Relationship is primary. If anything else you are doing threatens the relationship you have with the client, stop it, backtrack, and re-establish a good relationship.
Goals are structured around relieving distress for the client, not around therapist goals for making the client “normal.”
“Collaborative Empiricism” is the key approach. This doesn’t mean reasoning for the client, it means drawing the client into a collaborative investigation of various possibilities. This is best done if you are open to all the evidence, including that which contradicts your usual viewpoint.
Normalizing: rather than identifying psychotic experiences as categorically different from “sane” experiences, focus on the continuum of human experiences, and notice the connections between psychotic experiences and more conventional ones. Explain to clients that in distressing or overwhelming situations, it is normal for unusual experiences to occur.
Therapist self disclosure is an important part of this type of therapy. Disclosing your own less normal experiences helps your client see the continuity between their own experience and yours. You are not saying that your own experience is the same as theirs, only that there are understandable connections and similarities.
A formulation is a way of understanding how the psychosis came about and what maintains it. In developing a formulation, you collaborate with the client in assembling a story that shows how the client’s psychotic experiences may have naturally came about as a result of the client’s history, which includes events intertwined with coping attempts and interpretations of experiences. The formulation should be condensed, such as one diagram or a written paragraph. But it can also be very inclusive, including predisposing, precipitating, perpetuating, and also protective factors, allowing for a clear understanding of what happened and of what is happening. It may change with time as you learn more.
Cognitive therapy focuses on changing beliefs, and one of the most common ways people try to change beliefs is to argue with people about them. But this is unlikely to work with people with psychotic experiences, who generally feel critically vulnerable and who feel strong reasons to hang on to their beliefs. In fact, slipping into an argument with your client is likely to cause him or her to “dig in.”
A better idea is to use the following three methods:
- ? gently investigate beliefs, the evidence for and against them, and advantages and disadvantages of believing in them, while developing alternative beliefs that allow for the preservation of client self esteem and sense of safety.
- ? explore the story of how the person developed this belief, including everything from recent events and interpretations of events to early life experiences that may have contributed to a bias toward having such a belief.
- ? encourage the resumption of things like employment, school, and other aspects of social role, despite having the belief, knowing that this in itself can reduce preoccupation and distress
Hallucinations and hearing voices are not bizarre phenomena only experienced by the “insane” but can be seen as simply the person’s own thinking temporarily not recognized as belonging to one’s own mind. They are similar to thoughts and perceptions we recognize as coming from other parts of our mind, for example intrusive thoughts and images common after trauma.
Beliefs about hallucinations and voices are the intervention point for cognitive therapy. Three important categories of beliefs are those about the content of the hallucinations (for example the content of what the voices say,) about their power, and about their identity.
Paranoia can be understood as the cognitive process of continued attention to threatening stimuli, while delusional beliefs are a common product of this continued attention. Paranoia itself is helpful in some situations, though destructive in others. Normalizing paranoia for clients, helping them examine how it developed in their lives, and looking at its current effects, are all important elements of cognitive therapy for paranoia.
“Thought disorder” can be understood as much more than a “biological defect.” Like dissociation of other kinds, it can be intentional, for example as a strategy to break away from unpleasant associations. And confused or disordered mental states can be an understandable reaction to life events. Therapist attempts to make meaning out of confusing communications can be very effective in building empathy.
“Negative Symptoms” can be understood as a strategy for dealing with overwhelming stress. You cannot push a person out of negative symptoms, and efforts to do so are likely to backfire. Instead, try the paradoxical intervention of actually lowering expectations for now, with the focus on relaxation and healing. This does not mean discouraging any long-term goals, only that there is no need to take action on them currently. This “easing up” can eliminate the perceived need for negative symptoms, resulting in an emerging ability to function well. Eventually, you want to help the person learn how to “try, but not try too hard” in the pursuit of his or her dreams, which is key to regulating stress load.
Cognitive therapy is typically offered alongside medication, not as a replacement for it. However, learning skills through cognitive therapy could fit well into a client’s plan for long-term reduction and/or eventual elimination of medication. And cognitive therapy can be offered to clients who make the choice to refuse medication. While few formal studies exist for this latter approach, positive individual case reports, and one smaller study, have been published.
People diagnosed with serious mental illness are frequently told that their problems are not their fault, because they have a “brain disease” over which they have no control (other than to take medication.) Unfortunately, research shows that these kinds of beliefs make clients feel more hopeless, and result in the public and even mental health workers seeing the diagnosed people as more dangerous and desiring more social distance from them. Cognitive therapy is different: it does not “blame” people for having symptoms or problems, but does see people as capable of learning to manage their own mental functioning so that problems fade away.
- There are roughly 3 levels of possible integration of cognitive therapy for psychosis with the rest of the mental health system.
- At the first level, cognitive therapy for psychosis is used only as a backup when medications fail to adequately control psychotic symptoms. Cognitive therapy can most easily be introduced at this level.
- At the second level, cognitive therapy for psychosis is seen as potentially helpful to all who experience psychosis, and is typically offered alongside medication. It may be used to help consumers reduce reliance on medication or to address the needs of consumers who refuse medications. In the UK, the National Health Service recommends that cognitive therapy for psychosis be available for everyone diagnosed with schizophrenia.
- At the third level of integration, cognitive therapy for psychosis and other psychosocial interventions would be seen as the preferred treatments, with attempts made to minimize the use of medications. In Finland, an approach with some similarities to cognitive therapy for psychosis, the Open Dialogue approach, has achieved some outstanding results.