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Cognitive-behavioral therapy is effective only for patients who are not agitated, thought disoriented, or suffer from paranoia. For some patients, treatment with medication may improve these states to the point where the patient is more amenable to cognitive-behavioral therapy. In addition, there is no evidence that this therapy is effective for patients who refuse to take antipsychotic medications. There are at least 20 randomized control trials showing a beneficial effect of cognitive-behavior therapy on positive, negative, and depressive symptoms in schizophrenia.

Vocational Rehabilitation

Vocational rehabilitation focuses on vocational training and helping the patient integrate into the community. Treatment areas include issues such as:

• Job counseling
• Learning how to increase hours of work and wages (if already working)
• Money management
• Workplace communication skills
• Using public transportation to reach the workplace
• Providing support for the patient if any issues arise at work that require resolution

Training in Social Skills

Training in social skills enables the therapist to help the patient progress from the level at which social maturation was interrupted by the onset of schizophrenia. Group sessions provide opportunities for patients to practice their communication skills in a supportive atmosphere. The focus is on the patient learning how to:

• Improve social relationships through role playing and modeling
• Express feelings
• Be assertive
• Develop strategies for conflict resolution
• Make conversation
• Build self confidence
• Improve quality of life through social interaction

Promoting Patient Independence

Typically, the degree of severity of schizophrenia determines the extent to which the patient may be dependent on their families and may need to live at home, especially during psychotic episodes. This increased dependence on the family impacts the patient's desire as an adult to live independently and places significant stress on those living at home. Clinicians work together the patient and their families to develop acceptable, safe, areas of independence and encourage the patient to set reasonable goals for increasing their independence. The patient is also encouraged to participate in making decisions about important issues such as their treatment, compliance, attending medical appointments, communicating with professionals, and involvement in community projects or sheltered workshops.

Patients should learn about medical, local, and state benefits to which they may be entitled such as social security insurance benefits, rehabilitation programs in their community covered by their health insurance, support groups in the community, sheltered workshops that employ mentally ill patients, and community day care programs that accept patients with varying degrees of schizophrenia.

Counseling for Substance Abuse

Substance abuse is the most common comorbid condition in schizophrenia. Treatment is critical since substance abuse can exacerbate schizophrenia, cause harm to the patient, and reduce the efficacy of medications. The patient learns about the harmful effects of substance abuse, about the interaction of substance abuse and schizophrenia, and strategies to reduce and, hopefully, eliminate the abuse altogether.

Programs that work on substance abuse are most effective when integrated in to the complete treatment protocol for the patient rather than being implemented separately.

Illness Management

This is a forum in which the patients learn to make informed decisions about their treatment including: