CLINICAL HANDBOOK OF SCHIZOPHRENIA

39. Aggression, Violence, and Psychosis 407that angers the individual. This may then set the scene for work in a caregiver session thatmay allow the staff to handle the situation differently. At the same time, the individualcan examine the cognitions that may exacerbate the anger and do some CBT work withthe therapist to help to modify and reduce their impact. He or she may also becomeaware of how physiological arousal is adding to the distressful situation and use somestrategies to reduce this arousal.The use of a hierarchical system that pinpoints specific situations/states in which angeris problematic helps to identify salient situations in a graded fashion—ranging fromsituations of low anger to those in which anger is extreme. This anger hierarchy can beused to identify problematic situations and appropriate coping strategies. Individuals mayalso expose themselves to increasingly severe anger-provoking situations to test out newcoping strategies and practice “imaginal inoculation training” to deal with difficult situations.COGNITIVE RESTRUCTURINGTreatment usually includes some cognitive strategies for dealing with anger-relatedcognitions and beliefs. The anger hierarchy may help to identify thoughts and appraisalsin angry situations and facilitate the search for alternative appraisals and coping strategies.Traditional cognitive strategies may be used to elicit alternative thoughts and toquestion conclusions in relation to inaccurate or distorted thoughts. Behavioral experimentscan be used to test alternatives and to practice coping.In addition, discussion of key beliefs in relation to the function and meaning of angerfor the individual is important. This helps to identify key beliefs that may exacerbateanger in certain situations. Giving people the means to explore their ideas and attitudestoward anger and its expression highlights areas that reduce the potential for violence. Issuesrelated to the necessity to behave violently to maintain self-worth may need to be explored,along with alternative ways to build self-worth. This might involve training individualsto be assertive without becoming violent, or building their self-esteem strategies.INTEGRATING CHANGES INTO KEY GOALSIt is important to integrate the anger intervention into the overall formulation and to linkit to key goals for the individual. Successful anger control may involve key lifestylechanges, so it may be necessary to incorporate some short- and long-term goal planninginto the overall plan.ENVIRONMENTAL ISSUESEnsuring that the intervention takes into account the role of the environment and otherpeople is essential; the intervention is likely to be doomed if this is not done. For some individuals,engaging in one-to-one therapy is extremely difficult, and the environmentrather than individual CBT work, as described earlier, may be the main focus for therapeuticwork. However, the principles of the therapeutic CBT model apply, regardless ofthe main focus of the intervention and assessment and formulation of the difficulties describedearlier, are appropriate even if detailed assessment of the individual is not possible.Usually a particular staff member or caregiver who has most contact with the individualis identified as the coworker or facilitator of the CBT therapy. At a minimum, evenpeople who are engaged in individual work should be involved in joint meetings with the