Efficacy of a self-esteem module in the empowerment of individuals with schizophrenia

Group cognitive behavior therapy or social skills training for individuals with a recent onset of psychosis? Results of a randomized controlled trial

This study aimed at determining the effectiveness of group cognitive behavior therapy (CBT) for recent onset psychosis in comparison with a recognized intervention for individuals with severe mental illness-social skills training. One hundred twenty-nine participants took part in a single-blind randomized controlled trial with repeated measures (baseline, 3 months, and 9 months). Participants were randomized to 1 of 3 conditions: group CBT, group social skills training for symptom management, or a wait-list control group. Both interventions were delivered by mental health staff with minimal training. Both treatments resulted in improvements on positive and negative symptoms compared with the wait-list control group, with the CBT group having significant effects over time on overall symptoms, and post-treatment effects on self-esteem, and active coping skills compared with the wait-list control group and lower drop-out rates than the skills training group. Therapist fidelity was adequate for both treatment conditions. Group CBT for psychosis is a promising intervention for individuals with recent onset of psychosis and their mental health professionals.

Construct validity of a health questionnaire intended to measure the subjective experience of health among patients in mental health services

Mental health services have been lacking systematic health-promoting activities, and health is often perceived as the absence of disease from a biomedical perspective. It is vital to develop methods to assess perceived health among patients in a broader perspective. The aim of the study was to investigate construct validity of a newly developed health questionnaire intended to measure subjectively experienced health among patients in mental health services. A cross-sectional study, including a randomly selected sample of 139 outpatients in contact with the mental health services, was performed in order to explore the relationship between perceived health and self-reported levels of self-esteem, symptoms, empowerment, quality of life and experiences of stigmatization. Self-esteem, symptoms, empowerment and quality of life altogether accounted for 70% of the variation in overall perceived health. Overall perceived health showed positive associations to self-esteem, empowerment and quality of life and negative associations to psychiatric symptoms, discrimination and rejection experiences. The findings suggest that perceived health as measured by the health questionnaire can be a meaningful and valid construct that may be useful for measuring health in clinical mental healthcare practice and in mental health services research.

Hopelessness in schizophrenia: the impact of symptoms and beliefs about illness

Risk factors for the development of hopelessness in schizophrenia remain poorly understood. This study investigated how psychiatric symptom levels and beliefs about illness might be linked to hopelessness in 100 patients with DSM-IV schizophrenia. Participants were assessed on the Beck Hopelessness Scale (BHS), the Calgary Depression Scale for Schizophrenia (CDSS), the Personal Beliefs about Illness Questionnaire (PBIQ), the Brief Psychiatric Rating Scale (BPRS), and the Scale for the Assessment of Negative Symptoms (SANS). Severe levels of hopelessness were found in 25% of the sample. There were significant differences between the hopeless and nonhopeless participants on the PBIQ subscales, SANS and BPRS. Differences on the PBIQ subscales remained significant when depression scores were controlled for. The total CDSS score, the "humiliating need to be marginalized" PBIQ subscale, and total BPRS score contributed significantly to a model accounting for 60% of the variance in hopelessness scores. Processes potentially implicated in the emergence of hopelessness in schizophrenia are discussed.

The construct validity of a self-report questionnaire focusing on health promotion interventions in mental health services

Health promotion has become a widespread concept, although little empirical research as to its importance and outcome has been performed in the mental health field. The aim of the present study was to investigate the construct validity of a newly developed Health Promotion Intervention Questionnaire, intended to measure patients' subjectively experienced health-promoting interventions within mental health services. A total of 135 participants responded to the questionnaire and to validation measures assessing psychiatric symptoms, empowerment, helping alliance and satisfaction with care. Bivariate correlations showed that overall perceived health-promoting interventions were positively correlated to, helping alliance, client satisfaction with care and empowerment. Stepwise multiple regression analysis showed that the strongest relationship was found between perceived health promotion intervention and helping alliance. In conclusion, the construct validity of the scale was satisfactory, except for one of its subscales where further investigations are needed.

Supportive therapy for schizophrenia

BACKGROUND

Supportive therapy is often used in everyday clinical care and in evaluative studies of other treatments.

OBJECTIVES

To estimate the effects of supportive therapy for people with schizophrenia.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's register of trials (January 2004), supplemented by manual reference searching and contact with authors of relevant reviews or studies.

SELECTION CRITERIA

All randomised trials involving people with schizophrenia and comparing supportive therapy with any other treatment or standard care.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated these and extracted data. For dichotomous data, we estimated the relative risk (RR) fixed effect with 95% confidence intervals (CI). Where possible, we undertook intention-to-treat analyses. For statistically significant results, we calculated the number needed to treat/harm (NNT/H). We estimated heterogeneity (I-square technique) and publication bias.

MAIN RESULTS

We included 21 relevant studies. We found no significant differences in the primary outcomes between supportive therapy and standard care. There were, however, significant differences favouring other psychological or psychosocial treatments over supportive therapy. These included hospitalisation rates (3 RCTs, n=241, RR 2.12 CI 1.2 to 3.6, NNT 8) but not relapse rates (5 RCTs, n=270, RR 1.18 CI 0.9 to 1.5). We found that the results for general functioning significantly favoured cognitive behavioural therapy compared with supportive therapy in the short (1 RCT, n=70, WMD -9.50 CI -16.1 to -2.9), medium (1 RCT, n=67, WMD -12.6 CI -19.4 to -5.8) and long term (2 RCTs, n=78, SMD -0.50 CI -1.0 to -0.04), but the clinical significance of these findings based on few data is unclear. Participants were less likely to be satisfied with care if receiving supportive therapy compared with cognitive behavioural treatment (1 RCT, n=45, RR 3.19 CI 1.0 to 10.1, NNT 4 CI 2 to 736). The results for mental state and symptoms were unclear in the comparisons with other therapies. No data were available to assess the impact of supportive therapy on engagement with structured activities.

AUTHORS' CONCLUSIONS

There are insufficient data to identify a difference in outcome between supportive therapy and standard care. There are several outcomes, including hospitalisation and general mental state, indicating advantages for other psychological therapies over supportive therapy but these findings are based on a few small studies. Future research would benefit from larger trials that use supportive therapy as the main treatment arm rather than the comparator.

Supportive therapy for schizophrenia

BACKGROUND

Supportive therapy is often used in everyday clinical care and in evaluative studies of other treatments.

OBJECTIVES

To estimate the effects of supportive therapy for people with schizophrenia.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's register of trials (January 2004), supplemented by manual reference searching and contact with authors of relevant reviews or studies.

SELECTION CRITERIA

All randomised trials involving people with schizophrenia and comparing supportive therapy with any other treatment or standard care.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated these and extracted data. For dichotomous data, we estimated the relative risk (RR) fixed effect with 95% confidence intervals (CI). Where possible, we undertook intention-to-treat analyses. For statistically significant results, we calculated the number needed to treat/harm (NNT/H). We estimated heterogeneity (I-square technique) and publication bias.

MAIN RESULTS

We included 21 relevant studies. We found no significant differences in the primary outcomes between supportive therapy and standard care. There were, however, significant differences favouring other psychological or psychosocial treatments over supportive therapy. These included hospitalisation rates (3 RCTs, n=241, RR 2.12 CI 1.2 to 3.6, NNT 8) but not relapse rates (5 RCTs, n=270, RR 1.18 CI 0.9 to 1.5). We found that the results for general functioning significantly favoured cognitive behavioural therapy compared with supportive therapy in the short (1 RCT, n=70, WMD -9.50 CI -16.1 to -2.9), medium (1 RCT, n=67, WMD -12.6 CI -19.4 to -5.8) and long term (2 RCTs, n=78, SMD -0.50 CI -1.0 to -0.04), but the clinical significance of these findings based on few data is unclear. Participants were less likely to be satisfied with care if receiving supportive therapy compared with cognitive behavioural treatment (1 RCT, n=45, RR 3.19 CI 1.0 to 10.1, NNT 4 CI 2 to 736). The results for mental state and symptoms were unclear in the comparisons with other therapies. No data were available to assess the impact of supportive therapy on engagement with structured activities.

AUTHORS' CONCLUSIONS

There are insufficient data to identify a difference in outcome between supportive therapy and standard care. There are several outcomes, including hospitalisation and general mental state, indicating advantages for other psychological therapies over supportive therapy but these findings are based on a few small studies. Future research would benefit from larger trials that use supportive therapy as the main treatment arm rather than the comparator.

Predicting domain-specific insight of schizophrenia patients from symptomatology, multiple neurocognitive functions, and personality related traits

This study examines the contribution of various neurocognitive functions, clinical characteristics, and personality traits to the prediction of three insight dimensions. Clinically stable schizophrenia patients (n=107) residing in the community were evaluated using the Positive and Negative Syndrome Scale, the Scale for the Assessment of Unawareness of Mental Disorder, and a comprehensive battery of instruments to measure personality related variables and neurocognitive functioning. Step-wise multivariate regression analysis indicates significant association of variability in insight dimensions with neurocognitive functioning (20-41%), personality related traits (8-18% temperament factors, 4-7% self-constructs, 10-14% coping styles), severity of symptoms (about 7%), illness duration (6%), and education (about 5%). Poor insight was attributed to impairment in visual and movement skills, sustained attention, executive functions, intensity of autistic preoccupations and positive symptoms, as well as increased novelty seeking behavior, task and emotion oriented coping styles, better self-esteem, self-efficacy, and higher education. Better awareness was related to better performance of neurocognitive tasks, reward dependence behavior, avoidant coping style, and longer illness duration. Aside from common indicators for the various insight dimensions, we defined specific indicators for each insight dimension. Thus, insight dimensions in schizophrenia patients residing in the community were attributed to neurocognitive and personality related factors rather than to psychopathological symptoms. The findings enable better understanding of the multifactorial nature of insight and highlight targets for more effective intervention and rehabilitation.

Determinants of functioning and well-being among individuals with schizophrenia: an integrated model

Outcomes for health conditions are typically the result of multiple factors; however, studies tend to focus on a narrow class of variables. Functioning and well-being outcomes for schizophrenia are diverse and have resisted simple explanation; however, prior research has not offered an integrated understanding of the relative contributions of enduring and episodic environmental factors, personal resources and psychiatric factors, and cognitive appraisal and coping, on functioning and well-being outcomes in schizophrenia. The present article sets out an integrated model of the determinants of functioning and well-being among individuals with schizophrenia. To examine evidence that bears on the model, literature on hypothesized relationships is reviewed to identify areas for which there is strong evidence and areas where more research is needed. The article suggests areas for further research, and directs researchers and practitioners toward areas of intervention that can enhance functioning and well-being for persons diagnosed with schizophrenia.

Coping patterns as a valid presentation of the diversity of coping responses in schizophrenia patients

This study aimed to identify coping patterns used by schizophrenia inpatients in comparison with those used by healthy individuals, and to explore their association with selected clinical and psychosocial variables. The Coping Inventory for Stressful Situations (CISS) was used to assess coping strategies among 237 inpatients who met DSM-IV criteria for schizophrenia and 175 healthy individuals. Severity of psychopathology and distress, insight into illness, feelings of self-efficacy and self-esteem (self-construct variables), social support, and quality of life were also examined. Factor analysis, analysis of covariance and correlations were used to examine the relationships between the parameters of interest. Using dimensional measures, we found that emotion-oriented coping style and emotional distress were significantly higher in the schizophrenia group, whereas the task-oriented coping style, self-efficacy, perceived social support and satisfaction with quality of life were lower compared with controls. When eight CISS coping patterns were defined, the results revealed that patients used emotion coping patterns 5.5 times more frequently, and task and task-avoidance coping patterns significantly less often than healthy subjects. Coping patterns have different associations with current levels of dysphoric mood and emotional distress, self-construct variables, and satisfaction with quality of life. Thus, the identified coping patterns may be an additional useful presentation of the diversity of coping strategies used by schizophrenia patients. Coping patterns may be considered an important source of knowledge for patients who struggle with the illness and for mental health professionals who work with schizophrenia patients.

Efficacy of psychological therapy in schizophrenia: conclusions from meta-analyses

Over the past years, evidence for the efficacy of psychological therapies in schizophrenia has been summarized in a series of meta-analyses. The present contribution aims to provide a descriptive survey of the evidence for the efficacy of psychological therapies as derived from these meta-analyses and to supplement them by selected findings from an own recent meta-analysis. Relevant meta-analyses and randomized controlled trials were identified by searching several electronic databases and by hand searching of reference lists. In order to compare the findings of the existing meta-analyses, the reported effect sizes were extracted and transformed into a uniform effect size measure where possible. For the own meta-analysis, weighted mean effect size differences between comparison groups regarding various types of outcomes were estimated. Their significance was tested by confidence intervals, and heterogeneity tests were applied to examine the consistency of the effects. From the available meta-analyses, social skills training, cognitive remediation, psychoeducational coping-oriented interventions with families and relatives, as well as cognitive behavioral therapy of persistent positive symptoms emerge as effective adjuncts to pharmacotherapy. Social skills training consistently effectuates the acquisition of social skills, cognitive remediation leads to short-term improvements in cognitive functioning, family interventions decrease relapse and hospitalization rates, and cognitive behavioral therapy results in a reduction of positive symptoms. These benefits seem to be accompanied by slight improvements in social functioning. However, open questions remain as to the specific therapeutic ingredients, to the synergistic effects, to the indication, as well as to the generalizability of the findings to routine care.

Investigating self-esteem in individuals with schizophrenia: relevance of the Self-Esteem Rating Scale-Short Form

Studies investigating self-esteem in individuals with severe mental illness, either as a treatment goal, outcome or correlate to other variables, have increased over the past few years. One of the main difficulties in assessing self-esteem is the assessment itself, often measuring global and stable self-esteem as in the Rosenberg Self-Esteem Scale, or requiring extensive training and long interviews. The present article aims at demonstrating the relevance of the French and English versions of the Self-Esteem Rating Scale-Short Form with individuals with severe mental illness. The instrument's reliability and validity were investigated in a sample of 250 French Canadian college students, 247 British college students and three samples of English- or French-speaking individuals with severe mental illness (N=254, N=150 and N=171). Confirmatory factor analysis revealed that a shorter version of the instrument (20 items), with a positive and a negative self-esteem factor, had a great validity for all the samples studied. The Self-Esteem Rating Scale-Short Form, with its positive and negative self-esteem subscales, appears to be a valid and reliable self-esteem measure for individuals with mental health problems. Limitations of this study and future directions are discussed.

The long-term changes in coping strategies in schizophrenia: temporal coping types

This prospective study aimed to define the long-term changes in coping strategies used by schizophrenia patients and their relation to clinical and psychosocial factors. The Coping Inventory for Stressful Situations, psychiatric scales, and self-report questionnaires were administered to 148 schizophrenia patients at admission and 16 months thereafter. Based on trends of individual coping patterns to show change over time, four temporal coping types were distinguished: stable favorable and unfavorable, and becoming favorable and unfavorable. We found that coping patterns of 62.2% of patients remained stable over time, became unfavorable among 19.6% of patients, and became favorable among 18.2% of patients. Each temporal coping type is associated with a specific pattern of changes in clinical and psychosocial variables. The findings underscore the clinical relevance of temporal coping types and corroborate the appropriateness of focusing on aspects of coping behavior in treatment and rehabilitation of schizophrenia patients.

Consumer and Case Manager Perspectives of Service Empowerment: Relationship to Mental Health Recovery

This study examines the relationship between service empowerment and recovery. Service empowerment is defined as the extent to which consumers participate in service decisions and the level of reciprocity and respect within the relationship with their case managers. Assessments were made from two perspectives: consumers and their case managers. Structural equation models were developed to examine the direct and indirect effects of service empowerment on four recovery outcomes: Quality of Life, Level of Functioning, Consumer-Reported Symptomatology, and Case Manager-Reported Symptomatology. Consumers' perceptions of service empowerment were the most powerful predictor of recovery outcomes across the four models. Consumers' and case managers' perceptions were related but the magnitude of the relationship was small, indicating that considerable differences exist between their perceptions of service empowerment.

Enactment in schizophrenia: capacity for dialogue and the experience of the inability to commit to action

While research has steadily begun to explore thoughts and beliefs linked with helplessness and despair in schizophrenia, it is less clearly understood how to account phenomenologically for the related experience of being unable to commit to action in the midst of grave discomfort. To explore this issue, the current paper presents an analysis of the experience of volitional paralysis of two persons over the course of long-term integrative psychotherapy. In particular, we explore the experience of the inability to commit to action and the consequences of the gradual recovery of a sense that one is capable of action. Results suggest that in both cases inaction was tethered to a sense of self as insufficiently centered to survive action. In particular, we suggest both men appeared initially unable to commit to action because such a commitment threatened them with forces both felt would undo the tenuous conversations that comprised their identities. Finally, as a sense of self as capable of action emerged, both men began to experience themselves as relatively more complex human beings and to sustain more complex conversation within themselves and between themselves and others. Implications for psychotherapy and rehabilitation are discussed.

Recovering from Severe Mental Illness: Mutual Influences of Self Illness

A growing body of literature on the subjective experiences of people with severe mental illness (SMI) reveals the importance of the experience of self. The current study explored how the course of SMI is related to individuals' subjective experience of self. Bimonthly, comprehensive, semi-structured interviews with 43 people who had been discharged from psychiatric hospitalization were conducted over a 1-year period. Qualitative analysis of the data revealed mutual influences between the experience of self and illness over time. Conceptual and clinical implications of the relation between self and illness are discussed.

[Group interventions for people with refractory psychosis]

Various types of group interventions exist for people with severe mental disorders such as schziophrenia. The content and theoretical backgrounds vary according to the therapeutic goals as well as the clientele targeted. This article describes three group interventions : 1) one aiming at improving self-esteem, 2) one aiming at improving competence through stress management, and 3) one aiming at diminushing distress linked to psychotic symptoms with cognitive behavior therapy. Details on how to conduct these three group interventions, as well as their clinical and theoretical relevance for individuals with refractory psychosis will be described.

Longitudinal assessment of coping abilities at exacerbation and stabilization in schizophrenia

BACKGROUND

Coping strategies play an important role in one's ability to adapt to stressful life conditions such as schizophrenia. To better understand the nature of various coping mechanisms at various stages in schizophrenia, this study examined task-, emotion-, and avoidance-oriented coping strategies and explored associated clinical factors at exacerbation and stabilization phases of the illness.

METHOD

Patients with schizophrenia were examined twice (at exacerbation phase, N = 237 and at stabilization phase, N = 148) with the Coping Inventory for Stressful Situations, and standardized measures of psychopathology and emotional distress severity, side effects, insight, self-constructs, social support, and quality of life. Multiple regression analysis was performed with coping strategies as dependent variables at exacerbation and stabilization including analysis of any change during the 16-month follow-up period.

RESULTS

Analysis indicated that emotion coping strategies were used more at exacerbation than at stabilization phase. Regression analysis demonstrated emotional distress to be a strong predictor of emotion-oriented coping, with self-efficacy and social support being the best predictors of task and avoidance coping strategies, respectively. Individual changes in these variables also appear to be important predictors for fluctuations of these coping strategies over time. Severity of symptoms accounted for 3.5% and 5.5% to 9% of the total variance of emotion- and task-oriented coping strategies, respectively.

CONCLUSIONS

Emotion, task, and avoidance coping strategies and their predictors are influenced and may vary over the course of schizophrenia illness. Experienced emotional distress, self-efficacy, and social support are the best predictors of coping strategies both at exacerbation and stabilization phases of illness.

Community care for people with psychosis: outcomes and needs for care

People with psychosis living in developed countries in the era of community-based care are likely to be socially isolated, unemployed, and have poor quality of life, despite recent advances in the treatment and understanding of psychosis. Recent work in Australia illustrates the needs for care, especially for those with complex disabilities, and even for those in contact with well-organized clinical mental health services. Insufficient evidence in two key areas impedes progress: the use of effective psychosocial interventions; and the impact of changes in the community care system. Follow-up studies of programs and interventions assessing a range of outcomes in local settings are now required to encourage professionals and the community to address these needs.

Distraction techniques for schizophrenia

BACKGROUND

Distraction techniques are a form of coping strategies used in cognitive behavioural techniques. They may be of value as an adjunctive treatment for people with schizophrenia or schizophrenia-like illnesses.

OBJECTIVES

To review the effects of distraction techniques for people with schizophrenia.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's Register (October 2003), manually searched reference lists and contacted relevant authors.

SELECTION CRITERIA

We included all randomised controlled trials comparing distraction techniques with other treatments for schizophrenia.

DATA COLLECTION AND ANALYSIS

We reliably selected, quality assessed and data extracted studies. We excluded data where more than 50% of participants in any group were lost to follow up. For binary outcomes, we calculated a fixed effects risk ratio (RR) and its 95% confidence interval (CI), along with the number needed to treat/harm (NNT/H). For continuous data we calculated the weighted mean difference (WMD).

MAIN RESULTS

In terms of mental state, distraction techniques did not have a clear effect (n=60, 1 RCT, MD endpoint BPRS 1.60 CI -0.49 to 3.69). Distraction does not obviously engage people in the studies (n=159, 5 RCTs, RR leaving the study before completion 1.08 CI 0.72 to 1.63).

AUTHORS' CONCLUSIONS

Clinicians, researchers, policy makers and recipients of care cannot be confident of the effects of distraction techniques from the findings of this review. The few pioneering studies are small, short and poorly reported. Further data from already completed trials might help inform practice, but more trials do seem to be justified as some of these potentially simple techniques, even if their effect is negligible, could be widely implemented and prove more acceptable than other more intrusive treatments.

Self-efficacy and neurocognition may be related to coping responses in recent-onset schizophrenia

Although stressful life events can trigger psychotic and depressive symptom exacerbation in schizophrenia, many patients who experience stressful events do not subsequently relapse. Models of vulnerability, stress, and protective factors in schizophrenia suggest that effective coping responses may serve as protective factors. Coping behavior, in turn, may be influenced by a schizophrenia patient's level of self-efficacy and neurocognitive functioning. Using the Coping Responses Inventory, we examined how 29 recent-onset schizophrenia outpatients and 24 demographically matched normal comparison subjects responded to a negative interpersonal life event. Approach oriented coping responses, such as "Think of different ways to deal with the problem" and "Make a plan of action and follow it," were used significantly more often by normal subjects (M=2.27) than by schizophrenia patients (M=1.89; p < 0.02). Among schizophrenia patients, greater use of approach, problem-focused coping strategies was associated with high self-efficacy (r=0.55, p < 0.01) and better performance on a measure of sustained attention emphasizing perceptual processing (r=0.42, p < 0.05). Multiple regression indicated that self-efficacy and sustained attention accounted for 56% of the variance in the use of problem-focused coping, strategies by schizophrenia patients.

Self-esteem in patients who have recovered from psychosis: profile and relationship to quality of life

BACKGROUND

New developments in pharmacotherapy are likely to improve substantially the symptomatic recovery from psychosis but low self-esteem may compromise quality of life.

AIMS

To investigate the profile and correlates of self-esteem in individuals who have achieved symptomatic recovery from psychosis and determine its relationship with quality of life.

METHOD

Sixty-one individuals who had been free of psychotic symptoms for 6 months were selected during a community-based epidemiological survey of psychoses. Participants were evaluated for subjective assessment of self-esteem using a self-report questionnaire, for clinical and antecedent features of illness, and for quality of life.

RESULTS

Forty-three percent had scores in the range indicative of low self-esteem on the questionnaire. Level of self-esteem was unrelated to gender, employment status, the type of psychotic disorder, course of disorder or premorbid social adjustment. Depression was associated with reduced levels of self-esteem. However, independent of depression and other confounding variables, a low level of self-esteem was a risk factor for impaired quality of life.

CONCLUSIONS

Self-esteem is often low among persons who have achieved symptomatic recovery from psychosis, is associated with depression and is a predictor of quality of life.

Rehabilitative residential treatment in patients with severe mental disorders: personality features associated with short-term outcome

The aims of this study were to evaluate the outcome of inpatients with severe psychiatric disorders after 6 months of multimodal residential treatment. Ninety-one subjects admitted to residential prolonged treatment at an Italian rehabilitative complex were included in the study. Within 6 months, the program of treatment was effective in reducing symptoms and improving the patients' psychosocial functioning. The study of personality can be useful to "dose" symptomatic (pharmacological and psychotherapeutic) and rehabilitative treatments in the therapy program.

Depressive symptoms erode self-esteem in severe mental illness: a three-wave, cross-lagged study

Vulnerability, scar, and reciprocal-relations models of depressive symptoms and self-esteem were compared among people with severe mental illness (SMI; N=260) participating in a partnership-based intervention study. Assessments were conducted at baseline, midway through the intervention (after 4 months), and at termination (after 9 months). Cross-lagged, structural equation modeling analyses revealed that participants' baseline depressive symptoms predicted a decrease in self-esteem in the first 4 months but not in the subsequent 5 months of participation. Exploratory regression analyses indicated that improved social functioning buffered this deleterious effect of depressive symptoms. These findings, which are consistent with the scar model, highlight the fragile nature of the self and the importance of social functioning in recovery from SMI.

Baseline personality functioning correlates with 6 month outcome in schizophrenia

OBJECTIVE

The assessment of outcome in schizophrenic patients should consider both the response to treatment and the recovery of social skills. The aim was to evaluate the outcome and related psychostructural and clinical factors in schizophrenic patients after they underwent 6 months of residential multimodal treatment.

METHOD

Fifty-two schizophrenic patients enrolled in a multimodal treatment program were included in the study. Symptomatology and social functioning were assessed with the Brief Psychiatric Rating Scale (BPRS) and the Social and Occupational Functioning Assessment Scale (SOFAS). The Karolinska Psychodynamic Profile (KAPP) was used for the psychostructural evaluation.

RESULTS

After 6 months there was a significant improvement in the global scores of BPRS, SOFAS, and some areas of KAPP. The personality (KAPP) and social-occupational functioning (SOFAS) at baseline (T0) correlated with the global score of BPRS at 6 months (T6); moreover, SOFAS at T6 correlated with BPRS and KAPP at T0 and with the illness duration.

CONCLUSION

The better the personality functioning in schizophrenic patients the better seems to be the response to treatment, with regard to symptoms as well as rehabilitation. Personality assessment might be useful for the individualisation of therapies, even within the context of a standardised program.

Self-esteem in schizophrenia: relationships between self-evaluation, family attitudes, and symptomatology

Participants with schizophrenia (N = 59) were assessed on self-evaluation, symptomatology, and positive and negative affect (expressed emotion) from significant others. An interview-based measure of self-evaluation was used and two independent dimensions of self-esteem were derived: negative and positive evaluation of self. As predicted, negative self-evaluation was strongly associated with positive symptoms, a more critical attitude from family members was associated with greater negative self-evaluation, and analyses supported a model whereby the impact of criticism on patients' positive symptoms was mediated by its association with negative self-evaluation. The interview-based method of self-esteem assessment was found to be superior to the questionnaire because its predictive effects remained after depressed mood was accounted for.

The cognitive-behavioural treatment of low self-esteem in psychotic patients: a pilot study

Low self esteem in individuals with a psychotic disorder is common and may be related to poorer clinical outcomes. However, there has been little research on devising treatment methods to improve self-esteem either generally or in psychotic patients in particular. The aims of this study were to evaluate the efficacy of a simple cognitive behavioural intervention to improve self esteem in psychotic patients who scored poorly on a self-esteem measure. This pilot study was a randomised control trial with a convenience sample of chronic psychotic inpatients. The cognitive behavioural self-esteem intervention, as an adjunct to treatment as usual (TAU), was compared to TAU alone in patients with psychosis. The individual self-esteem intervention as described by Tarrier (The use of coping strategies and self-regulation in the treatment of psychosis. (2001)) consisted of working with participants to elicit positive self-attributes and then identify specific behavioural examples to provide evidence of this attribute. Emphasis was given to any consequential change in the patient's belief that they had the attribute. The results indicated that this cognitive behavioural treatment for self-esteem used as an adjunct treatment in psychosis, resulted in clinical benefits in terms of increased self-esteem, decreased psychotic symptomatology and improved social functioning. These benefits were largely maintained at 3-month follow-up.

A prospective study on the relationship between self-esteem and functioning during the first year after being hospitalized for psychosis

A recent body of literature on the subjective experience of severe mental illness has reported on the importance of a person's self-esteem. Using a longitudinal design, this study investigates the relationship between self-esteem and functioning during the first year after being hospitalized for psychosis. The findings are based on comprehensive assessments conducted over a 1-year period with 43 persons hospitalized for schizophrenia and related disorders. Results reveal that change in level of self-esteem is significantly related to outcome. These results emphasize the importance of helping patients sustain positive self-esteem in the midst of disorder and treatment.

Toward uncovering robust principles of change inherent to cognitive-behavioral therapy for psychosis

Cognitive-behavioral therapies for people with schizophrenia have added value to the existing treatment of psychotic symptoms. This article aims at taking a closer look at the research results of multiple studies in order to delineate the specific and nonspecific factors related to the cognitive-behavioral practice that influence treatment robustness.

Psychosocial rehabilitation in a public psychiatric hospital

Patients with chronic mental illnesses have complex treatment needs that often pose significant challenges to mental health professionals. This paper describes the implementation of a psychosocial rehabilitation program to meet the treatment needs of patients in a public psychiatric hospital providing long-term care. A core group of professional staff adopted psychosocial rehabilitation principles in order to transform a custodial model of care to a highly interactive educational and skills building program. A model of service delivery was established to address patients' skill deficits and barriers to returning to the community. This article describes the major steps and challenges faced in overcoming obstacles and implementing a psychosocial philosophy of treatment in an inpatient setting. It suggests that it is possible for the public hospital to reinvent itself into an environment that can stimulate recovery and hope.

Evaluating the impact of a locality based social policy intervention on mental health: conceptual and methodological issues

Urban regeneration initiatives provide an opportunity for examining the impact of changes in socio-economic circumstances on the mental health of different groups and individuals within localities. This paper sets out the conceptual and methodological bases for evaluating the impact of a population based social policy intervention on mental health. We suggest the need to integrate a range of disciplinary and methodological developments in research on health inequalities in exploring the impact of urban regeneration on mental health. A combination of multi-level modelling, subjective indicators and narrative accounts of individuals about mental health in the context of locality and personal changes are central for developing theories and methods appropriate for exploring the action and interaction of effects operating between structural and individual/agency levels.