Treating substance abuse among patients with schizophrenia.

Although substance abuse has reached epidemic proportions among people with schizophrenia, relatively little is known about the critical elements of effective treatment of substance abuse in this population. The authors discuss common assumptions about treatment of substance abuse and review the features of the transtheoretical model of change, which is based on the view that behavior change is a longitudinal process consisting of several stages. In this model, substance abusers must first be persuaded to reduce substance use and then be engaged in treatment before they can be taught the skills necessary to become and remain abstinent. The authors suggest an adaptation of the model that attempts to minimize the impact of the cognitive and motivational deficits associated with schizophrenia. The six-month treatment protocol contains four modules focusing on social skills and problem solving, education about the causes and dangers of substance use, motivational interviewing and goal setting for decreased substance use, and training in behavioral skills for relapse prevention. In the 90-minute, twice weekly sessions, behavioral rehearsal is emphasized, and complex social repertoires, such as refusing substances, are divided into smaller behavioral elements.