CLINICAL HANDBOOK OF SCHIZOPHRENIA

282 IV. PSYCHOSOCIAL TREATMENTCognitive RehabilitationMounting evidence suggests that CR interventions can effectively benefit patients withpsychosis. These interventions can be classified into three categories. Restorative interventionsuse task training to improve an area of cognitive deficit (e.g., repetitive practiceof a card sorting task with corrective feedback to improve cognitive flexibility). Compensatorystrategies adjust for the patient’s cognitive limitations by teaching ways to copewith deficits (e.g., learning to use notebooks and calendars to plan and schedule, learningproblem-solving skills). Environmental strategies involve modifying patients’ environmentsto better match their level of cognitive functioning (e.g., having simple remindersabout tasks posted in the bathroom). Whereas all three sets of interventions have someevidence of support, compensatory strategies and, to some extent, environmental strategiesare most relevant to group processes.The primary purpose for incorporating CR interventions in group therapy is to facilitateother aspects of the treatment. Particularly for education and skills-based treatments,compensatory strategies can be critical for providing patients the necessary skillsto engage in the treatment.Social Skills TrainingSocial skills training, as the term implies, emphasizes training patients in appropriate socialcues, including nonverbal communication, assertive verbal communication, active listening,and problem solving. SST is based on social learning theory, and emphasizes bothdirect practice and observational learning. Treatment includes a heavy reliance on roleplays and feedback on performance. The therapist videotapes role plays and reviews themwith patients. Each patient receives feedback from both the therapist and other groupmembers. By having the therapy in a group modality, patients learn by both observingand giving feedback to their groupmates, as well as practicing on their own.Cognitive-Behavioral TherapyCognitive-behavioral therapy for schizophrenia was developed initially as a treatment forreducing psychotic symptoms. CBT for psychosis is based on the assumption that cognitiveprocesses in schizophrenia share a continuum with normal cognition; that is, the delusionalcontent is not pathological (all people can report having unusual thoughts);rather, it is limited ability to question the delusion that is problematic. The interventionwas therefore designed to teach patients the skills of examining beliefs and developing alternativeexplanations for experiences, including psychotic symptoms. As the interventionhas been applied to patients with psychosis, additional target goals have been added,including facilitation of rewarding activities, medication adherence, social interactions,and vocational goals. Most interventions have been studied in an individual format, althoughthere are some promising studies of CBT in a group modality as well.CBT for psychosis differs from CBT for other disorders in several ways. Treatmentfor psychosis tends to have a longer course (greater than a year, compared to 12–20weeks for major depression) in part due to the greater emphasis on developing the therapeuticrelationship. Therapists treating patients with schizophrenia are much less directiveinitially in treatment (particularly in an individual model), and more flexible in termsof treatment structure, to facilitate the development of a trusting relationship.At its most basic level, CBT teaches patients to view their thoughts as hypotheses, togather evidence as to whether those hypotheses are true, and to generate new, more accu-