- Email: [email protected]
Relationships matter: The impact of the therapeutic alliance on outcome in schizophrenia
319
20. Therapeutics: Psychosocial Trials COGNITIVE-BEHAVIOURALTHERAPY IN THE PRE-PSYCHOTIC PHASE: AN EXPLORATORY STUDY A. B e c h d o l f , * M. W a g n e r
Dep. of Psychiatry, Universityof Cologne, Cologne, Germany Although the efficacy of cognitive-behavioural therapy (CBT) in schizo-phrenia in addition to pharmacotherapy has been established for persis-tent psychotic symptoms, no information is available on the effects of CBT in at risk mental states in the pre-psychotic phase.The present exploratory study was conducted to investigate the effectiveness of a comprehensive 12 month CBT programme in persons at risk of psychosis with regard to (1) improvement of present prodromal symptoms, (2) prevention of social decline/stagnation and (3) prevention or delay of progression to psychosis. 25 consecutive admissions to 3 Early Recognition and Intervention Centres in Germany were evaluated in an uncontrolled prospective design with pre- and post-treatment measures. There were significant and substantial improvements in prodromal symptoms and social adjustment and no tran-sition to psychosis according to our criteria. The observed within-group effect sizes on symptoms were up to three times higher than the effect sizes, which are known for CBT in clients with schizophrenia. CBT in the pre-psychotic phase needs further investigation but the first findings sup-port the notion that intervening in the early stages of the illness may be exceptionally effective.
TREATING SUBSTANCE ABUSE IN SCHIZOPHRENIA: PRELIMINARY ANALYSIS OF DATA FROM A RANDOMIZED TREATMENT TRIAL M. E. Bennett,* A. S. Bellack, J. S. G e a r o n
Psychiatry, Universityof Maryland School of Medicine, Baltimore, MD, USA People with schizophrenia and other severe mental illness show alarmingly high rates of substance use disorders. There have been few well-controlled studies of substance abuse treatment in this population, and most that have been done show modest effects. These patients experience a range of neurocognitive and social deficits that make it difficult for them to benefit from effective interventions designed for less-impaired populations, In 1993 we began development of Behavioral Treatment for Substance Abuse in Schizophrenia (BTSAS) to tailor strategies that are effective in reducing substance abuse more generally to meet the needs of this population. BTSAS involves five components: motivational interviewing; urinalysis contingency in which patients earn small sums of money for abstinence from a goal drug; drug refusal skills training; education about drug use in mental illness; and relapse prevention training. We are currently running a NIDA-funded trial that randomly assigns patients with schizophrenia or other SMI and substance use disorder to BTSAS or to a supportive therapy condition (STAR). Both interventions are delivered in mental health clinics in Baltimore. Experience to date suggests that the intervention is safe, that many patients will participate, and that therapists can learn to administer
the intervention reliably and competently. Previous analyses suggest that patients attend and benefit from BTSAS. Early comparisons of patients in both conditions suggests that BTSAS patients attend more sessions than patients in STAR and have more clean urine tests during treatment than STAR patients. An early analysis of data from the current trial found that BTSAS graduates showed a mean of 76% clean urine tests during treatment as compared to 38% for dropouts. Such results are highly encouraging. This poster will present the first examination of during-treatment and post-treatment outcome data from our current randomized trial. Approximately 64 patients will have engaged in treatment in the two conditions. We will present data regarding treatment retention, descriptive characteristics of the sample, treatment utilization data, urine data for patients in both conditions, and post-treatment and 6-month follow-up outcome data. Implications of these results for the BTSAS program and treatment of patients with shizophrenia and substance abuse will be discussed.
RELATIONSHIPS MATTER: THE IMPACT OF THE THERAPEUTIC ALLIANCE ON OUTCOME IN SCHIZOPHRENIA R. R Bentall,* S. Lewis, N. Tarrier, G. Haddock, R. Drake, J. D a y
Psychology, Universityof Manchester, Manchester, England, United Kingdom Research on the outcome of treatment for schizophrenia, whether evaluating pharmacological or psychosocial interventions, has tended to focus on technical aspects of treatment and to ignore non-specific factors such as the quality of patients relationships with their clinicians. However, there is at least smoking gun evidence that relationships matter. Some studies of the treatment environment have found that the presence of high expressed emotion clinicians is associated with poor adjustment in patients. Others have found that non-specific therapies such as supportive counselling or befriending, when used as control conditions in evaluations of cognitive-behaviour therapy (CBT), are associated with better outcome than treatment as usual without any kind of psychosocial intervention. Data on the impact of the therapeutic alliance on outcome in schizophrenia, obtained from two recent clinical trials, will be presented. In the SOCRATES study (PI: S. Lewis), 315 first or second episode schizophrenia patients were randomised to brief CBT, brief supportive counselling or treatment as usual. Patient ratings of the therapeutic alliance at the end of the 4th session significantly predicted positive symptoms, general psychopathology but not negative symptoms at 18 month followup, even when possible confounding factors were taken into account. Therapist ratings of the alliance did not predict outcome. In a second study of adherence to neuroleptic medication (PI: R. Bentall), 209 unsetected schizophrenia patients were examined shortly after admission to hospital following a psychotic episode. Patient perceptions of their relationships with prescribers were better predictors of attitudes towards neuroleptic medication than symptoms, insight, knowledge about medication or experience of side effects. These findings suggest that optimising therapeutic relationships between clinicians and schizophrenia patients may enhance the effectiveness of both pharmacological and psychosocial interventions.
International Congress on Schizophrenia Research 2003
20. Therapeutics: Psychosocial Trials COGNITIVE-BEHAVIOURALTHERAPY IN THE PRE-PSYCHOTIC PHASE: AN EXPLORATORY STUDY A. B e c h d o l f , * M. W a g n e r
Dep. of Psychiatry, Universityof Cologne, Cologne, Germany Although the efficacy of cognitive-behavioural therapy (CBT) in schizo-phrenia in addition to pharmacotherapy has been established for persis-tent psychotic symptoms, no information is available on the effects of CBT in at risk mental states in the pre-psychotic phase.The present exploratory study was conducted to investigate the effectiveness of a comprehensive 12 month CBT programme in persons at risk of psychosis with regard to (1) improvement of present prodromal symptoms, (2) prevention of social decline/stagnation and (3) prevention or delay of progression to psychosis. 25 consecutive admissions to 3 Early Recognition and Intervention Centres in Germany were evaluated in an uncontrolled prospective design with pre- and post-treatment measures. There were significant and substantial improvements in prodromal symptoms and social adjustment and no tran-sition to psychosis according to our criteria. The observed within-group effect sizes on symptoms were up to three times higher than the effect sizes, which are known for CBT in clients with schizophrenia. CBT in the pre-psychotic phase needs further investigation but the first findings sup-port the notion that intervening in the early stages of the illness may be exceptionally effective.
TREATING SUBSTANCE ABUSE IN SCHIZOPHRENIA: PRELIMINARY ANALYSIS OF DATA FROM A RANDOMIZED TREATMENT TRIAL M. E. Bennett,* A. S. Bellack, J. S. G e a r o n
Psychiatry, Universityof Maryland School of Medicine, Baltimore, MD, USA People with schizophrenia and other severe mental illness show alarmingly high rates of substance use disorders. There have been few well-controlled studies of substance abuse treatment in this population, and most that have been done show modest effects. These patients experience a range of neurocognitive and social deficits that make it difficult for them to benefit from effective interventions designed for less-impaired populations, In 1993 we began development of Behavioral Treatment for Substance Abuse in Schizophrenia (BTSAS) to tailor strategies that are effective in reducing substance abuse more generally to meet the needs of this population. BTSAS involves five components: motivational interviewing; urinalysis contingency in which patients earn small sums of money for abstinence from a goal drug; drug refusal skills training; education about drug use in mental illness; and relapse prevention training. We are currently running a NIDA-funded trial that randomly assigns patients with schizophrenia or other SMI and substance use disorder to BTSAS or to a supportive therapy condition (STAR). Both interventions are delivered in mental health clinics in Baltimore. Experience to date suggests that the intervention is safe, that many patients will participate, and that therapists can learn to administer
the intervention reliably and competently. Previous analyses suggest that patients attend and benefit from BTSAS. Early comparisons of patients in both conditions suggests that BTSAS patients attend more sessions than patients in STAR and have more clean urine tests during treatment than STAR patients. An early analysis of data from the current trial found that BTSAS graduates showed a mean of 76% clean urine tests during treatment as compared to 38% for dropouts. Such results are highly encouraging. This poster will present the first examination of during-treatment and post-treatment outcome data from our current randomized trial. Approximately 64 patients will have engaged in treatment in the two conditions. We will present data regarding treatment retention, descriptive characteristics of the sample, treatment utilization data, urine data for patients in both conditions, and post-treatment and 6-month follow-up outcome data. Implications of these results for the BTSAS program and treatment of patients with shizophrenia and substance abuse will be discussed.
RELATIONSHIPS MATTER: THE IMPACT OF THE THERAPEUTIC ALLIANCE ON OUTCOME IN SCHIZOPHRENIA R. R Bentall,* S. Lewis, N. Tarrier, G. Haddock, R. Drake, J. D a y
Psychology, Universityof Manchester, Manchester, England, United Kingdom Research on the outcome of treatment for schizophrenia, whether evaluating pharmacological or psychosocial interventions, has tended to focus on technical aspects of treatment and to ignore non-specific factors such as the quality of patients relationships with their clinicians. However, there is at least smoking gun evidence that relationships matter. Some studies of the treatment environment have found that the presence of high expressed emotion clinicians is associated with poor adjustment in patients. Others have found that non-specific therapies such as supportive counselling or befriending, when used as control conditions in evaluations of cognitive-behaviour therapy (CBT), are associated with better outcome than treatment as usual without any kind of psychosocial intervention. Data on the impact of the therapeutic alliance on outcome in schizophrenia, obtained from two recent clinical trials, will be presented. In the SOCRATES study (PI: S. Lewis), 315 first or second episode schizophrenia patients were randomised to brief CBT, brief supportive counselling or treatment as usual. Patient ratings of the therapeutic alliance at the end of the 4th session significantly predicted positive symptoms, general psychopathology but not negative symptoms at 18 month followup, even when possible confounding factors were taken into account. Therapist ratings of the alliance did not predict outcome. In a second study of adherence to neuroleptic medication (PI: R. Bentall), 209 unsetected schizophrenia patients were examined shortly after admission to hospital following a psychotic episode. Patient perceptions of their relationships with prescribers were better predictors of attitudes towards neuroleptic medication than symptoms, insight, knowledge about medication or experience of side effects. These findings suggest that optimising therapeutic relationships between clinicians and schizophrenia patients may enhance the effectiveness of both pharmacological and psychosocial interventions.
International Congress on Schizophrenia Research 2003