Commentary: what happens to psychosocial treatments on the way to the clinic?

Abstract

This issue of the Schizophrenia Bulletin presents a fascinating and challenging set of reviews and discussions on psychosocial interventions for persons with schizophrenia. I have two conflicting reactions to these articles. First, as a clinician I feel frustrated that my own practice and treatments in the service systems where I work fall far short of the standards of care implied in these articles. I strive to provide the best individualized care I can to my patients with schizophrenia, but I know this level of care does not include the well-developed forms of individual therapy, family psychoeducation, skills training, and cognitive-behavioral approaches described. Also, it is impossible for my patients to find access to rehabilitation programs that offer well-developed social skills training, substance abuse interventions, and vocational services, let alone neurocognitive retraining, of the caliber described. My experience undoubtedly mirrors that of many, if not most, clinicians. Indeed, the Schizophrenia Patient Outcomes Research Team (PORT; Lehman et al. 1998) project documented such difficiencies in psychosocial programs on a much larger scale, and these findings have since been replicated (Young et al. 1998). Most patients with schizophrenia do not receive any of the psychosocial interventions described in this issue, short of very generic supportive therapy and case management. My second reaction to these articles, although perhaps defensive, is that if these interventions are so great, why don't more clinicians use them? Perhaps the studies fall short by not reflecting the realities of caring for persons with schizophrenia. We are left, then, with two basic questions: Why aren't more psychosocial treatments available to patients and what are the barriers to their implementation? We might begin with clinicians' and systems' natural resistance to change. Many of us were trained prior to the invention of several of the psychosocial interventions described here, and almost none of us has received formal training in these approaches. To learn how to provide these types of psychosocial interventions would require considerable effort. Current job structures are unlikely to offer opportunities to devote the time required for this retooling, and service systems seem barely able to provide more than the most basic care for these patients. Ideally, one might argue that providing better psychosocial treatments will improve outcomes and reduce crises enough to allow systems to redirect resources toward better continuing care with state-of-the-art psychosocial programs. However, getting from A to B in this type of system change is extremely difficult and probably requires an influx of new resources, at least temporarily. Such efforts would be worthwhile if everyone were convinced that transitioning to these psychosocial treatments was warranted by the evidence. Fenton (this issue) describes old resistances to psychosocial interventions as driven by the biological versus social ideology wars of previous decades. No doubt some residue of these ideological conflicts plays a role in the resistance to adopt the newer psychosocial treatments. However, it is hoped that most practitioners are now open to the scientific evidence and less wedded to ideology. The main barrier to change today is probably the evidence itself. A strictly empirical assessment of the state of psychosocial treatments reveals that, whereas considerable evidence suggests that providing well-developed psychosocial interventions improves outcomes, it is not clear which interventions are essential or best. The empirical base for family psychoeducational programs is the strongest, with a few dozen randomized clinical trials. Yet even these programs have alternative models of varying intensity (and cost and effort). Families have been sufficiently dissatisfied with the lack of these services and thentheoretical underpinnings (e.g., expressed emotion) that they have created their own self-help psychoeducation pro-