Does a more effective clinical approach entail accepting or maintaining a neutral attitude toward the delusions, focusing on strengthening the therapeutic relationship? Or is it more helpful for the patient's progress to challenge delusions or utilize reality-testing techniques?
Apparently, this is a tougher question than I realized. My own clinical experience with patients with schizophrenia and delusional disorder is that it is almost impossible to talk patients out of their beliefs, regardless of the approach used. I would venture to say that new generation antipsychotics have the best chance of reducing (probably not eliminating) expressions of delusional beliefs.
All things considered, I believe that maintaining the therapeutic relationship is paramount to facilitating some degree of recovery for the patient, and that delusional content should not be challenged, or perhaps only in a very gentle manner.
As always - it depends on patient, clinical situation, treatment settings (in- or outpatient), etc. Usually, I begin with neutral approach to explore patient's delusions to understand them better. However, in most cases there is a moment when I try to confront patients with their delusions and indicate which parts of their beliefs I consider to be resulting from psychosis. Needles to say, such approach requires flexibility - patient may get angry or hostile and if so - there is no point in continuing such confrontation, I postpone it for time, when psychosis is better controlled by medications.
Henry Z. Lothane Icahn School of Medicine at Mount Sinai New York
Bleuler, the most important clinician and theoretician of schizophrenia, defined dreams, hallucinations, and delusions as DEREISTIC psychical formations. Dereistic is derived from Latin, res, reor, which means things perceived with the senses, they are a result of dreaming while awake, i.e., fantasizing, or, as Bleuler wrote in 1912 (after his textbook on the groups of schizophrenias), the are not about perception but imagination in a dreaming state of mind.
Confrontation has its place in the sense of saying to the patient: your are imagining. But the problem with that is that imagining and dreaming are real, it is only the objects and speeches and pictures of the dream that do not refer to things out there but the SCENES of the dream, of the hallucination, the delusion.
Therefore the more productive approach is to share that experience with the paient, to "enter" the scene of the dream, to ask them to describe it in the most detailed way, to describe the voice they hear, to ask them to say them if they whose voice are they reminded of, whose face are they "seeing", and when you get them to do that, some important recollection of their past may occur to them, or even some insight why these people are important to them. Finally, to ask them if the hallucination or delusion is in some way related to a recent experience which they found painful or scary. The finall connection has to be made with their feelings and emotions.
See
Lothane, Z. (1982). The psychopathology of hallucinations -- a methodological analysis. British Journal of Medical Psychology, 55 339-348.
There's an optimal sequence of treatment in which the former precedes the latter. Initially, the clinician needs to explore the delusion and build the relationship. Gradually, however, it is often helpful to sow seeds of doubt and help the patient really think through the logic of the delusion.
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