The first 2 modalities are incorporated into each of the modules and are framed in terms of the requirements of the model being used and the progression of the participants in the model. Home tasks allow participants to practice their skills in a real-life context that fully reproduces clinical exercises. In contrast, integration outings allow participants to generalize learning from the clinical exercises to other contexts in the presence of a clinician. The guidance participants receive eases the transfer of knowledge acquired in the clinical setting to concrete applications in everyday life.
The booster sessions reactivate some of the learning from the clinical setting but, more important, validate the concrete application of the knowledge gained to real-life situations. Topics proposed by participants during these meetings arise from the successes or difficulties they have encountered in managing events in their lives.
These additional sessions also serve as a bridge between the results obtained at the end of the IPT program and the development of postgroup life plans that participants have chosen and adapted to their particular situations. Such life plans may involve participating in a group in their community, returning to school, or reentering the workforce.
Table 2 [Table restricted. Please see print edition for content.] presents examples of exercises used in these 3 therapeutic modalities. These modifications to IPT, which are unique to the Quebec version, were created in response to weaknesses encountered during clinical applications and were influenced by recent applications of IPT15,17 and the new development of the cognitive-behavioral approach to rehabilitation.18,19Advantages of using IPT
Briand and colleagues16 reported that both participants and clinicians greatly appreciate IPT. It integrates several approaches to cognitive-behavioral rehabilitation that have, until now, only been applied separately. IPT also remains centered on the everyday difficulties faced by patients with schizophrenia. In addition, by offering a new series of therapeutic activities, IPT enhances the generalization and maintenance of skills learned and moves significantly closer to the lives of participants.
These factors make IPT more stimulating to apply, because it becomes a major component within a more complete rehabilitation and social reinsertion pro- cess. Indeed, IPT can be combined with other psychosocial rehabilitation models.2,20 For example, the model of human occupation adds a larger theoretical rehabilitation framework to the IPT approach and facilitates the development of personal objectives for each participant.21 The model of human occupation also provides a series of assessments that are easy to apply in clinical settings, and it measures functional changes in everyday activities.2
Despite the hierarchy of learning that is implicit in the 6 modules, IPT remains very flexible. The number and content of exercises can be changed to address the particular problems and specific needs of each participant.16 IPT is independent of the stage of the illness or the moment at which it is introduced to the rehabilitation process. Participants can thus progress at their own speed and absorb knowledge that is appropriate to their level of development. In fact, training in the Quebec version of IPT places greater emphasis on understanding the hierarchical structure of IPT and its different modules. This simplifies the use of a hierarchical approach to learning skills, particularly when clinicians choose to add new exercises to a given module.16 The meta-analysis published by Roder and associates5 shows the impact of using some or all of the IPT application modules.
The structure and substance of IPT responds to several needs in the continuum of rehabilitation services and fits perfectly into contemporary programs that attempt to fully respond to the various needs of patients with schizophrenia.Case vignette
Michael is a 23-year-old man who has exhibited functional difficulties for the past 3 years. Two years ago, Michael's illness forced him to abandon his studies in biology and move back with his parents. Paranoid schizophrenia was diagnosed and Michael required 2 hospitalizations and an interdisciplinary follow-up in an outpatient clinic. At the end of his second hospitalization (and as a result of numerous functional deficits measured in occupational therapy), Michael was referred to a clinic specializing in early psychosis.22 This interdisciplinary program, which involved input from an occupational therapist, a neuropsychologist, a nurse, a psychiatrist, and a social worker, provided a complete and standardized assessment of Michael and his family. It employed several treatment modalities (psychotherapy and psychoeducation) in individual and group approaches using the Quebec version of IPT and conceptual model of human occupation as the backbone of the rehabilitation intervention.
In this specialized program, IPT was managed by 2 occupational therapists. The model of human occupation functional assessment tools (Occupational Performance History Interview [OPHI-II] and Assessment of Communication and Interaction Skills [ACIS]) provided clinical measures (quantitative and subjective) of the positive effects of the 6 IPT modules on Michael's day-to-day functioning.
The data obtained with the OPHI-II and ACIS tools at the end of the IPT group sessions revealed clinically significant improvements in Michael's occupational identity, his day-to-day competence (including social skills), and the support he received from his environment.2 The positive impact of these improvements encouraged him to develop a new post-IPT life plan. At his own initiative, Michael began a progressive return to his studies under a back-to-work program run by a local nongovernmental agency, while remaining in contact with his public mental health team.
Table 3 presents examples of these benefits and more details about these 2 functional assessment tools.Principles of successful IPT implementation
Clinical practice has shown that IPT implementation is best learned by clinicians through a 3-day program of professional training, backed by a solid understanding of and experience in applying the principles of cognitive-behavioral rehabilitation to patients with psychosis.16,23 Clinicians with some experience directing groups centered on social skills development and problem solving who have already worked with the principles of classic cognitive therapy tend to gain more from IPT training and are better able to pass along its benefits to patients.
It also appears to be beneficial to have the support of a clinical reference team when applying IPT.24 Several studies have shown that the presence of a support team during program implementation is essential for success in this kind of specialized intervention.7,25
Finally, implementation of IPT is worth pursuing in settings that value professional expertise and continuing education, the development of specialized services for patients with psychosis, and work teams that subscribe to contemporary principles of rehabilitation and cognitive-behavioral approaches.24Costs
Implementing IPT requires an initial investment for training clinicians and for purchasing didactic materials for group work. Nevertheless, the costs incurred are no greater than the costs of resources and services currently provided for patients with schizophrenia. The multisite Quebec study demonstrated that during the period in which participants received IPT there were fewer visits to psychiatrists and emergency departments and fewer hospitalizations.26 This effectively represented a transfer of resources to outpatient IPT services. Total health system costs remained unchanged (and even fell slightly) during IPT implementation compared with the previous year.26Conclusion
IPT is used worldwide as an approach to rehabilitation. In Canada, and more specifically in Quebec, over 100 rehabilitation professionals have been trained in the use of the new version of IPT, and more than one third offer IPT to their patients in its full form. In October 2007, a 3-day professional workshop in Montréal will explain how to implement the new Quebec version of IPT in English.
There are no longer any doubts about the efficacy of IPT. However, future approaches to research and clinical practice will need to focus on selecting the most suitable clinical assessment tools and how they can be used to improve the continuum of services between evidence-based practice needs and the setting of specific objectives for each participant.2,21 This scientific approach will reinforce the integration of specialized interventions, such as IPT, into individualized rehabilitation service plans.