CLINICAL HANDBOOK OF SCHIZOPHRENIA

15. Treatment Planning 151Poor adherence to oral antipsychotic medication leads to relapses, derails the process ofrecovery, and contributes to the high cost of treating schizophrenia. With this in mind, itis important to ensure good adherence to medication. Medication adherence is importantin determining whether the selected treatment is effective, whether there should be dosageadjustments, and whether concomitant medications should be added. Because prescriberstypically are not able to identify accurately how much of the prescribed medication anindividual is taking, decisions about medication changes are often made with little or noaccurate data. To optimize treatment, adherence is extremely important. However, medicationadherence is infrequently a client-stated goal. Linking medication adherence tostaying out of the hospital, getting along better with family, and other client-identifiedgoals is essential in making adherence an objective of the treatment plan. The use of motivationalinterviewing can be helpful in raising the client’s awareness of the need for medication,and in dealing with his or her ambivalence regarding taking medication. However,the intention to take medication is not the same as adherence. Forgetting, failure to establishroutines consistent with taking medication, and chaotic environments contribute toproblem adherence even when the consumer is very willing to take medication. Environmentaladaptations such as signs, alarms, and pill containers may be used to prompt andto cue the client to take medications as prescribed. A thorough assessment of how the clientremembers to take medication, where medication is kept, and an understanding ofwhen missed doses occur can assist in planning strategies to enhance adherence. In-homeinterventions to promote medication adherence are part of the CAT intervention.Positive SymptomsAntipsychotic medications may reduce but not eliminate the positive symptoms of schizophrenia.Hallucinations and delusions often continue and may cause a substantial amountof distress to clients. Cognitive-behavioral approaches are designed to address these enduringpsychotic symptoms by helping clients to examine evidence for their perceived powerand origins (“What is the evidence that the voice is that of the Devil?”), and to alter cognitiveattributions associated with these symptoms, so that the symptoms, although present,create less distress. CBT can be a helpful adjunct to medication treatment.Negative SymptomsNegative symptoms such as amotivation, asociality, and poverty of speech and movementare predictive of poor community outcomes for patients with schizophrenia. Targetingnegative symptoms is important in improving outcomes for these individuals. There areno available psychosocial treatments designed specifically with negative symptoms as theprimary target. However, a variety of treatments may lead to decreases in negative symptomson standard assessments. Interventions that engage individuals’ participation andincrease functioning, ADLs, or leisure and recreational skills may lead to decreased negativesymptom scores.Cognitive FunctioningDeficits in psychomotor speed, attention, memory, and planning characterize individualswith schizophrenia. Evidence suggests that these cognitive impairments may underlie deficitsin social and role functioning. Cognitive remediation (CR) techniques seek to improvecognitive functions directly, utilizing a variety of pen-and-paper or computerizedtests requiring attention, planning, problem-solving, and memory skills. Several models