CLINICAL HANDBOOK OF SCHIZOPHRENIA

280 IV. PSYCHOSOCIAL TREATMENTpredictors of poor functional outcomes for patients with psychosis than positive or negativesymptoms.Psychotic symptoms also generate a series of secondary difficulties. Patients withpsychotic disorders, relative to the general population, have higher rates of physicalhealth problems and disability, as well as alcohol and substance dependence. Patientswith schizophrenia also tend to have very poor social networks and financial resources.This combination of symptoms, cognitive impairments, and associated health andpsychosocial impairments make schizophrenia one of the most disabling disorders, physicalor psychological. These patients have deficits in all the major resources needed to engageeffectively in therapy.However, within the context of a shift from hospitalization to community-based carein the 1970s, many patients with schizophrenia ended up being responsible for a muchhigher level of self-care than they could provide for themselves. The resulting high ratesof poverty, homelessness, and physical illness among those with severe mental illness arecontinuing challenges today. Current clinical research has moved beyond the originalmodels of psychotherapy for psychosis, which attempted to reduce symptoms throughtalk therapy informed by psychoanalytic conceptualizations of psychosis. New models,drawn from scientifically informed theories of psychopathology and human behavior, focuson a range of potential outcomes reflecting the heterogeneous nature of schizophrenia.Is Group Therapy a Reasonable Intervention for Schizophrenia?Because of a greater awareness of patient needs, group interventions (including classesand skills training, as well as psychotherapy) are becoming widely used for treatment ofschizophrenia. Unfortunately, although there is a growing body of evidence for the efficacyof both group and individual modalities for schizophrenia, there are no direct comparisonsbetween individual and group modalities. Nonetheless, there are several reasonsto emphasize the development of group treatments.In general, group treatment is considered a more efficient way to provide services topatients. In simple terms, group treatment allows a single therapist to serve more thanone patient at the same time. The actual cost-effectiveness is unclear, because groups maybe less effective than individual therapy. However, there are additional benefits inherentto group structure.One of the most important aspects of group treatment is the ability of patients tobenefit from the observation of others. Effective treatments, such as social skills training(SST), facilitate and capitalize on observational learning opportunities. Group therapyprovides a chance for patients to model skills, then observe as other patients practicethese skills. In addition group members can share experiences with other patients, andgive and receive feedback. Perhaps as importantly, groups actually provide social contactsand social feedback to patients who otherwise may have few such opportunities. Patientswho are otherwise isolated can interact with other patients who, to some extent, havesimilar experiences. Practically, this means patients have more opportunities to practiceskills they are learning in a supportive environment.Groups are limited, however, in several important ways. Most obviously, patients getless individualized attention. Some patients, particularly those with paranoid symptoms,may find group settings aversive. Others with grandiose symptoms or poor ability to attendto social cues may be disruptive within a group, interfering with the learning processof others. These limitations suggest several principles to consider when designing grouptreatments.