ICOSR 2011—In Schizophrenia, What Really Improves People’s Lives?
21 June 2011. At the Thirteenth International Congress on Schizophrenia Research, a session called “What really improves people’s lives? Surprising findings on functional outcome in schizophrenia” drew a roomful of people on 3 April. Session chair Sophia Vinogradov, University of California at San Francisco, told those who had braved the bracing Colorado Springs wind that, although another session had discussed biomarkers to gauge patients’ responses to treatment, what really matters is whether treatment helps people live better. Accordingly, the 10 talks that followed focused on predictors of how well people live and interventions to help them live better. Vinogradov kept the speakers on a strict timetable as they sailed through plenty of new and at times preliminary data, along with some fresh thinking about old problems.
Living well with others
To help patients develop life-enriching social ties, several of the speakers addressed social deficits in subjects with psychosis or a high risk for it. In the first talk, Raimo Salokangas, University of Turku, Finland, examined whether subjects at current risk for psychosis are more likely to develop a psychotic disorder if they think that other people harbor negative attitudes toward them. As part of the European Prediction of Psychosis Study, Salokangas and colleagues assessed the perceptions of 55 young psychiatric outpatients and then determined whether they developed psychosis in the follow-up period of up to 60 months. During that time, psychosis emerged in over half of subjects who reported at baseline that other people held poor attitudes toward them, compared to 9 percent of those who had described others’ attitudes toward them as moderate or good (Salokangas et al., 2011). The results suggest that asking people how others perceive them might flag those at risk for psychosis, said Salokangas.
The next talk continued the interpersonal theme. Maria Jalbrzikowski, University of California at Los Angeles, presented a study inspired by autism research. It focused on reciprocal social behavior, which she defined as the ability to process social information and to respond appropriately. To measure this ability in 50 teens at clinical high risk for psychosis and 26 healthy teens, she and her colleagues asked parents to complete the Social Responsiveness Scale. This revealed autism-like deficits in reciprocal social behavior in the high-risk group. These deficits not only encompassed expressive, motivational, receptive, and cognitive aspects of social behavior, but also autistic mannerisms such as rocking.
In preliminary analyses, the deficits stayed moderately stable over six to 12 months, but failed to predict conversion to psychosis. Even so, these findings point to a need to screen clinical high-risk youth for autism-like phenotypes, Jalbrzikowski said. To address such deficits, she proposed borrowing social skills interventions from the autism literature.
Interventions might also target patients’ negative attitudes, suggested Paul Grant, University of Pennsylvania, Philadelphia. He discussed whether defeatist beliefs, asocial beliefs, and low expectations that social activities will be pleasurable play a role in deficit syndrome schizophrenia, which involves persistent, primary negative symptoms. His recently published study (Beck et al., 2011) compared the beliefs and expectations of 22 patients with deficit schizophrenia and 72 with non-deficit schizophrenia, while controlling for depression. The results showed that deficit patients endorsed more defeatist beliefs such as “If I fail partly, it is as bad as being a complete failure.” Such patients were also more likely to endorse asocial beliefs, such as “People sometimes think I am shy, when I really just want to be left alone.” On the other hand, the two patient groups did not differ in their expectations of enjoyment from future social activities.
Putting these findings into context, Grant noted that deficit patients typically benefit little from available treatments. Perhaps goal-directed cognitive therapy could address their dysfunctional beliefs and increase their involvement in constructive activity, he said.
The next few speakers addressed predictors of functional outcomes. For example, Stephen Austin, Aarhus University Hospital, Risskov, Denmark, examined the effects of ramping up treatment for early psychosis. He presented findings from the OPUS study, which he described as the largest randomized controlled trial to evaluate the effects of early assertive treatment versus standard treatment in first-episode psychosis. The study randomized 547 subjects with schizophrenia spectrum disorder to either intensive treatment or care as usual. The intensive approach, which included community treatment, psycho-educational family groups, and social skills training, produced greater improvement than standard care on measures of positive symptoms, negative symptoms, and global functioning two years later. However, by the 10-year mark, the advantage of intensive treatment had disappeared, prompting Austin to suggest that achieving lasting improvement might require over two years of treatment.
Even so, Alexander Wunderink, University Medical Centre Groningen, Leeuwarden, The Netherlands, suggested that many patients with first-episode psychosis go into remission; some may not need to stay on antipsychotic medication. To study this issue, he and his colleagues used data from the MESIFOS study, in which 128 patients with first-episode psychosis were randomly assigned to either an antipsychotic discontinuation challenge or standard maintenance treatment. All of the subjects had previously experienced symptom remission within the first year of treatment. At 18 months, 43 percent of those in the discontinuation group had relapsed, compared to 21 percent of those still on medication, but the two groups had similar functional outcomes.
At the eight-year follow-up, 70 percent of patients were in symptomatic remission and a third in functional remission. A sizable fraction, 29 percent, had reached recovery, which required both symptomatic and functional remission. According to Wunderink, logistic regression found that discontinuation challenge actually predicted long-term functional remission and recovery, without causing adverse effects.
Many studies look at schizophrenia outcomes thought to be objective, but the next speaker examined the quality of life as perceived by individuals with schizophrenia. Matthew Kurtz, Wesleyan University, Middletown, Connecticut, said that researchers are showing increasing interest in using well-designed, reliable measures of subjective quality of life or life satisfaction in schizophrenia. In a recent meta-analysis (Tolman and Kurtz, 2010), Kurtz and Arielle Tolman, Wesleyan University, Middletown, Connecticut, found that measures of crystallized verbal ability and processing speed were inversely related to subjective quality of life in schizophrenia. This led them to think that better cognition might give subjects greater insight into their illness and the toll it takes on their lives.
To determine whether insight mediates or moderates the link between neurocognition and subjective quality of life, Kurtz presented recently published findings (Kurtz and Tolman, 2011) from a study of 71 “mid-career folks with schizophrenia.” It found that insight, three measures of cognitive function, and the severity of depression correlated negatively with subjects’ perceived life quality. Regression analyses suggested that insight neither mediates nor moderates the link between cognition and subjective life quality, leading Kurtz to think that neurocognition might affect life satisfaction directly. He raised the possibility that efforts to improve insight and neurocognitive functioning in schizophrenia might actually worsen patients’ subjective quality of life.
Without motivation, patients’ capacity for better living may be limited, an issue examined in a prospective study by George Foussias, University of Toronto, Canada. He and his colleagues hypothesized that motivational deficits would prove a key predictor of functional outcomes in 23 adults with schizophrenia. In stepwise hierarchical regressions, baseline motivational deficits emerged as the strongest predictor of functioning at baseline and a year later, overshadowing negative symptoms, positive symptoms, depression, cognition, and other factors. In fact, baseline motivation explained 70 percent of the variance in functioning at the one-year follow-up. Although Foussias said that positive symptoms, cognitive functioning, and diminished expression each added some predictive value, he sees motivational deficits as crucial to understanding long-term functional outcomes in schizophrenia, at least in subjects who were motivated enough to participate in a study.
Help for patients?
Functional outcomes remained front and center in the presentation by Kelly Allott, University of Melbourne, Parkville, Australia. Noting that cognitive behavioral therapy (CBT) does not help everyone, she said that research has yet to clarify the predictors of functional outcomes after CBT, which would help clinicians identify patients who would be likely to benefit from it. As a result, she and her colleagues reanalyzed data from a study (Jackson et al., 2008) that randomly assigned 62 subjects with first-episode psychosis to 14 weeks of treatment with either CBT or befriending. The latter, in which patient and therapist engage in small talk, controlled for nonspecific aspects of therapy, such as the therapist’s attention.
The study measured a range of possible predictors, including patient sociodemographic characteristics, cognition, and symptoms, but only the patient’s vocational status predicted functional outcomes after CBT. Specifically, whether the patient was working or studying at baseline predicted 35 percent of the variance in post-CBT function, suggesting that first-episode patients may gain more from CBT if they already have relatively high vocational function. For the others, Allott suggested alternative approaches, such as supported employment or education.
Switching the subject to a different kind of intervention, Katy Harper, University of North Carolina-Chapel Hill, Durham, discussed training patients in dating skills. This idea arose from focus groups in which young men with psychosis expressed keen interest in learning how to ask someone out and how to behave on a date. Consequently, Harper conducted a pilot study of a dating skills group for young men who were in the first five years of schizophrenia or schizoaffective disorder. For 12 weeks, the nine subjects were to attend an hour-long group session, where they received training in general social skills, such as how to read body language and build rapport. They also learned dating-specific skills, such as when to ask for someone’s phone number. They practiced their skills in role-playing with female volunteers.
According to Harper, most subjects reported finding the training helpful, fun, and at least somewhat easy to follow; only one dropped out of treatment. Yet, analyses showed only a trend for improved social skills, as rated by independent raters, at the three-month follow-up. More encouragingly, Harper said that during treatment, the appropriateness of the conversational topics raised by subjects with the female volunteers improved. Her study did not look at whether subjects actually dated.
The last speaker, Stynke Castelein, University of Groningen, The Netherlands, said that negative symptoms of schizophrenia predict poor social outcomes, but respond only somewhat to medication or to physical treatments such as transcranial magnetic stimulation. Therefore, she described a study that evaluated the effectiveness of psychosocial interventions for negative symptoms and the quality of evidence behind each approach. The systematic literature search examined papers published from 1990 to 2010.
As it turned out, CBT received the highest level of empirical support, with evidence from at least two independent randomized controlled trials. It produced a small improvement in negative symptoms, an effect that lasted at least two years. In contrast, social skills training, music therapy, psychomotor therapy, and peer support groups received less impressive support, with backing from either one single-blind or at least two poorer quality randomized controlled trials. Evidence supporting arts therapy as treatment for negative symptoms stood on shakier ground, and neither psychoeducation, consumer-run programs, family interventions, cognitive remediation, nor ergo therapy lightened patients’ load of negative symptoms. Closing out the talks, Castelein said that individual pharmacological, physical, and psychosocial interventions may lessen negative symptoms, but with only small to medium effect sizes.—Victoria L. Wilcox.
Comments on News and Primary Papers
Comment by: Ray Lay
Submitted 14 September 2011
Posted 15 September 2011
As a person living with schizophrenia, I can heartily state that the acceptance of my illness, fine-tuning of my medicines, psychotherapy, and family support have greatly helped me to live better with my illness. I am not symptom-free, but symptoms are fewer and psychoeducation has allowed me to better understand my illness, and although still confusing, it is not as confusing. I can at least now tell what the symptom is and properly react. I am grateful for my treatment and my providers, and I am an active participant in my recovery.
View all comments by Ray LayComment by: Elizabeth Molnar
Submitted 16 September 2011
Posted 3 October 2011
Dr. Matthew Kurtz is reported in the current dialogue on what really matters as discussing his two recent papers with Ms. Arielle Tolman, which imply that better neurocognitive functioning on some parameters, together with better insight, are associated with more severe depression and, subjectively, poorer quality of life. I respectfully suggest that if the carers of such persons were asked, they might offer that improved neurocognitive function and insight enable the carer to function more empathically, and that the carers’ burden is lessened while their quality of life and the sense of efficacy and meaning in continuing to care is enhanced. For example, in my practice, I do discuss such matters with family members and with the person being treated, and I hear, especially when clozapine is part of the treatment package, that families are able to include the proband more readily in family discussions and occasions, and are far less likely to exclude the family member, when insight is preserved, retained, or recovered, together with cognitive function and better adherence to treatment. Depressive phenomena, such as awareness of disappointment, may be accessible to treatment, and may be framed as understandable and part of the process of recovery and re-adaptation after an injury, even when some residue or scars remain.
Kurtz MM, Tolman A. Neurocognition, insight into illness and subjective quality-of-life in schizophrenia: what is their relationship? Schizophr Res . 2011 Apr 1 ; 127(1-3):157-62. Abstract
Tolman AW, Kurtz MM. Neurocognitive Predictors of Objective and Subjective Quality of Life in Individuals With Schizophrenia: A Meta-Analytic Investigation. Schizophr Bull . 2010 Jul 11. Abstract
View all comments by Elizabeth Molnar
Comments on Related News
Related News: Cognitive Therapy May Power a Cycle of Recovery in Chronic SchizophreniaComment by: Robert Paul Liberman
Submitted 14 October 2011
Posted 14 October 2011
This study of a well-established, psychosocial treatment, which has been documented to be effective for depression, anxiety disorders, and positive symptoms of schizophrenia (Salkovskis, 1996; Kingdon and Turkington, 2004), presents credible evidence of efficacy for some, but not all, negative symptoms and possibly for social functioning in schizophrenia. The study has a number of strong methodological features; for example, protecting the “blind” for assessors, appropriate frequency and duration of treatment sessions necessary to achieve therapeutic outcomes in this population, controls for differences in types and doses of antipsychotic medication, a “standard treatment” comparison group which is consistent with the vast majority of community mental health, a sample that includes different racial and ethnic groups consistent with an inner-city population, and appropriate statistical analyses for measuring outcome. My comments address a number of concerns that may attenuate the clinical significance of the authors’ findings and interpretations.
Selection Criteria for Subjects
There is no indication whether the subjects had primary negative symptoms (i.e., the deficit state defined by enduring negative symptoms not related to positive symptoms including anxiety and depression, under-stimulating environments, side effects of medication (e.g., sedation, akathisia, akinesia, weight gain) or negative symptoms secondary to the above listed remediable interferences. In fact, it is likely that they had secondary negative symptoms because, as noted by the authors, the subjects showed significant reductions in positive symptoms and social anxiety, which often are associated with reductions of negative symptoms.
While the subjects were described as “low functioning” and “highly regressed,” the eligibility criteria for entry into the study did not use a well-established and psychometrically sound assessment instrument for measuring social functioning. For some inexplicable reason, the Global Assessment Scale was chosen as the measure of “social functioning,” despite the authors appropriately pointing out how the GAS confounds symptoms with functioning and has woefully inadequate anchor points for rating psychosocial adjustment and poor inter-rater reliability. The finding that, at baseline, their subjects were rated by the GAS in the mid- to high 40s suggests functioning that reflects “serious symptoms” and “serious impairment in social occupational or school functioning,” with the latter exemplified by “no friends” and “unable to keep a job.” This range in the GAS is hardly consistent with schizophrenia patients who are “repressed” and “severely socially impaired.” Individuals with schizophrenia who are low functioning would ordinarily fall into the 25-40 range on the GAS (e.g., “unable to work,” “socially isolated with little contact with other persons outside the family”). Many persons with schizophrenia who would not be considered “low functioning,” even those in remission of their positive and negative symptoms, have no friends and are unable to keep a job.
While the authors point out in their discussion that the GAS is a poor indicator of social functioning, it is not clear why they chose this instrument for their design, since it is well known that the GAS has poor inter-rater reliability, poor anchor points, and confounds symptoms with functioning (Dickerson, 1997).
The authors fail to describe specific improvements in social functioning that would convince readers that the cognitive therapy resulted in clinically significant improvements in work, school, friendships, family life, self-care skills, medication and money self-management, independent living, and other convincing examples of successes in community living.
The therapeutic methods as described by the authors clearly confound cognitive therapy procedures with those developed and validated for social skills training (Liberman et al. Social Skills Training for Psychiatric Patients, 1989; Bellack et al. Social Skills Training for Schizophrenia, 2006; Liberman. Recovery from Disability: Manual of Psychiatric Rehabilitation, 2008). For example, as described in the description of cognitive therapy, the following techniques were used that are key elements of social skills training in particular, and other evidence-based practices for the treatment of schizophrenia as well (e.g., supported employment, behavioral family therapy and its variants, assertive community treatment, cognitive adaptive therapy):
- Goal-directed framework and personalized treatment planning
- Engaging the patient and strengthening the therapeutic relationship
- Therapy aimed to stimulate patients’ interest and motivation on achievable long-term, intermediate, and short-term goals
- Interpersonal exercises, games, role playing, community outings, and action plans for practice outside the session (i.e., “homework assignments”)
- Treatment tailored to the participant’s level of functioning with special adaptations for problems due to poor engagement, neurocognitive impairment, thought disorder, and lack of insight
- Prompts and signs in the home to remind the subjects to complete daily activities and other therapy assignments
Specificity of Cognitive Therapy for Negative Symptoms
It is possible that the many elements in the experimental treatment condition that were similar to those used in social skills training, rather than the specific cognitive interventions, could have brought about the improvements reported in negative symptoms and social functioning.
Contrary to the assertion of the authors that “studies of other psychosocial, behavioral, or cognitive remediation interventions…[have failed]…to find that treatment effects generalized adequately to psychosocial functioning,” there are a number of evidence-based, psychosocial treatments that have been shown to significantly improve psychosocial functioning and negative symptoms. These include social skills training, behavioral family management, supported employment, and assertive community treatment (Bellack, 2004; Liberman et al., 1998; Glynn et al., 2002; Bellack and Mueser, 1993; Heinssen et al., 2000; Kurtz and Mueser, 2008; Kopelowicz et al., 1997; Falloon et al., 1987; Falloon et al., 1999; Drake et al., 1999; Drake et al., 1996; Stein and Test, 1980).
The authors give examples of how subjects’ symptoms interfered with social functioning, such as social anxiety and positive symptoms of schizophrenia. Since anxiety disorders are very common comorbidities in schizophrenia and have been shown to be responsive to cognitive therapy (Rector and Beck, 2001), it is possible that the cognitive therapy improved social interaction and adjustment by reducing anxiety. It is also possible, as noted by the authors, that the cognitive therapy brought about reductions in three of the four domains of negative symptoms secondarily as a function of rather marked decrease in positive symptoms. The reductions in positive symptoms were much greater than the rather small reductions in negative symptoms. This reverse direction of causality is acknowledged as a possible explanation of their results on negative symptoms by the authors in their Comment section.
One finding of the authors strongly suggests that the cognitive therapy did not produce improvements in psychosocial functioning by reducing negative symptoms. In Figure 3, it is clearly seen that the cognitive therapy had nil therapeutic impact on alogia, which is the critical negative symptom that would be expected to mediate improved social functioning. If subjects’ speech and conversational skills showed little improvement, it is questionable to attribute improvements in social interaction and relationships to the other three negative symptoms. The non-specific effects of 18 months and 50 sessions of community-based activities and homework assignments to attain incremental goals, instigated by competent, upbeat, and engaging therapists, would be expected to reduce apathy, anhedonia, and flat affect temporarily—which might rapidly erode once the spirited and therapeutically active sessions ended.
Also acknowledged by the authors in their Comment section is the possibility that improvements in three of four negative symptoms and marginal changes in social functioning (difficult to conceptualize without more behaviorally specific examples and typologies of goals attained in the arenas of social functioning) might be attributed to non-specific factors in the therapeutic relationships and instigative array of interventions used in the active therapy condition. As they point out, it may be appropriate to withhold an evidence-based attribution of the therapeutic benefits found in this study until a study is conducted with a comparison treatment equated for therapist enthusiasm, duration, time involvement, and other elements not specifically related to cognitive therapy.
Finally, one further cautionary note stems from the failure of the investigators to assess adherence to medication in the two treatment conditions. While the prescribed types and doses of medication did not differ between the conditions, it is well known that adherence to medication regimens is rather poor among persons with schizophrenia. Improved adherence to pharmacotherapy may have contributed to the superior therapeutic outcomes, given the fact that the therapists in the cognitive therapy program offered “personalized treatment” that included “laminated cards” and “colorful signs that patients posted at home to remind them of daily activities and other therapy assignments” which may have included concrete or implicit reminders to take their medication.
Salkovskis PM: Frontiers of Cognitive Therapy. New York: Guilford Press, 1996.
Kingdon D and Turkington D: Cognitive Therapy of Schizophrenia. New York: Guilford Press, 2004.
Dickerson FB. Assessing clinical outcomes: the community
functioning of persons with serious mental illness. Psychiatr Serv . 1997 Jul 1 ; 48(7):897-902. Abstract
Liberman RP, DeRisi WJ, Mueser KT: Social Skills Training for Psychiatric Patients. Norwood MA: Allyn and Bacon, 1989.
Bellack AS, Mueser KT, Gingerich S and Agresta J: Social Skills Training for Schizophrenia. New York: Guilford Press, 2006.
Liberman RP: Recovery from Disability: Manual of Psychiatric Rehabilitation. Arlington VA: American Psychiatric Publishing Inc., 2008.
Bellack AS. Skills training for people with severe mental illness. Psychiatr Rehabil J . 2004 Jan 1 ; 27(4):375-91. Abstract
Liberman RP, Wallace CJ, Blackwell G, Kopelowicz A, Vaccaro JV, Mintz J. Skills training versus psychosocial occupational therapy for persons with persistent schizophrenia. Am J Psychiatry . 1998 Aug 1 ; 155(8):1087-91. Abstract
Glynn SM, Marder SR, Liberman RP, Blair K, Wirshing WC, Wirshing DA, Ross D, Mintz J. Supplementing clinic-based skills training with manual-based community support sessions: effects on social adjustment of patients with schizophrenia. Am J Psychiatry . 2002 May 1 ; 159(5):829-37. Abstract
Bellack AS, Mueser KT. Psychosocial treatment for schizophrenia. Schizophr Bull . 1993 Jan 1 ; 19(2):317-36. Abstract
Heinssen RK, Liberman RP, Kopelowicz A. Psychosocial skills training for schizophrenia: lessons from the laboratory. Schizophr Bull . 2000 Jan 1 ; 26(1):21-46. Abstract
Kurtz MM, Mueser KT. A meta-analysis of controlled research on social skills training for schizophrenia. J Consult Clin Psychol . 2008 Jun 1 ; 76(3):491-504. Abstract
Kopelowicz A, Liberman RP, Mintz J, Zarate R. Comparison of efficacy of social skills training for deficit and nondeficit negative symptoms in schizophrenia. Am J Psychiatry . 1997 Mar 1 ; 154(3):424-5. Abstract
Falloon IR, McGill CW, Boyd JL, Pederson J. Family management in the prevention of morbidity of schizophrenia: social outcome of a two-year longitudinal study. Psychol Med . 1987 Feb 1 ; 17(1):59-66. Abstract
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Drake RE, McHugo GJ, Becker DR, Anthony WA, Clark RE. The New Hampshire study of supported employment for people with severe mental illness. J Consult Clin Psychol . 1996 Apr 1 ; 64(2):391-9. Abstract
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View all comments by Robert Paul Liberman
Related News: Cognitive Therapy May Power a Cycle of Recovery in Chronic Schizophrenia
Comment by: Alan S Bellack
Submitted 10 November 2011
Posted 10 November 2011
Grant and colleagues are to be congratulated on their noteworthy trial. Anyone who has conducted clinical trials with seriously ill schizophrenia patients must be impressed by the ability of the research team to recruit a large cohort in an intensive treatment and keep them engaged over such a long period of time. The team also deserves credit for demonstrating that a psychosocial intervention can have a meaningful impact with this population. Added to the increasing literature on cognitive therapies with schizophrenia patients, and on recovery-based interventions, this report reinforces the argument that people with schizophrenia can and should be engaged as partners in the treatment process.
In a previous post, Bob Liberman identified a number of crucial limitations of this trial that raise questions about the findings and limit enthusiasm for the intervention. I concur with almost all of Bob's observations and analysis. The primary outcome variable (the GAS) has marked limitations and does not provide objective or detailed information about any changes in social or occupational functioning in the community. Thus, the authors' conclusion that "cognitive therapy can be successful in promoting clinically meaningful improvements in functioning" is not supported by the data. We simply do not know much about community functioning beyond what the patients report, and the reports are especially suspect given that subjects receiving the cognitive therapy attended weekly sessions with a study therapist in which a primary focus of discussions was enhancing community activities and role functioning. A related concern pertains to the course of change noted on both the GAS and SANS ratings. The graphic representation of the data indicates that most, if not all, of the change manifested across measures occurred before the first (six-month) assessment. This raises questions about the operating mechanism of the CT intervention, as well as the value of the succeeding 12 months of treatment. As stated in the article, "Early sessions focused on engaging the patient and strengthening the therapeutic relationship." This implies that any changes induced during that early period may have resulted from non-specific effects rather than any specific cognitive therapy activities. Given that (almost) no community program could afford to administer a weekly individual treatment for 18 months, it should be underscored that at best, the data do not support anything beyond six months of treatment.
Another important issue noted by Liberman was the multifaceted composition of the CT intervention. It included elements of cognitive therapy, skills training, behavior therapy, motivational enhancement, and cognitive remediation, among others. In fact, it is difficult to justify calling the intervention "cognitive therapy" when so little of it entails cognitive therapy per se. While most of the elements have face validity and independent empirical support, the resulting combination has two significant limitations. First, it is impossible to determine the active components of the treatment. Second, it would be virtually impossible to replicate or disseminate the intervention. This latter point is of particular concern, as the trial has been reported in the media (e.g., The New York Times) as demonstrating that cognitive therapy is effective for schizophrenia patients with negative symptoms. To the contrary, this trial does not demonstrate that CT is effective for reducing negative symptoms, or that CT is a cognitive therapy.
In sum, this is an important trial that should and will have an important heuristic role for the field. It is a trial that should have been done and probably could not have been done by any other research group. While acknowledging and applauding its strengths and value for the field, it is important to consider its limitations and be cautious about what conclusions can be drawn from the results.
View all comments by Alan S Bellack
Related News: Cognitive Therapy May Power a Cycle of Recovery in Chronic Schizophrenia
Comment by: Paul Grant
Submitted 31 January 2012
Posted 2 February 2012
We thank Professors Liberman and Bellack for their thoughtful critiques of our work and welcome the opportunity to answer their questions and concerns, and thereby clarify our study beyond the space limitations of the original paper.
Liberman and Bellack express several concerns regarding the number and types of techniques employed in therapy, as well as the length of therapy. Liberman states that our therapy is “confounded” with other treatment approaches because the intervention contains many treatment techniques (e.g., skills training, cognitive remediation, motivational enhancement) that overlap with other psychosocial treatments for schizophrenia; Bellack indicates that he does not believe our treatment should properly be called “cognitive therapy” because “so little of it entails cognitive therapy per se.” We appreciate that they have raised this issue because it affords us an opportunity to explain in greater detail why we use the term cognitive therapy and what we mean by it.
Our formulation of cognitive therapy is based on the cognitive model of schizophrenia (Beck et al., 2009) rather than specific techniques. Basically, we view the low-functioning problems in these patients as due to the interaction of neurocognitive deficits and negative attitudes about performance and social relations. Our basic research has shown both in cross-sectional (Grant and Beck, 2009; Grant and Beck, 2009) and longitudinal (Grant and Beck, 2010) studies that these low-functioning patients have very powerful negative attitudes about the possibility of achieving any goals (e.g., “there is no point in trying because I will only fail”), as well as negative attitudes about the desirability of social contact. In non-technical terms, these patients have given up and have walled themselves off from usual activities of everyday life because of their expectations that they are only going to fail if they try something. While there evidently is an upper limit on how much they can achieve due to their neurocognitive deficits, they do have considerable latent capacity that they are not utilizing. Since the negative attitudes seem to account for their loss of motivation, we use a variety of methods to ameliorate them. Since we frame the problems in cognitive terms, and our understanding of each case is based on a cognitive model, we utilize the term cognitive therapy. We would, therefore, expect that any change would be mediated by cognitive variables. To produce this change, we formulate each case in terms of the individual’s goals and identify the various obstacles to reaching these goals. We select specific techniques ranging from skills training, problem solving, explicit cognitive restructuring, etc., to overcome these obstacles. If the patient is blocked by social inhibition, we use assertiveness training; if the problem is fear of failing, we use cognitive restructuring. According to our thesis, each specific successful experience tends to undercut the negative attitudes that sap the patient’s motivation. Support for our formulation is based on an experimental study which showed that success experiences not only modify negative attitudes, but increase motivation and performance (Perivoliotis et al., 2011). Once the patients start to modify their attitudes, they become more engaged in real life and begin to take advantage of various rehabilitative services that are offered. The question of when and how to apply these strategies is described in the volume by Perivoliotis, Grant, and Beck (Perivoliotis et al., in press).
The multifaceted nature of our CT intervention prompts both Bellack and Liberman to wonder about the mechanism of change. In response to Bellack’s concern that it would be impossible to determine the “active ingredients” of the treatment, we propose that the beliefs targeted by the formulation-driven interventions are producing change. Mediation analysis (beliefs as mediators) would allow us to test this hypothesis. Liberman, in a similar vein, proposes several alternative explanations for our results: behavioral methods, social anxiety, positive symptoms, and medication adherence. He also proposes that, since we did not observe changes in alogia, we did not really affect social functioning. In regard of this last point, we think it is notable that the mean alogia ratings were in the questionable to mild range at baseline and remained in this range throughout the course of the trial. This finding suggests that if improvements were made, it is unlikely that they would be clinically meaningful due to a floor effect.
Additionally, it does not seem likely that the global improvement in the patients’ functioning was due to compliance with medication, since previous research has shown minimal impact from medication (Swartz et al., 2007). However, if medication compliance was improved, this would indicate a positive result from our multifaceted intervention. A similar argument extends to positive symptoms and social anxiety. Finally, while it is possible that behavioral methods could be the mechanisms of change in our study, it is also possible that cognitive change is produced by social skills training and cognitive remediation. We think that exploring beliefs in psychosocial treatments for schizophrenia is a rich area to pursue.
Bellack makes three final points regarding the CT treatment: he questions whether it would be possible to “replicate or disseminate the intervention”; he proposes that our data do not support providing more than six months of CT; and he suggests that “all of the changes induced during that early period may have resulted from non-specific effects rather than any specific cognitive therapy activities.” In regard to dissemination, we have already successfully trained masters-level community therapists in the manualized intervention, and have applied for funding to conduct a systematic study. As to the length of treatment, 50 sessions was the average for the entire group in the study: some participants completed therapy in fewer sessions and some required more. Thus, consistent with an individualized recovery orientation, we argue that some patients can benefit from shorter course of therapy whilst others will require more sessions. This is a matter for future study. And, in regard to non-specific factors, the best way to test this alternative hypothesis is to conduct a new study that compares CT to a supportive therapy control group.
Turning to the methods of the study, both authors are concerned about the measurement of functioning in our study. Liberman states that we did not use a well-established and psychometrically sound assessment instrument measuring social functioning for inclusion, while Bellack and Liberman both criticize our outcome measure as inadequate. We did not specifically describe social functioning as a key outcome, but rather global functioning. The Global Assessment Scale (GAS) was a conventional measure of global functioning at the time we initiated our study. Since that time, new measures have been developed, such as the Schizophrenia Objective Functioning Instrument (SOFI; Kleinman et al., 2009), and research by Phil Harvey’s group (Harvey et al., 2011; Leifker et al., 2011) has indicated that the preferred measure of functioning is the Specific Levels of Functioning scale (SLOF; Schneider and Struenging, 1983). In our next study, we plan to use the SLOF as the primary outcome measure.
Liberman proposes that our sample may not have been composed of patients with primary negative symptoms. In other words, the patients in the study had negative symptoms that were secondary to positive symptoms, with the observed improvement in negative symptoms being produced by improvement in positive symptoms. We did not formally assess primary versus secondary negative symptoms in the clinical trial. However, clinically, we observed that defeatist beliefs occurred independently of the presence of positive symptoms. And, as the beliefs were modified by the CT treatment, patients improved.
Finally, Bellack suggests our data do not support the conclusion that “cognitive therapy can be successful in promoting clinically meaningful improvements in functioning.” We disagree with his inference. We believe the intervention, by whatever name, produced successful results, as was evident in the collateral reports factored into the ratings of functioning.
The authors wish to acknowledge the contributions of Drs. Jessica Murakmi-Brundage and Yael Perry in developing this response.
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