Introduction

This chapter will describe a number of interventions which may be helpful when working with people who hear voices or express unusual beliefs. These experiences are often termed hallucinations and delusions and are viewed as symptoms of psychosis. People who have these experiences may be given a diagnosis of schizophrenia or mania. The interventions described here can also be useful when working with people with a range of other mental health problems and will add to your tool box of possible approaches to consider when you are planning care.

The approaches are underpinned by the Stress Vulnerability Model which is described in Chapter 3 and often come under the umbrella term of psychosocial interventions. They attempt to enable service users to develop their personal and environmental protective factors, minimise the influence of vulnerabilities or reduce current stresses. This is with the overall aim of supporting the service user to develop self-management strategies and promote a sense of personal control over their mental health. It is important to recognise that these interventions are not the starting point for therapeutic work. They are sometimes seen as a quick practical solution to a person’s problems. This approach overlooks the importance of engagement, assessment and developing a shared understanding with the service user (Mills 2006).

Before you begin to work with people who are experiencing psychosis it is essential to consider how their experiences might influence your approach. You may discover that the person finds it difficult to concentrate for long periods of time, keep appointments or complete tasks in between sessions. Some people do not feel motivated to take an active role in their care and are not used to being asked for their input and views. There is a possibility that a person’s strange thoughts or voices might become prominent during a session, particularly if it is a new and potentially threatening situation. This will often mean a more flexible or creative approach is needed, which takes into consideration these possible obstacles and adjustments should be made in response.

Responding to people who express unusual beliefs

Students often describe knowing how to respond to people who express usual beliefs or strange thoughts extremely challenging. There are conflicting ideas about the best way to respond and it is likely that you will observe a number of different approaches in practice.

Possible responses that your mentor could give:

Response 1 could be underpinned by the practitioner’s view that unusual beliefs should be challenged and failure to do so can result in the practitioner colluding with the service user and further confirming their belief. This approach can have a negative effect on the therapeutic relationship as the service user may not feel that you are making an effort to understand his distress. It also reinforces the idea that the practitioner is the expert and that their version of the truth is more valid than the service user’s. This implies an unequal position and contradicts a collaborative approach to working.

In response 2 the mentor is adopting a more humanistic approach by focusing on the emotion arising from the belief rather than the belief itself. This can be helpful in the short term to alleviate the person’s immediate distress and may strengthen the therapeutic relationship as the service user finds the mentor supportive and understanding. However, the distress is likely to return when the person refocuses on the belief as it has not been explored or addressed.

Response 3 is informed by a more collaborative approach. The mentor acknowledges the service user’s belief and suspends her own judgement of its accuracy until they have had an in-depth conversation about it. This offers the mentor the opportunity to encourage the service user to look for evidence, which supports or conflicts with their belief, in an attempt to encourage the service user to question their belief, which may reduce their conviction in it. It also enables the exploration of the meaning of the belief to the person and how this is influenced by their previous life experiences. This process will often need repeating and it may take some time to have an impact. It is therefore appropriate to be honest with the service user about your perception of their belief. This communicates genuineness and allows the service user to see that while you are open to discussing their view, you do not agree with it and therefore are not confirming it in any way.

Response 3 is based upon the following assumptions about the most effective way of responding to a person’s unusual beliefs, which is informed by the Stress Vulnerability Model (Zubin & Spring 1977):

Assessment of voices and unusual beliefs

The in-depth assessment of unusual beliefs and voices is essential when considering the best way to help the person to cope with them. It can also help service users to make sense of their experiences and find their own meaning or explanation for them. There are a number of specific assessment tools which can guide you through this process, however they will commonly focus on the following areas:

Coping skills enhancement

When working with someone to develop their coping strategies, there are three areas which should be taken into account:

The first step is to look at the person’s current ways of coping. This reinforces the message that they already have resources which they have developed and focuses on their existing strengths. It can be helpful to ask the person to think of a recent time when they have felt distressed by their voices or beliefs and ask them to identify what they did, what they thought about and how it impacted on how they felt. This will allow you to recognise the style of coping that the person finds most helpful which can often be classified into:

Table 10.1 gives some examples of each.

Table 10.1 Examples of coping strategies

Once you have identified these helpful coping strategies, you can suggest ways of increasing their effectiveness by encouraging the person to use them sooner and more frequently. You may also be able to suggest other ways of coping which may have the similar effect that the person is looking for. For example:

There may also be coping strategies, however, that the person finds helpful in the short term but that can have negative consequences in the longer term or lead to behaviour which is potentially harmful to the person’s wellbeing. These would be coping strategies which you would be aiming to reduce. Consider the following case histories.

These ways of coping may be the only way the person is able to feel in control of their distress and therefore they may be reluctant to consider alternatives. It may take time for them to agree to work with you on trying out other ways and it will be important to provide high levels of support to enable the person to feel safe to do so. Quite often a less harmful version of the same coping method can be identified which will maximise the beneficial effects and reduce the potentially damaging ones.

Testing unusual beliefs

People who experience unusual beliefs often have some common thinking styles which lead to a higher level of conviction in the belief and attempts to control the distressing emotions which arise from it by engaging in protective behaviours. Examples of these thinking styles include:

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