Balancing the cognitive–behavioural approach with an analytic perspective

Although traditional psychiatrists view delusional beliefs as being held in the face of contrary evidence normally sufficient to destroy them, Freeman & Garety (2006) contend that they are held by evidence powerful enough to support them and their validity. They also argue for a continuum in intensity from normal to overvalued ideas to delusions, inviting consideration of similar mechanisms by which paranoid thoughts arise in the normal population and delusions in psychosis.

As a general psychiatrist using a psychoanalytic framework to relate to patients in everyday practice and aiding junior doctors through weekly psychosis workshops, I would hold a different attitude. I would distinguish the genesis of paranoid thoughts, that can occur in all of us, from delusions in major psychotic disorders.

Delusions are held in the face of contrary evidence, but we still need to know how and why they are formed. I believe that cognitive–behaviourists are correct that both emotions and reasoning come into play. What I find missing in their formulations is the integration of analytic concepts, namely the domination of the internal fantasy world over external reality in psychosis, the use of pathological projective identification in delusion formation and the importance of our countertransference feelings and sensitivities.

In the psychoanalytic model, the person with schizophrenia projects troublesome thoughts and feelings into memories stored in the mind for the purpose of disowning them, thus forming the delusion. These insights arose originally from very detailed analytic case studies by Bion (1958). I have observed that what is often disowned in the delusion is the individual's sanity.

While being in agreement with the cognitive–behaviourists that there is meaning to delusions, I believe that the primary task is to decipher their meaning through understanding the projections and subsequent rationalisations.

For example, a patient might claim that he is Prince Edward, son of Henry the Eighth. His delusion becomes understandable when it emerges that he has been assaulting his young wife, who is in a women's refuge. The delusion can be seen as his disowned sanity critical of his manically aggressive behaviour. His sanity is saying that he is acting like a son of Henry the Eighth, inventing his own rules and doing what he wants to his wives, and he wishes to disown this awareness.

I believe that APT's online correspondence could provide a lively forum for reflection and debate on differences and similarities in psychological approaches towards the understanding of delusional content.