Activitas Nervosa Superior Rediviva Volume 52 No.

2 2010

PSYCHOTHERAPY

Narrative Cognitive Behavior Therapy for Psychosis

Jan Prasko 1,2,3,4, Tomas Diveky 1,2, Ales Grambal 1,2, Dana Kamaradova 1,2,
Klara Latalova 1,2, Barbora Mainerova 1,2, Kristyna Vrbova 1,2, Aneta Trcova 1,2
1 Department of Psychiatry, University Hospital Olomouc; 2 Faculty of Medicine, University Palacky Olomouc;
3 Prague Psychiatric Centre; 4 Centre of Neuropsychiatric Studies, Czech Republic.

Correspondence to: Assoc. Prof. Jan Prasko, MD. CSc., Department of Psychiatry, University Hospital Olomouc,
I.P.Pavlova 6, 77520 Olomouc, Czech Republic. email: [email protected]

Submitted: 2010-06-15 Accepted: 2010-07-15 Published online: 2010-09-29

Key words: narrative therapy; cognitive behavioral therapy; psychosis

Act Nerv Super Rediviva 2010; 52(1): 135–146 ANSR52010A04 © 2010 Act Nerv Super Rediviva

Abstract Several controlled studies indicate that cognitive behavioral interventions, in conjunction
with antipsychotic medication, reduce positive psychotic symptoms in acute as well as
chronic schizophrenia. However, a recent review found that CBT did not reduce relapse
and readmission compared to standard care. Nevertheless there is a need for searching
for new ways for the CBT therapy for acute psychotic patient. A central claim of narrative
therapy is to “narrate” our lives. It means that we form narratives of the past and future
these narratives do not only describe but also affect our lives. Psychotic patients have
problem-saturated stories and the aim of the therapeutic work is both to articulate negative
story and its effects upon the person and then to move on to the constructing and pre-
ferred narrative with more positive view on the story and consequently on the self, others
and the world. The CBT approach from Padesky has been adapted in narrative cognitive
behavioral therapy to use with most patients suffering from psychosis. Patients are asked to
state any negative beliefs they have about themselves, others, and world, and then are asked
to describe how they would prefer all these things to be. In narrative cognitive behavioral
approach the therapist searches, yields to surface and stabilize stories that don’t support
patients troubleshooting experiencing of the reality, develop alternative stories that lead
to new view of things, positive change of themselves – conception and to problem solving
that is in contemporary context detected.

Introduction
Psychosis consists of a combination of an individual’s process of growth and change that typically embraces
unique genetic, neurobioligical, psychological, and hope, autonomy, and affiliation as elements of estab-
environmental factors. The course fluctates and varies lishing satisfactory and productive lives in spite of
widely, often with remission and relapse cycles. Recent disabling conditions and experiences. Although
research indicates that about two thirds of all affected pharmacological treatment remains the front-line
will recover or substantially improve with treatment treatment for schizophrenia (Lehman et al. 2004),
(which includes both medication and psychosocial limitations such as noncompliance and persistent
approaches). Recovery is an arduous biological, psy- residual positive symptoms have led researchers to
chological, and social journey – a gradual process seek out ancillary treatments (Fenton et al. 1997). In
of restoring connections and health. It is a personal this regard, cognitive-behavioral therapy (CBT) has

Act Nerv Super Rediviva 2010; 52(2): 135–146

 Jan Prasko, Tomas Diveky, Ales Grambal, Dana Kamaradova, Klara Latalova, Barbora Mainerova, Kristyna Vrbova, Aneta Trcova

proven to be an effective strategy in the treatment of Cognitive Behavioral Therapy For

positive and negative symptoms of schizophrenia (Far- Schizophrenia
hall et al. 2007; Pilling et al. 2002; Newton et al. 2005).
Unfortunately, CBT is not widely accessible to persons Cognitive behavioral therapy (CBT) for schizophre-
with schizophrenia. This has prompted researchers to nia focuses on the core psychotic symptoms of hal-
examine more efficient ways of delivering this interven- lucinations and delusions (Farhall et al. 2007). The
tion, such as group therapy (Mueser & Noordsy 2005), observation that symptoms of schizophrenia may
which has comparable effect sizes to individual CBT be subjectively experienced as a stressor, and trigger
for psychosis (Wykes et al. 2008). Group CBT for audi- coping actions, is as old as the disorder itself (Jaspers
tory hallucinations has been shown to reduce negative 1913/1963), although scientific study of coping has
beliefs about voices (and voice severity) in a pilot open only emerged in the past two decades. Evidence that
trial (Pinkham et al. 2004), to reduce the distress asso- coping strategies for chronic voices can be learned has
ciated with auditory hallucinations in individuals early led to their inclusion in cognitive behavior therapy for
in their psychotic illness relative to wait-list controls psychosis treatments, and has stimulated their dissemi-
(Newton et al. 2005), and to reduce overall symptoms nation by training programs (Tarrier et al. 1998), and
and auditory hallucinations, and increase insight in a by the self-help literature (Baker 1996; Watkins 1993).
chronically ill sample (Wykes et al. 1999). However, The CBT approach to psychotic symptoms comprises
these findings were not replicated in a follow-up study two different stands each with their own theoretical
that compared group CBT to treatment as usual, instead basis, although both of late these two approaches have
finding that CBT was associated with improved social become conjoined in practice:
functioning (Wykes et al. 2005). The first approach – coping strategy enhancement
Stories, experiences and behavior of psychotic – is inspired by the stress-vulnerability model of psy-
patients place the truth to both conceptions. Many chosis. It is assumed that stressors capable of trigger-
aspects of illness can be known only from direct expe- ing or exacerbating symptoms may be generated or
rience. The narratives of those who have recovered modulated by the individual (e.g. stressors emanating
from psychosis come from voices not often heard. Like from the social environment are modulated by the
chronic pain, psychosis is often a silent, inner, and invis- patient’s own appraisal of their stressfulness and their
ible experience that leaves observers guessing. Psychotic coping strategies. Another class of stressors consists of
patients construct reality their original way, his story is the symptoms themselves. It is assumed that certain
sincerely subjective and not clearly understandable for strategies used to cope with symptoms are unhelpful
others, however at the same time we’re able to disclose, and generate stress in the individual, on the contrary
which way the subjective stories were build and why the exacerbating symptoms. These strategies are conven-
exact experience and behavior had come. The psychotic tionally divided into affective strategies (e.g. relaxation,
people are facing the truth that these metamorphoses sleep, etc.), behavioral strategies (drinking, being active,
are not so correspondent with other people demands etc.), and cognitive strategies (distraction, challenging
and that their world can be relatively inflexible and ste- voices, switching attention away from voices, etc.). This
reotypical, without any dependence on individual and underpins the approach known as Coping Strategy
family needs, or are incomprehensible to others. Nev- Enhancement (Tarrier et al. 1998) whereby patients are
ertheless it is possible to find the connection with the offered a range of strategies which are implemented in
life story, actual context and content of the symptoms. an empirical fashion to determine their effectiveness in
Narrative psychotherapy and cognitive behavioral the symptom control. This approach regards the indi-
therapy are seemingly nonintegrating psychothera- vidual as an active agent who attempts to reduce the
peutic approaches which differ in the basic philosophy threat of distress posed by psychotic symptoms, but
of the man. While narrative psychotherapy is based does not concern itself with the content or meaning that
on social constructivism with circular causality and psychotic symptoms may have to the individual. There
conviction, that people construct their stories and is also assumed to be a fundamental discontinuity
consequently their behaviour based on subjectively between normal and abnormal functioning that comes
experienced world, cognitive behavioural therapy about once the biological vulnerability is “online”.
stresses objective reality with its linear causality, in The second CBT strand draws its theoretical
which consequences governs the probability of mal- strength from the cognitive therapy approach (Beck et
adaptive behaviour repeating. Cognitive behavioural al. 1979). Birchwood and Chadwick (1997) showed that
therapy also stresses the subjective aspect of experience, delusions, like everyday beliefs, lead the individual to
because according to the theory, the cognition (subjec- recruit evidence to support them and to de-emphasize
tive thoughts, rules, assumptions) have the main impact or dismiss contradictory evidence. Authors argued that
on the consequent emotions and behavior. This cogni- certain beliefs about voices´ power may be considered
tion is formed according to the experienced life stories. as a quasi-rational response to anomalous experience.
Other work has drawn on the cognitive approach
in depression, which emphasizes the importance of

136 Copyright © 2010 Activitas Nervosa Superior Rediviva ISSN 1337-933X

 Narrative CBT for psychosis

evaluative beliefs about the self, in the genesis and about ourselves by imaginative listening to our own
maintenance of depressed mood (Garety et al. 1994). thoughts through the ears of the other. At the begin-
The application of this to psychosis also emphasizes ning of life, we need a witness to become a self. Later,
evaluative beliefs about the self. Delusions may serve patients listen to themselves as they imagine their
the function of defending the individual from the full therapist and group hear them, and in this way create
impact of low self-worth through blaming others for new narrative freedom (Stern 2009). Certain dominant
negative events rather than the self. The content of psy- narratives play a bigger role than other narratives in
chotic thinking often reflects such personal issues. In organizing perceptions, thoughts, and actions. All what
the cognitive model of psychosis (Garety et al. 2001) happened in the childhood, at the school and what
positive symptoms are hypothesized to begin with basic is happening in the present situation all the time has
cognitive disturbances leading to ambiguous sensory the influence on human approaches and subsequently
input, the intrusion into consciousness of unintended behaviour. The social, interpersonal and intrapsychical
material from memory, or to difficulties with the self- world of every person has developed in interactions
monitoring of intentions and actions, then they are with others, especially with significant others, as well
experienced to be alien. This result in anomalous con- as in interactions with institutions, and it is always in
scious experiences such as action being experienced as these interactions confirmed.
unintended, racing thoughts, thoughts appearing to be The main contribution of narrative psychotherapy to
broadcast, and thoughts experienced as voices. How- the field of psychosis has been the role of the life story in
ever, the authors argue that such anomalous experiences the development of theoretical and empirical approaches
alone do not develop into full-blown psychotic experi- to the psychotic patients. It presumes that individual’s
ences unless an individual appraises them as externally thinking and acting is based on the stories, which have
caused and personally significant. Such appraisals are an external structure and an internal reality. Individuals
the results of dysfunctional personal schemas (e.g. low retell their stories as they progress through their lives to
self-esteem born of adverse social experience), emo- make sense to them, and from a sociological perspec-
tional states, and appraisal of the experience of illness. tive. This retelling when carried out publicly provides
Several controlled studies indicate that cognitive considerable insights into various aspects of an indi-
behavioral interventions, in conjunction with antipsy- vidual’s experience of psychosis across the life course.
chotic medication, reduce positive psychotic symptoms A central claim of narrative therapy is that we “nar-
in acute as well as chronic schizophrenia. A review (Tar- rate” our lives: that we form narratives of the past and
rier & Wykes 2004) reporting the analysis of 19 CBT of future, and that these do not only describe our lives but
positive symptoms studies found the mean effect size might also influence our lives (Rhodes & Jakes 2009).
of 0.37. While present evidence does support the use For example, after a psychotic episode a patient may
of CBT led interventions in adjunctive management of form a narrative (assumption) to be the case of this
schizophrenia, the research is flawed and further, well episode – “I must be weak”. When this narrative is
controlled studies are necessary to determine a precise believed, they can stop the school or job, stop meet with
role of CBT. With regard to relapse prevention, CBT the friends etc. Patient with schizophrenia have prob-
appears to be more successful when the intervention lem-saturated stories and the aim of therapeutic work
is focused on relapse prevention, rather than relapse is both to articulate the negative story and its impact
prevention being on of a series of components (Tarrier upon the patient and then to move on to constructing
& Wykes 2004). However, a Cochrane review (Jones the alternative narrative with the patient. This can be
et al. 2004) found that CBT did not reduce relapse developed in many ways, but often involves describ-
and readmission compared to standard care (though ing events of characteristics that somehow do not fit
it did decrease the risk of staying in hospital). There the negative story (White 2004). It is sometimes useful
are shown in followed analysis that the results are due to investigate the origin of important narratives. The
the mixing the studies for chronically ill and studies therapist might discuss with the patient how such ideas
for acutely ill. The effect sizes for CBT versus standard have entered into the patient’s life.
treatment among patients with chronic illness were Stories offer insight, understanding, and new per-
greater than those among acutely ill patients. Neverthe- spectives. They educate us and they feed our imagina-
less there is a need for searching for new ways for the tions. They help us to see other ways of doing things
CBT therapy for acute psychotic patient. that might free us from self-reproach or shame. Hear-
ing and telling stories are comforting and bonds people
Narrative Psychotherapy together (Divinsky 2007). Story is one of the most
potent containers for meaning (Gold 2007). Narrative
Narrative has been characterized by the way individu- – a form of personal storytelling – represents a funda-
als use language connected to various psychological mental mode of thought, a way of ‘‘ordering experience’’
processes, such as memory, emotion, perception, and and ‘‘constructing reality.’’ Narrative gives meaning
meanings (Angus & McLeod 2004; Goncalves et al. to personal experiences, and through narrative the
2004). Even in the absence of others around, we learn speaker discloses personal forms of thought and feel-

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 Jan Prasko, Tomas Diveky, Ales Grambal, Dana Kamaradova, Klara Latalova, Barbora Mainerova, Kristyna Vrbova, Aneta Trcova

ing. Narrative also allows the individual to construct cal memory. The process of re-establishing a sense of
order from the disorder and chaos that sometimes coherence after trauma relies on the capacity for coher-
plague our daily lives and to come ‘‘to terms ... with a ent narration. This capacity is decreased in schizo-
problematic experience’’ (Jackson 2002). But narrative phrenic patients. Narrative approaches have become a
renderings are not simply free-flowing, disconnected significant means of understanding human experience
and largely incoherent ramblings. Rather, they tend in difficult circumstances, such as illnes and trauma
to be shaped by detailed, cultural, and often context- (Becker et al. 2000; Foxen 2000). The emotional injury
specific cognitive schemas, ‘‘interpretative processes, or trauma disrupts the person’s narrative processing
integral to the constructive nature of cognition, which (Wigren 1994). The victimization (and also psychotic
mediate our understanding of the world,’’ according to experiences, stigmatization and self-stigmatization)
Garro and Mattingly (2000). Schemas, they continue, creates a massive discontinuity in the person’s life nar-
‘‘are involved in conveying the specifics of a given story rative and meaning-making processes, breaking the
but also supply the narrative structures that character- previously unitary life narrative into pre and post-
ize stories more generally.’’ victimization stories. In addition, the trauma narrative
Anthropologists integrate the contextual nature of itself is likely to contain “narrative defects” (Wigren
the patients´ view; but they still largely envision the psy- 1994) in the form of memory gaps and explanatory
chiatric patient as a rational actor producing narratives discontinuities. The result is that the person’s trauma
based on common sense. However, in psychiatric prac- narrative neither sticks together as a story itself nor
tice, the client’s perspective is not something the patient fits with the interrupted pre-victimization story. Par-
individually produces; it is rather shaped by and in a ticular features of a situation, sometimes with only
context (Lovell 1997; Velpry 2008). Psychiatric patients, a remote similarity to those in the original traumatic
however, besides their immediate suffering, also suffer event, may elicit and evoke similar feelings. It is often
the consequences of being narrated as “outsiders” and useful for patient to retell stress and trauma-related sto-
as not as “rational” as others (Harper 2004). If patients ries more than once in the course of therapy, because
are ‘‘too independent,’’ they risk being discredited as the story will change over time as the patient comes
‘‘irresponsible’’. If they don’t show enough indepen- to trust the therapist more, as he or she accesses addi-
dence, they appear to be too passive and therefore‘‘too tional memories and as the meanings of the events in
sick to get well.’’ the story evolve and become clearer. In trauma retell-
ing the therapist tries to slow down patient’s recitation,
Narrative, Stress And Trauma dwelling on the details of the story, letting them sink
in, and sometimes asking the patient to back up and go
While some families might be negative in their style of over some things again. At the same time when work-
interaction, considerable evidence suggests that some ing with deeply painful experiences, the therapist allows
families engage in physical, emotional, and sexual himself to be moved by the story the patient is telling,
abuse, and that this might a very important contri- expressing this in a gentle, affirming manner. Using
bution to psychosis (Read et al. 2004). Many studies narrative unfolding responses, the therapist actively
have investigated reported abuse and 40% to 70% of helps the patient build exact, visual, and even physical
psychotic patients report having been abused as chil- representations of the traumatic event. As the patients
dren. There is o full range of possible mistreatments, recreate the traumatic situation, they begin to remem-
including sexual abuse, excessive violence to children, ber and re-experience painful and difficult events. The
inssufficient feeding or protection, exposure to rejec- therapist can encourage this by asking questions about
tion, humiliation, and neglect. Some patients have also the patient’s feelings, by using evocative reflections and
experienced cruel and persistent bullying at school. In by listening for and poignant elements of the narrative.
addition to abuse in childhood there is also evidence Through dwelling on the traumatic event, the patient
that adults with psychosis suffer an increase of negative gradually becomes more aware of additional aspects
events before the onset of psychosis (Bebbington et al. of the trauma and what it meant. The therapist listens
1996) and suffer very elevated levels of trauma related for, and supports these emerging new experiences and
to problems such as domestic violence and other forms meanings. The resolved retelling is a relatively complete
of assault (Mueser et al. 2004). narrative experienced by the patient as making sense or
Traumatic memories are characteristically not acces- fitting together, with a clear point or overall meaning for
sible to intentional recall nor integration into the matrix the patient (Wigren 1994). Resolved retelling may also
of autobiographical memory. Formally correct narra- be marked by an indication form the patient that he or
tives are characterized by three functions: orientation, she has developed a greater awareness or understand-
reference and evaluation. Through so-called “memory ing of the story. Another important function of helping
talk” with socio-culturally competent partners, children patients explore their emotional reactions to traumas
learn how to reconstruct memories and to represent is that it can help them get in touch with their needs
experience by narration. It is therefore suggested that and goals so that they can develop alternative ways of
narratives are the basic ingredient of autobiographi- meeting them in the present and future (Greenberg &

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 Narrative CBT for psychosis

Paivio 1997). It is important to help patients re-exam- The narratives that emerge, both in detail and in
ine and re-evaluate their actions during the trauma so meaning, cannot be seen as simple reflections of any
that they can begin to recover a sense of mastery. The single individual’s life but, instead, as composites
objective is to help them develop safety zones in their built on, and reflective of, cultural processes some-
world while also protecting themselves by being more what unique to the psychiatric context. Narrative, a
aware of their limits and the possible dangers they face fundamental mode of thinking and communication,
(Elliot et al. 1998). Re-experiencing is neither an exact necessarily challenges the directed nature of autobio-
reproduction of the original experience nor a “fabrica- graphical presentation derived from CBT. Using nar-
tion” instead; it is a reenacted synthesis of recall and rative metaphor is leading to the suggestion that the
imaginative reconstruction of experience. experiences of people suffering from psychosis, are
Meaning creation work is an important tool for purposeful and formed on the base of their life stories.
the patient facing painful life crisis, including cur- The social and interpersonal experiences have strong
rent and past trauma and loss. In such work, patients impact on schizophrenic patients´ perception of them-
often raise existential questions about the meaning of selves (self schemas), others (schemas about others)
what has happened to them. Traumas sometimes act as and the world (schemas about world) and have a strong
“limiting situations” in which patients directly encoun- impact on both the character of their abnormal psy-
ter major existential issues (Yalom 1980), which may chotic experiences and also to their strong human fea-
include the possibility of their own or someone else’s tures. The CBT approach from Padesky (1994) has been
death, a painful awareness of issues of powerlessness adapted in narrative cognitive behavioral therapy to use
and responsibility, and existential isolation in the form with most patients suffering from psychosis (Rhodes
of abandonment by potentially helpful others. Clarke & Jakes 2009). Patients are asked to state any negative
(1991) referred to these central assumptions as “cher- beliefs they have about themselves, others, and world,
ished beliefs”. Cherished belief include implicit, previ- and then are asked to describe how they would prefer
ously taken for granted assumptions, that the world is all these things to be. For example, patient might say
sensible or just, that we are invulnerable or worthy, or “I am weak!” and would prefer “I am strong enough!”
that others will always be there to provide support or Number of techniques can be used to build upon the
protection (Janoff-Bulman 1992). Resolution of such preferred option: for example, asking the patient to
meaning crises occurs when the patient makes changes collect any evidence of being “strong enough”, asking
in the cherished belief or beliefs, which are typically the group to say the patients in which aspects they are
tempered, qualified, or otherwise modified in order strong, asking the stories from the past when patients
to incorporate the discrepant life event. The therapist’s experienced them as a strong, etc. Padeskys´-style base
main tasks are to provide a caring, empathic environ- of preferred core belief about self and others is usually
ment and to act as an auxiliary information proces- carried out without first automatic thoughts examining
sor. In part, this means listening for and empathically as it has been traditionally recommended in classical
selecting patient’s experiences of the cherished belief CBT. Therapist does not set out to prove that a specific
and to challenging life event. thought are “false” but better say that another perspec-
tive, narrative, is possible.
Narrative Cognitive Behavioral All mention CBT approaches are combined with
Therapy ideas from the practice of narrative therapy. Each
patient is original and unique and appropriate therapist
Main therapeutic principles, derived from cognitive can use any of CBT techniques to construct a specific
behavioral therapy (CBT), work at cross-purposes to approach for an individual. For the phobias there can be
the attempts of inmates to emplot the stories of their used the hierarchic exposure approach, for low mood
lives and psychiatric symptoms in a manner that makes activity scheduling and planning etc. For working with
them personally meaningful. Given the importance of patients who have described difficult or abusive child-
life-events and the very strong likelihood that much hood, it is used narrative exposure therapy (Neuner et
psychotic meaning (like delusions, voice content, ideas al. 2002). That is, in the first phase of work therapist
about voices, meaning elaborated about any unusual attempts to put into a narrative the often disjointed
experience) relates, in diverse ways, to current and past traumatic events memories, but also consider the his-
events, motivations, core beliefs, then all these aspects tory of a person’s strengths and ways of coping.
must be part of understanding, explaining, and work- Many patients have no job, live alone, or if they live
ing with a person’s reactions and behaviors (Rhodes & in family, tend to have minimal contact. A great number
Jakes 2000). Many findings point at the fact that the avoid all social situations and very often they fear being
majority of patients have extremely low self-esteem and on the street and believe others know they are “insane
negative ideas about themselves. These findings sug- persons”. Exposure to stigmatizing comments in news-
gest the need to help patients build a more realistic and papers and TV is highly stressful and has strong impact
benign set of ideas about themselves. on their self-esteem. They are self-stigmatized but also

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 Jan Prasko, Tomas Diveky, Ales Grambal, Dana Kamaradova, Klara Latalova, Barbora Mainerova, Kristyna Vrbova, Aneta Trcova

because of “in-the-corner” life style are stigmatized by 1. Borrow techniques and approaches from both nar-
others. rative therapy and cognitive behavioral therapy;
Low self-esteem is of fundamental importance to the 2. Therapist goes with patient to work on goals what
understanding of affective disturbance in voice hear- is desired, what is hoped for, as presented by the
ers. Therapeutic interventions need to address both patient and in the language actually used;
the appraisal of self and hallucinations in schizophre- 3. Work is narrative – pays attention to a patient
nia. Measures which ameliorate low self-esteem can be story, use of language, metaphor, and complex
expected to improve depressed mood in this patient characterization of self and others. It is also nar-
group (Fannon et al. 2009). Self-esteem has been impli- rative in the sense of seeking an understanding
cated both in the formation of positive symptoms and of how problems are seen to develop over time
in their maintenance (Garety et al. 2001). Neuroticism (Rhodes & Jakes 2009);
and self-esteem at baseline predict psychotic symptoms, 4. Work also involves the exploration and the emo-
including auditory hallucinations at three year follow- tional expression of experienced difficulties and
up in people with no previous psychiatric disorder helps to find new understanding what happened;
(Krabbendam & van Os 2005) and low self esteem has 5. Strong emphasis is laid on constructing or build-
been shown to be associated with positive symptoms ing something new, or alternative, strengthening
independent of mood (Barrowclough et al. 2003). Cog- and on nonused strength of resource of the patient;
nitive and social interventions need to take account of 6. Has a strong emphasis on building or rediscover-
the prominent role of low self esteem in the experience ing resources in patient’s life and simultaneously
of auditory hallucinations. The association between building solutions, benign ideas, and narratives of
low self-esteem and neuroticism in predisposing to self and the patient’s world;
psychosis (Krabbendam et al. 2002) and the prominent 7. Psychoeducation is not used first but in the later
role that has been proposed for anxiety processes in the stages, and only if it is needed.
maintenance of psychosis (Freeman et al. 1998) sug- 8. Using the holistic model of explanation with range
gest that modification of related metacognitive beliefs of simultaneous influences.
will be more effective than a focus on the cognitive
appraisal of auditory hallucinations alone. Cognitive Why not just use CBT? There are several reasons the
intervention for dysfunctional core beliefs has been most important is the work with hospitalized severely
shown to be effective in delusional beliefs (Moorhead & ill patients in open group. Narrative cognitive behav-
Turkington 2001) and may be usefully applied to those ioral therapy allows the therapist to work in a very flex-
with auditory hallucinations. Working with psychosis ible way. The therapist can accept the presentation as
the therapist needs to make more effort than usual to given, if this is useful, and then work within patient’s
understanding the patient, because patients experience view of the world. Narrative cognitive behavioral
phenomena, that often seen almost unique to psycho- therapy is systemic; it naturally leads to considering
sis and unique to each person (Rhodes & Jakes 2009). problems in their context. This is crucial when working
In seeking to understand patients the therapist need with serious schizophrenic patients since such difficul-
to understand how a whole range of symptoms and ties inevitably occur in the context of psychiatric teams,
experiences interconnect, how they fuse into a whole, hospital, and of course, often in a context of a family
and how these are embedded in the daily world of the or social relations. Narrative cognitive behavior therapy
patient. For example, delusions are not usually just a for psychotic patients makes the possibility to work also
set of explicit belief: rather, there is a complex, chang- with the patients in acute state of the illness, early upon
ing account or narrative of what is going on, and these the hospitalization on the psychiatric department. It is
expressed beliefs link to perceptions of self and other. also possibility to work with open group, because the
The concept of “error of judgment” may be helpful in stories and their paraphrases is the patients capable to
thinking about possible cognitive mechanisms, but is listen also in acute state. Also the patients are capable
not a useful attitude in approaching a person with psy- to understand the others’ stories. There is in fact a
chosis for therapy (Bentall 2003). Sometimes a patient change of the core beliefs and conditional rules during
is open to new evidence, but this tends to occur only the retelling the stories. In addition, in contrast with the
after there have been great improvement in coping, psychoeducation or classical cognitive behavioral ther-
mood, self-narration, interpersonal relationships, and apy sessions the patient can concentrate better on the
emotional states. It seems that is better to gently con- stories than on something else. However therapy must
struct on alternative account of what is happening as be simple, parts of the life stories retold intelligible way.
opposed to a concentrated dismantling of the negative The aim is that patients paraphrases produce higher
belief system. self-acceptance and satisfaction with themselves and
Some key features of narrative cognitive behavioral also increase new understanding of the past and actual
therapy: context of/in life.

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 Narrative CBT for psychosis

Therapeutic Strategies Narrative cognitive behavioral approach uses all

mention strategies. Personal thematic priority of the
After assessment the most useful things to try are each therapeutic session, no matter if performed indi-
therapeutic activities that help the person cope with vidually or in group, is reserved on patient story or on
the present situation, and , if possible, help the person stories of the group, to what the therapist is fully open.
to feel calmer, less overwhelmed by negative emotions Methods named in classical CBT cognitive restruc-
(Rhodes & Jakes 2009). Many patients have undergone turing or works with the schemes proceed by helping
chronic stresses and various types of trauma. Fur- newly paraphraase patient’s story, which patient devel-
thermore, there appear to be gaps in the narrations of ops him or her during the Socratic dialogue. Original
patients concerning these areas. Quite often patients do story is deconstructed using the inductive questioning
not seem to mention very serious difficulties in their and step by step the change (restructuring) happened
lives. Their narrations appear to be focused on a specific the way, in which the patient can see the connections
area, for example what a voice says, the attack about to which old concept was built in and also new story
happen. Patients just do not place these experiences in a which can help new understanding and experiencing
wider context. These findings point to the need to build the self, world and future. However deconstruction and
narratives of their lives, to place sequences of events reconstruction are not only experiences from the thera-
within a wider context. peutic session but is followed by homework that further
When working with patients therapists are thinking extends or stabilizes the alternative concept.
about the interactions among stories, which patients Roman complains at group session, that he hears
experienced in their personal lives and about stories always unpleasant voices which dirtily jaw to him. Other
that the circulate in the context of their local culture and members of the group describe the same experiences.
also in the context of rules and assumptions of the social One patient says that these voices are not reality; it is the
system. Narratives are conceived as the basic instru- manifestation of the disorder. Roman disagree, it must be
ments for meaning making. Narrative therapy talks reality, because the voices said entire truth, comment his
about „ deconstruction of the story”. It aims to solve behavior, jaw to him, when he makes mistake or when he
problems by helping patients to describe situations in is lazy. Therapist asks, whether sometimes Roman him-
which the problem does not occur, that is, when there self either alone is jawing or reproaching, when he makes
are exceptions to the problem pattern (Rhodes & Jakes mistake is unsuccessful or is „lazy”. Yes, he jaw himself
2009). Exceptions might occur spontaneously, or might and criticized himself frequently. On the question, what is
involve deliberate activities by the patients. By knowing the content of his critics to himself, how it sounds Roman
more about exceptions and by thinking together how says: “You idiot! Bustle up! You are unworthy! You are
these might be augmented, it is hoped that the patient lazy like a pig!..” Therapist asks, if are these critical sen-
can begin to solve the presenting problem. There are tences similar, what voices say. According to Roman it
many areas of a patient’s life and every can be separately sounds exactly the same way. He is surprised when realiz-
viewed as positive or negative (MacLeod & Moore ing, that the voices sound completely the same way, what
2000). Areas of “strength” and “resource” may buffer or he says himself. Therapist further asks, whether Roman
prevent condition such as anxiety, tension or depression can recall, if somebody said him similar critical sentences
occurring and may prevent relapse. It may be a useful sometimes in past. Yes, it happened. Mother criticized
therapeutic strategy to focus on positive or “resource him the same way when he was a child and is still doing
building” changes rather than problems (Padesky 1994; this today. But she is doing it less frequently, than he is
Seligman et al. 2005). The therapy should aim at help- doing it to himself. Other patient from therapeutic group
ing a patient to notice and conceptualize any area of adds that the he also sometimes has voices that say things
strength or positive information, but also to engage in just like mother or father say to him. Therapist offers a
long-term activities which yield a sense of satisfaction, question to whole group: What do you think, is it truth,
achievement, and so on. Successful therapy might work that the Roman is nitwit, is lazy as a swine, unworthy
by strengthening a person’s capacity to retrieve positive and idiot? Or do you see him somewhat otherwise? Two
representations (Brewin 2006). He suggests that this patients who often talk with Roman say, that they see
may be influenced by features such as being distinctive, him very different way. He is a good fellow, interesting
being well rehearsed, or being significant. A therapy guy. Therapist asks Roman: What do you mean, are there
produces benign changes for a person when (Rhodes any experiences in your life which reflect, that you are
& Jakes 2009): different, than you are a lazy swine, unavailing, idiot and
a. there is an increase in the retrieval of positive nitwit? Has there been something other, what shows, that
representations and a person’s available concepts you are not so much lazy and do something well? Yes, I
for making sense of the “positive”, and was helping mother and father all my life, and the profes-
b. a person changes their habits, aspects of the self, sor at secondary school, before I started to be ill, told me,
ways of living, and external environment such that I am clever and handy. So that you were good at
that more positive events occur in the person’s school before the illness has came and also mother and
life. father saw you were clever and diligent as a child. Is it

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 Jan Prasko, Tomas Diveky, Ales Grambal, Dana Kamaradova, Klara Latalova, Barbora Mainerova, Kristyna Vrbova, Aneta Trcova

true?, Am I right? Yes it happened, says Roman delight- as metaphors, stories, and beliefs. Listening is healing
edly. Can we now write it on the table, all facts against as well as diagnostic. The best listeners hear both the
assumption, that you are lazy, unworthy, idiot or nitwit? patient and his story clearly, and regard every encoun-
Therapist wrote on the table facts Roman found: is sticky ter as potentially therapeutic. Patients are storytellers
when modeling airplanes, hardworking, assisting on the primary of their important relationships, that have the
garden, offers himself to help others, he offers mother to hope of being heard and understood. Their hearers
go to the shop and do shopping. At the same time other are therapists who are expected to listen actively and
patient from the group praise Roman: how clever he is, to be with the patient at a new level of understanding.
how they like chatting to him, how much he knows about Therapist notes exceptions, or unique outcomes, when
the music, how he trusts them, gives advices, how helping problems might have occurred but surprisingly did not.
he is etc. Now therapist asks Roman, if somebody from He notes what is happening at time when problems are
the family praised him anytime. Roman agrees, it hap- absent. Active listening remains one of the central skills
pened, for example mummy praises him, when he cleans of the therapist. The special meanings of words can be
court or goes shopping and dad always admired, how he the central focus of the treatment. Narrative-experien-
elaborated the model of airplane. Therapist writes it also tial listening is based on the idea that all humans are
on the positive list about Roman. At the end of the session constantly interpreting their experiences, attributing
therapist offers the homework for Roman and also other meaning to them, and weaving a story of their lives with
members or the group. The homework is to make a list of themselves as the central character. Listening involves
what and how the family is praising or rewarding them. not only hearing and understanding the speaker’s
Dialogical, or discursive, model of human experi- words, but attending to inflection, metaphor, imagery,
ence may be useful in helping someone who experi- sequence of associations, and interesting linguistic
ences verbal hallucinations (Davies et al. 1999). The selections. It also involves seeing – movement, gestures,
model regards verbal hallucinations as a variety of inner facial expressions, subtle changes in these – and con-
speech with dialogical properties (McLeod et al. 2007). stantly comparing what is said with what is seen, looking
The explication of these properties in the context of a for dissonances and comparing what is being said and
personal narrative allowed the individual to engage in with what was previously communicated and observed.
dialogue with the voices, through the medium of a new, Metaphors, often repeated phrases, and other evoca-
supportive and positive voice. This process made it pos- tive uses of language are noted as “doors to be knocked
sible also to introduce moral responses to distressing upon” by asking specific questions about patient’s
and potentially dangerous imperative verbal hallucina- stories of lived experiences that gave them mean-
tions, through the mediation of the new voice. ing. “Unique outcomes” or “exceptions” when prob-
Narrative approach to cognitive behavioral therapy lems might have been expected to occur, but did not.
consists of two phases: Narrative therapists also encourage patient to
1. First phase – elicit patient narratives that have become mindful how narratives from the broader cul-
been important in his influence upon patient’s life ture constraint their lives. They help patients learn from
and problems; those occasions when the problem is not occurring and
2. Second phase – authoring new narratives and re- to learn from those “exceptions” when the problem
authoring the old ones that have been too limiting might have been expected to occur but did not happen,
in their possibilities. patients can practice tasks that amplify the frequency
and intensity of these “solution sequences”.
Therapist focuses on creating a dialogue in which Therapy can provide a context in which patient
important personal narratives can be safely expressed, narratives that limit relationships and maintain the
heard, and reflected upon the patient and group mem- symptoms can be identified. Effects of constraining
bers. He asks the questions that elicit forgotten, or narratives can be attenuated when specific historical,
unnoticed, narratives of family life that open better cultural, health providers or political contexts out of
possibilities for solving problems with the current which they emerged are discussed, and the interpretive
narratives that have dominated the patient family dia- assumptions upon which they rest are made explicit.
logues. Narrative therapists, rather than focus upon Alternatively, more useful narratives can be identified
patient’s pathology, have made patient’s strengths, skills, that have gone unnoticed with forgotten experiences
resources, competencies and other sources of resilience patient has had.
their center-piece of the therapy. Therapy starts with lis- ■ Eliciting important narratives. First priority is cre-
tening. Listening work takes time, concentration, imag- ation of a therapeutic relationship within which
ination, a sense of humor, and an attitude that places the important first narratives can be safety told, ac-
patient as hero of his or her own life story. The listener, knowledged, and understood.
when hearing the story, experiences the world and the ■ Authoring new narratives and reauthoring con-
patient himself from the patient’s point of view, helping straining ones. As narratives important to the
to carry the burden of loss, lightening and transforming problem are told, the therapist craft inductive
the load. Listen for exact usage of language expressed questions that facilitate:

142 Copyright © 2010 Activitas Nervosa Superior Rediviva ISSN 1337-933X

 Narrative CBT for psychosis

a. Retrieval of other forgotten, or unnoticed, Writing about important personal experiences in an

narratives that might enhance solving the emotional way brings about improvements in mental
problem of the therapy, in contrast to a nar- and physical health (Pennbaker & Seagal 1999). Using
rative, that has been dominant. For example, a text-analysis computer program, authors discovered
a young schizophrenic man might be asked: that those who benefit maximally from writing tend to
“In what year of your life did you have? What use a high number of positive-emotion words, a mod-
you prefer in your days that time? Such a erate amount of negative-emotion words, and increase
question conceivably might bring forth sto- their use of cognitive words over the days of writing.
ries of good quality of life, activity and man’s Stiles et al. (1999) presented three current, comple-
preferred identity that had been forgotten in mentary formulations of the assimilation of problem-
the present area of his life, with voices and atic experiences model: (a) the schema formulation,
delusions, depressed mood, and conflicts based on cognitive developmental concepts: (b) the
with the mother. voices formulation, in which assimilation is understood
b. Asking questions about details of a constrain- as the construction of a meaning bridge between active
ing narrative that shift its meaning through internal voices; and (c) the cognitive science formula-
expanding awareness of its historical con- tion, which uses cognitive concepts of memory types to
texts; punctuating differently its time-line; understand the failure of memory in cases of warded-
adding forgotten characters whose actions off and avoided experiences. These views of assimila-
had also contributed to the story. tion are used to understand the varied functions that
■ Therapist employs such questions as circular, re- narratives (stories about real or imagined events out-
flexive, unique outcome, or relative influence side of therapy) may play in psychotherapy, including
questions to gather fresh descriptions of patient’s narratives that avoid encounters with threatening mate-
life that might constitute an alternative-preferred rial, narratives that approach such material indirectly or
narrative (White 1989). For example, a unique symbolically, narratives by which clients re-experience
outcome question such as “Have there been occa- trauma, and narratives that help construct a mature
sions when you had reason to expect your mother understanding.
to disobey the rules, but to your surprise she did Distress arising from voices was linked to beliefs
not? can elicit new accounts of a mother at time about voices and not voice content alone (Birchwood
can display warm and acceptance behavior. et al. 2000). Subordination to voices was closely linked
■ Therapist may assign patient the task of studying to subordination and marginalization in other social
segments of the time when the problem is not oc- relationships. Distress arising from voices was linked
curring, looking for exceptions. Examples of solu- not to voice characteristics but social and interpersonal
tion-focused questions include: cognition.
a. “Between now and the next time we meet, I For interventions that are complex and require life-
want you to observe what happens between style modifications, it is worthwhile to address patients’
you and your mother that you do value, beliefs, intentions, and self-efficacy (perceived ability
would not want to change, and would like to to perform action). This is because knowledge alone is
see happen more often in the future.” not sufficient to enhance adherence in recommenda-
b. The miracle question (de Shazer 1985) – tions involving complex behavior change. The power
“Suppose that one night, while you were imbalance between the individual and his persecutor(s)
asleep, there was a miracle and this problem may have origins in an appraisal by the individual of
was solved. How would you know? What his social rank and sense of group identification and
would be different? How would other family belonging.
members know without you even saying a
word about it?” Group Narrative Cognitive Behavioral
c. “If the problems between you and your part- Therapy
ner got resolved all of a sudden, what would
you do with the time and energy you have As wounded, people may be cared for, but as storytell-
been spending on fixing or worrying about ers, they care for others. The ill, and all those who suffer,
the marriage? Describe what you would to can also be healers. Their injuries become the source of
instead.” (Weiner-Davis 1992). the potency of their stories. Through their stories, the
d. “What might be one or two small things that ill create empathic bonds between themselves and their
you can do this week that will take you one listeners. These bonds expand as the stories are retold.
step closer to your goal?” (Weiner-Davis Those who listened then tell others, and the circle of
1992). shared experience widens. Because stories can heal, the
e. “What, if anything, might present a challenge wounded healer and wounded storyteller are not sepa-
to your taking these steps this week, and how rate, but are different aspects of the same figure (Gold
will you meet the challenge?” 2007).

Act Nerv Super Rediviva Vol. 52 No. 2 2010 143

 Jan Prasko, Tomas Diveky, Ales Grambal, Dana Kamaradova, Klara Latalova, Barbora Mainerova, Kristyna Vrbova, Aneta Trcova

Since narrative is a shared, often public, expression or community is an important possibility to come back
of one’s self at a particular moment, it is essentially per- to the people. Universality, the recognition that other
formative. But it is also intersubjective, and the reac- people experience very similar problems, was one of the
tion of the audience to the story being conveyed exists most beneficial factors of the intervention (McLeod et
as an important check on the meaning the story has for al. 2007).
the teller or the message the teller wishes to convey;
in other words, the teller’s account is affected by the Conclusions
listeners’ reaction (Wikan 2000). The audience has
considerable influence in shaping, affirming and even Story of the patient is an organizing metaphor which
altering that performance, both in form and in content, can help with understanding, why people experienced
as it unfolds. Narrative renderings are rarely seamless, them, the others and the world their own way. The
and audience interruptions in the telling of a story are patient’s story has developed from the experiences he/
common (Linde 1999). In this sense the performance of she had in childhood, parents´ and teacher’s stories and
the autobiographical narrative clearly involves a process also from the interaction in the actual context. In nar-
of negotiating events (or ‘‘facts’’) and meaning accept- rative cognitive behavioral approach in therapy thera-
able to both the audience and the narrator. It is not pist searches, yields to surface and stabilizes stories that
simply the inmate’s story, after all, but rather a story that don’t support patients troubleshooting experiencing
is guided by the narrative schema and created through a of the reality, but develops alternative stories leading
group process in which all have a vested interest. to new view of things, positive change of themselves –
It has been suggested by some that the development conception and to problem solving that is detected in
of a shared narrative between therapist and patient is the contemporary context.
necessary for a successful therapeutic outcome (Kir-
mayer 2000). This kind of therapeutic intersubjectivity Acknowledgement
is important to achieve in group program. The ‘‘shared’’
meaning of the narratives must not be too forced and Supported by the research grant IGA MZ CR NS
artificial. It involves many different actors with their 9752– 3/2008
own agendas and it is big task for the therapist to find
gentle connections between different stories. The
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