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New Breakthroughs in Cognitive Therapy: Applications to the Severely Mentally Ill (Part 3)

Aaron T. Beck, MD 
Note: This article summarizes Aaron Beck’s interview with Judith Beck at the Evolution of Psychotherapy Conference in Anaheim, CA, December 16, 2017, for which he received a standing ovation from over 7,000 conference participants.

Read Part 1 and Part 2.

A Case Illustration

When we work with individuals with schizophrenia who have been hospitalized for many years, we need to find out what their needs are. We are often able to draw on their delusions. For example, six inpatients had delusions that they were God or Jesus. In our attempts to find out what the delusions could tell us about the individuals’ needs, we asked the question, “What is good about being God?” We got a number of answers which then provided very strong clues regarding the individuals’ aspirations and needs.

To our surprise, several of the individuals responded to the question, “What is good about being God?” by saying, “You can help people.” This gave us the beginning of the pathway to a formulation and action plan. One of the individuals responded that if he were God, he would live forever. This pointed to the individual’s fear that he was suffering from a fatal disease and that he would die soon. Thus, living forever was protection from dying. Another individual replied, “I can control heaven and earth and all the planets.” This led to a discussion about the individual’s feeling that he had no control over his life. His delusion served a purpose: to compensate for lack of control. His action plan was to start a library on the unit. This gave him control over the books and some sense of control over the borrowers of the books, since they were obligated to return the books at a specific time, and the individual would remind them of this. The delusions served as a compensation for feelings of being insignificant, devalued, and helpless, thus providing a link to a treatment plan.

We also found that bizarre behavior and beliefs provided information we could use to formulate our treatment plan. A man in a structured residence would ask the male attendants to inseminate him. Although at first this was a source of amusement to the staff, they eventually simply ignored him. As a result, he became more persistent. Our therapist made contact with him, and after establishing a connection, the patient asked, “Would you inseminate me?” The therapist then asked our standard question, “What would be good about being inseminated?” The individual responded that he would then have a baby or a number of babies. In response to a question regarding the value of having a baby, the man said that he would feel important, have someone to take a care of, and have a friend. Next, the therapist asked, “When you think of being important or having a friend, what feelings do you get?” The individual responded by saying, “I feel good, secure, and comfortable.” The therapist then asked, “Do you recall ever feeling this way before?” The individual replied, “I once had a dog named Rex. We were great friends. I took good care of him, went for walks, I cleaned him up when I needed to, and in general we were very close. When I came home from school, he would start to bark and greet me at the door.”

The idea of having a dog transformed the clinical approach to this individual. The members of the staff started to collect pictures of dogs from calendars and other illustrations and pasted them on the wall. As the individual became more involved with animals, he started to talk about making this his career. Incidentally, he stopped talking about being inseminated. In less than a year, he began making a few trips to an animal shelter. Then he was ready to be discharged and indeed did get a position at an animal hospital. Interestingly, he eventually made friends with the other personnel. The point of all this is that by satisfying a basic need, the individual was able to progress into more realistic planning and thinking.