CLINICAL HANDBOOK OF SCHIZOPHRENIA

408 VI. SPECIAL POPULATIONS AND PROBLEMSnamed caregiver and the CBT therapist early in therapy, in midtherapy, and toward theend of therapy to consolidate generalization and to conform with the Staying WellManual (see below). The purpose of the meetings is to ensure that the approaches used intherapy are generalized to other team members, to assess how staff attitudes and behaviorinteract with the individual’s concerns and problems, to provide strategies that facilitateattitude and behavior change in staff members if necessary, and to ensure thatchanges implemented by both client and staff are agreed upon collaboratively. We findthis to be a key therapeutic strategy, because many aggressive individuals are living withininpatient and secure environments feel that they have little influence and control overtheir treatment and the future likelihood of discharge. This is the key goal for many peopleduring therapy, and joint meetings can be extremely helpful in promoting shared understandingbetween the mental health care teams and individuals.In addition, staff members on inpatient and secure units work in an extremely challengingenvironment, in which they are expected to take on a dual role of “caregiver” and“restrainer” that may hinder the development of a therapeutic role with clients and leadto problems in the relationship. Opportunities to explore incorrect attitudes, beliefs, andknowledge in caregivers should be sought in a manner that is nonjudgmental and encouraging.This may be empowering for staff members who inadvertently behave in ways thatexacerbate clients’ aggressive behavior with treatment regimens that are inappropriate orunhelpful. Individual sessions can help staff members to develop alternative ways of respondingto clients’ aggression and violence, by becoming aware of a cognitive-behavioralformulation of clients’ difficulties.THE STAYING WELL MANUALAND CONSOLIDATION OF PROGRESS“Staying well” strategies and methods to ensure that treatment gains are consolidatedand generalized should be incorporated into each client’s treatment package at somepoint, usually toward the end of therapy. It is extremely important to consolidate thesestrategies into the individual’s overall future care and to ensure that the approaches generalizeacross situations and time. The complexity of this is dependent on client progressand degree of engagement in treatment.A typical staying well/consolidation plan includes the following:1. A description of the key needs/problems identified during treatment.2. A summary of individuals’ understanding and formulation of their problems incorporating,where appropriate, the key areas of anger, substance use, environment, andaggression/violence.3. A summary of approaches that have been used to address these problems, who hascarried them out, and how these can be continued and developed in future4. A description of what strategies are in place to help the individual continue towork on areas of difficulty. These may often involve identifying key personnel, who maybe assigned certain tasks that extend beyond the initial, intensive treatment period. Thismay be a key worker or other ward staff member who agrees to take responsibility formeeting with the client regularly to monitor hot issues (distress over psychotic symptoms,anger hierarchies, etc.).5. Plans for monitoring lapse/relapse and danger times. The individual might be encouragedto use a “traffic light” system to help him or her (and others, if appropriate) tomonitor thoughts, feelings, and behaviors, and to identify when these might become