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Schizophrenia: Practical Strategies for Relapses & Reducing Symptoms
10 CEUs Schizophrenia: Practical Strategies for Relapses & Reducing Symptoms

Section 17
Addressing Delusions with Cognitive Therapy

Question 17 | Test | Table of Contents | Schizophrenia CEU Courses
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Similar to cognitive therapy for depression and anxiety, cognitive therapy for psychosis is active, structured, time-limited (between 6 and 9 months), and usually delivered in an individual format. The early sessions emphasize the development of the therapeutic relationship through gentle questioning and guided discovery. The therapist's aims are to understand and validate the patient's life perspective, creating a climate of openness and trust. The therapist gradually moves to a more formal assessment of symptoms and the establishment of mutually agreed-upon goals for therapy. Teaching about the role of personal vulnerability and stressful life circumstances and their interaction in the production of delusions, hallucinations, and emotional withdrawal is an integral component of therapy. This normalizing strategy, pioneered by Kingdon and Turkington, highlights the universality of the patient's experiences and reduces perceived stigma.

As in cognitive therapy for other conditions, the therapist socializes patients to the cognitive model by directing their attention to the relation between thoughts, feelings, and behaviors. Underlying beliefs and assumptions about the self (for example, "I'm unlovable"), about others (for example, "people are dangerous"), and about the world (for example, "it's malevolent") are identified and linked to the patient's past and present difficulties. This formulation provides an individual map for navigation in therapy and for the timing of specific cognitive and behavioral strategies.

Individual cognitive therapy sessions involve checking on the patient's mood over the previous week and identifying any irregularities in medication use. The therapist maintains continuity between sessions by reviewing the important areas addressed in the previous session and by checking for updates over the past week. Following this, a structured agenda is set that includes a mutually agreed-upon priority focus for the session (typically a problem from the problem list developed during the assessment phase). Following the implementation of in-session cognitive and behavioral strategies, homework is assigned to focus patients on monitoring and then testing their beliefs experimentally. While the format of cognitive therapy for schizophrenia is similar to that of other cognitive therapy interventions, sessions may be of shorter duration (15 to 45 minutes), may include breaks, may set more focused and limited homework tasks, and may offer greater flexibility in terms of session-to-session goals. Agitated or confused patients may be seen for multiple short visits rather than I comparatively long session.

Cognitive Focus in Delusions
Historical conceptualizations of delusions have maintained that they represent abnormal beliefs which are qualitatively different from normal beliefs. However, examination of their nature within the context of what we know about the role of specific beliefs in nonpsychotic conditions shows many similarities. For instance, dimensions common to both are pervasiveness (the extent to which the patient's consciousness is controlled by the belief), conviction (the degree to which the patient believes it), significance (the belief's importance in the patient's overarching meaning system), intensity (the degree to which it prevents or displaces more realistic beliefs), and inflexibility (the degree to which the belief is impervious to contradictory evidence, logic, or reason). In one extreme view, delusions have been said to be "empty speech acts, whose informational context refers to neither world nor self. They are not the symbolic expression of anything". Yet, it is possible to make sense of the seeming bizarreness of delusions and hallucinations and other aspects of the illness when they are understood within the interpersonal context of the person's life. The content of delusions often reflects everyday concerns, such as being demeaned, excluded, manipulated, and attacked. The content of delusions also often reflects the patient's predelusional beliefs. Strong religious beliefs, for example, provide the foundation for delusions about Jesus, whereas an interest in and network of beliefs about the paranormal may lead to delusions about alien control. Understanding the patient's predelusional belief system may provide direct clues to the delusions' formation and content. For instance, grandiose delusions may develop to compensate for an underlying sense of loneliness, unworthiness, or powerlessness, whereas the proximal antecedents of a paranoid delusion may include the fear of retaliation for having done something that offended another person or group. Increasingly, delusions are seen to lie at the extreme end of a belief continuum rather than to represent categorical abnormalities.

In contrast to the mechanistic and reductionist framing of delusions as representing fixed neuropsychological deficits, the cognitive approach tries to make sense of the way patients make meaning of their life experiences and the way common cognitive biases may distort the perception of these experiences. For instance, cross-sectional analysis of delusional thinking demonstrates several common cognitive characteristics. These include an egocentric bias, by which patients become locked into an egocentric perspective and construe even irrelevant events as self-relevant; an externalizing bias, in which internal sensations or symptoms are attributed to external agents; and an intentionalizing bias, which leads the patient to attribute malevolent and hostile intentions to other people's behavior. Further, experimental research has shown that, when some patients with persecutory delusions attempt to make sense of relevant life experiences, they have an exaggerated tendency to blame extraneous factors, particularly other people, when things do not go well. This exaggerated self-serving bias is especially prominent when the negative event is significant to the person, pointing to a potential function of this bias in protecting (vulnerable) self-esteem.

Another striking characteristic of delusional patients is their tendency to jump to conclusions and fail to consider alternative explanations for their interpretations. Experimental studies have demonstrated that delusional patients are disposed to make overly rapid and overconfident judgments based on limited information. This tendency is most pronounced when the judgment concerns emotionally salient material .

Just as depression patients are more likely to experience activated cognitive distortions of the self, others, and their future following a meaningful negative life experience, the distorted cognitive lens of delusional patients is likely to operate in situations where the outcome is deemed to be important and in which they experience personal threat and vulnerability.

Finally, the historical definition of delusions as fixed and impervious to change by rational methods has been disproven by observing both the natural flux in their content and form (that is, conviction, pervasiveness, and intensity) over time and the direct reduction in delusions that can be produced by cognitive therapy. Collectively, this set of conceptions provides an understanding that facilitates psychotherapeutic interventions. The cognitive approach to delusions will now be outlined.

Cognitive Therapy of Delusions
Fifty years ago, Beck described the first cognitive treatment of a man with a 7-year paranoid delusion. The patient was a 28-year-old World War II veteran who, upon returning home from the war, came to believe that former members of his military unit were working with the FBI to monitor his activities. Treatment focused on identifying the antecedents of his delusional system and their relation to the current context of his delusional system. Misperceptions of everyday occurrences that were taken as evidence of the FBI's persecution were identified and gently questioned. The questioning and testing of alternative explanations for events eventually led to changes in the patient's belief system. By the end of treatment, the patient was able to stand back and reason himself out of the erroneous beliefs whenever be became suspicious of being watched. Two decades later, this case report was followed by a report of cognitive interventions with 8 patients with ongoing delusions. Through careful questioning of the evidence that the patient held to support the delusion, the patient began to see the delusions as hypotheses about the meaning of events rather than as absolute, rigid "truths." Other clinical researchers using the same cognitive focus began to report similar benefits.

The therapeutic approach involves several cognitive and behavioral strategies aimed at undermining the rigid conviction and centrality of the delusion(s). Before attempting to shift the patient to a questioning mode, the therapist first attempts to understand the patient's life context, including important past life events and their appraisal. In the assessment phase, the patient's predelusional beliefs are ascertained by inquiring into fantasies and daydreams ("Did you ever have daydreams or images when you were growing up?" "How did you see yourself in your daydreams or images?"). The therapist also attempts to identify proximal events critical to the delusions' formation ("How were things going in your life when you started having this idea?") as well as current events likely to trigger the delusions. Specific triggers for delusions can be external (for example, a passerby in the mall) or internal (for example, sensations in the body). The specific consequences—both emotional (for example, fear, anger, or sadness) and behavioral (for example, withdrawal, avoidance, or confrontation)—created by the delusion's activation are also assessed.

Once the therapist has a thorough understanding of the patient's delusional beliefs and the past and current events that are interpreted as supporting them, the evidence is gently questioned. Patients are socialized to the cognitive model and learn to identify the links between their thoughts, feelings, and behaviors. Later, they learn the role of cognitive biases (for example, egocentricity) and distortions (for example, magnification and selective abstraction in their thinking). The approach is collaborative and Socratic. Initially, the therapist deals with interpretations and explanations that are peripheral to more central and highly charged beliefs. Take, for example, a patient with a 12-month delusion that he is being persecuted by school staff and police in a coordinated effort to have him framed for a crime he did not commit. On a given day, he arrives at school to find that his locker is ajar. His automatic thoughts (and conclusions) are that the staff have broken into his locker to plant incriminating evidence, that they will do whatever it takes to "put him away," and that he cannot trust anyone. The therapist might ask the following questions: "What leads you to believe this is likely?" "What is the evidence that supports this interpretation?" "Are there any possible alternative explanations?" By questioning the inference, the patient is able to consider alternative possibilities: "I'm not 100% sure I remembered to lock, it since I was rushed," or "They couldn't be sure how long I would be away at lunch, since I sometimes come right back, and so would they really take the risk?" and then, finally, "What difference would it make? There's nothing to find anyway." In considering this evidence, the patient states that this was likely a false assumption and experiences immediate relief. With repeated practice in generating alternative explanations in the therapist's office and then, increasingly, as part of assigned homework, the certainty of the patient's delusional beliefs gives way to more balanced and less distressing interpretations.

In addition to using verbal strategies, the cognitive therapist aims to change delusional thinking by setting up behavioral experiments that test the accuracy of different interpretations. For instance, one of our patients had a 9-year paranoid delusional belief that once a group reached critical mass (that is, 20 members) it was likely to become violent and attack him. Whenever he saw large groups of people, he would quickly escape to a quiet and safe place. The treatment approach included having the patient focus on his hypothesis about groups of 20 or more and observe their behavior. After initially watching groups on television and in the movies, he progressed to observing large-group behavior from a safe distance (for example, 100 yards from a large crowd watching varsity sport). Considering this evidence in relation to his delusional belief, "large groups have it in for me," provided enough change to permit this patient (aided by the therapist) to begin entering situations where large groups gathered.

Another of our patients was experiencing long-standing delusions of reference. She believed that when people spat on the ground they were actually spitting to communicate to her that she was not welcome there. After several sessions considering alternative explanations for this behavior, 2 hypotheses were entertained for testing: either people truly were spitting to communicate a message to her, or people sometimes spat, and this was not meant to communicate a specific message to her. Her experiment was to go to the busy downtown street where this happened often and to observe the frequency of this behavior, first while away from the sidewalk and then while walking on the sidewalk. The data generated by the behavioral experiment were reviewed (the frequency of the behavior was the same whether she was present or absent from the sidewalk), and the patient was able to accommodate this information and shift her interpretation. While this experiment aimed to produce an alternative perspective on the evidence for her delusions of reference, later sessions focused on identifying the underlying beliefs of inadequacy and unloveability that gave rise to her misinterpretations of others' behavior. Behavioral experiments near the end of therapy focused on testing the evidence for her old self-beliefs that she was inadequate and unloveable against newly created self-beliefs that she was sometimes adequate and sometimes loveable.
- Rector, Neil A.; Beck, Aaron T; Cognitive Therapy For Schizophrenia: From Conceptualization to Intervention; Canadian Journal of Psychiatry; Feb2002, Vol. 47 Issue 1

Personal Reflection Exercise #3
The preceding section contained information about addressing delusions with cognitive therapy. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Igra, L., Roe, D., Lavi-Rotenberg, A., Lysaker, P. H., & Hasson-Ohayon, I. (2021). “Making sense of my diagnosis”: Assimilating psychoeducation into metacognitive psychotherapy for individuals with schizophrenia. Journal of Psychotherapy Integration, 31(3), 277–290.

Mehl, S., Schlier, B., & Lincoln, T. M. (2018). Does CBT for psychosis have an impact on delusions by improving reasoning biases and negative self-schemas? A secondary mediation analysis of data from an effectiveness trial. Zeitschrift für Psychologie, 226(3), 152–163.

Opoka, S. M., Ludwig, L., & Lincoln, T. M. (2018). A systematic review of trials targeting depression and anxiety in patients with delusions: An emotion-focused perspective. Zeitschrift für Psychologie, 226(3), 142–151.

Sum, M. Y., Chan, S. K. W., Tse, S., Bola, J. R., & Chen, E. Y. H. (2021). Internalized stigma as an independent predictor of employment status in patients with schizophrenia. Psychiatric Rehabilitation Journal, 44(3), 299–302.

According to Rector, what are three common characteristics of delusional thinking? Record the letter of the correct answer the Test.

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