CLINICAL HANDBOOK OF SCHIZOPHRENIA

23. Cognitive-Behavioral Therapy 231being touched. In relation to this aim, we operationalized the goal in terms of distress,preoccupation, or belief in the psychotic experiences, first setting an initial goalin relation to finding out more about the phenomena. In relation to his desire to goback to work, we tried to operationalize this in small steps (e.g., applications, voluntarywork, part-time work or courses, etc., leading to the ultimate goal). His desireto lose weight was operationalized with a proximal goal (and linked to investigatingmedication reduction options).The establishment of a shared list of problems and goals that can then be collaborativelyprioritized is a central part of CT and is invaluable in engaging patients (whetherthey are psychotic or not).CASE CONCEPTUALIZATIONOnce assessment has been conducted, and problems and goals agreed upon, the processmoves on to the development of a shared case formulation. There are several levels atwhich a person’s difficulties can be formulated. Basic formulations can be easily constructed,summarizing recent incidents in the format of event–thought–feeling–behaviorcycles, as mentioned earlier, and these miniformulations can incorporate informationabout triggering events, maintenance cycles, and safety behaviors.Another level of formulation is the developmental or historical case conceptualization,which provides a more comprehensive account. This type of formulation incorporates earlyexperiences and life events, and the impact that these have had on core beliefs, proceduralbeliefs, dysfunctional assumptions, and compensatory strategies, in addition to data fromfive systems (cognitive, behavioral, emotional, physiological, and environmental) regardingcurrent maintaining factors. The cognitive model of psychotic symptoms suggests that thecultural acceptability of interpretations determines whether someone is viewed as psychotic,and that these interpretations are influenced by life experiences and beliefs. It also suggeststhat the initial interpretation of psychotic experiences, and the way people respond to suchexperiences, determines whether the experiences cause distress and recur. This model of psychosisis also easily translated into an idiosyncratic case conceptualization that can explainthe development and maintenance of psychosis (see Figure 23.2 for Andrew’s example).INTERVENTIONSOnce the therapist and patient collaboratively develop a case formulation, strategies forchange can be chosen on the basis of what is likely to achieve success quickly or to affectmost significantly the person’s quality of life. These options can be collaboratively discussedby the patient and therapist. Most change strategies can be described as verbal and behavioralreattribution methods, and each is considered in relation to working with Andrew.Verbal ReattributionAdvantages and DisadvantagesIt is important to consider the advantages and disadvantages of a particular belief or experienceprior to attempting to change a belief, even if the belief is associated with distress.Distressing psychotic experiences that are associated with positive beliefs can beidentified through a process of questioning and making inferences from the formulation,