A New Adaptation of Integrated Psychological Treatment for Patients With Schizophrenia

Integrated psychological treatment (IPT)-which was developed by a research group in Bern, Switzerland, for patients with schizophrenia-is a distinctive and practical approach to rehabilitation.¹ What sets IPT apart from other treatments is that it can integrate classic approaches of developing social skills with new approaches of managing neurocognitive deficits and cognitive bias for patients with schizophrenia.

IPT also focuses on helping patients deal with the difficulties that they encounter on a daily basis. It is based on a hierarchical progression of learning that allows individuals to acquire skills that are essential for social functioning and to reappropriate meaningful social roles.² The goal of IPT is to enhance psychosocial functioning and patients' abilities to cope with environmental stressors in their everyday lives. The first incarnation of IPT was published in the late 1970s,³ and the first IPT manual was printed in 1988 in German.⁴ The manual has since been translated into 10 languages, including English.

The effectiveness of IPT has been demonstrated in 30 independent evaluations worldwide and is documented in a meta-analysis in which IPT had greater positive mean effect sizes than placebo (group-attending attention training) or standard care.⁵ Findings from the analysis showed that all dependent variables, including psychopathology, neurocognitive deficits, and social behaviors, were positively affected. In addition, the beneficial effects of IPT increased during an average follow-up period of 8.1 months. These favorable effects were obtained at different stages of illness and in different clinical and organizational settings.

The results of a multisite implementation study (N = 55) in natural contexts involving 9 clinical settings in Quebec support these conclusions.⁶ Improvements were observed in general symptoms, cognitive and social functioning, and quality of life, despite differences among 9 groups of participants. The overall change was positive for patients in the early stages of the disease, for patients who had been treated for 5 to 10 years in a traditional outpatient clinic, and for patients who were receiving long-term care. In addition, skill levels continued to improve for 3 to 4 months after the intervention ended.

IPT is recommended as an effective intervention for patients with schizophrenia (in illness management and recovery skills practice).⁷ It does not, however, encompass all care that should be offered to these patients (ie, collaborative and optimal psychopharmacology, case management, assertive community treatment, psychotherapy, family psychoeducation, supported housing, and supported employment). For this reason, clinicians must offer IPT within the framework of a comprehensive care and rehabilitation process.

Basic principles of IPT

IPT is a cognitive-behavioral approach to rehabilitation. The content of clinical activities proposed under IPT combines the principles of neurocognitive remediation^8,9 (including the concept of social cognition) and classic cognitive therapy,^10,11 as well as social skills development and problem-solving approaches.^12,13 The therapeutic activities of IPT make it possible for a clinician to intervene at a patient's level of cognitive dysfunctions (ie, lack of attention, poor working memory, deficit of executive functioning), false perceptions and interpretations (ie, positive symptoms, cognitive schema, emotional perception), social inabilities, and management of stressful and emotionally charged situations (ie, coping style).

The original IPT approach consisted of 5 modules.¹ Later, a French version of IPT¹⁴ introduced an additional module, emotional management training (EMT).¹⁵ The new Quebec version of IPT, adapted from the French version, also includes EMT.¹⁶ It consists of 6 modules (Figure) [Figure restricted. Please see print edition for content.] of increasing complexity that are delivered to groups of 8 to 12 participants over 9 to 12 months (in 2-hour sessions twice weekly).^14,16

The 6 modules are designed so that each builds on the previous module. Learning gradually takes place through a series of progressive and well-framed situations that are cognitively simple, have few social or emotional requirements, and direct the patient toward experimenting with increasingly complex situations with progressively greater relational and emotional demands. In this way, participants are gradually given exercises and placed in situations that require ever-greater skills and that increasingly approximate real life.

According to Brenner's model, improved cognitive and perceptual skills have a positive effect on social behavior by reducing environmental stressors and cognitive distractions.¹ Improving patients' social skills and their ability to deal with the demands of everyday life also has a positive impact by reducing cognitive and perceptual difficulties and closing the cognitive-behavioral feedback loop required to maintain the functional behaviors that are needed for a better social life.

IPT subprograms

Module 1, cognitive differentiation, is intended to exercise basic cognitive functions (attention/concentration, memory, and the creation/manipulation of concepts) through abstract exercises in the form of learning games. These exercises solicit and improve patients' existing cognitive functions and permit the acquisition of compensatory strategies to reduce residual cognitive deficits. Module 1 not only stimulates cognitive functions, it also establishes the kind of safe learning environment that is essential for effective group processes, enabling participants to have successful experiences.²

Module 2, social perception, consists of participants working together to analyze images (slides or video sequences) that represent a variety of social situations. Initially, simple cognitive content and emotionally neutral situations give way to progressively more complex content in more emotionally charged situations. Participants are asked to describe objective aspects of the images and to interpret their content. The aims are to avoid inappropriate interpretations, focus on the objective aspects of the image, and correct mistaken cognitive schemata that often occur in patients with schizophrenia. Module 2 also allows facilitators to make an initial assessment of the cognitive schemata of participants that will have an impact on the way they manage their emotions and solve everyday problems (covered in modules 5 and 6).

Module 3, verbal communication, addresses patients' basic communication skills through learning games or role-playing. Participants acquire listening skills, develop understanding, and learn appropriate responses. Clinicians work with participants on the various communication deficits that are frequently observed in patients with schizophrenia (eg, poor language, loss of content, circumstantial language, perseveration). This is a key module in which greater demand is placed on individual participants, but in which progress is made toward establishing a cohesive spirit within the group. Thus, this module is well suited for exercises on acquiring new adjustment strategies proposed by clinicians.

Module 4, social skills, is a logical follow-up to the preceding module. It aims to develop an appropriate range of social skills in a variety of specific social situations. Participants are encouraged, according to their capacities and needs, to work through different social situations they encounter in their everyday lives using cognitive-behavioral techniques (eg, instructions, role-playing, modeling, repetition, reinforcement). This module is largely based on classic approaches to developing social skills.^12,13

Module 5, emotional management, helps patients develop the best strategies for managing emotions. The depiction of an emotion presented in a given situation (in a slide or short video sequence) allows participants to do a detailed analysis of their emotional reactions, question the appropriateness of the strategies they have adopted, search for better-alternative strategies, and then experiment with the strategies they have selected.

This module is an essential element to strengthen the learning skills that are needed for the management of stressful situations. The emotional intensity of stressful situations can disrupt the learning processes of patients and may prevent them from applying the skills they acquired during previous modules. Module 5 provides more emotional stability for the patients in their everyday lives and facilitates the application of compensatory strategies that are specifically adapted to the emotional vulnerability and residual symptoms of patients. This module reinforces the exercises on perceptions and erroneous interpretations that began in module 2. Module 5 was inspired by Green and Nuechterlein's model (social cognition)⁸ and by cognitive-behavioral therapy principles.¹⁰

Module 5 is demanding in that it requires clinicians to possess a solid mastery of group facilitation skills. The challenge is to maintain the established theoretical framework while increasing the complexity (cognitive, perceptual, and social) of the situations presented.¹⁶

Module 6, problem solving, involves analyzing problems experienced by the participants. These situations are examined according to the following steps of problem solving: identify and analyze the problem, engage in the cognitive conceptualization of the problem, search for alternative solutions, discuss the solutions, select a solution, implement the solution, and evaluate the solution's effectiveness. This module requires participants to use the skills they have acquired in the preceding modules and proposes real-life situations and exercises that facilitate the transfer of learning skills. Table 1 provides some examples of the types of exercises used in each module.

Generalization and maintenance of learning skills

Despite making some tentative suggestions about how the newly acquired knowledge can be generalized and maintained, previous versions of IPT proposed few therapeutic activities for attaining this objective.^1,14 The revised Quebec version of IPT (the result of an implementation study carried out in Quebec) seeks to fill this gap by using 3 additional therapeutic modalities¹⁶:

• Exercises or tasks to be done at home.
• Integration outings in the patient's day-to-day environment (in vivo sessions).
• Additional booster sessions after completion of IPT.

The first 2 modalities are incorporated into each of the modules and are framed in terms of the requirements of the model being used and the progression of the participants in the model. Home tasks allow participants to practice their skills in a real-life context that fully reproduces clinical exercises. In contrast, integration outings allow participants to generalize learning from the clinical exercises to other contexts in the presence of a clinician. The guidance participants receive eases the transfer of knowledge acquired in the clinical setting to concrete applications in everyday life.

The booster sessions reactivate some of the learning from the clinical setting but, more important, validate the concrete application of the knowledge gained to real-life situations. Topics proposed by participants during these meetings arise from the successes or difficulties they have encountered in managing events in their lives.

These additional sessions also serve as a bridge between the results obtained at the end of the IPT program and the development of postgroup life plans that participants have chosen and adapted to their particular situations. Such life plans may involve participating in a group in their community, returning to school, or reentering the workforce.

Table 2 [Table restricted. Please see print edition for content.] presents examples of exercises used in these 3 therapeutic modalities. These modifications to IPT, which are unique to the Quebec version, were created in response to weaknesses encountered during clinical applications and were influenced by recent applications of IPT^15,17 and the new development of the cognitive-behavioral approach to rehabilitation.^18,19

Advantages of using IPT

Briand and colleagues¹⁶ reported that both participants and clinicians greatly appreciate IPT. It integrates several approaches to cognitive-behavioral rehabilitation that have, until now, only been applied separately. IPT also remains centered on the everyday difficulties faced by patients with schizophrenia. In addition, by offering a new series of therapeutic activities, IPT enhances the generalization and maintenance of skills learned and moves significantly closer to the lives of participants.

These factors make IPT more stimulating to apply, because it becomes a major component within a more complete rehabilitation and social reinsertion pro- cess. Indeed, IPT can be combined with other psychosocial rehabilitation models.^2,20 For example, the model of human occupation adds a larger theoretical rehabilitation framework to the IPT approach and facilitates the development of personal objectives for each participant.²¹ The model of human occupation also provides a series of assessments that are easy to apply in clinical settings, and it measures functional changes in everyday activities.²

Despite the hierarchy of learning that is implicit in the 6 modules, IPT remains very flexible. The number and content of exercises can be changed to address the particular problems and specific needs of each participant.¹⁶ IPT is independent of the stage of the illness or the moment at which it is introduced to the rehabilitation process. Participants can thus progress at their own speed and absorb knowledge that is appropriate to their level of development. In fact, training in the Quebec version of IPT places greater emphasis on understanding the hierarchical structure of IPT and its different modules. This simplifies the use of a hierarchical approach to learning skills, particularly when clinicians choose to add new exercises to a given module.¹⁶ The meta-analysis published by Roder and associates⁵ shows the impact of using some or all of the IPT application modules.

The structure and substance of IPT responds to several needs in the continuum of rehabilitation services and fits perfectly into contemporary programs that attempt to fully respond to the various needs of patients with schizophrenia.

Case vignette

Michael is a 23-year-old man who has exhibited functional difficulties for the past 3 years. Two years ago, Michael's illness forced him to abandon his studies in biology and move back with his parents. Paranoid schizophrenia was diagnosed and Michael required 2 hospitalizations and an interdisciplinary follow-up in an outpatient clinic. At the end of his second hospitalization (and as a result of numerous functional deficits measured in occupational therapy), Michael was referred to a clinic specializing in early psychosis.²² This interdisciplinary program, which involved input from an occupational therapist, a neuropsychologist, a nurse, a psychiatrist, and a social worker, provided a complete and standardized assessment of Michael and his family. It employed several treatment modalities (psychotherapy and psychoeducation) in individual and group approaches using the Quebec version of IPT and conceptual model of human occupation as the backbone of the rehabilitation intervention.

In this specialized program, IPT was managed by 2 occupational therapists. The model of human occupation functional assessment tools (Occupational Performance History Interview [OPHI-II] and Assessment of Communication and Interaction Skills [ACIS]) provided clinical measures (quantitative and subjective) of the positive effects of the 6 IPT modules on Michael's day-to-day functioning.

The data obtained with the OPHI-II and ACIS tools at the end of the IPT group sessions revealed clinically significant improvements in Michael's occupational identity, his day-to-day competence (including social skills), and the support he received from his environment.² The positive impact of these improvements encouraged him to develop a new post-IPT life plan. At his own initiative, Michael began a progressive return to his studies under a back-to-work program run by a local nongovernmental agency, while remaining in contact with his public mental health team.

Table 3 presents examples of these benefits and more details about these 2 functional assessment tools.

Principles of successful IPT implementation

Clinical practice has shown that IPT implementation is best learned by clinicians through a 3-day program of professional training, backed by a solid understanding of and experience in applying the principles of cognitive-behavioral rehabilitation to patients with psychosis.^16,23 Clinicians with some experience directing groups centered on social skills development and problem solving who have already worked with the principles of classic cognitive therapy tend to gain more from IPT training and are better able to pass along its benefits to patients.

It also appears to be beneficial to have the support of a clinical reference team when applying IPT.²⁴ Several studies have shown that the presence of a support team during program implementation is essential for success in this kind of specialized intervention.^7,25

Finally, implementation of IPT is worth pursuing in settings that value professional expertise and continuing education, the development of specialized services for patients with psychosis, and work teams that subscribe to contemporary principles of rehabilitation and cognitive-behavioral approaches.²⁴

Costs

Implementing IPT requires an initial investment for training clinicians and for purchasing didactic materials for group work. Nevertheless, the costs incurred are no greater than the costs of resources and services currently provided for patients with schizophrenia. The multisite Quebec study demonstrated that during the period in which participants received IPT there were fewer visits to psychiatrists and emergency departments and fewer hospitalizations.²⁶ This effectively represented a transfer of resources to outpatient IPT services. Total health system costs remained unchanged (and even fell slightly) during IPT implementation compared with the previous year.²⁶

Conclusion

IPT is used worldwide as an approach to rehabilitation. In Canada, and more specifically in Quebec, over 100 rehabilitation professionals have been trained in the use of the new version of IPT, and more than one third offer IPT to their patients in its full form. In October 2007, a 3-day professional workshop in Montréal will explain how to implement the new Quebec version of IPT in English.

There are no longer any doubts about the efficacy of IPT. However, future approaches to research and clinical practice will need to focus on selecting the most suitable clinical assessment tools and how they can be used to improve the continuum of services between evidence-based practice needs and the setting of specific objectives for each participant.^2,21 This scientific approach will reinforce the integration of specialized interventions, such as IPT, into individualized rehabilitation service plans.

References:

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