Application to therapy

A central feature of CBT is the need to be able to share a clear, easily grasped, rationale with the person with whom you are working, and obviously the exposition of the Interacting Cognitive Subsystems model given above does not match that description However, it does lead to some very simple and user-friendly ideas that have been central to Helena's therapy. In summary, if the desynchrony between propositional and implicational levels, mediated by high arousal, is at the root of at least the...

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...

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...

Formulation

We formulated Karen's difficulties within a cognitive-behavioural framework, again focusing on the understandable conclusions to which she had arrived, given the experiences that she had suffered. We diagrammatically identified the important factors in the generation of persecutory ideas. These were (1) her imaginative and creative disposition, which contributed to her inclination to create scenarios in her mind from the most skeletal of stimuli (2) her experience of the anaesthetic accident,...

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...

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...

Psychometric testing

In order to test the hypothesis that Mary's cognitive state may have deteriorated and that paranoia maybe associated with this (Ballard et al., 1991), the CAMDEX test (Roth et al., 1986) was used. This part of the intervention assessment was designed to rule out global dementia, and also to test for specific cognitive strengths and weaknesses. It had the advantage of having specific short- and long-term memory subscales. The test results revealed no indication of global cognitive...

Treating coexisting depression

Janet had scored highly on the Beck Depression Inventory (Beck & Greer, 1987) suggesting her depression was of a moderate to severe level. One feature of her depression was sleep disturbance. Janet was going to bed at 8 p.m. and rising at 3 a.m. Interestingly, her paranoia was worse at 6 a.m. It was difficult for Janet to identify the way in which she could make her life worth while. To her, happiness equated to success and she believed many non-academic activities to be pointless. She...

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...

Session 1 Engagement and developing alternative explanations

The first thing that I noticed upon entering Kathy's house was the number of cats that she possessed. There must have been at least half a dozen of different breeds roaming about the house. As I began the session, the cats began climbing all over me, trying to take the pen from my hand. This was becoming a distraction so I asked Kathy if it was possible to use a room where the cats would not disturb us. Unfortunately Kathy was unable to feel comfortable without the cats, so they became a...

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...