The Principles of Recovery and Values in CBT
A Case Example with Aaron T. Beck, MD.
The following is a description of a consultation Dr. Beck had with an individual who has schizophrenia. Mary is a 47-year old woman who is upset about hearing voices (and hackers who will not leave her alone). She is divorced, unemployed, and somewhat hopeless. She has a good relationship with her 13-year old son.
At the beginning of the consultation, Mary is visibly upset. Dr. Beck starts by doing a mood check. Next, he asks her about some recent times when she felt good. Mary describes feeling relieved when she finally told her son she had schizophrenia. Dr. Beck reinforces the positive feelings, praising her, and asking whether this showed she was able to do difficult tasks. As he continues to ask about other positive experiences, Mary’s mood shifts, her face brightens, and she starts to open up to him more and more. As the session progresses, Mary moves into an adaptive mode of functioning, with clear thinking and communication.
Mary worked in sales prior to the onset of her hallucinations four years before. Her aspiration is to return to work, but she is worried about her voices. When Dr. Beck conversationally inquires, "What would be good about having a job?" she lists income, a better house and education for her son. He helps her realize that other good aspects would be a feeling of success and greater confidence. Dr. Beck summarizes her experience in common parlance: “I think you’ve lost your confidence,” a beautiful, humanistic description of her difficulties, which gives her hope that she can improve her life.
Throughout the session, Dr. Beck shows empathy and concern, while instilling hope in Mary by brainstorming: "How can we build your confidence, so you can do other things?" Among her other aspirations are reading and being free from the voices, which again brings her back to her greater aspirations of returning to work and being a better mother. Dr. Beck asks, “Can we make this our destination?" This demonstrates to her that he has hope and wants to be a partner in her recovery. It also normalizes Mary’s experiences, and indicates that these aspirations will require some time and effort. Dr. Beck asks Mary to expand on her aspirations and guides her in creating visual images of herself and her son in a new house and at her son's graduation from college. It is apparent that these images are boosting her sense of hope.
Dr. Beck asks Mary what would bring her closer to her aspirations, Mary refers to being free of the voices. With Dr. Beck's redirection, she realizes that her first steps would be to continue her education and obtain references.
Dr. Beck skillfully provides other important redirections. For example, Mary expresses a wish: “If only someone would believe in me." Dr. Beck points out: "It’s important to believe in yourself." Mary found this inspiring and she liked the idea that she would play a role in her own destiny. Mary and Dr. Beck agree on focusing on the future and improving her confidence (for example, by recording her daily successes, no matter how small). The consultation improved Mary’s mood and she now feels more empowered to have a new identity separate from her illness.