treatments are currently established as an important treatment alternative that must be accessible to further enhance the recuperation of individuals with schizophrenia, but that the paramount evidence of effectiveness is for family treatments and CBT. As regards CBT the rules specify (Whitfield & Davidson 2007, 49): again, that CBT is a treatment option that is made available for people with schizophrenia (A) But, in particular: CBT should be offered to those with persisting psychotic symptoms (A), and should be considered for those with poor treatment adherence (C) and to assist in the development of insight (B). As further stated in the guidelines, extended duration of CBT are required to alter symptoms of psychosis. Only depressive symptoms are affected by the briefer treatments of CBT (NICE 2003). Moreover, clinical studies have substantiated the efficacy of CBT for schizophrenia during different stages of the disorder and in a range of clinical subgroups. As mentioned, a number of studies reported positive outcomes in patients with chronic illness and treatment-unresponsive symptoms. Lastly, current studies have looked at the application of CBT as an early treatment or to deter the progression of mental disorder in individuals exhibiting early symptoms of mental disorder (Gaudiano 2006, 4). Gumley and associates (2003) reported that CBT had a pre-emptive outcome in patients susceptible to relapse. Lately, Morrison and associates (2004) made public findings of a clinical study evaluating CBT against usual treatment in patients highly susceptible to symptoms of early occurrence of mental disorder. The CBT syndrome, by twelve months, exhibited reduced vulnerability to mental disorder in comparison to usual treatment. Astonishingly, CBT lessened the need to administer antipsychotic treatment to treated patients. Even though the previously cited uses of CBT for schizophrenia need further studies to reproduce outcomes, these previous results are somewhat encouraging and demonstrate considerable efficacy of the treatment when applied during different stages of disorder. In general, Roth and Fonagy (2005) made a conclusion that family therapies positively affect relapse rates. On the other hand, individually administered CBT in patients who have chronic illness and in patients who have acute disorder usually seems to generate benefits with regard to improvement in symptoms but not with regard to preventing relapse occurrences. Similarly, a Cochrane Collaboration study reported that CBT for schizophrenia could alleviate symptoms over time, but found out that it could not moderate rates of relapse in comparison to usual treatment. CBT has been disapproved of because of its inapplicability to a large number of patients with chronic and acute types of schizophrenia, because a lot of these people do not have the required degree of cognitive ability needed for this kind of treatment (Whitfield & Davidson 2007, 48). It has been observed that these people usually do not grasp or have problems self-assessing their own cognitive functioning. Furthermore, individuals who are overwhelmed with emotions do not appear to achieve positive outcomes from CBT in that they have an urgent need to cope with their emotional issues first. Factors that can Hinder Successful Implementation of Evidence-Based Practice One hindrance to the successful implementation of evidence-based practice of CBTs for schizophrenia is that quite frequently researchers and health care professionals adhere to their own procedures and assumptions, which makes it difficult to locate continuities across these techniques. The appropriate application of CBTs is alongside case management procedures, general medical care, and antipsychotic treatment (Hersen & Sturmey 2012, 228). Currently, there are additional studies to substantiate the application of CBTs with individual patients, but additional studies are being carried out on the application of CBTs in groups. Moreover, there are more proofs for the application of CBTs to alleviate schizophrenia’s positive symptoms than the negative ones. CBT for schizophrenia is gradually being integrated into the preparation of nurses and psychiatrists. Without a doubt, courses of action have not been sluggish to promote it with integration into the National Service Framework for Mental Health and the National Health Service Psychotherapy Review (Turkington, Kingdon, & Turner 2002, 525). It has currently been adopted worldwide, with research coming from North America, Scandinavia, Holland, and Malaysia (Turkington et al. 2002, 525). A current statement of the Cochrane Collaboration about their study of CBT in schizophrenia claimed that it was a highly capable but inadequately studied treatment and remains unsupported by medical practice (Hersen & Sturmey 2012, 135). However, in spite of these factors, there is currently reliable medical confirmation and evidence for the application of CBT as component of the typical care management of patients with enduring symptoms of schizophrenia. Unfortunately, there are still significant hindrances to implementation, particularly when CBT is not regarded as a typical psychosocial treatment for schizophrenia. The preparation process in the UK suggests that gaining knowledge of vital CBT for schizophrenia mandates a minimum of two weeks of rigorous preparation in addition to continuous guidance of a professional CBT director for health care professionals who are skilled and knowledgeable in curing schizophrenia (Turkington et al. 2002, 525-526). Implementation of CBT is frequently viewed with doubt, including concerns about several of the exact methods employed and therapeutic denial. Conclusions Therefore, it is not astonishing that CBT does not generate positive outcomes for all kinds of patients. Some of the patients are plainly very paranoid and incapable of creating a workable therapeutic relationship. Some are plainly too disturbed or ill to receive CBT, even though the impact of medication could make them more responsive to therapy. There are no proofs thus far that CBT is effective for patients who are constantly unresponsive to antipsychotic treatment. Nevertheless, it is evident that CBTs for schizophrenia are progressing based on the research findings and clinical practice acquired handling patients with schizophrenia. References Drury, V., Birchwood, M., Cochrane, R., et al. (1996a) “Cognitive therapy and recovery from acute psychosis: a controlled trial. I. Impact on psychotic symptoms”, British Journal of Psychiatry, 169, 593-601. Drury, V., Birchwood, M., Cochrane, R., et al. (1996b) “Cognitive therapy and recovery from acute psychosis: a controlled trial. II.Impact on recovery time”, British Journal of Psychiatry, 169, 602-607. Drury, V., Birchwood, M. 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