CLINICAL HANDBOOK OF SCHIZOPHRENIA

246 IV. PSYCHOSOCIAL TREATMENTCognitive ImpairmentThe problems of seriously mentally ill patients in terms of memory, attention, and higherlevelproblem solving have been repeatedly demonstrated and must be taken into considerationin SST. Asymptomatic patients with schizophrenia can appear to maintain lucid conversations,seem to learn and understand well, and respond affirmatively to questions evenif they do not understand. Whether they do not remember, are easily distracted, or are thinkingso concretely that they cannot transpose ideas from situation A to situation B, patientsoften lack the capacity to learn from continuities across situations. The only effective solutionsthat we have found for this dilemma are (1) to impose as much structure as possibleand minimize demands on abstraction (use prompts and handouts, identify simple commonaltiesacross situations for the person to focus on, and keep instructions very simple andstraightforward) and (2) to practice, practice, practice (the more automatic the response in asocial situation, the less demand on working memory and analysis). Also, we do not ask participantswhether they understand; rather, we ask them to demonstrate their understandingthrough role playing and explaining things to other patients.Make Sessions InteractiveThe emphasis in SST is on teaching and collaboration rather than lecturing. Thus, thetherapist must direct the conversation back to the patient as much as possible. Therapistsshould stimulate participant input by asking for relevant examples and for participants’understanding of things. Note that this interactive strategy must also be tailored for eachindividual. Some participants, especially those who are low functioning, have a lot of difficultywith open-ended questions and high-level interactions. Thus, interactions must betailored to meet the needs and capabilities of each individual. If unbalanced participationbecomes a problem at any time during the group sessions, it is useful to establish a routineby beginning with a volunteer and soliciting a response from each member of thegroup in succession. It is important, however, that clients know that it is OK for them to“pass” if they do not wish to make a contribution during the group sessions.Maintain a Positive StanceOne key to making SST work well is to be consistently positive and reinforcing. Mostpeople with serious mental illness have long histories of failure and frustration. SST is oneplace that they can be assured of success, because (1) the level of demand is geared totheir capacity, not to some abstract or unreachable standard; and (2) communications arealways positive, emphasizing what they have done well, not what they have done poorly.SST trainers help participants set goals, explain behavioral contingencies, and rewardparticipants’ use of newly acquired skills in the real world. It is our hope that by makingthis reinforcement more explicit, we may also help patients to improve some of the socialdeficits caused by negative symptoms (e.g., avolition, social withdrawal).HandoutsHandouts outlining the steps of each skill provide a concrete focus for patients. Therapistsshould refer to the handouts throughout the training and draw participants’ attentionto the handouts as needed. Therapists can ask the participants to read material off ofthe handout, if it is clear that they can read. For example: “What’s the first step in askingfor feedback about your job performance? Can you read it for me?” They can also take