BACKGROUND
The past decade has seen a shift away from ideological disputes about the process of intervention with people identified as suffering from schizophrenia. It is no longer sufficient simply to stop aberrant behaviors through medication; we must now seek positive outcomes as well. To enhance this purpose, evidenced-based interventions are now considered the standard for psychology and the scientific documentation of effectiveness forms the basis upon which interventions are either considered viable or rejected.
Numerous surveys have shown that some persons with schizophrenia-spectrum disorders experience persistent residual psychotic symptoms, such as hallucinations and delusions. Psychotic symptoms in these clients almost always result in high levels of distress, add to additional manifestations [e.g., loss of self affirmation, anxiety, depression] and are predictive of a higher likelihood of future relapse. Although it has long been known that some clients experience such persistent psychotic symptoms, systematic efforts to modify those symptoms, or to decrease distress and secondary manifestations associated with such symptoms, have only recently been attempted.
The clinical application of cognitive behavior interventions to delusions and hallucinations, generally referred to as cognitive rehabilitation, has continued to gain empirical support. Originating in the cognitive social educational approach developed in the late 1950s and early 1960s by Beck and Ellis, it was primarily used for depression and anxiety. The rationale for cognitive intervention is that emotional reactions are filtered through an individual’s beliefs, thoughts, and style of processing information. Thoughts influence emotions that influence behaviors. The cognitive processes, which influence the emotions people experience, are subject to exploration and disputation.
People give meaning to experiences and it is important that these meanings are balanced and rational. If a meteor falls from the sky and hits someone you love, this can be thought to be an unfortunate incident of chance, an act of God, or even an attempted ‘hit’ by the Mafia. In fact, there are probably an infinite number of meanings that could be attributed to the experience. The emotional reaction to each of these thoughts will usually cause differing reactions. And the meaning, if it is distressing, can be modified – and of course the ensuing behavior is likely to change as well. However, all cognitive change is self-change. You cannot make a person believe what you want them to believe. That is why it is almost impossible to change satisfying beliefs. But if a thought is distressing and leads to difficult interactions with other people, the person is likely to be seeking more satisfying thoughts and may be willing to consider other options.
Successfully challenging and modifying dysfunctional beliefs is likely to decrease negative emotions and lead to more adaptive perceptions and beliefs about the world. Recent applications to people with psychosis involve systematically exploring, evaluating, and challenging clients’ thoughts and beliefs concerning the origins of psychotic phenomena as well as dealing with the secondary manifestations that limit functioning.
In addition to these difficulties, impairment in cognitive functioning, including executive functions, memory, attention, and abstract reasoning, have been recognized as a core feature of schizophrenia. Aside from attempting to ameliorate this prominent dimension of the disorder, there are two other reasons for addressing these deficits. First, cognitive impairment has been found to be associated with other aspects of functioning, such as social functioning, work, and capacity for independent living. Second, cognitive functioning is predictive of the course of schizophrenia, e.g., catastrophic meaning given to the symptoms creates increasing problems.
While researchers have found no evidence to support any positive effect of the use of psychodynamic, insight-orientated interventions for schizophrenia and have even commented about the possibility of negative effects, positive outcomes have been found for the cognitive behavior approaches that focus on the specific and current problems adversely affecting the client’s functioning. With this understanding, psychologists have moved away from interventions founded upon pathology and toward problem solving and cognitive behavior management.
The specific aims of the interventions are varied and extensive, in that they include a reduction in both frequency and severity of psychotic symptoms, a reduction in secondary effects such as depression, anxiety and hopelessness, an increase in social functioning, an increase in self-regulation, and the modification of dysfunctional schema. Cognitive rehabilitation focuses on rehabilitating the cognitive deficits of schizophrenia
In addition to persistent residual effect, Yale and Australian researchers have reported preliminary results suggesting that it might be possible to delay or even prevent schizophrenia in persons at high risk for the disease. This process is based on the development of a more balanced and rational ‘inner logic’ or belief system and reflects an increasing perspective that the early phase of a psychotic disorder has major influence on its long-term outcome . It is considered a ‘critical period’ which impacts on future impairments and disabilities. This period is associated with the risk of negative effects on cognitive and social functioning occurring as a reaction to changes in mental state and behavior.
There is also evidence that cognitive interventions achieve a high satisfaction rate with clients that helps in attendance and participation consistency. This is particularly helpful when working with adolescents and young adults. In addition to being more empirically based and often shorter-term in focus, cognitive rehabilitation views psychotic phenomena as a highly convoluted and distorted expression of what is, in fact, normal experiences. It is not the experience itself, but the interpretation of the experience that matters. From a cognitive perspective, once a difference has been identified, the individual must decide whether this is a ‘good’ or a ‘bad’ thing and attribute a cause. Making these decisions is imperative to how we perceive others and ourselves. For example, if we suddenly realize that we are not as intellectually competent as other people, it is important that we put this into a context. Is intelligence the most important value? How about honesty, loyalty, bravery, etc.? Finding a balanced and rational context in which to compare our deficits is a vital process of becoming serene about ourselves and other people.
CLINICAL IMPLICATIONS
Cognitive behavior counseling, identified elsewhere, as Cognitive Process Correction is the primary recommended clinical input. [See Techniques #01 – Perceiving Reflex Thoughts; #02 – Altering Limited Thinking Patterns, and #03 – Changing Distressing Thoughts] These manuals, designed primarily to deal with anxiety and depression should be read and understood before any cognitive involvement with clients. However, cognitive behavior counseling as practiced for schizophrenia is not identical to that used for depression or anxiety disorders. Rather, the techniques are modified to address some of the specific limitations imposed by the disorder (e.g., cognitive dysfunction) or its secondary effects (e.g., stigma and loss). To be illustrative and focus on the specific aspects of the cognitive theory that differ from those of other approaches, we identify some of the key stages of cognitive rehabilitation that include:
1) developing a therapeutic alliance based on the client’s perspective
2) developing alternative explanations of schizophrenia symptoms
3) reducing the impact of positive and negative symptoms, and
4) offering alternatives to the medical.
Cognitive behavior interventions, as their name implies, typically combine meta-cognitive skill building with classic contingency management systems. Kendall and Panichelli-Mindel describe them as follows:
“[CBI] focuses on how people respond to their cognitive interpretations of experiences rather than the environment or the experience itself, and how their thoughts and behaviors are related. It combines cognition change procedures with behavioral contingency management and learning experiences designed to help change distorted or deficient information processing.”
Although the specific instructional nature of the cognitive and behavior intervention components may vary greatly, there are some distinct commonalities that are present in all of these interventions. First, participants in these interventions are almost always taught, in classroom or clinical environments, a sequential strategy for recognizing one or more stimuli that have historically produced anxiety, stress, or violent responses by the participant, resisting the automaticity of their historical response, and identifying and implementing an alternative strategy that is more socially or emotionally appropriate.
Etscheidt provides a prototypical description of these strategies as a series of steps in which students are trained to engage through a variety of self-monitoring processes:
Step 1: Motor cue/impulse delay
Step 2: Problem definition
Step 3: Generation of alternatives
Step 4: Consideration of consequences, and
Step 5: Implementation
Elsewhere we have labeled these steps as awareness, attendance, analysis, alternatives and adaptation.
Often the instruction will involve training clients to actively resist impulses for a period of time, engage in self-relaxation and/or self-talk activities, and cycle through a series of problem-solving processes as alternative behaviors are envisioned and differential consequences of those behaviors are considered. Frequently role-playing is used as an instructional technique to train clients. A second feature of a cognitive behavior intervention is some form of behavioral contingency management.
Ideally, cognitive rehabilitation for schizophrenia should consist of at least twenty-six [26] planned sessions over six [06] months with specially trained counselors. The essence of cognitive change is to help the client find new meaning in the thoughts and beliefs s/he is having. In order to do so, the clinician will need to have the sanction of the client to explore these meanings.
Developing a Therapeutic Alliance Based on the Client’s Perspective
Engaging in a trust relationship with authorization to help is essential to any successful human service, including cognitive rehabilitation. Basic techniques include developing empathy, respect, unconditional positive regard, and honesty [See Rules of Engagement]. One of the cardinal features of cognitive behavior counseling is its focus on subjective and behavioral connections among the client’s beliefs, feelings, and actions, irrespective of whether these beliefs are ‘reality based’. The approach involves collaboration without preconceived ideas through guided discovery and understanding of the person’s experiences and beliefs.
The following example illustrates how a clinician with a cognitive rehabilitation orientation might respond when a client describes a delusional belief:
Client: “The Mafia has my house under surveillance!”
Clinician: “Well, that is possible…. But why do you think it is the Mafia? Could it be some other organization? Or is something else happening altogether? How could we find out?”
The clinician oriented in cognitive rehabilitation is interested in the specifics of the client’s experience. S/he tries to learn more about them and does not challenge the client’s beliefs while at the same time being careful not to collude with the delusion. In contrast, a clinician using a biomedical approach would be more likely to ignore the specific content of the delusion and, rather, discuss the delusion as a symptom of a neurobiological disorder.
Developing Alternative Explanations of Symptoms
Cognitive rehabilitation explores and develops the client’s own understanding of his or her symptoms. The goal is to find explanations of the client’s experiences that are acceptable to both client and clinician. It aims to improve understanding of the psychosis by using a vulnerability-stress model. Strengths and vulnerabilities are identified. The antecedent period is explored carefully, any pertinent stressors are elicited, and the possible effects of stress are discussed. A formulation is drawn up collaboratively with care to ensure that neither the client nor the client’s caregiver is led to believe s/he is to blame for the symptoms or the disorder. The following example illustrates working toward such a collaborative formulation:
Clinician: “Can you tell me your understanding of these voices that you hear?”
Client: “Well, they started during the Bosnian war. There was a lot of aircraft activity over my house. Some sort of military transmission from the planes set it off and it has continued since.”
Clinician: “Do you remember much about what was happening to you at the time?”
Client: “I know what you are trying to say. It is all in my mind.”
Clinician: “Well, we agreed that you hear somebody talking…. What is causing it seems less clear…. I accept that this started when aircraft were going over your house. However, do you think the sort of voices you hear could be worsened by loud noise and other things?”
Client: “What sort of other things?”
Clinician: “Well, for example, it is known that people who are deprived of sleep for substantial periods—maybe from the stress of loud noises—can hear voices, among other things. These voices can sound just like the ones you describe. Some people describe it rather like dreaming awake or even a ‘living nightmare.’”
Initially, such alternative explanations may be considered, but not necessarily accepted, by the client. With time, however, explanations that are mutually acceptable to both the client and clinician may evolve.
Reducing the Impact of Positive Symptoms
The goal of cognitive rehabilitation is not to try to persuade or force the client to agree that s/he has symptoms of a mental disorder. Rather, the goal is to reduce the severity of, or distress from, the symptom regardless of whether the client accepts a diagnostic label. Examining the attributions or explanations of presumed cause and finding new ways to interpret the experience provide for this possibility.
Delusions are appropriate targets for a collaborative formulation approach. One commonly used technique to start the formulation process is known as ‘peripheral questioning’. The clinician begins by asking a series of peripheral questions about the person’s belief system, with the goal of understanding how the client arrived at his or her convictions (e.g., “How could others control your thoughts? What mechanism would they use?”).
Peripheral questioning is linked with graded reality testing, which in turn can lead to the introduction of doubt and the generation of alternative hypotheses. Education about real-world issues can help clients understand the factual assumptions made to support their belief systems (e.g., “Can microchips really be inserted without your knowledge when you are asleep?”). Such ideas can be explored with appropriate homework exercises (e.g., “Shall we find out—perhaps on the Internet—what we can about the use of microchips in operations? Also we could check about regulations concerning such operations”).
For a client with more systematized delusions, the clinician can use ‘inference chaining’. This technique involves a process of looking for the key personalized meaning underlying a delusion, e.g., it can be used to respond to a statement like “I am the Second Coming of Christ”. A reply might be, “What does that [being the Second Coming of Christ] mean to you?” Should the client reply, “It means that the world will be put to rights”, the subsequent question might be, “Why is that so important to you personally?” The immediate answer, “All the wrongs from the past will be judged,” could be followed with, “And why is that so important?” The subsequent response, “I was always being bullied at school”, would represent a successful use of inference chaining. In this case, the client was a victim of bullying at school and responded to this traumatic experience by always demanding ‘fair’ treatment. He became very paranoid shortly after being fired from a job for what he believed to be unfair reasons. Inference chaining identified this current belief of life being unfair and his feeling powerless in relation to it and allowed specific discussion of it. This process in a sense bypassed the delusion and resulted in constructive engagement and discussion and a lowering of his distress from his delusional beliefs.
Hallucinations can also be better understood by discussing the details of the experience. The clinician might start with, “Is it like somebody talking to you? Or shouting?” Testing out the exact location of the voices can follow, as well as other details, such as “Do other people hear their voices? If not, why not?” Discussion of circumstances in which people without mental illness hear voices can be relevant (‘normalizing’). These symptoms can be provoked in ‘normal’ people, for example, by sleep deprivation, sensory deprivation, bereavement, trauma, and solitary confinement. Normalizing is commonly used during the initial engagement with an acutely psychotic client. Rather than try to explain that hallucinations are caused by a mental disorder, a clinician using cognitive rehabilitation will often focus on the effects of stress, such as sleep deprivation (as in the preceding example). While confrontation with contrary information may exacerbate or even trigger the client’s hallucinations, offers of a new meaning often brings improved understanding and hope, as well as reducing the sense of alienation from others. The functions of medication, in this context, might be described as improving sleep and acting directly on overactive regions of the brain.
Beliefs about the voices themselves can include omnipotence and omniscience. The content of voices can be usefully debated; for instance, if the voices are making abusive statements, the accuracy of these statements can be debated. Often clients are deeply ashamed and embarrassed by the voice content and will avoid social interaction because of the possibility that others might hear what the voices are saying. The ‘voice hearing’ experience may be better understood by using a ‘voice diary’ to look for variation among different points in the day or among different activities. Situations that trigger an increase in voice intensity can be identified, followed by the generation of improved coping strategies.
Affective responses to hearing voices (usually anger and anxiety) are often linked to unhelpful behaviors that maintain and exacerbate the voices. Once this pattern is identified, clients can gradually learn to engage more constructively with their voices. Clients can be trained to take a mindfulness approach to their voices, leading to acceptance and increased commitment to tackling normal day-to-day activities.
With regular counseling opportunities and homework, the client has an opportunity to create new meaning for his or her thoughts and beliefs that may enable them to function more effectively.
EDUCATIONAL IMPLICATIONS
The separation of clinical and educational responses is somewhat arbitrary, since both processes are based on the same principles. The difference is in the roles of the helpers and the expertise in engagement and implementation.
Developing a new meaning or context for distressing beliefs is not the only aspect of intervention. The fact that the client is at the point of needing this specialized intervention implies that there are secondary issues that have developed such as withdrawal from social interaction, self-appraisal issues and heightened emotionality. Some of these issues can be addressed through the cognitive rehabilitation process, but in any case the clinician will need to determine the sequence of these issues, and create the division of labor. Some issues will require types of cognitive behavior interventions that can be carried out by the education staff with support from the clinical staff.
One of these is social skill training. Through perusal of the Prepare Curriculum [1988] by Arnold P. Goldstein, the clinician should be able to select the appropriate areas for training and advise the school on how to carry out this process. A protocol – or sequencing of lessons should be developed with the collaboration and direction of the client.
In addition, a social emotional learning curriculum should be explored for pertinence to the student. Planning Alternative Thinking Strategies [PATHS], which is primarily for elementary students and Thinking, Feeling, Behaving: An Emotional Education Curriculum for children and adolescents, both provide lesson plans that might be useful in helping students learn the concepts necessary for expression and regulation of their emotional states.
Finally, the typical academics might be focused primarily on the functional necessities and the educators should examine the Mediated Learning manual that makes teaching cognitive strategies the main focus of academic learning. This intervention is specifically focused on executive functions [See Cognitive Behavior Protocol #17 – Executive Dysfunction.
DISCUSSION
Contemporary cognitive psychological theories suggest that distress plays a mediating role in delusion formation.
➢ Psychotic experiences are common and transitions to clinical disorder are in part determined by emotional factors
➢ Not only the presence of an unusual perceptual experience in itself but also the emotional appraisal by the subject are important risk factors for subsequent delusion formation
➢ Cognitive rehabilitation, in the context of early hallucinatory experiences, may be more efficient when specifically targeting the distress generated by the experience.
Hallucinations and delusions tend to occur both in clinical and in non-clinical samples. One possible explanation for this association may be that the experience of hallucinations gives rise to secondary delusional interpretations. Little is known, however, about the factors that mediate the transition from hallucinatory experience to delusional interpretation. Recent psychological hypotheses on delusion formation emphasize the role of attributional style, distress and worry in the etiology and maintenance of delusions. Thus, the experience of voices or visions may lead to full-blown delusional ideation, when it is attributed to an external source or when it is given personal significance.
Individuals experiencing hallucinations with distress, compared with those without distress had a fourfold increased risk of subsequent delusion formation. This finding corroborates the hypothesis that distress associated with early perceptual intrusions serves as a catalyst in the development of delusions.
The results show that those who experience negative emotional states associated with anomalous perceptual intrusions have a much greater risk of developing delusional ideation, including experiences of clinical relevance, than individuals who report similar experiences without distress.
Individuals reporting distress associated with their hallucinations show a much greater risk for developing clinical delusions than those reporting hallucinations without distress. Findings support the amplifying role of distress in current cognitive models of delusion formation. According to these models, feelings of uncontrollability and hopelessness associated with negative emotional states may contribute to the onset of delusional interpretations.
Emotions, based on prior personal experience and beliefs, may also make hallucinatory experiences personally significant or more intrusive, which in turn may trigger the individual to search for explanations of the experiences. The distress caused by hallucinatory experiences may in turn be related to the interpretation of the experience. The mechanism of delusion formation may depend on the initial interpretation individuals give to their unusual perceptual intrusions.
If this initial interpretation leads to distress, the individual may be more prone to selective attentional processes and safety behaviors, diminishing the opportunity to test the accuracy of the psychotic experience, resulting in increased levels of delusional ideation.
The role of distress associated with unusual experiences may also be crucial to understand further transitions over the psychosis continuum. Peters, et al, measured delusional ideation in the general population as well as in those with delusions using the Peters, et al, Delusions Inventory (PDI). The PDI scores of the general population and the client with delusions showed a large degree of overlap and nearly 10% of the general population scored above the mean of the group with delusions.
However, compared with those identified as clients, the general population displayed significantly less distress, preoccupation and conviction regarding their unusual perceptual experiences and ideas.
The focus on psychological factors need not rule out biological factors that may also be relevant. Hemsley’s cognitive model hypothesizes that the problem in schizophrenia encompasses the inability to integrate the moment-by-moment sensory input with stored memory. A neuronal circuit, including the limbic system, is proposed to be involved in this integration process. Distress can lead to an increased dopamine release that in turn may influence the functioning of these brain structures. Thus, a stress-induced dopamine response in humans could result in a heightened risk for positive psychotic symptoms in vulnerable persons, with possible subsequent sensitization of dopamine response and persistence of delusional ideation. This does not rule out the idea of cognitive modifiability, however. It matters not whether the cognitive problem is a distortion or a neurobiological deficit, cognitive rehabilitation can be used to modify the experience.
In summary, the findings have implications for early intervention in psychosis or psychosis-like experiences, and underline the significance of cognitive rehabilitation in treating psychotic disorders. If distress associated with hallucinations is involved in the development of delusions, ameliorating the distress may prevent the formation of delusions in some individuals.
The anxiety-reducing and reappraisal techniques of cognitive behavior intervention could be instrumental in preventing the development of delusions in those with anomalous experiences. The implications are that any process that helps the early onset client deal effectively with the distress of catastrophic interpretation of the experience can help the individual learn to function to a more optimal level in life. Since cognitive behavior management is specifically oriented toward developing more balanced and rational thoughts about experiences, it is an ideal early intervention for this population. The key to successful implementation is a well-trained staff that has demonstrated successful engagement with young clients.
Since there are manuals to support the process, the true importance is in the belief system of the staff itself. If they believe that the theory of cognitive psychology is correct and are knowledgeable in the implementation of the protocols, techniques and procedures, hope and rational optimism can be achieved and supported.
REFERENCES
CBT for Psychosis: A Review of the Current Evidence for the use of Psychological Interventions in Psychosis
Posted By: Radek
Date: Monday, 28 January 2002, at 7:46 a.m.
Community-Based Treatment of Schizophrenia
from Medscape General Medicine [TM]
Cognitive Behavior Therapy for Schizophrenia
Douglas Turkington, M.D., David Kingdon, M.D. and Peter J. Weiden, M.D.
Best Practice Guidelines for Cognitive Rehabilitation For People With Serious Mental Illness
Developed by Myla Browne, Jason Peer and Will Spaulding
University of Nebraska – Lincoln
Developed for Behavioral Health Recovery Management Project
An Initiative of Fayette Companies, Peoria, IL; Chestnut Health Systems, Bloomington, IL; and the University of Chicago Center for Psychiatric Rehabilitation
Clinical & Research News
Early Treatment May Delay Schizophrenia Onset
Joan Arehart-Treichel
PERFORMANCE MANUAL
Cognitive Therapy of Schizophrenia (Guides to Individualized Evidence-Based Treatment)
David G. Kingdon, Douglas Turkington
Drawing on the authors’ decades of influential work in the field, this highly practical volume presents an evidence-based cognitive approach for clients diagnosed as having schizophrenia. Guidelines are provided for collaborative assessment and case formulation that enable the clinician to build a strong therapeutic relationship, establish reasonable goals, and tailor protocols to each client’s needs. Described in thorough, step-by-step detail are effective techniques for working with delusional beliefs, voices, visions, thought disorders, and negative symptoms; reducing the risk of relapse; and helping clients stay motivated and engaged. Grounded in the latest research on schizophrenia and clinical responses, this cutting edge intervention guide includes reproducible client handouts and assessment tools.
The book teaches how cognitive interventions can be used to work with the beliefs that clients have about distressing symptoms, demonstrating how a collaborative formulation allows individuals to test out the validity of their beliefs and better cope or recover. Rich with clinical wisdom, the book includes step-by-step instructions that are helpful to experienced clinicians and students alike.
Hardcover: 219 pages
Publisher: The Guilford Press (November 15, 2004)
Language: English
ISBN: 1593851049
Product Dimensions: 10.2 x 7.2 x 0.9 inches
Shipping Weight: 1.29 pounds
RESOURCE MATERIALS
Case Study Guide to Cognitive Behaviour
David Kingdon and Douglas Tarkington
A practical volume that supports both training and clinical practice by presenting examples of clinical cases to illustrate the assessment, treatment planning and implementation processes of cognitive behavior management for psychosis.
• Based on extensive clinical experience and real life service settings
• Cases from a variety of settings: inpatient, outpatient community
• Describes techniques used with the full range of symptoms
* Paperback: 256 pages
* Publisher: John Wiley & Sons (February 1, 2001)
* Language: English
* ISBN: 0471498610
* Product Dimensions: 9.0 x 6.6 x 0.6 inches
* Shipping Weight: 12.80 ounce
Cognitive Therapy for Delusions, Voices and Paranoia
Paul Chadwick, Max J. Birchwood, Peter Trower
Psychologists, psychotherapists, psychiatrists and nurses are increasingly involved in providing psychological interventions, and particularly cognitive interventions, for serious mental disorders. The aim of this book is to guide such professionals toward better practice by addressing the individual symptoms of delusions, voices and paranoia, rather than by the categorization of schizophrenia. The authors provide an introduction to their cognitive model and show how the process depends crucially on a collaborative relationship with the client. While earlier approaches to these distressing symptoms depended on an overall model of schizophrenia which emphasized fundamental discontinuities with normal thought and psychological processes, the authors approach is supported by substantial research that indicates that delusions, voices and paranoia lie on a continuum of differences in thought and behavior, and do not arise from fundamentally different psychological processes. This book offers a practical, research-based and essentially hopeful approach to the assessment and treatment of psychotic disorders and also an argument for the development of a person model that is based on the persons enduring psychological vulnerabilities.
* Paperback: 230 pages
* Publisher: John Wiley & Sons (June 25, 1999)
* Language: English
* ISBN: 0471961736
* Product Dimensions: 8.8 x 6.0 x 0.5 inches
* Shipping Weight: 11.68 ounces
Cognitive Therapy for Psychosis
Anthony P. Morrison
No Book Description
Hardcover: 272 pages
Publisher: Brunner-Routledge; 1 edition (April 7, 2004)
Language: English
ISBN: 1583918108
Product Dimensions: 9.5 x 6.1 x 1.1 inches
Shipping Weight: 1.25 pounds
A Casebook of Cognitive Therapy for Psychosis
Anthony P. Morrison
A unique volume in which leading clinicians and researchers in the field of cognitive interventions for psychosis illustrate their individual approaches to the understanding of the difficulties faced by people with psychosis and how this informs intervention. Chapters include interventions 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, and adherence to medication
Paperback: 308 pages
Publisher: Routledge; 1 edition (October 11, 2002)
Language: English
ISBN: 1583912061
Product Dimensions: 9.4 x 6.2 x 0.9 inches
Shipping Weight: 1.13 pounds