CLINICAL HANDBOOK OF SCHIZOPHRENIA

468 VI. SPECIAL POPULATIONS AND PROBLEMSare not acutely distressed, and can maintain attention to a single topic of conversationover a 5- to 10-minute period (with prompting, if necessary).Planning behavior change should initially focus on preparations that specify whenand how action will occur, and strategies to support the person through the initial days.Potential challenges in the first 7 days are identified, and ideas on how to address themare generated, rehearsed, and practiced. Our version of this intervention (Start Over andSurvive [SOS]) totals 3 hours, including rapport development, motivational interviewing,and planning, and leaves participants with a series of pocket-sized personalized leaflets toremind them about their own situations and plans. In the case of participants who are livingat home, we also deliver a single session to relatives, to generate empathy and encouragetheir continued support, while setting appropriate limits. If there is a delay in appointingcase managers after discharge, we make brief, weekly telephone calls to clientsover the first month to acknowledge progress, to review their reasons for change, and tocue problem solving.Our research group uses individual sessions, because this provides maximum flexibilityin delivering coherent, integrated, and individualized treatment over the course ofshort inpatient stays (often 3–5 days), when consumers are acutely psychotic and thoughtdisordered. Within longer admissions or ongoing outpatient contact, group sessions maybe used to consolidate motivation and to model success. Obviously, care needs to betaken that negative modeling, supplying drugs to other members, and conflict areavoided.Skills Training and Ongoing Group SupportSome clients need training in problem solving, substance refusal, management ofdysphoria, medication adherence, or other specific skills, before they are on track for recovery.Many also need ongoing encouragement, reengagement after lapses or symptomexacerbations, or additional support when external stressors or dysphoria are higher thanusual. Development of pleasant activities, social relationships, and social roles that areunrelated to substance use (including employment) may be particularly important foroverall recovery. Ongoing peer groups can be a cost-effective way to provide social rewards,to alternate activities, and to assist with problem solving over a substantial period.One way to provide group support for abstinence has been through adaptations of 12-step approaches, although that is not the only model and may not be the best for all clients.Family members potentially offer extremely valuable support for substance use andsymptom management. However, comorbidity presents difficult challenges for them.Even in our brief SOS intervention, we routinely ask relatives to a single session to elicitempathy and help them to find ways to continue providing appropriate assistance. Apsychoeducational group workshop may provide similar benefits, if material is readilyapplied to each family’s situation. More extended support and training through relativesgroups or single-family interventions may improve the whole family’s quality of life andreduce relapse risks for an affected family member.Environmental StructureWhen people with very high disability pose a significant risk to themselves or others (e.g.,recurrent personal neglect or dangerous behavior), environmental support, such as assistancewith finances, shopping and cooking, or a staffed home environment, should beconsidered. More intrusive forms of care should, of course, be restricted to those with