Group Cognitive Behavioral Therapy

for Delusions: Helping Patients

Improve Reality Testing

Dr. Yulia Landa, Weill Medical College

of Cornell University
Presentation by Nick Mayer
 Outline for Presentation
• Introduction to Delusions
• Introduction to Cognitive Behavior Therapy (CBT)
• Why Group CBT?
• Current Study
– Overview
– Procedure
– Results
• Conclusions
• Schizophrenia affects 1% of the population
worldwide
• Delusions and hallucinations occur in 74% of
patients with schizophrenia, causing
significant morbidity
• Despite advances in antipsychotic medication,
such treatment leads to incomplete
improvement
• After 2 years of treatment with medication
more than 55% of patients still experience
delusions
 Delusions: Traditional Approaches
• “False beliefs held with unusual conviction,
which were not amendable to logic” (Jaspers,
1963)
• Involves perceptual aberration and the failure
of normal belief evaluation
• Delusional conviction, preoccupation and
distress fluctuate over time
 Delusions: Cognitive Theories
• Normal experiences of atypical perceptual
experiences
• Failure of self-monitoring
– Results in an experience in which one’s actions are
not the result of one’s intentions
• “Theory of Mind Deficit”
– Delusions of reference and persecution arise from
an inability to represent the beliefs, thoughts and
intentions of other people
 Characteristics of Delusions
• Patients with paranoia tend to make excessive
internal attributions for positive events and
excessive external attributions for negative
events
• Reasoning Bias
– A tendency for people with delusions to gather
less evidence than control subjects
– Jumping to conclusions
 Beck and Chadwick
• First attempt to modify patients’ delusional
beliefs using cognitive interventions
• Belief modification procedure
– Patients are encouraged to discuss evidence for
and against their beliefs
– Direct confrontations were avoided
• Identifying triggers
• CBT for Schizophrenia is focused on:
– Reducing distress caused by psychotic symptoms
by modifying delusions and beliefs about
hallucinations
– Enhancing coping skills for managing symptoms
– Reducing emotional disturbances such as
depression and anxiety by modifying
dysfunctional schemas (assumptions about
themselves)
– Providing psychoeducation (developing a shared
model of the nature of psychotic symptoms)
– Reducing stigma and sense of alienation
 Why Group Approach?
• Group interventions effective for:
– Coping with psychotic symptoms
– Decreasing isolation
– Improving relationships with others
– Strengthening ego functions
• Homogenous groups more effective than
heterogeneous groups
– Shared symptoms increases learning
 Current Study
• Goal: improve patients’ capacity for reality
testing by teaching them specific steps needed
to process information
– Patients will then be able to apply these skills and
re-evaluate their delusional beliefs
– Psychoeducation: patients learn information
processing strategies, not just new information
– Function of the group: not just to provide support,
amelioration and education, but also to facilitate
internal change
 Details of the Study
• 6 patients diagnosed with schizophrenia
• All patients taking atypical antipsychotic
medication
• Most patients were disturbed by their beliefs,
as well as disturbed by the fact that for years
they were told that their beliefs were delusional
• Goals told to the group:
– Discuss beliefs that group members held that the
majority of people in the community consider to be
delusional
– Learn how to reality test these beliefs
 Pre-Treatment Assessments
• In individual sessions, patients were asked to
choose one or two delusions they would like to
explore in the group
– The belief that leads to the most disruption in their
life / the one they would rather not believe in
 Samples of Delusions
• Someone who lives in my house is praying for me to
die so that he can have my girlfriend
• Someone is reading my mind and controlling me by
moving my body
• People can put thoughts into my mind/read my
mind
• I am being controlled by Satan because the voice I
hear in my head is the voice of Lucifer
• There are gangs out to put things in my brain to
make me forget things
• There are good and bad demons that follow me and
have sex with me
 Treatment Overview
• Group met weekly for 13 weeks for one-hour
sessions
• “Columbo style” questioning:
– To create a safe, supportive and engaging environment
– Patients can feel secure to share their beliefs
• Reality focused, structured approach
– Keeps anxiety at a minimum
– Free-association discouraged
• Session structure: warm-up exercise, review of
previous topic, discussion of new topic, homework,
review of the session
 13-Week Program
• Session 1: Introduction: How can we make this group
safe and comfortable?
– Learn to distinguish between Fact and Belief
• Session 2: Sharing goals for the group
• Session 3: Learn the ABC model
– 1. Activating Event: what triggers a delusional thought?
– 2. Belief: what is the difference between Event (Experience)
and Belief?
– 3. Consequences: What are the outcomes of having a belief?
Feelings, actions – both positive and negative
 13-Week Program
• Sessions 4-5: Applying ABC model to patients’ beliefs
• Session 6: Can we change our beliefs?
– Generate alternative explanations, look for evidence 
empirical testing
• Sessions 7-9: Evaluating and challenging specific
beliefs
• Session 10: Reinterpret past events in new light
• Session 11: Practice
• Session 12-13: Developing an action plan
 Example of ABC Model
• Allows for separation of Activating event (A) from
Belief (B)
• Morris’ Belief: “A person is praying for me to die
because he wants my girlfriend”
• Activating event: I see him praying
• Consequences:
– Feelings (paranoia) and behaviors (pray more)
– Positive (I have someone to blame) and negative (I do not
enjoy my living)
*negative examples motivate patients to change the belief!
 Exploring the Evidence
• Morris’ Belief: “A person is praying for me to die because
he wants my girlfriend”
Evidence For Evidence Against
I saw him praying He could have been praying
about something else

There are evil forces God wouldn’t honor such a prayer

that can get you

*coming up with alternative explanations helps the patient

give up his/her belief!
 Group Exercises
• Group members encouraged to look for other
explanations for each other’s experiences
• Mind reading experiment:
– Challenged the belief in telepathy
• After all alternative explanations were
considered, group members were asked to
choose an alternative explanation in place of
the previously held belief
 Addressing Concerns about Relapse
• What to do in the case the old belief
returned?
• Patients were given a card with ABC steps
• Patients encouraged to practice the logical
steps in evaluating beliefs
• Homework!
Results
Results
Conclusions: Benefits of Group CBT
• Allows for peer-peer discussion of irrationalities and
inconsistencies in each other’s beliefs
• By observing others’ irrational beliefs, members may
see how their own belief may be irrational, and also
how hard it is to see one’s own belief as irrational
• Helps to generate ideas about alternative points of
view
• Provides good learning environment
• Reduces isolation
• Allows more patients to receive treatment