Cognitive behavioral therapy is a proven treatment for a wide range of mental health conditions and emotional struggles, but many times is not used for treating schizophrenia. Schizophrenia’s symptoms of hallucinations and psychosis are assumed to be too complex for this type of therapy.
Host Rachel Star Withers, a diagnosed schizophrenic, and co-host Gabe Howard, explore the types of CBT that best work for schizophrenia. Rachel breaks down her “Monster Technique” that she uses daily to help her deal with her visual hallucinations.
Guest Cornelia Larsson, licensed psychologist and psychotherapist, joins to talk in-depth about CBT techniques for dealing with audio hallucinations like hearing voices.
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Dr. Cornelia Larsson is a licensed clinical psychologist and psychotherapist who spent most of her career working in Swedish psychiatric clinics. Currently, she’s a doctoral student working toward her PhD by researching psychological treatments for psychosis, and is a course coordinator in psychotherapist education at Centre for Psychiatry Research at Karolinska Institutet & Region Stockholm. She’s also a director of studies for the psychologists at the South-West Psychiatric Clinic in Region Stockholm and gives lectures mainly on cognitive behavior therapy and psychosis. Although Larsson has worked with individuals living with all sorts of psychiatric diagnoses during her career, her main focus the last 10 years have been on individuals living with psychosis and schizophrenia. Clinically, she has taken a special interest in helping individuals with distressing voices, who engage in frequent self-harm and suicide attempts, to change their relationships to their voices and thereby regain hope and quality of life.
Rachel Star Withers creates videos documenting her schizophrenia, ways to manage and let others like her know they are not alone and can still live an amazing life. She has written Lil Broken Star: Understanding Schizophrenia for Kids and a tool for schizophrenics, To See in the Dark: Hallucination and Delusion Journal. Fun Fact: She has wrestled alligators.
To learn more about Rachel, please visit her website, RachelStarLive.com.
Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.
Gabe makes his home in the suburbs of Columbus, Ohio. He lives with his supportive wife, Kendall, and a Miniature Schnauzer dog that he never wanted, but now can’t imagine life without. To learn more about Gabe, please visit his website, gabehoward.com.
Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.
Announcer: You’re listening to Inside Schizophrenia. Hosted by Rachel Star Withers, an advocate who lives openly with Schizophrenia. We’re talking to experts about all aspects of life with this condition. Welcome to the show!
Rachel Star Withers: Welcome to Inside Schizophrenia, a Healthline Media podcast, I’m your host, Rachel Star Withers here with my amazing co-host Gabe Howard, and this episode of Inside Schizophrenia is sponsored by Intra-Cellular Therapies. Now, when you talk about getting treatment for schizophrenia, Gabe, what’s the number one thing people think of?
Gabe Howard: Medication,
Rachel Star Withers: Yeah.
Gabe Howard: It’s medication and inpatient hospitalization, those are the two treatments that people think about when they think about treatment for schizophrenia, and I think we could probably just stop right there. I don’t think anybody is aware that there are any others.
Rachel Star Withers: Correct. It’s shocking how many times lay people have asked me, Oh, are you on antipsychotics? What antipsychotics are you on? So of like all the different drugs, people know antipsychotics are for schizophrenia, they’re for like crazy people. And that’s why it’s so important to consider other treatment methods. And today that’s what we’re talking about: cognitive therapy or cognitive behavioral therapy and how it can be used in the treatment of schizophrenia. And our guest today, all the way from Sweden is Cornelia Larsson, who is a licensed psychologist and psychotherapist, and she also teaches how to administer cognitive therapy.
Gabe Howard: All right, Rachel, before we get too far into the weeds, what exactly is cognitive behavioral therapy?
Rachel Star Withers: Cognitive behavioral therapy or cognitive therapy is evidence based talk therapy that attempts cognitive and behavioral changes in a patient. And the great thing about it is you have a psychologist and a patient work together in a collaborative fashion to develop an understanding for whatever the problem is and then figure out a treatment strategy. And one of the big things with CBT is that you have emphasis on the patient kind of becoming their own therapist. Now you’re not taking the place of the therapist, but you’re taking an active role in your recovery and your management of schizophrenia. You and your psychiatrist or psychologists come up with exercises and homework that then you put into your real life to managing your schizophrenia through different things. This has been widely used across all different types of mental disorders and not just mental disorders, but like problems, everyday problems that people have, whether marital drug abuse, alcohol problems, even just things like anger.
Gabe Howard: Or grief or your children leaving home or job loss. It really has a very broad appeal, and it’s useful to people in all walks of life with all types of mental health issues. And I like what you said about this partnership between patient and provider. That’s a vital importance because obviously, Rachel, we don’t live our lives in a therapist’s office. We don’t live our lives in a doctor’s office. We have to be able to take ownership of this to utilize this on a, you know, on a Thursday night when we’re sitting at home and these issues crop up. Now what other ways does it differ? Because as I understand it, it really focuses on the here and now, not the then and why.
Rachel Star Withers: Yes, I think many of us have like watched movies and TV shows, you know, iconic shows like Frasier and that type of therapy that we see is usually the person sitting down in the office and they’re talking about their lives, something that happened in childhood, some type of traumatic event, and the therapist is helping kind of talk them through it. That is a type of therapy, but it’s not cognitive. Behavioral, cognitive behavioral is focusing on what’s currently happening and what can we do in the moment when those things arise in your day to day life? So a lot of it is learning to recognize distortions in your thinking that could be creating problems or just sometimes problems actually happen. There’s nothing to do with you’re creating. But how do you then react to them to better understand like your behavior and the behavior of other people around you and their motivations? And then pretty much using problem solving skills to cope with these different situations? And I mean, Gabe, all of that right there, doesn’t that just sound like common sense?
Gabe Howard: Yes, yes, it does sound like common sense, so it’s it’s not a difficult thing, but you know, if we think about our lives, how many times in our lives have we taken something simple and made it difficult? And then somebody walks along and says, Hey, you know, if you do it this way, it’ll go twice as fast. You’re like, Oh, why didn’t I think of that? That’s a really bad analogy of CBT. But you know, obviously, when we’re in the middle of something, we have all the feelings of what’s going on. We’re not. Third party observers were not unbiased, were emotional wrecks, were whatever brought us to therapy in the first place and were tasked with trying to figure out how to solve this problem. The therapist is like a guide in this. That is what I love about CBT. Personally, the therapist is a guide. The therapist doesn’t tell you what to do. The therapist helps you figure out what to do and then master that coping skill.
Rachel Star Withers: Gabe, I have a personal question for you. Now you’ve been treated for bipolar for many years now, correct?
Gabe Howard: Yeah, yep, that’s true.
Rachel Star Withers: How much has cognitive behavioral therapy been a part of your personal treatment plan with bipolar?
Gabe Howard: It’s been huge. Medication helped control the symptoms, but once the symptoms were controlled, I still had. We’re going to go with lesser symptoms, right? I still had to manage my way through the world. I’m still a human and I still did have some symptoms of bipolar disorder and psychosis that I needed to learn how to recognize and how to manage. And CBT therapy was, I don’t even think vital is a big enough word. It helped me recognize symptoms before they became a problem and know how to manage them. It was instrumental. Instrumental in living well and living in recovery.
Rachel Star Withers: My second question to that is, did your doctors enroll you in programs, did they encourage you? Was this part of a recovery program who gave you CBT who helped you with cognitive behavioral therapy?
Gabe Howard: So I was diagnosed in an inpatient unit, and so that got me on my first medications, it got me a diagnosis and it got me put into just a variety of programs. So when I was released, I was released into what they called a step down program or an intensive outpatient program. And in that intensive outpatient program, there were many things. But one of the things was a one on one appointment with a psychologist who just happened to use CBT. So I want to disclose to the audience. I did not seek this out. I was just fortunate enough to be placed into this program, and I saw a tremendous amount of benefit. I don’t want to say rapidly because that’s probably a little bit disingenuous, but over months and years, the benefits really started stacking up for me. I’m a true believer. It has. It is very much worked for me.
Rachel Star Withers: That’s interesting to me. And we’re going to come back to that because your experiences with cognitive behavioral therapy is completely different than mine. And part of me wonders if it has to do with our two diagnoses being different, even though bipolar and schizophrenia are both very serious mental disorders. They tend to be thought of as those are two big ones, right? They have a lot of the same similarities. They’re not the same thing, but they do. We share a lot of the same symptoms, and even I would go as far as saying like quirks, because a lot of times
Gabe Howard: [Laughter]
Rachel Star Withers: People can just be like, Oh, that’s so funny. I know someone else who like, has this weird quirk. They might not even realize that it’s a symptom of something. So now let’s get to the question. Does cognitive behavioral therapy work OK? The answer, first off, is yes. There’s numerous studies showing that it leads to significant improvement in functioning and quality of life, just like you said, Gabe. It is one of the main forms of treatment for children and adolescents, especially when they’re hesitant to put them on medication so young. So it’s like one of the go to forms of treatment. But the question then is does it work for schizophrenia? And there’s a little bit of controversy there, Gabe, because the answer? It depends on where you are, which blows my mind. Here in a little bit, we have our amazing guest coming on and the reason I reached out to her, we shared some kind of back and forth conversation online, and she was shocked by the lack of CBT therapy that I had had, and I was so impressed and overwhelmed by it. Here she is, telling me all this great stuff for people with schizophrenia that I had never heard before. Most of the major research that have been done on cognitive behavioral therapy has actually come out of the United Kingdom, where their research has shown that CBT therapy is effective for the treatment of schizophrenia. The National Health Service there recommends that CBT therapy be delivered to all people with schizophrenia. That’s pretty amazing. Like they’re saying, if you got this diagnosis, you need to be going through this type of therapy. On contrast here in the U.S., the American Psychiatric Association guidelines describe CBT therapy as an adjunctive technique that may benefit people who have schizophrenia.
Gabe Howard: So obviously, Rachel, you can’t speak for all people all across the world with schizophrenia, but you can speak for yourself and
Rachel Star Withers: Yeah.
Gabe Howard: You’re generally a pretty well rounded and reasonable individual. You stay away from the extremes.
Rachel Star Withers: I do.
Gabe Howard: So, let’s talk about your personal experience with cognitive behavioral therapy.
Rachel Star Withers: No one. And it’s hard for me to say it’s because like when I just knowing for me, when I look at the between the United Kingdom saying yes, everyone with schizophrenia should have this and then the U.S. saying, Oh, they may benefit. And the fact that in my experience of all the years, I’ve been in treatment since being diagnosed in my early 20s, no psychiatrist Dr. program has ever brought up any sort of cognitive behavioral therapy to me, ever.
Gabe Howard: It’s never even? So you’ve never tried it.
Rachel Star Withers: I have. I seeked it out on my own.
Gabe Howard: What made you? What made you seek out CBT?
Rachel Star Withers: Because I was desperate, I was trying to find something that worked, I was on medications, I was doing everything for a while. I had to see a psychiatrist and a psychologist every single week. Two different ones. I would go to one on a Tuesday, one on a Thursday, and at no point did they ever bring that up that that was something that I should be looking into. That’s why I wanted to know about your personal story, because it’s completely different than mine. And I have benefited from CBT therapy, but it 100 percent was because I was trying to figure out what to do about this on my own. You know, in back in my early to mid-20s, it was much harder to find this. A lot of the techniques I had to come up with on my own, which is asking a lot for someone who’s in the middle of a psychotic episode.
Gabe Howard: It is a lot to ask of somebody who’s experiencing any health challenge. We don’t even have to say psychosis, just you’re in need of care and you also have to find it on your own. It is important to point out that I’m in Ohio and you’re in South Carolina and in America where you live plays a big role in the type of care that is available to you in the same way that what health insurance you have or what payer source you have, or if you have supportive parents or if you’re in a rural area versus an urban area, it’s tough. Now, once you found CBT therapy, what was your experience like? Did you have good outcomes? Did you get better? Did you learn coping skills? Was it? What was it like for you?
Rachel Star Withers: To me, it’s one of the main things that keeps me, quote unquote sane. I’m, obviously I am medicated, I have a counselor that I see every two weeks and different things like that, and that’s with her. We just talk about what’s going on in my life. We don’t actually come up with like techniques or anything, but it’s more just like a sounding board. She also helps me notice are my thoughts becoming delusional about things like she’s great with that? But CBT is what I have to do every single day. I’m constantly doing it to manage my hallucinations, to manage my thought patterns. What’s interesting is that still, so many doctors don’t push CBT because they kind of think people with schizophrenia aren’t going to do it, or they think that our problems are like, it’s just wait, our problems are way too big to really handle this. A really great example I found on the internet that I love was if you have a person who comes in to speak to a doctor and that they’re having sensations on their skin of like tingling and like pricks, and it’s due to job stress, they said. There’s lots of different CBT techniques and stuff. They’ll talk to you to help you manage your stress. But if an individual comes in and complains to the doctor that they feel there’s little microbes in computer chips implanted in their skin at their work, no one’s going to sit that person down and be like, Well, let’s talk about some cognitive behavioral therapy. They immediately assume that, whoa, this person is insane. This is outside of just normal talking, even though, like if you look back at it, like, no, what could be causing both of these issues is just stress. However, the person with schizophrenia, they are interpreting it differently. And I think that’s one of the biggest things when it comes to CBT for schizophrenia is that you kind of have to tweak some of the exercises and it is kind of the next level of, I don’t want, say, problems, but symptoms.
Gabe Howard: So let’s talk about cognitive behavioral therapy for schizophrenia techniques, I know that you have researched a few.
Rachel Star Withers: There are a few core ones that tend to work for schizophrenia. They’re not going to work every single time. They may work never for certain people. And of course, it depends on your mental state of being able to actually do these different treatments. One is Socratic questioning, and that’s where you kind of start to talk through a delusion or hallucination. So let’s say I’m having a delusion that God has called me to go and do something. So we use rational questions like, OK, Rachel, why do you think God’s called you to do this? Ok, well, well, I just feel this calling. Or let’s say I heard a booming voice. Well, what did the booming voice say? How often do people hear boom? And you kind of like question and help the person think their way through it. Is this rational thought? Now I can go and tell you that’s not going to work during a psychotic episode when I lose my arm in the bed. There’s no talking. You can’t be like, Well, Rachel, can you see your arm? Ok, you obviously didn’t lose it if you could see it.
Rachel Star Withers: That doesn’t work, but I can see that working for like smaller delusions. So that could be helpful, I think, for like baby things. The next one that’s real big is reality testing and behavioral experiments. So let’s say, Gabe, that, for instance, I think there’s some sort of devices in my walls that are listening to me. So me and the therapist would come up with, how could we test this? How could we test to see if there’s really bugs in the walls that are like kind of relaying that information to some secret society and we’d run our own little experiments? Again, I think for like a general delusion that could work if I’m in the middle of a psychotic episode, there is no testing anything, you know, so I can’t see these working, these first ones, but I can’t see them working for a really bad psychotic episode. And I don’t know Gabe with your bipolar if you’ve had any where you’ve just been like mentally out of your mind. There was no talking to you.
Gabe Howard: Obviously, the sicker you are, the less effective these methods will be, but. Bipolar disorder, schizophrenia, psychosis. It is on a spectrum. And one of the things that I found to be helpful is if I have enough consciousness and I know I’m, I’m using that word absolutely incorrectly. But if I, there’s enough of me there where I think, Hey, what coping skill or method can I employ to find out where I am on that spectrum? There’s hope, right?
Rachel Star Withers: Yes.
Gabe Howard: There’s hope. And being able to grab onto those things quickly and employ them quickly ups the odds of them working. Is it one hundred percent? Absolutely not. Nobody is saying that if you go to CBT, it’s going to work one hundred percent of the time and it’s going to be perfect. But having tools in your toolbox increase your odds and that’s what we’re trying to do here, right? We’re just trying to increase our odds for success. And there’s other methods, right? It’s just
Rachel Star Withers: Yes.
Gabe Howard: There’s not just that one, there’s there’s more.
Rachel Star Withers: My favorite one that I think has helped me and that I think will help other people and this isn’t even just like schizophrenia, but any type of serious mental disorder is what’s called normalizing. So let’s say I’m having a freak out that I have poison all over my hands, OK, and it’s burning me, so I’m freaking out. If you’re my doctor, Gabe, instead of you being like, Rachel, you’re crazy. There’s no poison. You’re fine. Stop acting like a nutcase. You’re like, Oh, wow, you think you’re poison on your hands? Well, no wonder you’re thrashing like that. Like, I would be, too if I had poison on my hands. If I thought I was being burned alive, I too would be trying to, like, take a shower suddenly with my clothes on. Normalizing is you break down what’s happening and kind of help the person understand that almost anyone would react that way? Real common one. And I think I’ve used it on this show before, but to help people understand the way my hallucinations and delusions work, I get really bad. Headaches literally feels like a nail in my head, and whenever I have headaches, my psychosis, honestly, it kind of gets out of control. So I feel like I have a nail in my head and then I go looking for a hammer. If you were to stop me and be like, Rachel, what are you doing out here in the garage? I’m looking for a hammer to get the nails out of my head. You don’t think, Oh man, Rachel has gone crazy. She’s over here thinking she has these invisible nails in her head like, Oh my gosh, we need to just lock her up. Like, Right, like, I’m over here trying to find hammers. But if you go to my actual thought process, my head hurts so bad it feels like there’s a nail. Well, of course. How would you get a nail out?
Gabe Howard: You get a hammer, yeah.
Rachel Star Withers: Like, that’s a rational thought, so there’s a rational thought to the whole process, but if you’re on the outside, you don’t see the rational thought. So that’s kind of what normalizing is. How did that person get to this reaction?
Gabe Howard: It does make sense, and it gives people something to work with.
Rachel Star Withers: Yes.
Gabe Howard: You know, like you said, there’s this knee jerk reaction to say, OK, you’ve gone off the deep end or and all kinds of other stigmatizing phrases, right?
Rachel Star Withers: Mm-hmm.
Gabe Howard: And that’s what it feels like to us. The people are just yelling insults at us, not taking us seriously. So now we’ve lost you as an ally. We don’t know what to do, and now we’re completely left to our own devices. Cognitive behavioral therapy helps us understand that, OK, here are our options. Again, they’re not always going to work, but it’s much better than what we’re used to, which is people just dismissing us and us having nothing to try.
Rachel Star Withers: And the way this plays out, then in my headache situation is from now on, every time that thought goes through my head, I have to be like, No, Rachel, you don’t need a hammer, but you do need to get the nail out. Let’s go take some headache medicine. That is how the therapy plays into that situation. It’s just something about the word hammer. I’ve trained myself the minute I start thinking about hammers, go take some ibuprofen, like that’s just how I’ve trained myself. So you won’t find me in the garage anymore looking for a hammer or something? I’ve learned that. Ok, whenever I think about hammers, that means I’m having a headache. I need to go take an ibuprofen and usually I’ll be fine within the next day or two.
Gabe Howard: Thank you, Rachel, so much for using your experiences to help us better understand or remember everybody. Your mileage may vary,
Rachel Star Withers: Oh, yes.
Gabe Howard: But these are some of the results that you could potentially get and that you could learn. And again, it’s so specific to your situation. Rachel is just our guinea pig because she’s our host, so don’t expect that your situation will be identical to Rachel’s situation. The amazing part of cognitive behavioral therapy is how it works on the individual level.
Rachel Star Withers: Ever since I was a little kid, I’ve had hallucinations. I’m one of the exciting few people who had childhood schizophrenia. I did start getting medicated at around age twenty two, but none of the medications have ever taken away my visual hallucinations. So I actually came up with what I call my monster technique. Gabe and I wanted to share it because so many people reach out to me who have similar issues with hallucinations that even though they’re on medication, they have these recurring hallucinations they can’t seem to shake. This was something I actually kind of developed for myself, and I turned it into a children’s comic called The Adventures of the Fearless Star. It’s for free download on Apple Books if you ever want to pull it up, but I’m going to break down the steps for anyone who’s out there. Ok, so it’s four steps. It’s very easy. Step one Draw your hallucination No matter how terrible a draw you are, that’s OK. Whatever you do, if you got to have like little stick figure drawing hallucinations, go for it. If it’s just like a blob. Awesome. Draw it whatever it is that keeps bothering you. Ok, what features stand out for me? I see a lot of like, very large, dark, menacing type characters. I don’t want to say humans. Sometimes they’re humanoid. They’re kind of hard to describe, but sometimes they’ll have features that are very distorted. So one of them, I’d say he’s like maybe nine feet tall. He likes to kind of loom over my bed when I’m at my computer, he’ll want to, like, loom over me.
Rachel Star Withers: That’s what I’m going to draw. Ok? Step two: name the hallucination. Now, very important, the hallucination cannot name itself. Ok? I cannot stress that enough because people will be like, Well, the hallucination is demonic, so it’s like a demon. I’m like, No, no, no, you name it. Ok, you’re the one that’s seeing it. You get to name it, and it needs to be something that’s like normal, unassuming or even silly. Ok, so let’s say I’m going to name my hallucination jiff. Ok, there’s Jeff over there. So I got my hallucination. He’s the big character that looms over me. His name’s Jeff. Number three, what is something that would scare the hallucination? So Jeff is like nine feet tall. I bet he would hate it if he had to have the middle seat on a nine hour flight. That would, oh man, that would probably wreck Jeff’s nerves. He’s huge. Like, he’s going to have such a hard time squished into that seat. His next going to be hurting him. He’s going to be all like, he knows these really long arms and like long fingers like he is going to be squished in there. Oh man. And then step four. Help the hallucination. So now you’re picturing I hope you guys are picturing with me my Jeff here, like I’m starting to feel bad for him. This guy is massive. This is not his fault. He got stuck with that middle seat. Ok, how can I help him? Well, first of all, Jeff, man, you have got to learn to buy your ticket sooner and you’ve got to get an aisle seat, man.
Rachel Star Withers: Ok, so that’s number one. We’ve got to just have that talk. Ok, I need to like bust out the app, show Jeff how to use like, how do you pick the airline seat? Ok, now if you’re listening, you’re thinking, Well, that’s kind of funny. It’s supposed to be. It’s taking the fear out of the hallucination. Do I still see Jeff? Yes, Jeff’s been like hanging out while we’ve been recording Gabe. He likes to just hang out and do that. He looms over me. Ok, he’s very annoying. I’ve taken it to where he’s kind of changed the thought. So he’s always looming over me because he just thinks I’m so cool and he always wants to know what I’m doing because I can’t make him go away. I cannot make Jeff go away. No medication has ever made him go away. He just is always here hanging out with me. So that’s what I call my little monster technique. And a young lady through my job. Once was having problems, she was a schizophrenic like me. She was having a real bad psychotic break, and she was being terrorized by this hallucination of this man who he was outside every window. She looked out and he wanted to slit her throat. That was she was terrified of this man, and I was like, Well, well, let’s draw him, describe him.
Rachel Star Withers: She’s like, I can’t draw on my just draw, just drop. So she draws them, and I’m like, What’s really scary? She goes, He has the worst teeth. They’re rotting. There’s like maggots in his mouth. It’s horrifying. And I’m like, What do you think would scare him? And she was like, Well, the dentist. I was like, Yeah, that would terrify me if if I have teeth rotting out of my mouth, I don’t want to go to a dentist. I’m scared to go to the dentist as it is because I know they’re going to fuss at me about flossing. And she goes, Oh my God, she would be terrified of the dentist. She drew the most hilarious little picture of this guy at the dentist, and his little eyes are like, so big and she let me have the drawing. And she never had a problem. After that, she told me she’s like every time she saw him outside her window, she would start talking to him about dental hygiene. And it was just so funny because she it stopped being scary, this guy who’s out there in her mind, threatening to slit her throat. She’d be like, OK, but we got to talk about brushing first because this is the bigger problem you have, sir. So this is a cute little thing to do. But yeah, these are ways to deal with hallucinations, especially ones that I’ve been medicated. The young woman I was talking about, she was medicated during all this, but she was still having these recurrent hallucinations.
Gabe Howard: And to tie this all back, Rachel, this is a form of cognitive behavioral therapy, it’s a technique that you came up with using CBT skills.
Rachel Star Withers: Absolutely, it’s what I did as a kid to pretty much be able to function, and I honestly assumed everyone was doing, I thought everyone when I was a kid hallucinated. I didn’t know I
Gabe Howard: [Laughter]
Rachel Star Withers: Was special. I thought everybody had monsters.
Gabe Howard: This is a common theme, right?
Rachel Star Withers: Yeah, the point is that CBT, it has so many uses. And unfortunately for a lot of us with schizophrenia, it is underutilized.
Gabe Howard: We’ll be right back after we hear from our sponsor.
Sponsor Break – 27:39 – 27:41
Rachel Star Withers: And we’re back talking about how cognitive behavioral therapy can be used in schizophrenia.
Gabe Howard: Rachel, as you’ve been alluding to this whole show, you got to interview a very, very cool doctor based in Sweden.
Rachel Star Withers: Yes, let’s play that interview.
Rachel Star Withers: We are excited to be talking with Cornelia Larsson, who is a licensed psychotherapist and psychologist, and thank you so much for being with us, Cornelia.
Cornelia Larsson: Thank you for having me.
Rachel Star Withers: Now, tell us a little bit about what exactly when I say, a licensed psychologist, psychotherapist, what is that?
Cornelia Larsson: Well, let somebody who talks to patients all day and usually through some type of therapy and tries to help patients manage their symptoms in a better way so they’re more free to do what they want in their lives.
Rachel Star Withers: You specialize in cognitive therapy, cognitive behavioral therapy, correct?
Cornelia Larsson: Yes. Cognitive behavioral therapy is a very close collaboration between the patient or the person seeking therapy and the therapist. So the therapist is a specialist in how people function in general in cognitive behavioral therapy, and the person seeking therapy is the expert in her or his symptoms or what has worked so far and in their history, how they’ve lived their lives, so to speak. And we work a lot through homeworks and exercises because in therapy, no one’s going to fix you. For example, if you go to the doctor with a tumor, you take it out and you’re fine. But in therapy, you’re working together towards the goal that the patient wants to achieve.
Rachel Star Withers: What are some basic, easy to understand cognitive therapy techniques that could be used for general schizophrenia symptoms, whether we’re talking hallucinations, delusions, a lack of motivation is obviously huge for people with schizophrenia.
Cornelia Larsson: I want to always encourage my patients to be experimental. Try something that you haven’t tried before and see how that works in this given situation. I also believe a very general cognitive behavioral therapy techniques where you’re kind of like compassionate to yourself and encouraging you yourselves. So, for example, you will track your symptoms, and if you’re doing good one day you will see that you will encourage yourself. I did great today and not just know scold yourself for every time where you don’t do well and, you know, track this. You know, if you have maybe bad self confidence that will not help you in many situations and then you can work with that. For example, you can start observing everything that you like about yourself or everything that you do good about yourself. Interview your friends or your family. What do they like about you? And then kind of remind you of that in difficult situations? Because then if you do this, usually you will be a bit more stable and then it will be easier to handle whatever symptoms you have. If you have problems with your with very strong emotions. There are lots of techniques that you can handle those. For example, you can count all white things in the room because when you have very strong emotions, you usually have strong emotions because you get caught in a train of thought
Rachel Star Withers: Ok.
Cornelia Larsson: About your how useless you are, for example. And then it’s kind of like putting on a blue glasses. You say everything in this blue light. And then you need to get out of this train of thought and you can do that, for example, by counting white things in the room. Describe the room in detail for yourself or someone you know, or do you exercise whatever that helps you focus away from this train of thought that says that you’re worthless or useless so that you get out of this very intense feeling?
Rachel Star Withers: I like that a lot. I’ve never I’ve never heard that before to count all the white things in the room. I get caught in those cycles of bad thoughts, and that’s really like, that’s just a very simple thing that you just shared right there to break that. Yeah, I’m definitely going to try that this week. Just like,
Cornelia Larsson: Yeah?Ok, good, because then it sounds like that strong feelings that that is the main thing and that is so common that the strong feelings is a huge problem and you need to get some way to handle them. Some people actually need physical pain to focus away because they need something really intense and you can do like two hundred squats or something. So they really get your the pain in your muscles so you can focus away from your whatever you’re thinking about.
Rachel Star Withers: Two hundred squats, I would be in pain the next day.
Cornelia Larsson: [Laughter]
Rachel Star Withers: No, I kind of like the idea of the squats because another issue, unfortunately that people have schizophrenia is that a lot of medications there, side effects cause weight gain. So I
Cornelia Larsson: Yes.
Rachel Star Withers: Kind of like the little mini physical workout kind of throwing that in there because it can have, you know, not just good effects like you’re talking about breaking train of thought, but also, you know, just healthy.
Cornelia Larsson: Yeah, and exactly, and as a therapist, that’s what you’re looking for. You want to find things that are helpful towards, you know, for example, the strong emotion, but also have something else to gain from it. I usually land this exercise wheel for the abdomen muscles to my patients, it’s so painful. If you do it for five minutes, you can’t focus on anything else.
Rachel Star Withers: I can imagine, yeah, yeah.
Cornelia Larsson: So you do that first and the squats and then you do something else after that, then you’re probably going to be somewhere else in your train of thought
Rachel Star Withers: Yeah.
Cornelia Larsson: And then you will be able to think more clearly.
Rachel Star Withers: Ok, so you actually have like a little exercise wheel that you give out.
Cornelia Larsson: Oh, yeah, I did.
Rachel Star Withers: Ok.
Cornelia Larsson: Yes.
Rachel Star Withers: I kind of like it because instead of people thinking I’m just like a crazy person having a meltdown, they’ll be like, Whoa, she’s a fitness freak. She just has to like, drop down and say, Oh, it’s time for her to, you know, get her 50 squats in. You go, girl. Just be in the, you know, in line at the bank and just, woo hoo. They won’t think it’s weird. They’ll be like, Wow, that’s impressive.
Cornelia Larsson: No, they won’t. But also, I just want to comment on that. You’re not just a crazy person. Everybody will experience those
Rachel Star Withers: True.
Cornelia Larsson: Very strong emotions. Everybody will do that sooner or later in life and will have to handle them somehow. So, if you’re kind of more like into more like worrying, first of all, for most people who worry, the worry is not leading anywhere.
Rachel Star Withers: Ok.
Cornelia Larsson: You’re not solving any problems. You’re just going around the round and round and round and round in your head.
Rachel Star Withers: Mm hmm.
Cornelia Larsson: And if you can recognize that you can kind of try to say stop, don’t worry now. I will have my worry time tonight at whatever time you choose, let’s say seven thirty, for argument’s sake.
Rachel Star Withers: Ok.
Cornelia Larsson: And then at seven thirty, you will sit down and you will write down every where you thought you have. Or if you have voices, you will listen to the voices at that time. And you write it all down.
Rachel Star Withers: Ok.
Cornelia Larsson: And then for, I don’t know, half an hour, an hour, and then whenever this comes back, you will say, No, no, no, I’ll do this at 7:30 tomorrow. So you will make time and space for it, and then you will do it, but on the rest of the day, you will say, No, no, I won’t go into this train of thought now.
Rachel Star Withers: If you’re someone who hears voices, is that good to notice? Is it good to listen to them sometimes? Or because so often with schizophrenia, we’re told, ignore the voices, ignore the hallucinations. Ignore, ignore, ignore. Are there times where, hey, it’s good to just like, let me listen to him or write down what they’re saying and see if, if, if there’s any legitimacy to this?
Cornelia Larsson: Well, I believe so. First of all, I believe that especially when you’re new to hearing voices, it can be so overwhelming. It’s I understood that it can be like being in the middle of a panic attack to have these voices talking to you and then, you know, just to step back and start observing, what are they saying? Who are they, actually? Is this one more of them children, grown ups? Who are these people? And what are they saying? What it does is it helps you to take a perspective. You’re not in the middle of it. You start seeing patterns. And first of all, that will be coming. But then you can also see time points when they show up and and and so on, and if you also listen to the negative ones and you can see the patterns, then you can try to find ways to manage with them. And I’ve also found that usually the voices will say, at least to my patients will say really horrible things
Rachel Star Withers: Yes.
Cornelia Larsson: That are really scary.
Rachel Star Withers: Yes.
Cornelia Larsson: If you take them for the exact word, which people do. However, when I as a therapist, listen to it, because when I listen to this as a therapist, I listen to what the voice say and what situation were you? What were you feeling? What had happened just before I listened to the big picture? And then maybe the voice will say something like, really brutal. So go and kill yourself. That’s horrible, right? Having someone say that to you, that is so overwhelming. So, so awful.
Rachel Star Withers: Yes.
Cornelia Larsson: However, what I will hear is not going to kill yourself. It’s stop feeling this because if you’re dead, you can feel it.So if I hear you stop feeling this, we can work with a feeling. The voices can actually point out a direction to you need to have this feeling or don’t go out, you might get hurt. It’s like handle the feeling that you’re scared. Or take care of this is, I don’t know, rough neighborhood or. You can find an intention that can actually be really helpful.
Rachel Star Withers: Hmm.
Cornelia Larsson: And if I may say so, I, you know, I’ve had people who’ve been chronically suicidal with this type of voices. And when we’ve worked this way or trying to listen to the intentions and changing problems all around things in their life and to handle their feelings and so on. It’s not the same with the voices anymore. The voice is getting nicer. Life is more stable. You don’t have to have these thoughts about killing yourselves, and the voices don’t say that anymore because life is more stable.
Rachel Star Withers: That’s interesting, I don’t think anyone’s ever explained it to me that way with the go kill yourself, I think unfortunately a lot of the very hostile voices and things that a lot of people with psychosis experience. Yeah, we’re mainly told at least I in the past have been told, you know, ignore them, that kind of thing. Whereas I really like the idea of, wait a second, why is it saying this? Stop feeling this way over something. Yeah, I don’t know that that’s that’s a different way of thinking about it. I like that.
Cornelia Larsson: Yes, it’s a different way, and also it’s, you know, if you think about it, I think every person has who was on this earth has ever encountered something that has been difficult. The the thought would cross their mind. Maybe I should kill myself, so I don’t have to feel this. I mean, it’s not unusual to have that thought. And so it’s not unusual for the voice to say something like that.
Rachel Star Withers: It’s a lot to take in because it’s it’s kind of like a deep thought when you’re like, Oh, OK, because I’m personally thinking back to different times. I’ve been very suicidal or I’ve heard things, you know, voices saying things like that and I’m thinking, you know, is usually probably it was tied to something I was going through. And I might not, though, of at the time realized that I was just so busy dealing with the horrible things I was hearing or feeling.
Cornelia Larsson: And that is my experience, too, with the people that I worked with. But life is so painful at the moment. And and then the voices start, and that makes life even painful, but it can change if you if you behave differently towards the voices. And with that, I mean, this was a way, way of describing behaving differently, like taking a step back and try to see patterns and and also see if you can find an intention of what what the voices are saying.
Rachel Star Withers: I like it, but so to put this in perspective, let’s say that my issue then is hearing kind of very negative loud voices at times just throughout the day. So if I were going to have different cognitive behavioral techniques to do, one of them was when they start, I could kind of ground myself, think about myself physically, where am I at? What am I doing? I could look around, count all the white things in the room. I could also be like, OK, I hear what you’re saying, I will deal with you tonight at seven thirty. I like that too. It’s like, OK, I got to finish doing what you know. I have to finish my work. I have to finish whatever I’m doing. Then I will listen and we’ll we’ll figure this out. You’re really on me about hurting myself today and then actually say, listening to the voices be like, OK, you’re telling me to do this? Why? Why, as I’m here trying to order coffee, are you screaming at me that I need to kill myself? What’s going on there? Would those be like an example of the different techniques I could use in the situation?
Cornelia Larsson: Yes. But, you know, over time, you will find these things. And usually what you do is is well, from my perspective, usually what you do is you try to to manage difficult feelings. And you try to challenge beliefs
Rachel Star Withers: I love to learn new techniques. Different ones are going to work at different times. Just like there’s no perfect medication, there’s probably no perfect one technique, but having a few you can kind of grab from and play with. Thank you so much, Cornelia, for joining us here today and sharing with us your knowledge about therapy.
Cornelia Larsson: Thank you, I hope this was helpful for someone.
Gabe Howard: Rachel, great job, very cool guest. And it’s awesome that you were able to get a doctor from Sweden. Listening, it did seem like you were uncomfortable and that it took a more serious tone sometimes. Am I reaching? Am I overreacting? Were you uncomfortable?
Rachel Star Withers: Yes, so I do feel that interview took a very sharp turn because we’re talking about we’re talking about how to break the train of thought. We’re talking about counting the white things in the room and I’m agreeing with her and I’m like, yes, you know how to ground yourself techniques all these very basic things. And Gabe, you know me, I try and be very upbeat. I try and be very happy. Even when I was talking about my monster technique, you know, I made it funny. I made it fun. It threw me when she suddenly started talking, saying about hallucinations, saying, Go kill yourself. I wasn’t expecting her to say that, and with the seriousness of it, and it shook me a little bit. It became intense, and that’s something I do want to hit on because schizophrenia is an intense disorder and that is a very real part of it. The reason I think it hit me when she said, Go kill yourself is because that’s what I’ve I’ve heard. Well, ever since I was a kid, that’s the kind of stuff my delusions and hallucinations I’ve been hearing and feeling my entire life. It shook me because I think whenever we hear talk like that, the kind of knee jerk reaction goes back to, Oh my God, this person needs help. We need to put them in a hospital, we need to get them on medication. And the truth is, a lot of us have done those routes and we’re still having those hallucinations and delusions. We’re still living with those very serious and scary thoughts of wanting to hurt yourself and do things like that. And it’d be great if I found a medication that took all that away. I’ve yet to ever find that, and in the meantime, I still have to use techniques to get through the day. And I really I appreciate the fact that Cornelia was able to kind of shed a light on that. Yeah. Like, yeah, schizophrenia, it is a very serious thing. We are talking about life or death a lot of times when it comes to managing schizophrenia.
Gabe Howard: Rachel, I love your eternal optimism, but you are right, I do think people who spend enough time with you start to forget how scary schizophrenia can be, and while on one hand that’s a good thing because being constantly terrorized by an illness is awful, but yeah, those reminders about how terrifying schizophrenia is. They probably hit you like a ton of bricks because you do put such a hopeful and positive front on. So often, well, always.
Rachel Star Withers: And with the loved ones, friends, caretakers out there, it is something I do want to make sure that they fully grasp to is sometimes it’s not just all person in your life with schizophrenia. Oh, they’re seeing things, they’re hearing voices, you know, take into account what it is that they’re saying, what they’re living with, what are those voices telling them constantly, what are they having to fight against 24/7? Sometimes voices that are telling them to do very scary things to themselves. Voices that, you know a lot of times are very, very mean. I think as a whole, we need to look at treating schizophrenia in all different ways. It isn’t like having a bacterial infection where I know I can just take some antibiotics and we’re good to go. If I take antibiotics for two weeks, I’ll be healthy again. You know, schizophrenia? Yes, medication can help. Therapy can help. Managing techniques can help. It’s a lot of different things that are going to go into living long term with schizophrenia and to be able to have like an amazing kick ass life with it. I think part of that, though, yeah, is learning techniques that work for you. You know, some of the ones we mentioned here today, I love some that Cornelia mentioned that I’d never thought of before, like counting all the white things in the room. Like, that’s such a simple thing that I was like, OK, that’s going now in my back pocket of techniques for when I start having trouble, because that’s just a simple thing for me to remember. Ok? To kind of break my train of thought, to silence everything that’s going on around me. As people who have schizophrenia, we need those. We need as many little techniques as we can to just kind of collect and try them out in our lives if it works. Awesome. If it doesn’t, that’s OK. Let’s figure out something else that might. Overall, that’s just all we can do and keep doing that, and I want to be upbeat about it, Gabe, because we have to be because here’s the deal. Schizophrenia is not going away, but we can still find incredible ways to keep pushing through. CBT therapy is just another thing we can add to our toolbox to help us manage schizophrenia. Thank you so much for listening to this episode of Inside Schizophrenia. Please, like share, subscribe and rate our podcast and we’ll see you next time here on Inside Schizophrenia.
Announcer: You’ve been listening to Inside Schizophrenia, a podcast from Psych Central and Healthline Media. Previous episodes can be found at PsychCentral.com/IS or on your favorite podcast player. Your host, Rachel Star Withers, can be found online at RachelStarLive.com. Co-host Gabe Howard can be found online at gabehoward.com. Thank you and we’ll see you next time.