The techniques of cognitive–behavioural therapy for paranoiaThe general strategy of trying to understand, in the context of an empathic and collaborative approach, are key whatever treatment is adopted. But for a cognitive–behavioural intervention there are many additional elements, and these are outlined here. There have been repeated demonstrations of the efficacy of cognitive–behavioural therapy (CBT) for delusions and hallucinations (e.g. see review by Zimmermann et al, 2005). The evidence base is strongest concerning CBT for persistent positive symptoms such as delusions. About 20% of patients with persistent symptoms do very well in treatment and another 40% show important improvements (e.g. Kuipers et al, 1997). Tarrier et al(1998) report that, in a comparison with routine care alone, CBT resulted in almost eight times greater odds of a reduction in psychotic symptoms of 50% or more. In acute psychosis, there is evidence that CBT can speed time to recovery (Drury et al, 1996; Lewis et al, 2002). Furthermore, there is a small amount of evidence that some forms of CBT may reduce relapse rates (Gumley et al, 2003). The intervention is certainly popular with patients. However, not all respond to this approach. It is recommended for people with distressing delusions, since it enables individuals to engage with the collaborative goal of reducing distress. It is much less likely to be of use for individuals who are not distressed by their paranoid experiences. Cognitive deficits are not a contraindication for treatment, nor is the absence of insight into having an illness.
It is important to note that at this stage of development CBT for delusions is not a brief treatment; typically, it needs to be provided weekly for at least 6 months. Although similar to CBT for other disorders, clinicians should be aware that modifications to the approach are needed for delusions. Therapists using CBT for psychosis are often working with people who have complex disorders and need a good understanding of the psychology of psychosis, cognitive therapy skills, and regular supervision and support. It is also important to be aware that CBT is provided as part of a multi-modal treatment that includes antipsychotic medication and, for example, assertive community treatment, rehabilitation, supported employment and family intervention.
Assessment and formulation: ‘making sense of psychosis’
The initial task is to develop an individualised formulation that accounts for the patient’s paranoid thoughts and the associated distress. This occurs through detailed descriptions of paranoid experiences and their development. The formulation is a personalised account of the development of paranoid thoughts based on the cognitive model and is not simply ‘education about illness’. The clinician should be thinking about the following sorts of questions:
On what evidence is the person basing their thoughts?
How do paranoid thoughts build on the patient’s ideas about the self and others and ordinary worries?
How do the thoughts make sense given previous life events?
Is the person reacting to puzzling and confusing experiences?
How is the person reasoning about their experiences?
What behaviours are keeping the thoughts going?
The answers to these questions are then fed back to the patient for their opinion (e.g. ‘I may have this wrong, but could it be that, given the things that have happened in the past, your first reaction now is to think that others will be bad to you?’ or ‘From what you’ve said, you seem to rely on your instinct to know that there is threat, rather than think of many different explanations for others’ behaviour and weigh up the evidence – do I have that right, do you think?’). Gradually the therapist will develop a formulation – a multifactorial account of the development of the paranoid thoughts. Sometimes all, sometimes parts, of the formulation are shared with the patient.
There are a number of benefits to good formulation:†a full description of the patient’s subjective experiences is made, which is empathic, normalising, makes the experiences understandable and does not treat the patient as if they were ‘mad’; it enables patients to revisit their decision-making processes with the benefit of time and new information; it can provide an alternative non-delusional account of experiences; and it identifies targets of therapy. One of the most important elements in the therapy is that the clinician slows down and ‘unpacks’ the decision-making processes that lead to paranoid thoughts. This enables patients to gain distance from their thoughts so that they are more likely to review (often implicit) interpretations at any or all of the different steps in the development of their paranoid accounts. It also allows the clinician and the patient to introduce fresh information and other ideas that enable a different sense to be made of experiences. Given this renewed attempt at making sense, patients can consider how they might proceed differently in thought or behaviour.
Cognitive therapies were developed in a tradition that interventions should be assessed for their efficacy, and therefore formal measures of symptoms are routinely taken by therapists in individual cases to monitor treatment effectiveness (using, for example, PSYRATS; Haddock et al, 1999).
Interventions after formulation
Making sense of persecutory experiences illuminates many potential therapeutic paths. Thus, if anomalous experiences are assessed as central to delusion formation – for instance, the paranoid thoughts are provoked by feelings of depersonalisation, a sense of reference, perceptual disturbances or hallucinations – therapy may aim to reduce the frequency of such experiences using a functional analysis (examining the triggers and reactions), to change the interpretation of the anomalous experiences, or simply to enhance coping strategies. Where anxiety and worry contribute to the persistence of paranoid ideas, other ways of dealing with thinking about fears can be introduced and worry-reduction strategies used (Wells, 1997). In some cases it is possible to review with patients the evidence for and against different explanations for their experiences and to conduct behavioural experiments (i.e. to test out the persecutory thoughts).
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