11

BEHAVIORIAL TREATMENTS
FOR SCHIZOPHRENIA
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Behavioral-psychological treatment for schizophrenia has been imple-

mented for more than 100 years. Although current psychological treatment
interventions do not typically focus on individual psychotherapy, particularly
dynamically oriented therapies, the implementation of various behavioral
interventions remains a cornerstone of the treatment of schizophrenia. These
interventions fall into three broad domains: cognitive-behavioral interven-
tions designed to reduce the severity of positive symptoms; skills training
aimed at social, independent living and self-care domains; and cognitive
remediation as a treatment strategy. Although each of these has been studied
in detail in younger patients, there are two completed studies that have
focused on older patients and one large-scale treatment intervention that
is in the works. Because many of these interventions may eventually be
applied to this population, the details of each domain of treatment is reviewed
briefly. In addition, because functional expectations are quite different with
older individuals, the applicability of previous interventions to older patients
is examined. Although there is little research to date with older patients,
the promise of these interventions in younger patients will certainly lead
to their being attempted in older patients in the near future.

163

http://dx.doi.org/10.1037/10873-011
Schizophrenia in Late Life: Aging Effects on Symptoms and Course of Illness, by
P. D. Harvey
Copyright © 2005 American Psychological Association. All rights reserved.
 COGNITIVE-BEHAVIORAL THERAPY

This therapeutic intervention was developed to provide a psychological

intervention to supplement or supersede pharmacological treatments with
psychotic symptoms. Based on the fact that, in particular, hallucinations
are perceptual experiences that have no real-world basis, this intervention
attempts to train patients to more carefully evaluate their experiences before
reaching the conclusion that hallucinations are truly “real.” Similarly, delu­
sional beliefs are evaluated and the schizophrenic patient is encouraged to
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reevaluate the decision-making process that leads to the development of

these beliefs.
These approaches are potentially useful in a large number of patients
with schizophrenia. In addition, the intervention itself is deliverable by
trained paraprofessionals, which allows for a broader delivery of these services
in environments where funding may be limited and a PhD-level psychologist
may not be available to treat the patients. These treatments can be delivered
in both individual and group formats, and manualized treatment interven­
tions have been shown to be delivered with high fidelity.

Strengths of Cognitive-Behavioral Therapy

It has been reported that the severity of delusions and hallucinations

is notably reduced in some patients with schizophrenia who receive this
treatment (Alford & Beck, 1994). In addition, ratings of patients’ awareness
of illness are also improved. Patients who fail to respond to treatment
with antipsychotic medications also may respond to cognitive-behavioral
interventions. Many schizophrenic patients commit offenses on the basis
of their hallucinations or delusions, so reduction of these symptoms is sure
to reduce the likelihood of legal involvement and risk to others.

Weaknesses of Cognitive-Behavioral Therapy

Positive symptoms are not as strongly correlated with functional out­

come as cognitive impairments. Thus, is it not clear whether functional
changes could reasonably be expected following this treatment. Cognitive
impairments on the part of patients receiving treatment may have the
potential to reduce the likelihood of success in this type of intervention.
Thus, many patients are likely to fail to benefit, particularly because patients
with treatment-refractory psychotic symptoms have the most severe cogni­
tive impairments. It is not yet clear the extent to which these interventions
are limited by cognitive impairments, but this is an important topic to
consider.

164 SCHIZOPHRENIA IN LATE LIFE

 Applicability to Older Patients

This intervention strategy is likely to be broadly applicable to older

patients with schizophrenia. Persistent psychotic symptoms are a feature of
many older patients with schizophrenia. There are many patients who would
seem likely to benefit. In addition, there are no age-related changes in the
need for reduction of psychotic symptoms, in contrast to the typical age-
related changes in expectations for aspects of functional outcome (e.g.,
employment and independent living).
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SKILLS-TRAINING APPROACHES

Skills-training approaches use educational and practice-related inter­

ventions to allow the participant to increase his or her skills levels in several
domains. These domains include social functions (conversational skills,
assertion skills), self-care (cooking, cleaning, clothing maintenance), and
independent living skills (e.g., household maintenance and bill paying).
Contemporary training methods often involve realistically simulated work
environments, patient-operated stores or restaurants, and video-taped feed­
back regarding social skills performance.
These interventions are aimed at disability reduction. As demonstrated
before, functional deficits are a major source of disability in schizophrenia,
and they are persistent into later life. Although there is some evidence that
pharmacological cognitive enhancement occurs with treatment with newer
antipsychotic medications, it is also likely that patients with schizophrenia,
particularly older individuals, will not be able to spontaneously learn func­
tional skills that have been absent from their repertoires for decades. Thus,
focused interventions are likely to be important.

Strengths of Skills Training

Skills deficits are directly linked to disability in schizophrenia, and the

more closely the skills-training approach simulates the task of focus, the
more likely that success will result. Many different skills are required for
functional success, and training in each of these domains is more likely to
lead to success than any type of generic approach. Many current training
environments simulate realistic work environments, and work placements
have been shown to enhance patients’ outcome, even in seemingly unrelated
areas such as positive symptoms and hospital readmission. As noted earlier,
spontaneous development of functional skills may be too much to expect
after decades of deprivation.

BEHAVIORAL TREATMENTS 165

 Weaknesses of Skills Training

Skills-training approaches are intrinsically learning-based approaches.

As a result, cognitive impairments, in domains of attention and episodic
memory, have the potential to interfere with the rates of skills learning in
these training programs. This has been demonstrated empirically, in that
patients with more substantial deficits in vigilance are less likely to benefit
from skills-training approaches (see Green, 1996, for a review). Similar to
cognitive-behavioral interventions described earlier, cognitive limitations
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may need to be addressed before the approach can be successful.

Applicability to Older Patients

As we saw before, persistent functional deficits characterize many

older patients with schizophrenia. Many patients have persistent social
deficits and impairments in self-care. Independent-living impairments have
increased importance in aging populations, because changes in indepen­
dent living skills are a common consequence of aging in healthy popula­
tions. Employment issues change with aging, because it is not expected in
Western culture that older individuals seek and maintain full-time com­
petitive employment. Although there are some minor changes in expecta­
tions, improving functional status is still important for older patients with
schizophrenia.

COGNITIVE REMEDIATION

This intervention directly attacks the problem of cognitive impairment

in schizophrenia by attempting to improve cognitive functioning (Wykes
& van der Gaag, 2001). Multiple different techniques have been used, based
on concepts initially developed from rehabilitation of head-trauma patients.
Patients are provided training on a variety of cognitive skills, including
attention, memory, and conceptual functioning. This training is often
presented on a fairly repetitive basis and is often presented via computer­
ized programs.

Strengths of Cognitive Remediation

The principal strength of this approach is that it directly attacks a major

problem in schizophrenia. Other approaches that require intact cognitive
functioning often find that cognitive impairments serve as a rate limiter.
In contrast, the direct remediation of cognitive impairments can proceed
even in patients with severe impairments, through adjustment of the initial

166 SCHIZOPHRENIA IN LATE LIFE

 difficulty of the training. In addition, by targeting critical areas of cognitive
deficits, the deficits most strongly related to functional outcome can be
worked on. This approach can combined with other interventions, such as
skills training, to simultaneously target multiple problem areas. A recent
meta-analytical review of the effectiveness of cognitive remediation has
suggested that, overall, cognitive remediation is effective in patients with
schizophrenia (Krabbendam & Aleman, 2003).

Limitations of Cognitive Remediation

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The principal limitation of the approach is that there has remained

little evidence of generalizability of the treatment to other cognitive func-
tions. For example, memory training does not lead to increases in problem­
solving performance (Medalia, Revheim, & Casey, 2001). In addition, the
statistically significant effects during training often do not lead to increases
in performance in real-world cognitive tests or in functional status domains
(Medalia, Dorn, & Watras-Gans, 2000). Some evidence (Harvey, Moriarty,
Serper, et ah, 2000) has suggested that patients receiving treatment with
newer antipsychotic medications are more likely to improve when exposed
to cognitive remediation or provided with extensive practice in performing
attentional tests.

Relevance to Older Patients With Schizophrenia

Cognitive impairments are persistent in older patients with schizophre­

nia, possibly even more persistent than psychotic and negative symptoms
(Jeste, Twamley, et ah, 2003). Cognitive impairments are the primary deter­
minant of functional impairments in older patients, just like in younger
ones. As a result, any interventions that reduce these impairments are
potentially important. Finally, because some cognitive benefit from treat­
ment with newer antipsychotic medications has been reported (Harvey et
ah, 2003), combined treatments with newer antipsychotic medications or
other cognitive-enhancing medications and cognitive remediation seems
most promising. In fact, several published reports suggest that treatment with
newer antipsychotic medications leads to more improvement for younger
patients involved in cognitive remediation interventions (Mortimer, 2001;
Naber, 2000).

Behavioral Interventions in Older Patients With Schizophrenia

There is no area of research on schizophrenia in late life in which

there is a greater lack of data than in the domains of behavioral interventions.
There are only three studies that have attempted to address this issue, all

BEHAVIORAL TREATMENTS 167

 with limited samples. McQuaid et al. (2000) developed the first training
program directly aimed at older patients with schizophrenia. In this pro­
gram they used a combination of two of the techniques described earlier:
cognitive-behavioral therapy (CBT) and skills training. The CBT was aimed
at reducing some of the negative beliefs present in this population that
interfere with participation in treatment and provided the patients with
assistance in symptom self-management. Skills training provided repetitive
practice in the areas of social and language skills. Role-plays, structured
feedback, and homework assignments were provided to the participants in
the program. Although the sample size of the study (n = 9) was too small
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for formal statistical analyses, case reports presented by the authors suggested
that some of the patients received significant benefit from their participation.
When the results of a randomized clinical trial, also with a small sample
size, were reported (Granholm, McQuaid, McClure, Pedrelli, & Jeste, 2002),
these results were confirmed. This is clearly an area in which additional
research is required.
Functional deficits are clearly persistent into later life. Treatments for
schizophrenia may be more effective at reducing functional limitations if
they are aimed directly at functional limitations. It is not at all clear that
cognitive enhancement alone would improve the execution of adaptive
skills without some assistance provided to the patient regarding the nature
of the skills, the environmental triggers for skills execution, and the need
for spontaneous execution of skills.
A structured program for training older patients in the performance
of functional skills has recently been developed. This program, referred to
as Functional Adaptation Skills Training (FAST), was developed by Patter­
son and colleagues at the University of California, San Diego (UCSD
Performance-Based Skills Assessment; Patterson et ah, 2003). This program
focused directly on six different areas of life functioning, including medica­
tion management, social skills, communication skills, organization and plan­
ning, and financial management. The program includes 24 twice-weekly
sessions for 120 minutes each, led by a master’s- to doctoral-level therapist.
In the pilot study, 16 patients who were residents in board and care facilities
received the pilot intervention and were compared to 16 patients who
received treatment as usual. Patients who received the treatment were found
to have statistically significant and relatively substantial improvements in
a performance-based measure of functional skills, the UPS A (Patterson,
Goldman, et ah, 2001). Improvements in functional skills performance
was stable three months after the termination of the intervention,
suggesting that there was reasonable persistence of these gains over an
intermediate term follow-up. There were no differences in scores on
measures of psychopathology, including both psychotic and general syrup-

168 SCHIZOPHRENIA IN LATE LIFE

 toms measured by the Positive and Negative Syndromes Scale (PANSS;
Kay, 1991).
These findings indicate that there is substantial promise for reducing
functional impairments that is not dependent on the reduction of other
symptoms of the illness. Although there is no evidence in this study regarding
changes in functional skills performance in the outside environment, this
appears to be a first step in the direction of improvement of functional skills
deficits in older patients with schizophrenia.
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SPECIAL CONSIDERATIONS WITH OLDER PATIENTS

There are multiple considerations that are unique to older patients

with schizophrenia when behavioral interventions are considered. These
include special needs of older patients and modifications in expectations
for outcome based on those generated in younger patients. Clearly, certain
expectations need to be modified, and these modifications may be more
important the older the patients who are treated.

Special Needs

With aging, medical burden increases. As with individuals without

any lifetime history of psychopathology, older patients with schizophrenia
need to be able to interact effectively with medical professionals and to be
able to manage the increasing number of treatments that they require for
their physical illnesses. Thus, medication management training for older
patients with schizophrenia will need to be more broadly focused than simply
on adherence with psychiatric medications. Studies such as FAST have
attempted to address this issue. Interacting with health care professionals
in an assertive manner may be required to enhance physical well-being as
well, given the fact that many patients with schizophrenia may not have a
primary care physician who sees them regularly and manages their overall
medical care. Being able to monitor one’s own physical condition, report
potential symptoms, and to persist in seeking appropriate treatment are
important skills in elderly individuals in general. For people with schizophre­
nia, handicapped by a lifetime of social skills impairments, this is a particu­
larly important challenge and is a more important area than it is for
younger patients.
An additional issue associated with successfully adapting to older age
is the need to overcome that “ageist” bias, one that would suggest that older
patients with schizophrenia have little potential for improvement in their
clinical and functional status. This bias may be reflected in the fact that

BEHAVIORAL TREATMENTS 169

 newer medication treatments are offered to older patients at lower rates
than younger patients, despite the evidence presented earlier that these
treatments have at least as great a benefit to older patients as younger ones.
Quality of life is often reduced in some older individuals. Although
schizophrenia patients, by virtue of being much less likely than the general
population to be married and to have children, are less likely to be affected
by the death of a spouse, there are many aspects of quality of life that are
adversely affected in aging patients with schizophrenia. Many institutional'
ized patients are moved from residential facilities where they have lived for
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decades and sent to nursing home care. As noted in previous chapters, there
appears to be adverse influences of these transfers. Moving to nursing home
care often leads to reductions in the opportunities for adaptive functions,
and quality of life in older patients may depend on their ability to perform
some of their own self-care activities and to have certain opportunities for
social activities as well.

Special Circumstances

Work and independent living expectations change with age in healthy

individuals. These changes occur in elderly patients with schizophrenia but
have somewhat different parameters. Older patients with schizophrenia are
often housed in residential settings that are different from those for younger
patients. Many of these patients are residents of nursing home care or other
supported residences and have limited opportunities to perform certain
adaptive skills. For instance, shopping and cooking may not be potential
areas for skills performance, and focusing on skills training in these domains
may not be productive.
Furthermore, social and sexual activities also have adjusted expecta­
tions in older individuals. It may be that the ability to participate meaning­
fully in structured and supervised social activities may be a more practical
goal than focusing on social skills in dating contexts. It will be important
to focus on enhancement of activities that are practical to perform, without
an exclusive reliance on the same areas of adaptive skills that are important
in younger patients, such as focusing on obtaining employment and living
as independently as possible.
Employment is also an area in which modifications of expectations
are potentially important. Full-time work may not be a reasonable goal, and
a certain proportion of older patients with schizophrenia have never worked
in their lives. It is unlikely that these patients will benefit from interventions
aimed at anything more than casual part-time employment. In addition,
there are notable disincentives for employment, such as reduction in social
security benefits. Despite the clear benefits of employment for younger

170 SCHIZOPHRENIA IN LATE LIFE

 patients, skills training in older patients may be more productively aimed
at social and self-care skills.

CONCLUSION

Treating older patients with schizophrenia is the area of greatest inat­

tention in the entire research literature. There are no empirically derived
treatment algorithms for older patients, either for purely pharmacological
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or behavioral interventions. Only one research group has attempted skills-

based interventions with older patients with schizophrenia.
As described in the next chapter, development of better behavioral
instruments is a situation that requires attention. As much as the lack of
attention is paid to adequate housing for older patients, the nearly complete
lack of attention to developing empirically validated treatments for older
patients with schizophrenia is quite troubling. This situation is made even
worse because older patients with schizophrenia respond as well to newer
treatments for the illness as younger patients. Because their pattern of
treatment response is so good, such treatment should inspire considerable
optimism. It is my concern that older patients with schizophrenia have not
received state-of-the-art treatments with the same frequency as younger
patients because of ageist bias and a general bias against individuals who
have lived a life of complete disability. This issue of lower standards for
older patients is addressed in much more detail in the next chapter.

BEHAVIORAL TREATMENTS 171