Behaviour Therapy

With Freud's conceptualisation of psychosis as a narcissistic process, there was very little effort at developing face-to-face interventions in sufferers of schizophrenia. Behaviour therapy, with its origins in empirical psychology, took up the challenge and used principles of differential reinforcement with problem behaviours in schizophrenia. As medication treatment brought promise to the treatment of positive symptoms, behaviour therapy found its applications mainly in the deficit symptoms of schizophrenia. Early behaviour therapy used case series and small trials and focused on behaviours resulting from symptoms of schizophrenia (Haddock et al., 1998).

Social Skills Training

Social skills training became a hallmark psychosocial intervention and empirical science found support through results of clinical trials (Benton & Schroeder, 1990; Dilk & Bond, 1996). Not only did behavioural techniques improve social skills, there is also some evidence that this was retained in longer term follow-ups (Eckman et al., 1992; Wallace et al., 1992). Social skills training is a highly structured approach to learning very specific skills like making conversations, asking for help and living in the community. Role playing, rehearsal and modelling are used. The training can be delivered to individuals and groups. Although there are studies showing retention of skills up to one year after training (Eckman et al., 1992; Holmes, Hansen & St Lawrence, 1984; Mueser, Wallace & Liberman, 1995; Wallace et al., 1992), a recent meta-analysis focusing only on randomised controlled trials reported no benefits from social skills training (Pilling et al., 2002a). This may mean several things: smaller trials with variable results are unable to show a clear effect with meta-analysis or, as the authors note, social skills training may not provide the same benefits in all settings. Huxley et al. (2000) suggested that the remit of skills training should be expanded to extend over wider areas of functioning.

Life Skills Training

Life skills training is a related concept. It applies to developing day-to-day skills required for functioning in an increasingly complex society, like shopping, paying bills or making enquiries. Behavioural principles of learning are used to break down the tasks and acquire them through modelling and repetition. There is initial evidence that this may be effective (Robertson, 1998).

Token Economy

To improve the functioning of patients with negative symptoms, the token economy was introduced in psychiatric practice in the 1970s. It involved reward of tokens for 'desirable' behaviours. The tokens could be exchanged for items that were important to the patient, like cigarettes or items of food.

Despite the issues of political correctness and freedom of choice, the token economy emerged as the only evaluated psychological method of producing concrete improvements in negative symptoms (McMonagle, 2000). Unfortunately the total number of subjects in controlled studies is not more than 100 and the treatment has virtually disappeared from mainstream psychiatry in the West.

Conclusion

Behavioural management today finds a place in rehabilitation units in psychiatry. Interventions are adapted for both individual and group work. There are concerns about whether behavioural improvements generalise to patients' own settings (Haddock et al., 1998).

Behaviour therapy did conceptualise the direct management of positive symptoms of schizophrenia, but possibly the time was not ripe for large-scale studies of psychological interventions for such symptoms in face of the pharmaceutical persuasion for the use of antipsychotics. Many of the techniques are found in the repertoire of cognitive behaviour therapy and will be addressed in that section of this article.

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