Taiwanese Journal of Psychiatry

EDITORIAL
Year
: 2021  |  Volume : 35  |  Issue : 2  |  Page : 47--49

Contemporary psychotherapeutic approaches to patients with schizophrenia in Taiwan


Shih- Ming Li1, Kun- Hua Lee2, Shu- Jen Lu3, Wen- Shing Peng4,  
1 General Education Center, National Yunlin University of Science and Technology, Douliu, Yulin, Taiwan
2 Department of Educational Psychology and Counseling, National Tsing Hua University, Hsinchu, Taiwan
3 Department of Psychiatry, Buddhist Tzu Chi Medical Foundation Taipei Tzu Chi Hospital, Taipei; Vocational Rehabilitation and Job Accommodation Resource Center for Individuals with Disabilities in Taoyuan-Hsinchu-Miaoli Region, Taoyuan, Taiwan
4 Department of Applied Psychology, Hsuan Chuang University, Hsinchu, Taiwan

Correspondence Address:
Ph.D. Shih- Ming Li
123 University Road, Section 3, Douliou, Yunlin 64002
Taiwan

Abstract




How to cite this article:
Li SM, Lee KH, Lu SJ, Peng WS. Contemporary psychotherapeutic approaches to patients with schizophrenia in Taiwan.Taiwan J Psychiatry 2021;35:47-49


How to cite this URL:
Li SM, Lee KH, Lu SJ, Peng WS. Contemporary psychotherapeutic approaches to patients with schizophrenia in Taiwan. Taiwan J Psychiatry [serial online] 2021 [cited 2021 Oct 20 ];35:47-49
Available from: http://www.e-tjp.org/text.asp?2021/35/2/47/319009


Full Text



Psychosocial treatments such as family therapy and cognitive behavioral therapy (CBT) are recommended for patients with schizophrenia and psychosis as adjunctive to antipsychotic drugs, and they have been found to be beneficial [1]. Many research in psychosocial interventions for patients with schizophrenia and psychosis without or with decreased antipsychotic dosages were conducted in from 1960s to 1990s [1]. These included psychoanalytic/psychodynamic therapy, family therapy, and psycho-education [1],[2]. Recently, psychosocial interventions have been evoluted to neuroplasticity and CBT [3].

Since 2000s, cognitive remediation therapy (CRT) is the mainstream psychotherapy for patients with schizophrenia [Table 1] [2]. In this editorial, the authors are reviewing some related studies in Taiwan and giving some suggestions for the readers of the Taiwanese Journal of Psychiatry.{Table 1}

 Cognitive Behavioral Therapy Approach



Cognitive behavioral psychological interventions, including particularly CBT, are recommended by the National Institute of Clinical Excellence guidelines of the Public Health Service of the United Kingdom for patients who are experiencing psychosis [4]. CBT is an evidence-based talking therapy that attempts to have cognitive and behavioral change based on an individualized formulation of a patient's personal history, problems, and world views [5]. CBT for psychosis, often considered as a second-wave cognitive behavioral psychological intervention, is an intervention that aims at reframing appraisals and modifying psychotic symptoms, facilitating the development of coping strategies, as well as improving quality of life by directly tackling negative appraisals and associated unhelpful coping behaviors [6]. A systematic review has demonstrated that CBT for psychosis is an effective treatment in reducing patients' symptoms of psychosis and improving their functioning and mood [7], even despite recent challenging evidence [8]. CBT is a time-sensitive, structured, present-oriented psychotherapy directed toward solving current problems and teaching skills to modify patients' dysfunctional thinking and behaviors [9]. In 2011, the classical book “Schizophrenia: Cognitive Theory, Research and Therapy” was translated into Chinese language, and clinical cases from Taiwan have been included for illustrations [10]. Recently, CBT has been used in clinical practice in Taiwan, but systematic study on its efficacy has been lacking [11].

Growing evidence exists to show that cognitive behavioral interventions are evolving and a number of new third-wave approaches have been developed with a developing but promising evidence base [5]. Mindfulness-based intervention is often referred to as the “third wave” of cognitive behavioral interventions, in contrast to the first wave that concerted on classical conditioning and operant leaning and the second wave that focused more on information processing and cognition [12]. Mindfulness-based interventions, including mindfulness, acceptance, and compassion, are moderately effective in treating negative symptoms and can be used as an adjunct to pharmacotherapy [13]. Patients with schizophrenia show vivid hallucinations and unreal beliefs, and as their condition progresses, those symptoms can become chronic. Therefore, negative symptom can worsen their capacity to maintain daily routines. Mindfulness-based interventions can help increase their awareness of their emotional status and improve their motivation to engage in daily activities [14].

CBT with mindfulness skills is used to reduce patients' psychotic symptoms and enhance their well-being. Mindfulness-based interventions provide patients with a method of regulating their emotions and reducing the effects of dysfunctional beliefs [14]. In Taiwan, the effectiveness of mindfulness-based interventions on improving negative symptoms of chronic schizophrenia was preliminarily supported by a clinical trial [15]. Overall, studies indicated that through mindfulness-based interventions, such as body scanning, mindfulness breath, and loving-kindness meditation, patients with schizophrenia can improve their self-concept and ability to adapt to changes as well as to live a more satisfactory life [13],[14],[15].

 Cognitive Remediation Therapy Approach



CRT is an evidence-based treatment for cognitive impairments in schizophrenia and aims at enhancing cognition with a further goal that improved cognition will affect community functioning [16]. Defined by the Cognitive Remediation Expert Working Group, “Cognitive remediation is a behavioral training intervention targeting cognitive deficit (attention, memory, executive function, social cognition, or metacognition), using scientific principles of learning, with the ultimate goal of improving functional outcomes [17].” CRT is widely recognized as an effective treatment for cognitive deficits in patients with schizophrenia, and its effects are durable and relate to improvements in everyday function [16],[17]. Meta-analytic findings suggest that functional improvements from cognitive remediation are moderated by whether participants are also engaged in additional rehabilitation programs such as those that focus on work, independent living, or adaptive living skills and also whether the remediation approach has a strong strategic learning component [16]. In Taiwan, Lu et al. used a 10-week occupational intervention involving a cognitive remediation computer program to improve the cognition of patients with psychoses in community. Compared with their preintervention state, the experimental group shows better immediate visual memory and auditory memory after the intervention [18].

CRT includes a plan for orienting participants to the program, including how to navigate a computer program and how to engage with noncomputerized tasks [17]. The Maker movement emphasized on “learning by doing,” and this approach involves idea creation and practical application related to cognitive function [19]. Some popular Maker activities such as cooking, banking, drawing, gardening, and knitting were used in the psychiatric ward as interventions for patients with schizophrenia. Recently, an eight-week knitting Maker activity group can reduce patients' psychotic symptoms and can enhance function, such as mood repair, social interactions, and present focus [20].

CRT involving Maker activities enhances patient's cognitive, social, and vocational function [17],[18],[19],[20]. As the cognitive function problem of the schizophrenia, the CRT with Maker will enhance one's cognitive function and the motivation to engage in activities. Some studies in Taiwan showed that the CRT and Maker activities are useful in the occupational therapy field to enhance patient's function [18],[19],[20].

 Schizophrenia Treatment



 Involving Two Approaches



Schizophrenia is a severe mental disorder with psychotic symptoms and impaired function. In the symptoms' domain, CBT- and mindfulness-based interventions can be used to reduce patients' psychotic symptoms and related distress [9],[13],[14],[15]. In the functional domain, CRT and Maker activities can enhance one's cognitive and social functions [17],[18],[19],[20]. The integration of those approaches as the psychotherapy as CM2 model [Figure 1] can improve the symptoms and function of patients with schizophrenia.{Figure 1}

 Conclusion



In the Taiwan Journal of Psychiatry, only four studies dealing with psychosocial interventions for patients with schizophrenia were published from 2016 to 2020. Those studies were focusing on Maker activities [20], horticultural therapy [21], contact theory for de-stigmatizing [22], and music therapy [23]. Although some psychosocial interventions have been used in Taiwan, few studies are related to the systematic psychotherapy such as CBT or CRT. Schizophrenia is a severe mental disorder with distressing symptoms and impaired function, and the psychotherapy can reduce one's distress and enhance one's function by CM2 approach. We suggest that more advanced studies must be conducted in the future as a new direction of the psychotherapy for schizophrenia such as CM2 approach.

 Acknowledgment



The authors thank Cheng-Ju Tsai for the help in drawing Figure 1. Opinions expressed are authors' personal opinions. Opinions are unnecessarily reflecting on any of those of their affiliations or organizations.

 Financial Support and Sponsorship



None.

 Conflicts of Interest



The authors have no conflicts of interests to declare in writing this editorial.

References

1Cooper RE, Laxhman N, Crellin N, et al.: Psychosocial interventions for people with schizophrenia or psychosis on minimal or no antipsychotic medication: a systematic review. Schizophr Res 2020; 225: 15-30.
2Tandon R, Nasrallah HA, Keshavan MS: Schizophrenia, “just the facts” 5. Treatment and prevention: past, present and future. Schizophr Res 2010; 122: 1-23.
3Medalia A, Beck AT, Grant PM: Cognitive therapies for psychosis: advance and challenges. Schizophr Res 2019; 203: 1-2.
4National Institute of Clinical Excellence (NICE): Psychosis and Schizophrenia in Adults: Treatment and Management. London: National Institute of Clinical Excellence, 2014.
5Tai S, Turkington D: The evolution of cognitive behaviour therapy for schizophrenia: current practice and recent developments. Schizophr Bull 2009; 35: 865-73.
6Dixon L, Dickerson F, Bellack A, et al.: The 2009 schizophrenia PORT psychosocial treatment recommendations and summary statements. Schizophr Bull 2010; 36: 48-70.
7Wood L, Williams C, Billings J, et al.: A systematic review and meta-analysis of cognitive behavioural informed psychological interventions for psychiatric inpatients with psychosis. Schizophr Res 2020; 215: 133-44.
8Lincolin TM, Peters E: A systematic review and discussion of symptom specific cognitive behavioural approaches to delusions and hallucinations. Schizophr Res 2019; 203: 66-79.
9Kingdon D, Turkington D: Cognitive therapy of psychosis: research and implementation. Schizophr Res 2019; 203: 62-5.
10Li SM, Chen CC: Schizophrenia: Cognitive theory, Research and Therapy (in Chinese). Taipei: Psychology Press, 2011.
11Yang YS, Wu JY: Applying cognitive behavioral therapy in nursing care for a patients with schizophrenia. St. Joseph's Hosp Med Nurs J (Taiwan) 2017; 11: 127-39.
12Hayes SC: Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapy. Behav Ther 2014; 35: 639-65.
13Khoury B, Lecomte T, Gaudiano BA, et al.: Mindfulness interventions for psychosis: a meta-analysis. Schizophr Res 2013; 150: 176-84.
14Tabak NT, Horan WP, Green MF: Mindfulness in schizophrenia: association with self-reported motivation, emotion regulation, dysfunctional attitudes, and negative symptoms. Schizophr Res 2015; 168: 537-42.
15Lee KH: A randomized controlled trial of mindfulness in patients with schizophrenia. Psychiatr Res 2019; 275: 137-42.
16Wykes T, Huddy V, Cellard C, et al.: A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. Am J Psychiatry 2011; 168: 472-85.
17Bowie CR, Bell MD, Fiszdon JM, et al.: Cognitive remediation for schizophrenia: an expert working group white paper on core techniques. Schizophr Res 2020; 215: 49-53.
18Lu SJ, Chen YL, Kao T, et al.: A computer-assisted cognitive rehabilitation for schizophrenia in mental health center. J Taiwan Occup Ther Res Pract (Taipei) 2015; 11: 10-23.
19Collier AF, Wayment HA: Psychological benefits of the “maker” or do-it-yourself movement in young adults: a pathway towards subject well-being. J Happiness Stud 2018; 19: 1217-39.
20Wang CY, Zheng LZ, Wu CY, et al.: Maker activities in psychiatric day care center. Taiwan J Psychiatry 2019; 33: 45-7.
21Hsieh YT, Lin SL, Huang TL: Horticultural therapy in chronic schizophrenia: a pilot study. Taiwan J Psychiatry 2019; 29: 238-43.
22Wang CH, Yen MH: The effect of contact theory for de-stigmatizing psychiatric patients. Taiwan J Psychiatry 2017; 31: 346-54.
23Lioa YH, Wu CC, Yang EL, et al.: Therapeutic factors in the group singing therapy by social robot for patients with schizophrenia: a pilot study. Taiwan J Psychiatry 2020; 34: 196-8.