CLINICAL HANDBOOK OF SCHIZOPHRENIA

23. Cognitive-Behavioral Therapy 237his mother. He decided that this would occur within 10 minutes, if he did not resistthe voices by these means. Considerable time was spent using verbal reattributionmethods and a review of evidence regarding any actual incidents in which he had attackedher (of which there were none) to allow experimentation to feel safe (to bothpatient and therapist). He then decided that an appropriate test of this belief wouldbe to try to stay in the same room as his mother when the voices were trying to makehim attack her, allowing the voices to come without trying to suppress them, andsimply responding by saying internally that he had no desire to hit her, and that henever had. He successfully practiced this in a role play in the session, then negotiateda therapist-assisted experiment in which he would do as planned, but with the therapistpresent in a family session that included his mother. Following these successes,Andrew felt sufficiently safe to do this on his own, and found that he had no troubleresisting the voices’ commands. This series of experiments resulted in a sustained decreasein both conviction and distress associated with the beliefs about the spirits.Negative SymptomsMany negative symptoms of psychosis, including apathy, withdrawal, flat or blunted affect,anhedonia, and poverty of speech are conceptualizable as safety behaviors. Suchsymptoms are frequently assumed to be the result of a biological syndrome or deficitstate, but many of these experiences can be understood using a cognitive case conceptualization.Andrew reported having developed flat affect as a deliberate survival strategy toavoid the feared outcome of physical punishment or humiliation from his father inchildhood. His isolation and social withdrawal appeared to be the result of avoidingpotential social contacts that he was concerned would harm or evaluate him negativelybecause of his mental health problems. He was also worried that he might attackother people as a result of the voices. It is also important to consider other possibilitiesfor the causes of negative symptoms, such as overmedication, depression,anxiety, or the consequences of substance abuse.ADJUSTMENT AND RECOVERYOnce people with psychosis have recovered from the distress associated with their psychoticexperiences, many other factors should be examined and are potential targets forpsychological intervention using CT. Such difficulties should also be considered at the beginningof CT, because many people prioritize problems that are traditionally viewed as“comorbid” as being more distressing than their experience of psychosis.PTSD is a common problem for people with psychosis, which is no surprise given theprevalence of traumatic life events in people with psychosis. Depression and hopelessnessare also common responses to an episode of psychosis, and such problems are clearly appropriatetargets for CT. Emphasis on promoting personal recovery should also be incorporatedwithin CT for people with psychosis, and the development of personal goals andvalued social roles should be encouraged. It is also important to facilitate access to appropriateeducation or employment.Andrew was encouraged to reevaluate his concerns about the stigma of a diagnosisof schizophrenia given information regarding the common occurrence of experiencessuch as hallucinations, the lack of evidence supporting the violent stereotypes of peoplewith psychosis, and the likelihood of recovery. He also addressed his weight gain