Module 3—Spirituality (Sessions 7–9)

Mounting evidence indicates that religion/spirituality (R/S) have multiple mental and physical health benefits for those who practice them, including for individuals living with schizophrenia and their families. This chapter introduces the spirituality module, which is aimed at creating a collaborative family environment that may utilize R/S to facilitate recovery. The chapter includes a rationale and goals for addressing R/S in culturally informed therapy for schizophrenia, ways of exploring individual family members’ beliefs and values surrounding R/S, and helping to build up adaptive aspects of R/S coping while correcting maladaptive uses of R/S. Sharing meaningful prayers and symbols is encouraged to develop therapist understanding and to reinforce the benefits of R/S for clients. Differences in how family members perceive and practice R/S are explored, guided by detailed handouts. A case illustration of a Muslim American father–son pair demonstrates the process.

Integrated CIT-S Illustration

This chapter illustrates a session-by-session progression through culturally informed therapy for schizophrenia (CIT-S). The case illustration of a mixed-race couple of White (Irish) and Native American (Arapaho) ancestries aims to demonstrate different aspects of a client’s illness and her treatment using CIT-S. The chapter includes examples of how a therapist may help clients navigate difficulties surrounding family, culture, illness, and religion/spirituality in ways that cater to the individual living with schizophrenia and foster his or her recovery. The importance of a low-key home environment, adjusting expectations, and including family members or caregivers as part of the healing process are highlighted. Ways to avoid or cope with the negative consequences of some common cognitive difficulties and communication deficits faced by individuals living with schizophrenia are practiced with the couple. Ideas for prayers commonly encountered in CIT-S are found at the beginning and end of each session.

Additional Considerations

This chapter discusses topics and obstacles not otherwise examined in previous chapters. For example, the chapter highlights research addressing whether clinician–client match on race/ethnicity and/or other cultural beliefs and values impacts therapy efficacy. More specifically, the chapter addresses how to deal with challenging families and clients, including those that are unmedicated, highly symptomatic, and/or who endorse delusional thought content. The difficult challenge of what to do when one or more family members wishes to distance themselves from their relative with mental illness is also addressed. Suggestions and skills that can be used for these and other difficult situations are discussed. Excerpts and example quotes are also provided for addressing difficulties such as inconsistent attendance, homework incompletion, or other difficulties that may be encountered during therapy.

Module 5—Problem-Solving (Sessions 13–15)

This chapter is designed to help clinicians teach clients an efficient, step-by-step approach for problem-solving. Family members are first taught to systematically examine their beliefs and values to help them identify issues worth tackling (e.g., to pick their battles wisely). Next, clients are taught a systematic technique, using detailed handouts, for operationalizing their chosen problems, identifying the best solution or set of solutions, and developing a plan to implement the solution/s. In subsequent sessions, clinicians are instructed to help families revise their implementation strategy, if needed, or move on to tackle a new problem. Several examples of relevant problem-solving homework assignments that families can complete together are provided. The chapter concludes with a case example of problem-solving with a Jewish mother and her adult daughter.

Module 2—Psychoeducation (Sessions 4–6)

This chapter is designed to help clinicians deliver psychoeducation about schizophrenia to families in a culturally informed manner. The chapter guides clinicians to systematically examine clients’ cultural conceptualizations of the illness and modify interventions (or the framing of interventions) in a manner that is palatable and relevant to clients. Clinicians are instructed to review core symptoms of the illness, common relapse triggers, and factors that protect against relapse using detailed handouts to guide each session. Clients learn the correct professional terminology for their symptoms, which equips them to communicate more clearly with their psychiatrists and other mental health practitioners. Examples of relevant homework assignments to increase knowledge about schizophrenia and how to manage it are provided. The chapter concludes with a case example of psychoeducation with a family of Mexican origin.

Module 1—Family Collectivism (Sessions 1–3)

The focus on the individual, typical of mainstream U.S. therapies, is alien to other cultures and can cause discomfort that leads to ineffective treatment and early termination. The aim of this chapter is to describe minorities collectivistic beliefs and introduce a rationale for incorporating them into family therapy in a way that creates a cohesive family environment. Skills from this chapter will aid families in emphasizing commonalities while de-emphasizing differences between family members. Therapists are provided suggestions for how to approach any differences that arise in how family members contribute to the family unit. The chapter provides notes on how to encourage family members to practice cultural traditions and destigmatize views of their ill family member. Examples of relevant homework exercises are provided. A case study of a Korean American family is used to illustrate the process.

Introduction

This chapter serves as an orientation to this book, a 15-week, family-focused, cognitive-behavioral approach for managing schizophrenia spectrum disorders. The chapter begins with an overview of the book’s purpose, which is to offer a how-to approach for conducting culturally informed therapy for schizophrenia (CIT-S). CIT-S is a treatment that draws upon clients’ own cultural beliefs, practices, and traditions to help people with schizophrenia and their loved ones to better manage the illness and improve the quality of their lives. Next, the suggested credentials for individuals who wish to deliver the intervention are discussed. This is followed by a description of the organization of the book and a brief overview of each of the nine chapters. Finally, a glossary of important terms and phrases that are used throughout the book is provided.

Module 4—Communication Training (Sessions 10–12)

This chapter introduces the Communication Training Module, which is aimed at improving communication patterns amongst family members in ways that prioritize their values and culture. The chapter reviews the role of communication in mental health, communication deviance within schizophrenia spectrum disorders, and notable cultural differences in communication styles. The communication module is then introduced, including key components of communication (i.e., the three Cs: clear, concise, and confirming what you hear) and guidelines for facilitating roleplays. Clinicians are instructed on how to discuss communication and culture with their clients and how to introduce multiple communication strategies through homework assignments and worksheets. Strategies such as expressing positive feelings, attentive listening, making positive requests for change, and expressing negative feelings about a specific behavior are included. A case illustration about two Black mothers and their son with schizophrenia demonstrates the process.

Background and CIT-S Overview

Chapter 2 describes the foundational research from which it is based and introduces the main outline and goals of culturally informed therapy for schizophrenia (CIT-S). The chapter begins by introducing the history of family therapy for people with schizophrenia, its empirical support, and the cultural gaps that limited its generalizability in early clinical trials. Notable predictors of wellness (e.g., expressed emotion, collectivism, religion/spirituality, and ethnic pride) are reviewed, and relevant cultural differences are explored. The research reviewed provides the framework for the five modules of CIT-S (family collectivism, psychoeducation, spirituality, communication training, and problem-solving) and its session structure. Clinicians are encouraged to not only build their own knowledge of culture, history, and religion/philosophy but also to recognize the unique variance within each family and to be open to the varied intersecting identities that will influence and provide richness to their sessions.