Rehab Rounds

An Integrated Psychological Treatment

Program for Schizophrenia
Oscar Vallina-Fernndez, Ph.D.
Serafin Lemos-Girldez, Ph.D.
Volker Roder, Ph.D.
Ana Garca-Saiz, R.N.
Aurora Otero-Garca, R.N.
Marta Alonso-Snchez, R.N.
Ana Maria Gutirrez-Prez, R.N.

Introduction by the column editors:

A solid body of evidence indicates
that therapy programs that combine neuroleptic medication with
behavioral intervention are more
effective in reducing relapse and
improving psychosocial functioning than those that use medication
alone to treat schizophrenia (1,2).
Although researchers have moved
away from a biologically simplistic
to a multifactorial approach to
treating schizophrenia, current
practice guidelines are rarely implemented at the clinical level.
One limiting factor in the dispersion of combined medication and
psychosocial programs has been
the lack of replicable and manualized psychosocial treatments that
can be readily implemented by
line-level clinicians.
One example of a manualized
cognitive-behavioral treatment
program for schizophrenia is integrated psychological therapy (IPT)
(3). Operating on the assumption
that patients with schizophrenia
have cognitive dysfunctionsfor
All of the authors are at the Sierrallana
Hospital in Torrelavega (Cantabria),
Spain, except Dr. Roder, who is with the
department of psychiatry at the University of Bern, Switzerland. Send correspondence to Dr. Lemos, Universidad de
Oviedo, Facultad de Psicologa, Plaza Feijo, s/n, 33003 Oviedo, Spain (e-mail, slemos@correo.uniovi.es). Alex Kopelowicz, M.D., and Robert Liberman, M.D.,
are editors of this column.

PSYCHIATRIC SERVICES

example, in social perceptionas

well as deficits in social and problem-solving skills, IPT offers remediation of all of these deficits in
group or individual settings. In
this report on the impact of IPT in
Spain, its combined value with behavioral family therapy is highlighted in a country other than
where the intervention was initially designed and tested.

PT comprises subprograms for remediating deficits in five areas: cognitive differentiation, social perception, verbal communication, social
competence, and interpersonal problem solving. The first two concentrate
on the basic cognitive functions; the
others proceed to the more complex
tasks of helping participants acquire
social and problem-solving skills once
they have succeeded in improving
their basic cognitive functions.
Each subprogram uses gradual increases in learning demands over the
course of therapy. In addition, the programs initial structure and task orientation gradually give way to greater
emphasis on spontaneous group interaction. With the aim of developing the
participants ability to deal adequately
with emotions and affects, the initial
exercises in each subprogram contain
neutral material that is assumed not to
be stressful. As therapy progresses,
emotionally loaded material is gradually introduced.
IPT has been used for persons with
schizophrenia in many countries, including Switzerland, Germany, Aus-

September 2001 Vol. 52 No. 9

tria, Chile, Japan, the United States,

and others. In this article, we present
our experience with group training
with four of the five subprograms
cognitive differentiation was not includedcombined with a family psychoeducation approach targeting both
patients and family members, in the
Spanish province of Cantabria.

Description
Subprograms of the integrated therapy package were implemented in separate groups of four to seven persons
with schizophrenia or of their families
for 12 months; follow-up assessments
were made nine months later. The intervention program and the follow-up
sessions took place in 1997 and 1998.
The groups were held in the psychiatric outpatient department of a general hospital sponsored by the National Health System.
Patients relatives attended, on average, 31 sessions in the first year, in four
stages. For the first ten weeks, relatives
attended weekly, hour-long psychoeducation sessions. (A list of the topics of
these sessions and examples of concerns expressed by family members is
available from the authors.) The sessions were organized to facilitate interactions between trainers and family
members and among family members.
This approach allowed a variety of experiences and viewpoints to be presented, which promoted group discussion.
Family members also were provided a
written guide, available in Spanish from
the authors, that included basic information about schizophrenia.
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Subsequent elements of the family

intervention were designed to train
the relatives in verbal communication
(three meetings), problem-solving
(nine meetings), and coping skills
(nine meetings). These sessions were
modeled on family psychoeducation
programs that have been shown to reduce family burden and stress levels
(4,5). The therapeutic method for
each meeting was highly structured
and organized and used several behavioral techniquesinstructions, rehearsal, modeling, social reinforcement, in vivo tasks, and homework. (A
list of topics for each group is available
from the authors.) All training sessions
were conducted in a group format,
without the presence of the ill relative.
In parallel with the program for
family members, an integrated therapy program for persons with schizophrenia was developed that combined
a psychoeducation approach with four
of the subprograms of the IPT (3). Its
purpose was to promote engagement
and self-management of illness and to
treat the cognitive and social deficiencies of schizophrenia. Before beginning the subprograms, patients participated in four group sessions that concentrated on psychoeducation and
used the same content and format as
the family sessions.
Ten sessions were designed to inculcate more accurate social perception.
In these sessions a set of 30 slides
(three per session) depicting one or
more persons was used in a three-step
processperception of the stimulus,
adequate interpretation, and correct
response. In the first step, the therapist directed participants attention to
the relevant details of the picture. By
highlighting the setting, the objects,
and the expressions on peoples faces,
this subprogram aimed to improve
participants apprehension and interpretation of social situations. In the interpretation phase, participants were
asked to focus on three questions:
What does the picture mean? How
can you justify your interpretation?
What do the other group members
think about this interpretation? The
therapist encouraged and reinforced
the various points of view generated by
group members that were relevant to
understanding the social content of
the picture.
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The verbal communication subprogram consisted of ten sessions of literal repetition and paraphrasing with
question-and-answer exercises. This
subprogram aimed to improve participants competence in three basic communication skills: listening, understanding, and responding to communications from others. The steps used to
accomplish these goals were literal
repetition of sentences; paraphrasing
or making up sentences with words
that would be appropriate in everyday
conversation; forming questions with
words such as where, when,
who, and why; asking questions
about themes decided on by the
group or the therapist, such as newspaper headlines, weekend activities,
and recent experiences; periodically
summarizing the information presented; and coaching participants in
paralinguistic and nonverbal aspects
of communication, including eye contact and voice tone and volume. Informative feedback and immediate
social reinforcement were important
in each phase, particularly if lowfunctioning group members were reluctant to participate.
The next subprogram comprised 24
sessions that were focused on social
skills training and used techniques
such as role-playing and assertiveness
training. These sessions started with
emotionally neutral and low-risk situations often encountered in everyday
life, such as starting a conversation,
thanking others, giving a compliment,
or getting information. Gradually the
emotional content and degree of risk
involved in these sessions increased
for example, making requests for behavior change, making an apology, or
starting a common venture. The first
step was to set up the role playto introduce it, define a title, prepare a dialogue, discuss anticipated difficulties,
assign observation tasks, and rate the
perceived level of difficulty. Then the
role play was enacted: the co-therapists demonstrated the role play and
conducted a feedback discussion, and
then group members reenacted the
role play and participated in a feedback discussion followed by in vivo exercises. Homework exercises at the
end of each session were assigned to
help group members generalize these
social skills to real-life situations.

The fourth subprogram, interpersonal problem solving, consisted of

nine behaviorally oriented sessions
that addressed personal problems
identified by group members (6). The
goal of the subprogram was to train
participants to solve complex problems by transforming them into simpler, clearer problems of more manageable proportions and using realistic
alternatives or solutions.

Evaluation
The program was implemented with
28 outpatients who met ICD-10 diagnostic criteria for schizophrenia and
who lived in a family setting. Their
meanSD age was 31.55.44 years,
and their mean duration of illness was
7.912.57 years; 70 percent were
male. Symptoms and community functioning were assessed by blinded
raters and by patient self-report at
baseline, after the intervention, and at
nine-month follow-up.
This groups results were compared
with those of 18 outpatients with schizophrenia who received standard treatment, which consisted of information
about schizophrenia and medication
supervision. The meanSD age for
this group was 30.04.64 years, and
their mean duration of illness was
8.642.60 years; 80 percent were
male. All participants were on stable
regimens of antipsychotic medications
at the time of initial testing. At baseline, participants did not differ significantly in demographic and clinical
variables or in symptoms or community functioning.
Participants in the IPT group
demonstrated significant improvement
in symptoms and community functioning over time, whereas control subjects
did not show significant changes on
these measures over time. The significant improvements in the IPT group
were also apparent at the nine-month
follow-up. (A more detailed description of the empirical evaluation is available from the authors.)

Case vignette
Mr. R was a 37-year-old man who,
since separating from his wife several
years earlier, had lived with his mother
and stepfather. He had been diagnosed at age 26 as having paranoid
schizophrenia, manifested by persecu-

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September 2001 Vol. 52 No. 9

tory delusions toward his mother, his

former wife, and several neighbors,
leading to several psychiatric hospitalizations. Since he first developed
symptoms, Mr. R had not worked or
maintained any peer relations. Family
relations were difficult, as he displayed
verbal and physical violence against his
mother and did not speak to his stepfather for two years. His compliance
with his medication regimen was inconsistent, resulting in high levels of
anxiety, hostility, and suspicion and
bizarre thoughts and perceptual disturbances before he participated in
the composite therapy program.
Mr. Rs treatment began with psychoeducation on the causes of schizophrenia. The social perception subprogram was tailored to teach him
how to differentiate concrete perceptions from overinterpretation. For example, in social situations, Mr. R
tended to focus on a limited aspect of
a social interaction, often making
paranoid interpretations that led to
negative opinions and unwarranted
criticism of others.
Over the course of several sessions,
Mr. R was helped to distinguish between the content of the visual presentation and his idiosyncratic interpretations. Through modeling and positive reinforcement, he learned to describe the situations presented in the
slides by using only the perceived
stimuli, without imposing his own interpretation. This skill carried over to
his peer interactions as well.
The main objective of the interpersonal problem-solving subprogram was
to improve Mr. Rs ability to interact
with his family by helping him identify
new ways of communicating with his
parents. Among these techniques were
how to take turns in a conversation,
minimizing the number of times he interrupted others; how to focus on a target idea and express himself clearly,
specifically, and succinctly; and how to
control the volume and pitch of his
voice to make himself understood.
The family psychoeducation component aimed to lower the level of criticism, hostility, and emotional overinvolvement that dominated family interactions and to alleviate Mr. Rs parents caregiving burden. Training included teaching the parents how to
cope with his symptoms and disruptive
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behaviors and helping them modify

their fatalistic perception of Mr. Rs future. Communication-skill exercises
were used to teach the parents how
and when interactions should take
place. The objective of the problemsolving therapy was to facilitate collaboration between Mr. R and his parents, including how to negotiate areas
of contention such as medication compliance and aggression.
For instance, a major cause of family tension was the conflict between
Mr. Rs need for privacy and his mothers desire to monitor his medications.
To avoid arguments, Mr. Rs mother
would count his medications, which
were in his drawer, when he was not
home. However, he would often discover that his mother had been
through his things, which led to aggressive behaviors such as throwing
objects and slamming doors. During
the family psychoeducation sessions, a
number of ideas were discussed to resolve this impasse. The strategysuggested by Mr. Rthat proved to be
successful was to keep the medications
in the kitchen so that he could more
easily remember to take them after
meals and not require his mothers supervision. This strategy not only decreased his anger toward his parents
but also added to his increasing sense
of responsibility and self-esteem.
By the end of the treatment period,
Mr. Rs adherence to his medication
regimen became more stable, his psychotic symptoms were greatly reduced, and his violent outbursts ended. He struck up a friendship with another group participant and began to
visit an old friend. For the first time in
11 years, his mother and stepfather
were able to enjoy a two-week vacation
away from Mr. R. The final assessment
indicated that he was maintaining his
gains and had enrolled in a vocational
training program. After completing a
two-month course on environmental
conservation, he obtained a full-time
position as part of a team responsible
for maintaining clean beaches.
Afterword by the column editors:
Broad-spectrum intervention programs such as IPT for outpatients with
schizophrenia are consistent with current guidelines from experts and professional organizations. IPT, in combi-

September 2001 Vol. 52 No. 9

nation with pharmacotherapy, case

management, and family psychoeducation, incorporates the essential requirements for ensuring the effectiveness of psychosocial intervention programs for schizophrenia (1). These include teaching practical elements in
daily problem-solving abilities and feasible goals; forging an alliance among
clinicians, participants, and relatives;
maintaining treatment continuity, with
a minimum of 12 months of active participation; focusing on environmental
stressors and personal deficits that are
related to relapse risk and social maladjustment; and coordinating and integrating pharmacological, psychosocial, and family services.
In the comprehensive psychosocial
treatment program that Vallina and
colleagues describe, it is impossible to
determine whether the same good
outcomes would have been obtained
with the family services and medication alone, especially since a number
of studies using structured and learning-based family interventions have
shown similar benefits (7,8). Randomized controlled trials are needed to determine which components are necessary for salutary results.
References
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Psychiatric rehabilitation, in Comprehensive
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2. Penn DL, Mueser KT: Research update on
the psychosocial treatment of schizophrenia.
American Journal of Psychiatry 153:607
617, 1996
3. Brenner HD, Roder V, Hodel B, et al: Integrated psychological therapy for schizophrenic patients. Bern, Hogrefe & Huber,
1994
4. Falloon IRH, Laporta M, Fadden G, et al:
Managing stress in families: cognitive and
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interventions for schizophrenia: a review of
long-term benefits of international studies.
Psychiatric Rehabilitation Skills 3:268290,
1999
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family psychoeducation for schizophrenia.
Schizophrenia Bulletin 26:520, 1999

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