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Psychosocial Rehabilitation for Schizophrenia

Psychosocial rehabilitation is a learning based approach using a token economy and social skill training to help patients with schizophrenia develop adaptive behaviors (Nevid, Rathus, & Green, 2003). To live successfully in the community, a variety of treatment approaches are available to people with schizophrenia. A few of the psychosocial rehabilitation options for people with schizophrenia include hospitalization, self-help clubs, family intervention programs, drug therapies and psychosocial treatments.

Many treatments have been researched with the most effective being a combination of more than one treatment being implemented simultaneously with others. Schizophrenia is an illness. The symptoms of schizophrenia usually last a lifetime. Persons suffering from schizophrenia have a distorted perception of reality which includes hallucinations and delusions affecting their thinking. They also have what are called negative symptoms; these include social withdrawal and blunted affect. Along with the thought and affect, there is also cognitive dysfunction. Symptoms of cognitive dysfunction are attention, memory, and learning difficulties.

Although genetic vulnerabilities for schizophrenia are believed to exist, they have yet to identify a single genetic determinant (Tamminga, 2003). Earlier studies of interventions for schizophrenia were almost entirely biological. These studies called controlled clinical trials were not successful; the sample sizes were too small and did not provide useful data. Researchers knew the studies designs and reporting of the results studies needed to be improved. However, the studies did conclude, one very important aspect in the treatment of schizophrenia had been left out.

Researchers needed to include the evaluation of psychosocial treatments of schizophrenia in order to show a complete picture (Wahlbeck, Adams, & Thornley, 2000). Understanding the social dysfunction of schizophrenia helps in the refinement of psychosocial therapy. The ability of people with schizophrenia to give a coherent account of their lives is severely impaired. The disruption in their stories could be due to an organically based process that limits their interest in the external world or affects their ability to make logical connections, and lastly this may affect their ability to connect their intentions to their actions.

A European standpoint “suggests that schizophrenia reflects an autistic relationship to reality or lack of attunement to others” (Lysaker, Wickett, Wilke, & Lysaker, 2003). All of the preceding factors contribute to the difficulties many people with schizophrenia face functioning in social and occupational roles. These difficulties, in turn, limit their ability to adjust to community life, even in the absence of psychotic behaviors (Nevid, Rathus, & Green, 2003). Self-help clubs commonly called clubhouses were created to help patients hospitalized with schizophrenia transition from a hospital setting back into their communities.

These self-help clubs offered a more structured psychosocial rehabilitation centers. The clubhouse’s objectives are to help people with schizophrenia find a place in society. Many of the clubhouses across the country and even in other countries such as Sweden, Japan, and Australia were founded by the very people who needed them most. These people with schizophrenia created environments where they could go and receive the supports necessary to deal with their illness.

This clubhouse movement began in 1948 after mental health agencies failed to provide adequate services to people being released from hospitals with schizophrenia and those suffering in the community. The first clubhouse, founded by released patients was called Fountain House. Since Fountain House more than two-hundred similar clubhouses opened. Although clubhouses do not provide residency to its users, they do offer other benefits for these special citizens (Goldberg, Rollins, & Lehman, 2003). Clubhouses offer their users a variety of useful benefits.

The first is a type of self- contained community within their own community. This smaller community provides a safe environment for people with schizophrenia to go and be themselves; everyone is aware and accepting of their impairments. Another very important component offered by the clubhouse is social support. The benefit of social support depends on the level of impairment of the individual and the utilization of services available (Goldberg, Rollins, & Lehman, 2000). If a person with schizophrenia is able to use the clubhouse they can expect to show improvement in their level of functioning.

The social support network for people with psychiatric disabilities is generally very low due to socially inappropriate behaviors. This is understandable considering the hallmark characteristic of schizophrenia is impairment in social functioning. Having social support and a larger support network increases cognitive functioning, quality of life, and self- esteem in people suffering from schizophrenia. People with even a moderate density of support benefit by having fewer episodes of psychotic symptoms and higher IQ’s.

Social networks have three types of characteristics, structural, interactional, and functional (Goldberg, Rollins & Lehman 2003). “Structural characteristics include the size and composition of the network and or frequency of contact. Interactional characteristics are defined as the extent to which social network members interact with or know one another, while functional characteristics specify the purpose served by the network members. ” Social networks provide instruction, companionship, and advice in and outside of the clubhouse atmosphere.

Participants receive help finding employment and may also avail themselves of educational opportunities. Research shows that social resources play a role in psychiatric rehabilitation. Social skills and network size are positively correlated. When social skills are high so are social networks, and the reverse is true; if one has few social skills, the social networks is smaller. Small networks for people without a disorder may include twenty to thirty members consisting of family, friends, neighbors, social and work acquaintances.

On the other hand, individuals with mental illnesses are able to name only about four or five names, most of whom are relatives. People with mental illness have fewer networks than substance abusers (Goldberg, Rollins, & Lehman, 2000). Factors contributing to smaller social networks are two known characteristics of schizophrenia, social withdrawal and blunted affect. Since social networks contribute to the quality of life for those suffering with schizophrenia, it is important to ensure clubhouses continue to be supported by medical professionals and the communities.

Clubhouses and community mental health centers provide clients a pool of people who may become part of their social networks. Increased social networks contribute to higher levels of social functioning, due to the skills attained while attending the center. While many aspects of a person’s life improve with larger social networks, the effect diminishes when the network size reaches between ten and twelve members (Goldberg, Rollins, & Lehman, 2003). More is only better up to a point. Approximately one third of schizophrenics live with their families.

Dealing with this illness is not only a financial burden, it leaves the responsible care-takers physically and emotionally exhausted (Harvard Mental Health Letter, 2001). Family dynamics play an important role in the functioning of the family member with schizophrenia as well as the functioning of the family dealing with this member. For loyal relatives, love and patience are not enough to meet the patient’s needs. Family intervention programs can help families acquire information and advice to help them deal more effectively with their anxiety and disappointments and also to deal with conflicts in the family due to this illness.

Family counseling, lectures, and videotapes can teach relatives how to recognize the signs of relapse, how to respond to psychotic behavior, and possibly lower the risks of relapse. By having learned strategies to deal with conflict more effectively, the family avoids negative interactions, resulting in the maintenance of peace in their home. Knowing how to supervise medications and avoiding negative interactions reduces stress for both the family and the person suffering from schizophrenia. This in turn, leads to fewer psychotic episodes.

The opposite of such a supportive family would be a family in conflict, producing many negative interactions between themselves and the afflicted family member, causing tremendous stress and leads to increased episodes for the ill family member. This leaves the family feeling burdened with having to cope and care for their loved one with schizophrenia. Research and clinicians can help families to cope with these burdens of care as well as assist them in developing cooperative and less confrontational ways of relating to one another (Nevid, Rathus, & Green, 2003). How can this be accomplished?

Supportive family counseling and behavioral family management are often able to meet these needs. In the 1960’s self- help groups emerged for families of patients with schizophrenia. These self-help meetings were sponsored by mutual aid groups. In 1979 they established the National Alliance for the Mentally Ill (NAMI). As of August 2001 the membership had grown to 30,000 families and sponsors over 1,000local support groups (Harvard Mental Health Letter, 2001). Families interested in being educated about the disease can participate in sessions that will teach them to focus on the practical everyday living aspects.

They can learn all they can about schizophrenia, as well as learning ways to improve family communication there by minimizing their hostility when they relate to what is “normal” schizophrenic behavior. This will give them the coping skills necessary to solve family problems. The results of this type of structured family interventions are improved social functioning and reduced family friction. The family member suffering from schizophrenia will also have a reduced relapse rate. It is uncertain whether modest benefits prevent or only delay relapses (Nevid, Rathus, & Green, 2003).

Schizophrenic patients suffering from addiction have more obstacles to overcome. Addiction therapy could be dangerous if not also combined with treatment for schizophrenia. Case management and assertive community treatment known as ACT help prevent problems by coordinating services. Intensive case management provides referrals and arranges treatment. Professionals from various fields such as psychiatrists, psychologists, nurses, social workers, and counselors organize and administer services to clients.

Treatment may be administered to schizophrenic patients where they live, work (10% of people with schizophrenia work part-time jobs) and in their communities. ACT consults with family members, supervises medications, and monitors heath care. Patients are even helped with daily living activities such as shopping laundry, transportation, and housing (Harvard Mental Health Letter, 2001). The hope is patients begin to trust their environment enough to receive help with their addictions and disease. Coordinated therapies will help those with schizophrenia to secure work, minimize hospitalizations, and improve their overall quality of life.

The affects of drug treatment for those suffering with schizophrenia cannot be overlooked. The affects of a new drug called Abilify was tested on 1,200 people. Delusions, hallucinations and paranoia were reduced. Researchers attribute this to Abilify’s affects on dopamine and serotonin receptors in the brain (Matus, 2003). Drug therapies combined with psychosocial treatment enhance the social outcomes for patients. Patients with schizophrenia are vulnerable to psychotic episodes. Stress consists of chaotic environments, difficult life events, stimulant drugs, loss of social support and increased emotionality.

Factors that can prevent the patient from breaking down are antipsychotic medications, social supports, and functional families (Marder, 2000). All of these factors contribute to an increase in coping skills which provides stabilization to the patients. Evidence supports combining pharmacological and psychosocial strategies. Studies revealed the following possible interactions between pharmacotherapy and psychosocial treatment (Marder, 2000). and increased emotionality. Factors that can prevent the patient from breaking down are antipsychotic medications, social supports, and functional families (Marder, 2000).

All of these factors contribute to an increase in coping skills which provide stabilization to the patients. Evidence supports combining pharmacological and psychosocial strategies. Studies reveal the following possible interactions between pharmacotherapy and psychosocial treatment (Marder, 2000). 1. Patients receiving an effective psychosocial treatment may require a lower dose of antipsychotic medication. 2. Patients who are receiving adequate medication might tolerate more intrusive and stimulating forms of psychosocial treatment than those who are unmedicated or improperly medicated. 3.

Patients who are receiving psychosocial interventions may be more likely to adhere to medication regimens. 4. The effects of combining treatments may be more than additive since each enhances the effectiveness of the other. 5. Drugs and psychosocial treatments may affect different outcome domains. (Points taken from an article titled Integrating Pharmacological and Psychosocial Treatments for Schizophrenia by Stephen R. Marder MD). In five out of seven studies, it was shown that multiple psychosocial treatments are more effective than giving just one at a time. Which combinations of treatments are most effective still needs to be studied.

Whether or not medication and psychosocial treatment needs to continue indefinitely will require further study as well. Future studies could reveal if specific methods of treatment would be more successful on specific groups of people suffering from schizophrenia, for example, treatment for men versus women, patients newly diagnosed compared to those who have been suffering years longer, or those with differing symptoms (Harvard Mental Health Letter, 2001). Recommendations for the families are as follows, behavioral family management training, multifamily groups, and joining NAMI.

ACT (assertive community treatment) may be the best alternative for those with schizophrenia who do not faithfully take their medications and possibly suffer from the affects of various addictions. Clubhouses are the best option for patients who responsibly take their medications and respond w schizophrenia ell to their prescribed regime (Harvard Mental Health Letter, 2001). Continuing to associate with social networks that provide modeling of appropriate social behavior in a safe environment, combined with psychosocial therapy, medication, and an educated supportive family help those suffering from schizophrenia to be happier and healthier.

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