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Article Index
Psychological Interventions for Schizophrenia
Methods
Do They Reduce Relapse?
Do They Improve Functioning?
Discussion
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Schizophrenia Bulletin, Vol. 21, No. 4, 1995
National Institute of Mental Health

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Abstract

This review examines the impact of dynamic and supportive psychotherapies (both individual and group) and psychosocial skills training on clinical and social outcomes for individuals with schizophrenia. The relatively few controlled trials of individual or group psychotherapies for persons with schizophrenia exhibit serious methodological problems that limit their generalizability. Reality-oriented approaches appear to be superior to dynamic, insight-oriented psychotherapies, but further research is needed to identify and evaluate disorder-specific models that target specific deficits and disabilities in schizophrenia. Research on psychosocial skills training models shows that target skills can be trained and maintained over time. Further work is needed to determine the extent to which trained skills generalize from the original training setting to "real life" environments.

Schizophrenia Bulletin, 21(4): 621-630, 1995.

This review considers evidence for the efficacy of three types of psychological interventions for persons with schizophrenia: individual and group psychotherapies (dynamic and supportive) and psychosocial skills training. Individual psychotherapies can be defined structurally as interventions with one-to-one contact between a patient and a therapist. A wide variety of therapies can be administered in this format, ranging from dynamic insight-oriented psychotherapies, to supportive psychotherapies, to social skills training and cognitive and behavioral therapies. However, individual psychotherapy historically connotes either dynamically oriented psychotherapy, which typically seeks to increase insight, or supportive psychotherapy, which typically seeks to build ego strength. This review will consider individual therapy in both these connotations.

Powles (1964) suggests three criteria for defining group psychotherapies: (1) a group of people is gathered for some therapeutic goal; (2) a professional expert leader is present to assist the group; and (3) the relationships and interactions between group members are used as tools for clarification, motivation, or behavioral change. As with individual psychotherapy, a variety of models can be used in a group format, including psychoanalytic, interpersonal, and educational approaches. Social skills training, cognitive and behavioral therapies, and family therapy also may be delivered in group settings, and patient-directed self-help groups by definition use this format. In this review, we will focus on group psychotherapies with largely dynamic or supportive orientations, although some of the group interventions reviewed target problem-solving and socialization skills.

Psychosocial skills training refers to a class of treatment interventions that uses methods and principles derived from social learning theories to train (or retrain) motor and interpersonal skills and competencies. Complex behaviors are analyzed and broken down into a smaller set of discrete behavioral elements that are then trained using various core behavioral techniques. These techniques include problem or skill specification, didactic instruction, modeling, role-play or behavioral rehearsal, coaching, feedback, verbal reinforcement, generalization training, and homework. Specific interventions may not use all these techniques, but, in general, interventions that are considered social skills training will use at least some of them; at least two reviews (Benton 1989; Benton and Schroeder 1990) define social skills training as an intervention using three or more of these methods.

Recently, there has been growing interest in including cognitive skill and/or cognitive remediation techniques in traditional social skills training approaches. For example, Brenner et al. (1992) reviewed research on the integrated psychological therapy (IPT) model, which combines cognitive and social skills training. There is also interest in applying cognitive remediation techniques in schizophrenia; see discussions by Spring and Ravdin (1992) and Liberman and Green (1992). However, while the application of various cognitive techniques with persons with schizophrenia has been a subject of studies for a number of years, there have been few randomized controlled trials that would support firm conclusions on efficacy or effectiveness. Because the trend is toward incorporating these cognitive approaches into social skills training, we have used the term "psychosocial skills training" rather than the more traditional "social skills training" in referring to these interventions.

In dividing psychological interventions into individual therapies, group therapies, and psychosocial skills training, we recognize that we run the risk of confusing the intervention's typology or modality with its format. We selected this organizational structure because it generally corresponds with the organization of the literature and of service systems that offer individual and group therapies. We also recognize that our categories of specific interventions may seem somewhat arbitrary. For example, a group therapy study may also use some skills training techniques This blending of components reflects the evolution of increasingly more disease-specific psychological interventions in the care of persons with schizophrenia over the last two decades. Our discussion and conclusions will accordingly consider the data from the perspective of both typology of treatment and format.

Assuming that patients are otherwise receiving adequate clinical care (including antipsychotic medications), this review addresses the following questions:

1. Do any of these interventions reduce relapse or psychopathology in persons with schizophrenia?

2. Do any of these interventions improve social or vocational functioning in persons with schizophrenia?

3. For psychosocial skills training, is there evidence that (1) this intervention results in skill acquisition by persons with schizophrenia? (2) the effects persist over time? and, (3) the effects generalize from the training setting into "real life"?

Disorders - Schizophrenia