Skip to main content
Department of Psychiatry

Delusions Roadmap

The outline below provides a roadmap for treatment of delusions within a CBT framework. The roadmap provides direction in the following areas: Assessment, Engagement and Psychoeducation, Cognitive-Behavioral Techniques, and Third-Wave Techniques.

Resources are drawn from a variety of sources including:

Assessment

Below, we list a few measures to consider when assessing paranoia. The PSYRATS can be used as either a self-report or interview-based measure. If you want something quicker and that will provide you a starting point for treatment targets, then use the Ideas of Reference and/or the Paranoia checklist from the IRT manual. Finally, we have included a new measure, the Paranoia Worries questionnaire, which is brief and can be used to track treatment progress.

  • Paranoia/Troubling Thoughts
  • Demonstrating Videos (for assessing delusional experiences
    • Examining the antecedents of delusional thinking (this is an interview in which the therapist attempts to explore the factors that precede delusions).
    • Assessment of thought broadcasting (the first 14 minutes of this video does an excellent job of illustrating how to obtain contextual information from a client about delusions. The last 9 minutes illustrate how to set up a simple in-session experiment on how thought suppression can lead to thinking more about a delusion. The therapist also does an outstanding job of using Socratic Questioning).Advantages and disadvantages of paranoia (in this interview, the therapist spends the first 13 minutes getting information about the context of the client’s paranoia and their conviction in their beliefs. The last 10 minutes are spent on a simple “pros and cons” of paranoid thinking. Also, note the use of Socratic Questions and the way the therapist uses empathy in the session).

Engagement and Psychoeducation

Establishing a trusting relationship and strong therapeutic alliance with the client is critical for any subsequent discussion or work around delusional beliefs. for persons with especially guarded presentations, you may consider using these suggestions across several sessions. The goal is to create an environment in which talking about these beliefs is safe/non-threatening:

Cognitive-Behavioral Techniques

Cognitive-behavioral techniques consist of cognitive restructuring and behavioral experiments. Cognitive restructuring uses guided discovery to develop evidence for and against a distressing, worrisome, or delusional belief. Behavioral experiments can supplement cognitive techniques by helping the client access disconformity evidence in their environment which was previously blocked from awareness.

  • Cognitive Restructuring (IRT Manual, p. 493)
    • Introducing the Cognitive Triangle (IRT Manual, pp. 406-409)
    • Common Styles of Thinking (IRT Manual, pp. 410-415)
    • Cognitive Restructuring (IRT Manual, pp. 416-432; video demonstration part 1 and part 2)
      • 5 Steps of Cognitive Restructuring Note Card (IRT Manual, pp. 402-403)
  • Using Distressing Thoughts or Delusions Timelines to identify core beliefs that maintain distressing thinking and emotions (Note: intensely negative core beliefs or “hot schemas” are protected by the delusional beliefs. Too much questioning or schema-level work early in the therapeutic process can result in a “retreating” into the delusional belief system, slowing progress. it is recommended to proceed cautiously when questioning core beliefs)
  • Behavioral Experiments

Third-Wave Techniques

Alternatives to shifting worrisome beliefs include third-wave techniques that focus on helping clients developing flexibility with their thoughts, rather than modifying the thoughts themselves. These techniques emphasize mindful acceptance of thoughts and emotions that are relevant to the distressing beliefs.

  • Acceptance/Mindfulness Strategies (IRT Manual, pp346-348; IRT Manual, p. 493; Worry Postponement Demonstration)
  • Values Clarification Handout: Can be useful for helping clients with delusions identify what they value most. In this client group, values are often disconnected from their practical realization in the world. The basic goal with this exercise is to seek ways in which clients can convert their ideal values into pragmatic matters.
  • Acceptance and Commitment Metaphors
    • Passengers on the Bus Metaphor: when emphasizing that sometimes certain aspects of their experience are impossible to control, you can use this metaphor to draw parallels between the person’s delusions and the annoyed passengers on the bus, and how people can handle unwanted or unpleasant thoughts while still moving toward their goals. (Video of Metaphor)
    • Polygraph Metaphor: This metaphor is useful for presenting the impossibility of controlling certain aspects of life. For example, delusions may be viewed as an attempt to control fear when paranoid ideas or feelings or failure appear -this metaphor can help clients identify situations in their life where these control strategies are counterproductive. (Video of Metaphor)