Alternative explanations can be explored. For example, a patient who believes he is being electrocuted because his fingers tingle is given information about anxiety and a controlled experiment is undertaken to reproduce the symptoms. By modifying the misinterpretation of events that served to reinforce the delusional belief, the cognitive cycles that maintained the delusion are broken. Exercises that use Socratic questioning to examine beliefs and to foster discussion are very useful in assessment and relationship building. Gentle probing by the therapist can provide additional information and build trust on the part of the patient.
When a patient lacks an absolute conviction in his beliefs, the process of gentle questioning can begin to evoke alternative explanations. When beliefs are very strong and a “chink of insight” cannot be found to build on, such discussion eventually begins to become repetitive and it may be necessary to agree to disagree. Frequently, the patient is open to moving on to other, more important topics about underlying concerns and life goals. Once these are addressed, the beliefs may change. By focusing on why the beliefs are important to the individual and empowering him by teaching him what he can do if beliefs are causing distress (eg, through coping strategy enhancement), the therapist can improve collaboration and begin constructive behavioral change.
Addressing the voices
Hallucinations are frequently but not always distressing. Some patients describe positive aspects, such as companionship or guidance; nevertheless, hallucinations are disturbing and negative in content and effect for most patients. A structured approach to assessing, understanding, and reattributing voices or other hallucinations is used.
This involves establishing the nature of the perception (“like me speaking to you?”) and then the uniqueness of the experience (“just you, nobody else can hear them?”). Inquiry into beliefs about the origin of the perceptions follows (“why do you think no one else hears them?”); followed by discussing the reasons (“It’s God”; “But would you expect God to say such unpleasant things to you?”).
Alternatively, especially if the patient is uncertain of the origin of the voices, psychoeducation and normalization about the nature of voices can be helpful. For example, explaining the role that the Broca area of the brain plays in inner speech and the similarity to “dreaming awake” can help patients reattribute voices to internal phenomena (“my mind is playing tricks on me”) rather than from external sources (“the neighbors are talking about me”). It then becomes more relevant to use personal ways of coping with them (eg, relaxation, distraction, and taking medication). Coping strategies that involve direct engagement with the voices have been used successfully in patients who have developed insight into the voices but in whom they persist and continue to cause distress. These include the development of an assertive dialogue or use of mindfulness techniques.
Negative symptoms
There is accumulating evidence that CBT can have an enduring effect on negative symptoms, including amotivation and social withdrawal.7 Rehabilitation methods—such as social skills training, target setting, and behavioral experiments, supported by cognitive interventions—are used for negative symptoms. For example, a patient may set himself a task but be unable to complete it. Through inquiry, the patient’s belief that when he goes outside he is being talked about in the street is uncovered. Work on this belief involves reasoning, ie, reality testing. The emphasis is on ascertaining precisely who is talking about him, what they are saying, and why they may be saying it. Diaries or detailed recall of circumstances can help unblock resistance. Assessing expectations and pressures with families can also be useful. Remember, you cannot push patients out of negative symptoms. It is essential that they are allowed to reestablish control.
Readily achievable and collaboratively developed short-term goals establish momentum. The goals are often initially very simple (eg, go downstairs for coffee in the late afternoon). When the initial goals are achieved, further steps are built on that foundation. Consider suggesting that the person take time off when he has been trying but repeatedly failing to achieve a goal: he may feel less pressured.
Improved concentration and cognitive ability enables work on positive symptoms that interfere with progress. When negative symptoms have emerged during periods of institutionalization, the identification of motivating factors—often long forgotten—can begin the process of reengagement in conversation and social interaction and subsequently set the stage for specifically therapeutic work. CBT techniques for behavioral activation that involve activity scheduling, mastery and pleasure rating (gauges how well the patient has mastered the task and how much he has enjoyed it), and graded task assignment can provide structured support.
Implementation of CBT in severe mental illness
Although sessional CBT is generally provided by clinical psychologists or nurse therapists, it is important for psychiatrists to be involved in the initial work with patients to develop agreement with them to be referred for psychological work. Work on attribution can be fundamental to this process: if the patient does not agree that there is anything wrong, why should he see a therapist to discuss anything?
Focused work on hearing voices, delusions, and negative symptoms can be successful in brief sessions with patients. This may be all that can be offered where availability of skilled therapists is limited. Psychiatrists can take the lead in alleviating the dearth of trained providers by advocating for improved availability through training and education.
After the patient has had sessions with therapists, psychiatrists often continue medication management and provide brief booster sessions with discussion and reinforcement of lessons learned and gains made.
Common pitfalls and challenges
Strong beliefs take time to change and CBT is rarely a quick fix. The major changes seen initially are usually behavioral (eg, increased social involvement rather than cognitive improvement and ability to cope with distressing symptoms). Most therapy courses involve 16 to 20 sessions over 6 to 9 months, and change often continues after completion of therapy. For acutely psychotic patients, CBT can improve engagement; combined with the effects of medication, CBT can allow work on symptoms to commence as agitation and thought disorder are reduced.
Patients with profoundly negative symptoms can be challenging to engage and often a “befriending” approach is helpful. Seeking out areas of interest with appropriate self-disclosure may be a necessary first step for the success of the work on formulation and symptoms, which will follow. Cultural issues are also important to consider and require adjustments to therapy.8
CASE VIGNETTE
Ellie, 50 years old, was housebound and lived alone. She had a long history of mental illness and had been abused as a child. She stated she had an “unhappy childhood.” Also, she had had a “lost year” of drinking and isolation. As a teenager she had 2 hospital admissions related to drugs, alcohol, and depression, and 4 years ago she was hospitalized for alcohol-related hallucinations. Since then, despite a history of overdosing, self-harming, depression, and disengagement, she has managed to stay out of the hospital. A violent incident with her ex-partner coincided with the onset of auditory hallucinations.
Rapport with Ellie was established using a nondirective conversational style: befriending was quite successful in reducing her initial anxiety. Ellie and the psychiatrist worked to normalize and decatastrophize experiences using the stress vulnerability model and psychoeducation. The cognitive model was explained early in therapy: links between the thoughts (perceived as voices), feelings (distress and anger), and behavior (drinking and withdrawal) were creating a self-perpetuating cycle. A history and time line were established, and symptom assessment was completed using a standardized rating scale.9
Ellie was highly anxious and depressed, with suicidal thoughts and behaviors. She said, “My life as a whole is black and gray. I’d love some respite from myself.”
Ellie experienced one voice but minimal delusional belief. She was assessed as relatively independent (moderate competence and performance on the Social Functioning Scale) but very socially withdrawn, with a lack of relationships, no social and recreational activities, and unemployment.10 She viewed the voice she heard as malevolent, omnipotent with no benevolence, using the Beliefs About Voices Questionnaire.11
