Psychosocial treatment in schizophrenia

Optimism about the use of psychosocial treatment for schizophrenia has waxed and waned over the years, but there is now a growing consensus that psychosocial interventions play an essential role in the rehabilitation and management of people with schizophrenia. ^1-3

Psychosocial treatment may not “work” if the term work is narrowly applied to remission of acute episodes, control of symptoms, and prevention of relapses. However, these are not the only criteria by which an intervention for this complex disease should be judged. Schizophrenia is characteristically a multiply handicapping, chronic disorder involving marked impairments in social role functioning (eg, as a spouse or a worker), excess rates of medical illness, and poor quality of life. Medication is generally a necessary component of treatment, but is rarely sufficient given the diffuse nature of residual neurocognitive impairment and the history of social and functional failures that mark adolescent and adult development. Psychosocial interventions can play a critical role in a comprehensive intervention program, and are probably necessary components if treatment is viewed in the context of the patient's overall level of functioning, quality of life, and compliance with prescribed treatments.

Current thinking suggests that, in addition to medication, effective care, and management, patients with schizophrenia require:

• Problem-specific psychosocial treatment

• Family psychoeducation

• Day hospital/vocational rehabilitation and educational opportunities

• Access to crisis counseling

• Easily available inpatient psychiatric care

• Supervised residential liging arrangements

• Case management to obtain entitiements and coordinate the various facets of treatment

Issues to be considered in the design and implementation of psychological treatment programs for schizophrenia

• Progress in treatment should be expected to be slow and marked by periodic disruptions and periods of regression. Consequently, it is important that treatment be long term, extending over months and years. Treatment should also be guided by concrete, short-term goals that are likely to be achieved (eg, to attend day hospital at least twice a week for 1 month).

• While there are a number of illness characteristics that are common to most patients, there are extensive individual differences, as well as differences within the same patient over time. Thus, treatment must be tailored to the needs of each patient and adjusted as the patient changes.

• Regardelss of the severity of illness, the patient must be included as a parther in treatment planning and goal setting in order to secure effective cooperation. Treatment should be conducted in collaboration with the patient, not done to the patient. Effective treatment targets specific skills or problem areas that the patient can agree to work on (eg, social skills, drug use, or vocational skills). Nonspecific group or individual psychotherapy is not effective.

• The illness is marked by significant deficits in memory, attention, and exectuve functioning that have major effects on the treatment process. Treatment must be adapted to these impaiments if patients are to be able to learn and retain what is discussed in sessions. Treatment should inadvertently become a memory or attention test.

Four psychosocial treatment approaches have received substantial empirical support and warrant further study:

• Social skills training. This treatment approach, which can be provided to patients either individually or in groups, involves systematically teaching patients specific behaviors that are critical for success in social interactions.^4,5 Developed over 25 years ago, it is probably the most widely studied psychological treatment method for individuals with schizophrenia, and there is an extensive literature documenting its efficacy.⁶

• Family psychoeducation. The most important development in psychosocial treatment over the last two decades has been the emphasis on the positive effects of family participation in the treatment process. Several different models of family intervention have been developed and tested.^7,8 The different approaches to working with families share a number of common elements referred to as psychoeducation: a collaborative, respectful relationship with the family, the provision of information about schizophrenia and its treatment, and teaching family members less stressful and more constructive strategies for communication and solving problems. A number of carefully controlled studies have shown that patients in families who receive this type of family therapy have better outcomes than patients with families who do not receive therapy, and that familymembers report less distress as well.

• Cognitive therapy. Antipsychotic medications are primarily effective for reducing positive symptoms, but even the new-generation medications are not highly effective for all patients. Recently, there has been increased interest in teaching patients coping strategies for controlling residual symptoms. A number of laboratories in the United Kingdom have reported very promising findings for interventions that employ cognitive behavior therapy techniques (eg, self-talk, rational analysis) to reduce distress associated with both hallucinations and delusions.^9,10 Further research is warranted to explore the stability and generalizability of these approaches.

• Cognitive rehabilitation. As indicated above, schizophrenia is marked by neurocognitive impairments that have a significant impact on community functioning and are only partially ameliorated bymedication. Consequently, considerable effort has been devoted to development of cognitive rehabilitation programs to increase memory capacity, attention, and high level problem-solving skills.^11,12 Most of these techniques employ repetitive practice on neurocognitive tasks using computers. The evidence to date documents that test performance can be improved, but it is yet to be determined if there is a real increase in cognitive capacity or, most importantly, if the effects generalize to the community.¹³

In conclusion, there is now a new generation of psychosocial treatment techniques that have yieldied very promising results. It is likely that, as more breakthroughs occur in the biological treatment of schizophrenia (eg, the effects of clozapine on improving the functioning of treatment refractory patients), psychological treatments will assume an even more important rolein both facilitating the adjustment of patients, as they move from institutional settings to the community, and improving their quality of life.