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Psychological disorders have begun to step out of the shadows in recent years. It’s no longer unthinkable for individuals to open up about their problems; you probably know someone who has done just that. Meanwhile, we’ve become used to hearing about mental health issues from the media and from public campaigns.
But though mental health has a higher profile these days, and therapeutic options have undeniably improved, some conditions remain both shrouded by stigma and, for too many people, stubbornly difficult to treat.
Persecutory delusions — the unfounded fear that people are out to harm us — certainly fall into this category. One of the main features of psychiatric diagnoses such as schizophrenia, persecutory delusions can cause enormous distress. Almost half of patients with the condition also suffer from clinical depression; indeed, their levels of psychological wellbeing rank in the lowest 2 percent of the population. This is hardly surprising given the torment of thinking, for example, that your friends or family are out to get you, or that the government is plotting to do away with you. The presence of persecutory delusions predicts suicide and psychiatric hospital admission.
Given all this, it’s regrettable that we still lack consistently effective treatment options. Medication and psychological therapies can make a difference and some amazing leaders in mental health are making advances in understanding, treatments, and service delivery. However, medication doesn’t work for everyone and the side effects can be so unpleasant that many people simply abandon treatment. Meanwhile, while psychological therapies such as first-generation CBT approaches have proved useful for many, the gains can be modest. Availability is also very modest, with a dearth of trained professionals able to deliver the therapy adequately.
Looking at the currently available options, and bearing in mind that many patients are still troubled by paranoid thoughts despite months or even years of treatment, the idea that delusions might be cured seems a pipe dream. But this is precisely where we want to set the bar. It’s an objective we think is realistic for many patients. And the first results of our Feeling Safe programme, funded by the Medical Research Council and building upon national expertise in understanding and treating psychotic experiences, provide grounds for optimism.
The practical therapy is built around our theoretical model of paranoia (in this respect it’s what’s known as a translational treatment). At the core of a persecutory delusion is what we call a threat belief: In other words, the individual believes (erroneously) that they are currently in danger. This is the kind of feeling that lots of us have had at some time. The persecutory delusions experienced by people with schizophrenia aren’t qualitatively different from everyday paranoia; they’re simply more intense and persistent. Persecutory delusions are the severest end of the paranoid spectrum.
Like most psychological conditions, for many people, the development of their threat beliefs lies in an interaction between genes and environment. Through an accident of birth, some of us may be more susceptible to suspicious thoughts than others. But that doesn’t mean that people with a genetic vulnerability will inevitably experience problems; far from it. Environmental factors — essentially the things that happen to us in our lives and the way in which we respond to them — are at least as important as genetics.
Once a persecutory delusion has developed, it is fueled by a range of maintenance factors. We know, for example, that paranoia feeds on the feelings of vulnerability created by low self-esteem. Worry brings fearful but implausible ideas to mind. Poor sleep exacerbates the anxious fearful feelings, And a range of subtle perceptual disturbances (the odd physical sensations caused by anxiety, for instance) are easily misinterpreted as signs of danger from the outside world. Delusions also thrive on so-called “reasoning biases” such as jumping to conclusions and focusing only on events that seem to confirm the paranoid thought. Understandable countermeasures — such as avoiding a feared situation — mean that the individual doesn’t get to find out whether they were truly in danger and thus whether their paranoid thought was justified.
The key aim of the Feeling Safe Programme is for patients to relearn safety. When they do that, the threat beliefs begin to melt away. After tackling their maintenance factors, we help the patients to go back into the situations they fear and discover that, whatever they may feel about past experiences, things are different now.
Though the Feeling Safe Programme is new, it’s built upon a careful and deliberate research strategy. Using epidemiological and experimental studies, we’ve tested the theory and highlighted the key maintenance factors. Next, we set out to show that we can reduce the maintenance factors and that, when we do, the patients’ paranoia diminishes. Over the past five years, the modules that target each maintenance factor have been tested by us and colleagues in clinical trials involving hundreds of patients. Feeling Safe is the outcome of a lengthy process of translating science into practice. Now we’ve reached the exciting stage of putting the different modules together in a full treatment for persistent persecutory delusions.
The results from the very first patients to undertake the Feeling Safe Programme are published this week. Our Phase 1 test involved eleven patients with longstanding persecutory delusions that hadn’t responded to treatment in services, typically for many years. The majority of the patients were also hearing voices. We first helped them to identify the maintenance factors that were causing them the most problems. Patients then selected from a treatment menu created especially for them, including, for example, modules designed to reduce time spent engaging in worry, build up self-confidence, improve sleep, be more flexible in thinking style, and learn how to manage without counter-measures and discover that the world is now safe for them.
Over the next six months, each patient worked with a clinical psychologist from the team on their personalised treatment plan, tackling his or her maintenance factors one by one. What causes delusions varies from patient to patient; the best way to deal with this complexity is to take it a step — or maintenance factor — at a time. The therapy is active and practical. It’s very much focused on helping patients to feel safer and happier, and to get back doing the things they want to be doing.
On average, patients received twenty one-to-one consultations each lasting around an hour, with the sessions often supported by telephone calls, texts, and emails. The sessions took place in a variety of settings: the local mental health centre, the patient’s home, or environments in which the patient could relearn safety (the local shopping centre, for example, or a park). Once a maintenance factor had been tackled successfully, the patient moved on to the next priority module.
The results were striking; the programme looks as though it may represent a step-change in the treatment of delusions. The science really may translate into a significant practical advance. More than half of the patients (64 percent) recovered from their long-standing delusions. These were people who had been begun the trial with persistent severe delusions, other troubling psychiatric symptoms, and very low psychological wellbeing — the toughest group to target with a new treatment. But as the programme went on, the patients made big gains in all these areas; several were also able to cut down on their medication. Moreover, the patients were happy to stick with the programme, with almost all stating that it had helped them deal more effectively with their problems.
It didn’t work for everyone and this is a very early test of a treatment that is continuing to evolve. A full randomized controlled trial funded by the UK's NHS National Institute of Health Research started in February. If these initial results can be replicated, the Feeling Safe programme will represent unprecedented progress. Our understanding of the causes of delusions has come on in leaps and bounds in recent years so when it comes to constructing a successful treatment we can proceed with much more confidence than in the past. Finally, it’s possible to envisage a future in which patients with persecutory delusions, for so long an apparently intractable problem, can be offered a robust, reliable, and far more consistently effective cure. Paranoia, it seems, may at last be about to emerge from the shadows.
Daniel and Jason are the authors of The Stressed Sex: Uncovering the Truth about Men, Women and Mental Health. On Twitter, they are @ProfDFreeman and @JasonFreeman100.
