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One interesting contrast between these 2 cognitive rehabilitation approaches is that compensatory approaches target specific behaviors with little, if any, expectation for generalization outside the trained-on behavior. In contrast, cognition-enhancing approaches target a range of cognitive abilities with the aim of improving a wide range of behaviors central for independent living and community functioning.

Growing evidence indicates that impairments in the domain of social cognition are important, unique determinants of poor functional outcome in schizophrenia. These findings have generated considerable excitement about the possibility of targeting social cognitive abilities as a means of resolving functional disability. An emerging body of research suggests that social cognitive impairments are indeed amenable to a range of psychosocial interventions. Social cognition is a multifaceted construct that refers to the mental operations underlying social interactions, which include perceiving, interpreting, and generating responses to the intentions, dispositions, and emotions of others.

There is a general consensus that social cognition is distinct from, though related to, basic neurocognition and other clinical features of schizophrenia. The modifiability of social cognitive impairments in schizophrenia is supported by 2 general types of studies. Several such studies that included training in the area of social cognition have demonstrated improvements in psychosocial functioning or on specialized measures of social cognition. For example, performance on facial affect recognition or theory of mind tests has been enhanced through brief eg, an hour or less intervention probes such as attentional manipulations, facial mimicry, or practice with commercially available computerized training exercises.

Psychosocial Supports in Medication-Assisted Treatment: Recent Evidence and Current Practice

These studies set the stage for a series of longer term treatment studies, primarily of inpatients, that have used a variety of training methods to improve performance on social cognitive tests. Some studies have targeted a single social cognitive domain. The training, which is administered to pairs of patients at a time, uses specially developed computerized facial emotion perception training exercises as well as a set of pictures of emotional faces for use in interactive exercises.

Following an encouraging initial uncontrolled feasibility study, this research group studied 77 inpatients who were randomized to 1 of 3 conditions: a TAR, b a time-matched neurocognitive remediation targeting attention, memory, and executive functioning, or c TAU, which enabled the authors to assess the specificity of treatment effects.

Results suggested but were not fully supportive of a double dissociation; the TAR group showed improved facial affect perception and verbal working memory but not improved verbal learning and long-term memory. In contrast, the neurocognitive remediation group showed improved verbal learning and long-term memory but not affect perception. These findings suggest that standard neurocognitive training alone is neither necessary nor sufficient to improve facial emotion perception.

Other targeted treatment studies have attempted to address multiple social cognitive domains. This is a 3-phase, session intervention that addresses emotion perception, attributional bias, and theory of mind in a small group 6—8 patients format. Phase 1 focuses on defining basic emotions and linking them to facial expressions through the use of a commercially available software program. The final phase involves integrating and generalizing these skills by applying them to increasingly realistic social situations. Two uncontrolled studies of SCIT in inpatients with psychotic disorders demonstrated significant, medium to large improvements in the 3 targeted domains of social cognition.

Because social cognitive interventions will most likely benefit stabilized patients who are living in the community, demonstrating their efficacy in community-dwelling outpatients is of particular importance. Two recent studies of outpatients provide encouraging initial support for benefits in this population. The SCIT group showed significant medium improvements in the area of facial affect perception, as well as improved performance on a role-play measure of social competence.

Using a randomized controlled design, Horan et al tested whether 31 outpatients who received an integrative session social cognitive skills training intervention demonstrated greater improvements in social cognition than controls who received traditional symptom management skills training. This program uses a highly structured skills training-based approach that grows out of psychiatric rehabilitation methods 17 to target 4 aspects of social cognition, including affect perception, social perception, attributional style, and theory of mind.

It combines successful elements from the TAR and SCIT programs , with a variety of novel training exercises and materials that go beyond the content of these programs to address social perception eg, nonverbal cue recognition and particular aspects of theory of mind, including training in identifying various forms of sarcasm and deception. The social cognition group demonstrated a large, significant improvement in facial affect perception, which was not present in the control group. Furthermore, this improvement was independent of changes in basic neurocognitive functioning or symptoms.

In conjunction with findings from Roberts and Penn, results support the feasibility and efficacy of applying a targeted treatment approach to stabilized patients in the community.

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Although psychosocial treatment of social cognitive deficits in schizophrenia is currently in its infancy, the initial efficacy results are encouraging. Using a variety of treatment approaches, existing studies indicate that individuals with schizophrenia are capable of improving their performance on tasks measuring a range of social cognitive processes particularly affect perception that have been linked to successful social functioning. Thus, continued development of interventions for social cognitive deficits appears to be worth pursuing in efforts to promote functional recovery.

We would be remiss without addressing the essential contribution of pharmacological treatment in enabling persons with schizophrenia to more fully benefit from participation in psychosocial treatment programs. Antipsychotic medications are effective for attenuating or eliminating psychotic symptoms in acutely psychotic patients with schizophrenia and other related psychotic illnesses and preventing relapse in individuals who are stable. In showing the importance of continued, ongoing antipsychotic medication treatment, a typical study design compares the risk of psychotic relapse between patients who continue to take an antipsychotic and those who stop medications or are changed to a placebo.

These studies demonstrate that those who remain on an antipsychotic have substantially lower risk of relapse. For example, studies have found that patients with schizophrenia who are not treated with antipsychotic medications can actually worsen when they were stressed with psychosocial treatments. Other studies indicate that the interactions between antipsychotic medications and psychosocial treatments can be more complex.

Marder et al 27 followed patients who were randomized to receive 2 pharmacological strategies as well as behavioral skills training and a control psychosocial condition. The more effective pharmacological treatment improved relapse rates but did not affect social adjustment. However, patients who received the more effective pharmacological treatment and behavioral skills training had the greatest improvements in social adjustment. In a subsequent study, this same group found that patients who experienced akathisia as a medication side effect were less likely to show improvements in social adjustment.

On the other hand, drug side effects may have negative effects on social functioning, perhaps due to medication side effects. Other studies reinforce the notion that better symptom control affects participation in psychosocial treatments. Rosenheck et al monitored the use of different levels of psychosocial treatments and rehabilitation in patients assigned to a comparison of clozapine or haloperidol.

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Patients receiving clozapine were more likely to utilize higher levels of psychosocial treatment. Moreover, the use of these higher levels was associated with greater improvements in quality of life. This suggests that patients who experience more improvement in symptoms on a better pharmacotherapy have a greater potential to benefit from psychosocial interventions. It also suggests that one of the long-term goals of pharmacotherapy is to facilitate participation in psychosocial treatments.

This is a goal that extends beyond just sustaining a remission. It is not surprising that antipsychotic medications do not appear to have direct effects on functional recovery.


This group of drugs appears to attenuate the severity of psychotic symptoms and has little effect on symptom domains such as negative symptoms and cognitive impairment that are more related to functioning. Most of the current drug development activities have focused on drugs to improve cognition. This collaboration among academia, industry, and government led to the development of a consensus battery for measuring cognition in clinical trials; an NIMH-Food and Drug Administration FDA consensus on trial design; advice from FDA regarding a path to drug approval; and recommendations for promising molecular targets.

A number of drugs are currently in different stages of development. The hope is that these agents could directly improve functioning by improving cognition. Alternatively, a cognition-enhancing drug could improve functioning by improving an individual's ability to participate in psychosocial treatments such as social skills training, CBT, cognitive remediation, or social cognition training.

In this article, we reviewed 4 psychosocial treatments for schizophrenia with differing histories. Social skills training is a well-established behavioral treatment that is effective at improving the knowledge base and skills of persons with schizophrenia in clinic teaching settings. Generalization to community functioning is also evident when efforts have been used to bridge skills taught in the clinic classroom to specific community activities.

The ties to relapse prevention are equivocal. CBT is effective at reducing positive and negative symptoms, and there are a number of independent studies that have shown improvements in mood and community functioning as well, perhaps providing suggestive evidence that improvement in the ability to cope with symptoms can lead to improvements in quality of life and community behavior.

Cognitive remediation is a somewhat newer enterprise that is an outgrowth of the treatment efforts with persons with traumatic brain injury. There are far fewer studies relevant to testing effects on recovery with this approach; however, those available are promising for both cognition-enhancing and compensatory approaches. Social cognition training is the newest approach. It has a sound conceptual basis with support from studies that have shown measures of social cognition to be mediators of the relationship between neurocognition and community functioning.

The few studies in this area are innovative, and the results thus far are promising.


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To date, most studies in this literature target components of functional recovery. All reviewed have merit but are seldom used in conjunction with one another. If traction is to be made at facilitating recovery in persons with schizophrenia, a greater number of studies need to evaluate the effects of combined treatment approaches. It is clearly evident from this review that no one psychosocial treatment leads to improvement in all components of recovery as measured using formal definitions that require evidence of prolonged symptom stability, freedom from relapse, normalized work and social functioning, and independent living.

Social skills training would appear to be a logical starting point for planning such efforts with adjunctive treatments added to address other components of recovery. Such efforts are obviously expensive in cost and time given the number of resources needed to carry them out and the length of time needed to measure recovery.

Unfortunately, without such efforts, we are left examining the effects of individual psychosocial treatments on selected areas of functioning that fall somewhat short of recovery definitions. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.

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Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents. Social Skills Training. Cognitive Behavioral Therapy. Cognitive Remediation. Social Cognition Training. Interaction of Psychopharmacology With Psychosocial Treatments. Oxford Academic. Google Scholar. Shirley M. William P. Stephen R. Cite Citation. Permissions Icon Permissions. Abstract A number of psychosocial treatments are available for persons with schizophrenia that include social skills training, cognitive behavioral therapy, cognitive remediation, and social cognition training.

Recovery, self management and the expert patient—changing the culture of mental health from a UK perspective. Search ADS. The Vermont longitudinal study of persons with severe mental illness: II. One hundred years of schizophrenia: a meta-analysis of the outcome literature.

Google Preview. The effects of instructions and reinforcement on thinking and language behavior of schizophrenics. Training skills in the psychiatrically disabled: learning coping and competence. Social skills training for patients with schizophrenia: a controlled clinical trial. A multiple-baseline analysis of social-skills training in chronic schizophrenics. Technique for training schizophrenic patients in illness self-management: a controlled trial. Skills training versus psychosocial occupational therapy for persons with persistent schizophrenia.

Supplementing clinic-based skills training with manual-based community support sessions: effects on social adjustment of patients with schizophrenia. An examination of the efficacy of social skills training for chronic schizophrenic patients. Psychosocial treatments for posttraumatic stress disorder: a critical review. Two-year outcome for social skills training and group psychotherapy for outpatients with schizophrenia. Meta-analysis examining the effects of social skills training on schizophrenia.

Psychological treatments in schizophrenia: II. Meta-analyses of randomized controlled trials of social skills training and cognitive remediation. A meta-analysis of controlled research on social skills training for schizophrenia. Assessment of enduring deficit and negative symptom subtypes in schizophrenia.

The relationship of clinical factors and environmental opportunities to social functioning in young adults with schizophrenia. Symptoms and cognition as predictors of community functioning: a prospective analysis. Symptomatic and functional recovery from a first episode of schizophrenia or schizoaffective disorder. Full recovery from schizophrenia: the prognostic role of premorbid adjustment, symptoms at first admission, precipitating events and gender.

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  • The relationship between positive symptoms and instrumental work functioning in schizophrenia: a 10 year follow-up study. Perceptual and cognitive abnormalities as the basis for schizophrenic symptoms. A neuropsychiatric model of biological and psychological processes in the remission of delusions and auditory hallucinations. Cognitive, emotional, and social processes in psychosis: refining cognitive behavioral therapy for persistent positive symptoms.

    Measurement of delusional ideation in the normal population: introducing the PDI Peters et al. Delusions Inventory. A comparison of metacognitions in patients with hallucinations, delusions, panic disorder, and non-patient controls. Successful outpatient psychotherapy of a chronic schizophrenic with a delusion based on borrowed guilt. Effectiveness of a brief cognitive-behavioural therapy intervention in the treatment of schizophrenia.

    A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Cognitive behavior therapy for schizophrenia: effect sizes, clinical models, and methodological rigor. Is symptomatic improvement in clinical trials of cognitive-behavioral therapy for psychosis clinically significant? What are the functional consequences of neurocognitive deficits in schizophrenia? Functional reorganization of primary somatosensory cortex in monkeys after behaviorally controlled tactile stimulation. Use-dependent alterations of movement representations in primary motor cortex of adult squirrel monkeys.

    Remodeling of hand representation in adult cortex determined by timing of tactile stimulation. Topographic reorganization of the hand representation in cortical area 3b owl monkeys trained in a frequency-discrimination task. Approaches to cognitive remediation of neuropsychological deficits in schizophrenia: a review and meta-analysis.

    Cognitive rehabilitation for schizophrenia and the putative role of motivation and expectancies. Are the effects of cognitive remediation therapy CRT durable? Results from an exploratory trial in schizophrenia. The effects of neurocognitive remediation on executive processing in patients with schizophrenia.

    Neurocognitive enhancement therapy with vocational services: work outcomes at two-year follow-up. Cognitive training and supported employment for persons with severe mental illness: one-year results from a randomized controlled trial. Cognitive training for supported employment: 2—3 year outcomes of a randomized controlled trial. A randomized controlled trial of cognitive remediation among inpatients with persistent mental illness. Errorless embedding in the reduction of severe maladaptive behavior during interactive and learning tasks.

    Errorless learning: reinforcement contingencies and stimulus control transfer in delayed prompting.

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    Implicit memory and errorless learning: a link between cognitive theory and neuropsychological rehabilitation? Errorless learning and the cognitive rehabilitation of memory-impaired schizophrenic patients. Applications of errorless learning for improving work performance in schizophrenia. Extensions of errorless learning for social problem-solving deficits in schizophrenia. Errorless learning for training individuals with schizophrenia at a community mental health setting providing work experience. Two case studies of cognitive adaptation training for outpatients with schizophrenia.

    A randomized single-blind pilot study of compensatory strategies in schizophrenia outpatients. Social cognition in schizophrenia: relationships with neurocognition and negative symptoms. The functional significance of social cognition in schizophrenia: a review. Social perception as a mediator of the influence of early visual processing on functional status in schizophrenia.

    Does social cognition influence the relation between neurocognitive deficits and vocational functioning in schizophrenia? Facial affect recognition: a mediator between cognitive and social functioning in psychosis? Social cognitive training for individuals with schizophrenia: emerging evidence. Remediation of emotion perception deficits in schizophrenia: the use of attentional prompts.

    Brief emotion training improves recognition of facial emotions in chronic schizophrenia. A pilot study. A pilot study to investigate the effectiveness of emotion recognition remediation in schizophrenia using the micro-expression training tool. Remediation of impairments in facial affect recognition in schizophrenia: efficacy and specificity of a new training program. Rehabilitation of theory of mind deficit in schizophrenia: a pilot study of metacognitive strategies in group treatment. Remediation of facial affect recognition impairments in patients with schizophrenia: a new training program.

    Best practices: the development of the social cognition and interaction training program for schizophrenia spectrum disorders. Social cognition enhancement training for schizophrenia: a preliminary randomized controlled trial. Social cognitive skills training in schizophrenia: an initial efficacy study of stabilized outpatients.

    A pilot study of social cognition and interaction training SCIT for schizophrenia. Social cognition and interaction training SCIT for inpatients with schizophrenia spectrum disorders: preliminary findings. Social cognition and intervention training SCIT for outpatients with schizophrenia: a preliminary study. Drug and sociotherapy in the aftercare of schizophrenic patients. Two-year relapse rates.

    Fluphenazine and social therapy in the aftercare of schizophrenic patients: relapse analysis of two year controlled study of fluphenazine decanoate and fluphenazine hydrochloride. Maintenance treatment of schizophrenia with risperidone or haloperidol: 2-year outcomes. Does participation in psychosocial treatment augment the benefit of clozapine? All rights reserved. For permissions, please email: journals. Issue Section:.

    Based on the overviews of these four topics, specific treatments that have been developed by the authors are described. Evidence concerning the effects and feasibility of these developments is expected from current intervention studies. Future studies are encouraged to examine whether the developed interventions are also effective when offered by trained physiotherapists or physicians in primary care. Psychosocial interventions in back pain BP patients are well established in treatment regimens in the general population. Such interventions are usually embedded in multimodal, multidisciplinary programs as a standard treatment for patients with chronic low back pain LBP; This current role of psychosocial approaches in BP management is based on a longer history: Already Turner 46 stressed psychological techniques as an essential part of multidisciplinary pain management.

    Later reviews improved evidence for the effectiveness of psychological interventions for BP in particular Despite this general evidence for effects of psychological treatments, different types of psychological interventions do not substantially differ 36 ; furthermore, besides the evidence that multidisciplinary rehabilitation is more effective than usual care 25 , the specific mechanisms responsible for such effects still need to be evaluated.

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    To explore and explain mechanisms of psychosocial treatments in BP patients, a theoretical concept is necessary; the biopsychosocial paradigm of BP exemplifies the most prominent approach From the biopsychosocial perspective, BP is a matter of interactions between biological, psychic and social determinants. One reason for the conceptual shift away from a restricted biomedical model towards a multi-factorial approach is grounded in the increased risk of chronicity in BP patients with distress and depressive mood 38 as well as dysfunctional pain coping 14, In the context of sport, the biopsychosocial paradigm has been extensively discussed in relation to the occurrence and rehabilitation of sport injuries.

    In the course of this discussion, models have been developed to explain how biological, psychic and social determinants work together in injury development 1, 9 or injury rehabilitation In these models, the psychosocial perspective entails stress, emotion, and motivation as important factors of sports injuries. Taking the biopsychosocial perspective and the existing models of injury rehabilitation in sport into account 52 , psychosocial interventions to prevent or decrease sport-related BP should include emotional, cognitive and behavioral aspects of BP in athletes with respect to their specific personal and situational conditions.

    State of Research Dysfunctional cognitive, affective and behavioral responses to pain represent modifiable risk factors for the development of chronic BP that are frequently addressed in psychosocial interventions Dysfunctional pain responses comprise emotions such as pain-related fear, anxiety or depression, automatic cognitions of catastrophizing, helplessness, and more general meta-cognitions such as fear-avoidance beliefs.

    Followed by extensive avoidance behavior, these patterns of pain processing are suggested to lead to physical inactivity and accompany disuse of muscular structures In contrast, due to the avoidance-endurance model of pain AEM, 13 , also cognitions such as pain thought suppression and endurance behavior, where people try to endure ongoing activities despite severe levels of pain, have been shown to predict pain and disability, presumably by physical overuse 10, Derived from a cognitive-behavioral approach of therapy CBT, 45 a number of treatment methods were developed, i.

    Although most of these interventions revealed a reduction in pain and disability, these effects are only marginal in size Thus, research is recommending reconsideration of content, delivery, place, and control of therapy 5. Furthermore, we argue for a change in delivery of these techniques from a standardized application in patients suffering from chronic pain to an individually tailored delivery, based on screening of psychosocial risk factors, preferably in early phases of the disease In a preliminary randomized trial in patients with subacute BP, this approach, delivered by trained psychotherapists, has been shown as highly statistically and clinically effective in reducing pain and disability Current Developments We are now interested, whether the GB approach is also effective when offered by trained physiotherapists or physicians in primary care, the primary professions frequented by patients with subacute pain.

    Thus, in a non-randomized intervention trial, we have trained a group of physiotherapists to conduct a risk factor screening and to implement phases of AEM-based education in the regular treatment of their patients. A special challenge is to address dysfunctional modes of pain processing in the group of athletes, as a certain level of pain endurance is afforded to establish high physical performance.

    State of Research Body experience and body concept are relatively new approaches in the context of psychosocial interventions for BP. Body experience is defined as a differentiated whole with different levels and functions concerning the body One of these levels is the body concept, which is described as formal knowledge about the body 40 , similar to the umbrella term body image, describing the subjective perceptions, feelings, beliefs, and thoughts with respect to the own body 3, 8.

    A heterogeneous use of these different terms respective to all facets of body experience lead to a difficulty in comparing the state of research in elite sport. Studies on LBP and body experience or body concept in elite sports are currently not existent. Moreover, the relationship between body image and elite sports seems to be ambivalent. Specifically, some authors assume that athletes are at higher risk for body image disturbances while others report that athletes reveal a more positive body image than non-athletes for an overview see Psychosocial interventions on body experience and body concept for BP patients have not been examined so far.

    Hence, our recommendations base on cognitive-behavioral approaches in the general population with the aim to modify body-related thoughts, feelings and behaviors 26, Such procedures are already established as treatments for body image disturbances containing psychoeducation, self-monitoring and cognitive restructuring Current Developments In terms of current developments, two approaches seem promising. First, pain patients unconsciously use cognitive strategies to disregard the body region affected by pain e.

    This might be one reason why competitive athletes with chronic pain are able to continue their training and participation at competitions Performing in spite of pain can intensify pain and result in serious injuries. This distortion of body concept could be a starting point for possible interventions to prevent further injuries by training the body perception e.

    Second, pain is perceived as dominant compared to other physical sensations, followed by a higher attention to the pain region 26 , potentially leading to a negative evaluation of the whole body. Consequently, the body image tends to be negative, which might affect the engagement in physical activity and exercise 8 : Some people avoid physical activity, others are stimulated to do more sports.