CLINICAL HANDBOOK OF SCHIZOPHRENIA

23. Cognitive-Behavioral Therapy 235When asked whether he was aware that other people experienced sexual thoughtsand images, and how often this might occur, Andrew said that he was sure thatwhereas some people did, most people could prevent this from happening, and that“good” people would not have such thoughts very often. Andrew was reluctant toconduct a survey, and his restricted social network made this difficult anyway. Thus,it was agreed that Andrew’s therapist would conduct a survey (anonymously) amongcolleagues on his behalf (Andrew believed that most people working for the healthservice would be “good”). Needless to say, Andrew was surprised by the results andbegan to reassess his unhelpful beliefs about the meaning of having unwanted sexualthoughts.ImageryRecent research has demonstrated that people with psychotic experiences have recurrentimages associated with them (Morrison et al., 2002).Andrew experienced a vivid mental image of the perceived source of his voices, seeingseveral “spirits” of people he knew, including his dead father. Such images can bea useful way to access personal meaning and core beliefs, and can be modified to becomeless distressing or powerful. For example, discussing the imagery of his fathermade Andrew reconsider the possibility that the voices might be related to bereavementin some way, and he began to notice similarities between the content of thevoices and the kind of things his father used to say to him.Core Beliefs and Content of VoicesCore beliefs, such as “I am vulnerable” or “Other people cannot be trusted,” can be evaluatedand changed using the techniques just outlined. They are also amenable to otherstrategies, such as historical tests (searching for information from any time in the pastthat is inconsistent with the belief), use of criteria continua (operationalizing factors suchas vulnerability and rating self or others on the resulting continua), and positive data logs(Padesky, 1994).Andrew was encouraged to identify events in his life (considered in 3-year “chunks”)in which he had successfully managed to be safe from harm and avoid danger. Theseexamples were then considered, and factors that appeared to have helped were identified(e.g., having a person available when a small child to whom Andrew couldturn for help, and having been assertive during his initial years at work). He wasthen encouraged to try to utilize these factors in his current situation and keep a positivedata log of the results.Beliefs about Traumatic ExperiencesGiven the high prevalence of trauma in patients with psychosis, it is likely that treatmentstrategies developed for patients with PTSD and dissociative experiences may be helpful.Such strategies include examining the idiosyncratic meaning, or the sequelae, of thetrauma and developing an explanatory narrative for the trauma to aid contextualizationin memory (Ehlers & Clark, 2000).Andrew was helped to reexamine the meaning of his childhood trauma, modifyingthe main problematic appraisals related to the sexual assault and its consequences.The therapist encouraged Andrew to reevaluate his belief that “I’m not normal and