CLINICAL HANDBOOK OF SCHIZOPHRENIA

CHAPTER 21ENVIRONMENTAL SUPPORTSDAWN I. VELLIGANALEXANDER L. MILLERWykes (Chapter 25, this volume) describes cognitive rehabilitation (or cognitiveremediation), a treatment designed to improve cognition and functional outcomes forpatients with schizophrenia. Whereas cognitive rehabilitation utilizes computerized orpen-and-paper tests designed to improve attention, memory, and problem solving, environmentalsupports focus on structuring the environment to compensate for or workaround impairments in these cognitive functions. Therapies that mainly work through thesystematic use of environmental compensatory strategies and supports are relatively uncommonfor schizophrenia but have a growing evidence base.Compensatory strategies and environmental supports attempt to bypass cognitivedeficits, negative symptoms, and disorganization by establishing supports in the environmentthat specifically cue and sequence adaptive behavior, and discourage maladaptivebehavior. For example, pill containers with alarms can cue an individual to take medicationon time. Daily-use pill containers can be used to discourage an individual from takingmultiple doses of medication. Checklists can be used to prompt specific behaviorsthat are necessary to live more independently (e.g., cleaning the kitchen). These techniqueshave been utilized for years in the rehabilitation of individuals with head injuriesand with mental retardation. More recently, these supportive strategies have been extendedto treatment of schizophrenia in an intervention known as cognitive adaptationtraining (CAT) with very encouraging results.COGNITIVE ADAPTATION TRAININGCAT is a series of manual-driven compensatory strategies and environmental supports(signs, checklists, electronic cueing devices) based on a comprehensive assessment of theindividual’s neurocognitive function and behavior. We know that impairments in executivefunctions (the abilities needed to plan and carry out goal-directed behavior) can leadto one of several types of behavior when performing daily living skills; (1) apathy; (2)207