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1. A Critical Review of Research on Psychosocial
Treatment of Schizophrenia
John Lauriello, Juan Bustillo, and Samuel J. Keith
In the following review, the evidence for the effectiveness
of the psychosocial treatments of schizophrenia are eval-
uated. Although most studies focus on relapse and hospi-
talization, when available, we present information on
other domains of outcome (e.g., social adjustment and
employment). We begin with family treatments for schizo-
phrenia, then intensive case management, followed by
social skills training, supported employment programs,
and finally, individual psychotherapy. The topics have
been chosen in descending order of available critical
supportive studies. Recommendations for specific psycho-
social interventions (including target populations) are
discussed. Overall psychosocial treatments have been
shown to reduce schizophrenic relapses but have not
convincingly generalized to improving other facets of the
illness. Despite this, psychosocial treatments should be
supported and further research to improve them is neces-
sary. Biol Psychiatry 1999;46:1409–1417 © 1999 Soci-
ety of Biological Psychiatry
Key Words: Schizophrenia, psychosocial treatment, so-
cial skills, expressed emotion, family therapy, cognitive
remediation
Introduction
The 1990s “Decade of the Brain” has seen great
advances in psychiatry including the development of
new treatments for schizophrenia. Most, if not all, of the
enthusiasm centers on the introduction of the “atypical or
novel” antipsychotics. Claims have been made that these
medications improve characteristics of schizophrenia
other than psychosis, including negative symptoms, cog-
nitive deficits, suicidality, and overall functional outcome.
In an era of competition for shrinking health care re-
sources, a financial justification for their higher costs
compared to older antipsychotics is that these medications
reduce expensive hospitalizations for schizophrenic pa-
tients, a group known for their inpatient recidivism.
Despite the promise of the new antipsychotics, full
recovery from schizophrenia is uncommon. In fact, an
early and full recovery casts doubt on the accuracy of a
diagnosis of schizophrenia. Often complete control of
psychosis does not translate to normal social and occupa-
tional functioning. Residual negative symptoms are com-
mon and separate patients with schizophrenia from their
community. Newer antipsychotics are seen as a potential
replacement for the continued role and need for nonbio-
logical “talking” treatments for schizophrenia. Once con-
sidered gold standard treatment for a patient with schizo-
phrenia, the talking or psychosocial treatments are
struggling to be recognized by both clinicians and provid-
ers of care (e.g., managed care groups, fee for service
insurance, and government programs). There are several
possible explanations for this situation. The first is the
belief that schizophrenia is a “brain disorder” and need
only be treated by correcting abnormal brain chemistries.
Second, there is no complimentary body like the Food and
Drug Administration (FDA) that gives a stamp of approval
for a psychosocial therapy and few large multisite studies
of psychosocial treatments with the impact of clinical
pharmaceutical trials. Finally, there have been few, if any,
studies linking the efficacy of psychosocial studies to cost
reductions for the various providers of care.
There have been several excellent recent reviews of
psychosocial treatments of schizophrenia (Bellack and
Mueser 1993; Penn and Mueser 1996). In the following
paper, we review those psychosocial treatments that give
the best evidence of efficacy. Although most studies focus
mainly on relapse and hospitalization, when available, we
present information on other domains of outcome (e.g.,
social adjustment and employment). We begin with family
treatments for schizophrenia, then intensive case manage-
ment, followed by social skills training, supported em-
ployment programs, and finally, individual psychotherapy.
The topics have been chosen in descending order of
available critical supportive studies.
Family Interventions
One historical misconception by the psychiatric field was
the blaming of families as the cause of schizophrenia in
From the University of New Mexico, Department of Psychiatry, Albuquerque, New
Mexico.
Address reprint requests to John Lauriello, MD, University of New Mexico,
Department of Psychiatry, 2400 Marble NE, Albuquerque, NM 87131.
Received September 22, 1998; revised March 29, 1999; accepted April 19, 1999.
© 1999 Society of Biological Psychiatry 0006-3223/99/$20.00
PII S0006-3223(99)00100-6

2. their children. Families were told that their children were
ill because of critical defects in parental bonding. Cur-
rently, biologic predispostions and markers of schizophre-
nia, which are varied and none conclusive alone, argue for
a genetic explanation of familial associations rather than a
psychosocial one (Cardno et al 1999). This does not
dismiss psychosocial factors having a significant role in
the expression and course of the illness. Important exam-
ples of environmental contribution to outcome were seen
in two major prospective multinational studies imple-
mented by the World Health Organization (International
Pilot Study on Schizophrenia and Determinants of Out-
come; Jablensky 1989). These studies found better out-
comes among schizophrenia patients from the under-
developed compared to Western industrialized countries
after accounting for similar clinical presentation, preva-
lence, and incidence. One possible explanation for the
better outcome is a more intact family and community
network of support in less developed countries. A second
explanation lies in the greater vocational demands of a
Western industrialized society compared to a developing,
and possibly, agrarian country. Finally, a greater accep-
tance of psychotic behavior as a normal variant of “ner-
vousness” with less overt criticism by underdeveloped
societies has been suggested. The importance of the last
issue, overt criticism, is a central focus of family research
in schizophrenia.
The significance of family criticism in the outcome of
schizophrenia was crystallized and developed into the
concept of “expressed emotion” (EE) by Brown and Rutter
(1966), in Britain, to explain relapses in adequately med-
icated schizophrenic patients following discharge from the
hospital. Patients who have extensive face-to-face contact
with family members that rated high on critical, hostile, or
over-involved comments (high EE families) had a higher
risk of relapse despite adequate medication compliance
(Leff 1996). The concept of high EE leading to relapse is
neither specific to schizophrenia nor specific to the family
environment. It has been shown in many illnesses (psy-
chiatric and nonpsychiatric), in nonfamily social groups,
and even in treatment approaches that are a source of
continual emotional stress for the patient (Fichter et al
1997; Friedman 1996; Hayhurst et al 1997; Honig et al
1997; Vitaliano et al 1996).
The recognition of the impact of family environment on
relapse led to advances in psychosocial treatments for
schizophrenia. A landmark study in Ventura, California
(Goldstein et al 1978) showed how the addition of a
6-week family therapy component provided significant
protection against relapse regardless of the medication
status of the patient. This benefit was seen at the end of 6
weeks, but perhaps more important, was also present at the
end of 6 months despite the brevity of the therapy. This
particular family therapy focused on teaching families
more effective communication skills and how to more
objectively problem solve disputes with their ill relative.
Several other studies have replicated the beneficial
effects of short term family interventions in families with
high EE (Bellack and Mueser 1996). A subsequent group
of studies addressed the question of whether more sus-
tained family interventions (between 9 and 24 months)
would have a clinically meaningful effect on relapse
prevention during longer follow-up periods (18 to 24
months), compared to standard community care. Six con-
trolled, randomized studies (Falloon et al 1982; Hogarty et
al 1986; Kottgen et al 1984; Leff et al 1982; Randolph et
al 1994; Tarrier et al 1988) have been completed which
meet these characteristics. Five of these (Falloon et al
1982; Hogarty et al 1986; Leff et al 1982; Randolph et al
1988; Tarrier et al 1988) found a clear advantage in
relapse-prevention in favor of family intervention (relapse
ranging between 14% and 33% for family vs. 40% to 83%
for control treatment). The one study that failed to find an
advantage (Kottgen et al) used a psychodynamic approach
that encouraged relatives to voice pent-up feelings and
develop insight into the origins of critical comments
directed towards the patient.
The successful treatments used a combined package
with several common principles: education of families
about schizophrenia, avoid blaming relatives or patient,
support medication compliance, avoid substance abuse,
and decrease stress in the household by improving com-
munication and encouraging family members to extend
their network of social supports. The models used by
Falloon and co-workers (1982) and Tarrier and colleagues
(1988) have, in addition to the general, psycho-educational
approach, a more explicit behavioral orientation (like
stress management, coping skills, and problem solving).
Although the above mentioned studies demonstrate effi-
cacy for relapse prevention, they did not generally focus
on other important outcome measures like social adjust-
ment and quality of life. An exception was Falloon and
Pedeson’s study (1985) that reported after 2 years of
treatment an advantage in “family burden” for the exper-
imental intervention, but no differences in social adjust-
ment.
Although the above mentioned studies demonstrate the
efficacy of family treatment for relapse prevention, ques-
tions still remain regarding which are the “active ingredi-
ents” that predict efficacy. All of these studies (with the
exception of Randolph et al 1994) enrolled patients at high
risk for relapse (residing in a family household rated as
high in EE). The experimental interventions were aimed
toward the reduction of EE, which in turn was hypothe-
sized to correlate with a decrement in relapse. Only three
of these studies (Hogarty et al 1986; Leff et al 1982;
1410 J. Lauriello et al
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3. Tarrier et al 1988) re-assessed EE as an outcome measure
(9 or 12 months later). In all studies, patients who did not
relapse were more likely to reside in a family household
that had changed from high to low EE during the experi-
mental treatment. Nevertheless, the numbers of subjects/
families re-assessed were small and there were no reports
of a clear correlation between reductions in EE and
relapse. Furthermore, it is possible that the high EE
household of a relapsed patient is due to the relapse itself.
Proving a causal role of EE for psychotic relapse would
require a controlled study that included interim EE assess-
ments. We are not aware of such a study.
A third group of studies has compared two or more
family treatments, with the goal of identifying “active
ingredients.” Some studies (Leff et al 1989; McFarlane et
al 1995; Schooler et al 1997) have compared an individ-
ualized single family approach with a less intensive
multifamily group approach. There was no advantage for
the single-family intervention, with 2-year relapse rates
ranging between 16% and 36% (these low rates of relapse
are similar to the positive effects of the studies that
compared family treatment with standard community
care). Actually in one study (McFarlane et al 1995), the
multifamily group had significantly fewer relapses. The
other studies that compared two active interventions also
failed to demonstrate differential efficacy for the experi-
mental family intervention (Lindzen et al 1996; Tarrier et
al 1988; Zastowny et al 1992).
The National Institute of Mental Health (NIMH) Treat-
ment Strategies for Schizophrenia (TSS) Study (Schooler et
al 1997) reported that a simple family intervention and a
more intensive family treatment showed no differences. This
large multi-center study compared an in-home intensive
behavioral family therapy (Falloon and Pedeson 1985) plus
monthly multiple family and patient group meetings to a
“control group” of monthly family and patient group meet-
ings alone. The overall outcome of the study showed no
differences between the intensive (with in-home treatment)
and the monthly group meetings by itself. An important
constraint to interpreting the results is the lack of a “true”
control group that received medication treatment alone.
Without a medication control group, the interventions were
equal but not necessarily proven effective. The fact that the
relapse rates in this study were comparable to earlier family
studies that employed a control group (i.e., low), implies that
both treatments had positive effects. Despite the reduction in
relapse, neither condition showed advantages in terms of
social adjustment at 1 year of follow-up (Keith, unpublished
observation, 1992).
In summary, providing a prolonged (. 9 months) psycho-
educational, supportive family program is an effective inter-
vention for reducing risk of relapse, especially in families that
are overly critical or hostile. The evidence is not compelling
that a more specific, intensive intervention is more effective,
or that there is a positive effect on social adjustment beyond
the effect on relapse. Despite these criticisms, the relapse-
preventing effects of family therapy should be enough to
recommend that this form of treatment be included and paid
for as standard of care treatment.
Assertive Community Training
The treatment of a patient with schizophrenia is often
accomplished utilizing a multidisciplinary team. A team
approach allows the simultaneous delivery of medical
treatment and the social support necessary for these
patients to function in the community. These teams often
include psychiatrists, nurses, social workers, vocational/
rehabilitation therapists, and case managers. Case manag-
ers are critical in this form of treatment, identifying the
needs of the patient and referring the patient to the
provider able to deliver these services. This approach (case
mangers as “brokers”) is often effective for psychiatric
patients with mild to moderate illness severity. Unfortu-
nately, many patients with schizophrenia suffer from
severe cognitive and social deficits and need a more
intense team intervention (increased patient contacts and
hands on coordination of care) to reduce their morbidity.
A notable example of team management and service
delivery is the Assertive Community Treatment (ACT)
program developed by researchers in Madison Wisconsin
in the 1970s (Stein and Test 1980). Patients, most often
severely impaired, including a study of homeless patients
(Lehman et al 1997) are assigned to a multidisciplinary
team (case manager, psychiatrist, nurse, general physician,
etc.) responsible for all the service needs of that patient.
The team has a fixed case-load of patients (with a high
staff to patient ratio 1:12) and is on call 24 hours a day, 7
days a week. A critical component is that the team
operates in both traditional settings (clinics and hospitals)
and in the community. The team can provide home
delivery of medications, monitoring of mental and physi-
cal health, in vivo social-skills training, and frequent
contact with family members.
The results of the original study from Wisconsin (Stein
and Test 1980) compared patients discharged from hospi-
tal assigned to ACT with a group given standard commu-
nity care. After 14 months, the ACT group showed
significant advantages in rates of hospitalization, sheltered
employment, independent living, and family burden.
There was essentially no difference in the cost of treating
each group. Unfortunately, once the patients were dis-
charged from the ACT program the differential advantages
of the program were not maintained.
Mueser and coworkers (1998) have recently completed
an excellent review of the extensive literature on ACT
Psychosocial Treatment of Schizophrenia 1411
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4. programs for the chronically mentally ill. Including the
original Madison study, there are now 30 studies of ACT
(or ACT-like programs) with a true experimental design
that examined effects on various outcome measures. The
most consistent effects were a reduction of time spent in
the hospital (in 14 out of 22 studies) and an improvement
in housing stability (9/11). On the other hand, only a
minority of studies found advantages in social adjustment
(3/14) or employment (3/7), and these were mostly in
sheltered, not competitive employment (see “Supported
Employment”). The disappointing effects on functioning
are perhaps accounted for by the emphasis of ACT in
directly assisting patients with their immediate needs,
without a formal component of rehabilitation (of either
social or vocational skills). One criticism of the ACT
approach is that it often reduces the self-determination of
patients by supporting treatment guardianship and finan-
cial oversight. If a reasonable goal for some patients is
self-sufficiency, a more systematic effort for rehabilitation
may need to be incorporated to ACT.
There are several limitations to the current ACT studies.
There is no data from existing studies that show the
minimal or optimal intensity necessary for a particular
program to maintain its initial gains. In addition, few
studies tease out which subgroups of schizophrenic pa-
tients might maintain their gains, which groups need
booster sessions, and which require continuous support.
ACT is a multidisciplinary, complex treatment that, by
design, incorporates a panel of services. It is unclear if it
is the quantity of services that accounts for its positive
effect on relapse and hospitalization. No study has deter-
mined the relative “quality” significance of its core com-
ponents (i.e., improved medication compliance, continuity
of caregivers, 24 hour coverage, site of service, intensity
of services, therapeutic alliance, or a combination of some
of these elements). It does appear that adherence to the
original ACT model tends to predict better results (Scott
and Dixon 1995). Significantly, in an era of cost con-
sciousness, it is unclear if ACT is more cost effective as
compared to other multidisciplinary team approaches.
In summary, when available, ACT-like programs are an
effective model for providing intensive services to patients
with more severe forms of schizophrenia, which can
reduce relapse and rehospitalizations. This effect may be
especially useful for those patients without families and/or
who are homeless. Once successful, however, further
efforts to foster independence should begin (including
social and vocational skills development).
Social Skills Training
Bellack and Mueser (1993) define social skills as those
“. . . specific response capabilities necessary for effective
social performance.” Despite the positive response pa-
tients with schizophrenia show to medications, most con-
tinue to have significant deficits in these social skills. In
response to these difficulties, rehabilitative approaches
have been designed and tested since the 1980s. Based on
experience of working with physical disabilities, Social
Skills Training (SST) utilizes learning theory in hopes of
improving social functioning. It is a direct approach
working hands on with patients to identify and remediate
problems in activities of daily living, employment, leisure,
and relationships. There are three forms of SST, the basic
model, the social problem-solving model, and the cogni-
tive remediation model.
Basic Social Skills Model
This training often involves severely impaired hospitalized
patients with marked social skill deficits. In this model,
complex social repertoires are broken down into simpler
steps and taught by the therapist modeling the correct
behavior and the patients learning it by repeated practice.
Once the steps are learned, they are assembled and the
patient role-plays the behavior in clinic. Finally, the social
repertoire is practiced and mastered in the natural setting.
The literature supports the effectiveness of the basic
model and has shown a maintenance effect up to 12
months (Bellack and Mueser 1993). Whether this social
mastery leads to gains in other important clinical mea-
sures, i.e., symptom severity and relapse rate is unclear.
Hogarty and co-workers (1986, 1991) compared relapse
rates at 12 and 24 months for schizophrenic outpatients
assigned to antipsychotic medications or antipsychotic
medication plus SST. At 1 year of follow-up, there was a
significant difference in the relapse rate of the SST group
plus drug compared to the medication alone group (30%
versus 46%) (Hogarty et al 1986). While the original
intention of the study was to taper SST to biweekly after
the first year, in reality, weekly treatment continued for 21
months. The researchers decided to provide a biweekly
treatment in the final 3 months to prepare for termination.
The superiority of the SST plus drug lasted only as long as
the weekly intervention was in place and could not be
sustained in a biweekly fashion.
For psychosocial interventions in general, and basic
SST in particular, “booster” sessions or continuous treat-
ment may be required in order to maintain a favorable
effect on relapse rates. Despite the benefits of SST in the
Hogarty study, SST failed to demonstrate a significant
impact on social adjustment. The lack of generalization to
social adjustment in this and other studies using the basic
model has been a major limitation (Bellack and Mueser
1993). To improve this problem, the addition of problem-
solving techniques to the basic SST model has been
developed.
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5. Social Problem-Solving Model
The social problem solving model focuses on improving
impairments in information processing that are assumed to
be the cause of social skills deficits. It shares with the
basic SST model an identification of complex behaviors,
which are broken down and corrected. The model targets
those domains needing changes including medication and
symptom management, recreation, basic conversation, and
self-care. Each module is taught to correct deficits in
receptive learning and processing and sending skills. The
goal is to make the patients learn to be more flexible and
able to generalize the skills to novel problems they might
encounter. In a study by Marder and colleagues (1996)
outpatient schizophrenic patients either received problem-
solving group therapy or supportive group therapy. Out-
come measures were rate of relapse and overall level of
social adjustment in outpatient schizophrenia treatment.
Both groups received the same intensity, frequency, and
overall length of intervention, an important methodologi-
cal refinement, which supports the specificity of any
experimental effects. There was only a small but statisti-
cally significant advantage for the problem-solving inter-
vention in two out of six measures of social adjustment
after 2 years. There were no differences in relapse rate.
Thus the study showed only modest benefits of a social
problem-solving therapy.
More recently Lieberman and coworkers (1998) pre-
sented results of the same outpatient problem-solving
group model compared to equally intensive occupational
therapy in 80 male veterans with schizophrenia. Subjects
received the psychosocial interventions for 6 months (3
hours/day, 4 times a week) and were followed for 2 years.
Although this trial was randomized and assessments of
social adjustment were blind to treatment assignment,
medication was not controlled and relapses were not
assessed. There was evidence of effectiveness of the
experimental condition in independent living skills (more
personal possessions, more skilled food preparation, and
money management) assessed through interview, which is
suggestive of generalization of some of the skills learned.
This effect was maintained even 18 months after complet-
ing the intervention. Lieberman and colleagues (1998)
posit that the effect on independent living skills suggests
generalization of skills learned. They explain this effect on
the fact that all subjects were assigned a case manager
(broker model) who actively encouraged them to apply the
skills learned in the community.
Cognitive Remediation
Patients with schizophrenia have a variety of cognitive
impairments (Braff 1993). The cognitive impairments are
generalized affecting attention, memory, and planning
most significantly. The hope of cognitive remediation is to
identify specific cognitive deficits that are the underlying
cause of poor social skills functioning. If the underlying
cognitive impairment can be improved then social skills
can be better taught and social competence should im-
prove globally. One area of cognitive remediation receiv-
ing attention is the are of vigilance and planning. Patients
can be taught skills to improve performance in these
domains. However, these new skills are limited to the tests
practiced and have not generalized to even similar tests, let
alone used to improve social competence. The best exam-
ple of cognitive remediation and its use in social skills
training is the Integrated Psychological Treatment (Bren-
ner et al 1992) for schizophrenia developed by Swiss
researchers. Patients attend a group three times a week for
3 months. They use computer games to improve card
sorting and concept formation in a phase termed the
“Cognitive Differentiation Subprogram.” This is followed
by social problem-solving exercises in the “Social Percep-
tion and Verbal Communication Subprograms” phases.
Finally, “Social Skills and Interpersonal Problem-Solving
Subprograms” resembling traditional social skills training,
is taught. The controlled studies of Integrated Psycholog-
ical Treatment in schizophrenia show some improvement
in cognition and social skills but did not predict which
specific social skills could be better learned. There have
been no studies that assess its effect on symptoms, social
adjustment, or competence.
In summary, all forms of SST can improve social
competence in the laboratory and the clinic. The problem-
solving approach may also have an effect on social
adjustment, but its clinical significance is not clear. Ther-
apeutic effects have been demonstrated for some SST
programs in clinical measures like relapse rate, but due to
the limited durability “booster” sessions may be required.
There is no evidence that patients that learn social skills
are more likely to become competitively employed.
Supported Employment
A devastating element of schizophrenia is its profound
effects on occupational functioning. Once a patient pre-
sents with the illness the chances of his or her returning to
previous employment is greatly reduced. Many patients
are stricken with the illness before any work history can
begin. Historically, work has taken on a therapeutic value
for those with schizophrenia. An important element of
humane treatment of the mentally ill was to provide
protected work environments. The concept of employment
as therapy continues today with mixed success. Programs
have been implemented to train, find, and maintain jobs
for schizophrenic patients. Despite these efforts, the rate of
competitive employment for chronic mentally ill patients
Psychosocial Treatment of Schizophrenia 1413
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6. is less than 20%, and lower for those with schizophrenia
(Lehman 1995). This low rate can be explained by a
number of things including the underlying illness, stigma
against hiring those persons with known mental illness,
and disincentives by the government support programs
that discourage working by terminating all benefits.
Most vocational therapies are outpatient based since
hospitalizations are now of short duration. Measures of
successful outcome include earnings, job performance,
and percentage of time employed. However, the gold
standard goal is full-time competitive employment. Unfor-
tunately, most vocational rehabilitation has only suc-
ceeded in helping schizophrenic patients in program-
owned transitional or sheltered employment and not
succeeded in obtaining and keeping regular jobs (Lehman
1995).
Growing out of the limitations of sheltered employment
is the concept of supported employment. Here, the patient
is referred to an outside regular job that is intended to be
permanent. The patient’s strengths are determined and a
job suitable to those skills is found. There is minimal
screening by the vocational rehabilitation professional and
no prevocational training. The patient learns the specific
skills for the job while receiving on the job training and
support from a job coach.
Evidence has been accumulating and provides a
hopeful outlook for supported employment programs.
To date, six randomized controlled studies of supportive
employment for persons with chronic mental illness
(between 35% and 66% diagnosed with schizophrenia)
have been completed and recently reviewed by Bond
and coworkers (1997). The unweighted mean rate for
obtaining competitive employment was 58% for the
supported employment programs compared to 21% for
traditional vocational rehabilitation programs, and all
studies favored the experimental condition. There was
no evidence for improvement (or worsening) on clinical
measures. Unfortunately, patients were not very suc-
cessful in keeping the competitive employment beyond
weeks or months (between 41% and 71% terminate a
supported employment placement within 6 months.
In summary, sheltered vocational programs enhance
job-related activities but do not extrapolate to competitive
employment. Supported employment programs signifi-
cantly increase competitive employment (without worsen-
ing relapse rates) but the effects are relatively short lived.
The demands of competitive employment are one area that
exposes both the severity of the illness and the limitations
of current treatments. A recommendation that would
improve employment would be to allow patients with
schizophrenia to work to their optimal capacity without
any fears of losing their government entitlements. This
view acknowledges the value of work but also the chronic
and intermittent course and stresses patients with schizo-
phrenia encounter.
Individual Psychotherapy
Prior to the 1960s individual dynamic psychotherapy was
seen as the gold standard treatment for all mental illness,
including schizophrenia. The first test of this assumption was
conducted at Camarillo State Hospital by May (1968). Five
options: antipsychotic medication alone, antipsychotic med-
ication plus individual psychotherapy, individual psychother-
apy alone, ECT, and milieu alone were compared. To some
surprise, the medication arms proved superior, ECT was
intermediate, and therapy or milieu faired the poorest. The
psychiatric establishment criticized the study for taking place
in a state hospital with “inexperienced therapists,” inadequate
intensity (only twice a week), and not following the patients
into the community. Responding to these criticisms, a study
was conducted in the 1980s at McLean Hospital and Boston
University (Gunderson et al 1984) comparing insight-ori-
ented psychotherapy with a once a week supportive therapy.
The study used therapists with more than 3 years of experi-
ence with insight-oriented psychotherapy with schizophrenic
patients and provided intensive therapy three times a week
with treatment that continued into the community. The results
were quite striking: the sicker patients in the intensive
psychotherapy dropped out but those as severely ill in the
supportive group stayed in that treatment. Even though the
supportive group was sicker after this attrition, the outcome
measures still favored the supportive group. The results of
this study effectively eliminated intensive psychodynamic
psychotherapy for most patients with schizophrenia.
The techniques described earlier in this paper for
cognitive remediation focus on improving faulty cognitive
processes. Recently, there has been an interest in another
form of psychotherapy, cognitive-behavioral therapy
(CBT) for schizophrenia. In this paradigm, the therapy
focuses on the content of the symptoms. In Great Britain,
a treatment called “coping strategy enhancement” (Tarrier
et al 1993) has been developed for unremitted psychotic
symptoms. The patient is taught distraction techniques to
help ignore their psychotic symptoms. Initial reports
suggest an improvement in delusions that could be main-
tained for only 6 months and did not generalize to other
symptoms or improve social functioning (Tarrier et al
1993). A related approach, following the use of CBT for
depression, utilizes a systematic verbal challenge to the
prevailing delusional belief (Chadwick et al 1994). This is
followed by a “behavioral experiment” contradicting the
delusion (reality-testing) that reinforces the verbal chal-
lenge. While there has been success with delusions,
chronic hallucinations seem particularly resistant to CBT.
One possible explanation is that the continued internal
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7. stimuli overwhelm any verbal or external challenge. A
recent approach focuses on the meaning of the hallucina-
tions to allow the patient to see that the voices are a
product of his or her own mind (Bentall et al 1994). These
CBT studies are preliminary, and need replication in well
controlled larger samples.
Hogarty and co-workers (1997a, b) recently published
the results of their 3-year randomized trial of individual
personal therapy (PT) for schizophrenia compared to
family therapy combined treatment and supportive ther-
apy. Personal therapy was conducted weekly for 30 to 45
minutes. The therapy followed an incremental approach
individualized for the patients’ stage of recovery. The
initial phase focused on the relationship between stress
and symptoms; the intermediate phase emphasized learn-
ing to use relaxation and cognitive reframing techniques
when stressed, while the advanced phase (which generally
started 18 months into treatment) focused on seeking
social and vocational initiatives in the community. Social
adjustment (a composite measure including work perfor-
mance, leisure, interpersonal relationships, etc.) clearly
favored the PT group (the greatest differential improve-
ment took place in the last 2 years of treatment). However,
there were no advantages in relapse for PT (relapse rates
were very low, only 29% in 3 years). This study incorpo-
rated several methodological refinements including two
aspects particularly relevant to the assessment of adjust-
ment: 1) the social adjustment measure was derived from
various sources: patient interview, therapist assessments,
and relatives’ perception, which argues for its validity; and
2) the confounding effects of relapse on adjustment were
minimized by reentering relapsed patients into their orig-
inal treatment conditions on recovery. Limitations were
that 40% of patients assigned to PT did not move on to the
advanced phase of therapy and that adjustment ratings
were not blind to treatment conditions.
The recent promise of individual psychotherapy for
patients with schizophrenia brings us nearly full circle
back to the pre-antipsychotic days. An important advance-
ment of the past 30 years is the acceptance of antipsy-
chotic medication as the preeminent treatment. Our
present use of individual psychotherapy focuses on im-
proving cognitive strategies, not the understanding of the
unconscious meaning of the patient’s illness and symp-
toms. Further study and refinement of psychotherapy for
schizophrenia may provide a promising avenue of therapy
for patients.
Conclusions
By definition, schizophrenia is a chronic illness with
profound effects on an individual’s level of function.
Medications have improved many of the overt symptoms
of the illness but often leave the core underlying deficits
untouched. Even when these deficits improve, many pa-
tients must be trained in skills that they never learned or
were lost because of the illness. The challenge for the
psychosocial treatments is to show significant and endur-
ing gains in the very symptoms that appear the most
resistant to medication. Our review highlights some of the
potential benefits of psychosocial treatment, but also the
limited gains reported and the incomplete research for
some modalities.
One recommendation that is clear from our review is
that working with families shows strong benefits, specif-
ically in reducing relapses. This is true regardless of
whether there are identifiable conflicts among the family.
All families that are involved with a schizophrenic patient
should be included in a psycho-education program. The
family interventions can be simple monthly meetings and
do not demand intensive in-home therapy. Multiple studies
show superiority of family therapy compared to no psy-
chosocial intervention but no one family therapy has been
proven superior to another active intervention. More
sophisticated programs may not provide significant added
benefit. Optimistically, this means simple interventions
are good enough, pessimistically, there has been little
successful evolution in differentiating or improving family
therapies. Further research is needed to determine new
ways of administering family therapy and may include
developing a sophistication in computer programming and
interactive networking.
A multidisciplinary team approach for the illness also
seems to be a recommended mode of service delivery,
especially in frequently relapsing patients with few social
supports. Previous reviews have confirmed the efficacy of
assertive community outreach, especially in terms of
improving treatment compliance and reducing relapses.
However, the team must guard itself from fostering an
overdependence by the patient and balance improved
compliance with encouraging greater independent func-
tioning.
Developing greater independence is an area of great
promise. Cognitive remediation through social skills and
targeted cognitive behavioral treatments holds promise but
needs more investigation. Almost all patients with schizo-
phrenia have some social skill deficit and a complete
evaluation of the patient should include their social
strengths and weaknesses. As with other psychosocial
treatments, positive effect, especially in psychotic relapse,
can be achieved but only as long as the intervention is
applied. Unfortunately, the current studies do not show a
generalization beyond the specific deficit the skill is taught
to improve. New research is needed to understand both the
underlying social and cognitive deficit and determine how
to develop an enduring correction.
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1999;46:1409–1417

8. Supportive employment holds the promise of tangible
improvements in patients’ functioning but the results have
been modest. Patients can be employed in supportive
employment programs but few can translate this to com-
petitive work. Some are too ill to sustain the concentration
needed to work. Social impediments to hiring the mentally
ill and the risk of losing precious government benefits are
also important factors. Research in social and cognitive
development must include a vocational component, and
community attitude about hiring mentally ill must be
understood and misconceptions corrected.
Finally, there has been resurgence in individual psycho-
therapy that is more problem solving in nature and not
psychodynamically oriented. The studies are preliminary
and need to be continued and designed in a double blind
fashion, if possible. Also, the cost effectiveness of such
interventions must be determined so that funding for
efficacious therapies is available.
Thus, as we complete the decade of the brain, there have
been accomplishments in both our biologic understanding
and treatment of schizophrenia but also an appreciation of
the merits of the talking or psychosocial disciplines.
Psychosocial treatment must continue to evolve and refine
its active ingredients. To counter the prevailing notion that
medications alone are adequate, psychiatrists cannot be
satisfied with just a quiet patient. Recovery to the fullest
extent must be sought and should include issues of
developing social relationships and gainful employment.
Psychosocial treatments may be the answer to developing
these last two areas.
This work was presented at the conference, “Schizophrenia: From
Molecule to Public Policy,” held in Santa Fe, New Mexico in October
1998. The conference was sponsored by the Society of Biological
Psychiatry through an unrestricted educational grant provided by Eli
Lilly and Company.
References
Bellack AS, Mueser KT (1993): Psychosocial treatment for
schizophrenia. Schizophr Bull 19:317–336.
Bentall RP, Haddock G, Slade PD (1994): Cognitive therapy for
persistent auditory hallucinations: From theory to therapy.
Behav Ther 25:51–66.
Bond GR, Drake RE, Mueser KT, Becker DR (1997): An update
on supported employment for people with severe mental
illness. Psychiatr Services 48:335–346.
Braff DL (1993): Information processing and attention dysfunc-
tions in schizophrenia. Schizophr Bull 19:233–254.
Brenner H, Hodel B, Roder V, Corrigan P (1992): Treatment of
cognitive dysfunctions and behavioral deficits in schizophre-
nia. Schizophr Bull 18:21–26.
Brown GW, Rutter M (1966): The measurement of family
activities and relationships: A methodological study. Hum Rel
19:241–263.
Cardno AG, Marshall J, Coid B, et al (1999): The heritability
estimates for psychotic disorders. The Maudsley twin psy-
chosis series. Arch Gen Psychiatry 56:162–168.
Chadwick P, Lowe C, Horne P, Higson P (1994): Modifying
delusions: The role of empirical testing. Behav Ther 25:35–
49.
Falloon IR, Boyd JL, McGill CW, Razani J, Moss HB, Gilder-
man AN (1982): Family management in the prevention of
exacerbations of schizophrenia. A controlled study. N Engl
J Med 306:1437–1440.
Falloon IR, Pedeson J (1985): Family management in the
prevention of morbidity of schizophrenia: the adjustment of
the family unit. Br J Psychiatry 147:156–163.
Fichter MM, Glynn SM, Weyerer S, Liberman RP, Frick U
(1997): Family climate and expressed emotion in the course
of alcoholism. Family Process 36:203–221.
Friedman EH (1996): Neurobiology of anger-hostility and coro-
nary risk. Psychother Psychosom 65:222.
Goldstein MJ, Rodnick EH, Evans JR, May PRA, Steinberg MR
(1978): Drug and family therapy in the aftercare of acute
schizophrenics. Arch Gen Psychiatry 35:1169–1177.
Gunderson JG, Frank AF, Katz HM, Vannicelli AL, Frosch JP,
Knapp PH (1984): Effects of psychotherapy in schizophrenia:
II. Comparative outcome of two forms of treatment. Schizo-
phr Bull 10:564–584.
Hayhurst H, Cooper Z, Paykel ES, Vearnals S, Ramana R
(1997): Expressed emotion and depression. A longitudinal
study. Br J Psychiatry 171:439–443.
Hogarty G, Anderson C, Reiss D, et al (1986): Family psycho-
education, social skills training and maintenance chemother-
apy in the aftercare treatment of schizophrenia: I. One-year
effects of a controlled study on relapse and expressed emo-
tion. Arch Gen Psychiatry 43:633–642.
Hogarty G, Anderson C, Reiss D, et al (1991): Family psycho-
education, social skills training and maintenance chemother-
apy in the aftercare treatment of schizophrenia: II. Two-years
effects of a controlled study on relapse and adjustment. Arch
Gen Psychiatry 48:340–347.
Hogarty GE, Greenwald D, Ulrich RF, et al (1997b): Three-year
trials of personal therapy among schizophrenic patients living
with or independent of family, II: Effects on adjustment of
patients. Am J Psychiatry 154:1514–1524.
Hogarty GE, Kornblith SJ, Greenwald D, et al (1997a): Three-
year trials of personal therapy among schizophrenic patients
living with or independent of family, I: Description of study
and effects on relapse rates. Am J Psychiatry 154:1504–1513.
Honig A, Hofman A, Rozendaal N, Dinemans P (1997): Psycho-
education in bipolar disorder: Effect on expressed emotion.
Psychiatr Res 72:17–22.
Jablensky A (1989): Epidemiology and cross-cultural aspects of
schizophrenia. Psychiatr Ann 19:516–524.
Kottgen L, Sonnichsen I, Mollenhauer K, Jurth R (1984): Group
therapy with the families of schizophrenic patients: Results of
the Hamburg Camberwell-Family interview study III. Int J
Fam Psychiatry 5:84–94.
Leff J (1996): First perceptions of treatment: The physician–
family–patient network. J Pract Psychiatr Behav Health
2:10–15.
1416 J. Lauriello et al
BIOL PSYCHIATRY
1999;46:1409–1417

9. Leff J, Berkowitz N, Shavit N, Strachan A, Glass I, Vaughn C
(1989): A trial of family therapy v. a relatives group for
schizophrenia. Br J Psychiatry 154:58–66.
Leff J, Kuipers L, Berkowitz R, Eberlein-Vries R, Sturgeon D
(1982): A controlled trial of social intervention in the families
of schizophrenic patients. Br J Psychiatry 141:121–134.
Lehman A (1995): Vocational rehabilitation in schizophrenia.
Schizophr Bull 21:645–656.
Lehman AF, Dixon L, Kerman E, DeForge BR, Postrado LT
(1997): A randomized trial of assertive community treatment
for homeless persons with severe mental illness. Arch Gen
Psychiatry 54:1038–1043.
Lieberman RP, Wallace CJ, Blackwell G, Kopelowicz A, Vac-
caro JV, Mintz J (1998): Skills training versus psychosocial
occupational therapy for persons with persistent schizophre-
nia. Am J Psychiatry 155:1087–1091.
Lindzen D, Dingemans P, Van Der Does JW, et al (1996):
Treatment, expressed emotion and relapse in recent onset
schizophrenic disorders. Psychol Med 26:333–342.
Marder SR, Wirshing W, Mintz J, et al (1996): Two-year outcome
of social skills training and group psychotherapy for outpatients
with schizophrenia. Am J Psychiatry 153:1585–1592.
May PRA (1968): Treatment of Schizophrenia: A Comparative
Study of Five Treatment Methods. New York: Science House.
McFarlane WR, Lukens E, Link B, et al (1995): Multi-family
groups and psychoeducation in the treatment of schizophre-
nia. Arch Gen Psychiatry 52:679–687.
Mueser KT, Bond GR, Drake RE, Resnick SG (1998): Models of
community care for severe mental illness. Schizophr Bull
24:37–74.
Penn DL, Mueser KT (1996): Research update on the psychos-
ocial treatment of schizophrenia. Am J Psychiatry 153:607–
617.
Randolph ET, Glynn SM, Paz GB, et al (1994): Behavioral
family management in schizophrenia: Outcome from a clinic-
based intervention. Br J Psychiatry 144:501–506.
Schooler NR, Keith SJ, Severe JB, et al (1997): Relapse and
rehospitalization during maintenance treatment in schizophre-
nia. The effects of dose reduction and family treatment. Arch
Gen Psychiatry 54:453–463.
Scott J, Dixon L (1995): Assertive community treatment and case
management for schizophrenia. Schizophr Bull 21:657–668.
Stein L, Test MA (1980): An alternative to mental hospital
treatment: I. Conceptual model, treatment program and clin-
ical evaluation. Arch Gen Psychiatry 37:392–399.
Tarrier N, Barrowclough C, Vaughn C, et al (1988): The
community management of schizophrenia. A controlled trial
of behavioral intervention with families to reduce relapse.
Br J Psychiatry 153:532–542.
Tarrier N, Beckett R, Harwood S, Baker A, Yusopoff L,
Ugareburu I (1993): A trial of two cognitive-behavioral
methods of treating drug-resistant psychotic symptoms in
schizophrenic patients, I: Outcome. Br J Psychiatry 162:524–
532.
Vitaliano PP, Scanlan JM, Krenz C, Fujimoto W (1996): Insulin
and glucose: Relationships with hassles, anger and hostility in
nondiabetic older adults. Psychosom Med 58:489–499.
Zastowny TR, Lehman AF, Cole RE, Kane C (1992): Family
management of schizophrenia: A comparison of behavioral
and supportive family treatment. Psychiatr Q 63:159–186.
Psychosocial Treatment of Schizophrenia 1417
BIOL PSYCHIATRY
1999;46:1409–1417