Front Matter
Publication: Decoding Delusions: A Clinician's Guide to Working With Delusions and Other Extreme Beliefs
Decoding Delusions
A Clinician’s Guide to Working With
Delusions and Other Extreme Beliefs
Decoding Delusions
A Clinician’s Guide to Working With
Delusions and Other Extreme Beliefs
Edited by
Kate V. Hardy, Clin.Psych.D.
Douglas Turkington, M.D., FRCPsych
Note: The authors have worked to ensure that all information in this book is accurate at the time of publication and consistent with general psychiatric and medical standards, and that information concerning drug dosages, schedules, and routes of administration is accurate at the time of publication and consistent with standards set by the U.S. Food and Drug Administration and the general medical community. As medical research and practice continue to advance, however, therapeutic standards may change. Moreover, specific situations may require a specific therapeutic response not included in this book. For these reasons and because human and mechanical errors sometimes occur, we recommend that readers follow the advice of physicians directly involved in their care or the care of a member of their family.
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Copyright © 2024 American Psychiatric Association Publishing
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First Edition
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Library of Congress Cataloging-in-Publication Data
A CIP record is available from the Library of Congress.
ISBN: 9781615372959 (paperback), 9781615379491 (ebook)
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
Contents
Foreword
Preface
Video Guide
Contributors
Mindful Language
Introduction
Douglas Turkington, M.D.
Kate V. Hardy, Clin.Psych.D.
PART I
Delusions
Theoretical, Historical, and Lived Perspectives
1 Delusional Beliefs and the Madness of Crowds: What Are Beliefs, and Why Are Some of Them Pathological?
Richard Bentall, Ph.D., FBA
2 The Lived Experience of Strongly Held Beliefs
Shaun Hunt, M.Sc., B.Sc.
3 Considering Delusions Through a Cultural Lens
Peter Phiri, Ph.D., RNMH, CBT (DipHE)
Farooq Naeem, Ph.D., MRCPsych
Kathryn Elliot, M.Sc.
Shanaya Rathod, D.M., MRCPsych
4 The Psychology of Paranoid Beliefs
Anton P. Martinez, M.Sc.
Vyv Huddy, Ph.D.
Richard P. Bentall, Ph.D., FBA
5 Linguistic Techniques for Clinicians Working With Patients With Delusions
Nazneen Rustom, Ph.D., B.A., GMBPsS
Gordon Turkington, M.Sc., B.Sc.
Appendix A
Adapted Transitivity Brainstorming Map: Applied Example
Appendix B
Adapted Transitivity Tool: Real-Life Examples
Appendix C
Cognitive-Behavioral Therapy–Adapted Vocabulary Chain Template
Appendix D
Adverb Use Tracking Template
6 Assessing Delusions
Dimitri Perivoliotis, Ph.D.
PART II
Treating Delusions
Types, Techniques, and Settings
7 Collaboration, Not Collusion: Befriending and Normalizing
Kathryn Eisen, Ph.D.
Melanie Lean, Clin.Psych.D.
Kate V. Hardy, Clin.Psych.D.
8 Cognitive-Behavioral Therapy for Paranoia: Conceptualization, Process, and Techniques
Douglas Turkington, M.D.
Kate V. Hardy, Clin.Psych.D.
9 At-Risk Mental State: Delusional Presentations
Mark van der Gaag, Ph.D.
10 The Curious Case of Schreber
Kristin Lie Romm, Ph.D., M.D.
Douglas Turkington, M.D.
11 Erotomania and Sexual Delusions
Tania Lecomte, Ph.D.
Audrey Francoeur
Briana Cloutier
12 A Bizarre and Grandiose Delusion: Persecution of a Goddess Using Social Media and Microbots
Douglas Turkington, M.D.
Helen M. Spencer, B.A.
13 Who Are You?: Capgras Syndrome and Other Delusions of Misidentification
Michael Garrett, M.D.
14 Thought Disorder or a Problem With Communication?
David Kingdon, M.D., FRCPsych
Kate V. Hardy, Clin.Psych.D.
Kenneth Sandoval Jr., M.S., M.S.W., LCSW
15 Cognitive-Behavioral Therapy for Delusions Within Japanese Culture
Akiko Kikuchi, Ph.D.
Douglas Turkington, M.D.
16 Trauma and Delusions
Charles Heriot-Maitland, Ph.D., D.Clin.Psy., M.A., B.Sc.
PART III
Working With Delusions in Different Settings
17 A Cognitive-Behavioral Therapy Approach to Working With Delusions in Forensic Settings
Patricia Cawthorne, D.N., M.Sc. (CBP), RMN
18 Using Digital Health Technology to Facilitate Measurement-Based Care in the Treatment of Delusions
Laura M. Tully, Ph.D.
Karina Muro, Ph.D.
Christopher Komei Hakusui, B.A.
Leigh Katharine Smith, Ph.D.
19 Cognitive-Behavioral Therapy–Informed Skills Training for Families Caring for a Loved One With Delusions
Sarah Kopelovich, Ph.D.
Maria Monroe-DeVita, Ph.D.
H. Teresa Buckland, Ph.D., M.Ed.
20 Decoding Delusions: Demonstration of Key Skills for Working With Unusual Beliefs
Douglas Turkington, M.D.
Kate V. Hardy, Clin.Psych.D.
Latoyah Lebert, M.Phil.
Sarah Robinson, B.Sc.
Index
Foreword
I really wish that Kate Hardy and Doug Turkington had produced this book when I was a psychiatric resident. I could have learned what they teach so effectively and used these techniques and approaches in my 30+ years working with individuals diagnosed with psychotic disorders.
One of the first things I learned, both from my family’s experience with schizophrenia and then as a physician, is not to argue with people about their delusions. Regrettably, few constructive alternatives were taught. And so I, along with many of my colleagues, tried to connect with individuals experiencing delusions in a humane and respectful manner. But now we have tested methods and can learn skills and approaches that layer effective techniques and treatment approaches on this humanity and respect.
I must admit that I have tried to learn more cognitive-behavioral techniques over the years from books and lectures and never fully succeeded. I could never quite adapt them to the clinical work I was doing. But this volume speaks to me and unpacks many of the mysteries of cognitive-behavioral therapy. The authors of each chapter present a different dimension of the approach, addressing the clinical, cultural, and social contexts of illness. The volume covers what to do and how to do it. I especially value the video demonstrations that complement the text and illustrate the skills and concepts, bringing them to life.
Why does this matter? Psychosis and psychotic ideation are common, highly stigmatized, and dehumanizing. This book provides the tools for clinicians to ally with individuals experiencing thoughts that some people would characterize as extreme beliefs and others would characterize as psychosis. The method is evidence based and recovery oriented. Our competence as clinicians in cognitive-behavioral therapy for psychosis can make a difference for the people we are committed to helping.
Lisa Dixon, M.D., M.P.H.
Preface
Delusions are one of the most important but confounding symptoms of serious mental illness. Delusions are important because they frequently co-occur with hallucinations; they often have a profound effect on impairing psychosocial functioning; and they play a central role in diagnostic symptoms used to classify different psychiatric disorders, most notably schizophrenia. Delusions are confounding to nearly everyone who encounters them because by their inherent nature (or definition) they are strongly held beliefs that appear patently false to anyone who hears them but nevertheless appear impervious to change in the face of countervailing evidence. Medication can be effective at reducing and sometimes eliminating delusions altogether. For many people, however, medications are an insufficient or ineffective treatment, and other interventions are needed to reduce the suffering and functional disability associated with delusions.
Cognitive-behavioral therapy for psychosis (CBTp), or the systematic application of the principles of CBT to people with psychotic disorders, is now recognized as the most empirically supported psychotherapeutic approach to treating delusions. This book provides clinicians who are already experienced in CBTp with a comprehensive, state-of-the-art resource for improving their skills and effectiveness when working with patients with delusions.
The first six chapters, which make up Part I of the book, are devoted to defining and assessing delusions and understanding their nature, both experientially and as shaped by personal experience and culture. After providing a useful history of how delusions have been viewed over the ages and in medicine in Chapter 1, “Delusional Beliefs and the Madness of Crowds,” Richard Bentall tackles the thorny issue of how to define delusions as a clinical phenomenon and what makes them different from false or outlandish beliefs that may erupt among and be widely held by many people in spite of a lack of evidence (i.e., the “madness of crowds”). Importantly, it is established that delusional beliefs cannot be distinguished from popular unsupported beliefs on the basis of their content alone; rather, one must consider the role of social factors in acquiring and potentially spreading the belief. Specifically, popular but unfounded beliefs are generally learned from other people and are spread socially, through direct interactions with people or through social or other media. Delusions, in contrast, generally do not develop through communication with other people and fail to spread from one person to the next.
In Chapter 2, “The Lived Experience of Strongly Held Beliefs,” Shaun Hunt provides a helpful review of the assessment of delusions in the context of CBTp. The central role of establishing a trusting and therapeutic relationship in assessing and treating delusions is emphasized, followed by description of methods for conducting a history of the development of the delusion, understanding the phenomenology of the delusion, evaluating the function it plays in the person’s life, and taking a collaborative and longitudinal approach to developing a case formulation with the patient. Hunt delves more deeply into the lived experience of having delusions and provides vital insights into connecting with and helping affected individuals. He emphasizes that the roots of delusional beliefs lie in the experiences and life history of the individual. Rather than labeling or explaining away such beliefs as symptoms of an illness, the critical task of a clinician is to help people make sense of their beliefs and the circumstances in which they arose.
In Chapter 3, “Considering Delusions Through a Cultural Lens,” Peter Phiri et al. address the important role of culture in shaping the beliefs of individuals, including the specific delusions people may develop. The costs of the clinician lacking awareness of the patient’s culture are discussed, including the potential for misdiagnosis, as well as mistrust and disengagement from treatment. In Chapter 4, “The Psychology of Paranoid Beliefs,” Anton P. Martinez et al. examine the psychology of paranoid delusions, the most common type of delusion in people with a psychotic disorder. The role of early life adversity in the development of paranoid delusions is reviewed, as is research showing that people with such delusions tend to have more generally negative views of other people and their intentions. Ironically, the lack of trust that people with paranoia have in others results in a lack of social identity and sense of belonging, leading to feelings of loneliness. People with paranoid delusions need other people, just like everyone else, but cannot trust others enough to let them into their lives.
In Chapter 5, “Linguistic Techniques for Clinicians Working With Patients With Delusions,” Nazneed Rustom and Gordon Turkington provide useful and innovative tools for helping clinicians connect with and better understand the world of their clients who experience delusions by delving deeper into language. Developing such an understanding requires attention not only to the client’s thoughts, perceptions, and language, but also awareness of the clinician’s own automatic thoughts about the client and treatment process. In Chapter 6, “Assessing Delusions,” Dimitri Perivoliotis provides a standard outline for the assessment and treatment of simple delusions (i.e., relatively circumscribed delusions that lack complexity, bizarreness, and extensive systematization). Strategies for identifying triggering events that led to the delusion are described, as are common factors that maintain delusional beliefs and the role of safety behaviors.
Part II addresses the treatment of delusions, with all chapters containing case examples to illustrate the approaches. In Chapter 7, “Collaboration, Not Collusion,” Katherine Eisen et al. begin Part II by focusing on the process of developing a collaborative and trusting relationship with the patient that serves as the foundation for all the psychotherapeutic work that follows. The use of befriending early on in the therapeutic relationship is explained, as are normalizing strongly held beliefs and showing genuine curiosity about the patient and their delusional beliefs. As noted in Chapter 2 on the lived experience of delusions, the clinician’s goal is to understand the cultural context of the patient’s life in which the delusions emerged without colluding or reinforcing those beliefs.
In Chapter 8, Douglas Turkington and Kate Hardy build on Chapter 7 by providing a standard outline of the treatment of paranoia. Paranoia lies on a continuum of abnormal beliefs ranging from normal beliefs to eccentric beliefs and then overvalued ideas to paranoid delusions and then primary delusions. Paranoid delusions are distinguished from primary delusions in terms of their relatively circumscribed nature and simplicity and the lack delusional mood and perception, bizarreness, and extensive systematization. After an interesting section on “Acknowledging and Investigating Our Own Strongly Held Beliefs,” the authors walk readers through seven basic phases of cognitive-behavioral therapy for paranoid delusions, including 1) open-mindedness and curiosity, 2) exploring the delusion, 3) peripheral questioning, 4) reality testing and behavioral experiments, 5) generating alternative explanations, 6) anxiety reduction and linking emotions with experience, and 7) working with grief and personal beliefs. Strategies for identifying the triggering events that led to the delusion are described, as well as common factors that maintain delusional beliefs and the role of safety behaviors.
In Chapter 9, “At-Risk Mental State,” Mark van der Gaag addresses the treatment of individuals at risk for psychosis, whose experience of delusions (and hallucinations) tends to be more transient. The hallmark distinction between people at risk for psychosis and those who have experienced the onset of a psychotic disorder is the greater uncertainty and doubt about the veracity of their beliefs in the at-risk group. As a result of this uncertainty, and because they have not usually experienced the momentary relief that often occurs when a delusional belief first crystallizes, at-risk individuals often have higher levels of distress than those with more frank psychotic symptoms. This higher level of distress accompanied by lower levels of delusional conviction makes individuals at risk for psychosis ideal candidates for CBTp.
In Chapter 10, “The Curious Case of Schreber,” Kristin Lie Romm and Douglas Turkington provide a reinterpretation of the famous Schreber case, a classic case in the psychoanalytic literature, from a CBTp perspective. This reexamination also includes a useful discussion of how Schreber’s treatment might have progressed with our current understanding of CBTp. The authors’ alternative case formulation suggests how a constructive and collaborative approach to understanding and treating delusions may have helped and illustrates the humanistic nature of the CBTp approach.
In Chapter 11, “Erotomania and Sexual Delusions,” Tania Lecomte et al. address the treatment of erotomania (a delusion in which a person believes that someone is in love with them) and delusions of having been sexually abused or having sexually abused others. All three types of delusions share the unique distinction in CBTp of not benefiting from the exploration of alternative explanations for the beliefs, regardless of how collaborative the process may be. The delusions experienced in erotomania are associated with feelings of exhilaration and euphoria, and patients therefore are not motivated to examine these beliefs or make them go away. Delusions of having been sexually abused or having abused others, in contrast, are based on events that supposedly happened many years ago, and attempts to find strong evidence disconfirming such delusions are doomed to failure. The authors also caution against using trauma-focused interventions that are effective in the treatment of PTSD (e.g., prolonged exposure) to treat delusions of having been sexually abused because the so-called memories are in fact distortions or transformations of other experiences in the person’s life. In line with this recommendation, I have observed that when trauma-focused interventions are used to treat people with delusions of sexual abuse, rather than anxiety habituating over time with repeated and prolonged exposure to images of the events, it actually increases as further elaboration of the delusion occurs, in terms of either distressing details or entirely new events. Instead of directly focusing on delusional beliefs of this kind, the authors wisely advise spending time trying to understand the function that the delusions may play in the person’s life (e.g., enhancing low self-esteem, providing a sense of purpose) and targeting the underlying needs in order to undercut the importance of holding on to the delusional beliefs.
Chapter 12, “A Bizarre and Grandiose Delusion,” complements the focus of Chapter 6 on simple delusions by addressing the treatment of complex, highly systematized delusions that frequently dominate a patient’s entire life. As detailed in the chapter by Douglas Turkington and Helen Spencer, the treatment of such delusions requires a rich armamentarium of CBTp skills, patience, flexibility, and the ability to improvise to keep the therapy moving forward. The authors observe that no matter how bizarre a patient’s delusions are, they always make more sense after the practitioner and patient explore the period of time before the person became psychotic and construct a timeline of events surrounding the emergence of the trauma. Numerous helpful pointers (illustrated in a detailed case example) are given for working with these challenging patients, such as the clinician initially taking the lead on completing collaboratively agreed-on homework assignments between sessions and then gradually engaging the patient in setting and following through on his or her own assignments.
In Chapter 13, “Who Are You?,” Michael Garrett focuses on the nature and treatment of delusions of misidentification, the most well-known of which is the Capgras delusion (the belief that a familiar person has been replaced by a double or impostor). This group of delusions includes others, such as the Fregoli delusion (the belief that other people who appear to be different people are the same person in disguise), intermetamorphosis (the belief that a person has physically and psychically changed into another person), the delusion of subjective doubles (the belief that someone else has transformed into a physical copy of oneself), and mirrored-self misidentification (the belief that one’s reflection in the mirror is someone else). The author reviews compelling evidence that delusions of misidentification are not separate disorders but rather reflect varied expressions of a singular underlying disturbance of mental representations of persons. CBTp strategies for treating delusions of misidentification are elucidated, informed, and enriched by psychoanalytic object relations theory.
In Chapter 14, “Thought Disorder or a Problem With Communication?,” David Kingdon et al. focus on working with patients who have delusions and formal thought disorder (i.e., disordered language) that interferes with clear communication with others (e.g., neologisms, loose associations). Most patients with formal thought disorder also have delusions, but getting at those delusions requires attending to the individual’s speech. Furthermore, formal thought disorder interferes with effective communication about other matters and can be very frustrating to patients; it is therefore important to improve the patient’s speech for the person’s overall social adjustment. A wide range of useful strategies for dealing with disorganized speech in the treatment of delusions are described, such as stress inoculation training.
Following Chapter 3, which addresses the influence of culture on the formation of beliefs, including delusions, in Chapter 15, “Cognitive-Behavioral Therapy for Delusions Within Japanese Culture,” Akiko Kikuchi and Douglas Turkington address the importance of the clinician being familiar with the patient’s culture in order to effectively treat the person’s delusions. The authors accomplish this by examining a very different culture from most cultures in North America and Europe—Japanese culture—and the implications of these differences for providing CBTp. For example, the authors describe how supportive relationships in Japanese culture are typically hierarchical, which indicates that the development of a collaborative approach in CBTp needs to occur very gradually over the course of therapy. For another example, in contrast to individualist cultures, in which the goals patients have in CBTp usually focus on desired personal changes, in collectivist cultures such as Japan, people are generally more motivated to work on changes for the betterment of the group than for themselves. This suggests a somewhat different approach from traditional goal setting in CBTp and the potential value of obtaining input from others, such as the family.
In Chapter 16, “Trauma and Delusions,” Charles Heriot-Maitland addresses the treatment of delusions in people with a history of interpersonal trauma, an essential topic given the impact of early life adversities on the development of psychotic (and other) disorders. The experience of trauma results in a primary focus of attention on detecting, processing, and responding to potential threats, with delusions serving as strategies with specific functions. Trauma-informed treatment of delusions needs to be sensitive to patients’ frequent perceptions of danger and vulnerability as well as their tendency to blame themselves for their victimization. Multiple clinical strategies are described for laying the groundwork needed to focus on delusions and the impact of trauma in these patients, including helping them cultivate states that signal safety and de-shaming the sense of responsibility for traumatic events through psychoeducation and collaborative examination of related beliefs.
Part III addresses the treatment of delusions across different settings, with specific chapters addressing the forensic population, the use of digital technologies, and supporting families with a loved one with delusions. In Chapter 17, “A Cognitive-Behavioral Therapy Approach to Working With Delusions in Forensic Settings,” Patricia Cawthorne calls attention to the multiple problems typically faced by persons with mental illness who are involved in the criminal justice system and discusses strategies for addressing common challenges when working with these individuals, such as their lack of trust and tendency to minimize problems. In Chapter 18, “Using Digital Health Technology to Facilitate Measurement-Based Care in the Treatment of Delusions,” Laura M. Tully et al. provide a useful guide to how different digital technologies can enhance the efficacy of CBTp in treating delusions. A range of different digital tools and uses are covered, such as the use of ecological momentary assessment to provide real-world tracking of symptoms, thoughts, and feelings in different situations and virtual reality environments in which people can experiment with different ways of responding in social situations.
In Chapter 19, “Cognitive-Behavioral Therapy–Informed Skills Training for Families Caring for a Loved One With Delusions,” Sarah Kopelovich et al. provide important guidance on supporting the family members of patients with delusions. Families are critical supports for many people with a psychotic disorder, and they are often in a unique position to facilitate their loved one’s involvement in treatment, including CBTp. However, the unique role of families in the lives of people with a major mental illness, and their potential to be allies in treatment, is all too often overlooked by mental health professionals. The authors review what families need in order to help a member get the most out of CBTp for delusions and describe approaches to addressing these needs, including psychoeducation, communication and problem-solving skills training, and the learning of CBT-informed skills.
The final chapter serves as a guide to one of the most useful resources provided by this book, a series of videos illustrating basic CBTp skills for working with patients with unusual beliefs and delusions. Douglas Turkington et al. have organized discussion of the videos into three broad categories of skills, including 1) befriending, normalizing, and questioning, 2) developing a formulation, and 3) change strategies. Of note, although most of the videos focus on the practical “how to’s” of CBTp for delusions, attention is also paid to some “how not to’s.” For example, in one video, the pitfalls of colluding with a patient’s delusion are illustrated, and another video shows how a lack of commitment to developing a working relationship with the patient can result in an impasse because everything the therapist says is perceived as a confrontation. These videos have much to offer both newcomers to CBTp and seasoned clinicians.
Decoding Delusions provides a comprehensive, richly textured guide to the art and science of treating patients with delusions. Although there is a wide array of technical skills to master when working with delusions, the relationship is front and center, and there is no substitute for being genuinely interested in and caring about the patient. Through collaboration and seeking to understand the unfathomable, therapists have the potential to help these distressed people make sense of their own experiences and, by doing so, to begin the process of regaining control over their lives.
Kim T. Mueser, Ph.D.
Video Guide
Callouts in the text identify the videos by name, as shown in the following example:
Video #: Video TitleThe instructional videos are streamed via the internet and can be viewed online by navigating to www.appi.org/Hardy and using the embedded video player. The videos are optimized for most current operating systems, including mobile operating systems.
Videos Discussed by Chapter
Complete descriptions of all 15 videos can be found in Chapter 20, “Decoding Delusions.”
Chapter 6
Video 8: Formulation (15:44)
Chapter 7
Video 1: Befriending (3:51)
Video 2: Normalizing (7:25)
Video 3: Confrontation as an approach to avoid (5:06)
Video 4: Collusion as an approach to avoid (6:37)
Video 5: Sitting on the collaborative fence (3:56)
Chapter 8
Video 7: Socratic questioning (8:21)
Video 15: Maintaining change (8:27)
Video 10: Behavioral experiment (6:00)
Chapter 12
Video 11: Coping (6:24)
Video 14: Metacognitive techniques (8:40)
Video 6: Downward arrow (4:45)
Video 12: Schema intervention (14:11)
Chapter 13
Video 13: Capgras delusion (13:04)
Contributors
Richard P. Bentall, Ph.D., FBA
Professor, Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
H. Teresa Buckland, Ph.D., M.Ed.
Psychosis REACH Family Ambassador and Trainer in the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington
Patricia Cawthorne, D.N., M.Sc. (CBP), RMN
Consultant Nurse, Psychological Therapies Service, The State Hospital; Consultant Nurse, Adult Mental Health Services, Glasgow City HSCP, NHS Greater Glasgow and Clyde, Scotland, UK
Briana Cloutier
Ph.D. candidate, Department of Psychology, Université de Montréal, Montréal, Québec, Canada
Lisa Dixon, M.D., M.P.H.
Edna L. Edison Professor of Psychiatry, New York State Psychiatric Institute, Columbia University Vagelos College of Physicians and Surgeons; Director, Division of Behavioral Health Services and Policy Research and Center for Practice Innovations, New York-Presbyterian, New York, New York
Kathryn Eisen, Ph.D.
Clinical Associate Professor, Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Stanford, California
Kathryn Elliot, M.Sc.
Research Assistant, Research and Innovation Department, Southern Health NHS Foundation Trust, Southampton, UK
Audrey Francoeur
Ph.D. candidate, Department of Psychology, Université de Montréal, Montréal, Québec, Canada
Michael Garrett, M.D.
Professor Emeritus of Clinical Psychiatry, SUNY Downstate Medical Center, Brooklyn, New York
Christopher Komei Hakusui, B.A.
Lived Experience Junior Specialist, Department of Psychiatry, University of California, Davis, Davis, California
Kate V. Hardy, Clin.Psych.D.
Clinical Professor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
Charles Heriot-Maitland, Ph.D., D.Clin.Psy., M.A., B.Sc.
Clinical Psychologist and Director, Balanced Minds, Edinburgh, UK
Vyv Huddy, Ph.D.
Lecturer, Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
Shaun Hunt, M.Sc., B.Sc.
Lecturer, Education and Training Department, SHSC, Sheffield, UK
Akiko Kikuchi, Ph.D.
Professor, Department of Human Sciences, Musashino University, Tokyo, Japan
David Kingdon, M.D., FRCPsych
Emeritus Professor of Mental Health Care Delivery, University of Southampton, Southampton, UK
Sarah Kopelovich, Ph.D.
Associate Professor, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington
Melanie Lean, Clin.Psych.D.
Clinical Assistant Professor, Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, Stanford, California
Latoyah Lebert, M.Phil.
Clinical Psychologist, Newcastle and Gateshead At Risk Mental State, CNTW NHS Foundation Trust, Cumbria, Northumberland, UK
Tania Lecomte, Ph.D.
Professor, Department of Psychology, Université de Montréal, Montréal, Québec, Canada
Anton P. Martinez, M.Sc.
Ph.D. candidate, Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
Maria Monroe-DeVita, Ph.D.
Associate Professor, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington
Kim T. Mueser, Ph.D.
Professor, Departments of Occupational Therapy and Psychological and Brain Sciences, Center for Psychiatric Rehabilitation, Boston University, Boston, Massachusetts
Karina Muro, Ph.D.
Assistant Professor, Department of Psychiatry, University of California Davis, Davis, California
Farooq Naeem, Ph.D., MRCPsych
Professor, Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
Shannon Pagdon, B.A.
National Certified Peer Specialist, Department of Psychiatry and Behavioral Health, University of Stanford, Stanford, California; Research Coordinator, School of Social Work, University of Pittsburgh, Pittsburgh, Pennsylvania
Dimitri Perivoliotis, Ph.D.
Psychologist, VA San Diego Healthcare System; Professor, Department of Psychiatry, University of California San Diego School of Medicine, San Diego, California
Peter Phiri, Ph.D., RNMH, CBT (DipHE)
Director of Research and Innovation, Research and Innovation Department, Southern Health NHS Foundation Trust, and Visiting Fellow. School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
Shanaya Rathod, D.M., MRCPsych
Consultant Psychiatrist, Research and Innovation Department, Southern Health NHS Foundation Trust, Southampton, UK; Visiting Professor, Faculty of Science, University of Portsmouth, Portsmouth, UK
Sarah Robinson, B.Sc.
Computer Animation and VFX Department, Northumbria University, Newcastle upon Tyne, UK
Kristin Lie Romm, Ph.D., M.D.
Head of the Early Intervention in Psychosis Advisory Unit for South East Norway, Division of Mental Health and Addiction, Oslo University Hospital; Associate Professor, NORMENT, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
Nazneen Rustom, Ph.D., B.A., GMBPsS
Supervised Cognitive Behavioral Therapy for Psychosis Clinician, Queen’s University, School of Medicine, Department of Psychiatry, Adult Psychiatry Division, Providence Care Hospital, Kingston, Ontario, Canada
Kenneth Sandoval, Jr., M.S., M.S.W., LCSW
Program Director, Clinical Administration, California Department of State Hospitals, Patton, California
Leigh Katharine Smith, Ph.D.
Department of Psychology, University of California, Davis, Davis, California
Helen M. Spencer, B.A.
Doctoral Researcher, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
Laura M. Tully, Ph.D.
Associate Professor, Department of Psychiatry, University of California Davis, Davis, California
Douglas Turkington, M.D., FRCPsych
Professor of Psychosocial Psychiatry, Newcastle University, UK
Gordon Turkington, M.Sc., B.Sc.
Assistant Psychologist, Northumberland Children and Young Person Services, St. George’s Park Hospital, Morpeth, UK
Mark van der Gaag, Ph.D.
Emeritus Professor of Clinical Psychology, Vrije Universiteit, Amsterdam, The Netherlands
Disclosures
The following contributors have indicated that they have no financial interests or other affiliations that represent or could appear to represent a competing interest with their contributions to this book:
H. Teresa Buckland, Ph.D., M.Ed.; Patricia Cawthorne, D.N., M.Sc. (CBP), R.M.N.; Michael Garrett, M.D.; Kate V. Hardy, Clin.Psych.D.; Charles Heriot-Maitland, Ph.D., D.Clin.Psy., M.A., B.Sc.; Akiko Kikuchi, Ph.D.; Sarah Kopelovich, Ph.D.; Maria Monroe-DeVita, Ph.D., M.Ed.; Shannon Pagdon, B.A.; Dimitri Perivoliotis, Ph.D.; Kristin Lie Romm, Ph.D., M.D.; Nazneen Rustom; Douglas Turkington, M.D.; Mark van der Gaag, Ph.D.
Mindful Language
: Using the Term PatientShannon Pagdon, B.A.
Language varies immensely across communities, professional disciplines, and personal preference. Although we can try our best to be mindful and intentional with words, it is an unfortunate reality that the words we choose may not resonate with everyone. It is difficult to strike the balance between more alternative and progressive advocacy terms while still recognizing that conventional terminology is more widely used and readily recognizable. Given these complicated intersections, it is not always easy to know when speaking up is warranted. The ethics of language clue us to values that support effective communication. First, language at its core should be simple. That is, it should be easy to understand, not full of jargon or inaccessible terms. Additionally, open-ended language (in this context, terms that individuals choose to self-describe their experiences of psychosis, including unconventional beliefs) honors the individuals’ autonomy in expressing their experiences in their own words (Pagdon 2022). Open-ended language invites new meanings and richer conversation, expanding the space for conversations that could be curtailed by stigmatizing labels or closed language. Essentially, ethical communication is about respect. Adhering to descriptors the individual chooses demonstrates this respect, as does allowing for people to use words differently, to communicate in their own way. These values of simplicity, openness, and respect were applied to the writing and review of this text.
Expressions contained in this text, such as patient or client spark mixed feelings, especially from service users and advocates in the mental health field (Richards 2018). Particular concerns around power dynamics in the therapeutic relationship and emphases of service users’ “illness”' are highlighted as difficulties with these terms (Neugerger 1999). Additionally, although many industries are shifting language they use to describe individuals who are provided services (e.g. guests, customers), the health care industry arguably continues to use outdated terms that emphasize providing care, not being a partner in care with the individual (Knight 2021). Given the current emphasis on person-centered care for psychosis (Allerby 2022), it is crucial to understand why some may not agree with the use of the terms patient or client. Instead, one can seek to use words that do not bear the burden of stigmatized context or invoke power dynamics. Ultimately, this is a challenging directive with mental health terminology. It is difficult to adopt new words, and it is hard for popularized language to shed connotations; both must first overcome cultural inertia and resistance. Still, it is worthwhile to seek the intersection between alternative terminology and standard language in mental health to find terms that encompass both perspectives meaningfully.
Throughout this book, readers will notice that the term patient has been chosen to describe individuals who are engaging with mental health services. The editors want to acknowledge that this term may not resonate with everybody. In writing and reviewing this book, simple language was valued to serve the practical ethic of being clearly discernible. The communicator bears the responsibility to be simple and comprehensible so that the text can be accessible for a global audience. This duty drove the choice of more common, if history-laden, words over alternative language.
That said, we invite you as the reader to develop your own questions and considerations around these terms. Although there are no perfect terms, some will speak to you more than others. We request that you take a moment to reflect on the language you would choose to describe these experiences, as well as why that language may resonate for you.
References
Allerby K, Goulding A, Ali L, Waern M: Increasing person-centeredness in psychosis inpatient care: staff experiences from the Person-Centered Psychosis Care (PCPC) project. BMC Health Serv Res 22(1):596, 2022 35505358
Knight S: Let’s banish the term “patient” from the health care lexicon, STAT, May 13, 2021. Available at: www.statnews.com/2021/05/13/lets-banish-term-patient-from-the-health-care-lexicon. Accessed March 20, 2023.
Neuberger J: Do we need a new word for patients? Let’s do away with “patients.” BMJ 318(7200):1756–1757, 1999 10381717
Pagdon S, Jones N: Psychosis Outside the Box: a user-led project to amplify the diversity and richness of experiences described as psychosis. Psychiatr Serv Dec 7:appips20220488, 2022 36475822
Richards V: The importance of language in mental health care. Lancet Psychiatry 5(6):460–461, 2018 29482994
Introduction
Douglas Turkington, M.D.
Kate V. Hardy, Clin.Psych.D.
Why Do We Need a Handbook on Working With Delusions?
There can be no doubt that the management of delusions is one of the main tasks facing all mental health professionals working with individuals with psychosis. As described beautifully in Chapter 2 (“The Lived Experience of Strongly Held Beliefs”) by Shaun Hunt, individuals can experience delusions as highly distressing with an enormous impact on functioning to the extent that they experience significant limitations in their lives. In addition, delusional beliefs have long captivated clinicians, with the earliest psychiatrists describing delusional beliefs and their challenges in addressing these with patients. Essential considerations for clinicians today include assessing the belief along a continuum of beliefs from nonpathological to pathological and grounding it within the individual’s cultural experience and society more broadly. As Richard Bentall describes in Chapter 1 (“Delusional Beliefs and the Madness of Crowds”), this is not an easy task for the clinician, and the definition of what might be considered delusional is not a fixed entity. Thus, careful assessment of the belief is essential, as is described in Chapter 6 (“Assessing Delusions”), and it is critical that assessment be conducted within a framework of cultural humility and consideration of cultural factors (Chapter 3, “Considering Delusions Through a Cultural Lens”). Since delusions were first described in the clinical literature there have been many advances in psychosocial treatment approaches. Frequently, however, these clinical interventions are described under the broad umbrella of cognitive-behavioral therapy for psychosis (CBTp), with limited discussion of delusions specifically. In this handbook international experts on psychosis have contributed chapters that speak to different clinical approaches to working with different types of delusions within a CBTp framework, thus broadening the scope of this area and allowing readers to become familiar with a range of effective interventions.
Augmenting Medication With Other Strategies for Delusions
The cornerstone of the treatment of delusions (and psychosis generally) is psychopharmacology, and many clients will achieve effective control of the distress caused by delusions using antipsychotic medication, including clozapine. However, as Kapur (2003) clearly pointed out, this therapeutic effect only lasts for as long as the antipsychotic medication is taken, and for some individuals antipsychotics have little to no impact on the distressing experiences they may be undergoing. Clients often discontinue their medication suddenly or take it intermittently, especially when there are problems with side effects or they experience the medication as ineffective. Kapur demonstrated that other strategies are needed along with the medication to allow a fuller resolution of the delusion. CBTp is an evidence-based intervention that focuses on the individual’s beliefs, including their formation and maintenance. It can be argued that for the client to gain an understanding of the delusion, and to integrate this experience into his or her life, the delusion needs to be processed psychologically and addressed directly. This book describes approaches that support the exploration of beliefs with the aim of reduced distress and meaningful recovery. Importantly, each of the clinical chapters provides clinical case examples to demonstrate the application of the techniques discussed. As practitioners who provide training in CBTp, we are frequently asked for video examples of CBTp techniques. Thus, this book includes role-play examples of key CBTp interventions for working with delusions, with further details provided in Chapter 20 (“Decoding Delusions”).
What Are These Techniques?
The techniques described in this book are drawn from a variety of schools and approaches but mostly have their origin in the CBT tradition. Key techniques discussed include forming a therapeutic alliance, befriending, and normalizing experiences (Chapter 7, “Collaboration, Not Collusion”). This core principle of normalizing is also adopted throughout the chapters with the inclusion by all authors of personal reflections on experiences that have been unsettling, distressing, or confusing. To support exploration of the belief the clinician draws on the use of different questioning styles and (using guided discovery) the generation of tentative alternative explanations. Joint homework exercises can explore information relating to delusional beliefs (e.g., “Let’s find out everything we can that has been published recently about telepathy, alien abduction, satellite functions, or possession by an evil spirit and then compare what we learn to your own experiences”).
Throughout the book, the collaborative nature of this approach is emphasized. This collaborative nature is seen, in particular, when client and clinician are engaged in a dialogue about the delusional content and its meaning. Unfortunately, the content of the delusion was historically dismissed as irrelevant by some practitioners. However, we know that it is important to understand the function of the delusion in order to better explore why the belief may have formed and what role it may play for the individual. This can be done by exploring the timeline by considering the pre-psychotic period to look for triggers and relevant life events from childhood and adolescence (see Chapter 12, “A Bizarre and Grandiose Delusion,” for an example of this). This book incorporates a number of third-wave therapies, including positive psychology, linguistic approaches, and compassion-focused techniques. The range of interventions for clinicians has expanded dramatically in recent years and continues to evolve. This book offers a summary of the primary interventions currently available.
When to Refer for Expert Psychological Treatment of Delusions
It is our position that all mental health professionals can benefit from understanding how to assess and address delusional beliefs rather than this being seen as the purview of specialist practitioners. CBTp-informed skills support the clinician to draw on key techniques within a recovery-oriented framework with the overarching aim of supporting a reduction in distress and the attainment of goals that are meaningful to the individual. However, there are instances when referral to expert clinicians with specialized training is warranted. In particular, this may include, for example, when one is working with individuals with complex delusional systems with minimal motivation for engagement in treatment or when a specialized intervention, such as eye movement desensitization and reprocessing, is warranted to address trauma.
Integrating a Dispersed Literature on Delusions
After the pioneering phenomenological work of Jaspers (1913/1963), there followed many decades when it was accepted as a self-evident truth that delusions were dichotomous psychotic symptoms with strong diagnostic validity. However, since the 1990s spectrum models of delusions have been increasingly described and investigated (Kingdon and Turkington 1994), and it is now accepted that delusions are more accurately described as existing on a spectrum of overvalued ideas, eccentric normal beliefs, overvalued yet nonpathological beliefs, and “normal” beliefs (see Chapter 1 for more details). It is also increasingly accepted that delusions can show fluctuation in conviction and linked distress and can be amenable to questioning approaches and an examination of the evidence (reality testing). This dispersed literature on the psychology of delusions has been brought together in this volume. In clinical practice, the term delusion is frequently applied very broadly; however, it is important to note that there are many different types of delusions seen in clinical practice, such as Capgras syndrome (a delusion of misidentification), Othello syndrome (delusional jealousy), Ekbom syndrome (a delusion of infestation), and de Clérambault syndrome (a delusion of being loved), to name but a few. It is essential for treatment planning that the form of the delusion be accurately assessed and formulated to determine the most effective intervention approach. This book provides clinically oriented chapters that focus on several common delusions (Capgras syndrome, erotomania, persecutory paranoia) as well as consider different pathways to the emergence of delusions (e.g., trauma and the presentation of those at risk for developing psychosis).
Scope of This Handbook
This book is divided into three parts, with Part I bringing readers up to date on the current state of the research literature on the etiology, characteristics, and parameters of delusions. This first section includes a chapter on recent breakthroughs in the linguistics of delusions and how this can be integrated into clinical practice. This introductory section grounds readers in how delusions are conceptualized historically and currently while also critically providing a lived experience perspective of living with delusions.
We then move into Part II, the main clinical section of the book, in which expert authors discuss formulation and intervention for different delusional presentations with corresponding clinical examples framed within a cultural context. Importantly, each author also provides a personal reflection to highlight how common it is for anyone to experience unusual thoughts and belief changes. This section includes a historical review of the Schreber case (Chapter 10, “The Curious Case of Schreber”) and discusses how Schreber’s bizarre delusional system of being the bride of God and yet persecuted by God might be understood today. This chapter provides a historical perspective on the understanding of delusions while also grounding it in current treatment modalities and highlights the shift in how we understand delusion formation and treatment. Part II incorporates third-wave CBTp models, including compassion-focused therapy utilized to explore the role of trauma and delusions (Chapter 16, “Trauma and Delusions”), and explores the integration of psychodynamic and cognitive-behavioral interventions (Chapter 13, “Who Are You?”). This is particularly important because these two approaches are frequently set up in opposition to each other; however, Michael Garrett deftly demonstrates the potential for integrating these two models and shows that the benefits of integrating them far outweigh the dismissal of either model by followers of CBT or psychoanalysis. Part II concludes with a discussion of CBTp in cultural settings, such as Japanese culture (Chapter 15, “Cognitive-Behavioral Therapy for Delusions Within Japanese Culture”).
Treating Delusions in Specific Settings
Part III explores the management of delusions in specific settings, with unique chapters about working with delusions in forensic settings and about working with delusions remotely using Zoom and digital media. It must be said that it is increasingly the case that clients with delusions are treated remotely and that this is, perhaps surprisingly, often more acceptable than a face-to-face session and a viable means of engaging individuals in care (Kopelovich and Turkington 2021). The most common delusion is of course persecutory paranoia, and when one is experiencing this delusion even making the journey to the clinician’s office can be a terrifying experience. Such clients can often feel more relaxed in their home environment interacting with the clinician via Zoom or Microsoft Teams as they begin to develop coping strategies and other possible alternative explanations that they can begin gradually to test out.
What Can Families and Friends Do?
Very often when we are delivering workshops and webinars families ask whether they can talk to their loved one about their delusions and how exactly to do this. This book provides insight into curious questioning and incorporates information for friends and families of those with delusions. There are many chapters that will be useful in terms of understanding delusions, including a chapter by an expert-by-experience (Chapter 2), the chapters on communication (Chapters 7, 14, and 16) and the link with trauma (Chapter 15), and the full chapter on CBT-informed caring for families who have a loved one with a delusion (Chapter 19, “Cognitive-Behavioral Therapy–Informed Skills Training for Families Caring for a Loved One With Delusions”).
Decoding Delusions: Future Evolution
As mentioned earlier, the treatment of delusions has come a long way since delusions were first described in the clinical case literature. Digital technologies offer an exciting new frontier for intervention, with advances in this area described in Chapter 18 (“Using Digital Health Technology to Facilitate Measurement-Based Care in the Treatment of Delusions”). We await with anticipation the impact of virtual reality interventions such as gameChange (Freeman et al. 2022) as these technologies become more accessible and available to the clinician and client. In addition, the field is moving toward the recognition that CBTp as an umbrella intervention has demonstrated efficacy but that we now need to focus on the presentation of distinct symptoms and utilize strong assessment and formulation to support targeted intervention. The recent publication of the impressive results of the Feeling Safe Programme trial (Freeman et al. 2021) demonstrates the impact of modular and symptom-focused interventions, and it is exciting to see what the next decade holds in terms of the further evolution of these treatments.
References
Freeman D, Lambe S, Kabir T, et al: Automated virtual reality therapy to treat agoraphobic avoidance and distress in patients with psychosis (gameChange): a multicentre, parallel-group, single-blind, randomised, controlled trial in England with mediation and moderation analyses. Lancet Psychiatry 9(5):375–388, 2022 35395204
Freeman D, Emsley R, Diamond R, et al: Comparison of a theoretically driven cognitive therapy (the Feeling Safe Programme) with befriending for the treatment of persistent persecutory delusions: a parallel, single-blind, randomised controlled trial. Lancet Psychiatry 8(8):696–707, 2021 34246324
Jaspers K: General Psychopathology (1913). Translated by Hoenig J, Hamilton MW. Manchester, UK, Manchester University Press, 1963
Kapur S: Psychosis as a state of aberrant salience: a framework linking biology, phenomenology and pharmacology in schizophrenia. Am J Psychiatry 160(1):13–23, 2003 12505794
Kingdon DG, Turkington D: Cognitive-Behavioural Therapy of Schizophrenia. New York, Guilford, 1994
Kopelovich SL, Turkington D: Remote CBT for psychosis during the COVID-19 pandemic: challenges and opportunities. Community Ment Health J 57:30–34, 2021 33001323
Information & Authors
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Decoding Delusions: A Clinician's Guide to Working With Delusions and Other Extreme Beliefs
Pages: i - xxxiv
History
Published in print: 12 June 2023
Published online: 5 December 2024
© American Psychiatric Association Publishing
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