Cognitive therapy to challenge delusions and dysfunctional assumptions

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The application of cognitive therapy in the challenging of delusions and dysfunctional beliefs draws upon the approach described by Chadwick et al. (16> and builds upon the pioneering work of Chadwick and Lowe.(H)

Those research groups that have been developing CBT approaches agree that engaging patients is perhaps the greatest challenge facing a therapist. It is noticeable that many individuals either never attend or do so for a few sessions and then stop. Once individuals get past the opening strategies of cognitive therapy they usually see therapy through. This pattern of high and early drop out is found in those few research trials so far carried out on cognitive-behavioural approaches to psychotic problems.(1 IM?)

Careful attention to appropriate therapeutic technique can maximize client engagement. Viewing delusions as beliefs, not facts

The first technical difficulty to be encountered is the necessary move to aid the client in conceptualizing a delusion as a belief and not a fact. This move is an essential part of CBT for all emotional problems, but is difficult at the best of times. With depression, for example, patients often struggle to appreciate that their sense of worthlessness, which is so concrete to them, is actually a belief they hold and is different from a knowledge of events and facts. With delusions there is the added complication that the therapist might be perceived as being just another person who disbelieves the patient.

There are two central points to bear in mind when seeking to reconceptualize delusions as beliefs, not facts—why it is being done and how it is done. (!6>

The purpose of clarifying that delusions are beliefs, not facts, is to empower the patient and offer a way of easing his or her distress. If the patient really is being persecuted by a powerful organization, or has a radio transmitter and receiver in his head, neither he nor the therapist can actually change this. The patient feels that he knows this as a fact, with the consequence that he feels frustrated and helpless as well as distressed. However, if the patient only believes this to be true, then he gains the freedom to examine his beliefs and perhaps change his distressing feelings and behaviour and experience himself. In this sense it is in his best interest for the delusion to be false.

How this process takes place is critical. The process of Socratic questioning is not one of persuading a patient that he is wrong and that you, the therapist, are right. This mistake is made all too often. Rather, in Socratic dialogue the therapist helps the patient to draw on his own doubt and experience in order to realize that there are other ways in which he is able to make sense of his experience. So, when the therapist pursues the conceptual step of clarifying that a delusion is only a belief, the patient's own doubt, past or present, his own contradictory experience and behaviour, and concerns about the possibility that the delusion is wrong are accessed. Many patients have 'double awareness' of delusions—on the one hand they believe them firmly and are distressed and disturbed by them, yet on the other hand they behave in ways that contradict the delusion, and they believe that working with a therapist might ease the problem. Finally, the therapist must accept that it is acceptable if the patient does not alter his belief. The process is 'collaborative empiricism, not indoctrination'. (16>

Developing a rationale for questioning the delusion

Patients are usually used to being told by family and carers that their beliefs are wrong, that they are deluded. It is easy for a therapist to prepare the intervention well and embark on it before the patient is clear of the purpose and possible benefit, thus causing early loss of engagement. It is revealing to turn the engagement question on its head and to consider why a patient should ever wish to engage in therapy. With emotional problems patients identify their problems as depression, anger, anxiety, guilt, etc.; with delusions and hallucinations this is not so—patients predominantly present problems which they believe are actual events (persecution, voices, passivity). This means that they have no clear objective and therefore have no particular motivation to engage. The key reason for a patient to reconsider delusional beliefs is that it will help him feel less distress and it will free him to behave differently and to pursue the things he wants more directly. What the therapist does gradually through the unfolding cognitive assessment is to clarify with the patient that he is experiencing emotional and behavioural problems, and that these are tied to his beliefs (delusional and evaluative). The therapist then needs to explore with the patient how the delusion affects his life and how his life would be different (i.e. better or worse) if the delusion were false. (16> In this way, the therapist slowly encourages the patient to view the delusion not as an important discovery but as a belief that results in distress (e.g. fear, anxiety) and causes him to behave in ways which he would rather not (e.g. avoid things he would otherwise like to do).

Using appropriate procedures for weakening delusions

Disputing comprises four elements^116

1. The evidence for the belief is challenged, in inverse order of its importance to the delusion.

2. The internal consistency and plausibility of the delusional system is questioned.

3. Following Maher,(20) the delusion is reformulated as being an understandable response to, and way of making sense of, specific experience, and a personally meaningful alternative is then constructed.

4. The individual's delusion and the alternative are assessed in the light of the available information.

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