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Adaptation of social skills training modules, developed by Anglo-American scientist-practitioners in the USA, must be attentive to the norms and values of Latinos if the methods are to achieve acceptance and be utilized effectively with Latino clients. Examples of the adjustments that may prove utilitarian when using social skills training with Latinos include: (1) involvement of families in the skills training enterprise; (2) setting goals for skills training that encourage the interdependence of clients with their relatives in lifestyles that enable the clients to be more functional members of the family household; and (3) loosening the structure of protocols for social skills training to make the 'process' of training more consistent with the cultural expectations, preferences and habits of Latinos.

Providing effective psychiatric rehabilitation to ethnic minority patients with serious persistent mental illness (SPMI) requires an understanding of the role of cultural values and ethnicity-relevant factors on the course and outcome of severe mental disorders. In this paper, the author identifies some of the cultural factors that are relevant for Latinos with SPMI, and describes how these factors were incorporated into existing rehabilitation modalities. The results of a pilot study designed to test the efficacy of culturally-modified social skills training are presented. The results suggest that the cultural modifications improved Latino patients' ability to learn the material and enhanced their use of these skills in their natural environments. Future research will be aimed at identifying and incorporating these salutary cultural forces into the rehabilitation process of the severely mentally ill.

Schizophrenia can no longer be viewed as a chronic, inexorably deteriorating disorder with little chance for rehabilitation or recovery. Felicitous outcomes, however, are achieved only if treatment and rehabilitative services are continuously provided to individuals and their families. Clinicians can no longer be content to rely solely on a biomedical model of treatment that reduces the disorder to the biological correlates of psychotic symptoms. Instead, a biopsychosocial perspective, which emphasizes the interaction of the brain, behavior, and the environment, serves as the foundation for the integration of psychopharmacology and psychotherapy. This integration has arisen specifically to develop, evaluate, and disseminate those techniques that improve the social functioning of people with serious mental illnesses such as schizophrenia. Employing the biopsychosocial approach to comprehensive care—including training in social and independent living skills, family psychoeducation, self-management of medication and symptoms—can amplify the impact of medication in fostering better outcomes and higher levels of personal functioning. © 1997 John Wiley & Sons, Inc.

Although it is clear that expressed emotion (EE) is associated with the course of schizophrenia, proposed models for this association have struggled to account for the relationship between the EE index of emotional overinvolvement (EOI) and relapse. To expand our understanding of the EOI-relapse association, we first attempted to replicate the finding that the EOI-relapse association is curvilinear among 55 Mexican-Americans with schizophrenia and their caregiving relatives. Second, we evaluated whether the caregivers' perception of their ill relative's efficacy may account for the EOI-relapse association. Our results comport with past findings with regard to the curvilinear nature of the EOI-relapse association among Mexican-Americans and suggest that EOI may only seem to be a risk factor of relapse because of its strong association with a true risk factor for relapse (i.e., caregivers' perception of their ill relative's efficacy). © 2013 by Lippincott Williams & Wilkins.

Objective The present demonstration project involved development of a training program designed to teach recovering consumers employed as peer advocates how to provide evidence-based supported employment services to consumers with severe mental illness. Methods A training curriculum was developed to teach the core competencies of the Individual Placement and Support (IPS) model of supported employment. Three peers participated in training and provided work outcome data from their caseloads. Assessments were conducted of peers' competence in implementing IPS and effectiveness in promoting job placements. Peer competency was assessed by the following: (a) a formal IPS fidelity review performed by two external reviewers to evaluate service implementation, and (b) the Kansas Employment Specialist Job Performance Evaluation, an objective measure of employment specialist attitudes and skills. Program efficacy was assessed by examining the number of job placements and corresponding tenure. Results The fidelity review revealed that peers met IPS standards of implementation on 7 of 14 items assessing service delivery. The Kansas scale results revealed attitudes to be a relative strength and job performance competency ratings fell in the average to above average range across skill areas assessed (e.g., vocational assessment, job development). Thirty-three percent of consumers from the peers' caseloads got competitive jobs; mean tenure was 26.1 weeks. Conclusions and implications for practice This demonstration project provides a starting point for future efforts aimed at expanding the role of peers as providers of evidence-based mental health services and provides a measured degree of optimism that this is a realistic, attainable goal.

The psychopathology and associated disabilities experienced by persons with schizophrenia have only partially responded to conventional pharmacological and psychosocial treatment approaches. Biobehavioral treatment and rehabilitation employs behavioral assessment, social learning principles, skills training, and a focus on the recovery process to amplify the effects of pharmacotherapy. Utilizing the Medline database, we review a selection of English-language studies published from 1970 to 1994 that support the effectiveness of each of the components of biobehavioral therapy, such as case management, psychopharmacology with behavioral assessment, psychoeducation, family involvement, and social skills training. An integrated biobehavioral therapy directed toward early detection and treatment of schizophrenic symptoms, collaboration between consumers and caregivers in managing treatment, family and social skills training, and teaching coping skills and self-help techniques has been documented to improve the course and outcome of schizophrenia, as measured by symptom recurrence, social functioning, and quality of life. A case vignette is presented to illustrate the successful integration of biobehavioral therapies into a treatment system that focuses on consumers' attempts to become increasingly responsible for recovering from illness.

The psychopathology and associated disabilities experienced by persons with schizophrenia have only partially responded to conventional pharmacological and psychosocial treatment approaches. Biobehavioral therapy employs behavioral and symptomatic assessment, social learning principles, and skills training, to amplify the effects of pharmacotherapy. Comprehensive, continuous, and integrated biobehavioral therapy--aiming at early detection and treatment of schizophrenic symptoms, family and social skills training, and teaching coping and illness self-management skills--has been documented to improve the course and outcome of schizophrenia as measured by symptom recurrence, social functioning, and quality of life. Biobehavioral therapies must be delivered in the context of a collaborative relationship among patients, families and clinicians that together can optimize outcomes. Services need to be provided by assertive, outreach, community-based teams that tailor the type, frequency and scope of services to the phase of the individual's illness.

The U.S. Surgeon General's report Mental Health: Culture, Race and Ethnicity--A Supplement to Mental Health: A Report of the Surgeon General (U.S. Department of Health and Human Services, 2001) identified significant disparities in mental health care for Latinos and recommended directions for future research and mental health services. We update that report by reviewing five groundbreaking research projects on the mental health of Latinos that were published since 2001. National studies of adults and children, longitudinal designs, and analyses of Latino subgroups characterize these investigations. Despite the increasing sophistication of disparities research, these landmark studies, as well as the research in the supplemental report, can be characterized as documenting disparities in care. We argue that the next wave of research should give greater attention to reducing and eliminating disparities. Accordingly, we apply Rogler and Cortes's (1993) framework of pathways to care to the study of Latinos with schizophrenia. Specifically, we draw on research regarding the recognition of illness, social networks (families) and their association with the course of illness, and interventions. We illustrate examples at each pathway that have the potential to reduce disparities. We argue that implementing interventions synchronously across multiple pathways has considerable potential to reduce and eventually eliminate disparities in mental health care.

Evidence-based interventions to improve medication adherence among patients with schizophrenia are lacking. Although family psychoeducation has demonstrated efficacy in improving outcomes in schizophrenia, empirical support for its ability to enhance medication adherence is scarce.To determine whether a culturally adapted, multifamily group (MFG) therapy would increase medication adherence and decrease psychiatric hospitalizations for Spanish-speaking Mexican Americans with schizophrenia.A total of 174 Mexican American adults with schizophrenia-spectrum disorder and their key relatives were studied in a 3-armed, randomized controlled trial of MFG therapy focused on improving medication adherence. Assessments occurred at baseline and at 4, 8, 12, 18, and 24 months.Two community mental health centers in Los Angeles, California.Patients had a diagnosis of schizophrenia or schizoaffective disorder with a recent exacerbation of psychotic symptoms and nonadherence to medication before enrollment. Intervention Patients participated in 1 of 2 MFGs (MFG-adherence or MFG-standard) or treatment as usual. Groups convened twice monthly in 90-minute sessions for 1 year.The Treatment Compliance Interview uses multiple sources of information to quantify medication adherence. Computerized records were used to collect information on the use of inpatient resources.At the end of the 1-year treatment, MFG-adherence was associated with higher medication adherence than MFG-standard or treatment as usual only (F = 6.41; P = .003). The MFG-adherence participants had a longer time to first hospitalization (χ(2) = 13.3; P = .001) and were less likely to be hospitalized than those in MFG-standard (χ(2) = 8.2; P = .04) and treatment as usual alone (χ(2) = 11.3; P .001). Increased adherence accounted for one-third of the overall effect of treatment on the reduced risk for psychiatric hospitalization.Multifamily group therapy specifically tailored to improve medication adherence through a focus on the beliefs and attitudes of the target population is associated with improved outcome for Mexican American adults with schizophrenia-spectrum disorders. Trial Registration clinicaltrials.gov Identifier: NCT01125267.

The psychopathology and associated disabilities experienced by persons with schizophrenia have only partially responded to conventional pharmacological and psychosocial treatment approaches. Biobehavioral therapy employs behavioral assessment, social learning principles, and skills training to amplify the effects of pharmacotherapy. An integrated biobehavioral therapy-aiming at early detection and treatment of schizophrenic symptoms, collaboration between patients and caregivers in managing treatment, family and social skills training, and teaching coping skills—has been documented to improve the course and outcome of schizophrenia as measured by symptom recurrence, social functioning, and quality of life. Biobehavioral therapies must be delivered in the context of continuous treatment teams, assertive case management, and a full range of medical, social, and community support services that together can optimize outcomes.

In this study, we investigate the feasibility and acceptability of a 9-month psychoeducational multi-family group (PMFG) intervention for adolescents who are at ultra-high-risk (UHR) for developing psychosis.The treatment programme was adapted from those previously shown to be effective in patients with established psychotic illness, but emphasizes content relevant to adolescence and to a pre-onset phase of illness.Participants report that psychoeducational presentations are highly useful, they attend the PMFG group sessions regularly and report feeling comfortable in meetings and benefiting from them, and adolescents demonstrate improvement in symptoms and functional outcome.This study was not a randomized controlled trial and multiple interventions were introduced simultaneously; thus, changes in outcome cannot be attributed to the PMFG intervention per se. Nonetheless, these results establish the acceptability of PMFG to adolescents and families, and encourage further research into the potential positive impact of PMFG with this at-risk population.

This study investigated the behavioural correlates of caregiver attitudes among parents of youth at risk for psychosis and with recent-onset psychotic symptoms.Forty adolescents identified as ultra-high-risk (UHR) for psychosis using the Structured Interview for Prodromal Syndromes, and their primary caregivers, participated in the Family Interaction Task (FIT), a 10-minute discussion of meaningful shared experiences that allowed families to demonstrate supportive as well as conflict-engaging behaviour. At the same assessment, caregivers were administered the Camberwell Family Interview (CFI). We examined cross-sectional relationships between these measures, as well as their association with youth symptom severity and functioning at 4-month follow-up.As predicted, caregivers who provided more positive remarks regarding their UHR and recent-onset adolescents during the CFI were also more likely to exhibit constructive behaviour during the FIT. Similarly, CFI critical comments were positively associated with caregivers' conflict-engaging behaviour during the FIT. Parents' positive remarks predicted a decrease in negative symptoms, and parent warmth predicted an increase in social functioning at follow-up assessment.The ability to maintain a constructive attitude and approach towards youth predicted symptomatic and functional improvement, and may be a teachable skill.

Past studies have demonstrated a clear relationship between expressed emotion (EE) and relapse for individuals with schizophrenia. However, little attention has been directed toward exploring whether EE may have negative health consequences for caregivers as well. We recruited 60 Mexican-American family caregivers of individuals with schizophrenia and examined whether EE predicted the health of caregivers and ill relatives approximately 13 months later. For caregiving relatives, the EE indices of emotional over-involvement and warmth were predictive of worse mental health among caregivers at follow-up. There was no association between EE and health outcome among individuals with schizophrenia. Our findings suggest that, among Mexican-Americans, family factors may be associated with health outcomes among individuals with schizophrenia and their caregiving relatives.

The 2007 incident at Virginia Tech brought the question of gun ownership by the mentally ill to the forefront of public attention. Moreover, it underscored the potentially devastating consequences of the imperfect connection between federal and state laws that apply to the right of gun ownership by a psychiatric patient. The laws are complex, and, as demonstrated in this article, conflicting. We present a case report of an involuntarily committed patient in the state of California, and discuss details of state and federal laws that applied to him.

The authors developed and tested a 35-min psychoeducational program with the goal of increasing Spanish-speaking persons' literacy of psychosis. The program uses popular cultural icons derived from music, art, and videos, as well as a mnemonic device--La CLAve (The Clue)--to increase (a) knowledge of psychosis, (b) efficacy beliefs that one can identify psychosis in others, (c) attributions to mental illness, and (d) professional help-seeking. Assessments were conducted before and after administering the program to both community residents (n = 57) and family caregivers of persons with schizophrenia (n = 38). For community residents, the authors observed increases across the 4 domains of symptom knowledge, efficacy beliefs, illness attributions, and recommended help-seeking. For caregivers, increases were observed in symptom knowledge and efficacy beliefs. La CLAve is a conceptually informed psychoeducational tool with a developing empirical base aimed at helping Spanish-speaking Latinos with serious mental illness obtain care in a timely manner.

This study prospectively examined the relationship between social problem solving behavior exhibited by youths at ultra-high risk for psychosis (UHR) and with recent onset psychotic symptoms and their parents during problem solving discussions, and youths' symptoms and social functioning six months later. Twenty-seven adolescents were administered the Structured Interview for Prodromal Syndromes and the Strauss-Carpenter Social Contact Scale at baseline and follow-up assessment. Primary caregivers participated with youth in a ten minute discussion that was videotaped, transcribed, and coded for how skillful participants were in defining problems, generating solutions, and reaching resolution, as well as how constructive and/or conflictual they were during the interaction. Controlling for social functioning at baseline, adolescents' skillful problem solving and constructive communication, and parents' constructive communication, were associated with youths' enhanced social functioning six months later. Controlling for symptom severity at baseline, we found that there was a positive association between adolescents' conflictual communications at baseline and an increase in positive symptoms six months later. Taken together, findings from this study provide support for further research into the possibility that specific family interventions, such as problem solving and communication skills training, may improve the functional prognosis of at-risk youth, especially in terms of their social functioning.

This article reports on the outcome of an expert consensus meeting in August 2005 sponsored by the National Institute of Mental Health, which assembled 15 senior researchers with a background in treatment and services research with the Hispanic population. The purpose of the workshop was to identify research issues most pertinent for improving quality and effectiveness of treatment for Hispanics experiencing persistent mental disorders, defined as psychiatric syndromes that are of sufficient severity and duration to cause long-term impairment in social and occupational functioning and significant disability. The spectrum of ideas and recommendations advanced at the one-day meeting was wide and overlapping; therefore, the rich body of material was subsequently organized into five topics: diagnosis, quality of care and culturally appropriate services, psychosocial intervention development, psychopharmacologic interventions, and access to care. Although the authors recognize that the review was broad and the agenda presented is ambitious and in many instances generalizes to priority areas in overall mental health services and treatment research, the recommendations are intended to stimulate research for addressing the unique problems and research deficits that affect Hispanics with persistent mental disorders.

Data from hundreds of intervention research studies validate a biopsychosocial view of treatment for schizophrenia that combines pharmacotherapy with psychosocial treatments and social support. Based on the stress-vulnerability-protective factors model, these treatments work by strengthening biological, personal, and environmental factors that protect against relapse while mitigating the stressors that adversely affect the course of schizophrenia. Psychiatric treatment and rehabilitation must be integrated in a seamless approach aimed at restoring persons with schizophrenia to their best possible level of functioning and quality of life.

Social skills training consists of learning activities utilizing behavioral techniques that enable persons with schizophrenia and other disabling mental disorders to acquire interpersonal disease management and independent living skills for improved functioning in their communities. A large and growing body of research supports the efficacy and effectiveness of social skills training for schizophrenia. When the type and frequency of training is linked to the phase of the disorder, patients can learn and retain a wide variety of social and independent living skills. Generalization of the skills for use in everyday life occurs when patients are provided with opportunities, encouragement, and reinforcement for practicing the skills in relevant situations. Recent advances in skills training include special adaptations and applications for improved generalization of training into the community, short-term stays in psychiatric inpatient units, dually diagnosed substance abusing mentally ill, minority groups, amplifying supported employment, treatment refractory schizophrenia, older adults, overcoming cognitive deficits, and negative symptoms as well as the inclusion of social skills training as part of multidimensional treatment and rehabilitation programs.

Investigations of how individuals with schizophrenia differ from non-patients in their responses to stressful life events are subject to the criticism that any between-group differences might merely reflect differences in the types of stressful events that each group experiences. This report presents new analyses of data collected from schizophrenia patients (n=96), bipolar disorder patients (n=18), and healthy controls (n=18) immediately after the Northridge Earthquake that struck Southern California in 1994, a natural experiment that confronted all groups with the same stressful event. Participants completed the Impact of Events Scale (IES; [Horowitz, M.J., Wilner, N., Alvarez, W., 1979. Impact of Events Scale. A measure of subjective stress. Psychosomatic Medicine 41, 209-218]) at 1 week and 5 weeks post-earthquake. At the 5-week follow-up, measures of coping, social support, and self-esteem were also completed. Both patient groups reported higher IES avoidance symptoms than controls immediately after the earthquake. The schizophrenia group also reported lower approach coping, self-esteem, and social support than controls, with the bipolar group reporting intermediate levels. Within the schizophrenia group, higher levels of avoidance coping predicted higher residual stress symptoms at follow-up. Results support the validity of prior reports of altered responses to stressful life events in schizophrenia and demonstrate the clinical relevance of individual differences in coping among affected individuals.

Psychiatric treatment and rehabilitation are integrated, seamless approaches aimed at restoring persons with major mental disorders to their best possible level of functioning and quality of life. Driven by a thorough assessment, treatment and rehabilitation are keyed to the stage and type of each individual's disorder. Examples of coordinated treatment and rehabilitation are pharmacotherapy, supported employment, social skills training, family psychoeducation, assertive community treatment, and integrated programs for persons with dual diagnoses. The authors conclude by proposing seven principles to guide mental health practitioners in their integration of pharmacologic and psychosocial interventions.

Persons with schizophrenia can substantially improve their functional capacity, quality of life and psychopathology if they are afforded an integrated mode of treatment and rehabilitation that is characterized by (a) the five “C’s” of high quality treatment, (b) an effective treatment delivery system, and (c) phase-specific interventions. The five “C’s” delineate the quality and adequacy of the treatment and rehabilitation, the delivery system assures that the various assessments and interventions are imbedded in an outreach program that brings the treatment to the patient, as necessary, in a flexible manner, that is consistent with the phase or type of disorder.

A large body of research supports the efficacy of psychosocial treatments for schizophrenia, particularly learning-based therapies. The Schizophrenia Patient Outcomes Research Team recommended that cognitive-behavioral therapies be used in schizophrenia, and skills training was included in the practice guideline for treating patients with schizophrenia published by the American Psychiatric Association. This article provides an updated review of empirical studies of psychosocial skills training, showing its value in treating patients with schizophrenia as well as its broader clinical effectiveness. Data supporting the efficacy of psychosocial skills training continue to accumulate. Such programs should continue to be included in best practices guidelines and treatment recommendations for schizophrenia. Future clinical service research could be directed toward integration of skills training with other psychosocial treatment methods.

Pharmacotherapy with antipsychotic, mood-stabilizing, and antidepressant drugs forms the basis of treatment for the major psychotic and mood disorders, which include functional disability as a diagnostic criterion. While the evidence for the efficacy of these agents for the acute and maintenance treatment of these disorders is quite robust, limitations in their impact have been noted for primary negative symptoms, cognitive deficits, psychosocial functioning, and quality of life (Liberman et al. 1995). Side effects of maintenance pharmacotherapy diminish the value of these treatments, with examples including the sedation, autonomic, and neurological side effects that can impair social and vocational functioning (Mintz et al. 1992).

Atypical antipsychotic medications have generally been found to be more effective than conventional antipsychotics in the treatment of negative symptoms. Whether the benefits derived from the atypical agents are the result of improvements in primary versus secondary negative symptoms is unclear. The authors examined the effects of olanzapine on primary and secondary negative symptoms for patients with severe negative symptoms who did or did not have the deficit syndrome.Thirty-nine outpatients with schizophrenia and severe negative symptoms were assessed for the presence of the deficit syndrome and entered into a 12-week, open-label study of olanzapine. Positive and negative symptoms, extrapyramidal side effects, quality of life, and level of functioning of the patients were assessed at baseline and endpoint.All 39 patients completed the 12-week protocol; 13 of the patients had deficit negative symptoms, and 26 had nondeficit negative symptoms. Patients who had nondeficit negative symptoms demonstrated improvements in positive and negative symptoms, level of functioning, and extrapyramidal side effects over baseline. In contrast, patients meeting criteria for the deficit syndrome improved significantly over baseline only in extrapyramidal side effects.The results of this study suggest that olanzapine is efficacious for secondary negative symptoms in schizophrenia but fail to support the contention that olanzapine has a direct beneficial effect on primary negative symptoms.

Background: previous research has been inconclusive about the nature of hemispheric asymmetry in emotional processing. Method: 13 patients with DSM-IV bipolar disorder received repeated QEEGs over 2 years in different mood states. Z-score measures of asymmetry were assessed. Results: asymmetry in frontotemporal slow-wave activity appeared to be in opposite directions in depression compared to mania/hypomania. Conclusions: mood change in bipolar disorder is associated with change in QEEG asymmetry. Limitations: study of larger numbers of more homogenous patients under similar conditions is needed. Clinical relevance: study of mood state-dependent asymmetry changes in bipolar disorder may lead to better understanding of hemispheric processing of emotion.

OBJECTIVE: The authors compared the community functioning of outpatients with persistent forms of schizophrenia after treatment with psychosocial occupational therapy or social skills training, with the latter conducted by paraprofessionals. METHOD: Eighty outpatients with persistent forms of schizophrenia were randomly assigned to receive either psychosocial occupational therapy or skills training for 12 hours weekly for 6 months, followed by 18 months of follow-up with case management in the community. Antipsychotic medication was prescribed through “doctor's choice” by psychiatrists who were blind to the psychosocial treatment assignments. RESULTS: Patients who received skills training showed significantly greater independent living skills during a 2-year follow-up of everyday community functioning. CONCLUSIONS: Skills training can be effectively conducted by paraprofessionals, with durability and generalization of the skills greater than that achieved by occupational therapists who provide their patie...

Objective The purpose of this pilot study was to compare the efficacy of social skills training for individuals with schizophrenia who did or did not have the deficit syndrome. Method Three subjects with the deficit syndrome and three with nondeficit negative symptoms received 12 weeks of social skills training. Social skills and negative symptoms were evaluated before and after training and at 6-month follow-up. Results Patients with schizophrenia who did not have the deficit syndrome demonstrated significantly better social skills and lower negative symptoms both after training and at follow-up than did those who had the deficit syndrome. Conclusions Schizophrenic patients with nondeficit negative symptoms appear amenable to intensive social skills training, but schizophrenic patients with the deficit syndrome may have significant deficits in skill acquisition.