Qualitative analysis of relevant variables for the application of the integrated psychological therapy program in patients with schizophrenia in three Southern Brazilian centers

Abstracts

OBJETIVOS: São dois os propósitos deste estudo: apresentar as principais dificuldades que temos encontrado com a aplicação do programa de terapia psicológica integrada para esquizofrenia Integrated Psychological Therapy (IPT), desenvolvido na Alemanha, e fundamentar as estratégias que temos utilizado para adaptar essa técnica à nossa realidade brasileira. MÉTODO: Abordagem qualitativa, com análise de dados, através do conteúdo das verbalizações dos pacientes, em grupos de discussão realizados após sessões terapêuticas da técnica, com três grupos de pacientes diagnosticados de esquizofrenia ou transtorno esquizoafetivo, de acordo com o Manual de Diagnóstico e Estatística das Perturbações Mentais, provenientes de três instituições diferentes, que trabalham com a aplicação do IPT - Instituto de Capacitação e Reorientação Ocupacional, Centro de Atenção Psicossocial do Hospital de Clínicas de Porto Alegre e Centro de Atenção Psicossocial de Tubarão (SC) -, totalizando 22 pacientes. RESULTADOS: Foram levantadas as seguintes categorias: repetição e monotonia; dificuldades de execução de alguns exercícios; falta de utilidade prática de alguns exercícios; e necessidade de saber mais sobre a doença. Também foram encontrados aspectos positivos da técnica relatados pelos pacientes. DISCUSSÃO: Os resultados evidenciam aspectos muito relevantes para entender a motivação dos pacientes para a adesão ao tratamento com essa abordagem desenvolvida em um país europeu. Nossos achados sugerem que as diferenças culturais podem interferir na aplicação do IPT quanto à sua estruturação; entretanto, a melhora de funcionamento, como relatado pelos próprios pacientes, motiva-nos a continuar buscando a adaptação dessa técnica para as características de nossos pacientes. Contudo, são necessários outros estudos no futuro, como ensaio clínico controlado, para avaliar mais especificamente a efetividade da adaptação do IPT para pacientes brasileiros.

Esquizofrenia; tratamento cognitivo-comportamental; terapia psicológica integrada; reabilitação psicossocial

ORIGINAL ARTICLE

Qualitative analysis of relevant variables for the application of the integrated psychological therapy program in patients with schizophrenia in three Southern Brazilian centers

Marilene Zimmer^I; Adriana Veríssimo Duncan^II; Paulo Belmont-de-Abreu^III

^IPsychologist. MSc. in Social Psychiatry, PhD in Medical Sciences: Psychiatry, Schizophrenia Program, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil

^IIOccupational therapist

^IIIPsychiatrist. Professor, Department of Psychiatry, UFRGS, Porto Alegre, RS, Brazil. Coordinator, Schizophrenia Program, HCPA, Porto Alegre, RS, Brazil

^{Correspondence}

ABSTRACT

OBJECTIVES: This study aims at (1) presenting the main difficulties in the application of the integrated psychological therapy (IPT) program for schizophrenia developed in Germany; and (2) documenting the strategies used to adapt this technique to the Brazilian reality.

METHOD: Qualitative approach with data analysis through the examination of the contents of patients' verbalizations in discussion groups carried out after IPT therapy sessions with three groups of patients with schizophrenia or schizoaffective disorder diagnosis, according to DSM-IV. These patients came from three different institutions that work with IPT: Instituto de Capacitação e Reorientação Ocupacional (Capacitation and Occupational Rehabilitation Institute), Centro de Atenção Psicossocial (Center for Psychosocial Care) at Hospital das Clínicas de Porto Alegre, and Centro de Atenção Psicossocial (Center for Psychosocial Care) in Tubarão (SC, Brazil), including a total of 22 outpatients.

RESULTS: The following categories were determined: repetition and monotony; difficulty in doing some exercises; lack of practical usefulness in doing some exercises; and need of knowing more about the disease. Positive aspects related to the technique were also reported by the patients.

DISCUSSION: The results reveal very relevant aspects for the understanding of the outpatients' compliance to a treatment developed in a European country. Our findings suggest that cultural differences may interfere with the application of IPT in terms of its structure. However, improvement in functioning, as related by the outpatients, motivates us to continue searching for the adaptation of this technique to our patients' characteristics. Nevertheless, further studies, such as controlled clinical trials, are necessary to assess the effectiveness of the IPT adaptation to Brazilian patients.

Keywords: Schizophrenia, cognitive-behavioral treatment, IPT, psychosocial rehabilitation.

INTRODUCTION

Nowadays, the integrated psychological therapy program for schizophrenia (IPT), developed by Brenner et al.,¹ stands out from rehabilitation programs offered to schizophrenic patients. It is known as the first systematic treatment with manual for application in groups of schizophrenic patients that combines psychosocial and cognitive strategies.² The German version of the IPT manual is in its fifth edition,³ and it has been translated into 10 languages, which shows the acceptance of this program of cognitive-behavioral therapy.

The IPT is a program of cognitive-behavioral psychotherapy divided into five subprograms: cognitive differentiation, social perception, verbal communication, social skills and interpersonal problem solving; each subprogram, in its turn, is organized into a series of stages of increasing complexity. The focus of the psychotherapeutic work of the first three subprograms is on the development of basic cognitive functions. The last two subprograms focus on the development of more complex tasks of social skill acquisition to repair inappropriate social interaction. This program includes instruction, model learning, role playing, feedback and positive reinforcement. The contents of psychotherapy involve situations of different areas in the everyday life, such as family and social interaction, difficulty in performing daily life tasks, search for work, household chores, interpersonal relationship, leisure activities and other social activities relevant for patients. The subprogram cognitive differentiation is divided into three stages: exercises with cards; verbal conceptual systems (conceptual hierarchies, synonyms, antonyms, word definitions); and, finally, search strategies. The subprogram social perception includes the description and analysis of slides about everyday life images. The subprogram verbal communication includes the following stages: literal repetition of sentences; repetition of self-formulated sentences according to their meaning; self-formulated questions with answers; the group questions one of the participants about a given topic; free communication. The subprogram social skills consists of role playing about the patients' social skills, such as knowing how to start and maintain a conversation; ask for information; assertively refuse a request; knowing how to defend their point of view, as well as accepting other opinions. In the last subprogram, interpersonal problem solving, the patients' individual problems are treated, with step-by-step strategies to search for possible solutions.

The authors of this technique have been following the research carried out about IPT evaluation over the past 24 years in different countries (Switzerland, USA, Canada, Japan, Germany, the Netherlands, Italy and Spain), where published studies evaluate the application of the complete program or a combination of several subprograms, in a total sample of 1,329 schizophrenic patients, whose results were presented in a recent meta-analysis.² Until the second semester of 2005, there were no publications regarding controlled studies about the application of IPT carried out in Brazil. In the meta-analysis performed by Muller et al.,² the authors found 28 studies; 14 were carried out in Germany, six in Switzerland, three in Spain and one in each of the following countries: the Netherlands, Japan, USA, Canada and England.

According to Muller et al.,² of all 28 studies, only nine used the complete IPT; the others used a combination of some subprograms; and in four studies other techniques were added to the IPT. There is substantial evidence, resulting from controlled studies, that indicate the benefits of IPT in the improvement of cognitive and social performance and in the reduction in severity of some schizophrenia symptoms.^2-11

One of the authors (M. Zimmer) was directly trained by Roder in 1994-96, during his master's degree in psychosocial rehabilitation, carried out in Barcelona, Spain. Since then, the first author has been working with the application of this program in schizophrenic patients and with training about the technique for health professionals in extension courses, followed by supervision and case discussion. However, we have experienced some difficulties as to the application of the complete IPT for the reality of each group of patients. Due to those difficulties, we decided to gather the material from the technicians who work with IPT and perform an evaluation of patients' perceptions through the content analysis of training registers, whose results represent the main focus of the present article.

Since 1999, we have developed a program of psychosocial rehabilitation, which started at the Institute of Occupational Capacitation and Reorientation (ICARO), in Porto Alegre (RS, Brazil), where the model of cognitive-behavioral approach proposed by IPT was used.¹ During the same period, the translation process of the IPT manual into Portuguese took place, with technical review performed by the first author (M. Zimmer) and follow-up by Roder.

The process of deinstitutionalization of mental patients in Brazil is recent, compared to other countries, since there is a lack of implementation of training and rehabilitation policies. Although these policies exist, they are not put into practice; there is also a lack of studies to guide and evaluate the approaches of psychosocial intervention that are being used in the Brazilian community.¹² In 2002, due to the absence of tested models of psychosocial rehabilitation, the main author (M. Zimmer) started, along with the research group of the Schizophrenia Program (Prodesq) at Hospital de Clínicas de Porto Alegre (HCPA), a randomized clinical trial to evaluate the efficacy of IPT, as well as the adaptation of the technique to our reality in Southern Brazil.

An initial study about the use of IPT was carried out,⁹ with a sample of 35 individuals, to evaluate the effectiveness of this technique in a sample of patients from a service of psychosocial rehabilitation in Porto Alegre. Despite some limitations of a naturalistic study, it was possible to identify the improvement in schizophrenic patients by comparing measures before and after the intervention, until loss to follow-up (because the patients were discharged from the institution where they were being given psychosocial and outpatient care or because they quit the treatment). Improvement indexes were verified as to general and social-occupational functioning, assessed by the General Functioning Assessment Scale and the Social and Occupational Functioning Assessment Scale, both taken from the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR - Fourth Edition - Text Revision (DMS-IV-TR).

During supervision meetings of IPT application, since 2002, with the participation of ICARO teams, Center of Psychosocial Care (CAPS) at HCPA and CAPS in Tubarão (SC, Brazil), it was possible to note that only a few patients considered important or were motivated to participate in all IPT stages. Based on case discussions, we started to identify that many factors could be associated with those difficulties: heterogeneity of participants as to clinical conditions, severity of symptoms, time of disease progress, age and socio-cultural conditions; and maybe the cultural aspect was the most important factor, due to the origin of the technique, developed in Germany in the 1980's, with all the cultural and time implications it may involve.

The main objective of the present study was to evaluate the main aspects of applying the IPT technique, through the content analysis of patients' verbalizations, in discussion groups performed after IPT therapy sessions. This study aims at documenting the strategies used to apply the IPT and generate evidence for the selection of stages that should be given priority in the development of a training program, considering its technical structure as a formal training model for schizophrenic patients.

MAIN ISSUES

The main issues of this research were the patients' perception about different aspects approached by the technique; which aspects of IPT technique may interfere with motivation and treatment adherence; what leads schizophrenic patients to abandon the IPT training; and whether it is possible to apply a program, which was developed in another country, from the European Community, with a different culture, education system and family structure and high social structuring, in patients treated by the Brazilian Unified Health System, which provides universal access, but to a different ethnic, social and cultural population.

METHOD

Participants

Twenty-two patients participated in the study, mean age of 39.05 (standard deviation - SD = 7.09), all literate, with diagnosis of schizophrenia or schizoaffective disorder according to the DSM-IV, from three different institutions in Southern Brazil. They were distributed into three groups: 1) training group with IPT at ICARO, 10 patients; 2) CAPS/HCPA group, eight patients; 3) CAPS/Tubarão group, four patients. All patients presented a condition of symptom stability (absence of delirium and hallucinations), were undergoing treatment with neuroleptics, and a had chronic condition. Cases that presented active symptoms were excluded (presence of delirium, hallucinations and disorganized thought), substance abuse and another associated diagnosis, such as mental retardation and conduct disorder. All individuals who agreed to participate in the study signed a consent term.

Procedures of data collection

Data were collected between 2002 and 2004 from all groups that applied IPT, detailed above. In the three institutions that participated in this study (ICARO, CAPS/HCPA and CAPS/Tubarão), the patients were grouped according to their ability of global functioning, defined through a clinical interview by the psychologist in charge. At the end of each stage of the IPT program, discussion groups were performed, in which patients were required to evaluate the exercises applied: what they liked the most, their opinion about the exercises, the difficulty level they found, what they could not perform and which positive aspects they considered most important for each one. Those who did not actively participate in performing the tasks were required to comment on their reasons for doing so. All information was registered in the training follow-up diary. After a 3-month training, patients were no longer motivated to continue the exercises. Then, each one was asked to write and/or talk about what they enjoyed the most and what they considered less important in the training. With regard to patients who could not write, verbalizations were recorded exactly as they were stated.

Procedures of data analysis

Based on the discussions of the professional teams during supervision meetings of IPT application, in which the possible reasons for patient dropout were discussed, the following categories for data analysis were defined a priori: 1) repetition and monotony; 2) difficulty in doing some exercises; 3) lack of practical usefulness in doing some exercises; and 4) need of knowing more about the disease. The comments about IPT positive aspects were also grouped.

The transcriptions of the patients' verbalizations were gathered after being obtained from the professionals in the three centers. Content analysis of those texts were performed according to Bardin,^13,14 following the criterion of semantic grouping to exemplify or identify predetermined categories.

RESULTS AND DISCUSSION

As to sociodemographic data, mean age was 39.05 years (SD = 7.09); 54.5% had completed the fifth grade of elementary school; 36.36% had between 5 and 8 schooling years and all patients were literate.

There were no losses over the 3-month period of the study.

The main patients' critiques were about the first IPT subprograms (table 1): cognitive differentiation (which involves classification exercises of cards according to classes and categories - geometric forms, colors, numbers and days of the week - and exercises about definition and classification of words - finding synonyms and antonyms to describe words according to the circumstances); and verbal communication (which consists of exercises of literal repetition of sentences, creation of questions with answers, discussion forum about predefined topics and interviews between the participants). Patients' verbalizations regarding those stages were grouped according to the categories described below.

Repetition and monotony

The exercises of cognitive differentiation and verbal communication are experienced as repetitive and monotonous, as can be seen by the patients' statements: "I don't like the exercises with cards, they are always repetitive;" "I think there's no use in separating cards, it's very boring;" "I get tired of separating these cards;" "I get tired of waiting for R to choose the cards;" "I'd like to do other things, this is tiring."

Difficulties in performing some exercises

The participants in the groups from the three centers that participated in this study demonstrated having difficulties in performing exercises that required writing sentences or taking instruction notes for home activities. This can be exemplified by the following statements: "I don't like writing, my handwriting is not good;" "I learned to read and write, but I don't know how to link the words, it's too difficult;" "This thing about knowing words is better for those who study;" "I was never good at it, it would be better if I had a dictionary;" "It's easier to give me a note so that my mother can do it at home;" "It'd be easier if you spoke it to us;" "I can't do it, I can't write, it's been a long time since I last went to school;" "I've studied, but I've never learned how to write well, it's too difficult;" "I can't read, my eyes get blurred because of the medication;" "I have headache, I need a lot of effort to read;" "This is too difficult;" "This activity is too difficult because it makes us think."

Lack of practical usefulness for some exercises

Most patients questioned the stages of cognitive differentiation and verbal communication, which refer to the exercises mentioned above, because they could not find any use for them in their daily life. The questions, recorded through their opinions, are something like "Why is this type of work for?;" "What's the use of these lists?;" "This seems like a children's game, I don't want to do it;" "I think this is useless, we're just pretending."

Need of knowing more about the disease

In many sessions, the patients demonstrated concern and interest about the disease, which can be identified by the following statements: "We could talk about the disease, instead of playing this game;" "Yes, we could talk about the drugs that are not good for us;" "One day I read that schizophrenia is a problem that has no cure, but I don't believe it;" "I think it's good to learn, but I'd like to know more about the disease, what do I have?;" "I think it'd be better to talk about the problems of our disease."

The patients' verbalizations, described in the four categories above, allow us to state that the patients have great difficulty in participating in more theoretical activities, such as discussion of word meanings, creation of sentences and writing of short texts. In many experiments with different groups of patients, which were grouped in each institution according to the degree of chronicity and involvement of the disease, we tried to work with the stages of synonyms and antonyms, word definition and writing questions and answers. It was possible to notice low motivation, lack of interest, as well as difficulties in performing the tasks, especially reading and writing. There were no illiterate patients, since 39.06% had completed the fifth grade of elementary school, and 36.36% had between 5 and 8 schooling years. Considering that the patients' mean age was 39.05 (SD = 7.09) years, they were away from school for around 25 to 30 years, and in most cases did not have the habit of reading. When organizing the training groups, we were careful to group patients according to homogeneity of characteristics, at the level of symptoms and cognitive conditions. It was possible to note that, the lower the schooling level, the more difficult it was to motivate them for verbal communication tasks; the patients also complained of having difficulties in reading and writing.

Due to the reduced number of participants in each institution, it was not always possible to have a completely homogenous group, especially as to schooling level. Those who had finished high school or started college did not like the exercises with cards and verbal communication activities. Their main complaint was that they could not find any practical use for this type of exercises.

As a consequence of the repetition of critical comments and reduction in the participation of patients, notes were taken and, at each session, we tried to explain in more details the meaning and the importance of following stages; each exercise was presented in detail, in which the importance of each one was stressed, besides the benefits they could bring. According to the patients' reports, it was possible to notice that, although they complained of exercises with cards, they had difficulties in concentrating and could not repeat the instructions; when patients were requested to separate the cards considering three criteria (for example: separate cards with circle, blue color and two digits), they had problems performing the task. Thus, the cards were used as an introduction for the sessions, in which some of these exercises were applied, and then another subprogram was started, such as social perception and verbal communication. This strategy is part of the IPT technique, which allows working with exercises from different subprograms in the same session, with the aim of improving the patients' motivation and participation in different groups.

It was possible to note that the patients understand the instructions, but do not like to participate in some stages; they prefer the practical exercises, such as those of the social perception, social skills and, more specifically, interpersonal problem solving subprograms. Before starting the subprograms, each one was required to think about their main everyday difficulties, so that it could be possible to select the topics that would be discussed during the sessions through role playing, being characterized as the first task they should perform at home. Almost all patients presented a short list of difficulties they found in their everyday life. Those who did not complete this task in written form were asked to comment on their difficulties, and their statements were recorded.

Based on the patients' statements, we could note that a great number was curious or needed to know more about the disease. As a result of this need, in ICARO and CAPS/HCPA groups, a material using an overhead projector was used, containing drawings and short explanatory texts about schizophrenia, which were extracted from a program of psychoeducation for relatives, proposed by Sotillo,¹⁵ based on the Leff's theory.¹⁶ In the group from CAPS/Tubarão, any audiovisual material was prepared, but the topic was approached in the form of a group discussion, in which the patients' doubts were answered, and the main aspects of schizophrenia and the main recommended treatment options were explained.

Contrasting with the critical aspects described in the categories above, our findings show that the patients are able to highlight the positive aspects of the technique. It was possible to note that, in exercises of social perception, social skills and problem solving, increase in participation and improvement in patients were verified by the patients themselves, as can be seen by their comments: "This activity makes us think;" "My mother says I'm less anxious, I don't keep walking back and forth;" "Now I can watch TV, before I couldn't sit for a long time;" "It's good to talk to the group, I like it, we understand things better;" "I liked it, it's good to be here, it's helping me figuring things out;" "I like debates, we learn things from other people's ideas." In all groups, there was in increase in the patients' enthusiasm to perform the tasks, and the justification for such change was that they found those exercises more useful, since they could help patients in real problems of their everyday life.

As to the discussions about the disease (psychoeducation) included in the groups at ICARO and CAPS/HCPA, the patients manifested their satisfaction through the following statements: "I was relieved to find out that other people also feel what I feel;" "Now I understand that these thoughts I have are because of the disease;" "I have all these things I've seen there;" "I thought the medications made us feel like this." The sessions in which the aspects of the disease were discussed received the most compliments by the patients, because, according to their verbalizations, this stage had helped them to understand many things about the disease; it was seen, in all groups, that the patients started being more interested in the tasks, showing more motivation to participate in the performance of activities and better group integration.

FINAL CONSIDERATIONS

In this study, we tried to analyze the patients' perceptions about their participation in a structured training based on the IPT manual, so that we could propose adaptations of this technique for our Brazilian reality.

Through the qualitative analysis of the records, whose findings justify the main focus of this article, very relevant aspects were found to understand the patients' participation in the treatment using an approach that was developed in a European country. The cultural differences between countries is evident, although Southern Brazil has been greatly influenced by the European culture. We are not used to using highly structured programs, following predefined stages and with increasing complexity. On the other hand, we believe the study of techniques to help us evaluate the programs of psychosocial rehabilitation is of great importance, especially to treat schizophrenic patients. In our opinion, the effort to implement and maintain an intervention for schizophrenia requires the knowledge of specific activities and objectives similar to those used by other centers that have reached positive results. For that reason, our interest in adapting the IPT technique is to make it easier to be used in Brazil. As major points of the IPT technique, we stress the orientations to evaluate and develop a list of problems, instruct/educate the patient about the objectives of the cognitive model and its importance in the training of behavioral skills, including self-management by remembering instructions and practical exercises of tasks to be performed in the patients' environment.

According to the evidence drawn from the findings of this study, it was possible to verify that the stages of cognitive differentiation and verbal communication present levels of difficulty for their execution, which are presented as justifications for the low motivation and participation index of patients in training groups.

In supervision meetings between the three centers working with IPT, there was the need of testing the application of this technique, by excluding the stages of cognitive differentiation and verbal communication and including an additional stage of psychoeducation, approaching topics about the disease as a reinforcement to what had already been suggested in a study recently carried out in Spain.¹⁰

After a consensus between all centers, we decided to maintain the exercises with cards in the subprogram cognitive differentiation, with the aim of training concentration, attention, memory and focus on the activities. Although the patients have criticized this stage, it seems to us that the use of these exercises is extremely important to achieve improvement in the cognitive functioning. Thus, it was suggested to apply this stage as an introduction to sessions, i.e., apply some of these exercises with the aim of improving concentration for the following activities.

Our findings show that cultural differences may interfere with the application of the IPT. Nevertheless, the positive results reported by the patients themselves, in terms of improvement in their everyday functioning, along with the critiques formulated by them, motivate us to keep searching for the adaptation of this technique to our patients' characteristics.

This study had strong points, such as the participation of three different centers that used the IPT technique, which offered specialized services with a multidisciplinary team and outpatient service for people with diagnosis of schizophrenic spectrum.

Based on this study, a randomized clinical trial was carried out with patients diagnosed with schizophrenia at the Outpatient Clinic for Schizophrenia and Dementia (Prodesq) at HCPA. The IPT was applied, excluding the stages in which it was necessary to performs tasks of reading and writing and the subprograms of cognitive differentiation and verbal communication (mentioned earlier) and including psychoeducation to test the validity of adapting the technique to those criteria. These results are discussed in another forthcoming article.¹⁷

Finally, it is also necessary to stress the need of having controlled studies comparing the IPT with other interventions, in larger samples of Brazilian individuals diagnosed with schizophrenia, to test the effects of this approach more specifically in our reality, since in our country there are no published studies assessing this technique.

ACKNOWLEDGMENTS

This study was supported as a scholarship by CNPq - CAPES - ICCTI - FAPERGS, Ministry of Education, Brazil. We would like to thank Prof. Maria Lucia Tiellet (PUCRS), Graciela I. de Jou (PUCRS), CAPS/HCPA team, CAPS/Tubarão team.

REFERENCES

Received March 3, 2006. Accepted December 8, 2006.

This study was carried out at the Psychiatry and Forensic Medicine Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil.

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Publication Dates

• Publication in this collection
  04 Apr 2007
• Date of issue
  Dec 2006

History

• Received
  20 Mar 2006
• Accepted
  08 Dec 2006