A New Rehabilitation-Oriented Approach in Schizophrenia.


Igor Salganik M.D. & Peter Soifer M.D.

Sha’ar Menashe Mental Health Center, Mobile Post Hefer 37806, Israel



Citation:
Salganik I. & Soifer P.  (2008). Reference Group Focused Therapy for Schizophrenics (RGFT-S)  -  A New Rehabilitation-Oriented
 Approach in Schizophrenia.   International Journal of Psychosocial Rehabilitation. 12 (2),

Correspondence:
Igor Salganik
Sha’ar Menashe Mental Health Center
Mobile Post Hefer 38814 Israel
e-mail :   salganik@shaar-menashe.org.il

Acknowledgment:
We express our deep gratitude to Wendy and Jeff Starrfield for their assistance in editing this manuscript. 

Abstract
‘Reference Group Focused Therapy for patients with Schizophrenia’ (RGFT-S) is presented.  This therapy is designed to modify patients’ social networks, spanning a continuum from rearranging contacts among members of existing social networks to creating entire new social networks. Based on the  holistic, contextualized view of ill persons within social systems it is an extension of the established psycho-educational approach as defined by Expressed Emotion (EE).   The focus of this therapy is the patient’s re-socialization through the assessment of the patient’s social matrix and providing patient-tailored social problem solving, based on Trigger Event Analysis (TEA). A series of case-reports illustrating the specific therapeutic interventions is presented.

Key words: Schizophrenia, Reference Group, Relapse, Rehabilitation, Trigger Event

“The ‘core’ of a schizophrenic is not schizophrenia.  The core is a human core, a divine core, with all the attributes and facets of any other human being.  Building a relationship of integrity with the client is to be willing to be with all of who they are; the sane and the insane aspects of their experience.”
Tanina Davanzo  (inspired by the movie “A Beautiful Mind”) http://www.schizophrenia-help.com/Schizophrenia__Trauma/schizophrenia__trauma.htm

“Over half century of psychodynamic research has proved that schizophrenia is not only a medical disorder, but a biographical facet of the human being-it is a challenge to the whole of society to understand, accept and reintegrate the psychotic patient amongst us.”(Ninth International Symposium on the Psychotherapy of Schizophrenia)

“It is in the psychotic’s suffering that the most serious problems of the human mind are encountered. Tackling them means illuminating the human being with signification and sense, gaining a better understanding of the human being in general, not only of the psychotic person.”(Tenth International Symposium for the Psychotherapy of Schizophrenia)
Professor Gaetano Benedetti

Introduction
Schizophrenia inflicts immense suffering on patients and their relatives and is a leading cause of disability (Geddes, 2002) with less than 20 percent of patients maintaining full recovery after the first episode (Cannon & Jones, 1996). The monthly relapse rates are estimated to be 3.5 percent per month for patients on maintenance neuroleptics and 11.0 percent per month for patients who have discontinued their medication (Weiden & Oltson, 1995). Psychosocial interventions such as family therapy, supportive, cognitive and other type of psychotherapies (McIntosh & Lawrie, 2001), are additional common approaches in preventing relapses. One of the important contributions to psychosocial management of relapse prevention is the concept of expressed emotion (EE) that refers to the inner dynamics of patient’s families (Brown, Birley, Wing, 1972; Vaughn & Leff, 1976). A meta-analysis which analyzed data from numerous studies showed a 48% median annual relapse rate in a high-EE environment, versus 21% in a low-EE environment (Kavanagh, 1992).  Marom et al studied the influence of EE with a follow up of 7 years.  They demonstrated prolonged predictive validity of EE and emphasized the role of therapies aimed at lowering high EE as a long-term preventive approach (Marom, Munitz, Jones et al, 2005). Since these studies generally measure the expressed emotion in the subject’s family, this may serve as evidence for the decisive influence of a single specific group upon a schizophrenic patient.  Extrapolating from this it may be inferred that the impact of the entirety of a patient’s social groups may be yet more profound.

In social psychology a person is regarded as a member of one or more social group(s). Thus, schizophrenic relapse may be analyzed, apart of biological causes, within the context of social trigger events that are specific for the patient and his/her interactions with the group.

Theoretical Background
In this paper, we attempt to investigate the contribution that Reference Group Theory (Hyman, 1942; Sherif, 1948; Deutsch &, 1955; Hyman & Singer, 1991) and other social-psychological approaches makes to the understanding and treatment of schizophrenic relapse (SR).
SR is commonly seen as an event with multi-factorial cause. Biological vulnerability, substance abuse, conflict, confusion and frustration, environmental stress, and social isolation are regarded as possible precipitating factors (Geddes, 2002).  

These factors, excluding biological vulnerability and, to a lesser extent, substance abuse, may be better understood if seen in the context of the person’s reference groups.  Reference group theory has been widely used in various cultural settings  (Cochran et al., 2004; Hurtado et al., 1994; Schlaupitz et al., 2000), including Israel (Murell Dawson & Chatman, 2001). Reference group theory has shown that sociocultural differences transmitted through interpersonal relations affect beliefs and practices (Erickson, 1988).  The use of theories exploring the social matrix with mental patients was discussed in an article on social psychology of illness support groups (Davison et al., 2000).
 
Reference group (RG) is defined as a group whose presumed perspectives or values are being used by an individual as the basis for his or her current behavior (Hyman, 1942).
 
In the framework of RG theory, a group influences an individual through specific control mechanisms (Hyman, 1942; Hyman & Singer, 1991). Complying with these controls promises wellbeing, non-compliance leads to strain. This strain is especially likely to occur within the normative RG (a group in which individuals are motivated to gain or maintain acceptance – (Hyman, 1942; Sherif, 1948; Deutsch &, 1955),  and in which an individual is especially sensitive to withdrawal of group acceptance. This acceptance might be withdrawn, for example, due to a violation of the RG norms.

A primary RG, in Tonnies terms (a social system in which an individual's basic roles are integrated – (Tonnies, 1940) is viewed here as a prime candidate to contribute to normative function. The quantity and quality of an individual’s RGs is seen to serve as another important factor in affecting his or her reaction to the stressor.

Social mobility – exchange of the RGs – is an additional factor that is reported to contribute to strain put upon a person’s adaptive mechanisms, particularly when a conflict takes place between the former and the new RGs (Merton &  Kitt, 1950).

A special problem for schizophrenic patient arises when there is a conflict between his imaginary RG and other RGs:

Definition: a person’s RG is described as imaginary if the members of this group, or the type of their interactions with the person, or both, do not exist in reality but solely in the person’s imagination. In the case of a psychotic patient, an imaginary RG may take the form of psychotic systematic delusion(s) and/or hallucination(s).

Inaccurate perception of the RG norms and behaviors - as a part of compromised social perception - can be a frequent source of considerable emotional strain in a schizophrenic patient (Corrigan & Green, 1993). Difficulties in adaptation to group norms because of misperception of emotional and social cues of the group, may play a crucial role for schizophrenic patients -  the issue generally addressed in Social Norms Theory -   (Knight Lapinski & Rimal ,2005; Rimal  & Real, 2005). Uncritical transfer of the “norms” of the imaginary RG to the real RGs has a potential for creating conflicts in its own right.

Absolute deprivation (person’s disease per se, loss of important others, stigmatization) as well as relative deprivation (failure to get promoted at work) may well be highly probable triggers for schizophrenic relapse (SR) (Groudace et al., 2000; Wilkinson & Marmot, 2000).
Cognitive dissonance (Festinger, 1957) in schizophrenic patient may develop as a result of frequent hospitalizations, stigmatization, degradation into low social status role, and lack of social contacts.  It may negatively influence his/her emotions, thinking, and behavior and place a considerable strain on the patient’s most vulnerable adaptive mechanisms and thus contribute to SR.

Self-esteem is clearly dependent on the corresponding RG (Korman, 1970.) and can be modified as a result of functional or structural change within the RGs or change in the hierarchy of individual’s RGs (Pratt et al, 2005).

Changes in the quality and significance of a patient’s imaginary RG may be of specific importance for schizophrenic patients. No less important are changes in the patient’s status in real groups as a result of changes in his/her mental state.

 
Suggestions for intervention
We propose a newly developed classification of triggers, Trigger Event Analysis (TEA). Trigger is defined as an event that produces a change in the individual’s mental state linked to changes in both temporal and causal relationships. The classification is a result of examining the range of triggers associated with mental breakdowns in both outpatients and inpatients (Kuppuswamy, 1962; Holmes & Rahe, 1967; Hudgens et al., 1970; Cochrane & Robertson, 1973; Brown et al., 1973; Cochrane & Robertson, 1975; Singhet et al., 1981; Turner et al., 1995).

TEA divides all triggers leading to some kind of  mental breakdown into 6 categories: Status, Norms, Attachment, Threat, Routine, Energy. These triggers have either explicit or implicit social characteristics, which means that they are associated with patients’ reference groups. The given context of mental deterioration leads to the conclusion that they have to be regarded as negative triggers - events that precipitate deterioration in mental states.

Here is a more detailed definition:

1.    Change of status within RG

Examples of these triggers include changes in work position, deterioration in marital relations, significant lottery wins, etc.

2.    Conflict with RG associated norms

Examples are RG pressure on a person to perform an action inconsistent with the person’s moral norms; inability to comply with RG norms (because of a decline in the intellectual level for example); unwillingness to accept RG norms; consequences of a violation of RG norms (that result in some punitive response by the RG), etc.

3.    Alteration (or the threat of alteration) of important personal attachments

Included are such events as loss or changes in social structures.  Examples of the former are the death of a significant other, the break-up of relations with a lover, the loss of face-to-face contact with a significant other (drafted into the army, admission to a boarding school).  Examples of the latter are events such as marriage, child birth,  entering a new RG group (new job, beginning of studies), etc. Included here are personal attachments to a pet or a highly valued object (e.g. collector’s item), or idea.

4.    Threats to an individual’s survival (physical or economical)

In this category belongs life-threatening illness, financial problems, etc.


5.    Rapid change in daily routine

Examples include moving to a new location, vacation, changes in work routine, and changes in roles and role identity (becoming a parent, going to pension, drafted into the army), etc.

6.    Deterioration of a person’s energy resources

Overwork, lack of sleep, unbalanced meals or under eating, or disease and illness are examples of factors which reduce a person’s energy.

Some of the above mentioned examples can be indexed into more than just one category. In addition, a number of triggers can occur in close temporal proximity resulting in a cumulative effect.

It is hypothesized that an individual reacts to all possible triggers in a unique and specific way. The same trigger that has a profound impact upon one particular individual may leave another totally unaffected. The personal sensitivity to specific triggers is categorized in exactly the same way as the triggers themselves. This means that each person will exhibit sensitivity (or lack of it) to such issues as changes in status, RG norms, attachments, threats, routine, and energy resources in a specific way. We call the corresponding personal sensitivities – sensitivity channels. This implies that provided that a person is sensitive to changes in his /her status (for example) within the RG and that such changes take place in reality, there will be a high probability for aversive mental response.

While considering only non-biological (psychological and social) causes for SR, we can infer that SR will result when specific personal sensitivities are matched by some corresponding RG impact. In other words, SR will be the consequence of interaction between the given person and his/her RGs.

The Reference Group Focused Therapy For Schizophrenics (RGFT-S) aims at producing one or a combination of the following changes:

 1. Reducing the significance to the individual of the RG that impinges upon the vulnerable sensitivity channel(s).
 2.  Enhancing the significance of the RG that ameliorates the vulnerable sensitivity channel.
 3. Improving the patient’s position within a pathogenic RG.
 4. Creating a new, empathic RG that ameliorates vulnerable sensitivity channel (s).
 5. Removing a pathogenic RG that hurts vulnerable sensitivity channel(s).
 6. Mediating (bridging) between specific RGs in order to reduce intergroup conflicts.
 7. Modifying Social Perception in order to reduce pathogenic influences on vulnerable sensitivity channels.

 
We define a certain RG as pathogenic for a person when in his/her case it exerts a profound negative emotional impact (causes significant mental distress) upon this person. We assume, in the context of TEA, that this negative impact will be at one or more vulnerable sensitivity channels.
 
In contrast, a certain RG is defined as an empathic group for a person if it has a profound positive emotional impact upon this person. Again, this influence will be mediated through one or more sensitivity channels involved.

Intervention Recommendations :
Patient selection criteria:

1.    An analysis of the patient’s relapse makes it probable that there is a major problem associated with his  RGs which comprises one or more of the following:
a)    Paucity of the number of RG’s
b)    One or more of his/her RG’s has a pathogenic influence on his/her vulnerable sensitivity channels (in other words, is a pathogenic RG)
c)    One or more of his/her empathic RG’s has undergone a recent functional or structural change.
2.    Before a patient is eligible for RGFT-S, he/she has to undergo proper psychopharmacological and/or other biological treatment to enable him/her to enter the rehabilitation program.
3.    A patient has to agree to the rehabilitation program and be capable of comprehending its goals.
4.    A patient has to possess basic social skills such as communication, problem solving, decision-making, self-management, and peer relations abilities that allow him/her to initiate and maintain positive social relationships with others.

 

Intervention modalities:
The RGFT-S comprises three stages and is conducted according to the Manual of RGFT-S (available from the authors):
 
Stage 1  -  Assessment.
TEA (Trigger Event Analysis) is completed both for the patient himself and for his/her RGs
In the diagnostic interview, in addition to the usual intake data,  information is gathered about his/her history of trigger events (Trigger Event History – TEH) as well as mapping the patient’s  RGs including their subjective significance for him/her (RG-map). The personal impact of a trigger upon the patient’s sensitivity channels is evaluated through the Trigger Event Impact questionnaire (TEI). Individual sensitivity to specific triggers is assessed through the Trigger Event Proneness for Individual questionnaire (TEP-I).  The proneness  of each RG to serve as a potential trigger is assessed through the Trigger Event Proneness for Reference Group questionnaire (TEP-RG) – (questionnaires can be  obtained from the authors).

The data collected in the assessment stage serves as the basis for intervention planning.

TEP-I of the patient in Case 1:

S   (+8)          N  (+2)          A  (+2)          T  (+2)           R  (+3)           E (+1)

 

Stage 2 -  Intervention Design
The primary goal of the intervention is to reduce negative impacts on the vulnerable sensitivity channel(s) on the one hand and/or to enhance positive impacts on the same channels on the other.
Another goal is to create a new empathic RG when the current number is not sufficient.

Real RGs and imaginary RGs are treated differently.

Real RGs:
The subjective significance of the patient’s RGs is most important for intervention planning. In the case of pathogenic RGs three possible interventions are available. The first is  improving the patient’s position within the group, e.g. reducing the negative impact on the patient’s vulnerable sensitivity channels.  The second focuses on reducing the pathogenic RG’s significance for the patient. The third is the most extreme measure – removing the pathogenic RG.
 
The significance of the empathic RG may be increased in order to enhance its positive effect on the patient’s vulnerable sensitivity channel(s).
A new empathic RG may be created when the total number of the patient’s RGs is insufficient; another indication for this intervention is to enrich the network of empathic RGs.  Examples of such new groups include protective living settings such as rehabilitation facilities or halfway houses, therapeutic settings such as out-patient clinics, psychiatric wards, or group psychotherapy, and social settings such as friends, clubs, etc.  


Imaginary (delusional) RG:
Initially, it has to be determined whether the imaginary RG is acute in nature or chronic where it has become an integral part of the patient’s inner world.
If it is clearly of acute character, the main intervention has to focus on reducing the personal significance of this group or removing it altogether. This can be accomplished by means of the proper biological therapy (psychopharmacological, ECT, etc.).

In case of chronic delusions that are resistant to modern biological interventions, including higher risk therapies such as  clozapine and other compounds, a patient has lived with his/her delusions for an extended period during which they have become an integral part of his/her life experience. The removal of such delusions is unlikely, at least until more effective biological therapies become available. The imaginary RG may have a positive effect (delusions and hallucinations of a supportive character). In this case, the main therapeutic effect has to be focused on reducing the patient’s tendency to incorporate his/her imaginary RG norms in real RGs. If, for example, the patient’s delusion is that he/she is the messiah with a special relation to God , it is plausible that he/she will tend to translate his/her inner belief into corresponding behaviors and, hence, encounter conflict situations. A therapeutic intervention could be directed towards identifying the borders between various RGs and the discrepancies within their group norms – by means of mediation technique (see Case 2). In the case of pathogenic imaginary RG (e.g., imperative hallucinations and/or delusions with negative content), the main goal of the intervention is to reduce the personal significance of this group - if removal doesn’t seem feasible.  Creation of real empathic RGs (rehabilitation facility, half way house, therapeutic group) may serve this purpose (see Case 3).

Stage 3. Intervention.
Interventions begin at the assessment stage as the patient becomes familiar with the concept of the RG. After the assessment and planning stages have been completed, a patient is introduced in a positive way to the RG focused approach and the influence of the RG on  aspects of his life such as self-esteem, status and self-efficacy. Interventions that are expected to lead to the most significant changes (increase in the patient’s subjectively perceived importance within the empathic group, increase of the relevance of the empathic group for the patient, decrease of the pathogenic group’s relevance, change of the group’s type from pathogenic to less pathogenic) are closely scrutinized.
 
The final treatment plan is developed together with the patient. One or more of the seven possible RGFT-S interventions is then applied.

We now present three cases to demonstrate some possible forms of intervention.
 
Case 1:
 H, male, 51, single, 2nd of 3 siblings, works as a clerk, diagnosed as suffering from residual schizophrenia. He became highly anxious, developed overvalued ideas of inadequacy, disturbed sleep and manifested a severe drop in functioning after he felt that he was intimidated by his superior at his working place. He is a resident of halfway house, has quite a few friends and a girl friend. His remissions are stable, lacking any secondary production. H. was on a low dosage anti-psychotic medication regimen.

On admission the patient was evaluated through a standard battery of RGFT-S related questionnaires (TEH, RG-map, TEI, TEP-I, and TEP-RG). His TEH disclosed three psychotic episodes with corresponding high TEI scores for Status sensitivity channel for each of the episodes. His TEP-I demonstrated (see graph) high vulnerability of the Status channel: 8 (out of 10). TEP-RG for the present RGs (working place, family, girl friend, and friends) has showed mostly positive influence from the side of his girlfriend on the Status sensitivity channel.

On the RG-map the patient stated that he evaluated his work group (colleagues, carrier) as 10 (out of 10) for personal significance.  He had few contacts with his family which was evaluated as 1 (out of 10) and his relevant social groups - friends and his girl friend were evaluated  as 3 (out of 10). 

It was obvious that a patient evaluated his professional life much higher than other RGs. It was also clear that while his girl friend could potentially play a desirable supportive role,  since the patient attributed a relatively low personal importance to his relation with her, it would likely not be fruitful. 

The rehabilitation effort concentrated on two of the seven possible RGFT-S interventions:

a) increase the significance of the particular RG that enhances the vulnerable sensitivity channel;

b) Social Perception Modification – for the Status sensitivity channel.

It was decided to assist the patient in strengthening his emotional involvement with the girl friend. Four couple sessions were conducted where his girl friend was exposed to the patient’s feelings about his superior and provided the necessary support. It turned out that a patient perceived a joke produced by his superior as an attempt to intimidate him though it was apparent that the joke had been misinterpreted. The patient was given a course of Social Perception Modification (basically techniques of Social Skill Training (Bellack et al., 2004) adapted to specific sensitivity channels) that was aimed at correcting the distorted perceptions in the social sphere (this approach is to be discussed elsewhere).  The patient’s girl friend’s supportive role was greatly enhanced by the therapeutic process.  The patient was encouraged to increase his involvement in the relationship with his girl friend: new shared activities such as trips, going to the movies, etc. were discussed.

At the conclusion of the therapeutic intervention, the RG-map assessment was repeated and showed an increase in the couple’s perceived relevance to 6 (out of 10) while other groups remained unchanged.   He was discharged in a state of good remission.

Case 2:
 D, male, 53, single, dairy equipment technician, diagnosed as suffering from paranoid schizophrenia. He lives on a kibbutz and has a married older sister.  D. regards himself as the historian of the kibbutz, and lives in an imaginary nostalgic world of the former kibbutz life. This idea has reached the dimensions of a psychotic delusion that has persisted for about 30 years notwithstanding various antipsychotic medications.  As a result of his delusion he attempts to transfer the norms of his imaginary group to real kibbutz life. He persistently criticizes the way of life of kibbutz members and tries to “convert” them into accepting the norms he believes in. He wrote a “hymn” about “his” kibbutz and sings it aloud at any occasion. He also tries to impose his beliefs upon the kibbutz children, sometimes in a rather aggressive manner. His interactions led to conflicts which culminated in a worsening of his mental state and consequently led to his psychiatric hospitalization.

After a decrease in his psychotic anxiety subsequent to antipsychotic medication, the patient was assessed using a standard set of RGFT-S questionnaires.

The patient’s TEH demonstrated that in all four psychotic exacerbations that preceded the current episode, his corresponding TEI scores were high for the Norms sensitivity channel due to conflicts between the inner norms (in this case the norms of his delusional group) and the norms of the kibbutz. This same tendency was evidenced by the patient’s TEP-I:  9 (out of 10) on the Norms sensitivity channel. The TEP-RG for the present RGs (kibbutz, family, imaginary (delusional) group) showed strong and incompatible norms both on the part of the kibbutz and the imaginary group.
The RG-map showed that the patient’s imaginary group was judged 10 (out of 10), followed by the kibbutz:  5 (out of 10) and his sister:  4 (out of 10) in their significance to the patient.  It was obvious that the imaginary group plays a major role in the patient’s life and that problems arise when his imaginary group norms clash with the real group norms of the kibbutz.

The applied RGFT-S approach was mediation between the patient’s imaginary group and the kibbutz that aimed for a clear delineation of the group norms within each and every group. The patient was assured of the importance of his inner group values but, on another hand, the issue of respecting other group norms, even if personally unacceptable, was discussed, and examples of inappropriate role behavior and the transfer of group norms from one group to another were presented (e.g., general manager of a big firm trying to act as a “big boss” in a hospital setting where he was admitted as a patient). Some representatives of the kibbutz management were invited to a number of therapeutic sessions where these issues were discussed.

As a result, the patient learned to differentiate between the norms of his imaginary group and the norms of the kibbutz more effectively. The kibbutz management, on the other hand, learned to accept the patient’s peculiarities as potentially valuable for the enrichment of the kibbutz’s local tradition. The patient was involved in creating an exhibition devoted to the history of the kibbutz thus generating a socially acceptable platform between his imaginary group and the real kibbutz. Additionally, it helped him to gain better acceptance by the kibbutz community.
 
 
Case 3:
 J., female, 28, single, painter, diagnosed as suffering from paranoid schizophrenia in good remission, developed an acute psychotic episode after an art gallery owner cancelled his agreement to sell her paintings.  She describes her work as of major importance to her, supporting her both emotionally and financially.  She developed persecutory ideas about the gallery owner as wanting to kill her, plotting with the owner of the local grocery shop where the patient bought her food and to whom she owed some money. She was involuntarily committed after an attempt to hang herself.
Following a course of medication therapy with 20 mg/day of olanzapine, her mental state stabilized sufficiently to enable her to take part in the rehabilitation program.
The evaluation showed that her TEH revealed two previous psychotic episodes for which the major trigger on the TEI was the Threat sensitivity channel with the Status sensitivity channel playing a lesser role. This impression was supported by the TEP-I with 8 (out of 10) for the Threat sensitivity channel and 5 (out of 10) for the Status sensitivity channel.
The TEP-RG for the present RGs (gallery, imaginary group) revealed a high level of stress on her vulnerable Threat sensitivity channels both in her real and imaginary groups.
The RG-map demonstrated a significant decrease in the imaginary group’s significance as a result of pharmacological therapy: from 10 (out of 10) down to 3 (out of 10), the real group (gallery) was evaluated as being of 8 (out of 10) significance.

She reported to have only sparse contacts with her family and siblings; the perceived relevance of this group was 1 (out of 10).  She had a boy friend; this relation was rated as 3 (out of 10) in importance, but the boy friend broke up with her after she developed the psychotic episode. She has only a few friends, whom she evaluated to be of 2 (out of 10) in importance. After completing the RG assessment, it turned out that the most important real RG for the patient had been her work group and that this RG suffered a major blow. She no longer had a relationship with her boy friend and her parents and friends seemed unable to compensate as support groups. It was also obvious that the imaginary group was pathogenic and only of temporary influence since it nearly disappeared within the short time she was receiving psychopharmacotherapy and hence it didn’t require inclusion in the intervention. It was suggested that the creation of a new support group might be of major importance for the patient.  Social Service assisted by connecting her to a sponsor who was interested in promoting mentally ill individuals. The sponsor was impressed by the patient’s paintings and committed himself to provide support in organizing exhibitions on a regular basis. This has encouraged the patient significantly:  she reported further improvement in her mental state and her delusions ceased completely. On the follow-up assessment with the RG assessment table (RG-map) she rated the impact of the new RG (new gallery) as 9 (out of 10) while her former gallery was rated as 1 (out of 10).
 
Discussion and Conclusion
The RGFT-S is a rehabilitation-oriented approach that takes into account the profound socialization problems of the schizophrenic patient. It’s goal is his/her re-socialization through analyzing the patient’s social matrix and promoting patient-tailored social problem solving.

Currently the main treatment approaches that face the problems of social adaptation in schizophrenic patient are as follows:

•    Supportive psychoeducational intervention provides the patients with support, information and management strategies. The relevant studies (Adams et al., 2000) suggested that even one year after the termination of the program the relapse rates were still lower than before its application. This is one of the more established methods in lowering EE.

•    Social skills training  uses behaviorally-based assessments of a range of social and interpersonal skills, stressing the role of both verbal and non-verbal communication, as well as the individual's ability to perceive and process relevant social cues and to respond to and provide appropriate social reinforcement. A number of study results suggest that some reductions in psychopathology, when they occur, may be time limited in duration and restricted to only certain categories of symptoms ( Hogarty et al.,1991; Eckman et al., 1992; Overall & Gorham 1962).

•    Problem/symptom focused therapies include Cognitive behavioural therapy (CBT), Cognitive remediation therapy (CRT),  and token economy.  In CBT the participant is encouraged to take an active part by examining the evidence for and against the distressing belief, challenging the habitual patterns of thinking about the belief, and using reasoning abilities and personal experience to develop rational and personally acceptable alternatives. Current studies show mixed results regarding the improvement in the relapse rate in schizophrenic patients subjected to CBT (Trower et al., 2004; Startup et al., 2004; Sensky et al., 2000; Lewis et al., 2002; Rector et al., 2003). Cognitive remediation therapy in schizophrenia is focusing on the specific cognitive deficits of the illness such as poor memory and difficulties in planning and decision-making. A study that  used computer-assisted cognitive rehabilitation to treat 16 patients with schizophrenia and 18 patients with schizoaffective disorder with chronic course, showed significant improvement on several measures of cognitive functioning, most noticeable being in verbal/conceptual learning and memory, and concentration ( Bellucci et al., 2003). A token economy is a behavioral therapy technique in which the desired change is achieved by means of tokens administered for the performance of pre-defined behaviors according to a program. This technique shows statistically significant improvement in negative symptoms of schizophrenia (McMonagle & Sultana, 2000; Bark et al., 2003).

As opposed to above mentioned therapies, RGFT-S conceptualizes a holistic approach to the re-socialization problem of a schizophrenic patient. It takes into consideration both the individual parameters of a patient as well as the qualities of his social matrix - in his/her own perception. The use of psychophysical variables that assist in quantifying the patient’s subjective experiences provides a basis for rational therapeutic planning.

Complementary to other approaches, RGFT-S addresses the patient’s current problems and is aimed at their solution with the patient’s full participation at all stages of treatment. It encourages the patient’s responsibility for change and growth and provides him/her with the tools necessary to deal with similar problems in the future. It assists the patient to identify, elaborate and reinforce his/her progress towards goals. It takes into account not only real RGs but also the patient’s long-standing imaginary RGs and assists him/her to integrate delusional experiences within the demands of reality thus improving the patient’s adaptation to the real world.

The RGFT-S extends the therapeutic impact of the well-established EE-oriented approach by taking into consideration not just an isolated RG but the entirety of the patient’s relevant RGs. Established therapeutic techniques such as CBT for schizophrenic patients, CRT, family therapy, behavior therapy and others can be easily implemented within the RGFT-S approach.

The impact of this approach on the improvement of long-term prognosis and relapse prevention has yet to be evaluated.

References

Adams C, P Wilson P, Bagnall AM.  Psychosocial interventions for schizophrenia. Quality in Health Care 2000; 9: 251-256

Bark N, Revheim N, and Hug F.  The impact of cognitive remediation on psychiatric symptoms of schizophrenia. Schizophr research 2003; 63: 229-235, 2003

Bellack AS, Mueser KT, Gingerich S, Agresta J. Social Skills Training for Schizophrenia: A step-by-step guide. New York: Guilford Press 2004

Bellucci DM, Glaberman K, Haslam, N. Computer-assisted cognitive rehabilitation reduces negative symptoms in the severely mentally ill. Schizophrenia Research 2003;  59: 225–232

Brown GW, Birley JLT, Wing JK. Influence of family life on the course of schizophrenic disorders: a replication. Br  J  Psychiatry 1972; 121: 241-58

Brown GF, Sklair F, Harris TO, Bearley JLT.  Life events and psychiatric disorders. Psychol. Med. 1973; 3: 74-87

Cannon M,  Jones  P.  Schizophrenia. J Neurol,  Neurosurgery, and Psychiatry 1996; 60:604-613

Cochrane R,  Robertson A.  The life events inventory:  A measure of the relative severity of psychological stressors. J. Psychosomat. Res. 1973; 17: 135-140

Cochrane R, Robertson A.  Stress in lives of parasuicides. Social Psychiat. 1975; 10: 161-171 (Life Experience Inventory (LEI)

Cochran JK et al. Religion, Religiosity, and Nonmarital Sexual Conduct: An Application of Reference Group Theory. Sociological Inquiry 2004; 74:102-127

Corrigan PW,  Green  MF.  Schizophrenic patients' sensitivity to social cues: the role of abstraction. Am J Psychiatry 1993; 150:589-594

Davison KP, Pennebeker JW, Dickerson SS. Who talks? The social psychology of illness support groups, American Psychologist 2000; 55(2): 205-217

Deutsch M, Gerard HB. A study of normative and information social influences upon individual judgement. Journal of Abnormal and Social Psychology 1955; 51: 629-636

Eckman TA, Wirshing WC,  Marder SR,  Liberman RP, Johnston-Cronk K,  Zimmermann K,  Mintz J. Technique for training schizophrenic patents in illness self-management: A controlled trial. American Journal of Psychiatry 1992;  149(11):1549-1555

Erickson B. The Relational Basis of Attitudes. in Social Structures: A Network Approach. pp. 99-122 , ed. Wellman B, Berkowitz SD. Cambridge: Cambridge University Press 1988

Festinger  L.  A Theory of Cognitive Dissonance.  Stanford, CA: Stanford University Press, 1957

Geddes J . Prevention of Relapse in Schizophrenia. Editorial. N Engl J Med 2002; 346 (1): 56-58

Groudace TJ, Kayne R, Jones PB, Harrison GL. Non-linear relationship between an index of social deprivation, psychiatric admission prevalence and the incidence of psychosis.  Psychol Med 2000; 30: 177-185

Hogarty GE, Anderson CM, Reiss DJ, Kornblith SJ, Greenwald DP,  Ulrich RF, Carter M. Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenia: II. Two-year effects of a controlled study on relapse and adjustment. Archives of General Psychiatry 1991; 48(4):340-347

Holmes, T. H. and Rahe, R. H.: The social readjustment rating scale. J. Psychosomat. Res. 1967; 11: 213-218 ( Social Readjustment Rating Scale (SRRS)

Hudgens RW, Robins E, Deland WB. The reporting of recent stress in the lives of psychiatric patients. A study of 80 hospitalized patients and 103 informants reporting the presence or absence of specified types of stress. Brit. J. Psychiat. 1970; 117: 635-643

Hurtado A, Gurin P,  Peng T. (1994) Social identities - A framework for studying the adaptations of immigrants and ethnics: The adaptations of Mexicans in the United States. Social Problems 1994; 41(1): 129

Hyman HH. The psychology of status. Archives of Psychology 1942; 269: 5–94

Hyman HH, & Singer E. An introduction to reference group theory and research.Journal of Applied Psychology 1991; 76: 675-689

Kavanagh DJ. Recent developments in expressed emotion and schizophrenia. Br J Psychiatry 1992; 160: 601-20

Korman AK. Toward a hypothesis of work behavior. J Appl Psychol. 1970; 56: 31-41

Kuppuswamy, B. Manual of Socioeconomic Status Scale (Urban). Mansayan, Delhi, 1962.

Knight Lapinski M, Rimal RN. An Explication of Social Norms. Communication Theory.  Oxford  2005; 15(2):  127

Lewis S, Tarrier N, Haddock G, et al.  Randomised controlled trial of cognitive–behavioural therapy in early schizophrenia: acute-phase outcomes. British Journal of Psychiatry 2002; 181 (suppl. 43): 91–97

Marom S, Munitz H, Jones PB, Weizman, A, Hermesh H. Expressed Emotion: Relevance to Rehospitalization in Schizophrenia Over 7 Years. Schizophr Bull 2005; 31(3): 751-758

McIntosh A,  Lawrie S. Schizophrenia. In: Barton S, ed. Clinical evidence. Issue 5. London: BMJ Publishing Group, 2001: 695-716.

McMonagle T, Sultana A. Token economy for schizophrenia. Cochrane Database of Systematic Reviews 2000, Issue 3

Merton RK,  Kitt A. Contributions to the theory of reference group behavior. Glencoe, Illinois: Free Press. Reprinted in part from Studies in the scope and method of  the “The American soldier”. 1950.

Murell Dawson E, Chatman EA. Reference group theory with implications for information studies: a theoretical essay. Information Research 2001; 6(3)

Overall JE & Gorham DR. The Brief Psychiatric Rating Scale. Psychological Reports 1962;.
 10:799-812

Pratt SI, Mueser KT,  Smith TE, Lu W. Self-efficacy and psychosocial functioning in schizophrenia: A mediational analysis. Schizophrenia Research. 2005; 78(2-3): 187-197

Rector NA, Seeman M, Segal ZV. Cognitive therapy of schizophrenia: A preliminary randomized controlled trial. Schizophr Res. 2003;  63: 1-11

Rimal  RN, Real K. How Behaviors are Influenced by Perceived Norms: A Test of the Theory of Normative Social Behavior . Communication Research. Beverly Hills  2005 32(3): 389

Schlaupitz S, Cochran J, Heide KM, Sellers C.  Race, Religion, and Attitudes toward Capital Punishment: An Indirect Test of Reference Group Theory. Annual Meeting of the Academy of Criminal Justice Sciences, New Orleans, March 2000. (Paper reviewed and revised by Kathleen Heide for distribution to Court personnel.)

Sensky T, Turkington D, Kingdon D, et al (2000) A randomized controlled trial of cognitive–behavioural therapy for persistent symptoms in schizophrenia resistant to medication. Archives of General Psychiatry 2000; 57: 165–172

Sherif  M. An outline of social psychology. New York, NY: Harper & Brothers Publishers, 1948.

Singh G,  Kaur D,  Kaur H. Stressful life events, development of a stressful life events scale for use in India. Mental Health Research Monograph No. 1, Department of Psychiatry, Government Medical College and Rajendra Hospital, Patiala, 1981.

Startup M, Jackson MC, Bendix S. North Wales randomized controlled trial of cognitive behaviour therapy for acute schizophrenia spectrum disorders: outcomes at 6 and 12 months. Psychol Med. 2004; 34(3): 413-22

Tonnies F. Fundamental concepts of sociology (Gemeinschaft und Gesellschaft). (C.P. Loomis, Trans.). New York: American Book Company. (Original work published 1887), 1940.

Trower P, Birchwood M, Meaden A, Byrne S, Nelson A,  Ross K. Cognitive therapy for command hallucinations: randomised controlled trial. Br J Psychiatry. 2004; 184: 312-20.

Turner RJ, Wheaton B,  Lloyd DA. The Epidemiology of Social Stress American Sociological Review 1995; 60(1): 104-125

Vaughn C, Leff J. The influence of family and social factors on the course of psychiatric illness. Br  J  Psychiatry 1976; 129: 125-37

Weiden PJ, Oltson M. Cost of Relapse in Schizophrenia. Schizophr Bull 1995; 21(3): 419-429

Wilkinson R, Marmot M, eds. Social Determinants of Health – The Solid Facts. European Office: World Health Organization, 2000.