Background and history

She was chronically neglected by her parents, her father having been alcoholic and her mother cold. Her mother apparently had an affair when she was young, and Mary described having been sent to live with her aunts before she was 8 years old. They apparently did not want her, and sent her back to her mother. She then described having taken on many of the household chores throughout her childhood. When her parents separated at around this time, she and her...

Beliefs About People With Mental Illness

As noted above, the Cognitive Therapy Checklist is used to assess clinical skills. The general skills may also be used to structure some of the educational experience and provide some of the course content. However, the main model for individual work with patients and service users broadly follows the sequence outlined by Nelson (1997) and includes engagement, coping strategies, psycho-education and modification of beliefs. The teaching is timetabled and taught in the same order.

Delusional beliefs

One particular aspect of cognitive therapy that I found intriguing was asking the client to rate conviction in his or her delusional beliefs. I had always assumed that those with delusions were absolutely 100 convinced of their beliefs and it never occurred to me otherwise. Using this approach I found that Janet had some doubt about her implant, though she was 90 sure it existed and was controlling her. The next stage of my intervention was to explore the evidence that Janet was using to...

Development of the problem

Mary's difficulties appeared to have started about a year before her presentation to the services. She initially painted a rather confused picture, involving her husband and his daughter. She had at some time believed that her husband was going to evict her from the house that they shared, which he had bought. She no longer believed this so strongly, but was convinced that the daughter would throw her out of the house if her father died. This, she reported, was because the daughter was...

Formulation

The following formulation was shared with the multidisciplinary team, who were struggling with Helena's continuing impulses to commit suicide and the problems of working towards discharge. They found it particularly difficult to cope with her constant talk of her voices and the urge to commit suicide, and the team was split into those who advocated for her, and those who had essentially lost patience. The meeting, which took place five sessions into the weekly therapy, served to increase...

Initial contact and voices group

Helena's keyworker initially asked me to do some work with her, focused on her dependence on particular relationships. From that initial contact it was clear that Helena had the capacity to make good use of cognitive therapy, as she was well able to identify key cognitions. In a short session, we identified that she felt herself to be worthless, and only felt good when someone else was treating her as special. She was receptive to the idea that she needed to work on treating herself well and...

Intervention with positive symptoms

With the working assumption that auditory hallucinations can be conceptualised as misattributed inner-speech, Malcolm was asked to compare what his voice said with his current concerns (Birchwood & Iqbal, 1998). His comparisons highlighted themes of desire for freedom and promise of rescue, low self-esteem and being the chosen one, motivation to pursue powerful goals outside of secure psychiatric care, and that he was above containment by virtue of his status. This comparison process is...

Negative symptoms

There is evidence that CBT improves negative symptoms (Sensky et al., 2000). Techniques involve eliciting specific positive symptoms, especially ideas of reference, thought broadcasting and hallucinations, which may emerge under stress. Patients may become essentially agoraphobic or socially phobic because of a fear of reactivating distressing positive or panic symptoms. They may also require a convalescence period after an acute episode, and a reduction in pressure and the postponement of some...

Psychological intervention

Initially, the psychiatrists managing her care thought that psychotherapy, especially for her feelings about the termination, was contraindicated. One entry in her notes says that this should not be attempted until 6 months stability on medication, providing she is motivated and can then be assessed. However, on consultation with a psychotherapist, it was agreed that such an approach was worth considering and was started relatively early in the course of her illness, initially using dynamic...

Session 5 How I see myself and others

As Kathy put on more weight she reached the point of leaving the house only if it was essential, could not be avoided or could not be done by someone else. The thoughts she remembered were of people laughing at her and thinking that she was ugly. We were able to look at how some of the beliefs she held had developed and again try to develop some alternative explanations for what people might think about her and why they might be laughing. PM Why do you think these people are laughing at you C...

Therapist time

How many therapists are needed Or, more specifically, what number of sessions of highly skilled therapist time is required for therapy, for training and for support and supervision Similarly, how much trained therapist time is required for therapy, for training and for support and supervision Finally, how can a basic cognitive behaviour approach to patients by all clinical staff be developed Most services develop incrementally, so that numbers of therapists needed becomes apparent as time...

Tracing antecedents of symptoms

Understanding the circumstances in which delusional ideas or hallucinations began, even when they may be 30 years previously, can be invaluable in finding out why particular beliefs have arisen. For example, paranoid delusions and hallucinations may have occurred for the first time during a drug-induced psychosis (bad trip) and need to be relabelled as originating with, although not currently caused by, that experience. Also, voices may relate to a specific traumatic event that is often...

Using A Cognitive Behaviour Framework

Although the Thorn course does not aim to provide training in cognitive behaviour therapy, nonetheless it does draw extensively on this model. The principles of cognitive behaviour theory and therapy are taught on the course by practising therapists and follow the format described by Hawton and colleagues (1989). The course team was also aware that the study day provided a number of opportunities for modelling some of the skills. This enables a mirroring between the clinical and educational...

Using analogue exercises to maintain skills

Please read through the following exercise and think about what you could do to tackle the problems described. Make some notes for a discussion and make an appointment with one of your Ward Nurses to discuss and practise dealing with the situation. Imagine yourself feeling sad compared to usual. You've noticed yourself not wanting to get up in the morning and not talking with other Patients and Staff. You noticed Staff laughing in the office and think they were laughing at you. While you've...

Working with voices

Before delving into any therapeutic intervention with Janet's voices I felt it was important to find out more. Did she recognise the voices What were they saying to her Could their occurrence be predicted After completing a 'voice diary', I realised that Janet heard one male voice that was worse in the morning when she was alone in her bedroom. The voice, identified as her sister, was generally offensive, saying she was a waste of time and knew nothing. Her usual response was to get angry and...

Case 8 Sarah Pauline Callcott and Douglas Turkington

Kingdon and Turkington (1998) suggest four therapeutic subgroups relating to schizophrenia. They emphasise the complicated nature of the phenomenology and have therefore argued for the existence of separate syndromes within the schizophrenia spectrum. These subgroups not only provide a broad spectrum for understanding and normalising individual symptoms they also help to provide a framework for Cognitive Behaviour Therapy interventions. One of the subgroups relates to psychosis which occurs...

Paranoia and delusions Process and product

Thinking psychologically about psychotic symptoms, a useful distinction can be made between paranoid thinking (characterised by particular cognitive distortions) and delusional ideation. The former can be considered to be a perceptual process, involving attending to stimuli salient to the individual because they are threatening. Delusions are considered as the explanatory hypotheses developed by the individual to account for the strange perceptions. This conceptualisation is a development of...

David Kingdon and Jeremy Pelton

Supervision is fundamental to developing skills in CBT, especially for patients with psychoses because of the need to adjust techniques learned in training to the realities of everyday clinical practice and to a very variable group of patients. Its goal has been described as modifying in-therapy behaviours by support and training. It can particularly enable the therapists to step back and review and reflect on their practice to learn and prepare for the next session. It is complementary and at...

Normalising

For many people the experience of psychosis is worsened by the fear that they see themselves as mad, a lunatic, a nutter. They are subject to the media portrayal of mental illness and fear the arrival of the knife wielding maniac that lies dormant within them. Many people diagnosed as having schizophrenia have little idea of what this actually means, clutching onto beliefs that it has something to do with a split personality or two minds. Along with that belief is the fear of the implications...

Case 9 Carole Ronald Siddle

I was initially trained as a psychiatric nurse. I left school at 15 having just sat my GCE O levels and was persuaded by a friend to apply to the local psychiatric hospital as a cadet nurse. After two years of working in the various departments of the hospital I started training as a student nurse. Towards the end of the RMN training I applied for the shortened post-registration RGN course and was able to finish that training in about a year and a half. Swiftly returning to the safety of...

Psychosocial Intervention Courses

'Thorn' courses and other courses in psychosocial interventions (e.g. in Sheffield) are more available around the UK, but these have generally recruited nurses and occupational therapists rather than other professions. These courses were originally set up in the early 1990s with a remit that was initially case management and family work, but the original courses at London and Manchester began to include CBT in the early-1990s and courses established since (e.g. in Nottingham, Hackney,...

Psychometric assessment

Three psychometric tools were used to assess Jane. Firstly, the modified KGV Scale (Krawiecka, Goldberg & Vaughan, 1977) highlighted the severity of any psychological phenomena present. This is a 14-point assessment tool, six areas being elicited by questioning and eight by observation. Secondly, the Social Functioning Scale (SFS Birchwood et al., 1990) examined Jane's social capability and highlighted any areas of concern. Finally, the Liverpool University Neuroleptic Side Effect Rating...