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Available research on the psychotherapy of schizophrenia has done little to slow a mean-spirited and profit-driven erosion of compassionate care for psychiatry's most vulnerable patients. This research was often based on now-outdated paradigms: psychotherapy versus medications or supportive therapy versus investigative treatment. Today we appreciate that no single treatment is definitive for schizophrenia, and comprehensive care requires integrating a variety of perspectives.
Ameliorating symptoms, reducing the risk of relapse, and improving psychosocial adjustment are the major goals of treatment in schizophrenia. Only rarely, however, is a single therapeutic modality prescribed in isolation sufficient to achieve these goals. More often, optimal clinical care demands the sophisticated integration of several pharmacologic, psychotherapeutic, and community support technologies (1). While some form of individual psychotherapy in combination with pharmacologic management represents the most common treatment provided for outpatients with schizophrenia, remarkably few empirical guidelines are available (2). Important articles by Hogarty and colleagues in this issue of the Journal provide substantive and clinically pertinent progress.
The authors describe a randomized clinical trial of personal therapy for schizophrenia. Personal therapy is disorder-relevant and disorder-specific insofar as it 1) is theoretically grounded in the stress-vulnerability model, 2) considers stress-related affect dysregulation as proximate to symptom exacerbation, 3) sequentially uses interventions of graded complexity based on the patient's stage of recovery, and 4) flexibly uses a range of therapeutic techniques to accommodate the individual needs, deficits, and preferences of patients with this heterogeneous disorder.
Basic-phase personal therapy is applied in the early months after discharge and targets goals of clinical stabilization, therapeutic alliance, and basic psychoeducation. The intermediate phase aims to promote self-awareness of internal affective cues associated with stressors and, as dictated by individual need and preference, uses training in self-protective strategies, social skills remediation, and exercises in relaxation and social perception. Focusing on the relation between the patient's life circumstances and internal state, the advanced phase strives to provide opportunities for introspection. Goals include developing self-recognition of the links between stresses, maladaptive responses, the reactions of others, and symptoms. Unsuccessful encounters in the community become the agenda for therapy, and advanced social skills training includes a focus on interpersonal relations, criticism identification, and conflict management.
The timing of interventions is titrated to individual response. Patients remain in a treatment phase as long as is necessary in order to meet criteria for progression. Hogarty et al. report that over the 3-year period allowed by their research design, about 50% of patients progressed to the advanced phase of personal therapy.
An innovative, albeit complex, experimental design is used to evaluate personal therapy. Individual psychotherapy is provided against a backdrop of pharmacologic treatment that aims to minimize the adverse impact of excessive neuroleptic doses on learning and cognition. Patients' case management needs are addressed, and concurrent trials are conducted for those living alone and those living with family. Psychosocial functioning is assessed independent of relapse prevention. Perhaps most important, however, individual therapy is evaluated over a 3-year period—a duration consistent with clinical experience of the time required to effect functional improvement in schizophrenia.
Does it work? For a disorder in which previous treatment trials have reported attrition rates approaching 66% (3), the treatments provided by Hogarty et al. were remarkably well accepted. Over 3 years, only six (8%) of 74 patients receiving personal therapy and 18 (23%) of 77 patients in contrasting treatments were dropped for noncompliance or administrative reasons.
The efficacy of personal therapy in relapse reduction was tied to residential status. Patients receiving personal therapy and living with family experienced fewer relapses. A more impaired group of personal therapy recipients who lived alone experienced a greater relapse rate. Consistent with the clinical dictum that psychologically oriented treatments are futile or perhaps harmful when applied before basic human service needs have been addressed, personal therapy patients who relapsed were more likely to have unstable housing, difficulty securing food and clothing, and a higher rate of arguments and conflicts with landlords and/or rehabilitation staff.
Independent of relapse reduction, personal therapy produced extensive differential improvements in social adjustment and role performance. Improvements in social adjustment seen with supportive and/or family therapy reached a plateau at 12 months. In contrast, the social adjustment of personal therapy patients continued to improve in the second and third postdischarge years with no evidence of a plateau. Thus, relative to supportive and family therapy, individual psychotherapy proved superior in promoting a progressive improvement in psychosocial adjustment.
It is likely that experienced and committed therapists providing continuity of care over a period of years contributed to a better-than-expected outcome among all patients in this study. Replication must determine whether comparable results can be achieved in other clinical settings. Nonetheless, the findings described here are sufficiently definitive to indicate that once housing and human service needs have been addressed and some degree of symptom stability has been achieved, a disorder-specific individual psychotherapy can be considered to be among the psychosocial treatments for schizophrenia that have demonstrated efficacy.
Most psychosocial treatments, including personal therapy, were evaluated before the availability of new neuroleptics. Similarly, new medications have typically been evaluated against a backdrop of "standard" or largely unspecified psychosocial treatments. The integration of new pharmacologic and psychosocial treatment strategies will be an important area for further exploration.
Research psychotherapies are often ignored by clinicians and have a limited impact on patterns of service provision (4). It would be a mistake, however, to dismiss personal therapy as a "manualized" treatment with limited relevance. Personal therapy is not tightly prescriptive but, rather, consists of a set of clinical principles and priorities that leave considerable room for individualization. Timing and titration of interventions based on accurate attunement to each patient's unique strengths and limitations is at the heart of the approach.
Effective psychosocial treatments require both didactic and experiential learning. Deficits or limitations in cognitive capacity can impose a ceiling on what can be learned, and for persons living hand-to-mouth in unstructured and neglectful circumstances, survival takes precedence over self-reflection. Ambitious interventions, when misapplied, may cause destabilizing cognitive overload. Patients with relatively few deficits and stable circumstances, however, may find a psychotherapeutic focus vital to recovery (5). Differentiating among these groups should offset pessimism about psychosocial treatments being countertherapeutic (6) and allow us to be more discriminating about how individual psychotherapy can be useful. Personal therapy facilitates a shift in clinical thinking away from global questions such as "What is the best treatment for schizophrenia?" Instead it challenges the clinician to consider the specific combination of interventions that will be most helpful for this particular patient with this particular type of schizophrenia at this particular phase of illness or recovery.
Clinicians have long believed that psychotherapy for schizophrenia must begin where the patient is (7). Similarly, where schizophrenia is concerned, one size doesn't fit all. Dr. Hogarty and colleagues successfully codify sound clinical practice and affirm its value.
Address reprint requests to Dr. Fenton, Chestnut Lodge Hospital, 500 West Montgomery Ave., Rockville, MD 20850.
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