Explorations in Personality. A Clinical and Experimental Study of Fifty Men of College Age, New York (Oxford University Press) 1938.

PAUL CHADWICK, MAX BIRCHWOOD, AND PETER TROWER: Cognitive Therapy for Delusions, Voices and Paranoia. John Wiley & Sons, Chichester, England, 1996, 210 pp., $55.00, ISBN 0-471-93888-2. It may seem anachronistic now, but there was a time when clinicians took seriously the psychotherapeutic treatment of schizophrenics and other psychotic patients. There used to be genuine optimism, at influential institutions such as Austin Riggs, that intensive psychoanalytic psychotherapy would be successful in alleviating psychotic symptomatology. With the remarkable efficacy of pharmacological treatments, clinicians currently pay little attention to the patient's internal psychological make-up, other than to use rehabilitation or psychoeducational approaches that represent efforts to help the patient accommodate to disturbing residual symptoms and functional deficits. In their new volume, Chadwick, Birchwood, and Trower challenge this pervasive skepticism, and take the psychotherapy of psychosis quite seriously. They claim that delusions, auditory hallucinations, and paranoia are amenable to relatively brief (20-30 sessions) psychotherapeutic interventions. Psychotherapy works, as they see it, because psychotic symptoms are merely exaggerations of normal psychological phenomena. Symptoms are not discontinuous with normal experience; rather, they are manifestations of basic cognitive mechanisms, regarding how people interpret and make inferences and attributions about events. As such, psychotic experiences will respond to cognitive therapy interventions. Although cognitive therapists have traditionally found psychotic patients to be untreatable, the authors label their approach "cognitive therapy," and scrupulously examine the beliefs and evaluations underlying psychotic experiences, engaging floridly paranoid individuals in ongoing psychotherapy. Using an ABC framework, they conceptualize all experiences and interactions in terms of Activating events, Beliefs, and emotional (or behavioral) Consequences. Delusions and paranoid thinking reflect beliefs about certain events and experiences, once those events are placed within an appropriate context. Even perceptual distortions, such as voices, are considered activating events, with associated beliefs and evaluations. As Chadwick et al. view it, these beliefs are the source of problems, not the psychotic experiences per se, and these beliefs may be changed. They will not directly confront a delusions, but they will subtly call it a belief (as opposed to a fact), challenge inconsistencies within the delusional logic, and ask about reactions to hypothetical contradictions. All these strategies are attempts to access the patient's self-evaluations. These three British psychologists ground their therapy in general social psychological theory, which may not be familiar to nonpsychologists. For example, they discuss self-other attributions, but make no mention of the concept of "projection." They speak of other-self or self-self evaluations in ways that are quite similar to object relations theorists, and yet there is no reference to this way of thinking. Considering the long tradition of conceptualizing psychosis in terms of lack of ego boundaries, it would have been useful to discuss the notion of paranoid delusions as a defense against fear of merger. …

Cognitive Therapy for Delusions, Voices and Paranoia

Objective: A meta-analysis was conducted to evaluate the effectiveness of solution-focused brief therapy (SFBT). Method: Hierarchical linear modeling software was used to synthesize the primary stu...

Examining the Effectiveness of Solution-Focused Brief Therapy: A Meta-Analysis:

It remains unclear what processes lead to the establishment of persecutory delusions in acute phases of schizophrenia. Recently, it has been argued that persecutory delusions arise from an interaction among a range of emotional, cognitive and social factors. In this work, we explored this possibility by first discussing the relevant aspects of recent theoretical models of the causes of persecutory delusions. Then, we offered an analysis of the literature, illustrated with clinical observations suggesting that persecutory delusions are triggered during stressful intersubjective transactions by the interactions of (a) an alteration in empathetic perspective taking and in pragmatic understanding of others' minds; (b) a perception/representation of the self as vulnerable or subordinate and of the other as dominant and threatening; and (c) a hyperfunctioning of the threat/self-protection system when faced with perceived danger. Implications for future research and treatment of people suffering from this symptom are discussed.

Vulnerable Self, Poor Understanding of Others' Minds, Threat Anticipation and Cognitive Biases as Triggers for Delusional Experience in Schizophrenia: A Theoretical Model

Cognitive psychologists have recently identified alterations in perception and reasoning that contribute to the formation and maintenance of beliefs that happen to be delusional. Clinically significant delusions, however, are often deeply unusual. An account of their formation and maintenance must explain not merely how someone can come to hold false or uncommon beliefs, but also how someone can arrive at beliefs that seem profoundly improbable and even bizarre. This paper uses the philosophical concepts of the Bedrock and the Background to provide an account of that foundational, nonrepresentational, non–rule-governed, dispositional structure of everyday understanding that underpins both our perception and our reasoning. The central claim is that the formation and maintenance of delusions becomes intelligible once they are seen to reflect disturbances to this foundational dispositional structure. Different dimensions of the Background are described along with the delusions that might follow from distortions to these dimensions. We challenge the assumption of much recent cognitive psychological theorizing that delusions can be understood as explanations of unusual experiences or as the product of hasty reasoning. Finally, the implications of the theory for the therapy of the delusional patient are briefly discussed.

Delusions, Certainty, and the Background

Background: A number of different systems of classification of delusional content exist. The basis for these systems is unclear.Aims: The objective of this study was to investigate the manifest themes of delusions.Methods: Semi-structured interviews were carried out with twenty-five participants. Interpretive phenomenological analysis was used to generate a typology of themes. A second type of analysis used a data-display matrix of participants and themes. The latter matrix displayed the pattern of themes for each individual. A range of verification methods was used.Results: A typology was constructed of 34 themes that fell into 6 general topic “domains” namely, negative self, negative interaction, special self, identity and relationships, specific mental experience, and entities. The majority of themes related to aspects of the self and social relationships. Each individual had a unique selection of themes that tended to cohere as a whole. We also found, as Freeman and Garety (2000) suggested, that some ...

A qualitative analysis of delusional content

During an assessment for therapy, one patient on an acute psychiatric ward proved to be extremely difficult to interview. He believed that demons were about to visit him, and this made conversation on the topic near impossible at first. Investigation of his beliefs resulted in him getting angry. At a later date, however, he requested meeting the first author. It was then decided to try out solution-focused therapy. Given this new start, it was then possible to begin systematic assessment of beliefs and emotional state. Over 6 months a fluctuating pattern of change emerged. Follow-up over 2 years suggested maintenance and considerable re-engagement with everyday activities. Beliefs were modified yet he retained notions of possible judgement by demonic forces. Copyright © 2002 John Wiley & Sons, Ltd.

Using solution‐focused therapy during a psychotic crisis: a case study

There are many descriptions in the research literature of the onset of delusions in psychosis: it is still not clear however whether there is one specific pathway to delusions or in fact several, and the role of social difficulties remains controversial. In this research we wished to explore the first person perspective of participants who had developed delusions. Interpretative phenomenological analysis was used to interview and analyse themes from 28 participants. An additional matrix analysis of themes was used to examine the importance of social difficulties in relation to types of onset and diagnoses. Our results suggest 3 types of onset: an eruptive sudden transformation of self or world; a slow progressive onset characterised by interconnected changes in meaning and experience; and onset beginning in childhood experience. Social difficulties were mentioned spontaneously by 17 participants in describing onset and a further 9 discussed social difficulties when explicitly asked. One feature that appears to be present both in the progressive and childhood onset is negative emotion about, and preoccupation with, a difficult interpersonal topic over long periods of time. The descriptions given suggest that certain ideas or images could take hold of a person and become interwoven in his or her thinking and perhaps even begin to influence the way the person experienced the world or self. We suggest that it may be important for therapeutic work with delusions to articulate a narrative of onset. Copyright © 2010 John Wiley & Sons, Ltd.

Key Practitioner Message: 


Exploring the onset of delusions can lead to useful information about social and emotional difficulties.


Most patients are able to give detailed accounts of onset, though some might only describe social and emotional difficulties if prompted.


Reported changes in experience and/or social difficulties may have occurred for some patients over many years and may even begin in childhood.


There may be a process of mutual influence between extreme negative ideas and experience over years for some patients.

Perspectives on the onset of delusions

This study is a contribution to the investigation of the active ingredient in psychological therapy for psychosis. Five people with chronic delusions were treated using a single-case experiment design. The treatment was broken down into components that were administered sequentially. A baseline phase was followed by three different treatment conditions (An A–B–C–D design). The treatments were (1) Solution-focused Therapy (2) Schema-focused cognitive therapy (3) Cognitive therapy focused on modification of the delusion. Three of the five clients responded to treatment with a large change in degree of belief in their delusion. Two clients improved during solution-focused therapy, one client improved during cognitive challenging of the delusion and one client changed during baseline. The implications of this study are discussed. Copyright © 2003 John Wiley & Sons, Ltd.

The effect of different components of psychological therapy on people with delusions: five experimental single cases

Objectives

Psychotic clients may be difficult to engage in psychological therapy, and many potential participants decline to participate in controlled trials of cognitive behavioural therapy. The aim of this study was to investigate psychotic patients' perspectives regarding therapy.



Design

The design was qualitative and used thematic analysis to investigate emerging themes.



Methods

A total of 46 inpatients with psychosis were interviewed about their views on therapy. Interview summaries were submitted to thematic analysis.



Results

A total of 41% of participants were rated as interested, 36% were rated as not interested and 23% appeared ambivalent, or their interest in therapy was unable to be assessed. Themes related to interest in therapy included the desire to build skills, to address (usually non-psychotic) symptoms and for a therapeutic relationship. Themes related to not wanting therapy included a denial of psychological problems, distrust in the healthcare system and psychologists and low perceived efficacy in therapy.



Conclusions

A large minority of psychotic patients may be interested in therapy, although mostly not to address psychotic symptoms. Future research on pre-treatment approaches to disconfirm negative perceptions and increase interest in therapy is warranted. Copyright © 2013 John Wiley & Sons, Ltd.




Key Practitioner Message

The reasons why some patients with psychosis are not interested in receiving psychological therapy may relate to past negative experiences with psychologists, negative perceptions of psychologists as a group and low perceived efficacy of therapy. These barriers may be addressed through interactions with psychotic patients during an admission to a hospital that disconfirms these perceptions and provides a positive alternative experience with a psychologist.
Patients who are hospitalized with psychosis may be interested in receiving psychological therapy; however, the reason for this likely will not be to address psychotic symptoms. Rather, the therapist should be willing to work with the patient on a range of other presenting problems.
If a patient has a lack of insight into their psychotic symptoms, this does not always negate them from perceiving other psychological problems for which they may desire support in addressing. Thus, therapists should be encouraged to approach all psychotic patients on a ward, even when there is an apparent lack of awareness of their psychotic symptoms.
The themes related to patients' perspectives were generated from psychologists' summaries of interviews with patients and not directly from verbatim transcripts. Although this meant that the reasons given for participants being interested or not interested in therapy were interpreted by the psychologist, efforts were made to relate the exact reasons provided by the participants.
Eighteen (29%) of the potential participants were not interviewed, usually as a result of their being discharged or transferred prior to arrangement of an interview. This meant we were unable to capture the views of these patients. Discharge prior to being seen by a psychologist is a barrier to engaging a patient in therapy and preventing them falling through the gaps of service provision.

Are young people hospitalised with psychosis interested in psychological therapy

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