There is a long-held belief in psychiatry that it is a pointless exercise to try to dissuade people from holding tenacious delusional beliefs. Recent research, however, reveals that talking to people about their psychotic symptoms and their meaning to the individual can lead to improvement in symptoms. Gently challenging the evidence used by people with psychotic disorders to support their delusions, suggesting alternative viewpoints, testing reality and enhancing coping strategies can, it emerges, be helpful. A course of cognitive behavioral therapy (CBT) often may extend for ten or more sessions. The therapist establishes a trusting relationship with the client and then gently tests the patient’s beliefs, as in the following illustration:
Client: “The Mafia has put my house under surveillance.”
Clinician: “Well, that’s possible…. But, what makes you think it’s the Mafia? Could it be another organization? Or something else altogether? How could we figure this out?”
CBT has been demonstrated to be effective for persistent psychotic symptoms in people who have failed to respond to treatment with antipsychotic medication. The goal is not to persuade the person that he or she has a mental illness. Rather, it is to reduce the intensity of the symptom and the distress it causes. Clients are helped to identify coping strategies that reduce the cues leading to hallucinations and delusions and the patient’s reactions to these symptoms. For one client, being alone or bored might be a cue leading to an increase in hallucinations; he or she can be taught to try out ways to cut down isolation or boredom. Others may learn to reduce auditory hallucinations by humming, talking to others, or even reasoning with the unpleasant voices and telling them to go away. Similarly, a person might be taught to test the reality of delusional beliefs against an alternative interpretation of events and, for example, return to her church social group about which she has harbored paranoid fears. This approach does not cut down on rates of relapse in psychosis, but it does reduce the distress that results from positive symptoms.
CBT for persistent psychotic symptoms is now one of the American Psychiatric Association’s practice guidelines for the treatment of schizophrenia and it has been incorporated into the Schizophrenia Patient Outcomes Research Team (PORT) recommendations. We now have an effective psychotherapeutic intervention for people with schizophrenia. Those clinicians who are accustomed to simply establishing the fact that hallucinations and delusions are present may now need to pay more attention to the content of these symptoms. Just talking to the client in detail about the thing that bothers him or her most may, in itself, prove to be therapeutic.
Cognitive Remediation
In recent years, more attention has been paid to the cognitive symptoms of psychosis – handicaps such as decreased processing speed, attention, concentration and working memory. Cognitive impairment, along with positive, negative and affective symptoms, is an important feature of schizophrenia. We know that it is correlated with work functioning, social relations and the capacity for independent living; it is also an impediment to gaining benefits from psychosocial rehabilitation. The increased attention to cognitive problems has stimulated greater attempts to rectify them. Pharmacological interventions have little effect on cognitive deficits but cognitive remediation programs, employing such strategies as repeated practice, strategies to compensate for impairments, teaching to improve cognitive functioning, and group discussion have shown promise. Cognitive remediation produces modest improvements in cognitive performance and functioning and the impact on social functioning is greater in studies that offer psychiatric rehabilitation in addition to cognitive remediation. Many remediation programs now employ computer-based training among their methods, but these advances in technology do not appear to have improved outcome appreciably. Programs that include strategy coaching – an approach that targets memory and executive functions by teaching strategies such as problem solving and chunking information to facilitate recall – have greater effects on functioning.
Social Skills Training
Social skills training is a way to teach people with mental illness who have social and emotional skill deficits strategies to improve these basic skills. Based on behavioral learning principles, the approach was developed by Robert Liberman in the 1960s. The method has enjoyed a good deal of recognition in the US but, although the social skills manual has been translated into 23 languages, it has not been adopted to a great extent in other countries.
A typical course of training begins by establishing a therapeutic alliance with the client and conducting a behavioral assessment. The trainer and trainee will establish long-term and short-term goals for tackling a specific interpersonal problem and will develop a scenario for achieving these goals through role-playing with other group members. The client is encouraged to perceive, through role-playing, how he or she might have handled a situation differently and gets positive feedback for improving his or her skills. When the client is demonstrating sufficient improvement, he or she may be given homework to practice with other people outside the class.
The last, and perhaps most difficult, step is to assist the client in generalizing these improvements in social skills into real-life, everyday settings. Doubts about whether this process of generalization can be accomplished successfully have put a damper on the diffusion of social skills training more broadly. A meta-analysis of studies of the treatment approach, conducted in 1996, revealed that, although skills training was effective in teaching clients interpersonal and assertiveness skills, few studies have examined whether training in the clinic setting generalizes to interactions in the community. For whatever reason, adoption of the social skills training approach has not been strong and Robert Liberman himself reports that “its use is still limited to a relatively small number of behaviorally oriented practitioners.”
