The Benefits of Individual Psychotherapy for People Diagnosed With Schizophrenia: A Meta-Analytic Review

Transcription

1 Ethical Human Sciences and Services, Volume 4, Number 3, Fall/Wter 2002 The Benefits of Individual Psychotherapy for People Diagnosed With Schizophrenia: A Meta-Analytic Review William H. Gottdiener New School University New York, NY Nick Haslam University of Melbourne Melbourne, Australia A comprehensive meta-analytic review was undertaken to determe the efficacy of dividual psychotherapy for people diagnosed with schizophrenia. Mean effect sizes were calculated for 37 studies conducted on 2,642 patients. Possible moderator variables cluded (1) randomization, (2) source of data (between-groups and with-groups), (3) type of psychotherapy, (4) use of conjot antipsychotic medication, (5) ity of the disorder, (6) treatment context, and (7) diagnostic criteria. Psychodynamic, cognitive-behavioral, and non-psychodynamic supportive therapies were all associated with improvement functiong. Similar effect sizes were found between psychotherapy combed with antipsychotic medication and psychotherapy used with medication, between studies that used randomization and those that did not, and between acute and schizophrenia. Larger effects existed for with-groups data compared with between-groups data, for patients compared with patients, and for studies conducted before the publication of DSM-III. Limitations of this review and suggestions for future research are discussed. :>r nearly 100 years, dividual psychotherapy has been used the treatment of Fs< schizophrenia, but its efficacy remas one of the most hotly debated subjects the hhistory of psychiatry. Durg that time, a large clical literature has accrued from multiple theoretical perspectives. Although psychotherapists gog back to Freud (1904) have questioned the utility of dividual psychotherapy for people diagnosed with schizophrenia, most of the clical literature describes creative terventions that psychotherapists and clical researchers have developed to achieve positive results. Some of the more proment psychotherapists and clical researchers clude psychoanalysts such as Arieti (1974), Boyer and Giovacchi (1980), Federn (1952), Fromm-Reichmann (1960), Lotterman (1996), Karon and VandenBos (1981), Robbs (1993), Searles (1965), and Sullivan (1962). Also cluded are cognitive-behavioral therapists such as Fowler, Garety, and Kuipers (1995), Haddock and Slade (1996), Kgdon and Turkgton (1994), and Ferris (1989), and clical researchers such as Hogarty and colleagues (1995) who have developed non-psychodynamically oriented supportive therapies Sprger Publishg Company J 63

2 164 Gottdiener and Hasten In contrast to the clical literature, research on the efficacy of dividual psychotherapy for people diagnosed with schizophrenia has been marked by contradictory fdgs. Two frequently cited studies exemplify these mixed results (Karon & VandenBos, 1981; May, 1968). Both were randomized controlled clical trials (RCT) that compared dividual psychotherapy used with and with medication to standard psychiatric treatment which antipsychotic medication was the primary tervention. May (1968) found that patients treated with supportive psychodynamic psychotherapy and conjot antipsychotic medication, or those treated solely with medication, had significantly greater improvement rates than patients who received only supportive psychodynamic psychotherapy. In the Karon and VandenBos (1981) study, also conducted the 1960s (see Karon & O'Grady, 1969, 1970; Karon & VandenBos 1970,1972, 1975), the opposite results were obtaed. Psychotherapists treated two groups of patients with dividual exploratory psychodynamic psychotherapy. One group did not receive medication and the other did, but only small doses that were ended with the first few weeks of treatment. These two treatment groups were compared to a third group of patients who received standard hospital care with antipsychotic medication as the primary treatment. The researchers found that significantly more patients treated with dividual psychotherapy (cludg those treated with psychotherapy and a brief course of medication) improved compared with those patients who received medication only. Sce these two landmark studies many others have been conducted from different theoretical perspectives, the results of which have been summarized a number of qualitative reviews (Fenton, 2000; Gomes-Schwartz, 1984; Herichs & Carpenter, 1981; Liberman, 1994; Mosher & Keith, 1980; Mueser & Berenbaum, 1990; Scott & Dixon, 1995). Most reviewers have concluded that little evidence exists to support the efficacy of psychodynamic psychotherapy, but evidence exists to support the efficacy of cognitive-behavioral and non-psychodynamic supportive therapies. When reviewg a body of literature, the decision to use meta-analysis or not, has potentially far-reachg implications. Two major policy papers establishg guideles for the treatment of schizophrenia relied on qualitative reviews of the empirical literature. They came to somewhat different conclusions ab the efficacy of dividual psychotherapy for people diagnosed with schizophrenia and made somewhat different recommendations ab its use. These guideles clude the Patient Outcomes Research Team (PORT) report (Lehman & Stewachs, 1998) and the guideles developed by the American Psychiatric Association (APA) (1997). Both sets of guideles recommend that dividual psychotherapy usg supportive terventions is an effective treatment for schizophrenia when combed with antipsychotic medications, but only the APA guideles state that exploratory terventions (e.g., psychodynamic) might be useful for at least some patients. The PORT report, however, states that: Individual and group psychotherapies adherg to a psychodynamic model (defed as therapies that use terpretation of unconscious material and focus on translerence and regression) should not be used the treatment of persons with schizophrenia. Rationale. The scientific data on this issue are quite limited. However, there is no evidence support of the superiority of psychoanalytic therapy to other forms of therapy, and there is a consensus that psychotherapy that promotes regression and psychotic transference can be harmful to persons with schizophrenia. This risk, combed with the high cost and lack of evidence of any benefit, argues strongly agast the use of psychoanalytic therapy, even combation with effective pharmacotherapy. (Lehman &. Stewachs, 1998, pp. 7-8)

3 Individual Psychotherapy for Schizophrenia 165 To date, four reviews have employed meta-analysis (Cormac, Jones, & Campbell, 2002; Malmberg & Fenton, 2001; Mojtabai, Nicholson, &. Carpenter, 1998; Smith, Glass, & Miller, 1980). Meta-analysis is the quantitative synthesis of similar empirical reports. Although like all statistical techniques, meta-analysis is not with its limitations (see LeLorier, Gregoire, Benhaddad, Lapierre, & Derderian, 1997; Wilson & Rachman, 1983), it is the most effective way to resolve controversial fdgs across a body of literature and has distct advantages over qualitative literature reviews (see Hunter & Schmidt, 1990; Rosenthal, 1991). Previous meta-analyses have come to different conclusions on this topic. Meta-analyses conducted by Smith and associates (1980) and Mojtabai and colleagues (1998) found that many schizophrenic patients improved who were treated with a variety of psychosocial treatments and antipsychotic medication. Of particular relevance to the current discussion, Mojtabai and colleagues (1998) found that dividual psychotherapy was the most efficacious psychosocial treatment they reviewed. Malmberg and Fenton (2001) reviewed RCTs only and concluded that the methods of existg research were too poor to draw defitive conclusions for or agast the efficacy of dividual psychodynamic psychotherapy. Cormac, Jones, and Campbell (2002) looked at cognitive-behavioral terventions for schizophrenia and concluded that there was no effect over standard treatment. THE NEED FOR A NEW META-ANALYTIC REVIEW Schizophrenia remas a significant public mental health problem, and any treatment that could help people who suffer from it ought to be known and available. Because meta-analysis is the most effective way to clarify conflictg results a body of empirical literature, a comprehensive meta-analytic review could resolve the debate surroundg the efficacy of dividual psychotherapy for people diagnosed with schizophrenia. The four meta-analyses cited above have not resolved the debate because of methodological differences. First, none of the meta-analyses has been comprehensive. Smith and colleagues (1980) and Mojtabai and associates (1998) vestigated the efficacy of dividual psychotherapy only when it was combed with medication. No review established the relative efficacy of dividual psychotherapy when used with medication because none examed this issue. Three of the four meta-analyses analyzed data only from betweengroup designs (e.g., two-group experimental designs); only Smith and associates also cluded studies with with-group designs (e.g., quasi-experimental, sgle group, pre-test/post-test designs and sgle group, post-test only designs). However, Smith and colleagues did not exame these studies separately. Furthermore, Malmberg and Fenton (2001) and Cormac and colleagues (2002) only reviewed RCTs. With-groups data are important because they provide formation on treatment efficacy absolute terms, whereas between-groups data provide formation relative terms. Second, fdgs from the Smith and associates metaanalysis are over 20 years old. The number of studies these authors reviewed is also unclear from their report and they combed the results of dividual, group, and family treatments. Third, although relatively up to date, the meta-analysis by Mojtabai and associates cluded only 10 reports of dividual psychotherapy when ab 40 have been published. Malmberg and Fenton cluded only three reports and Cormac and colleagues cluded 22 reports, but not all of the studies reviewed by Cormac and associates were of dividual psychotherapy. Fourth, none of the reviews reported the relative efficacy of the three major forms of dividual psychotherapy for schizophrenia psychodynamic, cognitive-behavioral, and nonpsychodynamic supportive.

4 166 Gottdiener and Haslam A new meta-analysis is also warranted because some empirical evidence dicates that psychosocial treatments enhance the recovery of people diagnosed with schizophrenia. Accordg to Hegarty, Baldessari, Tohen, Waternaux, and Oepen (1994), and Warner (1994), approximately 50% of people diagnosed with schizophrenia and treated durg the past 100 years have been shown to improve to at least the level of social recovery. A person this category is able to be self-sufficient and live dependently. Yet, as suggested by Warner's review, this level of recovery appears only to occur with those patients who have received psychosocial treatments. Prior to 1985, the overall success rate for somatic treatments (medication, electroconvulsive therapy, etc.) rose to just under 50%, but with a clear reason, it has sce dropped to approximately 35% despite the more widespread use of antipsychotic medications (Hegarty et al, 1994). These fdgs, culled from hundreds of come studies and long-term follow-up reports, dicate that somatic-only treatments are often sufficient by themselves and that psychosocial treatments are frequently necessary for the highest levels of improvement to occur. Clical experience with people diagnosed with schizophrenia and empirical research also reveal that most patients with schizophrenia believe psychosocial treatments and dividual psychotherapy particular enhance their lives (see Coursey, Keller, & Farrell, 1995). In order to determe the efficacy of dividual psychotherapy for people diagnosed with schizophrenia, we conducted a comprehensive meta-analytic review of the empirical literature, which cluded review of any study which an effect size was calculable regardless of study design. (An effect size is " 'the degree to which the phenomenon is present the population,' or 'the degree to which the null hypothesis is false.'... the null hypothesis always means that the effect size is zero" (Cohen, 1988, pp. 9-10). This procedure enabled us to determe the overall efficacy of dividual psychotherapy for schizophrenia. It also enabled us to determe (a) the effects of random assignment of participants, (b) the effects of the source of the data (with-groups and between-groups), (c) the relative efficacy of psychodynamic, cognitive-behavioral, and non-psychodynamic supportive therapies, (d) the efficacy of conjot antipsychotic medication, (e) the effects of the ity of the disorder, (f) the effects of treatment context, and (g) the potential effects of the narrowg of the schizophrenia diagnostic criteria that occurred with the publication of the Diagnostic and Statistical Manual of Mental Disorders-Third Edition (DSM-III) (APA, 1980). METHOD Inclusion Criteria In order to conduct a comprehensive review, we used broad clusion criteria to select reports. We chose to consider any come study that tested the efficacy of dividual psychotherapy for people diagnosed with schizophrenia which an effect size estimate was calculable. Therefore, we did not limit our review to studies that employed random assignment of participants, and we reviewed reports that contaed data from with-groups and between-groups designs. Inclusion of studies that did not use random assignment is justified because many clical reports do not employ random assignment. Furthermore, non-random assignment does not necessarily validate a study's come. Although we expand on this pot the discussion section, it is worth notg that the effect of randomization is an empirical one, and it has been poted recently that effect sizes and confidence tervals studies that employ random assignment are often comparable to those that do not employ random assignment (Benson & Hartz, 2000; Concato, Shah, & Horowitz, 2000).

5 Individual Psychotherapy for Schizophrenia 167 As noted, with the exception of Smith and colleagues (1980), past reviews of this topic have only considered the results obtaed from between-groups data (i.e., experiments) and have not reviewed results obtaed from with-groups data (pre/post), even if they were available. Such clusion criteria can create a potentially serious bias the review process. Review of between-groups data can only provide formation ab the results of experimental group versus control group, or as the case of most psychotherapy come studies, experimental treatment versus alternative treatment. The results of such studies can only provide formation ab relative efficacy. They cannot provide formation ab the magnitude of change the treatment group relative to where those patients began treatment or the proportion of patients successfully treated at come compared with those who were not successfully treated. Most reviewers exclude from review data or studies that were conducted usg a with-groups design the belief that lack of control or alternative treatment groups poses too serious a threat to the study's ternal validity. This, however, is not necessarily the case because, when the reliability of the dependent variable measure(s) is high, alternative explanations become less plausible (Hunter & Schmidt, This topic is more fully addressed the discussion section). In most psychotherapy research, the reliability of dependent variable measures is high because standardized measures are used. Exclusion of formation that comes from with-groups study designs means that potentially valuable formation is lost from consideration the review. To conduct this review we operationally defed dividual psychotherapy broadly as any system of psychotherapy where one dividual (the therapist) attempts to help another dividual diagnosed with schizophrenia (the patient) obta a relatively self-sufficient level of functiong by focusg on remedyg cognitive and/or emotional difficulties the patient with necessarily attemptg to change directly the patient's terpersonal or social-occupational functiong. We therefore excluded from review reports which the primary terventions were case management, social skills trag, or psychoeducation. We categorized the psycho therapies cluded for review as psychodynamic, cognitive-behavioral, or nonpsychodynamic supportive therapies. All studies we reviewed were published English; we located no pertent studies published other languages. Literature Search We obtaed reports by perusg past review articles, the troductions to reports that were eventually used this study, reference sections of books and articles, and the tables of contents of various journals, particular, the Journal of Abnormal Psychology, Schizophrenia Bullet, American journal of Psychiatry, Archives of General Psychiatry, journal of Consultg and Clical Psychology, and Journal of Nervous and Mental Disease. We searched through onle databases of Medle and Mental Health Abstracts (from 1967 through September 1999) and PsycINFO, which cludes dissertation abstracts (from 1899 through September 1999). We used the followg keyword phrases: psychotherapy and schizophrenia, and dividual and psychotherapy and schizophrenia or schizophrenic and results. In addition, we ran other searches by varyg the keywords and substitutg dividual and psychotherapy with words describg theoretical approaches such as psychodynamic psychotherapy, psychoanalytic psychotherapy, tensive psychotherapy, cognitive therapy, behavioral therapy, and cognitive-behavioral therapy. These words were selected on the basis of phrases that appear the clical and research literature on psychotherapy with people diagnosed with schizophrenia and those suggested by White (1994). These searches yielded 42 reports that satisfied our clusion criteria. Five reports did not yield effect sizes and were consequently excluded, leavg 37 reports our meta-analysis.

6 168 Gottdiener and Has lam Fail-Safe N Incomplete literature searches can bias meta-analytic results, especially if there are many unpublished reports with null results. However, null results are less likely to be published, which means such reports are difficult to obta. If studies with null results were retrieved and cluded a meta-analysis, they might reduce the mean effect size of the meta-analysis to a negligible magnitude or cause the results to reverse direction. Rosenthal (1991) has developed a method of determg the number of additional reports that would have to be retrieved to state that no relationship exists between the dependent and dependent variables beg vestigated a meta-analysis. That number is called the Fail-Safe N. To calculate it, one multiplies the total sample of retrieved studies by 5 and adds 10. In the present case, the Fail-Safe N would be 185, (5 x 37) 10, which means that one would have to fd 185 additional reports with null results to confidently say that no relationship exists between dividual psychotherapy and improvement schizophrenic symptoms. Hedges and Olk (1985, p. 306) offer an alternative formula to calculate the Fail-Safe N: k 0 = k(f - rj/r,. The number of studies needed to reduce the mean effect size ( a fixed-effects model) to a negligible magnitude is!cq. The mean effect size is f, r, is the proposed effect size that would be of negligible magnitude, which we set at r =.05, and k is the number of studies the metaanalysis. In the current meta-analysis, ICQ = 37( )/.05; ICQ = (i.e., an additional 192 studies with null results would be required to reduce the current effect size to a negligible level of r =.05). Meta-Analytic Procedures Our meta-analytic methods are based on the methods of Rosenthal (1991), Hedges and Olk (1985), and Hunter and Schmidt's (1990; 2000) approach. The latter authors focus on the correction of samplg error and the attenuation of effect sizes caused by study of artifacts like measurement error. Calculation of Effect Sizes We employed the Pearson Product Moment correlation r coefficient as the effect size dex and calculated most effect sizes with the aid of the DSTAT software (Johnson, 1995). The DSTAT software or probit transformations (Glass, McGaw, & Smith, 1981) were used to calculate effect size estimates for categorical comes, and the most conservative effect size estimate was always chosen. These effect size estimates were then converted to (r) coefficients. We also used the program Comprehensive Meta-Analysis (Borenste & Rothste, 1999) to calculate the mean effect sizes, confidence tervals, and standard errors. Effect sizes were weighted by the verse of their variance (Hedges & Olk, 1985; Hunter & Schmidt, 1990) so that studies with relatively large samples would weigh more than studies with relatively small samples. We employed a random-effects model and a Fisher Z transformation our calculation of the mean effect sizes. We used random-effects models because they provide the most accurate estimates of confidence tervals meta-analysis and have, therefore, been recommended over fixed-effects models by the National Research Council (Hunter & Schmidt, 2000). The advantage of reportg effect sizes the form of the Pearson r is that it is an easily understood measure of effect because it describes the magnitude and direction of the relationship between two variables of terest (Hunter & Schmidt, 1990; Rosenthal, 1991). Furthermore, it can be terpreted with the Bomial Effect Size Display (BESD), which

7 Individual Psychotherapy for Schizophrenia 169 permits r to be a measure of the percentage of people who were likely to have shown improvement from a given treatment (Rosenthal & Rub, 1982; Rosenthal, 1991). As an example, if an effect size of r =.50 were calculated, the mean overall treatment effect size of r =.50 is equal to a 50% improvement rate. A 50% improvement rate means that the number of patients who are likely to benefit from treatment went from approximately 25% to 75%. This means that if 25% of patients were to improve with treatment, then 75% would be likely to improve with treatment. To calculate the change improvement rate, come must be considered dichotomous terms, even though reality it might be contuous. Treatment come must be dichotomized to "improved" and "not improved" categories. The correlation coefficient is divided by 2 and.50 (which represents the 50% probability level) is added to the dividend. The formula is.50 /- r/2. It is important to realize that the BESD is not an dication of the degree to which patients lose symptoms. Rather, it dicates how many people are likely to improve functiong. It is possible that all patients at the end of treatment are still symptomatic, but that they are less symptomatic (i.e., they hallucate less often or have less cognitive slippage). The BESD works best with truly dichotomous comes (lived or died, improved or not improved). When comes occur on a contuum, as they do schizophrenia, then the BESD reflects the number of people who improved. It will not reflect whether patients improved to a pot where they can function with treatment. One of the important problems that meta-analysts encounter is how to treat reports with statistically significant results. We took a conservative approach and treated such results as if they had an effect size of zero (Cooper, 1989). If, on the other hand, we encountered reports that simply stated that a test was significant at the p <.05 or p <.01 level and so forth, we calculated the effect size by usg the next highest probability coefficient (e.g., ifp<.05 was reported, we calculated the effect size based on a probability equal to.049). As stated above, we cluded reports that contaed with-groups and between-groups data this review. This decision allowed us to use some reports more than once when they contaed with-groups and between-groups data, which allowed us to capture the different ways which dividual psychotherapy for schizophrenia has been researched. However, each report contributed only one effect size to the meta-analysis. Some reports contaed one come measure that yielded one effect size, whereas other reports contaed multiple come measures and yielded multiple effect sizes. In such cases we averaged the multiple effect sizes. In this way, each study, regardless of how many effect sizes it yielded, contributed a sgle effect size per meta-analysis order to mata dependence of effect sizes. After correctg for samplg error, we sought to correct the mean effect sizes for attenuation due to other artifacts (Hunter & Schmidt, 1990; Schmidt 6k Hunter, 2001). Correction for attenuation due to study artifacts provides a more accurate estimate of the mean population effect size. We only found formation on dependent variable measures our sample of reports, and thus, controlled for attenuation due to measurement error the dependent variables. Published reliability coefficients were gathered for 10 come measures, which are listed Table 1. These measures were chosen because their coefficients were provided the reports we reviewed. The mean of these coefficients provides an estimate of the mean reliability of all of the come or dependent variable measures that had been employed the various studies. We refer to this estimate as the artifact attenuation factor (Hunter & Schmidt, 1990) and calculated it as A =.85. To correct for measurement error the dependent variable, we divided the mean effect size by the artifact attenuation factor to yield an estimate of the population effect size.

8 170 Gottdiener and Haslam TABLE 1. Reliability of Outcome Tests Used to Calculate the Artifact Attenuation Factor Outcome Measure Reliability Coefficient Psychiatric Status Schedule.91 Mennger Health Sickness Ratg Scale.92 Camarillo Dynamic Assessment Scale.88 Rorschach (Holt's Scorg Method).93 Psychotherapy Outcome Interview.59 Golschalk Social Attenuation/Personal-Disorganization Scale.92 Behavioral Disturbance Index.94 Strauss-Carpenter Outcome Scale.92 Jenk's Symptom Ratg Scale.77 Brief Psychiatric Ratg Scale.77 Mean Reliability.85 We decided to look for moderator variables only if the standard deviations of the mean corrected effect sizes were larger than zero (Schmidt & Hunter, 2001). This rule of thumb allows for detection of moderators that have theoretical or practical importance (Hedges & Olk, 1985; Hunter & Schmidt, 1990) and does not rely on statistical methods for moderator detection, which tend to have low power (Schmidt & Hunter, 2001). The only moderators that provided enough formation to vestigate were (1) randomization, (2) source of data (between-groups or with-groups), (3) type of dividual psychotherapy, (4) use of conjot antipsychotic medication, (5) ity of the disorder, (6) treatment context, and (7) diagnostic criteria. Codg Reliability First author William Gottdiener coded all of the reports, and a clical psychology graduate student coded 10 randomly chosen reports as a reliability check. The variables cluded were study design, the existence of a control group, sample size, effect size, and treatment type. We chose these variables because the results of the meta-analyses revolved around them. The kappa coefficient (k), the contgency coefficient (c), and the Pearson Product Moment Correlation coefficient (r) were used as measures of reliability. Table 2 shows that each variable was coded with a high degree of reliability. RESULTS Our reason for conductg this meta-analysis was to learn if dividual psychotherapy actually benefits people diagnosed with schizophrenia. We answered this question by reviewg 37 studies that were published between 1954 and We calculated 232 effect sizes. These reports are based on the treatment of 2,642 patients with a mean age of 31.1 years. Treatment lasted for an average of 20.2 months with a mean of 1.4 sessions per week. In order to determe the overall efficacy of dividual psychotherapy for people diagnosed with schizophrenia, we averaged all of the effect sizes from all 37 studies. The results Table 3 show that dividual psychotherapy was associated with improvement overall functiong. The table presents the grand mean effect size, the corrected effect size (this is the grand mean effect size divided by the artifact attenuation factor), and improvement rates

9 Individual Psychotherapy for Schizophrenia 171 TABLE 2. Codg Reliability Variables Reliability Coefficient Study design c =.77 Control group used (/no) k -.74 Sample size r =.98 Effect size r =.93 Treatment type r = 1.00 determed by the BESD. The grand mean effect size was r =.31 (95% CI ±.22 to.41). The corrected effect size was r =.36. The BESD results showed that improvement rate creased from 35% to 66%, which means that 66% of patients are better off after treatment compared with 35% before treatment. What does this mean? Rosen thai, Rosnow, and Rub (2000) write: " r of.32 (or a r of.10) will amount to a difference between rates of improvement of 34% and 66% if half the population received psychotherapy and half did not, and if half the population improved and half did not" (p. 17). In this meta-analysis the BESD means that 65% of the population that received psychotherapy improved compared with only 34% of the population that did not receive psychotherapy. The grand mean effect size shows the general efficacy of dividual psychotherapy for people diagnosed with schizophrenia. Treatment efficacy was, however, moderated by a number of factors. As noted above, we examed only variables for which there was abundant formation through the database. We present these below. The distribution of moderator variables our sample of 37 reports is presented Table 4- The Effects of Random Assignment Studies that employ random assignment are thought to mimize threats to ternal validity and crease the accuracy of effect size estimates compared with studies that do not employ random assignment (Kazd, 1998; Shadish & Ragsdale, 1996). Shadish and Ragsdale found that psychotherapy come studies that employed random assignment reported larger effect size estimates than those that did not employ random assignment, which led them to conclude that failure to randomize leads to potentially less accurate effect size estimates. Because we reviewed studies that used random assignment and studies that did not, we were able to see if the studies differed. Neteen studies employed random assignment. The mean effect size for these studies was r =.31 (95% CI ±.17 to.43). Another 18 studies either did not employ random assignment or did not report if it was used. The mean effect size for these studies was r =.34 (95% CI ±.20 to.46). Thus, this database there was essentially no difference come between studies that employed random assignment and those that did not. This suggests that failure for primary studies to employ random assignment did not pose meangful threats to the ternal validity of this meta-analysis. Source of Data It has been stated that with-groups data tend to flate effect sizes compared with betweengroups data (Morris & DeShon, 2002). The advantage of combg both types of data one meta-analysis would be for the between-groups data to correct for effect size flation that could be caused by with-groups data. Whether or not with-groups data flate effect

10 172 Gottdiener and Haslam TABLE 3. Meta-Analysis Results: All Effect Sizes Combed Citation 1. Alanenetal. (1985) 2. Alanenetal. (1994) 3. Bookhammer et al.(1966) 4. Buchkremer et al. (1997) 5. Bullard etal. (1960) 6. Carpenter et al. (1977) 7. Coursey et al. (1995) 8. Falloonetal. (1985) 9. Fowler & Morley ( 1989) 10. Garety et al. (1994) 11. Glass etal. (1989) 12. Gottlieb & Huston (1951) 13. Grspoon et al. (1968) 14. Gunderson et al. (1984) 15. Hamill&Fontana(1975) 16. Hogarty et al. (1974) 17. Hogartyetal. (1979) 18. Hogarty et al. (1997) 19. Karon & VandenBos (1981) 20. Levene(1970) 21.Lszenetal. (1998) 22. Marks (1968) 23. Mathews(1977) 24. May (1968) 25. May etal. (1981) 26. McGlashan(1984) 27. Messier et al. (1969) 28. O'Brien etal. (1972) 29. Rubs (1976) 30. Sjostrom(1985) 31. Stone (1986) 32. Sverre(1991) 33. Tarrier et al. (1993) 34. Tarrier et al. (1998) 35. Walker & Kelley (1960) 36. Whitehorn & Betz (1954) 37. Whitehorn&Betz(1957) Totals Corrected Effect ESr 0.31 Effect Size Lower BESD Success rate Increased From To % % Upper N total* * r p value SE *The N total is the total sample used to calculate all of the effect sizes from a given study. If two effect sizes were calculated a study with 10 participants, then the N total for that study would be 20.

11 Individual Psychotherapy for Schizophrenia 173 sizes is open to debate. Rather than flatg effect sizes, with-groups data have been thought to simply address different questions from between-groups data. With-groups data exame change one group over time whereas between-groups data exame change one group relative to another group over time. Because of this it has been questioned whether or not it is appropriate to combe with-groups and between-groups data. Morris and DeShon (2002) suggest that it is appropriate to combe such data when effect size estimates are similar or when between-groups and with-groups data are conceptually addressg the same fundamental issues. We present both forms of data combed, as shown Table 3, and separately as follows. For between-groups data, the mean effect size was r -,10 (95% CI ±.02 to.18). We found that for with-groups data, the mean effect size was r =.58 (95% CI±.43 to.70). The between-groups results suggest that dividual psychotherapy provides a similar advantage to other treatments. In this meta-analysis there were seven comparisons which the comparison treatment was not exclusively antipsychotic medication. The comparison consisted of psychotherapy plus medication vs. another form of psychosocial treatment plus medication. The specific results of the between-groups comparisons are as follows: (a) dividual psychotherapy alone compared with antipsychotic medication was r = -.01 (95% CI ± -.21 to.19); (b) dividual psychotherapy plus antipsychotic medication compared with antipsychotic medication was r =.19 (95% CI ±.07 to.31); and (c) dividual psychotherapy plus medication compared with other psychosocial treatments plus medication was r -.08 (95% CI ± -.16 to.31). As can be seen, the only comparison that showed a distct advantage over another treatment was the comparison of dividual psychotherapy plus medication compared with antipsychotic medication. The with-groups data from above suggest that there is a dramatic change that occurs durg treatment and that most patients are much better off than they were before treatment. The fdgs show that the efficacy of treatment between dividual psychotherapy and alternative treatments (e.g., antipsychotic medication) was approximately equal. It is, therefore, plausible to thk that a similar amount of change occurs from pre-test to post-test patients treated with dividual psychotherapy and with antipsychotic medication. Because of this we thought it was justifiable to combe all of the effects irrespective of whether the data came from a with-groups or between-groups design. Although both types of data address different issues, they also address the same fundamental issue of whether or not dividual psychotherapy is an effective treatment for schizophrenia. Type of Individual Psychotherapy As noted above, there have been critiques leveled agast the use of psychodynamic psychotherapy for schizophrenia (Drake & Sederer, 1986; Lehman & Stewachs, 1998; Mueser & Berenbaum, 1990). Although Cormac and colleagues (2002) found equivocal results for cognitive-behavioral therapies, there has also been much praise for their use as well as the use of non-psychodynamic supportive therapies for schizophrenia (Bustillo, Lauriello, Horan, & Keith, 2001; Fowler et al., 1995; Liberman, 1994). We found similar effect sizes for each form of treatment. The grand mean effect size for psychodynamic psychotherapy was r =.33 (95% CI ±.21 to.44). The corrected effect size was r =.39. The BESD results showed that improvement rate creased from 34% to 67%. The grand mean effect size for cognitive-behavioral therapy was r =.35 (95% CI ±.08 to.58). The corrected effect size was r =.41. The BESD results showed that improvement rate creased from 33% to 68%.

12 TABLE 4. Meta-Analysis: Study Characteristics and Distribution of Moderator Variables Citation 1. Alanenetal. (1985) 2. Alanen et al. (1994) 3. Bookhammer et al. (1966) 4. Buchkremer et al. (1997) 5. Bullard et al. (1960) 6. Carpenter et al. (1977) 7. Courseyetal. (1995) 8. Falloon et al. (1985) 9. Fowler & Morley ( 1989) 10. Garety et al. (1994) 11. Glass etal. (1989) 12. Gottlieb & Huston (1951) 13. Grspoon et al. (1968) 14. Gunderson et al. (1984) 15. Hamill&Fontana(1975) 16. Hogarty et al. (1974) 17. Hogartyetal. (1979) 18. Hogarty et al. (1997) 19. Karon & VandenBos (1981) 20. Levene(1970) Zl.Lszenetal. (1998) 22. Marks (1968) 23. Mathews (1977) 24. May (1968) 25. May etal. (1981) 26. McGlashan(1984) 27. Messier et al. (1969) 28. O'Brien et al. (1972) Random Assignment no no no no no no Therapy Medications N CBT Sup. CBT CBT /Sup. /Sup. Sup. Sup. Sup. Sup. /Beh. - /- - - /- /- /- /- - / Chronicity acute acute acute acute/chr. acute/chr. acute/chr. acute acute/chr. acute acute Context / / / / / / Diagnostic Criteria O M LA. DSM-III-R LA. DSM-III U DSM-III U U M LA. U M O U LA. RDC U O DSM-III U LA. LA. LA. M LA. O

13 29. Rubs (1976) 30. Sjostrom(1985) 31. Stone (1986) 32. Sverre (1991) 33. Tarrier et al. (1993) 34. Tarrier et al. (1998) 35. Walker & Kelley ( 1960) 36. Whitehorn et al. (1954) 37. Whitehorn et al. (1957) no no no no no CBT CBT&Sup acute acute/chr. / LA. RDC DSM-III DSM-III DSM-III-R DSM-III-R LA. U U Notes. Diagnostic Criteria: LA. = Interviewer Agreement; RDC - Research Diagnostic Criteria (1975); O = other; U = ; M = multiple criteria DSM or RDC. Medication: = medication used; - = no medication used; /- = medication used with some participants, but not all. Meds = Medication; = psychodynamic therapy; Sup. = non-psychodynamic supportive therapy; Beh. = behavioral therapy; CBT = cognitive-behavioral therapy; N = sample size

14 176 Gottdiener and Has/am The grand mean effect of non-psychodynamic supportive therapy was r =.23 (95% CI ±.00 to.44). The corrected effect size was r =.27. The BESD results showed that improvement rate creased from 38% to 62%. These results contrast with some of the past literature reviews mentioned above and show that all three treatments are beneficial. Furthermore, psychodynamic and cognitive-behavioral therapies produce a similar degree of therapeutic benefit, which is more than that produced by non-psychodynamic supportive therapies. Use of Conjot Medication There is a long-standg controversy ab the use of conjot medication the psychotherapy of people with schizophrenia. For many years, psychotherapists were reluctant to employ antipsychotic medication as an adjunct to psychotherapy because they thought it would disturb the therapeutic process. However, sce at least the 1960s most therapists who treat people with schizophrenia have used antipsychotic medication conjunction with psychotherapy. Most therapists thk it is dispensable. However, between 40% and 75% of patients do not take their medication (Perks, 1999) and there are many for whom medications fail to work (Hegarty et al, 1994). For these patients and for therapists who choose to offer treatment with little or no adjunctive medication, it would be important to know if such treatments work. When antipsychotic medication was used with dividual psychotherapy, the mean effect size was r =.31 (95% Cl ±.19 to.42). When antipsychotic medications were not admistered with dividual psychotherapy, the mean effect size was also r =.31 (95% CI ±.12 to.48). The corrected effect size and BESD results for psychotherapy with medication and with medication was the same. The corrected effect size was r =.36 and the BESD results showed that the improvement rate creased from 35% to 66%. Chronicity of the Disorder People diagnosed with acute schizophrenia have long been thought to have better prognoses than people diagnosed with schizophrenia. For people diagnosed with acute schizophrenia the mean effect size was r =.37 (95% CI ±.10 to.59). The corrected effect size was r =.44- The BESD results showed that improvement rate creased from 32% to 69%. Some studies cluded people diagnosed with both acute and schizophrenia, and others the diagnosis was between acute and. For people this group of studies the mean effect size was r =.12 (95% CI ±.01 to.22). The corrected effect size was r =.14. The BESD results showed that improvement rate creased from 44% to 56%. For those people diagnosed with schizophrenia the mean effect size was r =.36 (95% CI ±.21 to.49). The corrected effect size was r =.42. The BESD results showed that the improvement rate creased from 32% to 68%. Fally, there were studies which the ity was not reported. The mean effect size of those studies was r =.26 (95% CI ±.10 to.41). The corrected effect size was r =.31. The BESD results showed that the improvement rate creased from 37% to 63%. The results were similar for people diagnosed with acute and schizophrenia, but it is difficult to know why. It could be a function of the way we defed acute and schizophrenia. We considered schizophrenia to be when it lasted at least two years. This was an arbitrary distction on our part, and other researchers and clicians might have defed ity differently.

15 Individual Psychotherapy for Schizophrenia 177 Treatment Context Clical lore suggests that treatment context has a strong fluence on treatment come. We could only exame this factor by lookg at which studies were conducted on patients or patients. For patients the mean effect size was r =.29 (95% CI ±.14 to.42). The corrected effect size was r =.34- The BESD results showed that improvement rate creased from 35% to 65%. For those that were treated both patient and patient facilities durg the study the mean effect size was r =.30 (95% CI ±.03 to.53). The corrected effect size was r =.35. The BESD results showed that improvement rate creased from 35% to 65%. Fally, for patients the mean effect size was r =.37 (95% CI ±.19 to.52). The corrected effect size was r =.44. The BESD results showed that improvement rate creased from 31% to 69%. The results show that patients improved at a higher rate than patients, which supports the prediction made based on clical lore. Diagnostic Criteria All of the participants each treatment were diagnosed with schizophrenia, but reports vary accordg to the specificity of the diagnostic formation provided. Table 4 shows the diagnostic criteria that were used for each of the reports cluded this meta-analysis. One study used DSM-II criteria, four used DSM-III, three used DSM-III- R, two employed Research Diagnostic Criteria (RDC, Spitzer, Endicott, & Robs, 1975), four used multiple criteria cludg either a DSM or RDC criterion, another four used other diagnostic criteria, 10 used terviewer agreements, and ne did not report the method they used. It is widely known that the diagnostic criteria for schizophrenia were broader before DSM-III (APA, 1980) was published. Before the publication of DSM-III, people with diagnoses of schizoaffective disorder and schizophreniform disorder were often diagnosed with schizophrenia. People with these latter two disorders tend to have better prognoses than people diagnosed with schizophrenia. Given this, patients pre-1980 studies might have improved more than those later studies, which would be reflected larger effect sizes for those studies. We examed the effect sizes for studies conducted prior to DSM- III's publication even if those studies were published after it. The mean effect size for studies conducted after the publication of DSM-III was r =.39 (95% CI ±.19 to.56). The mean effect size for studies conducted before its publication was r =.28 (95% CI ±.16 to.38). It is difficult to know why results published before DSM-III would produce a smaller effect sce this is contrary to what would be predicted. This meta-analysis addresses a variety of clically relevant questions. Most important, the meta-analytic fdgs suggest that dividual psychotherapy, whether combed with antipsychotic medication or not, is an effective treatment for schizophrenia. Individual psychotherapy with medication appears to have a roughly similar therapeutic efficacy to antipsychotic medication and each treatment seems to have a roughly similar, cremental benefit when combed with the other. Studies that employed random assignment did not have larger effects than those that did not. People diagnosed with acute and schizophrenia obtaed similar success rates. Outpatient treatment was associated with larger cremental benefit than patient treatment. Effect sizes were noticeably larger for studies published after the publication of DSM- III than before it.

16 178 Gottdiener and Has/am DISCUSSION The goals of this meta-analytic review were to determe the general efficacy of dividual psychotherapy for people diagnosed with schizophrenia and the effects of the followg potential moderator variables: 1. randomization, 2. source of data (between-groups or with-groups), 3. type of dividual psychotherapy, 4. use of conjot antipsychotic medication, 5. ity of the disorder, 6. treatment context, and 7. diagnostic criteria. To accomplish this, we retrieved 37 reports (none was a dissertation) published between 1954 and 1999 that met our clusion criteria. Our fdgs dicate that dividual psychotherapy is associated with improved functiong the majority of patients diagnosed with schizophrenia who receive it. We found that all forms of dividual psychotherapy (psychodynamic, cognitive-behavioral, and nonpsychodynamic supportive) were associated with an improvement functiong for people diagnosed with schizophrenia, but the largest improvement rates were associated with psychodynamic and cognitive-behavioral therapies. It is surprisg that the proportion of patients who were likely to improve with conjot medication is similar to the proportion of patients who were likely to improve with a combation of dividual psychotherapy and antipsychotic medication. This fdg is contrary to most therapists' clical expectations. The fdg that dividual psychotherapy can be effective with medication is not new (see Karon & VandenBos, 1981). However, it is important because it suggests that dividual psychotherapy alone might be a viable treatment option for some patients who do not improve from treatment with antipsychotic medications, for some patients who refuse to take medications, or for patients who are treated by therapists who choose to use little or no adjunctive medication. Effect sizes from with-groups data were considerably larger than those from betweengroups data. There were similar effects for people diagnosed with schizophrenia and for those diagnosed with acute schizophrenia. Psychotherapy with patients was, however, associated with lower effect sizes than with patients. In addition, we found that effect sizes were smaller for reports published before rather than after the publication of DSM-III. The results of our meta-analytic review might not, at first, appear to give a coherent account of the efficacy of dividual psychotherapy for schizophrenic patients. But closer spection reveals one clear trend: Individual psychotherapy is associated with improvement functiong people diagnosed with schizophrenia the overall meta-analysis and each moderator analysis of the data. These fdgs are not an aberration. They are consistent with those of the clical literature, the fdgs of Smith and colleagues (1980) and of Mojtabai and associates (1998), and the practice guideles of the APA (1997). The fdgs of our review, however, contradict Malmberg and Fenton's (2001) and Cormac and associates' (2002) fdgs, most previous qualitative reviews of the literature, and the PORT guideles (Lehman & Stewachs, 1998). The fdgs are especially contrary to suggestions that dividual psychodynamic psychotherapy is contradicated for people diagnosed with schizophrenia.

17 Individual Psychotherapy for Schizophrenia 179 Limitations Although this meta-analytic review is the broadest one conducted to date, it has certa limitations, which need to be addressed by future meta-analyses. First, there were a small number of studies to review. At the time of this writg, fewer than 60 published empirical reports existed on the efficacy of dividual psychotherapy for people diagnosed with schizophrenia. A larger sample of studies will enable more accurate estimates of effect sizes and analysis of more potentially important moderator variables, such as estimation of changes effect sizes over time durg treatment and through several follow-up periods. The small number of extant studies also limited the amount of formation available to conduct analyses of potential, clically important moderator variables, such as therapist experience or trag. The small number of reports also limited the amount of formation available to correct for attenuation due to study artifacts, such as the unreliability of the dependent variable of dividual psychotherapy. However, we would probably need a database of several hundred reports to mimize these problems. Second, ab half of the studies we reviewed did not assign participants randomly. The purpose of random assignment is to mimize potential threats to a study's ternal validity (Kazd, 1998). Random assignment specifically reduces selection biases, which are systematic differences groups on the basis of the selection or assignment of subjects. Obviously, the effects of an dependent variable among groups can be unambiguously ferred only if there is some assurance that groups do not systematically differ before the dependent variable was applied. (Kazd, 1998, p. 20) For random assignment to be useful the researcher must presume that there is no teraction between the participants and the dependent variable (Hunter & Schmidt, 1990). As already noted, we chose to clude all studies that would yield an effect size because we believe that throwg away data is treatg it as if it does not exist. Furthermore, it is simply not true that failure to randomize is equal to absolute validation of a study's results and, as we showed, the effects of randomization can be tested empirically. Most supporters of evidence-based medice believe that the RCT is the best method to determe causality and provides the best estimates of population effect sizes (see Hunter & Schmidt, 1990). Observational or naturalistic designs are believed to be ferior because they are thought to flate effect size estimates. These long-held assumptions ab RCTs have been challenged recently (Benson & Hart, 2000; Concato, Shah, & Horowitz, 2000; Pawson & Tilley, 1997; Shr, 1998). In two separate meta-analyses of medical treatments, no differences effect sizes and confidence tervals were found to exist between RCTs and observational studies (Benson & Hart, 2000; Concato et al., 2000). This means that many observational studies there is neither selection bias nor an teraction between the participants and the dependent variable. Statistical techniques such as structural equation modelg can also be used to help make strong causal ferences observational and naturalistic studies (Shr, 1998). Random assignment is, therefore, not necessary to draw causal ferences or to obta accurate estimates of population effect sizes. It might be the clearest way to do so, but it is not the only way to do so. In addition, we agree with Hunter and Schmidt (1990) that a notorious problem to deal with social science research is low power caused by samplg error. Most studies are underpowered and the consequences often result conflictg research fdgs, which disappear

18 180 Gottdiener and Haslam once samplg error is corrected via meta-analysis (Hunter & Schmidt, 1990). Therefore, we believed it appropriate to exclude studies not employg randomization. Despite the fdgs that randomization does not necessarily validate results, we believe that randomization is still important to use whenever it is feasible to do so. Third, another limitation to this meta-analysis is that we did not attempt to retrieve unpublished data. It is likely that a small number of unpublished treatment studies exist. We did not identify any through Dissertation Abstracts. As more dissertations are conducted, more of them will exame the efficacy of dividual psychotherapy for schizophrenia and will then be available for review. We also did not write to experts the field for unpublished studies, and we did not search all possible electronic databases (see Malmberg & Fenton, 2001, for an example of a very broad search). However, we searched the sources likely to brg the highest yield. We are confident that the limitations of our search strategy did not deleteriously affect our fdgs because of the results of the checks we employed (e.g., Fail-Safe N). Fourth, we did not report come variables, the effect sizes for each come variable, nor did we report effect sizes separately for dichotomous and contuous data. Fifteen effect sizes were reported as dichotomous comes; the rest were from contuous data. In addition, we calculated and reported all dichotomous comes usg a Pearson Product Moment Correlation coefficient rather than an odds ratio or relative risk. We did this to mata uniformity comes across dichotomous and contuous effect sizes. Because of the relatively small sample of existg studies, we thought that obtag a picture of the general relationship between treatment and come would be more formative than reportg specific comes by measurement or symptom. We realize, however, that an impressionistic picture like the one we have pated limits the ability to make fer-graed critiques of this meta-analysis. Fifth, we did not perform tent-to-treat analyses. Such analyses views treatment drops as treatment failures, which is not necessarily a correct terpretation. Patients drop of treatment for many reasons and rarely is it known why. However, such analysis might be worthwhile when more studies exist and if they have tracked reasons for attrition. Sixth, we were unable to conduct time-series analysis and estimate how much change occurred over time at different time periods, such as at 6 months or 2 years. All effect sizes were averaged regardless of how long treatment lasted, whether the effect was from follow-up data or from the immediate end of treatment. We did this because reportg effects for different time periods would produce the spurious impression of a treatment by time teraction that might not exist or that might differ among treatment types. Rather than create a false impression that a treatment by time teraction exists somethg we would be unable to test we thought it best to report one sgle treatment effect. Seventh, we were unable to use the Jacobson-Truax statistic (Jacobson & Truax, 1991) to determe how close toward beg a non-clical population patients were at the end of their treatments. We could not use the statistic because it requires the same come measures to be used all studies. Eight, our clusion of with-group, pretest-posttest effect sizes from change scores can face terpretative problems, given that change scores have the potential to be fluenced strongly by regression to the mean (Campbell & Kenny, 1999). Despite these potential difficulties, we thought that clusion of effect sizes from with-group designs was essential to derivg an overall sense of how much change could possible occur from pretest to posttest.

19 Individual Psychotherapy for Schizophrenia 181 Future Directions Additional studies would crease our understandg of the benefits of dividual psychotherapy for people diagnosed with schizophrenia. They would allow reviewers to assess which therapeutic terventions benefit which patients and when. A number of authors have poted that the goals of treatment and the terventions used will evitably vary as a function of the type of schizophrenia beg treated, the duration of the disorder, the personality of the patient, and the context of treatment (Eissler, 1951; Fenton, 2000; McGlashan & Keats, 1989). In addition, a number of therapists have developed psychotherapeutic approaches divided to stages that represent steps of progression that patients pass through as they recover (e.g., Arieti, 1974; Pao, 1979). Much of the clical literature also suggests that the most important issue the use of dividual psychotherapy for people diagnosed with schizophrenia is for therapists to mata flexibility and to use supportive and sight-oriented terventions as needed (see Fenton, 2000). Although none of the reports we reviewed reported comes specifically as a function of the type of tervention used, it is possible to fer from our review that both supportive and sight-oriented terventions are beneficial. Cognitive-behavioral and non-psychodynamic supportive therapies primarily consist of supportive terventions (see Hogarty et al., 1995; Kgdon & Turkgton, 1994), but not exclusively. Some cognitive-behavioral treatments use sight-oriented terventions extensively (see Ferris, 1989). Although psychodynamic therapies are generally thought to consist of sight-oriented terventions (see Robbs, 1993), they traditionally consist of supportive terventions the early stages of treatment with severely disturbed patients which, for some patients, will be the core of their treatment (see Rockland, 1989). What would be most useful to draw from future research is to learn which patients could benefit from which types of terventions at which stage of treatment. It would also be important to be able to employ the Jacobson-Truax statistic (Jacobson & Truax, 1991) to fd how much clically meangful change actually takes place for which patients under which conditions. A fal aspect that future research should address is the cost-benefit ratio of dividual psychotherapy. One argument agast usg dividual psychotherapy, even by those who believe its efficacy, is that its expense prohibits its use on a large scale. It is simply too costly to offer dividual psychotherapy to the majority of patients compared with medication management or other psychosocial treatments, such as group therapy, so the argument goes. Some would also argue that, because dividual psychotherapy does not seem to be considerably more efficacious than medication, it is simply not worth the added expense. Thus, the costs are presumed to weigh the benefits. There is some evidence, however, that suggests that the overall cost of treatg severely mentally ill patients decreases significantly with the use of psychotherapy (Gabbard, Lazar, Hornberger, & Spiegel, 1997; Karon & VandenBos, 1981). Compared with patients who are not psychotherapy, patients psychotherapy tend to use less patient treatment. They function at a higher level, and their psychiatric problems become less likely to terfere with obtag and matag employment (Gabbard et al., 1997). The current meta-analytic review shows that dramatic improvement rates are associated with the use of dividual psychotherapy, which suggests that over the course of a person's lifetime the use of dividual psychotherapy could actually help to reduce treatment costs. However, this is an empirical issue that requires further study.

20 182 Gottdiener and Haslam Related to the issue of cost-effectiveness of dividual psychotherapy is the related issue of costs due to the side effects or adverse reactions to antipsychotic medications. Seventyfive percent of patients diagnosed with schizophrenia stop takg their antipsychotic medication with two years, and problematic side effects are the primary reason (Perks, 1999). Antipsychotic medication is the primary treatment for schizophrenia, but if the compliance rate is so poor, then many people will ultimately forego treatment. It is thus plausible to speculate that the adverse effects of antipsychotic medications might contribute to the long-term high costs of treatment, lower capacity to be employed, and dimished psychosocial functiong. This hypothesis also needs to be empirically vestigated. FINAL REMARKS The fdgs of this meta-analysis clearly show that there is a relationship between the use of dividual psychotherapy and improvement overall functiong people diagnosed with schizophrenia, when dividual psychotherapy is used with medication and with medication. Furthermore, all major forms of dividual psychotherapy appear to be effective. However, primarily because of limitations of the available data on this topic, a more fe-graed understandg of the role of dividual psychotherapy for the treatment of schizophrenia remas to be elucidated by future primary research and by future meta-analyses. It is clear that much remas to be learned ab the utility of dividual psychotherapy for the treatment of schizophrenia, and we have mentioned some of the important topics needg further exploration. Nevertheless, this review shows that the pessimism and skepticism that has long surrounded the utility of dividual psychotherapy for people diagnosed with schizophrenia is unwarranted. It is now time to roll up our sleeves and learn more ab how this treatment works and how it can be made as effective and as available as possible. REFERENCES References marked with an asterisk dicate studies cluded the meta-analysis. *Alanen, Y. O., Rakkolaen, V, Rasimus, R., Laakso, ]., & Kaljonen, A. (1985). Psychotherapeutically oriented treatment of schizophrenia: Results of a 5-year follow-up. Acta Psychiatrica Scandavica, 7I(Suppl. 319), *Alanen, Y. O., Ugelstad, E., Armelius, B.-A., Lehten, K., Rosenbaum, B., & Sjostrom, R. (Eds.). (1994). Early treatment far schizophrenic patients. Oslo: Scandavian University Press. Arieti, S. (1974). Interpretation of schizophrenia. New York: Jason Aronson. American Psychiatric Association. (1997). Practice guidele for the treatment of patients with schizophrenia (1st ed.). Washgton, DC: Author. American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders (DSM-II) (2nd ed.). Washgton, DC: Author. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (DSM-III) (3rd ed.). Washgton, DC: Author. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (DSM-III- R) (3rd ed. revised). Washgton, DC: Author. Benson, K., & Hartz, A. J. (2000). A comparison of observational studies and randomized, controlled trials. New England journal of Medice, 342,

21 Individual Psychotherapy for Schizophrenia 183 *Bookhammer, R. S., Meyers, R. W., Schober, C. C., & Piotrowski, Z. A. (1966). A five-year clical follow-up study of schizophrenics treated by Rosen's "Direct Analysis" compared with controls. American Journal of Psychiatry, 123, Borenste, M., & Rothste, H. (1999). Comprehensive Meta-Analysis: A computer program for research synthesis (Version ) [Computer Software]. Englewood, NJ: Biostat. Boyer, L. B., &. Giovacchi, R L. (1980). Psychoanalytic treatment of schizophrenic, borderle, and characterological disorders (2nd ed.). New York: Jason Aronson. *Buchkremer, G., Klgberg, S., Holle, R. H., Schulze, M., & Hornung, W. P. (1997). Psychoeducational psychotherapy for schizophrenic patients and their key relatives or care-givers: Results of a 2-year follow-up. Acta Psychiatrica Scandavica, 96, *Bullard, J., Dexter M., Hoffman, B. R., & Havens, L. L. (1960). The relative value of tranquilizg drugs and social and psychological therapies schizophrenia. Psychiatric Quarterly, 34, Bustillo, J., Lauriello, J., Horan, W., Keith, S. (2001). The psychosocial treatment of schizophrenia: An update. American Journal of Psychiatry, 158, *Carpenter, W. T, McGlashan, T. H., & Strauss, J. S. (1977). The treatment of acute schizophrenia with drugs: An vestigation of some current assumptions. American Journal of Psychiatry, 134, Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates. Cooper, H. M. (1989). Integratg research: A guide for literature reviews (2nd ed.). London: Sage. Concato, J., Shah, N., & Horwitz, R. I. (2000). Randomized, controlled trials, observational studies, and the hierarchy of research designs. New England journal of Medice, 342, Cormac, L, Jones, C., & Campbell, C. (2002). Cognitive behaviour therapy for schizophrenia (Cochrane Review). Cochrane Database of Systematic Reviews (1) [Electronic database]. The Cochrane Library. *Coursey, R. D., Keller, A. B., & Farrell, E. W. (1995). Individual psychotherapy and persons with serious mental illness: The clients' perspective. Schizophrenia Bullet, 21, Drake, R. E., & Sederer, L. 1. (1986). The adverse effects of tensive treatment of schizophrenia. Comprehensive Psychiatry, 27, Eissler, K. R. (1951). Remarks on the psychoanalysis of schizophrenia. International Journal of Psychoanalysis, 32, *Falloon, I. R. H., Boyd, J. L., McGill, C. W., Williamson, M., Razani, J., Moss, H. B., Gilderman, A. M., & Simpson, G. M. (1985). Family management the prevention of morbidity of schizophrenia. Archives of General Psychiatry, 42, Fedem, P. (1952). Ego psychology and the psychoses. New York: Basic Books. Fenton, W. S. (2000). Evolvg perspectives on dividual psychotherapy for schizophrenia. Schizophrenia Buttet, 26, Fowler, D., Garety, P., & Kuipers, E. (1995). Cognitive behavior therapy for psychosis: Theory and practice. New York: John Wiley & Sons. *Fowler, D., & Morley, S. (1989). The cognitive-behavioural treatment of hallucations and delusions: A prelimary study. Behavioural Psychopathology, 17, Freud, S. (1904b). On psychotherapy (Vol. 7, pp ). London: Hogarth. Fromm-Reichmann, F. (1960). Prciples of tensive psychotherapy. Chicago: University of Chicago Press. Gabbard, G. O., Lazar, S. G., Hornberger, J., & Spiegel, D. (1997). The economic impact of psychotherapy: A review. American Journal of Psychiatry, 154, *Garety, P. A., Kuipers, L., Fowler, D., Chamberla, E, & Dunn, G. (1994). Cognitive behavioural therapy for drug-resistant psychosis. British Journal of Medical Psychology, 67, *Glass, L. L., Katz, H. M., Schnitzer, R. D., Knapp, P. H., Frank, A. E, & Gunderson, J. G. (1989). Psychotherapy of schizophrenia: An empirical vestigation of the relationship of process to come. American Journal of Psychiatry, 146,

22 184 Gottdiener and Haslam Glass, G. V., McGaw, B., & Smith, M. L. (1981). Meta-anafysis social research. Beverly Hills, CA: Sage. Gomes-Schwartz, B. (1984). Individual psychotherapy of schizophrenia. In A. Bellack (Ed.), Schizophrenia: Treatment, management and rehabilitation (pp ). New York: Grune &. Stratton. *Gottlieb, J. S., & Huston, P. E. (1951). Treatment of schizophrenia: A comparison of three methods: Brief psychotherapy, sul coma and electric shock. Journal of Nervous and Mental Disease, 113, *Grspoon, L., Ewalt, J. R., & Shader, R. (1968). Psychotherapy and pharmacotherapy schizophrenia. American journal of Psychiatry, 124, Gunderson, J. G., Frank, A. E, Katz, H. M., Vannicelli, M. L., Frosch, J. P., &. Knapp, P. H. (1984). Effects of psychotherapy schizophrenia II: Comparative come of two forms of treatment. Schizophrenia Bulkt, 10, Haddock, G., & Slade, P. D. (Eds.). (1996). Cognitive-behavioural terventions with psychotic disorders. London: Rledge. *Hamill, W. T., &. Fontana, A. E (1975). The immediate effects of chlorpromaze newly admitted schizophrenic patients. American journal of Psychiatry, 132, Hedges, L. V., &. Olk, I. (1985). Statistical methods for meta-analysis. New York: Academic Press. Hegarty, J. D., Baldessari, R. J., Tohen, M., Watemaux, C., & Oepen, G. (1994). One hundred years of schizophrenia: A meta-analysis of the come literature. American Journal of Psychiatry, 151, Herichs, D. W., & Carpenter, W. T. (1981). The efficacy of dividual psychotherapy: A perspective and review emphasizg controlled come studies. In S. Arieti and H. K. Brodie (Eds.), American Handbook of Psychiatry (pp ). New York: Basic Books. Hogarty, G. E., Komblith, S. J., Deborah, G., DiBarry, A. L., Cooley, S., Flesher, S., Reiss, D., Carter, M., & Ulrich, R. (1995). Personal therapy: A disorder-relevant psychotherapy for schizophrenia. Schizophrenia Bulkt, 21, *Hogarty, G. E., Goldberg, S. C., Schooler, N. R., Ulrich, R. E, & Group, T C. S. (1974). Drug and sociotherapy the aftercare of schizophrenic patients: II. Two-year relapse rates. Archives of General Psychiatry, 31, *Hogarty, G. E., Greenwald, D., Ulrich, R. E, Komblith, S. J., DiBarry, A. L., Cooley, S., Carter, M., & Flesher, S. (1997). Three-year trials of personal therapy among schizophrenic patients livg with or dependent of family, II: Effects on adjustment of patients. American Journal of Psychiatry, 154, *Hogarty, G. E., Komblith, S. J., Greenwald, D., DiBarry, A. L., Cooley, S., Ulrich, R. F, Carter, M., & Flesher, S. (1997). Three-year trials of personal therapy among schizophrenic patients livg with or dependent of Family, I: Description of study and effects on relapse rates. American Journal of Psychiatry, 154, *Hogarty, G. E., Schooler, N. R., Ulrich, R., Mussare, E, Ferro, P., & Herron, E. (1979). Fluphenaze and social therapy the aftercare of schizophrenic patients. Archives of General Psychiatry, 36, Hunter,]. E., & Schmidt, F. L. (1990). Methods o/meta-anafysis: Correctg error and bias research fdgs. Newbury Park, CA: Sage. Hunter, J. E., & Schmidt, F. L. (2000). Fixed vs. random effects meta-analysis models: Implications for cumulative research knowledge. International Journal of Selection and Assessment, 8, Jacobson, N. S., & Truax, P. (1991). Clical significance: A statistical approach to defg meangful change psychotherapy research. Journal of Consultg and Clical Psychology, 59, Johnson, B. T. (1995). DSTAT: Software for the Meta-Analytic Review of Research Literatures (Version 1.11) [DOS] [Computer Software]. Hillsdale, NJ: Lawrence Erlbaum Associates. Karon, B. P., & O'Grady, P. (1969). Intellectual test changes schizophrenic patients the first six months of treatment. Psychotherapy: Theory, Research, and Practice, 6,

23 Individual Psychotherapy for Schizophrenia 185 Karon, B. P., & O'Grady, P. (1970). Quantified judgements of mental health from the Rorschach, TAT, and clical status terview by means of a scalg technique. Journal of Consultg and Clical Psychology, 34, Karon, B. P., & VandenBos, G. R. (1970). Experience, medication, and the effectiveness of the psychotherapy with schizophrenics: A note on Drs. May and Tuma's conclusions. British Journal of Psychiatry, 116, Karon, B. P., & VandenBos, G. R. (1972). The consequences of psychotherapy for schizophrenic patients. Psychotherapy: Theory, Research, and Practice, 9, Karon, B. P., & VandenBos, G. R. (1975). Treatment costs of psychotherapy versus medication for schizophrenics. Professional Psychology, 6, *Karon, B. P., & VandenBos, G. R. (1981). Psychotherapy of schizophrenia: The treatment of choice. Northvale, NJ: Jason Aronson. Kazd, A. E. (1998). Research design clical psychology (3rd ed.). Boston: Allyn and Bacon. Kgdon, D. G., & Turkgton, D. (1994). Cognitive-behavioral therapy of schizophrenia. New York: Guilford Press. Lehman, A. E, Stewachs, D. M., &. project, a. t. C.-i. o. t. P. (1998). At issue: Translatg research to practice: The schizophrenia patient comes research team (PORT) treatment recommendations. Schizophrenia Bullet, 24, LeLorier, J., Gregoire, G., Benhaddad, A., Lapierre, J., Derderian, F. (1997). Discrepancies between meta-analyses and subsequent large randomized, controlled trials. The New England journal of Medice, 337, Levene, H. I., Patterson, V, Murphey, B. G., Overbeck, A. L, & Veach, T. L. (1970). The aftercare of schizophrenics: An evaluation of group and dividual approaches. The Psychiatric Quarterly, 44(2), Liberman, R. P. (1994). Psychosocial treatments for schizophrenia. Psychiatry, 57, *Lszen, D. H., Dgemans, P. M. A. J., Scholte, W. E, Lenior, M. E., & Goldste, M. (1998). Early recognition, tensive tervention and other protective and risk factors for psychotic relapse patients with first psychotic episodes schizophrenia. International Clical Psychopharmacology, 13(Suppl. 1), S7-S12. Lotterman, A. (1996). Specific techniques for the psychotherapy of schizophrenic patients. Madison, CT: International Universities Press. Malmberg, L., &. Fenton, M. (2001). Individual psychodynamic psychotherapy and psychoanalysis for schizophrenia and severe mental illness (Cochrane Review). Cochrane Database of Systematic Reviews (1) [Electronic database]. The Cochrane Library. Marks, J., Sonoda, B., & Schalock, R. (1968). Reforcement versus relationship therapy for schizophrenics: Journal of Abnormal Psychology, 73(4), Matthews, J. G., Burkhart, B. R. (1977). A-B therapist status, patient's diagnosis, and pychotherapy come a psychiatric patient population. Journal of Counsultg and Clcial Psychology, 45(3), *May, P. R. A. (1968). Treatment of schizophrenia: A comparative study of five treatment methods. New York: Science House. *May, P. R. A., Tuma, A. H., Dixon, W. J., Yale, C., Thiele, D. A., & Kraude, W. H. (1981). Schizophrenia: A follow-up study of the results of five forms of treatment. Archives of General Psychiatry, 38, *McGlashan, T H. (1984). The Chestnut Lodge follow-up study I.: Follow-up methodology and study sample. Archives of General Psychiatry, 41, *McGlashan, T. H. (1984). The Chestnut Lodge follow-up study II.: Long-term come of schizophrenia and the affective disorders. Archives of General Psychiatry, 41, McGlashan, T. H., & Keats, C. J. (1989). Schizophrenia: Treatment process and come. Washgton, DC: American Psychiatric Press. *Messier, M., Fnerty, R., Botv, C. S., & Grspoon, L. (1969). A follow-up study of tensively treated schizophrenic patients. American Journal of Psychiatry, 125,

24 186 Gottdiener and Haslam Mojtabai, R., Nicholson, R. A., & Carpenter, B. N. (1998). Role of psychosocial treatments management of schizophrenia: A meta-analytic review of controlled come studies. Schizophrenia Bulkt, 24, Morris, S. B., & DeShon, R. P. (2002). Combg effect size estimates meta-analysis with repeated measures and dependent-groups designs. Psychological Methods, 7(1), Mosher, L. R., & Keith, S. J. (1980). Psychosocial treatment: Individual, group, family, and community support approaches. Schizophrenia Bulkt, 6, Mueser, K. T., & Berenbaum, H. (1990). Psychodynamic treatment for schizophrenia: Is there a future? Psychological Medice, 20, *O'Brien, C. P., Hamm, K. B., Ray, B. A., Pierce, J. E, Luborsky, L., & Mtz, J ). Group vs. dividual psychotherapy with schizophrenics: A controlled come study. Archives of General Psychiatry, 27, Pao, P.-N. (1979). Schizophrenic disorders: Theory and treatment from a psychodynamic pot of view. New York: International Universities Press. Pawson, R., &. Tilley, N. (1997). Realistic evaluation. London: Sage. Perks, D. O. (1999). Adherence to antipsychotic medications, journal of Clical Psychiatry, 60 (Suppl.), Perris, C. (1989). Cognitive therapy with schizophrenic patients. New York: Guilford Press. Robbs, M. (1993). Experiences of schizophrenia. New York: Guilford Press. Rockland, L. (1989). Supportive therapy: A psychodynamic approach. New York: Basic Books. Rosenthal, R. (1991). Meta-analytic procedures for social research (Rev. ed., Vol. 6). Newbury Park, CA: Sage. Rosenthal, R., &. Rub, D. B. (1982). A simple general purpose display of magnitude of experimental effect, journal of Educational Psychology, 74, Rosenthal, R., Rosnow, R. L., &. Rub, D. B. (2000). Contrasts and effect sizes behavioral research: A correlational approach. Cambridge: Cambridge Press. *Rubs, J. L. (1976). Five-year results of psychoanalytic therapy and day care for acute schizophrenic patients. American journal of Psychoanalysis, 36, Schmidt, F. L., &. Hunter, J. E. (2001). Meta-Analysis. Unpublished manuscript. Scott, J. E., & Dixon, L. B. (1995). Psychological terventions for schizophrenia. Schizophrenia Bulkt, 21, Searles, H. F. (1965). Collected papers on schizophrenia and related subjects. New York: International Universities Press. Shadish, W. R., & Ragsdale, K. (1996). Random versus nonrandom assignment controlled experiments: Do you get the same answer? Journal of Consultg and Clical Psychology, 64, Shr, P. (1998). Causal modelg of epidemiological data on psychiatric disorders. Social Psychiatry and Psychiatric Epidemiology, 33, *Sj6strom, R. (1985). Effects of psychotherapy schizophrenia: A retrospective study. AcM Ps;ychiatrica Scandavica, 71, Smith, M. L., Glass, G. V, & Miller, T. I. (1980). The benefits of psychotherapy. Baltimore: Johns Hopks University Press. Spitzer, R. L., Endicott, J., & Robs, E. (1975). Research Diagnostic Criteria (RDC) for a selected group of functional disorders. New York: New York State Psychiatric Institute. *Stanton, A. H., Gunderson, J. G., Knapp, P. H., Frank, A. E, Vannicelli, M. L., Schnitzer, R., & Rosenthal, R. (1984). Effects of psychotherapy schizophrenia: I. Design and implementation of a controlled study. Schizophrenia Bulkt, 10, *Stone, M. H. (1986). Exploratory psychotherapy schizophrenia-spectrum patients: A reevaluation the light of long-term follow-up of schizophrenic and borderle patients. Bulkt of the Mennger Clic, 50, Sullivan, H. S. (1962). Schizophrenia as a human process. New York: W. W. Norton. Svvere, V. (1991). A retrospective follow-up vestigation of a group of schizophrenic patients treated a psychotherapeutic unit: The Kastanjebakken study. Psychopatholagy, 24,