Personal Therapy for Schizophrenia and Related Disorders: A Guide to Individualized Treatment

Rating:
Summary: New Hope for Schizophrenia!
Review: Gerard Hogarty's new volume, Personal Therapy for Schizophrenia and Related Disorders, is a groundbreaking work which presents an empirically-validated psychotherapeutic approach for schizophrenia based on a contemporary biopsychosocial understanding. Hogarty, a Professor of Psychiatry at the Western Psychiatric Institute and Clinic at the University of Pittsburgh Medical Center, has a long and distinguished career as a clinician/researcher with schizophrenia.

For over 30 years, Hogarty and his colleagues have developed a series of psychososcial interventions (major role therapy, family psychoeducation, social skills training, personal therapy , and, most recently, cognitive enhancement therapy) and submitted each to rigorous empirical trials. After each trial, he carefully examines the data and formulates new approaches which incorporate his prior research findings and empirical data from other sources.

In the volume, Hogarty presents an approach to individual psychotherapy which he entitles "personal therapy" (PT). He describes his prior research efforts, most notably his two-year study of family psychoeducation which demonstrated a dramatic reduction in relapse in the first year of treatment, but a reduction in therapeutic efficacy as time passed. While observing that ameliorating family stressors reduced relapse, he also observed that family psychoeducation had no significant impact on the personal or social adjustment of schizophrenic patients.

Based on these prior experiences, PT uses a three-phase approach, the first focusing on clinical and environmental stabilization, the second on symptom management, and the third on developing new social and vocational initiatives. Throughout all phases, all patients were maintained on antipsychotic medications which were carefully titrated to minimize side effects. The progression of patients through these phases was determined by each patient's rate of progress, not by a prearranged protocol. Until the goals of one phase were accomplished, the goals of the next phase were not initiated. The research protocol followed patients for three years, an unprecedented duration for any intervention study in schizophrenia.

Before describing the three phases of PT, Hogarty devotes a chapter to outlining "essential prerequisites" for this intervention in considerable detail noting "that for decades are program has been guided by a silent mantra: innovative psychosocial treatment is for naught unless the fundamentals of good care are firmly in place (Hogarty's emphasis). His definition of "good care" includes psychological support (attentiveness, empathy, and encouragement), material support (financial support, stable housing, case management) and skillful medication management. Unique in the treatment literature, Hogarty addresses both the oft-ignored subject of obtaining government disability benefits and the intricacies of medication management. While the details of the former will be of little interest to most British readers, his attention to such seemingly mundane, yet essential, matters is impressive. (The clinic spent over $6000 annually for transportation subsidies when these costs were an impediment to clinic attendance.)

With these prerequisites in place, the first "basic" phase of treatment is initiated as a therapeutic team continues medications, "joins" with the patient and family, and educates patients about their illness using a stress-vulnerability model. In the second "intermediate" phase, patients examine their own illness is greater detail, exploring the precipitants of relapse, and finally coping strategies for symptom management are taught. Finally, in the third "advanced" phase, patients maintain stability and apply these coping strategies as they undertake new social and vocational initiatives.

Besides outlining the essential elements of PT, Hogarty describes the three-year controlled research protocol in considerable detail. In his discussion of the data, he carefully explores the considerable improvement of the control "supportive treatment" group, examining the therapeutic effects of "good care" and clinical management enjoyed by both experimental groups. However, while there was little significant difference between both treatment groups in both symptomatic presentation and functional adjustment at the one year mark (both groups improved significantly), the control group's progress leveled off while the PT group made impressive gains over the next two years.

However, examining patters of relapse, Hogarty observed that a subgroup of PT patients who lived alone actually had a far higher rate of relapse than did patients who received "supportive treatment" only. He commented that "we wondered whether these historical negative effects of psychotherapy might have had less to do with the intervention per se and more with cognitively overwhelming life experiences" (p. 64). Not surprisingly, patients with strong family support had much better outcomes.

This sort of multidimensional data analysis is perhaps unprecedented in the field of schizophrenia research, whether involving biological or psychosocial interventions. Hogarty sifts through his research data with a refreshing deftness and honesty; when the data does not support the efficacy of his intervention model, he straightforwardly acknowledges this and attempts to learn from negative as well as positive findings. In doing so, he briefly notes his most recent attempts to enhance the cognitive functioning of schizophrenic patients, an approach which is yielding impressive results.

In spite of this impressive empirical data, many psychotherapists may reject Hogarty's embrace of biological psychiatry and his neglect of psychoanalytic conceptualizations. He has little patience with intriguing metaphors or sophisticated interpretations. Yet, among the impressive array of data, Hogarty writes with a passionate concern for the well-being of persons with schizophrenia that is so often overwhelmed by statistical analysis. Researchers of schizophrenia would do well to learn from his sophisticated, yet readable, analyses. At the same time, psychotherapists treating schizophrenic patients will emerge with a better appreciation of the interplay of the biological, psychological and environmental dimensions of this complex disorder.

Rating:
Summary: A Great Book for the Practioner
Review: This is a tremendous book as it's written by a Social Worker who uses an over all biopsychosocial model. You do not see many social workers writing about therapeutic interventions who even consider biological components.

Addditionally, Hogarty has two additonal components to the therapeutic strategy. He does a a concise review of entitlements with the proviso that its difficult to provide therapy when someone needs, food, medical care, and housing. The reader also gets a tool to understand the research in the appendices that reviews research terminolgy and methodology.

I have looked four years for a book that has a therapeutic technique for serious psychotic illness, accepts the biology of the illness, and recognizes the immediate needs of the client.

A book written by an obvious researcher whose heart comes through the pages.