International Journal of Psychosocial Rehabilitation
Reference Group Focused
Therapy for Schizophrenics (RGFT-S) -
Rehabilitation-Oriented Approach in Schizophrenia.
Igor Salganik M.D. & Peter Soifer M.D.
Sha’ar Menashe Mental Health Center, Mobile Post Hefer 37806, Israel
Salganik I. & Soifer P. (2008). Reference Group
Focused Therapy for Schizophrenics (RGFT-S) - A New
Approach in Schizophrenia. International
Journal of Psychosocial Rehabilitation. 12 (2),
Sha’ar Menashe Mental Health Center
Mobile Post Hefer 38814 Israel
e-mail : firstname.lastname@example.org
We express our deep gratitude to Wendy and Jeff Starrfield for their
assistance in editing this manuscript.
‘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.
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.”
(inspired by the movie “A Beautiful Mind”)
“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
“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 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.
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 &
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
In this category belongs life-threatening illness, financial problems,
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
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
6. Mediating (bridging) between specific RGs in order to reduce
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
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
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
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.
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
of the patient in Case
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
Real RGs and imaginary RGs are treated differently.
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
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
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
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
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
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.
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
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
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
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
Currently the main treatment approaches that face the problems of
social adaptation in schizophrenic patient are as follows:
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.,
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.
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
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
Corrigan PW, Green MF. Schizophrenic patients'
sensitivity to social cues: the role of abstraction. Am J Psychiatry
Davison KP, Pennebeker JW, Dickerson SS. Who talks? The social
psychology of illness support groups, American Psychologist 2000;
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;
Hyman HH. The psychology of status. Archives of Psychology 1942;
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
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;.
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;
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;
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.