CLINICAL HANDBOOK OF SCHIZOPHRENIA

234 IV. PSYCHOSOCIAL TREATMENTtion. Brainstorming exercises and the consideration of what other people have suggested,or would suggest, can facilitate this process. The alternative explanations that are generatedshould be rated for degree of belief or conviction on an ongoing basis, and recentproblematic situations and moderators can be evaluated in relation to consistency witheach explanation. This process can be applied to general beliefs or specific incidents.Andrew was encouraged to consider alternative explanations for phenomena such asthe voices, his sexual thoughts, and the tactile phenomena. It can be helpful to includehighly unlikely alternatives in addition to more plausible explanations, becausehumor can help develop the therapeutic relationship and lighten the tone in therapy.This process may yield a list such as the following:The voices that I hear are due to . . .Initial belief: The spirits wanting to persecute me 80%A form of mental illness 25%A reaction to stress and trauma 50%An unusual thought process 20%I am imagining the voices 10%Bereavement 0%The voices are being beamed at me from outer space 0%It can be very helpful to place each of these explanation into a pie chart to ensurethat the total adds up to 100%; in such circumstances, it is useful to leave the most distressingexplanation(s) until last.NormalizationThe use of normalizing information can help to combat the negative effects of stigma, reducedistress, and provide information to facilitate the generation of alternatives. Such informationoften includes facts and figures about the prevalence of psychotic experiencesand beliefs in the general population; for example, 5% of the population hear voices atany given time (Tien, 1991). When providing such information, calculating the implicationsfor the prevalence in one’s own country can increase the impact that results. For example,in the United States, nearly 15 million people hear voices, many of whom willnever have contact with psychiatric services. This kind of information can be extremelyliberating for people who believe they are the only persons with such experiences, or thatsuch experiences automatically mean that they are crazy.Information about the links between life events and specific psychotic experiencescan also be helpful in reducing distress and providing an alternative explanation for hallucinationsand delusions.There is evidence to suggest that Andrew’s auditory hallucinations are linked to experiencessuch as childhood trauma and bereavement, and that psychotic experiencesare related to urban living. Andrew was asked to read as a homework assignmentone week a good summary of the normalizing approach to the understanding of psychosis(Kingdon & Turkington, 1994); in the subsequent session, he asked the therapistfor more information about some of these factors, and as a result his convictionthat the voices were related to stress and childhood trauma increased.Encouraging patients to gather their own normalizing information can also be a usefulapproach.