CLINICAL HANDBOOK OF SCHIZOPHRENIA

254 IV. PSYCHOSOCIAL TREATMENT• 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 differentiatebetween successful and unsuccessful characteristics. But because there are some distinctchoices, some of these general models are described.Operant ConditioningThis type of treatment is based specifically on learning theory and incorporates the differentialreinforcement of successive approximations of behavior or shaping. Rather thanwaiting for a complete behavior to occur before offering reinforcement, reinforcement isprovided for successive approximations or steps toward the final behavior. This type oftraining has been used with the most severely disabled patients, and there is evidence ofboth complex (abstract thinking) and simple (sustained attention) positive outcomes.Changing the environmental contingencies may therefore have a role to play in cognitiverehabilitation (e.g., Silverstein, Menditto, & Stuve, 2001).Environmental manipulation has been taken even further in a program called cognitiveadaptation training. Participants in this program, following a neuropsychological assessment,are provided with an environment that compensates for their specific cognitiveimpairments. 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 ofmoney 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 environmentalmanipulation will continue to guide behaviors and to reduce response choices thatoften have a detrimental effect on performance. The evidence for the efficacy of this particulartherapy includes improvements in both symptoms and social functioning. Environmentalcontrol is, however, gross, and this may not be acceptable to all service usersor health care professionals.Integrated Psychological TherapyIntegrated psychological therapy (IPT) was one of the first programs to include a specificcognitive domain. There are five subprograms each of which has both social and cognitiveelements in differing amounts. The subprograms are cognitive differentiation, socialperception, verbal communication, social competence, and interpersonal problem solving.The explicit cognitive subprogram (cognitive differentiation) addresses a variety ofcognitive abilities, such as attention and conceptualization abilities. Activities are run in agroup, in which training is didactic. This method of training provides social contact thatmay also boost social functioning.This therapy has been subjected to rigorous evaluation; although most patients show someimprovement in cognitive ability, the specific improvements differ between studies and dependon the level of experimental control (Spaulding, Reed, Sullivan, Richardson, & Weiler, 1999).Cognitive Enhancement TherapyThis therapy amalgamates both group and partner working. It uses task materials oftenfrom those used to treat brain injury, as well as a comprehensive approach to work ther-