CLINICAL HANDBOOK OF SCHIZOPHRENIA

394 VI. SPECIAL POPULATIONS AND PROBLEMSadults in general. Popular “wisdom,” reflected in idiomatic expressions such as “Youcan’t teach an old dog new tricks,” has at times pervaded even well-intentioned clinicalsettings. This ageist attitude may be amplified even further when the public and cliniciansconsider older adults with schizophrenia.Fortunately, in the last several years, controlled trials of psychosocial interventionsspecifically for middle-aged or older adults with schizophrenia have yielded promising resultsfor improving certain functional disabilities that persist after adequate antipsychoticmedication treatment. These include three manualized and empirically tested psychosocialinterventions that use various forms of skills training. For example, CBSST (cognitivebehavioralsocial skills training), a 24-week, group-based intervention combining cognitivebehavioraltechniques (e.g., examining/challenging distorted beliefs) and social skillstraining (e.g., practicing conversational skills) successfully improved social functioningand cognitive insight among middle-aged and older adults with schizophrenia. This treatmentwas adapted for cognitive difficulties associated with both schizophrenia and normalaging, and it also included instructional material that was specific to troublesomesituations or beliefs commonly encountered in aging populations (e.g., challenging the belief“I am too old to learn,” or problem solving around sensory impairments).Another 24-week, modular intervention termed FAST (functional adaptation skillstraining) also successfully improved community functioning in middle-aged and olderadults with schizophrenia. Skills addressed by this treatment include organization/planning;social skills/communication; and management of medications, transportation, andfinances. A noteworthy similarity between CBSST and FAST is their emphasis on homeworkassignment and review, a key component originally emphasized in CBT, as developedby Beck, which has been tied to successful psychotherapy outcomes for a variety ofdisorders. Behavioral principles, including behavior remodeling, role playing, and reinforcement,also inform various aspects of the FAST intervention.A third empirically tested psychosocial intervention (skills training and health management)for older adults with severe mental illnesses (including schizophrenia) likewisefocuses on skills training but also includes helping patients to access preventive medicalcare and medical care for chronic conditions. This intervention improved social functioningand the appropriateness of medical care received. This highlights an issue that becomesincreasingly prominent as persons with schizophrenia age—medical comorbidity.Because medical care for physical health in persons with schizophrenia has been notoriouslyinadequate for a variety of reasons (patient-, clinician-, and system-related), clinicianstreating schizophrenia should be especially alert to the multitude of age-associatedhealth problems that may accrue with time. Lifestyle habits that often accompany schizophrenia(e.g., smoking, lack of exercise, poor diet) and metabolic side effects ofantipsychotic medications combine to necessitate proactive attention to physical healthscreening and treatment in the aging person with schizophrenia. Unfortunately, fragmentationof physical and mental health care systems may at times make psychiatrists defacto primary care physicians for persons with schizophrenia.Another psychosocial approach successfully used in younger patients with schizophreniais vocational rehabilitation, often through individual placement and support(IPS), a form of supported employment. Key components of supported employment arequick job placement, obtaining competitive (i.e., not specially set aside) positions, earningminimum wage or higher, unlimited time frames for vocational support efforts, and collaborationbetween the employer and the mental health team. Although one might assumethat older adults do not need or want to have occupations, employment can have asignificant positive impact on older adults’ quality of life in many situations, building asense of purpose and self-esteem. Recently an IPS intervention that resulted in significant