Introduction

Even though research describing the benefits of CBT with delusions has been published for some years, the clinical cognitive approach has been slow to make a mark. ‘Historically, schizophrenia has been psychology’s forgotten child’ (Bellack 1986, cited in Chadwick, Birchwood & Trower, 1996). As the latter point out, the concept of Schizophrenia is ‘laden with pessimistic and at times baffling presumptions which serve to banish psychological analysis’. This article will demonstrate the effective use of CBT in challenging delusional thoughts associated with psychosis, along with some reference to the related concept of hallucinations.

What is a delusion?

According to the Diagnostic & Statistical Manual (DSM-IV), a delusion is defined as: ‘A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary. The belief is not one ordinarily accepted by other members of the person’s culture or subculture (for example, it is not an article of religious faith). When a false belief involves a value judgement, it is regarded as a delusion only when the judgement is so extreme as to defy credibility. Delusional conviction occurs on a continuum and can sometimes be inferred from an individual’s behaviour. It is often difficult to distinguish between a ‘delusion’ and an ‘overvalued idea’ in which the individual has an unreasonable belief or idea but does not hold it as firmly as is the case with a delusion (American Psychiatric Association, 1994).

With regard to hallucinations, hearing voices has traditionally been regarded as an illness by psychiatry. Research, however, is challenging this view, showing that ‘at least twice as many people hear voices than are labelled as having a psychiatric illness such as schizophrenia’ (Coleman, Smith & Good, 2001). An inventive study by Romme and Esher (1993) revealed how a person’s response to voices are mediated by psychological processes so that, even though voices can be of a serious nature, the response may not bring a person to the attention of the helping services.

If we apply this new way of looking at hallucinations to the related experience of delusional thinking, the person experiencing such phenomena attempts to make sense of the experience of experiencing delusions (or hearing voices), and it is the beliefs that are subsequently generated that cause the stress and behaviours, rather than the content of the delusions or voices.

Introducing the ABC model

The now well-known ABC model (Activating events are followed by Beliefs, which in turn lead to emotional and behavioural Consequences) was originally introduced by Albert Ellis, the founder of Rational Emotive Behaviour Therapy. This model, in an adapted form, is now widely used by practitioners of other types of cognitive behaviour therapy.

When applying the ABC model to psychosis, it is important to recognise that delusional thoughts or voices are not thoughts (Bs) – they are activating events (As) to which an individual gives a meaning at (B); following which they experience emotional and behavioural reactions at (C). Distress and coping behaviour are consequences not of the hallucination itself, but of the individual’s beliefs about the hallucination. Following is an example used by Chadwick, Birchwood & Trower (1996, p.19)

Cognitive behaviour therapy does not aim to eliminate the actual voices or delusions, but rather to modify what the client thinks about these phenomena, in order to reduce the distress that follows.

Case Study

Megan, a young Maori woman with two children, has had a history of disorganised, hostile and aggressive behaviour. Her family reported that she had been placing cloths over mirrors, taking her five-year-old daughter out of school, and talking to herself. She had no previous history with mental health services, apart from a short hospitalisation for a brief psychotic episode six weeks prior to the current admission. The predominant type of inferential thinking Megan portrayed was mind-reading. ‘They think I’m mad’ ‘They think I’m useless’ ‘they think I’m stupid’. The evaluative thinking that followed was, typically, discomfort-intolerance, i.e. ‘I can’t stand this’, ‘I can’t stand being here’ and ‘I can’t stand the people’

Key Presenting Symptoms

• Paranoid thinking: Megan believed that staff members were talking about her and trying to read her mind;

• Hyperactivity and demanding/challenging behaviour;

• Incongruous mood (inappropriate giggling with no apparent stimulus);

• Poor insight into what was happening to her.

Behaviour

When experiencing thought disorder, Megan became verbally aggressive and confrontational with increased levels of anxiety and agitation.

Therapeutic aims

• To provide Megan with a safe, therapeutic environment.

• To help her develop alternative, less distressing explanations for her experiences.

• To control symptoms by combining medication with Cognitive Behaviour Therapy in order to develop effective coping strategies.

Engagement of the client

Therapeutically engaging a client experiencing delusions or hallucinations can be a challenge. Due to Megan’s, initial hostility and abuse engagement took some time. Chadwick, Birchwood and Trower (1996) outline seven major threats to engaging clients with psychosis:

1.       Failure in empathy. With many clients, the therapist is able to relate, to some degree, to the feelings they encounter; few therapists, though, will hear voices or hold delusional beliefs, so developing empathy will be a challenge.

2.       Therapist beliefs. A therapist may, for example, hold negative beliefs regarding psychosis or doubt that CBT can be an effective treatment for a disorder that has biological underpinnings.

3.      Client beliefs. Clients may believe that opening up to a therapist could result in higher doses of medication or incarceration in hospital. They may also believe that therapy will lead to disempowerment. Megan, at first quite confrontational in her manner towards all staff, required considerable reassurance over time. Time spent on the relationship will usually be time well spent, especially in the early stages of therapy, to alleviate such fears with reassurance, perhaps also using the ABC model to help the client combat fearful thinking.

4.       Relationship too threatening. The client may have little experience of safe interpersonal relationships and thus find it difficult or embarrassing to engage. They may find a one-to-one interaction stressful. Therapists may need to adapt sessions to fit the client, for example by shortening session length or making the sessions more informal in order to ease discomfort. Due to the acute state of Megan’s, psychosis on admission she experienced some discomfort with myself and with others, so I spent several days building up rapport in a gradual and reassuring way.

5.       Client sees no potential benefit. The client may expect the therapist to simply stop the voices, and be uncertain that the goal of learning to tolerate them is achievable.

6.       The client finds it hard to see that delusions are beliefs, not facts. The therapist’s task is to help the client recognise that the delusion is a belief (B), not a fact (A), and understand that this reframing will empower them to ease the distress associated with the delusion. I found that using Socratic dialogue with Megan was the most effective way to achieve this, as it reinforced her own questionings and doubts and prompted her to develop alternative ways of explaining what was happening to her.

7.       Difficulty developing a rationale for questioning delusions. With other forms of mental illness, the process of cognitive behavioural intervention can move quite quickly; but with delusions, it is a slow process that needs careful handling to prevent undue distress. As indicated above, it is important to help the client recognise the need to reconsider their belief if only to relieve the distress that the delusion causes.

 People with persecutory delusions tend to have an excessively negative self-image, and ‘persecutory delusions are closely linked to this defensive posture’ (Bentor, cited by Birchwood, 1994, p.5). In order to build a therapeutic relationship with Megan, I used the basic counselling skill of empathic listening to encourage her to feel comfortable and tell me her story. We began discussing both current events and early learning experiences that have helped Megan develop as a person. Early in these sessions I introduced the ABC model. Although Megan was quite disorganised in her thinking and her mood was labile at this early stage of treatment, it was still possible to help her see the connection between her belief system and her behaviour.

Assessment & beginning of treatment

Assessment in cognitive behaviour therapy is dynamic – it begins early and continues, to some degree, throughout an intervention. As well as the usual items that would form part of a psychosocial assessment, the therapist would also begin assessing the client’s belief system. The following description illustrates how assessment often involves some degree of treatment.

I asked Megan to concentrate on a specific activating event that was causing some distress. She chose to focus on her reaction when members of staff accumulated in the office area. The following questions to assist the assessment process:

• What is the belief? Megan believed that members of the staff talked about her and that they could read her mind.

• What evidence is the client using to support the belief? For the belief that staff members talked about her, Megan used as evidence the fact that nursing staff gathered in the office area. She could not identify any evidence she was using for the belief that other people were trying to read her mind.

• Is the evidence a feeling, real fact, distorted fact or delusion? The belief that members of staff were talking about her is a distorted fact. In comparison, the belief that others were trying to read her mind was a delusion.

• How firmly is it held? Megan firmly and continuously believed that members of staff were talking about her whenever she saw them congregate in the office area. The belief that people could read her mind was more infrequent, usually only becoming apparent when she was questioned

• How distressing is it? Holding onto this belief caused Megan to experience considerable fear and anxiety. This led her to behave uncharacteristically in a hostile, abusive, threatening manner, most likely as a reaction to her fear about what would happen to her. Her behaviour then added to her distress.

• How does it effect the client’s life? Megan’s, belief caused her to feel anxious and frightened. She was suspicious of nursing staff and other patients with whom she was unfamiliar. Also, Megan’s, friends and family were beginning to alienate from her because of her behaviour.

Summary: the early stages of intervention

Exposure via imagery

Before long, it was time to begin behavioural work. The purpose of exposure to help the client practice coping skills under controlled conditions, and gradually change erroneous perceptions through action.

Preparation

Cognitive procedures such as Rational-Emotive Imagery (Maultsby & Ellis, 1974) and Rational self–analysis (Froggatt, 2001 & 2003), were used to help Megan identify and dispute the thoughts that created her anger.

These cognitive strategies were combined with relaxation techniques. Everyday occurrences that caused her anxiety to increase were identified. At this point, Megan was acutely unwell and was finding it difficult to maintain self-control, so there were plenty of opportunities for her to practice her new coping skills, even though she found it difficult at first. Due to lack of concentration she required extra input and guidance. Having already established a good therapeutic relationship and level of trust with Megan made it easier for her to follow instructions.

Procedure

 Megan was asked to imagine staff congregating in the office area, then to describe the feelings she was experiencing, including both physical sensations and emotions. There was an obvious increase in anxiety levels. The relaxation instructions were repeated to guide her back to a level of anxiety that she was able to manage. This had a positive effect on the agitation and anger. Therapist and client practiced this procedure daily.

Reality testing

Megan was asked to consider who would trust to give her accurate feedback if she were to ask them about her belief that people were reading her mind. Megan chose her mother, who then attended a therapy session. She was able to accept her mother’s statement that it was not possible for others to read her mind.

Homework

A key feature of any form of cognitive behaviour therapy is homework (sometimes referred to as ‘self-help work’). This is therapeutic work the client carries out between sessions with the therapist. There are three main types of homework: educative (reading, listening to audiotapes, watching videos, researching on the internet, etc.); cognitive (using rational self-statements written on cards, completing thought records, etc.) and behavioural (e.g. carrying out exposure work, as described above, but without the therapist’s presence). Over time, Megan and I collaboratively agreed on a range of self-help work like the following:

• Read some written material, e.g. ‘Who Controls You’ and ‘What are you Really Afraid of?’ (from Froggatt, 2003).

• Keep an ABC diary to log any incidents that caused her significant concern, recording what was happening (A), how she reacted (C) and what thoughts she could recall (B).

• Prepare a short list of anger/anxiety provoking situations that she thought she could work on using the techniques already developed, then (later) place herself into these situations while using her new coping skills to keep anxiety levels at a manageable level.

• Compile a list of early signs of relapse to help her identify  and alleviate any deterioration in her mental state before it became unmanageable. Megan developed the following list of symptoms: thoughts begin to race, poor sleep, too much energy, thinking that people were talking about her, poor eating, covering up mirrors.

• Prepare a list of names and phone numbers of people to contact should certain signs develop, including family members, community psychiatric nurse, GP or psychiatrist.

Evaluation

Megan reached a point where she was able to manage all of the above tasks. It was clear that she benefited from cognitive behaviour therapy and the adjunctive relaxation techniques. Though concentration was problematical at the beginning due to the acuteness of her illness, with the combination of the correct medication, constant guidance and reassurance and a good working relationship, therapist and client were able to overcome a number of obstacles that her belief system had placed on her. Megan is now well educated in the effects her belief system has on her behaviours and no longer requires CBT input, though understands the desirability of requesting, whenever necessary, follow-up in the future.

Working as part of a team

Liaison with a Maori mental health worker at the beginning enabled me to practice in a culturally safe manner and ensure that any need for specialist input from a Maori practitioner would be identified.

It was important to educate other nursing staff on the inpatient unit about what I was trying to achieve, as CBT was not extensively practiced there at that time. There was clinical psychologist input, but usually further down the recovery path. What the work with Megan was able to show, albeit in a small way, was that early intervention with CBT can ease distress caused by delusional thinking. It also proves the benefits of perseverance with some clients who may initially be perceived as difficult.

Maintaining safety

Throughout the intervention, the therapist remained cognisant of the points made by Nelson (1997) to increase the safety of the intervention:

1. Set the goals of treatment and plan the possible lines of approach before making any attempt to challenge or modify a delusion or hallucination.

2. Prepare an alternative explanation before staring to challenge or modify the delusion or hallucination.

3. Always think about what you are doing before you do it – and do not do it unless you have good reason for doing it.

4. Go slowly and be gentle. Be prepared to withdraw if necessary. Do not be tempted to move too fast if progress appears too slow.

Conclusion

The goal of this article was to demonstrate the effective use of Cognitive Behaviour Therapy in challenging delusional thoughts associated with psychosis, using work with the client Megan as an example. Using the ABC model we have seen how the delusions are activating events; and that a useful focus of intervention is the beliefs clients have about their delusions, rather than the delusions themselves. This intervention showed how the distress caused by the experience of delusions can be reduced with a combination of appropriate medication and CBT. As Chadwick, Birchwood & Trower (1996) put it: ‘Psychosis sufferers experience the same emotional and behavioural problems as other people, therefore cognitive therapy is relevant and effective for this client group’.

References

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th Edition). Washington, DC: American Psychiatric Association.

Chadwick, P., Birchwood, M. &  Trower, P. (1996). Cognitive Therapy for Delusions, Voices and Paranoia. Chichester: Wiley

Coleman, R., Smith, M. & Good, J. (Eds.). (2001). Psychiatric First Aid in Psychosis. Gloucester, UK: Handsell Publishing.

Froggatt, W. (2001). Learning to Use Cognitive Behaviour Therapy: An integrated approach. Hastings: Rational Training Resources.

Froggatt, W. (2003). Choose to be Happy: Your step-by-step guide (2nd Edition). Auckland: HarperCollins.

Maultsby, M.C. & Ellis, A.. (1974). Technique For Using Rational-Emotive Imagery. New York: Institute For Rational Living.

Nelson, H. (1997) Cognitive Behavioural Therapy With Schizophrenia: A practice manual. Cheltenham: Stanley Thornes.

Romme, M. & Escher, S. (1993) Accepting Voices. London: Mind publications.