CLINICAL HANDBOOK OF SCHIZOPHRENIA

28. Group Therapy 285thoughts about the group itself. The primary emphasis of the thought challenging modelis to encourage patients to observe their thinking in all settings, and the group setting canbe a particularly potent environment for teaching patients about both the influence oftheir thoughts on mood and behavior, and the consequences of changing their beliefs.Asking for SupportThis module, which draws heavily from SST, provides patients with skills in identifyingwarning signs of symptom exacerbation, then trains patients in communication skills.The primary emphasis is on effective communication in situations related to treatment(e.g., talking with a doctor), but patients also apply the skills as relevant to their goalsand other relationships.The primary intervention in the module is the use of role plays of specific situations,with feedback from therapists and other group members. Patients have opportunities topractice both scripted role plays and role plays based on their goals, and they are givenvery detailed instructions on both nonverbal (e.g., maintaining eye contact, appropriatefacial expression) and verbal (e.g., use of “I” statements, expression of emotions, makinga specific request) skills. This includes having a posterboard present in the room that liststhe specific skills relevant to the role play. The role plays are videotaped and played backin group, so that patients can critique their own performance and receive feedback fromothers in the group.In the context of the module, each patient develops a plan to respond to an exacerbationof symptoms. The plan includes identifying a support person who can help the patientrecognize his or her symptoms and signing an agreement to listen to that supportperson’s feedback, if the patient’s symptoms become worse. The patient also practices discussingthe symptoms with his or her case manager (if the patient has one) and physician.Communication skills training is often the most difficult component of the treatment.For many patients, speaking in front of the group and on camera is initially quiteanxiety provoking. One advantage of the modular enrollments is that more experiencedgroup members who have previously participated in that section of the course can sharetheir experience with new members and help to reduce their anxiety. In addition, thegroup leaders can use cognitive restructuring techniques to address patient concernsabout participating in the exercises.Solving ProblemsThe Solving Problems module draws from both SST and CBT techniques. Patients learnbasic problem-solving skills using the acronym: SCALE—Specify the problem, Considerall possible solutions, Assess the best solution, Lay out a plan, and Execute and evaluatethe outcome. Goals and problems are identified in session, then the patient completes aworksheet for the problem, covering each point on the form. The goals of the patientguide the problems targeted. In addition, all patients work through the SCALE model oncommon problems, such as recurrent symptoms. The primary goal is to train patients tobe able to apply the model to any topic.Individual differences in effective reinforcement, abilities, symptoms, and goals requirethat treatment be as individualized as possible in the context of a group structure.To address these points, each module is structured first around education about thetheme of the module, followed by skills in assessing the topic. Participants then learn interventionsfor modifying the behavior, and the final session of the module provides additionalpractice. In each session, exercises are designed to aid group members in identifyingtheir specific goals and relevant interventions. As participants gain more experience,