CLINICAL HANDBOOK OF SCHIZOPHRENIA - PART 5 pptx

handouts home with them, which may increase the chances that they will practice the skills outside of SST sessions. Use Examples, Illustrations, and Modeling Therapists should make ample use of examples, metaphors, or relevant stories to illus - trate particular concepts or ideas generated by participants whenever possible. For exam - ple, in designing a role play during a conversation skills session for a person who says that she does not really talk to people that live in her apartment building, but that there is a person who moved in down the hallway to whom she would like to talk, the therapist could set up the role play as an interaction between the group member and the person who moved in down the hallway. Use of examples that are concretely tied to participants’ lives allows them to see the relevance of how they might use the skill. Similarly, therapist and/or group member’s modeling of the skills allows participants to see how they might use the skills in their own lives. Encourage Participants to Practice Skills between Sessions Homework practice between sessions enhances the generalization of skills from the ther - apy sessions to clients’ real-world experiences and gives them the opportunity to see first- hand how the new skills can improve their relations with others, social functioning, and so forth. Homework assignments developed at the end of each session can then be re- viewed at the beginning of the following session. This sets up the expectation that pa- tients use the skills taught in session outside of the clinic and gives them the opportunity to receive therapist feedback about ways they can improve application of the skills to real-life situations. It is best to develop the homework collaboratively, in such a way that the participant is able to practice the skill between sessions and has a high likelihood of successfully completing the assignment. Do Not Work in Isolation Participants in SST are likely to be receiving antipsychotic medications and to have a case - worker, therapist, or other clinician involved in their care. Therapists should keep in touch with their colleagues and find out when a participant has been put on a new medication or has receiveda majorchange indosage. Itis importantto learnhow heor sheis doingin other settings (e.g., Is this a particularly bad time for a patient? Is he or she exhibiting prodromal signs of relapse?). Of special note is whether the participant is giving the therapist but not others a hard time or vice versa. Similarly, what is going on in the person’s life outside of the clinical setting?Are thereconflicts athome? Asa generalrule, generalization of the effects of training is enhanced to the extent that the skills one teaches are (1) relevant to the person’s immediate environment, and (2) reinforced by the environment. KEY POINTS • Impairments in social skills and social competence are key features of schizophrenia that play a major role in disability. • Social competence is based on a set of three component skills (social perception, or receiv - ing skills; social cognition, or processing skills; and behavioral response, or expressive skills), which can be ameliorated by SST. 24. Social Skills Training 247 • SST is a highly structured educational procedure that employs didactic instruction, breaking skills down into discrete steps, modeling, behavioral rehearsal (role playing), and social re - inforcement to teach social behaviors. • SST is a structured teaching approach in which the key element is behavioral rehearsal, not conversation about social behavior and motivation. • SST is an evidence-based practice with strong empirical support. • SST is tailored to each individual, and fosters personal choice and growth in a manner con - sistent with the consumer recovery model. REFERENCES AND RECOMMENDED READINGS Bellack, A. S. (2004). Skills training for people with severe mental illness. Psychiatric Rehabilitation Journal, 27(4), 375–391. Bellack, A. S., Mueser, K. T., Gingerich, S., & Agresta, J. (2004). Social skills training for schizophre - nia: A step-by-step guide (2nd ed.). New York: Guilford Press. Benton, M. K., & Schroeder, H. E. (1990). Social skills training with schizophrenics: A meta-analytic evaluation. Journal of Consulting and Clinical Psychology, 58, 741–747. Dilk, M. N., & Bond, G.R. (1996). Meta-analyticevaluation of skills training research for individuals with severe mental illness. Journal of Clinical Psychiatry, 64, 1337–1346. Glynn, S. M., Marder, S. R., Liberman, R. P., Blair, K., Wirshing, W. C., Wirshing, D. A., et al. (2002). Supplementing clinic-based skills training with manual-based community support sessions: Ef - fects on social adjustment of patients with schizophrenia. American Journal of Psychiatry, 159, 829–837. Hayes, R. L., Halford, W. K., & Varghese, F. T. (1995). Social skills training with chronic schizo- phrenic patients: Effects on negative symptoms and community functioning. Behavior Therapy, 26, 433–439. Lehman, A. F., Kreyenbuhl, J., Buchanan, R. W., Dickerson, F. B., Dixon, L. B., Goldberg, R., et al. (2004). The Schizophrenia Patient Outcomes Research Team (PORT): Updated treatment rec- ommendations 2003. Schizophrenia Bulletin, 30(2), 193–217. Liberman, R. P. (1995). Social and independent living skills: The community re-entry program. Los Angeles: Author. Liberman, R. P., Blair, K. E., Glynn, S. M., Marder, S. R., Wirshing, W., & Wirshing, D. A. (2001). Generalization of skills training to the natural environment. In H. D. Brenner, W. Boker, & R. Genner (Eds.), The treatment of schizophrenia: Status and emerging trends (pp. 104–120). Seat - tle, WA: Hogrefe & Huber. Liberman, R. P., Wallace, C. J., Blackwell, G., Kopelowicz, A., & Vaccaro, J. V. (1998). Skills training versus psychosocial occupational therapy for persons with persistent schizophrenia. American Journal of Psychiatry, 155, 1087–1091. Marder, S. R., Wirshing, W. C., Mintz, J., McKenzie, J., Johnston, K., Eckman, T. A., et al. (1996). Two-year outcome of social skills training and group psychotherapy for outpatients with schizo - phrenia. American Journal of Psychiatry, 153, 1585–1592. Mueser, K. T., & Bellack, A. S. (1998). Social skills and social functioning. In K. T. Mueser & N. Tarrier (Eds.), Handbook of social functioning in schizophrenia (pp. 79–96). Needham Heights, MA: Allyn & Bacon. Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Martindale, B., et al. (2002). Psychologi - cal treatments in schizophrenia: I. Meta-analyses of randomized controlled trials of social skills training and cognitive remediation. Psychological Medicine, 32, 783–791. 248 IV. PSYCHOSOCIAL TREATMENT CHAPTER 25 COGNITIVE REHABILITATION TIL WYKES Unlike other therapies described in this book, cognitive rehabilitation is novel and has not yet been minutely examined. There is no consensus from its proponents on the lan- guage to describe the therapies or what their constituent parts should be. The underlying theory of how it works differs from one academic group to another, with suggestions about both compensating and repairing the cognitive system. But despite all these differ- ences, many training packages do look similar, even if the emphasis within each package is different. The outcomes have been positive even this early in development, and high- quality randomized controlled trials have shown that the effects are not due to nonspe- cific therapeutic variables (Bell, Bryson, Greig, Corcoran, & Wexler, 2001; Bellack, Gold, & Buchanan, 1999; Wykes & Reeder, 2005; Wykes et al., 2003), which is why cognitive rehabilitation is included here. But to understand the place of the therapy within the field of rehabilitation, this chapter has a slightly different structure, with the background of the therapy leading to a description of the therapy as currently developed, but with the promise of an integrated approach in the future. ARE COGNITIVE IMPAIRMENTS IMPORTANT IN SCHIZOPHRENIA? The early descriptions of schizophrenia by Kraepelin and Bleuler emphasized the cogni - tive difficulties at the heart of the diagnosis of schizophrenia. Although there is still some dispute about whether these are static or deteriorating impairments, it is clear that they are also present during and, for some people, between acute episodes (e.g., McGhie & Chapman, 1961). There is also evidence from studies of children at high risk of develop - ing schizophrenia, as well as populations of conscripted young people and birth cohorts, that people who later develop schizophrenia have lower overall premorbid cognitive ca - pacity than those who do not develop the disorder. Although the majority of people with a diagnosis of schizophrenia show impairments, the decrements differ in magnitude across the population; some people seem little affected, and a few achieve high intellec - tual recognition (e.g., Dr. William Chester Minor, who in the 19th century contributed to an early version of the Oxford English Dictionary while a patient in an English lunatic asylum). 249 The detailed investigation of cognitive difficulties in the past decade has concluded that there are general deficits in multiple functions of attention, learning, and memory. In particular, executive functions, which include planning and strategy use, have been shown to be deficient. Although measuring differences between cognitive functions de - pends on the sensitivity of the tests, the general consensus is that memory difficulties are pervasive and specific. In other words, they are present even when there are no obvious abnormalities in overall cognitive function. Severe cognitive impairments are not only important to service users but also have been shown to have a crucial association with functional outcomes, such as getting or keeping a job. They are also linked to the cost of mental health care. This relationship is often stronger than that with positive symptoms. But perhaps the clincher in the need to focus rehabilitation efforts on cognition is that there is now clear evidence that cognitive difficulties interfere with rehabilitation efforts in multiple domains of functioning. Cogni - tion not only interferes with everyday life but it also limits functional outcomes over long periods of time and hinders the rehabilitation of specific functioning (Green, Kern, Braff, & Mintz, 2000; McGurk & Mueser, 2004; Wexler & Bell, 2005). DEVELOPING THERAPIES FOR COGNITIVE DIFFICULTIES This slowness of therapy development was due largely to the assumption that cognitive impairments were immutable, based on observations of largely unvarying cognitive diffi- culties over the course of the disorder. It was also proposed that these difficulties were neurological problems similar to frontal lobe lesions. Because there was little positive evi- dence for the effects of therapy on cognition in patients with frontal lobe lesions, this pes- simism was transferred to schizophrenia and, when care moved from institutions to the community, had the effect of concentrating rehabilitation efforts on teaching specific life skills. The initial boost to the development of therapy for cognitive problems came from an unexpected source: research on the immutability of cognitive difficulties (Goldberg, Weinberger, Berman, Pliskin, & Podd, 1987). One major U.S. study purported to show that it was impossible to teach inpatients with chronic schizophrenia how to carry out a particular neuropsychological test, the Wisconsin Card Sorting Test (WCST), which mea - sures flexibility of thought. In the results of this study, shown in Figure 25.1, it is clear that training was not successful in improving performance until the participants were provided with specific, card-by-card instructions. However, as soon as this learning sup - port was removed, performance returned to baseline and was no different in the group that had just repeated the test five times. This study produced a boost in research, leading to a line of inquiry that attempted to find out whether any type of instruction would have longer lasting effects; in other words, the experiments were designed to test the null hy - pothesis that cognition was immutable. Although many studies supported immutability, a few showed that it was possible under some conditions not only to improve performance but also to produce durable improvements. These results produced the vital bit of thera - peutic optimism, and a new psychosocial rehabilitation technology was born. WHAT SHOULD BE A TARGET FOR COGNITIVE REHABILITATION? Cognitive difficulties cover a broad range and show interindividual variation. Clearly, an intervention designed to have the most impact on a person’s life needs to be targeted, but 250 IV. PSYCHOSOCIAL TREATMENT these targets may differ among different real-life functions. So far the targets have been highly correlated with particular functional outcomes. Obviously this may be a gross er - ror, because it is not clear that a change in an associated cognitive ability necessarily pro- duces a change in function, but at least this seems to be a sensible starting point. There are difficulties in comparing different cognitive measurements and different ways of measuring functional outcome. The most comprehensive reviews have concluded that memory and executive functions are important in predicting overall functioning, and that some basic functions, such as sustained attention, also show some relationships, al- though this may be a result of poor executive control. These difficulties have also been highlighted in rehabilitation programs. Supported employment programs can compensate for low-level impairments but are only partially effective at compensating for memory and executive functions (McGurk, Mueser, & Pascaris, 2005). Different cognitive prob- lems also affect rehabilitation at different times during a program. Sustained attention, response inhibition, and idiosyncratic thinking have been found to be important in the initial stages of a work rehabilitation program, but after the engagement phase, attention, verbal memory, and psychomotor speed became better predictors of within-program per - formance. This does fit with what is known about the rehabilitation programs them - selves. In the beginning there is a need for concentration on instructions, but later prac - tice and speed of response are important in becoming expert in the relevant tasks. To design the most efficacious cognitive rehabilitation program requires answers to a number of questions that can only be derived from empirical investigation: • Can we change functioning by improving one cognitive factor, or do we need im - provement across a range of cognitive abilities? • How much improvement is enough? Improving cognition by a smidgen may have dramatic effects on functioning, but this seems unlikely. What seems more likely is that a threshold of cognitive improvement is necessary. • Does improvement depend on the magnitude of the impairment? For instance, would it be easier to show effects with less improvement in those with the most cognitive difficulties or vice versa? • Are there personal characteristics that make cognitive change more or less likely? • Will the same cognitive functions that are associated with outcomes statically be associated with dynamic improvements? 25. Cognitive Rehabilitation 251 FIGURE 25.1. WCST performance with and without training. From Goldberg et al. (1987). Copy - right 1987 by the American Medical Association. Adapted by permission. None of these questions has received a conclusive answer, but that should not deter us from developing cognitive rehabilitation. Rather, the development of such a technology will provide answersto thequestions andallow theadvancement ofboth theoryand practice. EVIDENCE FOR SUCCESSFUL COGNITIVE REHABILITATION It seems that three types of theory are cited when cognitive rehabilitation programs are described. The first is the notion of restitution, in which the use of a particular cognitive function is repeatedly practiced, whereas in compensation, patients are provided with al - ternative strategies to achieve goals. In the last approach, learning theory, behavioral pro - cedures, such as shaping and modeling, are used to improve functioning. In fact, it is not clear that any program does anything differently based on any theory. These are all post hoc explanations for the results of clinical trials. Single-Test Interventions These interventions were designed to provide highly controlled comparisons of short in - terventions for particular tests of cognitive flexibility, memory, and attention. The results indicate that there is considerable room for optimism, and that it is possible to improve cognition. This corpus of studies also benefited the development of successful training programs in an unusual way. Published peer-reviewed data also include reports of nega- tive effects of training paradigms. These data can be used to prevent failure in our partici- pants. The main outcomes are that continued practice at some tasks may increase perfor- mance on that task, but there is little generalization to other, similar tasks. Too much information is detrimental to performance in some people, and training programs that fo- cus only on increasing motivation divert attention away from the key task requirements. Some forms of training, such as errorless learning (reducing the error rate when teaching the task), scaffolding (providing tasks in which effort is required but the solution still lies within the person’s range of competence), and verbal monitoring (overtly rehearsing the task rules and strategies for solution) were found to be successful. Positive and durable improvements with these techniques have been found for executive functioning, memory, and sustained attention, but the evidence for sustained attention tends to be task-specific. Clinical Interventions The second generation of studies progressed from attempts to influence performance on a single test to the rehabilitation of a variety of cognitive functions that might affect real- life functioning. Again, positive results have been found for the improvement of cogni - tion, although the effect sizes are considerably reduced. Figure 25.2 shows the range of effect sizes in three meta-analyses and also distinguishes different types of training, with rehearsal-based training showing less of an effect than training strategic processing. The confidence interval for the effect of rehearsal learning crossed zero, suggesting that this is not even a robust effect. There have now been more than 15 randomized controlled trials of cognitive train - ing to improve cognition, and these show moderate effect sizes (0.45), 1 identical to those 252 IV. PSYCHOSOCIAL TREATMENT 1 Effect size is here defined as the mean difference between treatment and control condition divided by the stan - dard deviation of the measure employed. of cognitive-behavioral treatments. All but one meta-analysis has shown a positive effect so there does seem reason to exploit this therapy (Krabbendam & Aleman, 2003; Kurtz, Moberg, Gur, & Gur, 2004; Twamley, Jeste, & Bellack, 2003). But improving cognition is not under dispute. The real question is, do these cognitive improvements have an effect on real-life functioning? There is evidence of modest effects on positive and negative symptoms (effect size for overall symptom severity = 0.26), and more robust effects for social functioning (0.51). There are also some emerging data that cognitive remediation affects the number of hours worked. Most importantly many of these effects are durable. For instance 58% people who receive cognitive remediation and work rehabilitation were still in paid employment 12 months after the end of treatment, whereas only 21% of those who received work rehabilitation alone were still at work at this time (Wexler & Bell, 2005). So there is evidence of positive effects on functioning outcomes. This assumes that remediation acts on cognition, and that this improvement leads to changes in real-life functioning. But the empirical data now point to a different model, one in which im - provements in cognition have to be moderated by cognitive rehabilitation, because even when cognition improves in the control group, there is little evidence of improvement on functioning; in addition, nonresponders to cognitive remediation have less chance of im - proving their functioning. The effect on outcome seems to depend solely on the cognitive improvements produced by cognitive rehabilitation. TYPES OF COGNITIVE REHABILITATION What is cognitive rehabilitation? This question has come rather late, because it is the most difficult to answer. Cognitive rehabilitation has been led by pragmatic studies that attempt to demonstrate individuals’ cognitive improvement. The training programs adopted have face validity, but there have been many different approaches: 25. Cognitive Rehabilitation 253 FIGURE 25.2. Average effect sizes for cognitive outcomes following CRT from meta-analyses. From Krabbendam and Aleman (2003). Copyright 2003 by Springer-Verlag. Reprinted by permission. • Individual or group treatment • Computer-driven presentation or paper-and-pencil tasks • Therapist presentation or automated presentation (or both) • Frequency of therapy—either weekly or intensive daily sessions • Type of training (rehearsal or strategic processing) Every combination of factors has been used, making it almost impossible to differen - tiate between successful and unsuccessful characteristics. But because there are some dis - tinct choices, some of these general models are described. Operant Conditioning This type of treatment is based specifically on learning theory and incorporates the differ - ential reinforcement of successive approximations of behavior or shaping. Rather than waiting for a complete behavior to occur before offering reinforcement, reinforcement is provided for successive approximations or steps toward the final behavior. This type of training has been used with the most severely disabled patients, and there is evidence of both complex (abstract thinking) and simple (sustained attention) positive outcomes. Changing the environmental contingencies may therefore have a role to play in cognitive rehabilitation (e.g., Silverstein, Menditto, & Stuve, 2001). Environmental manipulation has been taken even further in a program called cogni- tive adaptation training. Participants in this program, following a neuropsychological as- sessment, are provided with an environment that compensates for their specific cognitive impairments. For example, signs are placed on the bathroom wall about cleaning teeth; complete sets of clothes are provided for each day of the week; and daily rations of money are provided. In this case, there is no expectation of training particular behaviors, so that exercises may be carried out independently. The assumption is that the environ- mental manipulation will continue to guide behaviors and to reduce response choices that often have a detrimental effect on performance. The evidence for the efficacy of this par- ticular therapy includes improvements in both symptoms and social functioning. Envi- ronmental control is, however, gross, and this may not be acceptable to all service users or health care professionals. Integrated Psychological Therapy Integrated psychological therapy (IPT) was one of the first programs to include a specific cognitive domain. There are five subprograms each of which has both social and cogni - tive elements in differing amounts. The subprograms are cognitive differentiation, social perception, verbal communication, social competence, and interpersonal problem solv - ing. The explicit cognitive subprogram (cognitive differentiation) addresses a variety of cognitive abilities, such as attention and conceptualization abilities. Activities are run in a group, in which training is didactic. This method of training provides social contact that may also boost social functioning. This therapy has been subjected to rigorous evaluation; although most patients show some improvement in cognitive ability, the specific improvements differ between studies and depend on thelevel ofexperimental control(Spaulding, Reed,Sullivan, Richardson,& Weiler,1999). Cognitive Enhancement Therapy This therapy amalgamates both group and partner working. It uses task materials often from those used to treat brain injury, as well as a comprehensive approach to work ther - 254 IV. PSYCHOSOCIAL TREATMENT apy. Initially the therapist provides two patient partners with experience of computer pre - sentations of tasks involving attention or memory skills. The therapist, as well as patient partners, help to guide the use of the computer, providing positive reinforcement and sug - gestions about ways to approach the tasks. In addition, participants also attend groups in which they present and discuss information on how they might solve individual social or work problems. After 3 months of computer training, participants also enter larger groups of six to eight people. The group program takes an additional 6 months and com - prises exercises that focus on “gistful” interpretations of information, such as summing up an article in a newspaper to another person. Unlike most treatment programs for inpa - tients, this program is aimed at higher functioning patients (i.e., “stable outpatients”). The evaluations of cognitive enhancement and a similar program specific to sup - ported employment both indicated positive effects for cognition and specific functioning outcomes, such as number of hours worked. What this type of training offers is an imme - diate transfer of training into the functioning domain, which is likely to increase the gen - eralization of cognitive improvements from the specific cognitive rehabilitation therapy (CRT) part of the program (Hogarty et al., 2004). Educational and Remediation Software Programs Two types of software have been used in computer presentations: (1) that designed to treat head injury and (2) educational software that is easily available and designed to be engaging. Both sets of programs are based on models of practice, and individuals prog- ress through the various levels of the program. Currently there is no specific theoretical guidance on the presentation or inclusion of particular tasks. Rather they are chosen for their face validity, their appeal (in the case of educational software) and their comprehen- siveness, in terms of the underlying skills required. Software designed for educational use has not only been tested for its efficacy but it also provides the opportunity to control task levels and to introduce complex problem-solving and concept formation tasks. The tasks have some ecological validity, although, of course, much of the presentation can be too child oriented. Computerized training has shown mixed effects, with some studies showing general - ization and durability and others showing no between-group effects and no differential improvement compared to other types of cognitive skills therapy. The effects on function - ing are also mixed. The difficulty with the use of this therapy is that it is quite possible for the therapist to be involved and have high levels of contact, or for the participant to inter - act only with the computer. Higher levels of initial contact with a therapist may be responsible for cognitive improvement, because the therapist can respond with sensitivity and flexibility to the strengths and difficulties of the participant. There is little current evidence on the efficacy of computer- versus therapist-driven therapy, because most pro - grams studied have included supervision from a clinical specialist. It seems likely that such a person will be necessary, at least until a computer can suggest that a break and a cup of tea are needed. Executive Skills Training Several programs have been developed in this area, but the best-known one, initially de - signed in Australia, comprises three modules: cognitive flexibility, memory, and planning. Each of the 40 or so hour-long sessions contain different paper-and-pencil tasks, all of which had relevance to specific cognitive processing problems. The cognitive flexibility module includes a range of tasks that required engagement, disengagement, and reengage - ment of various cognitive information sets. Memory is targeted by a range of set mainte - 25. Cognitive Rehabilitation 255 nance, set manipulation, and delayed response tasks. Finally, planning involves tasks for set formation and manipulation, reasoning, and strategy development. The focus here is on both the development of new and efficient information-processing strategies and prac - tice of these strategies in new contexts and with different forms of information (e.g., ver - bal and visual). This emphasizes the generalization from task to task within the training protocol. Tasks are easy but can be adapted to higher functioning participants, so that the tasks require some effortful processing, which is known to be helpful for cognitive train - ing. The randomized controlled trial data show changes with this form of therapy in both cognition and social functioning. In particular, this form of training has shown improve - ments in patients’ memory abilities that were durable 6 months after the end of therapy. Medication Cognitive rehabilitation is also being approached from the viewpoint of medication to re - store function. Double-blind, randomized controlled trials have shown that there are small effects of antipsychotic medication on cognition. More recently, drug therapies have been developed that specifically target the cognitive system rather than being a side effect of current medications for positive symptoms. Although these possible cognitive enhancers may offer an initial boost to the cognitive system, it seems likely that psychosocial rehabilitation will also be required. One metaphor for this is mending a bro- ken bone. Although it is possible to set the bone in place for it to grow, it is also necessary to provide some physiotherapy to improve functioning and to develop the bone structure further. This is perhaps how cognition-enhancing drugs will be used within the compre- hensive set of rehabilitation techniques that mental health services will offer. Their use with cognitive rehabilitation techniques will be synergistic rather than a replacement for psychosocial techniques. A MODEL FOR THERAPY What is needed is a theoretical model for therapy development, and currently few exist. As discussed earlier, most theories were provided post hoc and have not been supported by current data. They are mostly descriptive and give little guidance for the development of the most efficacious therapy. Most of the attention has been given to the types of cog - nition that predict poor functioning, with little consideration of what cognitive abilities would be required to carry out real-life actions. Clare Reeder and I have considered what is required for cognition to be transferred into actions. Figure 25.3 shows our model, which contains a new component, metacognition. We categorize actions into those that are routine (i.e., are specified by cognitive schema as soon as the goal or intention has been defined) and nonroutine (i.e., not completely specified by a cognitive schema). Most actions are not routine. For example, if I intend to make a meal, I need to decide what kind of meal I would like to make, to look in a recipe book, to consider what ingredients are available, and so on. I must reflect upon my intention, my goals, my past experience, and the way in which these interact with the current circumstances to select a certain set of appropriate actions that will allow me to achieve my goal. This ability to reflect upon and regulate one’s own thinking is referred to as metacognition. It is the key to carrying out nonroutine actions successfully. This has profound effects on what we need to include in a cognitive rehabilitation program. Improvements in cognitive processes have a direct effect on routine actions because they improve the efficiency of cognitive schemas. But, 256 IV. PSYCHOSOCIAL TREATMENT [...]... relationships, and a stronger sense of purpose and self-confidence These long-term goals are often referred to as recovery, even when they occur in the context of persistent symptoms PRINCIPLES OF ILLNESS SELF-MANAGEMENT The principles of illness self-management are derived from the stress–vulnerability model of schizophrenia According to this model, the origins and course of schizophrenia are determined... Schizophrenia Bulletin, 25, 657 –676 Twamley, E W., Jeste, D V., & Bellack, A S (2003) A review of cognitive training in schizophrenia Schizophrenia Bulletin, 29, 359 –382 Wexler, B., & Bell, M D (20 05) Cognitive remediation and vocational rehabilitation for schizophrenia Schizophrenia Bulletin, 31, 931–941 Wykes, T., Reeder, C., Williams, C., Corner, J., Rice, C., & Everitt, B (2003) Are the effects of cognitive... literature review and meta-analysis of randomized controlled trials Journal of Nervous and Mental Disease, 191, 51 5 52 3 Wehman, P., & Moon, M S (Eds.) (1988) Vocational rehabilitation and supported employment Baltimore: Brookes C H A P TE R 27 ILLNESS SELFMANAGEMENT TRAINING KIM T MUESER SUSAN GINGERICH Illness self-management is a broad set of strategies aimed at teaching people with schizo- phrenia how better... K T (2005a) Coping skills group: A session-by-session guide Plainview, NY: Wellness Reproductions Gingerich, S., & Mueser, K T (2005b) Illness management and recovery In R E Drake, M R Merrens, & D W Lynde (Eds.), Evidence-based mental health practice: A textbook (pp 3 95 424) New York: Norton Hasson-Ohayon, I., Roe, D., & Kravetz, S (2007) A randomized controlled trial of the effectiveness of the illness... Innovations in the psychological management of schizophrenia (pp 147–169) Chichester, UK: Wiley Zygmunt, A., Olfson, M., Boyer, C A., & Mechanic, D (2002) Interventions to improve medication adherence in schizophrenia American Journal of Psychiatry, 159 , 1 653 –1664 C H A P TE R 28 GROUP THERAPY JOHN R McQUAID F or approximately the past 50 years, effective treatment of schizophrenia has depended on pharmacotherapy... that are not easily transferable between situations A CLINICAL MODEL OF CRT CRT aims to provide the participant with a comprehensive cognitive structure to reduce stimulus overload and facilitate efficient cognitive processing A detailed description of the process of therapy is given in Wykes and Reeder (20 05) The current therapy involves paper-and-pencil tasks that help people to consider thinking strategically... ILLNESS SELF-MANAGEMENT PRACTICES Reviews of research on teaching illness self-management skills have identified five specific practices that improve the course of schizophrenia: psychoeducation, behavioral tailoring, a relapse prevention plan, and coping and social skills training Psychoeducation involves providing factual information about the nature of schizophrenia and the principles of its treatment,... from an exploratory trial in schizophrenia Schizophrenia Research, 61, 163–174 Wykes, T., & Reeder, C (20 05) Cognitive remediation therapy for schizophrenia: Theory and practice London: Routledge C H A P TE R 26 VOCATIONAL REHABILITATION DEBORAH R BECKER The rate of unemployment for people with serious mental illness, and schizophrenia in particular, is approximately 85% Employment provides a means... These skills then are not context-bound but allow for the development of a new style of thinking that can be used in all aspects of the participant’s life Finally, and most important for transfer, through therapist prompts and discussions about their use, we emphasize how the skills might be used in the real world These trans- 258 IV PSYCHOSOCIAL TREATMENT FIGURE 25. 3 A model for cognitive remediation... therapy informed by psychoanalytic conceptualizations of psychosis New models, drawn from scientifically informed theories of psychopathology and human behavior, focus on a range of potential outcomes reflecting the heterogeneous nature of schizophrenia Is Group Therapy a Reasonable Intervention for Schizophrenia? Because of a greater awareness of patient needs, group interventions (including classes . range of tasks that required engagement, disengagement, and reengage - ment of various cognitive information sets. Memory is targeted by a range of set mainte - 25. Cognitive Rehabilitation 255 nance,. the results of clinical trials. Single-Test Interventions These interventions were designed to provide highly controlled comparisons of short in - terventions for particular tests of cognitive. difficulties of the participant. There is little current evidence on the efficacy of computer- versus therapist-driven therapy, because most pro - grams studied have included supervision from a clinical