Narrative CBT for Psychosis

John Rhodes, Simon Jakes

• Publisher: Routledge
• Year: 2009
• ISBN:
  9781134134083
• Edition: 1
• Topic: Psicología
• Subtopic: Psicología anormal

Designed to meet the complex needs of patients with psychosis, Narrative CBT for Psychosis combines narrative and solution-focused therapy with established techniques from CBT (cognitive behaviour therapy) into one integrated flexible approach.

In this book John Rhodes and Simon Jakes bring the practitioner up-to-date, as treatment and practice evolve to draw on other therapeutic approaches, creating an approach which is client centred and non-confrontational. The book contains many tried and tested practical ideas for helping clients, with several chapters including detailed and illuminating case studies.

Areas of discussion include:

• how to work with delusions, voices and visions
• working with core beliefs
• an exploration of narratives of past difficulties and traumas
• recovery and ending therapy

• 
  
  

Narrative CBT for Psychosis will be essential reading for all mental health professionals who deal with psychosis who wish to learn a new approach.

Chapter 1
Narrative CBT for psychosis

INTRODUCTION

Over several years we have developed a way of working with psychosis that for convenience might be termed narrative cognitive behaviour therapy (NCBT). In this chapter we discuss the origins of these ideas and practices. We will also look at what might justify adopting such an approach, and how it fits into wider theories of mental life.

Solution focused therapy

Solution focused therapy (SFT) developed from systemic family therapy by a process of observing what appeared to work, that is, what aspects of therapy seemed to help clients to make desired changes (de Shazer, 1985, 1988): it was not developed from any ‘grand theory’, psychological or otherwise (de Shazer et al., 2007). It is essentially a practice, a way of working with people. It aims to solve problems by helping clients to describe situations in which the problem does not occur, that is, when there are exceptions to the problem pattern. Exceptions might occur spontaneously, or might involve deliberate activities by the client. By knowing more about exceptions and by thinking together how these might be augmented, it is hoped that the client can begin to solve the presenting problem.

Another essential strand of SFT is to clarify with clients what their goals are, and in particular, to help clients describe how they would know in detail how they are making progress. Many therapies use the idea of ‘goal’ to some extent: SFT, however, is explicit in making this a central focus and in emphasising what might be thought of as the ‘phenomenology’ of a goal for a person, that is, how the achievement of a goal might appear in experience, how this specific client would know that specific goals were being achieved. It is not assumed that all clients arrive knowing their goals: often it is part of the therapy to articulate and to construct possible goals and this can be aided by focus on a picture of the future.

In line with systemic therapy, there is an attempt to understand problems and solutions within their interpersonal context. It is also explicit in emphasising not only that must one know a client’s goals, but also that one needs to understand how a client’s goals might or might not conflict with the goals of other persons involved in the client’s network or social system.

Narrative therapy

A central claim of narrative therapy (NT) is that we ‘narrate’ our lives: that we form narratives of the past and future, and that these not only describe our lives but might also influence our lives. For example, after a psychotic breakdown, a person may form a narrative idea such as, ‘All I did led me to this collapse… I must be weak’: believing such a narrative to be the case might then influence the person to give up college, for example.

The concept of narrative needs to be understood in its wider sense, that is, to potentially include descriptions of events, characterisations, metaphor, metonymy, and diverse forms of discourse. Furthermore, these aspects of narrative are not understood as first occurring in literature and then borrowed for use in everyday life. In fact the reverse: narrative might be considered to occur naturally in human experience and that literature borrows from this intrinsic phenomenon (Turner, 1996).

White and Epston (1990) argue that clients have ‘problem-saturated stories’ and the aim of their work is both to articulate the negative story and its effects upon the person and then to move on to constructing an alternative and preferred narrative with the client. The latter may be constructed in many ways, but often involves locating events or characteristics that somehow do not fit the negative story. White has called these ‘unique outcomes’, but recently termed them ‘initiatives’ (White, 2004).

NT suggests that it is sometimes useful to investigate the origins of these narratives. For example, a person might think that he or she is not a ‘success’. The therapist might discuss with the client how such ideas or discourses entered into the person’s life. NT considers a narrative to be constructed within a social and sociological context; for example, there are collective discourses about being a ‘success’ and these might influence people to choose certain goals and live certain lifestyles. Psychiatric patients, however, besides their immediate suffering, also suffer the consequences of being narrated as ‘outsiders’ and as not as ‘rational’ as others (Foucault, 1965; Harper, 2004).

NT has very strong overlaps with SFT, and many writers fuse the two traditions and borrow aspects from both (for example Eron and Lund, 1996). To contrast these two therapies one might say that it is typical of narrative therapy to narrate the negative story and move on to the preferred positive story, whereas solution focused therapy tends to concentrate where possible on constructing a positive narrative, and asks only the minimum concerning the presenting negative story. We will return to this topic in the chapter on solution focused approaches. Given the profound conceptual and procedural overlap of these therapies, we will refer to them when thinking of them collectively as narrative solution focused therapies (NSFT).

Unlike de Shazer, who did not use a theory as such to justify SFT, White and Epston from the beginning have always used ideas about narrative drawn from Bruner and ideas about the formative influence of discourse taken from Foucault. Like de Shazer, they developed their approach from a version of systemic therapy (Cecchin, 1987). We will return to the possible justification of NSFT in a later section.

Cognitive behaviour therapy

We draw upon a very wide range of approaches found in the general field of cognitive behaviour therapy (CBT): from work in which the main focus is changing daily behaviour patterns such as the ‘behavioural activation’ of Martell, Addis, and Jacobson (2001) or from coping enhancement strategy (Tarrier, 2002), to types of cognitive challenges as outlined by Beck, Rush, Shaw, and Emery (1979) for depression. We also use cognitive techniques adapted for psychosis (Chadwick and Lowe, 1990; Nelson, 2005; Fowler, Garety, and Kuipers, 1995; Kingdon and Turkington, 2004).

One approach we have adapted and use with most clients is taken from Padesky (1994). Clients are asked to state any negative beliefs they have about themselves, others, and the world, and then are asked to describe how they would prefer all these things to be. For example, a client might say ‘I’m horrible’ and would prefer ‘I’m pleasant’. Several techniques are used to build upon the preferred option, for example asking the client to collect any evidence of being pleasant. As this example indicates, there are clear parallels between this approach and the practice of narrative solution focused therapy to the extent that both aim to construct something useful and positive for the person.

We usually carry out a Padesky-style focus on preferred core beliefs about self and others without first examining ‘cognitions’ as has been traditionally recommended for conventional mood disorders (Beck et al., 1979). We agree with Lee (2005) that for some clients, usually those with complex and severe presentations, conventional cognitive challenging often does not seem to work as a first strategy. If conventional ‘challenging’ of cognitions is used, then we tend to do this in a penultimate stage of therapy and normally where there is pretty good evidence that various changes in emotional and social functioning have already occurred. Furthermore, as will be illustrated later, we tend to use very ‘gentle’ approaches; for example, we do not set out to prove that a specific ‘thought’ is false but rather that another perspective, another narrative, is possible.

When working with hallucinations, in particular, we tend to mix ideas and practices from both SFT and ‘coping enhancement strategy’ (CES) as developed by Tarrier (2002). SFT is certainly not just about coping, but can be used for that purpose, and as such blends coherently with CES. SF questions can be used to explore goals and what works, while CES introduces the idea of systematic ‘experimenting’ and consistent use.

If solution focused questions do not generate ideas of ‘what works’, we might then describe to the client certain techniques as outlined by Nelson (2005). In this book she lists some simple approaches, for example that some people have found the use of headphones helpful. We leave it up to the client to choose which to try out.

Each client is unique and if appropriate we might borrow any aspects from the full range of CBT techniques to construct a specific approach for an individual. We sometimes focus specifically on depression and use behavioural activation (Martell et al., 2001). For the fear of leaving the house, we might attempt adaptations of graded exposure therapy (Hawton, Salkovskis, Kirk, and Clark, 1989).

We have made extensive use of ‘narrative exposure therapy’ (Neuner, Schauer, Roth, Elbert, 2002), combined with narrative therapy ideas in general, for working with those clients who have described difficult, if not abusive, events in childhood. That is, in one phase of work we attempt to put into a narrative the often disjointed memories of traumatic events, but also consider the history of a person’s strengths and ways of coping.

All the above CBT approaches can be, and often are, combined with ideas from the practice of NSFT. So, for example, if we were working with a specific phobia using exposure we would do this with an additional focus of looking for exceptions, that is, times when the person has coped with the phobia.

We borrow techniques and approaches from both NSFT and CBT, producing what we believe to be a coherent and useful practice. We have carried out research that suggests that this combined approach may be effective for some cases (Jakes and Rhodes, 2003). While we borrow techniques and therapeutic practices from both of these types of therapy, we are not, however, wholly convinced by several of the theories or parts of theories involved in CBT nor those used by White and Epston. Like de Shazer, we tend to be more convinced of evidence that certain approaches work, help clients, than by the abstract theories which are supposed to justify these practices. Brewin (2006) has argued that the theories to explain CBT are not yet wholly convincing (we return to this later).

Some key features of our approach

The approach we use, NCBT, has the following key features:

1. There is a very strong emphasis on constructing or building something new, or alternatively, strengthening an under-used strength or resource of the person. This emphasis is present in SFT, NT, and Padesky’s work. This might be thought of as being ‘constructional’ and has also emerged in other areas of CBT, for example: Hall and Tarrier (2003), Hackman (2005). Hackman explores the possibility of building new benign imagery to help with difficulties involving negative images from the past.
2. Like most CBT, our work also involves the exploration and the emo- tional expression of experienced difficulties. Our commitment to being constructional does not take away recognition of the usefulness of expression of difficulties and the new understandings that might emerge. In fact, we tend to agree with Greenberg (2002) that in many cases it may be the case that a person first needs to attend to and articulate what the problem is, before they can move towards building solutions. The attempt to ‘put into words’ is a central part of narrative therapy (White, 2007).
3. Our work combines the notion of understanding problems within their context, as in behaviour therapy (Martell et al., 2001), but also within a ‘system’ or ‘network’ of others (Hedges, 2005). To this extent, we see our approach as systemic.
4. Our work is narrative in that it pays attention to a client’s use of language, metaphor, and complex characterisations of self and other. It is also narrative in the sense of seeking an understanding of how problems are seen to develop over time. Our assessment of delusions, for example, spends considerable time on the period of onset, on the time before onset, and how things developed over the months and years.
5. There is a movement in our work towards being ‘phenomenological’. Here phenomenology is to be understood as the attempt via our interaction and dialogue to grasp, to conceive, the ‘lived’ world of the other person, the world as experienced by the client. In SFT, in particular, there is an attempt to, as it were, go with the client, to work on ‘goals’, what is desired, what is hoped for, as presented by the client and in the language actually used. We very rarely take up an ‘educational’ stance as is sometimes suggested in some CBT (Hawton et al., 1989). We think this can be unhelpful by setting up a ‘passive pupil’ role. If giving information, we would tend to do that in later stages, and normally only if sought by the client. One other major consequence of taking a phenomenological stance is that we tend not to use simple linear models of explanation, for example that an automatic thought might lead directly to a response. Rather, to explain a response, one needs to consider a holistic range of simultaneous influences. This aspect is wholly consistent with a narrative emphasis, but is better illumined by a model of mental experience to be described later (in particular one based on the concept of intentionality).
6. Our approach might be thought of as cautious in seeking to make change, somewhat as Nelson advocates when she discusses how just a partial change in someone’s belief system might be helpful, but we also ‘go slow’ as outlined by Lipchick (2002). This contribution of being cautious, staying with a client’s concerns and goals, and not seeking to prove to clients that they have made errors all helps, we believe, in building a therapeutic alliance and therapeutic cooperation.

WHY NOT JUST USE CBT?

We think there are several reasons why NCBT is a useful modification of CBT. First and foremost is that it allows a therapist to work in a very flexible way; in particular, it outlines ways of working with clients other than just challenging beliefs. The therapist can accept the presentation as given, if this is useful, and then work within the world view of the client. Using NCBT one can in fact delay or avoid giving a formulation which, however careful, is understood by clients as rejecting their beliefs.

NCBT is also useful in complex situations and for presentations where it is difficult to think how to proceed, and where there might not be well practised ways of working: it is extremely flexible and of course uses the ingenuity of the client to generate solutions.

NCBT is useful for very challenging cases, that is, where any progress at all is difficult to achieve. For such cases often one has to aim for small steps or improvements over long periods of time: working in this way is intrinsic to a solution orientation.

NCBT is systemic, that is, it naturally leads to considering problems in their context: this is crucial when working with serious mental health since such difficulties inevitably occur in the context of psychiatric teams, hospital, and of course, often in the context of a family or social relations. We have developed our way of working in real situations of routine practice and believe there lies its greatest strength. We are not claiming that it would be superior at changing specific symptoms, but do believe it has allowed our work to be more pragmatic and allowed greater client cooperation.

ARGUMENTS IN SUPPORT OF NARRATIVE CBT

Our therapy has a strong emphasis on building or rediscovering resources in the life of the person and simultaneously building solutions, benign ideas, and narratives of self and the person’s world. What might justify this constructional orientation? In this section we first examine possible support based mainly on theory and then consider more direct empirical evidence.

Building resources

One major reason for being constructional in therapy is that positive and negative experiences do not form two ends of one single all-encompassing dimension, but rather, there are many areas of a person’s life, and each can be separately experienced as positive or as negative (MacLeod and Moore, 2000). Put simply, one person may receive a lot of bad news concerning one area of life such as work, yet at the same time continue to have several close positive relationships. However, another person might receive the same bad news concerning work, but has no relief or satisfaction in other areas of life such as relations, hobbies, and so forth. Furthermore, some people not only experience negative events, they also have no ways of understanding, conceptualising and thus retaining any positive events that do occur to them.

MacLeod and Moore (2000) review several studies that suggest that areas of ‘strength’ and ‘resource’ may buffer or prevent conditions such as depression occurring and may prevent relapse. Cohen and McKay (1985) described in particular the ‘stress-buffering’ effect of social support. Much of MacLeod and Moore’s arguments concerned mood disorders, but given that mood disorder is common in psychosis, and that emotion might have a central role in manifestations of psychosis (Freeman and Garety, 2003), then we believe the same arguments may apply to psychosis.

As well as therapists working in the solution focused tradition, several other authors have argued that it may be a useful therapeutic strategy to focus on positive changes rather than problems (Padesky, 1994; Fava, Rafanelli, Cazzaro, Conti, and Grandi, 1998; Seligman, Steen, Park, and Peterson, 2005). We are in broad agreement with this. The word ‘positive’ may have unhelpful connotations of being bright and optimistic in spite of all, and perhaps even an attitude of ignoring certain truths. A better phrase might be ‘resource-building’.

The implications of MacLeod and Moore’s review might be that therapy should aim at helping a person to notice and conceptualise any area of strength or positive information, but also to engage in long-term activities which yield a sense of satisfaction, achievement, and so on. The constructional parts of our therapy, and the therapies we borrow from have, we believe, those aims.

The retrieval of positive representations as a model for CBT

Brewin (2006) has recently published an article reviewing theories about the causal process of change in CBT, that is, what might make it an effective therapy. It has been traditionally suggested or assumed that CBT might help people to recover by changing negative ideas, cognitions, and emotional reactions such that these are transformed and permanently altered. So, for example, a person might no longer hold the belief that ‘people don’t like me’, this being replaced with ‘some people do like me’. Another person, for example someone with a spider phobia, might after therapy no longer have a tendency or disposition to react to spiders with fear. These changes, Brewin argues, are supposed to be due to a transformation of the relevant negative representations, for example the relevant meaning found either in explicit ideas or in those meanings or other types of feature, accessible or otherwise, that form part of an emotional reaction.

Considerable empirical evidence, however, suggests that the above claims are unlikely to be an adequate explanation. There is considerable evidence, reviewed by Brewin, that even after successful therapy, in certain extreme conditions, some clients are likely to revert to the negative thoughts and reactions they had before therapy.

Given these sorts of observations, Brewin has suggested the following alternative explanation. Successful therapy might work by strengthening a person’s capacity to retrieve positive representations. He suggests we could conceive of a sort of competition for retrieval between negative and positive representations, and successful therapy gives positive representations greater likelihood of winning any such competition.

He speculates on what might increase the likelihood of a representation winning a retrieval competition. He suggests that this may be influenced by, features such as being distinctive, being well rehearsed, or being significant.

Brewin argues that the theory of enhanced positive representations can explain what might be considered traditional CBT, but might also be a good explanation of various recent developments in CBT, which, on the whole, involve an orientation towards being constructional, namely Padesky (1994) on the...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Acknowledgements
• 1 Narrative CBT for psychosis
• 2 Understanding psychosis and implications for therapy
• 3 Assessment, engagement, and case conceptualisation
• 4 Finding solutions
• 5 Working with personal meaning
• 6 Narrative and trauma
• 7 Alternative perspectives
• 8 Voices and visions
• 9 Movement to recovery and ending therapy
• Appendices
• References