Home | | Psychiatry | Nonpharmacological Treatment of Schizophrenia

Chapter: Essentials of Psychiatry: Schizophrenia and Other Psychoses

Nonpharmacological Treatment of Schizophrenia

Essentials of Psychiatry: Schizophrenia and Other Psychoses

Nonpharmacological Treatment of Schizophrenia




Although psychopharmacological intervention has proved to be the foundation on which the treatment of schizophrenia depends, other approaches to the management of these patients serve a critical function. Studies have shown repeatedly that symptoms of schizophrenia have not only a genetic component but also an environmental aspect, and interactions with family and within the community can alter the course of the illness.


For many years, a dichotomous view of treatment options was tenaciously debated as dynamic psychiatry was challenged by developments in the neurosciences. A more unified view is now accepted, as it has become clear that psychopharmacological treatment strategies are most efficacious if combined with some type of psychosocial intervention and vice versa. It can be said that because of the chronic nature of schizophrenia, one or more treatments may be required throughout the illness and they are likely to have to be modified as symptoms change over time.


Psychosocial Rehabilitation


Bachrach has defined psychosocial rehabilitation as “a therapeu-tic approach that encourages a mentally ill person to develop his or her fullest capacities through learning and environmental sup-ports” (Bachrach, 2000). According to the author, the rehabilita-tion process should appreciate the unique life circumstances of each person and respond to the individual’s special needs while promoting both the treatment of the illness and the reduction of its attendant disabilities. The treatment should be provided in the context of the individual’s unique environment taking into account social support network, access to transportation, hous-ing, work opportunities and so on. Rehabilitation should ex-ploit the patient’s strengths and improve his/her competencies. Ultimately, rehabilitation should focus on the positive concept of restoring hope to those who have suffered major setbacks in functional capacity and their self-esteem due to major mental ill-ness. To have this hope grounded in reality, it requires promoting acceptance of one’s illness and the limitations that come with it. While work offers the ultimate in sense of achievement and mastery, it must be defined more broadly for the mentally ill and should include prevocational and nonvocational activities along with independent employment. It is extremely important that work is individualized to the talents, skills, and abilities of the individual concerned. However, psychosocial rehabilitation has to transcend work to encompass medical, social and recreational themes. Psychosocial treatment’s basic principle is to provide comprehensive care through active involvement of the patient in his or her own treatment. Thus, it is important that a holding environment be created where patients can safely express their wishes, aspirations, frustrations and reservations such that they ultimately mold the rehabilitation plan. Clearly, to achieve these goals, the intervention has to be ongoing.


Given the chronicity of the illness, the process of reha-bilitation must be enduring to encounter future stresses and chal-lenges. These goals cannot be achieved without a stable relation-ship between the patient and rehabilitation counselor, which is central to an effective treatment and positive outcome. Thus, psy-chosocial rehabilitation is intimately connected to the biological intervention and forms a core component of the biopsychosocial approach to the treatment of schizophrenia. In the real world, programs often deviate from the aforementioned principles and end up putting excessive and unrealistic expectations on patients, thus achieving exactly the opposite of the intended values of the program (see Bachrach, 2000 for more details).


Individual Psychotherapy


Individual therapy in a nontraditional sense can begin on meeting a patient. Even the briefest of normalizing contacts with an agitated, acutely psychotic patient can have therapeutic value. Psychody-namic interpretations are not helpful during the acute stages of the illness and may actually agitate the patient further. The psychia-trist using individual psychotherapy should focus on forming and maintaining a therapeutic alliance (which is also a necessary part of psychopharmacological treatment) and providing a safe envi-ronment in which the patient is able to discuss symptoms openly. A sound psychotherapist provides clear structure about the therapeu-tic relationship and helps the patient to focus on personal goals.


Often, a patient is not aware of or does not have insight into the fact that some beliefs are part of a specific symptom. A psychotherapist helps a patient to check whether his or her reality coincides with that of the therapist. The therapeutic intervention then becomes a frank discussion of what schizophrenia is and howsymptoms may feel to the patient. This objectifying of psychotic or negative symptoms can prove of enormous value in allowing the patient to feel more in control of the illness. A good analogy is to diabetic patients, who know they have a medical illness and are educated about the symptoms associated with exacerbation. Just as these patients can check blood glucose levels, schizophre-nia patients can discuss with a therapist their sleep patterns, their interpersonal relationships and their internal thoughts, which may lead to earlier detection of relapses.


Schizophrenia often strikes just as a person is leaving ado-lescence and entering young adulthood. The higher the premor-bid level of social adjustment and functioning, the more devastat-ing and confusing the onset of symptoms becomes. Young male patients with a high level of premorbid function are at increased risk of suicide, presumably in part because of the tremendous loss they face. These feelings can continue for years, with schiz-ophrenia patients feeling isolated and robbed of a normal life. Therefore, a component of individual work (which can also be achieved to some degree in a group setting) with these patients is a focus on the impact schizophrenia has had on their lives. Help-ing patients to grieve for these losses is an important process that may ultimately help them achieve a better quality of life.


Group Psychotherapy


Acutely psychotic patients do not benefit from group interaction. As their condition improves, inpatient group therapy prepares pa-tients for interpersonal interactions in a controlled setting. After discharge, patients may benefit from day treatment programs and outpatient groups, which provide ongoing care for patients living in the community.


Because one of the most difficult challenges of schizophre-nia is the inherent deficits in relatedness, group therapy is an im-portant means of gathering patients together and providing them with a forum for mutual support. Insight-oriented groups may be disorganizing for patients with schizophrenia, but task-oriented, supportive groups provide structure and a decreased sense of isolation for this population of patients. Keeping group focus on structured topics, such as daily needs or getting the most out of community services, is useful for these patients. In the era of com-munity treatment and brief hospitalizations, many patients are being seen in medication groups, which they attend regularly to discuss any side effects or problems and to obtain prescriptions.


Psychoeducational Treatment


One of the inherent deficits from which schizophrenia patients suffer is an inability to engage appropriately in social or occupa-tional activities. This debilitating effect is often a lasting feature of the illness, despite adequate psychopharmacological intervention. This disability often isolates patients and makes it difficult for them to advocate appropriate social support or community serv-ices. Furthermore, studies have found that there is a correlation between poor social functioning and incidence of relapse One of the challenges of this area of study is the great deal of variability in individual patients. However, standardized measures have been developed to ascertain objective ratings of social deficits. These assessments have become important tools in the determination of effective nonpharmacological treatment strategies.


The literature suggests that schizophrenia patients can benefit from social skills training. This model is based on the idea that the course of schizophrenia is, in part, a product of the environment, which is inherently stressful because of the social deficits from which these patients suffer. The hypothesis is thatif patients are able to monitor and reduce their stress, they could potentially decrease their risk of relapse. For this intervention to be successful, patients must be aware of and set their own goals. Goals such as medication management, activities of daily living and dealing with a roommate are achievable examples. Social skills and deficits can be assessed by patients’ self-report, obser-vation of behavioral patterns by trained professionals, or a meas-urement of physiological responses to specific situations (e.g., in-creased pulse when asking someone to dinner). Patients can then begin behavioral training in which appropriate social responses are shaped with the help of instructors.


One example of such a program, discussed by Liberman and colleagues (1985), is a highly structured curriculum that in-cludes a training manual, audiovisual aids and role-playing exer-cises. Behaviors are broken down into small bits, such as learning how to maintain eye contact, monitor vocal volume, or amelio-rate body language. The modules are learned one at a time, with role-playing, homework and feedback provided to the partici-pants. In several studies, Liberman and coworkers (1986) have shown that patients who were treated with social skills training and medication spent less time hospitalized, with fewer relapses than those treated with holistic health measures (e.g., yoga, stress management) on 2-year follow-up. Research such as this in the field of social skills training is growing as the inherent deficits in information processing, executive function and interpersonal skills are further elucidated.


Social Skills Training


In large number of patients, deficits in social competence per-sist despite antipsychotic treatment. These deficits can lead to social distress whereas social competence can alleviate distress related to social discomfort. Paradigms using instruction, mod-eling, role-playing and positive reinforcement are helpful. Con-trolled studies suggest that schizophrenia patients are able to acquire lasting social skills after attending such programs and apply these skills to everyday life. Besides reducing anxiety, so-cial skills training also improve level of social activity and foster new social contacts. This in turn improves the quality of life and significantly shortens duration of inpatient care. However, their impact on symptom resolution and relapse rates is unclear.


Cognitive Remediation


Patients with schizophrenia generally demonstrate poor perform-ance in various aspects of information processing. Cognitive dysfunction can be a rate-limiting factor in learning and social functioning. Additionally, impaired information processing can lead to increased susceptibility to stress and thus to an increase risk of relapse. Practice appears to improve some of the cognitive dysfunction. Remediation of cognitive dysfunctions with social skills training has been reported to have positive impact. Various types of cognitive behavioral therapies were particularly effec-tive. Social skills training program, cognitive training program to improve neurocognitive functioning and cognitive behavioral therapy approaches are oriented towards coping with symptoms, the disorder and everyday problems.


Cognitive Adaptation Training


Cognitive adaptation training (CAT) is a novel approach to im-prove adaptive functioning and compensate for the cognitive im-pairments associated with schizophrenia. A thorough functional needs assessment is done to measure current adaptive function-ing. Besides measuring adaptive functioning and quantifying apathy and disinhibition, a neurocognitive assessment using tests to measure executive function, attention, verbal and visual mem-ory, and visual organization is also completed. Treatment plans are adapted to the patient’s level of functioning, which includes patient’s level of apathy. Interventions include removal of distract-ing stimuli, use of reminders such as checklists, signs and labels.


Family Therapy


A large body of literature explores the role of familial interactions and the clinical course of schizophrenia. Many of these studies have examined the outcome of schizophrenia in relation to the degree of expressed emotion (EE) in family members. EE is gen-erally defined as excessive criticism and over involvement of rel-atives. Schizophrenia patients have been found to have a higher risk of relapse if their relatives have high EE levels. Clearly, a patient’s disturbing symptoms at the time of relapse may affect the level of criticism and over involvement of family members, but evidence suggests that preexisting increased EE levels in relatives predict increased risk of schizophrenic relapse and that interventions that decrease EE levels can decrease relapse rates.


Hogarty and colleagues (1986) examined the effectiveness of neuroleptics alone, neuroleptics plus psychoeducational fam-ily treatment (based on addressing EE levels), social skills train-ing for neuroleptic-treated patients with schizophrenia, and the combination of all three. Perhaps not surprisingly, they found a decreased relapse rate in the patients treated with medication and family therapy as well as in the group treated with neuroleptic and social skills training. The combination of the treatments had an additive effect and was far superior to medication treatment alone.


Though famly intervention studies suffer from methodo-logical limitations, the efficacy of family intervention on relapse rate is fairly well supported. This efficacy was particularly evident when contrasted with low quality or uncontrolled individual treat-ments. The addition of family intervention to standard treatment of schizophrenia has a positive impact on outcome to a moderate extent. Family intervention effectively reduces the short-term risk of clinical relapse after remission from an acute episode. There is evidence of effect on patient’s mental state and social functioning, or on any family-related variables. The elements common to most effective interventions are inclusion of the patient in at least some phases of the treatment, long duration, and information and edu-cation about the illness provided within a supportive framework. There is sufficient data only for male chronic patients living with high EE parents. Evidence is limited for recent onset patients, women, and people in different family arrangements and families with low EE. Research in family intervention is still a growing field. Thus, at present it is unclear if the effect seen with family therapy is due to family treatment or more intensive care.


Leff (2000) concluded from his review that family inter-ventions reduced relapse rates by one -half over the first year of combined treatment with medications and family therapy. Medi-cations and family therapy augment each other. Psychoeducation by itself is not enough. It also seems that multiple family groups are more efficacious then single family sessions. Attempts are being made to generalize training of mental health workers in effectively implementing these strategies.


Based on these findings, it is clear that there is a signifi-cant interaction between the level of emotional involvement and criticism of relatives of probands with schizophrenia and the out-come of their illness. Identifying the causative factors in familial stressors and educating involved family members about schizo-phrenia lead to long-term benefits for patients. Future work in this field must examine these interactions with an understand-ing of modern sociological and biological advances in genetics, looking at trait carriers, social skills assessments, positive and negative symptoms, and medication management with the novel antipsychotic agents.


Case Management


Assertive Community Treatment (ACT) is a community care model with a caseload per worker of 15 patients or less in contrast to standard case management (SCM) with a caseload of 30 to 35 patients. Intensive clinical case management (ICCM) differs from ACT by the case manager not sharing the caseload. In the ACT model, most services are provided in the community rather than in the office; the caseloads are shared across clinicians rather than individual separate caseloads. These are time unlimited services provided directly by the ACT team and not brokered out and 24-hour coverage is provided. Research on the ACT model confirms that it is successful in making patients comply with treatment and leads to less inpatient admissions. ACT also improves hous-ing conditions (fewer homeless patients, more patients in stable housing), employment, quality of life and patient satisfaction. No clear differences between ACT and standard or intensive clini-cal case management are reported with mental condition, social functioning, self-esteem, or number of deaths.


Combining Pharmacological and Psychosocial Treatments

The combination of pharmacological and psychosocial inter-ventions in schizophrenia can have complex interactions. For example, psychotherapies improve medication compliance on one hand but are more effective in the presence of antipsychotic treatment. Family psychoeducation has been reported to decrease the level of expressed emotion in the family resulting in better social adjustment and a need for lower dose of antipsychotic medications. Marder and colleagues (1996) found in their study that pharmacological and psychosocial treatments affect differ-ent outcome dimensions. Medications affect relapse risk whereas skills training affect social adjustment. The VA cooperative study by Rosenheck and colleagues (1998) found that patients who received clozapine were more likely to participate in these treatments and led to improved quality of life. The qualitative differences in the interactions between the newer antipsychotic agents and psychotherapy suggest a hopeful trend of better utili-zation of psychosocial treatments.


Self-directed Treatment


Groups such as the National Alliance for Mentally Ill (NAMI) and the Manic–Depressive Association offer tremendous re-sources to psychiatric patients and their relatives. They provide newsletters, neighborhood meetings and support groups to in-terested persons. These nonprofessional self-help measures may feel less threatening to patients and their families and provide an important adjunct to professional settings.


Structured self-help clubs have also been effective means of bolstering patients’ social, occupational and living skills. The Fountain House was the first such club aimed at social rehabili-tation (Beard et al., 1982). Patients who are involved are called members of the club, giving them a sense of belonging to a group. They are always made to feel welcome, useful, and productive members of the club community


The clubhouse model has expanded to provide services such as transitional employment programs, apartment programs, outreach programs, and medication management and consultation services, to name a few. A self-supportive rehabilitation program for mentally ill patients is an important option for many schizophrenic patients who might otherwise feel isolated and out of reach




Though tremendous progress has occurred in understanding and treatment of schizophrenia, stigmatizing attitudes still prevail (Crisp et al., 2000); in a survey, schizophrenia elicited the most neg-ative opinions and over 70% of those questioned thought that schiz-ophrenia patients were dangerous and unpredictable. Thus, stigma surrounding schizophrenia can cause people suffering from the ill-ness to develop low self-esteem, disrupt personal relationships and decrease employment opportunities. The World Psychiatric Asso-ciation (WPA) has initiated an international program aimed at de-veloping tools to fight stigma and discrimination (Sharma, 2001).

Study Material, Lecturing Notes, Assignment, Reference, Wiki description explanation, brief detail
Essentials of Psychiatry: Schizophrenia and Other Psychoses : Nonpharmacological Treatment of Schizophrenia |

Related Topics

Essentials of Psychiatry: Schizophrenia and Other Psychoses

Privacy Policy, Terms and Conditions, DMCA Policy and Compliant

Copyright © 2018-2024 BrainKart.com; All Rights Reserved. Developed by Therithal info, Chennai.