Transcript שקופית 1

COGNITIVE GROUP THERAPY FOR
PARANOID SCHIZOPHRENICS:
APPLYING COGNITIVE DISSONANCE
Joseph Levine
Yoram Barak
Ilana Granek
JOSEPH LEVINE
Associate professor (BGU)
EDUCATION
1957 -1969 Elementary School (Beit Yehezkel), and high school (Tager High
School), both in Ashkelon, Isreal.
Tel-Aviv University, MD,
Tel-Aviv University, M.A. Sci in Physiology– Pharmacology (Cum Laude)
Tel-Aviv University school of psychotherapy (3 years of studies and training in
psychotherapy)
Tel-Aviv University school of psychotherapy (2 more years of advanced
studies in family therapy)
Tel-Aviv University Senior Medical Administrative Certificate administered by
Post Graduate Institute of Education of Kupat Holim
WHAT IS THE MOTO OF
COGNITIVE THERAPY ?
Aaron T. Beck, M.D.
You feel the way you think
THOUGHTS
FEELINGS
Cognitive
dissonance
is a
condition
first
proposed by
the
psychologist
Leon
Festinger in
1956,
relating to
his
hypothesis
of cognitive
consistency.
Leon
Festinger
COGNITIVE DISSONANCE
• Cognitive dissonance is a state of opposition between
cognitions. Cognitive dissonance is a perceived
inconsistency between two congnitions in which the
person believes one thing but then acts in a different way
from what they believed. For the purpose of cognitive
dissonance theory, cognitions are defined as being an
any element of knowlege attitude,emotion, beleif or
value, as well as a goal, plan, or an interest. In brief, the
theory of cognitive dissonance holds that contradicting
cognitions serve as a driving force that compels the
human mind to acquire or invent new thoughts or beliefs,
or to modify existing beliefs, so as to minimize the
amount of dissonance (conflict) between cognitions.
Further propositions by Festinger
• Festinger proposed that cognitive dissonance is a "negative drive
state", a similar psychological tension to hunger and thirst and that
people will seek to resolve this tension.
• Reduction of cognitive dissonance may be good because one feels
better, and because one can come closer to consonance by
eliminating contradictions. On the other hand some of the ways of
reduction of cognitive dissonance involve a distortion of the truth,
which may cause wrong decisions. The harder way of changing
favourable cognitions may in the longer run be better
• When confronted with two beleif cognitions that contradict each
other, Festinger suggests the dissonance can be resolved by finding
and adding a third piece of information relevant to the two beliefs.
For example, if Sam believes that elected officials are trustworthy,
but also believes that elected officials have broken his trust, then the
cognitive dissonance can be resolved by discovering that all elected
officials lie. This enables Sam to (it is to be hoped)to still hold that
elected officials are still largely trustworthy, but that they also all lie.
• If dissonance is experienced as an unpleasant drive state,the individual is
motivated to reduce it. Now that the factors that affect the magnitude of this
unpleasantness have been identified, it should be possible to predict what
we can do to reduce it:
• Changing Cognitions
• If two cognitions ar discrepant, we can simply change one to make it
consistent with the other. Or we can change each cognition in the direction
of the other.
• Adding Cognitions
• If two cognitions cause a certain magnitude of dissonance, that magnitude
can be reduced by adding one or more consonant cognitions.
• Altering importance
• Since the discrepant and consonant cognitions must be weighed by
importance, it may be advantageous to alter the importance of the various
cognitions.
• The material above is the background reading for the Cognitive Dissonance
Lab. These are excerpts from Frederick M. Rudolph¹s page on Social
Psychology. For a more detailed discussion on cognitive dissonance and
related theories, visit
• The main criticism of the cognitive consistency
hypothesis is that it is impossible to verify or
falsify by experiment. Even so, experiments
have attempted to quantify this hypothetical
drive. Opponents of this hypothesis cite the
apparent ability of many human beings to
reconcile mutually exclusive or contradictory
beliefs with no apparent stress, though the
original theory would suggest that such beliefs
were not psychologically important.
Cognitive Therapy with
Schizophrenia
• The misinterpretation of events in the world
is common in schizophrenia. Using cognitive
therapy with schizophrenia requires the
psychologist to accept that the cognitive
distortions and disorganized thinking of
schizophrenia are produced, at least in part,
by a biological problem that will not cease
simply because the "correct" interpretation
of reality is explained to the client.
• Cognitive therapy can only be successful if the
psychologist accepts the client's perception of
reality, and determines how to use this
"misperception" to assist the client in correctly
managing life problems. The goal is to help the
client use information from the world (other people,
perceptions of events, etc.) to make adaptive coping
decisions.
• The treatment goal, for the cognitive therapist, is not
to "cure" schizophrenia, but to improve the client's
ability to manage life problems, to function
independently, and to be free of extreme distress
and other psychological symptoms
• Over the past 10 years, CBT for schizophrenia has received
considerable attention.
•
In this treatment, patients are encouraged to identify beliefs
and their impact and to engage in experiments to test their
beliefs. Treatment focuses on thought patterns that cause
distress and also on developing more adaptive, realistic
interpretations of events.
• Delusions are treated by developing an understanding of the
kind of evidence the person uses to support the belief and
encouraging the patient to recognize evidence that may have
been overlooked that does not support the belief.
• Furthermore, the assumed omnipotence of "voices" is tested,
and patients are encouraged to utilize various coping
mechanisms to test the controllability of auditory hallucinations
Schizophrenia- paranoid type
COGNITIVE GROUP
THERAPY FOR
PARANOID
SCHIZOPHRENICS:
APPLYING
COGNITIVE
DISSONANCE
Joseph Levine M.D.
M.Sc1,
Yoram Barak M.D.2
Ilana Granek M.A.2
• Bloch in 1993, reviewed the current
state of cognitive strategies in
schizophrenia and stated: "... recent
studies have suggested that systematic
cognitive interventions aimed at
reducing the convictions with which
these beliefs, (delusions), are held, may
be more successful than conventional
wisdom would suggest". (3).
• Further support for this unorthodox
approach was supplied by Perris in his
1989 book entitled: "Cognitive therapy
with Schizophrenic Patients". (4). Perris
stated that: "It must be emphasized that
cognitive psychotherapy can, when
used in individual format, represent an
answer to the search for a known
reductionstic psychotherapeutic
approach that takes into account the
heterogeneity of the schizophrenic
disorders and allows therapists to cope
with their complexity". (4).
• In the last few years several studies have
been published describing the use of
cognitive approaches in the treatment of
delusional patients. Among these, two studies
evaluated the efficacy of individual cognitive
psychotherapy in reducing the conviction with
which delusional beliefs are held (5,6).
• Lately, our team has published a single case
study wherein cognitive dissonance was the
tool for inducing change in a schizophrenic
patients' paranoid system (7). and a
theoretical model, illustrated by a case report
and preliminary results of applying such a
model in several additional schizophrenic
paranoid patients (8). These cases (7,8)
althought mainly treated by individual therapy
made use of structured pressure, induced by
a group serving as a vehicle enabling the
inducement of cognitive dissonance. Although
non - supportive group therapy is not
recommended as a mode of therapy in
paranoid schizophrenics. This technique was
well accepted by the patients.
• However, all the above mentioned studies,
(5-8), have several drawbacks. No controls
were used, selection criteria for entering
cognitive treatment were not clearly defined
and no standardized, validated instrument
was used for measuring changes in the
patients' psychiatric status and / or delusional
beliefs.
• The present study was designed as a
controlled study measuring the efficacy of
inducing cognitive dissonance in order to
change psychotic paranoid ideation. Taking
into consideration data gathered from our
previous work (7,8) demonstrating patient
acceptance of group work within the frame of
their individual therapy, we applied the above
technique in a highly structured group setting
with supportive group therapy as a control.
The PANSS (9) was used to assess baseline
status, change during the procedure and
outcome at follow-up.
• METHODS AND SUBJECTS
• SUBJECTS: The present study
encompassed 12 paranoid schizophrenic
patients. Inclusion criteria were: a)
diagnosis according to DSM - III - R
criteria (10). b) age: 20 - 45 years. c)
documented disease duration: 5 years at
least d) education: 8 years of schooling
and more. e) active delusional system,
and f) no change of antipsychotic drugs
in the last 3 months.
• Exclusion criteria were: a) alcohol and /
or drug abuse. b) chronic physical
conditions and, c) orthodox religious
convictions. [These patients were found
as relatively less responding to cognitive
therapy inducement (8)]
• Subjects were randomly assigned either
to group cognitive therapy or to a
supportive group. Table 1 presents the
clinical and demographic data for both
groups.
• METHODS: a) cognitive - dissonance group therapy: all researchers taking
part in the present study were previously trained in inducing cognitive
dissonance in paranoid patients. For further details of such training see
reference 8.
• Recruitment: staff members and each patient met for 30 minutes. One of the
staff presented to the other staff members several questions for which
alternative answers may be given. For example, "What may cause a traffic
jam?". Questions were carefully prepared beforehand in order to be neutral
and free of paranoid content, as much as possible. Following the staff's
"demonstration" of giving several alternative answers the patient was
presented with questions similarly constructed and encouraged to provide
alternative answers. This was repeated with the patient becoming proficient
in the procedure. At the end of each individual meeting, the staff followed by
the patient agreed to the formulation of the following statement: "It is
axiomatic that any event has several alternative explanations perceived by
the keen observer". This was put in writing and signed, first by all staff
members and than by the patient. It is important to note that social influence
and group pressure applied by figures perceived as more knowledgeable or
of higher status has been shown to be an effective method of inducing
conformity with group norms (11).
• The first group session began by introducing the co - therapists (male and
female) and the patients to each other. Each participant again announced
his / her acceptance of the axiom. The therapists than defined the group as
a "working group" enquiring into the various possibilities of understanding
life - events. Patients were informed that following each session, home
assignments will be given to be returned and discussed in the next session.
The first session than moved on to rehearse generating alternatives to
neutral occurrences. The assignment was to write 2 alternative explanations
to typed pre - prepared situations. If at any time during this session a patient
raised a delusional alternative the therapist acknowledged that it is only one
of many possible explanations and immediately encouraged generation of
further answers. In no may was the delusion contradicted by the therapist.
• The second session was opened by reviewing the
home assignment, with each patient. Than,
patients were trained to generate 3 alternatives to
neutral stimuli. Patients were encouraged to give
their own questions for the group to answer. Group
cohesiveness was increased by mutual aid in
alternatives generation by the patients when one
found it difficult to do so on his own.
•
The third session was opened by going over the
home assignment with each patient. Group
members were than presented and encouraged to
contribute their own examples of impersonal
elements capable of arousing paranoid ideation.
The elements were ones which could give rise to
paranoid alternatives in a general sense.
• Home assignment requested alternatives to
paranoid provoking occurrences. For example,
"What may explain a scene where two people
force a pedestrian into a car and drive off".
• The fourth session again opened with
review of home assignments. The session
was than devoted to explaining (via
alternatives) issues of insanity and
eccentricity. For example, patients were
asked to give several alternatives to
thought insertion, the reasons for
involuntary hospitalization etc. Again,
individuals who presented specific
delusions derived from their inner
experience were treated as though these
are just one of many other possible
alternatives. Home assignments were still
restricted to general issues of psychoses
• The fifth session again begun by reviewing the
assigments. The patients were encouraged to
present their own delusions, to give alternative
explanations to them, and to receive alternative
explanations offered by the other members. This
sessions was characterized by a highly affect
leaden participation of all members. The home
assignment was individually tailored to each
patients delusions - requiring him to generate 3
alternative explanations for each component of
the delusional system.
• The sixth session was along similar lines
described previously. The focus was on
the central private delusion of each
patient. All members were encouraged to
present several reason for their
hospitalizations and psychiatric treatment.
The session ended by the therapists
summarizing that now patients are in
control of a powerful method by which to
evaluate their inner experience in light of
the basic axiom that they have all
rehearsed.
• It should be stressed that the therapists
acted within an atmosphere of a joint
effort with the patients to try and
understand the dilemmas, ideas and
notions raised in the sessions. In
addition during the sessions, the
therapists channeled the patients to use
"true" alternatives and not "pseudo"
alternates. Positive verbal
reinforcement was the tool for
channeling. "Pseudo" alternatives were
defined as either variants of the same
answer, answers that are completely
opposite to each other (black and white
thinking; dichotomic thinking) or a
certain answer and one or more of it's
generalizations.
• VIGNETTE (SESSION 3):
One of the
patients asked the group for explanations
regarding his inability to sell his appartment.
The therapists rephrased the question in a
general manner: "Why would an apartment
not sell?" This type of question touches on
the periphery of paranoid thinking in patients
who may have had delusions in relation to
neighbours, planting of microphones etc.
Each group member than generated at least
2 alternatives; for example: Patient A: "The
price may be too high. However, it may be
that one of the neighbours moves furniture
around, bangs with a hammer. There may
be ghosts".... Patient B: "Ownership may not
be legal. The place may be booby - trapped,
or one could be a poor salesman".
• Therapist: "Patients C, What alternatives
can you add?"...
•
VIGNETTE (SESSION 6):
•
Patients D declares that the source of his troubles is
an unjust persecution by psychiatrists, leading to
involuntary hospitalization. Therapist: "Could there
be an even more central issue causing your
problems". Patient D: ""No. This is my burden".
Therapist: "Are there alternative explanations to
your experience?" Patients D: "No". Therapist
(addressing the group): "Is there any event with only
one explanation?" Group: Laughter. Patient D: "It
may be that there is an alternative view", for
example... Therapist: "What are the alternatives?".
Patients D: "I could be responsible to certain of the
happenings ... but I am not sure". Therapist: "If you
are responsible, what does it imply?". Patients D:
"That I am sick ... insane". The patient than looks
around the group, assessing the members
reactions,
and than states "I may have acted out of
madness...."
•
• SUPPROTIVE GROUP
• Patients of the supportive group
(controls) first met, individually with their
therapists, (a male and a female) for a
brief introduction and explanation
regarding the procedure. They than met
for 50 minutes, once weekly, for six
weeks. The content of the group
sessions focused on difficulties patients
presented with coping in everyday life.
Four weeks after the sixth session a
single follow -up meeting took place.
The group's therapists avoided relating
to delusional material and focused on
strengthening existing defenses.
• The PANSS, (9), (positive and negative
symptoms scale), and it's positive,
negative and general subscales, was
used to asses the patients status (both
groups) at: baseline, 2 weeks, 4 weeks,
6 weeks (study's completion) and at
follow - up, 4 weeks later (week 10).
The PANSS scale was scored by an
independent, board - certified,
psychiatrist.
• STATISTICAL ANALYSIS:
• results are presents as mean, and S.D.
Comparison between groups and
within - group - evaluations were
undertaken using the two - tailed
student - t - test. Significance was defined
as P<0.05.
•
•
•
•
•
RESULTS
There were 12 subjects in the present study. Table "1" presents
demographic and clinical variables regarding these patients. It should be
noted that all subjects were males diagnosed as suffering from paranoid
schizophrenia.
The PANSS results are presented in tables "2" and "3". Table "2" presents
the results of the cognitive (dissonance) therapy and table "3" of the
supportive therapy.
Statistically significant differences in total PANSS score were found between
CD and control groups baseline versus end of treatment (6 wks), (t=4.93, df
= 10, P<0.001), and between baseline versus follow - up (t = 4.92, df = 10,
P<0.001). In addition these were also significant differences for the positive
symptoms sub - scale for baseline to end of treatment and to follow - up, (t =
3.92, df = 10, P<0.01. t = 5.61, df = 10, P<0.001 = respectively). The
general psychopathology and the negative symptoms sub - scales
demonstrated a trend towards better effect of the CD treatment which did
not reach statistical significance, (P<0.08).
• In accordance with Melnick and Woods' salient
generalization that homogenous groups appear
to coalesce more quickly, offer more immediate
support to members, have better attendance,
less conflict and provide rapid relief (19); we
have designed the present research so as to
create a highly homogenous group. All
participants were relatively young adult males, of
the same diangosis and pharmacological
treatment.
• DISCUSSION
• Cognitive dissonance (CD) was first described by L.
Festinger in 1975 (11) who postulated that an individual
experiences discomfort and tension when holding two
dissonant beliefs simultaneously. Cognitive dissonance
has been used to explain a variety of psychiatric
phenomena, such as: smoking (12), alcohol abuse (13),
prediction of violence (14) and suicide (15). It has also
been used to explain phobias (16), and psychogenic
pain (17). However research focusing on cognitive
dissonance has not evolved into the therapeutic arena.
• Recently our group published two articles describing the application
of CD in the treatment of paranoid schizophrenic patients (7,8). Our
results demonstrate that CD has a potentially positive outcome as a
tool for changing paranoid ideation. However in order to establish
these preliminary limited cases we felt the need for a larger,
controlled study.
• Group psychotherapy as a mode of change for paranoid
schizophrenics with active delusions is not an obvious choice.
Although some authors have argued that paranoid, acutely
psychotic individuals are poor candidates for group treatment, others
have taken the opposite stance (18). This position is based, for
example, on the assumption that homogenous groups could be
designed to work effectively with such patients.
• The positive change among the CD group in our study may be
related to several factors. Public declaration and group pressure
have been shown by Asch (20) to be effective tools in causing
attitude changes. These strategies were used by our group during
the recruitment phase. The recruitment phase is a part of the role
preparation procedure, described by Orlinsky and Howard (21) as a
significant factor in better outcome of treatment. In addition, group
pressure and adherence to the original axiom continued to exert
influence throughout the therapy sessions. Various authors
recommend encouragement of intellectual criticism on the part of the
paranoid patients (22,23). The patients presented here,
(CD - group), cooperated willingly and with great interest in
investigating their inner worlds, feeling that their therapists and
fellow group members have become their partners in an effort to
understand their view of the world.
• The literature demonstrates that it is not
therapist activity per se, that is critical in causing
improvement, but rather interventions that define
the nature of the task (24,25). Our
co - therapists, (see methods), specifically
foucused on such interventions. Defining the
task as alternatives generation. More than that,
this was the only task requested, thus
maintaning a clear focus rehearsed again and
again.
• The question of the specifity of CD in the treatment of paranoid
patients is a central one in discussing the present study. In our
opinion, (7,8), one can perceive the paranoid system as an
end - product of a series of CD states that may arise in persons that
become paranoid. It is possible that the diathesis for such a process
is a low tolerance for CD. It might be that the treatment using
induction of CD, in a step by step manner, enabled a gradual
exposure of patients who accepted the axiom, to deal with neutral,
than low to high emotion leaden paranoid occurences, until
questioning the very existence of the paranoid system. One might
also speculate that the axiom offered may act as a center for
crytalizations of a new expanding system relatively more normal,
gradually displacing the old paranoid system. Such an explanation
has of course to be proven and we are engaged nowadays in a
clinical trial trying to test this hypothesis.
• We see our results as preliminary. Further
research in needed to substantiate our
data, to focus and clarify indications and
contraindications for patient's selection
and finally to assess this technique
amongst larger numbers of patients
Table "1"
DEMOGRAPHIC AND CLINICAL DATA
patient
patient
age
(yrs)
marital
status
schooling
(yrs)
dis. duration
(hospitalization)
treatment
AB AB
30
single
8
10
(5)
fluphenazine
25mg X 1/2 wks
RV RV
41
single
7
12
(6)
halidol - Dec.
100mg / month
mother;
brother;
p. schiz
35
single
11
14
(4)
fluphenazine
12.5mg X 1/2 wks
brother;
p. schiz
38
M+2
13
20
(2)
halidol - Dec.
200mg / month
30
divorced
10
10
(3)
halidol - Dec.
100mg / month
mother;
p. schiz
KM
39
M+3
12
16
(7)
halidol - Dec.
100mg / month
adopted
GY GY
41
M+2
10
10
(2)
clopixol
200 mg / 2 wks
WI WI
28
single
12
9
(3)
halidol - Dec.
200mg / month
BY BY
42
single
16
10
(2)
fluphenazine
12.5mg X 1/2 wks
JY JY
24
single
10
7
(4)
fluphenazine
25mg / 2 wks
SK SK
25
single
12
7
(2)
modal 800mg/d
AE AE
41
divorced
8
6
(2)
modal 600 mg/d
CY
CY
MD
MD
CYo
CYo
KM
other
mother;
p. schiz
Table "2"
COGNITIVE GROUP THERAPY
PANSS
PANSS
baseline
2 wks
4 wks
completion
6 wks
15.7
10.8
9.0
7.8
7.0
7.2
4.2
4.4
4.1
4.6
10.3
9.7
7.2
7.2
7.8
sub-scale SD
3.8
3.7
3.5
3.8
4.0
General mean
23.2
20.5
18.7
16.2
14.7
6.4
5.5
4.9
3.5
3.1
PANSS
Positive
Positive mean
sub-scale
sub-scale SD
Negative
Negative mean
sub-scale
General
sub-scale
sub-scale
Sd
follow-up
(4 wks later)
Table "3
SUPPORTIVE GROUP THERAPY
PANSS
PANSS
baseline
2 wks
4 wks
completion
6 wks
15.2
15.0
13.8
13.7
13.7
SD
2.3
2.5
2.5
2.5
3.0
Negative mean
16.3
16.3
15.8
15.2
15.0
SD
2.3
2.3
1.9
1.7
1.5
General mean
35.2
35.2
34
32.7
31.8
3.0
3.0
3.0
3.6
2.8
PANSS
Positive
Positive mean
sub-scale
sub-scale
Negative
sub-scale
sub-scale
General
sub-scale
sub-scale
Sd
follow-up
(4 wks later)
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