Re:Question about CBT with Schizophrenic

I'd like to preface my comments by saying that Schizophrenia is not one of my main specialties. I'd encourage you to take a look at the discussion earlier in this thread and some of the recent publications on the subject mentioned there. With that said, here are some suggestions:

1. The first thing I notice is that there is no mention of Bob's medication. My first questions would be "What medication(s) is he on?" "Is he taking it?" and "Does his medication need to be re-evaluated?" If he is on one of the older antipsychotics, I'd check with his psychiatrist regarding whether one of the newer atypical antipsychotics is worth considering or whether the dosage might need to be adjusted. I'd also check whether Bob is taking his medication as prescribed (by asking him to explain what he currently takes and when he takes it rather than just asking him if he is taking his medication) and would ask him whether it really is important to take the medication or not. Noncompliance often is a major problem with antipsychotic medication. If Bob is not taking his medication as prescribed, I'd try to identify the thoughts and beliefs that lead to noncompliance and address them collaboratively.

2. Bob appears to be operating on the idea "If I punish myself, God won't punish me by harming my family. If I don't punish myself, he'll punish me by harming them." One could address this in a variety of ways. A "harm-reduction" approach would involve working with Bob find other, more benign ways to punish himself if necessary. I might do this as a stop-gap measure to decrease his feces ingestion, etc. while we work towards better solutions.

One approach I would take is to help Bob frame his belief as a testable hypothesis ("If I punish myself __________________ will happen, if I don't punish myself ________________ will happen.") and then to test whether the belief really holds true. Bob will be reluctant to test his belief by refraining from self-punishment and waiting to see if a disaster strikes his family, so instead I would start by looking back at periods in his life when he was not engaging in self-punishment and comparing the frequency with which harm befel his family then as compared with the frequency with which harm befalls his family when he engages in self-punishment.

I would also work with Bob to weigh the pros and cons of going along with the conviction that he must punish himself in extreme ways versus trying to make realistic choices about when and how to punish himself.

3. One goal would be to gradually help Bob to find adaptive ways to handle fears about harm befalling his family and to handle guilt over his thoughts and behavior. I'd help him think through "What is good to do when I'm afraid something bad will happen to my family?" and "What is good to do when I feel guilty about things I've done or thought?" Over time we'd come up with plans for handling these situations and perhaps write them down on 3x5 cards that he can carry as a reminder. If Bob still is a Catholic, I'd consider whether going to Confession would be a good option for dealing with guilt.

4. Our psychodynamic colleagues would hypothesize that Bob's problem is due to using a variety of primitive defense mechanisms to deal with hostility towards his family. While I don't think that is a very useful way to understand Bob, I would be alert for signs of anger towards his family. If I spotted any, I would help him find adaptive ways of handling anger and hostility.

5. Our behavioral colleagues might think in terms of Differential Reinforcement of Other Behavior and this seems like a pretty good idea. I'd try not to reinforce aberrant behavior by giving it lots of attention or by responding in ways that seem to result in additional aberrant behavior. Instead, I'd try to respond to aberrant behavior in a matter-of-fact way (while making sure Bob notices the naturally-occuring drawbacks to his aberrant behavior). I would try to respond to appropriate behavior in ways that are likely to be reinforcing (attention, expressions of approval, pointing out the naturally-occurring benefits). I'd watch to see what responses on my part turn out to be reinforcing and use them. Over time I would try to reinforce other behaviors (such as exercise, distraction, involvement in productivity) in the situations where he currently self-punishes and I would reinforce increased social interaction and productive activity in general.

My experience with a limited number of psychotic clients has been that these interventions work pretty well but for data on effectiveness, I'd recommend checking some of the studies mentioned earlier in this thread.

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