DOI: 10.4324/9780203832677-6
Normalisation is a central process within cognitive behavioural therapy (CBT) and not just CBT for psychosis (CBTp). This is because CBT is based on the cognitive model which emphasises that the appraisal of an internal or external event determines emotion and behaviour (Beck, 1995). Central to the model is the notion that if we understand the cognition or appraisal, the emotion and behaviour will make sense to us. In fact, if we believed the same thought there is a good chance we would feel and act in the same way. The goal of treatment in CBT is to help the person appraise the world, other people and the self as they really are and to not overestimate threat (e.g. my palpitations are normal and a reaction to arousal not a sign of a heart attack), or overvalue the event if it has happened (e.g. just because I lost a job it does not mean I am a failure).
Normalising is used in CBT in a number of different ways. For instance, by drawing on the cognitive model we regard the distress arising from the experience as normal and understandable. The therapist will say to a person with compulsive washing something like “So you believed you had poison on your hands and that you would be reaponsible for killing your children, well no wonder you felt anxious, and wanted to wash your hands.” This style is evident from the first session and is a powerful form of normalisation. Furthermore, the therapist helps the clients see that they are not alone in experiencing certain feelings or thoughts, and this can be enhance feelings of self-esteem, facilitate improved coping and reduce stigmatisation. Normalising can help reduce secondary emotional reactions such as being anxious about anxiety or depressed about being depressed. Secondary behaviours which perpetuate the primary symptom are also reduced, e.g. safety behaviours and social withdrawal. This process can be carried out through the therapist providing the client with reading material (e.g. fight/flight response material to normalise physical sensations in anxiety and examples of people also suffering depressive symptoms after losing their job.)
Personal disclosure is also potent in the process of normalising. For instance, the therapist might describe how they had a phobia of public speaking and how they overcame this or perhaps reveal one of their own experiences of intrusive thoughts when working with a person with obsessions (Salkovskis, 1999). Normalisation can also be seen as an active element within group CBT as people can relate to one another within the group and see that other people experience similar problems.
Normalising experience is also at the heart of current appraisal models of anxiety disorders. In these problems, central to treatment is creating a change in catastrophic or unhelpful appraisals of normal phenomena such as bodily sensations (leading to panic disorder, health anxiety and social phobia), intrusive thoughts (leading to obsessive compulsive disorder and generalised anxiety disorder) and intrusive memories (leading to PTSD). A key treatment common to all these approaches is normalisation of these physiological or cognitive phenomena.
It is important to remember that this process is not purely restricted to CBT. For example, the medical model is, perhaps surprisingly, not exclusive of a normalising approach. A good example is asthma. It is useful for the person with asthma to know that anyone will wheeze with a severe chest infection. This reduces catastrophic thoughts about the meaning of the bronchospasm, e.g. “I am dying and this is untreatable.” Another example is epilepsy; again the person is reassured to hear that seizures are extremely common and that anyone can have one. This can lead to reduced shame and improved compliance with anticonvulsants.
When we describe normalisation the intention is not to say that the experiences are a sign of health or well-being. Rather, normalisation is a process that emphasises that the experiences a person finds upsetting exist within the range of normal functioning and can be experienced in the absence of distress, or disability. Some cognitive models of psychotic symptoms just as in obsessive compulsive disorder (Salkovskis, 1999) would argue that the development of delusional beliefs or hallucinations has its origins in normal experiences. The difference between non-distressing and distressing experiences lies not in the occurrence or even the uncontrollability of these experiences but rather in the interpretation by the person of the experience.
This view of what normalisation is immediately brings us up against the issue of whether we can normalise psychosis. Most of us would accept that we know what it feels like to be low or anxious. Our own experiences help us develop empathy for those with depression or anxiety problems. However, normalisation is not just about developing empathy. The message given is that these experiences are not in themselves problematic, and that other people can have them without being distressed. However, psychotic experiences (and in particular the label of schizophrenia) have been catastrophised rather than normalised, not just by the patient, but also by society and the media. Psychotic experiences were seen to be discontinuous with normal experience and a sign of a qualitative change in a person, presumably owing to a biological disease process (Bentall, 2003).
This view of psychosis has consequences. The mere act of labelling an individual with psychosis as mentally ill is linked with an increased perception of their unpredictability and dangerousness (Angermeyer and Matschinger, 2005). Clinicians have been known to catastrophise the diagnosis of schizophrenia and so find it hard to communicate the diagnosis to the person directly, thus leaving them to find out by other means. The person may then learn of their diagnosis from a carer or deduce it through recognition of the symptoms from a television programme, the internet, or reading the information accompanying any prescribed medication. This process then leaves the person to draw unhelpful conclusions about why they weren’t told directly, again often leading to catastrophisation of the problem such as beliefs that they are “mad”, there “is no hope” for their recovery or they will be “locked up” (Bentall, 2003). There has also been a general opinion that discussing psychotic symptoms with a client can lead to an exacerbation of the problem, but a lack of discussion can again lead to the client catastrophising their perceived “untreatability” which in turn leads to greater distress (Kingdon and Turkington, 2005).
However, it has become increasingly evident through research that psychotic experiences exist in the general population on a continuum of severity rather than as categorically different phenomena (van Os et al., 2001). Surveys of the general population have been carried out using questionnaires or interviews to measure psychotic symptoms, and findings show that a range of symptoms, from paranoia to hallucinations, are relatively common in apparently healthy community samples. For example, van Os et al. (ibid.) reported that 25 per cent of people had experienced psychotic symptoms. Freeman et al. (2005) reported that over a third of their sample of 1,200 undergraduates had experienced paranoid thoughts about the intentions of others within the last week. Their survey revealed thoughts that friends, acquaintances, or strangers might be hostile or deliberately watching them. Hence, suspiciousness and paranoid ideation appears to be an everyday occurrence for many people. In fact, 52 per cent endorsed the idea that “I need to be on my guard against others” as occurring on a weekly basis. To a lesser extent people believed that there may be someone plotting against them or an active conspiracy against them (8 per cent in the last week). The prevalence of symptoms in the generalpublic could provide a key element to the normalising process as it indicates the presence of psychotic symptoms and experiences is far greater than the level of identified mental illness.
Johns et al. (2004) investigated self-reported psychotic symptoms from the general public. The annual prevalence of psychotic symptoms in the general population was 5.5 per cent. They found that psychotic symptoms were more likely to occur in people with factors such as substance misuse, neurotic symptoms, adverse life events or victimisation in their lives, and each of the different factors has supporting literature that can be used as part of the normalisation process. One of the socio-demographic influences highlighted by Johns et al. (ibid.) was urbanisation, and previous research has highlighted that psychotic symptoms in the general community increase in prevalence as the level of urbanisation increases (van Os et al., 2001). People who live in highly urbanised areas may be able to identify with these findings, and it may be helpful for them to discover that the general public are affected in a similar way. Other studies show that victimisation and stressful life events specifically increase levels of paranoid ideation.
Significant life events often precede the onset of psychosis, in a similar way to the onset of depression or post-traumatic stress disorder (Zubin and Spring, 1977). For instance, hallucinations are common in those who have suffered prolonged or brutal sexual abuse (Ensink, 1992). Although many people will not disclose such things even when given the opportunity to do so, when they do it can be useful to highlight the possible connection to help give an understanding of symptom development. Grassian (1983) has also identified that prisoners who were kept for prolonged periods in solitary confinement were prone to develop psychotic symptoms. Excessive bed rest or other sensory deprivations have also been found to induce hallucinations (Slade, 1973). Research has also identified that sleep deprivation can be a trigger for psychotic symptoms, leading to illusions, hallucinations and paranoid ideation (ibid.). Such literature can be presented to people with such experiences so that they can identify with the triggers and feel less alienated by their experiences.
Hence, we have seen that normalisation is a common component of CBT when working with non-psychotic disorders, and also that the assumption psychotic experiences are categorically different from other experiences does not hold up when considering the circumstances in which these develop or the fact that they can be experienced without a person experiencing distress. Therefore, we turn our attention to the process of normalisation within cognitive behavioural therapy for psychosis (CBTp).
The first stage of CBTp is engaging the client and forming a therapeutic alliance that will allow a collaborative approach (see Chapter 5). This first step is crucial, and generally this is encouraged through empathy, warmth, genuineness and unconditional acceptance displayed by the therapist, who would also display a knowledge of typical modalities of psychotic expression (hallucinations, delusional perceptions, systematisation of delusions, etc.). Therapists can often be put off by the large delusional systems, but through the engaging phase you can work towards a formulation of symptom emergence to allow therapy to begin. The therapist can also provide reading material, case examples and personal disclosures about how one has used that particular technique to overcome problems (e.g. anxiety).
The process of normalisation can be used as a therapeutic tool towards forming this alliance through work on non-threatening exploratory areas prior to tackling the person’s own symptomatology, reducing the chances of experiencing shame. Normalisation can also help pave the way for collaborative formulation, thus helping the client become an active agent in his or her own treatment. The therapist should also convey accuracy and consistency in their approach to the client, being careful not to invalidate any experiences through verbal or non-verbal cues, for example directly confronting a belief. Care should be taken that normalisation is not used in the extreme, which may be perceived by the person as the therapist minimising the problem. If normalisation is used insensitively the client may perceive that his or her problem is something that other people just cope with (e.g. everyone hears voices), or therapeutic work could miss out important issues such as the person believing that he or she is bad (especially if his or her problem is normalised, e.g. “If this isn’t my illness making me think such things then I must be bad”). Therapists must remain aware of how far they are going in saying that psychotic symptoms are normal, and it is also important to identify possible influences from their own personal beliefs (Garrett et al., 2006).
After engaging the client it is useful to provide an explanation of puzzling and distressing symptoms as well as dealing with catastrophic cognitions concerning insanity. The person can be led towards an understanding that there is probably a discernable reason or reasons why the symptoms have occurred and the possibility that anyone stressed in certain ways would develop psychotic symptoms. If there is a family predisposition to respond in this way this can also be fully explored to help the person to feel less different and isolated. At this point literature detailing the prevalence of psychotic symptoms in the general population (Johns et al., 2004) or more specific literature about particular life experiences, such as sexual abuse or solitary confinement, could be discussed with the person.
The Stress Vulnerability Hypothesis (Zubin and Spring, 1977) could also be introduced as this model simply states that vulnerabilities and stresses combine to produce the symptoms characteristic of psychosis. A close examination of the antecedents of psychotic breakdown may be necessary, and it is often useful to itemise the types of stressors that can typically produce psychotic symptoms. The crucial period leading up to a breakdown should be worked through with inductive questioning, imagery and role play. Key cognitions can be detected from this period, pointing to underlying schemas concerning achievement, approval and control that may be addressed in later sessions.
The normalising approach can help the person realise that everyone has upsetting automatic thoughts, intrusive thoughts or even obsessions during times of stress and worry. Generally the experiences of these thoughts can be similar to voice-hearing experiences (e.g. they can be quite violent, sexual or religious), and it can be helpful for the person to discover that others get anxious about their thoughts, too, but most people choose not to act on them. This process of normalisation can pave the way for imagery, role play or schema level work to be undertaken to help deal with beliefs about voices and hence to manage to command hallucinations differently (Morrison et al., 2004).
We know that CBT is an effective treatment for people with persistent symptoms of schizophrenia (Sensky et al., 2000). Whilst its value is proven, there is less evidence as to what are the mechanisms of change. CBT, generally, consists of a number of core components (Beck, 1995) that include a good therapeutic relationship, a style of collaborative empiricism, the use of cognitive and behavioural change techniques, and the use of a disorder-specific model as the basis of the formulation. There has been limited investigation of the active and successful components of treatment in CBT generally. There is evidence that positive therapeutic alliance can potentiate the effectiveness of empirically supported therapies (Raue and Goldfried, 1994), and also evidence that the use of effective therapy approaches leads to a more positive therapy alliance (DeRubeis et al., 2005). However, there is virtually no such research undertaken about the effective components treating psychotic illness. Broadly speaking, there is only emergent empirical evidence that any or all of these components are necessary.
Despite the lack of empirical support the components mentioned above are also incorporated into the CBTp treatment manuals (i.e. Morrison et al., 2004). In these specialised approaches there is often an increased emphasis on engagement and rapport building, normalising unusual psychotic symptoms and decatastrophising distressing appraisals of what it means to have a psychotic illness such as schizophrenia (Kingdon and Turkington, 2005). Hence, it is apparent that CBTp relies on the core components of CBT as well as components more specific to psychotic conditions. However, within CBTp the process and role of formulation is considered to be especially important (Morrison et al., 2004).
Formulation is the process of integrating the person’s specific information with the cognitive model and serves to help understand the onset and maintenance of the current difficulties as well as directing the therapist to key points of intervention (Kuyken et al., 2009). Given this function, formulation is considered to be the linchpin of CBT (ibid.). Despite the central prominence given to the role of formulation there is actually an absence of evidence for the value of a formulation in producing a successful outcome (ibid.). Hence, even one of the most important components of CBT has strikingly little evidence for its therapeutic value. Formulation in work with people with psychotic illness helps provide a shared understanding, and this is particularly relevant when working with symptoms that can initially appear “incomprehensible” (ibid.). Formulation in CBTp is heavily reliant on normalisation as together the therapist and client are trying to generate and test a new, less threatening alternative explanation for the person’s experiences, and information about the symptoms is vital in this process.
To date, only two studies have investigated formulation in CBTp. The first was undertaken by Chadwick et al. (2003) who reported that formulation had no impact on the perceived therapeutic relationship from the client’s point of view, psychotic symptoms, or levels of anxiety and depression.
The second study (Dudley et al., 2007) investigated which components of CBTp were used most in working with those people with schizophrenia who respond to CBTp, in comparison with those who did not respond in a randomised controlled treatment trial (Sensky et al., 2000). Following each session of therapy the therapist completed forms indicating components of treatment that were used in that session. Individual techniques that differentiated responders and non-responders included the use of education about schizophrenia as well as the use of personal disclosure. Both would appear to be very normalising processes as they are used to help make sense of the development of psychosis and are the building blocks of a formulation.
Hence, we have some preliminary evidence for the value of formulation in CBTp and within that for the vital role of normalisation. However, it brings us back to how far we can normalise psychotic experiences. We have all experienced memory slips, perhaps forgetting someone’s name or the name of an object. However, few of us would say we could use this experience to normalise the experience of amnesia or dementia. The same issue applies to our normalisation of psychotic experiences. How far can we accept that these experiences are normal? We may have experienced feeling suspicious of other people, or heard a voice calling our name when waking from sleep, but does this really map onto the experience of believing that your parents are dead and have been replaced by alien impostors, or a voice shouting that you are evil for hours on end? There may be a point at which the frequency, loudness, and vividness of a voice or its content make the experience different to that experienced by people who are not distressed by these experiences. At present we do not know if it is a difference of degree or of quality. This is a challenge to us as clinicians and researchers, and there is difference within the CBTp models as to how far these experiences can be normalised. However, it is also the case that what makes an experience abnormal is to some extent culturally defined. The apparent improved outcome of people with psychotic experiences in non-Western societies (Bentall, 2003) may in part be attributable to differences in appraisal of these experiences. Moreover, as experiences are culturally defined as normal it is important to remember that these definitions can and do change over time.
While the evidence supporting its value is limited, normalising has been increasingly incorporated into CBT treament manuals for anxiety disorders and depression. It now appears that normalising may be one of the most important components of successful CBT for people with psychosis. It has been incorporated in recent treatment manuals (Kingdon and Turkington, 2005) and self help materials (i.e. Turkington et al., 2009), and it can be effectively taught to psychiatrists in training (Garrett et al., 2006). The challenge now is to disseminate this training more widely and to make formulation-based CBT available for those who need more intensive treatment due to chronicity or co-morbidity.