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To Believe or Not to Believe: Cognitive and Psychodynamic Approaches to

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CLINICAL CHALLENGE
To Believe or Not to Believe: Cognitive
and Psychodynamic Approaches
to Delusional Disorder
Sara Pontious Silva, LICSW, Christine K. Kim, MD, Stefan G. Hofmann, PhD, and E. Catherine Loula, MD
EDITOR’S NOTE
Given how desperately ill many of our patients are, it has
always seemed a shame that our field insists on divid-
ing itself—for example, biological vs. psychological, descrip-
tive vs. historical, psychodynamic vs. cognitive-behavioral.
Sometimes this is carried to such extremes that the patient’s
welfare appears to be secondary to the desire of a zealous
therapist to “score points” for his or her point of view.
This case report is refreshing in that it presents the his-
tory of a seriously ill woman who has been successfully
treated with a combination of medication and psychotherapy
strategies. A review of the cognitive-behavioral and psycho-
dynamic formulations contained here will reveal some sig-
nificant similarities: cognitive distortions and defense mech-
anisms, affect avoidance and affect intolerance, and so on.
The technical recommendations do of course differ between
models, but we should consider whether or not these schools
of thought, and perhaps many others not represented here,
might each include significant pieces of the same truths in
working with patients.
From Massachusetts Mental Health Center (Ms. Silva, Dr. Kim),
the Department of Psychology, Boston University (Dr. Hofmann),
the Department of Psychiatry, Beth Israel Deaconess Medical Center
(Dr. Loula), and the Department of Psychiatry, Harvard Medical
School (Dr. Loula), Boston, Mass.
Supported, in part, by a grant from the National Alliance for Re-
search on Schizophrenia and Depression (Dr. Hofmann).
Reprint requests: Sara Pontius Silva, LICSW, Massachusetts Mental
Health Center, 74 Fenwood Rd., Boston, MA 02115.
Harv Rev Psychiatry 2003;11:20–29.
°
c 2003 President and Fellows of Harvard College
20
Editor: Robert M. Goisman, MD
CASE REPORT
Jaya is a 30-year-old, single Indian woman of Muslim faith.
She is currently working close to full time as a nurse’s aide
and has just graduated from living in supported housing to
living independently.
Jaya entered the mental health system in 1995, when she
attempted suicide by taking 140 sleeping pills. She was then
hospitalized for 3 months, at five different hospitals. Records
are not available to indicate the reasons for her numerous
transfers. After discharge from the hospital, she came into
outpatient treatment at the local mental health center. The
therapist to whom she was assigned soon left the agency.
She then was assigned to another therapist, with whom she
has been working ever since. In addition, since entering the
mental health system, she has seen numerous different psy-
chiatrists for pharmacotherapy.
At her outpatient evaluation in 1995, Jaya talked about
a “little boy” named David, who was 9 years old. He was in
love with her and followed her around with a light that made
her appear naked. She said that at the time of her overdose,
he was shining the light on her a lot and turning it on “high,”
which was painful for her. She said that she couldn’t stand it
any longer and asked her brother to buy sleeping pills for her,
which he did. She took the sleeping pills, intending to die.
During her hospitalization, Jaya was started on risperi-
done and amitriptyline. Records are not available to indicate
the doses of these medications or why these agents were cho-
sen. At the time, her condition appeared to stabilize, but the
delusion about the “little boy” never went away. In March
of 1997 she informed her psychiatrist that she was stopping
her medications and then did so, against medical advice.
Jaya soon decompensated, becoming more paranoid and
delusional. At one point she came to an appointment with
her therapist but believed that the emergency-exit lights
were cameras and left without being seen. The therapist
spoke with her by phone. Jaya insisted that her psychiatrist
was outside her apartment, talking to the police. Although
Harv Rev Psychiatry
Volume 11, Number 1
her psychiatrist was in the office with the therapist and
joined the telephone conversation with Jaya, Jaya insisted
that somehow the psychiatrist was also outside speaking
with the police, even though she could not explain how this
was possible. Eventually she barricaded herself into her
apartment. She was subsequently admitted to a state hos-
pital, where she remained from July 1997 through August
1998.
Jaya’s condition was stabilized on clozapine, but she
stayed in the hospital until a suitable living situation could
be found. She did not want to return to her parents’ house,
where she had not resided for some time, and the staff agreed
with this decision. She also did not want to live alone; in
fact, her state hospitalization was precipitated not only by
her stopping her medications, but also by the hospitalization
of her roommate. She was eventually placed in supported
housing with a roommate, a situation that she wanted and
believed would be helpful. Since her discharge in the sum-
mer of 1998, Jaya has been relatively stable psychiatrically
and has stayed out of the hospital. She works and socializes,
but the delusion about the “little boy” never completely goes
away. At some times it is more prominent than others.
Jaya was born and raised outside of a major city in the
northeastern United States. Her parents came to this coun-
try from India and have an arranged marriage. She has
one brother, 2 years younger than she is. She states that
growing up as a girl in her family, she was treated dif-
ferently than her brother. According to Jaya, her younger
brother was allowed to do whatever he wanted, whereas she
had to stay home with no friends. Her mother emotionally
and physically abused her, and her father deferred to her
mother. She claims that when she was young, she told neigh-
bors about how her parents treated her, but no one would
help. Recently, she mentioned that her brother was rebel-
lious and that her parents focused their attention on him,
sometimes even seeming to reward him for such behavior.
She, as the “good one,” was largely ignored. Her childhood
seems to be characterized by loneliness and isolation: she
was invisible.
Jaya describes her mother as extremely obsessive,
perhaps with undiagnosed obsessive-compulsive disorder,
washing her hands many times a day. According to Jaya,
she is also quite paranoid, fearing secret messages in letters
written to her by extended family and cameras hidden in
the house. Her mother competed with her for her father’s
attention. Jaya describes her father as quiet. She reports no
history of sexual abuse, other than by David and his family
members.
Jaya states that despite being Muslim, she went to a
Catholic school. She did well there, although she was not
allowed to have any friends. After graduation she went to
nursing school. This was the first time she had the free-
Silva et al. 21
dom to make friends; as a result, she found it more im-
portant to socialize than to study, and her grades suffered.
She dropped out after 3 years, with very poor grades. After
working for a short time, she became increasingly paranoid
and delusional. Her attempted overdose occurred at this
time.
Jaya presents as very pleasant, engaging, and coopera-
tive. She is appreciative of therapy and her relationship with
her therapist. Her thought process is precise, clear, and co-
herent. She appears to be of average or above-average intel-
ligence. Her affect tends to be blunted, although this has im-
proved over the course of her therapy. When she began with
her present therapist, she had little spontaneous speech.
During their 30-minute sessions, the therapist would ask
numerous questions, to which she would receive very short
(sometimes one-word) replies. Jaya now has 50-minute ther-
apy sessions, during which she easily and spontaneously
brings up new material. She often laughs and jokes during
these sessions.
Since the overdose, Jaya has clearly and emphatically
denied any suicidal ideation. She acknowledges needing her
medications and is quite responsible about taking them. Al-
though she insists that she does not have delusional disor-
der, she knows that this is her diagnosis and seems to “agree
to disagree” with her clinician on the topic. She is aware that
the medication she is taking is an antipsychotic.
Jaya has had numerous significant medical problems,
including sleep apnea and achalasia. She developed sleep
apnea after a significant weight gain related to clozapine.
Initially she utilized a continuous positive airway pressure
machine, but the apnea spontaneously resolved after she di-
eted and lost some weight. Achalasia is a rare idiopathic
motility disorder characterized by the loss of esophageal
peristalsis and impaired relaxation of the lower esophageal
sphincter. Individuals with this condition frequently expe-
rience regurgitation, dysphagia, weight loss, and choking
sensations. Jaya believes that this condition was caused by
David’s light shining on her. The condition was resolved with
a laparoscopic myotomy.
Much more about the content of Jaya’s delusion has
emerged in the course of therapy. Jaya states that David
is in love with her and does not realize that what he is doing
is wrong. She claims that he is helped by his father, a police
officer, who drives him around.
Jaya states that she remembers being raped by David, his
father, and his uncle years ago. According to her account, she
could not see them but could feel and hear them. She could
also hear her father yelling in the next room, but he could not
get out of his room to help her. He kept crying, “What are they
doing to my daughter?” Jaya relates this story, which to her
therapist felt quite powerful, with no affect. Jaya says that
her family tells her it was a dream, but she knows it was real.

22 Silva et al.
Jaya says that sometimes she has wanted to try to press
charges against the three men for rape, but that because
David’s father is very influential, she cannot trust the police.
She is aware of how unusual her story sounds but maintains
that the police, even though they actually know her accusa-
tions to be true, would dismiss them because David’s father
is a police officer.
Jaya has occasionally expressed interest in going to
groups at the local rape crisis center but has never followed
through on this. She has sometimes stated that David’s fa-
ther may hurt her or her family, and that he tapes her ther-
apy sessions. She claims that people around her (including
her family and coworkers, and perhaps her therapist as well)
know that this is real and not a delusion, and that they
see her exposed but don’t tell her to protect her from the
truth.
Jaya seems to do best when not talking about the delusion
of this “little boy.” Around changes, such as the departure of
psychiatrists to whom she felt particularly close, she seems
to have an upsurge of symptoms, which generally means
that she feels more bothered by David or becomes more pre-
occupied with being exposed or raped.
At the time of her first hospitalization, Jaya was notably
isolated, reporting that she had never been allowed to have
any friends. Jaya has worked in therapy on building a social
network around her, and she has done well with this, making
friends with her roommates and people at work, as well as
developing relationships with extended family.
Jaya has never dated or been sexually active. She dis-
cusses sexuality only in the context of her delusion. During
one powerful session several years into therapy, she revealed
that she had once been in love, with someone she had known
from childhood. According to Jaya, she told her parents that
she wanted to marry him. She overheard her mother at a
party saying that he had asked for her parents’ permission to
marry her, as is the custom in their culture, and her mother
had refused, so he had married someone else.
When asked what she loved about this man, Jaya replies
that he really knew and cared about her, and that he really
listened to her—that he really saw her. When encouraged
to try dating, she reports a fantasy that if this man’s wife
should leave him, he would come looking for her, and she
wants to be available. She has responded positively to the
suggestion that she might be able to meet someone else who
would really know her and care about her, and agrees that
waiting also protects her from risking being hurt.
Last year Jaya was working for a time with a female In-
dian psychiatry resident. This brought up a lot of feelings in
her about her culture. She has since talked a lot about her
family’s expectations of professional employment, and about
how she is not where she should be in life—married, with
children, and building a career.
Harv Rev Psychiatry
January 2003
Working with this resident also seemed to bring up
a lot for Jaya about her relationship with her parents,
particularly her mother. She was much more emotional
and tearful during that time than she has been before or
since. She talked about feeling betrayed by her mother,
who—according to Jaya—feels that girls are worthless. Jaya
bought a book about being friends with one’s mother, but
it made her cry; she was unable to read it because she
thought that friendship with her mother was impossible.
She described craving a loving mother-daughter relation-
ship, which she was sure that she could never have.
In recent sessions, the conversation has again turned to
the possibility of dating. At one point, while admitting that
the idea was frightening because she had never dated, she
also revealed her concern that she had nothing to offer in
a relationship. Despite these fears, she seems more open to
the possibility of dating than ever before.
In terms of psychopharmacological management, Jaya
was first placed on amitriptyline and risperidone, as de-
scribed above, to which initially she responded well. When
she abruptly stopped taking the medications, she decom-
pensated and required rehospitalization. Other medication
trials included haloperidol, loxapine, and thioridazine, to
which she showed only a limited response. Finally, treat-
ment with clozapine (225–275 mg at bedtime) was initi-
ated during her last hospitalization. Following discharge,
she was stable on 200 mg of clozapine given at bedtime. As
she became more functional, the dose of clozapine was low-
ered to 175 mg at bedtime, with improvement in clozapine-
related sedation. Fluoxetine (30 mg daily) was subsequently
added to address emerging depressive symptoms. Her delu-
sion about the “little boy” persisted, but she was much less
preoccupied with it.
Work with the present psychiatrist started after the de-
parture of the Indian resident, who had met with her weekly
for hour-long sessions emphasizing ethnic and cultural is-
sues. This transition was particularly difficult for Jaya since
she had hoped for the same frequency and length of ses-
sions. Jaya sees her current psychiatrist for 30-minute psy-
chopharmacological sessions once a month. During the tran-
sition, her delusion became rather prominent. The “little
boy” reappeared and again beamed light on her, exposing
her nude body to the public and eliciting feelings of embar-
rassment and shame. This occurred when she was menstru-
ating, and the images became especially vivid and upsetting
for her. Furthermore, the memories of another rape emerged
as well. Fortunately, these delusions resolved quickly, mak-
ing medication adjustment unnecessary.
Since then, Jaya has been stable, without overt ex-
pressions of delusional material. Recently, she became en-
chanted with the main character of the movie A Beautiful
Mind and with his fixation on a little girl who was part of
Harv Rev Psychiatry
Volume 11, Number 1
his delusion. Jaya did not make any association between the
character’s delusion about a little girl and her own delusion
about a little boy. When she learned that her psychiatrist
had not seen the film, she suggested that her psychiatrist
and her therapist should go together to watch it on the big
screen—which was perhaps a wish to be seen and exposed.
QUESTIONS TO THE CONSULTANTS
1. Is there value in treating delusional thinking with
therapy, or is medication sufficient?
2. How can understanding of the dynamic meaning of a
delusion be used in therapy, or should it be used? For
example, with this patient the content of the delusion
seems very involved, with feelings of being seen, be-
ing loved, being exposed, and being invisible. How can
these issues be addressed?
3. In patients like Jaya, can it be helpful to explore affects
associated with delusional material? Is this something
worth focusing on?
4. How does one work with material when it is unclear
whether the material is real or delusional?
5. How does one work cognitively with delusions? How
does one challenge the content of a delusion when it
seems so fixed and challenges seem to go nowhere?
6. How would you diagnose this patient?
RESPONSES OF THE CONSULTANTS
Dr. Hofmann (Cognitive-Behavioral Therapy)
Cognitive-behavioral therapy (CBT) is a well-established
treatment for depression, anxiety disorders, and other psy-
chological problems. Studies suggest that it is also an ef-
ficacious intervention for delusions and paranoid beliefs
associated with psychotic disorders. Aaron T. Beck, the origi-
nator of CBT, published a case study 50 years ago suggesting
the potential utility of the technique for treating delusions
in patients with schizophrenia.1 Since then, a number of
controlled clinical trials have demonstrated the efficacy of
CBT for psychosis. Most of this work has been carried out
in the United Kingdom. In the largest trial to date, Lewis
and colleagues2 studied 309 patients during a first or sec-
ond psychotic episode. These patients received an average
of 16 sessions of either CBT or supportive counseling in ad-
dition to routine care, or routine care alone. The individu-
als receiving CBT experienced significantly faster improve-
ment than did the other groups. In another study with a
similar design, Tarrier and coworkers3 found that CBT im-
proved the positive and negative symptoms of patients with
chronic schizophrenia better than did routine care. These
researchers randomized 87 patients to one of three groups:
Silva et al. 23
CBT plus routine care, supportive counseling plus routine
care, or routine care alone. Patients were assessed before
treatment and 3 months after treatment. Compared to pa-
tients treated with routine care alone, those who received
CBT were nearly eight times as likely to show at least a 50%
reduction of psychotic symptoms. Other studies (for exam-
ple, Barrowclough et al.4 ), based on fewer subjects, produced
similar results. As a result of these and other trials, the Joint
British Psychological Society and Royal College of Psychia-
trists Guideline Development Group recently issued a report
endorsing CBT for psychosis.5 CBT has thus become part
of the mainstream intervention for psychosis in the United
Kingdom. A similar trend is likely to occur in the U.S.
Several CBT protocols have been developed for psychotic
symptoms.5−7 These approaches differ in minor ways but
generally share several characteristics: (1) the treatment
is time limited (approximately 20 sessions) and problem
focused; (2) it requires a collaborative, open, and respectful
relationship between therapist and patient; (3) the patient
is regarded as an active participant in the treatment and an
expert on his or her problems; (4) the distress associated with
psychotic symptoms is believed to result from cognitive mis-
perceptions and misattributions; (5) cognitive interventions
are regarded as complementary (rather than alternative)
approaches to routine psychiatric care and pharmacother-
apy; (6) treatment is carried out in a stepwise, yet flexible,
fashion; and (7) treatment is conducted by skilled and ex-
perienced therapists who are able to adjust the techniques
according to the patient’s idiosyncratic symptoms, personal
history, and social environment.
Jaya seems to be a good candidate for CBT. She has estab-
lished a good rapport with her therapist, functions well, and
is intelligent and motivated. At the same time, there are also
a number of complicating factors that will require a consid-
erable degree of flexibility in the therapist conducting CBT
with her. First, Jaya’s history of treatment noncompliance
and suicide attempts, although not unusual for a person with
her symptoms, might interfere with her treatment. There-
fore, her level of depression, suicidal ideation, medication
intake, and attitude toward medication should be followed
closely and assessed regularly. Second, her history of abuse
and her relationship with her mother may negatively affect
current interpersonal relationships, including the therapeu-
tic alliance. Third, as a Muslim Indian woman who was born
and raised in the U.S. and educated in a Catholic school,
Jaya is likely to struggle with a number of cultural con-
flicts affecting her self-perception and her perceived role as
a woman. The CBT therapist will need to consider these fa-
milial, social, and cultural factors when implementing treat-
ment. This information can be gained only by conducting a
thorough assessment that goes beyond the diagnostic level.
The therapeutic process of CBT, although varying from
case to case, consists of three phases: (1) the engagement

24 Silva et al.
phase, which establishes the therapeutic relationship;
(2) the assessment and formulation phase, which explores
the antecedent stimuli, the situational context, the emo-
tional response, and any short- or long-term consequences
associated with the patient’s psychotic symptoms; and
(3) the intervention phase. The specific strategies used dur-
ing the intervention phase depend on the results of the
assessment and formulation phase. Traditional CBT tech-
niques focus on changing the patient’s beliefs and attribu-
tions. The therapist helps the patient to identify these mal-
adaptive thoughts by means of Socratic questioning (i.e.,
by using guided, leading questions) and behavioral exper-
iments, and then to replace them with alternative, more
adaptive beliefs and attributions. For example, Jaya be-
lieves that people around her see her body exposed by the
light but ignore this to protect her. Using the Socratic ques-
tioning style, the therapist may ask Jaya for evidence that
other people notice it. Are people responding differently to-
ward her? If so, are there any alternative explanations for
these behaviors? At a later point, the therapist might ex-
plore and design behavioral experiments for Jaya to test
these different assumptions. Assumptions that are incor-
rect are called cognitive errors. Common cognitive errors,
as described by Beck,8 include arbitrary inference (arbitrar-
ily drawing a specific conclusion), selective abstraction (fo-
cusing on a detail taken out of context), overgeneralization
(drawing a conclusion on the basis of a single isolated inci-
dent), magnification (blowing something out of proportion),
personalization (relating external events to oneself), and di-
chotomous thinking (conceiving of things as opposites rather
than as points along a continuum). These errors are not
unique to any particular psychopathology. In Jaya’s case, ar-
bitrary inference, selective abstraction, overgeneralization,
and personalization seem to be the primary elements of her
delusion.
Jaya’s belief about David and his father is an example
of persecution paranoia, which Trower and Chadwick9 also
called the “poor-me” paranoia (as opposed to punishment,
or “bad-me,” paranoia). She sees herself as the victim and
blames others for her suffering. It has been proposed that
the psychological motivation for persecution paranoia is to
defend the patient’s self-worth against being neglected, ig-
nored, and devalued.10 By being the focus of persecution,
Jaya may be able to avoid feelings of emptiness and lone-
liness. This might partly explain her lack of affect when
describing her delusions. If this formulation of Jaya’s per-
secution paranoia is correct, challenging her beliefs alone is
unlikely to be a successful intervention. Instead, the ther-
apist may have to examine the vulnerabilities that would
be exposed if Jaya’s delusion ceased to exist. Socratic ques-
tioning can help to explore Jaya’s self-perception and self-
evaluation in a safe therapeutic relationship, with the goal
of enhancing her self-worth. As part of this process, the ther-
Harv Rev Psychiatry
January 2003
apist may also explore whether or not the rape trauma has
some basis in reality.
These treatment strategies are possible only if the patient
has a minimum level of insight into his or her problems. Jaya
seems to show little insight. However, she is aware of her
diagnosis and is currently compliant with treatment, which
indicates that she does not completely rule out alternative
views to her paranoid beliefs. To monitor and quantify her
level of insight, the therapist may ask Jaya to indicate the
likelihood of different explanations for events related to the
delusions at different points during treatment. Her level of
insight will in part determine the intervention strategy. Di-
rectly confronting and challenging Jaya’s delusional belief
systems when she shows little insight would be inadvisable.
Instead, the therapist should focus on her level of psychologi-
cal distress and explore alternatives to her delusional beliefs
that would reduce this distress. The initial treatment goal
is therefore to reduce Jaya’s level of distress rather than to
change her belief system. Later the therapist may help Jaya
to examine the evidence for and against her paranoid beliefs
and the alternative (nonparanoid) explanations.
In sum, the answers to the aforementioned questions are
as follows: (1) CBT, in combination with pharmacotherapy,
is likely to be a highly effective strategy to target Jaya’s
delusions. (2) Although CBT has its roots in psychodynamic
theory, the cognitive model does not assume that delusions
are the expressions of latent conflicts or hidden motives. The
CBT therapist works in the “here and now,” seeking to relieve
the patient’s subjective distress by replacing irrational be-
liefs with more adaptive and more rational thoughts. (3) Af-
fect occupies a central role in CBT. Cognitions and emo-
tions are causally related: cognitions can cause emotions,
and emotions can cause cognitions. If cognitions are difficult
to modify initially, then the associated emotions may offer
the first target of treatment. The early treatment goal for
Jaya may therefore include strategies to alleviate the dis-
tress associated with the delusions without attempting to
modify the delusional content.4–6 The question about Jaya’s
diagnosis is difficult to answer. Aside from the paranoid
delusions and the associated suicide attempts, there are no
other clear signs of psychotic disturbance. Her thought pro-
cesses are precise, clear, and coherent, and she shows good
social and occupational functioning. This suggests that she
is unlikely to meet the diagnostic criteria for the paranoid
subtype of schizophrenia. The next diagnosis that comes to
mind is delusional disorder. However, she is also unlikely
to meet the DSM-IV criteria for this disorder. For example,
some aspects of her delusions are bizarre (e.g., David follows
her around and beams a light on her, making her appear
naked), rather than nonbizarre. Other reports, such as her
rape experience, could be partly based in reality. Given the
information available, the most likely diagnosis is therefore
psychotic disorder, not otherwise specified. But regardless
Harv Rev Psychiatry
Volume 11, Number 1
of Jaya’s diagnostic status, and whether her reports are
delusional or real, the distress that she experiences is gen-
uine. Cognitive therapy applies to all distressing thoughts
and experiences, whether they are real, partly real, or
delusional.
CBT is a powerful tool for treating psychotic symptoms.
However, it is not the only psychological approach that is
effective, in conjunction with pharmacotherapy, in improv-
ing the lives of individuals suffering from this debilitating
condition. The skilled clinician can use numerous other
therapeutic techniques to tackle specific problems during
treatment—for example, motivational interviewing and be-
havioral techniques to deal with substance abuse issues or
noncompliance to pharmacotherapy, family intervention to
reduce the level of distress and the risk for relapse, so-
cial skills trainings to improve social functioning and facili-
tate rehabilitation; dialectical behavior therapy techniques
to deal with emotional dyscontrol, and interpersonal and
short-term psychodynamic techniques to deal with grief and
loss.11 Many of these techniques could be used in addition
to CBT and medication to help Jaya cope better with her
disorder.
Dr. Loula (Psychodynamic Approach)
Introduction to the psychodynamic approach. In many ways,
the distinctions between cognitive treatments and psycho-
dynamic treatments promote false dichotomies. For exam-
ple, enhancing the capacity for insight (a cognitive function)
is central to psychodynamic therapies. However, there are
some fundamental technical as well as philosophical dif-
ferences between cognitive and psychodynamic approaches
that may deserve some emphasis.
Overall, a psychodynamic approach to psychosis, whether
reckoning with the effects of genetically predisposed illness,
of psychosocial trauma, or both, assumes a diathesis-stress
model in which the interaction of psyche and soma, within
various social and developmental contexts, produces mean-
ingful symptoms that deserve recognition, understanding,
and relief. A dramatic illustration of a psychodynamic “cure”
is provided by a woman I once treated. During the course
of long-term treatment, she fell into a psychotic state for
a month, showing no significant response to medications.
In the context of a solid treatment alliance, we explored
the meaning of her symptoms and developed an interpre-
tation of underlying causes, in response to which her psy-
chosis remitted. Although treatment in such cases is rarely
so dramatically successful, evidence for the long-term suc-
cess of psychodynamic therapy in patients with psychosis
is ample and robust.12−14 Indeed, one is left to assume
that the drastic move away from psychodynamic treatments
has less to do with issues of effectiveness than with the
Silva et al. 25
political and economic battles of the health care industry in
general.15,16
Before turning to further examples and to the case report,
it should be said that the most basic difference between a
psychodynamic approach and a cognitive approach is the
difference between an interpretive model and a learning
model.17 With the psychodynamic approach, symptoms are
presumed to have meaning and perhaps to indicate underly-
ing conflicts, developmental problems, relational issues, or
deep-seated difficulties with self-esteem. And even though
the management of problematic symptoms may be the first
line of treatment, long-term change and even cure requires
exploration, understanding, empathy, and ultimately inter-
pretation (i.e., bringing new meaning to a patient’s suffer-
ing by locating his or her wounds in the context of personal
history, trauma, and feelings that have been ignored or re-
pressed because they were once too confusing or painful to
bear). In a cognitive model, many of these treatment con-
cerns may still pertain, but the central philosophical tenet
is that the patient, through means that remain largely at
the surface of his or her consciousness, can learn to think
in different ways and can learn to distinguish the rational
from the irrational; this is accomplished in a paradigm that
emphasizes homework and cognitive restructuring. A cogni-
tive model does not tend to hold to the psychodynamic belief
that factors outside the grasp of current consciousness (e.g.,
deep-seated conflicts, unrecognized developmental deficits,
unperceived guilt and shame, etc.) are powerfully, perhaps
inexorably, operating at the core of psychological difficulties,
including psychosis.18,19
Psychodynamics and psychosis. From the psychodynamic
point of view, delusional and psychotic symptoms exist for a
reason. Whether fixed and related to a specific delusion or
fluid and changing, symptoms serve as a sign that something
is wrong. Among other things, they may represent unbear-
able and as yet inarticulable past experience or the trans-
formation of historic trauma into symptomatic behavior via
the complex symbol-making processes of the psyche. They
require therapeutic exploration in which the patient devel-
ops an increasing capacity to notice, tolerate, and put words
to hidden feelings, experiences, and conflicts. Such symp-
toms cannot usefully be cajoled, explained, or learned away,
and by not taking seriously the meaningfulness of symp-
toms to the suffering patient, one risks either alienating
the patient or developing a kind of false or inauthentic co-
operativeness. The patient needs to sense (over time) the
therapist’s interest in all of what the patient does and is,
as well as interest in and capacity to tolerate what the pa-
tient finds most disturbing, hateful, or disgusting in him- or
herself.13,20
In work with psychotic patients, no matter how overtly
well functioning, a good preparatory assumption is that

26 Silva et al.
the normative boundaries between self and other, between
reality and fantasy, and even between inside and out, are
absent or severely compromised. So, for example, when the
therapist tries to convey something of the therapist’s reality,
the psychotic patient may not have the capacity to assess its
accuracy. The implications of such discriminatory deficits
is profound: the patient can easily feel intruded upon and
taken over by the therapist, thus moving even farther from
the work of developing a more sound, authentic, and robust
sense of self.
The psychodynamic therapist, from a position of genuine
empathy, must remain fundamentally interested in who the
patient is and what he or she has to say. (With a silent pa-
tient, the therapist must find ways to join in the silence or to
make tentative efforts at verbal contact.) The therapist must
be thoughtful in creating an atmosphere of safety, caring,
and interest, and be vigilant about the dangers of intru-
sion, judgment, “therapeutic ambition,”21 and any overlay
of narcissism.
In work with psychotic patients, it is important to be
familiar with their most commonly used defenses,22 which
might include projection, reaction formation, and psychotic
denial, among others. But it is also important to remem-
ber that at some level these are human defenses, employed
by anyone under particular conditions of duress, neglect, or
trauma. And it must be remembered that defenses (of which
psychotic symptoms may be an expression) once served to
protect the infant, child, or maturing adult from unbear-
able feelings of loss, pain, hatred, or despair, the longing for
merger, and the fear of being taken over, or even of disinte-
gration or annihilation.
In psychotic patients, ego strength (i.e., the capacity to
function adaptively within the norms of reality) may be lim-
ited or absent, and thus “primary process” thinking holds
sway.23,24 Primary process thinking implies a kind of primor-
dial bent of mind (as in the earliest fantasies of childhood, in
dreams or dream states, or in the undercurrents of imagina-
tion or even creative thinking, unmediated by a sense of the
reality of social norms). For the psychotic patient, primary
process thinking might mean:
r An absence of differentiation between thought and
deed—e.g., thinking harmful thoughts about someone
is the same as harming him or her.
r A timelessness, such that past and present become un-
differentiated or fused—e.g., an event of yesterday may
feel as though it were caused by something happening
today.
r Coexistence of mutually contradictory thoughts and
feelings—e.g., “I want to kill you; I love you and can’t
survive without you.”
r Absence of gradations of meaning—e.g., dislike is hate,
like is love.
Harv Rev Psychiatry
January 2003
r Psychic reality supersedes external reality—e.g., an in-
fant bumps into a chair and believes that the chair has
bumped into him.
r Concrete thinking—e.g., metaphors (such as, “raining
cats and dogs”) can only be taken literally.
Thus it is in psychotic patients’ language and symp-
toms that we must ultimately begin to discover the threads
of their history and their suffering. Because that history
and suffering cannot be represented in the normal symbolic
forms of language, internal anguish and conflict become ex-
pressed in more concrete ways.
A delusion can be seen as that kind of concrete repre-
sentation. We might find it hard to imagine that psychotic
reality would be less agonizing than living in the world of
normal reality, but there are many examples of the fright-
ening difficulty of leaving one’s psychotic defenses for more
“mature” forms of perception and interaction. For one pa-
tient, whose terrifying delusion of persecution by a “woman
in black” began to wane, there was the acknowledgment that
although “the woman in black was scary, it was one thing;
now there are many things to be scared about—and the real
things are much scarier!”
As long as this patient was preoccupied with the woman
in black, she remained somewhat protected from the diffi-
culties of interpersonal interaction and the risks of intimacy
and openness. Her delusion began to fade as she worked
through her projections of anger, and she slowly came to
realize (through psychodynamic treatment) that her anger
was not necessarily as damaging as her father’s anger and
aggression had been. As she took ownership of her own in-
ternal rage and fear and took back the projected feeling that
everyone was angry with her, she began to face her own in-
tense longings for people and the conflictual feelings of hate
and anger that her need for others stirred up inside her. In
dealing only with the woman in black, she maintained some
sense of control, thus avoiding the frightening fact that the
real people with whom her life was intertwined were not
fully subject to her self-protective control. By recognizing
and grappling with this dilemma, she was better able to
choose closeness within a fuller recognition of its dangers
and advantages.
Another patient whose delusion resolved through psy-
chotherapy acknowledged that his mind had played tricks
on him. He said that his world had gotten so small after
his girlfriend betrayed him that his mind created its own
world of people who knew him. But it was a world of peo-
ple who thought poorly of him. When asked why that might
be so, the patient was able to elaborate on painful details
of the past, ultimately recognizing that his girlfriend’s be-
trayal was a horrifying echo of his sense of betrayal by his
mother, a connection symbolized but also obscured by the
delusion.
Harv Rev Psychiatry
Volume 11, Number 1
Finally, regarding technique in general, it is essential
that the psychodynamic therapist create an environment in
which safety, trust, and connection can ultimately develop.
Providing, or at least attempting to provide, these most ba-
sic conditions opens the possibility of exploration, discovery,
and further social and emotional development. Empathy is
essential; insight can follow.
Psychodynamic therapy with Jaya. Clearly what has been
helpful to Jaya is finding a therapist who is genuinely
interested in her. Sorting out the delusional material is
not the essential path to recovery, because for Jaya what
she experiences is very real. For the therapist, creating a
position of empathy means suspending disbelief and thus
finding an entrée into understanding the patient’s world.
Jaya can only cling more strongly to her delusional be-
liefs if she feels that they are under the threat of removal.
They will abate as greater trust and security arise and
more-mature ways of coping with inner conflict begin to
develop.
Feelings (or their absence) have a kind of technical prior-
ity in psychodynamic treatment because they are windows
into a patient’s humanity and expressions of his or her at-
tempt to connect to the world or to be understood. Jaya ex-
presses feelings or shows greater emotional vulnerability in
a number of areas, and the psychodynamic therapist might
try to find points of connection, through curiosity, empathy,
and understanding, in these territories. For example, there
may be much to be learned about Jaya’s relationship with
the Indian resident and the complex feelings that arose in
losing her.
What kinds of curiosities and questions might be evoked
in a psychodynamic therapist attempting to make contact25
with Jaya? Certainly many of the following questions were
probably asked, but these particular kinds of questions may
illustrate the psychodynamic therapist’s psychological inter-
est and his or her desire not only for deeper emotional knowl-
edge of the patient, but also for pathways to empathy and
understanding.
r What does it mean to be a Muslim? To be a female Mus-
lim? A female Muslim growing up outside a large city
in the northeastern U.S.?
r Is Jaya’s experience of nakedness connected with her
religion or culture? What are its implications with re-
gard to her sexual history?
r What is her relational history, as she felt and experi-
enced it? Can she describe the boy who follows her?
What does he love about her? How can she tell that he
loves her?
r How might the rape be discussed? How did it happen?
Was violence involved? What was she left feeling, then
and now?
Silva et al. 27
r In Jaya’s opinion, why didn’t her mother allow her to
have friends? Why did her mother impede her opportu-
nities for marriage?
r What was it like for her to have a younger brother?
What was their relationship like? In her opinion, why
did he buy her the sleeping pills?
r What was her mother like in her earliest memories?
Did the level of abuse and neglect vary? How did her
mother treat her brother, and what feelings did that
evoke?
r How was sexuality expressed at home? How was it
talked about? What was the emotional tone of the
house? Was there anger? Were there fights? How did
people talk to each other?
r How did she manage her isolation and loneliness? What
was it like? What did she think about and fantasize
about? What gave her pleasure?
r When and how did her father interact with her? What
did she love about the man who wanted to marry her?
That he listened to her? Was interested in her? Loved
her?
Such questions are not simply to create a template
against which to separate what is rational from what is not,
or to try to discern historical truth from narrative truth.26
Rather, they are the beginning of an inquiry into the per-
sonhood of the patient—although, depending on the patient,
some of them might not be broached for weeks, months, or
even years. Indeed, when should a psychodynamic therapist
ask these questions, and in what manner?
Simply put, Jaya needs to lead the way, to be in control of
the process of sharing information and developing a relation-
ship. Her childhood suggests that she was not given much
respect for her own ways of thinking, choices, and needs.
Can she really believe that anyone would be deeply curi-
ous about what interests her and what is on her mind? The
psychodynamic therapist’s role is to be interested in feel-
ings, history, and details, but not to intrude into “protected”
territory or to put words into the patient’s mouth. The ther-
apist must have a feel for what is important to know, yet
simultaneously have sufficient restraint and understanding
to appreciate the patient’s vulnerability. Finally, the thera-
pist can join with the patient in a collaborative inquiry re-
garding the progress of the therapy: “How is it going?” “Am
I asking too many questions?” “Would you rather not tell me
about that?” “Do you mind if I ask you this?” “Am I making a
mess of things?” These are useful and legitimate questions
that the psychodynamic therapist must have the courage
to ask.
A working formulation. Information in the case history is
insufficient to allow a full psychodynamic formulation, but
a number of things can be said. First, about formulations,

28 Silva et al.
although they are essential as a kind of working model and
as a structure for gathering information, they must always
be open to change, evolution, and even rejection as the pa-
tient’s “true self ”20 begins to emerge within the therapeu-
tic alliance. A formulation is not something to interpret to
a patient unless its sharing might afford opportunities for
further connection and learning. Basically, then, a working
formulation serves as an internal guide to the therapist’s
inquiries and empathy, yet always remains subject to being
amended.
Jaya grew up in a family where females were not much
valued. She didn’t exist as a person in her own right, so
perhaps she created the delusion of a boy who could see
her completely. The seeing has an erotic element. When her
therapist leaves, the boy becomes more present, perhaps
mitigating the loss. Aggression is all but absent in Jaya’s
overt presentation, although self-directed aggression seems
apparent in the suicide attempt. Does aggression leave her
fearing loss, as it does with children who are forced to con-
tain even normative hatred toward their parents?
In short, Jaya seems to have grown up in an environ-
ment of deprivation and emotional trauma. The delusion
may serve to provide her with the feeling that she is at
least someone’s object of desire. On the other hand, desire is
shameful (the police will be after her) and evokes guilt. In
what ways may she ultimately be open to the raging forces
inside and to their interaction with her deep longings for love
and physical contact? These are among the kinds of ques-
tions to which a psychodynamic therapist would be attuned.
As Jaya feels more seen and heard (and understood) in
her therapy, she can become more aware of the longings,
conflicts, and prohibitions that rule her life. In having her
experiences (delusional or otherwise) validated as meaning-
ful expressions, she will feel increasing freedom to exist in
her own right in the world beyond her fantasies. Her delu-
sions will become less necessary as she comes to know and
accept herself, in part through the therapist’s knowing and
acceptance, which serve as a kind of “auxiliary ego.” To un-
derstand that her delusion expresses, as well as contains,
the pain and conflict inside her is to realize that trying to
dissuade her from her beliefs merely confirms her fear that
what she feels and thinks is unacceptable.
Conclusions. Cognitive work is occurring in any good
treatment because conscious learning and experience are
happening in many ways on many levels. However, psycho-
dynamic treatment is not about challenging or even chang-
ing a person’s beliefs or helping him or her to recognize
the path to “reality.” For the psychodynamic therapist, ex-
perience dictates that unless such changes and recogni-
tions emerge from a developmental transformation that
occurs within the context of a deeply accepting and un-
derstanding relationship—what Winnicott27 terms a “hold-
Harv Rev Psychiatry
January 2003
ing environment”—the sense of reality that emerges does
not have sufficient depth to effect cure. Jaya, like any pa-
tient vulnerable to psychosis, ultimately seeks just what her
symptoms defend so profoundly against: recognition and un-
derstanding. From there come transformation and cure.
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