By the fourth week, the therapist discovered that Mr. K liked to read and viewed the local library as a reasonably safe place. Mr. K agreed to visit the library once a week and to record his experiences commuting to and from there.
After roughly 8 weeks of treatment, Mr. K was visiting the library twice a week, usually for 90 minutes at a time. He reported that he “had a good time,” but still suspected other library patrons were talking about him. Upon exploring these suspicions, we learned that Mr. K feared other library goers viewed him as “stupid” and that this fear was exacerbating some of his paranoid delusions.
Table 1
POSITIVE SYMPTOMS THATMAYAPPEARASNEGATIVE SYMPTOMS
| Apparent negative symptom | Underlying psychotic symptom |
|---|---|
| Apathy |
|
| Social withdrawal |
|
| Poor hygiene |
|
Once Mr. K acknowledged that his mental illness was not outwardly recognizable, we could convince him that his fear of appearing “stupid” should not keep him housebound. He began to visit the library more frequently. Although he was still anxious, it no longer took him all day to summon the courage to leave home.
After about 10 weeks of treatment, Mr. K began going on bike rides twice a week. We were concerned that he was making too many changes at once, but he insisted he felt more “comfortable” and enjoyed the exercise.
Did cognitive-behavioral therapy contribute to Mr. K’s improvement? How did the therapist’s treatment differ from accepted protocols?
Dr. Weiden’s and Burkholder’s observations
You might be thinking, “This sounds no different from what I do in practice!” The patient was reassured and encouraged to go out and live his life despite having symptoms.
In practice, however, some techniques used in the CBT approach to psychosis are quite different; some techniques are not intuitive, and some contradict most standard teachings of supportive psychotherapy in this country.
The CBT approach used for Mr. K differed greatly from traditional “medical model” supportive psychotherapy. The therapist:
- rejected a “brain disorder” approach to describing his illness7
- used the stress-vulnerability model to explain positive symptoms
- viewed psychotic symptoms as normal reactions rather than pathologic response
- considered psychological factors behind specific psychotic symptoms (Table 2).8
The “brain disorder” explanation. The Kraepelinian model, which characterizes schizophrenia as a degenerative brain disorder, drives patient education. For example, one brochure for patients and their families refers to schizophrenia as “a brain disorder like Alzheimer’s disease.”
Such a comparison could devastate a young adult who is overwhelmed by symptoms and after being told he had a “brain disorder” that “interfered with his cognition.” While this corresponded with our knowledge of schizophrenia, he took this to mean he is “retarded” and “stupid.”
Table 2
UNDERSTANDING PSYCHOSIS WITHIN THE COGNITIVE-BEHAVIORAL MODEL
| Theory | Implications |
|---|---|
| Psychosis lies on one end of a continuum | Psychosis may be the extreme end of normal cognitive, perceptual experiences |
| Delusions can be modified by others under some circumstances | Consider reducing delusional belief or distress by verbal interventions* |
| The stress-vulnerability model represents a more appropriate explanation of symptoms | Emphasizes stress as a possible cause of symptoms; specifying a diagnosis of schizophrenia can be contraindicated |
| Psychotic symptoms may be a normal response | Normalize symptoms, behavior as much as possible |
| Nature of psychotic symptoms is based on specific circumstances | Explore life events that have a specific psychological context for the individual |
| Psychotic symptoms may be secondary to congnitiive dysfunction | Trace the origins of hallucinations or delusions to specific cognitive overload or stress |
| * This is not meant to endorse a confrontational approach. | |
Telling the patient that he or she has schizophrenia– known in some clinical circles as “the S word”–is not necessary and may even be harmful in some cases. We’re not saying that giving a diagnosis of schizophrenia or using a medical model approach is wrong. However, patient education based on symptoms instead of diagnosis may be more conducive in some cases.
The stress-vulnerability model explains psychosis without having to use a diagnostic label. Mr. K’s previous understanding of schizophrenia dovetailed with his low self-esteem. His self-perceived stupidity also had discouraged him from confronting his paranoid anxieties.
Once he realized that unrelenting psychotic symptoms—not his IQ—held him back, we could form a treatment plan. We explained Mr. K’s paranoid symptoms with the stress-vulnerability model: His fears and suspicions worsened whenever he was under stress. This allowed us to sidestep the “brain disorder” model that demoralized him.