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Section 15
Implementing Psychosocial Therapy with Schizophrenic Clients

Question 15 | Test | Table of Contents

Support from a psychotherapist can be a source of stability in the life of a patient with schizophrenia. The focus is practical. The therapist becomes familiar with the patient's attitude toward the illness and offers sympathy, reassurance, and morale-sustaining encouragement, along with information and advice. By explaining the nature and causes of the disease and the need for drug treatment, therapists can help patients to acknowledge the reality of their disorder and adjust to the limitations it imposes. The therapist generally accepts the patient's need for a relationship that is not too close or emotionally demanding. For many patients, group therapy provides an opportunity to make social connections and learn from others in the same plight.

In addition to supportive psychotherapy, cognitive behavioral therapy can be useful for patients with hallucinations and delusions that persist even when they take medications. The methods are the same as those used in cognitive therapy for depression and anxiety -- testing and correction of erroneous thoughts and perceptions. The therapist questions patients about the nature and basis of delusions, suggests other explanations, and asks them to evaluate the evidence. For example, if patients hear threatening or abusive voices, the therapist finds out when and where the voices emerge, how often and for how long, what makes them come and go, who is speaking, and what feelings they provoke. Then the patients can be shown how to turn the voices off, perhaps by listening to music with a headset, engaging in conversation, or simply repeating what the voices say.

Meanwhile, the therapist begins to discuss the source of the voices and asks why others cannot hear them. Through these exercises, patients may learn that their own minds are generating the threats and abuse and eventually come to understand that the voices reflect ordinary concerns -- especially fears of being attacked, manipulated, or humiliated. One common effect is to heighten their sense of self-efficacy, the belief that they have the power to achieve their goals and solve their problems. Even if psychotic experiences are not completely eliminated, this sense of control may greatly reduce the influence of hallucinations and delusions, relieving anger, anxiety, and depression. Cognitive therapy can also be used to combat the fear of social stigma, which may lead patients to conceal their illness and avoid all situations in which they might be rejected. That fear is one source of their withdrawal and apathy.

Cognitive treatment has been found effective in controlled studies. For example, an experiment reported last year compared cognitive behavioral therapy (twice weekly for ten weeks, plus four monthly booster sessions) with supportive counseling and routine care (mainly medications). The cognitive therapy included problem-solving, coping with hallucinations, and relapse prevention. One year later, it proved more effective in reducing symptoms than the other approaches (but after two years, counseling and cognitive behavioral therapy were equally effective). In another study, researchers found that 20 sessions of a cognitive behavioral program called coping strategy training were superior to routine care in reducing delusions and hallucinations. Meta-analyses (combined statistical analyses of many studies) indicate that cognitive behavioral therapy often lowers the intensity of delusions and may reduce the rate of relapse, but it does not consistently improve social functioning. It works best for patients with some insight into their condition and only mild cognitive deficiencies. Studies cannot always exclude the possibility that patients given this treatment show more improvement simply because they get more attention from therapists. Cognitive behavioral therapy requires special skills and training not possessed by all therapists, and it is likely to remain unavailable to many patients.

Social skills training: Disturbing thoughts, perceptions, and feelings are not the only problems for patients with schizophrenia. They usually lack the skills needed to manage their daily lives and negotiate human relationships. They may never have acquired the ability to follow social rules and act appropriately in social situations, or they may have lost those capacities because of disuse, apathy, and disorganized thinking.  Social skills training is a response to the need for learning or relearning. In its most common form, actions are broken down into smaller components that are taught separately, and the patient is praised for stepwise improvements. The behavioral shaping is often conducted through brief didactic dramas. As patients rehearse their roles, therapists and other patients provide models for observation while coaching, prompting, and correcting them. These exercises may allow people with schizophrenia to acquire various skills -- using the telephone, making appointments, cashing checks, paying rent, preparing for job interviews, grooming themselves, adjusting their facial expressions, refusing offers of alcohol and street drugs, and avoiding unsafe sex. In a more general form, problem-solving skills training, patients learn strategies for a variety of situations - how to listen, ask questions, request help, defend their rights, express their feelings, and even cope with surprises.  Research confirms the effectiveness of social skills training. For example, in one experiment it was compared to equally intensive occupational therapy, three hours a day four times a week for six months. Food preparation, money management, and handling of personal possessions improved in the patients given this training, and the effects lasted up to 18 months. Another study found a moderately reduced rate of relapse in the first year, but no difference in the second year, when training became less intensive.  A 20-year review and meta-analysis found that social skills training improved specific skills but did not reduce relapse rates and hospital time or improve overall social adjustment. Patients found it difficult to transfer the skills to novel or everyday settings. The UCLA Social and Independent Living Skills Program, a more elaborate form of training that teaches a broad range of skills including symptom management, conversation, and medication management, seems to be more effective in controlled studies and may have more relevance to social competence in everyday life.

Cognitive rehabilitation: Cognitive rehabilitation or adaptation resembles social skills training in its aims but not in its methods. It is less concerned with correcting or shaping specific habits or actions one by one with simple behavioral recipes. Instead, by various methods, patients are helped to assemble their thoughts and extract meanings from speech or reading. First they perform simple tasks, often with other patients, while therapists provide cues. Eventually they take on increasingly challenging group exercises that require them to pay attention, follow a conversation or line of thought, and solve personal problems. The aim is to improve memory and planning, reduce shame, and rectify the patient's poor social judgment and limited capacity for communication. These exercises in thinking can be supplemented by instructions on how to identify the signs of impending relapse and the kinds of stress that lead to psychotic symptoms.

However, cognitive rehabilitation has not been proved effective in controlled experiments. Three studies found no distinct effects on mental state, behavior, or cognitive functioning when it was compared with occupational therapy or routine care. In a 1999 study, therapists provided patients with a treatment called integrated psychological therapy, which includes cognitive rehabilitation. After six months, when compared with supportive group therapy, it produced improvements in problem solving, attention, and executive functions. But these might have been the effects of social skills and problem-solving training, which were also a part of the program.

Family education and management: About a third of patients with schizophrenia live with their families. Caring for a child or adult with this illness can be physically, emotionally, and financially exhausting -- a cruel test of loyalty, love, and patience. Relatives need information, advice, and other support -- help not only in providing for the patient's needs but also in coping with their own anxiety and disappointment. They may want to know how to supervise medication, respond to psychotic behavior, maintain peace in the home, and lower the risk of relapse. They have to be reassured that the patient will be able to get treatment when living with the family becomes impossible. One of their most difficult decisions is giving up full responsibility for an adolescent or young adult with schizophrenia. It is important to remember that few adult patients want to remain in the care of their parents permanently, and few parents want to remain permanently responsible for most aspects of the life of a son or daughter.

Supportive family counseling, family psychoeducation, and behavioral family management are designed to supply some of these needs. Lectures and videotapes explain the illness; behavioral management provides practical help for the patient and the family. Family members learn the signs of relapse and how to distinguish symptoms of the illness from other actions of the patient. They may be given suggestions on how to arrange a daily schedule for the patient and how to respond to irrational fears or threats of violence. Multiple-family groups are sometimes especially useful, because family members often speak more freely to one another than to therapists. They become more confident as they give and receive advice, and they accommodate suggestions for change more easily as they recognize in themselves what they have seen in others. Participation in the group reduces isolation and guilt, and its members may become friends who offer help in crises.

Many families of patients with schizophrenia now attend self-help meetings sponsored by mutual aid groups. These groups evolved in the 1960s and joined in 1979 to establish the National Alliance for the Mentally Ill (NAMI). Today it has a membership of more than 30,000 families and sponsors more than 1,000 local support groups. It also provides a family-to-family education program with the aid of state governments -- a three-month course combining information and support, with equal emphasis on the needs of the family and the patient.

The term "expressed emotion" is often used in the therapeutic literature as a guide for work with the families of patients with schizophrenia. It refers to signs of hostility, criticism (especially unflattering character descriptions), and intrusiveness or overinvolvement on the part of relatives. These reactions are said to raise the chance of relapse, and in some forms of family education and behavior management, reducing expressed emotion is one of the most important stated goals. But the emphasis on expressed emotion has also been criticized as a subtle way of blaming parents for symptoms that understandably evoke a mixture of exasperation and protectiveness. The emotional atmosphere in the family of a patient with schizophrenia may depend more on the patient's behavior and the course of the illness than on choices made by other members of the family. In any case, it is sometimes helpful for family members to learn how to avoid confrontations and lower the emotional intensity of their relationship with the patient.

There is evidence that both family and patient education lower relapse rates and improve the family atmosphere. Three studies found improved social functioning in patients two years after psychoeducation. In another study comparing it with standard care, psychoeducation reduced the rates of relapse and readmission to hospitals by 12% over a period of 9-18 months. It had no impact on the patient's insight or overall satisfaction with the treatment. In two studies, multiple family groups proved more effective than single-family groups in reducing negative schizophrenic symptoms, but not in improving social adjustment or reliability in taking medications. A meta-analysis of 18 controlled experiments found that, compared with standard care, family education and training lowered relapse rates and improved social functioning. The benefits of long-term (nine-month) family therapy lasted as long as two years. But results have been less impressive in the most recent studies.
- The Psychosocial Treatment of Schizophrenia--Part I;  Harvard Mental Health Letter, Aug2001, Vol. 18 Issue 2

Cognitive Behavior Therapy for People with Schizophrenia

- Morrison, A. K. (2009). Cognitive Behavior Therapy for People with Schizophrenia. Psychiatry (Edgemont), 6(12). p. 32-39.

Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 225 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section contained information about implementing psychosocial therapy with schizophrenic clients. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
European Psychiatric Association guidance on treatment of cognitive impairment in schizophrenia

Vita, A., Gaebel, W., Mucci, A., Sachs, G., Barlati, S., Giordano, G. M., Nibbio, G., Nordentoft, M., Wykes, T., & Galderisi, S. (2022). European Psychiatric Association guidance on treatment of cognitive impairment in schizophrenia. European psychiatry : the journal of the Association of European Psychiatrists, 65(1), e57. https://doi.org/10.1192/j.eurpsy.2022.2315


Peer-Reviewed Journal Article References:
Barrios, M., Guilera, G., Hidalgo, M. D., Cheung, E. C. F., Chan, R. C. K., & Gómez-Benito, J. (2020). The most commonly used instruments in research on functioning in schizophrenia: What are they measuring? European Psychologist, 25(4), 283–292.

Bechi, M., Bosia, M., Agostoni, G., Spangaro, M., Buonocore, M., Bianchi, L., Cocchi, F., Guglielmino, C., Mastromatteo, A. R., & Cavallaro, R. (2018). Can patients with schizophrenia have good mentalizing skills? Disentangling heterogeneity of theory of mind. Neuropsychology, 32(6), 746–753.

Diamond, D. (2018). Changes in object relations in psychotherapy with schizophrenic patients: Commentary on Carsky and Rand (2018). Psychoanalytic Psychology, 35(4), 410–413.

QUESTION 15
What are three important aspects of therapy with a schizophrenic client? To select and enter your answer go to Test.

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