Introduction by the column editors: A solid body of evidence indicates that therapy programs that combine neuroleptic medication with behavioral intervention are more effective in reducing relapse and improving psychosocial functioning than those that use medication alone to treat schizophrenia (1,2). Although researchers have moved away from a biologically simplistic to a multifactorial approach to treating schizophrenia, current practice guidelines are rarely implemented at the clinical level. One limiting factor in the dispersion of combined medication and psychosocial programs has been the lack of replicable and manualized psychosocial treatments that can be readily implemented by line-level clinicians.
One example of a manualized cognitive-behavioral treatment program for schizophrenia is integrated psychological therapy (IPT) (3). Operating on the assumption that patients with schizophrenia have cognitive dysfunctions—for example, in social perception—as well as deficits in social and problem-solving skills, IPT offers remediation of all of these deficits in group or individual settings. In this report on the impact of IPT in Spain, its combined value with behavioral family therapy is highlighted in a country other than where the intervention was initially designed and tested.
IPT comprises subprograms for remediating deficits in five areas: cognitive differentiation, social perception, verbal communication, social competence, and interpersonal problem solving. The first two concentrate on the basic cognitive functions; the others proceed to the more complex tasks of helping participants acquire social and problem-solving skills once they have succeeded in improving their basic cognitive functions.
Each subprogram uses gradual increases in learning demands over the course of therapy. In addition, the program's initial structure and task orientation gradually give way to greater emphasis on spontaneous group interaction. With the aim of developing the participants' ability to deal adequately with emotions and affects, the initial exercises in each subprogram contain neutral material that is assumed not to be stressful. As therapy progresses, emotionally loaded material is gradually introduced.
IPT has been used for persons with schizophrenia in many countries, including Switzerland, Germany, Austria, Chile, Japan, the United States, and others. In this article, we present our experience with group training with four of the five subprograms—cognitive differentiation was not included—combined with a family psychoeducation approach targeting both patients and family members, in the Spanish province of Cantabria.
Subprograms of the integrated therapy package were implemented in separate groups of four to seven persons with schizophrenia or of their families for 12 months; follow-up assessments were made nine months later. The intervention program and the follow-up sessions took place in 1997 and 1998. The groups were held in the psychiatric outpatient department of a general hospital sponsored by the National Health System.
Patients' relatives attended, on average, 31 sessions in the first year, in four stages. For the first ten weeks, relatives attended weekly, hour-long psychoeducation sessions. (A list of the topics of these sessions and examples of concerns expressed by family members is available from the authors.) The sessions were organized to facilitate interactions between trainers and family members and among family members. This approach allowed a variety of experiences and viewpoints to be presented, which promoted group discussion. Family members also were provided a written guide, available in Spanish from the authors, that included basic information about schizophrenia.
Subsequent elements of the family intervention were designed to train the relatives in verbal communication (three meetings), problem-solving (nine meetings), and coping skills (nine meetings). These sessions were modeled on family psychoeducation programs that have been shown to reduce family burden and stress levels (4,5). The therapeutic method for each meeting was highly structured and organized and used several behavioral techniques—instructions, rehearsal, modeling, social reinforcement, in vivo tasks, and homework. (A list of topics for each group is available from the authors.) All training sessions were conducted in a group format, without the presence of the ill relative.
In parallel with the program for family members, an integrated therapy program for persons with schizophrenia was developed that combined a psychoeducation approach with four of the subprograms of the IPT (3). Its purpose was to promote engagement and self-management of illness and to treat the cognitive and social deficiencies of schizophrenia. Before beginning the subprograms, patients participated in four group sessions that concentrated on psychoeducation and used the same content and format as the family sessions.
Ten sessions were designed to inculcate more accurate social perception. In these sessions a set of 30 slides (three per session) depicting one or more persons was used in a three-step process—perception of the stimulus, adequate interpretation, and correct response. In the first step, the therapist directed participants' attention to the relevant details of the picture. By highlighting the setting, the objects, and the expressions on people's faces, this subprogram aimed to improve participants' apprehension and interpretation of social situations. In the interpretation phase, participants were asked to focus on three questions: "What does the picture mean?" "How can you justify your interpretation?" "What do the other group members think about this interpretation?" The therapist encouraged and reinforced the various points of view generated by group members that were relevant to understanding the social content of the picture.
The verbal communication subprogram consisted of ten sessions of literal repetition and paraphrasing with question-and-answer exercises. This subprogram aimed to improve participants' competence in three basic communication skills: listening, understanding, and responding to communications from others. The steps used to accomplish these goals were literal repetition of sentences; paraphrasing or making up sentences with words that would be appropriate in everyday conversation; forming questions with words such as "where," "when," "who," and "why"; asking questions about themes decided on by the group or the therapist, such as newspaper headlines, weekend activities, and recent experiences; periodically summarizing the information presented; and coaching participants in paralinguistic and nonverbal aspects of communication, including eye contact and voice tone and volume. Informative feedback and immediate social reinforcement were important in each phase, particularly if low-functioning group members were reluctant to participate.
The next subprogram comprised 24 sessions that were focused on social skills training and used techniques such as role-playing and assertiveness training. These sessions started with emotionally neutral and low-risk situations often encountered in everyday life, such as starting a conversation, thanking others, giving a compliment, or getting information. Gradually the emotional content and degree of risk involved in these sessions increased—for example, making requests for behavior change, making an apology, or starting a common venture. The first step was to set up the role play—to introduce it, define a title, prepare a dialogue, discuss anticipated difficulties, assign observation tasks, and rate the perceived level of difficulty. Then the role play was enacted: the co-therapists demonstrated the role play and conducted a feedback discussion, and then group members reenacted the role play and participated in a feedback discussion followed by in vivo exercises. Homework exercises at the end of each session were assigned to help group members generalize these social skills to real-life situations.
The fourth subprogram, interpersonal problem solving, consisted of nine behaviorally oriented sessions that addressed personal problems identified by group members (6). The goal of the subprogram was to train participants to solve complex problems by transforming them into simpler, clearer problems of more manageable proportions and using realistic alternatives or solutions.
The program was implemented with 28 outpatients who met ICD-10 diagnostic criteria for schizophrenia and who lived in a family setting. Their mean±SD age was 31.5±5.44 years, and their mean duration of illness was 7.91±2.57 years; 70 percent were male. Symptoms and community functioning were assessed by blinded raters and by patient self-report at baseline, after the intervention, and at nine-month follow-up.
This group's results were compared with those of 18 outpatients with schizophrenia who received standard treatment, which consisted of information about schizophrenia and medication supervision. The mean±SD age for this group was 30.0±4.64 years, and their mean duration of illness was 8.64±2.60 years; 80 percent were male. All participants were on stable regimens of antipsychotic medications at the time of initial testing. At baseline, participants did not differ significantly in demographic and clinical variables or in symptoms or community functioning.
Participants in the IPT group demonstrated significant improvement in symptoms and community functioning over time, whereas control subjects did not show significant changes on these measures over time. The significant improvements in the IPT group were also apparent at the nine-month follow-up. (A more detailed description of the empirical evaluation is available from the authors.)
Mr. R was a 37-year-old man who, since separating from his wife several years earlier, had lived with his mother and stepfather. He had been diagnosed at age 26 as having paranoid schizophrenia, manifested by persecutory delusions toward his mother, his former wife, and several neighbors, leading to several psychiatric hospitalizations. Since he first developed symptoms, Mr. R had not worked or maintained any peer relations. Family relations were difficult, as he displayed verbal and physical violence against his mother and did not speak to his stepfather for two years. His compliance with his medication regimen was inconsistent, resulting in high levels of anxiety, hostility, and suspicion and bizarre thoughts and perceptual disturbances before he participated in the composite therapy program.
Mr. R's treatment began with psychoeducation on the causes of schizophrenia. The social perception subprogram was tailored to teach him how to differentiate concrete perceptions from overinterpretation. For example, in social situations, Mr. R tended to focus on a limited aspect of a social interaction, often making paranoid interpretations that led to negative opinions and unwarranted criticism of others.
Over the course of several sessions, Mr. R was helped to distinguish between the content of the visual presentation and his idiosyncratic interpretations. Through modeling and positive reinforcement, he learned to describe the situations presented in the slides by using only the perceived stimuli, without imposing his own interpretation. This skill carried over to his peer interactions as well.
The main objective of the interpersonal problem-solving subprogram was to improve Mr. R's ability to interact with his family by helping him identify new ways of communicating with his parents. Among these techniques were how to take turns in a conversation, minimizing the number of times he interrupted others; how to focus on a target idea and express himself clearly, specifically, and succinctly; and how to control the volume and pitch of his voice to make himself understood.
The family psychoeducation component aimed to lower the level of criticism, hostility, and emotional overinvolvement that dominated family interactions and to alleviate Mr. R's parents' caregiving burden. Training included teaching the parents how to cope with his symptoms and disruptive behaviors and helping them modify their fatalistic perception of Mr. R's future. Communication-skill exercises were used to teach the parents how and when interactions should take place. The objective of the problem-solving therapy was to facilitate collaboration between Mr. R and his parents, including how to negotiate areas of contention such as medication compliance and aggression.
For instance, a major cause of family tension was the conflict between Mr. R's need for privacy and his mother's desire to monitor his medications. To avoid arguments, Mr. R's mother would count his medications, which were in his drawer, when he was not home. However, he would often discover that his mother had been through his things, which led to aggressive behaviors such as throwing objects and slamming doors. During the family psychoeducation sessions, a number of ideas were discussed to resolve this impasse. The strategy—suggested by Mr. R—that proved to be successful was to keep the medications in the kitchen so that he could more easily remember to take them after meals and not require his mother's supervision. This strategy not only decreased his anger toward his parents but also added to his increasing sense of responsibility and self-esteem.
By the end of the treatment period, Mr. R's adherence to his medication regimen became more stable, his psychotic symptoms were greatly reduced, and his violent outbursts ended. He struck up a friendship with another group participant and began to visit an old friend. For the first time in 11 years, his mother and stepfather were able to enjoy a two-week vacation away from Mr. R. The final assessment indicated that he was maintaining his gains and had enrolled in a vocational training program. After completing a two-month course on environmental conservation, he obtained a full-time position as part of a team responsible for maintaining clean beaches.
Afterword by the column editors: Broad-spectrum intervention programs such as IPT for outpatients with schizophrenia are consistent with current guidelines from experts and professional organizations. IPT, in combination with pharmacotherapy, case management, and family psychoeducation, incorporates the essential requirements for ensuring the effectiveness of psychosocial intervention programs for schizophrenia (1). These include teaching practical elements in daily problem-solving abilities and feasible goals; forging an alliance among clinicians, participants, and relatives; maintaining treatment continuity, with a minimum of 12 months of active participation; focusing on environmental stressors and personal deficits that are related to relapse risk and social maladjustment; and coordinating and integrating pharmacological, psychosocial, and family services.
In the comprehensive psychosocial treatment program that Vallina and colleagues describe, it is impossible to determine whether the same good outcomes would have been obtained with the family services and medication alone, especially since a number of studies using structured and learning-based family interventions have shown similar benefits (7,8). Randomized controlled trials are needed to determine which components are necessary for salutary results.
All of the authors are at the Sierrallana Hospital in Torrelavega (Cantabria), Spain, except Dr. Roder, who is with the department of psychiatry at the University of Bern, Switzerland. Send correspondence to Dr. Lemos, Universidad de Oviedo, Facultad de Psicología, Plaza Feijóo, s/n, 33003 Oviedo, Spain (e-mail, email@example.com). Alex Kopelowicz, M.D., and Robert Liberman, M.D., are editors of this column.