Cognitive Behavioral Therapy for Psychosis Handouts

COGNITIVE BEHAVIORAL THERAPY FOR

PSYCHOSIS HANDOUTS

Valerie Kreider, Ph.D., LPCC-S, LICDC-CS

Harry Sivec, Ph.D.

Contents

Getting to Know your Client 3

Time Line…………………………………………………………………….….…… 4

Personal Goal Setting……………………………………………………..…… 6

Formulation 9

Formulation for Case Management………………………..……….….. 10

Making Sense Formulation (for Licensed Practitioners)…….… 12

Engagement Strategies 13

Engagement Strategy Check Sheet……………………………… .….…… 14

Clinical and Adaptive Mode Comparison………………………..…….… 15

What is Psychosis……………………………………………………….…..…...… 17

Working with Thoughts and Cognition 22

Aspects of Experience……………………………………………….…….…….. 23

Common Unhelpful Thinking Styles…………………………….….……… 24

What do We Know about Thoughts………………………….….………… 26

The Three Step Technique………………………………………….….………. 27

Practicing the Three Step Technique……………………………..….…… 31

Alternative Explanations………………………………………………………… 32

Working with Thoughts Practice…………………………..………..……... 34

Changing Troubling Thoughts………………………………………….…….. 35

De-centering…………………………………………………………….…….……... 36

Thought Record for Belief (and blank worksheets)………...….….. 37

360⁰ Pros and Cons (and blank copy)..……………………………….….. 41

Working with Emotions 43

Emotion Chart…………………………………………………….……….….…….. 44

Mood Diary……………………………………………………………………………. 45

Mindfulness Techniques

Grounding………………………………………………………….……… 46

Relaxation………………………………………………………….……… 47

Breathing………………………………………..………………….…….. 48

Mindfulness and Working with Voices………………….…… 49

Mindfulness Practice and Survey…………………………….… 50

Emotion Regulation and the Brain……………..…………………….……. 52

The Stress Bucket………………………………………………………..….…….. 54

Working with Behaviors 61

Behavioral Experiment……………………………………………………………. 62

Setting up the Investigation……………………………………………….……. 63

The Investigative Analysis Worksheet .……………………….…………… 64

Investigation Analysis Worksheet with Demo………….………………. 65

Blank Worksheets……………………………………………………………………. 66

Working with Voices and Hallucinations 68

Voice Diary…………………………………………………………….……………….. 69

Some Ideas about How to Cope with Voices…………….…..………… 70

Coping with Voices or Experiences………………………………..………… 87

List of Coping Strategies for Hallucinations……………...……………… 88

Working with Negative Symptoms 90

Daily Schedule……………………………………………………………………….… 91

Negative Symptoms…………………………………………………………………. 92

Positive Symptoms…………………………………………………………………… 93

Working with Delusions 94

Delusions Level 1 & 2………………………………………………………………… 95

CBTp Methods for Working with Delusions………………………………. 96

Special Topics 98

Suicide…………………………………………………………………………………….… 99

Homicide………………………………………………………………………….…….…. 100

Crisis Planning………………………………………………………………….………… 101

Adherence____________________________________________ _ 102

Adherence Factors……………………………………………………………………. 103

Adherence Solutions Card………………………………………………….……… 105

My Values and Goals…………………………………………………………………. 106

Outcome Measures 107

Beliefs about Voices Questionnaire (BAVQ)……………….……………… 108

Psychosis Symptom Rating Scale (PSYRATS)………………………………. 110

Recovery Assessment Scale: Domains and Stages (RAS-DS)…..…… 113

DIALOG……………………………………………..….……………..……………………. 116

Study Guides 118

Section 1.1: Introduction……………..……………………………………………. 119

Session 1.2………………………………………………………………………………... 120

Session 1.3………………………..………………………………………………………. 122

Session 2.1………………………………………………………………………..………. 124

Session 2.2………………………………………………………………………………… 126

Session 2.3………………………………………………………………………………… 128

Session 2.4……………………………………………………..…………………………. 130

Session 3.1………………………………………………………………………………… 132

Session 3.2……………………………………………………………………..…………. 134

Practicum Instructions 135

Getting to Know Your Client

Timeline

Age/Year

Experience

Health, Family, Education/Job, Significant Life Events, etc.

Meaning

What it meant to me at the time (e.g. I

was alone, unloved, unfairly treated,

others hurt me, rejected me…)

0 to 5

6 to 10

11 to 15

16 to 20

Timeline

Age/Year

Experience

Health, Family, Education/Job, Significant Life Events, etc.

Meaning

What it meant to me at the time (e.g. I

was alone, unloved, unfairly treated,

others hurt me, rejected me…)

Personal Goal Setting

1. Working from Values: It is helpful to develop personal goals from some value(s) that

we hold dear to our heart (such as family, worship and faith, work, friendship). Values

help us to know what is important in our life to feel really good about ourselves.

2. Identify some of your strengths – the things that you are (or were) good at, felt good

about, celebrated within yourself, that can become a goal or can help you reach your

goals. Maybe volunteer at an animal shelter, find a used instrument to play, experiment

with things you loved to do, but find yourself shying away from now.

3. Personal Goals: These are goals that people want to reach in order to better their own

lives. Reaching personal goals can create a sense of self-empowerment and success.

They can help to guide us back to what we are working for in our life.

Sample Values:

• Faith/Spirituality

• Family

• Independence

• Humor

• Adventurousness

• Compassion

•

Friendship

•

Honesty

•

Gratitude

• Responsibility

• Believing in yourself

•

Courage

•

Success

•

Creativity/Art

• Animal Lover

Sample Strengths:

• Good with people • Willing to ask for support

• Good with animals • Follow through on tasks

• Play the guitar/piano/instrument • Responsible

• Motivated • Hard worker

Sample Goals:

• Solving an ongoing problem

• Making it to appointments on time

• Re-connecting with the people with in your life relationships

• Taking better care of your health (eating well, losing weight, quitting a habit)

• Have some fun in your life

• Begin dating again

4. Decide on one or two goals to start with: It’s really hard to work on more than a couple

goals at a time. Start with one thing you would like to work towards right now. The

process of setting goals helps us to stay on track in our everyday life. If we can take care

of our goals each day, we are much more likely to reach a bigger goal down the line.

5. Define “Stepping Stones”: Creating a set of small goals can help us to achieve a large

and important goal. For example, if we want to get across a river, there may be several

steps involved before actually being able to cross it (finding a boat, finding supplies to

build a bridge, confronting a fear of water, etc.). So Stepping Stones are the small goals

we set that will lead us to reaching the bigger goal.

6. Review the goal you have set for yourself along the way:

1. What kind of progress have you made (0% to 100%)

2. What has gotten in your way of working toward the goal?

a. Unexpected obstacles along the way

b. Goal was too big

c. Discovered that the goal is no longer attractive

d. Keep forgetting the goal on a day to day basis

e. There may be many more valid reasons why someone might not hit the goal

target……

3. What kind of problem solving might help reach the goal, to overcome the barriers?

7. Rework the goal until you find it doable for you and on a time line that is right for you:

There is nothing wrong with continuing to work on a goal in the way you have been,

modifying it so that it is easier to keep track of and accomplish, or throwing the goal out

and starting with a new one. It’s your life, and so they are your goals. We are here to

support you in any way we can to help you reach the goals you want to reach.

Let’s say the goal is to “make it to my 3 appointments on time in the month of May

Sample Stepping Stones:

• Acquire a calendar (paper calendar, or use a calendar app on your phone)

• Write in your appointments on the calendar

• Set an alarm for yourself

• Keep all of your appointment reminder cards in one place

• Ask someone to remind you (ask if you can have a reminder call)

• Practice reviewing your calendar daily for 10 minutes

Goal # Recovery Enhancement Plan

Brainstorming…..What area of your life would you like to improve?

Values:

Strengths:

What obstacles might you face in trying to reach your goal?

Decide on Long Term Goal:

Target Date:

Stepping Stones and Target Dates: Target Date:

If the plan isn’t working as you wanted it to, there are three options (circle one):

Keep working at same goal Modify the goal Pitch the goal and

using a different strategy start with a fresh goal

Re-write the Recovery Plan for this goal if needed!

Formulation

Form for planning and practice review- Provider(s) Date:

Client initials and age:

Session #/how long in treatment with you?

Client’s recovery goals: what does client really want to work on?

What are the client’s strengths and supports?

Symptoms/behaviors that interfere with meeting goals?

Current stressors / Substance use:

What would you like help with? Question for today’s consult

What have you tried so far (attempted skills/action)? and what was the outcome?

What do we know about the client (indicate history, beliefs, behavior)?

History: any life experience that helps us to understand the symptoms and behavior?

Beliefs: What does client tell self that might affect the symptoms or behavior? How can we

help client to shape a positive, affirming belief about self?

Behavior: What does client do that helps or gets in the way of goals/values?

Consultation/team suggestions:

Action plan: Skill/strategy to practice:

Inter-professional strategy:

Options for interventions/skill to practice: Identify skills to practice with client

Teach about how thoughts affect emotions

Explore behavior choices/options:

Teach Emotion regulation skill:

Build on a strength/interest area:

Identify supports together (family, spouse):

Develop specific coping strategy for :

Come up with a strategy for learning about something together:

Other:

Provider Self-reflection and feedback: How did the practice go? What might you try differently next

time?

Making Sense Formulation

What Happened Before?

(Predisposing Factors)

What Happened? (Precipitating

Factors)

What Keeps it Happening?

(Perpetuating Factors)

What Might Stop It?

(Protective Factors)

Target areas (goals or concerns)

Values

Social Activity

Situation

Physiological Response

Thoughts

Moods/Feelings and emotional regulation methods

Behaviors- helpful and unhelpful

Underlying Concerns/Core beliefs/schemas (show links where possible thoughts, feelings, behavior)

Engagement Strategies

Engagement Strategy Check Sheet

Check off the strategies observed during the role-play or audio review. MHP=

Mental Health Provider

Helpful engagement strategies

Present √

Example

Comment

Observation

Chose a place that is comfortable for the client to talk

Socialized and inquired about areas of interest to the client

Actively listened and reflected content accurately (did not

over generalize or leave out important content)

Showed curiosity and interest- tried to learn more about

client’s experience

Congratulated client for successes and accomplishments

Affirmed client’s values and/or interests

Let the client lead by asking what he or she wanted to

work on- attempted to identify something important to

client that MHP and client could work on together

Let the client lead by asking for his or her views on what

steps to take next.

MHP checked for understanding of what the client was

trying to say

Asked the client for feedback about the pace of the

meeting and let client lead by adjusting the pace to fit his

or her requests

MHP Expressed reasonable optimism

MHP used appropriate self-disclosure

MHP used a normalization strategy: stress-vulnerability;

common experience; well-known person, etc.

Asked client to summarize what he/she learned today or

what was most helpful

Asked for feedback about what client liked/disliked about

the meeting today

Other: something you did that helped build the

relationship with the client (list):

Clinical and Adaptive Mode Comparison

Mode 1: Clinical mode (one person plays client; one person plays clinician)

•

What brings you in here today?

•

What are your main stressors, symptoms, problem areas or challenges that

you want to address?

•

What treatment have you received so far?

•

What are your main goals?

•

Where would you like to start?

Scan body- report out how you feel physically and emotionally

Mode 2: Adaptive mode (one person plays client; one person plays clinician)

•

To start, if you don’t mind, I would just like to learn a little about you. What

do you really like to do? What are the kinds of things that interest you?

•

When are you at your best? What do friends/family consistently say is your

strength? Would you mind telling me a little more about these areas?

•

What are your big dreams. What would you like to be doing in the next 2-3

years?

•

What gets in the way of reaching your goals/dreams?

•

I wonder how you would feel about us working together to help you move

toward one of your goals?

Scan body- report out how you feel physically and emotionally

What is Psychosis?

The word psychosis is used to describe conditions that affect the mind, where there has

been some loss of contact with reality

. About 1.1 % of the world population develops

this kind of condition. That comes out to about 3.5 million people in the US alone that

receive a diagnosis of “schizophrenia.” About 75% of those people begin to develop this

condition between the ages of 16 and 25 years old. In order to receive a diagnosis of

“schizophrenia” the person must have had experiences of psychosis for at least 6 months.

Sadly, about 50% of those who are diagnosed have not received any treatment.

Many people who develop psychosis get better faster when they receive treatment

early in the process

. With quicker treatment, folks can get back to work, school,

hobbies, and relationships more quickly. When psychosis becomes a factor in a mental

illness, it responds well to early identification and treatment.

Psychosis does not equal “crazy” or “violent.”

In fact, most people who experience

psychosis are more likely to be victims of violence rather than the perpetrators of

violence. Psychosis is not a result of anything a person does or doesn’t do well or right.

Physicians struggle to know why some people develop psychosis and others do not. We

do know that it seems to be a combination of genetics and environment. We also know

that undergoing a lot of stress can sometimes bring psychosis on.

It is important to know that psychosis is a symptom of an illness. Psychosis is not the

illness itself

. Psychosis can happen within mental disorders or physiologically based

disorders. Sometimes it happens with stressful but common events that anyone may go

through, such as grief, lack of sleep, drug reaction, or trauma of some kind. Almost all

human beings experience a misperception such as a cell phone ringing when it wasn’t, or

someone calling your name when no one was there. Most of us think nothing of it,

though by definition, that is experiencing something that never happened in reality.

About 6% of us will have a psychotic “episode” in our lifetimes, so the vast majority of

people who experience psychosis will get better and never have another episode. In fact,

less than 1% of people with a psychotic episode will go on to develop schizophrenia

Psychosis can involve up to 3 types of symptoms: positive symptoms, negative

symptoms, and disorganized symptoms

Positive symptoms are defined as something that is “added” to thoughts, emotions,

or behavior that was never there before. These are called hallucinations and/or

delusions.

Hallucinations are categorized in the following way:

Seeing things that others don’t see (visual hallucinations)

Hearing things that other people don’t hear (auditory hallucinations)

Tactile hallucinations are when there is a feeling of being touched when

there is no external cause.

Olfactory hallucinations occur when one smells something that has no

external cause. Often the smell is unpleasant or there is a sense the smell

is coming from the person him/herself.

Delusions

are fixed false beliefs that can be very frightening. This is when

someone has a belief that sounds possible but not plausible (fearing someone is

watching, fearing others want to hurt you), and when people have more

unusual beliefs that sound way out of ordinary. This becomes a problem only

when the delusion interrupts daily living and quality of life. There are different

common types of delusions and these include:

Delusions of Paranoia or Persecutory Delusions (i.e., belief that one is

going to be harmed by an individual, organization or group),

Delusions of Reference or Referential Delusions (i.e., belief that gestures,

comments, or environmental cues are directed at oneself),

Grandiose Delusions (i.e., belief that the individual has exceptional

abilities, wealth, or fame),

Erotomanic Delusions (i.e., a false belief that another individual is in love

with him/her),

Nihilistic Delusions (i.e., a conviction that a major catastrophe will occur),

Delusions of Grandeur: Feeling super important, feeling like one has

super powers, or is an important figure like a celebrity or Napoleon.

Delusions of Control: the belief that the mind is being controlled by

outside forces

Somatic Delusions (i.e., a preoccupation with bodily functions)

Distorted perceptions

mean that the person is having difficulty making sense

out of what they are experiencing (seeing, hearing, feeling, tasting, or smelling).

You may be having a hard time with experiencing lights as brighter and more

colorful, sounds that are louder than what you are used to. It can be increased

sensitivity to background or white noise. These are all distractions that you may

have never noticed before, and normally, you would be able to ignore them

without any hesitation.

II.

Disorganized Symptoms

include not being able to be understood by others when you

talk, or finding it hard to organize thoughts and actions and to plan ahead. This is

sometimes called a thought disorder.

III.

Negative Symptoms

are those things that have been taken away from a person

(emotions, behavior). When negative symptoms occur, the person feels so tired or so

anxious or depressed that they really don’t want to move. The instinct is to isolate and

hide away, limiting social contact, limiting time outside, little exercise, often not eating

well or eating too much. It may look like apathy or laziness, but it is not. Negative

symptoms are part of the array of symptoms that are seen in schizophrenia, bipolar,

or depression.

Are there warning signs before psychosis occurs? Often there are warning signs and

could include the following

•

Drop in grades, job performance, or other activities

•

Trouble thinking clearly or concentrating

•

Suspiciousness or uneasiness with others

•

Decline in self-care or personal hygiene

•

Withdrawing from family and friends and spending a lot more time alone

than usual

•

Stronger emotions (anxiety or sadness) than usual or having no emotions at

all

•

Sometimes experiencing things as louder or brighter than usual.

Sometimes people experience all of these experiences. Sometimes people

experience only one or two symptoms. We don’t really know why that is.

It could be hereditary, physiological, environmental, or any combination.

What does psychosis feel like? This is a tough question because everyone experiences

psychosis in their own way. Often, there may be experiences such as

•

Feeling like your mind is playing tricks on you

•

Things relate to you in a special way – a way that no one else notices

•

Hearing people talking or criticizing when you can’t see the person who is

talking (the talking person is nowhere to be found)

•

Feeling like certain things are super important in some special way

•

Making tenuous connections between things that are not usually connected

How can one begin to manage the symptom includes the following

•

Getting good sleep

•

Taking medications prescribed by your doctor

•

Avoid use of alcohol and other recreational drugs

•

Sticking with a Dr and a therapist and develop a plan for recovery

•

Staying active through exercise and social engagement

•

Stay in touch with people who support you

•

Talking with family or some trusted person in your life about what you are

experiencing.

Does recovery happen? Yes!

Sometimes these symptoms come in waves, and in

between the waves, the symptoms can be very manageable. A lot of people find recovery

in good solid medical help and working with a counselor and/or case manager. Many

people can go back to having the wonderful and full life they want to have.

This handout was adapted from:

Retrieved from: SARDAA (Schizophrenia and Related Disorders Alliance of America),

https://sardaa.org/resources/about-schizophrenia/

(NAMI), February 24, 2021

Retrieved from: Stanford Psychiatry Web Page:

http://med.stanford.edu/psychiatry/patient_care/inspire.html

. February 24, 2021

Retrieved from SARDAA (Schizophrenia and Related Disorders Alliance of America),

https://sardaa.org/wp-

content/uploads/2015/08/Nami_Understanding_Psychosis_Booklet.pdf February 24,

2021.

Smith, L., Nathan, P., Juniper, U., Kingsep, P., & Lim, L. (2003). Cognitive Behavioral

Therapy for Psychotic Symptoms: A Therapist’s Manual. Perth, Australia: Centre for

Clinical Interventions.

The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American

Psychiatric Association [APA], 2013)

Working with Thoughts and

Cognition

Aspects of Experience

Thoughts

Behavior Emotions

Curious

Driving a car

I got a letter from my probation officer

Listening to music

I was like so frustrated I wanted to hit something§

I couldn’t breathe I was so scared

The voices are loudest at night

Guilt

Someone told my sister that I was getting high

I think I’m feeling ok now

I want to stop talking now

Are you angry with me?

My heart aches, I can hear my pulse in my ears, my hands are clenched

Laughing

This is stupid

It’s always going to be this way

Breathing activity (e.g. Square Breathing)

I have to go shopping

Afraid

Demons

Overcoming Barriers to Getting Active: What got in the way of getting active for you?

Common unhelpful thinking styles: Ways of thinking and solving problems that often leads to

distress or prevents us from following our values and goals!

All or Nothing: Belief that a situation is “all

good or all bad”- no middle ground; no

variations.

This involves words like Always, Never,

Everybody, and Nobody. This assumes that

the thought is 100% true all the time. It a thinking mistake because

one instance would prove the thought was false. It is unhelpful

because it keeps our mind on the negative.

Jumping to Conclusions: Making

a quick decision without getting

all of the information.

This happens when we quickly

react to events before having all

the facts. It is unhelpful because

when inaccurate, it leads us to

feel worse and maybe take actions

that are not helpful. For example, if I assume someone is threatening

to me and it is not true, I may leave/avoid or react in anger that can

lead to problems.

Circular Sinking Thinking: Staying in the same

negative thinking loop over and over.

There is often the belief that spending more

time thinking about a concern will help.

However, more time does not necessarily lead

to more helpful outcome. For example, if

someone spoke rudely to you at the store and the thought stays with

you all day- “that was so rude and unkind, why would the person do

that?” Staying stuck on the thought only leads to more and more

distress. We sometimes refer to this as rumination or excessive

worry.

Emotional Reasoning: Believing

something is true based on a feeling.

For example, feeling fear and believing

there is danger even when there are

no apparent signs of danger around

Fortune Telling: Believing with great certainty

that we know what will happen in the

future.

For example, “I will never get a job”. Just

because a person has struggled to find work

in the past does not mean that they won’t find

work in the future. It is both inaccurate and likely to decrease my

motivation to look for work.

Catastrophizing: Assuming the worst possible outcome will

happen in a situation.

For example, preparing to the store and thinking-

“the car will break down and I will have to walk

home in the rain.”

Discount The Positive- Not paying

attention to positive information.

For example, a person may beat

themselves, “that job interview was

terrible”, but refuse to give themselves

credit for positive aspects of the

situation, e.g., earning the interview, making positive comments

during the interview, or receiving positive feedback.

Mind Reading: Belief that we know what others are thinking

without checking. In reality, we cannot know for sure what

another person is thinking unless we ask them. If someone looks

at you when you enter a store and you think, “they want to hurt

me”, it is important to ask ourselves, how do I know this is true?

Could they have that look on their face for some other reason?

Unhealthy thinking styles can create Automatic Negative Thoughts (ANTS).

Examples of common Automatic Negative Thoughts (ANTs) that get in the way of activity:



My mental health symptoms prevent me from achieving my goals.



I can’t figure out what is important to me.



I don’t think it is possible for me to achieve goals.



I am afraid to take a chance. It would be bad to fail.



I don’t have the knowledge to accomplish goals (I don’t know how).



I don’t have any support to change from family, friends and others.



My physical health problems get in the way. I am too tired or hurt too much!



I have failed before, there is no use trying again



I should be doing better in my life



I always screw things up



This is just too much for me



Things are out of control



I can feel it, something bad is going to happen.



Your own:



Your own:



Your own:

Discuss these automatic negative thoughts in group and talk about which unhealthy thinking style

matches with the automatic negative thoughts above.

It’s possible that we have been stuck in our own automatic negative thoughts for so long that we don’t

even realize we are having them. That makes it hard to identify them, and even harder to change them.

Fortunately, there is a good way to get from unhealthy thinking to healthy thinking….

What do we know about thoughts?

• Thoughts come and go

• Sometimes we think of things on purpose, other times thoughts just happen

• Thoughts represent ideas- they cannot hurt you

• Thoughts can be linked with distressing or uncomfortable feelings, sensations, and

memories

• Some thoughts are inaccurate or come from misinterpreting events and we sometimes

call these Automatic Negative Thoughts (ANTs)

So what are we to do? Check the Thoughts! Especially the ANTS!

Reasons to check thoughts:

Daily Practice: Catching the thought:

Situation 1: “I am late for my appointment!!”

Thought: They will be so mad, I am irresponsible ---  Outcome: Feel anxious,

tense, beat myself up

Thought: They may be upset, but will understand  Outcome: mildly nervous,

prepare a reason for lateness.

The Three-Step Technique (3Cs- Catch, Check, Change)

STEP 1: What am I thinking that is upsetting or troubling me? (Catch it):

What is the Automatic Negative Thought (ANT)?

Where am I? (what is the situation?)

STEP 2: Is there a better way to think about this? (Check it):

• Reality check: Is this thought really true/accurate? Could I be miss-reading the

situation? (What is the evidence?)

• Is this thought helping me or holding me back? Is the thought upsetting me? (What

will happen if I keep thinking this way? Is there another way to think about this

situation?)

STEP 3: Chose a better way to think and act (Change it):

• What other things could I say to myself (positive, balanced thoughts) that would be

more helpful? How might a close friend advise me to change my thinking? Look at the

situation and yourself in a kind and gentle way.

Situation: someone cuts in front of you in the store

Thought: That is rude and insulting

Feeling: Angry, upset

Behavior: Yell at person

Use your imagination:

Situation: Picture a beautiful lake, warm sun, sitting in a comfortable chair

Thought:

Feeling:

Behavior:

u pick a situation:

Thought:

Feeling:

Behavior:

Situation: “No one said hi to me at the store”

Step 1: What am I thinking that is upsetting or troubling me? (Catch it):

List the ANTs (automatic negative thoughts): Nobody likes me; I’m always

alone; I should leave and go home.

Step 2: Is there a better way to think about this? (Check it):

Reality check: That's not true. There are people who like me, others in the

store may just be busy or focused on their own stuff.

Step 3: Chose a be

tte

r way to think and act. (Change it):

Better thought: I can smile and say hi to others and get my shopping done.

Catch the thought

Change the thought

Check the thought

Situation:

Step 1: What am I thinking that is upsetting or troubling me? (Catch it):

List the ANTs

automatic negative thoughts):

Step 2: Is there a better way to think about this? (Check it):

Reality check::

Step 3: Chose an effective way to think and act. (Change it):

Better thought:

Check the thought

Catch the thought

Change the thought

Daily practice:

1. Think

one

two

situations

this

week

and

practice

identifying

your

thoughts

these

situations

(

Catch

practice!

)

Situation

Thought:  Outcome:

Situation 2:

Thought:  Outcome:

Pick a situation that was distressing or difficult and practice the 3Cs method

(use the Catch it, Check it, Change it Handout)

•

Catch the thought: What thought is troubling? What is the situation?

•

Check the thought: What would other people say about the thought? Is

there another possible explanation? What facts do I have (remember fact is

different from thought); When I thought this way before, was it helpful?

•

Change the thought: What is another way to think about this situation?

Alternative Explanations

What is the thought/belief:

The medicine is poison and will kill me!

How much do you believe it: 0 – 100:

How much does it bother you: 0 – 100:

Evidence supporting the thought

Evidence NOT supporting thought

Pulling the information, what do you make of this?

What is the thought/belief:

How much do you believe it: 0 – 100:

How much does it bother you: 0 – 100:

Evidence supporting the thought

Evidence NOT supporting thought

Pulling the information, what do you make of this?

What is the thought/belief:

How much do you believe it: 0 – 100:

How much does it bother you: 0 – 100:

Evidence supporting the thought

Evidence NOT supporting thought

Pulling the information, what do you make of this?

Alternative Explanations Activity:

You say “Hi” to someone at the store and they do not say “Hi” back.

Possible Interpretation

Likely Emotional Response

They don’t like me Upset and sad

he phone rings and when you answer, you hear the phone hang up.

Possible Interpretation

Likely Emotional Response

Somebody is pranking me Mad

st you own recent example:

Possible Interpretation

Likely Emotional Response

Adapted with permission from Friedman-Yakoobian, M., Gottlieb, J., Hollow, L., Pinninti, N., Carther, C. (2007).

Cognitive Behavioral Therapy (CBT) guide for case managers: Client Workbook.

Working on Cognitive Model Practice

Part 1: Working with Thoughts Practice

Scenario: Client holding mouth; complains of pain. When asked to describe- “spirits are beating me up in

the face”. “Demons used to be nice and now they are mean”. There is noticeable redness and swelling

near jaw and under client’s eye.

One person role-play client.

Other person role play case manager or therapist.

Practice: Ask client to describe the experience, and your job is to:

Step 1: Practice getting a full description of the experience. Then stop and identify the components

below: Remember to stick with the concrete details and facts!

•

Experience/Situation

•

Thought

•

Feeling

•

Behavior

Step 2: Summarize concerns into the components above. Check with client to see if you understood the

client’s experience accurately (validate/accept – (“I hear and understand”). Consider the other ways to

think about the event with the client (the person may or may not be ready to hear alternatives, follow

the client’s lead).

Part 2: Working with Emotions Practice

Step 1: Client agrees to get help, but there is a fear of provider and/or need to wait a few days before

seeing provider.

Step 2: Identify one emotion regulation or relaxation strategy that may ease the distress

One person play the client

Other person plays therapist who teaches an emotion regulation strategy/self-soothing strategy

consistent with your scope of practice.

Process:

What was helpful/effective?

More comfortable working with thoughts or emotions? Flexibility of your thinking? What was easy or

hard about this for you?

What is your practice action plan?

Changing Troubling Thoughts

Practice: Pick a situation in your life where you identify an automatic negative thought and check the evidence

Situation:

Automatic Negative Thoughts (ANT)

How distressing is that ANT (0-10 with 10 being the

worst?

How much do you believe the ANT (0-10 with 10 being the highest belief)?

Evidence for Thought

Evidence Against Thought

Look at the above evidence:

1. Staying in the present moment

2. In a balanced way

3. With kindness toward yourself (and others)

Outcome - New Action Thought (NAT):

Action plan - How will I put this New Action Thought into place in my life?

De-Center means to look at things from more than one perspective.

And then to choose the perspective that is likely to be most helpful.

Distressing belief/experience: example “Knocking on door”

Perspectives=

•

“It’s bad, just ignore”; leads me to feel and do

•

“Let me evaluate and decide”

ok to protect my space; not answer door ok with that (their issue not mine)

Answer door and be ok to say “no”- stand up for self (their issue not mine)

Answer door and respond to request if it is reasonable and I chose to help

Pick another situation that concerns you:

Suspicious/other thought=

Because of this thought I feel=

Because of this thought, I do=

What are the facts? (did I check all the facts?)

What would other people say (write down another person’s view or alternative explanation)

hat makes the most sense to think and do at this time?

Name:

Date(s)

Thought Record for Belief

Situation: Sees Mary walking down the street. Waves at Mary, but Mary doesn’t wave back

First Thought and Then alternative Thoughts Feelings Behaviors

She hates me

Sad

Avoid Mary; Back out of

social involvement

She doesn’t like me

Worried

Could ask Mary if she is mad

at me for some reason

She didn’t see me

Neutral

Say “Hi” to Mary next time

Practice First Thought

Practice Second Alternative Thought

Practice Third Alternative Thought

Name:

Date(s)

Thought Record for Belief

Situation:

First Thought and then Alternative Thoughts Feelings Behaviors

First Thought

Alternative

First Thought

Alternative

First Thought

Alternative

Name:

Date(s)

Thought Record for Belief

Situation:

First Thought and then Alternative Thoughts Feelings Behaviors

First Thought

Alternative

First Thought

Alternative

First Thought

Alternative

Name:

Date(s)

Thought Record for Belief

Situation:

First Thought and then Alternative Thoughts Feelings Behaviors

First Thought

Alternative

First Thought

Alternative

First Thought

Alternative

Pros Cons

Do ………

Behavioral

Experiment

• Maybe the boss could work with me.

• M

aybe the cameras could be off

sometime.

• M

aybe I could learn about why they

have the cameras are on.

• They’re gonna think I’m a weirdo.

• T

hey’ll notice that I might not be a safe

person and I might get fired.

Don’t do…..

Behavioral

Experiment

• They wouldn’t know that I have

thoughts or that I get anxious.

• T

hey wouldn’t treat me differently than

they do now.

• T

hey wouldn’t have that I might not b

ble to take of the dogs.

• They would have more faith in me.

• I would continue to worry about why

the cameras are on and why they are

• I

’ll get anxious and leave or I’ll get fired.

360⁰ Pros and Cons

Pros Cons

………

•

Don’t

do…..

•

Working with Emotions

EMOTION CHART

Sad Depressed Disappointment

Apathy Grief

Anger Mad Irritation Frustration Rage

Happy Joyful Glad Cheerful Loving

Fear Anxious Panic Nervous Shaky

Guilt/Shame Embarrassment Regret Humiliation Disgust

Jealous Envious Hurt Discouragement

Lonely

Content Calm Compassionate

Grateful Curious

Mood Diary

Monday

  

1 2 3 4 5 6 7 8 9 10

+ Good things today:

- Bad things today:

Tuesday

  

1 2 3 4 5 6 7 8 9 10

+ Good things today:

- Bad things today:

Wednesday

  

1 2 3 4 5 6 7 8 9 10

+ Good things today:

- Bad things today:

Thursday

  

1 2 3 4 5 6 7 8 9 10

+ Good things today:

- Bad things today:

Friday

  

1 2 3 4 5 6 7 8 9 10

+ Good things today:

- Bad things today:

Saturday

  

1 2 3 4 5 6 7 8 9 10

+ Good things today:

- Bad things today:

Sunday

  

1 2 3 4 5 6 7 8 9 10

+ Good things today:

- Bad things today:

Mindfulness Techniques

Grounding Techniques:

Normally, “grounding” techniques are a mindfulness technique that is a guided process that instructs

the participant to take in information through the five senses. Often, it is taught as a “practice”, and

there is some, what I often call, mindfulness “fluff” to it. This can be inspiring to some, and offensive to

others.

When working with people who are panicked or are bordering on experiencing memories, simply giving

them concrete instructions works best. But the participant must have had the instructions prior to the

urgent incident taking place.

Education for Grounding: Simply describe “grounding”.

“Grounding is a technique that helps to keep someone in the present moment. Lots of times, we

get lost in memories or thoughts, and we can get upset by them. We get so lost in them that we find

ourselves right in those memories and thoughts instead of being right here in the moment. Grounding

helps to simply keep us in this moment. We do this (I’ll say “I do this” because it is true that I do this) by

looking at the place I am in – the walls, the floor, the colors, the sounds, the sights, even the smells, and

maybe even the touch of things. Feel the wood of the chair frame you are sitting in, listen to the music

playing in the next room, notice what colors are on the walls. Describe the pictures on the walls. I’m

going to remind you to breathe as you do this. Maybe even breathe with me and match my breath (then

match their breath, and begin to slow the pace down a bit, if that is necessary). Remind yourself of

where you are, when you are, and who you are with. Say those things out loud.”

As I am asking them to feel, see, touch, and smell all these things, I ask them to very briefly

describe them to me (The walls are blue. The arm of the chair is smooth wood or metal. The door to the

room is made of wood. I smell rain in the air. etc.). Breathe with them until their breath slows down, and

they can calmly state where and when they are and can identify you.

It is best to teach them this skill when things are going well. Practice this skill when things are

going well. To slow down their own breathing when they are alone, they can put their hand on their own

belly and feel how quickly they are breathing and attempt to slow the breath by that simple feedback

method. Perhaps at the beginning of every meeting for a quick minute or two. That way, when panic or

terror begins, they have a method that they have practiced and are familiar with.

Relaxation Techniques: Isn’t it hard to relax when that is exactly what you are trying to do? I think so

too. That makes relaxation very hard to teach. Relaxation is about giving one’s self a rest. We hold our

bodies so rigidly when we are anxious. There are many ways to teach relaxation and many aids to help

guide one through a relaxation technique.

Find a relaxation technique that you like and share that with your client

Sometimes, relaxation is more about giving your mind a rest than your body

I often play piano or guitar to relax

Sometimes I watch TV to relax

Sometimes a listen to relaxing music

Sometimes I practice yoga – relaxing yoga

Sometimes I paint to relax

Walking

Playing with my dog

It’s not always about letting go of muscle tension, it can be about letting go of all the

thoughts and memories and chores and judgments we have going on in our heads.

Education for Relaxation: Sometimes relaxation is about letting go of muscles:

Preparation: “Sit in a chair, or lay down on a mat or comfortable place and pay

attention to your breathing. Attend to your breath moving in and out of your body,

paying more attention to the out breath than the in breath. Attempt to make the

out-breath longer than the in-breath (this cues the parasympathetic nervous system

to go “online” and will naturally calm down the central nervous system without

conscious awareness.) As you breathe out, allow your muscles to let go and rest.

With each out-breath, allow your muscles to let go even more. Feel the heaviness of

your body in (the chair, sofa, bed, yoga mat, etc.).

Mindfulness: Just rest for a moment and feel yourself breathe. This is a kindness you

are giving to yourself, to relax, to let go of your tension for just a moment. When

you find yourself thinking of other things, congratulate yourself for catching that,

and gently and lovingly bring yourself back to letting go of your muscle tension with

each breath.

Closure: When you are ready, begin listening to the sounds in the room, feel the

clothes you are wearing, feel whatever it is you are laying on, hear yourself

breathing, Remind yourself that you deserve to have a rest and rejuvenate yourself,

and gently bring yourself back to the moment, ready to go on with the rest of your

day.

Progressive relaxation can be helpful (there are guides everywhere) but the process can

often be so long that it is hard to pay attention to. Give it a try if you’d like to. It can have

profound effects if one has worked up to the task of relaxation periods of longer than 15 to

20 minutes at a time.

Breathing Techniques:

Posture: A few words should be said about posture. With breathing (as with mindfulness when we come

to it), posture is important. The idea is that we want to pair a sense of dignity and honor to the

experience of being in our bodies, and being in our bodies in the here and now. Having a fairly upright

posture is best. I suggest having feet on the floor, or legs gently crossed if the participant is sitting.

Shoulders and hips square to the body and relaxed. Jaw gently dropped. Hands on thighs palms down.

Sitting in a dignified manner, as if one were the King or Queen of this particular spot on the earth. Sitting

with honor and dignity begins to introduce a felt sense of honor and dignity. No manipulation of the

breath is necessary.

Visibly work with them on posture – practice the posture with them yourself. Do this each time. Make

these associations frequently, and clients may begin to follow your lead regularly.

Square Breathing:

Breathe in to the count of four

Hold your breath to the count of four

Breath out to the count of four

Do this four times

Mindful Breathing:

Breathe normal breaths. Count each out-breath only. Count up to 10 out-breaths. Begin again if

you need to.

Or….

Sit quietly for several moments. Say to yourself as you breathe normally…

“I am breathing in” – when you are taking an in-breath

“I am breathing out” – when you are taking an out-breath

With any mindfulness technique such as breathing, always put into the directions or instructions that

minds wander, and that is natural and normal. Do not be dismayed by constant mind wandering. On the

contrary, congratulate yourself that you have done exactly what mindfulness practice is designed to do

– c

atch ourselves doing something other than what we are targeting, so that we can gently and

compassionately bring ourselves back to our frame of reference – our breathing. Excellent job!

Mindfulness Techniques and Working with Voices

These mindfulness activities are particularly good for helping clients to manage dealing with voices. Give

instructions and practice with clients or have them practice with you. Then process the experience with

them. Have them practice daily. Motivation, effort, and practice will help these particular activities work

proficiently. The name of the game here is PRACTICE.

Sub-vocalizations:

There is something about sub-vocalizing that interrupts the process by which auditory hallucinations

seem to be produced. This can work for intrusive memories and thoughts as well. Simply reading a

book to one’s self does not seem to work. Reading it out loud does seem to work.

Read a book out loud

Read a book at whisper level

Read to someone

Look Point Label:

Have them look around the room or area where they are and find an object. Have them point at it.

Have them say the name of it out loud. Do several rounds of this. This pulls them back into the

present moment.

Mindfulness Practices and Survey

Helpful

Have used the

skill outside of

group

Not helpful or

don’t remember

Session 1

Mindfulness to Breath

Square Breathing

(4 in; hold for 4; 4 out; 4 times)

Session 2

Mindfulness to Thoughts

Using words to notice changes

In thoughts and physical experience

(Peace, Loss, Lama Spit, Compassion)

Session 3

Mindfulness to Listening

Using music to identify changes in

body sensations and emotions

(Moonlight Sonata, Jazz, Choir)

Session 4

Mindfulness to Touch (Grounding)

Examining a stone – noticing all aspects

of the stone – color, texture, size, turning

it over, being curious about the stone

Session 5

Mindfulness to Eating (Savoring)

Used raisin or “craisin”, allow it to be in

your mouth without chewing, feeling the

texture, biting it without breaking into it

savoring the flavor as you finally bite;

Chew with conscious deliberation

Helpful

Have used the skill

outside of group

Not helpful or don’t

remember

Session 6

Mindfulness to Gratitude

Share with another person what

you have learned from them – what you

are grateful about what they have taught you

Session 7

Loving Kindness

“May I be filled with loving kindness;

may I be held in loving kindness”

See handout – Session 7

Session 8

Mindfulness to Thoughts

Relax into breathing

Focus on breath

When thoughts arise, as they always

will, label them and place them on

a cloud to pass by, or on a leaf

in a river to float down the stream

Session 9

Mindfulness to Sight

Browse the paintings in the hallway

share with a friend the items that you

enjoy or don’t enjoy, or have feelings or

thoughts about – describe what came

up for you, listen to what came up for them

Session 10

Mindfulness to Discomfort

Focus on your breath

Scan your body from head to toe

Notice any tightness or discomfort

Open up space inside your body for

that experience to begin to dissipate

and lose its tenseness.

Send imaginary heat or light to that

area to relax the sensation

Extra

Progressive Muscle Relaxation

Starting with the top of your head, gently

squeeze and then release each major muscle

group: scalp, eyes, jaw, neck, shoulders,

triceps and biceps, forearms, hands, chest

muscles, abdomen, buttocks, thighs, shins and

calves, feet, and finally toes. Feel the warmth

coming into your muscles when you release

the squeeze. Relax

Emotion Regulation in the Brain

Definition of Terms

INSULA

• The Insula helps combine physical experience of the body and the emotion experienced –

helps us to be aware, emotionally and physically, in the present moment

• Controls autonomic functions through the regulation of the sympathetic and

parasympathetic systems – works for homeostasis

• Regulates the immune system

AMYGDALA

• Responsible for perception of emotions

• Stores memories of events and emotions so we can recognize similar events in the future

Both the amygdala and the insula are vital in the experience of shame

ALEXITHYMIA

• Multidimensional construct

o Difficulty identifying emotions

o Difficulty describing emotions to others

o Difficulty appraising their bodily sensations

o Constricted imaginary processes

o External locus of control (externally focused)

• 2 subcomponents of Alexithymia

o Cognitive-emotional component (verbalizing & analyzing)

o Subjective-Emotional component (emotionalizing & fantasizing)

• Individuals with schizophrenia tend to score very high in the construct of alexithymia

The Stress Bucket

Everyone experiences stress at some time in their lives. It’s part of being human.

Sometimes, we will choose a path in life that is stressful, but we choose it because we believe that

the decision is a good one for us. We believe it will keep us safe, well, and happy. Even good

changes are stressful sometimes.

• Getting a new job

• Going back to school

•

Moving to a new home

• Starting a new relationship

• Ending a toxic relationship

• Beginning counseling or treatment

Can you think of times when you have made a decision that was “good for you” to make, but was still

stressful?

The Stress Bucket Model shows that too much stress is not good for our bodies, no matter who

we are or what we struggle with. When we get overwhelmed with stress, symptoms begin to

show up whether they are symptoms of depression, anxiety, diabetes, getting a cold, irritability,

and the list could go on and on. This model shows that symptoms arise for anyone.

If you can imagine stress as water that flows into a bucket, it’s easier to see how stress affects

us. It’s like water flowing into a bucket, and there’s nowhere for all that stress to go.

Water (or stress) begins to fill the bucket, the bucket becomes full of stress (or water). After a

while, there’s no more room in the bucket and it begins to overflow. When that happens, we

begin to have some symptoms related to that stress. This can include:

• Panic or anxiety

• Depression

• Hallucinations (auditory, visual)

• Sleep problems

• Headache, stomach ache, back pain

• Vulnerable to colds and flu

• Jittery or irritability

Vulnerabilities

Vulnerabilities can make our bucket

leaky, and the water, or stress,

begins to find another way out, but

usually not in an effective way. These

can increase our stress too.

Vulnerability can be thought of what makes us more fragile to stress. The more vulnerable we

are, the more likely we are to feel the stress. Vulnerability can be thought of as the size of the

bucket.

Some of us have a smaller bucket, which

means that it won’t take much stress

before the bucket overflows.

Some of us have a big bucket, which

means that it can take lots of stress

before the bucket overflows.

Daily Practice

Interpersonal Stressors

General Stressors

New Coping Skills

Unhelpful coping

strategies. What do you

need to work on?

Symptoms

Vulnerabilities

Resilience

When we are not sure how best to manage the stress, we do whatever we can to cope with it.

If we haven’t learned healthy ways to deal with stress, we will use ineffective ways to cope,

like…

• Drug or alcohol use

• Yelling or getting into fights

• Feeling so hopeless that we stay in bed

• Anxiety that is so high that we begin to fall into circular sinking thinking

• Miss appointments with therapist, case manager, or physician (avoiding because the

transportation is hard, the doctor might not say what we hope they will say, not really

feeling like sharing with my counselor or case manager).

• Just not paying the bills because we are afraid to look at them

Are you aware of ways of coping you use that haven’t been very effective at reducing stress,

and in fact, may increase your stress, adding more water to the already full bucket.

Using ineffective coping skills like drug use, alcohol use, avoidance, staying in bed all day, or

watching TV, works in the short term, but not all the way, and after a while, our bucket begins

to leak anyway. It’s just like hooking a hose from the bucket, and putting it right back in at the

top again. The hose doesn’t even help with our vulnerabilities either.

But what we can do is to use some effective coping skills. That allows the stress to come out in

a way that we choose.

Coping Skills

The faucets in the bucket represent coping skills. It’s possible to learn to manage the

amount of water (stress) that stays in the bucket in a variety of ways:

• Lower the number of stressors

o Reduce your workload if possible

o Ask for help around the house

o Get some extra rest if you need to

o Improve sleep (which is different than “get some extra sleep”

• Improve coping strategies

o “Catch it, Check it, Change it”

o Grounding

o Mindful breathing, and other mindful activities

o Taking medications regularly if that is on your treatment plan

o Talk to your counselor or case manager if you need to

o Monitor your emotions

o Exercise

• Build up resiliency – work with the strengths you already have. Think about some

effective and healthy ways of behaving that you already demonstrate that have

been helpful to you.

Stress Bucket

Daily Practice

Interpersonal Stressors

General Stressors

Begin to work on and

change the unhelpful

coping strategies. What

do you need to work on?

Resilience

Symptoms

Vulnerabilities

New Coping Skills

Stress Bucket

Interpersonal Stressors

Daily Practice

General Stressors

Resilience

Begin to work on and

change the unhelpful

coping strategies. What

do you need to work on?

Symptoms

Vulnerabilities

New Coping Skills

Working with Behavior

Behavioral Experiment

Prediction

What is your prediction?

What do think will happen?

Experiment

What experiment might test this prediction?

What safety behaviors need to be reduced?

How would you know if your prediction came true?

Outcome

What happened?

Was your prediction accurate?

What did you learn?

Behavioral experiments: Setting up the Investigation

We have learned that our thoughts are different from facts

 Remember: if I think “chair will break” does not mean that it will break

We have learned that there are many reasons why our thoughts may not be totally 100%

accurate

 Remember: unhelpful thinking habits

We have also learned to identify the thoughts that bother us and to check those thoughts by

• Coming up with alternatives

• Using a pie chart to see how strongly we believe different thoughts

• De-center and see how other people see the situation.

Sometimes we may also need to get additional information to check our thoughts. It is like

being a detective whose job it is to evaluate the accuracy of certain thoughts.

• Who is your favorite detective?

• How does that person get to the facts or what really happened?

See below for the most common ways we can address our thoughts by being our own “inner

detective”.

Research: Look up information from a reliable source or take a survey of those you trust

Experiments: When a detective has a good theory, he or she may set up an experiment to

check out his or her theory. See below for ways to investigate thoughts

The Investigation Analysis Worksheet 1

What is the troubling thought or experience?

What is important about this thought or experience?

How sure am I about the accuracy of my belief about the thought or experience?

Is there another way to think about this situation?

What additional information would help me with this troubling thought?

Where would I find information that I need or want?

Can I do research from resources that are objective?

Is it testable in some way?

Can I take pictures?

Can I make a recording?

Can I ask questions with people I trust (taking a survey)?

Write out your experiment.

What is the expected outcome of my experiment? What would it mean if your thought was

confirmed or disconfirmed?

What is the actual outcome of the experiment?

What do you conclude from going through these steps?

Investigation Analysis Worksheet

Thought

Belief %

Alternatives

Belief %

Investigation

Research/Experiment

Expected

Outcome

Actual

Outcome

New Thought

People are

monitoring me

– I answer the

phone and the

other party

hangs up.

90%

Could be wrong

number

Could be an

auto-dialer from

a solicitor

10%

Research

Look up info on

telemarketing

Look up info on auto-

dialers

Ask other people I trust

if they get hang-up calls

and what they think

about them.

Not sure what I

will find with

the research

Still get hang-

ups, but I have

new info on

telemarketing

and auto-dialers

Could be an

auto-dialer

50%-50%

Things in my

home have

been moved

since the last

time I was here

90%

Forgot where I

left things

Pets moved

them or

knocked them

over

Furnace air or

wind from the

window

10%

Experiment

Set things in specific

places

Take a picture

Cage the pets for a day

GO OUT for period of

time; return

Things will be

moved

Things didn’t

move

Sometimes I

just don’t

remember

where I put

things

Maybe it was

the pets

Meta-thinking

(Alternative

explanations)

Pie Chart

(List alternative

explanations)

De-Centering

(Get another’s

perspective)

Investigation Analysis Worksheet

Thought

Belief %

Alternatives

Belief %

Investigation

Research/Experiment

Expected

Outcome

Actual

Outcome

New Thought

Investigation Analysis Worksheet

Thought

Belief %

Alternatives

Belief %

Investigation

Research/Experiment

Expected

Outcome

Actual

Outcome

New Thought

Working with Voices and

Hallucinations

Voice Diary

Situation

Where are you?

When? Day and Time?

What are you doing?

Voice Present

Yes/No

Voice Content

What did voice (s)

say?

Distress Level

1(None)-10

(Extremely

Distressed)

Response

What did you do

(behavior)?

Outcome

What happened?

Voices- stop or continue?

Distress- go up or down?

Re-rate (1-10)

Some Ideas about How to Cope with Voices

Frustrating the Voice by Repeating Everything:

- Some voice hearers have found it helpful to repeat to themselves everything that the

voice says, word for word, in your mind. For many people, this causes the voice to

stop, or at least become calmer. A variation on this has worked when the voices

seem very loud: when you repeat to yourself what the voice says, just slowly reduce

the “volume;” this tends to lead to a lowering in the volume of the voice itself.

Using Earplugs:

- Putting an earplug in just one ear has helped a lot of people, at least for a little

while! Experiment with using either the plug in either your left or right ear. If it

doesn't work, try taking the earplug out: for some people the voices stop when the

earplug is taken out!

Figuring out what is, and what isn't, actual sound waves

- If you are often unsure whether you are "hearing voices" or just hearing say the

neighbors talk, or the TV, you can try the following exercise. Get a tape recorder.

When you are starting to wonder what you are hearing, start recording. While it is

recording, maybe just for a few minutes, make a guess as to whether what you are

hearing is going to show up on the tape as being normal sound. Then play the tape

back and see whether you were right or not. Over time, you should be able to get

better and better at guessing.

Focusing on the voices

Anything you do to study the activity of the voices fits in this category.

- For example, one method is to notice each day how intense and disruptive the

voices were that day, and to give them a rating on a 1 to 10 scale. You can even

collect more detail and rate them on how intense they are in each hour. This

information could be kept on a chart which might allow you to see when the voices

become stronger and when weaker.

- Another method of focusing on the voices might be paying attention to triggers:

things that seem to occur right before the voices get stronger. You can then work on

better ways to cope with those triggers, so they don’t bother you so much.

- Studying the voices. This might include asking them questions about themselves,

while noticing any inconsistencies and asking about those as well. You might ask

them how old they are, what benefit they get from pestering you, what they like to

do for recreation, anything that crosses your mind. By actively studying and by

asking questions you are taking the initiative, rather than letting the voices have all

the initiative.

Adapted from Ron Unger, 2018 blog; https://recoveryfromschizophrenia.org/cbt-for-psychosis-t

rauma-

psychosis-handouts/2097-2/

- You can write down exactly what the voices say, and then notice any themes, any

issues the voices are preoccupied with.

Distraction. (avoid over-use of distraction, as those who cope best don’t seem to focus on

using this method.)

This category includes anything you do to divert your attention away from the voices. Some

possibilities include:

- Going out for a walk, doing some shopping, travelling around on public transport as a

form of diversion than without serious intent to travel to any particular place, going

out for a drive or even visiting a transport hub like an airport or busy railway or

station..

- Doing routine domestic chores at home, washing, ironing, cleaning or gardening etc.

- listening to a radio, a walkman or stereo (music without words might be better if

hearing words in the music gets voices going for you).

- It might be a good exercise to create your own list of things that you particularly like

to do as a reminder that you refer too when you having a particularly hard time with

the voices.

Concentration

This includes anything you do that really requires you to concentrate on something other

than the voice.

- reading, studying (but not if studying is a major stressor for you,) writing a journal or

diary, or creative writing, doing art work or sculpting or something related, putting

together models, jigsaw puzzles, repairing things at home or maybe at someone

else’s place, Playing chess, shooting pool, going to a bowling alley, playing racket

sports, playing a musical instrument e.g. guitar, drum, violin or keyboard instrument

synthesizer: it could be things like singing specific tunes or songs, even attending a

choir etc.

- Another form of concentration activity is what is termed SUBVOCALISATION.

Essentially this means doing specific tasks in your head that you might otherwise use

your mouth for. Examples of this method would be ‘counting’ (in your head up to

100 rather than aloud), or singing a song under your breath

Physical Exercise

- like taking a walk or a bike ride, working out at the Gym, Yoga, or swimming.

Physical activity can improve mood as well as help calm the voices.

Social Activities

This means undertaking activities that involve others.

- You might take time to speak with a partner, a close friend, or even a sympathetic

worker, if you for example live in some kind of formal residential setting.

- Telephoning a friend/s

- Visiting (fairly supportive) friends or relations who are fairly supportive to you even

they may not necessarily understand your experience.

- Attending groups, such as peer support groups such as one for voice hearers, or

joining a hobby/activity groups.

- Be careful to avoid social situations where people are likely to be “negatively

critical.” Experiences with people with these attitudes frequently results in feeling

worse. Instead, seek out people who know how to be constructive, people who can

see some good in you and help you see how to build on that.

- Also, don’t expect too much out of yourself in social situations. No one can please all

of the people all of the time, and if you try to make yourself please everyone, you

can make yourself miserable!

THINKING (cognitive approaches)

Thinking (termed Cognitive) strategies means using your thoughts in a self-aware way to

challenge or in some way diminish the sense of voices having power over you.

- ‘Reality testing’ The voices may be saying something about your friend or partner,

for example, saying that your friend is angry at you about something. Providing that

your friend is understanding and are not likely to take offence, you might try asking

your friend directly if this is true. You may have to be cautious about the content of

what you wish to check out with person the voices are speaking about, as some of it

may just be too intrusive or personal and may actually cause offence! And it may be

the voices just want to get you into trouble or bring trouble in your friendships or

with the people the voices are attacking.

- Negotiating ‘TIME OUT’ with the voices or otherwise postponing (delaying) listening

to the voices. In exchange for giving the voices your positive attention say for a half

hour or an hour you ask them to go away for half or a whole day. You may have to

experiment with this awhile to get some effect. Its’ like saying I will reward you with

positive attention for a while if you then shut-up for the next four hours or so. Or you

say if you go away now I will give positive attention towards the end of the day say

5pm etc.

- Providing you don’t feel too frightened of the voices you could practice bringing

them on then dismissing them: this can really work for some people and build up

their confidence over controlling some of the voices.

- Thinking positive thoughts of yourself. Thinking positive thoughts about yourself

when the voice are around (voices are often negatively critical), perhaps writing

something positive about yourself, your achievements or what you might want to do

in the future etc. You may have a portfolio (or album) containing mementos of things

you achieved in the past, it can be helpful to look at these as a way of recalling

positive aspects of your life.

- Changing what we think about the voices. Changing the way we think about the

voices may be more difficult to do on your own and it may be better to speak to

someone possibly trained in some form of therapy like Cognitive Behavioral Therapy

(CBT) to help with this. Sometime the meaning we put on our belief of voices is

termed ATTRIBUTION. Psychological therapies like CBT as previously mentioned can

be used to help us to more objectively weigh the evidence for and against particular

ideas about the voices: therefore, help us REATTRIBUTE our ideas about the voices:

that is changing our beliefs about the voices. This can be especially helpful if we find

ourselves stuck with certain ideas about the voices which continually distress us and

may not be true.

Getting to know the emotions behind the voices

- If you watch voices carefully, you might notice certain voices that pop up at certain

times, or say particular kinds of things at certain times. For example, it may be at

times when you are alone, or when something embarrassing or unpleasant has

happened. Try to observe and appreciate what you are feeling at the time. Focus on

the emotion you are feeling as what is really going on; you may find the voice

becomes less important as you give yourself permission to directly feel the

unpleasant emotion.

- Once you know the emotions that stir up the voices, you can also work on

encouraging counter-emotions. For example, if voices are stronger when you

are bored, work at making your life more interesting. If they are stronger

when you are feeling disgusted with yourself, work on ways of increasing

your self-respect and reasons for respecting yourself. This can be an

extremely important way of fighting voices!

- Imagining that you are the voice & try to understand why you would want the say to

your “self” the things the voice says. Try to get inside the “head” of the voice, the

way you might try to get inside the "head” of a character in a novel or movie,

understanding its emotions, drives, and strengths and weaknesses.

- Once you understand the life of the voice better, you can start wondering

about what it needs, and even showing care and compassion for it. For

example, maybe it bothers you because it is scared, and you could imagine

ways to help it find peace. Or maybe it is very rigid, and you could look for

ways to help it be more flexible. This is not about giving in to the voice at all,

but is about helping to give it what it really needs instead of what it may

demand from you all the time.

Questioning the Voice:

- Voices love to act like they are big authorities, and often people get sucked into

believing them! You can help yourself by questioning their authority. Example: a

voice is disturbing you by saying that you are evil, and you don’t know why the voice

is saying this. You can challenge the voice, and say “Prove it!” Either the voice will

shut up, or it will have to try to prove it, and then you can dispute whatever “proof”

it comes up with.

- Voices also like to give themselves fancy identities, such as claiming to be famous

people or important spiritual beings, etc. You can dispute this by thinking of some

question that you yourself don’t know the answer to, but that the voice should know

if it really is who it says it is. Get the voice to answer the question, and then look up

its answer to see if it got it right.

Using Art

- You can draw the voices, or sculpt them, or make some other representation of who

or what they seem to be. This can help you deal with the voices in a new way.

- Another approach, perhaps more advanced, is to "take the role" of the voice, or to

mimic it, the way an actor or actress takes on the role of a character in a play or a

movie. For example, if you have an "evil voice" you could play the role of this voice

the same way that an actor plays the role of an evil character. If the "evil voice" tells

you to kill yourself, then when you play the role of the voice you would pretend to

be telling someone to kill themselves. You can even play this role in an exaggerated

way, being more dramatic and "evil" than the voice usually itself is. You could try

this with your therapist if your therapist agrees, or practice in front of a mirror. This

method can help you step out of the role of feeling like a "victim" of the voice. It will

only be helpful if you feel ready for it and if you can keep it clear in your mind that

you are just acting an evil role, not being evil or going to do evil things yourself.

Seeking out positive and constructive voices while tuning out voices that tend to be

negative:

- This involves, first, making an effort to distinguish which voices are really offering

something constructive versus those that are just causing trouble. Then, for

example, when you hear a negative voice, you can instead seek out the company of

one of your more positive voices. (One way of calling it up might be just being

curious about what the positive voice might say, or imagining what it would say, or

remembering the kinds of things your positive voice said in the past.) You might

even try asking the positive voice for advice on how to deal with the negative voices.

- If you tell someone, "don't think about elephants," it's elephants that they'll think

about. So don't worry about trying to "not hear" destructive voices; instead just

focus on paying attention to constructive ones.

Seeking out positive and constructive thoughts & activities while tuning out voices that

tend to be negative:

- Any focus on something constructive, that makes you feel good about yourself and

what you are doing in the world, can help create good feelings that protect you from

the voices.

- Remember that to really make the constructive things you are doing count, you have

to give yourself credit for them. One way of doing this is to write each day in your

journal about what you did that day that was constructive, and perhaps what you

plan to do in the next day.

Using imagination or visualization to protect yourself.

- For example, you might imagine a sort of "halo" or protective light around yourself.

Or, you might find an inner guide who can give you advice or help defend you from

the voice. You can imagine whatever it might be that you would need to overcome

the voice: there are no limits on what you can imagine! You might start out thinking

that the voice is more real than your imagination, but remember that the voice

depends on you paying attention to it and believing that it has power: if you pay

more attention to and put more belief into what you imagine that is protecting you,

the voice will lose power.

Learning to quit expecting the voice:

- This method takes advantage of the fact that people tend to hear the voices they are

expecting to hear. If you create a counter-expectation, that counter-expectation can

eventually overpower the expectation to hear the voice. For example, suppose you

are used to hearing voices and getting preoccupied with them when you go home in

the evening. Instead, think about what you would like to be preoccupied with in the

evening. For example, maybe you would rather be focused on some good music, or

a novel you are reading, or working on a project. Focus on expecting that from

yourself, and if the voices try to intrude anyway, expect them to become less

important as you focus on what you really want to pay attention to.

Notice how the voices are not all that original:

- To do this, you need to keep 2 written records of what happens when you are in a

distressing situation. In one record you write down the thoughts that come to you

automatically about yourself when you are in the distressing situation. In the other

record you write down what the voices say when you are in those situations. Later,

you can look at these records and see how much they are the same or different.

Reframe what the voices are saying as something positive

- Using this method, you assume that the voices are really trying to help you in some

way, though perhaps they are misguided or overly enthusiastic in what they are

trying to do. For example, if the voice tries to convince you that everyone hates you,

you might reframe it as trying to make sure you aren't overly self-confident. If the

voice wants you to kill someone, you might reframe it as the voice wanting to make

sure that person doesn't take advantage of you. If the voice wants you to kill

yourself, you might reframe it as the voice wanting to save you from a distressing

situation that it is worried will be too painful for you to endure. By finding a possible

positive intention in what the voices say, you can then focus your attention to

handling those concerns, and you can even thank the voice for its concern and ask it

to help you. For example, you can tell a voice that wants you to kill someone that

you appreciate its desire to not let you be taken advantage of, that you do not want

to go so far as to kill the other person, but that you are open to other suggestions

about how to protect yourself from this person. When you reason with the voices in

this way, you might find that a healthier dialogue begins inside you.

Reframe hostile voices as helping you get in touch with difficult feelings:

- This one is a little tricky but potentially very helpful. Hostile voices can be verbally

abusive, and can even encourage people to give up on themselves or hurt

themselves or others. People can then get into long and emotionally exhausting

battles with these voices. This method asks you to try something a little different.

- Instead of fighting back against the hostile voice, imagine that the voice has

won, that the voice has all the power and that it has already hurt you in the

ways it is trying to hurt you. How does it look or feel to you that this has

happened? What is most difficult to you about this feeling?

- What do you need when you are wounded or overwhelmed like this?

- Once you get in touch with the sad or wounded feelings, then let yourself

notice that there is also a healthier you that can provide some of what you

need at this moment. You can then focus on giving yourself some of what

you need, you can practice self-comforting.

- The magic of this method is that you quit fighting with the voice, by focusing instead

on how it feels to be the victim of the voice. (But you do it without actually hurting

yourself - for example if the voice wants you to cut yourself, you focus on what it

feels like to be a person forced by someone to cut themselves, how it feels to be sad

and overwhelmed, you don't actually cut yourself.)

- The notion behind this method is that voices often try to get people to feel horrible

or vulnerable feelings which the person has disowned: by accepting and owning the

bad feeling, and then taking care of yourself around it, the voice loses its purpose for

existence and fades away, at least till next time there is a difficult feeling you are

resisting!

Letting the voice time share in your body.

This is probably more likely to be helpful for someone who is not totally intimidated by the

voices and who feels they are not likely to get completely out of control. The way it works is

to just to set a time when you can experiment with having a particular voice have "control"

of your body, at a time when it is unlikely to cause any problem. (You should only attempt

this if you feel you could take back control should the voice attempt anything that will cause

trouble.) What is helpful about doing this is that you get to know the voice in a different

way, and may even find something positive about it. For example, you may find that an

angry voice has a very firm, strong way of acting in your body, and you may find you can

eventually borrow some of this strength when you need it in various situations in your life.

You may also eventually come to see the voice as more just a "side" of yourself, and less

threatening because less alien. Not taking voices literally

- This means considering the possibility that voices may not literally mean what they

say: instead, they may be speaking in metaphor, they may be speaking poetically.

So while the voice may insist for example that you "jump in the river" it might really

mean that you should get more into the flow of things, and not hold yourself back so

much. So, instead of just doing what the voice says, or just fighting with it because

you don't want to literally jump in the river, you could think about what the voice

might be really trying to say.

- Another way to not take the voices literally is to try out carrying out their demands

in your imagination, rather than literally. For example, if the voice wants you to cut

yourself, try imagining that you are cutting yourself, or that you already have done

so, and notice what changes, notice what the feelings are and what shifts inside you.

(This is very similar to the method above, where you focus on how it feels to be a

victim of the voice.)

Allowing your identity to be wider than you are in the habit of letting it be:

- Consider example of someone who wants to lose weight: they are sure who they are

is a person that entirely wants to lose weight, and is willing to give up desserts in

order to do so. Then they see a piece of chocolate cake, and suddenly, there is the

temptation to eat it. If the person is rigid about who they think they are, that they

are a person who doesn't want desserts, then they can only see the temptation to

eat the cake as coming from someone or something else, maybe a demon or an

unpleasant voice. The chocolate cake example is kind of silly, because usually people

are able to accept that there are two parts of themselves, one part that wants to diet

and another part that wants cake, so they can be wide enough in their identity to let

both parts in. But what about bigger conflicts?

- A person who wants to live may find it really difficult to accept an urge to kill

themselves. A person who wants to be conventional sexually may have a hard time

accepting urges to be gay or otherwise different sexually. A person who wants to be

peaceful may have a hard time with urges to kill or hurt others. These are very

serious conflicts. One way people can try to resolve them is to simply decide that

"the real me" only wants what is good or conventional, while the "evil" or "nasty"

ideas and impulses come from something else, like from voices.

- This solution could be called "making the self more narrow." Making the self more

narrow has its advantages, in that it can help a person feel that his or her own self is

good and peaceful. But the disadvantage is that the urges and temptations are still

alive somewhere, and they will live as voices and demons if not allowed to live as

parts of the self.

- Another way the self can get narrow: let's say the person identifies themselves as

kind of weak and incapable, for whatever reason. Something strong within them

might be seen as foreign, as not themselves. So maybe the person connects with the

strong part by thinking of it as an exterior spirit and feels helped by this. This can be

helpful, but since the strength is seen as exterior to the person, in time it can take its

own direction that may not be helpful to the person. For example, they might start

out noticing a "spirit" as helping in some strong way, but later the "spirit" wants to

take some direction that the person doesn't want to go. So "spirit helpers" can

easily become "demon opponents."

- Allowing yourself to be wider, means seeing the thing that seems to be either

opposing you or helping you as being part of the bigger you. In other words, you can

see yourself as wider, more complex than how you usually see yourself. You can be

wide enough to include things like urges to hurt yourself or others, urges to do

strange things, to be different sexually, or whatever. Being wider doesn't mean you

will necessarily let these urges take over, but it means allowing them to be part of

the mix that makes up you.

- Advantages to allowing yourself to be a wider person: You can talk about your

experience more the way most people do, which allows you to relate better to

conventional people. In other words, you can talk about how you are "beating

yourself up" instead of being attacked by a spirit, or how "part of me wants to kill

him" instead of "the voices are telling me to kill him" etc. By allowing yourself to be

wider, you are no longer as "pure" but you also don't have to feel as different from

"normal" people.

- This is not to say that the way "normal" people look at things is always the best way,

or always right. Maybe there are times when we would be better off identifying

ourselves in a narrow rather than a wide way. But if we have a choice about it at any

given time, we may be able to choose a way of looking at it that is most helpful to

ourselves at any given time.

Being kind to the voice

- Voices are often distressing, but it's easy to forget that they may be even more

distressed themselves. Treating them with kindness may really surprise them, and

result in some big changes! When you hear the distressing voice, take a step back

mentally, and imagine that it may really be troubled, and is causing trouble only

because it is desperate. You can take an attitude toward the voice similar to the

attitude a parent might take toward an injured, frightened, or tired child who is

being obnoxious.

- For example, a man may be bothered by a voice that calls him names and is very

threatening when he has to be around strangers. He may be planning to go the

store and knows this is likely to upset the voice. Instead of arguing or fighting with

the voice about his plans he could say to it: "I know that going to the store with all

the people around is really hard for you! Do you have any ideas about anything that

might help you feel safer while I do the shopping?" The voice might be helped by

something that is strictly imaginary, like imagining a tropical beach that the voice

can go to while the person is shopping. Or perhaps the voice would have a more

practical suggestion, like going to the store at a time when fewer people are around,

or having a better shopping list so the trip is less confusing.

- Notice in the above example, the person did not give in to the voice, but was kind to

it and considered its needs. This might not work right away (the voice may still be

distrustful and obnoxious) but eventually the relationship between the person and

the voice might change.

Getting better at telling the difference between "voices" and what actual people are

saying.

- Some people seem to always be able to tell when it is their "voices" talking and

when it is that they are listening to actual people, or the radio announcer, or

whatever. Other people have a harder time with this, and sometimes the voices

trick them into thinking that other people are saying things that they aren't. This can

cause lots of confusion and chaos! If this is a problem for you, here are some things

you can try:

- It might help to just pay attention and be on the lookout for this. Voices

trick people much more easily when they are being inattentive.

- Notice if there are certain things the voices really like to say. If you start

hearing people around you, or the radio announcer, saying these things, be

alert: it might really be the voices.

When what you are doing for coping isn't working:

- Try something different! Anything at all that you do differently might be just what

you need to be successful.

- You could even try something "completely different" or even the exact opposite of

what you were trying before.

Rediscovering your dreams and getting on with your life

While doing something just to distract yourself from the voices may have limited

usefulness, doing something because it connects with your dreams and because it makes

you feel fulfilled as a human being may be much more helpful! In other words, instead of

thinking you can't pursue your dreams because the voices cause too much trouble, try

finding right now some things you can do to take steps toward your dreams. Every time you

take some meaningful step, you win, and you prove that you and not the voices are in

control of your life!

Keep in mind that for this to work, you don't need to make the voices stop, you just

need to find ways to do what is most important to you whether the voices continue or not.

This focuses your attention on what you want to do, not on the voices.

What to do if you are trying to pay attention to some constructive activity but then

you notice you have started paying attention to the voices instead: just direct your

attention back to the constructive activity. Remember why you are doing it and why it is

important to you.

Other Types of Coping

- You may fine entirely different methods of coping as you pay attention to what

works for you: good luck in your experiments!

Basic Idea: that the origin of psychosis is in a retreat into the imagination, trying to make

imagination substitute for the extended world. This is fun at first but then the mind (or

imagination), in an attempt to re-engage the person with the extended world, quits

presenting positive images and presents images of danger, force, and hostility, attempting

to push the person into coping with what is unfriendly. The person, however, because he or

she is believing that the world of imagination is the extended world, finds him or herself

reacting to the imagined challenge as though it wore an actual challenge from the extended

world. Since the challenge is not "real" however it cannot be defeated, and so the person is

entirely stuck. One solution is for the person to notice that the imagined challenge can itself

be fought with the force of active imagination; doing so restores the neutrality of

imagination, leaving the person able to re-engage with the extended world.

Or, voices could start as a scared person tries to protect him or herself by imagining all

possible danger and anticipating it. The person goes from "this is ambiguous - it might be

that those people are talking about me" to actually "hearing" what it is feared they might be

saying. The person then reacts to what "might be" happening as though it really were

happening - classic panic. Similar only opposite causality on the grandiose side, where

person instead imagines what might really be great that is going on.

In the first model above, the voices begin as a kind of "addiction" or seduction, into which

the person buys into a positive feedback loop because of the appearance of a payoff. This

creates a dependence. The person then fears the absence of the voice and can be bullied by

the voice as a result, with the positive feedback then being the panic related to the

withdrawal. In the second model, it is panic that starts directly to create the feedback.

(Even then, we could say there is a hidden grandiosity or addiction, in that the person

imagines they cannot cope with losing whatever it is they are panicking that they are losing.)

Another way of looking at voices: as a dramatization of emotion. The brain may attempt to

dramatize an emotion that is being cut off or ignored (maybe because the person is already

overwhelmed). The problem gets worse as the person, or the persons around the person,

see the dramatization as "craziness" and cuts that off rather than see the sense, or the

emotion, within it.

Developing judgement about voices is key. If a "negative" voice, need to decide to what

extent it is helping one deal with a negative situation, and to what extent it is being too

extreme. The same is true of positive voices: to what extent are they helping and to what

extent are they getting one too carried away. This is really the same task as deciding when

emotions are helping and when they are going too far. Of course, when one is traumatized

the ability to judge what is too much, is overwhelmed.

Can think of voices as part of self, or think of all entities as part of one consciousness, think

of them as split off but really part of one mind.

Can just agree to disagree with voices, rather than get sucked into arguing. "Yes I know that

you think I'm worthless, it's ok with me if you think that, you have a right to your opinion. I

on the other hand see some value in what I am doing and in what I am capable of doing in

the future. I understand you don't agree. It's ok with me that you disagree with me."

When a negative voice speaks up, use that as a reminder to do some self-care for yourself.

Or use it as a reminder to do some constructive self-talk - say to yourself the things that a

friend or a good coach or a positive voice might say to you. Focus on that positive,

constructive message instead of what the negative voice has been saying.

Make an audiotape of the worst things voices might say. Play it over and over again until it

doesn't make you anxious anymore.

If unclear if voices are physically real (like hearing voices while alone at one's apartment,

that might be the neighbors) try making an audiotape & check it out.

Paying attention to how you set yourself up to be vulnerable to voices. For example,

thinking you have to live up to some standard of perfection, then whenever you don't you

are vulnerable to a voice that berates you for not doing it.

Focus on creating periods without being bothered by voices, rather than paying attention to

the voices. At first these might be short, later they could get longer. Pay attention to what

makes these periods happen, measure them, etc.

If you tell yourself you will have to stop the voices before you succeed, then you will pay lots

of attention to them as you try to figure out how to stop them (and less attention to the

world.) But if you actually pay more attention to the world, and less to the voices, then they

lose power. Sort of like bullies - often the best way to control them is to ignore them.

Make fun of voices as a method. First write out a script of what voices usually say. Then,

have a friend help you (it helps to make a tape of this you can listen to later.) Have the

friend say the statements on the script in his/her most silly voice possible. (They might try

to sound like a cartoon character, or say things in a very high pitched voice.) You repeat

back exactly what the "voice" said each time. Later you can listen to the tape as a reminder

that you don't have to take the voice seriously.

Making peace with the voices, "peace with justice." A bullies into buddies kind of thing.

Just as in meditation one identifies a thought by just thinking "thought" and then redirecting

ones attention, one could just identify "voice" and then redirect attention.

Voices - in addition to not taking them literally, can try not taking them "all the way." Voices

may represent parts of the brain that don't talk in shades or subtleties - they say then turn

right & go over cliff, but really mean turn right & act as if you were going over cliff, they

assume other parts will click in and get you to change course before you actually go over the

cliff. Like voices that ask for suicide - maybe really they just want you to kill something

about your current pattern of living.

Can have a person role play someone in their life who causes problems for them, to develop

a wider perspective on that person. Can use the same method, have the client role play a

voice, have it explain its perspective.

Making friends with voices - treat disagreements as temporary and consider attributions of

positive intent underneath surface hostility (either for self-protection by the part or to aid

the whole self in some way (at least an intent to do so.)

Something like eft - even though my voice is hyperactive, I accept myself and look forward

to a great future. Or even though I'm feeling very anxious about the voice, I accept my mind

just as it is in this moment. (NOTE how eft puts "acceptance and commitment" into one

sentence.

How voices are like poorly behaved children, feed off negative attention.

Being kind and open to reasonable influence, but also having firmness and boundaries (like

in good parenting or other relationships.)

Have people role play the voices, to find out more about it. Also to shift their sense of a

center, so they can sense that in some sense they have always been the voice. So their

sense of identity can "decenter" resulting in an expanded sense of self.

"love your enemy" is key with voices - or MPD - if you learn this, you can expand

your sense of identity, I'm not just my body I'm the world.

A person often jumps quickly to the perspective of another person looking at self, makes a

statement from that perspective, then jumps back to seeing the statement from the

perspective of self before becoming conscious of having done it. (dissociating having don it,

and/or the problem is just speed.) If a person actually takes that outside perspective for a

while, to own it, and own the process of saying things to self from that perspective, then it is

more likely to be seen as a habit that can be changed.

Becoming your own boss: how to invent a better boss that the voices that order you

around.

The do-over. Whatever a voice tells you, see what may have been of value in its expression.

For example, if it says you are stupid, it may be reminding you that there are important

things you don't know. In the do-over, tell yourself the same critical content in a more

adult, subtle, and balanced way, in your own words. As what you tell yourself becomes

more well-rounded and complete, you won't need the voice as much, will pay less attention

to it, and it will fade.

Getting people to reflect on where other people may be coming from, or an improved

"theory of mind" is a similar skill to seeing where a voice may be coming from, what

interests it may have

An over-emphasis on trying to control one's inner world leads to more confusion between

inner and external - because stuff one fails to control is what is seen as external. But getting

confused between internal and external worlds leads to inner confusion and distress,

leading often to greater attempts to control the inner world! This creates a vicious circle,

much like the circle created when people try too hard to get rid of anxiety.

Voice feeds on attention - so a voice that no one listens to isn't much. Can use Izzy Kalman's

"feed the pigeons" to make them go away as an example.

Negotiation - find interests under positions - voices may threaten torture but may be most

interested in attention - integration is the goal, like with MPD

How something healthy may be a center of something that initially seemed totally sick. Like

one of my clients working on recovery, a voice that once almost killed him in a horrible way,

is now part of his personality that helps him take on healthy challenges. Like in fairy tales,

you meet some strange character, have to fight at first to establish respect, then it can

become an ally

People block their feelings, become less aware of the sources of the feelings, feelings

become more problematic - then the mental health system makes it harder for people to

relate to such feelings by encouraging people to not even look for sources, "it's a

biochemical imbalance". Same goes for blocking a voice or a perspective.

A general method to get along with people with a different perspective “that’s so

interesting! …. that you experience it that way! Here’s how it is for me…. Someone attacks

you, you make a self-deprecating remark, this shows you can find some truth in their

perspective.

A good worksheet: look at what is for me to decide vs. what is for voice to decide, what is

for voices to decide for themselves. Like, it’s up to the voice to decide if it likes what I’m

doing, while it’s up to me to decide if I like it, it’s up to voice to decide if it would like me to

kill myself, but up to me to decide if I really want to or not.

Technique for deal with voices: take a 3

position, I am not the voice or the one who hears

the voices, I am the one who has to understand and integrate both of them.

For a disturbing voice, either find or create a counter voice, that effectively contradicts the

disturbing voice. Then you can choose to either listen to the disturbing voice, the counter

voice, or to anything in between. You have a range of options.

Stress interpretation: see voices as a sign of too much stress, respond by taking it easy

rather than stress about the voices being present. (The voices are just an indicator of stress

not the cause, they are the smoke, not the fire. Though stressing about the voices can feed

the fire.)

Interpreting voices as something less extreme, or finding something less extreme to do to

honor the impulse behind the voice. This can work with more than just anger.

Can use a negative voice as a reminder to focus on one’s positive intention, as being like the

Zen master with a stick. Can thank it for its reminders.

Look around the room, name every object you see. This lowers anxiety and gets the more

“objective” part of your mind activated.

How starting and stopping voices can give you a sense of control. You can’t always be

controlling them but you know you have influence if you decide you need or want to.

If voices are just thoughts or imagining a monologue or dialogue, plus imagining what it

would sound like, then it figures that the less one cares about it or has an interest in it, the

less likely it would be to occur. But of course catastrophic thoughts about the meaning of

voices, or grandiose thoughts about the meaning of them, would lead to a greater interest

in imagining it further. (Part of the problem in psychosis is loss of distinction between

imagining what something might be, and seeing what it might be. When the thing is the

imagination itself, of course, there is no distinction.)

A “stress interpretation” of how to cope with voices – don’t concern oneself with the voice

at all directly. Instead, do two things. One, find a way not to stress about the existence of

the voice or what it is saying. Second, find a way to reduce the stress that probably

triggered the voice in the first place. (The voice itself can often be used as a clue to what

the stress was that triggered it. For example, if a person is viciously attacked by a person for

a particular failure, that suggests the person is stressing over that failure, and could work on

how to stress less about it, perhaps by understanding it better, making some changes, or

some focused self-forgiveness.)

People who hear an apparently destructive voice often over-rely on making themselves

smaller than the voice, which is what is involved in distraction, or trying to shut out the

voice. These methods involve focusing the person away from the voice, on an area of

consciousness that is smaller than the whole person, so that the voice is shut out. A

problem with this strategy is that it gives the person a smaller sense of themselves, since

they are training themselves to only identify with the part of them that doesn’t include the

voice. This can ultimately lead to a person feeling small and weak, while the voice, free to

move around in all of the person’s consciousness, can increasingly seem large and powerful.

No wonder people feel weak in comparison to it.

One alternative strategy is to deliberately focus on the voice, as an object of study.

So one can record exactly what it says, how often it says it, what identity it claims, ask it

questions, etc.

A person who can both focus away from the voice, and focus on the voice, can allow

themselves a broader focus as well, sensing themselves as a bigger human being who

includes the voice as just one part or aspect. This allows the person to feel bigger than the

voice, accepting its existence while being in no danger from it.

Stages of dealing with voices:

“Oh my God what is it!”

“I need to do anything so I don’t hear it (but I still do).

This is trying to make one’s focus smaller. Can work as a temporary measure to regroup and

get strength to face the voices, but is a poor permanent method, because it makes the

person feel smaller, and gives the voice more power.

“Fuck it I’m going to have a life anyway, so what if I hear a voice”

Person turns and faces the voice, expands focus to include the voice as just one aspect of a

much larger mind and life. If this is done sincerely, voice may fade away, or become just

part of overall self.

Same dynamics are involved in dealing with panic or other emotional problems. These

dynamics can be diagramed, with a large circle showing the whole self, with the initial “oh

my god” shown as focus on distress around the voice, then the avoidance stage shown as

focus on a small area away from the voice which makes the person seem small and voice

bigger, then the third stage shown as willingness to face any distress and see self as bigger

than the voice (maybe could use a stage of expanding focus to also include the voice while

keeping in mind the more peaceful resolved areas of self, rather than just focusing on

distress. How this applies to trauma too.

Trying to make a voice go away is like trying to make a critic go away, which is a variation of

trying to be CERTAIN. The person wants certainty beyond any doubt, and sees it as a

problem if doubt is being expressed anywhere, so the voice is seen as a huge problem. (The

setup for having a voice is that the person avoids thinking through their doubts, so that

these can easily self-organize into a voice.) It is actually accepting the voice and the doubt it

expresses that is likely to cause the voice to disorganize, as it loses its purpose. Since the

person accepts that doubt exists, there is no longer a sharp distinction between the

perspective of the voice and that of the person. If the voice continues, it is more likely to be

friendly.

Use of disarming method with voices. A key technique. This allows a way out of combat

with voices, and allows the person to work on integrating any positive intent or helpful

fragment from the voices while appropriately resisting any bad ideas. Avoids over-reactions

of any kind.

Talking to oneself in terms of “we” and “us” and “ourselves.” As in “Why are some of us

wanting to cut our wrists? How will we be better off if we do that?” This highlights the way

there is diversity but that we all hang together – could encourage teamwork. A downside if

it makes people have more trouble transitioning to using “I” when dealing with the external

world.

Coping with distressing voices or experiences

Step 1: Identify when and how the voices or distressing experience interferes with an identify value or

life goal

Describe voice or experience:

How/when does voice interfere?

How intense is your Distress with voices right now:

(0-10, with 10 being the most distressing)

Voices significantly interfere with my life when it is at a rating of: (0-10)

Step 2: Examine past coping and plan for future coping. Make a List

Helpful things I have done to deal with this experience

Unhelpful things I tried to deal with this experience

New ideas: look at list to identify new ideas for coping that will help me reach my valued goals

Adapted with permission From Yakoobian et al., 2007 CBT client manual.

Best Practices in Schizophrenia Treatment (BeST) Center

Cognitive Behavioral Therapy (CBT-p) Initiative

Selected Resources

List of Coping Strategies for Hallucinations

Distraction Focusing Meta-cognitive

Methods

Humming Correct the cognitive distortions in the voices Use schema focused

techniques

Talking to yourself Respond rationally to voice content Acceptance

Listen to modern music Sub vocalization Assertiveness

Listen to classical music Dismiss the voices Use a biological model

Prayer Remind yourself that no one else can hear

the voice

Consider shamanistic views

of voice hearing

Meditation Phone a voice buddy and tell them the voice

is active

Consider cultural aspects of

voice hearing

Use a mantra Remember to take antipsychotic medication Use positive logging to

refute negative beliefs

about the self

Painting Demonstrate controllability by bringing the

voices on

Use a continuum relating

your own worth to that of

other people

Imagery Give the voices a ten minute slot at a specific

time each day

List your positive

experiences in life

Walking in the fresh air Play a cognitive therapy tape discussing

voice control

List your achievements,

friendships etc.

Phone a friend Use a normalizing explanation Act against the voices

(show them that you are

better than they say)

Exercise

Use rational responses to reduce anger

Use a relaxation tape List the evidence in favor of the voice content

Yoga List the evidence against the voice content

Warm bath

Use guided imagery to practice coping with the

voices differently

Call your mental health

professional

Role play for and against the voices

Best Practices in Schizophrenia Treatment (BeST) Center

Cognitive Behavioral Therapy for Psychosis (CBT-p)

Selected Resources

List of 60 Coping Strategies for Hallucinations

Distraction Focusing Meta-cognitive

Methods

Attend the day center/

drop in

Remind yourself that voices are not actions

and need not be viewed that way

Watch TV Remind yourself that the voices don’t seem to

know much

Do a crossword or other

puzzle

Remind yourself that you don’t need to obey

the voices

Play a computer game Talk to someone you trust about the voice

content

Try a new hobby Use rational responses to reduce shame

Use rational responses to reduce anxiety

Use a diary to manage stress

Use a diary to manage your time

Plan your daily activities the night before

Use a voice diary in a scientific manner

Mindfulness

Try an earplug (right ear first if right handed)

Working with Negative

Symptoms

Daily Schedule

Day/Time Planned Activity Actual Activity How it Felt

Pleasant 0-10:

Productive o-10:

Pleasant 0-10:

Productive o-10:

Pleasant 0-10:

Productive o-10:

Pleasant 0-10:

Productive o-10:

Day/Time Planned Activity Actual Activity How it Felt

Pleasant 0-10:

Productive o-10:

Pleasant 0-10:

Productive o-10:

Pleasant 0-10:

Productive o-10:

Pleasant 0-10:

Productive o-10:

Negative Symptoms: A diminishment of normal functioning – something that has been taken away.

According to the DSM-5:

Diminished emotional expression – “Reduction in the ability to express emotion in the face, eye

contact, intonation of speech and movements of the hand, head, and face that normally give an

emotional emphasis to speech.”

•

Appearing to lack emotion.

•

Decreased capacity for intimacy

•

A lack of warmth and thoughtfulness

Avolition – “A decrease in motivated self-initiated purposeful activities.”

•

Loss of interest in everyday activities

•

Reduced ability to plan or carry out activities

•

Neglect of personal hygiene

•

Social withdrawal

•

Loss of motivation

•

Diminished ability to focus

•

Reduced pride in taking a sense of responsibility

•

Apparent lack of willingness to follow a treatment plan when ill

Alogia – “Diminished speech output.”

Anhedonia – “The decreased ability to experience pleasure from positive stimuli, or a

degradation in the recollection of pleasure previously experience.”

•

Activity monitoring diary can be particularly helpful.

•

Have the client rate their sense of pleasure or contentment before, during, and after the

activity they have chosen. Because they have a hard time remembering pleasure they

experienced during an activity, they have a difficult time anticipating pleasure, so it is

important to highlight their responses to pleasurable activities.

Asociality – “An apparent lack of interest in social interactions and may be associated in

avolition, but it can also be a manifestation of limited opportunities for social interactions.”

•

Inability to read social signals such as body language

•

Social withdrawal

Negative symptoms are present with other psychotic disorders, but are particularly prominent with

schizophrenia. Diminished emotional expression and avolition tend to be the two negative symptoms

that are particularly noticeable with schizophrenia.

Positive symptoms: Behaviors not seen prior to the onset of the illness. These aspects of personality are

added as the illness progresses.

According to the DSM-5:

Delusions - Fixed beliefs that are not based in reality.

•

Are not changed in light of contradictory evidence

•

Subtypes include:

• Persecutory – beliefs that one is going to be harmed is the most common

• Referential – beliefs that certain comments, gestures, or cues are directed

at oneself

• Grandiose – believing that one has exceptional abilities

• Erotomanic – falsely believing that someone is love with him/her

• Nihilistic – believing that a major catastrophe will occur

• Somatic – preoccupations regarding health and organ function

•

Bizarre – if they are not plausible and not understandable to same culture peers, and

are not part of normal experience (e.g., “there is a chip in my brain”, or “some of my

internal organs are not my own”).

•

Thought withdrawal – “Someone or something has taken away my thoughts”

•

Thought insertion – “Someone or something as inserted thoughts into my brain”

•

Delusions of control – “I’m being acted upon or manipulated by some outside

force”

•

Non bizarre – Beliefs that do not have convincing evidence, such as “I’m under

surveillance by the police or the FBI.”

Hallucinations – “Perception like experiences that occur without external stimuli.”

•

Appear very real and have the impact of normal perceptions

•

Not under voluntary control

•

Can occur through any of the senses, but the most common is auditory

Not perceived as one’s own thoughts

ii.

Usually perceived as voices that can be familiar or unfamiliar

Disorganized thinking/speech – Difficulty speaking and organizing thoughts

•

May result in stopping speech in mid-sentence

•

Putting words together in meaningless ways (“word salad”)

Disorganized motor behavior – May show in a number of ways

•

Childlike silliness

•

Unpredictable agitation

•

May be noted in any type of goal directed behavior which can disrupt ability to

perform activities of daily living (ADLs)

Working with Delusions

Delusions Level 1

Delusions Level 2

Engagement

•

Make talking about beliefs safe

•

Find time and place that is safe

Gain understanding

•

What are client’s beliefs

•

Help client explore the many ways –

unassuming questions that explore how

client’s beliefs affect him/her

•

Don’t confront delusions

Improve daily living

•

Focus on reachable goals

•

Work on stress reduction and emotion

regulation

Relaxation

Activities tied to personal interests and

values

•

Try to improve sleep

Neutral, Curious stance

•

Suspend disbelief

•

Ask questions to help you understand – again,

unassuming questions

•

Small checks for flexibility of thinking

Re-focus on another activity, topic, goal if needed.

All of Level 1

Formal Assessments; Consider

•

PSYRATS

Explore using peripheral, unassuming questions

•

How does that work?

•

I’m curious…etc.

•

Ask eye-witness type questions

Who, what, when, where…

Consider impact of trauma

Develop a formulation

•

On what evidence are they basing thoughts

•

Given past history/experience, discover how

current beliefs make sense

Work with self esteem

•

Are they experiencing an unusual sensations?

Help them make sense of that

•

What cognitive errors might they be making

•

What behaviors keep the behavior going

Lower distress and improve coping

•

Stress reduction

•

Improve sleep

Belief modification - meta-cognitive methods

•

Alternate beliefs activity

•

Pie Chart activity

•

De-centering

•

Cost/benefit analysis of dwelling on a concern

of belief

•

Identify ways to check out new belief systems

Behavioral experiments

Reality testing

CBT-p methods for working with delusions (paranoia)



Engagement: Alliance building strategies such as conversations about neutral topics and look for

areas that client feels confident to tell you about (hobbies, interests, etc.)



Exploratory questions (peripheral and Socratic)- to gain understanding and help client to explore

belief objectively; explore clients’ goals and purpose and check to see if delusion causes

DISTRESS or INTERFERENCE with goals and purpose (this is key)



May use self-monitoring forms to organize experiences (thought, mood, physio record)



Formulation: Key information to be identified and reviewed with client (Freeman & Garety, 2006)

On what evidence are they basing their thoughts? Teach them how to explore how they

are making sense of their experience and to check evidence

Thinking about the person’s life and past experience, how do current concerns make

sense? Were they bullied or abused in their life? Would make sense that they would

expect others to be threatening.



Self-esteem concerns often underlie paranoid and suspicious beliefs. One target

may be to find ways to improve self-esteem in other aspects of their life

Is person responding to confusing or puzzling experience (e.g., physiological, odd

sensory experience). It is not uncommon for individuals to interpret unusual sensory

experiences (e.g., depersonalization; detachment; dizziness) as threatening or imposed.

Normalize and help client to develop alternative explanations for the experience.

How is the person reasoning about their experience (jumping to conclusions, leaving out

information, tendency to blame others for coincidental or chance events, or other

thinking error?). The most common reasoning error in paranoia is jumping to

conclusions (40-70%). Other key areas are over-estimating risk and assigning blame for

chance events. Educate clients re commonness of these thinking habits and practice

identifying this type of thinking in other aspects of their life.

What behaviors keep the thoughts going? Anxiety and worry; sleep loss? Avoidance or

other safety behaviors? Help client to modify these areas



When the person is well, what type of behaviors do they engage in?



Action phase: Lower stress and improve coping (in order to be more functional, less isolating)

Stress and anxiety reduction strategies

Improve sleep



Action phase: Belief modification:

Identify what it would mean for the client if the belief changed. What would be

better/worse?

Introduce idea of continuum (rather than all or nothing, maybe a scale of 0 – 100)

Generate alternative perspectives/explanations for experiences (can be organized with

pie chart, or other tool). Need to proceed carefully when considering alternative

explanations.

Identify ways to check beliefs and test new explanations or (Behavioral experiments/

Reality checks). Will need to help client make clear predictions and carefully evaluate

their predictions based on evidence, including how the client will interpret evidence that

supports and/or refutes their current belief.

Find ways to support new beliefs if they are more functional for the client

Freeman, D. & Garety, P. (2006). Helping patients with paranoid and suspicious thoughts: A cognitive-

behavioral approach. Advances in Psychiatric Treatment, 12, 404-415.

Special Topics

Suicide

•

50% suffer from comorbid substance use disorder

•

50% suffer from comorbid depression

•

10% suffer from comorbid anxiety disorder

•

Childhood adversity (ACEs) can be a causative factor in onset of

schizophrenia

•

Odds of suicide attempts are 6xs higher among those with schizophrenia

when compared with those w/o SZ; up to 15% commit suicide

•

Substance use and depression resulted in higher rates of suicide attempts

•

A comorbid anxiety disorder resulted in 70% less likely to attempt suicide

(better problem solving, communication, better skills to negotiate the world

•

Highest risk post discharge and in the first 90 days

100

Homicide

•

Those who commit a homicide are more likely to have delusional beliefs at the

time of the event

•

Delusional beliefs have been reported in 33-95% of murderers with MMD

•

This has more to do with the fear for his/her own life that is provoked by

the delusion – it is generally not about an intent to harm out of anger or

revenge

•

More likely to be committed when intoxicated at the time of the event

•

Important to pay attention to patients who are fatigued, in despair, delusional,

depressed, particularly when there is a lot of stress happening in client’s life

occurring

•

Ask about

•

Depression, delusion, chronic stress

•

Thoughts of killing children (in women with schizophrenia)

•

Specific perceived perpetrators (in men with schizophrenia)

101

Crisis Planning

Among the treatment team and other caregivers,

including family:

•

Decide how the plan will be triggered – What will that first person do?

•

Have a contact list ready (names and phone numbers) – therapists, case

managers, physicians, nurses

•

Put together an emergency crisis card that includes the list of contacts

•

Decide if a power of attorney needs to be identified

•

Decide what will trigger a 911 call

Adherence

103

Adherence factors:

PORTANCE

Generally, how important is it for you to take your medication(s) on a scale from 1 (not important) to 10

(very important)?

Why did you place yourself at that particular point on the scale?

hat would have to change for it to become more important for you to take your medication?

ONFIDENCE

Generally, how confident are you that you will take your medication as prescribed on a scale from 1(not

confident) to 10 (very confident)?

Why did you place yourself at that particular point on the scale?

hat would have to change for you to become more confident in taking your medication?

104

SATISFACTION

Generally, how satisfied are you with your medication on a scale from 1(not satisfied) to 10

(very satisfied)?

Why did you place yourself at that particular point on the scale?

What would have to change or be different for you to be more satisfied about your medication?

105

ADHERENCE SOLUTIONS CARD

Include dose and time of day that the medication is taken

hings I need to talk to my doctor about at my next appointment:

Record strategies that will help me to remember to take medication

(e.g., reminders- keep medication next to the coffee pot to remember

to take morning medication) in the box below:

eview the things that help me with taking medication (e.g., “the

benefits of medication are…”) and record them in box below:

Record ways that I can reward myself for taking medication and steps to

goals:

Box 1

Box 2: I would like the medicine to help me with:

So that I can reach my goal of:

Box 3

Box 4

Box 5

106

My Name: ___________________________________

I am at my best when I am doing the following:

________________________________________________________________________

_______________________________________________________________________

________________________________________________________________________

My Values and Goals:

Values: The most important things in my life are…

________________________________________________________________________

___________________________________________________________________

Goals For Recovery: I would like medicine to help with these goals

________________________________________________________________________

___________________________________________________________________

Inspired by: Deegan, P., Carpenter-Strong, E., Drake, R., Naslund, J., Luciano, A., Hutchinson, S. (2017). Enhancing clients’

communication regarding goals for using psychiatric medications. Psychiatric Services in Advance. doi: 10.1176/

appi.ps.201600418

107

Outcome Measures

BAVQ – R

108

CHADWICK, PAUL, LEES, SUSAN, BIRCHWOOD, MAX

The revised Beliefs About Voices Questionnaire (BAVQ-R)

(from The British Journal of Psychiatry 2000 177: 229-232)

There are many people who hear voices. It would help us to find out how you are

feeling about your voices by completing this questionnaire. Please read each

statement and tick the box which best describes the way you have been feeling in

the past week.

If you hear more than one voice, please complete the form for the voice which is dominant.

Thank you for your help.

Name: .....................................................

Age: .....................................................

Disagree

Unsure

Slightly

Agree

Strongly

Agree

My voice is punishing me for

something

I have done

My voice wants to help me

My voice is very powerful

My voice is persecuting me for no good

reason

My voice wants to protect me

My voice seems to know everything

about me

My voice is evil

My voice is helping to keep me sane

My voice makes me do things I really

don’t want to do

My voice wants to harm me

My voice is helping me to develop my

special powers or abilities

I cannot control my voices

My voice wants me to do bad things

My voice is helping me to achieve my

goal in life

109

My voice will harm or kill me if I

disobey or resist it

Disagree

Unsure

Slightly

Agree

Strongly

Agree

My voice is trying to corrupt or destroy

I am grateful for my voice

My voice rules my life

My voice reassures me

My voice frightens me

My voice makes me happy

My voice makes me feel down

My voice makes me feel angry

My voice makes me feel calm

My voice makes me feel anxious

My voice makes me feel confident

When I hear my voice, usually ...

Disagree

Unsure

Slightly

Agree

Strongly

Agree

I tell it to leave me alone

I try and take my mind off it

I try and stop it

I do things to prevent it talking

I am reluctant to obey it

I listen to it because I want to

willingly follow what my voice tells

me to do

I have done things to start to get in

contact with my voice

I seek the advice of my voice

Psychotic Symptom Rating Scale (PSYRATS)

110

PSYCHOTIC SYMPTOM RATING SCALES

A Auditory hallucinations

1 Frequency

Voices not present or present less than once a week

Voices occur for at least once a week

Voices occur at least once a day

Voices occur at least once an hour

Voices occur continuously or almost continuously i.e. stop for only a few seconds or minutes

Duration

Voices not present

Voices last for a few seconds, fleeting voices

Voices last for several minutes

Voices last for at least one hour

Voices last for hours at a time

Location

No voices present

Voices sound like they are inside head only

Voices outside the head, but close to ears or head. Voices inside the head may also be present

Voices sound like they are inside or close to ears and outside head away from ears

Voices sound like they are from outside the head only

4 Loudness

Voices not present

Quieter than own voice, whispers

About same loudness as own voice

Louder than own voice

Extremely loud, shouting

Beliefs regarding origin of voices

Voices not present

Believes voices to be solely internally generated and related to self

Holds < 50% conviction that voices originate from external causes

Holds ≥ 50% conviction (but < 100%) that voices originate from external causes

Believes voices are solely due to external causes (100% conviction)

Amount of negative content of voices

No unpleasant content

Occasional unpleasant content (<10%)

Minority of voice content is unpleasant or negative (<50%)

Majority of voice content is unpleasant or negative (≥ 50%)

All of voice content is unpleasant or negative

Psychotic Symptom Rating Scale (PSYRATS)

111

Degree of negative content

Not unpleasant or negative

Some degree of negative content, but not personal comments relating to self or family e.g.

swear words or comments not directed to self, e.g. ‘the milkman’s ugly’

Personal verbal abuse, comments on behavior e.g. ‘shouldn’t do that or say that

Personal verbal abuse relating to self-concept e.g. ‘you’re lazy, ugly, mad, perverted

Personal threats to self-e.g. threats to harm self or family, extreme instructions or commands to

harm self or others

Amount of distress

Voices not distressing at all

Voices occasionally distressing, majority not distressing (<10%)

Minority of voices distressing (<50%)

Majority of voices distressing, minority not distressing (≥50%)

Voices always distressing

Intensity of distress

Voices not distressing at all

Voices slightly distressing

Voices are distressing to a moderate degree

Voices are very distressing, although subject could feel worse

Voices are extremely distressing, feel the worst he/she could possibly fee

Disruption to life caused by voices

No disruption to life, able to maintain social and family relationships (if present)

Voices causes minimal amount of disruption to life e.g. interferes with concentration although

able to maintain daytime activity and social and family relationships and be able to maintain

independent living without support

Voices cause moderate amount of disruption to life causing some disturbance to daytime

activity and/or family or social activities. The patient is not in hospital although may live in

supported accommodation or receive additional help with daily living skills

Voices cause severe disruption to life so that hospitalization is usually necessary. The patient is

able to maintain some daily activities, self-care and relationships while in hospital. The patient

may also be in supported accommodation but experiencing severe disruption of life in terms of

activities, daily living skills and/or relationships

Voices cause complete disruption of daily life re9uiring hospitali6ation. 8he patient is unable to

maintain any daily activities and social relationships. Self-care is also severely disrupted.

Controllability of voices

subjec5t believes they can have control over the voices and can always bring on or dismiss them

at will

Subject believes they can have some control over the voices on the majority of occasions

Subject believes they can have some control over their voices approximately half of the time

Subject believes they can have some control over their voices but only occasionally. The

majority of the time the subject experiences voices which are uncontrollable

Subject has no control over when the voices occur and cannot dismiss or bring them on at all

Psychotic Symptom Rating Scale (PSYRATS)

112

B Delusions

Amount of preoccupation with delusions

No delusions, or delusions which the subject thinks about less than once a week.

Subject thinks about beliefs at least once a week

Subject thinks about beliefs at least once a day

Subject thinks about beliefs at least once an hour

Subject thinks about delusions continuously or almost continuously

Duration of preoccupation with delusions

No delusions

Thoughts about beliefs that last for a few seconds, fleeting thoughts

Thoughts about delusions last for several minutes

Thoughts about delusions last for at least 1 hour

Thoughts about delusions usually last for hours at a time

3 Conviction

No conviction

Very little conviction in reality of beliefs, < 10%

Some doubts relating to conviction in beliefs, between 10-49%

Conviction in belief is very strong, between 50-99%

Conviction is 100%

Distress

No distress

Beliefs cause slight distress

Beliefs cause moderate distress

Beliefs cause marked distress

Beliefs cause extreme distress, could not be worse

Disruption to life caused by beliefs

No disruption to life, able to maintain independent living with no problem in daily living skills.

Able to maintain social and family relationships (if present)

Beliefs cause minimal amount of disruption to life, e.g. interferes with concentration although

able to maintain daytime activity and social and family relationships and be able to maintain

independent living without support

Beliefs cause moderate amount of disruption to life causing some disturbance to daytime

activity and/or family or social activities. The patient is not in hospital although may life in

supported accommodation or receive additional help with daily living skills

Beliefs cause severe disruption to life so that hospitalization is usually necessary. The patient is

able to maintain some daily activities, self-care and relationships while in hospital. The patient

may be also be in supported accommodation= but experiencing severe disruption of life in

terms of activities, daily living skills and/or relationships

Beliefs cause complete disruption of daily life requiring hospitalization. The patient is unable to

maintain any daily activities and social relationships. Self-care is also severely disrupted.

113

Name: ......................................................

RAS-DS (Recovery Assessment Scale – Domains and Stages)

Instructions: Below is a list of statements that describe how people sometimes feel about themselves and

their lives. Please read each one carefully and circle the number to the right that best describes you at the

moment. Circle only one number for each statement and do not skip any items.

DOING THINGS I VALUE

UNTRUE

A bit

TRUE

Mostly

TRUE

Completely

TRUE

It is important to have fun

It is important to have healthy habits

I do things that are meaningful to me

I continue to have new interests

I do things that are valuable and helpful to others

I do things that give me a feeling of great pleasure

LOOKING FORWARD

UNTRUE

A bit

TRUE

Mostly

TRUE

Completely

TRUE

I can handle it if I get unwell again

I can help myself become better

I have the desire to succeed

I have goals in life that I want to reach

I believe that I can reach my current personal goals

I can handle what happens in my life

I like myself

I have a purpose in life

If people really knew me they would like me

If I keep trying, I will continue to get better

I have an idea of who I want to become

Something good will eventually happen

I am the person most responsible for my own improvement

I am hopeful about my own future

I know when to ask for help

Recovery Assessment Scale – Domains and Stages (RAS-DS – Research Version 3).

Not to be copied or used for any other purpose without written permission from the author

(nicola.hancock@sydney.edu.au)

114

LOOKING FORWARD (continued)

UNTRUE

A bit

TRUE

Mostly

TRUE

Completely

TRUE

I ask for help, when I need it

I know what helps me get better

I can learn from my mistakes

MASTERING MY ILLNESS

UNTRUE

A bit

TRUE

Mostly

TRUE

Completely

TRUE

I can identify the early warning signs of becoming unwell

I have my own plan for how to stay or become well

There are things that I can do that help me deal with

unwanted symptoms

1 2 3 4

I know that there are mental health services that help me

Although my symptoms may get worse, I know I can handle it

My symptoms interfere less and less with my life

My symptoms seem to be a problem for shorter periods of

time each time they occur

1 2 3 4

CONNECTING AND BELONGING

UNTRUE

A bit

TRUE

Mostly

TRUE

Completely

TRUE

I have people that I can count on

Even when I don’t believe in myself, other people do

It is important to have a variety of friends

I have friends who have also experienced mental illness

I have friends without mental illness

I have friends that can depend on me

I feel OK about my family situation

Recovery Assessment Scale – Domains and Stages (RAS-DS – Research Version 3).

Not to be copied or used for any other purpose without written permission from the author

(nicola.hancock@sydney.edu.au)

115

THE RECOVERY ASSESSMENT SCALE – DOMAINS AND STAGES (RAS-DS)

•

Untrue • Mostly true

•

A bit true • Completely true

•

Doing Things I value

– Personal, not societal values

•

Looking Forward

–

Viewing self outside context of illness

–

Hopeful for the future

•

Mastering My Illness

–

Focus on control and management of symptoms, not amelioration of

symptoms

•

Connecting and Belonging

–

Greater diversity in social relationships

–

Family and broader communities

–

Reciprocated and personally satisfying

38 items with Likert scale with 4 rating categories from:

Four recovery domains

You can use one section at a time, or all sections at the same time. It’s up to you

and wheat you believe your client needs.

Find the free manual and workbook online at https://ras-ds.net.au/

“Or type in RAS-DS My mental health recovery measure” in your browser to get complete

instructions and workbook for use with clients

Nicola Hancock et al., 2014 If you choose to use the RAS-DS, please email Nicola at:

nicola.hancock@sydney.edu.au. She will automatically send you updates as they are created.

116

Name: Rating interval: B, 3, 6, 9, 12 Date:

DIALOG

Totally

Dissatisfied

Very

Dissatisfied

Fairly

Dissatisfied

In the

middle

Fairly

Satisfied

Very

Satisfied

Totally

Satisfied

Additional help

Wanted? Yes/no