CLINICAL HANDBOOK OF SCHIZOPHRENIA

28. Group Therapy 283rate hypotheses. Techniques include learning to record thoughts, to identify the relationshipof thoughts to feelings and actions, to identify alternative thoughts, and to gather evidenceon the accuracy of the beliefs.A MODEL COMBINING CR, SST, AND CBT: CBSSTOverviewAs the name implies, cognitive-behavioral social skills training (CBSST) integrates CBTand SST in a group therapy intervention. The primary goal of the combined treatment isto build on the strengths of SST in achieving functional outcomes, and to enhance treatmentresponse by using CBT and compensatory strategies to address cognitive factorsthat interfere with patients’ effective engagement in the treatment. The manual comprisesthree eight-session modules: Changing Your Thinking (cognitive interventions), Askingfor Support (communication), and Solving Problems. Patients begin the treatment at thefirst session of any module, then complete all three modules twice, for a total of 48weekly treatment sessions. Each session is 2.5 hours long, including a half-hour lunchbreak that is an integral part of the treatment. During the break, patients and group leaderspractice interpersonal skills in a more “real-world” environment.To facilitate participation of new members, the first session of each module includesan orientation section in which patients introduce themselves to each other and learnabout the treatment model of the therapy. This allows patients to join the group every 8weeks, dramatically reducing the potential wait time compared to a traditional closedgroup. At the same time, patients receive a more extensive orientation to the treatmentthan would be available in a traditional open group, and the fact that orientation is builtinto the group structure minimizes disruption to the skills training.Each session includes multiple compensatory strategies to aid learning and memory.In fact, many of the standard CBT and SST components are in part CR techniques, includingthe use of role plays to train cue recognition, structured problem solving, and useof forms to record data (e.g., thoughts and associated emotions). Cognitive therapy andproblem-solving training interventions are designed to improve the ability of patients toobserve and to examine their thinking and planning, which in turn may improve cognitiveflexibility, inductive reasoning, and abstract thinking. In addition, CBSST incorporatesseveral additional compensatory strategies. All patients receive a group manual thatincludes not only the materials but also the tracking forms specific to each session andspaces for notes. They also receive laminated cards that list specific skills, and remindthem how and when to use the skills. In class the group leaders present information usingmultiple modalities, including writing on a dry-erase board, using posters, having patientsread from the manual, as well as lectures and group discussion. There is an emphasison repetition and eliciting paraphrasing comments (i.e., summaries of the therapist’sstatements) from patients to assess their level of understanding and to aid development oftherapeutic alliance. Exercises in the manual include developing action plans to respondto anticipated needs (e.g., the name and number of the patient’s doctor, along with whatto do if the patient is experiencing symptoms associated with relapse). Throughout themanual, simple mnemonics are used to help patients remember tasks. For example, thethought challenging technique is called “the three C’s,” which stands for catch thethought, check it, and change it. Finally, during the group patients receive reinforcement(including verbal praise and tokens acknowledging success) for responses that representan improvement over previous efforts, however small. The incorporation of these strategiesis intended to facilitate engagement in treatment and to improve skills acquisition.