CLINICAL HANDBOOK OF SCHIZOPHRENIA

27. Illness Self-Management Training 273Questionnaires containing the early warning signs of relapse and worksheets for developinga relapse prevention plan can be found in the work of Gingerich and Mueser(2002; Mueser & Gingerich, 2006).Teaching Stress Reduction TechniquesAs noted earlier, stress can precipitate symptom relapses. However, living a full and rewardinglife invariably involves some exposure to stress, so rather than telling clients toavoid all stress, it is important to teach them strategies to manage stress. Prior to teachingstress management, it is helpful to talk with the client about what situations or events heor she finds stressful, and how to recognize the signs of stress (e.g., rapid breathing, racingheart, muscular tension, confusion, anxiety). Awareness of when one is experiencingstress can serve to cue a person to use stress reduction techniques.The same methods used to teach stress management in the general population arealso effective in people with schizophrenia, including relaxed (deep) breathing, positiveself-talk, progressive muscle relaxation, and imagery. The specific combination of thesebasic elements can be determined individually for each client. Examples of relaxation exercisesmay be found in popular books by Gingerich and Mueser (2002; Mueser &Gingerich, 2006).In addition to learning relaxation exercises, it can also be helpful for clients to get involvedin meaningful, but not overly demanding, structured activities. Lack of meaningfulstimulation can be stressful and precipitate symptom relapses. Involvement in meaningfullystructured activities, such as part-time work, school, sports, volunteer programs,or a local club, can engage clients in a positive, constructive manner that gives them asense of meaning and purpose in their lives.Developing Coping Strategies for Persistent SymptomsMany clients experience persistent symptoms, such as hallucinations, anxiety, and depression,in spite of taking their antipsychotic medications regularly. These symptoms oftenlead to distress and interfere with functioning. Learning to use coping strategies can reducethe negative effects of persistent symptoms.When persistent symptoms are distressful or lead to problems in functioning ofwhich the client is aware, he or she usually feels motivated to learn more effective copingstrategies. In the absence of distress or functional impairment, the clinician can explorewith a client how symptoms may interfere with personal goals (e.g., hearing voices mayinterfere during job interviews) to motivate the client to learn coping strategies. Copingstrategies may be taught by using the following steps:1. Identify persistent symptoms. Work on one symptom at a time, and elicit from theclient a detailed description of the nature of that symptom.2. Teach the client to self-monitor the symptom on a daily basis. Keeping track ofthe frequency and intensity of the symptom can both increase the client’s awarenessof it and help him or her to identify situations in which it is more versus lessproblematic.3. Identify current coping strategies used by the client and strengthen those that arehelpful through additional practice in sessions and by developing plans to practicethe strategies at home.4. Select a new coping strategy collaboratively with the client, demonstrate it, en-