Responding to Stressors and Building Resilience in Individuals with Schizophrenia
By Aaron T. Beck, MD
Throughout their lives, individuals with schizophrenia have been subjected not only to an unusual amount of negative traumatic events, but also to many minor stressors, reflecting society’s attitude that they are “maladjusted.” The resulting impact of these major stressors and/or the accumulation of minor stressors on the self-esteem is that these individuals develop a picture of themselves as worthless, useless, ineffective, and helpless. As they become psychotic, this baggage of negative self-attitudes and attitudes towards and beliefs about others’ image of them becomes exaggerated and they tend to withdraw from any productive activities, including associations with other people. Thus, the individual may have the thought, “I am worthless,” in response to frustrations on the job; “I am useless,” to slurs from other people; “I am unlikable,” to others’ social rejection; and, “I am unsafe and vulnerable,” from others’ intimidation. Also, they tend to feel helpless when they are being controlled.
The key element in developing resilience is focusing on the meanings that the individual attaches to the major or minor stressors. The meaning may be unraveled by elucidating the negative automatic thought or by directly asking the individual what meaning he or she attaches to the event. Meaning may also be extrapolated from auditory hallucinations (e.g., voices saying, “You are stupid… weak… useless… worthless”). In any event, the impact of the dysfunctional meaning is observable in the individual’s reaction. These reactions can take the form of maladaptive behaviors (such as regression and total passivity, avoidance and inactivity), or hostile reactions (including getting into fights), or self-harm (such as swallowing objects or lacerating the self).
To insulate the individual against such reactions, it is useful to conduct a chain analysis of the sequence. This chain analysis can then be used to reframe the meaning of the event and change the reaction to the event from dysfunctional to more functional. Once the sequence of self-derogatory meanings and the dysfunctional behavior are explicated, it may be feasible to conduct a role play in which the individual rehearses the reaction, and then subsequently a different, more adaptive reaction. Additionally, it may be helpful to the individual to mobilize some common phrases such as, “When you’re in a hole, stop digging,” “Don’t make a mountain out of a molehill,” “You have to make mistakes in order to find the right path,” etc.
Through the general course of treatment, the individual’s resilience becomes enhanced. Also, the byproducts of the therapeutic program— namely increases in the individual’s sense of safety, worthwhileness, efficacy, connection, and power— work to further amplify and maintain resilience. Thus, when the individual is subjected to minor traumas, the hurt to their self-esteem may be neutralized by the individual’s having built up resilience in the form of a number of positive beliefs about themselves, allowing for more rapid recovery. Also, the individual is less likely to misinterpret other people’s attitudes and situations, and instead activate learned principles such as correction of misinterpretations and other cognitive biases.