|Sponsored by the HealthcareTrainingInstitute.org providing Quality Education since 1979|
When antipsychotic drugs were introduced nearly 50 years ago, they seemed to promise schizophrenic patients not only relief from their delusions and hallucinations, but also a more complete functional recovery. That promise was so seductive that some regarded psychosocial treatment - supportive, behavioral, and cognitive therapies - mainly as a way to get patients to keep taking drugs. If they relapsed, it was because they had stopped. Yet studies showed that patients who were given pills they might throw away did not relapse faster than patients who had no pills to throw away because they were taking injectable (depot) medications. So it was not only drug treatment that mattered.
In the earliest studies, psychosocial treatment took the form of training in problem-solving and supportive therapy with no direct relationship to the symptoms of schizophrenia. The results were provocative - often positive when the treatment was combined with drugs but negative when combined with a placebo. It is now clear that psychosocial treatments with a better theoretical grounding, when combined with medication, can improve the adjustment of schizophrenic patients and prevent relapse far better than drugs alone. Methods that address cognitive vulnerabilities are especially effective.
One form of psychosocial treatment is family psychoeducation, which helps the family provide a home environment that accommodates the patient's limitations. There are also behavioral approaches, such as the token economy, which have evolved into what is now called social skills training. At first it was used for specific deficiencies in communication -- for example, in tone of voice, eye contact, and gestures. The techniques of instruction, modeling, role play, feedback, and rehearsal have now been incorporated into formal training systems aimed at improving the skills needed to conduct a social life and live independently in the community. There is evidence that social skills training is more effective than supportive group therapy in one recent study and more effective than occupational therapy in another. But these methods have limitations. They affect certain specific kinds of behavior and may help to prevent relapse, but it is not clear that they apply to broader areas of personal and social adjustment.
Researchers in Europe have developed a form of cognitive therapy with a special emphasis on delusions and hallucinations. With the help of problem-solving and coping skills training, schizophrenic patients are encouraged to evaluate the evidence for their beliefs and experiences and consider other explanations. In controlled experiments, this treatment has been found to reduce delusions and hallucinations, especially in patients with some cognitive flexibility and insight. But the patients were hospitalized, their numbers were small, and it was not clear that the results could be transferred to community life.
My colleagues and I have tested a technique we call personal therapy. We regard the poor control of mood as a major cause of relapse and poor social adjustment, and we try to reduce patients' anguish by using behavioral, educational, and supportive techniques to help them detect the onset of psychotic symptoms. When compared with family or supportive psychotherapy, these methods have been shown to reduce relapse rates among patients living with their families. The effects on social adjustment are especially encouraging. In our studies, patients who receive personal therapy continue to improve in the second and third years of treatment, whereas control groups who receive only medication and supportive therapy peak after one year. Still, these patients have not fully recovered. Only 26% are doing better than their own best levels of adjustment, and the main problem is their poor social judgment.
We now know enough to treat cognitive impairment in schizophrenic patients more specifically. Deficits in attention and verbal memory are important reasons for their limited social competence. Cognitive remediation and skills training for hospitalized patients can be effective where social skills training alone is not enough. The brain abnormalities of schizophrenic patients leave them dependent on modes of cognitive processing that are, in a sense, characteristic of younger people. Even before psychotic symptoms appear, they may have failed to learn the informal rules that govern adult social roles. Their deficit in social understanding often causes others to avoid them, which makes their situation even worse when psychotic symptoms develop. Rehabilitation specialists have noted that although schizophrenic patients can acquire vocational skills, they often "fail coffee break."
The human brain can be molded throughout life, and procedural learning has strong effects on long-term memory and behavior, so it should be possible to enhance social cognition in these patients. Our aim is to enhance their ability to "act wisely" - a matter of practical or social intelligence that is largely independent of formal IQ. We concentrate on their failure to take the perspective of others, their difficulties in appraising social situations, and their limited skills in communication and negotiation. We are now conducting a controlled study of cognitive enhancement therapy with 120 outpatients who have largely recovered from their psychotic symptoms. For two years we provide 112-hour treatment sessions twice a week using interactive software and group exercises, many of which are adapted from the treatment of traumatic brain injuries. We try to enrich impoverished thinking by helping patients develop elaborate cognitive schemas and working memory plans and experience pleasure during social activity. We use various techniques to help disorganized patients assemble their thoughts, extract the gist of readings and conversations, and control their feelings while they perform tasks. We alter rigid cognitive styles by encouraging divergent thinking and a tolerance of ambiguity.
First, we attempt to facilitate purely neuropsychological cognition, using interactive software to develop an understanding of the rules that govern a task. For example, patients perform simple tasks while we provide auditory, visual, and motivational cues. These exercises often require collaboration with another patient and Socratic questioning by a coach. Eventually the cues are systematically eliminated and the task is made so difficult that the patient cannot succeed without understanding the basic principles. Increasingly challenging group exercises are introduced, each one requiring the patient to maintain attention, keep the details of a discourse plan in mind, and solve interpersonal problems using abstract concepts rather than recipes for behavior. Six to eight patients collaborate as a group on tasks, typically in pairs, while others provide feedback. Our aim is to make the patients comfortable with abstraction, active information processing, flexible norms, and judgment in personal situations.
The curriculum includes 11 activities, each in multiple versions, ranging from exercises designed to communicate the themes of newspaper editorials to the development of motivational accounts and "condensed messages," which require a patient to clarify personal crises in 8 to 10 words. Patients solve real social dilemmas, and their choices are systematically reviewed and negotiated. They practice challenging routines, such as ways of making introductions. We regard these as exercises in secondary socialization - a way of learning the vocabularies and informal rules associated with adult social roles. The training fosters adult thinking and reduces the patients' reliance on cognitive processes that may have been appropriate at an earlier time of life. We also offer patients specific information about their own illnesses (rather than simply general information about schizophrenia) in up to 50 brief sessions, along with homework. This individual psychoeducation helps them develop plans for their own rehabilitation.
Our preliminary findings are encouraging. In a one-year comparison of cognitive enhancement therapy with an enriched version of supportive therapy, we have found significantly improved attention, memory, and social cognition leading to reduced disability by the standards of the Social Security Administration. After two years we are observing similar and sometimes even better results. This therapy seems more effective than any other psychosocial treatment we have developed, and we believe it works because it is so closely tailored to the specific nature of schizophrenia. The effects seem greater for patients who have been ill for a shorter time and therefore (we suspect) have more adaptable brains. Unfortunately, today fewer than 10% of schizophrenic patients have any access to psychosocial rehabilitation. Cost constraints and clinicians' lack of training are part of the problem. Another obstacle is the belief that multiple controlled studies must be conducted before more programs are implemented. But such studies would not respond to the main concern of mental health administrators, which is whether a treatment will work with a given staff, patients, and resources. Providers do not seem to want more studies of effectiveness; they ask for training and supervision in the approaches that have already been proved successful. Unfortunately, there is little national funding for this kind of training, and we will not have it until the public understands that reversing our long history of neglecting the psychosocial treatment of schizophrenia is a social, political, and moral imperative.
Others who bought this Schizophrenia Course