Like with any therapy, the most important aspect of therapy is the therapeutic relationship between the person and their therapist. And so, that element of trust, that element of willingness to engage and interact is important.
So, the first job of a therapist is to engage the person in a trusting, working relationship. That's the first element of cognitive behavioral therapy, or CBT, for schizophrenia.
The next is to develop motivation. And there's a sort of offshoot of cognitive behavioral therapy that's called motivational interviewing, which identifies the person's goals and values, and then seeks to help them move through the process of change. So, to think, "Where am I at now? What are my goals and values, and how can I make the journey from where I am to where I hope to be? And what does taking care of myself, exercise and eating healthy, taking my medications, what does all of that have to do with my image or goals and dreams?" So, that's the motivation part of CBT for schizophrenia.
And then, the next is psychoeducation. It's a big word to say, "learn about your illness". Learning about what schizophrenia is, so not blaming yourself for the symptoms, but understanding that you have a condition. Just like diabetes or lupus are conditions, you have schizophrenia. You can self manage it.
So, learning how to recognize the things that trigger your schizophrenia, the things that lead to relapse, and what a relapse looks like, so that you can nip it in the bud, those are very important parts of CBT for schizophrenia.
There's a lot of skills training, too. So, learning to self manage and learning, also, how to find support. Social skills development and life skills development may be a part of, or related to, CBT for Schizophrenia.
Then, once those things are addressed, once there is a strong therapeutic relationship in place, a person with schizophrenia can start to examine their delusions or hallucinations in therapy. So, some people have a delusion, a fixed false belief that's not shared by other people, that could be, for instance, that they're paranoid, for example, that the government has a plot against them and maybe they're being videotaped.
So, the therapist then works with that person to say, "Okay. What are the things that give you evidence that you're being taped by the government? Why would the government be interested in you? What's on the side of this being true, and what kind of goes against that theory that the government is monitoring you"
Starting to explore that, so the person can sort of get the evidence together and break down some of these beliefs, so they can incorporate more information from their environment to inform their decision that there's a plot against them. That helps a person to organize their thinking, and also to relax a little bit, to be less anxious about the world if they're less paranoid that other people are out to hurt them.
With hallucinations, what we work on in CBT is to not necessarily be able to block out the hallucinations. It's a brain phenomenon. It's hard to shake it. Medication helps to reduce the symptom but, for many people, they never are able to get rid of the symptom entirely.
So, what CBT does is to help people to recognize, "Okay. That's a hallucination. It sounds like it's a real person talking to me, but I know from experience that I don't see that person. I've never met them. I don't know who they are. And my doctor tells me it's part of something that's going on in my brain." So, being able to recognize that and then to be able to start to filter it out so you can pay attention to what you want to pay attention to, and not the distracting voice, is really important.
Also, for people who have command hallucinations, or hear the voice telling them to do things, being able to say, "It's just a voice. I don't have to do that," is really important. So, a learning exercise for somebody with schizophrenia.
If you've seen the movie, "A Beautiful Mind", you know that John Nash, at the end, the famous mathematician, at the end of the film, at the end of his career, he's still seeing visual hallucinations and yet he's able to filter it out, go and receive his award. And that's sort of the goal for many people with schizophrenia who aren't able to shake their hallucinations.
So, there's managing delusions and hallucinations. And then, the history of CBT is that initially we worked a lot on eliminating symptoms and saying, "Your thinking is distorted. Here is how to make it go the right way." But, what we're realizing is that there's not always a right answer to everything. In fact, our goal is often to live with the medical conditions or disabilities that we have, rather than to say, "Let's eliminate them". Sometimes, trying to eliminate something that you legitimately have and cannot be cured is more frustrating than just living with it.
So, with mindfulness-based cognitive behavioral therapy, what we try not to do is just say, "We have to get rid of your symptoms." What we say is, "You have the symptom. It's disruptive to you. But, let's see if there are ways in which you can live differently with the symptom."
So, it's like watching a movie and you're sitting at the edge of the theater and there's some other movie going on next door. It's very loud and you're hearing explosions, and you're watching a romantic comedy and going, "Well, that is really disruptive." You could spend all your time focusing on what's going on next door and how disruptive it is to your experience.
Or, you could say, "Alright. I'm just going to tune that out and watch the movie that's in front of me and enjoy it as much as I can." And that's what mindfulness-based CBT is about. Sometimes, you can't kick all of the symptoms of your illness, but you can learn to live with them and to still achieve your goals and dreams and find the things that are important to you.