Cognitive Therapy for Delusions, Voices and Paranoia
Wetzler, Scott, American Journal of Psychotherapy
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. …