Challenging the evidence for the belief

Watts et al.'argued that a danger when trying to modify delusions, indeed, all strongly held beliefs, was psychological reactance, whereby too direct an approach served only to reinforce the belief. They offered two principles to minimize this possibility: begin with the least important belief, and also work with the evidence for the belief rather than the belief itself.

Accordingly a 'verbal challenge' of delusions begins by questioning the evidence for the belief, and this process begins with the least significant item of evidence and works up to the most significant one. Our preferred approach is that with each item of evidence the therapist questions the patient's delusional interpretation and puts forward a more reasonable and probable one. The customary approach in CBT is for the patient to be asked to generate the alternative interpretation(s), rather than the therapist supply one, but we have found that for certain patients this conventional tactic is a weak intervention.

When the therapist questions the evidence for a delusion there are two distinct but related objectives. One is to encourage to question and perhaps even to reject the evidence for his belief, and in this way perhaps to undermine the patient's conviction in the delusion itself. For some individuals challenging the evidence is a very powerful intervention and one that produces a substantial reduction in delusional conviction. However, more commonly this does not happen, but challenging evidence is still valuable in that it does impart insight into the connection between events, beliefs, affect, and behaviour. This is the second objective of challenging evidence, namely to convey the essentials of the ABC approach, i.e. that strongly held beliefs influence affect, behaviour, and cognition (i.e. interpretation) for all people. Core beliefs recruit or bias everyday inferences and automatic thoughts. However, this means that people often impose an interpretation on to events which is unwarranted, and because we are prone towards selectively processing information that confirms our beliefs, this goes undetected. In other words, it is understandable that a patient should interpret a particular event in line with his delusion because this is merely one occurrence of a general tendency, and confirmation bias, common to us all. In therapy, it is helpful to convey the ordinariness and normality of this process with everyday examples.

Having considered the alternatives, the patient is then asked to rate his conviction about each; regardless of how convinced he remains that the delusional interpretation is correct, it is usual to move on to the next piece of evidence. The therapist does not have to change what the patient thinks, but only to offer a fresh insight into the way he is thinking.

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