ABSTRACT | PDF
FACULTY FORUM
Psychosocial management of schizophrenia
Kamal Nath
Although pharmacological interventions have been the mainstay of treatment since their introduction in the 1950s, the limited response of large number of patients to antipsychotic treatment, the high incidence of side effects and the poor compliance to treatment due to various reasons, have necessitated a more broadly based approach combining different treatment options, tailored to the needs of individual service users and their families. Such options include psychological and psychosocial interventions. These options can be applied as treatment in combinations with antipsychotic medications and may involve individuals, group and families.
General principles
1. It should not be an optional addition to treatment but a part of the routine care of the patients with schizophrenia.
2. Psychosocial and pharmacological interventions compliment each other and maximise the chance of better outcome in schizophrenia.
3. The approach should be tailored to meet the needs of the individual with schizophrenia, as it may vary from individual to individual.
4. Psychosocial interventions require highly trained clinicians with expertise in specific areas.
Aims of psychological/psychosocial interventions
The use of psychological and psychosocial interventions in the treatment of schizophrenia is intended to
1. To decrease the persons vulnerability to stress.
2. To reduce the impact of stressful events and situations.
3. To improve the quality of life and decrease distress and disability.
4. To enhance the treatment adherence.
5. To improve social communications and coping skill.
Therapeutic approaches
Contemporary approaches to the psychological/psychosocial interventions of schizophrenia include the following
1. Cognitive–behavioural therapy.
2. Cognitive remediation.
3. Counselling and supportive psychotherapy.
4. Family interventions.
5. Psycho-educations.
6. Social skills training.
7. Vocational rehabilitations.
8. Compliance therapy.
9. Substance abuse rehabilitations.
10. Psychoanalysis and psychoanalytic/psychodynamic psychotherapy.
(no. 2, 6, 7 and 9 are the integral parts of rehabilitation of schizophrenia)
1.Cognitive-behavioural therapy (CBT)
It was originally developed by Beck, 1976, for the treatment of depression. Its use in psychotic disorder is a later development. Its initial focus was to work with the people with persistant delusions and hallucinations, though later its use was extended to wide range of service users, rather than in symptom reduction only.
In the management of schizophrenia, the wide variety of applications of CBT, have all generally attempted to modify psychotic experiences and their effect upon a person’s thoughts, feelings and behaviour. As with other psychological interventions, the CBT also depends on the development of positive therapeutic alliances.
CBT allows recipients to re-evaluate their perceptions, beliefs, or reasoning related to the target symptoms and involves at least one of the following
a. Monitoring of recipients own thought, feelings or behaviour with respect to the symptom.
b. Promotion of alternating ways of coping with the symptoms.
c. Reduction of stress.
Results
It is found that CBT produces stronger and more consistent effect patients with persisiting symptoms than in those with acute symptoms, and appears to have greater efficacy when the duration of treatment is longer then 6 months and includes more the 10 sessions. Shorter term treatment with CBT may produce modest improvement in depressive symptoms but not in psychotic symptoms.
Overall there is good evidence that CBT reduces symptoms of schizophrenia at upto 1 year of follow up. It also improves insight and compliance to drug treatment and have a positive effect upon the social functioning. It also decreases the suicidality and reduces the relapse rate in long run.
It is also more likely to be cost effective than conventional treatment and non specific counselling only.
2. Cognitive remediation
Introduction
The presence of specific cognitive deficit in schizophrenia has been recognised long back though the precise cause is still unknown. Specific deficit identified include memory problem [Berner 1986], attention deficit [Olmanns and Neale, 1975] and problem in executive function [Weinberg et al, 1986]. Despite the controversy regarding the end result and to which method should be used, the major methods to date concentrate on repeating laboratory based cognitive tests or repeated practice of procedures specifically designed to address a particular cognitive deficit. The theory behind this approach asserts that cognitive deficit contribute to a persons vulnerability to schizophrenia and therefore correcting these deficit should, atleast in theory, render a person less vulnerable.
Definition
Cognitive remediation was defined as a programme focused upon improving specified cognitive functions, using procedure implemented with the intention of bringing about an improvement in the level of the specified cognitive function.
Results
So far the results of the cognitive remediations in the control trial is equivocal. Consequently all the major international guideline including the National Institute of Clinical Excellence (NICE) have concluded that there is currently not enough evidence to recommend cognitive remediation in the routine treatment of schizophrenia.
3. Counselling and supportive psychotherapy
Counselling and supportive psychotherapy may be defined as a discrete psychological interventions in which
1. The intervention is facilitative, non-directve, and/or relationship-focussed.
2. The content of sessions largely determined by the service users.
The supportive and caring nature of the relationship between the therapist and the patients and the enhanced engagement of the service user may in themselves be therapeutic.
Results
Although there are no strong evidence to suggest that counselling and supportive psychotherapy is superior to any standard care in the treatment of schizophrenia, the supportive empathic relationship between the patients and the therapist is an essential part of any good clinical practice.
4. Family interventions
Family interventions in the treatment of schizophrenia have evolved from the study of ‘the family environment and its possible role in affecting the course of schizophrenia’ (Brown et al, 1962). Family is broadly defined as those who have an emotional and practical relationship to the schizophrenic patient and often play an important role in both caring the patient as well as helping the patient to care themselves.
Family interventions in schizophrenia covers a wide variety of practices which are conducted in variety of situations. They can be psycho-educational, therapeutic, or skill based, can be conducted with or without the patients, with multifamily group or with one family alone.
Results
A Cochrane review of 13 studies of family interventions in patients with schizophrenia found the following
1. It has no effect on mortality.
2. The mental state of the patients improve after interventions.
3. It is well accepted and drop-out rate is low.
4. There are positive trends towards employment and independent living.
5. It is effective in reducing the burden of illness, increases knowledge and decreases ‘expressed emotions’.
6. It reduces the relapse rate up to 50% in some series, compared to medication alone.
So it is found that family therapy is a well accepted and effective intervention and so it should be integrated at all stages and with all aspects of care.
5. Psycho-education
Definition
Psycho-education is a mean whereby the consumer of mental health services [and/or their families] is educated about their illness and its treatment.
According to the drug and therapeutic bulletin, 1993, published by the Consumer’s Association, UK, people have a right to know as much as possible about their treatment and care. Over and above the legal and ethical reasons for providing reliable information to the service users and their carer, it is also necessary for them to be able to participate meaningfully in the clinical decision making process.
For people with schizophrenia and their carer, the provision of good and accurate information is arguably even more important then people with serious physical illness, for the following reasons
1. Chronic course of the illness in many cases, with high rates of relapse.
2. Lack of acceptance, by the patients as well as close family members, of the illness as a mental problem.
3. Strong social stigma and myriad of misunderstanding that surrounds the diagnosis of schizophrenia.
4. Requirement of long term treatment and possibility of some serious side effects in the process of treatment.
Results
1. Possibly it reduces the relapse rate through improved compliance.
2. Yet there is no definite evidence in its favour in the long term outcome of the service users.
3. Psycho-education for families is also effective and should be provided routinely.
6. Social skills training (SST)
Given the complex and often debilitating behavioural and social effects of schizophrenia, social skills training was developed as a more sophisticated treatment strategy derived from behavioural and social learning traditions. Social skills training, also called life skills training is a widely practiced intervention and designed to help people with schizophrenia regain their social skills and confidence, improve their ability to cope in social situations, reduce social stress, improve their quality of life and aid symptom reduction and relapse prevention.
Social skill training programme begins with a detailed assessment and behavioural analysis of individual social skill, followed by individual and group interventions using positive reinforcement, goal setting, modelling and shaping. Initially smaller social tasks (such as response to nonverbal social cues), are worked on and gradually new behaviours are built up into more complex social skills such as conducting a meaningful conversation. There is strong emphasis on homework assignments to help generalise newly learned behaviour away from the treatment setting.
Social skill training may be a component of more complex rehabilition interventions like token economy and other milieu based approaches.
Results
Evidence shows that SST improves social adjustment, enlarges social network of the patients and significantly improves the independent living skill. NICE guidelines suggest that social and physical activities should be a required part of the care plan for all patients with schizophrenia.
7. Vocational rehabilitation
One of the associated important sociodemonic factor of schizophrenia is low socioeconomic status. Even in the developed countries, more then two third of the patients are unemployed. Apart from being a fundamental right, being occupied in any capacity in a paid job may have clinical impact by increasing the self esteem and reducing dependancy and relapse. An intervention that aims to address this issue of employment of schizophrenic patients is vocational rehabilitation.
Currently there are two main models of vocational rehabilitation
1. Prevocational training, where a preparation is engaged in before seeking competitive employment and
2. Supported employment, in which people are placed in competitive employment with provision of on-the-job support.
People with schizophrenia should be encouraged to find a meaningful occupation. They may also be linked with agencies that provide these services early in the course of illness. Vocational rehabilitation programme can imrove self esteem, economic independence, better treatment compliance and reduction of relapse and number of rehospitalisation.
8. Compliance therapy
One of the important issues in the treatment of schizophrenia is the issue of compliance. There are many reason why the patients are non compliant — longterm treatment, side effects of medication, life style changes, economic factor and low insight due to the illness itself and so many. Being aware of the link between compliance and favourable out come, Kemp et al have developed a therapy that specifically addresses compliance.
Comliance therapy uses motivational interview and cognitive behavioural techniques to help clients explores issues around compliance. Compliance therapy may be useful when applied early or later phase of the recovery. However, further reaserch is needed to confirm the validity of these interventions.
9. Substance abuse rehabilitations
Substance use disorder is the most common and clinically significant comorbidity with schizophrenia. Approximately 50% of the adult schizophrenic has concurrent substance use and are therefore dually diagnosed. Substance use disorder complicates their life in myriads ways, leading to increase symptoms, relapses, hospitalisations, violence, homelessness, victimisations, and serious medical problems like human immunodeficiency virus (HIV) infections, hepatitis. It was recognised in the early 1980’s that there are serious limitations and problems in the health care systems when these patients have to go to two different agencies for the treatment of these dually diagnosed disorder. And then the efforts began to integrate or combine mental health and substance abuse interventions for people with dual disorder. Several features of these integrated dual diagnosis treatment are associated with better outcomes and thus are considered evidence based principle. The principles are
1. Integrations
It means one clinician or team takes responsibilities for helping the patients with dual diagnosis of schizophrenia and substance use disorder and the interventions are specifically tailored to fit the patients. Most programme accomplishes integration by combining multidisciplinary teams which include substance abuse treatment expert, mental health expert, and others having expertise in housing, vocational training and so on.
2. Stage wise intervention
In the simplest concept, stages of treatment includes
A. Engaging the patient for trusting relationship.
B. Increasing the motivation to pursue recovery.
C. Helping the motivated patients to gain skill and support to achieve personal goals and
D. Helping the stable patients to use strategies to prevent relapse.
3. Establishing assertive outreach centre for those patients who can’t access the service easily. If needed to utilise existing health care network.
4. Motivational interventions
Effective programme should be incorporated for motivational interventions at various levels.
5. Counselling
To promote cognitive and behavioural skills to pursue an abstinent life.
6. Social support interventions
Strengthening the patients immediate environment to help the patient to modify their behaviour — like peer group interventions, social network and family interventions.
7. Longterm and comprehensive service – psychological, physical, vocational etc. in a comprehensive and combined manner for long time.
10. Psychoanalysis and psychoanalytic/psychodynamic psychotherapy
Introduction
Psychoanalysis and its derivatives, often termed psychoanalytic and psychodynamic psychotherapies were originally regarded as unsuitable for the treatment of the psychosis (Freud, 1914). However, number psychoanalysts made attempts to treat people with schizophrenia and other psychosis, using more or less modified versions of psychoanalysis (Stack-Sullivan, 1974). Research into the effects of psychoanalysis in the treatment of schizophrenia has been repeated more recently with mixed results (Jones et al, 1999).
Types
1. Insight oriented individual psychodynamic psychotherpy.
2. Supportive psychotherapy.
3. Cognitive behaviourally oriented psychotherapy.
4. Group psychotherapy.
Author is Associate Professor of Psychiatry at Silchar Medical College Hospital, Silchar.
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