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Delusions Douglas Turkington & Ronald Siddle Advances in Psychiatric Treatment (1998), vol. 4, pp. 235-242 Cognitive therapy for the treatment of delusions Douglas Turkington & Ronald Siddle Traditionally, delusions have been viewed as false, formulation driven, and focused on schema change, unshakeable beliefs which arise out of internal while cognitive-behavioural therapy was tradition morbid processes and are out of keeping with a ally more behaviourally oriented. Now the position person's educational and cultural background is much less clear, with the terms cognitive therapy (Hamilton, 1978). Primary delusions appear to arise and cognitive-behavioural therapy being used more without understandable cause, and secondary or less synonymously; in this paper, the terms delusions appear more understandable in relation cognitive therapy and cognitive-behavioural to the prevailing affective state or cultural climate therapy refer to the same therapeutic stance and (Sims, 1995), for example. However, during the range of techniques. cognitive therapy process we would expect that even Most of the research on cognitive therapy so far primary delusions might become more under has been done on depression. Cognitive therapy has standable as the patient's life history and belief been shown to be effective in both endogenous and profile are gradually disclosed. non-endogenous depression (Blackburn et al, 1981) Roberts (1991) describes some primary delusions and also has a value in relapse prevention (Evans et as being potentially adaptive, leading to protection al, 1992). Its efficacy in anxiety disorders (Blackburn from depression and to an enhanced sense of & Davison, 1990) is relatively well known. Recent, meaning. Also, Harrow et al (1988)estimate that 70% randomised controlled trials which have been of delusional ideas relate to non-delusional beliefs evaluating cognitive therapy in the treatment of that pre-date the delusion. Delusions are, according schizophrenia are coming to fruition (Kuipersef al, to a number of researchers, points along a continuum 1997) to support an early promising but uncon with overvalued ideas and normal beliefs (Strauss, trolled study (Kingdon & Turkington, 1991) 1969; Chapman & Chapman, 1988;Jones & Watson, indicating the potential benefits to be gained from 1997). This continuum hypothesis, along with other this method of treating schizophrenia. The cognitive research postulating that delusions are a reflection therapy approach to schizophrenia is much broader, of a defensive attributional style protecting against including components directed towards coping low self-esteem (Lyon et al, 1994), provides the skills (Tarrier et al, 1993), medication compliance theoretical basis for many of the techniques and (Kemp et al, 1996) and negative symptoms (Hogg, approaches used in the cognitive therapy of 1996). Delusions as treated within schizophrenia delusions. are tackled within this broader framework and Cognitive therapy is a psychological treatment techniques integrated within the overall direction used nowadays in the majority of psychiatric of therapy (Fowler et al, 1995). In this situation one disorders with differing levels of proven efficacy. It of the key predictors of response is cognitive is active, directive, time-limited, structured and flexibility concerning delusions (Garety et al, 1997). collaborative (Beck et al, 1979).Some time ago, there Huq et al (1988) have shown that deluded patients was a wider divide between cognitive therapy and require less information and controls on probabilistic cognitive-behavioural therapy. Cognitive therapy reasoning tasks and express greater certainty over having a more cognitive focus, and being much more their judgements; that is, deluded patients tend not Douglas Turkington is a consultant psychiatrist at St Nicholas Hospital, Jubilee Road, Gosforth, Newcastle upon Tyne NE3 3XT and a cognitive therapist specialising in cognitive therapy with psychotic disorders. Ronald Siddle is a research fellow at the University of Manchester and an accredited cognitive therapist working in the Socrates Study investigating cognitive- behavioural therapy in early schizophrenia. APT(1998),vol.4,p.236 Turkington& Siddle/Martinâale to take into account the available evidence, jump to conclusions and then hold their conclusion with Box 1. Pioneers of cognitive therapy for greater certainty. This research would seem to hint delusionsBeck, that a cognitive therapy approach towards delusions, which involves collecting and re-examining the 1952Milton of the techniques evidence and generating hypotheses, would seem outlinedBelief to be of potential benefit. It would also point towards et al, modification the benefits of cognitive remediation (Brennerei al, 1978Lyon preferredconfrontationDelusionsto 1990) in improving attentional deficits and other 1994Roberts,et al, providing a neuropsychological deficits which are often present protective function for self in schizophrenia and which hinder such reality- esteemAdaptive testing work. This paper takes a narrower focus on 1991Hemsley function of specific techniques as applied to delusions and their impact on the patient's affect and behaviour. delusionsReasoning & processesMeasurement 1986ChadwickGarety, Historical development &Löwe, andmodificationCognitive-behavioural 1990Kingdon & Given that delusions are defined as unshakeable, Turkington, therapy in schizophrenic there would seem little point in attempting to use 1991Turkington delusionsRedefinition valuable resources on such lost causes, regardless et al, of delusion of progress made in people with schizophrenia. 1996Many However, there are one or two investigations which suggest the contrary; that delusions can be held with varying degrees of belief, and are amenable to appropriate methods of treatment (see Box 1). Hemsley & Garety (1986) showed two factors to be pertinent to the development and maintenance of Measures of change abnormal beliefs. They were, expectation and current relevant environmental information. These are the same factors which mediate the development of Cognitive therapy is a scientific psychotherapy, normal beliefs which, like delusions, are also highly which relies on a focused approach with a measur resistant to change with a tendency to disregard able outcome. Attempts to measure delusions have contradictory information. Perhaps delusions are provided a wealth of models and scales (Chadwick not categorically different from normal beliefs. Beck & Lowe, 1990,1994; Buchanan et al, 1993; Wessely (1952) provided an early case example of the use of et al, 1993), of which none has really been widely what is now called cognitive therapy in the case of accepted as providing a 'gold standard' against a man with a long history of a systematised which others can be validated. Of these, the persecutory delusional system. This delusion was Maudsley Assessment of Delusions Schedule completely given up, mostly using a questioning and (MADS) described by Buchanan et al (1993) is one of reality-testing approach. Beck's work suggested that the most comprehensive. This measure offers a delusions might be modifiable by appropriate reliable semi-structured interview, with sensitivity methods, and a number of small-scale studies and face validity, though it is somewhat cumber provide some support for this. Watts etal (1973),Hole some and lacking in its ability to offer a simple etal (1979),Lowe & Chadwick (1990)and Turkington scoring system for severity. et al (1996) using small sample sizes confirmed these In practice it is often difficult to separate clinical findings, and did so using only six or eight sessions assessment from treatment (Alford & Beck, 1994), of therapy. Milton et al (1978) concluded that the an assertion supported by Hole et al (1979) whose most effective style of therapy was to attempt to attempt at merely the measurement of delusional modify beliefs collaboratively rather than by ideas by interview produced surprising reductions adopting a confrontational style. Though these in conviction ratings. Because of the idiosyncratic papers support the role for a cognitive therapy nature of delusions Alford & Beck (1994) suggest approach to delusional ideas, it must be said that individualised rather than nomothetic assessment this assertion has not yet been effectively tested using procedures, focusing upon frequency of related appropriate methodology concentrating specifically behaviour, conviction and emotions which ac on delusions alone. company delusions. Cognitive therapy for delusions APT (1998),vol. 4,p. 237 Harrow et al (1988) propose three basic di all times if possible. It will often feel as if the patient mensions to a delusional idea. These are: belief with the delusion is attempting to draw the therapist conviction; the patient's awareness of how others in to a confrontational stance. It seems very will view his delusional ideas; and the immediacy important to avoid this by using responses such as: or urgency which the patient attaches to the "well, that is a possible explanation, but could it be delusional idea. Others such as Kendler et al (1983) anything else?" or "let's explore the evidence and propose five dimensions to their measurement of see if your ideas are right". delusions. These researchers' proposed dimensions The attitude in such sessions is of being two are: conviction; the degree to which the belief extends research workers looking for the evidence to test out into other aspects of life; bizarreness; disorganis one hypothesis after the other to see which is the
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