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.
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 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.
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.
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.
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.
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 (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.
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.
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.
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.
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).
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