Imagine trying to live in society without the ability to understand facial expressions. Your sister frowns, but instead of guessing that she might be sad, you decide she is annoyed. And you're convinced that she must be angry with you.
Now imagine that in addition to this, you can't understand other people's intentions. One day your spouse says pointedly, "I'd like to wear this shirt, but unfortunately no one has done the laundry!" The hint is wasted on you, since you're immune to this kind of prodding.
The condition described above is schizophrenia, a severe brain disorder that usually emerges during young adulthood, and affects one percent of Americans, according to the National Institute of Mental Health (NIMH). People with this condition are typically treated with a variety of drugs and various group and individual therapy sessions.
But now a new non-drug therapy called Social Interaction and Cognition Training (SCIT) is generating interest from clinics across the country as a promising way to help people with schizophrenia interact with others. Creators David Penn and David Roberts at University of North Carolina at Chapel Hill and Dennis Combs at the University of Texas at Tyler hope that SCIT will help participants understand intentions and dispositions.
Lost in Translation
The disease can cause obvious symptoms such as paranoia, or hallucinations. But many people with schizophrenia also suffer from ailments such as memory loss, or inability to pay attention -- which make it incredibly difficult to lead normal lives.
Researchers believe paranoia, difficulty communicating and poor social functioning are some of the most debilitating aspects of the disease. Without the basic social skills most of us take for granted, it's nearly impossible to hold down a job, make friends, or, for some, simply co-exist. There is often a sense of loneliness, and fear.
Standard therapies for schizophrenic patients focus on coping with emotions or specific behaviors, according to Joanna Fiszdon, a clinical research psychologist at Yale. But SCIT is broader -- not only does it address the way patients interpret emotions, it also asks patients to look at different social situations and come up with alternative ways of coping with them.
"Whether you like people or not you have to interact with people," said Fiszdon. "If we can make those interactions with other people less stressful and less difficult that would be a great thing."
Although research is still in the early stages, Psychiatric Services, an American Psychiatric Association journal, identified SCIT as a "potential best practice" earlier this year. Pilot testing with 18 inpatients demonstrated SCIT therapy improved emotion perception, ability to understanding people's intentions, and reduced the tendency to attribute hostile intent to others. Patients were also less likely to act out in an aggressive way.
Potential to Change Lives
The NIMH approved a larger, randomized control study that started during the summer to find out if the results from their pilot studies will hold up.
Combs, now an assistant professor of psychology at the University of Texas at Tyler, recounted one particularly memorable moment from the study group at an Oklahoma treatment facility last spring. Several schizophrenic inpatients approached the nurse on duty to share a lesson they had learned in SCIT group therapy. Having noticed she was in a bad mood, they calmly suggested that her emotions were most likely affecting her interactions with other people.
The nurse was reportedly stunned at their perception. Despite difficulty with social interaction and empathy, these patients had overcome their natural inclinations to remain socially isolated.
It was one of the many moments that made Combs realize SCIT had the potential to change lives.
"I was pleased with the fact that they learned the material and were able to recognize it in others and use it in their daily lives," he said. "Knowing it and then actually using it are different things."
'Therapy That's Fun'
During SCIT therapy sessions, therapists use video tapes, computers, role playing and other methods. The interaction is one reason why participants keep coming back.
"Normally when we do treatment we just stand there and lecture," Combs said. "This way the videos are engaging and fun, and teach important social skills."
Attendance was more than 90 percent during the 18-week long study program in Oklahoma.
Penn said their approach was to make teaching as fun as possible. "It's not just us sitting in front of the TV with people. That's not it at all. We use these things as models," Penn said.
The idea to use video came from David Roberts, a graduate student in psychology at the University of North Carolina-Chapel Hill who helped develop SCIT. He had spent six years working with schizophrenic inpatients before he began to wonder whether they were appreciating television the way he did.
People with schizophrenia tend to have blank expressions, something psychologists refer to as "flat affect." But watching TV can bring out subtle reactions: smirks, winces, and even the occasional chuckle. This kind of enjoyment is hard to see, however, in part because patient medications mute emotional expression.
Over the past several years, psychologists have come to expect more from people with schizophrenia, Roberts said.
"There is a large subset of people who pick up on more than they are typically given credit for," he said. "There is a lot of subtlety and nuance and thought that is happening behind the flat face of someone with schizophrenia."
Eventually Roberts approached Penn, his advisor, and told him about the patients' interest in television.
"If you went to an old-school behaviorist and said these things, it doesn't mesh with their understanding of the illness," Roberts said. "But my advisor, he was game. He was definitely willing to explore and talk about it."
Roberts started showing clips of HBO's "Curb Your Enthusiasm" during therapy sessions, and it turned out that the Larry David comedy was more than an entertaining string of embarrassing, socially awkward circumstances. It was also a case study for the negative consequences that can arise when people jump to conclusions, or misinterpret behavior.
"'Curb' was so chock full of appropriate scenes that it just made more sense to focus on it?and I thought it was funny," Roberts said. "I see 'Curb' as being similar to some Woody Allen movies in its use of only vaguely scripted dialogue. I wanted to shoot for something that felt closer to patients' real lives, and less like a fictional movie."
Eventually, Roberts and Penn began writing and shooting their own skits.
"It was kind of difficult to come up with the situations," Roberts said. They ended up drawing from examples on TV shows, clinical experience and their own lives.
"Think of the last few days of your life," Roberts said. "Have there been social encounters that left you feeling kind of bad, frustrated, confused, guilty? We could likely build a SCIT skit out of that kernel."
It turned out that patients responded just as well to the homemade videos.
"I think we succeeded in capturing awkwardness and discomfort in a way that may not have been as comedic as the shows, but was probably more true to life," Roberts said. "Also, we were able to fashion our scenes to hit exactly the notes that we wanted. If Larry David called now and offered to let us use the show, we'd probably stick with our scripts."
The Patients Respond
Patients agree that they've been helped. One person who completed a SCIT intervention in North Carolina said, "I used to think people were laughing at me when I came into the room. Now I know they're not."
Another wrote in response to a survey, "SCIT has helped me become more effective in interpersonal interactions by teaching the difference between facts and guesses, helpful and harmful feelings, the importance of non-verbal communication (which is responsible for fully 70 percent of social interchange), and the necessity of recognizing the difference between thinking and knowing."
Alice Medalia, a clinical psychiatry professor, is implementing the new therapy at the Columbia University's Lieber Recovery and Rehabilitation Clinic for Psychotic Disorders, which opened in April.
"I have found that SCIT is very helpful for people whose cognitive skills have been improved and the next step is how are you going to use them," she said.
Medalia combines neurocognitive therapy with SCIT to help people gain the skills to make friends again and go back to work.
"SCIT is really very different because the focus is to help people develop skills to be able to function better in everyday life," said Medalia. She explained that people with severe psychological illnesses often stop developing social skills, in part because the illness may present itself during young adulthood.
The therapy is also being used at the Federation Employment and Guidance Service, Inc., a non-profit group that provides health-related services to New Yorkers.
"Our staff love it, our clients love it, we're getting a lot of people engaged in it," said Amy Dorin, senior vice president of behavioral health services at FEGS. "Clients keep coming to the groups and we feel it has the potential to really help people with social cues."
Hope for Autistic Teens
After an eye-opening experience last summer where Penn observed a group for people with autism, he is now adapting SCIT for high-functioning autistic adolescents. He plans to use a separate set of videos to address situations focused more on emotions rather than paranoia.
Penn and Lauren Turner, a postdoctoral research fellow, will begin studying SCIT with autistic adolescents this December. They hope to teach kids how to pick up on social cues.
"A lot of these kids really want to interact socially, they want friends," Turner said. "People with autism often respond well when they have visual examples rather than through auditory means. There are a lot of programs out there that are very similar -- what I liked about this program is that it is not just focusing on the skills themselves but social thinking, and understanding social situations better."
Penn is the first to acknowledge that more research is needed, and that the results of his prior studies could change with a larger randomized trial. But he's optimistic that these tools could help people express emotions, and live happier lives.
"This could be the seed of helping people develop empathy," he said.