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Delusions: How cognitive therapy helps patients let go

Vol. 3, No. 7 / July 2004

Patients with psychosis often hold on to delusional beliefs while on medication. Learning more about these beliefs through cognitive therapy can improve drug efficacy, engagement, and coping skills for any chronically or acutely psychotic patient who is willing to discuss his or her delusions.

Start by asking these five questions:

1. How strong is your belief? When starting therapy, ask the patient to rate the certainty of his belief from 0 to 100%. A patient who remains 100% certain over several visits probably will not respond to treatment.

Then engage the patient by suggesting that together you’ll view the belief as a scientist or detective would, carefully evaluating all evidence before reaching a conclusion.

2. How long have you had this belief? Some patients say they have always held a specific belief. Beliefs that have lasted years may be harder to change than more-recently adopted ones.

Looking back, some patients acknowledge initial doubts and recall considering alternate beliefs, which the physician can help strengthen.

3. How has the belief affected your life? Have the patient write down the advantages and disadvantages of his delusional thinking; 1 seeing the consequences in writing may discourage the belief. For example, a patient might stop thinking he is a prophet if he realizes the belief could lead to alienation and hospitalization.

4. Until now, how have you coped with negative aspects of this belief (such as ‘death threats’)? For 10 years, one patient believed gangsters were trying to kill him. We asked how he survived attempts on his life. He identified activities and situations in which he felt safer, such as being with his parents, playing basketball with others, and visiting the doctor. We encouraged him to spend more time in these situations. He acknowledged his role in improving his sense of safety and felt empowered to confront the delusion.

5. What if the delusion is/is not true? Asking this question may uncover other dysfunctional thinking that can be addressed in therapy.

Have the patient rate certainty at each visit, and document changes in score. Patients with delusions usually are relieved that they are not being judged and that their beliefs are not invalidated. They often start questioning their delusions and develop coping skills to deal with them.

Some patients feel depressed after abandoning a delusion that once shielded them from low self-esteem (eg, “the FBI is after me because I’m important”). Steer patients toward various activities and have them rate their enjoyment and mastery of them. This will help them find alternate beliefs.


1. Rector N, Beck A. Cognitive therapy for schizophrenia: from conceptualization to intervention. Can J Psychiatry 2002;47:39-48.

Dr. Pinninti is assistant professor of psychiatry, School of Osteopathic Medicine, University of Medicine and Dentistry of New Jersey, and is medical director, Steininger Behavioral Care Services, Cherry Hill, NJ.

Dr. Sosland is a child and adolescent psychiatry fellow, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA.

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