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CASE DESCRIPTION AND CONCEPTUALIZATION Carol is a 26-year-old single White female.

She is a high school graduate and completed 1 year of college. She was raised in an upper-middle-class family where academic and career successes were extremely important as was their conservative Christian faith. She was the third of five children. Carol was a good student, hard working and somewhat self-critical. She was shy but had several friends and dated occasionally. After graduation from high school Carol went out of state to college. She received passing grades her first year but began to experience auditory hallucinations and delusions. She began to act in bizarre ways and withdrew from people. She was hospitalised at age 18 for 1 month and dropped out of college. In the past 7 years she has been hospitalised 12 tunes. She has been unable to work and was supported by SSI. There was no history of psychiatric illness in the family. Her family was supportive of her financially. Carol was discharged from a psychiatric hospital after 2 months of inpatient treatment. Her diagnosis was schizophrenia, undifferentiated type, chronic. Her Global Assessment of Functioning (GAF) at discharge was 30. She lived with her parents and was on SSI. She took 500 mg of thorazine daily and was medication compliant. Carol was referred by her psychiatrist for ongoing psychotherapy as part of her discharge plan to help her adapt to the demands of community living and manage her illness. Cognitively she experienced auditory persecutory hallucinations and delusions as well as frequent cognitions like, "I'm no good," "I can't do anything," "I'll always be this way." Affectively she had flat affect and anxiety related to interpersonal situations and tasks and the content of the hallucinations and delusions. Interpersonally she was withdrawn and socially isolated. Behaviourally she was inactive, unable to work or live independently. Her basic self-care was severely limited. Carol's psychosocial functioning was significantly impaired by the interaction of her illness and her methods of coping. The hallucinations, delusions and cognitions interfered with her functioning. Her coping methods of avoidant behavior toward tasks and interpersonal situations and the increase in negative symptoms (apathy, avolition, anhedonia) to deal with stress in turn increased anxiety, negative cognitions and psychotic symptoms. ASSESSMENT MEASURES Four outcome variables were used in this study: symptomatology, psychosocial functioning, attainment of treatment goals and hospitalisations. Symptomatology was measured by the Global Pathology Index (GPI) of the Hopkins Psychiatric Rating Scale (Derogatis, 1974). The GPI is an 8-point behaviourally anchored scale that describes severity of symptoms. Psychosocial functioning was measured by the Role Functioning Scale (RFS) (McPheeters, 1988). RFS is made up of four subscales: work, social, family and independent living subscales. Each scale is a 7-point behaviourally anchored scale. The RFS and GPI are rater-based scales. Hospitalisation was measured by the number of times hospitalised and total days in hospital. Attainment of treatment goals was measured by Goal Attainment Scaling (GAS) (Kiresuk & Sherman, 1968). In GAS behavioural descriptions of functioning for various levels of goal achievement are developed and scored with the client. A score ranging from -2 (regression in goal attainment) through 0 (attainment of goal) to +2 (exceeds standards) is given for each goal based on the client's attainment. The GPI, RFS and hospitalisation data were independently obtained by the case manager on a quarterly basis throughout the 3-year treatment period and at 6 months and 1-year follow-up. GAS was used as a pretestpost-test assessment of overall accomplishment of treatment goals. THERAPIST CLIENT JOINING The development of a therapeutic relationship is critically important in work with persons with schizophrenia (Frank & Guncerson, 1990; Lamb, 1982). Rapport took some time to develop (approximately 3 months) and

The normalising destigmatising procedure described by Kingdom & Turkington (1991. The therapist and client would label the A (activating event) and C (the emotional consequence) of an emotional episode and the therapist would help the client figure out possible self. Using a blank calendar Carol recorded her activities in three time blocks: morning. For example. Initial focus was on daily living skills (self-care. Carol would spend much of her time in bed. friendly and used feedback. She and the therapist reviewed the activities to identify what things improved or exacerbated her condition and to help Carol understand her reactions to different events. 1984) was useful in helping her cope with the loss of structure she experienced after leaving the hospital and the symptoms she experienced. Length of sessions were determined by the client's capacity at the moment and would range from 15 minutes to an hour or more. 1970) was used to teach the cognitive view and process of treatment. watching TV and smoking. The ABC model (Ellis. Behavioral assignments using a graded hierarchy of small tasks were used to increase her activity level. The worker was directive. containment of feelings. . reality testing and selfdisclosure to develop the real relationship and lessen transferential problems. It was initially difficult for Carol to do this in times of stress or when applying the ABC model to significantly loaded situations. active. SOCIALIZATION PHASE The goals of this phase were to develop the therapeutic alliance regarding the rationale of treatment. Exploration of previous interests and the use of an interest inventory were helpful in stimulating her interests and expanding the range of her activities. to facilitate the client's understanding of the process of cognitive-behavioural treatment and to establish agreement about treatment goals. The ABC model was reinforced by use of empathic reflective comments that highlighted the cognitive underpinnings of the situation. This phase of treatment (approximately 2 months) involved the therapist taking an active role educating the client about schizophrenia and the process of treatment. Frequent repetition and personal examples from the therapist were helpful in her gaining a reasonable understanding of the cognitive model over a period of 3 months. Issues from the client's daily life were used to highlight the cognitive components of feeling and behavior. Mastery and pleasure ratings were later assigned to activities to evaluate the benefits of the activities and to identify cognitive distortions that minimised her sense of accomplishment and pleasure. afternoon and evening. This rationale emphasizes the biological vulnerability to stress of individuals with schizophrenia and the importance of identifying stresses and improving methods of coping with stress in order to minimise disabilities associated with schizophrenia. She coped with the stress of her symptoms by apathy and withdrawal. She had previous experience in arts and crafts and began to do paint by number paintings. The weekly activity schedule (Beck. This was followed by learning macramé and adding other activities such as bowling that could be done with other people. she would become anxious and hallucinations and delusions would increase. cooking. respect and accurate empathy. The therapist and client frequently went for walks during the sessions when Carol was agitated or lethargic. Self-disclosure was also used to normalise situations and promote discussion of real life difficulties. Carol had enjoyed playing softball and had been an avid baseball fan. When she would consider doing some activity or was requested by her parents to do something. cleaning.was established by consistent use of the core conditions of genuineness. time management).statements (B) that could have led to the emotional consequence or that would lead to other emotional responses. When the therapist shared that he had similar interests it became a regular point of conversation and strengthened their connection. 1994) was used to explain the experience of schizophrenia. EARLY PHASE OF TREATMENT The focus of the early phase of treatment (approximately 12 months) was on her inactivity and her difficulty managing stress and anxiety. She would think that the task was too much for her and would withdraw to her room.

Burns. Similarly. habitual stress situations were defined and meditation was used to cope with anticipated stressful events. exploring alternative explanations and generating new coping selfstatements to replace the automatic thoughts (Beck & Weishaar. began to go out weekly with a friend and worked 10 hours a week as a volunteer at a food shelf. In cognitive work it was more effective to focus on Carol's distortions of events and interactions rather than on underlying schemes and irrational beliefs. Social interaction is a well-documented source of stress for schizophrenic clients (Wing. Carol frequently had problems reading social cues and would interpret them by overgeneralising. cognitive modelling. 1974) and they practised meditation for short periods in each session. These were organised as low. 1989. Third. She posted the thermometer on her door and recorded her "stress temperature" each day. Three major areas of cognitive work emerged: dealing with social situations. These included expressing feelings and assertiveness. but were interpreted as reactions to stress. especially independent living skills. Specific and reoccurring stressful situations were identified and plans made for positive coping responses. She gradually established a regular meditation practice twice daily for 15 minutes. guided discovery. nothing I do can change it. She was assisted to develop skills in "checking it out" and identifying the difference between "confirmable" and "perceived" reality in order to develop more realistic ways of interpreting events (Waler. 1983). Two social skills deficits were addressed.Stress management skills were developed in three ways. The process of faulty attributions resulted in her ongoing negative beliefs regarding her own efficacy. evaluating evidence. Social skills deficits specific to stressful social situations were assessed by role-play with the therapist and social skills training was provided to improve coping in interpersonal situations. a variety of relaxation methods were discussed and Carol expressed an interest in meditation. the impact of schizophrenia on Carol's sense of self and fears of relapse. Many problems in social relations were due to errors in social perceptions of self and others. Thoughts like "I can't do it. DiGiuessepe. I have no control over things" predominated in the early stages of treatment and were a major target of behavioural treatment using graded task assignment. Fears of Relapse . medium and high signs on her stress thermometer. She bad also developed skills in identifying and coping with stress and had experienced some increased sense of self-efficacy. role-play and homework assignments. Carol took a class at the community college. This was worked on behaviourally by planning activities in a way that ensured she had a sufficient balance of time alone and time with others and by the use of planned regression in which Carol would take a day off in which she stayed in her apartment and had no contact with others. events in the world and her own behavior. personal or interpersonal concerns. Second. personalising. MIDDLE PHASE This phase (approximately 16 months) emphasized identification of habitual stressful situations and cognitions and utilization of cognitive strategies to cope with them. she was assisted to identify her personal signs of stress and symptoms of relapse. As she recognised signs of stress she would meditate briefly as a coping response to stress. During this period Carol's symptoms lessened and her functioning. The therapist taught her meditation (Bensen. rehearsal. improved and she moved into an apartment by herself. First. She significantly underestimated or overestimated her ability to control others. hallucinations and delusions were not directly challenged. & Carol. Social Situations Social situations were a major source of stress. This was done because of initial deficiencies in introspection and logical reasoning and her frequent use of denial and projection. 1980). 1980). & Wessler. Cognitive coping skills were developed by collaborative empiricism. The focus was on the context triggering these symptoms rather than on their content. She was trained to "check it out" by identifying automatic thoughts. and selective abstraction. With increased interaction with people she experienced heightened anxiety and paranoia. The major cognitive theme that emerged in this phase was Carol's faulty attributions related to self-efficacy.

1996). Fears of relapse were dealt with in several ways. employment or household tasks. sleep patterns. fears were examined using Socratic questioning. Powers. Carol had a limited self-concept. First. 1997. Warner. was developed by the author to train clients to more positively appraise situations and themselves (Bradshaw. severe disability and long-term nature of her illness. Cohen & Gara. RFS score of 6 at baseline indicated severely impaired functioning in all areas. exercise. achievement of goals. independent living. Diamond. Living with schizophrenia impacted her in two major ways: limited self. 1989. schedule of activities. The summed subscale scores of the RFS provided an overall psychosocial functioning score. skiing and her desire to get married. primarily. The plan included agreed upon procedures to handle emergencies. She would experience anxiety. preventive actions were taken that focused on reviewing her stress thermometer. education about her illness and interpretation of her experiences as normal responses to stress helped her understand and normalise her experience. Impact on the Self As Carol became more confident of her stability and experienced success in her life. ability to independently manage personal and household tasks and performance of school. "I'm just a mental patient. social and family relations.concept and low self-esteem. PSOB. Second." Her experience of vulnerability and issues of low frustration tolerance. & Hyman. friend.appraisal and enhance self-esteem. Selective perception and attributions of negatives to oneself and positives to others were common. she began to talk about the impact of schizophrenia on her sense of self. Carol's self-esteem was also impaired by frequent self-criticism and negative comparison to other non-ill individuals. 1989. Taylor. overgeneralising and catastrophising contributed to this problem. disorganised conceptual processes. PSOB was very useful as a daily exercise to promote positive self.. 1990). FOLLOW-UP DATA Data indicated that Carol experienced improvement in psychosocial functioning. employee and by exploring other areas of life interests including travel. . gradual reduction of sessions. reduction of symptomatology and number of hospitalisations that were maintained at 6 months and I-year follow-up (cf. Second. ENDING PHASE Two major tasks were addressed in this phase (approximately 3 months): dealing with thoughts and feelings regarding ending treatment and developing plans to maintain treatment gains. First. impaired judgement. Symptomatology as measured by GPI was reduced. disabilities in volitional and motor areas and inability to care for self and risk to self. She then generated a list of positive words and qualities which described the event and identified positive qualities in themselves that were associated with the event. pat self on back. Third. these were written down on cue cards and reviewed each day by the client. examining evidence and alternative explanations. fatigue or depression that was of a low level and within normal limits and interpret them as "I'm going crazy.As Carol made major progress in various areas of her life. Given the early onset. planned phone contact and booster sessions. Carol was trained to identify three positive events in her life each day." This limited and negative view of herself was worked with by examining evidence that supported other roles she currently was performing. signs of stress and effective coping strategies. hallucinations and delusions. no matter how minor the event may be. Carol's baseline score of 7 indicated severe levels of symptomatology including inappropriate mood. she frequently experienced anxiety. Table I) Regarding psychosocial functioning she showed major improvements in work. 1993). Because individuals with schizophrenia have exceptionally negative and distorted appraisals of themselves and events (Robey. & Factor. e. student.g. (Padesky. Wilson. fears and hopelessness regarding relapse. a cognitive technique. diet and level of stimulation in order to protect against relapse. Several techniques were used to facilitate maintenance of change. Third. Her score of 27 at the conclusion of the study indicated major improvements in psychosocial functioning: relationships with family and friends. a 3month termination plan was developed. a review was done of stresses.

Give simple explanations of what you want to do or learn and why. (Kingdon and Turkington. 45) Psychoeducation and Normalization Introducing the stress-vulnerability model can be a very useful starting point. Provide a rationale. Be collaborative and try to establish common goals. How to use this procedure. lack of pleasure). It is best to start by trying to understand the person¶s experience even if it seems frightening. It is mainly useful for clients who are distressed by their symptoms. 2005). p. For example. there may be good reasons for thinking and feeling the way they do. lack of interest. First develop the therapeutic alliance. While recogizing the biological aspects of the illness (vulnerability). It seeks to develop a strong therapeutic alliance based on understanding the client¶s perspective and experience.     Instill hope and try to help the person understand their experience. uses gentle questioning techniques to test out strongly held beliefs (delusions). schizoaffective disorder. 2005). Many people would!´ . I can understand why you might have these thoughts. ³Given what you¶ve told me. this model underlines the value of helping the client discover coping strategies to help reduce stress. direct discussion of delusions and hallucinations does not lead to worsening of symptoms.allow the patient to know why you are doing what you are doing. It can be effective even if the client does not appear to have insight into his/her illness. hallucinations and negative symptoms (lack of motivation. cope with voices (auditory hallucinations. and.What is Cognitive Behavioral Therapy (CBT) for Schizophrenia? CBT for Schizophrenia is an evidence-based treatment which directly addresses key symptoms of schizophrenia including delusions. What types of clients should you use this procedure with? This procedure can be used with clients who have schizophrenia. Do not make assumptions about what the person thinks or believes. clients feel relieved that someone is listening and trying to make sense of their distressing and confusing experiences. compassionate and honest relationship with the person. What is the evidence that CBT is effective for people with Schizophrenia? More than sixteen randomized controlled studies using CBT for Schizophrenia have been published that demonstrate positive outcomes in treating both the positive and negative symptoms of the disorder (Kingdon & Turkington. from their perspective. This approach can greatly assist in engaging clients in treatment. alleviates distress and psychological pain (Kingdon & Turkington. 2005. Use a clear and understandable session structure. as long as the client can be engaged in a helping relationship.). and with delusional disorders. ³help´ might be more specifically helping the person deal with their distress over hearing voices. Contrary to common clinical wisdom. Often. Reassure the client that. Check out the patient¶s level of understanding frequently using open-ended questions. The main goal is to instill hope by developing a respectful. bizarre or confusing.

It can be very useful to help the client develop an understandable narrative (³what this all means´) about the problems that they are experiencing. frightened and overwhelmed by their disturbing symptoms (voices. ³How long do you think others have been talking about you?´ ³Do you think think this happens all the time?" ³Education that normalizes effectively can be highly valued´ (Kingdon and Turkington. moods. 2005.´ Therapist ³It must have been a very uncomfortable time for you. Use of Guided Discovery Techniques Typically. Take time to show the client the relationships between thoughts. 83).people hated me. It should be noted that Kingdon and Turkington (2005) recognize the risks of normalizing are minimization of the client¶s problems and not dealing with actual consequences. feelings and behaviors as outlined below. their internal experiences and their responses. moods.³The key to the client¶s being able to understand the distressing and confusing experiences that occur in schizophrenia is psychoeducation based on the case formulation´ (Kingdon and Turkington. and experiences attributed to other individuals who are not diagnosed as ill´ (Kingdon and Turkington. Often clients feel confused. matter-of-fact approach. ³When did start thinking that the people might be talking about you or bugging your phone?´ What was happening when the client first became upset or distressed? What were they thinking? What were they feeling? ³Did you notice that after you heard those voices you got scared and went up to your room right away?´ What did they do? What was the outcome? ³What happened after that?´ Did you feel better or worse?´ . Beliefs. Client: ³I keep thinking about the stalker. Do you get nervous around people a lot?´ Using the µABC¶ Model to find connections between Activating Events. frighteneing beliefs.´ Therapist: ³When did these thoughts first start to bother you?´ Client: ³When I began working at that first job I told you about. and experiences are compared and understood in terms of similar thoughts. behaviors. It was awful.´ Therapist: ³So when you first started work in the new office. p. ³Normalization is the process by which thoughts. that was when you began to worry that someone was watching you´ Client: ³Yes. guided discovery involves gentle questioning about problems designed to help the client uncover relevant patterns in thoughts feelings and behavior that might contribute to ongoing problems or make existing problems worse. 2005. behaviors. It is not useful to avoid or minimize significant problems that may have a very negative impact on the client. 85). and Consequences. p. 87). etc). It is best to take a direct. p. Explaining this all in an understandable way can be very reassuring and lead to useful solutions and possible coping strategies. 2005. This means avoiding the use of jargon and technical terms that can be confusing to a client.

Some possible questions you might use:  ³Are there any other possible explanations for what happened?´  ³What about this as a possibility«?´  ³Do you think just possibly«?´  Are you 100% certain that this is true?´ (Kingdon and Turkington. p. o Identify significant life events and circumstances. and developing coping strategies. Clients may benefit from several basic cognitive behavioral strategies including reattribution. The aim is to allow client to see that the voices may be his/her own thoughts. o Review negative thoughts and dysfunctional (maladaptive) assumptions. (Kingdon and Turkington. This will likely strengthen the bond between therapist and client. 105) First work on establishing any evidence for the delusion with the client.this is where the client is interested in and attentive to the conversation with the therapist. ³Why do you think others can¶t hear the voices?´  Reattribution (changing the client¶s assumptions and beliefs about the voices being µout there¶). 103) Intervening with Auditory Hallucinations (Voices) Auditory hallucinations or voices are viewed as automatic thoughts that are misperceived by the client as originating from the outside. p. o Identify relevant perceptions and thoughts. Discussing and gently debating delusions: o Establish engagement. 2005. understanding how the hallucination might reflect some underlying beliefs. For some. it¶s often a good idea to talk about something else for the rest of the session.If patient gets distressed. Discuss the client¶s specific experience with voices Is it only the client who can hear the voices? Discover beliefs about the origin of the voices Look for possible alternative explanations and discuss with client  Create more helpful alternative explanations. o Trace the origins of the delusion. o Build a picture of the prodromal period (just before the person became ill). Keep discomfort and anxiety low! D E V EL OP IN G A L TE R N A T IV E E XP LA N AT IO N S O F S C H IZ O P H R E N IA S YMP T O M S Intervening with Delusions The goal here is to generate alternative explanations for delusions and further explore how they developed without being directly challenging. externalizing distressing thoughts may help them cope with severe distress. . This won¶t worsen the delusion or become part of it. 2005. especially µtaking things personally¶ and µgetting things out of context¶ or µjumping to conclusions¶. debating the content of the hallucination (evidence for and against what the voice is saying).

CBT is now recognized as an effective intervention for schizophrenia in clinical guidelines developed in the United States9 and in Europe. David Kingdon. MD | June 20.  Help the client understand how the voices might reflect problematic beliefs. medication compliance remains a major problem despite the introduction of modern atypical antipsychotics.  Help the client use cognitive behavioral strategies that apply to handling automatic thoughts such a rational responding. drawing on the principles and intervention strategies previously developed for anxiety and depression. the general availability of this treatment approach within community settings is still low. Only after cognitive therapy had been firmly established for depression and anxiety.  (Kingdon and Turkington. In the 1950s.11 This article will examine the procedure of CBT for psychosis. keep a Voices Diary to record triggers and fluctuations in the voice-hearing experience. the evidence for its use. 2006 Cognitive-behavioral therapy (CBT) in schizophrenia was originally developed to provide additional treatment for residual symptoms. Attempts are made to empathize with the patient's unique perspective and feelings of distress and to show flexibility at all times. and actions in a collaborative and accepting atmosphere. Diagrams and written material can be most useful. Agendas are set and used but are generally more flexibly developed than in traditional CBT. The formulation of symptom causation and maintenance is also shared with the patient and evolves throughout the therapy as new information is considered. 2005.  Work on helping the client coping strategies.2 Furthermore. and uncontrolled trials to methodologically rigorous. controlled trials that include patients from both the acute4 and the chronic end of the schizophrenia spectrum.10 In spite of the evidence base and absence of side effects. MD. with Beck in the forefront. Throughout the therapy. PROCEDURE The therapeutic techniques used for patients with schizophrenia are based on the general principles of CBT. challenging. randomized. even when the patients are compliant with their medication instructions. 120) The ABCs of Cognitive-Behavioral Therapy for Schizophrenia By Lars Hansen MD. think of the socially anxious person who attends a party but immediately exits when they start to feel nervous. (³What has worked in the past with the voices?´)  Reduce safety behaviors if they are maintaining symptoms. Pharmacologic therapy can leave as many as 60% of psychotic patients with persistent positive and negative symptoms. generally between 12 and 20 sessions. Aaron Beck1 had already treated a psychotic patient with a cognitive approach. CBT for psychosis usually proceeds through the following phases.57 Subsequent meta-analysis8 and systematic reviews have further strengthened the evidence base. This tends to increase their anxiety and make them more likely to escape the next time. but thereafter the research in this specific area lay dormant for decades. Links are established between thoughts. however. and examining the evidence. case series. and the results are shared with the patient. The duration of therapy varies according to the individual's need. so that the patient . feelings. p. A vulnerability-stress model is used. in the 1990s. For example.Have client begin to monitor experiences. This involves drawing out the person's own understanding of his situation and ways of coping with it through a process of guided discovery.3 The evidence for the efficacy of CBT in treating patients with persistent symptoms of schizophrenia has progressed from case studies. Engagement stage Initially the therapist will state clearly what the therapy is about (including a safe and collaborative method of looking at causes of distress). but often with an option of ongoing booster sessions. especially for patients with chaotic lifestyles. the use of Socratic questioning is emphasized. and the implications for practicing psychiatrists. The use of rating scales²both specific and general²is encouraged to monitor progress. Assessment The assessment begins by allowing the patient to express his or her own thoughts about his experiences while the therapist listens actively. did the research into psychological treatments for psychotic conditions gather force²again. Safety behaviors are problematic ways of responding or efforts the client makes to reduce distress or anxiety that actually reinforce the problem. Studies have shown treatment discontinuation in an estimated 74% of patients in both outpatient and inpatient settings. and Douglas Turkington.

. ABC model The ABC model. The therapist assesses the patient's belief.13 is helpful in decatastrophizing psychotic experiences. hunger. ie. since we know for a fact that he has never been to this country?´ Testing the evidence for and against maladaptive beliefs can safely be carried out without causing distress as long as the therapist remains nonjudgmental. Critical collaborative analysis To proceed to this stage. jumping to conclusions). simple examples can be provided to facilitate understanding. Normalization A normalizing rationale11. and achievable. dichotomous thinking. etc) reduces anxiety and the sense of isolation. genuineness. Reviewing antecedents (stress. and empathy are of great value in this type of therapy. It includes the following steps: Based on a scale of 0 to 10. which was originally developed by Ellis and Harper. the patient rates the intensity of distress..Maybe some friends might find it interesting. The goals are revisited both during and at the end of therapy.´ This may lead to a change in C. less sadness and isolation.12 can be used to give the patient a way of organizing confusing experiences. the patient will often feel less alienated and stigmatized. Some people will and some won't. as in all other therapeutic encounters. How do you explain your rape by this famous actor. The patient's own belief (B). using the distressing consequences (C) to fuel the motivation for change. why can't anyone else hear them?´ or ³Hold on for a moment. is then discussed. It is the therapist's job to ensure that the goals are measurable. trauma. The therapist uses gentle Socratic questioning to help the patient appreciate potentially illogical deductions and conclusions: ³If your voices came from the radiator. emotional reasoning. Education regarding the fact that many people can have unusual experiences in a range of different circumstances (stressful events. The consequence (C) is assessed and divided into emotional and behavioral Cs. this can be rationalized. such as life events. loss) that prepare the . the therapeutic relationship must have developed a degree of trust. realistic. and open-minded. It involves slowly and thoroughly moving the patient through the various steps using Socratic questioning to clarify the links between the emotional distress the patient is experiencing and the beliefs he holds (Table). Table Clinical illustration of the ABC model (see Case study)12 Activating Beliefs event Voices ³Voices are driving me mad´ ³I¶ll never find the truth´ ³The doctors will not tell me the truth´ ³I¶ll never be normal´ ³Voices are in control of my life´ Consequence Emotions Sorrow Depression Loneliness Desperation Behavior Isolation y y Goal-setting Realistic goals for therapy should be discussed early in the therapy with the patient. The patient gives his own explanation as to what activating events (As) seemed to cause C. and a B such as ³nobody will like me if I tell them about my voices´ can be disputed and changed to ³I can't demand that everyone likes me. or physical illness. An assessment is made of how the beliefs occurred²through inferences or cognitive distortions (eg. The therapist provides feedback to the patient to acknowledge the A-C connection. which is actually the cause of C. this puzzles me. By having the psychotic experiences placed on a continuum with normal experiences. evaluations. and images and communicates to the patient that a personal meaning is lacking in the A-C model. selective inference. As a consequence. empathic. falling asleep.y y y y y y can understand that vulnerability is a dynamic concept that can be influenced by many factors. often. thirst. hyperventilation. The therapist stresses that he or she does not have all the answers but that useful explanations can be developed in cooperation. humor. The typical nonspecific therapeutic factors of warmth. torture. the possibility of recovery seems less distant. coping mechanisms. and the therapist ensures that the factual events are not ³contaminated´ by judgments and interpretations.

If the patient is not forthcoming with alternative explanations. preferably by looking for alternative explanations and coping strategies already present in the patient's mind. new ideas can be constructed in cooperation with the therapist. Developing alternative explanations It is of crucial importance to let the patient develop his own alternatives to previous maladaptive assumptions. It can be dangerously tempting to force the therapist's readymade explanations onto the patient.ground for psychotic change can be an eye-opening exercise for both patient and therapist. Identification of misattributions and attempts to reattribute are as productive as homework tasks. The patient's own healthier explanations might just be temporarily weakened by either external factors or dysfunctional thinking patterns. . Certain seeds might have been sown earlier in the therapy (from leaflets and previous discussions) that can now be used as building blocks.