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CHAPTER 

5

Psychosocial management

It is obvious that the successful management of
schizophrenia requires careful attention to much
more than just pharmacology. All good clinicians
spend a large proportion of their time dealing with
issues that can broadly be described as ‘psycho-
social’. However, because it is very difficult to
distill the relevant psychosocial issues down to a
set of rigorously evaluable interventions, this
important aspect of treatment is under-researched
and relatively unacknowledged. Research into
specific areas of psychosocial management falls
into two main categories: the effectiveness of
individual psychological therapies, and the
optimal organization of mental health services.
Research in both areas suffers from the perennial
methodological difficulties of adequate control
groups and statistical power, and from questions
over the extent to which one can generalize from
small research settings to large-scale clinical
implementation. Nevertheless, psychosocial inter-
ventions have become increasingly prominent
components of health policy

1

.

PSYCHOLOGICAL THERAPIES

Psychoanalytic psychotherapies have largely been
discredited in the management of schizophrenia,
and indeed cast something of a shadow over the
development of more effective approaches to
treatment. However, a number of very promising
new approaches are now emerging.

Cognitive behavioral therapy 

Cognitive behavioral therapy (CBT) encompasses
a variety of interventions. At its core is the idea
that if patients can be presented with a credible
‘cognitive’ model of their symptoms, they may
develop more adaptive coping strategies, leading
to reduced distress, improved social function and
possibly even symptom reduction. CBT involves
regular one-to-one contact over a defined time
period between patient and therapist, the latter
often (but not always) a clinical psychologist
(other professionals including community psych-
iatric nurses and psychiatrists are becoming
increasingly involved as trained therapists) 
(

Figure 5.1

). The treatment packages emphasize

engagement and insight, and devote considerable

Figure 5.1

Professor Elizabeth Kuipers, one of the pioneers

of cognitive behavioral therapy (CBT) for psychosis,
treating a ‘patient’ [played here by a colleague]

©2002 CRC Press LLC

attention to agreeing a common therapeutic
agenda. Relatively non-specific elements form an
important component of all treatment packages,
including basic information about schizophrenia
and its drug treatment, strategies to manage
associated anxiety and depression, and inter-
ventions to tackle negative symptoms and social
function. More specific strategies to target positive
symptoms include formulating, together with the

patient, alternative, more adaptive explanatory
models for delusions and hallucinations.

There are, however, substantial differences of

detail between published studies, for example
with respect to the duration of the intervention, or
the incorporation of family work. A distinction is
also made between CBT for acute and for chronic
schizophrenia, although results are encouraging in
both contexts (

Figure 5.2

)

2–5

. However, at the

0.

0

–1.5

–1.0

–0.5

–2.0

Change in score

Distress

Conviction Preoccupation

CHANGE IN DELUSIONAL VARIABLES

CBT      Control

Figure 5.2  

Sixty patients with

chronic schizophrenia were
randomized to nine months of
cognitive behavioral therapy (CBT)
and standard care, or standard care
alone. At 18 months, patients with
delusions who had received CBT
were found to hold these with a
reduced level of conviction, and
were less preoccupied and distressed
by their delusional beliefs. Figure
reproduced with permission from
Kuipers E, Garety P, Fowler D, 

et al.

The London-East Anglia randomised
controlled trial of cognitive-
behavioural therapy for psychosis: III.
Follow-up and economic evaluation
at 18 months. 

Br J Psychiatry

173:61–8

60

50

40

30

20

10

0

Responders (%)

Admitted stopping 

taking medication

Compliant

with medication

No answer

NON-COMPLIANCE: THE PATIENTS' PERSPECTIVE

Figure 5.3 

Over half of a group of

615 patients admitted to having
stopped their medication. Figure
reproduced with kind permission
from Hellewell, JSE. Antipsychotic
tolerability: the attitudes and
perceptions of medical professionals,
patients and caregivers towards the
side effects of antipsychotic therapy.

Euro Neuropsychopharmacol

1998;8:S248