CLINICAL HANDBOOK OF SCHIZOPHRENIA

28. Group Therapy 281• Provide targeted structure. Most current, evidence-based group treatments forschizophrenia emphasize therapeutic structure. This includes use of manualized treatments,heavy emphasis on psychoeducation, use of clearly defined skills training exercises,and defined courses of treatment (e.g., programs with a set number of sessions withspecific agendas). By increasing the structure of treatment, the clinician helps to compensatefor both the cognitive deficits and the negative symptoms. In addition, skills-basedinterventions (e.g., cognitive-behavioral therapy) show significantly better long-term outcomesthan less structured supportive therapy.• Incorporate individualized treatment plans. Although structure aids learning, acompeting requirement for matching treatment to the specific needs of patients is particularlyclear when one considers both the wide variety of symptom manifestations, and thebroad range of functional impairments in patients. Successful treatments are characterizedby the application of specific exercises to help patients develop unique treatmentplans. For example, cognitive-behavioral interventions for psychosis often include exercisesto identify “warning signs” of symptom exacerbation that are unique to eachindividual, then to define treatment plans to intervene if the warning signs occur. SSTincorporates role plays of specific situations that patients anticipate they will face. Byits nature, group interventions limit the ability of treatment to be matched to a specificpatient’s needs; therefore, interventions need to be designed to account for thislimitation.• Provide a multimodal intervention. Research suggests that patients with psychosistend to have multiple deficits, and that specific skills training in one area does not necessarilylead to improvements in other areas. Therefore, it is preferable for treatments toprovide a broad range of effective interventions that are appropriate to patients’ needs.This need must be balanced with the concern that a skills training treatment with toomany components may be either unfocused or too superficial. Therefore, an interventionmust be applicable to a range of problems and incorporate a variety of techniques, but doso in a relatively concise and coherent manner.• Facilitate a trusting relationship. Paranoia and ideas of reference can severely interferewith the ability of patients to benefit from group. If a patient is more concernedabout the motives of the clinician than the material of the group, it is very hard for him orher to participate. Alternatively, negative symptoms may present obstacles to engagementwith other group members and group leaders. Therefore, in the context of group, therapistsneed to incorporate common listening skills to provide a sense of safety to patientsand facilitate their connection to the group.In summary, effective interventions need to provide enough structure to keep patientswith limited resources on task, focused, and involved in the intervention. Somelevel of individualization is needed to increase the likelihood that a patient will benefit.The intervention needs to be broad enough to address the variability among patients withschizophrenia, and the therapeutic relationship needs to be nurtured.REVIEW OF RELEVANT INTERVENTIONSWith these considerations in mind, three interventions are particularly relevant for consideringgroup treatment for schizophrenia: cognitive rehabilitation (CR), social skillstraining (SST), and cognitive-behavioral therapy (CBT). These interventions are reviewedin other chapters in this volume, so the focus here is on the application of these techniquesin the context of a group format.