A Casebook of Cognitive Therapy for Psychosis

Anthony P. Morrison

• Publisher: Routledge
• Year: 2014
• Print ISBN: 9781583912058
• eBook ISBN: 9781317710837
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

This book is a unique volume in which leading clinicians and researchers in the field of cognitive therapy for psychosis illustrate their individual approaches to the understanding of the difficulties faced by people with psychosis and how this informs intervention. Chapters include therapies focused on schizophrenia and individual psychotic symptoms such as hallucinations and delusions (including paranoia). Beck's original case study of cognitive therapy for psychosis from 1952 is reprinted, accompanied by his 50-year retrospective analysis. Also outlined are treatments for: • bipolar disorder • dual diagnosis • schema-focused approaches • early intervention to prevent psychosis • adherence to medication This book will be useful to clinicians and researchers alike, and will be an invaluable resource to mental health practitioners working with individuals experiencing psychosis.

Part I
Cognitive therapy basics

Chapter 1
Successful outpatient psychotherapy of a chronic schizophrenic with a delusion based on borrowed guilt

A 1952 case study¹

Aaron T. Beck

The increasing number of case reports of successful psychotherapy of patients with chronic schizophrenia has attested to the validity of this approach and has done much to dispel the former pessimism and skepticism (Arnow, 1951; Betz, 1946; Kellerman, 1949; Knight, 1946; Lafourge, 1936; Lindsay, 1948; Rosen, 1947; Sechehaye, 1951). Most of the papers, however, have dealt with hospitalized patients; relatively little has been written on the treatment of schizophrenia on an ambulatory basis.

This report of the outpatient psychotherapy of a chronic schizophrenic with paranoid delusions is presented because of three noteworthy features. First, although patients as acutely disturbed as this man would generally have been referred to a mental hospital, he was treated (for reasons to be described below) in a mental hygiene clinic where he was seen only once a week for a total of 30 interviews. With this arrangement, and without being removed from the setting in which his delusion was anchored, he experienced an almost immediate improvement in his general condition and level of functioning. Second, despite the fact that his delusional ideas were of seven years’ duration, they proved to be amenable to interpretation and, as the patient gained insight into them, they faded away. Thirdly, a prominent mechanism in the formation of the delusion was found to be the phenomenon of “borrowed guilt”, which has found scant attention in the literature (Lampl, 1927).

This report will include a discussion of the reasons for the favorable outcomes of the therapeutic venture, of the techniques that were employed, and of the dynamics of the delusional formation.

Presenting Illness

A 28-year-old World War II veteran was first seen in February 1951 on a referral from his family physician who felt he needed immediate attention. At that time he reported his chief complaint as follows:

Fifty men, many of whom were in my outfit overseas, are now being employed by the FBI to investigate me. They appear one at a time in the store where I work and secretly observe my speech and behavior. They have concealed, somewhere in the store, an elaborate system of microphones that can pick up anything I say and, possibly, can even record my thoughts. They are trying to build up some case against me, the substance of which is unknown to me.

This idea first began to take form when he was overseas in 1944. It was preceded by obsessional thoughts that he had syphilis, that he looked like a “queer”, and that he might stab somebody. Also, he experienced compulsions to use “blasphemous language” and to gouge his eyes out. Shortly afterwards he began to believe that 50 men in his medical outfit, whom he thought were actually encephalographic technicians, had been given the special assignment of looking after him and checking his movements. After he returned to the United States in 1946 and started to work in his father’s small retail store, he spotted some of these men posing as customers. There also appeared, so he thought, to be a number of recent additions to the group. Although he assumed at first that their function was to protect him and look out for his interests, he felt a good deal of annoyance that they were going about it in this way, and that they would not admit what they were up to. When one of these men would enter the store, he would react in one of several ways. He would either put up his guard so as to prevent the man from detecting his real reactions, or he would try to imitate him—that is, he would respond to a smile with a smile, to a stare with a stare, and so on. He finally came to the conclusion that these men were actually FBI agents, and, a few months before starting therapy, he began to suspect that they were trying to convict him of something and were probably out to harm him.

Concomitantly, he began to experience severe episodes of anxiety, fears of going out of control, repeated nightmares, bizarre physical symptoms, and feelings of unreality. As his condition deteriorated he found himself unable to work, and, on the advice of his family doctor and his frantic parents, he sought help at the clinic.

Background

The patient is the oldest of three children of foreign-born parents. His two married sisters show no gross evidence of emotional disturbance. The patient’s father had encephalitis while serving overseas during World War I, and a few years later began to develop post-encephalitic Parkinsonism. This was slowly progressive until two years ago, since which time it has been fairly well controlled with drugs; his chief symptoms have been weakness of the right arm and leg, spasmodic blinking of the eyes, facial tics, and a constant state of drowsiness. The father is an outgoing person and is fairly well liked, but has shown signs of “weak character” at times by cheating in business, lying, and carrying on clandestine extramarital flirtations. The patient feels a good deal of shame about this and also suspects that his father may have associated with prostitutes in the past.

His mother is a highly moralistic, overprotective, fearful woman who has constantly reminded the children of all the sacrifices she has made for them and has placed great emphasis on integrity, duty, and achievement. She has never tired of demonstrating to them that she has exceptional judgement and foresight. The patient always felt that his mother knew what was best for him and that all of her predictions would inevitably come true. He came to believe that he didn’t have a mind of his own. He was extremely attached to her and considered himself “tied to my mother’s apron strings”.

In the course of therapy the patient gained some understanding of his strong need to idealize his mother and to assume a completely passive puppet-like role in the relationship with her. However, these feelings appeared to be too deeply buried to be accessible to scrutiny. On the other hand, his resentments towards his father were relatively close to the surface and could be mobilized and ventilated. Evidently the hostility towards his mother was of a more primitive and violent character and therefore had to be more vigorously defended against. Successful attempts to break through the repressions might have aroused a dangerously high level of anxiety and led to a further disintegration.

On the surface, the father and mother had a happy marital relationship, with the mother maintaining the dominant position and indulging the father’s various needs in a maternal way. At times, however, she betrayed a contemptuous attitude towards her husband for his lack of success in business and his great dependence on her.

The patient was a sad, lonely, withdrawn child to the extent that contemporaries nicknamed him “Blue Boy”. On his mother’s caution he avoided contact sports and any other activity that might have exposed him to injury. He was not expected to perform any chores around the house; he recalls ruefully that his mother made his father, instead of him, take care of the garbage. He had at times almost overwhelming feelings of weaknesses, inferiority, and inadequacy. One of his most vivid memories is of being chased by a gang of rough boys in the neighborhood. Nevertheless, he got good grades in school and gradually developed a few close friendships.

The age of 13 stands out in his mind as a turning point in his life. At that time class work began to slip. He started to feel increasingly self-conscious, and he suspected from time to time, when called on for a recitation, that his teachers could detect his reactions, such as embarrassment, resentment, and competitiveness. He would then try to foil them by acting contrary to the way he was feeling. Despite his difficulties, he succeeded in getting through school without anybody suspecting that there was anything wrong with him. After graduating from high school he went to college for two years. He was drafted at about the time he felt he was developing self-confidence and forming rewarding friendships with other students. He served three years in the armed forces overseas and was discharged on the point system in 1946.

Course in Therapy

When first seen in the mental hygiene clinic, the patient appeared anxious and tense and in some distress over his paranoid obsessional ideas. He showed facial grimacing and verbal peculiarities. He spoke of feeling that he was falling apart, of being a Jekyll–Hyde personality, and of spells in which his mind was completely blank. Although he seemed to be very precariously balanced, the staff felt that it was worth taking the risk of treating him on an outpatient basis rather than recommending hospitalization. On the positive side he showed a fairly good preservation of intellectual functioning, a strong motivation for therapy, and a capacity to view his symptoms and experiences with some objectivity. Although there was some inappropriateness of affect, he was in general responsive and sensitive and revealed a fairly free play of emotional expression. The initial diagnostic impression was chronic schizophrenia, and this diagnosis was later supported by a battery of psychological tests, which showed numerous signs of chronicity and paranoid thinking.

The patient was seen for a total of 30 interviews over a period of 8 months. At the very beginning I felt a good deal of interest in and empathy for him. In the earlier interviews I was quite active in discussing his current problems with him, counselling him about his relations with other people, and recommending recreational activities. My role in this phase was predominantly supportive and educative. At the same time I was relatively non-directive in allowing him to bring up whatever he felt was important. He expressed a wish to go over his war experiences with me, and experienced a profound catharsis in bringing out his resentments toward the other members of his outfit who had belittled and humiliated him. He reported an almost immediate relief from his anxiety, feelings of depersonalization, and nightmares. After the third interview, he remarked that he felt that the FBI men would soon feel they had accumulated all the evidence they wanted, would decide that he wasn’t guilty, and would “close the case”.

The patient then expressed a strong inclination to understand the various elements in the development of his illness and began to survey his past experiences with a good deal of thoughtfulness and reflection. At the outset of an appointment that proved to be probably the most dramatic one, he stated that he wanted to tell me about a family secret that had tormented him for a long time and that he had never before confided to anyone. This had to do with disability compensation (for the sequelae of his encephalitis) that his father had begun to receive when the patient was 13 years old. He stated that when his father had first filed for the disability benefit he had made a false or misleading statement in the application. Each month thereafter when the check arrived, his parents acted in a very furtive manner, as though they were afraid that the circumstances of his father’s dishonest act might leak out. The patient himself was under almost constant dread that a Federal investigator would be summoned to look into the case and would expose his father’s misrepresentation. He recalled having experienced intense guilt over this, just as though he himself had committed perjury.

In presenting this material the patient spoke with a great deal of emotion. While describing his present feelings about his father’s misdeed, he remarked that he now felt as bad about it as he ever did. He stated that he had been feeling worse ever since “the FBI men moved in and started checking on my father in the store”. He went on to say that “they are coming in posing as customers and have planted microphones in the store to gather evidence against my father”. He described his reactions to them as follows:

When one of them comes in I cover up and make out I don’t know what he’s up to or else if he smiles, I smile back. If he stares, I stare back at him.... I wish they would leave him [his father] alone. He’s such a good guy. Sometimes I suppose they know what a good guy he is and won’t do anything to him. Maybe they’re really looking out for him.

It was quite striking that this account was couched in practically the same language the patient had used previously in referring to the men who were supposedly assigned to investigate him. I promptly pointed this out to the patient. He appeared to be dazed for a moment and then with an expression of surprise he blurted out that somehow he had himself all mixed up with his father. As he tried to straighten this out he arrived at the conclusion that basically he must have thought the men were checking on his father, but in order to protect his father he had concealed this idea from himself by assuming himself to be the victim. We discussed at length how he had put himself into his father’s shoes, had taken over the guilt for his father’s dishonest act, and had expected punishment for it. At the end of this hour the patient declared that he felt he had really accomplished a great deal during the appointment.

Following this interview he discussed the disability insurance with his father and, for the first time, scolded him for always complicating things unnecessarily. His father reacted in a sheepish way, and the patient felt relieved that he had talked it out with him. This interview was, in retrospect, a turning point in the therapy. From that time on the patient found it increasingly easy to reject his irrational ideas. In the next few interviews he brought out a good deal of important historical material, which filled in many of the gaps in the original history and paved the way to further formulations and interpretations (described later).

It was easily recognized that one of the most critical periods in his life had occurred in his thirteenth year. It was at that time that he felt the full impact of the fact that his father was a sick man. Up until then the patient had been able to write off his father’s tendency to doze off during the day as being due to “laziness”, which was the explanation his mother had given. As his father...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of figures and tables
• List of contributors
• Preface
• PART I Cognitive therapy basics
• PART II Specific cognitive therapies for psychotic symptoms
• PART III New developments in cognitive therapies for psychoses
• Index