Cognitive therapy in schizophrenia

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Gibbons, F. X. & Gerard, M.

Gibbons, F. X. & Gerard, M. (1989)(1989)Effects of upwardEffects of upward and downward social comparison on mood states.

and downward social comparison on mood states.

Journal of Social and Clinical Psychology Journal of Social and Clinical Psychology,,11,14^31., 14^31.

Haghighat, R.

Haghighat, R. (2001)(2001)A unitary theory ofA unitary theory of stigmatisation. Pursuit of self-interest and routes to stigmatisation. Pursuit of self-interest and routes to destigmatisation.

destigmatisation.British Journal of PsychiatryBritish Journal of Psychiatry,,178178,, 207^215.

207^215.

Hughes, P.

Hughes, P. (2000)(2000)Stigmatisation as a survival strategy:Stigmatisation as a survival strategy:

intrapsychic mechanisms. In

intrapsychic mechanisms. InEvery Family in the LandEvery Family in the Land(ed.(ed.

A. H.Crisp). www.stigma.org.

Nunnally, J.

Nunnally, J. (1961)(1961)Popular Conceptions of MentalPopular Conceptions of Mental Health:Their Development and Change

Health:Their Development and Change. New York: Holt,. New York: Holt, Rinehart & Winston.

Rinehart & Winston.

R. Haghighat

R. Haghighat Adult Department,TavistockAdult Department,Tavistock Clinic,120 Belsize Lane, London NW3 5BA Clinic,120 Belsize Lane, London NW3 5BA

Author's reply:

Author's reply:Dr Haghighat's responseDr Haghighat's response toto my invited editorial comments (Crisp, my invited editorial comments (Crisp, 2001) upon his paper (Haghighat, 2001) 2001) upon his paper (Haghighat, 2001) adds to his overall discourse and may adds to his overall discourse and may illuminate this matter for readers of these illuminate this matter for readers of these articles. I respect his proposition that self- articles. I respect his proposition that self- interest is a basis of the stigmatisation interest is a basis of the stigmatisation process and all that flows from it. It process and all that flows from it. It advances thinking on the matter. Self- advances thinking on the matter. Self- interest could be proposed as an explana- interest could be proposed as an explana- tory hypothesis for much of human nature.

tory hypothesis for much of human nature.

Within the arena of stigmatisation of Within the arena of stigmatisation of people with mental illness probably it can people with mental illness probably it can range across human experiential and in- range across human experiential and in- grained biological needs, from its protective grained biological needs, from its protective value for preservation of self-esteem through value for preservation of self-esteem through to selective mating subserving evolutionary to selective mating subserving evolutionary purposes. He has emphasised cultural, poli- purposes. He has emphasised cultural, political and socio-economic factors. I have tical and socio-economic factors. I have suggested that greater emphasis is needed on suggested that greater emphasis is needed on our existential concerns and fears and the our existential concerns and fears and the biological substrates to our personal survival biological substrates to our personal survival strategies in the face of such perceived threats.

strategies in the face of such perceived threats.

All require our attention if we are to maximise All require our attention if we are to maximise our capacity to change.

our capacity to change.

He appears to despair of us changing He appears to despair of us changing our biologically driven nature and behav- our biologically driven nature and behav- iours which, in this context, translate into iours which, in this context, translate into crude defensive categorisations and labelling crude defensive categorisations and labelling of those with mental illness, often leading to of those with mental illness, often leading to distancing rather than exploitation. I be- distancing rather than exploitation. I be- lieve that the best chance of achieving such lieve that the best chance of achieving such change is first to acknowledge the power of change is first to acknowledge the power of human biology. In civilised society we have human biology. In civilised society we have usually striven then to shape and curb it by usually striven then to shape and curb it by influencing attitudes and behaviour via influencing attitudes and behaviour via moral, educative and legislative channels.

moral, educative and legislative channels.

We have sometimes succeeded. Impor- We have sometimes succeeded. Impor- tantly, we also need to address individual tantly, we also need to address individual vulnerabilities and related triggers to such vulnerabilities and related triggers to such innate mechanisms. I reiterate that they innate mechanisms. I reiterate that they probably importantly include the degrees of probably importantly include the degrees of

personal psychological fragility and related personal psychological fragility and related defensiveness, along with their social ex- defensiveness, along with their social ex- tensions and projections such as Haghighat tensions and projections such as Haghighat emphasises. It may also benefit from emphasises. It may also benefit from clarification of the social handicaps and clarification of the social handicaps and sometimes the advantages that can accom- sometimes the advantages that can accom- pany some mental illness diatheses.

pany some mental illness diatheses.

The College's anti-stigma campaign is The College's anti-stigma campaign is about to go public after 3 years of develop- about to go public after 3 years of development and planning. Thoughtful input within ment and planning. Thoughtful input within contributions such as Haghighat's paper, contributions such as Haghighat's paper, along with this welcome support from the along with this welcome support from the Journal

Journal, are at its heart., are at its heart.

Crisp. A.

Crisp. A. (2001)(2001)The tendency to stigmatise.The tendency to stigmatise.BritishBritish Journal of Psychiatry

Journal of Psychiatry,,178, 197^199.178,197^199.

Haghighat, R.

Haghighat, R. (2001)(2001)A unitary theory ofA unitary theory of stigmatisation. Pursuit of self-interest and routes to stigmatisation. Pursuit of self-interest and routes to destigmatisation.

destigmatisation.British Journal of PsychiatryBritish Journal of Psychiatry,,178178,, 207^215.

207^215.

A. H. Crisp

A. H. Crisp Psychiatric Research Unit, AtkinsonPsychiatric Research Unit, Atkinson Morley's Hospital, 31Copse Hill,Wimbledon, London Morley's Hospital, 31Copse Hill,Wimbledon, London SW20 0NE

SW20 0NE

Stigma caused by psychiatrists Stigma caused by psychiatrists

Chaplin (2000) could have made an Chaplin (2000) could have made an interesting read but unfortunately seemed interesting read but unfortunately seemed to miss making any particular point. The to miss making any particular point. The effects of medication and Mental Health effects of medication and Mental Health Act assessments can and do have powerful Act assessments can and do have powerful effects on both the ill person and his or her effects on both the ill person and his or her family. Alas, Chaplin failed to expand on a family. Alas, Chaplin failed to expand on a major issue ± the attitudes some psychia- major issue ± the attitudes some psychiatrists hold have far more devastating effects trists hold have far more devastating effects on their patients than either medication or on their patients than either medication or the Mental Health Act.

the Mental Health Act.

I have written elsewhere (Corker, 2001) I have written elsewhere (Corker, 2001) about the deeply harming effects that about the deeply harming effects that stigmatisation and discrimination by psy- stigmatisation and discrimination by psychiatrists can have on people who may have chiatrists can have on people who may have suffered mental illness and may or may not suffered mental illness and may or may not have been their patients. While many have been their patients. While many articles have been written about the stigma articles have been written about the stigma of mental illness, too little has been said of mental illness, too little has been said about the effect that the attitude of mental about the effect that the attitude of mental health professionals may have on patients.

health professionals may have on patients.

For the patient the mental health For the patient the mental health professional must maintain a position of professional must maintain a position of trust and also remember that they provide trust and also remember that they provide the building blocks for modelling at a point the building blocks for modelling at a point of extreme vulnerability in the life of the of extreme vulnerability in the life of the patient. As a mental health professional for patient. As a mental health professional for 20 years, both in the National Health 20 years, both in the National Health Service and private practice, I have also Service and private practice, I have also experienced the discrimination and stigma experienced the discrimination and stigma of being a patient during and following two of being a patient during and following two

major depressive illnesses. The experience major depressive illnesses. The experience of being ill has certainly changed my life of being ill has certainly changed my life and resulted in major losses; worse is the and resulted in major losses; worse is the way in which the illnesses have been used way in which the illnesses have been used by fellow professionals, both medical and by fellow professionals, both medical and non-medical, to stigmatise and discrimi- non-medical, to stigmatise and discrimi- nate. I do admit to making mistakes as a nate. I do admit to making mistakes as a result of illness but would have expected result of illness but would have expected that this would be seen as the result of that this would be seen as the result of illness, where poor decision-making is illness, where poor decision-making is acknowledged as one of the key signs.

acknowledged as one of the key signs.

I agree with Chaplin that psychiatrists I agree with Chaplin that psychiatrists

``must be prepared to identify and challenge

``must be prepared to identify and challenge our own prejudices and attempt to modify our own prejudices and attempt to modify our clinical practice''. First and foremost, our clinical practice''. First and foremost, this requires a sense of humility to examine this requires a sense of humility to examine a personal approach. Second, attitudes and a personal approach. Second, attitudes and practices that need to be changed must be practices that need to be changed must be identified. Third, the responsibility needed identified. Third, the responsibility needed to make the change must be accepted.

to make the change must be accepted.

Chaplin, R.

Chaplin, R. (2000)(2000)Psychiatrists can cause stigma tooPsychiatrists can cause stigma too (letter).

(letter).British Journal of PsychiatryBritish Journal of Psychiatry,,177, 467.177, 467.

Corker, E. (2001)

Corker, E. (2001)Stigma and discrimination ^ theStigma and discrimination ^ the silent disease.

silent disease.International Journal of Clinical PracticeInternational Journal of Clinical Practice,,5555,, in press.

in press.

E. Corker

E. Corker Address supplied.Correspondence c/oAddress supplied.Correspondence c/o The British Journal of Psychiatry

The British Journal of Psychiatry,17 Belgrave Square,,17 Belgrave Square, London SW1X 8PG

London SW1X 8PG

Cognitive therapy in schizophrenia Cognitive therapy in schizophrenia

In the course of a favourable review In the course of a favourable review of cognitive therapy in schizophrenia, of cognitive therapy in schizophrenia, Thornicroft & Susser (2001) cite the recent Thornicroft & Susser (2001) cite the recent trial by Sensky

trial by Sensky et alet al (2000), but fail to(2000), but fail to mention that it had negative results. This mention that it had negative results. This 90-patient, 9-month randomised controlled 90-patient, 9-month randomised controlled trial, carried out under blind conditions, trial, carried out under blind conditions, compared this form of treatment with a compared this form of treatment with a control intervention (befriending) and control intervention (befriending) and found no significant difference between found no significant difference between the two. It is true that differences emerged the two. It is true that differences emerged 9 months after completion of treatment, 9 months after completion of treatment, but this latter part of the study was but this latter part of the study was uncontrolled.

uncontrolled.

Of the other trials of cognitive therapy Of the other trials of cognitive therapy cited in their article, that of Drury cited in their article, that of Drury et alet al (1996) did not use blind evaluations, and (1996) did not use blind evaluations, and that of Kuipers

that of Kuipers et alet al (1997) employed(1997) employed neither blind evaluations nor a condition neither blind evaluations nor a condition to control for the non-specific effects of to control for the non-specific effects of intervention (the Hawthorne effect). Only intervention (the Hawthorne effect). Only one other published study (Tarrier one other published study (Tarrier et alet al,, 1998) incorporated both these design 1998) incorporated both these design features; this found a non-significant features; this found a non-significant advantage of cognitive therapy over sup- advantage of cognitive therapy over sup- portive counselling (Curtis, 1999).

portive counselling (Curtis, 1999).

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Rather than being ready for an assess- Rather than being ready for an assess- ment of its effectiveness and cost-effective- ment of its effectiveness and cost-effectiveness in non-experimental settings, as ness in non-experimental settings, as Thornicroft & Susser argue, cognitive Thornicroft & Susser argue, cognitive therapy may be in the process of meeting therapy may be in the process of meeting the fate of an earlier treatment for schizo- the fate of an earlier treatment for schizophrenia where advocacy preceded rigorous phrenia where advocacy preceded rigorous evaluation ± insulin coma.

evaluation ± insulin coma.

Curtis, D.

Curtis, D. (1999)(1999)Intensive cognitive behaviour therapyIntensive cognitive behaviour therapy for chronic schizophrenia. Specific effect of cognitive for chronic schizophrenia. Specific effect of cognitive behaviour therapy for schizophrenia is not proved behaviour therapy for schizophrenia is not proved (letter).

(letter).British Medical JournalBritish Medical Journal,,318318, 331., 331.

Drury,V., Birchwood, M., Cochrane, R.,

Drury,V., Birchwood, M., Cochrane, R.,et alet al(1996)(1996) Cognitive therapy and recovery from acute psychosis: a Cognitive therapy and recovery from acute psychosis: a controlled trial. I. Impact on psychotic symptoms.

controlled trial. I. Impact on psychotic symptoms.BritishBritish Journal of Psychiatry

Journal of Psychiatry,,169, 593^601.169, 593^601.

Kuipers, E., Garety, P., Fowler, D.,

Kuipers, E., Garety, P., Fowler, D.,et alet al(1997)(1997) London^East Anglia randomised controlled trial of London^East Anglia randomised controlled trial of cognitive^behavioural therapy for psychosis. I. Effects of cognitive^behavioural therapy for psychosis. I. Effects of the treatment phase.

the treatment phase.British Journal of PsychiatryBritish Journal of Psychiatry,,171171,, 319^327.

319^327.

Sensky,T.,Turkington, D., Kingdon, D.,

Sensky,T.,Turkington, D., Kingdon, D.,et alet al(2000)(2000)AA randomised controlled trial of cognitive^behavioural randomised controlled trial of cognitive^behavioural therapy for persistent symptoms in schizophrenia therapy for persistent symptoms in schizophrenia resistantto medication.

resistant to medication.Archives of General Psychiatry,,Archives of General Psychiatry5757,, 165^172.

165^172.

Tarrier, N.,Yusupoff, L., Kinney, C.,

Tarrier, N.,Yusupoff, L., Kinney, C.,et alet al(1998)(1998) Randomised controlled trial of intensive cognitive Randomised controlled trial of intensive cognitive behaviour therapy for patients with some behaviour therapy for patients with some schizophrenia.

schizophrenia.British Medical Journal,,British Medical Journal317317, 303^307., 303^307.

Thornicroft, G. & Susser, E.

Thornicroft, G. & Susser, E. (2001)(2001)Evidence-basedEvidence-based psychotherapeutic interventions in the community care psychotherapeutic interventions in the community care of schizophrenia.

of schizophrenia.British Journal of PsychiatryBritish Journal of Psychiatry,,178178, 2^4., 2^4.

P. J. McKenna

P. J. McKenna Fulbourn Hospital, CambridgeFulbourn Hospital, Cambridge CB1 5EF

CB1 5EF

No long-term benefit for cognitive No long-term benefit for cognitive therapy in acute psychosis: a type II therapy in acute psychosis: a type II error

error

Drury

Druryet alet al(2000) reported no significant(2000) reported no significant difference in relapse rates, positive symp- difference in relapse rates, positive symptoms or insight between a cognitive therapy toms or insight between a cognitive therapy group and a recreational activities and group and a recreational activities and support group of patients who had an support group of patients who had an acute episode of a non-affective psychosis.

acute episode of a non-affective psychosis.

This 5-year outcome study assessed 34 out This 5-year outcome study assessed 34 out of an original cohort of 40 patients.

of an original cohort of 40 patients.

Working on the basis of small trials Working on the basis of small trials having a large type II error, the group size having a large type II error, the group size for each group can be estimated. If the for each group can be estimated. If the anticipated mean response in one group is anticipated mean response in one group is mm11and the standard deviation isand the standard deviation isss, to show, to show a significant result the mean relapse of one a significant result the mean relapse of one group can be estimated at 2 (

group can be estimated at 2 (mm11) and the) and the standard deviation can be estimated at 1.5 standard deviation can be estimated at 1.5 ((ss). The estimated difference between the). The estimated difference between the groups (

groups (dd) can be set at 0.5 () can be set at 0.5 (mm227m7m11). A). A formula to calculate the number (

formula to calculate the number (nn) in each) in each

group (Pocock, 1983: 127±128) can be group (Pocock, 1983: 127±128) can be used as follows:

used as follows:

n 2s²

(m₁ m₂)²f(a,b) The

Thea(type I error) is by convention set(type I error) is by convention set at 0.05, and the

at 0.05, and theb(type II error) can be set(type II error) can be set at 0.2. The power of finding a true result at 0.2. The power of finding a true result ((1 b) will therefore be 0.8 or 80% and,) will therefore be 0.8 or 80% and, by using a statistical table,

by using a statistical table, f(a,,b) is 7.9.) is 7.9.

Therefore,

Therefore,nncan be calculated ascan be calculated as 21:5²

0:5² 7:9142 patients in each group.

patients in each group.

It would therefore take a very large It would therefore take a very large sample to prove the null hypothesis in the sample to prove the null hypothesis in the above hypothetical estimate. In the study above hypothetical estimate. In the study by Drury

by Drury et alet al (2000), it would be mis-(2000), it would be mis- leading to extrapolate that there was no leading to extrapolate that there was no long-term benefit of using cognitive therapy long-term benefit of using cognitive therapy in schizophrenia in terms of relapse. Larger in schizophrenia in terms of relapse. Larger studies are needed in this rapidly evolving studies are needed in this rapidly evolving area.

area.

Drury,V., Birchwood, M. & Cochrane, R.

Drury,V., Birchwood, M. & Cochrane, R. (2000)(2000) Cognitive therapy and recovery from acute psychosis: a Cognitive therapy and recovery from acute psychosis: a controlled trial. 3. Five-year follow-up.

controlled trial. 3. Five-year follow-up.British Journal ofBritish Journal of Psychiatry

Psychiatry,,177177, 8^14., 8^14.

Pocock, S.

Pocock, S. (1983)(1983)Clinical Trials: A Practical ApproachClinical Trials: A Practical Approach..

Chichester: John Wiley & Sons.

K. Marlowe

K. Marlowe Lambeth Mental Health Services,Lambeth Mental Health Services, South London and Maudsley NHS Trust,108 Landor South London and Maudsley NHS Trust,108 Landor Road, London SW9 9NT

Road, London SW9 9NT

Seasonal variation in suicides:

hidden not vanished hidden not vanished

Yip

Yip et alet al (2000) demonstrated that, in(2000) demonstrated that, in England, the seasonal variation in suicide England, the seasonal variation in suicide rates in the 1980s and 1990s decreased rates in the 1980s and 1990s decreased considerably when compared with that in considerably when compared with that in the 1960s and 1970s. From monthly suicide the 1960s and 1970s. From monthly suicide frequencies, they concluded that current frequencies, they concluded that current data hardly show any seasonal effects on data hardly show any seasonal effects on suicide rates, and they predicted that suicide rates, and they predicted that seasonal variation in suicide rates would seasonal variation in suicide rates would disappear completely in the years to come.

disappear completely in the years to come.

Although we fully agree with Yip Although we fully agree with Yipet alet al (and several other authors) that there is a (and several other authors) that there is a global decline in the amplitude of seasonal global decline in the amplitude of seasonal variation in suicide rate, we do not agree variation in suicide rate, we do not agree with the conclusion that seasonal influences with the conclusion that seasonal influences are beginning to fade away. We came to are beginning to fade away. We came to this conclusion by a recent study of train this conclusion by a recent study of train

suicides (i.e. suicide by jumping before a suicides (i.e. suicide by jumping before a moving train) in The Netherlands (van moving train) in The Netherlands (van Houwelingen & Beersma, 2001). In this Houwelingen & Beersma, 2001). In this study (

study (nn=30) we confirmed the absence of a=30) we confirmed the absence of a seasonal pattern in suicide rates as observed seasonal pattern in suicide rates as observed in 28-day intervals. We did, however, in 28-day intervals. We did, however, observe a strong seasonal influence on 24- observe a strong seasonal influence on 24- hour patterns. Whereas the winter season hour patterns. Whereas the winter season showed two daily peaks in suicide rates, at showed two daily peaks in suicide rates, at around 9±11 am and 7±10 pm, the summer around 9±11 am and 7±10 pm, the summer season revealed one major peak around 12±

season revealed one major peak around 12±

4 pm and a smaller peak shortly before 4 pm and a smaller peak shortly before midnight. The timing of the major summer midnight. The timing of the major summer peak is in the trough between the two peak is in the trough between the two winter peaks.

winter peaks.

This more subtle influence of time of This more subtle influence of time of year on suicide rates adds a different year on suicide rates adds a different dimension to what has been considered dimension to what has been considered seasonality in suicidal behaviour and may seasonality in suicidal behaviour and may generate new ideas concerning relevant generate new ideas concerning relevant factors involved. In train suicide data, factors involved. In train suicide data, seasonal influences are clearly present. This seasonal influences are clearly present. This may also be true of other methods of may also be true of other methods of suicide. In order to see this, time of day suicide. In order to see this, time of day and time of year have to be taken into and time of year have to be taken into account simultaneously.

account simultaneously.

van Houwelingen, C. A. J. & Beersma, D. G. M.

(2001)

(2001)Seasonal changes in 24-h patterns of suicideSeasonal changes in 24-h patterns of suicide rates: a study on train suicides inThe Netherlands.

rates: a study on train suicides inThe Netherlands.

Journal of Affective Disorders Journal of Affective Disorders, in press., in press.

Yip, P. S. F., Chao, A. & Chiu, C.W. F.

Yip, P. S. F., Chao, A. & Chiu, C.W. F. (2000)(2000)SeasonalSeasonal variation in suicides: diminished or vanished. Experience variation in suicides: diminished or vanished. Experience from England and Wales,1982^1996.

from England and Wales, 1982^1996.British Journal ofBritish Journal of Psychiatry

Psychiatry,,177177, 366^369., 366^369.

C. A. J. van Houwelingen

C. A. J. van Houwelingen GGz Eindhoven, POGGz Eindhoven, PO Box 909, 5600 AX Eindhoven,The Netherlands Box 909, 5600 AX Eindhoven,The Netherlands D. G. M. Beersma

D. G. M. Beersma Department of PsychiatryDepartment of Psychiatry and Zoological Laboratory,University of Groningen, and Zoological Laboratory,University of Groningen, PO Box 14, 9700 AA Haren,The Netherlands PO Box 14, 9700 AA Haren,The Netherlands

Soviet-style psychiatry is alive Soviet-style psychiatry is alive and well in the People's Republic and well in the People's Republic

The involuntary committal to psychiatric The involuntary committal to psychiatric institutions of political dissenters has long institutions of political dissenters has long been associated with the abuses of psy- been associated with the abuses of psychiatric practice perpetrated in the former chiatric practice perpetrated in the former Soviet Union. The detention of dissenters Soviet Union. The detention of dissenters may be based upon psychiatric judgement may be based upon psychiatric judgement but political factors are relevant when such but political factors are relevant when such abuse becomes widespread. International abuse becomes widespread. International concern has been growing following the concern has been growing following the decision of the Chinese Government to decision of the Chinese Government to outlaw the practice of

outlaw the practice of Falun GongFalun Gong andand forcibly to assign psychiatric treatment to forcibly to assign psychiatric treatment to practitioners of this meditative discipline.

practitioners of this meditative discipline.

Falun Gong

Falun Gong, also known as, also known as Falun DafaFalun Dafa,,

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