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The significance of coping as a therapeutic variable for the outcome of psychological therapy in schizophrenia
European Psychiatry 18 (2003) 149–154 www.elsevier.com/locate/eurpsy
Original article
The significance of coping as a therapeutic variable for the outcome of psychological therapy in schizophrenia Karl Andres *, Mario Pfammatter, Alexander Fries, Hans Dieter Brenner Department of Social and Community Psychiatry, University Psychiatric Services Bern, UPD, Bolligenstrasse 111, 3000 Bern 60, Switzerland Received 7 July 2002; received in revised form 20 October 2002; accepted 6 December 2002
Abstract Although there is now strong evidence confirming the efficacy of psychological therapies in schizophrenia, the therapeutic processes which they activate remain widely unknown. In order to effectively implement them in clinical practice, identification of these processes is essential. In a controlled study, the efficacy of a coping-oriented therapy approach for schizophrenia patients was tested. Furthermore, the study aimed at establishing preliminary hypotheses on the therapeutically relevant factors. Treatment effects were found in the prominence of psychopathology, the extent of cognizance of the disorder, and the level of social functioning. Moreover, a better psychopathological and social outcome as measured 12 and 18 months after completion of therapy was best predicted by the patients’ mastery of active, problem-focused coping strategies immediately after completion of therapy. The findings underscore the clinical relevance of specific coping styles and corroborate the appropriateness of focusing on aspects of coping behavior in psychological interventions for schizophrenia patients. © 2003 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. Keywords: Schizophrenia; Coping; Cognitive behavioral therapy; Psychoeducation
1. Introduction
2. Subjects and methods
No other psychological treatment for schizophrenia patients has been so intensively investigated in recent years as psychoeducational and behavioral therapy approaches focusing on the patients’ and their families’ coping resources [10]. A multitude of efficacy studies demonstrates that such interventions foster a better knowledge of the disorder among patients and relatives, enhance medication compliance, reduce relapse rates, shorten inpatient care, improve social functioning and decrease the family’s burden [9]. They have also proved to be cost-effective [2]. Nonetheless, many questions require further empirical clarification. A central issue pertains to their specific therapeutic factors. Especially, it has not been established whether it is the patients’ and their relatives’ coping behavior or, whether it is improved medication compliance that is mainly instrumental in their success. The present explorative study examines the aspect of the therapeutically relevant factors of a psychoeducational and behavioral therapy oriented towards coping with the illness.
2.1. Aims
* Corresponding author. E-mail address: [email protected] (K. Andres). © 2003 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. DOI: 10.1016/S0924-9338(03)00042-7
The study had two aims: the first aim was to test the general and differential effects of a coping-oriented group therapy for schizophrenia and schizoaffective patients [15]. The second was to establish preliminary hypotheses on the therapeutically relevant factors of this therapy. The crucial question was whether coping behavior really is an important effect factor of the therapy. 2.2. Treatment conditions For the purpose of these questions, the coping-oriented group therapy was compared to a supportive group therapy control condition. The coping-oriented group therapy approach presented here comprises four parts. The objective of the first, psychoeducational part is to impart information on the illness and diagnosis as well as on the vulnerability model and course of illness and treatment. In the second part of therapy, a definition of stress is elaborated. Afterwards, a stressful situation selected by the group is analyzed from cognitive, emotional,
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K. Andres et al. / European Psychiatry 18 (2003) 149–154
Table 1 Clinical characteristics of study samples Characteristics Age at index hospitalization (years)a Duration of illness (years)a Number of hospitalizationsa Total duration of hospitalization (days)a Number of men/women a
Experimental group (n = 17), mean (S.D.) 30.4 (5.8) 8.7 (5.3) 5.5 (3.8) 573.1 (411.6) 12/5
Control group (n = 15), mean (S.D.) 31.6 (8.9) 6.1 (5.7) 3.5 (2.8) 519.6 (601.9) 9/6
t-Tests for independent samples revealed no significant between-group differences in these variables.
physiological and behavioral perspectives followed by the training of appropriate coping behavior using a problemsolving approach and role play methods. Health behavior is the central focus of the third part of therapy. Potentially pleasant situations are identified and ways to structure the day and leisure time are discussed and practiced in real-life situations. The fourth part comprises psychoeducational sessions with family members [16]. In the supportive group therapy—based on clientcentered, therapeutic principles—the patients were given free choice of the topics they wished to discuss and no specifically cognitive or behavioral therapy methods were applied. The patients’ relatives were also offered the opportunity of taking part in informative discussion sessions. Both therapy approaches were applied in groups of four to seven patients. A total of 24 90-min sessions spread over a period of 3 months were provided. 2.3. Subjects Thirty-two patients, all diagnosed with schizophrenia spectrum disorders according to ICD-10, were included in the study. They were informed about the treatment conditions and the scientific assessments. After giving their informed consent they were successively assigned to the alternating coping-oriented or supportive therapy groups. Seventeen took part in coping-oriented therapy and 15 in supportive therapy. Randomization could not be performed due to clinical reasons. The characteristics of the study samples—shown in Table 1—point to a rather severely and chronically disturbed population. Although the clinical setting of the study precluded the possibility of randomization, t-tests for independent samples revealed no significant between-group differences in these variables. 2.4. Outcome measures In line with the schedule of questions to be investigated, the following assessments were made. Patients completed a modified version of the Knowledge Questionnaire developed by Hahlweg et al. [3] to determine the scope of existing knowledge of the disorder and the related treatment. Psychopathological variables were assessed by using the Brief Psychiatric Rating Scale by Overall and Gorham [12] and the Scale for the Assessment of Negative Symptoms by Andreasen [1]. Psychosocial functioning was assessed by means of the Social Interview Schedule developed by Hecht
et al. [4]. Furthermore, we administered The Scale for Concept of Illness by Linden et al. [8], which served to ascertain the degree of confidence in medication, plus several additional measures to assess how patients cope with their illness, namely: the Stress Coping Questionnaire developed by Janke et al. [5], the Freiburg Questionnaire on Coping with Illness by Muthny [11], the Competence and Self-control Questionnaire by Krampen [7] and the Questionnaire on Coping with Stress in the Course of the Illness by Reicherts and Perrez [14]. The assessments were performed immediately prior to and after completion of therapy, as well as at intervals of 6, 12 and 18 months after completion of therapy. 2.5. Statistical analysis In a first step, analyses of variance for repeated measures were performed in order to examine within and betweengroup differences. Secondly, we pooled the data of both samples and carried out factor and multiple regression analyses in order to identify the therapeutically relevant effect variables. 3. Results In general, the examinations of within and between-group differences indicate that in both treatment groups knowledge of the disorder and its treatment was significantly enhanced from baseline to post-treatment and to the follow-ups (Table 2). Likewise, the severity of overall psychopathology and the degree of negative symptoms were reduced in both treatment groups from pre- to post-treatment and once again during the interval to the follow-ups. Moreover, the quality of the residential and work situations as well as the quality and quantity of social contacts had clearly improved in both conditions during treatment and the follow-up period. However, with reference to confidence in medication and coping behavior as assessed on the various coping rating scales no substantial effects were ascertainable in either treatment condition. Overall, there were only very few differences between both treatment groups. The only significant difference was found in regard to the scope of knowledge of the disorder and its treatment indicating a more pronounced effect in the experimental treatment condition immediately after completion of therapy. This advantage was no longer ascertainable at the follow-up assessments. After the examination of the general and differential treatment effects, we pooled the data of both samples and carried
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Table 2 Differences in treatment outcome at the 18-month follow-up
Knowledge of the disorder and its treatment Knowledge Questionnaire [3]
Analysis of variance with repeated measuresa Effect F Time 25.22 Time × group 0.078
P 0.000 nsb
Severity of symptoms Brief Psychiatric Rating Scale, BPRS [12]
Time Time × group
12.67 0.58
0.001 ns
Negative symptoms Scale for the Assessment of Negative Symptoms, SANS [1]
Time Time × group
11.30 0.60
0.002 ns
Quality of residential conditions Social Interview Schedule, SIS [4]
Time Time × group
12.42 1.10
0.001 ns
Quality of work situation Social Interview Schedule, SIS [4]
Time Time × group
18.20 0.626
0.000 ns
Quality and quantity of social contacts Social Interview Schedule, SIS [4]
Time Time × group
6.44 0.713
0.017 ns
Confidence in medication Scale for Concept of Illness [8]
Time Time × group
0.65 0.006
ns ns
Outcome variables
Coping behavior No significant time or time × group interaction effect on the various scales Stress Coping Questionnaire [5]; Freiburg Questionnaire on Coping with Illness [11]; Competence and Self-control Questionnaire [7]; Questionnaire on Coping with Stress in the Course of the Illness [14] a b
Analysis of variance with repeated measures over five occasions (pre- and post-treatment, 6, 12 and 18 months after completion of therapy). Not significant.
out factor and multiple regression analyses in order to obtain an idea about the therapeutically relevant effect variables. Above all, we wished to examine the significance of coping behavior on the outcome of therapy. To avoid including too many variables in the regression analysis, we first reduced the rather large number of coping items to a few main dimensions by factor analysis. Specifically, we carried out a principal component analysis with varimax rotation using the post-treatment values of 24 items of the various coping scales which were chosen on the basis of theoretical considerations and covered a broad range of coping behavior aspects. The most convincing solution of this factor analysis was a structure with four factors that we defined as follows. Factor 1 may be called active, problem-focused coping. This factor accounts for about 16% of the variance of the values and is characterized by items such as “to make an active effort to solve a problem” or “to resolutely combat the illness”. Most of the items that were assigned to this factor were taken from the Freiburg Questionnaire on Coping with Illness [11], which is based on ratings by a significant other. Factor 2 represents avoidance coping. This factor also accounts for about 16% of the variance. It is best characterized by items such as “in a stressful situation, I make certain to myself that the situation is not serious or important” or “in a stressful situation, I try to calm down”. Most of the items of
this factor stem from the questionnaire on Coping with Stress in the Course of the Illness [14], based on self-ratings. Factor 3 may be called resignation and helplessness. It accounts for nearly 14% of the variance and has high loadings with items such as “to grapple with fate” or “selfcommiseration”, which also are primarily taken from the Freiburg Questionnaire on Coping with Illness [11], rated by a significant other. Factor 4 reflects the attitude that successful coping is attributable to external influences. This factor explains about 10% of the variance and is defined by items such as “whether I’ve got a puncture or not, depends on the behavior of others” or “I’ve got the feeling that many occurrences in my life depend on others”. Most of the items associated with this factor are included in the Competence and Self-control Questionnaire (self-rating) [7]. Taken together, the four coping factors explain 57% of the variance of the values measured by the coping behavior questionnaires completed immediately after therapy. In order to examine how these coping factors relate to outcome, they were defined as predictors and tested for their predictive value on diverse outcome criteria in multiple regression analyses. The following variables—assessed 12 and 18 months after completion of therapy—served as outcome criteria: the sum-scores of the Brief Psychiatric Rating Scale
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Table 3 Prediction of psychopathological and social outcome by coping factors Predictors (coping factors)
Outcome-criteria (beta-weights) SANSb BPRSa
Follow-up (months) Factor 1 Active and problem-focused coping Factor 2 Avoidance-based coping Factor 3 Resignation and helplessness Factor 4 Success is attributable to external influences
12
18
12
Days in hospital 18
12
18
Residential conditions (SISc) 12 18
Work situation (SIS) 12 18
Social contacts (SIS) 12
18
–0.462** –0.409*
–0.504** –0.401*
–0.447*
–0.382*
0.053
0.081
0.545**
0.512**
0.326*
0.413*
–0.091
–0.026
–0.011
0.052
0.121
0.096
0.124
0.065
0.189
0.136
0.156
–0.123
0.381*
0.005
0.442**
0.082
0.076
0.102
–0.148
0.029
–0.068
0.042
–0.202
–0.131
0.053
–0.160
0.085
0.143
0.034
0.019
–0.183
0.053
–0.326*
–0.277
–0.351*
–0.217
a
Brief Psychiatric Rating Scale [12]. Scale for the Assessment of Negative Symptoms [1]. c Social Interview Schedule [4]. * P ≤ 0.05. ** P ≤ 0.01. b
[12] and the Scale for the Assessment of Negative Symptoms [1], the number of days in hospital as well as the quality of the residential and working conditions, and the quantity and quality of social contacts all assessed by the Social Interview Schedule [4]. The standardized beta-weights in Table 3 show the predictive power of the four coping factors for forecasting overall psychopathology, the severity of negative symptoms and the number of days in hospital 12 and 18 months after completion of therapy. It is evident from the weighting on the first coping factor—indicating a high degree of active, problemfocused coping behavior at the end of therapy—that this factor is a powerful predictor for both a low degree of overall psychopathology and negative symptomatology and also a reduced number of inpatient days as measured at the 12 and 18-month follow-up. The third coping dimension, characterized by resignation and helplessness, seems to be another relevant predictor for the degree of psychopathology 1 year after therapy. In other words, a high degree of resignation and helplessness at the end of therapy forecasts both high overall psychopathology and negative symptomatology 1 year after completion of therapy. An active, problem-focused coping style also proved to be important for the prediction of a favorable outcome with regard to the quality of the work situation and the quantity and quality of social contacts 12 and 18 months after completion of therapy. On the contrary, the attitude that successful coping is attributable to external influences—coping factor 4— seems to predict maladjustment in regard to work and social relations as assessed at the 12-month follow-up. To compare the relevance for outcome of an active, problem-focused coping style with the predictive significance of other central treatment goals, such as the enhancement of knowledge of the disorder and its treatment or a favorable change in attitude towards medication, further multiple regression analyses with the predictor variables defined
as active, problem-focused coping, knowledge of the disorder and confidence in medication at the end of therapy were carried out. The standardized beta-weights presented in Table 4 demonstrate once again that active, problem-focused coping is a strong predictor of the degree of overall psychopathology, the severity of negative symptoms, the number of inpatient days as well as the quality of the work situation and social relationships as compared to knowledge of the disorder and confidence in medication. It is noteworthy that particularly the patients’ knowledge of the disorder and its treatment turned out to be a poor predictor of symptomatology and the duration of hospitalization as measured 12 and 18 months after therapy.
4. Discussion The explorative nature of this pilot study and the small sample size permit only preliminary and tentative conclusions to be drawn from the findings. In summary, it still may be concluded that non-specific treatment effects were found in the extent of knowledge of the disorder and its treatment, the degree of overall psychopathology, the prominence of negative symptoms, and in some aspects in the level of social functioning. However, the experimental coping-oriented treatment group showed only one transient significant advantage over the supportive treatment condition in regard to a more pronounced increase of knowledge of the disorder and its treatment as measured immediately after completion of therapy. The absence of further significant differential effects between both treatment conditions may be due to the small sample size. Furthermore, a between-group comparison of the therapeutic contents of both treatment groups unexpectedly showed that these strongly overlapped since 80% of the topics in the coping-oriented therapy were identical with
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Table 4 Prediction of outcome by active and problem-focused coping, knowledge of the disorder and confidence in medication Predictors (therapeutic aims)
Outcome-criteria (beta-weights) SANSb BPRSa
Days in hospital
Follow-up (months) Active and problem-focused coping (coping factor 1) Knowledge of the disorder and its treatmentd Confidence in medicatione
12 18 –0.461** –0.346*
12c 18 –0.506** –0.366*
–0.131
0.268
–0.053
–0.242
–0.183
–0.069
Work situation (SIS) 12 18 0.563** 0.522**
Social contacts (SIS)
12 18 –0.498** –0.426*
Residential conditions (SISc) 12 18 0.016 0.044
12 0.344*
18 0.361*
0.147
–0.152
–0.057
–0.285
–0.250
0.131
0.143
0.149
–0.219
–0.108
0.269
0.359*
–0.117
–0.066
0.044
0.153
0.079
0.153
a
Brief Psychiatric Rating Scale [12]. Scale for the Assessment of Negative Symptoms [1]. c Social Interview Schedule [4]. d Knowledge Questionnaire [3]. e Scale for Concept of Illness [8]. * P ≤ 0.05. ** P ≤ 0.01. b
those discussed by the participants in the supportive therapy group. Neither treatment condition brought about decisive changes in coping behavior, either because the measures used were insufficiently sensitive to change or because both forms of therapy were ineffectual in this respect. Therefore, the coping-oriented therapy may be judged to have failed to achieve one of its central therapeutic aims. In this connection, the various unresolved problems in areas of conceptualizing and operationalizing coping should be borne in mind [18]. However, the clinical relevance of specific coping strategies is underscored by regression analysis. Notably the fact that active, problem-focused coping behavior was shown to be the strongest predictor of several outcome criteria indicates the appropriateness of focusing on coping in psychological therapy for schizophrenic psychosis. This is in line with a study of Pallanti et al. [13]. According to their findings the use of problem-focused coping strategies by young schizophrenia patients demonstrably lessened the impact of stressful life events and lowered the risk of relapse. Nevertheless, many open questions remain in regard to coping with the disorder of schizophrenia. For example, it is not clear in what way coping style and symptoms are interrelated. Our results do not unequivocally answer the question whether adaptive coping itself has a positive effect on the course of the illness or whether it is just a lower degree of symptoms which possibly underlies successful coping behavior and which may be responsible for the better outcome. However, the findings in a study of Ventura et al. [17] indicate that using an active, problem-focused coping style is predicted by a better neurocognitive performance and a positive selfefficacy expectation, but not by negative symptoms. Another important issue is whether and to what extent psychoeducational and behavioral interventions actually do improve the coping strategies of schizophrenia patients and their relatives. As the relapse rate is heavily dependent on compliance, the efficacy of these therapy approaches may be mainly
ascribable to heightened compliance and thus, they may only fulfill an adjuvant role in pharmacotherapy. Should this prove the case, then one must more precisely speak of “compliance therapy” [6]. To date, investigations have seldom directly addressed this issue. Our data may indicate that short-term group therapy is unsuccessful in improving the patients’ and their relatives’ coping strategies. Longer-term interventions tailored to the specific needs and resources of individual patients and families could prove more effective in achieving significant improvements in coping behavior. Solving these problems is essential in order to (cost-)effectively implement successful psychological therapies in standard psychiatric care. Therefore, we need to intensify the research on the relationship between therapy process and therapy outcome as a means of identifying the significant specific effect factors of psychological therapy in schizophrenia and the therapeutic change processes they may activate. During the past 20 years considerable progress has been made in the development of psychological treatment of schizophrenia. Nevertheless, many issues have yet to be clarified. Questions revolving around differential indications, specific effect factors and therapeutic change processes, the optimum combination of effective psychological therapy approaches with appropriate pharmacotherapy strategies and specific rehabilitation programs must be the object of intensive, systematic investigation in coming years. Ultimately, the future of psychological treatment approaches will be decided by the core issues of whether these approaches achieve the same effects under routine clinical conditions as in experimental settings, and whether, how and for whom the cost-effectiveness of these interventions will permit their integration into routine clinical care. Acknowledgements We thank the Swiss National Science Foundation and the Ciba-Geigy-Jubilee Foundation, which funded this study. We
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also thank all patients for their willingness to join the study and for filling out all the questionnaires.
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Mari JJ, Streiner D. Family intervention for schizophrenia (Cochrane Review). The Cochrane library, issue 2. Oxford: Update Software; 1998. Mueser KT, Bond GR. Psychosocial treatment approaches for schizophrenia. Curr Opin Psychiatr 2000;13:27–35. Muthny FA. Freiburger Fragebogen zur Krankheitsverarbeitung, FKV. Weinheim: Beltz Test; 1989. Overall JE, Gorham DR. The Brief Psychiatric Rating Scale. Psychol Rep 1962;10:799–812. Pallanti S, Quercioli L, Pazzagli A. Relapse in young paranoid schizophrenic patients: a prospective study of stressful life events, P300 measures, and coping. Am J Psychiatry 1997;154:792–8. Reicherts M, Perrez M. Fragebogen zum Umgang mit Belastungen. Bern: Huber; 1993. Roder V, Zorn P, Andres K, Pfammatter M, Brenner HD. Praxishandbuch zur verhaltenstherapeutischen Behandlung schizophren Erkrankter. Bern: Hans Huber; 2002. Schaub A, Andres K, Brenner HD, Donzel G. Developing a group format coping-orientated treatment programme for schizophrenic patients. In: Böker W, Brenner HD, Genner R, editors. Towards a comprehensive therapy for schizophrenia. Seattle: Hogrefe & Huber; 1997. p. 228–51. Ventura J, Nuechterlein KH, Subotnik KL, Gitlin M, Bartzokis G, Sharou J. Coping responses and neurocognitive functioning in schizophrenia. Paper presented at the 151st meeting of the American Psychiatric Association. Toronto; 30 May–4 June 1999. Wiedl KH, Schottner B. Coping with symptoms related to schizophrenia. Schizophr Bull 1991;17:525–38.
Original article
The significance of coping as a therapeutic variable for the outcome of psychological therapy in schizophrenia Karl Andres *, Mario Pfammatter, Alexander Fries, Hans Dieter Brenner Department of Social and Community Psychiatry, University Psychiatric Services Bern, UPD, Bolligenstrasse 111, 3000 Bern 60, Switzerland Received 7 July 2002; received in revised form 20 October 2002; accepted 6 December 2002
Abstract Although there is now strong evidence confirming the efficacy of psychological therapies in schizophrenia, the therapeutic processes which they activate remain widely unknown. In order to effectively implement them in clinical practice, identification of these processes is essential. In a controlled study, the efficacy of a coping-oriented therapy approach for schizophrenia patients was tested. Furthermore, the study aimed at establishing preliminary hypotheses on the therapeutically relevant factors. Treatment effects were found in the prominence of psychopathology, the extent of cognizance of the disorder, and the level of social functioning. Moreover, a better psychopathological and social outcome as measured 12 and 18 months after completion of therapy was best predicted by the patients’ mastery of active, problem-focused coping strategies immediately after completion of therapy. The findings underscore the clinical relevance of specific coping styles and corroborate the appropriateness of focusing on aspects of coping behavior in psychological interventions for schizophrenia patients. © 2003 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. Keywords: Schizophrenia; Coping; Cognitive behavioral therapy; Psychoeducation
1. Introduction
2. Subjects and methods
No other psychological treatment for schizophrenia patients has been so intensively investigated in recent years as psychoeducational and behavioral therapy approaches focusing on the patients’ and their families’ coping resources [10]. A multitude of efficacy studies demonstrates that such interventions foster a better knowledge of the disorder among patients and relatives, enhance medication compliance, reduce relapse rates, shorten inpatient care, improve social functioning and decrease the family’s burden [9]. They have also proved to be cost-effective [2]. Nonetheless, many questions require further empirical clarification. A central issue pertains to their specific therapeutic factors. Especially, it has not been established whether it is the patients’ and their relatives’ coping behavior or, whether it is improved medication compliance that is mainly instrumental in their success. The present explorative study examines the aspect of the therapeutically relevant factors of a psychoeducational and behavioral therapy oriented towards coping with the illness.
2.1. Aims
* Corresponding author. E-mail address: [email protected] (K. Andres). © 2003 Éditions scientifiques et médicales Elsevier SAS. All rights reserved. DOI: 10.1016/S0924-9338(03)00042-7
The study had two aims: the first aim was to test the general and differential effects of a coping-oriented group therapy for schizophrenia and schizoaffective patients [15]. The second was to establish preliminary hypotheses on the therapeutically relevant factors of this therapy. The crucial question was whether coping behavior really is an important effect factor of the therapy. 2.2. Treatment conditions For the purpose of these questions, the coping-oriented group therapy was compared to a supportive group therapy control condition. The coping-oriented group therapy approach presented here comprises four parts. The objective of the first, psychoeducational part is to impart information on the illness and diagnosis as well as on the vulnerability model and course of illness and treatment. In the second part of therapy, a definition of stress is elaborated. Afterwards, a stressful situation selected by the group is analyzed from cognitive, emotional,
150
K. Andres et al. / European Psychiatry 18 (2003) 149–154
Table 1 Clinical characteristics of study samples Characteristics Age at index hospitalization (years)a Duration of illness (years)a Number of hospitalizationsa Total duration of hospitalization (days)a Number of men/women a
Experimental group (n = 17), mean (S.D.) 30.4 (5.8) 8.7 (5.3) 5.5 (3.8) 573.1 (411.6) 12/5
Control group (n = 15), mean (S.D.) 31.6 (8.9) 6.1 (5.7) 3.5 (2.8) 519.6 (601.9) 9/6
t-Tests for independent samples revealed no significant between-group differences in these variables.
physiological and behavioral perspectives followed by the training of appropriate coping behavior using a problemsolving approach and role play methods. Health behavior is the central focus of the third part of therapy. Potentially pleasant situations are identified and ways to structure the day and leisure time are discussed and practiced in real-life situations. The fourth part comprises psychoeducational sessions with family members [16]. In the supportive group therapy—based on clientcentered, therapeutic principles—the patients were given free choice of the topics they wished to discuss and no specifically cognitive or behavioral therapy methods were applied. The patients’ relatives were also offered the opportunity of taking part in informative discussion sessions. Both therapy approaches were applied in groups of four to seven patients. A total of 24 90-min sessions spread over a period of 3 months were provided. 2.3. Subjects Thirty-two patients, all diagnosed with schizophrenia spectrum disorders according to ICD-10, were included in the study. They were informed about the treatment conditions and the scientific assessments. After giving their informed consent they were successively assigned to the alternating coping-oriented or supportive therapy groups. Seventeen took part in coping-oriented therapy and 15 in supportive therapy. Randomization could not be performed due to clinical reasons. The characteristics of the study samples—shown in Table 1—point to a rather severely and chronically disturbed population. Although the clinical setting of the study precluded the possibility of randomization, t-tests for independent samples revealed no significant between-group differences in these variables. 2.4. Outcome measures In line with the schedule of questions to be investigated, the following assessments were made. Patients completed a modified version of the Knowledge Questionnaire developed by Hahlweg et al. [3] to determine the scope of existing knowledge of the disorder and the related treatment. Psychopathological variables were assessed by using the Brief Psychiatric Rating Scale by Overall and Gorham [12] and the Scale for the Assessment of Negative Symptoms by Andreasen [1]. Psychosocial functioning was assessed by means of the Social Interview Schedule developed by Hecht
et al. [4]. Furthermore, we administered The Scale for Concept of Illness by Linden et al. [8], which served to ascertain the degree of confidence in medication, plus several additional measures to assess how patients cope with their illness, namely: the Stress Coping Questionnaire developed by Janke et al. [5], the Freiburg Questionnaire on Coping with Illness by Muthny [11], the Competence and Self-control Questionnaire by Krampen [7] and the Questionnaire on Coping with Stress in the Course of the Illness by Reicherts and Perrez [14]. The assessments were performed immediately prior to and after completion of therapy, as well as at intervals of 6, 12 and 18 months after completion of therapy. 2.5. Statistical analysis In a first step, analyses of variance for repeated measures were performed in order to examine within and betweengroup differences. Secondly, we pooled the data of both samples and carried out factor and multiple regression analyses in order to identify the therapeutically relevant effect variables. 3. Results In general, the examinations of within and between-group differences indicate that in both treatment groups knowledge of the disorder and its treatment was significantly enhanced from baseline to post-treatment and to the follow-ups (Table 2). Likewise, the severity of overall psychopathology and the degree of negative symptoms were reduced in both treatment groups from pre- to post-treatment and once again during the interval to the follow-ups. Moreover, the quality of the residential and work situations as well as the quality and quantity of social contacts had clearly improved in both conditions during treatment and the follow-up period. However, with reference to confidence in medication and coping behavior as assessed on the various coping rating scales no substantial effects were ascertainable in either treatment condition. Overall, there were only very few differences between both treatment groups. The only significant difference was found in regard to the scope of knowledge of the disorder and its treatment indicating a more pronounced effect in the experimental treatment condition immediately after completion of therapy. This advantage was no longer ascertainable at the follow-up assessments. After the examination of the general and differential treatment effects, we pooled the data of both samples and carried
K. Andres et al. / European Psychiatry 18 (2003) 149–154
151
Table 2 Differences in treatment outcome at the 18-month follow-up
Knowledge of the disorder and its treatment Knowledge Questionnaire [3]
Analysis of variance with repeated measuresa Effect F Time 25.22 Time × group 0.078
P 0.000 nsb
Severity of symptoms Brief Psychiatric Rating Scale, BPRS [12]
Time Time × group
12.67 0.58
0.001 ns
Negative symptoms Scale for the Assessment of Negative Symptoms, SANS [1]
Time Time × group
11.30 0.60
0.002 ns
Quality of residential conditions Social Interview Schedule, SIS [4]
Time Time × group
12.42 1.10
0.001 ns
Quality of work situation Social Interview Schedule, SIS [4]
Time Time × group
18.20 0.626
0.000 ns
Quality and quantity of social contacts Social Interview Schedule, SIS [4]
Time Time × group
6.44 0.713
0.017 ns
Confidence in medication Scale for Concept of Illness [8]
Time Time × group
0.65 0.006
ns ns
Outcome variables
Coping behavior No significant time or time × group interaction effect on the various scales Stress Coping Questionnaire [5]; Freiburg Questionnaire on Coping with Illness [11]; Competence and Self-control Questionnaire [7]; Questionnaire on Coping with Stress in the Course of the Illness [14] a b
Analysis of variance with repeated measures over five occasions (pre- and post-treatment, 6, 12 and 18 months after completion of therapy). Not significant.
out factor and multiple regression analyses in order to obtain an idea about the therapeutically relevant effect variables. Above all, we wished to examine the significance of coping behavior on the outcome of therapy. To avoid including too many variables in the regression analysis, we first reduced the rather large number of coping items to a few main dimensions by factor analysis. Specifically, we carried out a principal component analysis with varimax rotation using the post-treatment values of 24 items of the various coping scales which were chosen on the basis of theoretical considerations and covered a broad range of coping behavior aspects. The most convincing solution of this factor analysis was a structure with four factors that we defined as follows. Factor 1 may be called active, problem-focused coping. This factor accounts for about 16% of the variance of the values and is characterized by items such as “to make an active effort to solve a problem” or “to resolutely combat the illness”. Most of the items that were assigned to this factor were taken from the Freiburg Questionnaire on Coping with Illness [11], which is based on ratings by a significant other. Factor 2 represents avoidance coping. This factor also accounts for about 16% of the variance. It is best characterized by items such as “in a stressful situation, I make certain to myself that the situation is not serious or important” or “in a stressful situation, I try to calm down”. Most of the items of
this factor stem from the questionnaire on Coping with Stress in the Course of the Illness [14], based on self-ratings. Factor 3 may be called resignation and helplessness. It accounts for nearly 14% of the variance and has high loadings with items such as “to grapple with fate” or “selfcommiseration”, which also are primarily taken from the Freiburg Questionnaire on Coping with Illness [11], rated by a significant other. Factor 4 reflects the attitude that successful coping is attributable to external influences. This factor explains about 10% of the variance and is defined by items such as “whether I’ve got a puncture or not, depends on the behavior of others” or “I’ve got the feeling that many occurrences in my life depend on others”. Most of the items associated with this factor are included in the Competence and Self-control Questionnaire (self-rating) [7]. Taken together, the four coping factors explain 57% of the variance of the values measured by the coping behavior questionnaires completed immediately after therapy. In order to examine how these coping factors relate to outcome, they were defined as predictors and tested for their predictive value on diverse outcome criteria in multiple regression analyses. The following variables—assessed 12 and 18 months after completion of therapy—served as outcome criteria: the sum-scores of the Brief Psychiatric Rating Scale
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Table 3 Prediction of psychopathological and social outcome by coping factors Predictors (coping factors)
Outcome-criteria (beta-weights) SANSb BPRSa
Follow-up (months) Factor 1 Active and problem-focused coping Factor 2 Avoidance-based coping Factor 3 Resignation and helplessness Factor 4 Success is attributable to external influences
12
18
12
Days in hospital 18
12
18
Residential conditions (SISc) 12 18
Work situation (SIS) 12 18
Social contacts (SIS) 12
18
–0.462** –0.409*
–0.504** –0.401*
–0.447*
–0.382*
0.053
0.081
0.545**
0.512**
0.326*
0.413*
–0.091
–0.026
–0.011
0.052
0.121
0.096
0.124
0.065
0.189
0.136
0.156
–0.123
0.381*
0.005
0.442**
0.082
0.076
0.102
–0.148
0.029
–0.068
0.042
–0.202
–0.131
0.053
–0.160
0.085
0.143
0.034
0.019
–0.183
0.053
–0.326*
–0.277
–0.351*
–0.217
a
Brief Psychiatric Rating Scale [12]. Scale for the Assessment of Negative Symptoms [1]. c Social Interview Schedule [4]. * P ≤ 0.05. ** P ≤ 0.01. b
[12] and the Scale for the Assessment of Negative Symptoms [1], the number of days in hospital as well as the quality of the residential and working conditions, and the quantity and quality of social contacts all assessed by the Social Interview Schedule [4]. The standardized beta-weights in Table 3 show the predictive power of the four coping factors for forecasting overall psychopathology, the severity of negative symptoms and the number of days in hospital 12 and 18 months after completion of therapy. It is evident from the weighting on the first coping factor—indicating a high degree of active, problemfocused coping behavior at the end of therapy—that this factor is a powerful predictor for both a low degree of overall psychopathology and negative symptomatology and also a reduced number of inpatient days as measured at the 12 and 18-month follow-up. The third coping dimension, characterized by resignation and helplessness, seems to be another relevant predictor for the degree of psychopathology 1 year after therapy. In other words, a high degree of resignation and helplessness at the end of therapy forecasts both high overall psychopathology and negative symptomatology 1 year after completion of therapy. An active, problem-focused coping style also proved to be important for the prediction of a favorable outcome with regard to the quality of the work situation and the quantity and quality of social contacts 12 and 18 months after completion of therapy. On the contrary, the attitude that successful coping is attributable to external influences—coping factor 4— seems to predict maladjustment in regard to work and social relations as assessed at the 12-month follow-up. To compare the relevance for outcome of an active, problem-focused coping style with the predictive significance of other central treatment goals, such as the enhancement of knowledge of the disorder and its treatment or a favorable change in attitude towards medication, further multiple regression analyses with the predictor variables defined
as active, problem-focused coping, knowledge of the disorder and confidence in medication at the end of therapy were carried out. The standardized beta-weights presented in Table 4 demonstrate once again that active, problem-focused coping is a strong predictor of the degree of overall psychopathology, the severity of negative symptoms, the number of inpatient days as well as the quality of the work situation and social relationships as compared to knowledge of the disorder and confidence in medication. It is noteworthy that particularly the patients’ knowledge of the disorder and its treatment turned out to be a poor predictor of symptomatology and the duration of hospitalization as measured 12 and 18 months after therapy.
4. Discussion The explorative nature of this pilot study and the small sample size permit only preliminary and tentative conclusions to be drawn from the findings. In summary, it still may be concluded that non-specific treatment effects were found in the extent of knowledge of the disorder and its treatment, the degree of overall psychopathology, the prominence of negative symptoms, and in some aspects in the level of social functioning. However, the experimental coping-oriented treatment group showed only one transient significant advantage over the supportive treatment condition in regard to a more pronounced increase of knowledge of the disorder and its treatment as measured immediately after completion of therapy. The absence of further significant differential effects between both treatment conditions may be due to the small sample size. Furthermore, a between-group comparison of the therapeutic contents of both treatment groups unexpectedly showed that these strongly overlapped since 80% of the topics in the coping-oriented therapy were identical with
K. Andres et al. / European Psychiatry 18 (2003) 149–154
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Table 4 Prediction of outcome by active and problem-focused coping, knowledge of the disorder and confidence in medication Predictors (therapeutic aims)
Outcome-criteria (beta-weights) SANSb BPRSa
Days in hospital
Follow-up (months) Active and problem-focused coping (coping factor 1) Knowledge of the disorder and its treatmentd Confidence in medicatione
12 18 –0.461** –0.346*
12c 18 –0.506** –0.366*
–0.131
0.268
–0.053
–0.242
–0.183
–0.069
Work situation (SIS) 12 18 0.563** 0.522**
Social contacts (SIS)
12 18 –0.498** –0.426*
Residential conditions (SISc) 12 18 0.016 0.044
12 0.344*
18 0.361*
0.147
–0.152
–0.057
–0.285
–0.250
0.131
0.143
0.149
–0.219
–0.108
0.269
0.359*
–0.117
–0.066
0.044
0.153
0.079
0.153
a
Brief Psychiatric Rating Scale [12]. Scale for the Assessment of Negative Symptoms [1]. c Social Interview Schedule [4]. d Knowledge Questionnaire [3]. e Scale for Concept of Illness [8]. * P ≤ 0.05. ** P ≤ 0.01. b
those discussed by the participants in the supportive therapy group. Neither treatment condition brought about decisive changes in coping behavior, either because the measures used were insufficiently sensitive to change or because both forms of therapy were ineffectual in this respect. Therefore, the coping-oriented therapy may be judged to have failed to achieve one of its central therapeutic aims. In this connection, the various unresolved problems in areas of conceptualizing and operationalizing coping should be borne in mind [18]. However, the clinical relevance of specific coping strategies is underscored by regression analysis. Notably the fact that active, problem-focused coping behavior was shown to be the strongest predictor of several outcome criteria indicates the appropriateness of focusing on coping in psychological therapy for schizophrenic psychosis. This is in line with a study of Pallanti et al. [13]. According to their findings the use of problem-focused coping strategies by young schizophrenia patients demonstrably lessened the impact of stressful life events and lowered the risk of relapse. Nevertheless, many open questions remain in regard to coping with the disorder of schizophrenia. For example, it is not clear in what way coping style and symptoms are interrelated. Our results do not unequivocally answer the question whether adaptive coping itself has a positive effect on the course of the illness or whether it is just a lower degree of symptoms which possibly underlies successful coping behavior and which may be responsible for the better outcome. However, the findings in a study of Ventura et al. [17] indicate that using an active, problem-focused coping style is predicted by a better neurocognitive performance and a positive selfefficacy expectation, but not by negative symptoms. Another important issue is whether and to what extent psychoeducational and behavioral interventions actually do improve the coping strategies of schizophrenia patients and their relatives. As the relapse rate is heavily dependent on compliance, the efficacy of these therapy approaches may be mainly
ascribable to heightened compliance and thus, they may only fulfill an adjuvant role in pharmacotherapy. Should this prove the case, then one must more precisely speak of “compliance therapy” [6]. To date, investigations have seldom directly addressed this issue. Our data may indicate that short-term group therapy is unsuccessful in improving the patients’ and their relatives’ coping strategies. Longer-term interventions tailored to the specific needs and resources of individual patients and families could prove more effective in achieving significant improvements in coping behavior. Solving these problems is essential in order to (cost-)effectively implement successful psychological therapies in standard psychiatric care. Therefore, we need to intensify the research on the relationship between therapy process and therapy outcome as a means of identifying the significant specific effect factors of psychological therapy in schizophrenia and the therapeutic change processes they may activate. During the past 20 years considerable progress has been made in the development of psychological treatment of schizophrenia. Nevertheless, many issues have yet to be clarified. Questions revolving around differential indications, specific effect factors and therapeutic change processes, the optimum combination of effective psychological therapy approaches with appropriate pharmacotherapy strategies and specific rehabilitation programs must be the object of intensive, systematic investigation in coming years. Ultimately, the future of psychological treatment approaches will be decided by the core issues of whether these approaches achieve the same effects under routine clinical conditions as in experimental settings, and whether, how and for whom the cost-effectiveness of these interventions will permit their integration into routine clinical care. Acknowledgements We thank the Swiss National Science Foundation and the Ciba-Geigy-Jubilee Foundation, which funded this study. We
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also thank all patients for their willingness to join the study and for filling out all the questionnaires.
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