Improving police response to persons with mental illness: A Multi-level conceptualization of CIT
Amy C Watson, Melissa Schaefer Morabito, Jeffrey Draine, and Victor Ottati
Amy C Watson, University of Illinois at Chicago;
Corresponding Author: Amy C Watson, PhD, Assistant Professor, Jane Addams College of Social Work, University of Illinois at Chicago, 1040 W Harrison Street, MC 309, Chicago, IL 60607, 312 996-0039, 312 996-2770 fax, ude.ciu@nostawca
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The large numbers of people with mental illness in jails and prisons has fueled policy concern in all domains of the justice system. This includes police practice, where initial decisions to involve persons in the justice system or divert them to mental health services are made. One approach to focus police response in these situations is the implementation of Crisis Intervention Teams (CIT). The CIT model is being implemented widely, with over 400 programs currently operating. While the limited evidence on CIT effectiveness is promising, research on CIT is limited in scope and conceptualization-much of it focusing on officer characteristics and training. In this paper we review the literature on CIT and present a conceptual model of police response to persons with mental illness that accounts for officer, organizational, mental health system and community level factors likely to influence implementation and effectiveness of CIT and other approaches. By moving our conceptualizations and research in this area to new levels of specificity, we may contribute more to effectiveness research on these interventions.
The large numbers of people with mental illness in jails and prisons has fueled policy concern in all domains of the justice system. Strain in the justice system is generated when its commitment to efficiently control deviance and assure public safety is complicated by calls to respond to mental illness in a manner that is more clinical, or therapeutic. This includes police practice, where the initial discretionary decisions are made for a person’s formal involvement in the justice system. The options for these on-the-street decisions by police officers are to do nothing, to resolve a situation informally, to arrest, or to seek other formal resolution, such as psychiatric hospitalization. Added tension comes from the awareness that these encounters may be more likely to result in injury to both police officers and people with mental illness (Cordner, 2006). A police officer makes a decision quickly to resolve the disturbance of social order. In that moment, what factors shape more or less effective responses on the part of the officer?
One approach to focusing law enforcement response in these situations has been the implementation of Crisis Intervention Teams (CIT). CIT programs are hypothesized to improve officers’ abilities to effectively, respectfully and safely interact with persons with mental illness and subsequently divert more of them away from the criminal justice system and to mental health services. CIT is being widely implemented in medium and large size cities across the United States as a policy initiative to improve responsiveness to mental illness.
While the evidence of CIT’s impact on key outcomes is positive, research on CIT is limited in scope and conceptualization. To date, research has focused primarily on the effects of training on officer ability to identify persons with mental illness and their confidence in responding. This research could be biased by allegiance effects (Luborsky, 1999), where the promotion of the idea has driven its dissemination without a sufficiently critical look at the elements of intervention and effectiveness. Despite the limited and possibly biased evidence, there has been an organized effort to diffuse Crisis Intervention Teams across police agencies (Bureau of Justice Assistance, 2006).
In this article, we briefly review relevant literature on police interactions with persons with mental illness and consider the available evidence on CIT. We then present a model for understanding CIT implementation and effectiveness that expands beyond the currently narrow focus on training and outcomes of training. Drawing from the organizational behavior, criminology and sociology of deviance literatures, we consider individual, organizational and community level factors that may influence implementation and outcomes in a local policy context.
Framing the Issue
Studies indicate that up to six percent of individuals considered suspects by police have a serious mental illness (Engel & Silver, 2001; Teplin & Pruett, 1992). Medium and large police departments estimate that 10% of their contacts with the public involve persons with mental illness (Cordner, 2006; Deane, Steadman, Borum, Veysey, & Morrissey, 1999). Considering the larger category of impaired individuals (e.g. intoxicated, experiencing psychiatric symptoms) in arrest situations, this number becomes much higher with estimates around 20% (Kaminski, DiGiovanni, & Downs, 2004). Furthermore, police officers typically spend more time dealing with a mental disturbance call than they spend on calls involving traffic accidents, burglaries or assaults (Cordner, 2006). Police officers report such situations as problematic because persons with mental illness may not respond well to traditional police tactics (Engel, Sobol, & Worden, 2000). Because the mental health system offers limited options for resolving these situations (Borum, Deane, Steadman, & Morrissey, 1998), police officers become the gatekeepers of the criminal justice and mental health systems. Their abilities and capacity to manage these encounters significantly influence whether individuals receive treatment, remain in their current situation, or face the problems inherent in a criminal justice system ill prepared to meet their needs (National Counsel of State Governments, 2002). Lack of knowledge and skills on behalf of police officers can cause them to respond with undue force (Ruiz, 1993; Ruiz & Miller, 2004); fail to assist a victim with mental illness (National Council of State Governments, 2002; Watson, Corrigan, & Ottati, 2004a, 2004b); or fail to refer a person to appropriate community services. Lack of resources may also influence the options they have available to resolve the call, and in some cases lead to “mercy booking,” an arrest intended for the safety and care of the arrestee (Bureau of Justice Assistance, 2006; Wells & Schafer, 2006).
Outcomes of police encounters with persons with mental illness
These encounters can be dangerous for police officers and persons with mental illness. The majority of individuals that assault police officers are under the influence of drugs or alcohol and/or have a psychiatric disorder (Kasminski et al., 2004). However, these incidents may be most dangerous for people with mental illness (Cordner, 2006; Ruiz and Miller, 2004)). One explanation for assaults/injuries in these encounters is the manner in which officers respond to persons with mental illness. Often, officers perceive mental disturbance to be dangerous. Lacking the de-escalation skills necessary for working with people with mental illness, officers may approach forcefully in order to resolve the situation quickly. This approach may escalate the situation to violence and injuries to the officer and the person with a mental illness (Ruiz & Miller, 2004).
While arrest is the disposition most often associated with police encounters among the general population, order maintenance activities are actually more descriptive of how police spend their time. When arrest is employed, it is largely explained by officer characteristics, situational characteristics, organizational policies and available options (Bittner, 1970; Chappell, MacDonald, & Manz, 2006; Goldstein, 1976; Klinger, 1997). Among other factors explaining the decision to arrest in a community setting are the unpredictable demeanor of a subject (c.f. Crank, 1998), a high level of conflict between the subject and the officer (Alpert & Dunham, 1988), the presence of family members and family member demands for action (National Council of State Governments, 2002), and neighborhood structural disadvantage (Terrill & Reisig, 2003).
Training such as the CIT curriculum may influence an officer’s knowledge and attitudes about mental illness (Compton et al., 2006) and subsequently, their assessment of some of these situational factors. Officers who can reliably understand how these factors relate to mental illness may be more apt to decide to access mental health treatment in lieu of arrest (Wells & Schafer, 2006). But to fully explain the use of mental health services, the availability of mental health treatment options should also be accounted for.
Pre-booking diversion interventions such as CIT are promoted to increase the tools available to the police so that they will make fewer arrests and instead refer more people with mental illness to treatment (Draine & Solomon, 1999). Originally, the primary goal of CIT was to reduce officer and citizen injuries. Over time, the goal of diverting persons with mental illness from the criminal justice system when appropriate has emerged as equally as important among many stakeholders (Thompson & Borum, 2006).
Advocates, researchers, and policy makers have asserted that in encounters between police and persons with mental illness, diversion to treatment instead of arrest is more “appropriate” (Teplin, 1984). Given the research on both persons with mental illness in the community and the complexity of police decision making, it is difficult to operationalize what is meant by “appropriate.” Such normative judgments may serve to further stigmatize people with mental illness by further removing them from the roles of citizenship. However, we can conceptualize and empirically assess the extent to which police encounters are more or less likely to result in arrest or other outcomes and the mechanisms by which interventions such as CIT may influence these outcomes.
A Rapidly Spreading Police Based Intervention, CIT
Based on a model developed by the Memphis Police Department, Crisis Intervention Teams are a police-based pre booking approach with specially trained officers that provide first line response to calls involving a person with mental illness and who act as liaisons to the mental health system (Borum et al., 1998). Rooted in a problem solving approach, the Memphis Model aims to address the issues underlying the reason for the call rather than “simply incapacitating the individual or removing him or her from the community” (Thompson & Borum, 2006, p. 27). Patrol officers volunteer to become CIT officers, and if selected, receive 40 hours of specialized training. When a call is identified by dispatch as involving a person with mental illness, a CIT officer is dispatched and is given the authority of officer in charge, regardless of rank. This officer assesses the situation and may resolve it via de-escalation and negotiation, transport to emergency psychiatric services, provision treatment referrals or arrest if appropriate (Cochran, Deane, & Borum, 2000). Key to the model is partnerships with local advocacy groups and providers. In particular, the Department has an arrangement with the University of Memphis Medical Center’s psychiatric emergency department that serves as a no refusal central drop off for police, accepting all police referrals immediately and minimizing officer waiting time.
Essential elements of CIT believed to enhance police response are specialized training of officers (usually 40 hours), forging law enforcement partnerships with mental health community resources and shifting police roles and organizational priorities from an exclusively traditional law enforcement model that reluctantly dealt with persons with mental illness to a more service oriented model that responds to mental illness as a community safety and public health concern (National Council of State Governments, 2002). Jurisdictions have adapted these essential elements based on the needs and available resources of their local realities. The Consensus Project report provides valuable information about differences in CIT programs including specific examples of departments that have altered the implementation of CIT in their locality (National Council of State Governments, 2002). Modifications in training and staffing best exemplify these differences. For example, because of the agency’s small size, in Athens-Clarke County, Georgia, every officer receives CIT training to respond to people with mental illness. The centralized drop off is another component of CIT that is frequently adapted due to available local resources. Some communities have agreements to fast-track people with mental illness brought to the emergency rooms, others rely on a mobile crisis team to transport people with mental illness for medical care and still others have centralized registries to help officers find empty hospital beds for people with psychiatric needs (National Council of State Governments, 2002). Unfortunately, for some jurisdictions attempting to implement CIT, the development of arrangements with mental health providers falls to the wayside, leaving officer training as the primary element of the program (Wells & Schafer, 2006). Since the Consensus Project report, more localities have adopted CIT including Philadelphia, PA and Chicago, IL, which have both created their own training modules.
A recent Bureau of Justice Assistance report estimated there are over 400 CIT programs operating in the United States (Bureau of Justice Assistance, 2006). With such rapid diffusion of the intervention, the quantity and quality of CIT activities implemented across police departments is difficult to assess. We know that many communities have adapted the Memphis CIT curriculum and model to their own needs. What is less clear is how the programs differ across communities and whether these variations relate to the effectiveness of the program in meeting its goals and objectives. A more fully specified model of effectiveness could account for variance in the model implementation and link these variations to the effectiveness of CIT.
Programs like CIT can be difficult for organizations to fully adopt because they involve making large scale changes to almost every facet of police operations—from training and scheduling to dispatch and patrol as well as forging partnerships with the mental health community. In the current landscape of CIT, one organization can make changes to their training requirements while another can make systemic changes to all standard operating procedures and both agencies can purport to practice the program. These differences make it difficult to measure the effectiveness of CIT as whole—rather it is the extent to which CIT is being implemented that should be of interest to researchers measuring its effectiveness.
CIT requires that a strong commitment be made on the part of the agency and community partners to insure full implementation. The diffusion literature suggests that in a hierarchical organization like a police department, the acceptance of an innovation may be difficult to obtain (Rogers, 2003). In general, organizations that have a greater degree of openness—meaning the degree to which members of a system are linked to other individuals located external to the system—are more innovative. Police departments may have difficulty in collaborating with external agencies because of their culture and often quasi-military operations (Bittner, 1970) making innovations more difficult to adopt. For a new innovation such as CIT to be successful, both patrol officers and middle managers as well as citizens and community partners must accept that this program will be beneficial for them. Without winning “the hearts and minds” of officers, the adoption of CIT is inhibited (Lurigio & Skogan, 1994).
Police history is littered with similar innovations that police agencies have failed to fully adopt for these reasons. For example, in the 1950s police departments adopted Police/Community Relations units designed to reach out to citizens living in the community. This program ultimately failed because its mission was viewed as out of line with ‘real policing’ (Trojanowicz & Bucqueroux, 1990). Based on these experiences, team policing initiatives were developed in police agencies during the 1970s. Team policing was also intended to build better relations with the community by making police assignments geographically based allowing citizens to become familiar with the officers on the team assigned to their neighborhood (Trojanowicz & Bucqueroux, 1990). Team policing was unsuccessful because it was viewed by officers as just another program that was unlikely to survive and was believed to be separate from the organizations’ other activities. As such, for CIT to fare differently from these other programs, its stated goals have to fall within the mission of police organizations and have clearly beneficial consequences for its users or adopters.
The Evidence So Far
Traditionally, police work has been measured in terms of crime suppression and control. As a result, low crime statistics, fast response times and high clearance rates have become the standard to which police agencies are held. Changes in crime rates, however, may not be the most effective way to measure the impact of CIT. This creates a significant challenge for police departments, many of which lack the internal record keeping capabilities to determine if CIT has met its goals. Because of these difficulties, the empirical evidence base for CIT’s effectiveness in terms of those and other goals is limited, but growing. However, as we will discuss, the existing conceptualizations and research on CIT effectiveness have been narrow in scope and lack attention to broader contextual forces that may shape implementation and outcomes.
Two early related studies involved comparisons of three types of specialized response: police-based police response, which involves specially trained police officers; police-based mental health response, which involves mental health clinicians working as civilian employees of the police department; and mental health based mental health response, which involves partnerships with mobile mental health teams that are part of a community mental health center. One of the studies compared case dispositions from three departments, each with one of the specialized response programs. All three departments had relatively low arrest rates for mental health calls. The rate for the department with CIT (Memphis) was the lowest at 2% (Steadman, Deane, Borum, & Morrissey, 2000).
The other study surveyed officers’ perceptions of the effectiveness of their department’s specialized response (Borum et al., 1998). Both CIT and non CIT officers from the department with CIT were significantly more likely to rate their department’s response as effective in meeting the needs of individuals in crisis, diverting persons from jail, minimizing officer time spent, and maintaining community safety.
A more recent study of CIT in Akron, Ohio examined police dispatch log data on mental disturbance calls pre and post CIT implementation (Teller, Munetz, Gil, & Ritter, 2006). While they did not find significant changes in arrest rates for these calls, there were significant increases in the number and proportion of mental disturbance calls identified, overall rates of transports to emergency treatment facilities by CIT-trained officers, and voluntary transports subsequent to CIT implementation. This suggests CIT improved identification and response to persons with mental illness.
Other outcomes of CIT programs have been explored in the literature. A recent study in Louisville, KY found that CIT trained officers were able to correctly identify individuals with mental illness (Strauss et al., 2005). The authors did not have a baseline comparison so it is not clear if officers were equally efficient prior to the adoption of CIT. Several recent studies that have surveyed officers pre and immediately post CIT training have found improvements in both attitudes and knowledge about mental illness (Compton et al., 2006) and improvements in officers’ confidence in identifying and responding to persons with mental illness at post test (Wells & Schafer, 2006).
Thus, evidence to date suggests that CIT training improves officer knowledge, attitudes and confidence, at least in the short term (Compton et al., 2006; Wells & Schafer, 2006). These studies, however, do not detail the extent to which CIT is adopted or the role of the mental health system. In the limited studies available, CIT implementation appears to increase officer confidence in responding to persons with mental illness (Borum et al., 1998); identification of mental illness; and transports to emergency treatment facilities (Teller, Munetz, Gil, & Ritter, 2006). There is no evidence to suggest that the other outcomes of CIT have been realized. In particular, it is not clear that the implementation of CIT has decreased arrests of persons with mental illness. Given the various methodological and resource constraints inherent in evaluating applied interventions, none of these studies included control groups or modeled important organizational and contextual factors likely influence CIT implementation and the outcomes of interest. The literature does not tell us which components of CIT are most important to which outcomes, or under what conditions CIT is likely to be most effective.
The basic assumptions underlying CIT, that training coupled with new policies for dispatch and patrol along with partnerships with mental health providers will increase linkage to mental health services for people with mental illness, reduce the use of force during encounters, and decrease arrests and injuries to both citizens and officers, remain untested against a rival hypothesis that the availability and ease of linkage to mental health treatment is the principal mechanism for effecting these outcomes. If this rival hypothesis were supported, then CIT would be one of several ways to achieve the goal of greater police access to treatment options and safer interactions. Other policies and service schemes could be also marshaled to the same end and may be necessary where treatment options are scarce.
CIT can be conceptualized as supporting a shift in police discretion that accounts for mental illness. This shift includes institutional supports as well and training and education. The implementation of CIT is presumed to have wide ranging effects. It should enhance the skills of officers in encounters with those who have mental illness and their families, reduce the need for force by officers, reduce the incidence of violence in these encounters by persons with mental illness, reduce the incidence of arrest, reduce the incidence of injury to all parties involved, and increase access to crisis and other psychiatric treatment. These concepts can be readily measured. A more challenging question is how to study change in these concepts in a way that can assess the effectiveness of police interventions such as CIT. This challenge is apparent in outcomes such as reduced shootings. In a police department, what does a change of one or two shootings over a year mean in terms of effectiveness of CIT? By more thoroughly conceptualizing these outcomes, we may find opportunities to develop evidence for components of the logic of CIT effectiveness, refine the model, and move toward testable outcome models.
Conceptualizing Police Response at Multiple Levels
As highlighted above, much of the literature and research on CIT has focused on the effect of training on officer attitudes, recognition of mental illness, injuries, and call dispositions. While some of the literature acknowledges the importance of other “key elements” (e.g. centralized mental health drop off), the conceptualizations and evidence are not well developed. Here we present a model that includes considerations of individual officer characteristics and behaviors and the effect of training. We further develop our conceptual model to incorporate “key” organizational, community and systems level factors that influence police response and the outcomes of these encounters (See Figure 1).
Individual officer characteristics and the impact of specialized training on knowledge, attitudes and de-escalation skills
A cornerstone of the CIT model is 40 hours of specialized training for a select group of officers. This training typically involves education about the causes, signs, symptoms and treatment of mental illness; information on commitment criteria and procedures; personal stories from consumers and family members; visits to treatment providers; and training in communication and de-escalation skills, which often includes role play exercises (Rueland, 2004). Some would argue that de-escalation training is the “active ingredient” that effects officers’ ability to resolve a call without the use of force, injury, or arrest (Cordner, 2006) and several studies examining CIT effectiveness focus on the training as the intervention and report pre-and post measures of individual officer variables such as knowledge, attitudes, and behavioral intentions (Compton et al., 2006; Wells & Schafer, 2006). While it seems common sense that the training is a necessary component to improving interactions with people with mental illness, the existing research does not discuss whether training and how much is sufficient for improving outcomes.
It has been noted as important that CIT officers are a select group of volunteers (Spaite & Davis, 2005). Such volunteers may have specific characteristics that enhance the likelihood of reduced arrests and injury in encounters with persons with mental illness and increased psychiatric service access (Thompson & Borum, 2006; Watson & Angell, in press). These characteristics may be associated with pre CIT knowledge, attitudes and skills as well as the effect of CIT training on outcomes of interest. Thus, we include individual officer characteristics such as demographics, prior training, and familiarity with mental illness and completion of CIT training in our model. We do not stop there; however, as we hypothesize that other components of CIT and contextual factors determine the opportunities and options for individual officers to apply their knowledge and skills on the job.
The Organizational Context: Saturation and Champions
As Major Sam Cochran, Memphis CIT Coordinator and founding member, has stressed, “CIT–It’s more than just training” (Cochran, 2004). CIT is an organizational intervention that represents a shift in operating practices in relation to persons with mental illness. Thus, organizational factors are important to conceptualize when considering CIT implementation and effectiveness. For smaller police departments, it may be sufficient to conceptualize these factors at the departmental level. Larger urban police departments are responsible for larger areas and populations and tend to be divided into organizational subunits called districts or precincts in which the work of officers is geographically bounded. Areas bounded by districts may vary significantly in terms of the community demographics and resources. Districts have their own supervisory structure under the central command of the department. Therefore, when conceptualizing organizational factors, it may be useful to consider them at both the Department and District/Precinct level. We include two organizational/district level factors in our model of CIT implementation and effectiveness: saturation and the presence of a champion (see figure 1).
Recommendations on optimal CIT staffing range from 15–25% of all patrol officers in order to ensure 24/7 CIT coverage (Rueland, 2004; Thompson & Borum, 2006). However, the optimal numerical saturation level has not been empirically tested. Our model conceptualizes saturation as a factor influencing implementation and outcomes and allows for consideration of optimal saturation levels under varied conditions.
Another form of saturation is attitudinal. To what extent do officers in the district accept CIT as legitimate and valuable approach to responding to persons with mental illness? In most departments, there is likely to be some resistance to a new way of responding to mental disturbance calls. This begs two questions, what level of attitudinal saturation (among CIT and other officers) is necessary for CIT to influence encounter outcomes? And at what point are enough officers involved in CIT (numerical saturation), before it is accepted at the District/Precinct level and by the larger organization? Rogers (2003) refers to the critical mass in the diffusion of an innovation. Critical mass is the point after which diffusion becomes self-sustaining and has mainly been used to understand the diffusion of technological innovations by individuals (c.f. Fischer, 1992) but can be applied to other organizational innovations as well. Rogers (2003) gives the example that a single log in a fireplace will not continue to burn by itself. A second log must be present so that each log reflects its heat onto the other (p. 349). Based on this literature, we can expect CIT to have an impact because small changes can trigger larger changes. For example, a small change in the response to persons with mental illness by a small group of officers, triggers a big change in how the department overall treats this population. It may not be necessary to have officers trained for every shift or in every district- the change triggered by a small group of CIT officers may be enough. Just how many officers must be trained before CIT is an accepted service of the department? Until there is a significant change in practice and outcomes? Our model will allow this to be examined.
A key element of a new police program such as CIT is that of the “champion” (Rogers, 2003). In most jurisdictions, officers become part of the CIT program by choice, rather than by top down assignment. The decision and motivation to accept the legitimacy of the CIT program or to take the next step and volunteer may be largely dependent on the strength and influence of the “champion”. Officer support for new program is often based on cues that the new program is important and supported by command staff and will aid their advancement in the organization (c.f. Nowicki, 1997, 2000). If officers do not believe that participation in or cooperation with the CIT program will affect their performance evaluation and opportunities for promotion, individual saturation will be negatively affected. A ‘champion’ can send the message to line officers that CIT participation and cooperation is valued within the agency. The presence of a champion can therefore, positively influence the level of numerical and attitudinal saturation of officers (Rogers, 2003).
The Broader Context: Service system and community factors
A “key element” of CIT is the development of linkages between police and mental health providers in the community (National Council of State Governments, 2002). Steadman and colleagues (2001) have noted that a no-refusal drop off center at the local psychiatric emergency room key to the success of CIT in Memphis and as a core component of effective police based diversion programs generally (Steadman, et al., 2001). However, availability of services and other contextual factors have not been systematically considered or examined.
The lack of attention to the broader context in police research is not unique to studies of CIT. Klinger (2004) laments the failure to examine these factors in police studies, despite the call to do so almost 40 years ago (Reiss & Bordua, 1967). Reiss & Bordoau (1967) noted that police must regularly transact with external entities, many of which are antagonistic. They asserted, and Klinger (2004) echoes “police actions can be substantially influenced by the nature of the tasks they are called upon to do in the environment, by the qualities of the external entities with which they must interact, and by the broader social contexts in which these interactions occur (p. 120).” In this vein, characteristics of the community police officers are working in may influence both the nature of and frequency of mental disturbance calls and the resources available to officers for responding.
Availability of Mental Health Treatment Linkages
A key outcome espoused by CIT proponents is the diversion of persons with mental illness from the criminal justice system to appropriate mental health treatment. There is extensive documentation concentrated over the past forty years or so of the often frustrating experience of police officers in accessing crisis and emergency psychiatric treatment for persons with mental illness (Bittner, 1967; Green, 1997; Teplin & Pruett, 1992) and their dissatisfaction with available options (Wells & Schafer, 2006). In order to divert individuals with mental illness to the mental health system, officers must interact with providers from the mental health system. This can only occur if responsive mental health services exist; and if officers are able to efficiently link individuals to treatment to resolve a mental health call. Police must also have access to community mental health resources to respond to individuals who are in need of services but do not meet criteria for emergency evaluation at the hospital. Availability of mental health linkages can be conceptualized concretely in terms of the number of providers of different types of services (centralized drop off, mobile crisis units, psychiatric emergency rooms, inpatient beds, outpatient providers) in a jurisdiction, or within a reasonable distance. Levels of public mental health spending in districts/communities may also be indicative of availability of mental health linkages
For officers to use mental health system resources, they would need to perceive the resources as plausible, efficient, and consistent with resolving the situation on the street (c.f. Finn & Stalans, 2002; Fry, O’Riordan, & Geanellos, 2002). Therefore, availability of psychiatric services can be conceptualized as including the perception, by officers, of the usefulness linking someone with treatment. These perceptions can be shaped by prior experience with the linkages, training in using them, the proximity of the treatment facility, and the perceived effectiveness of available treatment. Officers who experience treatment facilities as contentious or time consuming would be less likely to link to treatment than officers who experience treatment as collaborative and efficient. Changes in these perceptions can be expected over time as they relate to training, such as that given as part of CIT. It can also be attributed to knowledge of others’ experiences of linking to treatment resources, which can be connected to the extent of implementation of an intervention such as CIT. Thus, treatment linkage availability and officer perceptions of linkage availability are important constructs in our model (See figure 1).
In addition to the availability of mental health system resources, the broader social context in which police interact with persons with mental illness is likely to influence what police are expected to respond to and the resources available to for doing so. Here, we consider community conditions that are indicators of social disorganization. Police officers’ orientations toward citizens in general and their responses to crime and deviance vary based on characteristics of the neighborhood in which they work (Klinger, 1997; Smith, 1987). Neighborhood structural conditions such as poverty, wealth, family structure, employment, residential stability, housing stock, and racial/ethnic composition at the neighborhood level (Sampson & Groves, 1989; Sampson & Lauritsen, 1994; Silver, 2000) have long been considered important determinants of crime and violence (Sampson, 1985, 1990; Sampson & Groves, 1989; Shaw & McKay, 1931, 1942, 1969); violence among persons with mental illness (Silver, 2000); victimization (Sampson, 1983; Sampson & Lauritsen, 1994); police-community relations (Alpert & Dunham, 1988; Klinger, 1997; Weitzer, 1999; Weitzer & Tuch, 1999); police behavior (Smith, 1987); citizen compliance with police requests (McCluskey, 2002), and outcomes for persons with mental illness (Faris & Dunham, 1939). Hence, officers working in different neighborhoods have very different work experiences shaping their attitudes and behavior. Social disorganization theory provides an explanation for how neighborhood-level factors exert their influence. These factors reflect structural conditions that affect the community’s ability to realize the common values of its residents and to maintain effective social control (Bursik, 1988; Sampson, 1988; Silver, 2000).
This logic can be extended to include the value of, and access to mental health treatment. Access to treatment is facilitated by social networks and community ties (Hohmann, 1999; Pescosolido, 1992; Pescosolido, Gardner, & Lubell, 1998; Wells, Sherbourne, Sturm, Young, & Burnam, 2002). These social networks and ties may be more efficient toward this goal in socially organized neighborhoods. In disorganized neighborhoods, residents tend to have fewer ties to formal and informal social networks (e.g. church groups, friendship and kinship networks) that socialize community residents and are a mechanism of influence to promote public order (Bursik & Grasmick, 1993; Sampson & Groves, 1989). Individuals are less able to intervene informally with individuals exhibiting deviance such as overt symptoms of mental illness. As a result, intervention is delayed and such situations may be more likely to escalate to crisis requiring police response. Thus, officers working in disorganized neighborhoods may have more contacts with persons with mental illness experiencing crisis due to lack of earlier intervention. Responding to these situations can be dangerous and stressful for officers. Additionally, as neighborhood deviance increases, police become more cynical, losing faith in the “system” and the utility of vigorous action (Klinger, 1997). This may make them prone to relying on stereotypes about persons with mental illness, less inclined to provide assistance, and less optimistic that an intervention such as CIT could improve their ability (and the systems’) to effectively respond.
The effect of CIT programs may vary across geographic areas due to variation in community conditions. In this regard, we consider two possibilities. It is possible that CIT interventions will be maximized in disorganized neighborhoods given that these neighborhoods possess more openings for formal intervention due to fewer informal avenues. Likewise, in more organized communities the effect of CIT interventions may not be as pronounced simply because there is less need for formal intervention. Alternatively, it is possible that CIT interventions are maximized in these neighborhoods. This might occur because some degree of social organization is required for CIT interventions to be effectively implemented.
Optimal saturation levels may be different in communities that are more or less disorganized. For example, in communities with higher crime rates and fewer resources, saturation levels may need to be higher to ensure that not only is there a CIT officer on duty, but that there is a CIT officer available (not involved in other calls) to respond.
In considering the complexities of police work and the implementation of a police based intervention such as CIT, one might conceptualize the effectiveness as illustrated in figure 1.
In this model, the effectiveness of CIT is assessed by a variety of outcomes. Relying only on outcomes documented in official records may limit us to high intensity but relatively low frequency events such as arrest, use of lethal force and serious injury. Determining the meaning of a reduction from 9 to 7 police shootings from one year to the next may be difficult. Thus, our model includes additional outcomes and data sources relevant to determining CIT effectiveness. One outcome is the use of specific skills when responding to calls involving persons with mental illness. These may include assessing for the likely presence of mental illness, using communication and de-escalation techniques, communicating with mental health providers and completing emergency evaluation petitions. If officers employ these skills, the resistance/violence on behalf of the person with mental illness and the need for force by the officer and resulting injuries to all parties should be reduced. Police officers and, potentially, the subjects of the encounter can rate these outcomes. While arrests and transports to the hospital are likely to be documented, said documentation may or may not also include information identifying the call as a mental disturbance call. Thus, triangulating official documentation with officer reports may be useful. In theory, when individuals are in need of services but do not meet emergency hospitalization criteria, CIT officers will provide referrals and linkages to appropriate community services and supports. This is an important outcome that is unlikely to be captured current reporting systems, but could be obtained directly from officers.
The impact of CIT on these outcomes is moderated by the availability of mental health treatment linkages in the community. If appropriate mental health treatment linkages are not (or are perceived as not) available, the application of CIT skills may seem futile to officers. Incorporated into the model are two organizational factors: saturation (numerical and attitudinal) and the presence of a “champion”. What level of these factors is necessary for a true shift in police practice? Does this vary based on the availability of services and community conditions? The box for Community Characteristics includes the broader context in which police interact with persons with mental illness. Specifically, this includes characteristics of the community in which police officers work (indicators of social disorganization and crime rates), which may shape the availability of psychiatric services as well as police practice more generally. The overall model is controlled by baseline characteristics of the officers.
Implications for Research and Practice
Our model directs us to consider the extent to which CIT is embraced and supported by the agency, as well as mental health system and community factors that may influence both implementation and outcomes. It suggests measurable constructs at the individual officer, organizational and community level. By applying this model we will begin to build our understanding of CIT implementation and effectiveness, and determine which components of CIT, as well as organizational and community factors are important to predicting which outcomes. We may find that the primary influence on arrests of persons with mental illness is the availability of and ease of linkage to mental health resources. Reduction of injuries and increased voluntary transports to the hospital my result from an interaction between training and treatment availability/ease of linkage (see figure 1). This type of information is critical for targeting resources to local policy and resource contexts.
Some jurisdictions are going against the CIT tide and adopting different approaches or significantly modified versions of CIT. For example, many jurisdictions have enhanced training in mental health issues for all officers and some have done this in addition to the use of mental health system based mobile response units or police –mental health co-response teams (Reuland & Cheney, 2005; Rueland, 2004). Portland, Oregon implemented CIT in 1994. More recently, they have made plans to adapt the model and provide CIT training to all officers based on the belief that all officers need to be prepared to effectively respond to persons with mental illness. Major Sam Cochran has criticized this approach, suggesting that “some officers are not well suited to be CIT officers” and stressing the importance of having the right officers designated to respond to mental health crisis calls (Bernstein, 2006). It is likely that effective police response to persons with mental illness will depend on more than whether a specialized group or all officers receive training. More research is needed before rival approaches are dismissed as not following the practice “model.” Our proposed conceptual model allows for consideration of varied approaches and contexts and can guide research that examines effectiveness of competing practice models.
Key research implications for our proposed conceptual model are sampling and unit of analysis. Mental health programs are customarily researched using an individual consumer/client level of analysis. Typically, this research follows clients of a service over time to look for changes in outcome. In the case of CIT, this may be appropriate to assess outcomes such as changes or differences in risk of injury in the context of police encounters. However, this will only capture one, limited aspect of the impact of CIT.
The essence of CIT is as a systemic intervention, not an individual intervention. Future research on effectiveness of CIT needs to look for impact on populations at risk and on change in systemic behavior not only in police systems as our model suggests, but in the mental health and substance use systems as well. To reflect this, research could be designed so that individual consumer level data, to have value in this outcome conceptualization, be collected to represent populations at risk of arrest, not “clients” of a diversion program. For example, if the unit of analysis were higher order units, such as police precincts, divisions or jurisdictions, this model may support more systems change oriented analysis. Data could include repeated population surveys of individuals in the geographic area who have a greater risk of arrest or police encounter, such as those with mental illness and co-occuring substance abuse disorder, or previous arrest history. Change in the outcome could be measured over time within one system as CIT is implemented, or in controlled and naturalistic comparisons of these units. Admittedly, such research would require extensive resources. However, it would allow us to gain a deeper understanding of the impact of CIT programs in the complex, multi-system environments in which they operate.
Law enforcement agencies find the CIT program model appealing, which contributes to its relatively fast dissemination. While there are state and national efforts to identify key elements of CIT and support CIT programs, we lack a solid evidence base for CIT or other interventions to improve police intervention with mental illness. In this article, we presented a multi-level conceptualization of police based interventions for interactions with persons with mental illness. This model expands beyond the common focus of the impact of training to explain important outcomes, such as injury, use of force, violence, arrest and linkage to treatment, and connect these outcomes to the implementation of CIT and other models of police response.
The current research supports CIT as a promising approach to improving police response to persons with mental illness. By moving our conceptualizations and research in this area to new levels of specificity, we may contribute more to the effectiveness of these interventions. This in turn can drive policy and practice towards more effective law enforcement response to persons with mental illness. Our proposed model should also encourage innovation in mental health systems as well. We expect that accessibility, responsiveness, and quality of treatment in the mental health system may explain a great deal about the effectiveness of police interventions in a community context.
This work was supported in part by the Center for Mental Health Services and Criminal Justice Research, NIMH Grant T20-MH068170.
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Amy C Watson, University of Illinois at Chicago.
Melissa Schaefer Morabito, University of Massachusetts Boston.
Jeffrey Draine, University of Pennsylvania.
Victor Ottati, Loyola University-Chicago.
- Alpert G, Dunham R. Policing Urban America. 1. Prospect Heights, IL: Waveland Press; 1988.
- Bernstein M. Potter wants $500,000 to train police to deal with mentally ill. The Oregonian 2006 October 31, 2006;
- Bittner E. The police on skid-row: A study of peace keeping. American Sociological Review. 1967;32:699–715.
- Bittner E. The functions of police in modern society. Washington, DC: U.S. Government Printing Office; 1970.
- Borum R, Deane M, Steadman H, Morrissey J. Police perspectives on responding to mentally ill people in crisis: Perceptions of program effectiveness. Behavioral Sciences & the Law. 1998;16:393–405.[PubMed]
- Bureau of Justice Assistance. Law Enforcement/Mental Health Partnership Program. 2006. Retrieved December 22, 2006, from http://www.ojp.usdoj.gov/BJA/grant/LE_MHPartnership.pdf.
- Bursik R. Social disorganization and theories of crime and delinquency: Problems and prospects. Criminology. 1988;26:519–551.
- Bursik R, Grasmick H. Neighborhoods and crime: The dimensions of effective community control. New York: Lexington; 1993.
- Chappell A, MacDonald J, Manz P. The organizational determinants of police arrest decisions. Crime & Delinquency. 2006;52(2):287–307.
- Cochran S. In my opinion: Fighting stigma in law enforcement: The message has to come from the heart. ADS Center memorandum. 2004. Winter. Retrieved February 22, 2007, from http://www.adscenter.org/memoranda/indexwinter2004.htm.
- Cochran S, Deane M, Borum R. Improving police response to mentally ill people. Psychiatric Services. 2000;51:1315–1316.[PubMed]
- Compton M, Esterberg M, McGee R, Kotwicki R, Oliva J. Crisis intervention team training: Changes in knowledge, attitudes, and stigma related to schizophrenia. Psychiatric Services. 2006;57(8):1199–1202.[PubMed]
- Cordner G. Office of Community Oriented Policing Series, U.S. Department of Justice. People with mental illness. Problems-Specific Guides Series. 2006. Retrieved October 17, 2006, from http://www.popcenter.org/problems/PDFs/MentalIllness.pdf.
- Crank J. Understanding police culture. Cincinnati, Ohio: Anderson; 1998.
- Deane M, Steadman H, Borum R, Veysey B, Morrissey J. Emerging partnerships between mental health and law enforcement. Psychiatric Services. 1999;50(1):99–101.[PubMed]
- Draine J, Solomon P. Describing and evaluating jail diversion services for persons with serious mental illness. Psychiatric Services. 1999;50(1):56–61.[PubMed]
- Engel R, Silver E. Policing mentally disordered suspects: A reexamination of the criminalization hypothesis. Criminology. 2001;39(2):225–252.
- Engel R, Sobol J, Worden R. Further exploration of the demeanor hypothesis: The interaction effects of suspects’ characteristics and demeanor on police behavior. Justice Quarterly. 2000;17(2):235–258.
- Faris R, Dunham H. Mental disorders in urban areas: An ecological study of schizophrenia and other psychoses. Chicago: University of Chicago Press; 1939.
- Finn M, Stalans L. Police handling of the mentally ill in domestic violence situations. Criminal Justice and Behavior. Criminal Justice and Behavior. 2002;29(3):278–307.
- Fischer C. America calling: A social history of the telephone to 1940. Berkeley: University of California Press; 1992.
- Fry A, O’Riordan D, Geanellos R. Social control agents or front-line carers for people with mental health problems: police and mental health services in Sydney, Australia. Health & Social Care in the Community. 2002;10(4):277–287.[PubMed]
- Goldstein H. Policing a free society. Cambridge, Mass: Ballinger Publishing Company; 1976.
- Green T. Police as frontline mental health workers: The decision to arrest or refer to mental health agencies. International Journal of Law & Psychiatry. 1997;20(4):469–486.[PubMed]
- Hohmann A. A contextual model for clinical mental health effectiveness research. Mental Health Services Research. 1999;1(2):83–91.
- Kaminski R, DiGiovanni C, Downs R. The use of force between the police and persons with impaired judgment. Police Quarterly. 2004;7(3):311–338.
- Klinger D. Negotiating order in patrol work: An ecological theory of police response to deviance. Criminology. 1997;35(2):277.
- Klinger D. Environment and organization: Reviving a perspective on the police. Annals of the American Academy of Political and Social Science. 2004;593:119–136.
- Lurigio A, Skogan W. Winning the hearts and minds of police officers: An assessment of staff perceptions of community policing in Chicago. Crime & Delinquency, Special Issue: Community Policing. 1994;40(3):315–330.
- McCluskey J. Coercion, procedural justice, and compliance in police-citizen encounters. Albany, NY: 2002. Unpublished manuscript.
- National Council of State Governments. Criminal Justice Mental Health Consensus Project. 2002. http://consensusproject.org/
- Nowicki D. Are our officers being sent mixed messages? September 30. New York: Law Enforcement News; 1997.
- Nowicki D. Mixed messages. In: Alpert G, Piquero A, editors. Community policing: Contemporary readings. 2. Long Grove, Illinois: Waveland Press; 2000.
- Pescosolido B. Beyond rational choice: The social dynamics of how people seek help. American Journal of Sociology. 1992;97:1096–1138.
- Pescosolido B, Gardner C, Lubell K. How people get into mental health services: Stories of choice, coercion and “muddling through” from “first-timers” Social Science & Medicine. 1998;46(2):275–286.[PubMed]
- Reiss A, Bordua D. Environment and organization: A perspective on the police. In: Bordua D, editor. The police: Six sociological essays. New York: Wiley; 1967.
- Reuland M, Cheney J. Enhancing success of police-based diversion programs for people with mental illness. New York: GAINS Technical Assistance and Policy Analysis Center for Jail Diversion; 2005.
- Rogers E. Diffusion of innovations. 5. New York: The Free Press; 2003.
- Rueland M. A guide to implementing police-based diversion programs for people with mental illness. Delmar, NY: Technical Assistance and Policy Analysis Center for Jail Diversion; 2004.
- Ruiz J. An interactive analysis between uniformed law enforcement officers and the mentally ill. American Journal of Police. 1993;12(4):149–177.
- Ruiz J, Miller C. An exploratory study of Pennsylvania police officers’ perceptions of dangerousness and their ability to manage persons with mental illness. Police Quarterly. 2004;7(3):359–371.
- Sampson R. Structural density and criminal victimization. Criminology. 1983;21:276–293.
- Sampson R. Neighborhood and crime: The structural determinants of personal victimization. Journal of Research in Crime and Delinquency. 1985;22:7–40.
- Sampson R. Local friendship ties and community attachment in mass society: A multilevel systemic model. American Sociological Review. 1988;53:766–779.
- Sampson R. Crime and deviance over the life course: The salience of adult social bonds. American Sociological Review. 1990;53:766–769.
- Sampson R, Groves W. Community structure and crime: Testing social-disorganization theory. American Journal of Sociology. 1989;94:774–802.
- Sampson R, Lauritsen J. Violent victimization and offending: Individual-, situational-, and community-level risk factors. In: Reiss A, Roth A, et al., editors. Understanding and preventing violence. Vol. 3. Chicago: University of Chicago; 1994. pp. 1–114.
- Shaw C, McKay H. Report on the Causes of Crime, National Commission of Law Observance and Enforcement. Vol. 2. Washington, DC: Government Printing Office; 1931. Social factors in juvenile delinquency.
- Shaw C, McKay H. Juvenile delinquency and urban areas. Chicago: University of Chicago Press; 1942.
- Shaw C, McKay H. Juvenile delinquency and urban areas. Rev ed. Chicago: University of Chicago Press; 1969.
- Silver E. Race, neighborhood disadvantage, and violence among persons with mental disorders: The importance of contextual measurement. Law & Human Behavior. 2000;24(4):449–456.[PubMed]
- Smith D. Police response to interpersonal violence: Defining the parameters of legal control. Social Forces. 1987;65:767–782.
- Spaite P, Davis M. The mentally ill and criminal justice system: A review of programs. 2005. Retrieved October 18, 2006, from http://www.namiohio.org/REVIEW_PROGRAMS.pdf.
- Steadman H, Deane M, Borum R, Morrissey J. Comparing outcomes of major models of police responses to mental health emergencies. Psychiatric Services. 2000;51(5):645–649.[PubMed]
- Steadman H, Stainbrook K, Griffin P, Draine J, Dupont R, Horey C. The need for a specialized crisis response location for effective police-based diversion programs. Psychiatric Services. 2001;52:219–222.[PubMed]
- Strauss G, Glenn M, Reddi P, Afaq I, Podolskaya A, Rybakova T, Saeed O, Shah V, Singh B, Skinner A, El-Mallakh R. Psychiatric disposition of patients brought in by crisis intervention team police officers. Community Mental Health Journal. 2005;41(2):223–228.[PubMed]
- Teller J, Munetz M, Gil K, Ritter C. Crisis intervention team training for police officers responding to mental disturbance calls. Psychiatric Services. 2006;57(2):232–237.[PubMed]
- Teplin L. Criminalizing mental disorder: The comparative arrest rate of the mentally ill. American Psychologist. 1984;39(7):794–803.[PubMed]
- Teplin L, Pruett N. Police as streetcorner psychiatrist: Managing the mentally ill. International Journal of Law & Psychiatry. 1992;15:139–156.[PubMed]
- Terrill W, Reisig M. Neighborhood context and police use of force. Journal of Research in Crime and Delinquency. 2003;40(3):291–321.
- Thompson L, Borum R. Crisis Intervention Teams (CIT): Considerations for knowledge transfer. Law Enforcement Executive Forum. 2006;6(3):25–36.
- Trojanowicz R, Bucqueroux B. Community policing: A contemporary perspective. Cincinnati: Anderson; 1990.
- Watson A, Angell B. Applying procedural justice theory to law enforcement’s response to persons with mental illness. Psychiatric Services in press. [PubMed]
- Watson A, Corrigan P, Ottati V. Police officer attitudes and decisions regarding persons with mental illness. Psychiatric Services. 2004a;55:49–53.[PubMed]
- Watson A, Corrigan P, Ottati V. Police responses to persons with mental illness: Does the label matter? The Journal of the American Academy of Psychiatry and the Law. 2004b;32(4):378–386.[PubMed]
- Weitzer R. Citizens’ perceptions of police misconduct: Race and neighborhood context. Justice Quarterly. 1999;16(4):819–846.
- Weitzer R, Tuch S. Race, class, and perceptions of discrimination by the police. Crime & Delinquency. 1999;45(4):494–507.
- Wells K, Sherbourne C, Sturm R, Young A, Burnam M. Alcohol, drug abuse, and mental health care for uninsured and insured adults. Health Services Research. 2002;37(4):1055.[PMC free article][PubMed]
- Wells W, Schafer J. Officer perceptions of police responses to persons with a mental illness. Policing: An International Journal of Police Strategies & Management. 2006;29(4):578–601.
Current approaches to treatments for schizophrenia spectrum disorders, part II: psychosocial interventions and patient-focused perspectives in psychiatric care
Wai Tong Chien,Sau Fong Leung,Frederick KK Yeung, and Wai Kit Wong
School of Nursing, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
Correspondence: Wai Tong Chien, School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong, Tel +852 2766 5648, Fax +852 2334 1124, Email email@example.com
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Neuropsychiatr Dis Treat. 2013; 9: 1463–1481.
Published online 2013 Sep 25. doi: 10.2147/NDT.S49263
This article has been cited by other articles in PMC.
Schizophrenia is a disabling psychiatric illness associated with disruptions in cognition, emotion, and psychosocial and occupational functioning. Increasing evidence shows that psychosocial interventions for people with schizophrenia, as an adjunct to medications or usual psychiatric care, can reduce psychotic symptoms and relapse and improve patients’ long-term outcomes such as recovery, remission, and illness progression. This critical review of the literature was conducted to identify the common approaches to psychosocial interventions for people with schizophrenia. Treatment planning and outcomes were also explored and discussed to better understand the effects of these interventions in terms of person-focused perspectives such as their perceived quality of life and satisfaction and their acceptability and adherence to treatments or services received. We searched major health care databases such as EMBASE, MEDLINE, and PsycLIT and identified relevant literature in English from these databases. Their reference lists were screened, and studies were selected if they met the criteria of using a randomized controlled trial or systematic review design, giving a clear description of the interventions used, and having a study sample of people primarily diagnosed with schizophrenia. Five main approaches to psychosocial intervention had been used for the treatment of schizophrenia: cognitive therapy (cognitive behavioral and cognitive remediation therapy), psychoeducation, family intervention, social skills training, and assertive community treatment. Most of these five approaches applied to people with schizophrenia have demonstrated satisfactory levels of short- to medium-term clinical efficacy in terms of symptom control or reduction, level of functioning, and/or relapse rate. However, the comparative effects between these five approaches have not been well studied; thus, we are not able to clearly understand the superiority of any of these interventions. With the exception of patient relapse, the longer-term (eg, >2 years) effects of these approaches on most psychosocial outcomes are not well-established among these patients. Despite the fact that patients’ perspectives on treatment and care have been increasingly concerned, not many studies have evaluated the effect of interventions on this perspective, and where they did, the findings were inconclusive. To conclude, current approaches to psychosocial interventions for schizophrenia have their strengths and weaknesses, particularly indicating limited evidence on long-term effects. To improve the longer-term outcomes of people with schizophrenia, future treatment strategies should focus on risk identification, early intervention, person-focused therapy, partnership with family caregivers, and the integration of evidence-based psychosocial interventions into existing services.
Keywords: schizophrenia, psychosocial intervention, patient-focused perspectives
Schizophrenia is characterized by profound disruptions to cognition and emotions, often resulting in progressive loss of self-care and social functioning in affected individuals. As discussed in another review, “Current approaches to treatments for schizophrenia spectrum disorders, part I: an overview and medical treatments,”1 a narrowly focused biological model has been shown to be inadequate if treatment and care for schizophrenia and these patients’ potential are to be optimized. Although psychopharmacological treatment is essential and considered the mainstay for achieving better physical and cognitive functioning in schizophrenia, several limitations such as unavoidable adverse effects (eg, acute extrapyramidal symptoms and other neurocognitive impairments in long-term treatment with these drugs) and medication refusal or noncompliance have reduced its efficacy in the treatment of schizophrenia.1,2 The optimism that medication use alone can result in full recovery, early discharge, or reduced risk for relapse is not justified in many cases. Recent guidelines on treatment and care for schizophrenia have recommended that sufficient knowledge about the illness and its treatments and other strategies in psychosocial and/or person-focused interventions should be provided to patients (and/or their family carers) to maximize their acceptance and satisfaction with the treatments and to improve the experience and outcomes of care for these patients.2,3 Health professionals should work in partnership with patients and their family carers, offering treatment, education, support, and psychosocial care in an atmosphere of hope and optimism.4
During the last three decades, clinical research has increasingly indicated that community-based psychosocial interventions can improve the longer-term outcomes of patients with schizophrenia and other severe mental illnesses. A critical review of the common approaches to psychosocial intervention for people with schizophrenia was therefore performed. First, the concepts and research evidence of five main approaches to psychosocial interventions for schizophrenia (ie, cognitive therapy, psychoeducation programs, family intervention, social skills training programs, and assertive community treatment [ACT]) are discussed. Second, this review provides a summary of and discussion on the relative efficacy of the most commonly used approaches to psychosocial interventions in terms of their effect sizes on their most commonly reported patient outcomes. Third, the importance of person-focused perspectives such as quality of life, patient satisfaction and acceptability, and adherence to treatment and its use in research on psychosocial interventions for schizophrenia are also discussed. Finally, we have made several recommendations for best practice in schizophrenia treatment on the basis of this review, as well as another related review published in Neuropsychiatric Disease and Treatment.1 These findings and discussions can increase our understanding of the most effective means for people with schizophrenia to be better managed within the community, as well as suggesting ways to improve community-based interventions and rehabilitation for schizophrenia.
Psychosocial interventions for people with schizophrenia
Recent research and systematic reviews suggest that both pharmacological and psychosocial treatment, offered early to people presenting with schizophrenia and other psychotic disorders, can improve their prognosis and even help prevent their illness chronicity.5–7 There has also been increasing evidence that psychosocial interventions are effective in relieving these patients’ psychotic symptoms and improving their functioning, thus providing support for recommendations that they be considered an indispensable part of the treatment options available for promoting patient recovery from schizophrenia. It is suggested that psychosocial interventions can not only directly address a wide range of patients’ health needs, such as symptom reduction, relapse, and treatment adherence, but also provide a more cost-effective intervention than the standard treatment for schizophrenia.8
Five major categories of psychosocial intervention have been used in the community-based treatment of patients with schizophrenia, with evidence of efficacy on relapse prevention and symptom control. The five categories are cognitive therapy (mainly cognitive behavioral therapy [CBT] and cognitive remediation therapy), psychoeducation programs, family intervention, social skills (and other coping skills), training programs, and case management or ACT.9,10 Nevertheless, there are also a few other traditional approaches to psychosocial interventions, such as psychodynamic psychotherapy;11,12 client-centered, supportive, and insight-oriented psychotherapy;13–15 and behavioral modification techniques (eg, token economy),16,17 which have been believed to be potentially effective but are lacking empirical, systematic outcome studies that support each as an evidence-based intervention for schizophrenia.
Even though the process of these interventions is not always described clearly, each type of intervention model has an individual set of goals and objectives, as well as a treatment agenda, and all have been found to be effective in improving different aspects of the functioning of patients with schizophrenia. However, it should be noted that there are difficulties in implementing these interventions in everyday clinical practice in community care settings. First, staff may not be adequately trained to implement the intervention. Second, as these interventions need to be implemented for 9–12 months, there may be insufficient resources to deliver and evaluate them adequately.18 Finally, there may be inadequate recognition and support from service managers in terms of the service strategy collaboration, resources, and time needed to embed these interventions in existing mental health services.4,19
For this literature review, electronic searches of the most common and major databases were performed. These databases included Biological Abstracts (1980–2012), CINAHL (1982–2012), the Cochrane Library and Cochrane Schizophrenia Group’s Register of Trials, EMBASE (1980–2012), MEDLINE (1966–2012), PsycLIT (1887–2012), SIGLE (1990–2012), and Sociofile (1980–2012). Keywords used for the searches were “schizophrenia,” “psychosocial intervention or program,” “psychological treatment or therapy,” “psychotherapy,” “cognitive or cognitive behavior therapy,” “skills training,” “psycho-education,” “family intervention,” and “case management or assertive treatment.” There were 472 articles retrieved from the initial searches. After initial screening of the abstracts, those found relevant to the topic of interest (n = 145) were reviewed and checked for methodological rigor and validity by two authors; only randomized controlled trials and review articles and those studies with a primary diagnosis of schizophrenia or its subtypes were considered for inclusion. All reference lists of the selected articles were also searched to identify further relevant trials. Finally, there were 92 articles included in this review, including 25 for psychoeducation, 22 for CBT, 15 for family intervention, 10 for cognitive remediation therapy, and 7 for social skills training. Among them, 15 were review articles.
Developed in the 1950s, CBT has been considered an effective therapy for depressive disorder for several decades; this therapy and some of its well-established techniques have eventually come to be used as a promising treatment modality for individuals with schizophrenia whose psychotic symptoms are not controlled by medication.20 CBT is a highly structured and standardized therapy to help patients with schizophrenia cope with their psychotic symptoms by examining and reevaluating their thoughts and perceptions of experiences. It can only be successful if the therapist accepts the patient’s perception of reality (and the illness and its symptoms) and determines how to use this “misinterpretation” to assist the patient in correctly managing his/her life problems.21 In CBT, the patient would be encouraged to actively participate by examining the evidence for and against the distressing belief, challenging the habitual patterns of thinking about the belief, and using reasoning and personal experiences to develop rational and acceptable alternative explanations and interpretations for coping, problem solving, and self-management of the illness and its symptoms. Although some studies have found CBT to have positive benefits in terms of reduction of positive symptoms and recovery time over the course of 9–12 months in comparison with standard care and a few psychological approaches, it has not yet shown promising evidence of reduction of negative and persistent severe psychotic symptoms for people with schizophrenia, particularly over a longer-term (ie, 2-year) follow-up.22,23 Although CBT for schizophrenia was mainly designed with an individual treatment, there has been some evidence its group delivery may be more cost-effective.24
Previous prospective, nonrandomized controlled trials of CBT for schizophrenia in the 1990s also indicated several limitations, including small sample sizes (eg, 3–30 patients per group), lack of other psychosocial interventions for comparison, lack of blinding for independent assessors, and lack of validity and fidelity checking of the intervention sessions. Although the effect sizes for improving the positive symptoms in more recent randomized controlled trials (2000–2006) were mainly very low to medium (ie, 0.02–0.62; mean weight effect size, 0.37), there were no significant differences in target symptoms (both positive and negative) between individual and group CBT.24–27 In addition, controlled trials of CBT for relapse prevention have yielded inconsistent findings. Gumley et al28 showed the significant effect of CBT in identifying prodromal signs of relapse from schizophrenia during a 12-month follow-up, whereas Durham et al29 found a modest effect in relapse prevention and reduction of positive symptoms with newly trained and minimally supervised therapists for psychosis.
Overall, the research evidence on CBT favors its use among people with schizophrenia, and it is recommended in the United Kingdom and United States that it be included as the main approach to interventions for schizophrenia.2,3 Although there are differences in duration, number of sessions, comparative treatment, and outcomes in controlled trials, recent systematic reviews of these trials reported a similar significant positive effect of CBT on improving psychotic symptoms over the course of 6–12 months follow-up when compared with standard psychiatric care.28,29 In seven controlled trials reviewed by Gould et al,30 CBT can also produce a large effect size in residual or persistent positive symptoms immediately after the intervention (effect size, 0.65) and over the course of 1 year (effect size, 0.93).
A specific technique used in CBT for patients with schizophrenia is the normalizing rationale, in which the patient with poor coping ability and social withdrawal from mental health services is empowered and facilitated to collaboratively develop effective coping strategies, leading to symptomatic improvement.22,23 Tarrier et al24 conducted a multicenter randomized controlled trial with an 18-month follow-up of CBT for in-hospital patients with acute schizophrenia and reported that CBT was more effective in symptom control than routine care. However, there were no significant differences on relapse, rehospitalization, or level of functioning between groups. Similar to the findings of the recent systematic reviews,21–23,26 the evidence identified for the effectiveness of CBT in terms of controlling positive, negative, and mood-related symptoms and relapse prevention, particularly in terms of the specificity and durability of these intended benefits, is not conclusive or consistent. When compared with supportive psychotherapy and psychoeducation, CBT for schizophrenia showed relatively lower effects on relapse, reduction of rehospitalization, and mental state both medium term (6 weeks–3 months) and long term (>3 months–1 year).21,22
In addition, CBT requires experienced and skilled practitioners, a clear definition of the essential and effective components in the intervention, and management of the practical demands on patients in terms of time for regular sessions and the necessity for high levels of concentration and insight. As Tarrier et al31 and Turkington et al32 point out, these requirements exclude a high proportion of more disabled patients and limit its widespread dissemination into routine practice. These contradictory findings and limitations of CBT for schizophrenia reveal a need for more randomized controlled trials focusing on the durability of the effect, with an expansion of the targeted symptoms, including negative symptoms, depression, and anxiety. As suggested by Barrowclough et al33 and Addington et al,34 CBT could be used as an adjunct to other psychosocial interventions to improve symptoms or psychosocial functioning, particularly for young people with a high risk for psychosis or for those with a dual diagnosis and/or substance abuse. For instance, although cognitive remediation focuses on neurocognition and social cognition, there is a possibility of synergy with CBT for improving the cognitive and social functioning of patients with schizophrenia.
Cognitive remediation therapy
In response to the impaired cognition that occurs in many patients with schizophrenia, recent research has also raised concerns about the aspects of psychomotor function, attention, working memory, executive function, and other cognitive functions. These impairments could persist in the course of schizophrenia, limiting the psychosocial and work functioning of the patients, and thus reducing the efficacy of CBT, which requires high levels of self-monitoring, attention, rational thought, and insight into the illness and its symptoms. As a result, several approaches to cognitive remediation have been developed since the 1990s to enhance executive function and social cognition through information restructuring or reorganization, effective use of environmental aids and probes, and a wide range of techniques concerning cognitive functioning (mainly neurocognition and social cognition).
Neurocognition refers to the basic cognitive processes involved in thinking and reasoning and supporting attention, memory, and executive function abilities.35 Social cognition is defined by the cognitive abilities that support the processing, interpretation, and regulation of socioemotional information, which involves perspective taking, theory of mind, emotional perception and regulation, social cue recognition, and casual attributions of social phenomena.36 Despite a variety of cognitive remediation approaches or techniques for schizophrenia, a set of practice principles has emerged, including development of mental strategies to optimize cognitive performance and task completion, repetition of cognitive exercises on key and complex targeted tasks, progression of targeted cognitive abilities from basic to complex ones, use and gradual removals of external aids (mainly auditory and visual) to support cognitive performance, adjustment of difficulty and linking of cognitive exercises to real-world behaviors and domains of functioning, and integration of these cognitive performances with other treatments.37 Impairments in social cognition appear to have negative effects on interpersonal relationships, community adjustment, and vocational functioning, and thus functional recovery in schizophrenia.38
Most recent controlled trials have used only cognitive remediation for cognitive rehabilitation of people with schizophrenia and have shown its medium-sized effects (effect size, 0.30–0.48) in improving attention, processing and working memory, and executive functioning.39 Despite the inconsistent and questionable generalizability and durability of the benefits found in cognitive and other functional outcomes, one recent meta-analysis of 26 controlled trials (involving around 1,150 patients) proposed that cognitive remediation could significantly improve cognitive performance (effect size, 0.41), psychosocial functioning (effect size, 0.36), and psychotic symptoms (effect size, 0.28) in people with schizophrenia during a short-term (eg, 1 year) follow-up.39 Similar to the findings of another meta-analysis on 40 controlled trials in 2011,40 it is suggested that cognitive remediation can produce moderate improvements in global cognition and functioning when it is provided together with other strategies in psychiatric rehabilitation, such as vocational training, or when patients are mentally stable. Although effect sizes did not differ in terms of types of remediation training used, a larger effect size in verbal memory was associated with more time of remediation training.39 Although the effects of most cognitive remediation programs on most domains of basic cognitive functioning are significant but modest, the intervention is likely to be more successful when the skills trained closely relate to those needed in individual patients’ daily living, thus reflecting how patient variables such as intrinsic motivation may interact with the training to produce an optimal response to cognitive remediation.41
Fewer studies on social cognition training are found. Two recent clinical trials of 12-week individual-based and 20-week group-based (ie, Social Cognition and Interaction Training) social cognition training programs, both with 31 outpatients with schizophrenia, found significant improvements in emotional perception.42,43 Another controlled trial compared the effect on social competence and social and occupational functioning between a 12-session social cognitive training program (ie, Training of Affect Recognition) and another 12-session remediation training program among 38 patients with schizophrenia spectrum disorders.44 The findings indicate that the social cognitive training program demonstrated significantly greater improvements in social functioning and competence than neurocognition training at the completion of the intervention. Although there were no significant effects found on some domains of social recognition and emotional functioning in this and most previous studies of social cognitive training, more broad-based approaches with a combination of training in social cognitive, neurocognitive, and behavioral skills are recommended to enhance its effect on more functional outcomes in schizophrenia.
A few cognitive enhancement programs such as Cognitive Enhancement Therapy45 and Social Cognition and Interaction Training43 have been designed to provide enriched cognitive training and experiences through integrated neurocognition and social cognitive training strategies. More research with longer follow-up and larger, diverse samples is recommended to conclusively show the substantive positive effects of these integrated cognitive remediation training programs and its active components among people with schizophrenia spectrum disorders.
The psychoeducational model of patient care, as conceptualized by its pioneers, focused on the plight of people with mental illness, particularly on their higher risk for relapse and rehospitalization and its considerable cost to the patient and to society as a whole.46 Although psychoeducation is broadly used to characterize a range of approaches of educational intervention for patients with schizophrenia, there are several features common to the effective ones, including structural components, philosophical perspectives, and the goals and content of the programs. First, their common structural components are that the programs are designed and led by health professionals; they are mainly medium term, lasting between 9 months and 2 years; they are an integral part of the patient’s treatment plan, along with medication and other psychiatric treatments; they may be delivered to single or multiple participants at the patient’s home or in a clinical setting; and they mainly include both the patient and his/her family members during the intervention sessions.47 Second, the philosophical perspectives of these interventions are common in their emphasis on the present situation and improving the future while avoiding delving into the past and placing blame.48 The treatment team seeks to establish a collaborative relationship with the patient and/or family to share the burden of managing the illness and working toward patient recovery. Last, in terms of the goals and content of the programs, all focus on providing information about the illness and its treatment, management of the patient’s illness behavior, problem-solving and coping skills in illness management, and access to community mental health care services.49 Such information is crucial in enabling these patients to cope with the illness and its management.
It is also believed that psychoeducation for the family members of these patients is useful and effective in improving patient outcomes because a positive and supportive family environment and behaviors can encourage patients and enable them to improve their functioning and self-management of the illness, thus reducing their likelihood of relapse.2 With the strategies and skills taught in coping with schizophrenia, psychoeducation programs for both patients and their family members have accumulated much evidence regarding their efficacy in overall mental state, treatment compliance, relapse prevention, and satisfaction with mental health services,50 and it is therefore suggested that they be integrated into a family-based or multicomponent psychosocial intervention (including illness management, supported employment, and interpersonal and social skills training for both patients and their families), as well as the standard care, for more effective and longer-term patient outcomes.
During the last 20 years, several models of psychoeducation for schizophrenia have been developed and empirically tested. The theoretical foundations for these interventions are mainly derived from stress vulnerability and coping models and other psychological theories such as cognitive–behavioral, social learning, and crisis theories.51 Teaching patients (and their families) in a variety of forms according to the ability and interest of the individual or group of patients with a view to improving their treatment compliance and illness management is the main goal in mental health care to minimize relapse and optimize the patients’ health condition. Nevertheless, some studies indicate that psycho-education alone enhanced patients’ knowledge about the illness but could not improve other patient outcomes or their behaviors.52,53 The nonsignificant changes in psychosocial functioning and illness-related behaviors could be a result of their lack of attention and emphasis on the adequate dose (length) of education and skills practice, as well as the inflexibility of the learning process through progressive changes in behavior, skill, and attitude.50
A recent systematic review of 44 randomized controlled trials conducted between 1988 and 2009 indicated that people with schizophrenia (n = 1,200–1,400) in psychoeducation programs for schizophrenia reported a significant increase in treatment compliance and reduction in readmission and relapse rates in the short term (ie, within 6 months) when compared with those receiving standard psychiatric care.50 Psychoeducation also promoted social and global functioning. In the medium term (ie, 6–18 months), it was found that when treating four participants with psychoeducation instead of standard care, one additional person would show a significant improvement in medication compliance, relapse, and knowledge about the illness. In addition, the participants (n = 236) who received psychoeducation were also more likely to be satisfied with mental health services in the short term and with improved quality of life in the medium term. Although most of the 44 trials reported favorable results for psychoeducation, it is noteworthy that there were no significant differences in their primary outcomes (ie, compliance, relapse, and mental state) between psychoeducation and standard care across countries. The review also noted that a majority of the studies reviewed were conducted in hospitals, whereas most people with schizophrenia are taken care of in the community. It is recommended that further research be conducted to test the efficacy of psychoeducation in the context of community mental health care to understand and apply its “true” effect to the current community-based care.
A prospective randomized study by Feldmann et al51 examined the influence of pretherapy duration of illness on the effects of psychoeducation for 191 outpatients with schizophrenia in Germany. Psychoeducation showed the most preventive effect in patients with a medium duration of illness (eg, 2–4 years) who had already accepted their illness but were not yet adhering to fatalistic assumptions often established to explain the manifestation of illness as nonretractable and unrecoverable. A randomized, multicenter controlled trial based in Munich, Germany, showed that psychoeducation for schizophrenia, consisting of individual behavioral therapy, self-assertive and problem-solving training, communication skills training, and further family therapy, could produce a significant reduction in rehospitalization rates from 58% to 41% and shortened hospital stays from 78 to 39 days.52 The researchers suggest that the effective therapeutic elements of psychoeducation programs were therapeutic interactions (relationships), clarification (about schizophrenia and its causal attributions), and enhancement of coping competence and skills for the illness and patient’s life problems.
Most successful or effective psychoeducation programs have consisted of a wide coverage of patient needs and concerns in relation to the illness and its treatment and self-management. Bisbee and Vickar53 recommended that psychoeducation topics for schizophrenia include clear orientation to patienthood, adequate and up-to-date knowledge of the illness and its care, theories and practices of medication, stress and illness management, effective communication and coping skills, satisfactory family relationships and interpersonal interactions, maintenance of good nutrition and health, and prevention of relapse and substance use. Although many psychoeducation programs have shown positive effects in terms of relapse prevention, increase of knowledge about the illness, and medication compliance among people with schizophrenia, there are still uncertainties about their efficacies in other important patient outcomes (eg, global functioning, insight into the illness and its treatment, and quality of life), especially in the longer term (ie, >2 years).52,55 More well-structured and standard psychoeducation programs should be designed and evaluated, with clear and detailed descriptions of their contents, to help mental health professionals implement evidenced-based mental health care intervention and services for people with schizophrenia and their families.
Family (or family-based) intervention
Schizophrenia can cause disabling experiences and distress to both people with schizophrenia and their families. Because family members are the main carers for patients in the community, the effect of caring for patients is often described as burdensome and includes the different subjective and objective aspects of physical, emotional, or psychological and socioeconomic health problems.4 Although different terminology is used for family-focused interventions in schizophrenia, Pharoah et al6 suggested the terms psychosocial, psychoeducation, and behavioral management approaches to family interventions generally refer to those interventions in an individual or group format, in which patient and family members meet together, there is a skills acquisition component in addition to a didactic teaching element, and the primary aim of the program is to reduce patient relapse and readmission. However, family education, consultation, support, and counseling and relatives’ groups usually refer to interventions directed at family members alone (excluding the patient), and their primary focus is on family members’ needs. Since the early 1960s there has been a better understanding of the effects of the family’s expressed emotion in relation to the course of the illness and relapses, resulting in the increased study of family partnership in schizophrenia care over the last three decades.56
The National Institute for Clinical Excellence, in their clinical guidelines to National Health Service trusts in England and Wales,3 as well as the Schizophrenia Patient Outcomes Research Team Programs for treatment and research on schizophrenia in the United States,57 recommend that pharmacological treatment for people with schizophrenia be better integrated with other psychological, social, and educational interventions at the earliest opportunity. Working with families appears to be one of the most effective ways of delivering community-based intervention to these patients.
There are several other reasons for providing interventions to families of people with schizophrenia. First, studies on expressed emotion, which refers to the critical or emotionally overinvolved attitudes and behavior displayed by family members toward their relative with schizophrenia, has revealed that family dynamics and emotional climate affect the recurrence of positive symptoms, and therefore the course of the illness.58 Although a supportive and caring family environment can be induced through family education and partnership in treatment planning and implementation, an enhanced competence and ability of the families to detect and notify mental health professionals about any warning signs of relapse are crucial for relapse prevention in schizophrenia,22,59 to avoid contributing to long delays in treatment and to achieve early recovery. Second, having an intimate relationship with a relative with schizophrenia and providing care for such a person can place a great burden on family members. Reducing caregiver burden is an important goal of family support and care that, in turn, can help these carers take better care of their loved ones while maintaining their own health and well-being. Last, high levels of expressed emotion and perceived burden within a family can have a negative effect on a patient’s illness, increasing their vulnerability to relapse.60 The intimate relationship and interactions between patients with schizophrenia and their family members warrant the application of family-centered interventions to improve both the families’ and patients’ ability to cope with the illness management.
Recent reviews of more than 50 controlled trials (>4,800 patients) of different modes of family-based intervention from 1980 to 2010, such as family behavioral management and psychoeducation programs,6,61 reveal that family intervention, as an adjunct to drug treatment and routine care, can significantly enhance family members’ knowledge about the illness, reduce family burden and patients’ relapse up to 2 years, and improve patients’ medication compliance. Both single-family and/or multiple-family group programs, lasting from 3 months to 3 years and consisting of a wide variety of psychotherapeutic techniques, were associated with fewer patient relapses and rehospitalizations, with rates about half those of patients receiving routine psychiatric care. Even though these families may have different health needs and expectations across the course of the illness, they have a few common needs for psychoeducation, including understanding about the nature of the illness, ways of coping with psychotic symptoms, methods of medication and illness management, psychological support and practical assistance during times of crisis, and means of getting links to community mental health services.3,19
Family psychoeducation, which has been derived from stress reduction and coping models and other psychological theories such as cognitive–behavioral, social learning, and crisis theories,2,7 is the most frequently used model of family-based intervention for people with schizophrenia in both Western and Asian countries. As these psychoeducation programs mainly focused on the patient’s mental condition, the studies paid little attention to the family’s burden or the family members’ perceptions of their problems and needs. Treatment teams seek to establish a collaborative relationship with the family to share the burden of managing the illness and working toward patient recovery.62 Behavioral family management is another frequently used approach to family-based intervention for schizophrenia. Developed by McFarlane et al55 in the United States, the program uses family education, training in communication skills, and practice in problem solving and has been delivered successfully across countries in the context of multiple-family groups via 10 sessions during a 3-month period.63–65 It has been shown to be effective in reducing patients’ symptoms, promoting remission, strengthening social functioning, and reducing family burden.
Other approaches to family-based intervention for schizophrenia care include professional-led or peer-led multiple-family support and education groups (aimed at providing continued education, caregiving skills training, and support for these families), family-aided ACT (providing family crisis intervention and case management for those with chronic or treatment-resistant schizophrenia), and family consultation or supportive counseling (using an individualized approach of support and adaptation training for a family member or the whole family).48,64 Most family education approaches adopt a strengths perspective, in which families are encouraged and assisted in developing their stress management and coping skills and improving their psychological well-being and ability to adapt to dealing with their relative’s illness.64
Comparing the effects of different models of family intervention on patient and family outcomes, studies in mainland China (eg, Chien and Wong65 and Li and Arthur66), Europe (eg, Stengård),67 and the United States (eg, Dyck et al68 and McFarlane et al55) have consistently demonstrated that family psychoeducation and/or behavioral approaches to intervention spanning at least 10 sessions over the course of 6 months are more effective and have a relatively long-lasting effect (ie, >2 years) in terms of preventing patient relapse than individual psychosocial treatment or medication alone. However, the psychoeducation and behavioral approaches to intervention, as described by researchers in previous studies, expressed variety of content, format, and techniques. The common elements in several of the more effective family psychoeducation programs include social support, education about the illness and its treatment, guidance and resources during a crisis, and training in problem solving.2,69 However, little is known about the major therapeutic components of psychoeducation and other psychosocial family-based interventions for schizophrenia. With better understanding of these crucial therapeutic elements within family intervention, it may be possible to develop a more consistent, reliable, and effective family intervention program for people with schizophrenia. The specific effects of family intervention on family members’ psychosocial needs such as family functioning, psychological distress, and burden of care and home-based patient care have not been studied adequately; thus, data are few and equivocal.6
Anderson and Adams70 and Drake et al71 have suggested there are difficulties in employing family intervention in everyday clinical practice, with groups of patients with schizophrenia in receipt of community care because of inadequate mental health care services, staff training, and resources. Multiple-family groups may have very high noncompliance or attrition rates resulting from the group members’ time constraints on attending groups because of their work and busy domestic lives, as well as the inconvenience of transport and meeting times. In addition, they may not be able to arrange alternative care for the patient when attending the group, and running a family group requires a highly skilled and experienced therapist for effective management of patients’ psychotic symptoms and disturbing behaviors and/or those highly distressed family carers.19,72
Stanley and Shwetha73 suggest that an integrated therapeutic approach to family-based intervention consisting of multiple components such as pharmacotherapy, psychosocial therapies, and spiritual therapy is more successful in improving the mental status and psychosocial functioning of people with schizophrenia, together with reducing family burden and increasing quality of life in their family caregivers.
Social skills training
Social skills represent the constituent behaviors that, when combined in appropriate sequences and used with others in appropriate ways and social contexts, enable a person to have the success in daily living that reflects social competence.74 A lack of social skills is one of the major deficits in psychosocial functioning among people with schizophrenia.74 It can provoke stressful interactions with the social environment and lead to social withdrawal and isolation. Social skill training originated from the social skills model of Robert Liberman75 and consists of three main components: receiving skills (social perception), processing skills (social cognition), and sending information skills (behavioral responding or expression). In contrast, social competence generates social resources and improves community integration and role functioning.76 This training, practiced mostly in groups, aims to enhance patients’ social competence in terms of interpersonal and communication skills, illness management, community reintegration, workplace social skills, and instrumental activities of daily life. Although the content of the current training programs can vary, a common set of training strategies found across them included goal setting, behaviorally based instruction, role modeling, behavioral rehearsal, corrective feedback, positive reinforcement, and homework to foster generalization of skills.77
When patients with schizophrenia have been equipped with skills to deal with stressful life events and daily hassles, they are proficient in solving their life problems and challenges, and consequently, those life stressors are less likely to trigger exacerbations or social decompositions of schizophrenia.78 Social skills compliance can also expand patients’ participation and partnership in treatment decisions and partnership, as evidenced by its effectiveness in teaching medication self-management skills. When the patients learn how to properly use medication, they are more in control of their own illness, experience greater responsibility for their treatment, and achieve greater insight into their illness.79 Three critical reviews of more than 50 controlled trials of social skills training for schizophrenia and other psychotic disorders suggest that participants in diverse community and in-patient mental health care settings can retain their improvements in knowledge and behaviors in different aspects of learned social skills for up to a 2-year follow-up.80–82 Therefore, social skills training programs have demonstrated positive effects on workplace and social functioning generalized to different community settings.80 However, the results of most studies during the last three decades are discouraging for transferring the learned social skills (particularly those complex steps/procedures and high stimulus gradients) to participants’ real environments. Therefore, recent studies suggest that incorporating generalization techniques into a skill training program, thus creating opportunities for using the skills in the living environment and receiving appropriate feedback and social reinforcements, would increase the likelihood of skill transfer to everyday life situations.82
Of the psychosocial interventions for schizophrenia discussed in this article, social skills training has the longest history, having been used to help patients learn to cope with interpersonal relationships since the 1960s. Although most studies of this training in the 1980s and 1990s reported considerable effects on improving patients’ living skills and social adjustment, more recent studies have failed to provide evidence to support its benefits for chronic schizophrenia sufferers, particularly in reducing positive symptoms and improvements in community functioning and other complex social skills such as assertiveness and job-related skills.83 One recent meta-analysis of 22 randomized controlled trials conducted between 1973 and 2007 concluded that such training programs can produce a moderate but significant and consistent improvement in social functioning (effect size, 0.41–0.52) and negative symptoms (effect size, 0.40–0.47) of people with schizophrenia, and considerably reduce rehospitalization rates over the course of 1–2 years of follow-up.77 By using performance-based measures, the participants’ mastery of social skills and daily living skills (effect size, 0.48–0.52) could be consistently and sustainably maintained during the follow-up period. However, these training programs could not demonstrate any significant effect on other patient outcomes, such as mild improvements in general psychopathology, relapse prevention and positive symptoms, and cognitive function.75–78
The role of social skills training has also been indicated as important in combination with other psychosocial interventions, such as cognitive remediation, to generalize the learned skills to real-life accomplishments in social and vocational duties. For instance, in the Cognitive Enhancement Program developed by Hogarty and Flesher,84 patients with schizophrenia were involved in practicing structured social interactions weekly, solving social dilemmas in real life, and appraising affect and social contexts, conversations with and feedback from other patients, and coaching and home assignments to implement skills in life problems or situations. With concurrent use of computer-aided neurocognition and social cognitive remediation (to improve attention, verbal learning, memory, and social adjustment and competence), the participants receiving social skills training could significantly improve their participation in employment situations and mastery of living and working skills. For achieving an optimal effect of work and living skills accomplishment, innovative combinations of conventional rehabilitation programs and social skills training and/or other psychosocial interventions should be considered. Similar to the results of most recent reviews,80,85 Dixon and his patient outcomes research team recommend that social skill training can be used as an adjunct to cognition and community skills training to produce synergic effects in the performance-based social and community skills and functioning of people with schizophrenia.2 More research is also needed to examine the predictors of therapeutic effects or responses to social skills training in schizophrenia, as well as the durability and generalizability of its benefits.
ACT is a persistent, intensive outreach or case management model that targets difficult-to-engage or refractory schizophrenia. This treatment approach was found to be particularly effective for those who make particularly high use of inpatient services, have a history of poor engagement with services leading to frequent relapse and/or social breakdown (eg, as manifested by homelessness, noncompliance with treatment, social withdrawal, loss of contact with routine services, or seriously inadequate accommodation), or need urgent or immediate access to assistance or support in crises.86 These treatment teams are characterized by very low staff-to-patient ratios (eg, 1:10), high frequency of contacts/visits, provision of comprehensive medical and social advice in a home or supervised care environment, and multidisciplinary care with 24-hour coverage and shared caseloads. Although frequent home visits can facilitate medication compliance, crisis intervention, and establishment of therapeutic relationships, health assessment of patients and their families is more accurate and comprehensive because treatment team members can observe patients’ behaviors directly rather than depending on patients’ self-reporting. Bond et al87 suggested that every community have ACT teams with a capacity to serve 0.1% of the general population or 20% of all patients with severe mental illness.
In the 1990s, ACT conducted in the United States was shown to reduce patients’ hospitalization and increase community service use at a reduced cost.88,89 Bond et al’s study87 in Australia reported that ACT not only reduced patients’ symptoms and rehospitalizations but also improved their housing and quality of life when compared with routine care. Nevertheless, recent studies have suggested that most benefits of ACT could not be replicated outside the United States; for example, in the United Kingdom89,90 and other European countries,91 except for maintaining contact with these patients. The United Kingdom studies indicated that ACT did not demonstrate any consistent positive effect on social adjustment and functioning. In addition, the dynamic and fluid nature of its service provision causes difficulty in identifying or defining the therapeutic components contributing to positive patient outcomes.
However, in agreement with two systematic reviews, Clarke et al,92 in their review on 25 randomized controlled trials with 3–36 months’ follow-up, suggest that ACT can substantially reduce psychiatric hospitalization by 78% (74% of the trials reviewed), increase housing stability (67%), and moderately improve positive symptoms (44%) and quality of life (58%) among patients with schizophrenia and other severe mental illnesses. In contrast, it has been suggested that ACT has little effect on patients’ social and vocational functioning, substance use, and satisfaction with services. Several British studies of ACT have indicated disappointing results, and thus Marshall and Creed93 conclude that low caseload ratios do not necessarily result in better patient outcomes but, rather, specific organizational characteristics of the ACT model (eg, multidisciplinary collaborations, daily team meetings, comprehensive needs assessment, and shared caseloads and responsibilities) are essential and important to its effectiveness. More evidence on the efficacy and practice standard or the program structure and content of ACT should be found before it can be widely used as an evidence-based intervention. As ACT targets individualized management and intensive care for difficult-to-engage or refractory patients with schizophrenia or other severe mental illness, one of the major barriers to the development of this treatment model may be the absence of valid methods to determine these patients’ health needs. Such tiered case management approaches can work best when the functions and roles of multidisciplinary teams are carefully organized.87,88
Relative efficacy of different approaches to psychosocial intervention
From the literature reviewed between 1995 and 2008, the estimated efficacy of the five main approaches to psychosocial intervention for schizophrenia (ie, CBT, psychoeducation, family intervention, social skills training, and cognitive remediation) is presented in terms of the effect sizes on two of their most commonly reported patient outcomes. The effect sizes of CBT in terms of relapse (over the course of 24 months) and positive symptoms (using Hedger’s g) are 0.20–0.52 and 0.19–0.50, respectively,40,94 and those of psychoeducation are 0.25–0.50 and 0.21–0.48, respectively.50 For family intervention, the effect sizes in terms of mental state and family burden are 0.21–0.45 and 0.28–0.50, respectively.6,63 In addition, the effect sizes of social skills training based on improvements in interpersonal skills and community functioning are 0.58–1.12 and 0.45–0.89, respectively, whereas those of cognitive remediation in terms of cognitive functioning and social behaviors are 0.13–0.70 and 0.28–0.50, respectively.26,95
Table 1 summarizes the mean weighted effect sizes of the controlled trials (between 2000 and 2012) of three most commonly used modalities of psychosocial interventions, namely, CBT, family intervention, and psychoeducation, in terms of four reported outcomes (positive and negative symptoms, level of functioning, and relapse rate). CBT has indicated moderate effects on positive and negative symptoms and functioning (mean effect sizes, 0.40–0.42) during a 12-month follow-up, whereas psychoeducation could have moderate effects on positive symptoms and relapse prevention (mean effect sizes, 0.45 and 0.49, respectively). For family intervention, the effects are more prominent on improvement of patient functioning and relapse rate (mean effect sizes, 0.34 and 0.40, respectively). Most consistently, these three kinds of interventions have demonstrated significant reduction of relapse during a 12-month follow-up (mean effect sizes, 0.40–0.49).
Mean effect sizes of three psychosocial interventions for schizophrenia on selected outcomes during a 12-month follow-up
During the last few decades, approaches to treatments of people with schizophrenia and their outcomes have mainly been judged and directed by paternalistic views of medical or other mental health care practitioners. Despite the emergence of psychosocial interventions or other alternative treatments, there is limited attention and minimal efforts to plan for these interventions and evaluate their outcomes on the basis of the perspectives of these patients.69 From the literature review of the psychosocial interventions and pharmacological treatments (in part I of “Current approaches to treatments for schizophrenia spectrum disorders,” by Chien and Yip1), limited evidence was found on the efficacy of interventions for schizophrenia based on patient-focused perspectives, in which the patients’ quality of life, satisfaction with and acceptability to the service received, and adherence to and uptake with the interventions offered to them are targeted. In contrast, the focus in treatment of these patients has been moving from symptom control and chronic and maintenance care to improvements in functioning, collaborative decision-making, and recovery from the illness.22,69
For better understanding of the clinical evidence regarding patient-focused perspectives used in current research, a literature search was conducted, mainly using the databases of CINAHL, MedlinePlus, and PubMed (from 1982–2013). Several key words were used independently or in combination to search all the literature published in English, including “schizophrenia,” “intervention,” “treatment,” “quality of life,” “patient perspective or satisfaction,” “service/treatment acceptability,” “adherence,” and “uptake.” The inclusion criteria of the clinical research were experimental, quasi-experimental, or longitudinal cohort studies with at least a single outcome in terms of patient-focused perspectives (eg, patients’ quality of life, treatment adherence and satisfaction with services received), patients primarily diagnosed with schizophrenia or its subtypes, brief and full description of the interventions or services received, and clear description of the outcome measures used. From 260 studies initially retrieved from the databases, only 25 met all of these criteria and are included in this section for discussion. These 25 studies were mainly randomized controlled trials, although three used a longitudinal, prospective cohort design or mixed research methods. Surprisingly, the outcome measures in terms of patient-focused perspectives were mainly medication or treatment adherence (n = 17), and only a few studies measured patient satisfaction (n = 7), social functioning (n = 4), and quality of life (n = 8) as secondary outcomes. Among those with at least a 1-year follow-up (n = 18), quality of life and treatment adherence were the most frequently measured patient-focused outcomes.
The 25 studies reviewed with outcomes in terms of patient-focused perspectives mainly evaluated the efficacy of adherence therapy, the integrated treatment approach, or second-generation antipsychotics for people with schizophrenia (eg, Anderson et al,102 Gray et al,103 Lindenmayer et al,104 Kilian et al,105 and Wiersma et al106) and were conducted in the United States or Europe. Five selected recent studies with outcomes measured in terms of patient-focused perspectives,102,103,106–108 mainly including patients’ quality of life, satisfaction with services, and medication adherence, are summarized in Table 2. The selected studies are also discussed here to better understand to what extent the patient-focused perspectives are being considered in recent schizophrenia research. Several reviewed clinical trials that evaluated the effects of medication adherence therapy using the techniques of CBT and/or motivational interviewing109 revealed mixed results on patients’ perceived quality of life. Gray et al103 compared the effects of adherence therapy and routine psychiatric care for people with schizophrenia on improving medication compliance, quality of life, and several other outcomes in a 52-week European multicenter randomized controlled trial. The study identified no significant differences between the adherence therapy group (n = 204) and the control group (n = 205) on the patients’ quality of life and psychopathology during a 1-year follow-up. Puschner et al110 found that psychotic patients’ perceived health-related quality of life after undertaking adherence therapy might have been compromised with their symptom severity and the adverse effects of the antipsychotics used. In another adherence therapy trial, Anderson et al102 explored the efficacy, acceptability, and patient satisfaction with the adherence therapy used among a small sample (n = 26) of patients with schizophrenia in the United States. The results showed that the patients (n = 12) reported a high degree of acceptability and satisfaction with the 8-session adherence therapy even though they did not show significant improvements in mental state and medication adherence at the post-tests when compared with the routine-treatment group (n = 14). In addition, most of the reviewed studies of adherence therapy for people with schizophrenia found that over a longer-term follow-up, these patients could show neither significant improvements in their level of adherence to medication and quality of life nor satisfactory control or reduction of psychotic symptoms, particularly negative symptoms.
Selected research with outcomes from patient-focused perspectives
An integrative approach to treatment for people with chronic schizophrenia and persistent hallucinations (n = 31) has been evaluated in a randomized controlled trial to ascertain its effect on their quality of life and social functioning compared with routine psychiatric outpatient care (n = 32).106 This approach integrates CBT, coping skills training, community rehabilitation services, and crisis intervention into a family-focused intervention, as well as the use of antipsychotic medication. The treatment group indicated significantly better quality of life and social functioning than seen with those patients receiving routine care at the 8- and 18-month follow-ups, indicating that this integrated approach appeared to be effective for people with chronic schizophrenia in a medium-term follow-up. Recently, there have been an increasing number of integrative treatment programs for these patients, but there is no systematic and empirical evidence of their effects, particularly during a longer follow-up period. Although some of these innovative programs were developed from the service-users’ or patients’ perspectives or based on a collaborative decision-making model, their components for the integration of schizophrenia treatment varied considerably in terms of structure, format, and content, making it difficult to identify the active and therapeutic components contributing significant benefits to patients, if any. It is recommended that more research be conducted to test the efficacy of these integrative models of care in terms of both illness-related and longer-term patient-focused outcomes and that the therapeutic elements contributing to patient recovery from schizophrenia be explored.
It is interesting that a few comparative studies were conducted in the 1990s to identify the effects of first- and second-generation antipsychotics on the health-related quality of life of people with schizophrenia.111–113 Similar to other controlled trials of the effects of antipsychotics in schizophrenia,98,105 none of these studies could support the superiority of the second-generation (atypical) antipsychotics in improving patients’ quality of life and their cognitive and social functioning. In two controlled trials with 227 and 307 patients with schizophrenia,104,114 second-generation antipsychotics could not demonstrate any better quality of life or cost-effectiveness than different types of first-generation antipsychotics during more than a 1-year follow-up. Nonetheless, more recent research and reviews on long-term use of second-generation antipsychotic therapy such as quetiapine