Psychosocial Treatment for Severe
and Persistent Mental Illness
Greg Horn
Appalachian State University
Spring 2008
Overview

SPMI and schizophrenia
 Impact on family and social functioning
 Epidemiology and etiology
 Medication
 Social Skills Training
 Family interventions and
psychoeducation
 Empirical support
Severe and persistent mental illness (SPMI)

Serious mental illness (SMI) Defined by Federal regulations
referring to mental disorders that
interfere with some area of social
functioning
– One-year prevalence 5.4 %
(NIMH)

Severe and persistent mental
illness (SPMI) - severe impairment
over time
– One-year prevalence 2.6%
(NIMH)

No standardized criteria

Experts agree it involves:
– Diagnostic severity
– Degree of disability
– Duration of problem

Relies on assessment of overall
functioning, Brief Psychotic Rating
Scale-Extended (BPRS-E)
(Burlingame et al., 2006)
– Thought-disturbance, pos Sx
– Anxiety-Depression
– Withdrawal – neg Sx
– Hostile – suspicious, paranoid
– Activity / mania

Current or previous GAF of 40 or
less

Due to schizophrenia, psychotic
disorders, bipolar disorder, Major
depressive disorder, panic disorder,
obsessive-compulsive disorder

Definitions vary by state
Schizophrenia: Diagnostic criteria
•
Characteristic Sx, 2 or more for 1 month
• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behavior
• Negative Sx
•
Note: Only one is required if delusions are bizarre or hallucinations consist of a
voice keeping up a running commentary on the person’s behavior or thought, or
two or more voices conversing with each other
•
Social / occupational dysfunction

Duration: Continuous signs for at least 6 months

Schizoaffective and mood disorder exclusion

Substance / general medical condition exclusion

Pervasive developmental disorder: Additional diagnosis of
schizophrenia if prominent delusions or hallucinations
(DSM-IV-TR)
Schizophrenia subtypes

Paranoid type: Preoccupation of 1 or more delusions or frequent auditory
hallucinations

Disorganized type, all 3:
– Disorganized speech
– Disorganized behavior
– Flat or inappropriate affect

Catatonic, at least 2:
– Immobility
– Excessive activity
– Extreme negativism - motiveless resistance
– Peculiarities
– Echolalia or echopraxia
Catatonic type takes precedence, then disorganized, then paranoid
Undifferentiated type
Residual type



(DSM-IV-TR)
Epidemiology

Prevalence
–
–
–


Gender differences
– Women
• More affective Sx, paranoid
delusions, & hallucinations
• Better prognosis, attenuates with
age
– Men
• Negative Sx – flat affect, avolition,
social withdrawal

Higher rate in urban areas
– Deprivation
– Neighborhood composition
– Ethnic composition

Populations
– Occurs at similar rates across
ethnic groups (Mueser & McGurk, 2004)
– Higher for some populations
• African Caribbeans living in UK
– Culturally insensitive?
One-year - 1.3% (NIMH)
Among adults .5 – 1.5%
Slightly higher in men (DSM-IV-TR)
Onset
–
–
–
Early and late onsets do occur,
but they are rare
Men: late teens, early 20s
Women: late 20s, early 30s
•
Late onset is more common (DSM-IV-TR)
(www.schizophrenia.com)
Etiology: Genetics
www.schizophrenia.com
Etiology: Early environment
Odds ratio is determined by comparing the odds of each group to
the odds of the average person with no family history of
schizophrenia
www.schizophrenia.com
Biopsychology and anatomy

The Dopamine Theory (positive Sx)
– Reserpine, extrapyramidal side effects (EPS) and Parkinson’s
– Amphetamines and cocaine
– Haloperidol and D2 receptors

The Glutamate Theory (positive and negative Sx)
– N-methyl-D-aspartate (NMDA), a glutamate receptor is
compromised
– Complex behaviors
– Neural pathways

Small differences in brain anatomy
–
–
–
–
–
Fluid-filled ventricles are larger
Cerebral cortices are smaller
Lower gray matter volume
Less or more metabolic activity
Different distribution of brain cells
(Mueser & McGurk, 2004)
Features of SPMI interfere with social
and family functioning

Isolation

Disturbances in eating and
sleeping cycles

Poor insight: A product of
disease rather than a coping
mechanism

Violence





No higher then general population
10% commit suicide
20%-40% attempt
Low life expectancy (DSM-IV-TR)
Comorbidity
–
–
Panic disorder
OCD

Victimization

Homelessness and housing
Psychotic symptoms
 Motivational factors
 Affective states

Stigmatization


Cigarette smoking (88%,
Hughes et al., 1986)
Comprehensive treatment

Combination of optimal medication and
targeted psychosocial treatment

Psychoeducation
–
–
–
–

Symptoms
Medication and importance of adherence
Treatment and strategies
Relapse prevention
Family involvement
– Education
– Ongoing contact with treatment team
(Lehman et al., 2003)
Psychosocial Treatment

Behavioral and psychosocial
– Social skills training
– Family interventions
– Cognitive-behavioral psychotherapy
– Supported employment
– Assertive community treatment
– Token economy social learning intervention (Lehman et al., 2003)

Domain specific
– Psychoeducation improves knowledge of mental illness
– Behavioral tailoring improves medication adherence as prescribed
– Relapse prevention reduces rates of symptom relapses and
rehospitalizations
– Cognitive-behavioral coping skills training reduces the severity and
distress of persistent symptoms (Mueser et al., 2002)
What is recovery?










Development of new meaning and purpose
Short-term and long-term relief
Social successes and personal accomplishment
Personal meaning is critical
Self-confidence and self-efficacy
Self-concept beyond the illness
Enjoyment and pleasure in daily activities
Sense of well-being, hope, and optimism
Gain mastery of their symptoms
Improvement coping with stresses of daily life
(Mueser et al., 2002)
Types of pharmacotherapy

Traditional medication
– Stelazine, flupenthixol, loxipine, perphenazine, chlorpromazine,
haldol, and prolixin

Second generation
– Aripiprazole, clozaril, geodon, risperdal, seroquel, zyprexa,

Both old and new medications can help

All can have side effects depending on the person and the type of
medication

Schizophrenia medication treatment
www.schizophrenia.com
Limitations to medication

Not a cure

They don’t always work

Can take many years to find an optimal drug

Side effects

Adherence and compliance

Expensive
– Assistance programs for those who are eligible
(Taylor, 2003)
What is Social Skills Training (SST)

Behaviorally based instruction, modeling, corrective
feedback and contingent social reinforcement aimed to
improve social competence through:
– Social skills
– Self-care
– Independent living skills

Characteristics
–
–
–
–
–

Highly interactive
Structured
Systematic
Educational
Incremental approach to skills acquisition
Advantage: SST provides a useful format of teaching in
which other skills can be inserted
(Heinssen et al., 2000; Lehman et al., 2004)
Components of social skills




Expressive skills
– Speech content
– Paralinguistic features
– Nonverbal behaviors
Receptive behaviors
– Attention to and interpretation of cues
– Emotion recognition
Interactive behaviors
– Response timing
– Use of social reinforcers
– Turn taking
Situational factors
– Social “intelligence”
(Bellack et al., 2004)
Theoretical basis for SST

Social skills model (Mueser, 1998)
–
–
–
Specific social skills make up general social competence
Skills are learned or learnable
Social incompetence is a result of:
•
•
•
–

Reinforcement, shaping, overlearning
Social learning theory (Bandura, 1969)
–

Social skills training can improve social competence
Operant conditioning (Skinner, 1938, 1953)
–

A lack of required social skills
Using a social skill at the inappropriate time
Performing socially inappropriate behaviors
Modeling, generalization
Stress-vulnerability model (Zubin & Spring, 1977)
–
–
–
–
–
Perceived severity of the life event stressor
Perception of the stressfulness of the load
The capacities of the individual in dealing with the stressful event
Coping efforts exerted in dealing with the stressful situation
Vulnerability of the individual
Multi-method, multi-rater
assessment of social functioning

Comprehensive clinical interview
– Attention to social deficits
• Specific situations
• Probable source
• Observation of current behavior
– General question followed by specific questions:
• Can you remember the last time you had an argument with someone at
home/ where you live?
– When was that?
– Can you describe the situation for me?
– What exactly did you say?
– Social Functioning Interview
•
•
•
•
Role functioning, past and present
Problematic social situations
Personal goals
Social skills strengths and weaknesses
(Bellack et al., 2004)
Multi-method, multi-rater
assessment of social functioning

Assessment tools
–
Social Behavior Schedule (informant)
•
–
Katz Adjustment Scale (self & informant)
•
–
Social withdrawal, interpersonal functioning , prosocial activities, recreation, level of independence, level of
dependence, and employment
Social-Adaptive Functioning Evaluation (designed for geriatrics, but can be used for low functioning individuals
with schizophrenia)
•
–
Self-care, social contact, appropriateness of communication, social responsibility, & social turbulence
Social Functioning Scale (self & informant)
•
–
Role functioning, household chores, finances, family relationships, social leisure, friendships and dating
Life Skills Profile (informant)
•
–
Social behavior, leisure time, social participation
Social Adjustment Scale-II, client and family versions
•
–
Ability to converse, social comfort and appropriateness, degree of social contact and personal strife
Self-care, impulse control, basic social behaviors, social engagement, participation in treatment
Independent Living Skills Survey (self & informant)
•
Self-care, care of personal possessions, money management, use of public transportation
(Pratt & Mueser, 2002)
Multi-method, multi-rater
assessment of social functioning

Observation

– Informal
•
•
•
•
•
•
•
Looking down
Whispering
Tangential speech
Rapport
Positive response
Verbal and nonverbal skills
Situation appropriate
behavior
– Direct
• Social skills checklist
• Role-play test
• Maryland Assessment of
Social Competence
(MASC)
Interviewing significant
others
– Environment
• Supportive
• Social reinforcement
• Model appropriate behavior
– Conflict
– Clinician seeks objective,
specific reports
(Bellack et al., 2004)
On-going assessment


From sessions
– Goals, dates, skills,
number of role-plays
– Attention & cooperation

Evaluating effectiveness of
specific social skills
– Interviewing about
certain situations
– Informal observation
– Obtaining perspective of
significant others
– Observation of role-play
test
Homework
– Brief description of what
took place
– Self-rating of
effectiveness
– Assignment descriptions
– Due dates
– Name of leader who
assigned homework
– Date, time, and location
that the skill was
practiced
(Bellack et al., 2004)
Logistics: Established before first session

Format

Pacing

Group composition

Location

Group size

Session duration

Evaluation procedures

Timing

Group duration
(Bellack et al., 2004)
Attendance

Important due to hierarchical nature
– Simple to complex skills

Emphasize attendance
– Promote the view that attendance is a key
component to their treatment
– Strategies to encourage attendance
• Reward with money, increased privileges, recreational
opportunities, food, time with staff, or tokens (used to buy
goods at a hospital or clinic)
(Pratt & Mueser, 2002)
Group leadership

Can be paraprofessional

Competent leadership style is necessary

Co-leaders

Consistent

Supervision
(Pratt & Mueser, 2002)
Preparing clients for group meetings

15 to 30 minutes with each client

Build rapport

Orient client to social skills training (rationale)

Screen clients who are not ready
– If not, stay in contact

Both co-leaders should meet the client together

Set goals for the group
– If they cannot, prompt them
– If goals are too ambitious, don’t discourage
• Help the client to break it down into manageable steps
(Bellack et al., 2004)
Goals related to social skills deficits
Problems in social functioning
Possible goal for social skills training
No friends, social isolation
To start conversation on a regualr basis
Lack of interest in leisure activities
To participate in at least one form of
recreation
Gives in to unreasonable demands
To refuse inappropriate requests
Becomes physically aggressive when
angry
To express anger appropriately
Speaks in a monotone
To vary voice tone and expression
Speech is delusional and tangential
To stay on the converstional topic
Makes frequent demands
To make positive requests of others
(Bellack et al., 2004)
Break goals into smaller steps
Goal
Possible steps to achieve goal
Make friends
1. Start a conversation with one person at
work
2. Attend the next social event at the dropin center
3. Introduce self to one person per week
Shop for clothes
independently
1. Choose one item of clothing to purchase
2. Shop with the assistance of a relative
3. Establish size needed, approximate price
4. Select item for purchase
(Bellack et al., 2004)
Breaking down goals (cont.)
Goal
Possible steps to achieve goal
Respond effectively to
criticism from employer
1. Use reflective listening when receiving
supervisory feedback
2. Ask clarifying questions to obtain more
information
3. Request suggestions for improvement
Use public
transportation to all
locations
1. Obtain schedule for buses stopping
nearby
2. Choose a relatively close destination
that does not require transferring buses
3. Ask friend to accompany on first trip
(Bellack et al., 2004)
Implementation


Steps
1. Establish a rationale for
the skill
2. Discuss the steps of the
skill
3. Perform role-play
exercises
4. Assign homework
5. Use generalization
strategies
Presentation style
– Slowly
– Repetitively in small
“chunks”
– Positive
reinforcement
– Gradually combining
simple behaviors to
complex sequences
(Bellack et al, 2004)
Step 1: Establish a rationale

Elicit reasons for learning the skill from group
participants
– Helps them to take greater ownership
– “Why might it be be helpful to be able to start a
conversation with somebody?”

Provide additional reasons

Emphasize relevance of learning skill to
achieving important life goals
(Bellack et al., 2004)
Step 2: Discuss the steps of the skill

Display the steps of the skill on the board or
poster

Explain each step

Elicit reasons for and importance of each step
from group participants

Provide additional reasons not provided by
group participants
(Bellack et al., 2004)
Step 3: Role-play exercises
Plan in advance
 Value
 Description of scenario
 Leaders model
 Participants identify steps
 Participants evaluate effectiveness

(Bellack et al., 2004)
Step 3: Role-play exercises

Understanding of roles and expectations

Elicit a volunteer

Others participants observe the volunteer

Elicit positive feedback

Redirect
(Bellack et al., 2004)
Step 3: Role-play

Provide additional positive feedback

Offer one suggestion

Encourage repetition

Elicit and provide additional positive feedback

Use supplementary modeling, discrimination
modeling, and coaching, if necessary
(Bellack et al., 2004)
Step 4: Assign homework

Completed in a natural environment

Value of practicing skills in real-life situations

Tailor assignments to match level of mastery

Identification of when, where, how and with whom

Review homework at the beginning of the next session
(Bellack et al., 2004)
Step 5: Use generalization
strategies

Staff at treatment facility

Invite indigenous community supports

Regular meetings
Choosing which skills to teach

Depends on the group
–
–
–
–
–

Age
Severity
Types of symptoms
Social deficits
Environment
Basic skills are typically taught in all cases
Categories of curricula

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Basic social skills
Conversation skills
Assertiveness
Conflict management
Communal living
Friendship and dating
Health maintenance
Vocational/ work
Coping skills for drug and alcohol use
Basic social skills




Expressing positive feelings
Making requests
Listening to others
Expressing unpleasant feelings



They are taught in this order
They are building blocks for other skills
Help clients feel comfortable with the process
of social skills training
(Bellack et al., 2004)
Curriculum menus: Anger
management
Expressing unpleasant feelings
 Leaving stressful situations
 Responding to untrue accusations
 Expressing angry feelings
 Disagreeing with another’s opinion
without arguing
 Responding to unwanted advice

Guidelines for using skill sheets

Each social skill has its own skill sheet

Provides a framework for learning the skill

Leaders can tailor the skill sheets to meet the
needs of the clients
– It is not necessary to use any of the suggested
role-plays provided
– Leaders can make role-plays more relevant to the
lives of the clients
(Bellack et al., 2004)
Follow the model

Go step by step

May be a struggle for new leaders

Experienced leaders may stray

Maintain positive communication style

Use checklists to ensure adherence to the model
(Bellack et al., 2004)
Example lesson plan:
Anger management

Session 1
– Generate a list of early warning signs and solutions
– Discussion

Session 2
– Generate a list of coping strategies for dealing with angry
feelings
– Discussion
Example lesson plan

Session 3
– Introduce the skill Leaving Stressful Situations.
– Leaders model and then practice with each group member, tailoring the
scenes to specific experiences.
– Assign homework

Session 4
– Review homework
– Continue with the skill Leaving Stressful Situations.
– Group members practice the skill with each other, using role-play scenes
that are relevant to their experiences.
– Assign homework

Session 5
– Review homework
– Finish with the skill Leaving Stressful Situations.
– Leaders practice the skill with each member while increasing the difficulty of
the role-play scene.
– Assign homework

Continue down the curriculum menu at an appropriate pace
When the curriculum breaks down

Teach problem solving
– Steps
•
•
•
•
•
•
Define the problem
Use brainstorming to generate possible solutions
Identify the advantages and disadvantages to each solution
Select the best solution or combination
Plan how to carry out the solution
Follow up on the plan at a later time
– Use same format (rationale, role-play, etc.)
– More complicated, so may take more time than other skills

Develop a new curriculum
Common problems

Poor attendance

Cognitive difficulties

Responding to psychotic symptoms

Distractibility

Disruptions

Social withdrawal/Low level of participation
(Bellack et al., 2004)
General principles in dealing with
problems

Keep communication brief and to the point

Be consistent in maintaining structure and holding group at
same time and in same place

Praise efforts and small steps toward improvement

Teach and review basic skills frequently
(Bellack et al., 2004)
Highlights of empirical support

Improves targeted skills and social adjustment in general (Chambon &
Marie-Cardine, 1998)

Simple and complex behaviors (Heinssen et al., 2000)

Retention up to 1 year after treatment (Eckman et al., 1992)

Protective role - less anxiety, less stress (Heinssen et al., 2000)

Effective across severity (Heinssen et al., 2000)

Little impact on level of psychopathology or relapse rates (Liberman et
al., 1998)

Males acquire more skills than females (Mueser et al., 1990)

Females have higher skills scores at baseline (Mueser et al., 1995)
Empirical support of SST




Purpose: Compare two-year community functioning between
psychosocial occupational therapy and SST
Participants: Eighty-four medicated men with schizophrenia were
randomly assigned to OT or SST
Pretreatment: A psychiatrist blind to psychosocial treatment prescribed
antipsychotics as he would ordinarily
Treatment: Twelve hours per week for six months
– Both groups received subsequent case management community
follow-up for 18 months
– SST focused on
• Basic conversation skills
• Leisure and recreational skills
• Skills for medication management
• Sx management skills
(Liberman et al., 1998)
Empirical support

SST group had significantly better independent living
skills and lower levels of stress
OT
SST
Mean
F
p
Personal possessions
2.97
11.54
4.81
0.03
Food preparation
4.71
9.89
3.76
0.05
Money management
3.03
11.78
4.64
0.03
Life distress
0.17
-0.20
5.45
0.02
(Liberman et al., 1998)
What is a family intervention?



Home visits
Behavioral strategies
The aim: To mprove the family's ability to cope with a members' severe mental illness.

Techniques include:
– Active learning through guided practice
– Therapist demonstration
– Role-play
– Homework
– Coaching
– Psychoeducation

Format
– Group (family) setting
– 60 to 75 min sessions
– 9 months to 3 years
– Repeated practice among family members
– Similar to social skills training
(Falloon, 2002)
Theoretical assumptions

Improved communication in families alleviates stresses of
reintegration

Strength of the family is one of the greatest natural resources

Families can be the target of blame (i.e., genetics, bereavement,
separation/divorce)

Family care extends beyond the confines of the family home

Improvements in telecommunications and transportations

Family = intimate social network, not necessarily a biological
family
(Falloon, 2002)
Clinical strategies

Assessment of functioning of the family unit

Education about specific disorders

Communication training

Structured problem-solving training

Specific cognitive-behavioral strategies

Home-based crisis intervention

Variability of approaches
(Falloon, 2002)
Assessment

What is the vulnerability, stress, and problem-solving
capacity of the family unit?
– Camberwell Family Interview
• Expressed Emotion Index
–
–
–
–
Critical remarks (high interrater reliability)
Hostility (low)
Emotional overinvolvement (high)
Warmth and positive remarks (low) (Swedish sample; Orhagen &
d’Elia, 1991)
– What are each family members goals?
– Problem analysis for each family member
• What triggers a family argument?
• What increases or decreases the intensity of agitated behavior?
• What happens when a person experiences rejection while
attempting to develop a friendship?
(Falloon, 2002)
Family psychoeducation




First few sessions
Handouts are provided
Stress-vulnerability model
Revision of education, when necessary
– A stressor is emerging


Recognition of early warning signs
Checklists are available, though it is best to
determine an individual’s idiosyncratic warning signs
(Falloon, 2002)
Communication training (CT)

Goal: Facilitate the ability of the family unit to conduct its own problemsolving discussions

CT enhances
–
–
–
–

Specificity
Positive reinforcement of progress
Prompting behavior change w/out coercion
Empathy
Method
– Repeated practice among family members
– Similar to social skills training
• Role-play
• Homework

Family members do not have social deficits, but optimal communication
will make life easier living with someone who is vulnerable to a stresssensitive disorder
(Falloon, 2002)
Structured problem-solving training

Goal: Enhance the problem-solving efficiency of the family unit

Steps
– Define the problem or goal
– List alternative solutions
– Evaluate the consequences of proposed solutions
– Choose the optimal solution
– Make a plan
– Review and evaluate implementation

Therapist assists to convene at least weekly

Therapist avoids getting personally involved or offering solutions
(Falloon, 2002)
Cognitive-behavioral strategies

Use when family is struggling to think of a
solution of their own
– Operant reinforcement
– Desensitization
– Cognitive restructuring
– Strategies to address sexual dysfunction

Integrate into problem-solving process
(Falloon, 2002)
Empirical support for family
interventions




Purpose: To compare the efficacy of family management and patientoriented therapy on family functioning
Constructs assessed: family burden, family coping, psychotic
symptoms, social behavior
Two groups randomly assignment
– Experimental: community management based on family support
(n=18)
– Control: Patient-oriented treatment with supplementary family
support (n=18)
Family management treatment
– Twenty-three weekly sessions of behavioral family therapy
– Two additional sessions of family education about schizophrenia
(Falloon, & Pederson, 1985)
Empirical support for family
interventions
Sessions were conducted at family
residences
 Results: People in the family
management group reported
significantly less:

– Disruption of activities
– Physical and mental health problems
– Subjective burden
(Falloon, & Pederson, 1985)