Issues in the Design of Psychosocial Interventions
The potential benefits of psychosocial treatment are often not achieved in the community due to poor understanding of the spe-cial needs and liabilities of schizophrenia patients. Five factors need to be taken into account when implementing psychosocial interventions and evaluating the results: 1) timing and duration of treatment; 2) individual differences in treatment needs; 3) the role of the patient in treatment; 4) the limitations imposed by impairments in information processing; and 5) the need to base interventions on a compensatory model.
The APA Practice Guidelines for the Treatment of Patients with Schizophrenia makes a number of important points that are germane to rehabilitation programming, not the least of which pertains to the need for multimodal, long-term care: “Schizophrenia is a chronic condition that frequently has devastating effects on many aspects of the patient’s life and carries a high risk of suicide and other life-threatening conditions. The care of most patients involves multiple efforts to reduce the frequency and severity of episodes and to reduce the overall morbidity and mortality of the disorder. Many patients require comprehensive and continuous care over the course of their lives with no limits as to duration of treatment”. This guideline is widely reflected in case management and pharmacotherapy but has not been adequately addressed in rehabilitation programs.
The role for psychosocial treatment and rehabilitation in-creases as the patient becomes more stable and shifts from support and stress reduction to specific rehabilitation strategies such as social skills training and cognitive rehabilitation. This three stage model and associated treatment emphasis has good face validity.
Treatment planning must be individualized. While this might seem like a given, many outpatient treatment systems are designed with a one-size-fits-all model, in which most patients are assigned to a standard set of group treatments paired with case management. This is a strategy that maximizes dropouts and minimizes effec-tiveness. This is a population that is difficult to treat effectively under the best of circumstances. Positive outcomes are likely only if both the content of treatment and the format of treatment are tai-lored to the individual patient’s needs and learning capacities.
The combination of psychosis, thought disorganization and negative symptoms (especially anergia, apathy and anhedonia) often lead to the false assumption that patients are not capable of being active participants in their own treatment. Indeed, many patients seem unmotivated and are noncompliant, but such seeming disinterest and passivity should not be interpreted as accurate reflections of the person’s goals and desires or as immutable traits. Negative symptoms are not always stable, and they may be secondary to demoralization, psychotic symptoms, medication side effects and other factors that vary over time (Carpenter et al., 1988; McGlashan and Fenton, 1992). Paul and Lentz (1977) have shown that even extremely withdrawn, chronic schizophrenia patients can be motivated by a systematic incentive program. Similarly, desire to change and inclination to do the work required for treatment also vary over time in the same way that motivation to lose weight or quit smoking varies in nonpatient populations.
As cogently argued by Strauss (1989), schizophrenia pa-tients have an active “will”. Much of their behavior is goal di-rected and reflects an attempt to cope with the illness as best they can. Consequently, it is essential to view the patient as a potentially active partner and involve him or her in goal setting and treatment planning. Too often, treatments are imposed on patients by the treatment team and family members, with little consideration of the patient’s own desires or capacities. It should not be surprising in such circumstances if the patient fails to adhere to treatment recommendations, increasing the risk of re-lapse and creating tensions in relationships with family members and treatment providers. To be sure, engaging the patient to es-tablish treatment goals can be a long, arduous process, but failure to do so courts the larger risk of undermining the very purpose of the intervention.
It is now well established that impaired information process-ing represents one of the most significant areas of dysfunction in schizophrenia. The illness is marked by neuropsychological deficits in multiple domains, including verbal memory, work-ing memory, attention, speed of processing, abstract reasoning and sensorimotor integration (Braff, 1991; Green and Nuech-terlein, 1999). These deficits are highly related to social func-tioning and role performance in the community, as well as to performance in skills training programs (Green, 1996; Green et al., 2000).
A related issue concerns the impact of neurocognitive defi-cits on the generalization of treatment effects. A basic assumption of all psychotherapies is that skills acquired in treatment sessions must be transferred or generalized to the patient’s natural envi-ronment. Yet, such generalization is contingent upon cognitive processes that are often disrupted in schizophrenia, especially “executive functions” mediated by the dorsolateral prefrontal cortex (Weinberger, 1987).
Unfortunately, clinical rehabilitation programs have lagged behind the experimental literature in this arena and neu-rocognitive deficits generally are not well addressed in a system-atic manner.
A rehabilitation model is more appropriate for treatment of most patients with schizphrenia than the standard treatment model as: 1) it implies a narrower focus on specific skills and behaviors, and 2) it aims to improve functioning in specific areas, rather than eliminating or curing an entire condition. As indicated above, cognitive impairment is a central feature of the disorder, evident in childhood and progressing sharply with the onset of psychotic illness. It is reasonable to speculate that the impairments observed in ill adult patients are at least of two types: 1) those present from early in development; and 2) those that are related to clinical psychotic illness. The existence of such early, developmentally based impairments suggest that the concept of “premorbid” functioning in schizophrenia may no longer be tenable; rather, there is a prepsychotic period during which there is subtle evidence of the “morbid” process. Thus, the challenge confronting attempts at cognitive enhancement may not be restoration of function, but instead may be the development of critical competencies and strategies for coping with deficits.
Consistent with this hypothesis, a compensatory approach to treatment may be more appropriate than the restorative or reparative approach characteristic of most treatment programs. Cognitive adaptation training (CAT) is a creative compensatory approach developed by Velligan and colleagues (2000). Case managers provide patients with home-based, compensatory en-vironmental strategies to help structure the patient’s living en-vironment which maximizes the likelihood that she/he can com-plete requisite activities of daily living. Examples include posting reminders about appointments on the exit door from the apart-ment, listing items of clothing to be worn on the closet door, and
placing medications in a location that makes it maximally likely that the patient will see it and be reminded to take it. Prompts and other environmental aides are individually tailored to the pa-tients’ level of apathy, disinhibition and executive dysfunction. CAT can be administered in a time limited fashion, but may be a lifelong service for severely impaired patients. Velligan and colleagues found 9-months of CAT to be superior to an atten-tion placebo and standard outpatient care on positive symptoms, negative symptoms, motivation, community functioning, global functioning and incidence of rehospitalization. This is an excel-lent model for compensatory interventions, and warrants further study (Table 73.1).