CLINICAL HANDBOOK OF SCHIZOPHRENIA

236 IV. PSYCHOSOCIAL TREATMENTnever will be” using guided discovery and Socratic questioning, such as “I mighthave struggled with these experiences, but they are normal reactions to severetrauma and I am learning to cope with them.” Andrew had also thought, “I shouldhave stuck up for myself,” but this was reappraised as “Nobody my age could havefought off an adult.” Andrew also utilized pie charts for his feelings of guilt and selfblame,listing other factors that contributed to the assault (e.g., the neighbor’s sexualattraction to young boys, the proximity of his house, being left alone at such a youngage, and having been an only child). Finally, as an alternative to his initial core belief“I’m vulnerable,” he generated an alternative explanation: “I’m no more vulnerablethan anyone else; in fact, I’m a resilient person who has coped with a lot.” Andrew’snew belief was held with little conviction, but it was built up over time.Behavioral ReattributionThe use of behavioral strategies within a cognitive framework are arguably the most effectiveway to achieve belief change and reduction of distress. Behavioral experiments area vital component of CT, and safety behaviors that are used to prevent the feared outcomesassociated with psychosis can be particularly important to address. Each of theseaspects is considered in greater detail in relation to Andrew.Behavioral ExperimentsThe use of behavioral experiments is central to effective CT for psychosis, and beliefsabout voices and delusional ideas are frequently translatable into testable hypotheses thatcan be investigated collaboratively by patient and therapist. Behavioral experimentsshould be designed very carefully to ensure a no-lose outcome. Predictions should bestated in a concrete way, and the possible results should be reviewed in advance to ensurethat the outcome is meaningful and will not be dismissed or accommodated within thepatient’s problematic belief system. Examples of behavioral experiments include the useof activity scheduling to evaluate beliefs about the consequences of activity or lack ofpleasure (which can be helpful for negative symptoms), or exposure to feared situationsto evaluate beliefs about voices or paranoid ideas.Safety BehaviorsSafety behaviors, first identified in relation to anxiety disorders, are behaviors adopted toprevent a feared outcome (Salkovskis, 1991); these can be problematic for people whenthey prevent disconfirmation of the catastrophic beliefs about the feared outcome. Empiricalstudies have demonstrated the presence of such behaviors in people with psychoticexperiences. Examples of such safety behaviors include avoidance of particular places,thought control strategies, hypervigilance and selective attention, and idiosyncratic strategiesto prevent psychosis-related fears. Voices that produce anxiety are typically associatedwith safety behaviors.Andrew sometimes believes that the voices of the spirits will make him harm someoneelse, such as his mother. He adopts various safety behaviors, such as trying tosuppress the voices, resisting them, and trying not to be in the same room as hismother. Such safety behaviors can be manipulated to demonstrate their counterproductiveeffects, and are amenable to being omitted in behavioral experiments to evaluatethe relevant beliefs. For example, an experiment was devised in which Andrewwas asked to operationalize the timescale in which the spirits could make him attack