Old approach versus new approach

Our old approach, which probably resembles CBTp in a number of respects, concentrates on reflection and disqualification of the negative beliefs, especially those underlying the psychotic symptoms. Our new approach concentrates on building up positive beliefs that will fit into the broad categories of increasing self-confidence, improving self-empowerment and increasing hope as well as individual and interpersonal relations or group activities. 

I have long wondered about the tenacity of dysfunctional beliefs. For example, it was widely held that we were winning in Vietnam during the war although people on the scene recognized that we were losing battle after battle. It actually took the people on the ground a long time for the facts to surface. Similarly, we have found that individuals in our care cling on to dysfunctional beliefs even when they acknowledge that these beliefs could be wrong and irrational.  

The new approach represents a shift away from my basic theory that was to deactivate the dysfunctional beliefs and to activate the positive. I found that dwelling on the negative, even disqualifying, helped to keep the focus on the dysfunctional beliefs and what the patients are doing wrong. The new approach, in contrast, capitalizes on the notion that focusing on the negative attitudes helps to perpetuate the focus on the negative, whereas the stress on positive beliefs and attitudes shifts the activation from the negative to the positive ( what the individuals are doing right). In other words, references to individuals’ symptoms or to the underlying beliefs related to the symptoms help to keep people in the negative mode. 

In the new approach, we try to build up the positive belief in one’s self, one’s abilities, and future. We do not use behavioral experiments (as in the old way) to disprove the negative beliefs but rather to demonstrate the positive beliefs. For example, a staff member might say the following to an individual: “You were successful in this experiment and this should give you the confidence to go to the next step towards meeting your aspirations” or “Even though you were not successful, you were able to make an effort which is a step forward”. Please note that a major motivator to undergo the behavioral experiments and/or follow structured positive experience is the installation of aspirations. The therapist emphasizes such things as “You are now living up to your values!”, “You feel better when you have a sense of accomplishment.”, and  “You are stronger than you thought you were.” 

Relationship of Modes to Psychopathology

The excitation of a specific mode serves as an explanation for the resurgence of a particular disorder. In the case of phobias, for example, the modes are fairly narrow and are activated only by imaging of the feared object or when in proximity to the object. In depression, the modes are broader and may dominate the individual’s functioning for a protracted period of time. At least two modes are involved in the production of symptoms of schizophrenia. First, the psychotic mode consisting of delusions, hallucinations, and probably the disorganized thinking and secondly, the negative syndrome mode, which when activated, leads to withdrawal and a general slowing down of functions such as motivation. 

One example of the psychotic mode in schizophrenia is that of a man who believes that an influencing machine was influencing his brain. The therapist persuaded him to keep busy all day and notice what happened to the machine. He reported when he kept busy that the machine no longer influenced him. The therapist questions this explanation: the individual replied, “I guess they turn the machine off”. Another approach would have been to emphasize the positive, that is, to keep the positive mode activated. The therapist asked, “Now that you are free of the machine how do you feel? Do you feel stronger? More in control of your life? Do you feel that you can do things on your own without being influenced?”, “What would you like to do right now that you have control of yourself”. These questions are all asked with a positive tone. The individual responded by calling his family which the machine had ordered him not to do.  

Another example is a woman who believed that her family was poisoning her food. It would have been possible to demonstrate her feelings of inferiority, of being devalued by the family, etc. Instead, the therapist tried to build up the individual’s self- confidence and empowerment by focusing on a major challenge of the individual. She started by making cookies for herself and then for the staff and worked her way up towards helping to prepare a meal for other individuals. She then progressed to preparing a meal for her family. By demonstrating her capability and equality with the family, she no longer believed that her family was poisoning her.

 In these two examples, the therapist converted a positive experience (being free of the influencing machine (example 1) and becoming involved in cooking (example 2)) into constructive action.

 One could argue that if the individual were in the adaptation mode, it would be safe then to have the individual reflect over some of the dysfunctional ideas. However, a counter-argument would be if you already have an individual in the adaptation mode (it is assumed that you have been able to activate this mode via positive experiences and positive feedback), then why upset a winning combination and risk activating the psychotic mode?

 Conclusion: As long as the clinician asks questions regarding beliefs about psychotic symptoms or pursues disqualifying the negative dysfunctional ideas, the more the negative beliefs may be activated. By shifting, focus on the individuals’ strengths and assets (as with the cook), the greater the activation of the positive mode and the deactivation of the negative mode. 

-ATB