The debate about Positive Core beliefs

My colleague and I presented the information from the Padesy workshop I recently described to one of our therapy teams.

The debate was electric.  People were intrigued by the integration of different ideas in CBT.  It came to a raucous debate surrounding Padesky’s emphasis on clients to develop positive core beliefs; the “new system”.

We are so used to asking clients to think of realistic alternative thoughts that we almost frown on positive thoughts.  One colleague that introducing the possibility of building new positive beliefs was dangerous as it would definitely disappoint clients the world is not “safe” all the time- why would we encourage someone to think that?  He felt this was just as dangerous or more than negative beliefs; in fact I got the sense that the negative beliefs seemed safer to him. 

It got me thinking on my bike ride home regarding the role of “positive schemas”.  When we are working with those in distress we do not ask them to think of a “so so” place for a “safe place”- the place they invoke is usually one full of positive feeling.  This is an internal positive image that they begin to build inside them; in some sense it is a new internal model they can draw on- it is not the real world. 

When we are motivating people to change our goal must be something worthwhile- something worth striving for.  What the positive core belief is an alternative to the negative belief on an internal level that can stand in competition with the old belief that judges every situation, regardless of whether or not it applies (an overdeveloped strategy).  It is not a representation of the world as it is- if that makes sense. The core belief is an ideal that can find a home in someone’s mind.  Her theory is that strong experiential affect (negative and positive) make a considerable mark ; they are hotter than a hot thought.  Realistic thoughts don’t necessarily have that edge to carry someone into something new.  To give someone the courage to try an underdeveloped strategy in a new situation the hope is that positive affect and memory associated with the new system will do that.

Padesky’s behavioural experiments and new strategies allow someone to carry this into the world with them to access to begin to explore the possibility of something new and promising even if it is just a few moments of the world.  I’m not sure this makes total sense. I’m still grappling with that.  It’s a fascinating topic to contemplate.

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Challenging therapy clients : Psychosis

When most people think of challenging clients in therapy they immediately think of a few different labels: one of which is borderline personality clients- few think of those with schizophrenia.

Today I’m weighing on a challenging client group: those with psychosis/schizophrenia.  I find these clients tricky to figure out if and how to do therapy. 

Historically in the psychoanalytic schools of thought some people thought it was inadvisable to do therapy with those with psychosis, as classical psychoanalysis (going back to childhood) can be indeed in some cases cause more harm than benefit for someone with psychosis.  (However- this is not to say that it is never helpful- please see Elyn Saks’ book- The Centre Cannot Hold a story of a woman with schizophrenia who found medications and psychoanalysis helpful). Jung however, formed his theories by observing those with psychotic illnesses and worked directly with them.  Currently there are numerous articles on CBT for psychosis, some of which I’m trying to wade into.

Here are the challenges:

1) For  psychotic illnesses the first line of treatment is medication management with antipsychotics.  For many when this is accomplished they have nearly eliminated positive symptoms of hallucinations and voices- although some have residual symptoms. For those folks for whom medications are working therapy seems unnecessary however even those successfully on medication relapse sometimes due to stress and other times because they go off their medications.   Do you do CBT for psychosis for those in remission?  Or just educate about warning signs?  Mostly we just check that people are sleeping well and not getting too stressed out. 

2) Those with residual symptoms of paranoia, voices, and delusions can be hardest to engage personally due to fixation on ideas, or fear of their voices.  Some with delusional ideas it seems that their connection to the ideas are so strong that it can be hard to find a window of uncertainty to introduce doubts are hypothesis testing around their beliefs.

I’m struggling to offer my clients some therapy but end up offering a conversation here and there and am uncertain how to and when engage these clients.

I’ve been reading a lot about psychosis these days to help and finding various models in addition to the purely biological vulnerability model that is espoused that help me think of windows to address psychotic illnesses.  I think for clear-cut cases of schizophrenia with an average onset age and classical symptoms that there is likely a strong biological component.  However, there have been numerous other studies that have linked mood disorders, anxiety, and experiences of trauma with psychosis.

If you are a therapist what have you found works in therapeutically working with those with symptoms of psychosis?

If you have experienced psychosis yourself and attended therapy or had psychiatric treatment, what helped and what didn’t help?

From therapy to case management

In my new job I’ve switched from doing therapy with people 100% of the time do now doing 80% case management and about 20% therapy in my new role working with adults with chronic mental illnesses mostly those with psychosis of some sort, and also those with bipolar or longstanding and complex mental illness of varying sorts.

Some would call it a fall from grace other people would call it a chance to directly impact people’s lives.

The work I do now puts me squarely in the medical model as I work closely with the psychiatrists monitoring medication adherence and tolerance, as well as working together with the client on a movement to recovery in their mental illness. 

One positive aspect of my job is now working more closely with Occupational Therapists at our centre who do a wonderful job of connecting people with activities, socialization and even housing.  The job of the OT and case manager overlaps at times as I may be actively working on some areas that OT’s may also help with (housing for example).  The OT’s run groups at some of the community mental health clubhouses and by doing this they introduce the clients to a new community support network.

Because of the short-term nature of my previous job doing therapy I did not usually refer my clients to these resources as they were not appropriate supports, or the person was independent enough to connect individually.

I miss doing therapy greatly.  I have a number of clients I have offered to do therapy.  For example, one client with schizophrenia (now under control with meds) and OCD.  We will be working on the OCD together in therapy.  This will be a new challenge for me as I have not worked with someone on OCD before and because of his also having a diagnosis of schizophrenia. 

Working in therapy on this team is generally harder for a couple of reasons.  Firstly my caseload is at least double and almost triple what it was before- so I am caring for more people with the same amount of time in a week- so in this model I cannot do therapy with everyone but with somewhere between 5-12 people at a time.

People come to our team because they have had a mental illness for some time; this can make therapy harder as they and those around them have accepted that this is how life is for them.  Therapy can feel threatening as if to challenge the equilibrium they may have found.  Most people have had case management for a long time (usually meeting once a month for a 1/2 hour) that they are accustomed to the care they have. 

Other people benefit so much from medications and are well-supported by family and involved  in their community (many of my clients are christians who go to church regularly) that the focus is much different; on relapse-prevention planning and re-enforcing and maintaining good support.

 What I have noticed is that in some people with psychotic disorders there is  a strong anxiety component.  For example, a cleint may  have had hallucinations and delusions in the past but they are now managed by medication but still they have significant fear and worry in their lives, and have difficulty handling difficult emotions, like shame or embarrassment.

These are the folks that I would like to do some basic therapy for anxiety.  However, given their chronic nature and how negatively their mental illness has impacted their ability to function in basic areas of their life they may have a harder time engaging in traditional CBT therapy- some of them are just not interested as well. 

This is the challenge ahead.  I hope there will be some encouragement in undertaking this work with those who are ready and providing support to all of my clients in meeting their goals and needs wherever they are on their road towards greater wellness.