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Helping patients with paranoid and suspicious thoughts: a cognitive–behavioural approach

  • Daniel Freeman and Philippa Garety


Paranoid and suspicious thoughts are a significant clinical topic. They regularly occur in 10–15% of the general population, and persecutory delusions are a frequent symptom of psychosis. In the past, patients were discouraged from talking about paranoid experiences. In contrast, it is now recommended that patients are given time to talk about them, and cognitive–behavioural techniques are being used to reduce distress. In this article we present the theoretical understanding of paranoia that underpins this transformation in the treatment of paranoid thoughts and summarise the therapeutic techniques derived. Emphasis is placed on the clinician approaching the problem from a perspective of understanding and making sense of paranoid experiences rather than simply challenging paranoid thoughts. Ways of overcoming difficulties in engaging people with paranoid thoughts are highlighted.

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Helping patients with paranoid and suspicious thoughts: a cognitive–behavioural approach

  • Daniel Freeman and Philippa Garety


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Helping patients with paranoid and suspicious thoughts: a cognitive–behavioural approach

  • Daniel Freeman and Philippa Garety
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Yes I I !

gunjan khandpur, senior house officer (adult psychiatry)
23 January 2007

Declaration of Interest: None

Paranoia is a fascinating, yet challenging symptom. It still remains relatively unexplored. The extent to which it brings both subjective and objective distress or dysfunction influences its under reporting. More relevant to psychiatrists is how it is understood and managed in clinical practice.

This article is of immense help in dealing with paranoid symptoms of patients. It provides an insight into the multiple dimensions of delusions. Different components have been segregated, allowing each tobe addressed individually and equally. It is useful to understand the importance of the emotional set of the individual, prior to the development of delusional themes. This has been well described by the authors. It must not be forgotten that intelligence is largely wellpreserved in people with paranoia. Often responses and behaviours are consistent with the paranoid ideas. As early as 1962, psychological interventions were offered early in the illness for these reasons.

CBT helps professionals to clarify clinical issues, but also the purpose of the therapy. This becomes a guided discovery into the relevanceand the understanding of individual experiences. A genuine curiosity and much empathy is required in a therapist. It is worth noting that the passivity that often develops during therapy, on the part of the patient, can be a hindrance. However, it can also have more constructive uses. Trials have shown that good outcome can be predicted by the degree of cognitive flexibility concerning delusions. Applied in the acute phase of a non-affective psychotic disorder, evidence has demonstrated enduring and significant benefits of cognitive therapy. Patients who receive CBT show significantly more insight and fewer negative symptoms (Birchwood et al, 2000). Trials of brief therapy, demonstrate protection against depression and relapse. Those who do relapse have a delayed time to admission and significantly reduced time spent in hospital. Turkington et al also highlight the role of mental health nurses trained in brief CBT for schizophrenia, to supplement case management and family interventions. More detailed therapy can be focused on the treatment resistant (Turkington et al, 2006).

The use of CBT in psychosis remains underdeveloped compared to its take up in neurotic disorders. Further complications are its restricted availability in the NHS, the paucity of trained therapists, and haphazard CBT supervision for psychiatric trainees.

CBT not only reduces distress, but has also been shown to help in engagement, including treatment concordance. It helps to promote insight and prevent relapse as highlighted above. We believe that CBTshould be further emphasised during psychotherapy and routine consultant supervision for psychiatric trainees.

There is also a rationale for the role of longer- term individual, group and family dynamic psychotherapies within early intervention teams (Martindale, 2007). Less evident are the benefits of non-specific, supportive counselling (Grich, 2002).


1.Daniel Freeman and Philipa Garety, 2006; Helping Patients with Paranoid and suspicious thoughts: Cognitive behavioural approach. APT; Vol12,404-415

2.V Drury, M Birchwood, Cochrane- Cognitive therapy and recovery from Acute Psychosis: A controlled trial 5-year follow up. BJPsych (2000) 177 (8-14)

3.D Turkington, D Kingdon, S Rathod et al: Outcomes of an effectiveness trial of cognitive-behavioural intervention by mental healthnurses in schizophrenia; BJPsych (2006) 189:36-40

4.B Martindale, 2007; Psychodynamic contribution to early intervention in psychosis. APT; Vol 13, 34-42

5.Ethan Grich, 2002: A review of the current evidence for the use ofpsychological interventions in psychosis. International Journal of Psychosocial Rehabilitation; 6, 79 - 88
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Conflict of interest: None Declared

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Balancing the CBT approach with an analytic perspective

Richard Lucas, Consultant Psychiatrist / Psychoanalyst
17 December 2006

I read with interest the article “Helping patients with paranoid and suspiciousthoughts: a cognitive-behavioural approach” by Daniel Freeman and PhillipaGarety.

Whilst traditional psychiatrists view delusional beliefs as being held in the face of contrary evidence normally sufficient to destroy them,Freeman and Garety contend that they are held by evidence powerful enough to support them and their validity.

They also argue for a continuum in intensity from normal to overvalued ideas to delusions, inviting consideration of similar mechanisms by which paranoid thoughts arise in the normal population and delusions in psychosis.

As a general psychiatrist using a psychoanalytic framework to relate to patients in everyday practice and aiding junior doctors through weekly psychosis workshops, I would hold a different attitude. I would distinguish the genesis of paranoid thoughts, that can occur in all of us,from delusions in major psychotic disorders

Delusions are held in the face of contrary evidence, but we still need to know how and why they are formed. I believe that cognitive-behaviourists are correct that both emotions and reasoning come into play.What I find missing in their formulations is the integration of analytic concepts, namely the domination of the internal phantasy world over external reality in psychosis, the use of pathological projective identification in delusional formation and the importance of our counter-transference feelings and sensitivities.

In the psychoanalytic model, the patient with schizophrenia projects out troublesome thoughts and feelings into memories stored in the mind forthe purpose of disowning them to form the delusion. These insights arose originally from very detailed analytic case studies by Bion. I have observed that what is often disowned in the delusion is the patient’s sanity.

While fully in agreement with the cognitive-behavioural approach of there being meaning to the delusion; my emphasis, as the primary task would be to approach delusions like crossword puzzle clues, through understanding the projections and their subsequent rationalisations.

For example, a patient might claim that he is Prince Edward son of Henry the Eighth. His delusion becomes understandable when it emerges that he has been assaulting his young wife who is in a women’s refuge. The delusion can be seen as his disowned sanity critical of his manically aggressive behaviour. His sanity is saying that he is acting like a son of Henry the Eighth, inventing his own rules and doing what he wants to his wives, and he wishes to disown this awareness.

I believe that APT’s on-line correspondence could provide a lively forum for reflection and debate on differences and similarities in psychological approaches towards the understanding of delusional content.
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Conflict of interest: None Declared

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