Behavioural Psychotherapy, 1990, 18, 283-293

Clinical Section
Coping Strategy Enhancement (CSE): A
Method of Treating Residual Schizophrenic
Symptoms

Nicholas Tarrier Department of Psychology,

University of Sydney
Susan Harwood, Department of Psychology,
Lawrence Yusopoff Prestwich Hospital,
Richard Beckett Manchester
and Amanda Baker National Drug and Alcohol
Research Centre,
University of New South Wales
A method of teaching coping skills to patients with schizophrenia who experience
unremitting psychotic symptoms is described. This method (Coping Strategy
Enhancement CSE) is based on a thorough behaviour analysis of each symptom
and the assessment of any coping strategy the subject may already employ. The
subject is then systematically trained in the use of appropriate coping strategies i n
response to the occurrence of their psychotic symptoms. Two case studies are
described in which CSE was used. Both patients showed considerable
improvements over treatment. In one patient improvement continued at 6 month
follow-up, in the other there was some deterioration at follow-up. Possible
reasons for these results were discussed.

Introduction
Schizophrenia is probably the biggest mental health problem, both in terms of the
disability it causes and in terms of economic cost. Nearly 40 years ago the introduction
of neuroleptic medication allowed great advances in the management of schizo-
phrenia, but even though neuroleptics have consistently been found to be superior to a
placebo in controlled trials (Davis, 1975) a considerable number of patients with
schizophrenia experience persistent, distressing and disabling symptoms. For
example, Johnstone, Owens, Gold, Crow and MacMillan (1984) found in a follow-up
study in London that 5-9 years after discharge over half of schizophrenic patients still
experienced psychotic symptoms. Other studies of both in-patients and out-patients
have shown similar results (Curson, Barnes, Bamber, Platt, Hirsch and Duffy, 1985;
Curson, Patal, Liddle and Barnes, 1988; Harrow and Silverstein, 1977; Silverstein
and Harrow, 1978).

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284 Clinical section

Over the last two decades there has been an increasing awareness of the sensitivity
of schizophrenic patients to environmental variables and how symptomatic relapse can
be precipitated by deleterious environments (Leff and Vaughn, 1985). One successful
approach to relapse prevention has been to teach significant others to modify the home
environment (e.g. Tarrier et al., 1988; 1989). Another potentially useful approach is
the use of behavioural management to control individual psychotic symptoms. These
have included: operant methods such as social reinforcement (Liberman etal., 1973),
time out (Davis, Wallace, Liberman and Finch, 1976), and punishment (Fonagy and
Slade, 1982); stimulus control methods (Slade, 1972); self-instruction (Meichenbaum
and Cameron, 1973); belief modification (Watts, Powell and Austin, 1973); thought
stopping (Lamontagne, Audet and Elie, 1983) and self-control (Alford, Fleece and
Rothblum, 1982). For comprehensive reviews of this area see: Marzillier and
Birchwood (1981), Hemsley (1986), Heinrichs (1988), Slade and Bentall (1988) and
Tarrier (1990a; 1990£).
Falloon and Talbot (1981) argued that to advance such management procedures "a
better understanding of contingencies surrounding persistent psychotic symptoms"
was required. In a descriptive study of coping mechanisms for auditory hallucinations
they found that successful coping resulted from the "systematic application of widely
used coping strategies". In another descriptive study, Tarrier (1987) found that
although nearly 30% of patients reported that the coping strategies they used were
ineffective, patients who used multiple coping strategies were more successful at
alleviating their symptoms. Other studies have all indicated the widespread use of
coping by patients who continue to experience persistent or residual psychotic
symptoms (Breier and Strauss, 1983; Cohen and Berk, 1985; Carr, 1988).
Since the majority of patients who do experience persistent psychotic symptoms do
use identifiable strategies to attempt to reduce their impact and since at least some of
these are moderately successful, naturally occurring coping strategies would seem a
reasonable starting place for teaching self-management skills. The further investi-
gation of the antecedents and consequences of the patient's symptoms with systematic
training in coping skills as a self-management programme would appear to have
clinical potential for patients experiencing persistent drug-resistant symptoms. This
paper reports a method of training patients to improve their coping abilities, and
reports the results of such training with two subjects.

Coping strategy enhancement (CSE)

Many, if not all people who experience a schizophrenic illness will attempt to cope in
some way with the symptoms they experience (Estroff, 1989). Symptoms of schizo-
phrenia usually result in dramatic alterations in perceptions and thought processes
which are frequently distressing for those experiencing them. In some patients
symptoms continue over long periods of time and appear resistant to medication. The
majority of these patients have, by trial and error, developed ways of coping with these
symptoms although they are often inconsistently applied or poorly practised. The
premise of this intervention is that systematic training in already existing coping
strategies in the context of a thorough behaviour analysis, supplemented by further
 Clinical section 285

coping strategies if required, could form the basis of an intervention that would
successfully alleviate these residual symptoms. The need for systematic training was
further suggested by Buss and Lang (1965) who concluded in their review of
performance deficits in laboratory tasks, that such deficits were due to poor on-task
self-instruction.
It was also thought that enhancement of already existing coping strategies would
be more acceptable to this patient group and hence would be more readily applied. A
treatment programme was developed that aimed to teach patients who experienced
drug-resistant residual psychotic symptoms, methods of coping with these symptoms
and the emotions that accompanied them. The programme consisted of 10 sessions of
approximately 1 hour duration spread over 5 weeks.
CSE differs from other self-management procedures in that: (1) it attempts to
build on coping methods already in the patient's repertoire; (2) an array of different
techniques are utilized; and (3) coping is practised with either simulated or actual
symptoms (if they occur) during the practice session. (The latter characteristic is not
exclusive to CSE as Fowler and Morley, 1989, also used in vivo training). Homework
exercises of utilizing coping strategies in stressful situations that have previously
elicited symptoms are also heavily emphasized. Although many of the strategies have
been utilized and evaluated in other studies, for example self-instruction (Meichen-
baum and Cameron, 1973), the rationale and combination of an array of coping
strategies constitutes a novel approach.
The first session involved clearly explaining the rationale for the assessment and
treatment procedure. Each psychotic symptom was elicited and defined by means of
the appropriate part of the Present State Examination [PSE, (Wing, Cooper and
Sartorius, 1974)]. A behavioural analysis was then carried out to determine the
frequency, duration and severity of each symptom; the antecedents; the emotional
reactions in terms of physical, cognitive and behavioural responses; and the conse-
quences of each symptom. This analysis followed a semi-structured interview devel-
oped in a previous study (Tarrier, 1987). From this topographical description it was
possible to elicit the environmental determinants of each symptom and classify and
evaluate any coping strategies used by the patient. Coping methods used by the
patient were classified as appropriate or inappropriate depending upon their desir-
ability or long-term consequences. For example, excessive alcohol use would be
classified as undesirable, and frequent social withdrawal would be inappropriate
because of its negative long-term consequences. Whereas temporary social
disengagement could be classified as an appropriate way of coping with the increased
stress of certain social interactions. Patients were also taught to monitor the occurrence
of target symptoms. Symptoms were targeted in agreement with the patient either on
the basis of potential ease of treatment (i.e. clearly identified antecedents or where
coping strategies were already being implemented with reasonable success) or when
reduction of the symptom was a high priority (i.e. when the symptom was causing
considerable distress or was disruptive to the patient's functioning).
In the next session a potential coping strategy was identified. This would be one
that was already being used by the patient unless an alternative appeared more
appropriate or potentially successful. During the session the coping strategy was
286 Clinical section

practised under simulated conditions in which the symptom occurred. If the patient
was experiencing symptoms during the session then this situation was utilized for in
vivo practice. However, where possible simulation was practised first before in vivo
practice was attempted. Homework exercises to practice between sessions were then
set. If reasonable progress was being attained or if no progress was occurring after 2 to
3 sessions then the next symptom was targeted and so on. Throughout the subsequent
sessions progress with these symptoms was reviewed and the patient encouraged to
generalize coping skills to other symptoms and situations. During the final session
potential difficulties that may occur in the future were rehearsed.

Assessment
For the purpose of evaluation an independent assessment was carried out 1 week before
treatment commenced (pre-treatment), 1 week after treatment terminated (post-
treatment) and at 6 months follow-up.
Each individual symptom elicited by use of the PSE was rated on the 7-point BPRS
(Lukoff, Neuchterlein and Ventura, 1986) scale for hallucinations or unusual thought
content (the rating was changed slightly from a 1-7 scale to a 0-6 scale). Each
symptom was further rated on conviction (a 6-point scale, where 0 = do not believe, to
5 = absolutely certain), preoccupation (a 6-point scale, where 0 = none, to 5 =
absolutely all the time) and interference (a 4-point scale, where 0 = none, to 3 =
severe disruption) (Brett-Jones, Garety and Hemsley, 1987). At post-treatment and 6
month follow-up each psychotic symptom identified on the PSE was rated on an
8-point change score {where 0 = completely remitted, 4 = unchanged, 7 = markedly
worse (Tress, Bellenis, Brownlow, Livinston and Leff, 1987)].

Clinical effectiveness
Two case studies are presented to demonstrate the use of CSE.

Case A
The subject was a 26 year-old single man who lived with his parents. He had first been
admitted to hospital 8 years previously and he had been admitted on three further
occasions, the last 12 months before starting treatment. At the time of entry into the
treatment programme he was experiencing five identifiable symptoms including:
hearing his thoughts broadcast out loud, auditory hallucinations (both in the third
person and directly hostile voices), persecutory delusions that teenage gangs were out
to do him harm (he had previously been arrested for physically attacking a teenage
youth whom he believed was out to harm him) and delusions of reference. He also
occasionally experienced visual hallucinations. He experienced these phenomena when
he went out of the house and especially in the presence of other people. They also
occurred in the evening when he was alone when he heard voices of people plotting
against him. He coped with these experiences by increased social withdrawal and
avoidance of going out, and by telling himself to ignore the ideas or voices. This,
however, was not very successful. He also frequently asked other people if they had
 Clinical section 287

heard his thoughts or himself talking out loud. Thought broadcast was selected as the
first target symptom due to the distress it caused him. He was instructed to re-label
the experience as illness-related and to switch his attention to a positive image. This
was initially performed by overt self-instruction with the therapist simulating
thought broadcast. Training was then completed with covert self-instruction. He
reported experiencing great difficulty in coping when out, especially when travelling
or waiting for buses. This caused him great anxiety as he needed to travel twice a week
to attend the day hospial. He experienced considerable muscle tension in the face and
jaws, which was apparently due to his belief that he spoke out loud when he heard his
thoughts and he was attempting to clamp his jaws shut so as not to speak. He was
taught specific relaxation techniques to relax his jaws and face muscles along with
systematic training in labelling these beliefs as due to his illness even though they
appeared real to him at the time. He was also trained to de-catastrophize the
consequences of talking out loud.
Self-instruction training was also given to facilitate him preventing himself from
accusing or arguing with other passengers on the bus, especially teenage boys, when he
experienced paranoid ideas. Homework exercises to practice these coping strategies
were then set. In the final session the possibilities of coping with future stresses and
recurrence of symptoms were discussed.

Case B
The subject was a 47 year-old married man who lived with his wife. He had
experienced his first episode 28 years previously and had 10 further admissions, the
last being 7 years before he entered the treatment programme. Since his last admission
he had been unable to work and he had attended a day hospital intermittently over this
period.
On entry into the treatment programme the subject was experiencing nine
identifiable psychotic symptoms including: thought broadcast, thought echo, de-
lusions of his thoughts being read, auditory hallucinations (both in the third person
and directly hostile voices) and delusional explanations (e.g. telepathy). He reported
that thought echo, delusions of his thoughts being read and auditory hallucinations
occurred one to three times each day for a duration of between 1—6 hours, most
frequently during the evening. These symptoms were selected as target symptoms as
he could accurately identify their occurrence and because they seemed sufficiently
frequent and disruptive to engage him in the proposed intervention. He coped with
them in a number of ways: by trying to sleep, by listening to music to drown them out
and by singing to himself.
Initially he was taught to monitor his symptoms carefully. He was then instructed
to re-label them cognitively as illness phenomena and to distract himself. This was
then combined with environmental distractions guided by self-talk. Training was
given in non-responding to auditory hallucinations by exposure to increasingly hostile
voices (simulated by the therapist) whilst the subject engaged in coping strategies
taught in the earlier sessions. He was then taught progressive muscle relaxation over
two sessions as a further coping strategy. At this point (session 7) the subject reported
288 Clinical section

he had been symptom-free for a number of days but was experiencing low moods. He
was instructed over the next two sessions in methods to cope with low moods
including behavioural targeting to increase his activity level. During the final session
the coping techniques were summarized and practised and possibilities discussed on
how to cope if the symptoms returned.

Results
The frequency of the target symptoms of each subject over the pre-treatment baseline
period and five week intervention period are shown in Figures 1 and 2.

140

Baseline I 5 Post-T
Time in weeks
FIGURE 1. The frequency of target symptoms per week for Subject A during the baseline
period, treatment period (Week 1-5) and post-treatment (Post Tl) periods.

Baseline ok I wk 2 wk 3 wk 4 wk 5 PT I PT 2

Time in weeks

FIGURE 2. The frequency of target symptoms per week for Subject B, expressed as the
number of days in each week that symptoms occurred, during the baseline period, treatment
period (Week 1—5) and post-treatment (Post Tl and 2) periods.
 Clinical section 289

300

Baseline wk I wk 2 wk3 wk 4 wk 5 PT I PT 2

Time in weeks

FIGURE 3- The duration in minutes of target symptoms for each week for Subject B during
the baseline period, treatment period (Week 1—5) and post-treatment (Post Tl and 2) periods.

For Subject A the number of times the symptoms were experienced each day has
been summed to give a weekly total. For Subject B the symptom frequencies are
expressed in the number of days in each week that symptoms were experienced and in
their duration in minutes summed over each week. These different ways of displaying
the data are more meaningful for each case. Subject B continued to record his
symptoms for 2 weeks after the end of treatment hence data for both these
post-treatment weeks are presented.
The ratings of seventy, conviction, preoccupation and interference were summed
for all symptoms experienced by each patient at each assessment and are presented in
Table 1.

TABLE 1. Summed measures of seventy, conviction, pre-occupation and interference for all
the psychotic symptoms experienced by subjects A and B (the possible range of scores for each
subject for each measure is also given)

Severity Conviction Pre-occupation Interference

Case A
(possible range) (0-30) (0-25) (0-25) (0-15)
Pretreatment 25 14 14 9
Post-treatment 9 3 5 4
Follow-up (6 months) 15 4 13 8
Case B
(possible range) (0-54) (0-45) (0-45) (0-27)
Pretreatment 36 33 16 18
Post-treatment 4 5 0 0
Follow-up (6 months) 1 0 0 0
290 Clinical section

Subject A had experienced five psychotic symptoms at pretreatment. At post-

treatment two of these had completely remitted, two were minimally improved and
one remained unchanged as rated by the PSE change scale. At 6 month follow-up the
remitted symptoms had not returned, two symptoms remained unchanged and one
had minimally worsened. Subject B had experienced nine psychotic symptoms at
post-treatment. At 6 month follow-up no remitted symptoms had returned and a
further three were in complete remission and one remained markedly improved.
Overall both patients showed a considerable decrease in psychopathology over the
treatment period (see Figures 1, 2 and 3). At follow-up Subject A showed a return of
pre-occupation and interference to near pretreatment levels, his conviction that the
symptoms were real remained at the post-treatment level. This apparent worsening
was due to the continued experience of three of his symptoms, whereas two symptoms
present at pretreatment were still remitted at follow-up. For Subject B the benefits at
post-treatment show a continued improvement at follow-up.

Discussion
There appears to have been considerable clinical improvement in both subjects over
the treatment period. This occurred in two men who had a long history of unremitting
chronic psychotic symptoms. Although there was some loss of benefit at follow-up for
Subject A, it is important to note that two symptoms had completely remitted. The
other three symptoms remained unimproved and there had been a worsening in one of
these. Why one patient continued to improve over follow-up and the other showed
some deterioration is difficult to say. Both patients experienced stressful home
environments which might be predicted to influence symptom occurrence (Leff and
Vaughn, 1985). Subject A lived with his parents and experienced considerable conflict
with his mother and Subject B lived with his spouse and experienced continuing
marital problems.
Another important factor in the case of Subject A was that during the follow-up
period the responsibility for his psychiatric care was transferred to another health
authority and he discontinued attending the day hospital. Possibly the stress of his
transfer combined with the cessation of day hospital attendance and the frequent
opportunity to practice coping strategies in vivo could explain the loss of some of the
treatment benefits. Treatment of a very severe disorder such as schizophrenia may, in
some cases, require continuing treatment or booster sessions to maintain
improvements. This has certainly been the conclusion of family intervention studies to
prevent schizophrenic relapse (Tarrier et al., 1989).
As these case studies were uncontrolled it is not possible to conclude that the
treatment programme itself effected change. Both patients appeared to show consider-
able improvements early in treatment. This may have been an effect of non-specific
factors, although no such improvements were made during the baseline period after
the pretreatment assessment as might have been expected if non-specific factors only
were operating. However, it is possible that the attention and relationship with the
therapist may have been influential. We are of the opinion that an empathic
therapeutic relationship, in which the experience of the psychotic symptoms is taken
 Clinical section 291

seriously but an alternative explanation for their causality is given, is certainly very
important.
Interestingly Subject B reported feeling depressed during treatment and at
follow-up. He explained this as being due to the absence of his symptoms, especially
the auditory hallucinations. Although, this is at first analysis a surprising comment,
other workers have reported on the strong relationship some patients have with their
symptoms (van Putten, Crampton and Yale, 1976; Benjamin, 1989). It is possible
that if a person's experience has largely been filled with psychotic symptoms which are
then removed they may experience a sense of loss and/or boredom with this change.
This in combination with low levels of activity could result in lowered mood. In
clinical practice CSE should be combined with a comprehensive treatment strategy to
promote increased levels of functioning and provide a range of alternatives with which
to engage the patient.
These results are encouraging in that they achieve some success in alleviating
drug-resistant psychotic symptoms in patients living in the community where
traditional treatments had failed. Whether these results could generalize to other
schizophrenic patients requires further investigation. In a recent study Fowler and
Morley (1989) reported on a cognitive-behavioural intervention that also attempted to
teach patients coping strategies. Four out offivepatients reported an increase in their
ability to control hallucinations, but only one patient reported a decrease in the
frequency of, and strength of belief in the reality of, the hallucinations. Fowler and
Morley (1989) have indicated the difficulty in producing treatment gains in all
patients, taken in context their results suggest a note of caution in extrapolating too
enthusiatically from the improvements in the two cases cited here. However, it should
be remembered that in patients who are not responding further to medication and who
are severely disabled by their symptoms, even small improvements can be considered
clinically significant. To address the question of external validity we are presently
carrying out a randomized control treatment trial of CSE.

Acknowledgement
This work was supported by a grant from the North West Regional Health Authority, UK
(grant number 5 107).

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