Working through Delusions in Therapy

November 7, 2019
Therapy for certain conditions on the schizophrenia spectrum can become complicated when delirium is involved. That's why we wanted to dedicate and article to giving some recommendations on how to get through these sessions and eventually be able to work on the delirium itself.

Is it possible to convince someone who’s experiencing a delusion that what’s going on in their head isn’t real? Do you have to pretend you believe them in order to continue with a session? Is it possible to avoid entering a patient’s delusion to treat them? We’re going to try to answer the question of how to work through delusions in therapy in this article.

This symptom isn’t always linked to conditions on the schizophrenia spectrum, but in many, if not most cases, it is. For example, you have delusional disorder (which basically means your only symptom is having delusions), brief psychotic disorder, or schizophrenia per se.

Delusions are basically erroneous beliefs or poor interpretations of a person’s perceptions or experiences. One of the main issues with a delusion is that it’s hard to get rid of. Evidence to the contrary, or the fact that most other people don’t share this idea, usually isn’t enough to get someone out of their delusion.

One example of a delusion would be someone who thinks their partner is cheating on them. They may not have proof, and there may be nothing to suggest this idea to them, but they still believe it. In spite of the lack of evidence, these poor interpretations of reality (in other words, their delusion), keep the person from moving beyond that belief.

An overwhelmed woman sitting down with her hands on her temples.

Delusions vs. hallucinations

It’s important, especially in the context of therapy, to understand the difference between delusions and hallucinations. Hallucinations involve experiencing something with your senses, even without a real stimulus present. 

They’re entirely involuntary, extremely unpleasant, disruptive, and stressful for people who experience them. What happens is that you hear, see, smell, feel, or taste something that’s not really there.

There are also cases where hallucinations take place within a delusion. For example, a person with persecutory delusions may hear voices and think the people who are “after them” have put speakers in their home to make them go crazy.  In this case, that person is actually experiencing a delusion and a hallucination at the same time.

There are also cases where a person experiences a hallucination on its own. They may hear voices criticizing them, without having any delusion, and they may even be aware that they’re hallucinations. Of course, there are also cases where someone experiences a delusion on its own, without experiencing any fake sensory information.

Delusions in therapy

The goals of therapy for someone with schizophrenia or delusional disorder may be different than they are for other patients. If you’re doing therapy with someone who has delusions, you have to help them manage their stress and reduce their risk of having hallucinations, delusions, or a psychotic break

That means reducing their levels of arousal as well as helping them to improve basic functions that have been altered by the psychosis. You have to work on everything from attention, perception, cognition, and reasoning to the simple act of learning.

You also have to help them get better at social skills, problem-solving, confrontation strategies, and any other daily life activities. This isn’t as easy as it may sound. How do you treat all the things we’ve just talked about if you haven’t first treated their delusion?

Treating delusions

In cognitive-behavioral therapy, professionals use debate as their first weapon in the fight against a delusion.

In this debate (similar to cognitive restructuring), a therapist will try to argue against all the supposed evidence a person has that their delusion is real, offer up alternative explanations, and make sure their patient is able to find those explanations for themselves. They’ll also do some reality tests if possible.

However, the cognitive processes involved in persecutory delusions can make it extremely hard to help a person understand the evidence and find it for themselves. This means that these debates aren’t always helpful if a therapist hasn’t first treated their patient’s cognitive biases, probabilistic logic, and covariation biases.

You can work through these things in therapy, there’s no doubt about that. But that doesn’t mean it’ll be quick. A therapist may have to spend a long time working with a patient’s delusions before they can really get into the content and focus on bringing them back to reality.

Working through delusions in therapy: Do you pretend to believe them or not?

One potential approach in therapy is to pretend to believe the person’s delusion. The goal here would be to strengthen the therapeutic relationship and make sure the patient trusts you. But this isn’t a good idea. You may end up reinforcing their delusion when they see that someone else believes them.

To put it more simply: at no point during therapy should a therapist make it seem like they believe the things their patient tells them. That being said, it’s still important to create a strong bond with the patient. They probably already have lots of friends and family trying to refute their delusions with evidence.

With that in mind, you don’t want them to see therapy as just another one of those situations. You won’t create a strong relationship with this kind of patient if you take a path so many other people have tried. The best thing to do is simply not go into the content of their delusion at first. You can believe them without really believing them.

You have to avoid falling into the temptation of making your thoughts about their delusion clear until the patient is ready for a debate. The therapy will always work better if you have a well-established bond with a patient. Telling them what they think isn’t real isn’t the best way to do that.

The therapist as another player in the delusion

A delusion can become problematic within therapy, though. This happens when a patient takes your refusal to believe them as proof that you’re part of their delusion. To be clear, though, this would only happen in the case of delusions of grandeur, control, or persecution.

It’s not something that would happen with patients who experience a somatic delusion, when they believe something about their body has changed, such as having a square face or one arm being longer than the other). Nor will it happen with people who have delusions of guilt, when they think they’ve committed an unforgivable sin.

In the case of a delusion of control, a patient might think that other people are implanting thoughts into their mind (thought insertion). When they realize that their therapist doesn’t believe them, and is doing these reality tests, they may end up believing that the therapist is part of the delusion.

The therapist will suddenly become one of those outside figures trying to influence them. At that point, it’ll be impossible for that specific therapist to help the patient. 

This is obviously something you need to avoid. It’s hard enough to get someone delusional to go to therapy voluntarily. Imagine how much harder that would be if they thought their therapist was part of the problem.

With that in mind, you should be patient and not move too fast. Don’t start trying to prove to them that what they’re saying is impossible at first. Start by focusing on the cognitive aspects of their problem before you get into the delusion itself.

A patient talking to his therapist.

Doing therapy within the delusion

A patient maintaining a delusion or false belief doesn’t make any therapy pointless. Think about it: one of the main goals of therapy is to improve that person’s well-being and ability to function. To do that, a therapist can work within the person’s delusion.

For example, let’s take a patient with a delusion of reference, where they think certain occurrences or details in the outside world are directly related to them. In this case, you can talk to them about the emotional impact of those things. Focus on why they feel so affected by these messages or how they feel when someone is “telling them” these things.

But remember, at no point should you believe them or make them think you do. Your goal is to do cognitive restructuring around their concept of “reality”. But in this case, you’re doing it within their framework, not yours.

By focusing less on disproving their delusion and more on analyzing its emotional and cognitive impact on them, you can start to make improvements. Take things slowly, one step at a time. The best form of therapy to help someone through their delusions may not be a direct attack. An indirect approach is often the key.