Rehabilitation and Recovery in Schizophrenia

Psychiatr Clin N Am 30 (2007) 535–548

PSYCHIATRIC CLINICS OF NORTH AMERICA

Rehabilitation and Recovery in Schizophrenia Dawn I. Velligan, PhDa,*, Jodi M. Gonzalez, PhDb a

Department of Psychiatry, Division of Schizophrenia and Related Disorders-MSC 7792, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl, San Antonio, TX 78229–3900, USA b Department of Psychiatry, Division of Mood & Anxiety Disorders, University of Texas Health Science Center at San Antonio, University Plaza, 7526 Louis Pasteur, San Antonio, TX 78229–3900, USA

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chizophrenia is a severe and persistent mental illness characterized by a constellation of signs and symptoms including positive symptoms (hallucinations, delusions, disordered speech and behavior), negative symptoms (amotivation, asosicality, poverty of speech and movement), and cognitive deficits (impaired information-processing speed, attention, memory, and executive functions [1,2]. Moreover, multiple domains of functional outcome, including performance of independent living skills, social functioning, and occupational/educational performance and attainment, are impaired for individuals who have schizophrenia [1,3]. Schizophrenia remains one of the top 10 leading causes of disability worldwide in young adults. The focus of psychiatric rehabilitation is the management of persistent symptoms and the reduction of the long-term disability often associated with schizophrenia [4]. Medication management forms a foundation for the process of recovery which seeks to help each individual maximize his or her potential and outcomes [5,6]. The recovery model focuses on instilling hope for the future, setting individual goals, capitalizing on strengths, and building skills to allow the individual to grow and to achieve meaningful work, supportive social relationships, and a better quality of life [7]. Psychiatric remediation and rehabilitation techniques to promote recovery include a comprehensive and coordinated range of services addressing many domains of outcome. The advent of novel medications for schizophrenia in the past decade has been paralleled by the development of a number of innovative, evidence-based rehabilitation strategies designed to improve specific areas of functional outcome [6]. This article describes a variety of psychosocial interventions targeting

This work is supported by National Institute of Mental Health grant R01 MH074047–01A1 to Dr. Velligan.

*Corresponding author. E-mail address: [email protected] (D.I. Velligan). 0193-953X/07/$ – see front matter doi:10.1016/j.psc.2007.05.001

ª 2007 Elsevier Inc. All rights reserved. psych.theclinics.com

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improvements in psychiatric symptoms, cognition, and a broad range of functional outcomes and discusses the evidence base regarding the impact of these interventions on the recovery process for individuals who have schizophrenia. COGNITIVE BEHAVIOR THERAPY Cognitive Behavior Therapy (CBT) for schizophrenia is a treatment designed to address positive symptoms that remain after medication treatment has been optimized. Although available antipsychotic medications reduce positive symptoms, many patients continue to struggle with hallucinations or delusions that impact adjustment and quality of life. CBT is focused on helping individuals develop alternative explanations for the symptoms of their illness and reduce the impact of these symptoms on their behavior [8,9]. CBT is based partly on the evidence that emotional processes, information-processing deficits, and reasoning and appraisal biases contribute to the formation and maintenance of delusions and hallucinations and that these processes can be changed through cognitive intervention [10,11]. During the process of CBT, in the context of a strong therapeutic alliance, the client and therapist discuss and evaluate the specific content of delusions and hallucinations. The therapist works first to understand thoroughly the patient’s perspective as to how the hallucinations and beliefs described have developed (eg, ‘‘The Secret Service started tapping my phone after I broke up with my girlfriend.’’), later raising questions about the sources of the problem (eg, ‘‘Could it be any agency other than the Secret Service’’? ‘‘Did you know that when people have a relationship breakup they are under a great deal of stress?’’), and eventually helping the individual conduct behavioral experiments to test explanations (eg, asking trusted family members whether they hear the clicks on the telephone line) and suggesting alternative explanations for events [8]. This process slowly allows clients to evaluate their own explanatory model for their experiences and to consider other possible explanations and interpretations of events. A series of prospective, randomized, controlled clinical trials has demonstrated the efficacy of CBT for the treatment of persistent positive symptoms in patients who have schizophrenia [9,12–15]. The average effect sizes for CBT versus control treatments for reducing symptomatology are in the moderate range [9,16]. CBT is considered standard of care in the United Kingdom, and interest in this method of treatment continues to grow in the United States. [8,17]. Although researchers have worked to extend CBT into group settings, results have failed to demonstrate the efficacy of group CBT for decreasing symptoms [18]. Group CBT, however, has been found to lead to more positive evaluations of oneself and the future [18]. Research on CBT suggests it is a promising approach to addressing persistent symptoms in schizophrenia. CBT approaches have also been applied to individuals who do not comply with medication because of poor insight into having a mental disorder [19–22]. The CBT approach provides more freedom to attempt to frame the issue of adherence in a way that is most acceptable to the patient’s own perspective

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of the problem and the treatment options. Previous treatment failures, contradictory information, and disappointments in attaining goals are discussed. The clinician withholds comments and interventions regarding adherence until the client’s perspective is fully understood. Over time the therapist helps clients make the connection between their own goals for recovery, the barriers to reaching those goals, and how medication may be able to assist in this process. Evidence supporting CBT-based compliance therapies has been mixed [21,23,24], but more methodologically rigorous trials of CBT for medication adherence are needed [25]. INTERVENTIONS TARGETING COGNITIVE IMPAIRMENTS In the context of a generalized intellectual deficit, specific cognitive impairments are present in schizophrenia in the areas of information processing speed, attention, memory, and executive functions [1,26]. These cognitive impairments are believed to underlie much of the functional role impairment observed in schizophrenia [1,3]. Moreover, impairments in cognitive functioning have been found to interfere with skill acquisition in rehabilitation programs. The increasing recognition of the importance of addressing cognitive impairment has led to the development of several cognitive rehabilitation strategies for individuals who have schizophrenia. Some of these techniques seek to improve or restore cognitive abilities directly; others are considered compensatory in nature and attempt to bypass impairments in cognitive functioning to improve community outcomes [27]. Cognitive Remediation Cognitive Remediation (CR) seeks to improve and/or restore cognitive functions directly using a variety of pen-and-paper or computerized tests requiring cognitive skills such as attention, planning, problem solving, and/or memory [27–32]. CR approaches are based on theories of cognitive development and approaches adapted from the treatment of brain-injured populations. A basic tenet of CR is that the brain’s neuroplastic reserve can be enriched by cognitive experiences provided through training [33]. Improvements in cognitive and functional outcomes may be accomplished through a combination of drill and practice exercises and group or individual training sessions focusing on higher-level abstraction of social, work-related, or problem-solving themes [27]. Many successful CR programs are embedded in comprehensive rehabilitation programs where cognitive exercises work synergistically with psychosocial groups or other treatment modalities. Many independent CR programs have been developed. The neuropsychologic educational approach to rehabilitation program created by Alice Medalia [31,32] is based on teaching techniques developed within educational psychology that promote intrinsic motivation and task engagement. The conceptual model favors a top-down approach that emphasizes higher-order, strategybased methods of learning over drill and practice exercises that focus on learning of elementary cognitive skills (a bottom-up approach). Training involves participation in computer-based cognitive exercises (eg, computer games such

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as ‘‘Where in the World is Carmen San Diego?’’) that are designed to be engaging, enjoyable, and intrinsically motivating and require the recruitment of several cognitive skills within a contextualized format. The Neurocognitive Enhancement Therapy program developed by Bell and colleagues [34,35] focuses on CR in the context of work rehabilitation. This program uses computerized software programs targeting attention, memory, and executive functions. Training begins with relatively simple exercises and proceeds to more complex ones. As an individual masters a task at a prespecified level, the parameters of the task are changed to allow mastery of increasingly difficult material. This approach is designed to keep motivation at optimum levels. In addition to computerized exercises, participants attend a weekly social-processing group where they are given feedback on work performance and suggestions for improvement are discussed. Cognitive Remediation Therapy developed by Til Wykes [30] focuses on teaching patients to develop their own individualized set of problem-solving strategies. The individually delivered training program targets deficits in executive processes including cognitive flexibility, working memory, and planning. This program uses paper-and-pencil exercises for training, begins with simpler tasks and proceeds to more difficult ones, and emphasizes teaching through procedural learning, scaffolding, and errorless learning [36]. Cognitive Enhancement Therapy developed by the late Gerald Hogarty [33] is a comprehensive rehabilitation program designed to enhance abstraction of social themes and alter cognitive schemas for individuals who have recent-onset schizophrenia. Cognitive Enhancement Therapy is based on a neurodevelopmental model of schizophrenia that suggests that disturbances in neurodevelopment result in delays in social cognition. Social cognitive milestones such as perspective taking are therefore the focus of treatment. Computer-based cognitive exercises focus on attention, memory, and problem-solving abilities. In addition, participants attend a social-cognition training group. Social interaction is emphasized throughout treatment, and even the computer sessions are conducted in pairs of patients who assist one another by suggesting strategies and offering encouragement. Reviews of the CR literature generally have been positive and have concluded that CR improves multiple domains of cognitive functioning not limited to the tasks used in the cognitive training [27,37–39]. Moreover, studies have established that improvements for individuals who have schizophrenia and who participate in CR programs are not limited to cognitive improvements. Depending on the type of CR program, improvements have been found in a range of outcomes, including independent living skills, obtaining employment, job tenure, hours worked, and money earned in vocational rehabilitation, improved social problem-solving skills, and social adjustment [27,28,30–34,40]. Effect sizes for improvements in specific training exercises generally have been large, with more moderate effect sizes for other cognitive outcomes and improvements in community functioning [40]. Although there is no consensus regarding which approach to CR is best for particular patients,

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the importance of an adequate amount of treatment, proper training of therapists conducting CR and motivational factors within the participant are mentioned as important factors for maximizing outcomes [27,40,41]. Compensatory or Adaptive Strategies to Bypass Cognitive Impairment Rather than attempting to alter neurocognitive function per se, adaptive strategies attempt to bypass cognitive deficits by establishing supports or prosthetic devices in the environment to improve functioning. These techniques have been used for years in the rehabilitation of individuals who have head injuries or mental retardation. More recently, cognitive adaptation training (CAT) has applied these strategies to individuals with schizophrenia [42–44]. CAT is a psychosocial treatment that uses environmental supports such as alarms, signs, checklists, and the reorganization of belongings to cue and sequence adaptive behavior in the home environment. CAT treatment focuses on impairments in adaptive functioning in areas such as medication and appointment adherence, grooming and hygiene, care of living space, and leisure and social activities. Treatment strategies are based on a comprehensive assessment of cognitive functioning, behavior, and environment. CAT is based on the idea that impairments in executive functioning lead to problems in initiating and/or inhibiting appropriate behaviors. Using behavioral principles such as antecedent control, environments are set up to cue appropriate behaviors, discourage distraction, and maintain goal-directed activity. In addition, adaptations are customized for specific cognitive strengths or limitations in attention, memory, and fine motor control (eg, changing the color of signs frequently to capture attention, using Velcro closures instead of buttons for someone who has fine-motor problems). Examples of CAT interventions include signs asking ‘‘Did I take my medication?’’ placed on the back of the front door, medication containers with alarms to cue taking medication at specific times, reorganization of closets to prevent soiled or inappropriate clothing from being worn, money management or job-hunting notebooks, and checklists reminding the individual to perform specific grooming or leisure tasks. CAT has been shown to improve adherence to medication, community functioning, and rates of relapse for individuals who have schizophrenia [42–44]. Large effect sizes (Cohen’s D > 1.0) have been found for improvements in functioning and medication adherence with CAT relative to control and treatment-as-usual conditions [43–45]. Larger randomized trials are underway currently to examine issues regarding the length and durability of treatment effects and factors mediating treatment outcomes. Recent evidence suggests that environmental adaptations are highly likely to be used in a comprehensive program such as CAT in which supports are individualized and set up in the patient’s home environment. Supports are far less likely to be used when they are generic and given to patients in the clinic rather than on home visits [45]. Adaptive supports for specific problems such as medication adherence also are available. One example is the Med-eMonitor (Informedix, Rockville, MD)

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device, which stores up to a month’s supply of five different medications, cues the taking of medication at specific times with an alarm, asks the patient whether the medication has been taken, and downloads adherence data to a secure Website for retrieval by a case manager. Preliminary data suggest that such devices improve adherence to medication in schizophrenia [22]. Given the advances in the development of new technologies, it is likely that the use of electronic environmental supports will continue to increase in the treatment of schizophrenia. Fig. 1 illustrates the two primary approaches to cognitive rehabilitation: restorative/enhancing versus compensatory. The ultimate goal of both strategies is to improve community functioning in individuals who have schizophrenia. SOCIAL SKILLS TRAINING Social skills deficits are common among individuals who have schizophrenia. Based on a neurodevelopmental model for schizophrenia, individuals who go on to develop schizophrenia have cognitive deficits that may have prevented or interfered with the acquisition of adequate social skills during development [46]. Many of these individuals may not have mastered the skills necessary to maintain adult relationships and to function successfully in their social roles. Social skills training teaches specific skills that lead to effective behavior in social interactions. Specific skills may include nonverbal behavior, such as appropriate eye contact and voice volume, conversational skills such as introducing

COGNITIVE REMEDIATION (CR)

Directly attempts to enhance or restore cognitive functioning in these areas. Better cognition leads to improved community outcomes. PROBLEMS IN COMMUNITY OUTCOMES

COGNITIVE IMPAIRMENTS Psychomotor Speed

Poor Independent Living Sills

Attention

Social Impairment

Memory

Vocational Impairment

Executive Functions

COGNITIVE ADAPTATION TRAINING (CAT) Environmental Supports

Attempts to bypass cognitive deficits using environmental adaptations. Cognitive impairments remain, but no longer lead to impaired community functioning.

Fig. 1. Restorative and compensatory approaches to cognitive rehabilitation.

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oneself to a new person and taking the perspective of another person, and problem-solving skills such as expressing dissatisfaction and generating solutions to interpersonal problems [46]. Although there are different models of social skills training, many interventions attempt to reduce cognitive demands by using visual aids and by modeling desired behaviors [47]. Most break complex social behaviors down into components that can be addressed through specific teaching techniques. Participants may be taught in a didactic manner the steps to perform a behavior, watch the behavior of a model, and then practice the behavior while receiving coaching and corrective feedback from the group [46,48]. When skills are improved, patients’ interactions with others may become more successful and rewarding, leading to increased social participation. Social skills training has been found to increase specific behaviors necessary to communicate effectively [46–49]. In addition, research indicates that social skills training decreases rates of relapse, reduces symptomatology, and improves social functioning [50–52]. Maintenance of gains in learning lasting as long as 2 years after training have been found [53]. It is difficult, however, to determine the extent to which these new social skills are generalized to the individual’s environment outside the training context. Specific mechanisms to generalize training to the natural environment may be necessary to ensure transfer of skills to everyday life [53]. INTEGRATED TREATMENTS FOR COMORBID SUBSTANCE ABUSE IN SCHIZOPHRENIA Between 20% and 75% of individuals who have schizophrenia have comorbid substance abuse disorders [54,55]. Comorbid substance abuse increases the likelihood of poor adherence to medication and is associated with more severe positive symptoms, more frequent hospitalizations, and poorer prognosis [55,56]. Moreover, individuals who have co-occurring substance abuse and schizophrenia are more likely than those who have schizophrenia alone to exhibit poor occupational and role functioning, to demonstrate higher levels of depression and anxiety, and to have unstable housing, poor access to health care, and more involvement with the legal system [55,57,58]. Although traditional 12-Step programs such as Alcoholics Anonymous or Narcotics Anonymous may be helpful for some patients, available data suggest that outcomes for patients are better in programs that integrate mental health and substance abuse treatments [59–65]. Integrated treatment has been found to decrease costs associated with the hospitalization and contact with the criminal justice system [55,66]. Integrated treatments for dual-diagnosis patients make use of many different treatment modalities including intensive case management, motivational interviewing, 12-Step programs focused on dual diagnosis, CBT, social skills training, contingency management, and family psychoeducation [66]. Many successful programs do not have abstinence from substance use as a goal but instead use a harm-reduction model that focuses on reducing the harmful

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consequences of substance abuse for the patient and society. One example of integrated treatment using a harm-reduction model is called ‘‘behavioral treatment for substance abuse in schizophrenia’’ [63]. The treatment involves motivational interviewing to develop treatment goals, urinalysis with social and small monetary reinforcements for ‘‘clean’’ urine, social skills training aimed at providing the patient with the skills necessary to refuse drugs when offered and to develop friendships with those who do not use drugs, education regarding how drugs affect the brain and medications for psychiatric illness, and teaching ways to cope with high-risk situations. This treatment has been found to decrease drug use and increase the frequency of ‘‘clean’’ urine drug screens [63]. More than 54% of individuals in integrated treatment had at least one 4-week period of clean urine test results compared with just over 16% of those in supportive group treatment. Multimodal treatments for substance abuse and schizophrenia are important to provide to assist individuals who have a dual diagnosis with the process of recovery. VOCATIONAL REHABILITATION AND SUPPORTED EMPLOYMENT Gainful employment is an important goal for many individuals who have schizophrenia. Gainful employment can enhance economic independence, self-esteem, and community adaptation [67,68]. Although most individuals who have schizophrenia state they want to work, employment rates range from only about 10% to 20% [69]. Train-and-place models of vocational rehabilitation that focus on prevocational training to prepare individuals for the job market have not been found to be particularly successful in helping individuals who have schizophrenia secure jobs in the competitive market place and have fallen out of favor [70]. In contrast, supported employment programs, including the individual placement and support model, emphasize rapid placement in a competitive job tailored to the individual’s interests and strengths, the job training specific to the duties of the position, and ongoing support from a collaborative team [67,71,72]. Supported employment programs follow a place-thentrain philosophy in which training takes place in the job setting with a job coach. This approach eliminates the need for generalization of behaviors to new settings. Numerous randomized, controlled trials have found that individuals participating in these specialized vocational programs are more likely to obtain employment and to earn more money than those in comparison rehabilitation services [67,68,71–73]. More than 50% of individuals in supported employment programs have been found to work competitively versus less than 20% in comparison groups. This difference translates into an effect size close to 80 [68]. Retention of employment and achieving the full benefits of supported employment for a wider range of individuals remain obstacles that must be addressed. Factors that influence retention and success include negative symptoms of schizophrenia, recent hospitalization, cognitive deficits, and persistent psychotic symptoms [69,74]. Recent efforts that combine cognitive remediation

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and supported employment have demonstrated beneficial effects on both cognitive skills and employment outcomes [34,69]. Continued enhancements of the supported employment model are likely to extend positive outcomes to a broader range of individuals who have schizophrenia. FAMILY PSYCHOEDUCATION Research has consistently indicated that high levels of criticism and overinvolvement by family members can increase the risk of relapse for a person who has schizophrenia [7,75]. Moreover, being the primary caregiver for an individual who has schizophrenia can cause a significant amount of distress. Family psychoeducation offers information and support for family members who care for their relatives who have schizophrenia. Although there are a number of different family treatment strategies, common elements include providing education about mental illness, helping members develop realistic expectations that take the illness into account, and providing training in communication and problem-solving skills. Family treatment can be provided for individual families or in group settings where members can learn information and effective coping skills and gain perspective from one another. Decades of research indicate that family treatment results in lower rates of relapse in comparison to standard care or control treatments [76]. On average, the rate of relapse for individuals whose families participate in psychoeducation treatment is 24% compared with a rate of 64% for those receiving treatment as usual [75,77]. Treatments lasting 9 months or more have been found to produce more favorable outcomes than those of shorter duration [7]. Family intervention has been found to decrease the family’s experience of burden and to increase members’ ability to cope with the illness [78]. Moreover, there is evidence that participation in family treatment decreases health care costs resulting from the illness [7]. SUMMARY A number of promising interventions have demonstrated efficacy for various aspects of schizophrenia. Much of the efficacy is domain specific. Interventions to address vocational needs or social skills do not necessarily improve symptomatology. Interventions designed to improve symptomatology and distress do not result in improved occupational functioning or social skills [75]. This experience suggests that an integrated approach to treatment involving multiple strategies may enhance the process of recovery and maximize a range of outcomes for individuals. Implementation of Evidence-Based Psychosocial Rehabilitation Techniques into Community Practice Although ways to treat many aspects of schizophrenia successfully have been identified, the illness remains one of the top 10 disabling conditions worldwide for young adults. Evidence-based treatments often are unavailable to large numbers of individuals who need or could benefit from them [79,80]. Issues

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of cost and reimbursement, the availability of trained service-delivery personnel, and overburdened health care systems remain significant obstacles. The Website of the National Mental Health Information Center of the Substance Abuse and Mental Health Services Administration (http://mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/default.asp). provides tool kits designed to assist public mental health authorities in implementation of best practices such as supported employment and family psychoeducation. Information for consumers, families, and treatment providers is available. Recommendations include assembling a group of stakeholders to include consumers, families, and provider agencies to work on implementation of a specific practice, ensuring that all stakeholders have information about the efficacy, core principals, and resources necessary to deliver the intervention, identifying and overcoming practical and financial barriers to implementation and ensuring that performance outcome measures and financial incentives be put in place for service-delivery personnel. The use of a demonstration project is recommended to establish the effectiveness of the intervention for the stakeholders and to overcome financial and organizational barriers to implementation. By addressing these issues as they arise in a small demonstration project, implementation of the intervention on a larger-scale becomes possible. Consideration should be given to shifting resources from less successful programs to evidencebased practices. This strategy may improve the services delivered and outcomes for consumers while minimizing the financial burden for the agency. It also is important to establish mechanisms for ongoing training and supervision of staff at all levels and to continue to assess the fidelity with which the intervention is being applied. Research on implementation strategies for applying evidence-based practices in community settings continues to be important. A great deal of knowledge regarding what works has been gained. Putting in place the mechanisms to provide what works remains a significant challenge that must be addressed. References [1] Green MF. What are the functional consequences of neurocognitive deficits in schizophrenia? Am J Psychiatry 1996;153(3):321–30. [2] Andreasen NC, Arndt S, Alliger R, et al. Symptoms of schizophrenia methods, meanings, and mechanisms. Arch Gen Psychiatry 1995;52:341–51. [3] Velligan DI, Mahurin RK, Eckert SL, et al. Relationship between specific types of communication deviance and attentional performance in patients with schizophrenia. Psychiatry Res 1997;70:9–20. [4] Liberman RP, Kopelowicz A, Smith TE. Psychiatric rehabilitation. In: Sadock BJ, Sadock V, editors. Kaplan and Sadock’s comprehensive textbook of psychiatry. 7th edition. Baltimore (MD): Lippincott Williams & Wilkins; 1999. p. 3218–45. [5] Bellack AS. Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and implications. Schizophr Bull 2006;32(3):432–42. [6] Corrigan PW. Recovery from schizophrenia and the role of evidence-based psychosocial interventions. Expert Rev Neurother 2006;6(7):993–1004.

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