Blake exhibits behavior related to schizophrenia, paranoid-type criteria. He is twen- ty-four years old and was diagnosed with schizophrenia during his freshman year of college. He believed his roommates were reading his e-mail, and soon he believed his e-mail was available to everyone on campus. He was kicked out of the dormitory after he destroyed his roommates’ computers. He was hospitalized and, after his release, had assault charges filed against him after he threw a toxic substance at his chemistry profes- sor during a laboratory class. (Blake believed that the professor was trying to poison him with toxic fumes.) The charges were later dropped. Then he was expelled.
Since being expelled from school, Blake has been hospitalized eight times. He lived with his parents for a while, and they kicked him out of their home three years ago because they feared for the safety of their other children after Blake threatened them while acutely psychotic and delusional. Today Blake lives in a hotel room rented by the month. This is his fifth housing placement in three years. He receives disability income. He has held a series of jobs and reports that he would like to be employed full-time.
Each time he is hospitalized, the cyclical pattern is similar: He leaves the hospital with antipsychotic medication and a plan for outpatient treatment. He has a housing placement and sometimes gets a part-time job. He stops taking his medication, then misses appointments with his treatment providers. He becomes delusional and some- times he experiences command hallucinations where voices order him to harm others. He drinks to lessen the intensity of the voices. He quits his job or leaves his home or threatens people he lives or works with. He is hospitalized again.
Functional Analysis and ACT Assessment 49
The criteria for Blake’s type of schizophrenia are that a person experiences perse- cutory delusions, auditory hallucinations, and, unlike other subtypes of schizophrenia, negative symptoms are absent (APA, 2000). The primary intervention for treatment of schizophrenia is pharmacotherapy. There is much research on biological causes of schizophrenia and biological causes dictate a biological cure. Some clients also receive psychosocial interventions including skills training, cognitive therapy, and assertive community treatment.
Considered functionally, “schizophrenia” is not a useful descriptor. If we consider Blake’s delusional beliefs and hallucinations as target clinical concerns, first-wave behav- ioral approaches might aim to instruct him not to talk about delusional thought content. If this were successful, he would experience fewer negative social consequences. Skills training might be used to teach him “symptom management skills” such as distraction and self-soothing for coping with auditory hallucinations.
Cognitive theories of delusional beliefs posit that delusional beliefs function to maintain self-esteem (Bentall, 2001); that is, the individual’s self-esteem is preserved if he believes that he has failed because others wish to harm him rather than because he is a failure. Cognitive interventions for delusional beliefs emphasize verbal challenges to beliefs and behavioral tests of delusional beliefs (Kingdon & Turkington, 1994). In Blake’s case, a therapist might challenge a delusional belief—such as a belief that his landlord is stealing from him—by asking him to provide evidence for that belief and disputing the evidence Blake provides. As a test, he may be asked to leave money out on a day the landlord is scheduled to visit to see if the landlord steals it. The goal is to change the content of Blake’s beliefs.
Considered in terms of emotional avoidance, a functional assessment suggested that Blake was engaging in several forms of emotional avoidance. First, he stopped taking his medication because he did not want to be mentally ill and taking his medication was related to mental illness and reminded him of his mental illness. When he stopped taking medication, he had fewer thoughts about himself as a mentally ill person. Unfortunately he also had more delusional thoughts.
Blake also appeared to engage in avoidant behavior around auditory hallucinations. He drank or followed command hallucinations “to make them stop talking.” Considered functionally, the hallucinations are not seen as the problem. Instead the relationship between the hallucinations and overt behavior is considered problematic. Hallucinations can be treated as similar to any thoughts Blake might have, and defusion and acceptance strategies can be used by the clinician (Bach & Hayes, 2002).
With respect to delusional beliefs, one fruitful approach can be to explore the rela- tionships among Blake’s symptoms, his overt behavior, and his desired life outcomes. He would like to be employed and he acknowledges that when he stops taking his medi- cation, his symptoms interfere with his functioning. He avoids thinking of himself as “crazy” by not taking medication, and then he actually behaves in a “crazy” manner and loses jobs, friends, and apartment leases. Defusion can also be used to target responses to delusional beliefs. Considered functionally, instead of seeing a delusional belief as a
problem to be eliminated, the clinician can explore Blake’s behavior in relation to his symptoms. Defusion can be used to change Blake’s relationship to his symptoms so he relates to the process rather than content of his symptoms. He also avoids paranoid beliefs by acting in accordance with the content. He can get rid of the thought that “they’re trying to harm me” if he quits his job or attacks the threatening other “harmer.” In contrast, defusion can also be useful for distancing him from the content of delusions. His thought content does not have to change if he can relate to it differently.
What if Blake could see schizophrenia as a problem that affects cognitive processes and learn to relate to verbal content differently? What if he were willing to be present with avoided content and no longer needed to avoid the thought “I’m crazy?” What if he accepted rather than avoided or tried to change content?