CLINICAL HANDBOOK OF SCHIZOPHRENIA

228 IV. PSYCHOSOCIAL TREATMENTThe aims of CT for psychosis are worth considering. The primary aim of CT for psychosisis to reduce the distress experienced by people with psychosis and to improve theirquality of life. The aim of CT is not necessarily to reduce the frequency of distressing psychoticsymptoms; rather, it is to help patients to achieve the goals they have set in relationto the problems they have identified. CT for panic disorder does not aim to eliminatebody sensations, and CT for obsessive–compulsive disorder does not attempt to eliminateintrusive thoughts; instead, the aim is to help people generate less upsetting appraisals ofthese experiences. CT for psychosis works similarly, focusing on generation of less distressingexplanations for psychotic experiences rather than attempting to eliminate theseexperiences. Indeed, CT should recognize that psychotic experiences may well serve afunction for the person. The variable targets for treatment are negotiated with the patientand often include problematic appraisals of, and responses to, psychotic experiences. Itmay be that this results in decreased levels of conviction, frequency, preoccupation, anddistress relative to psychotic experiences; however, the main aim is to change the person’srelationship to psychotic experiences, making them less troublesome. In essence, the interventionin CT focuses on whatever is put on the problem list.The process of CT for psychosis begins with establishment of the patient’s trust anda sound therapeutic relationship; without this, it is unlikely that CT will be effective. Assessmentand the identification of problems and goals occur early on in the process, andthese elements can facilitate the development of a good working alliance. CT then involvesthe development of an idiosyncratic case conceptualization, based on a cognitivemodel, that guides the selection of treatment strategies. These strategies are implementedand evaluated, and the outcome data of interventions are used to modify the formulation,if indicated. The process ends with relapse prevention in an attempt to consolidate andmaintain treatment gains. Each of these stages is now described in detail in relation to aspecific (hypothetical, for purposes of confidentiality) case based on several real cases,and illustrates many of the common issues in delivering CT for psychosis.ASSESSMENTClinical assessment of a person with psychosis is very similar to a cognitive-behavioral assessmentof a nonpsychotic patient. After setting the scene, and explaining confidentialityand the practicalities of therapy, it is often helpful to begin with an analysis of a recentproblematic incident. The aim of this is to generate useful information in understandingthe development and maintenance of problems, and in suggesting change strategies. Themain purpose of an assessment is to generate information that can be used to develop acase conceptualization. The cognitive model of psychosis should, therefore, guide theprocess of assessment. The therapist should ask questions to identify problematic eventsor intrusions, and subsequently interpret these and the patient’s emotional, behavioral,cognitive, and physiological responses. Specific factors to focus on include culturally unacceptableinterpretations, selective attention, control strategies, positive beliefs aboutpsychotic phenomena, imagery in relation to psychotic phenomena, and metacognitivebeliefs (thoughts about thought and thought processes). It is also important to examineenvironmental factors that may be involved in the maintenance of the problem (e.g., thekind of neighborhood in which a person lives, housing, and financial situation).Andrew was a 30-year-old man who had developed psychosis 5 years earlier, followinga period of significant stress at work (he was a clerical assistant for the police).He currently lived at home with his mother and did very little during the day. He hadreceived a diagnosis of paranoid schizophrenia, had been taking antipsychotic medi-