Social skills deficits can affect the patient’s ability to blend in, have successful social interactions, and obtain jobs. Social skills training focuses on dress, conversation, and behavior to help the patient become more assertive and accepted—and also to navigate situations that might lead to drug or alcohol(Drug information on alcohol) use.7 Cognitive deficits, common in schizophrenia, affect attention, memory, and planning; decrease the effectiveness of therapy; impair the patient’s ability to plan and finish tasks; and are associated with a poor prognosis. Direct advice, task analysis, and practice help.7 Cognitive remediation, either as a computer-based practice of cognitive tasks or via analysis and rehearsal of tasks of daily living, shows great promise.28
Residential care and assertive community treatment teams
Some patients may be motivated to transfer what they learn in a clinic to their outside lives. Many others, however, are precontemplative, highly paranoid, cognitively challenged, or have transportation or financial constraints. Assertive community treatment (ACT) teams go out to the patient, attempt to engage him, support his recovery in the real world, and introduce skills where application will be needed. Emergency coverage is always available. Patients may need help with practical issues, such as food and shelter, criminal charges, work, and relationships.
Because the work is intense, clinician to participant ratios are low (eg, 1:10). ACT teams are cost-effective, and they result in superior outcomes relative to standard care.29 Ideally, a team would work closely with a residential or inpatient program to provide continuity of care in case of acute deterioration.
Identity can easily become defined by addiction and mental illness. Work can bring self-respect, a sense of accomplishment, independent living skills, and interaction with a healthier peer group. A pay check is highly valued in our culture.30 Patients may need to learn skills, such as routine, attendance to hygiene, and symptom management, to succeed in the workplace. A vocational rehabilitation specialist can help patients identify their personal criteria and readiness, increase motivation, and forge relationships with employers. They often go out to the work site to provide on-site coaching and side-by-side facilitation. Work can start early in the recovery process, and skills and confidence increase gradually. Work can be broadly defined and might include shopping for neighbors or attending classes if such routine activities confer esteem and independence.
Families are often frustrated, alarmed, and demoralized, and they act accordingly. Expressed emotion, particularly criticism, correlates with early, frequent, and prolonged relapse, and poor medication adherence in patients with severe mental illness and addiction. Families may also express a desire for involvement that must be harnessed.31,32
Behavioral family therapies provide support and education and are solution-focused. They teach the family to communicate directly, to be tolerant, to be less critical and hostile, and to manage crises effectively. When a family’s coping skills improve, members can weather the turbulent course of recovery better. Multifamily groups enhance peer support, thereby reducing hospitalizations and improving medication adherence.33
Motivation and understanding can be high by the end of a session, but exposure to cues or stress can easily undo gains and push patients to pick short-term deleterious rewards (drugs or alcohol) over long-term goals (parenthood, work). In contingency management, the longer-term goals are broken down to smaller achievable steps, which are reinforced. Desired behaviors might be attendance or attention at meetings or negative urine toxicology results; rewards can be money, vouchers, or gifts.
Once staff members stop focusing on the negative, attention shifts to achievement. Contingency management has emerged as one of the most reliable interventions to reduce relapse.34 Outcomes are robust, and the process is considerably more enjoyable for all.