Making sense of events

The key opening for the psychological understanding of paranoia is that such thoughts are individuals’ attempts to explain their experiences, that is, to make sense of events (Reference Maher, Oltmanns and MaherMaher, 1988). The sorts of experiences that are the proximal source of evidence for persecutory delusions are external events and internal feelings.

Clinical experience indicates that ambiguous social information is a particularly important external factor. Such information is likely to be both non-verbal (e.g. facial expressions, people’s eyes, hand gestures, laughter/smiling) and verbal (e.g. snatches of conversation, shouting). Coincidences and negative or irritating events also feature in persecutory ideation.

Unusual or anomalous internal feelings often lead to delusional ideation. For example, the individual might be in a heightened state or aroused; feel that certain events are significant; experience perceptual anomalies (e.g. things may seem vivid or bright or piercing, sounds may feel very intrusive); feel that they are not really ‘there’ (depersonalisation); and might have illusions and hallucinations (e.g. hear voices). Experiences of this sort can also be caused by use of illicit drugs or sleep deprivation.

Typically, individuals who exhibit paranoid thinking are trying to make sense of their internal unusual experiences, often by drawing in negative, discrepant or ambiguous external information (e.g. others’ facial expressions). For example, a person may go outside feeling in an unusual state and rather than thinking ‘I’m feeling a little odd and anxious, probably because I’ve not been sleeping well’, interprets their feelings, together with the facial expressions of strangers in the street, as evidence of a threat (e.g. ‘People don’t like me and may harm me’). But why a persecutory interpretation? We interpret internal and external events in line with our previous experiences, knowledge, emotional state, memories, personality and decision-making processes and therefore the origin of persecutory explanations lies in such psychological processes.

Emotions

Suspicious thoughts often occur in the context of emotional distress. They are often preceded by stressful events such as difficult interpersonal relationships, bullying and isolation. Further, the stresses may happen against a background of previous experiences that have led to beliefs about the self (e.g. as vulnerable), others (e.g. as potentially dangerous) and the world (e.g. as bad) that make suspicious thoughts more likely (Reference Fowler, Freeman and SmithFowler et al, 2006).

Anxiety may be especially important in the generation of persecutory ideation. This is because anxiety and suspiciousness have the same cognitive theme of the anticipation of danger. In our model we hypothesise that anxiety is central in the interpretation of internal and external events and provides the threat theme of paranoia. Hence, we argue that emotion has a direct role in delusion formation (for a review see Reference Freeman and GaretyFreeman & Garety, 2003); this is in contrast to a popular view that delusions conceal emotional distress or low self-esteem (e.g. Reference ColbyColby, 1975; Reference Bentall, Kinderman and KaneyBentall et al, 1994). Typically, therefore, in paranoid thinking a person having unusual experiences that they find it hard to identify and correctly label interprets them in line with their emotional state. If they are anxious it is more likely that the interpretation will be of threat.

Anxious thoughts are truly persecutory when they contain the idea that harm is actually intended by the perpetrator. The cause of this idea of intent is underresearched. We think that most often ideas of threat contain an implicit attribution of intent. Irritation, resentment or anger – often not expressed because of fears of others’ reactions (‘timidity’) – may perhaps contribute to this idea of hostile intent, since judgements of blame and attributions of intent are central to anger. A lack of trust in others, an unwillingness to discuss emotions, or social isolation mean that the feelings of threat and intent are not shared with others but are ruminated on alone, preventing disconfirmation of their persecutory nature.

Reasoning

The final piece of the puzzle is reasoning. It needs to be remembered that persecutory delusions are inherently a judgement and therefore reasoning processes are of central importance. Persecutory ideas are more likely to reach a delusional intensity if there are accompanying biases in reasoning such as reduced data gathering (jumping to conclusions) (Reference Garety and FreemanGarety & Freeman, 1999), failure to consider alternative explanations (Reference Freeman, Garety and FowlerFreeman et al, 2004) and a strong belief confirmation bias (Reference WasonWason, 1960). When reasoning biases are present, suspicions become near certainties; ideas of threat are held with a conviction unwarranted by the evidence and may then be considered delusional.

Our model contains further hypotheses concerning the maintenance and emotional reaction associated with persecutory delusions. For example, since the explanations contain threat beliefs, the fears will be maintained by processes similar to those outlined in the anxiety disorders literature, such as the use of safety behaviours (e.g. avoiding other people) which prevent the processing of disconfirmatory evidence (Reference ClarkClark, 1999). Furthermore, the individual’s relationship with the persecutor may be important in determining emotional reactions; the belief that the persecutor is powerful has been associated with higher levels of depression (Reference Birchwood, Meaden and TrowerBirchwood et al, 2000b ; Reference Freeman, Garety and KuipersFreeman et al, 2001). Thus, we conceptualise paranoia as resulting from individuals’ attempts to understand their experiences, particularly unusual internal states, while under the influence of emotional states such as anxiety and biases of reasoning. Careful assessment is needed to determine the relevant factors in each individual case.

Therapeutic style

Therapeutic style is, of course, important for any type of intervention. For instance, the quality of the therapeutic alliance has been found to be a predictor of patients’ adherence to antipsychotic medication regimens (Reference Day, Bentall and RobertsDay et al, 2005). The cognitive–behavioural approach to reducing the distress of people with paranoid thoughts follows directly from the theoretical understanding outlined above. As we have said, there is a consensus that delusions are explanatory accounts of experiences. Delusions are the most compelling explanation that the person has arrived at on the basis of previous childhood and adult events, knowledge, emotional state, memories, personality and reasoning processes. It can be helpful for clinicians to keep in mind Maher’s idea that ‘the delusional belief is not being held “in the face of evidence normally sufficient to destroy it,” but is being held because of evidence powerful enough to support it’ (1974: p: 99). Therefore the clinician will want to learn more about the chain of events, experiences, feelings and judgements that has led to suspicious thoughts. Thus, the style of engagement is based on what Reference Kingdon and TurkingtonKingdon & Turkington (2002: p. 3) have called ‘a journey of exploration into patients’ beliefs’, which should be undertaken with an open mind and a willingness to understand the individual and find out about them.

This ‘voyage of discovery’ attitude will be more helpful in engaging the patient than any simple implementation of a set of techniques. The exploratory approach must be combined with an empathic, collaborative style. The patient needs to feel that their problems are being taken seriously. The therapist should listen empathically and regularly give brief summaries of what the patient has been saying. This will ensure that the clinician has understood and will help structure the discussion. The therapist should comment on the distress caused by the experiences, but without agreeing that the perceived threat is real, for example ‘It must make you very anxious’ or ‘Believing that the neighbours are trying to harm you must feel very intrusive and be upsetting’. The clinician should be collaborative, drawing up a list of goals with the patient, discussing what will happen in the meetings and regularly asking the patient for both positive and negative feedback on the meetings. Providing written information on paranoid thoughts can be helpful (Reference Freeman, Freeman and GaretyFreeman et al, 2006). Any immediate concerns (e.g. thoughts of suicide, difficulties getting to therapy sessions) should be dealt with before a full assessment is carried out. The clinician needs to be flexible in both the length of sessions and the degree to which key material is focused on. They must also keep a close eye on whether there are aspects of the sessions that the patient finds upsetting. In the early sessions, the therapist should not start challenging delusions, but perform the more difficult task of listening and trying to understand the patient’s perspective: challenging delusions in an inexpert way is equivalent to not listening to the patient’s experiences. It can also be extremely helpful not always to focus on problems but to find out about the positive aspects and achievements of the individual and show that you have noticed them. Patients with suspicious thoughts often present with low self-esteem, difficulties with trust and fears that others think they are ‘mad’. A clinician who shows positive regard can help circumvent these negative self-views, which sometimes hinder engagement.

Obstacles to good engagement

There are, of course, obstacles to forming a good collaborative relationship with an individual who has paranoid thoughts. Elements of the role of a psychiatrist bring problems. Two key issues are hospitalisation and medication. An individual with paranoid thoughts may be worried about revealing these and being admitted compulsorily to hospital (or not discharged, if already an in-patient). The psychiatrist will often be keen to prescribe medication, which the patient may take as an indication that the clinician’s mind is already made up or which might conflict with the wishes of the patient. Such difficulties need to be acknowledged, discussed openly and resolved by negotiation. Specific techniques for developing appropriate medication adherence, including forming a collaborative relationship, using motivational interviewing, provision of information, and monitoring symptoms and side-effects, are described elsewhere (e.g. Reference Randall, Wood, Day and MorrisonRandall et al, 2002).

There is also the issue of the use of language. Mental health professionals may use diagnostic terms such as schizophrenia and give only biological explanations for experiences. Illness accounts of experiences can be helpful to some patients but there are two main difficulties with them. The first is that they contain within them a number of potential further or other meanings. For example, for some patients ‘schizophrenia’ carries connotations of madness and violence, they believe it to be an uncontrollable organic condition that will not improve and they fear that they will be shunned by others. There is an emerging and important literature indicating that careful attention should be given to appraisals of illness – concerning, for example, cause, course, outcome, loss, entrapment and humiliation – because they can lead to distress (Reference Birchwood, Iqbal and ChadwickBirchwood et al, 2000a ; Reference Lobban, Barrowclough and JonesLobban et al, 2003).

The second difficulty with illness models is that they mostly provide a poor causal description of a person’s subjective experiences. For example, telling Mr Smith that he is ‘ill’ does not necessarily provide a compelling account of why, when he goes outside, he feels very anxious, senses that something odd is going on and notices that people in the street are looking at him. A delusional explanation that people seem to recognise and know about him, are aware of bad things about his past and, as a consequence, are hostile may provide a richer account for Mr Smith of his subjective experience and draws on his own knowledge. Patients may favour the delusional account, being richer, over the illness account.

In psychological therapies, as shall be seen, an elaborated alternative account that draws on both the patient’s and the therapist’s knowledge is made: for example, that the patient has had previous adverse experiences with others (e.g. has been bullied) and therefore expects threat, may be more prone to notice it in ambiguous social information and to jump to the conclusion that they are to be harmed whenever there is any sign of danger. The therapist also tries to ensure that there is a simple, non-stigmatising label for such an account (e.g. that the person is ‘alert’ or ‘sensitive’ to threat). These accounts developed in therapy, similar in explanatory power to the delusional accounts, may make a more plausible alternative than either the ‘illness’ or the ‘delusional’ accounts.

Another obstacle to engagement can be that the clinician becomes incorporated into the delusional system. If the clinician’s approach is empathic and based on understanding, this happens less often than they fear it might. However, the clinician should anticipate the problem by checking at the end of initial meetings whether the patient has any concerns about them (e.g. ‘You have described mistrusting people. I therefore wondered whether you’ve had any such worries about me?’). If the patient does have such concerns the clinician should first explain their role very clearly. If the patient does not respond to simple reassurance the clinician should use problem-solving techniques to address the difficulty in the therapeutic relationship. For example, the clinician might suggest that the patient does not talk about the most private aspects of their experiences until they feel greater trust or may ask whether there is anything that they could do to ease the patient’s worries about them. It can be helpful for the clinician to show the patient the notes being taken in the meeting. It can bring down the emotional impact of paranoid thoughts in meetings if the clinician points out that it is not surprising that the patient is suspicious about the clinician, given the delusional system, and that it is simply a problem that can be discussed like any other and compromises and solutions can be found.

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:

1. • On what evidence is the person basing their thoughts?

2. • How do paranoid thoughts build on the patient’s ideas about the self and others and ordinary worries?

3. • How do the thoughts make sense given previous life events?

4. • Is the person reacting to puzzling and confusing experiences?

5. • How is the person reasoning about their experiences?

6. • 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; Reference Haddock, McCarron and TarrierHaddock 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 (Reference WellsWells, 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). In other cases, the therapist and patient will be ‘working within’ persecutory delusions, and distress may be reduced by, for example, focusing on the interpretations associated with the most distressing aspects of the delusion (e.g. the degree to which the person is powerless, whether the threat is as widespread as thought), or Ed. by developing alternative ways of reacting to the threat. In our self-help book on overcoming paranoid and suspicious thoughts (Reference Freeman, Freeman and GaretyFreeman et al, 2006), intervention for paranoid thoughts is crystallised into six key steps (Box 2). These encourage the reader to:

1. 1 become a detached observer of their fears;

2. 2 develop a detailed understanding of the causes of suspicious thoughts

3. 3 review paranoid interpretations rather than just accepting them;

4. 4 test out suspicious thoughts;

5. 5 ‘let go’ of a suspicious thought if it comes;

6. 6 reduce the time spent worrying about paranoid thoughts.

Frequently, clinicians also work with patients on improving low self-esteem (Reference Hall and TarrierHall & Tarrier, 2003), reducing depression, increasing activities and structuring time. Our theoretical model clearly indicates that reducing emotional difficulties should also lead to lessening of suspiciousness.

Finally, the therapist and patient may try to prevent relapse by identifying vulnerabilities and early warning signs and rehearsing compensatory strategies.