Schizophrenia Care: Improving Social Cognition and Motivation

Announcer:
Welcome to On the Frontlines of Schizophrenia on ReachMD. On this episode, we’ll hear from Dr. Michael Green, who’s a Distinguished Professor in the Department of Psychiatry and Biobehavioral Sciences at UCLA and Director of the VA Rehabilitation Research and Development Center on Enhancing Community Integration for Homeless Veterans. He’ll be discussing how we can understand and improve social cognition and motivation in patients with schizophrenia. Let’s hear from Dr. Green now.

Dr. Green:
When we talk about social cognition, we talk about cognitive abilities that help us understand our social environment, for example, how well we can identify emotion in faces and how well we can infer and make good guesses as to what other people around us are thinking or feeling. The problem with schizophrenia is that often there are impairments in social cognition, which means the social world is a little harder to understand, make sense of, and interpret, and this affects the degree to which people with schizophrenia are likely to be successful with social engagements.

Now, in contrast to being able to process social information, there’s the desire to engage in social interactions. This is referred to as social motivation, and it comes in two types. One is wanting to approach other people and motivation, and one is to avoid other people and motivation: approach because being with other people normally makes people feel better, and avoidance because sometimes it’s distressing or uncomfortable to be with other people. And so these are areas in which people with schizophrenia differ. There’s less of that approach. There’s more of that avoidance. So when you have the combination of some problems with interpreting social information as well as some differences in whether or not someone wants to engage in social interactions, you have these factors that contribute to reduced social functioning in the community, which is what we see on average in schizophrenia. 

So now that we understand more about social cognition and social motivation in schizophrenia, the natural question is, what can we do to make things better? And there’s actually a fair amount of work already on improving social cognition, and these take the form of skills training exercises. There are several programs that have been developed for this. And so these would be programs in which people would be trained on what the characteristic features of an emotion are, for example, what does the voice sound like when it’s angry? What does the face look like when it’s happy? What would be an example of surprise? What do you look at either in facial or vocal features? So that’s an area in which there’s been pretty good success in improving these abilities.

Areas where it’s a little bit harder is making good inferences or being what sometimes is called a good social detective, for example, questioning, what did someone really mean by this? Maybe their first impression about what someone is thinking or feeling might not be right. How do we gather more information? So there are intervention techniques to improve this. It’s sometimes called mentalizing or theory of mind: making good inferences about what other people are thinking or feeling. That’s a harder area to improve, but there are these skills training approaches that are successful in improving these.

In terms of motivation, that has been something of a holy grail for schizophrenia research. There’s a lot of interest in improving motivation. For the most part, the pharmacological treatments have not been terribly successful in terms of psychosocial interventions. In some ways, cognitive behavioral therapy, which is very commonly used in people with psychotic disorder, is a way of improving some aspects of motivation, but what it seems to be good at is reducing distress associated with it.

So on the flip side, there’s another type of motivation, which is approach motivation. How do we increase the willingness to approach? On our own team, one of the most successful approaches so far has been to combine motivational interviewing with cognitive behavioral therapy. That specifically involves two types of psychosocial intervention, one of which focuses on defining goals, setting goals, and working towards them, and then the cognitive behavioral therapy part of that package structures activities to achieve them. It assumes that people want to maintain social connections, and frankly, most people with schizophrenia do. It’s just hard for them to do so. It’s usually fairly straightforward to have them identify the kind of socially relevant goals they’d be interested in achieving. So they’d like to have a boyfriend or girlfriend, they’d like to get closer to their family, or they’d like to reconnect with people that perhaps they lost contact with. These are not uncommon goals, but working towards them, maintaining those goals, identifying steps in that direction that are feasible and achievable, and then having it go over a period of weeks all requires additional psychosocial structure and help.

Announcer:
That was Dr. Michael Green discussing strategies for improving social cognition and motivation in patients with schizophrenia. To access this and other episodes in our series, visit On the Frontlines of Schizophrenia on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!