The Management of Schizophrenia

Psychosocial / environmental therapies

Once the acute episode has been treated the focus of care should change from medication and risk management to recovery of psychosocial functioning and improved quality of life. Poor motivation, tiredness and loss of concentration resulting from, negative symptoms and residual symptoms of illness and the sedative effects of medication can also prevent the person from returning to their previous level of function. The person may not wish to return to their previous routine, especially if they are concerned about how they behaved when they were unwell. Loss of confidence can also limit recovery. In people with dual disability it is important to ensure that they have sufficient additional residential and community support to allow a graded return to pre morbid function. In the early stages of recovery the priorities may be improving self-care, increasing activities of daily living and ensuring that the person has a number of preferred positive activities (for example, seeing their family, going out for food or going to the movies) which they do not find stressful. Frequent reassurance, plenty of positive feedback and simple explanation of recent events will be required. Additional funding may be required (short or long term) to ensure that the person receives sufficient support, and this may be required long term. Some people require one to one staff support to gain any benefit from participating in group activities and for some supported community access will be required. A flexible approach is required that allows for the gradual re-introduction of a normal routines at a rate that is suitable for the individual. In some cases it is either unsuitable or not possible for the person to return to their previous activities and less demanding alternatives may be required. More intensive rehabilitation may be necessary when a person experiences significant ongoing psychiatric disability. Sadly in psychotic illness with poor prognosis some people experience a progressive loss of skills and increasing negative symptoms which do not respond to treatment or to rehabilitation and this has implications for the level of support they will need in the future. 

Psychological therapies

Psychological therapies are increasingly used in the treatment of psychosis in the general population. Examples include counselling, education, relapse prevention and specialist targeted therapies (such as cognitive behavioural therapy to challenge auditory hallucinations). Psycho education should be provided to everyone who has experienced a mental illness, their families and carers. Whilst the evidence regarding the effectiveness of these therapies in the general population is slowly growing this is not the case for people with intellectual disability. It is often necessary to adapt the format, process and content of the psychological therapies when working with people with intellectual disability.  The modifications will depend on the person’s specific skills and can range from typical word based therapy, through social stories based on the person’s own experience to the use of visual and picture information, such as the books without words series. People with significant intellectual disability may understand only the simplest information about having been unwell and getting better. In such cases it will be important that families and carers have a full understanding of the person’s mental illness to ensure that they receive correct and timely treatment. Counselling can provide general support but it is not appropriate to explore past trauma just after an acute episode of illness. The topic of psychological therapies is covered in more detail in Module 11.