What don’t you like about feeling that other people are whispering about you>

Are there any good aspects of feeling this way?

Could you feel good in the same way by not believing that this was completely true?

Start with weakest beliefs first

Quicker shifts, practice, believing something true doesn’t mean that it is true, realisation tWhat
don’t you like about feeling that other people are whispering about you>

Are there any good aspects of feeling this way?

Could you feel good in the same way by not believing that this was completely true?

Start with weakest beliefs first

Quicker shifts, practice, believing something true doesn’t mean that it is true, realisation that he is
capable of holding inaccurate beliefs.

Partial modification within the delusional system

Can be helpful to focus on the impact of the delusional belief on others

Assessment of suitability for Partial/Total modification

Why is the delusional belief causing distress or having an adverse effect on the patient’s life and
how does it do this?

Are there any advantages for the patient in holding this belief? If not, consider the goal of total
modification. It is good practice to speculate about the advantages or disadvantages of a patient’s
delusional beliefs but do not set goals on the basis of your speculation alone. Check them out first
by asking neutral, non-challenging questions, such as ‘What would it be life if…?” or ‘Do you wish
that … wasn’t so? Or ‘Supposing…:. Then set the goals on the basis of his responses.

If there are some advantages to the patient in holding his belief, could they be replaced from
elsewhere? If so, a total modification could still be considered if you are successful in replacing the
source of positive gain by something else. If you are unable to do this, is it possible to achieve a
partial modification that leaves the beneficial parts of the delusion intact?

If there are some advantages and some disadvantages in holding the belief, is it possible to do a
partial modification> What bits of the delusional belief should stay intact? Wat re the goals of the
parts being changed, i.e. what will the patient end up believing? Are these new beliefs compatible
with the parts of the delusional system left intact or would the partial modification have
unwanted knock on effects on the parts of the system to be retained?
If the partial modification is not possible, does the overall gain from a total modification outweigh
the losses or is it better for the patient that his whole system be left intact?

If a total modification has been unsuccessful, would a partial modification be therapeutically

useful and achieved in practice?

Setting the Goal

Problems: Anxiety around others invading personal space, anxiety-anger-lashing out-voices

reinforced –social isolation-increased voice hearing-unhelpful coping-maintenance of voice hearing

Focus of partial modification

1. Other people are focussed in on me all the time

2. There is something about me/my behaviour that makes other people watch/whisper/judge
me
3. I am absolutely correct in what they must be saying about me all the time
4. I must have done something bad to deserve negative attention

Impact of these beliefs: anxiety when outside, avoidance, isolation, voice-hearing, cannot relax

New beliefs: other people are focussed on things other than me, I can be incorrect in my
thoughts/beliefs at different times, people get attention for good/bad things, my self-attention
when outside makes me feel that others must also be paying attention to me.

Information required for Goal Setting and Treatment Planning

1. For each delusion:

What is it?
What evidence does the patient have to support it?
Is the evidence a feeling, real fact, distorted fact or delusion?
How firmly is it held?
How distressing is it?
How does it affect the patient’s life?
Are there any relevant (psychotic or non-psychotic) underlying beliefs?
2. For each hallucination:
What are the physiological characteristics of the voice?
Where and who does it come from?
How does the patient know the voice comes from a particular person/entity?
What does the voice say (or what sort of things does the voice say)?
Does the voice tell the truth?
What power/authority does the voice have?
Can the voice or source of the voice harm the patient?
Does the voice command the patient, and if so, how?
IS the voice difficult to resist?
What does or could happen if the patient resists?
Does the patient have any evidence of the voice power?
How frequent is the voice?
 How distressing is the voice?
How does it affect the patient’s life?
Are there any relevant (psychotic or non-psychotic) underlying beliefs affecting the
content?
3. Insight and attitude to psychosis
Does the patient acknowledge that he has an illness?
What is the patient’s attitude to schizophrenia?
Does the patient relate the symptoms/experiences to his illness?
Would the patient to be upset if his symptoms were attributed to his illness?
4. Is the patient unwilling or unable to engage in therapy?

Psychoeducation re automatic thoughts

1. Thoughts and ideas all the time most of which are unconscious to us
2. This makes sense because then we can process events quickly
3. Part of the brain selects the most useful ideas into awareness so we can think about them
more carefully
4. Production of thoughts occurs so quickly sometimes there can be errors
5. These ‘erroneous’ thoughts usually drop out but sometimes our brain will latch on and
give it more value than its worth
6. Our automatic thoughts reflect our worries and concerns
7. We cannot control our automatic thoughts and hence cannot be held responsible for them

Responsibility for automatic thoughts – implications for guilt and shame

We cannot be guilty for what we cannot control

Thinking of delusions like intuitions – intuitions are based on very little objective evidence and yet
are carried with conviction and certainty. Brain is very used to producing intuitions. Also
equivalent to your brain ‘jumping to conclusions’.

Underlying fear e.g., others are dangerous has created an automatic bias in perception of all
stimuli and situations. E.g., someone boarding a plane who believes that it is going to crash –
influence emotions, behaviour and experience.

Certainty once it has been attached is difficult to dislodge. ‘Better safe than sorry’ response. If I
have learned that X means danger, we are programmed to not have this shifted easily.

Experience is not the same as fact – problem with psychotic experiences is that they are self-
evidently true. Perceiving something to be self-evidently true does not mean that it is true.

Examples:

1. I hear my neighbours having a furious row but later discover that it was the television
2. I hear my friends criticising my new hairstyle but later discover they were discussing
something else
3. I bend down to pick up a piece of mud on the carpet and discover that it is an ink stain
 4. I walk along and the moon in the sky seems to follow me wherever I go
5. I pull my hand away sharply as an insect lands on it, but it was only a leaf
6. I interpret the pain in my chest as a massive heart attack but later realise it must have
been indigestion
7. I enjoy a slice of bread and butter and later discover it was margarine!
8. My friend forgets to send me a birthday card, but I later discover that it was actually
sitting at the post office due to a strike
9. I think that my daughter has done very well to get a grade 1 in her maths exam until she
tells me that the usual way of marking is flipped and 9 is the top grade

Past beliefs no longer held – beliefs strongly endorsed in the past no longer endorsed at
maintained intensity now.

Use of the dream analogy – same brain producing thoughts/experiences/feelings of conviction

awake/asleep. My brain sometimes acts as if it were dreaming, even though I am awake. It was
one of my waking dream experiences. Examples – imagine things good/impossible/bad does not
affect their actual occurrence in reality.

Two-route model. CBT attempts to balance the rational route of thinking to counter the more
automatic intuitional route. The latter may be helpful but less accurate and there’s the higher
route that takes more time but is more accurate. For some people, as we talked about the
intuition route is more active and stronger, is that right? The feeling of certainty that can be
produced by the quicker processing can be misleading. It will be challenging to overcome this
feeling of certainty but we will work out a way to strengthen the rational route.

Where the delusion is based on a very strong feeling of certainty that is not backed up by objective
evidence. The approach to modification is to promote awareness that a feeling no matter how
persuasive does not necessarily guarantee that it is true.

The shift in the delusion starts with the availability of an alternative explanation that is more
plausible. Generation of the alternative explanation generated first then shown to be consistent
with the evidence overall.

1. I was wondering if … is that a possibility at all or have I got it quite wrong?

2. Do you think there is any chance that … or is that not a possibility?
3. It seemed form what you were saying that it could be that… but have I got that right?
4. Someone else I knew had an experience that sounded a bit like yours and he found in his
case that it was due to … Do you think something like that could be going on with you or is
your experience of … quite different?
5. If I asked … to tell me what they thought might be going on when… what would they be
likely to say?