Cognitive-Behavioral Therapy of Schizophrenia

David G. Kingdon, Douglas Turkington

• Publisher: Psychology Press
• Year: 2022
• Print ISBN: 9780863773280
• eBook ISBN: 9781000446197
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Cognitive-behavioural therapy has been successfully employed in the treatment of such problems as depression, panic disorder and phobias. Providing an approach to patients with the most intractable problems, this book details the practical application of cognitive-behavioural therapy to the pervasive disorder of schizophrenia. The techniques described in this book, drawn from relevant theory and research, are designed to complement other treatments for schizophrenia, including medication, rehabilitation and family therapies.; Making a clear distinction between the diagnosis of schizophrenia and the debilitating label of insanity, the authors contend that people with this disorder are not inherently irrational but instead suffer from a circumscribed set of irrational beliefs. The book presents easily learned techniques that professionals can employ to help patients alleviate the impact of these beliefs, and start drawing upon the strengths and rationality they possess to improve their daily lives.; Illustrated with numerous case examples, this book describes how to: work with the person to construct credible explanations of distressing and disabling symptoms; explore the personal significance of life events and circumstances and their interactions with the person's strengths and vulnerabilities; introduce reality testing for hallucinations and delusions; disentangle thought Disorder And Ameliorate Negative Symptoms; And Demystify Psychotic symptoms for individuals and their families. The book also delineates the relationship of thought, identity, insight and coping strategies to schizophrenia.; This text should be of interest to professionals working with people suffering from schizophrenia - from psychologists, psychiatrists and residential care workers to social workers, occupational therapists and nursing staff - as well as to students in these fields.

PART ONE

THEORETICAL BACKGROUND

CHAPTER ONE

Explanations of Schizophrenia

Knowledge, understanding, and fear are bound together, so that the fear of the unknown is perhaps the greatest fear of all. If people know what they are faced with, they can devise a strategy to cope with or even overcome it. And even if they are faced with an overwhelming situation, they can at least adjust psychologically to the consequences they can see developing. Not knowing, just fearing, is commonly the situation both with those suffering from schizophrenia and with those caring for and about them. Providing a framework, however tentative, on which they can base an understanding of the confusing and frightening experiences of schizophrenia would seem likely to provide reassurance, reduce anxiety, and ease feelings of depression;, in other words, it may have direct therapeutic potential. In an investigation of coping strategies described in more detail later, Carr (1988) goes still further and suggests “the admittedly speculative notion that the timely introduction of a plausible objective explanation for subjectively inexplicable experience could perhaps inhibit the development of delusional beliefs, the basic characteristic of madness” (p. 341).

In the treatment of depression (Beck et al., 1979) or anxiety (Beck et al., 1985), providing an explanation of the symptoms involved is fundamental to the application of cognitive therapy. Similarly, explanations of schizophrenic symptoms would seem to be necessary if we are to develop the use of cognitive therapies in treating schizophrenia. Such explanations may be biological, psychological, or social. Alternatively, they may be multifaceted, with elements of all three. Biological theories are based on genetic, neuropathological, and neurochemical findings (reviewed by Murray et al., 1988); psychological theories are based on psychoanalytic theory (e.g., Arieti, 1979); and social theories are based on theories of stigmatization (Goffman, 1961) and labeling (Scheff, 1963), perceived abnormal family dynamics (Bateson et al., 1956), and societal pressures (Laing, 1960).

Laing and Esterson (1964) specifically aimed to demonstrate the “social intelligibility” of what “psychiatrists …call …schizophrenia” (p. 11)—that is, to produce explanations demonstrating how schizophrenia can be understood in a social, particularly a family, context. However, their work has been interpreted as “blaming” the family and society in general for schizophrenia (Hudson, 1975), which has been a factor in its rejection by most psychiatrists. Unfortunately, but understandably, some families have taken this work to mean that they are responsible in some way for their relatives’ illness. Not surprisingly, there have been difficulties in validating the conclusions reached in comparative studies with nonschizophrenic families.

Laing’s publications are widely available and thus have been read by those both in and outside the mental health professions; their influence on social and political changes, particularly the move toward “normalization” philosophies and specifically “care in the community,” has quite probably been more profound than is currently recognized. Nevertheless, their incorporation into individual management of the patient group that it has such difficulty defining has probably been limited.

Patient’s Own Explanations

It is important to recognize that patients develop their own explanations of what is happening to them, and these can be extremely varied. Romme, a Dutch psychiatrist, and colleagues (Romme & Escher, 1989; Romme et al., 1992) describe the importance to their group of patient who all heard “voices” of developing rationales for their symptoms as a method of coping with them. Their interest in this began when one of Romme’s patients described reading The Origin of Consciousness in the Breakdown of the Bicameral Mind by Jaynes (1976). She found helpful his statement that “hearing voices [was] the normal way of making decisions until about 1300 B.C.,” and that “hearing voices has disappeared and been replaced by what we now call ‘consciousness’” (Romme, 1989, p. 207). After this patient and Romme appreared on a television program to describe this, 450 people who heard voices made contact with them.

A great many frames of reference were used by this group—psychodynamic, mystical, parapsychological, and medical. Jung’s work appealed to many, with his suggestion that “impulses from the unconscious speak to humans in visions or voices” (Romme, 1989, p. 213). Some felt that reading his books helped them to develop a better understanding of their voices. Others subscribed to the psychodynamic theory that trauma repressed returns to consciousness in the form of flashbacks, “feeling pursued,” aggressive voices, or terrifying images. Mystics, it was said by some, “often assume they know that people have the capacity to expand their consciousness by developing spirituality. Voices may be viewed as part of that expansion” (Romme, 1989, p. 213). In parapsychology, “voices may be viewed as originating from a special gift or sensitivity” (p. 213). Biological or medical explanations were based on our current understanding of how the use of medication alleviates symptoms through receptor blockade. Romme and colleagues cautioned, however, that explanations placing the phenomena beyond the patients’ grasp or influence could be unhelpful to them in coping, and in fact could induce feelings of hopelessness. Thus it seems that providing a purely medical explanation of schizophrenia may lead to alienation, depression, and poor compliance with treatment.

Increasing amounts of psychoeducational material about schizophrenia have been produced over the last decade. However, as Ascher-Svanum (1989) has commented, most psychoeducational programs have been designed for family members rather than patients themselves. This is clearly evident from a survey of the otherwise excellent pamphlets (e.g., Leff et al., 1987) and books (e.g., Arieti, 1979; Kuipers & Bebbington, 1987) readily available in the United Kingdom, which are virtually all written for the caregiver or professional. Ascher-Svanum (1989), however, describes a program aimed at increasing compliance with medical treatment, which uses both didactic and experiential techniques to educate patients. She discusses with patients the nature of schizophrenia, causes, prevalence, drug treatments, and the use of community resources (including advocacy). Such programs may be becoming increasingly common, but nevertheless the relative neglect of educating the patient about his own illness needs to be noted.

This neglect also needs to be questioned. It may be occurring because untested assumptions are made that patients will be unable to participate in educational programs. When a patient is catatonic or grossly thought-disordered, this may be the case, but in most circumstances this seems to be patently untrue. Such assumptions probably demonstrate the extent of “catastrophization” among mental health professionals in relation to schizophrenia. Overgeneralization from a stereotype also seems to be occurring. It is likely that even the most disabled patients are far more aware of surrounding events and circumstances than may be apparent, and that even if participation is initially minimal, explanations as part of a rehabilitation program can be therapeutic. Failing to give even inadequate explanations and to involve a patient in his own treatment program—perhaps just giving such information to relatives, or not at all—must increase the patient’s paranoia, helplessness, and even belief that control of his own life is not in his hands. This may even exacerbate or precipitate delusions that the patient is being controlled by external forces or simply other people (i.e., “passivity phenomena”). As such, current practice could be a factor contributing toward failure to recover.

Distinctions Between Schizophrenic and “Normal” Experience?

Current psychiatric practice emphasizes distinctions between schizophrenic symptoms and “normal” experience, ostensibly to simplify diagnosis and classification. This can, however, make understanding of the symptoms more difficult than if they could be related to culturally or personally familiar experiences. Such distinctions also more readily lead to stigmatization of a patient by others, lowering his self-esteem. Finally, such divisions would seem to be quite artificial.

Strauss (1969) examined Present State Examination data collected as part of the World Health Organization’s (1973) International Pilot Study of Schizophrenia. A total of 119 patients were interviewed. The researchers found that many of the responses to their questions were difficult to categorize precisely. They scored half as many delusions “questionable” as they did “definite,” and three-quarters as many hallucinations “questionable” as “definite.” Their difficulties arose from consideration of “external reality factors” (e.g., fundamentalist religious training) and uncertainties about, for example, voices heard through walls, which might be misinterpretations of things said rather than true hallucinations. Some of this uncertainty could presumably have been resolved if an interviewer had been in possession of more relevant information—if, for example, the interviewer had been with the patient when he heard voices through the wall and could determine whether misinterpretation was occurring.

Nevertheless, on the basis of the evidence as a whole, Strauss (1969) concluded that “phenomena like delusions and hallucinations represent points on continua function” (p. 586). In a later paper (Strauss, 1989), he expanded this to say that “all intermediate gradations of experience exist, from normal perception to hallucinations and from normal ideation to delusions. …many patients, for example, experience something that is more perceptual than just a strange idea but is not quite a voice” (p. 27). This is not a new assertion; Sedman (1966b) reported that in 1911, “Jaspers … pointed out [that] there is an infinite variety of image-phenomena ranging from normal imagery to fully developed pseudo-hallucinations” (p. 489). This view was substantiated later in a comparative study of imagery and pseudohallucinations (Sedman, 1966a).

Strauss (1989) also stressed the importance of following patients over time, as considerable evidence indicates that “over periods of improvement symptoms may fade slowly through intermediate levels of experience. Hallucinations may be more and more dimly perceived until they disappear entirely. Delusions can gradually lose their power and then cease to exist” (p. 27). Strauss (1969) did not suggest, as others have done, that schizophrenia does not exist, but that “schizophrenia …might be more adequately described as a point or a series of points on a functional continuum” (p. 585). He added that

schizophrenia and the symptoms that characterise it are understandable exaggerations of normal function and not exotic symptoms superimposed on the personality. When the distortions and exaggeration of certain psychological functions reach a certain level of eccentricity or begin to impair social function they are called symptoms. (p. 585)

Strauss (1969) suggested that “tentative criteria for defining the continua” (and thus where normal behavior merges into that of schizophrenia) are as follows:

• 1. The degree of the patient’s conviction of the objective reality of the bizarre experience (how strongly he holds it).
• 2. The degree of absence of direct cultural or stimulus determination of an experience (how unrelated it appears to be to his situation).
• 3. Amount of time spent preoccupied with the experience.
• 4. Implausibility of the experience (e.g., seeing a man from Mars, as compared to mistaking seeing a car outside one’s house [and thinking it related to himself, how unlikely the experience appears to be]). (p. 586)

Psychopathological terminology (i.e., the language of the science of mental disorders) also provides some evidence for functional continua—for example, in the use of the term “pseudohallucination.” This term has been used in two alternative intermediate ways (Kraupl-Taylor, 1981) as referring to “self-recognized hallucinations” or to “introspected images of great vividness and spontaneity” (p. 265).

The use of “overvalued ideas” as a term referring to beliefs which are neither normal or delusional, but somewhere in between, also suggests at least gradations of experience. McKenna (1984) reported that Wernicke established the concept as

a solitary belief that came to determine an individual’s actions to a morbid degree, while at the same time justified and a normal expression of his nature … [which] could sometimes progress to full psychosis…. [Over-valued ideas] …grew out of adverse experience in a way which made it comprehensible. (p. 579)

McKenna has suggested that

passionate political, religious and ethical convictions are as inextricably bound up with personality and experience, arise just as unpredictably, and have the same ability to alter an individual’s whole way of life. The overvalued idea may thus be only the pathological expression of a pattern of behavior of which we are all capable. (p. 584)

In developing an acceptable explanation of schizophrenia, the work discussed here is fundamentally important, because the danger with categorical definitions (e.g., biological explanations as presented currently) in relation to dimensional ones is that the former require a change in type rather than degree. They can be stigmatizing, in that they imply that ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Introduction
• One. Theoretical Background
• Two. Process of Therapy
• Three. Evaluation and Evolution
• References
• Index