CLINICAL HANDBOOK OF SCHIZOPHRENIA

406 VI. SPECIAL POPULATIONS AND PROBLEMSabout his medication were being taken into account, and that people were listeningto his perspective. With his anxiety and anger reduced, John was able to admit thatsome of his experiences were related to having schizophrenia. This allowed the therapistand staff to utilize some CBT techniques to assist with managing these experiences.John illustrates a key issue in working with people with schizophrenia and highlightswhy motivation must be considered an important part of the engagement process. Individualsoften need to believe that there is something in it for them to make changing theirbehavior worth the effort. It is common for clients’ anger and aggression to play an importantrole for them, and giving this up may involve considerable effort. Without an importantgoal to motivate them, change efforts are unlikely to be successful.Further description of CBT approaches for working with psychotic symptoms arenot discussed further here. The reader is directed to more comprehensive texts (Referencesand Recommended Readings) listed at the end of this chapter.Strategies for Working with AngerComprehensive interventions for working with anger have been described fully by RayNovaco and adapted to apply in a number of settings. The approach has been modifiedfor working with people with active psychotic symptoms and substance use problems (seeReferences and Recommended Readings). The approach has a number of key elements.PSYCHOEDUCATIONProviding people with a good understanding of anger, its components, and functions is anextremely useful starting point, once they realize that their anger may be an important issue.It is important that people understand that anger is a state and is not directly linkedto aggression and violence, and that anger itself may be a positive and welcome emotion.Anger can become problematic if it leads to negative consequences, such as unwanted aggressionor violence, but it can also be a useful emotion to stimulate positive and usefulaction when necessary (e.g., running away from danger, being assertive). Helping peopleto become sensitive to their anger and to use it positively can be especially important,given that mental health services have previously given the message that anger is a badthing. Information about the components of anger in terms of a CBT model may also beextremely useful in helping people to recognize their own anger and to see that there maybe strategies to overcome its negative aspects.SELF-MONITORING AND USE OF ANGER HIERARCHIESHelping people to monitor the way their anger influences their cognitive, emotional, orphysiological state and their behavior can then be an important step in devising the bestinterventions. People may want to keep diaries or to make a mental note of their day-todayactivities between therapy sessions, then discuss and examine these data with thetherapist to investigate when their anger was not helpful and what factors fed into it (psychoticbeliefs, substance use, etc.). This may make the type of solutions obvious to theindividual. For example, individuals who notice that they become upset and angry wheneverthey have particular interactions with staff members become aware that somethingabout the way staff members interact with them is upsetting. Staff members who are unawareof an individual’s particular delusional beliefs may inadvertently behave in a way