Emil Kraepelin, a German psychiatrist, wrote in 1913 that the causes of schizophrenia were “wrapped in impenetrable darkness.” He outlined the symptoms that still characterize the disorder, including delusions, hallucinations and disorganized thinking. Kraepelin used a different term—“dementia praecox”—that reflected his belief in the disease's unremitting downward course (dementia) and its early onset (praecox).

Today we no longer embrace either dementia or praecox as components of schizophrenia, but the impenetrable darkness he described still lingers. Schizophrenia's causes and mechanisms remain poorly understood, and the most common treatments do little to restore patients to health. Between 70 and 80 percent of individuals who have schizophrenia are unemployed at any given time, and the vast majority of these sufferers will remain dependent on disability insurance throughout the course of life. The cost of the disorder to society, in terms of lost wages and lifelong medical care, is on the order of billions of dollars. And for the approximately 1 percent of the population that struggles with the disorder and their families, the effects can be devastating.

With drug development proceeding gradually, a suite of cognitive interventions has emerged with the potential to significantly upgrade patients’ quality of life. These training programs target the core skills that support our ability to navigate social encounters and keep track of the day's demands. Although most of us take these capabilities for granted, they are all too often lacking in schizophrenia sufferers. With heightened awareness of these psychological techniques, more individuals with schizophrenia should be able to lead full and productive lives.

Social Solutions

In May the American Psychiatric Association is expected to release a new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the psychiatric bible for classifying mental disorders. The book represents the first major update in how clinicians approach diseases of the mind in almost two decades. For schizophrenia, the revisions met with general approval. Until now, psychiatrists had to choose among a number of subtypes, such as paranoid, disorganized or catatonic, that held little diagnostic value. The new version will do away with all those labels.

Less prominent in the manual and in most discussions of schizophrenia are the social symptoms: persistent difficulties associated with living independently and maintaining meaningful relationships. Clinicians typically rely on drugs to treat the most prominent features of the disease, namely, the visions and false beliefs outlined by Kraepelin, whereas these equally debilitating lifestyle factors are often neglected. Antipsychotic medications, first discovered in France in the early 1950s, have severe limitations. Major side effects, such as weight gain and rigid limbs, often accompany their use, and in some cases the medication does not restore patients’ sense of reality. More to the point, no studies link a drug-induced reduction in symptoms with the ability to hold down a job, live independently and sustain interpersonal bonds. None.

For patients to regain health and independence, psychiatrists also need to address the common deficits in attention, memory, planning and social awareness. For example, most if not all people with the disorder struggle with impaired cognitive skills, such as the ability to pay attention to directions or to remember which items to purchase at the store. Also quite common are difficulties with social skills. These include, for example, trouble reading your boss's angry expression when you inform her you will miss an important deadline or understanding why a friend is upset when you arrive half an hour late to dinner. When in a predicament, these individuals also tend to blame others, rather than themselves or the situation.

The development of methods for enhancing schizophrenia patients’ social and cognitive skills has traditionally lagged behind pharmacotherapy in the U.S. In part, the legacy of Sigmund Freud is to blame. He believed that people with schizophrenia were not amenable to psychoanalysis, and the idea stuck. Recent research, however, has found that certain psychological training regimens can ameliorate deficits in people with schizophrenia.

A review of several dozen studies on patient outcomes, published in 2011, suggests that allaying these challenges has a closer relation with many measures of successful coping—such as holding down a job, maintaining a strong social network and participating in community activities—than does addressing with drugs the disease's more prominent symptoms. False beliefs of persecution and illusory voices are not the biggest obstacle to normal interactions for most schizophrenia sufferers; instead problems following what others say to them or anticipating what another person is thinking tend to cause more disruption. Most of us working in this area have met people with the disorder with good cognitive and social skills who function just fine in professional and community settings as long as no one mentions the CIA. Helping less fortunate schizophrenia sufferers achieve this level of social functioning would go a long way toward easing the burden for all.

The good news is that a rapidly growing set of psychological interventions aim to shore up such elementary cognitive skills. One therapy is called cognitive remediation. First developed to treat traumatic brain injury, this approach is geared to improving patients’ ability to concentrate, remember, plan and solve problems, either by restoring skills through repetitive practice or by acquiring strategies for bypassing those deficits.

Cognitive Boot Camp

Cognitive remediation therapies typically use computer software or paper-and-pencil exercises. They can occur individually or in groups, at home or in the clinic, and they always include high doses of positive reinforcement. Computerized exercises might involve distinguishing between brief sounds, for example, teasing apart “bah” and “boh.” Visual training might focus on improving scanning abilities, perhaps by detecting a small yellow box amid distractions. An attention-shifting task might include identifying items of a particular color in several rows of streaming objects.

My colleagues and I decided to test whether such exercises can improve concentration skills in schizophrenia patients. In a study published in 2007 we divided our recruits into two groups. Half our participants performed these exercises, and the other half—our control group—learned basic computer skills, namely, how to use Microsoft Office programs. At the end of the study, all the patients were asked to keep in mind a list of numbers and mentally manipulate those figures. Compared with their peers who had learned generic computer tasks, the subjects who had practiced cognitive remediation performed much better, demonstrating a strengthened working memory. This study suggests that the effects are not caused by mere exposure to a computer or to general cognitive stimulation but arise from reinforcing the building-block sensory and cognitive skills that support many thought processes.

Other cognitive remediation programs focus on more complex activities. For example, a patient might see a computer screen with an array of numbers and letters and be asked to count how many numbers appeared. At the flash of a red light, the patient was to start alphabetizing the letters in the array instead. At the next flash, the person was to return to tallying numbers. In a 2007 paper psychologist Til Wykes of King's College London and her research group compared how patients fared when practicing these kinds of interventions as opposed to when they received only typical support services. The subjects who performed these exercises, but not the control group, saw substantial gains in their working memory and cognitive flexibility. They also improved on several measures of social function, such as maintaining hygiene, initiating appropriate interactions with others and avoiding confrontational situations.

Remarkably, these therapies appear to create demonstrable changes in the brain. Recent work has shown that cognitive remediation can increase activation in the medial prefrontal cortex, an area involved in decision making that sits right behind the forehead. In a 2012 study, for example, neuroscientist Karuna Subramaniam of the University of California, San Francisco, and her colleagues found that this heightened brain activity is linked with schizophrenia patients’ improved performance during “reality monitoring,” which is the ability to differentiate between internal experiences and the outside world. When people begin receiving cognitive training at the time of diagnosis, during the earliest stages of the disease's progression, they can also stave off the loss of brain volume in key parts of the temporal lobe. Abnormalities in these areas of the brain, which deal with processing sensory information and language, are often associated with schizophrenia.

Newer treatments, called social cognitive training programs, are also aimed at assisting people with the disorder become better social detectives: among other skills, by helping them to decipher emotional cues and take another person's perspective. These interventions include practice recognizing the aspects of facial expressions that signal certain emotions, for example, that raised eyebrows indicate surprise. A social cognitive training regimen might also help schizophrenia sufferers avoid jumping to conclusions by prompting them to compose alternative explanations for an unpleasant interaction. Consider a schizophrenia sufferer who is cut off on a highway exit ramp by another driver. That individual might first assume that the offending driver is a member of the CIA conducting surveillance on him and trying to force him into an accident so he lands in the hospital. These therapies encourage the patient to consider other interpretations, such as by noting that it is nearly 9 a.m. and the other driver simply might be late for work.

Initial studies have produced promising support for social cognitive interventions, which involve, among other tasks, conducting repeated, detailed analyses of facial expressions or scenarios. A 2012 meta-analysis by my colleague Christi L. Richardson and me showed that rehearsing these skills two to three times a week for several months helped practitioners learn such skills as appropriate language and tone of voice, which improved their interactions with others. These individuals participated more often in their community, developed more meaningful friendships and performed better at their jobs. They also demonstrated fewer symptoms of anxiety and depression, which often accompany the disease, as compared with patients in the control group, who were given typical community treatment.

Sadly, few treatment centers offer these psychological interventions. Although change is always gradual, greater emphasis on providing access to the rich array of psychological treatment technologies developed for schizophrenia could have a profound influence on the way we view outcomes for this devastating disorder. The evidence suggests that we can protect people from developing full-blown versions of schizophrenia using these therapies or at least slow the disease's progression.

We might even be able to assist people before the first symptoms manifest. New studies are applying psychological therapies to people at an elevated risk of developing psychosis, with promising early results. Much as practicing scales and arpeggios can help a pianist maintain good form, reinforcing fundamental cognitive skills could let schizophrenia patients stay connected with society. Drugs may help stitch together a broken sense of reality, but that is just half the battle.