The following case study is connected to the questions below: Please assist with answering the following questions in a synopsis format related to case study:

Brief Overview of Client

DSM Diagnosis and rationale (Including code)

Approach to Treat Disorder (including assessment techniques or tools)

Treatment Plan (Minimum THREE goals with measurable objectives) with following format:

Goal 1:

Objective 1:

Objective 2:

Objective 3:(Complete for minimum three goals)

Anticipated discharge criteria (i.e., When is process complete?)

Additional Information (What more information about the client would need to be gathered to better understand the client

What are the statistics for development of schizophrenia among identical twins?

What were three of Lucas's initial symptoms that signaled a mental disorder?

What was the diagnosis Lucas received after he was hospitalized?

Why did he stop taking his medication and what symptoms returned when he stopped taking his medication?

Explain Dr. Hart's theory of the diathesis-stress model of schizophrenia.

Describe the combination of biomedical and behavioral therapy used by Dr. Hart.

What are some abnormalities in the brains of individuals with schizophrenia?

How do antipsychotic drugs work to reduce the symptoms of schizophrenia? What are some of the downsides of using these medications?

Why are the newer second-generation antipsychotic drugs usually preferred over the earlier first-generation antipsychotic drugs?

What six factors were a part of the psychosocial skills training program for Lucas in conjunction with his medication program?

What were the two long-term priorities for Lucas once his medication stabilized some of his symptoms?

Why was it important to involve Lucas's family in his rehabilitation?

What particular communication skills were important for Lucas's family to learn?

What were some individual behavioral skills Lucas learned in order to become more independent?

Why did Lucas eventually decide to continue to live with his parents rather than on his own?

Case Study:

Lucas's parents were born and raised in a small city in Brazil. They met when his father was 36 and his mother was 21 and decided to marry soon after his mother became pregnant. They then immigrated to the United States where they hoped to open a business. Their first few years on American soil were happy ones, but difficult financially. The couple went through several business failures before Lucas's father started a leather clothing manufacturing company that became successful.

After arriving in the United States, Lucas's mother, Maria, gave birth to three healthy baby boys in close succession. Lucas, born in 1973, was the third boy. Maria's oldest son became sick with a rare illness and died when Lucas was 2 years old. Devastated by the tragedy, Lucas's father, Antonio, soon stopped eating properly and began drinking heavily. His performance at work deteriorated over time, culminating in several situations where he lost his temper with employees. He eventually became so depressed that he could not function and had to be hospitalized briefly. The notion of being hospitalized for mental health reasons particularly concerned Antonio because his own mother and younger brother both had been repeatedly admitted to psychiatric facilities back in Brazil. During his hospitalization, Maria managed all of the affairs of the house. Despite her own unremitting grief, she managed to take care of the children and the home, all while spending as much time as she could at the hospital during visiting hours to see her husband. At nights, after everyone had gone to sleep, Maria would lock the door to her bedroom and weep for the loss of her child.

Two years after Antonio's hospitalization, Lucas's mother became pregnant again. This lifted Antonio out of his protracted depression, and he was able to stop drinking. By the time the new baby was born, he seemed restored to his former self. It was another boy. He later told family members that the birth of this child had been his "salvation." Maria was beyond herself with joy and excitement about the new baby. Throughout their childhoods, Lucas and his younger brother were the best students of the three boys and, as such, received most of the attention from their parents. Lucas was a prized pupil of his teachers, as well. He was enthusiastic and motivated, and he typically finished at the top of his class. As head of the debate club in high school, he led the school's debate team to victory in several tournaments. He was also among the top scorers on the state-wide scholastic achievement test. He was smart, analytical, and motivated to succeed. Everyone who knew him had high hopes for his future.

If one identical twin develops schizophrenia, there is a 48% chance that the other twin will do the same (Hany et al., 2020; Gottesman, 1991). If the twins are fraternal, the second twin has a 17% chance of developing the disorder.

He was less socially skilled than he was academically gifted. He had a few friends, but mostly stayed home and did schoolwork or spent time with his brothers. There were many occasions when he would start talking rapidly about something he knew a lot about and could spend the next 20 minutes talking without a response from others. He was so smart that people usually chalked it up to him being a genius, but the truth is that most of the time he was misunderstood it was because he was not always making sense: Circumstantial and tangential thinking masqueraded as genius.

However, things began to change for Lucas toward the end of high school when Antonio suffered a serious heart attack. He was discharged after having surgery and given several medications known to prevent future cardiac problems after a heart attack. The incident was terrifying to Lucas. He became obsessively worried about his father, his mother, and the rest of the family. Thoughts swirled around his head throughout the day: What would happen to them all if his father died? How would they afford to live? Would they have to move? His schoolwork was suffering, as he wasn't able to concentrate or study as he used to. He coped as well as he could by using daily prayer and frequent attendance at church. Some weeks, he would pray throughout the day and go to church in the evening. His father did recover eventually, and Lucas became convinced that it was due to his prayers.

Despite poor grades in his final semester, Lucas graduated in the top quartile of his high school class; however, he seemed to have lost his sense of direction in life. He registered at a community college in the fall, but after a few weeks became lax about attending classes. He was bored with school and beginning to doubt the purpose of more education. Eventually, he stopped going to classes altogether and spent more and more time with some friends he had met in his community college classes. They would sit in their cars and spend time at local trails and parks drinking alcohol and smoking marijuana. Lucas had used marijuana in high school a few times but had never been in a group of friends that used it frequently. Now, with his new friends, smoking was common. It was illegal, but it was fairly easy to find at Lucas's age. Most people his age knew someone who could find marijuana for them if desired.

As the weeks and months went on, Lucas was using marijuana more and more, sometimes several times a week. On other days, he and his friends would eat psilocybin mushrooms. And, on other days, Lucas would spend practically the whole day watching TV in his bedroom. The extended time streaming and endlessly sifting through social media was not due to laziness, or lack of ambition, or lack of interest in people. Rather, Lucas was starting to believe that he had special powers. He would closely observe the movements of people on the screen, imagining he could communicate to them and trying to determine the extent of his influence. The more he watched, the more his suspicions were confirmed. He was seeing how his own thoughts were influencing what people would say or do. Sometimes, he noticed how people were wearing clothes or had tattoos with hidden messages intended for him. His effect on the characters was becoming too obvious to deny.

At first, this belief was just a suspicion, but eventually Lucas concluded that a specific change had occurred: He was acquiring the capacity to control other people's emotions and behavior. He explored this by going into movie theaters or to the mall and observing how people behaved when he thought about them. He noticed that if he looked at people long enough, he could cause them to rub their eyes, scratch their noses, or make other simple gestures. At first, he thought he had to be within a close range to have this effect. However, as time went on, he concluded that he could project this influence over great distances. He discovered this one day as he watched the morning news. While watching, Lucas observed that the reporter glanced down at her notes periodically. Lucas knew that he himself was directing these movements. From that moment on, he believed that he could guide characters on television to move in ways that they ordinarily would not. Gradually, he became convinced that not only people but objects, such as traffic signals and automobiles, were responding to his influence. If he stood on a street corner, for example, and observed the flow of traffic, he found he could direct the cars' movements.

In the beginning, Lucas was not sure how he controlled people and things, but one day, while pondering his situation, he had a flash of insight. He concluded that he, like God, must have a "life force" in his breath. In effect, he influenced people and objects through his breathing.

This was a momentous revelation for him. It meant that his power was not just your garden-variety black magic or wizardry. Rather, he had been selected for some sort of holy mission. This suspicion seemed to be confirmed soon afterward when Lucas heard God's angels whispering that he had been chosen to be the Messiah.

With this discovery, Lucas also became increasingly convinced that people were talking about him in public. One day, for example, while picking up a pizza, he concluded that some of the customers in the restaurant were talking about him and that others were glancing at him and pointing. This, he presumed, meant they knew about his power. Another time, he saw a well-known movie star in a television advertisement for leather clothing, and he assumed the person was talking to him directly. In this instance, he felt confident and proud that he was being spoken to by the celebrity. He was certain that he was gaining a reputation with famous people for his newfound capabilities.

After having several experiences in which he walked into restaurants or other public settings and saw people talking about him, Lucas became extremely anxious. As confident as he was about the positive potential of his mind-influencing powers, he was afraid that other people, particularly those with evil intent, might somehow gain control of his power and use it for destructive purposes. The best solution, as he saw it, was to stay away from people as much as possible. He also began to use greater and greater amounts of marijuana because, he believed, "it reduces the oxygen in the breath and that reduces its effect."

As Lucas's discovery of his special powers evolved into the hearing of voices, then into his understanding that he would be the Messiah, and, finally, into his realization that others were talking about him, he became more and more confused. One day, as he emerged from his room after being alone for nearly 24 hours, his mother asked him how he was feeling, and he could only respond by babbling incoherently about "angels" and a "life force" in his breath. He was disheveled and growing long whiskers from his chin. He didn't smell very good either. His parents, who previously had seen their son as socially a bit awkward and withdrawn, now were alarmed, and they arranged for Lucas to see the family physician. At the clinic, the doctor was quick to notice Lucas seemed odd in his mannerisms and speech. She had in fact wondered in the past whether Lucas might be on the autism spectrum, but this time she was worried that his thinking and speech were strange and somewhat paranoid. He wasn't taking care of his basic needs, had little insight, and described hearing and seeing things that sounded delusional. She referred Lucas for the first of what turned out to be several psychiatric hospitalizations.

Lucas's parents were at first devastated and then, over the years, exhausted by his schizophrenic condition. Particularly hard-hit was his mother, Maria. Having lived through difficult times at a young age, she found her son's deterioration to be a last straw, of sorts. Occasionally, she would attend a support group for members of the families of people with severe mental disorders. The people in the group were nice, and the discussions sometimes helped her cope with Lucas's condition. During one session, the focus was on her and she reflected on her reactions over the years to Lucas's disorder.

Psychosis is a loss of contact with reality. Various disorders or conditions (for example, substance misuse) can produce psychosis; schizophrenia is one of the most common causes.

At first, I just didn't want to let myself believe that his problem was serious. I'd been through so much, and I basically didn't want to think about anything. Lucas was one of the only things in my life that seemed truly fine. He was my hope that some day I would be able to look back on my life with a sense of pride and accomplishment.

Then, there was Antonio's heart attack. When Lucas kept talking about how he had saved his father's life, I indulged him. For one thing, I sort of believed it. We were all terribly upset and anxious, and I really did believe that Antonio survived through our love and our prayers to God. Even when Lucas started to insist that he and he alone had saved his father through prayer a direct line of communication with God I figured simply that he was being overly emotional about the situation. I thought that he had been overwhelmed by the horror of not knowing whether his father would die, and so he was now experiencing an unusual kind of relief and joy that Antonio had pulled through.

Soon after that, I became aware that Lucas had started using marijuana. But, again, I didn't think that was too bad. I'd tried it myself when I was young. I don't think I realized until later that he gradually was using more and more over time. And don't forget the problem with his room. He would spend increasing amounts of his time alone there. I guess I really didn't look into that closely enough. It just seemed normal for a teenage boy. His older brother was like that too, but not quite as bad. I just figured Lucas needed more alone time. I never tried to stop his withdrawal from others, and in hindsight, I never really saw how big his problems were.

But after this went on for a while, my shining honor student was starting to retreat into his own world. Of course, as a mother I had wanted him to become someone important, to do good for the world when he grows. It sounds silly, but I thought he could one day be a famous scientist or doctor. He was just so smart that it seemed inevitable. But then he seemed to start giving up, and nothing Antonio or I did seemed to help. At dinner, he would pull away from the conversation and stare at his food, mumbling when we asked questions, otherwise not talking or even acknowledging us. He was so moody, no longer the boy I had known. I didn't know what to think, but in our hearts we knew something might be terribly wrong. It wasn't just that he was ignoring us; that would have been hard enough. But he actually seemed to be paying attention to something else, something we could not sense.

Finally, one night he came out of his room muttering, like he was talking to someone in his room. He walked past me in the hallway as if I wasn't even there. Like he didn't even see me. When he passed by, I peeked into his room and saw that his TV was on and someone on it was talking. I went back down the hall to the living room and asked Lucas whom he was talking to. He cocked in head, paused, then said he was talking to the person on the TV. He said it in a mater-of-fact way, then started talking to me about something else. I asked him what he was talking to the person about on the TV. He told me he could make the people on the screen move and that he heard voices that confirmed this power. I froze. I had no idea what to say. I was just petrified. I called Antonio home from work and we got Lucas to see our family doctor the next day, thinking she could fix whatever was wrong with him. But it wasn't that easy. Our doctor told us Lucas seemed to have symptoms of schizophrenia. We didn't know exactly what it meant, but we knew it wasn't good. She told me that my precious little boy may be seriously mentally ill and in need of antipsychotic medications. I hoped so much that this was wrong. I just couldn't face the idea that she might be right. At the same time, I couldn't think of any other explanation for what had been happening.

That was almost 10 years ago, and since then, our problems have been endless. For periods of time, Lucas will take his medicines, but even then he basically seems depressed and slow; and he is still, I am certain, focused somewhere else. And sometimes he has flare-ups; he gets really intense and has terrible psychotic episodes. He hears voices and may even scream back at them, which is terrifying for a mother to see.

We've had to spend so much money over the years, to put him in and out of hospitals, and to pay for his medications, that we've nearly gone into debt. We've never been able to move into the home we wanted, or to travel to the places that we've always wanted to see. We know now that it is unlikely that he, or our lives, will ever be normal again.

Approximately 10% of the first-degree relatives of people with schizophrenia (parents, siblings, and children) manifest the same disorder (Fischer & Buchanan, 2020b; Hany et al., 2020; Gottesman, 1991). Generally, the more closely related persons are to an individual with schizophrenia, the more likely they are to develop the disorder.

After the support group session, one of the members, a man Maria had not seen at past sessions, approached her. He said that he and his family had moved to the area around a year ago, and at that time he and his wife had sought a therapist for their 23-year-old daughter, whose severe problems sounded a lot like Lucas's. They made numerous calls to their physician, to a referral service for people with severe mental disorders, to the leader of a support group, and to a university professor. The name Dr. Michael Hart kept coming up during these calls. Apparently, this psychiatrist had built a reputation for his successful treatment of people with schizophrenia even individuals who had previously shown little improvement. Dr. Hart believed strongly that evidence-based psychological interventions must supplement antipsychotic medications if people with this disorder are to make successful and lasting recoveries.

The man said that his daughter had now been seeing Dr. Hart for the past 6 months and had been making real progress for the first time in years. When he heard Maria tell her story, it reminded him of his own situation, and he really believed that she should give Dr. Hart a try.

Maria had just about run out of hope, and so she was inclined to ignore the man's suggestion. But something about his enthusiasm, his joy perhaps it was his hope called to her. That night, she discussed everything with Antonio, and they decided to gear up for yet one more try. The next day, they had a long talk with Lucas, trying to persuade him to see Dr. Hart.

It was once theorized that people with schizophrenia typically had mothers who were cold, domineering, and impervious to their children's needs so-called schizophrenogenic mothers. Research does not, however, support this theory. As Dr. Hart directed his questions to his new patient, Lucas gave only minimal replies. Most of the time, he averted his eyes, looking miserable and frightened. Finally, however, he showed a spark of interest when the psychiatrist changed his approach and asked him what he considered to be the "real problem." In reply, Lucas stated that he had been seeing therapists since age 19, and this was the first time anyone had shown an interest in his view of the situation. "Usually, they only want to know about the voices," he said under his breath.

Lucas then told Dr. Hart, at length, about the special powers he possessed and the problems that this had created for him. He eventually explained that he didn't like secluding himself in his room at home, but he felt it wasn't safe in public and that he could use his unique abilities more easily when alone in his room. "It was like having the power of God," he explained. "At first it was fun," he went on, "but then it became a major burden something I don't really want anymore." To cope with his predicament, he told Dr. Hart, he could emerge only for occasional meals, bathroom visits, and church services on Sunday mornings. By restricting his activities in this way, Lucas said he minimized the chance of doing anyone unintentional harm; also, it kept his power from falling into the hands of evil forces.

The patient admitted to Dr. Hart that he continued to hear the voices of angels; he also remained anxious that others were talking about him. Most recently, he said, he had been trying to understand his situation by immersing himself in Bible study, looking for scriptural evidence that he had been chosen for a special mission. He began to spend more and more time at this endeavor and, as his parents described it, his room was now strewn with biblical texts that he would study until the early hours of the morning.

"I shouldn't precisely have chosen madness if there had been any choice, but once such a thing has taken hold of you you can't very well get out of it." Vincent van Gogh, 1889

Although at first skeptical about seeing yet another therapist, Lucas was grateful that Dr. Hart was interested in hearing him out on the subject of his religious concerns. Perhaps, he stated, the psychiatrist would help him explain to his parents why his recent biblical studies were his own business and not "craziness," as they believed.

After talking to Lucas and his parents at length and reviewing Lucas's history, Dr. Hart was certain that the young man's condition did indeed meet the DSM-5-TR criteria for a diagnosis of schizophrenia. He exhibited delusions, particularly the belief that he could control others with his breath; he experienced auditory hallucinations; and he suffered from avolition, the inability to initiate or persist in normal, goal-directed activities, such as work, education, or a social life. In addition, his social and occupational functioning were far below what might have been expected on the basis of his capabilities as a child and adolescent. Finally, Lucas's symptoms had lasted for a number of years and were causing significant impairment and distress in Lucas's life.

Like many clinicians and researchers, Dr. Hart believed that schizophrenia is best explained by a diathesis-stress model. That is, certain individuals may have a predisposing vulnerability (a diathesis) to schizophrenia, but the risk of actually developing the disorder is affected by the degree of stress in their lives. Theoretically, the diathesis must exist to some degree in order for a person to eventually develop the disorder; however, the diathesis can vary in severity. People who have a severe diathesis might develop schizophrenia even if placed in a mildly stressful environment. Those with a less severe diathesis, in contrast, might develop the disorder only in a very stressful environment. And those without the diathesis the majority of the population are unlikely to develop schizophrenia, no matter how severe their environmental stress.

Research suggests that people with schizophrenia have excessive activity of the neurotransmitter dopamine, or abnormal interactions between dopamine and other neurotransmitters such as serotonin, glutamate, and GABA (Reid, 2021; Correll & Schooler, 2020).

Given this view of the disorder, Dr. Hart used an approach that integrated medication management with psychosocial interventions. This treatment approach included attending to protective factors available in Lucas's life factors that could potentially lessen his vulnerability to schizophrenia or lessen the effects of stress on him. Medications could lessen his biological vulnerability; behavioral training in social and independent living skills could lower his behavioral vulnerability; and acceptance-based cognitive skills could help him learn to be less distressed by his delusional thinking or hallucinations. Similarly, the degree of stress in his life could be lowered by family counseling or supportive services, such as case management, special group housing, and a sheltered work setting.

Phase 1: Engaging Lucas as a Collaborator

Dr. Hart educated Lucas and his parents as thoroughly as possible about schizophrenia, including the diathesis-stress model. The psychiatrist also explained that symptoms would likely recur without continued medication and a combination of cognitive, behavioral, family, and case management interventions.

Dr. Hart's treatment for schizophrenia followed a biobehavioral program that was initially developed in the late 1980s (Psychiatric Rehabilitation Consultants, 1991). This program includes 5 behavioral training modules designed to teach basic skills in areas where patients with the disorder are often lacking: medication and symptom management, grooming and self-care, recreation, job finding, and basic conversational skills. The approach also engages the patient as a collaborator in the treatment program.

The most challenging part was in getting Lucas to try a medication treatment once again. Currently, the young man was not taking any medication, nor was he interested in returning to an approach that he felt had had no benefit for him in the past, only unpleasant side effects. Thus, Dr. Hart suggested that they work together to eliminate the burden of his "special powers," which Lucas was finding so troublesome.

Dr. Hart: I know these powers have been a huge problem for you for a long time, and I want to help make things better. You have a diagnosis of schizophrenia, and I believe that the power that you've noticed in your breath is a result of this illness. If we can treat your illness properly, I believe that this power will go away, or at least be weakened. Do you feel that this would be desirable?

Lucas: Yes. But I hate taking medications. They make me so tired, so tuned out from everything. I can't even think with them. You know I have taken so many different kinds of medications. Every time the doc tells me they will help. And you know what happens? Every time? They help at first, and then I hate how I feel and think. Or I forget to take them. Or I lose them. Or, and this also happens, I know that they are a way for the evil to take away the good in me. Doc, meds don't work. They don't get rid of any voices. The voices are much, much stronger than any pill ever made. You don't know. But here is one thing you should know: My power is as strong as ever.

Dr. Hart: I understand your reluctance to try medications again, but I'm going to take somewhat of a different approach. I think it is important that you feel that the medicine I prescribe is helping, otherwise I wouldn't blame you for not taking it. Therefore, I'm going to seek your guidance on this question, rather than just telling you what to take.

Lucas: What exactly do you want me to do?

Dr. Hart: I'm going to ask you to take some medicine, and then to keep track of the medicine's effect on specific symptoms, using a special record-keeping form. This way, we'll both be able to tell whether the medicine is producing any benefits.

Lucas: What if I don't think the medicine is working?

Dr. Hart: I'm going to take your opinion very seriously, and if you don't feel the medicine is working I'll accept that fact, and we'll have to consider our options. However, in return, I'm going to ask you to give the medicine a fair trial. It's going to take a little bit of trial and error. But I'd like you to bear with the process until we've had a chance to figure out how much benefit we can get from the medicine. This will mean living through a period when the medicine is not yet working to the maximum, or not working at all. I will tell you when I think I've got the best possible dose, and I'll seek your input about how much symptom reduction you've experienced each step of the way.

Lucas: It sounds okay. But I'm warning you, I'm not going to take it if I don't notice any change.

During the early sessions devoted to behavioral family management a set of procedures designed to improve family functioning Dr. Hart had Lucas and his parents discuss the problems they had been having. The parents started to discuss the problem of their son's remaining in his room continually, and things soon broke down into a shouting match. Lucas explained that the time he spent in his room was necessary for his Bible reading, but Antonio was soon arguing that the main problem was his son's laziness. Maria interrupted, saying that Antonio had no idea what went on most of the time because he was usually away at work. Antonio in turn replied that he was able to see enough to figure out that his son had become a "good-for-nothing" and that his wife was enabling him. Lucas listened to most of this conversation with his eyes turned upward in the "Oh, brother!" mode. Other times, he looked down and stared at the carpet. Eventually, however, he joined the conversation, saying that a major reason he stayed in his room was so he didn't have to listen to "this kind of crap." Antonio yelled that "this crap" was due to their utter frustration in dealing with their son's problems. In no time, all of the family members were yelling.

Dr. Hart could see that family interactions were characterized by high levels of expressed emotion. Research has shown that individuals whose families display high levels of expressed emotion frequent critical, hostile, or intrusive remarks during family communication are more likely to experience a relapse of schizophrenia than those whose families have lower levels.

Dr. Hart: I can see that you all have been experiencing a lot of frustration in connection with Lucas's problems, which has led to a lot of arguing. Having a family member with an illness such as Lucas's is stressful for most families. It would benefit everyone if we could reduce the general tension and bad feeling. In particular, it will be helpful for Lucas and for you all if there is a focused effort to reduce the criticism and hostility expressed in the house. One thing we have learned through studies is that these kinds of communications in the family may make it more difficult to recover from schizophrenia. I would like to hold several sessions devoted to showing you how to reduce the arguing and improve communications.

The family agreed, and the next 12 sessions with the psychiatrist were devoted to behavioral family management.

Several of the first of these sessions concentrated on education: simply sharing some of the latest scientific information with the family about schizophrenia. Dr. Hart gave the entire family some written material on the disorder, including descriptions of the problems produced by it. The psychiatrist also had the family watch a video that explained that most people with schizophrenia have difficulty performing routine activities. In the video, a series of examples were given of patients who had stopped being able to work, go to school, or attend to even the most basic needs, such as eating or taking showers on a regular basis.

Lucas's mother and father acknowledged the resemblance between Lucas and the cases shown in the video. They had previously believed that Lucas's limitations were largely due to his not trying hard enough or to his downright refusal to face up to his responsibilities. Now they were feeling regret at having criticized him constantly for his failures. Dr. Hart cautioned the couple not to blame themselves unfairly for their reactions or for Lucas's illness. He reminded them of something else shown on the video, that families typically react with a certain degree of distress over the limitations of the disturbed family member, finding it difficult to understand how someone who once seemed so capable and full of promise had fallen to such a level. The task now, he said, was to put their new knowledge to good use, beginning with the next phase of family therapy, which would be devoted to communication skills training.

Brain scans indicate that people with schizophrenia have a dysfunction of the brain circuit that includes the prefrontal cortex, hippocampus, amygdala, thalamus, striatum, and substantia nigra (He et al., 2021; Bristow et al., 2020).

Among the communication skills that Dr. Hart attempted to teach the family members were acknowledging positive actions in others, making positive requests of others, and expressing negative feelings constructively. They also learned how to communicate with Lucas in a way that better respected his boundaries and need for autonomy. Lucas's parents were open to these suggestions.

The psychiatrist explained that in many troubled families the simple art of praising one another for positive actions is lost. Criticism of a person's shortcomings or mistakes becomes the sole form of providing feedback, while the person's positive efforts are taken for granted or ignored. Lucas's parents, for example, found it easy to point out whenever Lucas failed to pick up his clothes, forgot to take out the trash, or spent an entire day holed up in his room. But they had given up praising any positive efforts by Lucas, such as his mowing the lawn or sticking to his medications. Similarly, for his part, Lucas had gotten into the habit of noting only what his parents failed to do for him, while ignoring their positive efforts.

Thus, Dr. Hart had the family members perform an exercise. Each of them had to identify something positive that one of the others had done in the past few days. Each member was then to practice stating their appreciation in Dr. Hart's presence. Lucas, in particular, was coached to make better eye contact and to make his statement of appreciation with more vocal emphasis: "Mom, when you made my favorite meal the other night, I really felt good. Thanks a lot." To keep up with this task on a daily basis, the family had to record, over the next 2 weeks, all occasions when this skill was successfully practiced. With time, this kind of communication increased in frequency and became more natural.

To learn another skill, how to make positive requests, the family was asked to cite examples of things that irked them, and how they had specifically communicated that annoyance to one another. Lucas's mother volunteered that just that morning she had gotten fed up with the pile of laundry in Lucas's room. When asked what she had told her son, she replied that she had said, "The laundry in your room is a disgusting mess. You simply must start shaping up." Dr. Hart then used this example to explain to the family how to rephrase concerns or requests in positive and specific terms rather than negative and global terms. "Positive" statements indicate what the person should do under the circumstances, as opposed to what the person should not do or should stop doing. "Specific" statements clarify what should be done; they are not just some vague demand for better performance. Maria was asked to restate her concern in line with these guidelines. Her new statement was: "Lucas, please bring the laundry from your room down to the basement at the end of the week." Again, the family members were told to record each successful practice of this skill over the next few weeks.

Similar training was carried out for expressing negative feelings constructively, that is, effectively letting persons know how their actions upset you. Often, family members neglect this piece of the communication process, keeping feelings of dissatisfaction or disappointment to themselves and then moving directly to criticism and insults. Expressing a feeling is a way of telling a person that there is a problem but without making incorrect assumptions or accusations. Thus, for example, Lucas's father was guided to say to his son, "When you look away while I'm talking, it makes me feel that you don't care what I'm saying," instead of, "You don't care about anything you're told."

According to some studies, family therapy particularly when combined with drug therapy helps reduce tensions within the families of people with schizophrenia and therefore helps relapse rates go down (Worthington et al., 2020).

Over the course of six sessions, the family members became more able to use the new communication skills, and the skills became a more natural part of their interactions.

As some of the stress in Lucas's life became relieved through medication and behavioral family management, he expressed his growing desire to function independently, inspired in part by the example of other patients he had met in his self-management classes. One friend there, John, had improved to the point where he got a paying job as a clerical assistant at a small social services agency called Helping Hands, which housed people experiencing homelessness. Lucas visited John at his job and was impressed to see that he had his own desk and was given respect and responsibility. Lucas thought about developing his own work skills, with the hope that he could ultimately live independently. He raised this hope with Dr. Hart, who encouraged him and had him enroll in the mental health center's training group on personal effectiveness for successful living.

"I feel cheated by having this illness." Individual with schizophrenia, 1996

This group was set up along the same lines as the medication- and symptom-management groups that Lucas had already attended, but this group was geared toward individual problems. Led by a social worker, the group used traditional behavioral techniques, such as modeling, role playing, corrective feedback, and behavioral practice exercises, to train members in various skills needed for managing in the world. The group also applied newer evidence-based acceptance interventions designed to help group members learn ways to tolerate unpleasant thoughts with a distanced perspective.

After a few sessions, Lucas told Ms. Candace, the social worker, and the other group members that his immediate goal was to go on interviews for jobs advertised online, something he had never done before and had no idea how to approach. The group broke the process down into separate skills: (1) researching online for appropriate ads, (2) telephoning or e-mailing for further information and requesting an interview, (3) arriving at the appropriate time and place, and (4) being interviewed. First, the group focused on telephoning or e-mailing for an interview. One member, who had a fair amount of interview experience, played the prospective employer, while Lucas acted out his own role as the applicant. The pair went over the process repeatedly, while Ms. Candace and group members gave Lucas corrective feedback on his telephone conversation. Lucas also wrote several sample e-mail requests for an interview and brought these to the group where the e-mails were edited and revised.

Lucas's homework assignment was to make five telephone calls in response to ads and to report the results at the next group meeting. The point of the homework exercise was not for him to obtain actual interviews, just to practice his telephone behavior. In fact, to reduce pressure, it was understood that he would not be going on any of the interviews he might actually obtain. He would simply cancel them for now.

At the next session, Lucas was excited to report that he had made the five phone calls. On three of them, he was told that the positions had been filled. On two others he was told he could complete an online application. He felt he had become much more comfortable with the process by the fifth call, and he decided to make five calls each week.

During this time, Dr. Hart had been continuing to work with Lucas in individual therapy to find a medication level that would make a further dent in the young man's belief that he had power over others. Although Lucas had certainly improved while taking risperidone, he felt that his breath still had some power to affect people. Dr. Hart tried increases and then decreases in the level of risperidone and added and subtracted some additional drugs as well. Perhaps it was the medication changes or perhaps it was the impact of the personal effectiveness group, or perhaps it was both but at one point, psychiatrist and patient hit on a medication combination that made a large difference. Lucas began to notice a significant drop in the intensity and frequency of his main symptom. He told Dr. Hart that the medicine seemed to have "neutralized" his capacity to influence other people through his breath. The patient also noticed that other people had stopped talking about him when he went out in public.

In addition to the medication, Dr. Hart helped Lucas practice acceptance-based techniques. He taught Lucas to be able to notice when his thoughts were odd or even delusional. Once he noticed such thoughts, he learned to recognize that they may not be literally true but rather experiences produced by his brain that he could observe and describe. This didn't make his thoughts less distressing, but he learned that even if his thoughts were distressing, he did not have to believe they were true, thus allowing him to gain a helpful perspective, and, in turn, enabling him to make choices about what to best do with regard to his actions and decisions.

The acceptance-based intervention for psychosis is largely derived from the cognitive-behavioral approach Acceptance and Commitment Therapy. The intervention tends to be most helpful in reducing positive symptoms such as hallucinations (Yildiz, 2020).

Stabilization Phase

This change produced a sense of confidence and optimism that Lucas had not felt in years. For the first time, he believed he was ready to seek paid employment. He discussed this with the members of his group, and he eventually decided to try a volunteer position as a stepping-stone. He chose to pursue a lead given to him by John, his friend who worked at Helping Hands. John told him about another agency that delivered hot meals to homebound elderly people. Despite all his years of disability, Lucas was able to drive and had in fact maintained his driver's license in good standing.

Once again, the various components of obtaining the job the initial call, the interview, the first day on the job were practiced in the group setting, with group members playing the roles of phone screener, interviewer, and fellow employees.

Lucas made the initial call and several days later was accepted for an interview. At the interview itself, he was well-prepared to ask and answer questions. The interviewer was impressed with his sincerity and motivation, and told him that they would be glad to accept him on a trial basis as a volunteer assistant to one of the paid drivers. He could begin the following Monday, working 3 half-days a week.

The following Monday, at noon, Lucas arrived at the agency to meet the driver for his assigned route. He was extremely nervous at first, but once he began working and saw how readily he took to the job, his confidence rose. Over the course of the next several weeks, he worked hard and, eventually, was offered a job as a paid driver. Over the following years, Lucas continued both to take medications and to attend his group meetings on a weekly basis. It would not be accurate to say that he made it all the way back to a fully functioning and productive lifestyle. In fact, he experienced several periods in which his notion of having power over others and his belief that others were talking about him returned to some degree. On the other hand, those ideas never again took over his life as they had in the past, and they were always temporary. Adjustments to his medications eliminated the ideas within days or, at most, weeks, and in the meantime, Lucas was able to use the acceptance-based techniques he had learned to keep these ideas from derailing his life.

As much as he wanted his independence, Lucas was not able to make it out of his parents' house and into his own apartment. He tried moving out several times, but found life on his own too stressful. He had great difficulty keeping up with making his own meals, cleaning his clothes, and keeping things straight, and so he eventually concluded that he did indeed need the help of his parents. Furthermore, his job, although a huge improvement over years of unemployment, did not represent the level of work or responsibility that he had seemed destined for when he was young. Although he hadn't made it all the way to a full recovery, his progress was clear. A decade of repeated hospitalizations, full-blown delusions, isolation, and confusion had come to an end. He was now leading a much more normal life and Lucas and his parents were relieved and grateful.