It is fitting that the first mini-series issue of Behaviour Change should be devoted to an exposition of current cognitive-behavioural treatments for various aspects of schizophrenia. The disorder has a surprisingly high incidence in the population. Approximately 1 in 100 people will develop schizophrenia during the course of their life-time (Cancro, 1980). Arieti (1981) observes that more hospital beds are occupied by individuals suffering from schizophrenia than from any other psychiatric or medical problem, including cancer or cardiovascular disease.

The introduction of the phenothiazines in the 1950s resulted in dramatic increases in hospital discharges for schizophrenic patients but did little to change the “revolving-door” phenomenon. This chronic relapsing population is characterized as “the patient's having been admitted to an inpatient mental health facility several times and/or having been hospitalized for a period of at least a year on a single admission,” as well as possessing “a number of deficits in adaptive behavior” (Matson, 1980, p. 169). Indeed, whilst the schizophrenic individual's most florid symptoms e.g. delusions, hallucinations and thought disorder, may be well controlled on even minimal dosages of the neuroleptics (generally leading to that person's discharge from hospital), other social and self-care deficits may remain prominent reminders of the patient's difficulties in everyday living.

The chronic schizophrenic patient's deficits are characterized by an ambivalent relationship with the outside world. On the one hand he displays a lack of willingness or ability to interact appropriately with other people, and on the other hand, he depends on significant others such as a parent, other relative, or even a health professional. Despite this, he has a poor social network. He has reduced expectations of himself, is unable to effectively problem-solve, and his lifestyle reflects a desire to have an uneventful existence, free from harrassment. He becomes alienated from society, and may be unable to seek and gain employment, live independently, or manage routine responsibilities, e.g. financial budgeting.

An overview of schizophrenia is presented. The epidemiology and clinical features of this common but serious psychiatric disorder are outlined. Four case vignettes illustrate different presentations and, to some extent, the varying course of the disorder. Diagnostic issues are discussed and the heterogeneity of the disorder highlighted. The major aetiological hypotheses are outlined, including evidence for genetic and biochemical involvement, the role of family, social and personality factors, psychological mechanisms and life events. A diathesis-stress view is presented, in which biological vulnerability and psychological and environmental factors are necessary for the development of the clinical disorder. Somatic and psychosocial treatments are briefly discussed as are the course, possible outcomes and factors affecting prognosis. Finally some future research directions in both the biological and psychosocial areas are considered.

Deficiencies in social skills are a major problem in the rehabilitation of schizophrenic patients. To adapt to community life, schizophrenic patients must meet certain minimum levels of socially acceptable behaviour. Over the last two decades, social skills training procedures have been used to systematically teach these behaviours. Procedures typically used in social skills training include instructions/coaching, modelling, behavioural rehearsal and role play, feedback and reinforcement, and homework assignments. These and other procedures are discussed in this review. In addition, the outcome of social skills training for the schizophrenic patient is discussed with reference to short- and long-term changes in social behaviour.

A change has taken place in the role ascribed families in the treatment of schizophrenia. Rather than being implicated etiologically, families are seen more as the natural support system in preventing relapse of schizophrenic illness after discharge from hospital. The factors predicting relapse are reviewed including expressed emotion, communication deviance and medication compliance. From these, a set of objectives for treatment have been derived and the behavioural family intervention programme of Falloon and Liberman is described. Outcome research on the efficacy of this and the psychoeducational family approaches show short term benefits in relapse prevention and symptom amelioration but that more long term follow up data are needed. Further research also needs to address the relationship between outcome, specific treatment modality, medication use and the behavioural disturbance of the patient.

Developments over the last twenty years in the use of token economies in psychiatric institutions are reviewed. Token economies are considered in the context of two systems: the internal social system of psychiatric institutions and the mental health service system as a whole. Two themes emerge: the first concerns difficulties in establishing and maintaining token economies and the second, the impact of deinstitutionalization policies. It is argued that, although token economies remain viable for intervention goals internal to the institution, they have not been proven viable in furthering the goals of deinstitutionalization. Post-institutional programmes and community alternatives to institutions are of more current value than token economies in institutions.

Trends in behaviour therapy are considered from the advent of cognitive behaviour modification to the more recently suggested emphases on affective and unconscious processes. The thrust towards integrating different schools of psychotherapy is also briefly reviewed. The gains and losses associated with the trends are discussed. Some suggestions for the future are offered with respect to potentially profitable directions for behaviourally orientated researchers, practitioners and teachers to follow. A general theme of the paper is that behaviour therapy appears to be fractionating at an accelerating rate, and whilst this carries the potential for some very significant advances, it also carries the potential for destroying the unique contribution of the behavioural approach.

The investigators explored whether electromyographic (EMG) mediated biofeedback would help patients with cervico-brachial pain syndrome (CBPS) reduce muscle contraction and aid in pain relief. Twenty seven volunteer subjects with medically diagnosed CBPS were randomly assigned to two groups. The experimental group received EMG biofeedback mediated muscle relaxation of the neck for five, 40 minute sessions. The participants in the other group acted as "wait list" controls, and in turn, received treatment at the end of the study. Pre and post intervention measures consisted of EMG recordings of neck muscle activity; self-report measures of neck and general body relaxation, level of pain intensity, depression, anxiety and functional impairment. The results indicated that neck muscle activity, as measured by EMG, was significantly lower at the end of training. Associated with this reduction were a significant increase in self-reported neck and body relaxation and a significant reduction in the average intensity level of pain experienced by subjects over the pre to post intervention period. No changes were reported for the other measures.

Many parents experience considerable difficulty in getting their children ready for school or kindergarten in the morning. The “Beat the Buzzer” procedure described by Drabman and Creed on (1979) has been used extensively by clinicians to eliminate morning confrontations between parents and their children. The steps to be followed in the use of the procedure are outlined, and two case studies illustrating modification to the basic procedure are presented. Finally, discussion is given to issues that need to be considered when using the procedure and suggestions for further research evaluations are made.

Mild punishment, overcorrection and reinforcement of an alternative behaviour were used to reduce and eliminate the incidence of severe self-injurious behaviour in an autistic 12-year-old boy who had sustained major damage to his wrists and fingers. Data were collected over 10 × 30-minute periods per day and showed that banging and touching of a protective cast and later the injured hand itself were reduced to zero in approximately three weeks. The injury had healed and self-injurious behaviour was still extinguished at 10-month follow-up.

In an earlier contribution to Behaviour Change, a five-factor framework which recognizes both environmental and internal mediating determinants of behaviour was presented (Molloy, 1984). The five factors constitute a dynamic interdependent system whereby a change in any one of the components affects one or more of the other elements. The model is intended as an heuristic device for formulating and testing hypotheses and to illustrate how human behaviour, beyond simple habits and reactions, is multiply determined.

The article by Smith, Henriques and Parsonson (1985) published in Behaviour Change raises some interesting points, not the least of which is the validity of one of the major conclusions drawn by the authors. They claim “The results of this study indicate that the two treatment conditions employed were not equally effective in increasing the subject's range of supination” (p.56). Putting the clinical utility of their study aside, data available suggest this conclusion is unwarranted.

Essentially, the three conditions (Tml, Tm2, Bl) may be considered to be components of a multiple schedule. Thus, the functional relationship between behaviour and a specific intervention is established if the behaviour co-varies in a predictable fashion with changes in experimenter operations (treatment). On the face of it, the data of Smith et al., appear to meet this criterion.

However, when these same data are plotted in order of presentation, with the data for each session within each condition averaged so as to reduce variability, a different possibility emerges. (See Figure 1.) There is steady improvement in the subject's performance over time, regardless of which treatment condition is in effect in a particular session. These are parallelled with slow increments in baseline response rates. This strongly suggests generalization between conditions or a treatment process common to both interventions.