CLINICAL HANDBOOK OF SCHIZOPHRENIA

238 IV. PSYCHOSOCIAL TREATMENTwith a combination of reducing his medication, seeing a dietician, and instigating anexercise program. He addressed his desire for a more meaningful life by seeking careerguidance in relation to work opportunities (both paid and voluntary), and byactivity scheduling (in relation to both pleasure and achievement) to increase his opportunitiesfor social reinforcement. Andrew was also encouraged to “reclaim” hisformer self by reinstating previously valued activities.RELAPSE PREVENTIONCore beliefs and conditional assumptions, as well as positive beliefs about psychotic experiences,may be conceptualized as vulnerability factors for relapse. The therapist canaddress these factors at this stage of therapy, providing that the patient consents, usingthe strategies outlined earlier. For example, Andrew’s beliefs about vulnerability and hispositive beliefs about the utility of paranoia were considered in this way. In addition, ablueprint of therapy is very useful. The therapist was provided with a summary of whathad occurred in therapy, and Andrew prioritized strategies that he would use should heexperience difficulties in the future. Evidence also suggests that CT for people exhibitingearly warning signs of relapse is feasible and can reduce relapse rates by 50% (Gumley etal., 2003). It is also important to help people distinguish between a lapse and relapse, andto ensure that they do not overcatastrophize the emergence of early signs, which couldpotentially fuel the development of a relapse.EVIDENCE FOR EFFECTIVENESS OF CTRecent studies examining CT for schizophrenia-like psychoses have shown that it is effectivein reducing residual positive symptoms on an outpatient basis, and in maintainingthese gains at follow-up. CT has been shown to be superior to other psychological treatments,such as supportive counseling and treatment as usual involving case managementand antipsychotic medication, and routine psychiatric care. A recent meta-analysis concludedthat CT is an effective treatment for persistent psychotic symptoms, that the effectsof CT are robust over time, and that dropout rates are low (Zimmerman, Favrod,Trieu, & Pomini, 2005). Therefore, it appears that CT methods can be used to promotesymptom reduction and reduce time spent in the hospital, and relapse prevention. In theUnited Kingdom, this has led to the recommendation that CT be delivered routinely aspart of the treatment package offered to people with a diagnosis of schizophrenia.KEY POINTS• Psychosis is amenable to conceptualization as relatively normal experiences with understandableemotional and behavioral consequences due to the appraisal of and response tosuch experiences, rather than as an illness.• A shared case formulation is important for engaging the patient and allowing collaborativeselection of treatment strategies.• A shared list of problems and goals aids engagement and provides a map to target suchtreatment strategies.• Standard cognitive and behavioral change methods are effective in reducing the distressassociated with psychotic experiences.• All patients with psychosis should be offered access to cognitive-behavioral therapy.