Beyond Psychopharmacology: Emerging Psychosocial Interventions for Core Symptoms of Schizophrenia

In the United States, treatment of schizophrenia is focused on the biological model of disease causation and treatment, the so-called “medical model.” The medical model is oriented to view schizophrenia as a brain disorder originating from latent neurobiological vulnerabilities. Likewise, symptoms of schizophrenia have traditionally been thought of as being amenable only to pharmacologic intervention. The point here is not to debate whether schizophrenia is a brain disorder, but to emphasize the predominant position of the medical model in informing many psychosocial interventions. A consequence of the medical model was the belief that only medication or other somatic therapies could improve core symptoms of schizophrenia and that core symptoms would not, and could not, respond to psychotherapy (5).

This traditional view of the secondary role of psychotherapy has been challenged by the emergence of a form of CBT modified for persons with schizophrenia. Starting in the 1980s, case reports originating from the United Kingdom described successful outcomes from initiation of CBT-oriented psychotherapy with patients who still exhibited ongoing positive symptoms of schizophrenia. The clinicians involved observed noticeable improvements in core psychotic symptoms. The success of these individual cases formed the impetus for further studies using CBT techniques and for modifying these techniques along the way to better address specific challenges arising from the person’s schizophrenia (6–8). These successes were then developed into formalized treatment manuals and books that were published in the 1990s (9). This literature marked the beginning of the designated branch of CBT that was focused on improving outcomes for patients with schizophrenia and other psychotic disorders and that has now been renamed CBTp.

This literature was met with intense skepticism. The skepticism was based on the assumption that psychotic symptoms would respond only to pharmacologic intervention (e.g., “You can never talk a patient out of her delusions”). This debate (occurring primarily in the United Kingdom in the 1990s) was the impetus for funding randomized controlled trails (RCTs), usually consisting of a comparison of about 15 to 20 sessions of CBTp given by a trained therapist versus a control condition. The earliest studies compared CBTp with treatment as usual. These studies showed that adding CBTp reduced psychotic symptoms over and above their reduction by usual care. The findings challenged the belief that psychotic symptoms are not amenable to verbal interventions and were encouraging enough to support further research in the efficacy and effectiveness of CBTp for schizophrenia. The next wave of studies compared CBTp with other types of psychotherapeutic interventions, controlling for nonspecific effects of therapy (10). This literature is now well established, and CBTp is considered a mainstream evidence-based psychosocial intervention. However, the availability of CBTp (and training in CBTp) in the United States continues to lag far behind that in the United Kingdom.

A formal CBTp intervention is intended as a course of individual psychotherapy to be delivered by a CBTp-qualified therapist. The number of sessions is given in a flexible but time-limited period, usually between 15–20 sessions over a period of three to six months, with less frequent “booster” sessions allowed upon completion of the formal course of CBTp. In the United Kingdom and some other countries (but not the United States), a clinician has to complete a training program in CBTp to be qualified as a CBTp therapist. Most clinicians who train in CBTp start out already experienced in working with severe mental illnesses and then go on to get specialty training and ongoing supervision.

The major criterion for suitability for a course of CBTp is that the patient reports some kind of problem(s) and the willingness to discuss those problem(s) in therapy. The current U.K. National Institute for Health and Care Excellence (NICE) guidelines state that CBTp should be offered for any patient with schizophrenia who requests it. Of note, it is not necessary for the patient to agree to or even acknowledge the presence of a mental illness to be eligible for CBTp because the intervention is not based on a diagnostic or disease model of treatment.

There are several stages that are sequenced during the course of CBTp, which are summarized in the box below (11). These phases are hierarchical, but some flexibility is allowable based on the tempo (how fast or slow to go) and needs of the patient and the specific problems or symptoms that are the focus of the therapy.

At the time of this review, in the United States, it is unlikely that patients with schizophrenia have access to fully trained CBTp therapists or that comprehensive training for CBTp delivery is easily available to clinicians. However, many of the principles of CBTp lend themselves to day-to-day work with patients. There are now many introductory textbooks available for interested readers, and courses in CBTp are also available at major psychiatric meetings such as those of the American Psychiatric Association or the Beck Institute in Philadelphia (www.beckinstitute.org/get-training/). Some of the advances in CBTp can also be used to improve the therapeutic relationship and quality of communication in day-to-day work with patients with schizophrenia. There is general consensus that an overall approach that follows many of the CBTp principles can be taught without the rigorous training required to complete a CBTp course of therapy (14–17).

Table 3 reviews some of the key principles that can be adapted to day-to-day interactions with patients with schizophrenia. These are applicable across disciplines and can be useful for medication management, case management, nursing staff, and other mental health teams (18).

There is growing recognition that certain kinds of childhood adversity and trauma are causal risk factors for the later onset of schizophrenia and other psychotic disorders. It is hard to describe just how much the current research findings have altered the understanding of schizophrenia from where it was a only few decades ago. A major federal initiative defined the 1990s as the “Decade of the Brain,” and this initiative reflected the firm belief that diseases such as schizophrenia were best explained as being inherently caused by biologic factors that had little to do with social environment. The research at the time did not find any causal relationship between environmental conditions in childhood and schizophrenia onset but did find a genetic relationship between family history of schizophrenia and schizophrenia risk that was independent of environmental factors. The classic family risk studies at the time found that most of the identifiable latent risk for future schizophrenia was from heritable genetic risk (19). Using case registry and adoption studies, researchers concluded that the schizophrenia risk “followed the DNA, not the home environment.” Although there remained a significant portion of risk of schizophrenia that was not explained, there was no obvious association between stressful childhood events (e.g., parental divorce) and future schizophrenia risk. Therefore, it was accepted that the origin of schizophrenia had little to do with psychological trauma during childhood. While childhood trauma was an important risk factor for many other psychiatric disorders, schizophrenia was not considered to be one of them.

Epidemiologic research methods are much more sophisticated now. The ability to detect environmental risk factors for schizophrenia has greatly improved with the use of larger population-based cohorts, more detailed surveys, and more sophisticated statistical methods. There now is a robust and growing literature showing that childhood trauma substantially increases the risk of psychosis and the likelihood of schizophrenia onset, and specific trauma events include sexual trauma, bullying, emotional abuse, parental loss, and neglect (20). While it is beyond the scope of this review to go into further detail on these studies, this research has provided a compelling impetus to reduce the likelihood of further trauma after onset of schizophrenia and to study psychosocial interventions that are focused on comorbid schizophrenia and PTSD.

Even if trauma is a risk factor prior to schizophrenia onset, one might wonder if the problems associated with schizophrenia eclipse those of PTSD symptoms. Cross-sectional surveys of adults with severe mental illness such as schizophrenia report much higher prevalence of PTSD among them, with estimates in the 40% range (21), compared with estimates of 7% to 12% in community samples of the general population (22, 23). As shown in Table 4 (24–30), the reasons for the high comorbidities include antecedent risk factors, plus those arising after the onset of schizophrenia, such as traumatic memories of psychotic behaviors, traumatic events associated with receiving mental health services, and susceptibility to being victimized or incarcerated. Surveys of severe mental illness populations consistently show enormous increases in risk of being victims of violent and sexual offenses, relative to the general population (31–33). The overall relationship between trauma prior to and trauma after the onset of schizophrenia is summarized in Table 5 (34–36).

Before discussing specific psychosocial interventions targeting comorbid PTSD, I want to emphasize that the main point for the practicing psychiatrist is that both cognitive and exposure therapies are feasible for patients with schizophrenia. The notion that treating comorbid PTSD is too stressful and therefore will induce a psychotic relapse is not a reason by itself to withhold treatment of PTSD. The important caveat is that one must make sure that the individual is motivated to address the comorbid PTSD symptoms.

The epidemiology of comorbid PTSD as well as concerns about the stress of trauma-focused work have served as the impetus for interventions targeting mentally ill patients who exhibit symptoms of PTSD. Of note is that most of the relevant studies are not limited to patients with a primary diagnosis of schizophrenia but capture a broader range of diagnoses associated with severe and persistent mental illness.

Schizophrenia is a mental health condition characterized by broad impairments in cognition. Cognitive symptoms may or may not be identified in routine clinical practice but are almost always present in formal testing of cognition. Cognitive problems are present at the time of the initial diagnosis and continue through the course of illness. Cognitive functioning cannot be described as a single entity or test score; cognitive testing usually covers a range of cognitive domains (29). Because there are differences in cognitive abilities in the general population, the same is true for people with schizophrenia. The determination that cognitive dysfunction is a part of the disease itself is based on several converging lines of evidence: Cognitive difficulties predate onset of psychotic symptoms in individuals followed over time who later convert to schizophrenia; there are consistent findings of worse cognitive testing scores in schizophrenia samples than in samples of normal control peers matched for age and education; and cognitive dysfunction is enduring and relatively independent of the degree of psychotic symptoms at any point in time. As reviewed in the landmark paper by Green (30), relative to its detectability in a routine clinical visit, cognitive dysfunction accounts for a disproportionate amount of enduring disability in schizophrenia patients (34).

It is known that cognitive pathways are not fixed and immutable, but rather are able to adapt and change to compensate for central nervous system injury. The principles of neuroplasticity and the promoting of brain recovery through the use of programmatic training modules targeting cognitive functioning go back to the 1960s (35). Cognitive remediation was a general term that described training programs (usually administered as a computer program) that provided cognitive exercises to either directly improve one or more aspects of cognitive functioning or circumvent remaining cognitive problems. Interest in this kind of approach for schizophrenia was kindled in the 1990s by the greater recognition of the central role of cognitive dysfunction in schizophrenia as a pernicious but silent driver of disability (36). The 1990s also was a decade of rapid change in the personal computer, which made it much easier to modify and adapt remediation programs developed for brain trauma patients to schizophrenia patients. Early studies showed encouraging results (37) and marked the beginning of what is now a well-established treatment for schizophrenia. Almost by default, the term “cognitive remediation” was used for schizophrenia, as it had been for brain injury. However, more recently, Vinogradov and others have criticized the use of the word “remediation” to describe a wholesale category of these approaches with psychiatric diagnoses. Not only is “remediation” too narrow, it is not a good fit for a recovery-oriented treatment intervention. They have proposed replacing “cognitive remediation” with “cognitive training” as a preferred description (38).

The first level of outcome is change in test scores of standard measures of cognition. Because there are practice effects from repeating cognitive tests before and after the cognitive training intervention, outcome research using cognitive testing has to be very careful with appropriate control conditions. In 2007, McGurk and colleagues published the first major review of cognitive remediation (cognitive training) in the American Journal of Psychiatry (39). That review found that cognitive training demonstrated the potential to improve cognition scores over and above practice effects. Although the magnitude of the benefit was modest and did not restore cognitive function back to “normal,” it was “something.” Compared with disappointments so far in finding effective pharmacologic interventions, “something” in cognitive training is a lot better than the “nothing” shown by pharmacologic interventions. The other major finding was that functional outcomes were much better when the intervention combined the computerized practice training with coaching given by a trained clinician, who then could help the patient with goals set out in a psychosocial rehabilitation program. A later meta-analysis by Wykes and colleagues published only four years later in the American Journal of Psychiatry (40) also identified the impact of linking the cognitive training exercises to other psychotherapeutic or psychosocial interventions. As might be expected in the formative years of a promising treatment, there were many differences in how these interventions were developed and tested, including type of software program, number of sessions, the goals of the training, and how the cognitive, symptom, and functional outcomes were measured. The main take-home point is that there is enough evidence to say that cognitive problems associated with schizophrenia, under the right circumstances, can be treated with a cognitive training platform that has its roots in parallel work in using neuroplasticity in the adult brain to counteract the cognitive losses associated with brain injury.

As reviewed by Fisher and colleagues (41), several computer programs originally developed for brain injury or developmental disorders were then adapted to and recalibrated for patients with schizophrenia; other programs were designed specifically for schizophrenia. These cognitive training programs included Psychological Software Services’ CogRehab (42), Marker Software’s Cogpack (43), Medalia and Freilich’s neuropsychogical and educational approach to cognitive remediation (NEAR) (44), and Posit Science’s Brain Fitness Program (BFT) auditory module (45). It is beyond the scope of this review to compare these programs, but they vary in the specific domains that are the focus of the intervention, the amount of training time, and the quantity and quality of research into their use.

The difference in the software used is only one of many differences in how cognitive training is conducted. Other differences include the intensity (dose) of the exposure, the specific cognitive domains of interest, the level of integration with other psychiatric services, and whether the cognitive training has other (human!) therapies that make a combination “package.” Further differences include which test is used to measure cognitive changes and whether or not there are additional measures of possible “real-world” improvements above and beyond the cognitive test scores. It is beyond the scope of this review to go into all the details and variations; there are excellent reviews available for interested readers. Instead, I will discuss the variations that have been described and studied in the world of cognitive training.

There are variations in the way the intervention aims to improve cognitive outcomes. Strategies are sometimes divided into restorative or compensatory techniques or some combination of the two. “Restorative” means directly improving cognitive performance in areas of relative weakness. An example of a restorative approach is to use drill and practice for targeting the areas of greatest weakness and making them “stronger.” This is often accomplished with repeated practice sessions using software programs designed to work on those parts of cognition that are lagging. Analogously to a video game in which difficulty levels change automatically as the player improves, so too do the computer practice drills adapt to the relative accuracy of the patient’s responses. If successful, the drills enable the patient to “catch up” to be closer to his or her expected (premorbid) performance. “Compensatory” means teaching better “work-around” solutions for cognitive problems that are more fixed. An example of compensatory work is setting up structured written reminders for someone with significant working memory problems. In addition to these programs, others are trying to tackle the cognitive equivalent of problems in social cognition. As one might guess, social cognition software will focus on how to “read” nonverbal social cues and learn to respond in socially appropriate ways.

It should be noted that patients do not engage in these computerized training sessions in isolation; these programs can be tedious or taxing for anyone, let alone a person dealing with schizophrenia. Therefore, another important aspect in the evolution of cognitive remediation training has been an effort to improve the level of interest in or sustaining motivation associated with these exercises, a process sometimes referred to as “gameification.” Another variable in such programs is the extent to which there are “real life” face-to-face interactions with a trainer or cognitive therapist. Staff can provide personal support and encouragement. The therapist often provides the individualization of the cognitive support, helping the patient match any gains in cognitive tasks with real-world tasks and goals. Or, the training may be done individually but linked to group therapy work that can help patients address social cognition and other uses.

As mentioned, integrating cognitive training and other kinds of evidence-based psychosocial therapy seems to produce the greatest changes in functional outcomes with sustained improvements that continue for some time after the formal training has ended (40). Sometimes the cognitive training and rehabilitation work are integrated (46), and sometimes these components are given sequentially (47). The underlying rationale is that improved cognitive test scores are not meaningful without a reason to put one’s mind to use.

Although medications in general do not change cognitive functioning very much, in practice, certain medication-prescribing practices interfere with the effectiveness of cognitive training. The most important finding is that patients given medications that impair cognition, especially anticholinergics, show more cognitive dysfunction at baseline and a less favorable response to the cognitive training intervention than do patients who have not been exposed to a significant anticholinergic load (48–51). Another related finding is that lower antipsychotic doses predict better response to cognitive work, so presumably the opposite is true in that excessive doses will also interfere with optimal cognitive training. Taken together, it seems that optimizing the antipsychotic regimen to get to the lowest maintenance antipsychotic dose, and thus lowering the anticholinergic burden, will improve the effectiveness of most if not all of the cognitive training interventions.

The future of cognitive training depends on whether it can succeed in reversing (or even attenuating) the terrible impact that cognitive problems have on outcome. Such success will depend on several assumptions: that the cognitive problems associated with schizophrenia are not progressive and that, therefore, any cognitive gains are likely to endure after the intervention is over; that patients will find in themselves sufficient motivation to do the cognitive training; that the improvements will endure once the intervention is finished; that patients benefiting from training will have the opportunity to develop further and to put new learning to good use; and that there will be adequate investment in the entire rehabilitation process to better allow for meaning changes in the patient’s life trajectory.

The clubhouse model is the predecessor of peer-based interventions and is exemplified by Fountain House, whose history is described on its website: “The Fountain House traces its roots to the late 1940s at Rockland State Hospital in Orangeburg, New York. Six patients formed a group that met in a hospital ‘club room’ where they shared their stories, read, painted and participated in social functions. Soon after leaving Rockland, they joined together to re-create the respectful and supportive group they had formed in the hospital. . . . All believed they could offer each other support in life’s challenges and sustain their social community” (www.fountainhouse.org/about/history). Clubhouse models also can provide community outplacement to “real” work settings in companies that provide a supportive work environment and, in return, rely on the clubhouse to guarantee adequate staffing. This arrangement offers clubhouse members real work that is also shared with the others in the clubhouse community. This approach is known as transitional employment. Clubhouse models have been enormously successful in supporting important aspects of personal recovery such as a sense of contribution, personal growth, and inclusiveness.

The sense of community that has been part of the success of the clubhouse model (52) has also been an impetus for other peer support programs. One such program is known as Wellness Recovery Action Planning (WRAP). WRAP uses peers to help participants manage their own long-term illnesses whether or not they are also receiving traditional mental health services. In fact, WRAP peer educators are trained in using formal diagnoses or medical jargon. As an inherent part of the social inclusion aspect of the program, WRAP uses a group format that mixes coursework and personal narratives. The topics go beyond “mental illness” and encompass (as the program’s name implies) a broader range of health and wellness strategies (53, 54). The overall results of a study using a version of WRAP targeting physical health issues showed positive changes, reduction of anxiety and depression, along with some reduction in use of more traditional mental health services (54). From an evidence-based intervention perspective, clubhouse and peer models have been quite varied in their approaches and methods of service delivery, and even the most disseminated programs (e.g., Fountain House, WRAP) have not yet been adequately studied enough for definitive statements about them to be possible. Having said that, I should note that their shared attributes of social inclusion, respect, sanctuary, freedom of self-expression, and safety from the demands of formal treatment services are laudable, since there is widespread agreement among service users and mental health clinicians of the value of programs that can undo some of the damage caused by stigma and social exclusion (55, 56).

For most of us, work is much more than a way to make a living. Work (or its academic equivalent) is a major part of our identity, providing meaning, structure, context, and social status. Schizophrenia often begins around a time of key changes in responsibilities and expectations, with work and career challenges that are often crucial to successful adulthood. The timing of disease onset could not be any worse in terms of disrupting this part of adult development, and it should not be a surprise that under- and unemployment are the rule, not the exception, among those given a diagnosis of schizophrenia.

Previously, the mainstream view in psychiatry had been that schizophrenia is permanently disabling. Before research on supported employment showed otherwise, it seemed obvious that returning to a “real” job would rarely, if ever, happen for a person with schizophrenia. Furthermore, even if returning to work was theoretically possible, it was not worth exposing patients to the stress of the competitive workplace because the stress would easily trigger a relapse. Therefore, before the arrival of the supported employment (SE) model, almost all “rehabilitation” programs for schizophrenia took place under sheltered conditions. In other words, patients would often go to another location to learn, rehearse, or practice job skills. Often the rehabilitation agenda would be “one size fits all,” and there would not be much communication between the patient’s mental health team and the rehabilitation service. On some level, “failure,” meaning that the patient would not transition to a real job, was perfectly acceptable to the mental health team, simply because the risk of potential relapse with the addition of more responsibilities was just not worth it. It was not a surprise that many of these “vocational” programs were actually more directed to other goals such as leisure time management or socialization skills.

Fortunately, a small cadre of rehabilitation specialists did not see it this way. They believed that persons with severe mental illness were not destined to fail. They believed that lack of employment was not the same as lack of capacity for employment. Their efforts in programmatic development and evidence-based research over the last few decades have resulted in the recognition that SE programs can often help disabled, persistently ill patients achieve their goal of competitive paid employment (57, 58). There was enormous initial skepticism about the SE model, but its success has been replicated and it is now one of the accepted evidence-based psychosocial interventions. SE is now an accepted evidence-based practice whose aim is to help “people with [psychiatric] disabilities participate as much as possible in the competitive labor market, working in jobs they prefer with the level of professional help they need” (59). The key elements of the SE model are shown in Table 6 (60).

As summarized in the 2009 Schizophrenia Patient Outcome Research (PORT) recommendations, “At this point, about 50% of patients enrolled in these [SE] programs will return to competitive employment at some point [in the course of their rehabilitation]” (1, p. 51). The 2009 PORT recommendations also addressed and dismissed the concern that returning to work was too stressful and would worsen symptoms: “There is no evidence that [enrolling in an SE program] leads to … negative outcomes” (1). The progress made in SE is tempered by the relative lack of access to these services nationwide. Also, the SE outcomes speak to the continued challenges in helping patients with ongoing employment. Success in SE is generally limited to roughly one half of patients who start SE actually achieving any competitive employment for a set period of time. Furthermore, many of those who achieve competitive employment in the short run do not go on to sustained employment or economic self-sufficiency (61). Nonetheless, the current outcomes would not have been thought possible 25 years ago, so we can continue to be cautiously optimistic for even better outcomes for the next generation of rehabilitation interventions (62).