Chapter 21. Individual and Family Psychotherapies

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Wayne S. Fenton: Chapter 21. Individual and Family Psychotherapies, in Gabbard’s Treatments of Psychiatric Disorders, 4th Edition. Edited by

Glen O. Gabbard. Copyright ©2009 American Psychiatric Publishing, Inc. DOI: 10.1176/appi.books.9781585622986.254845. Printed

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Gabbard’s Treatments of Psychiatric Disorders > Part IV. Schizophrenia and Other Psychotic Disorders >

Chapter 21. Individual and Family Psychotherapies

INDIVIDUAL PSYCHOTHERAPY AND THE ROLE OF THE PSYCHIATRIST

The role of the psychiatrist in the treatment of schizophrenia varies widely based on treatment setting and

availability of resources. In strained public systems and cost-conscious managed care environments, economic

constraints circumscribe the psychiatrist’s role to that of “medication management.” In some instances medication

management and crisis services are the only care provided to individuals with schizophrenia. This practice is

contrary to substantial evidence that combining medication with psychosocial treatment yields better outcomes than

medication alone, particularly for those with the most severe disabilities (Mojtabai et al. 1998).

As described in the American Psychiatric Association’s Practice Guideline for the Treatment of Patients With

Schizophrenia (Lehman et al. 2004b), therapeutic efforts in schizophrenia must be comprehensive, multimodal, and

empirically titrated to the individual patient’s response and progress. Individual psychotherapy, whether provided

by a psychiatrist or another mental health professional, addresses the human aspects of adaptation to schizophrenia

and targets problems such as denial, demoralization, treatment compliance, personal relationships, and self-esteem.

Its focus is on understanding the patient’s beliefs, attitudes, aspirations, and experiences and supporting the

patient’s efforts to achieve self-defined goals. Surveys of both family members and individuals with mental illness

consistently indicate that next to medication, psychotherapy is among the most highly valued and rated service

provided in mental health systems (Hall et al. 2003; Hatfield et al. 1996). The coordination of psychosocial

treatments with medications, rehabilitation, and treatment settings (i.e., treatment integration) can often be best

accomplished by a psychiatrist who knows the patient as a person and can provide continuity of care over what may

be a prolonged course of illness.

Current clinical approaches to psychotherapy represent an amalgamation of practices described by the term flexible

psychotherapy. This approach draws from perspectives derived from the traditions of investigative and supportive

psychotherapy to inform the clinician–patient relationship while encouraging the use of specific interventions

defined by evidence-based medicine. Therefore, in this chapter I summarize selected elements of investigative and

supportive psychotherapy prior to describing more contemporary research-based therapeutic approaches.

INVESTIGATIVE PSYCHOTHERAPY

Psychotherapy for schizophrenia in the United States originated as a modification of psychoanalysis (McGlashan

1983). Early psychoanalysts such as Brill advocated an active effort to promote rapport and arouse the patient’s

interest in his or her own malady. In time, he observed, confidence in and a “passive attachment” to the physician

could develop so that the latter might become a bridge between the patient and reality. Observing difficulties

schizophrenia patients had in maintaining relationships led Harry Stack Sullivan to formulate the paradigm of

“interpersonal psychiatry.” Psychopathology was viewed as difficulties in living arising largely from personal and

social relations and the lasting residue of earlier unsatisfactory interpersonal experiences. The predecessors of ego

and self psychology, interpersonal psychiatry and psychodynamic psychotherapy became dominant paradigms in

American psychiatry in the 1940s, 1950s, and 1960s (Fromm-Reichman 1950).

The goal of investigative psychotherapy is alleviation of the patient’s emotional difficulties and elimination of

symptoms. This is accomplished by undertaking a thorough scrutiny of the patient’s life history (especially the

history of his or her interpersonal relationships), reviewing the realities of the patient’s current relationships and

life situation, and understanding the historical roots of maladaptive interpersonal patterns as reflected in the

doctor–patient relationship and in daily life. Therapist attributes cited as important in investigative psychotherapy

include a basic respect for the patient that stems from a conviction that the patient’s problems are not too different

from one’s own. Examining the patient’s reactions to the therapist (transference) is considered useful in allowing

the patient to understand distorted perceptions and respond more realistically to people in his or her current life.

Likewise, feelings evoked by the patient (countertransference) are used as a source of information about the

patient’s state of mind and as a means of understanding how others typically react and respond to the patient.

Successful management of these emotional reactions allows the therapist to create a “holding” relationship that

creates an environment of interpersonal safety.

The literature on intensive psychotherapy emphasizes establishing a trusting relationship with the patient. Elvin

Semrad viewed the core tasks of psychotherapy as helping the patient acknowledge, bear, and put into perspective

feelings and painful life experiences (Rako and Mazer 1980). Exploring the patient’s feelings and painful experiences

becomes pertinent once a relationship has been established. Strategies include listening, narrowing the focus,

seeking concrete detail, acknowledging feelings (especially loss, anger, sadness), and naming or labeling emotions.Print: Chapter 21. Individual and Family Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=254849&print=yes…

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Examining the patient’s day-to-day life in detail allows the therapist to develop a picture of the patient’s difficulties,

frustrations, and characteristic reactions to others. Tolerating affects corresponds to Semrad’s concept of “bearing”

painful feelings that have been acknowledged. Patients experience themselves being accepted and, learning from

the therapist’s example, become better able to accept unwanted aspects of themselves. Broadening patients’

understanding of themselves and their situation corresponds to the third part of Semrad’s triad: helping patients put

into perspective their painful affects, life experiences, and maladaptive solutions. This should leave the patient with

a more accepting and complex view of him- or herself.

SUPPORTIVE PSYCHOTHERAPY

Supportive psychotherapy is grounded in the medical model in which the patient is seen as having an organically

based illness requiring treatment from a physician. The person who is ill is exempt from normal social

responsibilities and excused from customary obligations so he or she may attend to the process of getting well. At

the same time, the patient has the obligation to want to get well, obtain technically competent help, and cooperate

with treatment (Parsons 1951).

The short- and long-term goals of supportive psychotherapy include 1) relief from the immediate crisis and

restoration of equilibrium, 2) removal of symptoms to pre-illness levels, 3) reestablishment of psychic homeostasis

through a strengthening of defenses, 4) fostering of adaptation, and 5) preservation of capacities to enable optimal

functioning and minimize the impact of persistent deficits. Supportive therapy uses the physician–patient

relationship to create a background of adequate clinical care that supports the prescription of effective

pharmacological interventions (Winston et al. 1986).

The overall technical approach of supportive psychotherapy is one of pragmatism. As such, the therapist employs

techniques that include defining reality, offering direct reassurance, giving advice on current problems of living,

urging modification of expectations, and actively organizing the environment for patients who cannot do so

themselves. To help stabilize the patient’s environment, the therapist often maintains close contact with the

patient’s family and other treatment team members and may intervene on the patient’s behalf with family,

employers, and social agencies.

Tracking and targeting symptoms for pharmacological intervention are a major focus for the supportive

psychotherapist. Psychopathology is discussed in a medical context as the unwanted emergence of signs of illness.

The basic content of psychotherapy focuses on teaching and relearning—the patient is educated regarding the

nature of the illness and taught to monitor symptoms and act promptly to suppress their exacerbation. The therapist

is active in helping the patient learn new ways of adapting and may use or prescribe cognitive, behavioral, or social

skills training techniques. The therapist fosters positive transference as a benign authority; negative transference is

avoided.

EMPIRICAL STUDIES

Randomized clinical trials conducted during the 1960s and 1970s provided little or no evidence for the efficacy of

individual psychotherapy as the sole treatment for schizophrenia (Fenton 2000). Studies of combined treatment,

however, noted an additive therapeutic effect when a problem-oriented psychotherapy was provided along with

appropriate pharmacotherapy (Hogarty and Goldberg 1973; Hogarty et al. 1974a, 1974b, 1979). An influential study

from McLean Hospital in the 1980s compared the combinations of medication treatment and either insight-oriented

psychotherapy (three times per week) or reality-adaptive supportive psychotherapy (once a week) in newly

discharged patients with schizophrenia (Gunderson et al. 1984). Neither treatment emerged as superior, and as

actually practiced, the different techniques tended to converge. Both included significant supportive elements, and

for both, patient improvement was associated with the therapist’s demonstration of a sound dynamic attunement to

the patient’s psychological concerns (Glass et al. 1989). Investigators and clinicians began to advocate the use of a

broad-based psychotherapy that relies at various times on supportive, directive, educational, and investigative

strategies applied flexibly depending on the individual patient’s type of schizophrenia and phase of illness

(Carpenter 1986; Dingman and McGlashan 1989; Fenton 2000).

CURRENT RESEARCH PERSPECTIVES: EVIDENCE-BASED PRACTICE

As part of a shift in medicine from reliance on theory and traditional authority to reliance on research evidence from

clinical trials, evidence-based practice has now become the basis for informing treatment decisions in schizophrenia

and other psychiatric disorders. This practice has been defined by the Institute of Medicine as the integration of best

research evidence with clinical expertise and patient values (Institute of Medicine 2001; Sackett et al. 2000), which

implies that individual patient care decisions should be based on scientific information concerning the efficacy

(outcomes), costs, and cost-effectiveness of alternative treatments. No single scientific or governmental agency is

responsible for defining “official” evidence-based practice for mental illness. Thus, knowledge of this practice

requires current and continuous familiarity with the scientific literature related to the treatment of mental disorders.

Important recent compilations of evidence-based practice for patients with schizophrenia and other mental illnesses

have been published by the U.S. Department of Health and Human Services (1999), the American Psychiatric

Association (Lehman et al. 2004b), the Schizophrenia Patient Outcomes Research Team (PORT) Project (Lehman

and Steinwachs 1998b), and the Cochrane Collaboration (Cochrane Review Topics 2005).Print: Chapter 21. Individual and Family Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=254849&print=yes…

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A frequent criticism of evidence-based practice is that it ignores intuition, experience, and clinical judgment and

deemphasizes the importance of the physician–patient relationship. Contrary to these criticisms, most proponents

would agree that “a cookbook is not a cook.” As made explicit in the Institute of Medicine’s definition, an

evidence-based approach values clinical experience but would ultimately strive to extract testable and teachable

practices employed by expert clinicians in order to rigorously evaluate their validity.

Treatments for schizophrenia with substantial evidence of efficacy include psychopharmacological treatments,

family psychotherapy or psychoeducation, integrated dual-diagnosis treatment, individual placement and support

vocational rehabilitation, skills training, behavioral token economies, and assertive community treatment (Lehman

et al. 2004a). Within the framework of evidence-based practice, a firmer empirical basis for specific approaches to

individual psychotherapy is also emerging. Two significant research-based approaches are 1) time-limited and

illness phase–specific cognitive-behavioral therapy (CBT) and 2) personal therapy, a broad strategic outline for

post–hospital discharge individual therapy that matches techniques with individual patient progress.

ILLNESS PHASE–SPECIFIC COGNITIVE-BEHAVIORAL THERAPY

CBT for schizophrenia originated in the United Kingdom to provide time-limited enriched psychological care in a

mental health system where “routine treatment” typically consists of a short psychiatrist visit every 3 months,

support from a drop-in center or day hospital, and medication visits with a community psychiatric nurse (Turkington

et al. 2004). CBT for schizophrenia is not a unitary model and is regarded as an approach rather than a specific

technique. Some therapies are protocol driven and standardized, whereas others are individualized based on a

patient-specific assessment and case formulation. Important elements of CBT common to these treatments include

1) emphasizing the development of a therapeutic alliance with the patient as the first and most critical element; 2)

understanding illness within a stress-vulnerability model that posits psychotic experiences are possible in anyone

given sufficient stress; 3) efforts by the therapist and patient to develop a shared view of the illness and goals of

treatment; 4) developing the agenda for each session collaboratively, although a focus on delusions and

hallucinations and the distress they cause is common; 5) encouraging the patient to engage in a collaborative

process of examining the evidence and considering alternate explanations (termed collaborative empiricism) for

delusions and hallucinations rather than confronting their validity directly; 6) encouraging hopefulness by

“normalizing” psychotic experiences and modifying negative beliefs about the diagnostic label of schizophrenia; and

7) exploring in detail the patient’s attitude toward medications within the framework of understanding the patient’s

individual goals and aspirations and collaboratively evaluating the role of medication in promoting progress toward

those goals. CBT for schizophrenia is generally time limited and focuses on specific goals and illness phase–specific

issues (Tarrier and Wykes 2004; Turkington et al. 2004).

Acute-Phase Cognitive-Behavioral Therapies

Compliance therapy is a four- to six-session intervention for acutely ill inpatients that targets improved attitude

toward medication and postdischarge adherence as treatment goals. Based on motivational interviewing, this

treatment involves nonjudgmental exploration of the patient’s attitudes and beliefs about medication, assessment of

sources of ambivalence, and an effort to link medication adherence with the patient’s self-defined goals. Studies

have documented both better postdischarge adherence and longer community survival at 18 months for patients

receiving this brief intervention (Kemp et al. 1996, 1998). The goal of other acute-phase CBT administered in the

hospital and immediately after discharge is to reduce the duration of acute psychosis and the level of residual

symptoms. An initial study of inpatient CBT (3 hours per week with postdischarge “booster” sessions for 8 weeks) in

combination with family education sessions found that this combination reduced duration of acute psychosis,

severity of residual symptoms, and relapses over a 9-month postdischarge follow-up period (Drury et al. 1996a,

1996b). This study, however, only included patients judged suitable for the treatment. Of two subsequent studies of

acute-phase CBT, one did not replicate the original findings (Haddock et al. 1999), and the other provided some

evidence of faster recovery with CBT compared with treatment as usual but not compared with a supportive therapy

control group (Lewis et al. 2002). Although acute-phase CBT may reduce hospital duration, there is no evidence of

reduced postdischarge relapse rates.

Post-Acute-Phase Cognitive-Behavioral Therapies

Most post-acute-phase CBT targets delusions and hallucinations that have not fully responded to pharmacological

treatment. Conceptually these treatments are based on the observation that patients are able to discover, learn, and

use coping strategies to reduce symptom severity or distress associated with medication-resistant symptoms.

Techniques employed derive from individualized assessment and vary based on individual patient preference. They

may include belief modification, self-management techniques, and coping strategy enhancements such as attention

switching, attention narrowing, increasing or decreasing social activity, modifying sensory input, using relaxation

techniques, and utilizing psychoeducation. In vivo practice and homework assignments are often prescribed, and an

overall attempt is made to build on coping methods already used by the patient. Clinical trials of post-acute-phase

CBT added to routine care have typically included patients with long illness duration; most patients receive 20

sessions over 9 months and are followed up 3–9 months later. In aggregate, studies of post-acute-phase CBT

indicate positive short-term outcomes in terms of reduced residual positive symptoms and distress associated with

symptoms, but further research is required to establish its effectiveness in longer-term symptom relief or relapsePrint: Chapter 21. Individual and Family Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=254849&print=yes…

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reduction (Jones et al. 2004).

Current treatment development efforts focus on the adaptation of CBT to individuals with psychotic prodromes

(McGorry et al. 2002) and patients with co-occurring social anxiety (Kingsep et al. 2003), substance abuse (Haddock

et al. 2003), obesity (Brar et al. 2005), or nicotine dependence (Steinberg et al. 2004).

Although results from randomized clinical trials suggest an advantage for adding time-limited CBT to usual care for

patients with schizophrenia, not all studies have been positive, and substantial refusal and dropout rates indicate

that these treatments are not appropriate for all patients. Patient characteristics that predict a good therapeutic

response to CBT include ability to form a positive therapeutic relationship, presence of subjective distress (e.g.,

ego-dystonic symptoms), and some pretreatment insight into illness. Factors associated with poor outcome include

prominent negative symptoms, affective flattening, and alogia (Garety et al. 2000). Because of these considerations,

most reviews conclude that although results from CBT trials are promising, further research is required to define for

which patients and under what conditions these treatments are optimal. Because nearly all research on CBT has

taken place in the context of the U.K. National Health Service, the generalizability to other care settings must also be

assessed.

Personal therapy was created by Gerry Hogarty at the University of Pittsburgh as a form of individual psychotherapy

and strategy for treatment integration (Hogarty et al. 1995). It is designed for recently discharged outpatients with

schizophrenia and aims to enhance personal and social adjustment and forestall late (third-year) relapse. Within a

stress-vulnerability model, individual-specific stress is seen as precipitating affective dysregulation. This loss of

control over mood is seen as resulting in poorly reasoned dysfunctional behavior that negatively influences the

reciprocal behavior of others in a cycle that may end in relapse. Based on individual patients’ needs, personal

therapy uses a range of interventions to promote self-awareness and foresight and to equip patients with adaptive

strategies that facilitate self-monitoring and self-control of affect.

Personal therapy includes three phases, each with explicitly defined goals and corresponding interventions. Phase 1

begins at hospital discharge and uses supportive (acceptance, empathy) and problem-solving approaches to

promote therapeutic joining and agreement on a treatment contract. Phase 2 is initiated when positive symptoms

have stabilized, maintenance medication dosage is achieved, and regular attendance at appointments is established.

Individualized psychoeducation, self-reflection, exploration of individual stresses and vulnerabilities, and exercises

to improve social perception and conflict management are used to enhance personal adjustment. In Phase 3,

initiated only for those patients able to maintain stability and to benefit from more intensive psychoeducation,

individualized investigation of strengths and persistent limitations and advanced social skills exercises are employed

to promote self-awareness, prodrome recognition, and understanding of the relationship between felt affect,

expressed affect, and the reactions of others. Within each phase, the exposure of patients to specific interventions is

varied based on individual preference. Although the therapy continues over 3 years, patients spend as much time at

each level as required to meet advancement criteria, and not all patients progress through all three phases. Personal

therapy is provided with medication treatment that aims to minimize side effects by using the lowest dosage needed

to prevent symptom exacerbation.

Results of two randomized trials with newly discharged patients with schizophrenia and schizoaffective disorders

found that over 3 years, only 8% of those receiving personal therapy compared with 23% of patients in contrasting

treatments were dropped for noncompliance or administrative reasons. Patients receiving personal therapy who

were living with family members experienced fewer relapses; more impaired patients receiving personal therapy

who were living alone experienced a greater relapse rate. Consistent with the clinical dictum that psychological

treatments can be futile or harmful when applied before basic human services needs are addressed, personal

therapy patients who relapsed were more likely to have unstable housing and difficulty securing food and clothing

(Hogarty et al. 1997a, 1997b).

Independent of relapse reduction, personal therapy produced substantial differential improvements in social

adjustment and role performance. The social adjustment of patients receiving supportive and family therapy

reached a plateau at 12 months, but the personal adjustment of personal therapy patients continued to improve

over the second and third postdischarge years with no evidence of a plateau. Hogarty et al. (2004) recently tested a

recovery-phase intervention termed cognitive enhancement therapy for patients who successfully proceeded

through phases of personal therapy. This treatment uses computer-based attention training exercises and small

group–based psychological treatment to promote abstract thinking and problem solving and enhance social

functioning.

TREATMENT INTEGRATION AND FLEXIBLE PSYCHOTHERAPY

Determining what particular combination of interventions is optimal for a particular patient with a particular type of

schizophrenia at a particular phase of illness is an aspect of clinical practice that can be called treatment integration.

Treatment integration strategies are difficult to rigorously test and often must be specified in terms of assumptions,

principles, and priorities. Flexible psychotherapy is one attempt to integrate clinical perspectives and available

evidence into a coherent treatment strategy.

Assumptions About Schizophrenia Guiding Flexible PsychotherapyPrint: Chapter 21. Individual and Family Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=254849&print=yes…

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Flexible psychotherapy is based on assumptions about schizophrenia that recognize the joint contributions of

biological, psychological, and social/environmental factors:

A stress–diathesis or vulnerability–stress model represents the best available integration of data pertinent to the etiology,

course, and outcome of schizophrenia. This model postulates that schizophrenia results from an interaction between

environmental and experiential stress in a person who is “vulnerable,” by virtue of genetic and/or environmental risk factors

(Dean and Murray 2005; Weinberger 2005), to react to this stress with schizophrenic symptom formation.

1.  

Schizophrenia is heterogeneous, as are individuals afflicted with it. The clinical diversity of schizophrenia suggests that the

disorder is heterogeneous in regard to etiology (Carpenter et al. 1993). As with the illness itself, individuals afflicted with

schizophrenia differ substantially in adaptive capacities, intelligence, and instrumental and verbal competence.

2.  

Schizophrenia has a phasic course. Illness phases may include 1) prodromal periods during which a highly individualized

constellation of symptoms that represent early manifestation of clinical decompensation emerge; 2) acute or active phases

often associated with the full-blown emergence of positive symptoms superimposed on preexisting deficits; 3) subacute,

convalescent, or stabilization phases characterized by gradual restoration of some functioning, perhaps associated with

postpsychotic depression; and 4) stable phases characterized by relatively greater or lesser levels of recovery or residual

deficits and/or positive symptoms (Fenton 1997).

3.  

Outcome in schizophrenia is variable. Among groups of patients, there are substantial interindividual differences observed

in both short-term treatment response and longer-term functional outcome. In addition, for any given individual, outcome is

not unitary but may vary considerably across different domains of functioning (McGlashan 1988).

4.  

Flexible Psychotherapy: Hierarchy of Clinical Needs

The clinical needs of people with schizophrenia can be ordered hierarchically. The crucial question is which

interventions are of potential value for a specific individual at a particular phase of illness. As outlined in Table

21–1, different clinical needs assume greater importance during different illness phases. In addition, although some

goals are clearly relevant for all patients receiving integrated treatment, others are pertinent for only a small

subgroup of patients. This model assumes the therapist’s ability to “shift gears” flexibly and change based on

changing circumstances, always keeping in mind the goal of helping the patient accept, learn about, and

self-manage what may often be a serious and devastating illness.

Table 21–1. Flexible psychotherapy hierarchy of clinical needs: interventions, goals, and evidence-based practices

Clinical needs Clinical focus Interventions Goals Illness

phase

Evidence-based

practice

Psychiatric–medical

stabilization

1. Crisis

intervention

2. Psychiatric,

substance abuse,

medical diagnosis

3. Safety
4. Acute symptom

management

1. Psychiatric,

medical, neurological

assessment

2. Hospitalization or

community alternative

short-term care

3. Directive and

supportive

communication, limit

setting

4. Pharmacological

treatment

1. Diagnose or

rule out medical,

neurological

disorders

2. Ensure safety
3. Minimize

effect of acute

episode on life

situation

(housing, job,

family)

4. Effect rapid

symptom

reduction

Prodromal,

acute

Assertive

community

treatment

Day hospital

Crisis residencies

Pharmacological

algorithms and

guidelines

Psychosocial assessment

and case management

1. Stress and

vulnerabilities

2. Social supports
3. Living

arrangements, safe

housing, medication

access,

daily activities

4. Adaptive

strengths

5. Access to

economic and

treatment resources

1. Skilled

psychological and

psychosocial

assessment

2. Evaluation of

human service needs

3. Linkage with social

services, human

services, and

community

support services

1. Mobilize social

support

2. Assess

postepisode

psychosocial

services needs,

including day

treatment or

supportive

housing

3. Ensure access

to all required

entitlements

4. Enlist

cooperation

of family or other

Subacute,

convalescent,

stabilization

Assertive

community

treatment

Compliance

therapy

Family

psychoeducation

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Clinical needs Clinical focus Interventions Goals Illness

phase

Evidence-based

practice

caregivers

Establishment of supportive

relationship and treatment

1. Treatment

relationship and

alliance

2. Denial,

suspiciousness,

disorganization

3. Self-esteem
4. Early adherence
5. Co-occurring

substance abuse

1. Continued

medication—attention

to complaints and

medication

adverse effects

2. Support, positive

regard, reassurance,

bolstering of defenses

3. Promote comfort

with therapist and

treatment

1. Encourage

sufficient

acceptance of

illness to allow

cooperation with

treatment

2. Promote trust

in therapist and

comfort with

therapeutic

routine

3. Support

strengths and

adaptive

defenses

4. Monitor for

relapse

5. Encourage

substance abuse

treatment as

needed

Subacute,

convalescent,

stabilization

Assertive

community

treatment

Family

psychoeducation

Post-acute-phase

CBT

Integrated

dual-diagnosis

treatment

Psychoeducation 1. Understanding

and acceptance of

illness

2. Human concerns

associated with

disability

3.  

Self-management

of illness

4. Understanding of

medications and

side effects.

5. Medical self-care
6. Teaching and

support

2. Identification of

individual-specific

stresses

3. Awareness of

individual-specific

prodromal and active

symptoms

4. Determination of

lowest effective

prophylactic

medication dosage

1. Prevent

relapse

2. Learn stress

management

strategies

3. Foster

self-recognition

of prodromal

symptoms

4. Establish

maintenance

regimen

5. Promote

collaborative

self-management

of illness

Subacute,

stable phase

Maintenance

medication

guidelines (e.g.,

PORT study)

Personal therapy

Family

psychoeducation

CBT for

treatment-resistant

symptoms

Rehabilitation 1. Social,

vocational, self-care

skills

2. Learning or

relearning

3. Establishment of

realistic

expectations

4. Adaptation to

deficits

5. Employment or

other self-defined

goals

1. Attention to details

of daily self-care and

social and

occupational

functioning

2. Modeling and

practice of new skills

3. Cognitive,

problem-solving,

social skills

enhancement

4. Environmental

intervention,

family education,

supported

employment

1. Promote

highest adaptive

functioning

within limitations

imposed by

defeats

2. Promote

activities that

enhance

self-esteem

through

accomplishment

and productivity

3. Encourage

activities that

improve quality

of life

4. Promote

attainment

of self-defined

goals

Subacute,

stable phase

Personal therapy

Social skills

training

Placement and

support vocational

services

Group therapy

(social skills

oriented)

Integrated

dual-diagnosis

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Clinical needs Clinical focus Interventions Goals Illness

phase

Evidence-based

practice

5. Learn

strategies that

allow functioning

despite deficits

Investigative/insight-oriented

tasks

Conflicts, emotions,

acceptance of loss,

transference,

countertransference

1. Exploration of

feelings, conflicts,

ambivalence

2. Focus on past

events, life history

3. Examination of

important

relationships,

including relationship

with therapist

1. Integrate

psychosis into

expanded

concept of self

2. Construct life

narrative

3. Work through

conflicts

4. Improve

capacity

for intimacy and

productivity

Motivated

patients

during stable

periods

No evidence-based

approaches

Note. CBT = cognitive-behavioral therapy; PORT = Patient Outcomes Research Team.

Consideration of the patient’s schizophrenia subtype, current and pre-illness functioning, and self-defined treatment

goals is relevant to the determination of appropriate treatment goals. For patients with severe disorganized or

deficit forms of schizophrenia, the most practical goal may be establishing a supportive ongoing treatment within a

sheltered setting that minimizes stress and provides for basic human needs. For the majority of patients who reside

in the community, some degree of psychoeducation and rehabilitative tasks should be planned, with the aim of

minimizing acute relapses and promoting maximal functioning and quality of life. A focus on investigative goals is

reserved for motivated patients who exhibit an interest in and ability to make constructive use of such techniques.

Although many of the goals outlined in Table 21–1 overlap with the concerns and expertise of other service

providers, all should be the concern of the individual psychotherapist and a focus for individual psychotherapy.

Although other professionals may be relied upon to accomplish specific tasks, the psychiatrist should consider him

or herself responsible for ensuring the results of these efforts.

The following general treatment strategies apply for each clinical task and focus:

Evaluation. A thorough evaluation of the patient initiates the treatment process. In the acute phase, medical assessment

and stabilization include ruling out identifiable medical conditions, assessing competence to consent to treatment and

dangerousness, and determining symptom response to medication. Available psychosocial assessment inventories support

and aim to measure the degree to which the patient’s adaptive capacities match the stresses and demands of his or her

living environment. Efforts to establish a supportive ongoing treatment test the patient’s capacity to trust and rely on others

for support and guidance. When applicable, psychoeducational, rehabilitative, and investigative interventions are preceded

by an assessment of the patient’s cognitive strengths and deficits, allowing interventions to be formulated that match the

patient’s talents.

1.  

Continuous reevaluation. The fluid nature of schizophrenia and an individual’s adaptation to it over time demand periodic

reassessment of course, prognosis, phase of illness, and target problems. As these change, so do treatment goals. Providing

concrete support in the form of a ride to work, for example, may be helpful early in the effort to promote vocational

rehabilitation but later may promote unwarranted dependency and prolong disability.

2.  

Timing. The phasic natural history of schizophrenia requires attention to when particular treatment goals are attempted. For

many patients, in order to minimize stress and forestall relapse, relatively little beyond assessment, stabilization with

medication, and establishment of a supportive ongoing treatment should be attempted in the early months after an acute

episode. Once symptoms are minimized or stable, rehabilitation and more complex psychoeducational elements may be

introduced.

3.  

Titration. Treatment interventions should be applied with graded increases of intensity and complexity. Substantial

rehabilitation, for example, will rarely be possible until progress has been made in securing human services and attaining a

stable, supportive treatment relationship. Likewise, there is evidence that early, active, and ambitious psychologically

oriented treatment may be disorganizing or toxic for certain patients. Gradualism can be frustrating for patients keen to get

on with their lives, but trial periods of part-time school or work are often valuable before full-time resumption of activities.

4.  

Integration with psychopharmacology. Control and prevention of psychotic symptoms using the lowest effective dosage of

medication are the overall treatment goals. Decisions regarding pharmacological management are often linked to the

relative success or failure in accomplishing other therapeutic goals. Considerable psychoeducation, for example, should

precede attempts at maintenance medication dosage reduction. Long-acting injectable antipsychotics may be useful for

patients too disabled to remember to take oral medications or those unable to maintain a reliable treatment relationship.

5.  

Evidence-based practices.As outlined in Table 21–1 and described in other chapters in this section, specific evidence-based

practices are appropriate for application at various illness phases. Research-based medication algorithms and guidelines for

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side-effect monitoring are available to inform acute and maintenance treatment. Evidence-based psychosocial treatment can

enhance medication adherence in the postacute phase, teach disease management skills to reduce relapse risk, and (if

needed) provide assertive community support to maintain a therapeutic contact. During stable phases, employment can be

promoted through place and support rehabilitation models.

SHARED DECISION MAKING AND RECOVERY

Patient and family expectations have changed since Talcott Parsons’ classic description of the sick role. Access to

information through the media, Internet, and direct patient marketing have rendered patients and families more

knowledgeable than at any time in history. For many patients, “illness self-management” becomes a significant

treatment goal. “Shared decision making” is a promising template for the physician–patient relationship that is an

alternative to both the “paternalistic model” in which the physician unilaterally renders an opinion from on high and

the “pure consumerism” that reduces the physician to a dispassionate technocrat dispensing information about

statistical risks and benefits of alternate treatment approaches. Shared decision making recognizes that the relative

importance assigned to risks, outcomes, and side effects by the doctor and by the patient is not necessarily

congruent and substantially respects the patient’s self-defined goals and priorities.

Recovery is a concept introduced in the writings of mental health consumers in the 1980s and in part reflects a

change in attitudes as a result of the consumer movement and self-help activities. Recovery has been described as a

process, an outlook, a vision, and a guiding principle. The overarching message, supported by contemporary

research, is that hope and restoration of a meaningful life are possible despite serious mental illness. Beyond a

narrow medical view of mental illness, recovery implies restoration of identity, self-esteem, and meaningful roles in

society. On a practical level, the recovery movement is evidenced by greater participation by consumers and families

in the design and oversight of services and service systems, the creation and support of family- and

consumer-operated services to supplement traditional care, active efforts to eliminate stigma associated with

mental illness, and the creation of new definitions of outcome that are expanded to emphasize self-esteem,

empowerment, optimism, and self-efficacy. Shared decision making as a model of the physician–patient relationship

supports contemporary perspectives of recovery as a treatment goal.

INITIATION OF OUTPATIENT PSYCHOTHERAPY

When scheduling an initial outpatient visit for a patient with schizophrenia, the clinician should set aside sufficient

time (1½–2 hours) to conduct a thorough preliminary assessment. If the referral is initiated over the phone by

someone other than the patient, it is useful to use the phone contact to obtain a cursory outline of the patient’s

history and current mental status. Information about symptom severity, current medications, and current and past

suicidality and aggression should be sought, with the aim of determining whether outpatient evaluation can proceed

safely. If preliminary contacts suggest the possibility of a need for hospitalization or other acute care, specific

information about what acute care resources the patient is eligible to access should be obtained.

It is common for patients with schizophrenia to arrive for a first appointment accompanied by a family member, case

manager, or other caregiver. Following introduction to the patient and those arriving with him or her, an initial

assessment interview can be conducted with the patient alone. In this interview, the clinician may need to make an

active effort to promote the patient’s comfort. This can be done by, for example, offering coffee, pointing out the

specific place to sit, outlining what will be discussed, and (if necessary) patterning the assessment interview with a

specific set of questions. With the patient’s permission, it is then often useful to spend some time alone with the

accompanying family member or other caregiver. This interview allows the person accompanying the patient to

express specific concerns or worries in private and can provide important additional information about the patient’s

situation. Refusing contact with the patient’s family under the banner of “confidentiality” is almost always ill

advised. During an initial assessment, patients rarely object to such contacts, which can be presented in a

matter-of-fact manner as a standard part of the initial consultation.

Ideally, the outcome of the initial visit will be a mutually agreed-upon plan for further assessment or treatment. This

plan should include the frequency and duration of visits, payment, medication regimen, and arrangements for the

patient and/or caregivers to contact the physician (or other team member) in the event of a crisis between

scheduled appointments. Attention should also be given to practical considerations such as who will provide

transportation to appointments and how and where prescriptions will be filled. If psychotherapy is recommended, a

general statement of its methods and goals may be useful (“We will meet so that we can talk together, better

understand your difficulties, and work with you on your medications to improve your situation”). In addition,

defining some mutually agreed-upon area (problem, concern, goal, medication side effect) in which the therapist

can be seen as potentially useful to the patient will set the stage for a positive therapeutic relationship.

The frequency and duration of clinical visits are individualized. If psychotherapy will be used, 30- to 50-minute

sessions are most common in an outpatient setting, but the frequency of visits may be increased during periods of

clinical instability or if insight-oriented psychotherapy is prescribed. Less frequent visits of shortened duration

(15–20 minutes) may be negotiated during periods of stability for patients who have learned to self-manage their

illness or for those who find contact with a clinician aversive, disorganizing, or irrelevant.

In addition to setting the stage for establishing a working relationship with the patient, the clinician’s managementPrint: Chapter 21. Individual and Family Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=254849&print=yes…

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of the initial interview should promote collaboration with the patient’s family member, case manager, or other

caregiver. Both the patient and the caregiver can be told that the patient’s confidentiality will be respected but that

if the therapist at any time believes that a relapse or other dangerous situation is developing, the help of family

and/or other caregivers will be solicited. The family members can be encouraged to contact the clinician if they

develop concerns, and the frequency of future family contacts may be agreed upon. Family and/or caregiver support

is crucial to the outcome of treatment and will most likely be extended to a clinician who is felt to be empathic,

responsive to concerns, and available.

MEDICATION COMPLIANCE

Noncompliance with effective psychopharmacological treatments during both acute and maintenance therapy is a

major cause of morbidity among patients with schizophrenia. When prolonged and/or repeated, noncompliance

contributes to a downwardly spiraling cycle of relapse, recidivism, and deterioration of social and instrumental

functioning. Empirical correlates of noncompliance include 1) patient-related factors (greater illness severity or

grandiosity, lack of insight, substance abuse comorbidity), 2) medication-related factors (dysphoric medication side

effects, ineffective or excessively high dosages), 3) environmental factors (inadequate support of supervision,

practical barriers), and 4) clinician-related factors (poor therapeutic alliance). Available research underscores the

multiplicity of explanations for reduced compliance and highlights the necessity of an individualized assessment

(Fenton et al. 1997). Of particular relevance to psychotherapy are patients’ health beliefs and the psychological

meanings attached to their illness and its treatment.

Among the psychological meanings associated with medication noncompliance, the following have been described:

1) pervasive denial about having an illness and needing treatment; 2) reactive efforts to regain control of one’s life

and maintain a sense of self-cohesion by organizing in opposition to the will of others; 3) the concrete equation of

taking medication with being ill (if I need drugs, I must be sick; the higher the dosage, the sicker I am; I’ll stop

being ill if I stop taking drugs); 4) lack of knowledge or incorrect beliefs about medications (taking drugs is a sign of

weakness); 5) paranoid views of medication as being poisonous, controlling, or damaging; 6) secondary gain from

psychosis—that is, grandiose delusional gratification or escape from normal expectations and responsibilities; 7)

pain and anguish accompanying symptom reduction, with the attendant recognition that one has been ill and that

the illness is severe; 8) displacement from transference—for example, discontinuing medication as an expression of

anger toward the therapist or family; and 9) an expression of unconscious ambivalence or fear of autonomy—as in

discontinuing medication immediately prior to beginning a new job or rehabilitation program.

General recommendations for improving adherence in the context of psychotherapy have included 1) conveying

interest and concern about medication by asking specific questions about how much medication is being taken, as

well as effects and side effects; 2) assuming many patients will at times take more or less medication and creating a

therapeutic environment where such “experiments” are legitimized and can be talked about; 3) involving patients to

the greatest extent possible in their own medication treatment, for example, allowing self-regulation of dosage

within bounds; 4) arranging for the taking of medication under the supervision of family, friends, or others and

enlisting their support for medication; 5) using direct praise and support for medication compliance; 6) providing

education in the areas of medication side effects, relapse prevention, and biological basis of major mental illness; 7)

promoting self-monitoring through recordkeeping and other behavioral interventions; 8) attending to and building

the therapeutic relationship as a lever to change; and 9) helping the patient experience activities that promote

self-esteem and compete with psychosis as sources of gratification. The choice of specific interventions should be

based on a differential diagnosis that generates hypotheses regarding which specific factors are operative in the

individual patient. When lack of knowledge and cognitive deficit are major factors in noncompliance, specific

cognitive and behavioral procedures can enhance cognitive mastery and skills attainment. When noncompliance

represents the unconscious wish to regress, dynamic exploration and interpretation are required. When severe

denial or disorganization is a major factor, arrangements for supervised medication administration may be

necessary.

Finally, it must be recognized that some patients who appear to be clear candidates for benefiting from medication

will continue to refuse despite all efforts. Allowing the noncompliant patient who leaves treatment against medical

advice to do so with dignity can set the stage for greater collaboration should the patient return in the future. The

reader is also referred to the proposed educational interventions with respect to medication in Chapter 22,

“Psychiatric Rehabilitation.”

FAMILY SUPPORT

Between 30% and 65% of adults with serious mental illness live with their families (Murray-Swank and Dixon

2004). Family caregivers provide emotional support, ensure that medications are taken, provide transportation to

appointments, and negotiate bewildering and user-unfriendly bureaucracies in order to obtain entitlements and

treatment services. In addition, they may have to set limits on disturbing behaviors such as smoking, day-night

reversal, and impaired hygiene and cleanliness; make painful judgments regarding involuntary treatment; and

provide harried mental health clinicians with an accurate picture of the patient’s functioning and response to

treatments. The elderly parents of individuals with long-term mental illness must devise plans to secure the safety

and well-being of their children when they themselves become too ill or infirm to provide care (Lefley 1987).Print: Chapter 21. Individual and Family Psychotherapies http://www.psychiatryonline.com/popup.aspx?aID=254849&print=yes…

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Although caring for an ill relative can sometimes be rewarding, the concept of “family burden” summarizes the

long-term physical, emotional, and financial strain that accrues in the course of prolonged or indefinite caregiving

for a disabled child, parent, spouse, or sibling (Magana et al. 2004; Schene et al. 1994).

The sense of loss associated with schizophrenia in one’s child is well expressed by Martin S. Willick, an American

psychiatrist whose 28-year-old son at Harvard was diagnosed with schizophrenia:

We experience this terrible feeling of loss and grieve for the son we knew. There is also that terrible loss of our expectations.

We feel cheated out of watching him mature and flower the way adolescents do when they grow into young adults. . .it is a

mourning without end because, of course, Gary is not dead at all. He is very much still with us, seeming eternally twelve

years old, needing constant care and attention. This “mourning without end” is tempered only by the lingering hope that one

day Gary will be returned to his former self. (Willick 1994, pp. 9–10).

The legacy of theories from the 1940s and 1950s that posited family dysfunction as the cause of schizophrenia and

other serious mental illnesses may be the persistence of guilt or shame as reactions to mental illness in the family.

Because of this, the diagnosis of mental illness may be concealed, depriving the family of sources of support that

might be forthcoming in the context of other illnesses (Canavan 2000). Family members caring for people with

mental illness often progress through a series of psychological phases that includes disillusionment with mental

health professionals and the mental health system (Tessler et al. 1987).

Modern family psychoeducational treatments have been studied in more than 30 randomized clinical trials and are

among the most effective treatments in clinical psychiatry (Pitschel-Walz 2001). They consistently reduce

posthospital relapse rates by about 50% (McFarlane et al. 2003). Current evidence-based practice standards

recommend that psychoeducation be offered to all patients who have ongoing contact with their families (Lehman et

1. 2004a). Despite substantial evidence of efficacy, professionally led family psychoeducation appears to be rarely

provided in routine care (Lehman and Steinwachs 1998a).

FAMILY PSYCHOEDUCATION IN ROUTINE CARE

The absence of available organized family intervention programs should not preclude the adaptation of principles of

effective family care in routine practice. In almost all cases, clinicians who treat patients with schizophrenia should

meet with the patient’s family at the time of initial assessment and at periodic intervals thereafter to provide

education, emotional support, and problem solving. “Privacy concerns” or “confidentiality” should not be used as a

reason to eschew family contact. Few patients will object to family contact if notified at the time of initial

assessment in a matter-of-fact manner that the physician will need to have family contact from time to time,

particularly should he or she feel the patient’s condition is worsening. Similarly, many families will agree to keep the

doctor informed of any important changes in the patient’s condition. Referral to the National Alliance for the

Mentally Ill (NAMI) or other local resources can reduce family isolation and enhance support (Glick and Dixon

2002). Most NAMI affiliates offer monthly educational meetings, and in at least 45 states, NAMI offers a formal

12-week Family-to-Family (formerly called Journey of Hope) educational program (Burland 1998). By 2004, an

estimated 80,000 family members had participated in Family-to-Family classes in a program that has 300 volunteers

and more than 250 trainers of new teachers (Dixon et al. 2004).

CONCLUSION

The contemporary integration of psychopharmacology, cognitive remediation, and psychiatric rehabilitation with

more traditional and updated psychosocial therapies and community-based care enhances the possibility for better

outcomes in schizophrenia and other psychotic disorders. In this chapter, the phase-specific combination of

cognitive-behavioral and flexible psychotherapies and family psychoeducation bring an increasingly effective,

hopeful, and patient-centered approach to these disorders.

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