Rehab Rounds: Improving Recreational, Residential, and Vocational Outcomes for Patients With Schizophrenia
Abstract
Introduction by the column editors: As Roder and colleagues propose, we have seen three eras in the development and refinement of social skills training for individuals with schizophrenia. In the 1960s, skills training relied on the use of operant conditioning, as exemplified by the token economy. Reinforcement contingencies succeeded in activating patients with negative symptoms and in improving their social behavior. Contemporary psychiatric rehabilitation can profit from the identification and use of reinforcers to motivate anergic individuals who lack insight to participate actively in community-based programs.During the second era, in the 1970s, social learning through modeling, coaching, role playing, and behavioral assignments was introduced into skills training. These techniques were used to improve nonverbal skills, such as eye contact, fluency of speech, gestures, and facial expression, as well as conversational skills, assertiveness, and emotional expressiveness.Intervention programs of the third and current era are incorporating cognitive methods into the skills training enterprise. For example, in the modules for training social and independent living skills developed and validated by Liberman and his colleagues at the University of California at Los Angeles (1), the deficits in attention, memory, and verbal learning often experienced by persons with schizophrenia are overcome by repetition, shaping of incremental behavioral improvements, video modeling, and feedback for galvanizing attention. Procedural learning techniques that do not rely on the brain capacities that mediate verbal awareness and insight are also used.In this month's Rehab Rounds column, Roder and his colleagues present another example of a skills training approach of the third era that includes elements of cognitive remediation. As autonomous offsprings of integrated psychological therapy (IPT), which was originally developed by Hans Brenner and Volker Roder and their colleagues at the University of Bern in Switzerland (2), the new programs address deficits in the residential, vocational, and recreational domains of community functioning. Overall, social skills training has been shown to be effective in the acquisition and maintenance of skills and their transfer to community life. Moreover, evidence is accumulating that structured and systematic skills training is more effective than other psychosocial treatments with which it has been compared, such as supportive group therapy and expressive modes of occupational therapy.
IPT is a comprehensive treatment for schizophrenia. The first three subprograms of the treatment combine principles of behavior therapy to remediate deficits in patients' basic cognitive functions. The second set of subprograms builds on these gains by providing training in social and problem-solving skills.
Three new programs have been designed to complement IPT. The programs focus on providing skills training in the residential, vocational, and recreational domains. The aim of these new interventions—which can be delivered completely independently of IPT—is to integrate skills training within the context of a comprehensive and individualized psychiatric treatment and rehabilitation service that includes antipsychotic medication, case management, and existing vocational services. Patients participate in the programs that are most suited to their individual therapeutic and rehabilitative needs, as determined by psychiatric and functional assessments.
The three programs are structured identically, allowing for ease of clinical use. Each program comprises four stages. In the first stage, patients are taught to clarify their own needs and to use existing resources in the relevant area of intervention. In the second stage, patients are encouraged to set attainable and realistic individual goals. These goals are determined collaboratively by the patient and the treatment team, and they may involve modifying, stabilizing, or adapting to existing situations.
In the third stage, social skills that are relevant for both day-to-day living and for achieving the goals established by the patient in the second stage are learned and practiced in vivo. In the residential and vocational programs, for example, these skills may include the ability to independently make telephone calls about housing or employment, compose letters of application for an apartment or a job, or prepare for and present oneself as a candidate in interviews.
The fourth and final stage comprises interventions that focus on applicable problem-solving and coping skills. Examples of problems that patients may encounter include rejection of an application for a job or an apartment, boredom or diminished motivation for participating in leisure activities, or interpersonal difficulties with coworkers or roommates.
Treatment focuses primarily on the patient's most acute or frequent difficulties, such as coping with deficits in attention, concentration, and self-esteem and complying with the requirements of the rehabilitative process by participating in case management, family psychoeducation, or sheltered workshops, and on more idiosyncratic interpersonal and emotional difficulties. The high degree of personal relevance in the problem-solving and coping techniques is intended to promote the transfer and generalization of skills. Interventions are provided in four formats: training in groups, individual training sessions, in vivo exercises, and homework assignments. Groups usually consist of six to nine participants, with a therapist and cotherapist assigned to each group.
All three of the programs use various cognitive-behavioral techniques. Table 1 presents some examples of the topics and the techniques used in each of the four stages of the vocational program. Each program consists of 12 intervention units that are distributed over the four stages. Detailed and standardized therapy manuals describing each intervention have been developed for each of the programs (available from the first author).
Empirical evaluation of the programs
To test the efficacy of the new methods, subjects were recruited from eight psychiatric institutions—five in Switzerland, two in Germany, and one in Austria—all of which offered a comparable standard of care in the areas of pharmacotherapy, sociotherapy, and work therapy. Participants started therapy as inpatients and continued after discharge as outpatients.
Participants were assigned to one of the three programs according to their preferences and needs. For example, a patient whose primary aim was to live independently in an apartment was assigned to the residential program. Participants in each program were then matched for age, duration of hospitalization, duration of illness, dosage of antipsychotic medication, psychopathology, and level of motivation as measured by the Therapy Motivation Questionnaire (3). Participants were offered a three-month treatment phase consisting of two 90-minute group sessions and one 30-minute individual session a week, followed by a three-month aftercare phase with one group session a week and one individual session every other week. The follow-up interval was one year after entry into the study.
Three types of assessment instruments were used. Cognitive abilities were assessed with a battery of cognitive tests for concentration, attention, and memory. Social functioning was measured with the Global Assessment of Functioning Scale (4), the Social Interview Schedule (5), and the Disability Assessment Schedule (6). Psychopathology ratings were derived from the Brief Psychiatric Rating Scale (BPRS) (7) and the Scale for the Assessment of Negative Symptoms (8). Assessments were scheduled at baseline (before the start of the treatment phase), after the treatment phase (three months after baseline), after three months of aftercare (six months after baseline), and at follow-up (12 months after baseline).
Seventy-three patients participated in one of the three experimental groups. Sixty-one percent of the participants were male. The mean±SD age of the participants was 33.5±7.1 years, and the mean IQ was 102.2±12.4. The mean duration of illness was 6.7±4.7 years, the mean duration of the index hospitalization was 12.2±11.9 months, and the average daily dose of antipsychotic medication was 325.6±288.5 chlorpromazine equivalents. The mean score on the BPRS was 41.2±8.6. The mean motivational level on a 5-point Likert scale was 2.72±.33, with higher scores indicating greater motivation. The groups did not differ significantly on any of the demographic or clinical history variables.
By means of factor analysis, we grouped the dependent variables into five factors—speed of information processing, maintenance of concentration, social interest and social integration, self-perception of well-being and psychosocial coping, and psychopathology—resulting in z-transformations of the means and standard deviations. Global effect sizes were calculated by determining the means of the effect sizes of the five factors for each program. An effect size of .5 represents a difference of one-half of one standard deviation. Such a difference is considered clinically meaningful (9).
At the three-month assessment, medium effect sizes were observed for all three programs: recreational, .35; vocational, .40; and residential, .51. All the participants continued to improve during the aftercare phase. Effect sizes at the six-month assessment were .48 for the recreational program, .47 for the vocational program, and .60 for the residential program; at one-year follow-up they were .58, .66, and .73, respectively.
Afterword by the column editors: Increased diversity of skills training approaches should facilitate a greater individualization of rehabilitation, with implementation of specific programs based on symptom and functional assessment. By taking the participant's rehabilitation needs and motivation for therapy into consideration, new training programs in residential, vocational, and recreational domains constitute promising extensions to multimodal treatment approaches for individuals with schizophrenia.
Roder and his colleagues have designed and favorably evaluated three new programs for skills training. Their next step in validating the programs is to document that participants show improvements or gains in the focal goals of each of the three programs, a prerequisite for causal impacts on psychopathology and neurocognition. A wealth of treatment research in schizophrenia and most other disorders suggests that outcomes are specifically linked to the aims and nature of the intervention. For instance, studies reported by the UCLA group on specific modules for teaching skills in recreation, work, conversation, and medication self-management have revealed predictable changes in these areas of functioning (1,10,11). Only when a combination of many skills training modules is delivered in the context of a long-term and intensive partial hospitalization or outpatient service have broader improvements in social functioning been found (12,13).
Further research can then be undertaken to reduce confounding sources of influence on outcomes. Controlled clinical trials can be designed using random assignment and raters who are blinded to the participants' group assignment and medication administration.
Acknowledgment
This project was supported by grant 32-45577.95 from the Swiss National Science Foundation.
The authors are affiliated with the department of psychiatry at the University of Bern in Switzerland. Send correspondence to Dr. Roder, University Psychiatric Services Berne, Department of Social and Community Psychiatry, Bolligenstrasse 111, 3000 Berne 60, Switzerland (e-mail, [email protected]). Alex Kopelowicz, M.D., and Robert Liberman, M.D., are editors of this column.
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Table 1. Stages of the vocational skills training program and examples of topics and therapeutic techniques
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