CLINICAL HANDBOOK OF SCHIZOPHRENIA

284 IV. PSYCHOSOCIAL TREATMENTGoal SettingAt entry to treatment, regardless of the module, patients meet individually with a therapistto identify goals. The patient defines his or her goals (e.g., starting a relationship, gettinga job), and the therapist provide guidance in terms of making the goal as specific andquantifiable as possible. The therapist then helps the patient to identify specific steps inachieving the goal. This is particularly important when goals are extremely ambitious.The therapy goals are written into the patient’s manual and used in relation to all otherinterventions learned in each module. Throughout the course of treatment, patients areencouraged to review and update their goals based on what they have learned in treatment,and on any changes in their living environment.Module ContentChanging Your ThinkingThe focus of this module is on the development of cognitive restructuring skills. In treatmentsfor other disorders (e.g., major depression or anxiety disorders) cognitive restructuringis used to modify cognitions that lead to the distressing target affect. The goal oflearning cognitive restructuring in CBSST is somewhat broader. One of the key characteristicsof psychotic thought process is that thinking is fixed, and patients have poor insightinto the nature of their cognitions. Patients engage in many common cognitive distortions(overgeneralization, selective attention, emotional reasoning), then hold these beliefs withextreme confidence, regardless of external evidence. Although these patterns are most obviousin terms of psychotic beliefs or attributions about the nature of hallucinations,these same cognitive biases can have implications for more mundane aspects of functioning(e.g., beliefs about competence to take a bus or to speak to a treatment provider).The Changing Your Thinking module provides patients with extensive practice incognitive restructuring skills, which include recognizing cognitive processes, assessing theeffect of the cognitions on emotion and behavior, and modifying thoughts that interferewith desired outcomes. Patients first learn that cognitions, emotions, and behavior all influenceone another, and the rationale that modifying cognition can therefore modifyemotions and behavior. Patients are then taught the three C’s mnemonic to remind themof the three tasks of cognitive restructuring. Separate sessions are dedicated to practice ofeach of the C’s. For the “check it” component, patients learn to identify common cognitivedistortions, and to engage in behavioral experiments to get evidence with which tojudge the accuracy of thoughts. To change thoughts, patients learn to generate alternativeexplanations based on the evidence from behavioral experiments.The model is applied to nearly every experience of the patient, including beliefsabout symptoms, treatment, their relevant treatment goals, and the group process itself.Patients in groups for schizophrenia, who often have had very negative learning experiences,may have unhelpful beliefs about the intervention or their ability to do the activities.Prediction of the future (“It won’t be fun”), negative beliefs about competence (“Ican’t do anything”), and beliefs associated with psychotic symptoms (“The Devil willpunish me”) can reduce the likelihood of the patient successfully achieving a goal. Whennew materials are assigned, patients are encouraged throughout the manual to identifythought content, and if those thoughts interfere with active engagement in treatment, patientsare coached in interventions to increase their likelihood of successfully completingthe task. By applying cognitive techniques, patients both increase the likelihood of engagingin the task and gain additional practice with the skills.Although cognitive therapy is often seen as educational rather than as a means to addressrelationship issues, therapists use cognitive techniques to help patients notice their