The Effects of Psychotherapy on

Subjective Recovery of Schizophrenia

Patients A Systematic Review

Christine Adamus, Martin grosse Holtforth &

Mario Pfammatter
University Hospital of Psychiatry
University of Bern
christine.adamus@upd.ch

Outline

Background
The burden of schizophrenic disorders
The significance of recovery as a treatment goal in schizophrenia
The different facets of recovery
Psychotherapy and recovery in schizophrenia
Aims of the study

Methods

Preliminary Results

Discussion

2
The Burden of Schizophrenic Disorders

Schizophrenic disorders
represent a disorder with grave consequences for the patients, their
relatives and the society
have a bad disease process with repeated acute illness episodes
and extensive impairments regarding social functioning in 80% of
cases
cause 1.1% of all worldwide Disability Adjusted Life Years (DALY),
which represents the fifth highest rate of all illnesses
have a high risk of mortality and suicide
have high direct and indirect costs: They are the most expensive
psychiatric disorders in industrial countries causing 1.5% - 2.5% of
healthcare costs
Rssler (2011)

The Significance of Recovery as

Treatment Goal in Schizophrenia
The prevention of negative events such as hospitalization or the
control and stabilization of psychotic symptoms has long been
considered as the main focus of schizophrenia treatment

However, it has been noted that many people with schizophrenia

move beyond stability and recover substantially

This has led to the suggestion that the goal should be recovery and
not stability

(Lysaker & Buck 2006)

4
The Different Facets of Recovery

There is no consensus with regard to the definition of recovery

The term is generally used for clinical remission, functional
rehabilitation and constructive changes in peoples appraisals of
themselves and their future potential (Lysaker & Buck 2006)
Recovery, therefore, includes 3 different facets:
Clinical remission or symptom recovery
State in which none of the core symptoms (DSM-IV) is present above
distinct thresholds for a period of at least 6 months (Andreasen et al., 2005)
Functional recovery
Multidimensional construct which includes social functioning and quality of
life
Subjective recovery (SR)
Focus on recovery as an ongoing process regarding the development of a
constructive and consistent subjective narrative of oneself integrating the
illness
5

Psychotherapy and Recovery

Hundreds of efficacy studies and a large number of meta-analyses

have established different psychotherapy approaches as effective
treatments in schizophrenia

Evidence based psychotherapy approaches generally focus on clinical

and functional recovery

However, in recent years different psychotherapy approaches have

been applied to promote subjective recovery

6
 Psychotherapy and Recovery
Integrated Effect Sizes
PSYCHOTHERAPY META-ANALYSES N OUTCOME VARIABLES INTEGRATED 95%- HOMOGENEITY
APPROACHES OF RANDOMIZED INCLUDED EFFECT SIZES CONFIDENCE TESTS
CONTROLLED TRIALS STUDIES (Hedges g) INTERVALS
Psycho-educational Pilling et al. 2002 18 Medication compliance 0.36 0.25 0.54 Q2 = 3.52, p = 0.28
behavioral family Pfammatter et al. 2006 31
Relapse rate -0.32 -0.47 -0.14 Q = 4.56, p = 0.15
interventions Lincoln et al. 2007 13
Pharoah et al. 2010 43 Family burden -0.47 -0.53 -0.11 Q = 0.33, p = 0.96
Social Skills Training Pilling et al. (2002) 9 Social skills 0.68 0.52 0.86 Q = 1.07, p = 0.32
Pfammatter et al. (2006) 19
Social functioning 0.42 0.20 0.65 Q = 0.23, p = 0.65
Kurtz & Mueser (2008) 22
Hospitalization rate -0.34 -0.63 -0.09 Q = 4.32, p = 0.17
Cognitive Remediation McGrath & Hayes (2000) 3 Cognitive performance 0.37 0.13 0.63 Q = 0.51, p = 0.48
Therapy Pilling et al. (2002) 5
Twamley et al. (2003) 17 Social perception 0.55 0.25 0.88 Q = 0.11, p = 0.65
Pfammatter et al. (2006) 19
McGurk et al. (2007) 26
Social functioning 0.46 0.19 0.67 Q = 0.22, p = 0.89
Grynszpan et al. (2011) 16 Negative symptoms -0.24 -0.42 -0.06 Q = 1,83, p = 0.23
Wykes et al. (2011) 35
Cella et al. 45
CBT for positive symptoms Rector & Beck (2001) 7
7 Positive symptoms -0.34 -0.47 -0.19 Q = 1.45, p = 0.33
Pilling et al. (2002)
Zimmermann et al. (2005) 14 Overall symptoms -0.42 -0.84 -0.26 Q = 2.68, p = 0.26
Pfammatter et al. (2006) 17
Lincoln et al. (2008) 18 Social functioning 0.51 0.36 0.81 Q = 0.22, p = 0.89
Sarin et al. (2011) 22
Burns et al. (2013) 12
Jauhar et al. (2014) 32
van der Gaag et al. (2014) 18
Mehl et al. (2015) 19

CBT as early intervention Hutton & Taylor (2013) 5

5 Delay of illness onset 0.19 -0.05 0.45 Q = 6.61, p = 0.12
van der Gaag et al. (2013)
2
Q = Sum of weighted squared deviations
7

Psychotherapy and Recovery

Hundreds of efficacy studies and a large number of meta-analyses

have established different psychotherapy approaches as effective
treatments in schizophrenia

International treatment guidelines now recommend 2 psychotherapy

approaches with an A- and 2 psychotherapies with a B-degree of
evidence

Evidence based psychotherapy approaches generally focus on clinical

and functional recovery

However, in recent years different psychotherapy approaches have

been applied to promote subjective recovery

8
Psychotherapy and Recovery
Guidelines Recommendations
Psychotherapy Degree of
Effects on
Approaches Evidence
Compliance with medication
Psycho-educative Prevention of relapses or rehospitalisations
A*/**/***
Family Interventions Social functioning
Family burden (reduction of High EE)
Psycho-education with Insight into illness
B*/**/***
Patients Compliance with medication
Positive and negative symptoms
Cognitive Behavioral
A*/**/*** Depression
Therapy
Social functioning
Social skills
Social Skills Training A*, B**/*** Social functioning
Duration of hospitalization
Cognitive performance
Cognitive Remediation B*/**, C*** Social cognitive functioning
Negative symptoms
* American Psychiatric Association (APA, 2009)
** National Institute for Clinical Excellence (NICE, 2014)
*** Deutsche Gesellschaft fr Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN 2006)
9

Psychotherapy and Recovery

Hundreds of efficacy studies and a large number of meta-analyses

have established different psychotherapy approaches as effective
treatments in schizophrenia

International treatment guidelines now recommend 2 psychotherapy

approaches with an A- and 2 psychotherapies with a B-degree of
evidence

Evidence based psychotherapy approaches generally focus on

clinical and functional recovery

However, in recent years different psychotherapy approaches have

been applied to promote subjective recovery

10
Psychotherapy and Subjective Recovery
(SR)

Third Wave Cognitive Behavioral Therapy Approaches:

Acceptance and Commitment Therapy (ACT)
Mindfulness-based Therapies (MBT)
Metacognitive Narrative Therapies (MCN)
Training of Emotional Competences (TEC)
(Heidenreich & Michalak, 2013;
Khoury, Lecomte, Gaudiano, & Paquin, 2013)

11

Aims of the Study

A large number of intervention studies have examined the

effectiveness of SR-oriented psychotherapies in schizophrenia
To date no systematic review has been performed to examine the
effectiveness of psychological interventions on subjective recovery
in schizophrenia
The aim of this study is to systematically review studies evaluating
the effectiveness of SR psychotherapies in schizophrenic patients:
What are the characteristics of the patients included?
Which designs and control groups have been implemented?
Which outcome variables were examined?
Which effects were achieved?
Are the effect sizes of SR interventions comparable with those of
evidence based therapies?
How high is the risk of bias due to researcher allegiance (RA)?

12
Methods:
Search Strategy

PubMed, PsycINFO and PSYndex were searched for prospective

intervention studies published to the end of 2016.
Furthermore, the reference lists of published meta-analysis and systematic
reviews were searched.
Search terms:
((Acceptance and Commitment) OR (ACT) OR (Acceptance based))
((Mindfulness-based) OR (Mindfulness) OR (MBCT) OR (MBSR) OR (MBRP))
((Meditation) OR (Meditation-based))
((Metacognitive) OR (Meta-cognitive))
((Mentalization-based) OR (Mentalisation-based) OR (Mentalizing) OR
(Mentalising) OR (Mentalization) OR (Mentalisation))
((Emotional Competence) OR (Emotional Competences))
((Social Cognition) OR (Social Cognition and Interaction) OR (SCIT))
((Narrative identity) OR (Self-narrative) OR (narrative sense of self) OR
(narrative self))

AND ((schizophrenia) or (schizophrenic) or (psychosis) or (psychotic))

13

Methods:
Flow Chart of the Study Selection
Records excluded
Reason: Theoretical papers (N = 187)
Records identified after duplicates
removed: (N = 499) Meta-analyses and systematic reviews
identified for manual searching
(N = 19)

Records identified through manual

Abstracts screened: searching: (N = 12)
(N = 305)
Excluded: (N = 202)

Full text analysis:

(N = 103) Excluded: (N = 69)

Included in qualitative analysis: Excluded: (N = 22)

(N = 34) Case studies: (N = 13)
Within-group studies: (N = 9)

Included in quantitative analysis:

(N = 12)
14
Methods:
Reasons for excluding

Abstract Fulltext
Reason
Screening Analysis
No prospective intervention study N = 79 N = 26
No psychotherapy condition N = 20 N=3
Intervention not related to SR N = 97 N = 36
Not schizophrenic patients as target population N=3 N=2
Mixed diagnoses (< 33.3% F2) N=2 N=2
Not German or English N=1 -
Total: N = 202 N = 69

15

Methods:
Data Collection

The following information was extracted from each included study by

consensus:
Characteristics of the study:
Year of publication, design, number of participants, type of outcome
measures, follow-up time
Characteristics of the participants:
Mean age, gender, diagnosis, illness progression, attrition rate
Characteristics of the intervention:
Number of participants, treatment protocol, target population, length of
treatment, attendance, home practice, treatment setting and format
Characteristics of the comparison condition in controlled studies:
Number of participants, type of treatment, length of treatment, treatment
setting, follow-up time
Risk of bias:
Researcher allegiance (RA)

16
 Preliminary Results

N = 21 studies included in qualitative analysis

ACT: N = 4 (5 publications)
Mindfulness: N = 14
Metacognitive: N=3

ntotal = 952 participants included

ACT: ntotal = 233
Mindfulness: ntotal = 595
Metacognitive: ntotal = 124

nintervention = 574; ncontrol = 357

17

Preliminary Results
Acceptance and Commitment Therapy

Intervention Comparison
Study Type of Participants (n) RA?
group (n) group (n)
Bach & Hayes
Indiv. ACT + TAU Inpatients with chronic
(2002) TAU (40) Yes
(40) psychosis (80)
Bach et al. (2012)
Outpatients with early and
Johns et al. (2016) Group ACT (69) - Yes
established psychosis (83)
Shawyer et al. Indiv. ACT-CBT + Befriending + Outpatients with chronic
K/A
(2012) TAU (21) TAU (22) psychosis (43)
Indiv. ACT + TAU Outpatients with stable
White et al. (2011) TAU (13) No
(14) psychosis (27)

18
Preliminary Results
Acceptance and Commitment Therapy

Number of studies: N=4

Number of RCTs: N=3

Number of participants: n = 219

Intervention: n = 144
Control: n = 75

Mean treatment duration: m = 8.75 weeks

19

Preliminary Results
Acceptance and Commitment Therapy
Outcomes N ES* 95%-CI Q
Number of rehospitalisations 1
Number of inpatient days 1
Global functioning 1
Overall symptoms 1
Positive symptoms 2 0.23 -0.31 to 0.85
Negative symptoms 2 0.37* 0.04 to 0.74
Frequencies of hallucinations and/or delusions 1
Distress related to hallucinations and/or delusions 2 0.27 -0.15 to 0.67
Preoccupation with hallucinations and/or delusions 1
Conviction of hallucinations and/or delusions 2 0.03 -0.57 to 0.65
Acceptance of hallucinations and/or delusions 3 0.39* 0.06 to 0.72
Mindfulness 1
Awareness of illness 1
Social functioning 1
Quality of life 1
*ES = effect-sizes (pre-post effect-size differences between experimental and control groups according
to Grawe et al., 1994) 20
 Preliminary Results
Metacognitive Narrative Therapies

Intervention Comparison
Study Type of Participants (n) RA?
group (n) group (n)

Barenquast & Outpatients with chronic

MNT (14) - Yes
Schweitzer (2014) Schizophrenia (18)

De Jong et al. Inpatients with stable

MNT (12) - Yes
(2016) Schizophrenia (12)
Schrank et al. In- and outpatients with
MNT + TAU (47) TAU (47) Yes
(2016) chronic psychosis (94)

21

Preliminary Results
Metacognitive Narrative Therapies

Number of studies: N=3

Number of RCTs: N=1

Number of participants: n = 120

Intervention: n = 73
Control: n = 47

Mean treatment duration: m = 13.8 weeks

22
 Preliminary Results
Metacognitive Narrative Therapies

Outcomes N ES* 95%-CI Q

Global functioning 1
Overall symptoms 1
Positive symptoms 1
Negative symptoms 1
Degree of recovery 1
Self-Reflexivity 1
Narrative development 1
Narrative coherence 1
*ES = effect-sizes (pre-post effect-size differences between experimental and control groups according
to Grawe et al., 1994)

23

Preliminary Results
Mindfulness-based Therapies Uncontrolled Studies

Intervention Comparison
Study Type of Participants (n) RA?
group (n) group (n)
Chadwick et al. Group MBT + TAU Patients with chronic
- Yes
(2005) (14) psychosis (15)
Dannahy et al. Group MBT & CBT Patients with chronic
- Yes
(2011) + TAU (62) psychosis (62)
Johnson et al. Outpatients with sig. negative
Group MBT (18) - K/A
(2011) symptoms (18)
Khoury et al. Group MBT + TAU
- Inpatients with FEP (17) K/A
(2015) (17)
Samson & Outpatients with psychosis
Group MBT (10) - No
Mallindine (2014) for Early Intervention (10)
Van der Valk et al. Patients recently recovered
Group MBT (16) - K/A
(2013) from FEP (17)

24
 Preliminary Results
Mindfulness-based Therapies RCTs
Intervention Comparison
Study Type of Participants (n) RA?
group (n) group (n)
Braehler et al. Group MBT Outpatients with chronic
TAU (18) Yes
(2013) + TAU (22) psychosis (40)
Chadwick et al. Patients with chronic
Group MBT (11) Waitlist (11) Yes
(2009) psychosis (22)
Chien & Lee Group MBT & PE Outpatients for early PP Y.,
TAU (48)
(2013) + TAU (48) intervention (96) MB No
Chien & Group MBT & PE PE + TAU (35) Outpatients for early PP Y.,
Thompson (2014) + TAU (36) TAU (35) intervention (107) MB No
Group MBT Support + Voc. VA-outpatients with chronic
Davis et al. (2015) No
+ Voc. Rehab.(18) Rehab.(16) Schizophrenia (34)
Langer et al. Patients with stable
Group MBT (11) Waitlist (12) No
(2012) psychosis (23)
Lpez-Navarro et Group MBT Rehabilitation
Outpatients with SMI (44) K/A
al. (2015) + Rehab. (22) (22)
People with confirmed Sch.
Moritz et al. (2015) Web MBT (52) Web PMR (38) No
(90) 25

Preliminary Results
Mindfulness-based Therapies

Number of studies: N = 14
Number of RCTs: N=8

Number of participants: n = 593

Intervention: n = 357
Control: n = 236

Mean treatment duration : m = 11.36 weeks

26
Preliminary Results
Mindfulness-based Therapies
Outcomes N ES* 95%-CI Q

experimental and control groups according to Grawe et al., 1994)

Number of rehospitalisations 2 0.56* 0.29 to 0.85

size differences between

Number of inpatient days 2 1.11* 0.68 to 1.56
Overall symptoms 6 0.37* 0.03 to 0.71 sig.
Positive symptoms 3 0.31 -0.07 to 0.69
Negative symptoms 3 0.46* 0.13 to 0.83
Distress related to hallucinations and/or delusions 2 0.43* 0.07 to 0.79 sig.
1

*ES = effect-sizes (pre-post effect-size

Voice intrusiveness
Conviction of hallucinations and/or delusions 2 0.19 -0.26 to 0.47
Acceptance of hallucinations and/or delusions 1
Voice control 1
Mindfulness 8 0.63* 0.32 to 0.94
Emotion regulation 1
Narrative avoidance 1
Awareness of illness 3 1.03* 0.52 to 1.73
Social functioning 3 0.51 -0.06 to 1.07 sig.
Work performance 1
Quality of life 2 0.26 -0.21 to 0.73 27

Summary

N = 21 prospective quantitative intervention studies examined the

effects of SR-oriented psychological interventions in schizophrenia.
N = 12 studies are randomized controlled trials, and N = 9 have a
within-group design.
Intervention studies on SR psychological therapies in schizophrenia
comprise a considerable amount of studies on MBT and a small
number of ACT and metacognitive narrative studies.
SR interventions predominantly include samples of stable chronic
in- and outpatients with schizophrenic disorders or first episode
psychosis.
Risk of bias due to researcher allegiance is relatively high with N =
11 having a clear risk of bias, N = 5 did not give any information
about the authors of the treatment manual and only N = 5 without
risk of RA-bias.

28
Summary

Assessed clinical outcomes include:

o Symptoms (overall, positive, negative)
o Number of rehospitalisations and inpatients days
o Frequencies of hallucinations and/or delusions
o Global and social functioning
o Emotion regulation
o Work performance
o Awareness of illness
o Quality of life
Significant clinical outcomes include overall, positive and negative
symptoms, rehospitalisations and number of inpatient days.
Significant effect-sizes for clinical outcomes range from g = 0.37* to
g = 1.11*, that means medium to large effect-sizes.
The effect-sizes for symptoms are comparable to the effect-sizes of
CBT for psychosis. However, they lack consistency.
(Jauhar et al., 2014; Wykes et al., 2008) 29

Summary

Assessed SR-outcomes include:

o Mindfulness
o Acceptance and conviction of hallucinations and/or delusions
o Narrative avoidance, development and coherence
o Self-reflexivity
o Distress related to and preoccupation with hallucinations and/or
delusions
o Voice control and voice intrusiveness
o Degree of recovery
Significant SR-outcomes include acceptance of and distress related
to hallucinations and/or delusions and mindfulness
Significant effect-sizes for SR-outcomes range from g = 0.39* to
g = 1.03*, that means medium to large effect-sizes.

30
Limitations and Need for Further
Research
In general, due to the limited number of (controlled) studies, the
effect-sizes presented are not very reliable.
Two significant outcomes revealed significant heterogeneity, so
they are not very consistent and valid.

Therefore, there is a clear need for more well controlled intervention

studies, especially with regard to
ACT and metacognitive narrative therapies
Subjective recovery outcome variables
Avoiding Researcher Allegiance

31

Conclusions

In recent years, SR has become an important outcome variable in

schizophrenia.
In this context, third wave CBT-approaches have also been applied
to schizophrenic patients.
To date, a relative large number of controlled intervention studies
has examined the effects of MBT, and a few studies examined the
effects of ACT and MNT.
Their findings seem to confirm improvements with regard to SR,
specifically mindfulness, the acceptance of voices and delusions
and the self-reflexivity of schizophrenic patients.
Thus, these approaches hold promise to complement the effects of
CBT for psychosis with regard to SR.

32
 33

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ACT
Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to
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J. (2016). The feasibility and acceptability of a brief Acceptance and Commitment Therapy
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MNT

Bargenquast, R., & Schweitzer, R. (2014). Metacognitive narrative psychotherapy for

people diagnosed with schizophrenia: An outline of a principle-based treatment manual.
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36
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MBT
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37

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MBT II
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M. (2011). A pilot study of loving-kindness meditation for the negative symptoms of schizophrenia.
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regulation in early psychosis: a pilot study. Early Intervention in Psychiatry, 9(1), 7683.
https://doi.org/10.1111/eip.12095
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group of psychotic individuals: a controlled study. Behavioural and Cognitive Psychotherapy, 40(1),
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Chadwick, P. (2015). Mindfulness improves psychological quality of life in community-based patients
with severe mental health problems: A pilot randomized clinical trial. Schizophrenia Research,
168(12), 530536. https://doi.org/10.1016/j.schres.2015.08.016
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(2015). Mindfulness and relaxation treatment reduce depressive symptoms in individuals with
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38