CLINICAL HANDBOOK OF SCHIZOPHRENIA

384 VI. SPECIAL POPULATIONS AND PROBLEMStherapy and to select appropriate interventions for the therapeutic relationship based onthe client’s developmental level and symptomatic presentation. The strategies for engagementare similar to those mentioned earlier for supportive therapy.The cognitively oriented therapy developed at PACE for the high-risk group usesstrategies developed for acutely unwell and recovering populations. Cognitive models approachthe core symptoms of psychosis as deriving from basic disturbances in informationprocessing that result in perceptual abnormalities and disturbed experience of theself. Cognitive biases, inaccurate appraisals, and core self-schemas further contribute tomaladaptive beliefs. Cognitive therapy aims to help people to develop an understandingof the cognitive processes (including biases and maladaptive appraisals) that influencetheir thoughts and emotions, and to develop more realistic and positive views of themselvesand events around them.The stress–vulnerability model of psychosis informs the treatment approach. Acentral assumption of this model is that environmental stressors (e.g., relationshipissues, substance use, lifestyle factors) are key factors in precipitating illness onset invulnerable individuals. This implies that the implementation of appropriate copingstrategies may ameliorate the influence of vulnerability. Therefore, strengthening the individual’scoping resources forms a core component of the cognitive therapy offered atPACE.Although stress management forms the backbone of this therapy, it is important toaddress the wide array of presenting symptoms in this population. To this end, a range oftreatment modules have been developed within the cognitive therapy: Stress Management,Depression/Negative Symptoms, Positive Symptoms, and Other Comorbidity. Theassessment of the presenting problem(s), and the client’s own perception of his or herfunctioning, informs the selection of modules to be implemented during the course oftherapy. Although the therapy comprises individual modules targeting specific symptomgroups, it may not be appropriate to target one group of symptoms in isolation (i.e., anycourse of therapy, indeed, any individual therapy session may incorporate aspects ofmore than one module). The therapy was designed to be provided on an individual basis,but it could potentially be adapted to suit a group treatment situation. Young people cancurrently attend PACE for a maximum of 12 months, with session frequency varyingfrom weekly to every 2 weeks, and even monthly in the final stages, depending on clientneed.The treatment modules are described below.Stress ManagementIn keeping with the stress–vulnerability model of psychosis, elements of the Stress Managementmodule are provided to all patients. This module has the added advantage ofproviding an easily understood introduction to cognitive–behavioral principles, whichsets the direction of future sessions. Strategies include the following:• Psychoeducation about the nature of the stress and anxiety.• Stress monitoring that encourages patients to record varying stress levels over specifictime periods and to identify triggers and consequences of anxiety or stress.• Stress management techniques, such as relaxation, meditation, exercise, and distraction.• Identification of maladaptive coping techniques (e.g., excessive substance use, socialwithdrawal).