IJSP Number 4, 2022

76 therapist’s own internal psychosis, and so she can feel either omnipot ent, or helpless [14]. 2.3. Difficulties in cognitive restructuring Schizophrenia is one of the most serious mental problems at present, its main characteristic being the distorted perception of reality and the decrease of functional capacity. The schizophrenic patient cannot distinguish between herself in her inner world and the reality from the outside world [15]. Interventions at the level of cognitive axis are first of all for the schizophrenic patient’s cognitive deficiencies, and not for cognitive restructuring (although most beginner therapists are tempted to restructure the patient’s delusions, an impossible task that has a negative impact on the therapeutic alliance and relationship). On the cognitive axis, psychotherapy focuses on: psychoeducation regarding symptoms and associated problems, improvement of coping abilities, so that the patient can manage better hallucinations and negative symptoms, cognitive restructuring for delusional ideas, problem solving skills, improvement of social skills, management of social anxiety, and management of post-traumatic stress syndrome and substance abuse [9]. The patient’s relationship with the voices is defined by four central dysfunctional beliefs: the voice has absolute power and control; the patient must submit to the voice or else she will be severely punished; the voice identity (for instance the devil); and the meaning attached to the voice (for instance the patient is being punished for past bad behavior) [16]. Hallucinations and delusions are the pat ient’s reality, and this is the reality we are working with. Practically, we do not confront the patient regarding the beliefs about the voices she hears, but we are trying to reduce distress, by helping the patient re-evaluate beliefs, working on four areas: the meaning of the experience of hearing voices (the meaning of symptoms); the relationship between the patient and the voice (the relationship with internal experience); positive and negative aspects of the self (schema); and the self experienced as dynamic and ever-changing (the symbolic self) [17]. 2.4. Difficulties in problem solving skills training Social problems solving skills are very important for the schizophrenia patient [18]. In order to solve a problem, the individual must materialize a series of cognitive activities such as discrimination, generalization, keeping in memory and recovering information from memory. Schizophrenia on the other hand is characterized by serious impairment of cognitive functioning. For instance, schizophrenics have major difficulties in establishing a purpose and planning activities [19]. Problem solving involves four aspects: (1) problem investigation; (2) problem analysis and solution generation; (3) problem solving; and (4) matching the solution to the problem to personal goals [20]. Practically, psychotherapeutic interventions for problem solving involve [20]: