The case for social-cognitive remediation in schizophrenia: A life well lived is more than remission from psychosis

The case for treating social-cognitive impairments in schizophrenia is compelling. The most recent Australian statistics show that most people (90.4%) with a psychotic illness have impaired social functioning, with over one-half (63.2%) showing a profound level of dysfunction in their ability to socialise, 37% feeling socially isolated, and over two-thirds unable to maintain close relationships or engage in social and recreational activities (Morgan et al., 2011).

These stark statistics invite two questions: (a) why do only a little over one-third (36.5%) of consumers receive any rehabilitation and only 28.9% have an individually tailored recovery plan (Morgan et al., 2011)?; and (b) what can we do to improve this situation? Below we discuss why social-cognitive remediation (SCR) for schizophrenia is important, what the potential barriers are to translating existing programs from the research environment into the clinical setting, and the importance of strong collaborations between researchers, clinicians and consumers as a way forward.

Background

Increasing evidence shows that impaired social-cognitive abilities significantly contribute to impaired social functioning in schizophrenia (Couture et al., 2006). Social cognition refers to the ways in which people understand the actions, intentions and thoughts of others (Horan et al., 2008). It is defined as ‘the mental operations that underlie social interactions, including perceiving, interpreting, and generating responses to the intentions, dispositions, and behaviours of others’ (Green et al., 2008 p.1). The most commonly researched domains of social cognition in schizophrenia are: (a) basic emotion cue recognition; (b) ‘theory of mind’ (ToM; inferring others’ causal mental states, primarily beliefs and intentions) (Langdon, 2005); and (c) social attributional reasoning (biases in attributing the causes of positive and negative events to self, others or circumstances) (Kinderman and Bentall, 1997). The ability to filter and selectively process salient social information across these social-cognitive domains allows people to accurately receive, interpret and respond to social signals (Horan et al., 2008). Impairments in these social-cognitive domains cause profound difficulties with communicating and understanding one’s own and other people’s perspectives.

During real-world social interactions, we rely on social-cognitive abilities to infer what other people might be thinking, feeling or believing; it is only via an intact ToM that we can understand the use of deceit, irony, metaphors, humour or indirect hints in speech. Social cognition is specifically impaired in schizophrenia, contributing to impaired social functioning (Horan et al., 2008). It is often the odd or bizarre behaviour resulting from these social deficits that mark people with schizophrenia as ‘abnormal’ (Brune, 2005), leading to increased isolation and social disability. Social deficits are a defining characteristic of schizophrenia, often evident premorbidly, predictive of relapse, poor illness course and unemployment, and are relatively impervious to the antipsychotic drugs used to treat this illness (Horan et al., 2008). Thus, there has been an increasing drive to produce evidence-based psychosocial treatments to treat these problems.

Approaches to SCR

The approach taken to developing SCR treatments for schizophrenia has varied, but can be dichotomised into ‘targeted’ treatments focusing on specific impairments (e.g. emotion perception: Combs et al., 2011; Marsh et al., 2010) or ‘broad-based’ treatments which target both emotion recognition and the more complex abilities needed to understand other people’s mental states (Horan et al., 2011; Marsh et al., 2013; Penn et al., 2007). Before we focus on the evidence for these two types of SCR program, we will briefly discuss how SCR fits within the broader context of other psychosocial programs for schizophrenia.

Psychosocial treatment approaches vary, but generally differ with regard to focusing on social-cognitive impairment as a ‘bias’ or a ‘deficit’ (reviewed in Wölwer et al., 2010). For example, cognitive behavioural therapy (CBT) and meta-cognitive training (MCT) rely on de-biasing strategies to make clients aware of their faulty thinking and the effects of this biased thinking on their behaviour (Wölwer et al., 2010). CBT approaches target mainly positive symptoms, rather than social deficits, exploring links between individuals’ symptoms and the faulty beliefs and consequent feelings that are thought to underlie the problem behaviour and distress. Change is elicited via belief modification, reality checking and normalisation (Wölwer et al., 2010).

SCR also attempts to change behaviour in the real world by changing thinking (Fiszdon and Reddy, 2012), but diverges from CBT by targeting online social-cognitive processes (rather than belief content) by actively engaging these very same processes. For example, emotion recognition training (ERT) programs work by drawing attention to salient facial features that are important for accurate recognition of others’ emotions; thus, they overtly target the online visuo-attentional processing of emotional facial information (e.g. Combs et al., 2011; Marsh et al., 2010).

Targeted treatments of emotion recognition

Two recent meta-analyses of emotion recognition in schizophrenia compared to healthy controls confirmed large differences in emotion recognition abilities (effect size 0.91: Kohler et al., 2010; effect size for identification 0.71, effect size for discrimination 1.01: Kurtz and Richardson, 2012). Recent studies have demonstrated the efficacy of various ERT programs for remediating these deficits (Horan et al., 2008).

For example, Russell and colleagues (2008) used Ekman’s Micro Expression Training Tool CD (METT; www.paulekman.com) to improve emotion recognition in people with schizophrenia. The METT uses a series of videos showing facial expressions with verbal commentary to direct attention to relevant facial features of commonly confused emotional expressions (e.g. using the eyebrows to distinguish fear from surprise). Russell and colleagues found that training with the METT improved emotion recognition in an active training group compared to a group who passively viewed training videos without any verbal commentary. The improvements generalised to novel face stimuli not used in training, improved recognition of subtle emotional expressions (i.e. 50% intensity of a full expression) and of emotional stimuli presented in video vignettes, and endured for 1 month after training (Marsh et al., 2010). These improvements are associated with changes in how people attend to the salient features of facial expressions of emotion (Combs et al., 2011; Marsh et al., 2012; Russell et al., 2008). Taken together, this evidence indicates that ERT is producing changes in the underlying online visuo-attentional processes associated with impaired emotion recognition in schizophrenia.

Broad-based approaches to SCR

Whereas ERT uses more compensatory skills-based learning (teaching where to look and how to interpret different facial movements), broad-based approaches attempt to improve a wider range of social-cognitive processes, often with a focus on ToM. By definition, ToM involves understanding that others have a mental life that is different to one’s own and then making correct inferences about that mental life. Thus, it is clear that improving ToM skills cannot be simply reduced to a ‘recipe’ of correct interpretations that follow from a standard set of social cues. Thus, there has been a focus on developing social- cognitive treatments to include the remediation of ToM and attributional bias. These include, but are not restricted to, Penn’s Social Cognitive and Interaction Training (SCIT: Penn et al., 2007), Horan’s Social Cognitive Skills Training (SCST: Horan et al., 2011) and our SoCog program (Marsh et al., 2013).

These programs each combine a suite of interventions to treat impaired emotion recognition, social perception, attributional bias and ToM in a group format. The SCIT and SCST have been reviewed elsewhere (Fiszdon and Reddy, 2012); therefore, as an example, we use SoCog, which comprises 12 1-hour sessions over 6 weeks (vs 20 sessions for SCIT/SCST). Training is conducted in groups of up to six people using a manual-driven suite of activities comprising games and short films. The training approach ensures that participants receive repeated exposure to varying cues to enhance the same complex mental-state reasoning abilities (e.g. interpreting and predicting other people’s actions/behaviours in terms of causal mental states: ‘Fred will do ‘x’ since he wants ‘y’ and believes ‘z’ about the situation’). All activities centre on vignettes of social situations with a focus on making inferences and predictions about characters’ thoughts, feelings and behaviours with frequent repetition of training concepts. The programs discussed above rely on various training methods; however, they all encourage participants to engage their own social-cognitive abilities to infer other people’s likely thoughts to explain and predict others’ behaviour. This is done by exploring different possible interpretations and inferences in response to ambiguous social situations.

A recent meta-analysis of 19 controlled SCR studies found moderate to large effects of SCR on the identification and discrimination of facial affect recognition (d = 0.71 and 1.01) and moderate effects on ToM (d = 0.46), but no significant effects on attributional biases (Kurtz and Richardson, 2012). Effects did not differ between programs of a longer duration and greater intensity compared with shorter, less intense programs.

SCR and social and vocational functioning in the real world

The underlying assumption of SCR is that improving social-cognitive abilities will improve real-world social functioning. This is based on evidence of consistent relationships between social-cognitive abilities and social functioning outcomes (reviewed in Couture et al., 2006), and stronger direct relationships between social cognition (16% variance explained) and community functioning than between neurocognition (6% variance explained) and community functioning (Fett et al., 2011; Kurtz and Mueser, 2008). In their meta-analysis, Kurtz and Mueser (2008) found a moderate–large effect size for improved observer-rated community functioning in outpatients and institutional functioning for inpatients following SCR. Regarding vocational outcomes, it would seem unreasonable to expect that SCR would directly result in obtaining work in the short-term; however, occupational functioning is significantly associated with social-cognitive abilities (Kurtz and Mueser, 2008), so it would be reasonable to expect that interpersonal interactions at work would be improved by SCR, although this has yet to be examined in any studies to our knowledge.

Barriers to implementing SCR into mental health services and translatability into clinical practice

There remain significant barriers to implementing SCR into mental health services (MHS). Although the ultimate aim of any SCR treatment is to become a routine part of clinical practice, SCR treatments have yet to be exposed to full-effectiveness trials within MHS where the expectations of rigorous science and clinical treatment can diverge in terms of clinician variability (e.g. regarding competency and motivation), broad inclusion/exclusion criteria (e.g. not excluding participants with active substance abuse problems) and a well-developed treatment manual that allows for clinician flexibility whilst still ensuring treatment fidelity.

Additionally, difficulties in engaging people with profound negative symptoms in a program that requires a commitment of several months can lead services to perceive new treatments as not being cost-effective and lessen their commitment to the program. There is also a lack of incentive for MHS to participate in research developing new psychosocial treatments.

Although these obstacles are surmountable, they serve to emphasise the need for researchers to work collaboratively with MHS clinicians and administrators and consumers and their carers to ensure the development of readily generalisable treatments. In developing SoCog, we attempted to overcome some of these obstacles by designing a program that is readily translatable into clinical practice and can be implemented by any clinician (nurses, psychologists or other allied health staff) at little cost to services. An important aspect of SoCog is that, from its inception, the implementation and feasibility of the program has been tested within the Western Sydney Local Health District in collaboration with clinicians. Staffing turnover and shortages proved significant barriers to testing and implementation. We also sought and implemented feedback from consumers in the early stages of development (Marsh et al., 2013) and we have drawn on the experiences of PJM who has everyday experience of living with a son with schizoaffective disorder: PJM discusses her lived perspective below.

Significance of SCR from a consumer-carer perspective

The statistics and evidence present a compelling case for SCR; however, until we have the opportunity to ‘walk in another’s shoes’ we cannot fully understand the impact on individual lives.

The most notable aspect of PJM’s son’s illness is his extreme social isolation. He has identified the worst aspect of his illness as the inability to ‘get on with my work mates’. So, although he is able to work in the building industry, he is equally unable to sustain healthy and ongoing relationships with those around him. He struggles to understand basic social interactions and frequently perceives threat in interactions that those of us without a psychotic illness would perceive as innocuous. He has difficulty understanding others’ feelings and facial expressions. He has a tendency to interpret the abstract literally; humour often passes him by; and jokes must be explained. This is the confusion that PJM’s son experiences most days as he tries to negotiate the social world around him and this experience parallels the experience of many people with a psychotic illness.

In daily life, PJM and her partner are frequently explaining to their son others’ possible thoughts, feelings and beliefs because, for him, this does not come automatically. As a parent, one of the most striking aspects of this is that PJM understands this about him from her research focus but so many parents are not given this information. In her work, PJM repeatedly encounters similar stories from consumers, their carers, and clinicians, and yet treatment for social impairments remains one of the greatest unmet needs in treatment identified by all involved, including the consumers themselves. The challenge for SCR programs is to meet this need so we can redress the devastating impact of social-cognitive impairment on individuals’ lives. We should never lose sight of the fact that remission from the psychotic symptoms of schizophrenia is a small part of recovery and in and of itself it is insufficient for a life well lived.

Conclusions

There is an urgent need for the development and implementation of psychosocial programs to treat the profound social-cognitive impairments that characterise schizophrenia. There is increasing evidence that SCR is an effective treatment for these deficits and that improvements generalise to enhance social functioning. However, there is still much work to be done to strengthen the evidence base, particularly regarding the generalisability of programs to distal measures of social functioning and the durability of improved social cognition and social functioning. We advocate that with strong collaborative links between researchers, clinicians and consumers this is an achievable goal. Our ultimate long-term aim remains the implementation of SCR programs throughout all MHS and to increase the number of people accessing these important services from only a little over one-third to all those who need or request it.