Therapy

Between one-fifth and one-third of all patients with schizophrenia do not respond adequately to drug treatment. Many patients who have been successfully treated with medications experience the "awakenings" phenomena, which are painful reactions that are manifested as inner emotions and the recognition of real losses. The effects of the disease, in any case, are profoundly emotional and psychological therapies can be helpful for many patients.

Cognitive-Behavioral and Other Psychosocial Therapies

The use of cognitive-behavioral therapy is showing particular promise for improvement in both positive and negative symptoms in some patients, and the benefits may persist after treatment has stopped. This approach attempts to strengthen the patient's capacity for normal thinking using mental exercises and self-observation. Patients with schizophrenia are taught to critically analyze hallucinations and examine underlying beliefs in them.

In a 2000 study, for example, patients underwent the following process:

• In order to think analytically about the origins and the nature of their auditory hallucinations they kept a diary of the nature of the voices and the times they were heard.
• They were then taught ways of coping with the voices.
• Patients also learned to think objectively about the source of their delusions and to find the links between thoughts that jumped from topic to topic.
• After the patients gained some mastery over positive symptoms, the therapist worked on negative symptoms.
• The patients received an average of 19 individual sessions over 9 months. At a follow-up period of 9 months, patients continued to improve. (A comparison group of patients who received so-called befriending therapy, which involved empathy and non-directed support, also improved during treatment, but did not get better after treatment stopped.) Another interesting behavioral approach used memory exercises to correct verbal deficits.

In another 2002 study, training in social and interpersonal skills using behavioral methods resulted in improvement in functioning, relationships, and overall adjustment.

Not all psychosocial interactions are helpful and some can even endanger the patient. For example, brief education intervention that is not extensive or therapeutic enough to lead to behavioral change may increase suicidal thoughts.

Family and Outside Support Structures

Positive social interaction is extremely important for people with schizophrenia and may help reduce symptoms, including the number of delusional moments.

Family Support. It is deeply painful for anyone to interact with a loved one whose behavior is determined by a mysterious internal mechanism that has gone awry. Given support and direction, however, families or other caregivers can be very helpful in a number of ways:

• They can encourage patients to comply with drug treatments and to recognize early signs of serious treatment side effects.
• They can be taught to recognize impending symptoms of relapse and help the patient avoid situations that might trigger them. (Symptoms for an impending relapse after remission may include feeling distant from family and friends, being increasingly bothered by persistent thoughts, and having an increased interest in religion.)

Unfortunately, the family's own mental health is often threatened and they need help almost as much as the patient. Numerous studies have shown that patients with schizophrenia do worse in families who are too emotional, hostile, critical, or even overly involved. The problem is an emotional loop:

• When affection and reason have failed to bring a loved one back to reality, overly critical or emotional family members typically react with anger and frustration.
• This generates anxiety and depression in patients.
• The subsequent expression of these emotions by the patient triggers yet more criticism or acting out. So the cycle continues.
• Eventually, out of despair and fear, the family may reject the patient completely.

Studies indicate that once the patient receives appropriate treatment and support, the family's over-emotional state also recedes. And, two studies reported that when families received help for themselves (group support or cognitive therapy) the relapse rates for the related patients were significantly lower than for patients whose families did not seek help. For example, when families received cognitive therapy, the patient relapse rate was 37% versus 72% in the group without family support. Still, fewer than 10% of families of patients with schizophrenia receive the support and education needed not only for the patient but also for themselves.

Community Treatment Programs. Community treatment programs, in which a team of professional caregivers provides treatment and support for patients in their homes, is highly beneficial and cost effective (compared to frequent hospitalization). At this time, however, only between 2 - 10% of patients now participate in such programs.

Vocational Rehabilitation. Paid work is very important in the health of the patient. One study reported that after 1 year, 40% of workers with schizophrenia who were paid for their labor reported much improvement in all symptoms, and 50% reported much improvement in positive symptoms. Those who were not paid for their work did considerably less well. (The arts and crafts activities that are often used to enhance self-esteem in rehabilitation programs offer few real benefits to the patient.)

Unfortunately, at this time, less than a quarter of patients with schizophrenia are in programs that assist them in finding and keeping jobs, and up to 90% of patients with severe mental problems are unemployed.