Should CBT Target the Social Impairments Associated With Schizophrenia?

Transportability and feasibility of Social Cognition And Interaction Training (SCIT) in community settings

BACKGROUND

Social Cognition and Interaction Training (SCIT) is a manual-based group intervention designed to improve social cognition in schizophrenia. Initial studies conducted by the developers of SCIT suggest that the intervention has promise in ameliorating social cognitive dysfunction in both inpatients and outpatients.

AIMS

The current study is a preliminary evaluation of SCIT in community samples.

METHOD

An uncontrolled, pre-post design was used in this initial feasibility study. A collaborative research-clinical approach was employed to enable research evaluation while also meeting the administrative goals of participating clinics, and working within the constraints of real-world clinical practice. Transportability, acceptability, and feasibility of SCIT were evaluated in terms of pre- and post-treatment evaluations, client attendance data (N = 50), and clinic administrators' decisions about whether to integrate SCIT into regular programming. Social-cognitive outcome measures assessed emotion perception, Theory of Mind, and attributional bias.

RESULTS

These support the transportability, acceptability, and feasibility of SCIT in community settings. SCIT has been integrated into routine practice at several test sites. Tentative support was found for improvement in emotion perception and Theory of Mind, but not attributional bias.

CONCLUSIONS

SCIT may be a promising intervention for community agencies serving individuals with psychotic disorders who seek to improve their social functioning.

Neuropsychological predictors of functional outcome in Cognitive Behavioral Social Skills Training for older people with schizophrenia

Cognitive Behavioral Social Skills Training (CBSST) is a 24-session weekly group therapy intervention to improve functioning in people with schizophrenia. In our prior randomized clinical trial comparing treatment as usual (TAU) with TAU plus group CBSST (Granholm, E., McQuaid, J.R., McClure, F.S., Auslander, L., Perivoliotis, D., Pedrelli, P., Patterson, T., Jeste, D.V., 2005. A randomized controlled trial of cognitive behavioral social skills training for middle-aged and older outpatients with chronic schizophrenia. Am. J. Psychiatry 162, 520-529.), participants with schizophrenia in CBSST showed significantly better functional outcome than participants in TAU. The present study was a secondary analysis of neuropsychological predictors of functional outcome in our prior CBSST trial. We examined (1) whether neuropsychological impairment at baseline moderated functional outcome in CBSST relative to TAU, and (2) whether improvement in neuropsychological abilities mediated improvement in functional outcome in CBSST. Attention, verbal learning/memory, speed of processing, and executive functions were assessed at baseline, end of treatment, and 12-month follow-up. Greater severity of neuropsychological impairment at baseline predicted poorer functional outcome for both treatment groups (nonspecific predictor), but the interaction between severity of neuropsychological impairment and treatment group was not significant (no moderation). Effect sizes for the difference between treatment groups on functional outcome measures at 12-month follow-up were similar for participants with relatively mild (d=.44-.64) and severe (d=.29-.60) neuropsychological impairment. Results also did not support the hypothesis that improvement in neuropsychological abilities mediated improvement in functioning in CBSST. Adding CBSST to standard pharmacologic care, therefore, improved functioning relative to standard care alone, even for participants with severe neuropsychological impairment, and this improvement in functioning was not related to improvement in neuropsychological abilities in CBSST.

Cognitive approaches to schizophrenia: theory and therapy

A theoretical analysis of schizophrenia based on a cognitive model integrates the complex interaction of predisposing neurobiological, environmental, cognitive, and behavioral factors with the diverse symptomatology. The impaired integrative function of the brain, as well as the domain-specific cognitive deficits, increases the vulnerability to aversive life experiences, which lead to dysfunctional beliefs and behaviors. Symptoms of disorganization result not only from specific neurocognitive deficits but also from the relative paucity of resources available for maintaining a set, adhering to rules of communication, and inhibiting intrusion of inappropriate ideas. Delusions are analyzed in terms of the interplay between active cognitive biases, such as external attributions, and resource-sparing strategies such as jumping to conclusions. Similarly, the content of hallucinations and the delusions regarding their origin and characteristics may be understood in terms of biased information processing. The interaction of neurocognitive deficits, personality, and life events leads to the negative symptoms characterized by negative social and performance beliefs, low expectancies for pleasure and success, and a resource-sparing strategy to conserve limited psychological resources. The comprehensive conceptualization creates the context for targeted psychological treatments.

Do baseline client characteristics predict the therapeutic alliance in the treatment of schizophrenia?

This study examined clinical predictors of client and therapist alliance ratings early in therapy, the relationship between client and therapist alliance ratings, and the psychometric properties of the Working Alliance Inventory in individuals with schizophrenia receiving manual-based treatment. Assessment of clinical symptoms and social functioning were conducted at baseline, and alliance ratings were obtained at 5 weeks. The Working Alliance Inventory had high internal consistency, but there were low correlations between client and therapist ratings. Results also indicated that social functioning and the activation and autistic preoccupation factors on the Positive and Negative Syndrome Scale were significant predictors of therapists' alliance ratings. There were no significant relationships between clinical predictors and clients' therapeutic alliance ratings. The findings indicate that client interpersonal factors are significant predictors of the therapist-rated alliance in the treatment of schizophrenia. Low correlations between clients' and therapists' ratings of the alliance should be examined in future research.

Functional cognitive-behavioural therapy: a brief, individual treatment for functional impairments resulting from psychotic symptoms in schizophrenia

This paper describes a novel cognitive-behavioural approach to treating psychotic symptoms--functional cognitive-behavioural therapy (FCBT)--which was developed with the primary aim of remediating social functioning deficits in patients with residual psychotic symptoms. In FCBT, symptom-focused cognitive-behavioural therapy (CBT) interventions are delivered in the context of working on functional goals: a premise of FCBT is that the therapeutic alliance and patient motivation are enhanced by linking interventions to life goals. The paper outlines the rationale for expanding existing approaches to target social functioning impairment and uses case illustrations to exemplify particular phases of treatment as well as specific CBT interventions. Results from a pilot study of FCBT are summarized, together with suggestions for new research directions.