Abstract
Approximately 30%-50% of people with schizophrenia worldwide have treatment-resistant schizophrenia (TRS). Currently available standard psychopharmacological and psychological treatments have proven insufficient to achieve full recovery in these patients. Alternative psychological interventions focused on improving emotion regulation, such as the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), could potentially improve treatment outcomes in this difficult to treat population. The aim of the present case study is to demonstrate how the UP can be adapted for the treatment of TRS. We decided to use UP to treat this particular patient due to the presence of intense unpleasant emotions, aversive reactions, and emotional avoidance strategies. After completing the full treatment protocol, the patient showed significant decreases in scores on the Difficulties in Emotion Regulation Scale (DERS), including total and emotional rejection, life interference, and emotional lack of control. A significant reduction was also observed in anxiety (OASIS) and depressive symptoms (ODSIS). The intervention had a positive impact on auditory hallucinations, with decreased severity, less intense anxiety, and less interference in life. The treatment led to greater control over voices and the patient reported feeling more confident in her relationship with those voices. These results provide preliminary support for the use of UP for the treatment of TRS.
1. Theoretical and Research Basis for Treatment
Schizophrenia is a severe mental health disorder affecting around 24 million people worldwide (WHO, 2022). Schizophrenia is usually a chronic condition associated with high disability levels (GBD 2016 Disease and Injury Incidence and Prevalence Collaborators, 2017). It is a highly complex condition, mainly due to the high risk of mental and physical health comorbidities. As a result, the care of these patients can impose a significant burden on informal caregivers and the health care system (Kennedy et al., 2014). Although the efficacy of antipsychotics in the treatment of schizophrenia has been demonstrated in randomized, double-blind, placebo-controlled clinical trials (Howes et al., 2017), first-line antipsychotics are only beneficial in around 50% of patients and thus the other 50% obtain scant benefit from this treatment (Kennedy et al., 2014; Nucifora et al., 2019). This lack of response (or an insufficient response) to pharmacological treatment is known as treatment-resistant schizophrenia (TRS), which is characterized by a poor response together with the persistence of delusions and hallucinations that distort reality and lead to behavioral alterations. In TRS, the therapeutic alternative of choice is clozapine, which has shown greater efficacy compared with standard antipsychotic medications (Howes et al., 2017). Nevertheless, around 40% of patients with TRS do not respond to this drug either (Siskind et al., 2017). In fact, overall, only 13.5% of people with schizophrenia achieve recovery in clinical and social outcome (Jääskeläinen et al., 2013). In addition, the effect size in terms of a reduction in positive-negative symptoms and improvement in emotional well-being is small (Eack & Newhill, 2007).
Apart from pharmacotherapy, several different psychological interventions can be used to treat schizophrenia. Clinical guidelines recommend two psychological treatment modalities for schizophrenia (NICE, 2014; Working Group of the Clinical Practice Guideline for Schizophrenia and Incipient Psychotic Disorder, 2009). The first of these is Cognitive Behavioral Therapy in psychosis (CBTp; Morrison, 2017), in which the objective is to reduce the discomfort generated by positive symptoms. The second recommendation is Cognitive Remediation Therapy (CRT; Wykes et al., 2011), in which the aim is to improve cognitive functions. Both of these psychological interventions have been shown to improve clinical symptomatology and the cognitive processes associated with the development and maintenance of the disease. Although these interventions can help to achieve clinical (remission of symptoms) and functional (adequate psychosocial functioning) dimensions of recovery, they do not appear to improve personal recovery (a way of living with connectedness, hope, identity, meaning in life and empowerment) (Bighelli et al., 2018; Pankowski et al., 2016; Vita et al., 2021). This is an important point, as the personal recovery process is considered critical to both emotional and psychological well-being in schizophrenia (Schrank et al., 2014). Given that emotion regulation influences well-being (Fredrickson, 2000) and deficits in emotion regulation have been associated with psychosis (Kimhy et al., 2020; Ludwig et al., 2020), interventions that target this facet could be beneficial in patients with schizophrenia. There is previous evidence supporting interventions targeting emotions for psychosis with promising results, for example, Acceptance and Commitment Therapy (Spidel et al., 2018) or Dialectical Behavior Intervention-the Managing Emotions Group (Lawlor et al., 2022).
In this context, the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP; Barlow et al., 2017) could potentially reduce deficits in emotion regulation. In particular, the literature suggests that people with schizophrenia present maladaptive strategies (worry, rumination, suppression), which seems to be related to the maintenance of positive symptoms, and a global emotional dysregulation, which seems to be associated with both positive and negative symptoms (Ludwig et al., 2019).
The UP is an evidence-based psychological treatment targeting shared dimensions associated with the etiology and maintenance of emotional disorders, such as neuroticism, rumination, and avoidance (Barlow et al., 2014). To date, three systematic reviews—two of which were meta-analyses—have demonstrated the efficacy of UP in reducing anxiety and depressive symptoms, and in improving the quality of life and functional status of patients with emotional disorders (Carlucci et al., 2021; Cassiello-Robbins et al., 2020; Sakiris & Berle, 2019). In recent years, there has been a growing interest among clinicians and researchers to investigate whether the UP could be adapted for the treatment of emotional disorders and/or symptoms in people whose primary diagnosis is other than an emotional disorder, for example, borderline personality disorder (Sauer-Zavala et al., 2016) or bipolar disorder (Ellard et al., 2017). The preliminary results of those studies have been good. Based on the findings of those studies, we hypothesized that an intervention focused on improving emotion regulation strategies in people with TRS could be clinically beneficial by reducing symptoms of anxiety, depression, and interference, while also improving quality of life. In the present study, we describe a patient diagnosed with TRS who received an adapted version of the UP.
2. Case Introduction
At the time of the UP intervention, Blossom (a pseudonym) was a 36-year-old woman who had completed primary education. She worked at a factory on the assembly line for eight years until her mental illness forced her to stop working. She was receiving a disability pension and was living with her boyfriend in a metropolitan area. She had good family support from her mother and sister (her father was deceased).
3. Presenting Complaints
The patient reported the presence of positive (hallucinations, delusions) and negative (e.g. apathy, isolation) symptoms of psychosis. She experienced auditory verbal hallucinations at least once a day, the content of which was always negative and unpleasant (“you are bad”, “they’re going to fire you”, “be careful with mobbing”). As a consequence, she was largely isolated from society; her only relationships were with her family and boyfriend. She also presented anxiety and fear of leaving home. Her symptoms also included apathy, and she had great difficulty engaging in daily routines including both low and high demand activities such as personal hygiene and cooking, respectively.
4. History
Blossom was diagnosed of schizophrenia six years ago. She was admitted to the emergency psychiatric unit for psychotic symptoms (delusion of prejudice and auditory hallucinations) and received treatment at the outpatient unit. She believed she was suffering from mobbing at work: “My co-workers were always criticizing each other”; “I felt that something bad was going to happen at work”. She also presented magical thinking with regard to her workmates: “They began to make gestures at me; if they touched something black, I touched something black”, “I began to follow them stealthily”. These thoughts turned into delusional interpretations: “When I did something well, following the instructions of one of my workmates, another one would come up behind him with a large box that said Medallion, which I thought it was a medal for doing it well”.
Delusional symptoms were also common outside of work: “When I was driving my car, I was followed by trucks with a V, which meant “everything was fine””; “I left my family’s house to rent a flat because I followed these clues: I often saw moving trucks”. Regarding the auditory hallucinations, she experienced hostile, critical and imperative voices: “you are bad”, “don’t do that”, “they’re going to fire you”, “be careful with mobbing”.
Initially, the antipsychotics ziprasidone (240 mg/day) and paliperidone (50 mg/month, injection) were prescribed. However, the prescription was later switched to clozapine (300 mg/day) due to a lack of clinical response. After this change in antipsychotic medication, she achieved complete remission of her symptoms, but treatment had to be discontinued because she developed a severe, medication-related side effect (neutropenia). Nevertheless, since her psychotic symptoms had fully remitted, pharmacotherapy was not restarted and her psychiatrist recommended that she return to work.
Nine months later, she presented a second psychotic episode involving delusion of reference, auditory hallucinations, disorganized behaviors, and thought blocking. She was admitted to the inpatient unit where she received several different antipsychotics (ziprasidone 240 mg/day and quetiapine 100 mg/day), but these only partially improved her symptoms. She was then referred to a treatment program specifically designed for patients with TRS, which consisted of a specialized intervention involving both pharmacological and psychological measures.
5. Assessment
Clinical Diagnosis
The diagnosis was made in accordance with the criteria established in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders criteria (DSM-5; APA, 2013).
Primary Measures
The Difficulties in Emotion Regulation Scale (DERS: Gratz & Roemer, 2004; Hervas & Jodar, 2008) is a self-report measure designed to assess emotion regulation difficulties. The DERS contains 28 items grouped into five dimensions of emotion regulation, as follows: lack of emotional attention; emotional confusion; emotional rejection; life interference; and emotional lack of control. The response options are given on a 5-point Likert scale ranging from 1 (almost never) to 5 (almost always) to indicate the frequency of the behavior described in each item. The higher the score, the greater the difficulty in the regulatory component evaluated. The internal consistency of this scale in a sample of patients in Spain was α = 0.74 (Hervas & Jodar, 2008).
The 5-level EQ-5D visual analogue scale (EQ-5D-5L VAS: Herdman et al., 2011) is a self-rated measure of health-related quality of life presented on a vertical visual analogue scale ranging from 0 to 100. The higher the score, the greater the perceived health. Scores are subclassified according to the number of points as follows: poor (0-40 points); fair (41- 53); good (54- 76); very good (77- 80); and excellent (90-100).
Longitudinal Assessment Measures
The Overall Anxiety Severity and Impairment Scale (OASIS: Norman et al., 2006; Osma et al., 2019) is a 5-item self-report measure evaluating the frequency, severity, avoidance, and interference of anxiety symptoms experienced in the past week. The items are rated on a 5-point Likert scale ranging from 0 (no anxiety in the past week or none) to 4 (constant anxiety or extreme/all the time). Higher scores indicate more severe anxiety. The internal consistency of the OASIS in a Spanish sample was α = 0.87 (Osma et al., 2019).
The Overall Depression Severity and Impairment Scale (ODSIS: Bentley et al., 2014; Osma et al., 2019) is a 5-item self-report measure evaluating the frequency, severity, anhedonia, and interference of depressive symptoms experienced in the past week. The items are rated on a 5-point Likert scale ranging from 0 (no depression in the past week or none) to 4 (constant depression or extreme/all the time). Higher scores indicate greater severity. The internal consistency of the ODSIS was α = 0.94 in a Spanish sample (Osma et al., 2019).
Secondary Measures
The Psychotic Symptom Rating Scale-Auditory Hallucinations (PSYRATS-AH: Haddock et al., 1999; González et al., 2003) is a semi-structured interview designed to provide a dimensional measure of hallucinatory experience over the past week. The scale contains 11 items grouped into three factors: physical, cognitive, and emotional. The items are rated on a 5-point Likert scale ranging from 0 to 5, with higher scores indicating greater severity of auditory hallucinations.
The Beck Cognitive Insight Scale (BCIS: Beck et al., 2004; Gutiérrez-Zotes et al., 2012) is a self-report measure designed to assess cognitive insight capacity. This scale contains 15 items grouped into two factors: self-reflectiveness and self-certainty. Items are rated on a 4-point Likert scale ranging from 0 (do not agree at all) to 3 (agree completely). Higher score in self-reflectiveness indicate greater objectivity and lower score in self-certainty indicate mental flexibility in the interpretation of the experience. The internal consistency for self-reflectiveness was α = 0.59 and for self-certainty was α = 0.62 in the Spanish sample (Gutiérrez-Zotes et al., 2012).
The Brief Core Schema Scales (BCSS: Fowler et al., 2006) is a 24-item self-report assessment of schemata concerning self and others in psychosis. The scales assess four dimensions of self and other evaluation: negative-self, positive-self, negative-other, positive-other. The items are rated on a 5-point Likert scale ranging from 0 (don’t believe it) to 4 (believe it totally). Higher scores indicate higher endorsement of positive-negative beliefs to oneself and/or to others.
All of the measures described above were administered pre- and post-treatment (at one year).
6. Case Conceptualization
To properly conceptualize this case, it is important to assess the three components of the functional model of emotional disorders (Bullis et al., 2019), as follows: (a) presence of intense unpleasant emotions, (b) aversive reactions to these emotional experiences, and (c) emotional avoidance strategies.
Blossom reported difficulties in managing several negative emotions, including fear, blame, sadness, and anger. Her fear was mainly related to having to leave her home (“I am afraid that outside voices appear and make me feel bad, something happens”). In terms of blame, she had negative thoughts about her social environment (“when I was ill, I thought that my uncle had abused me; how could I believe that?”) and low behavioral activation. She felt sadness related to her inability to achieve her daily goals (e.g., housework). She felt anger due to the presence of the voices and her lack of energy. As a consequence, she experienced cognitive aversive reactions, as exemplified in statements such as “I’m fed up” or “What a disgusting life, sometimes I wish I was dead, but I’m not going to do anything to myself”.
In response to these negative reactions, she used several emotional avoidance strategies, as follows: 1) explicit behavioral avoidance (situational/escape): not meeting with her friends, not having her nephew at home, not contacting anyone via her mobile phone (WhatsApp), and locking herself in the room; 2) subtle behavioral avoidance: covering herself with a blanket on the sofa or closing her eyes to avoid following the signals; 3) cognitive avoidance: ruminating on the past; 4) safety signs: having medications on hand; and 5) emotion trigger behaviors: for example, when anger appeared she argued with the voices.
7. Course of Treatment and Assessment of Progress
Course of Treatment
Original Order of the Unified Protocol (UP) Modules and How They Were Implemented in the Present Case Study, Including the Aims of Each Module.
The treating therapist was a clinician (E.G.) with a PhD and more than 20 years of experience in the assessment and treatment of patients with schizophrenia. The therapist received specific training in the UP intervention and a certified supervisor (J.O.) reviewed her work during the first phase of treatment.
Module 1. Setting goals and Maintaining Motivation
The first sessions of the UP are considered essential to work on developing therapeutic alliance, one of the main drivers of motivation and change in patients with schizophrenia (Browne et al., 2021). In this case, the patient also needed help to normalize her psychotic experiences, giving her space to explain her personal and clinical history. In this regard, certain evaluation instruments (such as the PSYRATS scale) proved highly valuable.
During the intervention, we identified several possible precipitating factors (i.e., substance abuse –cannabis-, high expressed emotion in the family, stressors such as the death of the grandmother and/or work problems) and symptom maintainers (social isolation, not sharing worries) as well as protective factors of well-being (extroverted, socially skilled). Identification of these factors allowed us to take advantage of Blossom’s own experiences to introduce UP and give her examples of her ability to improve her condition. The information shared through the assessment and case formulation helped Blossom to identify her main goals and to determine the intermediate steps that would be necessary to achieve those goals. We agreed on the following: (1) improving personal care; (2) getting together with family and friends; (3) performing certain daily tasks; and (4) participating in activities outside of the home (e.g., volunteering).
Module 2. Understanding Emotions
This module is especially important for people with schizophrenia (Lawlor et al., 2020). In a clinical context, it is unusual to approach emotions from a self-knowledge perspective; similarly, it is not common to ask patients to observe and reflect on emotions. With Blossom, we identified her usual emotions through the use of images. Cognitive deficits (alterations in short-term memory and executive function), together with the habitual presence of voices, made it difficult that Blossom could retain all the information given during the treatment sessions. We decide to use the new technologies, sending an audio summary of the sessions to her smartphone. We also suggested that she verbally record her experiences using her smartphone and the different tasks to be performed in therapy. In this way, we were able to get the patient to perform her homework assignments.
She listed four common emotions: sadness (“when I get up, when I see that I don’t do what I wanted to do”), anxiety (“before going out or when I do something, I am afraid of voices appearing”), anger (“because of the presence of the voices”, “because I felt powerless to do things”), and tiredness (“it’s the most annoying thing”, “I feel I have no energy, I can’t do anything”). We introduced the concept of how to record these emotions using the Antecedent-Response-Consequences (ARC), with a special focus on the short- and long-term consequences of her emotional responses.
Module 3. Mindful Emotion Awareness
Our clinical experience in treating patients with affective and anxiety disorders has shown us that patients with schizophrenia seem to relate to their emotional experiences in a similar way. Feeling bad is experienced as a state to be ashamed of; it is synonymous with weakness and a source of anger and guilt. Primary and secondary emotions merge and the patient maladaptively copes with the emotional burden through self-medication or isolation. Blossom experienced anxiety as a primary emotion and guilt and shame as secondary emotions. She presented a constant pattern of ruminating about her past experience at work (“everything that happened was my fault, I didn’t want to be fired and I behaved badly”), which ended up affecting other areas in her life. Several factors—the presence of intrusive thoughts, together with the phenomenon of thought-action fusion (“I realized that I was looking at my nephew’s butt”, “thoughts came to me as if I were going to abuse him”, “the voices told me to be careful”, “I was afraid of hurting him”) and the associated guilt—all contributed to her tendency to turn to avoidance and suppression as coping strategies (“I prefer not to be alone with my nephew”, “when I see someone and they remind me of my father, or my ex, I force myself not to think; I don’t want to have bad thoughts about the way they behaved and be bad”). At the end, a dysfunctional self-perception pattern had been generated which was based on past negative assessments (“I’m bad”, “I deserve what happens to me”) and future actions (“I should clean my house, but I’m tired”, “I should be with people, but I have no conversation”). This pattern confirmed her personal disability believes (“I’m a bad friend”, “I’m useless”). To help the patient decenter from her emotional experiences (including voices) and to learn how to observe these experiences in order to break the vicious circle existing between sensations, thoughts and behaviors, we trained her in three exercises: 1) informal mindfulness tasks (washing, showering), 2) anchoring through breathing, and 3) emotional induction with songs associated with powerful aversive and rewarding emotions. During the informal practice, we observed that other elements (apart from the voices) in her daily life may have played a role in her discomfort. For example, she noticed that the emotion of tiredness generated thoughts of “stop, lie down”, which led her to interrupt the tasks she was doing; as a result, this became a source of discomfort.
Module 5. Countering Emotional Behaviors
Distressing Situations Identified by the Patient, Associated Reactions, and Possible Alternatives.
Blossom realized that she needed to find a way to handle these situations of discomfort differently. Consequently, she gradually began to use the mindfulness tools that worked so well in dealing with intrusive thoughts while doing chores around the house. The emotional avoidance behaviors that she routinely turned to in order to curb her tendency to “follow the signs” (e.g., pulling the blanket up or closing her eyes), actually made her more focused on the voices, thus increasing her discomfort. She realized that she could not turn to medication every time this happened. She did not want to be dependent on medications to deal with anxiety, and she needed to stop “hiding” from the signs because this simply ended up perpetuating the same situation.
Module 7. Emotion Exposures
In this module, Blossom was exposed to situations associated with anxiety. We worked with her to define an exposure hierarchy in which the situations were ranked in order (low, medium and high) in terms of the level of distress and avoidance that they caused. For instance, low distress situations included performing (without interruption) a household chore on a daily basis or communicating with friends every week by messenger (WhatsApp). Medium distress situations included meeting once a week with her mother or sister and deciding, in advance, how much time she would spend with them (increasing the exposure time gradually). High distress situations included looking at her partner while he was playing with his mobile phone without “following the signs” or staying with her nephew (being alone with him at home, increasing the time gradually). In all of these exposures, she was told to apply the emotion regulation strategies she had learned and practiced in Module 3. For example, the exposure to daily chores while she was practicing mindfulness helped her to observe the emotion of tiredness, to let go the thoughts of “stop” and to continue with the tasks.
Module 4. Cognitive Flexibility
Examples of Automatic Thinking, Thought Distortions, and Alternative Explanations.
Module 6. Understanding and Confronting Physical Sensations
Module 6 was the last to be performed because we expected that it would be the most difficult module for the patient. We also modified the content of this module in order to focus on understanding and confronting the voices. The rationale behind this change was as follows. First, although patients with schizophrenia are able to pay attention to emotions, they often have problems with clarity (i.e., localizing emotions in the body) (Torregrossa et al., 2019). Blossom found it difficult to identify the part of the body associated with the emotion. Second, according to the cognitive model of schizophrenia, voices are similar to physical sensations in panic disorder (Morrison, 1998). Thus, we decided to induce hallucinatory experiences through behavioral experiments. Then we reviewed the evidence for and against possible alternative explanations for the hallucinations’ origin with the patient.
For Blossom, the voices were the signal that something bad was going to happen or that she was behaving badly. Through the experiments, Blossom started to think and behave differently with the voices (see Table 4). For example, she stopped talking to and obeying the voices’ orders; instead, she started to believe that “they speak more subtly to me”, “they resemble my thoughts”, “they are kinder” and “they give me advice”. We suggested that she establish a relationship with the voices, similar to the relationships she had with people close to her. We explained that even people close to her are not always right, can be contradictory, and we do not always pay attention to them.
Module 8. Moving Up From Here
In this module, we reviewed all of the work done with Blossom up to that point, including her level of achievement with regard to the four objectives established at the start of treatment. Based on this review, we decided that we needed to continue working on objectives 2 (getting together with family and friends) and 4 (activities outside home) in order to continue making progress in therapy and towards recovery.
Assessment of Progress
Examples of Hallucinatory Experience Induction.
Pre- and Post-Intervention Raw Scores and Reliable Change Index (RCI) Values.
Note: DERS: Difficulties in Emotion Regulation Scale; EQ-5D-5 L VAS: 5-level EQ-5D visual analogue scale; OASIS: Overall Anxiety Severity and Impairment Scale; ODSIS: Overall Depression Severity and Impairment Scale; PSYRATS-AH: Psychotic Symptom Rating Scale-Auditory Hallucinations; BCIS: Beck Cognitive Insight Scale; BCSS: Brief Core Schema Scales.
*Significant change: p = 0.05.
As Table 5 shows, scores on Total and Emotional rejection, Life interference, and Emotional lack of control factors in DERS decreased significantly after intervention. The EQ-5D-5 L VAS score (personal well-being) improved from fair to very good. Changes in the PSYRATS showed a decrease in severity of auditory hallucinations. Although the frequency of the hallucinations remained unchanged (occurring at least once a day), with a longer duration (the voices could last for hours), we did observe a decrease over time in terms of volume (the hallucinations became quieter than her own voice), intensity of anxiety (from extreme to low), interference in life (from moderate to minimal impact), and control over voices (from “occasionally” to “most of the time”). On the BCSS, pre-post intervention changes were observed in negative-self score, with a decrease in the number of negative beliefs and in the associated intensity.
Finally, OASIS and ODSIS scores decreased significantly after completion of the UP. Figure 1 shows the evolution of the OASIS and ODSIS scores over the course of the full intervention. At the start of the intervention, she scored 16 points (out of a maximum of 20) on both questionnaires. On the ODSIS, her scores progressively decreased from 16 to < 10 points, the cut-off point established for the Spanish clinical population (people with emotional disorder diagnosis; Osma et al., 2019), until finally falling to 0 points in most of the sessions. The increase observed in session 27 (score = 13) was due to the anniversary of her father’s death. On the OASIS, the scores declined below 10, but only later in the therapeutic process, with more peaks compared to ODSIS due to the influence of the psychotic symptomatology on anxiety. It is notable that the OASIS scores first started to fall below the cut-off point when Module 3 (Mindful Emotion Awareness) was presented. The increases observed in OASIS scores in sessions 11 (score = 14) and 20 (score = 11) were due to the emotional impact of the voices. Changes in OASIS and ODSIS scores over the course of the intervention.
At the end of the full intervention, we asked the patient to qualitatively evaluate the intervention. Her feedback was positive. The patient affirmed that she felt more confident in her relationship with the voices, stating that “now, the anxiety caused by the voices has decreased”, “I have more control over them”, and “voices interfere less in my daily life”.
8. Complicating Factors
Notwithstanding the important advances in Blossom’s condition, some issues remained. For example, in cases when the voices remained in her mind for a long period of time, she continued to return to her previous anxiety-related patterns (e.g., staying in her bedroom or taking medication to feel better). The sessions with the therapist helped her to understand the importance of decentering from the voices, independently of their negative content and/or persistence. Another unresolved issue was her delusional belief that other people could read her mind. She continued to feel vulnerable and presented deficits in communicating with other people. Her belief in this idea was almost inflexible and hindered her capacity to contact people outside of her close circle. In fact, this symptom blocked the progress of objective #4 (doing activities, such as volunteering, outside of the home).
9. Access and Barriers to Care
There is a clear need to explore and develop novel therapeutic approaches for the treatment of TRS due to the fragmentation of current interventions (Mohr et al., 2018). In addition, most community programs for schizophrenia patients focus primarily on first episodes or negative symptomatology. As a result, patients with persistent positive symptoms usually do not participate in such programs and are thus practically excluded from current intervention streams. In this regard, the UP offers several interesting advantages that could help to address these issues. First, the main focus of UP is on targeting the key problems of the disorder while also allowing the therapist to work on the comorbid affective symptoms (Abdullah et al., 2020). A second advantage of UP is its flexible, modular design (Sauer-Zavala et al., 2019), which allows for a highly customized intervention. This means that the time spent on learning a specific skill can be extended or reduced depending on the patient’s particular characteristics.
10. Follow-Up
There was no follow-up in this clinical case, which can be considered an important limitation.
11. Treatment Implications of the Case
The case report described here, which involved the application of the UP in schizophrenia, emphasizes the affective dimension, an important factor in the recovery process of patients with schizophrenia (Best et al., 2020). Interventions targeting emotional experiences in TRS can help patients learn to distance themselves from those emotions, to manage their situation through more adaptive strategies, and to obtain a greater sense of self-efficacy and confidence in their ability to achieve their aims. These changes can positively influence personal recovery by increasing the degree of perceived autonomy while simultaneously reducing the feeling of being permanently sick and disabled. In the present case, the application of UP to manage Blossom’s psychotic symptoms—specifically in how she experienced these symptoms—allowed her to begin to live in closer accordance with her personal values. Of the four objectives established at the beginning of therapy, the patient felt that she had fully achieved two of these objectives (improved personal care and cleanliness; carrying out daily tasks), while also largely meeting a third objective (getting together with family and friends).
The patient’s therapeutic compliance was high. As her ability to cope with the voices improved, these voices increasingly lost their capacity to influence her behavior, thus enabling her to attend most of the scheduled sessions at the hospital, despite the voices.
Even though the nature of the hallucinations remains unchanged (frequent, negative, a source of anxiety), it is interesting to observe how the patient—after completing the various UP modules—learned to transform her relationship with these hallucinations, by becoming more assertive and learning to ignore the orders given by the voices. Importantly, this transformation resulted in an increase in her perceived quality of life. In addition, the skills learned through the UP (focusing on skills through awareness, emotion exposure), allowed Blossom to better manage her emotions, especially through greater acceptance, regulation, and non-interference in functioning. However, she still has difficulty understanding and differentiating between emotions. Nonetheless, as she has decentered from distress, she has increased her sense of self-efficacy and her self-concept: her strong beliefs and thoughts (such as “I am worthless, weak, vulnerable”) have weakened.
At the cognitive level, we were unable to improve the self-certainty component of cognitive insight, and thus the patient’s certainty about erroneous ideas has not decreased. Our proposed approach to managing the content of the voices was similar to that used to handle intrusive thoughts. However, we encountered certain difficulties in this area, mainly due to the origin of the phenomenon. People can quickly identify intrusive thoughts as a mental product, with an easily recognizable origin, but for Blossom it was hard to do this. Blossom did not clearly understand that the voices were originated in her mind, due to the disease. Her doubts about the origin gave the voices power over her. Although the UP intervention has enabled her to relate to the voices in a more adaptive way, she still presents a firm belief in delusional ideas associated with hallucinations, despite the evidence against this belief. The time spent during the sessions on discussing and treating “errors in thinking” is probably insufficient to generate significant changes in persistent delusional symptoms in patients with TRS. This finding suggests that, once all of the UP modules have been completed, repeating Module 4 (Cognitive Flexibility) during the follow-up could help to further consolidate patients’ capacities in this area.
To our knowledge, this is the first time that the UP has been applied to a person with schizophrenia. In this case, we show how emotion regulation strategies can be improved through an intervention targeting the affective sphere of the disorder. In turn, this allowed the patient to better tolerate intense emotions, leading to improvements in personal recovery. These promising results position UP as a possible treatment of choice in people with persistent psychotic symptoms. However, future studies on the application of the UP in a larger number of cases would help to more accurately establish the profile of TRS patients who could benefit from this approach and the extend duration of the improvement. Similarly, future studies could assess the effectiveness (in terms of achieving the desired changes) of the sequencing of the modules used in the present case.
12. Recommendations to Clinicians and Students
For clinicians interested in applying the UP to patients with schizophrenia, we offer the following advice based on our experience. First, in refractory patients, we suggest to consider the application of the UP in an individual format (rather than a group format) (Lockwood et al., 2004). Second, the assessment process should be used to promote patient engagement with the therapeutic relationship. Third, clinicians should consider including new technologies in the therapy (e.g., audio summaries of the session contents) to improve patients’ understanding of the content and encourage them to complete homework assignments. Fourth, it is important to invest time in psychoeducation to help the patient better understand how to differentiate between emotions and thus improve clarity. Fifth, it may be advisable to deliver the modules in a different order to suit the specific characteristics of a given patient. In this regard, one interesting option to consider might be to induce hallucinatory experiences as a substitute for the module on “confronting physical sensations”. Finally, it may be advisable to consider increasing the number of sessions dedicated to cognitive flexibility, perhaps by including this module as an additional follow-up in order to strengthen the patient’s understanding of this key skill.
Footnotes
Acknowledgments
The authors wish to thank the participant for giving her permission for this publication.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the AMA DABLAM programme (EC/16/272/4723), the regional government of Aragón (Departamento de Innovación, Investigación y Universidad), FEDER “Construyendo Europa desde Aragón” (research team S31_20D), and ONA CORPORATION (Barcelona, España).
