Psychiatric rehabilitation of schizophrenia: Unresolved issues, current trends, and future directions

Applied & Preventive Psychology 9:227-248 (2000). CambridgeUniversityPress. Printed in the USA.

Copyright © 2000 AAAPP0962-1849/00 $9.50

Psychiatric rehabilitation of schizophrenia: Unresolved issues, current trends, and future directions STEVEN M. SILVERSTEIN Weill Medical College of Cornell University and New York Presbyterian Hospital

Abstract Psychiatric rehabilitation refers to a treatment philosophy and to a set of assessment and treatment techniques designed to reduce disability and maximize environmental adaptation. The field of psychiatric rehabilitation of schizophrenia is now well developed, and successful interventions exist for teaching many essential community-living skills and for promoting maintenance and generalization of these gains. Recent developments include the creation of new skillstraining interventions and cognitive rehabilitation techniques and improvements in the delivery of vocational and substance abuse treatments. As a field, psychiatric rehabilitation is continuing to develop in a manner that is responsive to perceived treatment needs, shortcomings of existing interventions, and developments in related fields (e.g., social psychology, neuroscience of schizophrenia). Some of these developments in theory and research point to areas of conceptual/theoretical weaknesses in existing treatments and assessment measures and suggest directions for further development. This article reviews the current status of a number of areas within the psychiatric rehabilitation of schizophrenia, highlighting future needs. Key words: Assessment, Cognitive rehabilitation, Psychiatric rehabilitation, Schizophrenia

The consequences of schizophrenia, in terms of both public health costs and effects on lives, is enormous. For example, the lifetime prevalence of schizophrenia is approximately 1% of the population 18 years and older, with a current worldwide incidence calculated at over 20 million people. It has been estimated that as many as 10% of all disabled persons in the United States have schizophrenia (Rupp & Keith, 1993), and the disorder accounts for 75% of all mental health expenditures and approximately 40% of all Medicaid reimbursements (Martin & Miller, 1998). Among people with the disorder, only between 10% to 30% are employed at any one time (Attkisson et at., 1992), and few of these people are able to maintain consistent employment (Policy Study Associates, 1989). Studies have consistently found that quality of life among people with schizophrenia is significantly poorer than among the rest of the population (Lehman, Ward, & Linn, 1982). Schizophrenia typically is diagnosed in late adolescence or early adulthood and in approximately 50% to 70% of cases is characterized by a chronic, relapsing course with I would like to thamkMichi Hatashita-Wong,Nadine Revheim,Joanna Fiszdon, and LindsaySchenkelfor their helpfulcritiquesof earlier versions of this article. Send correspondenceand reprintrequeststo: StevenM. Silverstein,Weill Medical College of Cornell University, 21 Bloomingdale Road, White Plains, NY 10605. E-mail: [email protected]

high morbidity and permanent disability. In addition, rates of mortality and somatic morbidity are higher in schizophrenia than in the general population (Lieberman & Coburn, 1986), and the rate of attempted suicide equals that of major depression (Simpson & Tsuang, 1996). The economic costs of treating schizophrenia have been estimated at over $33 billion per year in the United States, with direct costs of treatment equaling indirect costs (e.g., lost business productivity due to patient and family caretaker work absence) (Rice, Kellman, & Miller, 1991; Rice & Miller, 1993, 1996). Despite advances in psychopharmacology, many patients have suboptimal responses, and relapse rates remain high (Kane & Marder, 1993). Perhaps the biggest reason for the latter is that medications do not and can not address the social disability and skills deficits that many people with schizophrenia have, due to the social and cognitive consequences of having a psychotic disorder and to premorbid developmental abnormalities. These deficits in living skills are thought to be major factors involved in the high stress levels and impoverished support systems of many patients and in their high vulnerability to relapse (Liberman & Corrigan, 1993). It is generally agreed, therefore, that in addition to optimal medication treatment schizophrenia patients require interventions that directly teach them the life skills needed to live successfully in the community. This statement is sup227

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ported by research indicating that: (a) psychiatric symptoms are not strong predictors of treatment outcome or community functioning (Green, 1996), whereas the presence of specific skills deficits and cognitive deficits have been related to poorer outcomes across a number of domains (Green, 1996; Green, Kern, Braff, & Mintz, 2000; Presly, Grubb, & Semple, 1982; Schretlen et al., 2000; Silverstein, Schenkel, Valone, & Nuernberger, 1998c); and (b) the likelihood of successful discharge from a hospital and adherence to an outpatient treatment program can be predicted by degree of social and adaptive living skills (Kopelowicz, Wallace, & Zarate, 1998; Paul & Lentz, 1977). Moreover, a recent meta-analysis of 106 studies indicated that combined psychosocial and pharmacologic treatment demonstrated outcomes that were .39 standard deviations better than with medication alone, in addition to relapse rates that were 20% lower over a 12month period (Mojtabi, Nicholson, & Carpenter, 1998). A class of assessment and intervention strategies that focuses on the goal of directly improving psychosocial functioning has come to be known as psychiatric rehabilitation. It should be noted at the outset that the paradigm underlying psychiatric rehabilitation is different from that of the traditional medical model. While the medical model focuses on the identification of signs and symptoms of illness and their removal through medical intervention, rehabilitation focuses on the reduction of disability and the promotion of more effective adaptation in the individual's environment. Psychiatric rehabilitation is based on the assumption that adequate community adaptation is a function of three factors: the characteristics of the individual (e.g., symptoms, cognitive abilities, personality, etc.), the community's requirements for adequate functioning, and the supportiveness of the environment (Wallace, Liberman, Kopelowicz, & Yaeger, 2000). Therefore, each of these three domains is a focus of assessment and treatment. Over the past 25 years, the field of psychiatric rehabilitation has developed and expanded greatly, and much is now known about the application of this approach to schizophrenia (Corrigan & Liberman, 1994; Heinssen, Liberman, & Kopelowicz, 2000; Liberman, 1992; Wallace et al., 2000). At the same time, large areas of the field lack strong theoretical bases, and more research is needed regarding a number of interventions. In this article, I will review the current status of psychiatric rehabilitation of schizophrenia, paying particular attention to those areas needing further conceptual and theoretical development. Because it is impossible to thoroughly review all areas in this growing field within the space of one article, and indeed each topic could fill its own lengthy review, the focus of this article will be on specific assessment and skill-building techniques that are administered or delivered directly to patients themselves. Therefore, certain important innovations in the treatment of schizophrenia that do not fall strictly into these categories will not be covered. These include outreach programs such as assertive community treatment (ACT; Burns & Santos, 1995), family-based

treatments (Dixon, Adams, & Lucksted, 2000), and the use of consumers as providers of services (Sherman & Potter, 1991). In addition, other important interventions that can be considered well developed, such as therapeutic contracting (Heinssen, Levendusky, & Hunter, 1995), will not be reviewed. The reader interested in further information on these important topics is urged to consult the references noted previously. Assessment The cornerstone of any good treatment plan is a thorough assessment of a person's strengths and weaknesses. Therefore, it is not surprising that a great deal of effort has gone into developing and validating assessment instruments relevant to psychiatric rehabilitation. At this point in the field's evolution, three trends are noteworthy. One is the continued development of functional assessment techniques. A second is a focus on cognitive assessment. The third represents a shift from static to dynamic assessment methods. Each of these will be considered in turn in the next section, followed by a brief discussion of the role of symptom assessment in psychiatric rehabilitation. Functional Assessment Wallace (1986) published a thorough review of functional assessment methods available in the mid-1980s. At that time there were already a number of available instruments. One of the issues Wallace's review highlighted was the different loci and methodology of the rating scales. For example, some of the scales led to global ratings of performance in roles such as employee, whereas others provided detailed assessments of performance in more narrowly defined areas, such as money management and personal hygiene. In addition, some of the scales were meant to be completed by patients, some by significant others, and some by staff. Many of the scales reviewed by Wallace (1986) are still in widespread use and provide useful data. Reviews by Vacarro, Pitts, and Wallace (1992) and Dickerson (1997) provide comprehensive reviews of older and more recently developed functional assessment instruments, highlighting their strengths and weaknesses. One difficulty with many older scales is that a comprehensive assessment of functioning across areas requires the assembly of a potentially large battery of measures. More recently, a number of instruments have been developed with the goal of providing the information needed for a comprehensive assessment in a single measure. This is consistent with recent literature reviews and consensus conferences of stakeholders of mental health services that have developed criteria for functional assessment instruments (IAPSRS, 1987; Liberman, Kuehnel, & Backet, 1998; Menditto et al., 1999; G. R. Smith, Manderscheid, Flynn, & Steinwachs, 1997). Characteristics of these newer measures include: (a) the ability to assess, in both inpatient and outpatient settings, functioning in the types of roles characteristic of people with serious mental illnesses; (b) the inclusion of

Psychiatric Rehabilitation

information from multiple sources; (c) a focus on strengths and skills rather than on deficits and symptoms; (d) assessment of a wide range of skills relevant for successful community living; (e) an easy-to-administer format; and (f) established reliability and validity (Menditto et al., 1999). One such new measure is the Client's Assessment of Strength, Interests, and Goals (CASIG; Wallace, Lecomte, Wilde, & Liberman, in press). The CASIG is administered as a structured interview that begins by eliciting the individual's medium-term goals in five areas of community living: housing, money/work, interpersonal relationships, health, and spiritual activities. Follow-up questions clarify these domain-specific goals and ask the patient to specify to the best of his or her ability the services needed to achieve them. The rest of the CASIG involves questions assessing current and past community functioning, medication compliance and side effects, quality of life, quality of treatment, symptoms, and performance of intolerable community behaviors. The current version of the CASIG includes a computer program that accepts the data, summarizes it, and generates a rehabilitation plan. Another useful measure is the Independent Living Skills Inventory (ILSI; Menditto et al., 1999). The ILSI was developed at the University of Nebraska to measure a person's ability to perform a range of skills needed for successful community living. A unique feature of the scale is that each item is rated along two dimensions. One is the degree to which the skill can be performed, and the other is the degree of assistance required to perform the skill. This scoring method is useful in planning a rehabilitation program because it distinguishes between skills deficits and performance deficits, each requiring different forms of intervention. The current form of the ILSI consists of 11 subscales, each representing a different domain of community functioning (e.g., money management, home maintenance, cooking, etc.). A similar but slightly older measure is the Independent Living Skills Survey (ILSS; Vaccaro et al., 1992). The ILSS consists of 188 items that assess performance in 12 areas of functioning. Both self-report and staff-rated versions of the ILSS are currently available. A recent study of the ILSS and ILSI demonstrated that they have excellent reliability and validity, and that they are sensitive to treatment effects (Menditto et al., 1999). In addition, both measures are relatively brief to administer and have high face-validity making them relatively user-friendly. The CASIG, ILSI, and 1LSS represent the new wave of assessment measures in that they provide comprehensive measurement of a number of areas known to be important for community living and they provide results that lend themselves easily to planning a rehabilitation program. Increased use of measures such as these can provide a relatively seamless transition from assessment to treatment and can assist in monitoring progress. Despite the many favorable characteristics of these measures, however, they remain underused (Menditto et al., 1999). Part of the reason for this is that func-

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tional assessment has traditionally been the domain of occupational therapists, with psychologists not receiving training in this area. All of these instruments were developed by psychologists, however, so at least within the clinical-research field, psychologists have gotten more involved in functional assessment. Therefore, the lack of widespread use of these measures is probably largely a symptom of the bigger problem of disseminating effective techniques and interventions, an issue that will be covered later in this article. One potential problem with self-report-based measures of behavioral functioning is that patients with severe cognitive impairment, thought disorganization, and/or delusional thinking may provide inaccurate information. In general, selfreport measures such as the CASIG are most useful for outpatients or for higher functioning inpatients and day-hospital patients who are clearly able to articulate realistic goals and whose behavior approximates community standards. For other patients, where the treatment focus is on the elimination of inappropriate behaviors and the generation of independent living skills, performance-based and observational measures are the most appropriate. Multimodal behavioral assessment techniques (Barlow & Hersen, 1984; O'Brien & Haynes, 1993) can be useful in this regard. One class of behavioral assessment techniques involves role plays (e.g., Bellack, Morrison, Mueser, Wade, & Sayers, 1990; Bellack, Mueser, Gingerich, & Agresta, 1997). These have been found to provide important data that can guide treatment planning and gauge response to treatment. In the end, the decisions as to how much self-report data can be relied on and how much direct observational data are needed to plan treatment and/or discharge must be determined clinically on a case-by-case basis based on interview and other assessment data. In addition to the ILSI previously described, there are several comprehensive, observational assessment systems that have demonstrated utility for long-term inpatient treatment. A number of these were initially described in Paul and Lentz's (1977) landmark study of inpatient social-learning treatment. One of these measures is the Time Sample Behavioral Checklist (TSBC; Paul, 1987), which is an observational rating scale used by staff to indicate the frequency of a range of appropriate and inappropriate behaviors. TSBC observations are made on a regular schedule during all waking hours for all patients in a residential treatment program, yielding a weekly average of about 100 observations per person. These observations allow a treatment team to track behaviors as specific as degree of social interactiveness, bizarre behavior, facial expression, and many others. A second measure developed by Paul and colleagues is the Clinical Frequencies Recording System (CFRS; Paul & Lentz, 1997). This is also an observational scale, but it uses event-sampling procedures to record the occurrence of clinically relevant behaviors (e.g., aggressive outbursts) as they occur. The third key measure developed as part of the Paul and Lentz (1977) project is the Staff-Resident Interaction Chronograph (SRIC; Paul, 1988). Data for the SRIC is

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recorded by noninteractive observers on the unit using stratified time-sampling techniques similar to those used with the TSBC. The purpose of the SRIC is to obtain data on the nature of staff-patient interactions. SRIC data can therefore be used to monitor both patient social skills as well as the adherence of staff to prescribed therapeutic behaviors. The TSBC, CFRS, and SRIC have all demonstrated excellent psychometric characteristics and have been successfully disseminated to treatment programs other than where they were developed, although the number of such programs is far fewer than would be expected given the results they can help produce. Together, these instruments can form the backbone of a residential treatment program. Indeed, to this day the Paul and Lentz (1977) study remains the most comprehensive study of different models of inpatient treatment, demonstrating clear superiority for the unit integrating the previously described behavioral assessment measures within a program based on social-learning principles. In short, although underused, a number of powerful functional assessment measures exist for the psychiatric rehabilitation of schizophrenia. As empirically demonstrating outcomes is becoming increasingly important in the current managed-care environment, it is likely that these measures will see more widespread use, and that additional, similar measures will be developed.

Cognitive Assessment The rationale for performing cognitive assessments of schizophrenia patients is now clear. Impairments are often found in the areas of visual information processing (Green, 1998; Knight & Silverstein, 1998), attention (Nuechterlein, 1991; Silverstein, Light, & Palumbo, 1998), working memory (Docherty et al., 1996; Park & Holzman, 1992), shortterm memory (Calev, Korin, Kugelmass, & Lerer, 1987; Silverstein, Osborn, & Palumbo, 1998), executive functioning (Goldberg, Weinberger, Berman, Pliskin, & Podd, 1987), context processing (Cohen, Barch, Carter, & Servan-Schreibet, 1999; Cohen & Servan-Schreiber, 1992; Silverstein, Matteson, & Knight, 1996), and social perception and cognition (Silverstein, 1997). Although no single profile of cognitive deficits has been found to characterize all schizophrenia patients, the majority have impaired ability in at least one area of functioning. For example, Morice and Delehunty (1996) found that 94% of outpatients with schizophrenia had a deficit in at least one component of executive functioning. Palmer et al. (1997), examining a wide range of abilities, found abnormal neuropsychological performance in 89.9% of 171 schizophrenia patients. Moreover, as the authors noted, this figure might have been even higher had computerized, experimental, information-processing paradigms been used instead of neuropsychological tests. This is because computerized cognitive measures allow for more precise control of stimulus exposure and measurement of relevant variables (e.g., reaction time, critical stimulus duration required to develop a memory trace, etc.) and are typically

less confounded by extraneous cognitive processes. Thus, these tests can often detect subtle impairments that might go undetected when clinician-administered or paper-and-pencil neuropsychological tests are used. The data cited previously indicate the generally high prevalence of neurocognitive deficits in people with schizophrenia. Of course, individual patients vary in the types and severity of deficits they have, and this is another reason why individual assessments are necessary. Another rationale for performing a cognitive assessment is that different types of deficits are related to specific types of poor outcomes. For example, a growing body of evidence indicates that deficits in sustained attention and verbal memory are associated with less skill acquisition in treatments such as the UCLA Social and Independent Living Skills modules (Bowen et al., 1994; Corrigan, Wallace, Schade, & Green, 1994; Kern, Green, & Satz, 1992; Mueser, Bellack, Douglas, & Wade, 1991; Silverstein, Light, et al., 1998; Silverstein, Schenkel, et al., 1998; Wallace, Liberman, MacKain, Blackwell, & Eckman, 1992). One conclusion that can be drawn from these studies is that patients who are impaired in their ability to sustain attention to a task and/or to remember material presented to them will benefit little from the treatment. Neurocognitive deficits, including poor attention span, are also predictive of poorer outcome in other domains, including community outcomes, work performance, and social problem solving (reviewed in Green, 1996; Green et al., 2O00). Although the rationale for performing cognitive assessments in schizophrenia is clear, there is less clarity on the best way to proceed. For example, although traditional assessments have been successful in identifying performance deficits in schizophrenia, many of these tests are confounded by multiple cognitive processes, are not strongly tied to theories of cognition, and/or cannot aid in determining whether poor performance is caused by a specific cognitive dysfunction or to a generalized performance deficit. These are serious problems because they reduce the ability of the clinician to use the test data to develop or choose specific interventions. Over the past several years, approaches for ensuring the construct validity of cognitive assessment data have been proposed (e.g., Knight & Silverstein, 1998, 2000). Arecent suggestion involves the exploration of the generalized deficit itself in order to determine whether multiple performance deficits in schizophrenia may be the result of a common underlying deficient process (Knight & Silverstein, 2000). This can now be explored because of recent developments in cognitive psychology, cognitive neuroscience, computational neuroscience, and related fields. For example, investigators in these fields have begun to explore processing algorithms that are common to diverse cortical regions and that may subserve various forms of low-level to high-level cognition (Grossberg, 1999; Phillips & Singer, 1997). In addition, the traditional exclusive focus on localization of brain dysfunction has begun to be balanced by a recognition of the importance of disrupt-

Psychiatric Rehabilitation

ed neural circuitry (Andreasen, Paradiso, & O'Leary, 1998; O'Donnell & Grace, 1998; Hoffman & McGlashan, 1993). These trends have infiltrated theory development about cognitive deficiencies in schizophrenia, where unifying models have been proposed to account for what initially appeared to be multiple cognitive impairments (Cohen & ServanSchreiber, 1992; Knight & Silverstein, 1998; Phillips & Silverstein, 2000; Silverstein & Schenkel, 1997). For example, Cohen and Servan-Schreiber (1992) demonstrated how a dopaminergically mediated impairment in the ability to maintain an internal representation of context during ongoing behavior could account for performance on seemingly diverse tasks such as the Stroop Interference task, the A-X continuous performance test, and a lexical disambiguation task. In addition, several studies have demonstrated theoretically meaningful links between specific cognitive deficits and aspects of behavior, symptomatology, and/or prognosis (Knight & Silverstein, 1998; Silverstein, Bakshi, Chapman, & Nowlis, 1998; Silverstein, Kov~ics, Corry, & Valone, 2000). These findings suggest that the presence of multiple impairments in schizophrenia may be both meaningful and explainable and ought not to be regarded either as a nuisance variable that must be controlled or as reflecting numerous separate cognitive deficits. In particular, these data suggest that, rather than reifying poor neuropsychological test performance into new variables with limited meaning (e.g., a deficit on the Wisconsin Card Sorting Test), a framework is developing within which we can view multiple performance deficits as reflecting dysfunctions in cortical processing algorithms that cut across multiple areas of functioning. This is an exciting development whose application to psychiatric rehabilitation interventions has not yet begun. A necessary first step toward bridging cognitive neuroscience with a neuroscientifically informed psychosocial rehabilitation approach is the development of or use of preexisting measures that can assess constructs that are theoretically tied to both overt behavior and underlying biological processes. Thus far, little attention has been paid to this issue, even though cognitive psychology can provide a number of such measures. This is unfortunate since neuropsychological assessment, which has been the dominant paradigm for cognitive testing in schizophrenia, has major theoretical and empirical problems when applied to schizophrenia. These include but are not limited to: (a) the use of tests developed to detect a single lesion in cases of acute/acquired brain injury among patients with a psychiatric disorder that is neurodevelopmental in origin; (b) the use of tests, designed to be given to patients with known brain injury to determine behavioral sequelae, among patients for whom the nature of the brain dysfunction is not known and must be inferred from performance; (c) the use of tests that are confounded by multiple cognitive processes in a population with multiple performance deficits; and (d) the poor convergent and discriminant validity of many neuropsychological tests (Strauss & Summerfelt, 1994). Indeed, arguments have been made sug-

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gesting that paradigms from cognitive psychology have greater utility for assessing schizophrenia patients' impairments than do neuropsychological tests (Knight & Silverstein, 1998, 2000; Strauss & Summerfelt, 1994), and that developmental disorders represent more appropriate comparison groups than brain-injured adults (Silverstein & Palumbo, 1995). As with recent functional assessment measures, however, few treatment settings routinely use measures developed from within cognitive psychology, even though they are often easier to administer than conventional neuropsychological tests. Fortunately, relevant cognitive psychological paradigms exist that can readily be administered to patients with schizophrenia. For example, Neath, Surprenant, and Crowder (1993) developed a measure of context processing that conforms closely to Cohen and Servan-Schreiber's (1992) model. This measure has already been used to demonstrate a context processing deficit in schizophrenia (Silverstein et al., 1996), and it provides between-condition results that are theoretically meaningful and can be distinguished from results caused by poor motivation. Another potentially useful paradigm involves contour integration. Contour integration is a basic process of the visual system, involving the linking of visual features so that they are perceived as coherent wholes (Kovfics, 2000). On the other hand, it is thought to involve long-range horizontal connections between spatial filters in the visual system (Kovfics, Kozma, Feh6r, & Benedek, 1999) that are thought be identical to the long-range connections necessary to link relevant bits of information together in other areas of cognition such as selective attention, lexical disambiguation, memory, and learning (Phillips & Singer, 1997), all of which are impaired in schizophrenia (Carr & Wale, 1986; Cohen et al., 1999; Cohen & Servan-Schreiber, 1992; Patterson, Spohn, Bogia, & Hayes, 1986; Silverstein et al., 1996; Silverstein, Bakshi et al., 1998). Therefore, studies of contour integration can be viewed as a "window" into a core processing deficiency in schizophrenia. In addition, contour integration is thought to be a paradigmatic example of synchronization of neural activity. Although the functional significance of neuronal synchronization is still being debated (e.g., Eckhorn, 1999; Lamme, Supbr, Landman, Roelfsema, & Spekreijse, 2000; Singer, 1999), synchronization of neuronal responses, especially within the gamma band, is thought to be critical for a number of aspects of cognitive processing and has been hypothesized to be deficient in schizophrenia (Green, Nuechterlein, Breitmayer, & Mintz, 1999; Phillips & Singer, 1997; Silverstein & Schenkel, 1997; Silverstein, Bakshi et al., 1998; Silverstein et al., 2000). Studies have already demonstrated that schizophrenia patients (Chen, 2000; Silverstein et al., 2000) but not unaffected relatives (Silverstein, Dworkin, Wynne, & Carr, 1999) are deficient in contour integration, and that this reduced ability to organize stimulus elements is related to clinical aspects of disorganization. Moreover, schizophrenia patients have demonstrated a reduced ability to benefit from cues that could facilitate learn-

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ing how to improve contour integration performance (Chen, 2000). Data from nonclinical populations indicate that contour integration ability continues to develop through late adolescence and can improve with practice over several days (Kov~cs et al., 1999). Taken together, this evidence suggests that level of development and degree of improvement with practice may provide useful information about the cortical plasticity and therefore the learning potential of the patient (see next section for further discussion of learning potential). To date, advances in the field of cognitive neuroscience have had virtually no impact on the field of psychiatric rehabilitation, even though they have revealed much about processes (e.g., context processing, emotion processing, learning, etc.) that rehabilitation practitioners are attempting to address in their patients. The previous discussion highlighted a small portion of interdisciplinary work that is relevant to the field of psychiatric rehabilitation. Greater appreciation of this work has the potential to refine our understanding of schizophrenia, which in turn could lead to improved assessment and intervention techniques.

Dynamic Assessment Most traditional cognitive and functional measures can be viewed as forms of static assessment in the sense that they measure the skills a person has at any given moment, as opposed to what he or she is capable of learning and therefore of a person's potential ability. This issue has been faced earlier in other areas, such as intelligence testing, and has led to the development of methods of "dynamic assessment" or, more specifically, "learning potential assessment" (Budoff, 1987). The goal of dynamic assessment is to quantify learning potential This is accomplished by incorporating sensitive methods for assessing the ability to improve with instructions and/or practice into the testing conditions. Some traditional neuropsychological tests, such as measures of verbal/list learning, use change over time as key test indices. However, degree of change typically has not been used as an index in studies of schizophrenia, even though both initial learning (immediate memory) and total amount learned have been found to be related to treatment outcome (Green, 1996; Green et al., 2000; Silverstein, Schenkel et al., 1998). Recently, dynamic assessment methods have been applied to the Wisconsin Card Sorting Test (WCST; Berg, 1948). This is a commonly used measure of executive functioning on which schizophrenia patients typically perform poorly. Using a specific training protocol for the WCST, Green, Ganzell, Satz, and Vaclav (1990) demonstrated clinically meaningful differences between learners and nonlearners. These findings have recently been replicated and extended by Weidl and Weihhobst (1999). As with many of the other measures noted previously, this technique has not achieved widespread use among rehabilitation practitioners, despite the potential for classifying patients in ways that could enhance the effectiveness of their treatment plans. A more face-valid form of dynamic assessment, called the

Micro-Module Learning Test, has been recently developed by Charles Wallace and colleagues at the UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation (Robert Liberman, M.D., Principal Investigator; Liberman, 1999; Silverstein, Schenkel et al., 1998). The MMLT, which has seven psychometrically equivalent alternate forms, is a brief measure of responsiveness to the three core components involved in skills training (see the text that follows): verbal instruction, modeling, and role play. The MMLT was developed, in part, because there was a need for a relatively brief and accurate assessment tool that would predict a patient's performance before being placed in a skillstraining intervention, which often lasts from 3 to 6 months. Although successful prediction of performance in skills training has been achieved using traditional neuropsychological measures (see previous text), an assumption driving the development of the MMLT was that it uses a basic structure and content that are similar to skills-training procedures, and that this would achieve greater ecological and predictive validity than previously used predictor measures. In this way, clinicians can determine, before placing a patient in a group, whether they are likely to benefit from that group or whether they initially need other interventions, such as cognitive rehabilitation (see the text that follows). To date, few dynamic assessment methods have been developed to assist in the psychiatric rehabilitation of schizophrenia. This is therefore an area that needs much further development. There is cause for optimism, however, as the importance of measuring learning potential has now been discussed in several articles on or related to psychiatric rehabilitation of schizophrenia (e.g., Green et al., 2000; Liberman, 1999; Silverstein, Schenkel et al., 1998). Moreover, there is now a growing body of data indicating that impairments in learning potential are related to symptoms (Knight & Silverstein, 1998; Silverstein, Bakshi et al., 1998; Silverstein, Schenkel et al., 1998), and that poor performance on measures reflecting an ability to generate effective top-down (e.g., learned) strategies during cognitive tasks relates to both poorer premorbid functioning and long-term prognosis (Silverstein, Schenkel et al., 1998). Hemsley and Murray (2000) note that Green et al.'s (2000) discussion of learning potential overlaps with the older concept of automatization of task performance, which also overlaps with the concept of topdown influences on cognition (e.g., Silverstein et al., 1996). Several studies have already demonstrated that failures to automatize processing are related to a more severe form of schizophrenic illness (e.g., Knight, 1992, 1993; Knight & Silverstein, 1998). In addition, the importance of incorporating the concepts of automatization and learning into both models of social cognition in schizophrenia and rehabilitation technology was suggested several years ago (Silverstein, 1997) and is now receiving more attention in the cognitive rehabilitation literature (Hogarty & Flesher, 1999a, 1999b). All of these developments suggest that the zeitgeist in the fields of rehabilitation and cognitive science is converging

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in their recognition of the importance of assessing ability to modify performance. If this trend continues, it may eventually allow for an integrated determination of: (a) the plasticity of basic learning mechanisms or overall learning potential (using measures such as the contour integration paradigm); (b) the ability to learn specific types of skills (using measures such as the MMLT and as-yet-developed dynamic, functional assessment measures); and (c) which skills need to be learned, using static functional assessment measures such as the ILSS and ILSI (Liberman, 1999).

Symptom Assessment A comprehensive assessment of schizophrenia should always involve a thorough assessment of symptoms. Careful description of the frequency and intensity of symptoms can guide the choice of pharmacologic and behavioral methods targeted at symptom reduction (Haddock, Sellwood, Tarrier, & Yusupoff, 1994; Schwarzkopf, Crilly, & Silverstein, 1999; Spaulding, Storms, Goodrich, & Sullivan, 1986). It is important to note, however, that symptom response is relatively independent of response to other targets of treatment (Carpenter, Bartko, Carpenter, & Strauss, 1976; Wallace et al., 2000). Thus, symptom assessment alone is insufficient as an assessment strategy for schizophrenia, where many other areas of potential disability (e.g., social and instrumental role functioning) will affect long-term prognosis. A number of symptom rating scales are currently in widespread use. These include the Brief Psychiatric Rating Scale (BPRS; Ventura, Lukoff, Nuechterlein, Liberman, Green, & Shaner, 1993); Scale for the Assessment of Negative Symptoms (SANS; Andreasen, 1984a); Scale for the Assessment of Positive Symptoms (SAPS; Andreasen, 1984b); and the Positive and Negative Syndrome Scale (PANSS; Kay, Opler, & Fiszbein, 1987). Each of these provide important information on symptom dimensions and are based on theoretical models of symptomatology in schizophrenia. These measures are not without their conceptual and psychometric weaknesses, however. These include problems in the operationalization of symptom constructs, in the determination of which symptoms define a syndrome (e.g., positive versus negative versus disorganized syndromes), and in the specification of what relationships syndromes have with each other (Knight, 1987). For example, among a number of rating scales that were developed after the positive versus negative symptom distinction in schizophrenia gained popularity in the 1980s, a symptom (e.g., attention deficit/distractibility) that was classified as positive on one scale might be classified as negative on another. Although it could be argued that factor-analytic approaches can resolve this issue by tying syndrome assignment solely to the results of statistical analysis, the situation is not so simple. One potential confound is poor specificity of individual items. For example, in a review of the literature on Andreasen's (1982) Affective Flattening Scale and Abrams and Taylor's (1978) Scale for Emotional Blunting, Knight and Roff (1985) found that several items on

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these scales did not differentiate between flat affect and depression. Moreover, some items used to judge the presence of flat affect were actually more likely to select for depression (Knight, 1987). Further adding to the complexity of symptom ratings are the often poorly defined behavioral criteria used to define symptoms. This increases the likelihood of different research and/or clinical sites adopting different criteria for the same symptoms (e.g., Boeringa & Castellani, 1982; Knight, 1987). Finally, the field is not in general agreement about the actual number of symptom clusters in schizophrenia. During the past 15 years or so, this number has been found to be two (Kay et al., 1987), three (Buchanan & Carpenter, 1994; Liddle, 1987; Liddle & Barnes, 1990), four (Cuesta & Peralta, 1994; Lenzenweger & Dworkin, 1996), and five (Lindenmeyer, Bernstein-Hyman, & Grochowski, 1994). Often, these differences are caused by variations in the patient sample, including differences in stage of illness, time since onset of psychotic episode and/or initiation of treatment, and setting (e.g., acute inpatient ward versus VA hospital versus state hospital versus outpatient clinic). The importance of this is that, if the number of syndromes to be derived from a rating scale is not appropriate for the population being rated, then the items comprising each scale may have low correlations with each other in that sample, producing misleading syndrome diagnoses and differences in the meaning of syndrome labels across sites. A number of these issues were highlighted in a recent study of the PANSS in which data from a sample of 1,233 patients were used to test the fit of 20 previously proposed syndrome models to empirical data (White, Harvey, Opler, Lindenmayer, and the PANSS Study Group, 1997). None of the models met criteria for adequate fit to the empirical data. In contrast, a new model was proposed that organizes 25 of the 30 items into five factors. To date, however, this model has received little use. Another important consideration in assessing symptoms is that their expression may vary over time. For example, negative symptoms have been found to be more persistent than positive symptoms (Lewine, 1990). Thus, as with functional assessment measures, symptom ratings should be repeated on a regular basis to determine treatment response and the interference of symptoms on other areas of functioning. As will be discussed below in the section "Successful Integration of Psychiatric Rehabilitation and Pharmacotherapy," medication side effects can have deleterious effects on the ability to benefit from rehabilitation interventions. This situation requires that the medication prescriber carefully assess the severity of symptoms and the minimum amount of medication required in order to achieve a balance of symptom control and cognitive functioning that would be optimal for role functioning in each case. Finally, an almost completely neglected issue in symptom assessment is the context in which the assessment takes place. Several largely ignored studies have demonstrated that symptomatology severity and frequency can vary as a func-

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tion of context. For example, Alpert (1985) noted that, in recruiting schizophrenia patients at a city-run hospital for a research study, sufficient numbers of hallucinating and nonhallucinating patients could be found, whereas at a local VA hospital, no nonhallucinating patients could be found. This difference could not be accounted for by demographic, patient, or clinician factors, leading Alpert to the conclusion that "the symptoms are responding to different contingency systems. In Bellevue, when the patient hallucinates they raise the dose. At the VA, they raise the compensation" (p. 264). This observation is consistent with older data on impression management in schizophrenia (e.g., Braginsky, Grosse, & Ring, 1966) and with findings that level of psychotic symptoms displayed on an inpatient ward could be increased or decreased by altering discriminative stimuli (Salzinger, 1984; Zarlock, 1966). For example, during 10 days in which a large "day room" was filled only with medical information (e.g., posters, brochures, etc.), 324 instances of bizarre speech occurred. In contrast, when the same room was altered to include either occupational, social, or recreational stimuli only, the frequency of bizarre speech events was 12, 12, and 3, respectively. Similar results were obtained on the variable of bizarre behavior (Zarlock, 1966). Although it is important not to conclude from these data that symptoms are purely a function of environmental stimuli, it is also important to recognize the context in which symptom expression occurs, and that this expression may be very different in contexts other than a traditional mental status exam given by a psychiatrist. Thus, including an assessment of contextual factors during symptom rating and of degree of variability across contexts could potentially produce a more valid assessment of a patient's real-world level of symptoms, functioning, and outcome than a single exam conducted in a doctor's office. Psychiatric Rehabilitation Interventions The development of psychiatric rehabilitation interventions in schizophrenia can be seen as a response to the stress-vulnerability model of schizophrenia (Zubin & Spring, 1977). This model's focus on stress as a precipitating factor in symptom emergence implies that increasing patients' level of coping skills should lead to increased protection against relapse. The primary goal of psychiatric rehabilitation interventions, therefore, is to modify the patient's behavioral repertoire so that he or she can more effectively cope with life stressors. Additional goals involve modifying the patient's environment (e.g., via family-based interventions) to reduce stress levels. The goal of increasing skills levels has been met in a number of ways. Several of these methods will be discussed in the text that follows, including skills training, cognitive rehabilitation, vocational rehabilitation, and substance abuse interventions. It should be noted at the outset that, despite their demonstrated effectiveness, skills-training approaches are sometimes criticized because their gains may disappear over time.

It is a curious phenomenon that this criticism can be, but is almost never, applied to pharmacotherapy, where cessation of treatment leads to reemergence of the target symptoms in the overwhelming majority of cases. This underscores the need for a greater appreciation of schizophrenia as a lifelong illness. Indeed, all the evidence points to schizophrenia being a chronic condition that requires intensive treatment, with a focus on relapse prevention as well as acquisition, maintenance, and generalization of appropriate living skills, both in the hospital during acute episodes and in the community over the long term. All of the interventions that will be described can be, but are often not, used across the spectrum of care, from inpatient to outpatient. A challenge for service-delivery systems is to ensure that these effective interventions are integrated into all levels of care.

Skills Training For many clinicians, the "bread and butter" of psychiatric rehabilitation of schizophrenia is skills training. Skills-training approaches directly teach patients how to perform the skills that are necessary for effective community functioning. Current skills-training approaches are an outgrowth of older operant-conditioning methods. For example, early behavioral methods used primary reinforcers (e.g., food) to increase the frequency of spontaneous speech in patients (Wallace & Davis, 1974). These interventions were found to be successful in the treatment room, but did not generalize. Later developments incorporated cognitive-behavioral methods such as exercises to promote generation of appropriate topics and recognition and production of appropriate nonverbal cues (Wallace, 1982). Eventually, it was recognized that effective skills training for schizophrenia would need to address a variety of issues in addition to the skills deficits themselves, including attention, memory, learning, and problemsolving deficits, the lack of opportunities to perform many skills outside of the skills-training experience, and the necessity to promote generalization to nontreatment environments (Corrigan & McCracken, 1997; Wallace & Boone, 1984). In addition, it was recognized that effective rehabilitation of schizophrenia would need to simultaneously target the multiple deficits that characterize many schizophrenia patients to maximally affect outcome (Anthony & Liberman, 1992). In response to these challenges, investigators at the UCLA Clinical Research Center for Schizophrenia and Psychiatric Rehabilitation developed a number of highly structured interventions called the Social and Independent Living Skills (SILS) modules (Liberman & Corrigan, 1993). Currently, eight SILS modules are available: Medication Self-Management, Symptom Self-Management, Substance Abuse Management, Recreation for Leisure, Basic Conversation Skills, Interpersonal Problem Solving, Workplace Fundamentals, and Community Re-entry. Additional modules, such as one for friendship and dating skills, are currently under development. Each of the SILS modules breaks down the skills to be taught into

Psychiatric Rehabilitation

their smallest components and then uses repetition and a variety of presentation modalities to promote overlearning of the material. Each module uses the same methodologies and format to teach its targeted skill. Only the content varies across modules. For example, the Basic Conversation Skills module is divided into five skill areas: recognizing verbal and nonverbal cues, starting a friendly conversation, keeping a conversation going, ending a conversation politely, and putting it all together. In contrast, the Workplace Fundamentals module teaches nine skills: knowing how work changes your life, knowing your workplace, knowing your workplace stressors, solving problems, solving health and substance abuse workplace problems, solving mental health workplace problems, coping with supervisors and improving task performance, coping with peers and informal socializing, and getting support and maintaining enthusiasm. The learning activities used to teach each skill are: introduction to the skill area, videotaped presentation of the skills, role playing, resource management, outcome problems, in-vivo exercises, and homework assignments. The first two learning activities present the material to the patients, and question-and-answer sessions are used to ensure that the material is being learned. Role plays provide patients with opportunities to practice the skills and receive feedback and to observe and comment on the role plays of other patients. Resource management teaches patients to understand what steps must be taken to put them in a position to enact the new skill. Outcome problems teach problem-solving techniques that can be used when a skill is performed correctly but the desired result is not obtained. Finally, in-vivo exercises (performed with staff) and homework (done outside of group) encourage generalization of the skills to nontreatment environments. The similarity in format across interventions provides a predictable learning environment for patients who are exposed to multiple groups from the SILS series. In addition, staff can quickly become proficient in additional modules after learning the first one. The UCLA SILS modules have been the subject of numerous studies (see Heinssen et al., 2000, for a recent review). These studies have examined three major outcome domains: (a) skill acquisition and retention, (b) generalization to nontreatment environments, and (c) generalization to other areas of functioning. Studies of skill acquisition and retention have consistently demonstrated that patients learn the skills they are taught (e.g., Eckman et al., 1992; Kopelowicz et al., 1998; Liberman, Wallace et al., 1998; Marder, Wirshing, Mintz, & McKenzie, 1996; Wallace et al., 1992, 2000). In addition, patients have demonstrated retention of their new skills for up to 2 years, the maximum duration measured. There are fewer data on transfer of new skills to outpatients' environments (Wallace et al., 2000). In general, this is an area that needs to be studied. It is clear, however, that certain conditions are necessary for transfer to occur, including opportunities to perform the behaviors, reinforcement for performance, and periodic "booster" training sessions. Recently, efforts have been made to improve the general-

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ization of skills training gains in the community. One method, called In-Vivo Amplified Skills Training (IVAST), uses specially trained case managers who routinely and frequently conduct additional training sessions in participants' environments. These sessions help patients perform and practice their new skills in their community residences. An initial study of IVAST found that patients receiving the intervention achieved higher levels of interpersonal problem.solving skills, significantly greater social adjustment, and better quality of life over a 2-year period than participants with skills-training alone (Blair, Glynn, Liberman, Ross, & Marder, in press; Wallace et al., 2000). A second procedure for promoting generalization involves engaging the preexisting people in the patient's life, including residential care staff, peers, and relatives. People from these groups are selected by patients based on the criteria of cooperativeness, accessibility, and familiarity with the patient's environment. The intervention consists of structured meetings between the patient and the chosen supporters to review the use of the new behaviors, explore the causes of problems in successful performance of the behaviors, and problem solve around how to be more effective. No constraints are placed on the frequency or duration of a pair's meetings (Wallace et al., 2000). Tauber, Wallace, and Lecomte (in press) recently evaluated this procedure. Participants who received both the skills training and the added support improved their interpersonal and community functioning during training and continued to improve during the 18 months following training. In contrast, those without support lost some of their improvements during the follow-up. These data have two important implications. First, including specific interventions for generalization can help improve patients' outcomes. Second, use of these procedures should become a practice standard, given that loss of skills is likely without them. Finally, recent developments in Medicaid reimbursement strategies have begun to shift part of the responsibility for providing care to community residences. This macro-level development provides clinicians and researchers with the opportunity to develop and apply integrated approaches to closing the gap among the skills acquisition, performance, and generalization aspects of skills training. However, this inevitably means that more attention will have to be paid to training community-residence staff on how to deliver the interventions correctly. Almost all studies have reported that there are no significant differences between patients in skills training and control conditions (typically occupational therapy interventions) in changes on measures of psychopathology, rehospitalization, and relapse (Dobson, McDougall, Busheikin, & Aldous, 1995; Eckman et al., 1992; Hayes, Halford, & Varghese, 1995; Liberman, Wallace et al., 1998; Marder et al., 1996). This independence has also been found between improvement in cognitive rehabilitation and changes in symptomatology (Silverstein, Pierce, Saytes, Hems, Schenkel, & Streaker, 1998; Spaulding et al., 1986). As Wallace et al. (2000) noted,

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the relative independence among the outcomes of schizophrenia treatment has been well documented (e.g., Carpenter et al., 1976), and it offers one benefit for skills training. This is that skills training can be successfully conducted regardless of symptoms, even with acutely ill inpatients (Kopelowicz et al., 1998; T. E. Smith, Hull, MacKain, & Wallace, 1996). The exception to this is that severely disorganized patients or those with severe attentional impairment do not show substantial gains unless the procedures are modified to directly address these problems (see the text that follows) (Silverstein et al., 1999; Silverstein, Menditto, & Stuve, in press). The data on the learning potential of acutely psychotic, nondisorganized inpatients are consistent with improvements seen on acute inpatient services using token economies (LePage, 1999). In general, the earlier the rehabilitation process is started, the more opportunities there will be to learn, practice, and adapt one's skills (Wallace et al., 2000). The UCLA SILS modules are widely used in the United States and have been translated into 15 languages. It would not be an exaggeration at this point to say that they form the backbone of many inpatient and outpatient rehabilitation programs. In addition to the UCLA modules, other skillstraining interventions using a similar format have been developed by other groups. These include a self-esteem module (Lecomte et al., 1999) and a sleep module (Holmes, Corrigan, Knight, & Flaxman, 1995). Recent articles are also calling for the development of new interventions for important roles, such as parenting (Nicholson & Blanch, 1994). One of the few drawbacks of manualized treatments is that all patients receive the same set of exercises regardless of their individual needs. Although it is of course assumed that any patient chosen for a group has a need for the intervention (e.g., a social skills deficit in a global sense) and that the interventions break down the global skill into components during teaching, manualized treatments often do not allow for a sufficient focus on specific components of a skills deficit, especially where these are of an idiosyncratic nature. For cases in which such a focus is necessary, structured skills-training approaches that nevertheless allow for individualized intervention foci to be developed within the context of treatment have been created (e.g., Bellack et al., 1997; Liberman, DeRisi, & Mueser, 1989). User-friendly materials for these interventions have now been published and are readily available. The benefits of skills-training approaches can now be taken for granted. In addition, approaches such as IVAST underscore potential new applications for existing technologies. It would be unfortunate, however, if all new efforts are limited to applications of existing technologies, at the expense of developing novel training approaches based on theoretical and empirical developments within education, social psychology, developmental psychology, and related fields. Indeed, despite the success of current skills-training approaches, their linkage to models of social cognition that were long ago superseded in the social psychology literature raises the question of whether further paradigmatic develop-

ments in this approach are possible (e.g., development of interventions based on nonlinear models of social cognition, integration of new findings on affect expression and emotion, etc.) (Silverstein, 1997). Because such developments have occurred in related areas such as cognitive rehabilitation (see the text that follows), it can be assumed that the full power of skills-training technology has not yet been tapped, and that incorporating more recent insights from other fields could enhance the effectiveness of our efforts. Cognitive Rehabilitation Data on the high prevalence of neurocognitive deficits in schizophrenia (Palmer et al., 1997) and their association with poorer outcomes (Green, 1996; Silverstein, Shenkel et al., 1998) have created interest in treatments that can improve neurocognitive functioning in this illness. Because traditional antipsychotic medications have had minimal or sometimes deleterious effects on cognition after the acute phase (Corrigan & Penn, 1995; Schwarzkopf et al., 1999), the majority of direct neurocognitive enhancement efforts thus far have focused on psychological interventions. These nonpharmacologic treatments are typically grouped together under the rubric "cognitive rehabilitation." To date, this term has been applied to treatments such as practicing cognitive skills in individual (Spaulding et al., 1986; van Der Gaag, 1992) or group (Brenner et al., 1994; Spaulding, Reed, Sullivan, Richardson, & Weiler, 1999) formats and computer-assisted training (Medalia & Revheim, 1999). Perhaps the earliest attempt to directly treat cognitive impairment in schizophrenia was carried out by Carl Jung. In his posthumously published autobiography (1963/1989), he described one of his early cases (from around the turn of last century) in which, at the patient's request, he included in his treatment the regular assignment of Bible passages for her to learn. In subsequent sessions, the patient was then tested for recall of the passages from the most recent session. He reported that this treatment "kept alert" the patient's attention and, by doing so, prevented further deterioration and eventually led to a reduction in hallucinations. Jung reported that "this was an unexpected success, for I would not have imagined that these memory exercises could have a therapeutic effect" (1989, p. 127). Despite this success, treatments of this type did not resurface until many years later. In 1952, Beck reported successful treatment of delusions using cognitive techniques similar to those used later in the treatment of depression. This type of work was further developed by Beck, Meichenbaum, and others and has led to what is now called cognitive psychotherapy for schizophrenia (Henriques & Beck, 2000). All of these approaches have in common the use of reasoning exercises to reduce specific symptoms (typically delusions) or dysfunctional thoughts about symptoms. In contrast, Jung's approach presaged a wave of treatments that focus on neuropsychological deficits. This approach, usually referred to by the term "cognitive rehabilitation/reme-

Psychiatric Rehabilitation

diation," and will be the focus of the next discussion (see Henriques & Beck, 2000, for a discussion of cognitive psychotherapy of schizophrenia). These two approaches continue to exhibit little overlap even today. One approach to treating neurocognitive deficits involves the adaptation of methods from experimental and clinical psychology. For example, while dichotic listening procedures have been used to demonstrate auditory selective attention deficits in schizophrenia, they have also been adapted to enable patients to practice attending to relevant stimuli and ignoring irrelevant stimuli (e.g., Spaulding et al., 1986). In addition, one case report described how the Thematic Apperception Test was used as a technique to promote cognitive flexibility. Rather then giving the test on a single occasion as a projective test, specific cards were shown repeatedly across numerous sessions to a cognitively rigid and paranoid patient with the goal of increasing the frequency of stories without paranoid and aggressive themes. This cognitive flexibility exercise had the effect of reducing the observed rate of hostility and paranoia demonstrated by the patient (Spaulding et al., 1986). To date, the total number of patients treated using such techniques, as has been reported in published articles, is quite small, and no systematic procedures for using this approach have been developed. Nevertheless, there would appear to be great potential for the development and effectiveness of these methods, if they are developed in a clinically informed manner to specifically address an individual patient's difficulties. Another recent approach uses computers to administer tasks based on neuropsychological tests or exercises developed for remediation of cognitive deficits in learning disabilities (Brieff, 1994). Data from studies of neuropsychologically oriented computer exercises indicate that improvement in neurocognitive functioning occurs, as assessed via laboratory procedures (e.g., Burda, Starkey, Dominguez, & Vera, 1994). As yet, however, there is little evidence that the improvements generalize to other areas of functioning, or that they enhance response to other rehabilitation efforts. Studies using a neuropsychological educational approach to rehabilitation (NEAR; e.g., Medalia, Aluma, Tyron, & Merriam, 1998; Medalia & Revheim, 1999) have also relied heavily on computer-assisted training. A core aspect of the NEAR model is the use of educational techniques designed to facilitate learning by increasing intrinsic motivation and task engagement. Examples of techniques used to accomplish these goals are contextualization of the learning activity in real-world situations, multisensory stimulation, personalization of and control over the learning activity, and the use of opportunities to use information actively (Medalia & Revheim, 1999). Data indicate that use of the NEAR model in outpatient and chronic inpatient settings was associated with enjoyment of the training, cognitive improvement, and gains on independent measures of problem solving (Medalia, Revheim, & Casey, 2000). Another recent study demonstrated improved problem solving in acute schizophrenia pa-

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tients as well as improvements in the ability to cope with symptoms and to modify the impression made on others (Medalia, Dorn, & Watras-Gans, 2000). Thus, preliminary data are encouraging regarding both the effectiveness and the generalizability of the NEAR approach. The most widely reported approach to neurocognitive remediation of schizophrenia has been group-based therapy. The most popular of these treatments is Integrated Psychological Therapy (IPT) develop by Brenner and his colleagues (Brenner, Hodel, Roder, & Corrigan, 1992; Brenner et al., 1994). This intervention targets skills in a hierarchical fashion, beginning with conceptual differentiation (executive functioning) and moving through social perception, verbal communication, basic social skills, and interpersonal problem-solving segments. Skills are targeted through group practice and problem solving using a series of exercises that increase in complexity over time. Results from studies of IPT have been mixed (Brenner et al., 1992, 1994; Spaulding, Reed et al., 1999). In Brenner's studies, some cognitive effects were found, along with little evidence of generalizability of the effects to real-world behavior. Spaulding, Reed et al. (1999) reported an additive effect of cognitive rehabilitation above social-learning treatment on cognitive functioning and improvement on a measure of social cognition, suggesting that changes in social functioning may result from IPT. Approaches similar to 1PT have been developed for use in individual treatment sessions (e.g., van Der Gaag, 1992, Wykes, Reeder, Corner, Williams, & Everitt, 1999). For example Wykes et al. developed an intensive treatment for addressing executive functioning deficits in schizophrenia patients. Some positive effects were observed on neuropsychological test scores, but no effects were noted on behavioral functioning. In addition, the effects of these interventions outside the treatment context are unknown. Because of the lack of consistently convincing effects from prior studies of neurocognitive remediation in schizophrenia, some researchers have suggested using approaches that focus on helping patients manage cognitively demanding tasks in the real world (Flesher, 1990; Hogarty & Flesher, 1999a, 1999b; Velligan & Bow-Thomas, 2000). One such approach is Cognitive Adaptation Training (CAT), which involves the use of cues and compensating features in the patient's environment (Velligan & Bow-Thomas, 2000). As the authors note, CAT has more in common with case management then with traditional cognitive rehabilitation in that it involves home visits and in-vivo supports and is not viewed as a method for strengthening cognitive functions or their neural correlates. Preliminary data on this approach are encouraging. The strength of CAT, however, is clearly with outpatient populations who are already living and working in what is hoped to be a relatively permanent environment for them. For long-stay inpatients in state hospitals and other residential facilities, interventions are needed that can improve their basic attentional abilities so that they participate more fully in psychosocial rehabilitation and eventually be dis-

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charged to the community. Flesher's (1990) cognitive habilitation intervention is more amenable for use in a hospital setting, although he also notes that "Cognitive habilitation will be most useful for ameliorating the residual deficits in relatively stable remitted patients" (Flesher, 1990, p. 226). Recently, Hogarty and Flesher (1999a, 1999b) described a new treatment called cognitive enhancement therapy (CET). This approach was developed for use with outpatient populations. CET represents a breakthrough in the development of cognitive rehabilitation interventions in two respects. It is theoretically tied to developmental models of schizophrenia and therefore understands many of the deficits patients have in terms of their failures to develop age appropriate cognitive and social cognitive skills. Over the past several years, the field of social cognition in schizophrenia has received increasing attention (e.g., Penn, Spaulding, Reed, & Sullivan, 1997), and it is now clear that several cognitive impairments in schizophrenia can be usefully conceptualized from within the framework of social cognition (as opposed to more basic aspects of cognition) (Hogarty & Flesher, 1999a; Silverstein, 1997). Although CET needs to be studied in controlled trials, it is nevertheless setting a new standard for paradigms for the cognitive rehabilitation of schizophrenia. In short, the good news is that the field of cognitive rehabilitation for schizophrenia is continuing to develop, and that developments in the field are responsive to shortcomings of existing approaches and to advances in related fields. The not-so-good news is that current approaches to treating neurocognitive deficits in schizophrenia do not provide strong evidence of their effectiveness and/or generalizability, and most of them are not appropriate for the patients with most severe attentional impairment. This is because these patients (who often have attention spans of under 5 minutes) cannot attend to the material presented to them for any significant length of time, and exercises targeting higher level cognitive skills such as executive functioning may lead to clinical deterioration in patients with impairments in more basic functions such as sustained attention (see Silverstein et al., in press). For this group, improvements have been reported using the behavioral technique of shaping. Shaping is the application of several fundamental techniques of learning to bring about new behavior or to modify a certain aspect of an existing behavior. As such, shaping can be viewed as a method to achieve operant conditioning, with duration of attentive behavior being a specifically targeted response. The primary technique involved is differential reinforcement of successive approximations to the final target behavior. For example, rather than waiting for the complete behavior (e.g., a 30-minute attention span) to occur before offering reinforcement, reinforcement is provided for successive approximations or small steps toward the final behavior. When the initial step toward a behavior (e.g., 3 minutes of continuous attention) has been reinforced and occurs fairly regularly, the criterion for reinforcement is raised to a more challenging

level (e.g., 4 minutes of continuous attention). This sequence of reinforcing, changing criteria for reinforcement, fading reinforcers for previous "versions" of the behavior, and limiting reinforcers to behavior meeting the new criterion, is then repeated until the behavior resembles the final desired response. A strength of shaping therefore is that it allows the patient to develop and strengthen behavior that does not normally occur or only occurs at a very low frequency. This makes it suitable for treatment of patients whose severely impaired attention spans preclude them from active participation in other forms of psychosocial treatment, including many forms of cognitive remediation. A number of published reports have demonstrated the effectiveness of shaping techniques for chronic inpatients that had been considered treatment refractory. Spaulding et al. (1986) examined the effects of shaping on the continuous work performance of nine inpatients with severe and persistent schizophrenia who, at baseline, demonstrated an inability to focus their attention on a simple work task for more than 5 minutes. Seven of the original nine subjects graduated from training, having achieved continuous work performance scores of 30 minutes for five consecutive sessions. Menditto, Baldwin, O'Neal, and Beck (1991) used shaping procedures to increase the attention span of seven forensic inpatients with severe and persistent schizophrenia or schizoaffective disorder. After 12 months of training, six of the seven patients had demonstrated substantial improvements in attentional functioning, and of these six, four graduated from shaping classes and progressed to more traditional academic classes on the ward. They continued to perform quite well in those classes, with 1-year follow-up showing successful completion of academic class assignments an average of 84% of the time. Silverstein, Pierce, and colleagues (1998) replicated the findings of Spaulding et al. (1986) and Menditto et al. (1991) using a four session per week shaping intervention with four patients who had been unable to tolerate any form of group treatment. All patients demonstrated improvements over the course of 50 to 55 training sessions, with average ontask behavior increasing to 45 to 55 minutes. This included a patient with an IQ within the mentally retarded range as well as a patient with borderline intellectual functioning. Bellus, Kost, Vergo, Gramse, and Weiss (1999) compared the academic skill performance of seven lower functioning patients in shaping classes that employed procedures described in Menditto et al. (1991) to a group of seven higher functioning patients in traditional academic classes over a 9-month period. Patients in shaping classes increased their reading and mathematics performance close to one and two grade levels, respectively. In contrast, patients in traditional academic classes did not show significant performance improvement in these subjects. Silverstein, Valone et al. (1999) integrated shaping techniques within a UCLA SILS module by identifying inattentive behaviors characteristic of each patient and then using shaping techniques to improve these behaviors

Psychiatric Rehabilitation

and facilitate acquisition of new knowledge and skills during group sessions. Two findings were noteworthy from this project. First, all patients demonstrated significant increases in attentive behavior using this procedure. Second, for one patient who did not respond initially to the 15-minute reinforcement schedule, a continuous reinforcement schedule was implemented wherein he was given five cents and a piece of candy each time he opened his eyes. This eventually led to increases from 10% to over 80% of the time in keeping his eyes open, with subsequent greater spontaneity and participation, and responses that were more relevant to the group. A technique similar to shaping is known as errorless learning (O'Carroll, Russell, Lawrie, & Johnstone, 1999). Errorless learning involves beginning training on tasks for which there is a high expectation of success and proceeding through a graded series of tasks that become increasingly more complex. The goal of this procedure is to minimize the commission of errors while at the same time achieving performance mastery. Once a given level of performance is achieved, tasks at the next level of complexity are introduced. Errorless learning has demonstrated effectiveness in the treatment of developmentally disabled and neurologically impaired individuals (Baddeley, 1992; Kern, 1996). Moreover, it has been used as a technique to improve the performance of people with schizophrenia on neuropsychological tests of attention and memory (Bellack, Blanchard, Murphy, & Podell, 1996; Benedict et al., 1994; O'Carroll et al., 1999; Stratta, Mancini, Mattei, Casachia, & Rossi, 1994; Summerfelt et al., 1991; Vollema, Guertsen, & Van Voorst, 1995; Wexler, Hawkins, Rounsaville, Anderson, Sernyak, & Green, 1997) and to treat executive functioning impairments within the context of a larger neurocognitive rehabilitation program (Wykes et al., 1999). Shaping and errorless learning approaches are consistent with findings from human education and animal learning that: (a) a student's level of competence must be taken into account when developing an educational plan; (b) learning is accelerated within social contexts that resemble the realworld situations in which the learner will be functioning (e.g., vocational rehabilitation settings); and (c) interactions that model a new behavior that differs only slightly from current behavior require processing information that is only slightly novel or completing a task that is only marginally more difficult than what has been accomplished and thus are most easily learned (Joanjean-L'AntEone, 1997; Masur, 1988; Pepperberg, 2000; Piaget, 1954). These principles also apply to skills training and may account for the success of integrating shaping techniques and skills training approaches, as described previously (Silverstein, Valone et al., 1999).

Vocational Rehabilitation The high rate of unemployment among people with schizophrenia has driven a number of different attempts to improve their job skills. The majority of the techniques used in-

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volved a "train-place" model that trains people on specific skills outside of the workplace and then tries to place them in job settings. In general, the results of these efforts have been disappointing (Cook & Razzano, 2000; Wallace et al., 2000). Recently, a different approach has been suggested. Individual Placement and Support (IPS; Drake & Becket, 1996) involves quickly placing people into competitive employment and providing them with all of the services they need to keep them performing successfully in the workplace. Results from studies of IPS (e.g., Drake, McHugo, Becket, Anthony, & Clark, 1996) indicate clear superiority over traditional vocational rehabilitation interventions. Another technique for assisting vocational rehabilitation is the UCLA Workplace Fundamentals Module noted previously. Results from a preliminary pilot study using this group were encouraging (Wallace, Tauber, & Wilde, in press). Recently, Cook and Razzano (2000) proposed guidelines for developing an integrated approach to vocational rehabilitation. This approach involves the integration of vocational skills training with a focus on cognitive, social skills, and other deficits that are likely to impair performance. A recent study designed to train vocational counselors to deliver social skills training interventions at their settings demonstrated both significant staff learning effects and major programmatic changes involving the introduction of these interventions across a variety of sites (Silverstein & Jewell, in press). In addition, promising results have been obtained in efforts to integrate cognitive and vocational rehabilitation (Bell, 2000; Lysaker, Bell, & Bioty, 1995). In short, the field of vocational rehabilitation for schizophrenia appears to be moving toward a greater focus on the "ecological niche" (Dauwalder & Hoffman, 1992) in which people with schizophrenia find themselves in the workplace and on the need to address the specific cognitive and instrumental skill profiles of the recipients of services. Continued integration of vocational services with other forms of rehabilitation, which are themselves developing (e.g., social-skills training and cognitive rehabilitation), should lead to increasingly positive work outcomes for schizophrenia patients.

Rehabilitation of Comorbid Substance Abuse Conditions Studies over the past 10 years have clearly indicated that there are alarmingly high rates of substance abuse in schizophrenia patients, and that this is associated with a number of aspects of poor outcome (e.g., Fowler, Carr, Carter, & Lewin, 1998; Mueser et al., 1990, 2000). In response to this, greater attention has been paid to reducing substance abuse as part of a comprehensive rehabilitation program. Traditionally, services to treat schizophrenia and services to treat substance abuse have been delivered separately, either sequentially or in parallel. This approach has been largely unsuccessful, prompting the call for an integrated treatment specifically designed for people with schizophrenia (Lehman & Dixon, 1995). Drake and Mueser (2000) summarized the common

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characteristics of integrated approaches that have been developed thus far. These include: (a) the inclusion of substance abuse treatment services within the context of mental health services rather than vice versa; (b) the integration of material targeting substance abuse behaviors into a number of treatments (e.g., family management, vocational rehabilitation, etc.); (c) continuous outreach to ensure that patients receive the services they need; (d) the adoption of a long-term perspective, based on data indicating that short-term intervention is ineffective; and (e) recognition that most patients are not motivated to achieve abstinence and thus an initial focus on motivational techniques. A recent review of 10 studies of integrated treatment indicated that it was associated with lower rates of substance abuse and more stable periods of symptom remission (Drake, Mercer-McFadden, Mueser, McHugo, & Bond, 1998). Unfortunately, however, adoption of this approach has been slow, because of organizational and economic factors (Drake & Mueser, 2000). Recent publication of organizational guidelines for establishing integrated programs (Mercer, Mueser, & Drake, 1998) should facilitate new program development. Dissemination of Rehabilitation Interventions Despite the demonstrated utility of the assessment and intervention techniques described previously, they remain undefused. The successful implementation of a psychiatric rehabilitation program is a complex process that faces many potential obstacles (Corrigan & McCracken, 1997; Franco & Kelly, 1994; Liberman & Corrigan, 1994; Liberman & Eckman, 1989). Developing a facility-wide staff that both adopts the treatment philosophies inherent to rehabilitation techniques and delivers these interventions as originally intended involves a multimethod, multistep approach (Corrigan & McCracken, 1997; Krupa, Eastabrook, Blake, & G0ering, 1992; Liberman & Eckman, 1989; Rogers, Cohen, Danley, Hutchinson, & Anthony, 1986; Silverstein, Bowman, & McHugh, 1997). Often, outside consultation is required. Unfortunately, research has demonstrated that most training programs fail to produce their intended results, especially over the long term (Corrigan & McCracken, 1997). In response to the poor track record of most training programs, Corrigan and colleagues (Corrigan, 1998; Corrigan & McCracken, 1997) have developed a staff-training approach, called Interactive Staff Training (IST), that integrates traditional training approaches with a focus on organizational psychology. IST involves an interactive, multistep process of working with both facility administration and front-line staff to identify programmatic needs and plan and evaluate the new program. This approach has led to the development of a number of new programs. It has also been criticized as being too focused on staff (as opposed to patient) needs and for not stressing the implementation of interventions with demonstrated effectiveness, especially with regard to inpatient social learning programs (Paul, Stuve, & Cross, 1997). This

controversy underscores the need to attend both to interventions with demonstrated efficacy as well as to organizational factors that could impede development and maintenance of the program. A number of articles have described organizational and personnel factors that can, or did, undermine useful programs (e.g., Franco & Kelly, 1994) and methods to avert some of these factors (Silverstein et al., 1997). Even armed with this information, however, rehabilitation program directors are often challenged to protect a program's resources and to defend a program's mission in the face of managed care, wherein short-term financial gain is often the primary focus. Successful Integration of Psychiatric Rehabilitation and Pharmacotherapy As noted at the outset, combining psychiatric rehabilitation and pharmacotherapy is now considered standard practice, and evidence exists that this combination is more effective than medication alone. This integration, however, is not a simple process of providing medication and then delivering rehabilitation (Schwarzkopf et al., 1999). During the past 15 years, significant advances have been made in our understanding of the interactions between these forms of treatment (Kopelowicz & Liberman, 1995). We now know, for example, that certain medications impair cognitive functions that are critical to rehabilitation success (Corrigan & Penn, 1995). This requires that the people prescribing medication, the rest of the treatment team, and the patient reach a decision regarding a balance of residual symptoms and cognitive deficits that will maximize performance success in realworld roles. In addition, behavioral treatments have now successfully reduced positive symptoms such as hallucinations and delusions in both medication responders and nonresponders. This suggests that, among responders, medication dosages required to suppress these symptoms may be able to be lowered after behavioral treatment is initiated (Haddock et al., 1994). Ongoing assessment is also required to determine if changes in cognition and/or symptoms over time require redesigning either the medication or psychosocial treatment strategy. Although combining pharmacotherapy and psychiatric rehabilitation is a generally accepted principle, it should be noted that the degree to which medication must be the cornerstone of treatment in all cases of schizophrenia remains unclear. For example, Paul and Lentz (1977) reported that many of their treatment-refractory patients made substantial gains in their program and were discharged with successful community tenure, even though they were not on medication. In addition, Mosher and colleagues (e.g., Mosher & Bola, 2000; Mosher & Menn, 1978) demonstrated that in many cases young patients undergoing their first or second psychotic episode can be successfully treated without medication in community residences with high staff-patient ratios

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that employ a treatment model based on existential psychological principles. In light of these generally ignored data and because (a) medication noncompliance rates in schizophrenia can reach up to 75% (Kissling, 1992) and (b) side effects (e.g., weight gain, sedation, etc.) are complicating factors, treatment providers need to continually and empirically determine the lowest amount of medication that is required in any individual case. Just as important, it behooves clinicians to make the fullest use of psychosocial interventions, given their demonstrated effectiveness. Along these lines, more research is needed into the degree of medication necessary to achieve good outcomes within the context of an optimal psychosocial treatment matrix. For example, the Paul and Lentz and Mosher studies cited previously were conducted in the 1970s before the introduction of atypical antipsychotic medications. Many of the patients in the Paul and Lentz study who were discharged off medications were nonresponders to conventional drugs, and thus it made sense to not continue to subject them to the unwanted effects of medications. However, it is not known whether the patients in these studies would have achieved even better outcomes had the newer, atypical antipsychotic medications been available. Just as important, however, it is safe to say that nearly all studies of medication effectiveness have been conducted without the benefit of the full arsenal of effective psychiatric rehabilitation interventions. Thus, we still really do not know the impact that rehabilitation interventions can have relative to pharmacotherapy in treating people with schizophrenia. Conclusions The field of psychiatric rehabilitation of schizophrenia has expanded greatly in the past decade. Moreover, it continues, or is poised, to expand in response both to developments in related fields (e.g., cognitive neuroscience, educational psychology, social psychology, organizational psychology, etc.) and shortcomings of existing treatments. This promises to provide an increased theoretical grounding for the next generation of interventions. The conceptual shifts that could result from this should lead to advances in our ability to treat the instrumental skill and cognitive deficits of schizophrenia. Early efforts in this direction are already underway (e.g., development of CET). In addition, new treatments are consistent with more recent conceptualizations of schizophrenia that view the illness as more than the sum or intensity of positive symptoms. There is now an increased recognition of the role of negative symptoms, cognitive deficits, and socialskills deficits in producing disability. This trend promises to generate an even wider array of interventions in the future. Currently, it appears as if the field is moving toward greater integration of services and a greater provision of services in real-world environments, such as the workplace, the community residence, and the family home. Overall, the future of

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psychiatric rehabilitation looks promising, which is in itself promising, because far too many people with schizophrenia remain unable to fulfill their potential. In the previous discussions I have highlighted the strengths of a number of areas of psychiatric rehabilitation of schizophrenia and noted places where further work appears to be necessary. In closing, two final challenges need to be mentioned. One is the issue of integrating research and practice, and the second involves interfacing with the wider society to overcome obstacles to implementation of effective interventions. These issues are not unique to the rehabilitation of schizophrenia although they are highly relevant to it. Perhaps they are even more relevant to schizophrenia than to some other disorders because of the severe disability caused by the illness, the stigma that is still attached to it, and the inability of most people with schizophrenia to effectively advocate for themselves. The issue of integrating research into practice is primarily a challenge to clinicians. Clinicians in many areas of psychotherapy have been criticized for not adapting their approaches to patients in the face of evidence for newer, more effective approaches. It can be argued that this has been less of an issue for psychiatric rehabilitation as many interventions have been developed and modified from within a research-oriented, behavioral approach. Nevertheless, many effective interventions remain underused by practitioners in general. In addition, there is always the danger of growing complacent with existing treatments at the expense of continued development efforts. For example, most forms of social-skills training have remained unchanged since the 1970s despite an accumulation of knowledge about social skills and social cognition deficits in schizophrenia (Bellack & Mueser, 1993; Silverstein, 1997). This behooves clinicians and clinical researchers to attempt to integrate these findings into novel intervention approaches and then to ensure that these new approaches are widely disseminated to other practitioners. The issue of ensuring that patients who need rehabilitative treatments are receiving them is a very complex one. Clinicians and clinical administrators now take it for granted that a component of their job involves regularly battling costmanaging agencies to ensure that their patients receive more than minimal care. In the case of psychiatric rehabilitation of schizophrenia, there remain the related goals of ensuring continuity of care regarding the interventions and obtaining financial reimbursement for delivering the treatments in various locations (e.g., in community residences, day-treatment programs, etc.). Increased collaboration among clinicians, researchers, patients and their families, advocacy groups, and political representatives may be necessary to produce change in the health-care delivery system. Such changes are critical, however, both to motivate clinicians to learn and deliver interventions in a wider range of locations and to improve outcomes and quality of life for the patients who need greater exposure to these effective interventions.

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