February 2007, Vol. XXIV, No. 2
The present state of research provides sound evidence for the efficacy of psychological therapy in the treatment of schizophrenia.”1
It used to be clear that talking about symptoms to those with delusions and hallucinations was not only unwise but might also make things worse. This view related to old ideas that “madness” was a way of preserving the ego, and if the madness were dismantled by insight, the resulting collapse would lead to depression and suicide. It also related to the newer idea that talking about symptoms would positively reinforce them. Either way, it was something to be avoided. Published evidence confirmed some of this caution. Intensive psychodynamic therapy had been shown to make some symptoms worse2 and a subsequent meta-analysis of psychodynamic treatment for psychosis found no evidence for a positive effect.3
However, other verbal and social interventions have begun to show some promise when used with optimal medication, and this article will focus on these interventions. Specifically, there is good evidence that family intervention (FI) in schizophrenia can reduce relapse rates and improve social functioning.4 There is also evidence that cognitive-behavioral therapy (CBT) can be adapted from its successful treatment of panic disorders,5 posttraumatic stress disorder,6 obsessive-compulsive disorder,7 depression,8,9 and borderline personality disorder10 for treating patients with positive symptoms of psychosis.4,11 In addition, there is some evidence that therapies such as social skills training12 or cognitive remediation aimed at improving memory and attention13 can be helpful for negative symptoms by improving motivation or poor confidence, or by helping to recover work skills. However these are not “psychotherapies” as the term is usually understood.
FI has quite an extensive evidence base, with more than 30 randomized controlled trials. The evidence suggests that a combination of education and improved communication (particularly listening and negotiating skills), problem solving, and processing of emotions such as grief and loss can be helpful both for family members and for affected individuals once there has been an episode of schizophrenia.1,4,14,15 In the United Kingdom, the National Institute for Health and Clinical Excellence guideline for schizophrenia recommends FI when the patient has persistent or relapsing symptoms and has access to a caregiver.16 Although several manuals have been written and disseminated,17-21 one of the problems in trying to apply FI to patients with schizophrenia is that social networks are dramatically reduced22 and, particularly in the inner cities, there may be fewer than 30% of patients who either can or are willing to identify a caregiver.
FI is also rather intensive in time and staff effort. The evidence is currently best for individual family treatment and for it to continue for longer than 6 months, or at least 10 sessions.16 Most manuals suggest that teams of 2 staff members work with the families, and home visits are encouraged to improve engagement; thus, family visits may need to take place outside of normal working hours. Because of these, as well as other logistical reasons, such as lack of support for trained staff, the use of FI has been limited.23 The one exception is the use of teams during early intervention, when families are more likely to be intact and patients may not yet have left home. Involving caregivers in the early stages is reasonable, and there is evidence that it has had some success.24,25