Author’s Accepted Manuscript
Speech and language therapies to improve
pragmatics and discourse skills in patients with
schizophrenia
Marilyne Joyal, Audrey Bonneau, Shirley Fecteau
www.elsevier.com/locate/psychres
PII:
DOI:
Reference:
S0165-1781(15)30190-6
http://dx.doi.org/10.1016/j.psychres.2016.04.010
PSY9571
To appear in: Psychiatry Research
Received date: 19 August 2015
Revised date: 3 January 2016
Accepted date: 3 April 2016
Cite this article as: Marilyne Joyal, Audrey Bonneau and Shirley Fecteau, Speech
and language therapies to improve pragmatics and discourse skills in patients
with
schizophrenia, Psychiatry
Research,
http://dx.doi.org/10.1016/j.psychres.2016.04.010
This is a PDF file of an unedited manuscript that has been accepted for
publication. As a service to our customers we are providing this early version of
the manuscript. The manuscript will undergo copyediting, typesetting, and
review of the resulting galley proof before it is published in its final citable form.
Please note that during the production process errors may be discovered which
could affect the content, and all legal disclaimers that apply to the journal pertain.
Speech and language therapies to improve pragmatics and discourse skills in patients with
schizophrenia
Marilyne Joyal, M. Sc. SLP*, Audrey Bonneau, M. Sc. SLP, Shirley Fecteau, Ph. D.
Centre interdisciplinaire de recherche en réadaptation et en intégration sociale, 525, boul. WilfridHamel, bureau H-1312, Quebec, Quebec, Canada G1M 2S8 ; Centre de recherche de l’Institut
universitaire en santé mentale de Québec, 2601, de la Canardière, Quebec, Quebec, CANADA G1J
2G3 ; Faculté de médecine, Université Laval, 1050, avenue de la Médecine, Quebec, Quebec, Canada
G1V0A6
*Corresponding author. Marilyne Joyal, Postal address: 525, boul. Wilfrid-Hamel, bureau H-1312,
Quebec city QC G1M 2S8, Tel.: 418 649-3735. Email: marilyne.joyal.1@ulaval.ca
Abstract
Individuals with schizophrenia display speech and language impairments that greatly impact their
integration to the society. The aim of this systematic review was to identify the importance of speech
and language therapy (SLT) as part of rehabilitation curriculums for patients with schizophrenia
emphasizing on the speech and language abilities assessed, the therapy setting and the therapeutic
approach. This article reviewed 18 studies testing the effects of language therapy or training in 433
adults diagnosed with schizophrenia. Results showed that 14 studies out of 18 lead to improvements in
language and/or speech abilities. Most of these studies comprised pragmatic or expressive discursive
skills being the only aim of the therapy or part of it. The therapy settings vary widely ranging from
twice daily individual therapy to once weekly group therapy. The therapeutic approach was mainly
operant conditioning. Although the evidence tends to show that certain areas of language are treatable
through therapy, it remains difficult to state the type of approach that should be favoured and
implemented to treat language impairments in schizophrenia.
Keywords
Psychiatry, rehabilitation, communication, speech-language pathology
1. Introduction
Pragmatics is a major component of language referring to the use of language in context. It involves
verbal, paralinguistic and nonverbal aspects of communication, such as the ability to introduce a topic
of conversation, respect turn-taking, detect emotions in someone else voice and adopt appropriate body
posture and facial expression according to the social context (Prutting & Kirchner, 1987). Pragmatics
deficits are reflected in discourse skills, and more specifically in discourse coherence (i.e. continuity
across adjacent utterances and in the overall meaning) (Ulatowska & Olness, 2007). Indeed, nonrespect of the topic and situation in which the conversation takes part make the discourse lacking of
coherence. Pragmatics deficits are observed in many clinical populations such as individuals with
schizophrenia (Haas et al., 2015), autism spectrum disorders (Simmons et al., 2014), specific language
impairments (Mäkinen et al., 2014) and right brain damage (Sobhani-Rad et al., 2014).
Since the beginning of the 20th century (Bleuler, 1950; Kraeplin, 1919), communication impairments,
and more specifically in the areas of pragmatics and discourse understanding (Byrne et al., 1998; Haas
et al., 2015; Meilijson et al., 2004; Pavy, 1968; Salavera et al., 2013; Tavano et al., 2008), have
constantly been considered as an indicator of schizophrenia. Communication impairments in
schizophrenia can be apparent both in oral production and comprehension (DeLisi, 2001). Some
authors reported impaired pragmatic and discursive abilities in schizophrenia: low self-disclosure in
conversation (Byrne et al., 1998), less information provided in narratives (Byrne et al., 1998; Tavano et
al., 2008), difficulty to produce appropriate interpretations (Tavano et al., 2008), and deficits in proverb
comprehension and use of less connectors in discourse (Haas et al. 2015). With the Pragmatic Protocol
(Prutting & Kirchner, 1987), Meilijson et al. (2004) also identified 5 clusters of pragmatic deficits:
topic, speech acts, turn-taking, lexical (e.g. conciseness, prosody) and non-verbal aspects. The authors
formed three different profiles of inappropriateness according to the deficits exhibited: minimal
impairment, lexical impairment and interactional impairment. Further, pragmatic deficits in
schizophrenia have been associated with formal thought disorders (Salavera et al., 2013) and
impairment in theory of mind (i.e. a difficulty in representing the emotional and intellectual state of
mind of the interlocutor) (Brüne & Bodenstein, 2005; Mazza et al. 2007). It has also been suggested
that pragmatic deficits are key features of schizophrenia (Tavano et al., 2008).
In our current first-world reality, the slightest deficit can create a substantial handicap since
communication and interpersonal skills are put forward and play a crucial role in social integration,
2
personal recognition, working purposes, etc. As stated by the Schizophrenia Society of Canada (2014),
the reality underlying these impairments is that as many as 70 percent of people living with
schizophrenia would like to be engaged in competitive employment, but fewer than 15 percent are
actually employed. Social difficulties are one of the hallmarks. Communication impairments associated
with a diagnostic of schizophrenia are hence a central issue to assess regarding any goal for optimizing
their quality of life and functioning in society on both a personal and professional level.
Speech and Language Therapy (SLT) comprises behavioral interventions addressing oral and written
communication impairments and are provided by speech language pathologists and has been shown
effective in various clinical populations of adults (Brady et al., 2012) and children (Law et al., 2003).
These interventions entail direct training of linguistic behaviors and/or environmental adaptations to
facilitate communication. They can be delivered within a functional approach when the aim is to
improve communication during daily activities (LPAA Project Group, 2008). Other interventions might
also be used for individuals with schizophrenia in order to improve language or speech, such as
cognitive remediation, operant conditioning therapy, cognitive behavioral therapy, integrated
psychological therapy or general psychiatric rehabilitation. Cognitive remediation can be defined as an
‘intervention targeting cognitive deficit (attention, memory, executive function, social cognition, or
meta cognition) using scientific principles of learning with the ultimate goal of improving functional
outcomes’ (McGurk et al., 2013). Operant conditioning therapies implies the use of explicit and
systematic reinforcement to a specified response in order to modify behavior (Keutzer, 1967).
Cognitive behavioral therapy aims at promoting accurate and balanced thinking with the goal of
producing changes in behavior (Farmer & Chapman, 2015). Integrated psychological therapy entails
training in cognitive functions, social perception, verbal communication and social skills (Taksal et al.,
2015). Psychiatric rehabilitation can also address speech and language deficits through individualized
rehabilitative programs based on patient’s disabilities and strengths, including realistic goals and
regular measures of progress (Gigantesco & Giuliani, 2011).
The National Institute of Mental Health (2009) and the Schizophrenia Society of Canada (2014) along
with the Canadian Psychiatric Association currently provides the population with information
regarding language and social skills training for individuals with schizophrenia, taking place in
different rehabilitation facilities and provided by social workers or occupational therapists. In both
booklets, there is no mention of SLT involved in the rehabilitation process. This is in line with the fact
3
that few studies specifically examined the efficacy of SLT to treat language deficits in individuals with
schizophrenia. Language deficits have recently been targeted in cognitive remediation programs, but
SLT is not yet systematically part of a comprehensive intervention in schizophrenia. One reason is that
pragmatic and discourse deficits might not always be the most preoccupying symptoms, in comparison
with other symptoms such as hallucinations. However, considering that pragmatic deficits compromise
the integration of individuals with schizophrenia, and that pragmatic deficits can be assessed and
treated as part of SLT, it could be an appropriate approach to treat language deficits observed in
individuals with schizophrenia. Furthermore, when adopting a mindset in which therapeutic care for
individuals living with schizophrenia is specialized and complete, it comes obvious that the place of
SLT in psychiatry is small and circumscribed. This hampers the diffusion of the clinical expertise and
to a stronger degree, the recognition of SLT as a science based on scientifically proven data. However,
in the recent years, projects have started to explore the potential development of SLT in adults with
schizophrenia in hopes of legitimating SLT in adult psychiatry (Findlay, 2012). Through experimental
designs, attempts have been made to answer a need for using and eventually developing standardized
tests for this population (LeBar & Mahouet, 2011). The findings of the latter suggest that non-verbal
communication, verbal perseverations, inference and deduction are areas that should be explored in
therapy for schizophrenia.
It is important to consider all fields of expertise that have previously tested language as a variable in
studies as SLT is part of medical and rehabilitation facilities where science is supported by high
degrees of evidence and the amount of required scientific data available is currently minimal. This is of
capital importance especially when aiming at providing patients with the most accurate support
possible based on an evidence-based practice.
Due to the lack of evidence, there is currently no consensus on the most efficient language or
communication therapy available for treating patients with schizophrenia (National Institute of Mental
Health, 2009; Schizophrenia Society of Canada, 2014). This systematic review hence aims at
identifying the importance of SLT as part of rehabilitation curriculums for patients with schizophrenia
and addressing the various approaches used for therapies while providing an insight on the different
conclusions reached by those studies. The main factors discussed to highlight which approaches might
be beneficial are 1) the therapeutic approach of the studies reviewed; 2) speech and language abilities
assessed; 3) the therapy setting.
4
2. Methods
2.1 Search strategy
The search for articles included in this systematic review was used CINAHL and PubMED databases
with no year restriction up to December 2015. Keywords used the following combination:
((schizophrenia) AND ((language) OR speech)) AND ((((therapy) OR intervention) OR training) OR
remediation). We applied filters to identify relevant literature in English and examining humans. This
search yielded to 1355 results. After removal of doubles, 1287 articles remained.
2.2 Selection criteria
In a first phase of study selection, we excluded those abstracts (1) not reporting original data (e.g.,
reviews, meta-analyses), (2) not including subjects who were adults (older than 18 years of age) and
diagnosed with schizophrenia, (3) not assessing speech or language component before and after
therapy, and (4) not delivering behavioral intervention (i.e., pharmacotherapy) as therapy. From the
1287 articles found in the initial search, 1217 were excluded after title and abstract reading because
they did not meet these inclusion criteria. Then 70 articles were full-text reviewed and 52 were
excluded because they did not meet the inclusion criteria. This selection resulted in 18 articles (see
Figure 1 for the flowchart).
Please insert Flowchart about here
3. Results
Eighteen studies were retained for this systematic review. Together they included 433 adults diagnosed
with schizophrenia: 326 subjects received language therapy or training and 107 subjects received
control intervention. In the thirteen studies reporting the ratio of men and women, men were more
represented with two exceptions, Mundt et al. (1995) with 60% of females and Allen et al. (1978) who
conducted a case study with a woman. The number of subjects included in these studies varied between
single cases studies (Allen et al., 1978; Foxx et al., 1988; Clegg et al., 2007) and studies with large
sample size (e.g., 93 participants with schizophrenia; Ojeda et al., 2012). Details on these 18 studies
5
can be found in Table 1.
Please insert Table 1 about here
3.1 Therapeutic approach
The therapeutic approach that was the most represented for realising the interventions was based on
operant conditioning (5 studies). The main goal of these five studies was to enhance communication.
This approach led to improvement in pragmatic skills, discourse production or naming in these five
studies (Allen et al., 1978; Baker, 1971; Cliff, 1974; Foxx et al., 1988; Hart et al., 1980). However,
improvements were sometimes observed only for some participants (Cliff, 1974) or were not
transferred in everyday life (Allen et al., 1978). Three studies (Hoffman & Satel, 1993; Kramer, 2001;
Ryu et al., 2006) used so-called metacomprehension (explicit training on communication skills) or
metalearning (self monitoring, self learning). Both approaches led to significant improvement in
pragmatic skills or discourse production, whether the goal of the intervention was to improve
communication (Hoffman & Satel, 1993; Kramer, 2001) or social abilities and clinical symptoms in a
wider perspective (Ryu et al., 2006). Cognitive remediation was used in the three most recent studies,
which aimed to improve cognitive functions in general (Man et al., 2012; Ojeda et al., 2012) or
autobiographical memory (Blairy et al., 2008). Only Ojeda et al. (2012) found a significant
improvement in language, specifically in phonological fluency. The remaining seven studies used
different approaches (psychiatric rehabilitation, cognitive behavioral therapy, functional approach,
integrated psychological therapy and vestibular stimulation) alone or combined to treat speech and/or
language deficits in patients with schizophrenia. The efficacy of these various approaches remains
unclear to treat speech and/or language deficits in this population.
3.2 Speech and language abilities assessed
Among the eighteen studies analysed, twelve measured pragmatic skills and/or discourse as part of the
therapy (see Table 1). Eleven of them reported significant changes in pragmatic skills and/or discourse,
for at least some participants. The following skills have been treated and measured in several studies:
discourse coherence, amount of speech, clarity, intelligibility, appropriateness and elaboration of
responses. Clegg et al. (2007) and Kawabuko et al. (2007) targeted non-verbal aspects of pragmatics;
an improvement was reported by Clegg et al. (2007). Within the twelve studies which assessed
pragmatic skills and/or discourse, five conducted follow-up assessments after the last therapy session
6
ranging from 8 weeks to 2 years. Verbal fluency have been assessed in 3 studies, and improved in one
of them (Ojeda et al., 2012). Naming have been assessed in four studies, and improved in two of them.
Nevertheless, improvement in naming was not retained at one month follow-up (Kondel et al., 2006)
and did not lead to improvement of verbal behavior in everyday life (Allen et al., 1978). The four
studies that did not reach any significant changes in speech or language with therapy measured
repetition, naming, comprehension, verbal or phonological fluency, and one measured pragmatics.
We extracted quantitative data (Glass’s Delta) from six studies; the remaining twelve studies did not
report means and standard deviations of performance before and after therapy or they were case studies
so we could not calculate effect sizes. We considered that effect size values lower than 0.5 were not
significant, values between 0.5 and 1 reflected small positive effects of therapy, and values between 1
and 2 were clinically relevant. We found clinically relevant improvement for discourse production
(score of intelligibility, appropriateness and elaboration of responses) (Baker, 1971), small positive
effects for phonological fluency (Ojeda et al., 2012) and naming (Kondel et al., 2006), but no
significant changes for sentence comprehension, repetition and naming (Man et al., 2012), verbal and
semantic fluency (Blairy et al., 2008; Ojeda et al., 2012), and pragmatic non-verbal skills (Kawabuko et
al., 2007).
3.3 Therapy setting
Individual therapy was preferred by researchers in fourteen studies, whereas the four other studies
favoured group therapy. Eleven out of fourteen studies using individual therapies led to improvements,
and three out of the four group therapies also induced to improvements.
4. Discussion
The main objective of this systematic review was to identify the importance of SLT as part of
rehabilitation curriculums for patients with schizophrenia, as well as characterize interventions that
seems to be beneficial to treat speech and language impairments highlighting 1) the therapeutic
approach; 2) the speech and language abilities assessed, and 4) the therapy setting.
4.1 Therapeutic approach
7
Operant conditioning was the most favoured approach in our reviewed articles. Operant conditioning
has been documented and used in psychology for decades, it is not surprising that this was also the
preferred approach used by researchers in this last decade. As new theories emerged, approaches
became more eclectic and this shows in the sample of studies used in this review. Cognitive
remediation also seems to be privileged in recent years. There was no clear evidence from the studies
reviewed here that this approach leads to significant improvement in speech or language, and changes
in social cognition or social skills appear inconsistent. Social cognition was improved with cognitive
remediation (Mendella et al. 2015) but not when cognitive remediation was combined with a program
of social skills-training (Kurtz et al. 2015) or with an integrated supported employment (Au et al.,
2015). Efficiency of cognitive remediation on speech and language abilities may vary according to its
aim: the one specifically targeting communication may lead to better results than the one targeting
cognitive functions in general. Finally, social skills-training seems to reduce social impairments in
individuals with schizophrenia (Bellack, 2004), which may also improve pragmatics and discourse
skills in these individuals.
Unfortunately it is not possible to connect articles to each other based on similar underlying theories.
As stated by Kramer et al. (2001) “despite the significance of the language of patients who are mentally
ill, there are no satisfactory descriptions of their language and as a consequence no published
hypothesis driven therapy programmes to remediate their language”. Further progress of a unified
conceptual model would greatly contribute to better describe speech and language impairments, as well
as to develop SLT interventions specifically for patients with schizophrenia.
4.2 Speech and language abilities assessed
This review indicates that pragmatics and discourse are skills that can be trained in patients with
schizophrenia and that this training can be retained over time. From the eighteen studies reviewed here,
twelve targeted pragmatic or discursive skills that are impaired in individuals with schizophrenia, and
eleven of them showed an improvement. Five of these twelve studies also assessed pragmatics and/or
discourse skills with follow up assessments. The all reported improvements that were maintained at
follow-up assessment ranging from eight weeks to two years. We could not calculate effect sizes for
most of these studies, it is thus difficult to compare the efficiency of these therapies on language or
speech skills. These findings are coherent with current knowledge on language and speech impairments
in patients with schizophrenia. Impairments in pragmatic rules along with general cognitive deficits
8
greatly affect the construction of a coherent discourse (Marini et al., 2008). However, one study
targeted pragmatics with therapy and reported negative findings (Kawakubo et al., 2007). These results
might be explained by the choice of the therapy, social skills training based on a medication selfmanagement module (Liberman & Martin, 2002), a therapy that might not be specific enough to teach
and train pragmatics. Studies targeting communication impairments as a whole and including formal
testing of language in areas known to be less affected in patients with schizophrenia reported that
therapy did not lead to significant changes (Lewis et al., 2003; Man et al., 2012). These approaches
indicate that skills such as naming, repetition, and verbal comprehension may not be sufficiently
impaired to be targeted in therapies and/or therapies have yet to be developed for this clinical
population. It is also possible that some deficits would be endophenotypes of schizophrenia, these
deficits being more resistant to treatment. For instance, semantic verbal fluency impairments remain
unchanged in individuals with schizophrenia despite treatment (Szöke et al., 2008) and appear to
discriminate responders from non-responders to a pharmacological treatment (Stip et al., 1999). In sum,
pragmatic and discourse skills can be improved with therapy in patients with schizophrenia. However,
only nine studies out of eighteen measured speech and language skills with follow-up assessments. It is
thus difficult to conclude on the long-term benefits of an intervention targeting speech and language
deficits for patients with schizophrenia. Future studies should further test retention of gained skills over
time.
4.3 Therapy setting
Both individual and group therapies led to improvements or no changes in the studies reviewed here.
Most studies preferred an individual setting for therapy, however this choice did not seem to be based
on previous evidence. This trend of favouring individual therapy is common in current rehabilitation
setting. It should also be noted that some studies delivering group therapy targeted hospitalized patients
(Ojeda et al., 2012; Ryu et al., 2006) who were likely more severely impaired than outpatients.
In terms of duration of therapeutic sessions and frequencies, they greatly differed across studies.
Duration of therapies ranged from 15 days to 2 years and each lasted from 15 to 90 minutes. Frequency
of the sessions delivered went from twice a day to once a week. It seems that shorter durations with
higher frequencies such as in Cliff (1974) that reported beneficial changes using a similar approach
may be privileged over longer durations with spaced times. This is also in line with other field such as
in aphasia (Godecke et al., 2012) and children with language difficulties (Barratt et al., 1992), in which
9
the subjects receiving intensive individual therapy, 5 and 4 times a week respectively, had better
improvement on communication outcomes than those receiving individual therapy once a week.
Unfortunately, duration of therapy was not reported in all the studies reviewed here.
4.4 Limitations and future directions
This systematic review has limitations to be considered. The number of participants was limited,
participants were diagnosed based on different editions of the DSM and gender ratio was not
representative of the general population of schizophrenia. In studies with smaller samples, interindividual variations might account for a high percentage of the success or failure of the therapies
tested taking in account also intrinsic motivations of patients. This is why using larger sample sizes as
it was done by Ojeda et al. (2012) who tested 93 patients are encouraged in order to formulate broader
generalizations on the efficiency of these treatments. This is especially important when considering the
various disorders recognized by the Diagnostic and Statistical Manual of Mental Disorders 5th edition
(DSM-5; APA, 2013) and the different presentations of speech and language impairments due to illness
ranging from muteness (Baker, 1971) to lengthy utterances (Kramer, 2001). For instance, the 5
subtypes of schizophrenia were removed in the 5th edition due to limited diagnostic stability, low
reliability, and poor validity. Moreover, five studies included in this review did not conduct statistical
analyses as they were case studies. Also, gender ratio in the reviewed articles was not fully
representative of the general population. In the eighteen studies, men were always more represented
than women with two exceptions. However, as reported by the National Institute of Mental Health
(NIMH) (2009), the proportion of male and female living with a diagnostic of schizophrenia around the
world is of 50/50. Recruitment processes greatly varied across studies. For instance, Ryu et al. (2006)
systematically offered therapy to an entire facility dedicated to patients with schizophrenia, whereas
Man et al. (2012) used randomized, controlled, double-blind selection and treatment of patients with
schizophrenia. It is thus difficult to generalize findings from this work to the general population of
adults with schizophrenia. Moreover, methodological aspects of the studies reviewed vary widely (e.g.
therapy settings, length and intensity of interventions, speech and language abilities that are trained)
which made the results difficult to compare and interpret. Consequently, despite improved pragmatic
and discourse skills with therapy, the strength of evidence should be considered with precaution and the
need for more studies with follow-ups remains.
In future studies, it would be interesting to investigate whether improved language and communication
10
skills in patients with schizophrenia enhances their quality of life and/or reduces frequency and severity
of positive and negative symptoms of schizophrenia. Hoffman and Satel (1993) found reduced severity
or frequency of auditory hallucinations in patients who improved their language abilities following
SLT. Nevertheless, most studies reviewed here did not measure the impact of the intervention targeting
language and communication on patient’s quality of life with standardized questionnaires.
In accordance to the strength of the evidence presented here, therapies should focus on pragmatic skills
and discourse production should be the areas where on. Improved pragmatic and discourse skills can
certainly help patients in social reintegration and quality of life. There is however much work to be
done. Moreover, we believe that the place of the expertise of SLT is yet to be made in schizophrenia as
most studies reviewed here appear to come from psychology (e.g. studies using operant conditioning)
and neuropsychology (e.g. studies using cognitive remediation). Best case practices and rigorous
scientific studies are rare in a young and emerging discipline such as SLT. The field of SLT can
contribute at characterizing speech and language impairments across life span of patients with
schizophrenia in a detailed manner, as well as identifying and developing efficient approaches to treat
speech and language impairments with evidence based data. Existing multidisciplinary service offered
to these patients might consider including SLT speciality in the future, as well as strong incentives
within the SLT field should be put forward in order to develop standardized tests for evaluating speech
and language skills of patients with schizophrenia.
Role of the Funding Source
M. Joyal was supported by a Centre Interdisciplinaire de Recherche en Réadaptation et Intégration
Sociale PhD scholarship. This work was supported by the National Sciences and Engineering Research
Council of Canada grant (402629-2011) and Canada Research Chair in Cognitive Neuroplasticity to S.
Fecteau.
Acknowledgments
None
References
Allen, D.J., Antonitis, J.J., Magaro, P.A., 1978. Reinforcing effects of prerecorded words and delayed
speech feedback on the verbal behavior of a neologistic schizophrenic. Percept. Motor Skill. 46,
11
343-346.
American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders (5th
ed.). Washington, DC: Author.
Au, D.W.H., Tsang, H.W.H., So, W.W.Y., Bell, M.D., Cheung, V., Yiu, M.G.C., Tam, K.L., Lee,
G.T.H., 2015. Effects of integrated supported employment plus cognitive remediation training for
people with schizophrenia and schizoaffective disorders. Schizophr. Res. 166, 297-303.
Bailey, D.M., 1978. The effects of vestibular stimulation on verbalization in chronic schizophrenics.
Am. J. Occup. Ther. 32(7), 445-450.
Baker, R.,1971. The use of operant conditioning to reinstate speech in mute schizophrenics. Behav.
Res. Ther. 9(4), 329-336.
Barratt, J., Littlejohns, P., Thompson, J., 1992. Trial of intensive compared with weekly speech therapy
in preschool children. Arch. Dis. Child. 67(1), 106–108.
Bellack, A.S., 2004. Skills training for people with severe mental illness. Psychiatr. Rehabil. J. 27(4),
375-391.
Blairy, S., Neumann, A., Nutthals, F., Pierret, L., Collet, D., Philippot, P., 2008. Improvements in
autobiographical memory in schizophrenia patients after a cognitive intervention: A preliminary
study. Psychopathology. 41, 388-396.
Bleuler, E., 1950. Dementia praecox : On the group of schizophrenias (J. Zimkin, Trans.). International
Universities Press, NY. (First published 1911).
Brady, M.C., Kelly, H., Godwin, J., Enderby, P., 2012. Speech and language therapy for aphasia
following stroke. Cochrane Db. Syst. Rev. 5, CD000425.
Brüne, M., Bodenstein, L., 2005. Proverb comprehension reconsidered-‘theory of mind’ and the
pragmatic use of language in schizophrenia. Schizophr. Res. 75, 233-239.
Byrne, M.E., Crowe, T.A., Griffin, P.S., 1998. Pragmatic language behaviors of adults diagnosed with
chronic schizophrenia. Psychol. Rep. 83, 835-846.
Canadian Psychiatry Association, Schizophrenia Society of Canada, 2007. Schizophrenia : The Journey
to Recovery (A consumer and Family Guide to Assessement and Treatment). Retrieved
December 14th, 2015, from: http://www.schizophrenia.ca/journey_to_recovery.php
Clegg, J., Brumfitt, S., Parks R.W., Woodruff P.W.R., 2007. Speech and language therapy intervention
in schizophrenia – a case study. Int. J. Lang. Comm. Dis. 42(S1), 81-101.
Cliff, M.J., 1974. Reinstatement on speech in mute schizpohrenics by operant conditioning. Acta.
Psychiat. Scand. 50(6), 577-585.
12
DeLisi, L.E., 2001. Speech disorder in schizophrenia: Review of literature and exploration of its
relation to uniquely human capacity for language. Schizophrenia Bull. 27(3), 481-496.
Farmer, R.F., Chapman, A.L., 2015. Behavioral interventions in cognitive behavior therapy: practical
guidance for putting theory into action, second ed. Washington, DC.
Findlay, C., 2012. Intérêt de la prise en charge orthophonique des personnes souffrant de
schizophrénie, dans une perspective de réhabilitation psychosociale: Étude de cas. Université de
Nancy.
Foxx, R.M., McMorrow, M.J., Davis, I.A., Bittle, R.G., 1988. Replacing a chronic schizophrenic man’s
delusional speech with stimulus appropriate responses. J. Behav. Ther. Exp. Psy. 19, 43-50.
Gigantesco, A., Giuliani, M., 2011. Quality of life in mental health services with a focus on psychiatric
rehabilitation practice. Ann. Ist. Super. Sanità. 47(4), 363-372.
Godecke, E., Hird, K., Lalor, E.E., Rai, T., Phillips, M. R., 2012. Very early poststroke aphasia
therapy: A pilot randomized controlled efficacy trial. Int. J. Stroke. 7(8), 635–644.
Haas, M.H., Chance, S.A., Cram, D.F., Crow, T.J., Aslan, L., Hage, S., 2015. Evidence of pragmatic
impairments in speech and proverb interpretation in schizophrenia. J. Psycholinguist. Res. 44,
469-483.
Hart, B.B., 1980. Speech modification in near-mute schizophrenics. Brit. J. Psychol. 71(2), 241-246.
Hoffman, R.E., Satel, S.L., 1993. Language therapy for patients with persistent ‘voices’. Brit. J.
Psychiat. 162, 755-758.
Kawakubo, Y., Kamio, S., Nose, T., Iwanami, A., Nakagome, K., Fukuda, M., 2007. Phonetic
mismatch negativity predicts social skills acquisition in schizophrenia. Psychiat. Res. 152, 261265.
Keutzer, C.S., 1967. Use of therapy time as a reinforcer : application of operant conditioning
techniques within a traditional psychotherapy context. Behav. Res. Ther. 5, 367-370.
Kondel, T., Hirsch, S., Laws, K., 2006. Name relearning in elderly patients with schizophrenia:
Episodic and temporary, not semantic and permanent. Cogn. Neuropsychiatry. 11(1), 1-12.
Kraeplin, E., 1919. Dementia praecox and paraphrenia. Robert E. Krieger, New York.
Kramer, S. Bryan, K., Frith, C.D., 2001. Mental illness and communication. Int. J. Lang. Comm. Dis.
36(137-2).
Kurtz, M.M., Mueser, K.T., Thime, W.R., Corbera, S., Wexler, B.E., 2015. Social skills training and
computer-assisted cognitive remediation in schizophrenia. Schizophr. Res. 162, 35-41.
Law, J., Garrett, Z., Nye, C., 2003. Speech and language therapy interventions for children with
13
primary speech and language delay or disorder. Cochrane Db. Syst. Rev. 3, CD004110.
LeBar, M., Mahouet, C., 2011. Schizophrénie et orthophonie: Évaluation des compétences
pragmatiques, par le protocole MEC, de patients adultes schizophrènes. Lille.
Lewis, L., Unkefer, E.P., O’Neal, S.K., Crith, C.J., Fultz, J., 2003. Cognitive rehabilitation with
patients having persistent, severe psychiatric disabilities. Psychiatr. Rehabil. J. 26, 325-331.
Liberman, R., Martin, T., 2002. Social skills training for people with serious mental illness. Retrieved
August 15th, 2015, from : http://www.bhrm.org/guidelines/mhguidelines.htm
LPAA Project Group, 2008. Life-participation approach to aphasia: A statement of values for the
future, in Chapey, R. (Ed.), Language intervention strategies in aphasia and related neurogenic
communication disorders (5th ed.). Lippincott, Williams & Wilkins, Philadelphia, pp. 279-289.
Mäkinen, L., Loukusa, S., Laukkanen, P., Leinonen, E., Kunnari, S., 2014. Linguistic and pragmatic
aspects of narration in Finnish typically developing children and children with specific language
impairment. Clin. Linguist. Phonet. 28(6), 413-427.
Man, D.W., Law, K.M., Chung, R.C., 2012. Cognitive Training for Hong Kong Chinese with
schizophrenia in vocational rehabilitation. Hong Kong Med. J. 18(6), 18-22.
Marini, A., Spoletini, I., Rubino, I.A., Ciuffa, M., Bria, P., Martinotti, G., 2008. The language of
schizophrenia : An analysis of micro and macrolinguistic habilities and their neuropsychological
correlates. Schizophr. Res. 105, 144-155.
Mazza, M., Di Michele, V., Pollice, R., Roncone, R., Casacchia, M., 2007. Pragmatic language and
theory of mind deficits in people with schizophrenia and their relatives. Psychopathology. 708, 110.
McGurk, S.R., Mueser, K.T., Cicerone, K.D., Silverstein, S.M., Myers, R., Bell, M.D., Covell, N.H.,
Drake, R.E., Medalia, A., Bellack, A.S., Essock, S.M., 2013. Mental health system funding of
cognitive enhancement interventions for schizophrenia: Summary and update of the New York
office of mental health expert panel and stakeholder meeting. Psychiatr. Rehabil. J. 36(3), 133145.
McPherson, F.M., Cockram, L.L., Grimes, J., Fraser, D., Presly, A.S., 1979. The restoration of one
aspect of communication in chronic schizophrenic patients. Health. Bull. (Edinb). 37(5), 227-231.
Meilijison, S.R., Kasher, A., Elizur, A., 2004. Language performance in chronic schizophrenia: a
pragmatic approach. J. Speech Hear. Res. 47(3), 695-713.
Mendella, P.D., Burton, C.Z., Tasca, G.A., Roy, P., St. Louis, L., Twamley, E.W., 2015. Compensatory
cognitive training for people with first-episode schizophrenia: Results from a pilot randomized
14
controlled trial. Schizophr. Res. 162, 108-111.
Mundt, C., Barnett, W., Witt, G., 1995. The core of negative symptoms in schizophrenia: affect of
cognitive deficiency? Psychopathology. 28(1), 46-54.
National Institute of Mental Health, 2009. Schizophrenia. Retrieved August 4th, 2015, from:
http://www.nimh.nih.gov/health/publications/schizophrenia/index.shtml
Ojeda, M., Peña, J., Sánchez, P., Bengoetxea, E., Elizagárate, E., Ezcurra, J., Gutiérrez, G., 2012.
Efficiency of cognitive rehabilitation with REHACOP in chronic treatment resistant Hispanic
patients. NeuroRehabilitation. 30, 65-74.
Pavy, H., 1968. Verbal behavior in schizophrenia : A review of recent studies. Psychol. Bull. 70, 164178.
Prutting, C.A., Kirchner, D.M., 1987. A clinical appraisal of the pragmatic aspects of language. J.
Speech Hear. Disord. 52, 105-119.
Ryu, Y., Mizuno, M., Sakuma, K, Munakata, S., Takebayashi, T., Murakami, M., 2006.
Deinstitutionalisation of long-stay patients with schizophrenia: the 2-year social and clinical
outcome of a comprehensive program in Japan. Aust. Nz. J. Psychiat. 40(5), 462-470.
Salavera, C., Puyuelo, M., Antoñanzas, J.L., Teruel, P., 2013. Semantics, pragmatics, and formal
thought disorders in people with schizophrenia. Neuropsychiatr. Dis. Treat. 9, 177-183.
Schizophrenia Society of Canada, 2014. Learn More About Schizophrenia. Retrieved July 21st, 2015,
from : http://www.schizophrenia.ca/learn_more_about_schizophrenia.php
Simmons, E.S., Paul, R., Volkmar, F., 2014. Assessing pragmatic language in autism spectrum
disorder : The Yale in vivo pragmatic protocol. J. Speech Lang. Hear. R. 57, 2162-2173.
Sobhani-Rad, D., Ghorbani, A., Ashayeri, H., Jalaei, S., Mahmoodi-Bakhtiari, B., 2014. The
assessment of pragmatics in Iranian patients with right brain damage. Iran J. Neurol. 13(2), 8387.
Stip, E., Lussier, I., Ngan, E., Mendrek, A., Liddle, P., 1999. Discriminant cognitive factors in
responder and non-responder patients with schizophrenia. Eur. Psychiatry. 14, 442-450.
Szöke, A., Trandafir, A., Dupont, M.E., Méary, A., Schürhoff, F., Leboyer, M., 2008. Longitudinal
studies of cognition in schizophrenia: meta-analysis. Br. J. Psychiatry. 192, 248-257.
Taksal, A., Sudhir, P.M., Janakiprasad, K.K., Viswanath, D., Thirthalli, J., 2015. Feasibility and
effectiveness of the Integrated Psychological Therapy (IPT) in patients with schizophrenia: a
preliminary investigation from India. Asian J. Psychiatr. 17, 78-84.
Tavano, A., Sponda, S., Fabbro, F., Perlini, C., Rambaldelli, G., Ferro, A., Cerruti, S., Tansella, M.,
15
Brambilla, P., 2008. Specific linguistic and pragmatic deficits in Italian patients with
schizophrenia. Schizophr. Res. 102, 53-62.
Ulatowska, H.K., Olness, G.S., 2007. Pragmatics in discourse performance : Insights from aphasiology.
Semin. Speech Lang. 28(2), 148-157.
Figure 1. Flowchart of the study selection process.
Table 1. Summaries of the studies investigating the effects of therapy or training on speech and
language abilities in adults with schizophrenia.
*mo/mos, month/months; wks, weeks; yr/yrs, year/years.
Therapeutic
approach
Speech and
language
abilities
assessed
Therapy
setting
N of
subjects
Male
sex
ratio
Followup
measur
e
Results
Effect size
(Glass’s
delta)
Man et al. (2012) Cognitive training for Hong Kong Chinese with schizophrenia in vocational rehabilitation.
80
(includin
individua
g 30
N/A 3 mos
negative
0.40
l
control
patients)
Ojeda et al. (2012) Efficiency of cognitive rehabilitation with REHACOP in chronic treatment resistant
Hispanic patients.
phonologica
93
l fluency :
semantic,
improved
cognitive
(includin
0.9
phonological
group
78% no
phonological
remediation
g 46
semantic
fluency
fluency
control
fluency :
patients)
0.48
Blairy et al. (2008) Improvements in autobiographical memory in schizophrenia patients after a cognitive
intervention
cognitive
remediation
combined with
27
principles of
(includin
cognitive
verbal fluency
group
g 12
53 % 3 mos
negative
-0.05
behavioural
control
therapy
patients)
(autobiographical
memory
intervention)
cognitive
remediation
(errorless training)
sentence
comprehension
, repetition,
naming
Clegg et al. (2007) Speech and language therapy intervention in schizophrenia- a case study.
16
combination of
cognitive
behavioral therapy
(desensibilisation)
and functional
approach (less
structured
conversations)
repetition,
naming, word
association,
reading
comprehension
, discourse
comprehension
, discourse
production
(selfdescription, use
of emotional
words),
pragmatics
(eye contact,
facial
expression)
individua
l
1
100
%
no
improved
discourse
production and
pragmatics*
(negative
attitude to
communicatio
n remained
unchanged)
N/A
Kawakubo et al. (2007) Phonetic mismatch negativity predicts social skills acquisition in schizophrenia.
psychiatric
rehabilitation
(medication selfmanagement
module of a social
skills training
program)
pragmatic
skills (eye
contact, facial
expression,
voice loudness,
voice tone,
maintaining
conversation,
fluency of
conversation,
clarity of
message, social
validity of the
interaction and
goal
attainment)
individua
l
13
69%
no
negative
0.07
Kondel et al. (2006) Name relearning in elderly patients with schizophrenia : Episodic and temporary, not
semantic and permanent
name relearning
(naming with
repetition of good
answers)
naming
individua
l
10
N/A
1 mo
improved
naming but not
0.53
maintained at
follow-up
Ryu et al. (2006) Deinstitutionalization of long-stay patients with schizophrenia- the 2-year social and
clinical outcome of a comprehensive intervention program in Japan.
17
metacomprehensio
n
(explicit training
on communication
skills)
pragmatic
skills/discourse
production
(speech skills :
amount and
initiation of
speech,
disturbed
speech : speech
sense and
clarity)
group
60
63%
2 yrs
improved
speech skills
and disturbed
speech scores
N/A
Lewis et al. (2003) Cognitive rehabilitation with patients having persistent, severe psychiatric disabilities.
Integrated
Psychological
Therapy
phonological
fluency,
verbal
comprehension
individua
l
38
N/A
3 mos
negative
N/A
no
improved
discourse
production
(more
essential
frames, no
more
irrelevant
frames)*
N/A
Kramer (2001) Mental illness and communication
metalearning
(self monitoring
and self learning)
discourse
production
(macrostructur
e of narrative
discourse :
inclusion of
essential
frames)
individua
l
2
100
%
Mundt et al. (1995) The core of negative Symptoms in Schizophrenia: Affect or Cognitive Deficiency?
psychiatric
rehabilitation
discourse
production
(coherence)
individua
l
25
40%
no
improved
discourse
production
N/A
Hoffman & Satel (1993) Language therapy for schizophrenic patients with persistent 'voices'.
qualitative
improvements
prosody,
in a range of
combination of
semantic,
individua
100
language
metacomprehensio discourse
4
no
N/A
l
%
exercises
n and metalearning production,
(including
comprehension
coherence of
discourse)*
Foxx et al. (1988) Replacing a chronic schizophrenic man's delusional speech with stimulus appropriate
responses.
18
operant
conditioning
(errorless training)
pragmatic
skills
(connectedness
of responses
and contextual
appropriateness
)
individua
l
1
100
%
8 wks
15 mos
improved
pragmatic
skills*
N/A
no
greater
improvements
in discourse
production
after
modelling and
operant
conditioning
N/A
Hart et al. (1980) Speech modification in near-mute schizophrenics.
modelling and
operant
conditioning
(reinforcements)
or modelling only
discourse
production
(mean number
of words
produced)
individua
l
12
(includin
g4
control
patients)
100
%
McPherson et al. (1979) The restoration of one aspect of communication in chronic schizophrenic patients
improved
number of
words (results
confounded at
individua
21
71% 24 mos
follow-up
N/A
l
because of
other
treatment
programmes)
Allen et al. (1978) Reinforcing effects of prerecorded words and delayed speech feedback on the verbal
behaviour of a neologistic schizophrenic
improved
operant
naming after
conditioning
both kinds of
(reinforcement
reinforcement
with singly
individua
*, no
naming
1
0%
No
N/A
presented
l
remarkable
prerecorded words
improvement
or delayed speech
of verbal
feedback)
behaviour in
everyday life
treatment based on
behavioural
principles,
employed
instruction, verbal
prompting and
social
reinforcement
discourse
production
(number of
words in
responses and
spontaneous
speech)
Bailey (1978) The effects of vestibular stimulation on verbalization in chronic schizophrenics
vestibular
stimulation
(sensorystimulating
activities designed
to promote sensory
integration)
discourse
production
(speed of
responses,
number of
words used,
relevance of
responses)
group
14
(includin
g7
control
patients)
N/A
No
negative for
speed and
number of
words,
improvement
for relevance
of responses
N/A
Cliff (1974) Reinstatement of speech in mute schizophrenics by operant conditioning.
19
operant
conditioning
(reinforcements)
discourse
production
(intelligibility,
appropriateness
and elaboration
of responses)
individua
l
13
77%
1 yr
improved
discourse
production for
6 subjects
N/A
Baker (1971) The use of operant conditioning to reinstate speech in mute schizophrenics.
discourse
production
operant
(intelligibility,
conditioning
appropriateness
(reinforcements)
and elaboration
of responses)
* Not statistically tested
individua
l
18
(includin
g8
control
patients)
N/A
1 yr
improved
discourse
production
1.43
Highlights
 Pragmatic and discourse skills can be improved in people with schizophrenia.
 It remains difficult to state the type of approach that should be favoured.
 The expertise of speech and language therapy is yet to be made in schizophrenia.
Articles identified through database
searching
n = 1287 articles
(after removal of doubles)
Exclusion criteria (n = 1217) :
1- Not reporting original data
2- Not including subjects who were adults and
diagnosed with schizophrenia
3- Not assessing speech or language component
in a systematic way before and after therapy
4- Not delivering behavioural intervention as
therapy
Studies scanned for subsequent
inclusion :
n = 70 articles
Subsequently excluded studies (n = 52) :
1- Studies meeting the exclusion criteria
2- Not describing sufficiently the methodology
3- Gathering people with different mental
illnesses in the same experimental groups
Eligible articles :
n = 18 articles
20