CLINICAL HANDBOOK OF SCHIZOPHRENIA

23. Cognitive-Behavioral Therapy 233Andrew receives significant benefit from believing that the spirits puts his sexualthoughts into his head, since his religious beliefs suggest that it would be wrong (andpossibly evil) for him to experience such thoughts. Andrew and the therapist mayneed to discuss this prior to any further evaluation of this experience, and it may bethat education about intrusive thoughts, a survey among Andrew’s peers, or a discussionwith an enlightened priest may be of use.At times, it is necessary to recognize that the benefits of a psychotic experience are outweighedby the disadvantages, and that proving the advantages may not be achievable orrealistic; in such cases, patients should be enabled to make their own decision and be supportedas much as possible in relation to their environment. In most cases, however, it iseither possible to provide an alternative way to achieve the benefits, or the advantages areoutweighed by the disadvantages. If a decision is reached to proceed, then therapist andpatient can continue to evaluate, and possibly change, the belief or reduce the frequencyof occurrence or distress associated with the experience.Evidential AnalysisA standard procedure in CT is to examine the evidence for and against a particularthought or interpretation of events. This process begins with the identification of a specificthought or belief to be considered and some discussion of what can be construed asevidence (e.g., a feeling that something is true is unlikely to be viewed as evidence in acourtroom). Two columns can then be used to collate evidence for and against the particularbelief.In relation to Andrew’s beliefs that the spirits are putting sexual thoughts into hishead, the therapist should elicit the evidence. Socratically, using questions such as“What makes you think that this is true?” and “Is there anything that is incompatiblewith your belief?” Consideration of modulating factors can also be helpful ingenerating evidence, as can questions related specifically to the content of the belief.This process can identify further psychotic experiences or beliefs that can also beevaluated using similar techniques (e.g., Andrew’s belief regarding the voices beingspirits).Evidence for “Spirits are putting sexualthoughts into my head”• It feels like they are doing this.• They are not the kind of thoughts that Iwould have.• It happens when the spirits’ voices aretalking to me.Evidence against “Spirits are puttingsexual thoughts into my head”• Feelings can be misleading.• The thoughts happen when the voicesare not there.• It happens more often when I amstressed.• Other people have sexual thoughts.• It does not happen when I am listeningto music.Generation of Alternative ExplanationsThe generation of alternative explanations is another useful strategy to help reduce thedistress associated with psychotic experiences. Delusional ideas and beliefs about voicesare open to examination, and it is important to help people to consider a wide variety ofpossible explanations for their experiences, if they are distressed by their current explana-