Psychosocial Treatment and Rehabilitation of Schizophrenia

Although medication is almost always necessary in the treatment of schizophrenia, it is not usually enough by itself. People with schizophrenia also need services and support to overcome the illness and to deal with the fear, isolation, and stigma often associated with it. In the following sections, we present the experts' recommendations for the kinds of psychosocial treatment, rehabilitation services, and living arrangements that may be helpful at various stages of recovery. These recommendations are intended to be guidelines, not rules. Each patient is unique, and special circumstances may affect the choice of which services are best for a specific patient at a particular time during recovery. Also, some communities have a lot of different services to choose from, while others unfortunately have only a few. It is important for you to find out what services are available to you in your community (and when necessary to advocate for more).

Key components of psychosocial treatment

Patient and family education. Patient, family, and other key people in the patient's life need to learn as much as possible about what schizophrenia is and how it is treated, and to develop the knowledge and skills needed to avoid relapse and work toward recovery. Patient and family education is an ongoing process that is recommended throughout all phases of the illness.

Collaborative decision making. It is extremely important for patient, family, and clinician to make decisions together about treatments and goals to work toward. Joint decision making is recommended at every stage of the illness. As patients recover, they can take an increasingly active part in making decisions about the management of their own illness.

Medication and symptom monitoring. Careful monitoring can help ensure that patients take medication as prescribed and identify early signs of relapse so that preventive steps can be taken. A checklist of symptoms and side effects can be used to see how well the medication is working, to check for signs of relapse, and to figure out if efforts to decrease side effects are successful. Medication can be monitored by helping the person fill a weekly pill box or by providing supervision at medication times.

Assistance with obtaining medication. Paying for treatment is often difficult. Health insurance coverage for psychiatric illnesses, when available, may have high deductibles and co-payments, limited visits, or other restrictions that are not equal to the benefits for other medical disorders. Public programs such as Medicaid and Medicare may be available to finance treatment. The newer medications that can be so helpful for most patients are unfortunately more expensive than the older ones. The treatment team, patient, and family should explore available ways to get access to the best medication by working through public or private insurance, co-payment waivers, indigent drug programs, or drug company compassionate need programs.

Assistance with obtaining services and resources. Patients often need help obtaining services (such as psychiatric, medical, and dental care) and help in applying for programs like disability income and food stamps. Such assistance is especially important for people having their first episode and for those who are more severely ill.

Arrange for supervision of financial resources. Some patients may need at least temporary help managing their finances--especially those with a severe and unstable course of illness. If so, a responsible person can be named as the patient's "representative payee." Disability checks are then sent to the representative payee who helps the patient pay bills, gives advice about spending, and helps the patient avoid running out of money before the next check comes.

Training and assistance with activities of daily living. Most people who are recovering from schizophrenia want to become more independent. Some people may need assistance learning how to better manage everyday things like shopping, budgeting, cooking, laundry, personal hygiene, and social/leisure activities.

Supportive Therapy involves providing emotional support and reassurance, reinforcing health-promoting behavior, and helping the person accept and adjust to the illness and make the most of his or her capabilities. Psychotherapy by itself is not effective in treating schizophrenia. However, individual and group therapy can provide important support, skill building, and friendship for patients during the stabilization phase after an acute episode and during the maintenance phase.

Peer support/self-help group. Almost all mutual support groups are run by peers rather than professionals. Many of these groups meet 1-4 times a month, depending on the needs and interest of the members. Guest speakers are sometimes invited to add education to the fellowship, caring, sharing, discussion, peer advice, and mutual support that are vital parts of most consumer support groups. Peer support/self-help groups can play a very important role in the recovery process, especially when patients are stabilizing after an acute episode and during long-term maintenance.

Types of services most often needed

Doctor and therapist appointments for medication management and supportive therapy. It is very important to keep appointments with your doctor and therapist during every phase of the illness. These appointments are a necessary part of treatment regardless of where you are in the recovery process--during an acute episode, stabilizing after an acute episode, and during long-term recovery and maintenance. It may be tempting to skip appointments when your symptoms are under control, but continued treatment during all phases of recovery is extremely important in preventing relapse. Many people with schizophrenia also need one or more of the services described below to make the best recovery possible.

Assertive community treatment (ACT). Instead of patients going to a mental health center, the ACT multidisciplinary team works with them at home and in the community. ACT teams are staffed to provide intensive services, so they can visit often--even every day if needed. ACT teams help people with a lot of different things like medication, money management, living arrangements, problem solving, shopping, jobs, and school. ACT is a long-term program that can continue to follow the person through all phases of the illness. The experts strongly recommend ACT programs, especially for patients who have a severe and unstable course of illness.

Rehabilitation. Three types of rehabilitation programs may help patients during the long-term recovery and maintenance phase of the illness. Rehabilitation may be especially important for patients who need to improve their job skills, want to work, have worked in the past, and have few remaining symptoms.
  • Psychosocial rehabilitation: a clubhouse program to help people improve work skills with the goal of getting and keeping a job. Fountain House and Thresholds are two well-known examples.

  • Psychiatric rehabilitation: a program teaching skills that will allow people to define and achieve personal goals regarding work, education, socialization, and living arrangements.

  • Vocational rehabilitation: a work assessment and training program that is usually part of Vocational Rehabilitation Services (VRS). This type of rehabilitation helps people prepare for full-time competitive employment.

Intensive partial hospitalization. Patients in Partial Hospitalization Programs (PHPs) typically attend structured groups for 4 to 6 hours a day, 3 to 5 days a week. These education, therapy, and skill building groups are designed to help people avoid hospitalization or get out of the hospital sooner, get symptoms under control, and avoid a relapse. A PHP is usually recommended for patients during acute episodes and while stabilizing after an acute episode.

Aftercare day treatment. Day Treatment Programs (DTPs) typically provide a place to go, a sense of belonging and friendship, fun things to do, and a chance to learn and practice skills. They also provide long-term support and an improved quality of life. DTPs can help patients while they are stabilizing after an acute episode and during long-term recovery and maintenance.

Case management. Case managers usually go out to see people in their homes instead of making appointments at an office or clinic. They can help people get the basic things they need such as food, clothes, disability income, a place to live, and medical treatment. They can also check to be sure patients are taking their medication, help them manage money, take them grocery shopping, and teach them skills so they can be more independent. Having a case manager is helpful for many people with schizophrenia.

Types of living arrangements

Treatment won't work well if the person does not have a good and stable place to live. A number of residential options have been developed for patients with schizophrenia--unfortunately, they are not all available in every community.

Brief respite/crisis home: an intensive residential program with on-site nursing/clinical staff who provide 24-hour supervision, structure, and treatment. This level of care can often help prevent hospitalization for patients who are relapsing. Brief respite/crisis homes can be a good choice for patients during acute episodes and sometimes during the stabilization phase after an acute episode.

Transitional group home: an intensive, structured program that often includes in-house daily training in living skills and 24-hour awake coverage by paraprofessionals. Treatment may be pro-vided in-house or the resident may attend a treatment or rehabilitation program during the day. Transitional homes can help patients while they are stabilizing after an acute episode and can often serve as the next step after hospitalization or a brief respite/ crisis home. They can also be helpful during an acute relapse if a brief respite/crisis home is not available.

Foster or boarding homes: supportive group living situation owned and operated by lay people. Staff usually provide some supervision and assistance during the day and a staff member typically sleeps in the home at night. Foster homes and boarding homes are recommended for patients during long-term recovery and maintenance, especially if other options (living with family, a supervised/supported apartment, or independent living) are not available or do not fit patient/family needs and preferences.

Supervised or supported apartments: a building with several one- or two-bedroom apartments, with needed support, assistance, and supervision provided by a specially trained residential manager who lives in one of the apartments or by periodic visits from a mental health provider and/or family members. These types of apartments are recommended for patients during long-term recovery and maintenance.

Living with family: For some people, living with family may be the best long-term arrangement. For others, this may be needed only during acute episodes, especially if other types of residence are not available or the patient and family prefer to live together.

Independent living: This type of living arrangement is strongly recommended during long-term recovery and maintenance, but may not be possible during acute episodes of the illness and for patients with a more severe course of illness who may find it hard to live independently.