Six months into experiencing psychosis, Susan Weiner woke up from a nightmare with a disturbing realization: An evil dictator had gained access to her unconscious, and was going to make her a serial killer. As she wrote in Schizophrenia’s Bulletin’s First Person Account series, “By this time, there were implants activated in my teeth and I believed that DNA was being extracted through my eyes. I could no longer feel the sensation of love. I only remembered that I had felt love before. Thus, 3 weeks later, when I tried to electrocute myself, I was teetering on the edge. As I reasoned, it was better to be dead than to be Ted Bundy.”
Weiner recounted how much of her day-to-day life became consumed with beliefs that she was being watched, her phone was being tapped, or that her friends were spies for the CIA. These are all examples of persecutory delusions, an immensely difficult and frightening symptom of psychosis and conditions like schizophrenia or schizoaffective disorder involving the conviction that others are out to harm you in some way. During a first episode of psychosis, over 70% of people have a persecutory delusion.
Despite being common for psychosis, persecutory delusions are very hard to treat. People can be given antipsychotic medications, but two-thirds of them won’t have their symptoms reduced even by half. Psychological therapies, like cognitive-behavioral therapy (CBT) for psychosis can be helpful—but not by a lot. When CBT is given to people who haven’t responded to medication, only 10% have their symptoms cut in half.
That’s why the results of a randomized trial of a new cognitive-behavioral treatment for people with psychosis, called the Feeling Safe program, has garnered some excitement. The people in the trial had persecutory delusions for at least three months, and held those delusions with at least a 60% conviction. By the end of the trial, 50% of the people had no delusions, and another 25% made moderate improvements, making Feeling Safe the most effective psychological treatment for persecutory delusions. The study was published in The Lancet Psychiatry earlier this month.
The program targets several aspects of delusions that first author Daniel Freeman, a professor of clinical psychology at the University of Oxford, and his colleagues have been studying in detail for about 15 years: that delusions are often paired with worrying, low self-confidence, sleeping troubles, and safety-seeking behaviors. The treatment helps people re-enter situations that made them previously feel unsafe, alongside targeting those other negative side effects. The therapy also provides a large amount of autonomy to the participants; it’s modular and people can choose which treatment focuses they’d like to take on first, guided by clinical psychologists.
As one participant from the trial said, “I missed out on so many things in life, meeting my friends, family events, meals, training, sports, I was just in a very paranoid state. After a life-changing study—for me—I feel very, very safe. It worked. It really did. You get better sleep, feel more confident, and active in the day. It’s profoundly changed my life. I don’t have to worry any more about people potentially attacking me. That’s all floated away.”
Feeling Safe could be a foreshadowing of increasingly systematic psychotherapy approaches for serious mental illnesses. Freeman and his colleagues had been naming and investigating specific factors of delusions for over a decade, and then put all of the pieces of their prior research together into a targeted approach. Of course, as with any treatment that shows promise, the concern is now about implementation, replication, and accessibility for all the people who might benefit from the program.
Motherboard spoke to Freeman about what makes the Feeling Safe program unique, how perspectives on treating delusions are changing, and the benefits of having both medical and psychological treatment options available for people with psychosis.
This interview has been lightly edited for length and clarity.
Motherboard: There are many kinds of delusions. Can you describe what the Feeling Safe program focused on and why?Daniel Freeman: This was about the treatment of persecutory delusions, when people have unfounded or exaggerated ideas that others are deliberately trying to harm them. People feel very unsafe around others. They worry that others are going to physically, psychologically, socially, or financially harm them. People might think if they go outside that anyone or everyone might attack them physically. Or, that people are checking up on them in order to inform on them. They might fear that others are spreading nasty rumors around the neighborhood about them. In effect, everyday situations get filled with fear.
What we know is that persecutory delusions are the severe end of a continuum of paranoia in the population. When people have persecutory delusions they often, because they feel so unsafe, retreat from the world. They spend a lot of time inside doing nothing. And that means the mind works overtime and people feel worse. It also affects their physical health because they're less active. We know they have very poor psychological well-being. There's high levels of suicidal ideation, and these problems can lead to admission to psychiatric hospitals.
[Delusions] are typically treated as a key symptom of diagnoses such as schizophrenia, schizoaffective disorder, or delusional disorder. There are problems with these diagnoses. This research tries to focus much more on the individual’s experience, which in this case is persecutory fears. But the people in our trial typically had a diagnosis of schizophrenia.
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What options might a person with persecutory delusions typically have for treatment? The main treatment people get given is antipsychotic medication. Increasingly, psychological therapy is also recommended, particularly cognitive behavioral therapy for psychosis. And there's certainly evidence that that helps reduce delusions too.
What you typically see with antipsychotic medication is that around a quarter of people have a very good response. When you add cognitive behavioral therapy for psychosis onto this, another smaller percentage of people get a good benefit too. But it’s very clear that many people do not respond, or do not respond sufficiently, to current treatments. I think it's readily acknowledged that we need to transform outcomes for this patient group.
Historically, psychological therapies are much more readily available for people with anxiety, depression, whereas they're much less available for people with psychosis. We have to keep evaluating and testing the Feeling Safe program, but I think it potentially is one of the largest breakthroughs in three decades of the treatment of a severe mental health problem.
If it was a medication, I think people would probably be shouting from the rooftops about its potential. But as a specialized psychological therapy, it will probably take longer to get accepted, and even longer before it becomes readily available for those who would benefit.
The Feeling Safe program was tested in a randomized trial against “befriending” therapy. What is that, and why was it a good comparison? There is an idea called the Dodo Bird Verdict which is that all psychological therapies are similar, and they work through the formation of a good relationship—therefore the content doesn't matter. I think that's simply not true. There are demonstrations across mental health disorders where you get some therapies that perform better than others—but we've not seen that in psychological therapy for delusions until now.
What we wanted to do is show that our therapy, based upon a really good theoretical understanding of paranoia, leads to changes above those provided by just having a very good therapeutic relationship. So we did a comparison of a befriending intervention, which was all about developing a very good relationship with the person. Lots of people said it's a brave thing to do, to compare to befriending—because other psychological therapy for psychosis has not beaten befriending before. We did a very tough test, but it was clear that the Feeling Safe program does better than befriending.
Having said that, befriending is really good. That approach is helpful. But if you want to make the largest change and get higher recovery rates, greater recovery in persecutory delusions, then a specialized, targeted cognitive therapy is better.
Some of the elements you target in the program feel very intuitive and reminiscent of other mental health treatment targets, like the focus on self-confidence, worry, or sleep. Can you talk about how those facets were chosen?
Psychosis is often studied and treated separately from common emotional disorders such as anxiety and depression. We’re arguing that actually there's lots of commonalities, and that all mental health problems are made worse by people having low self-esteem, by spending time worrying, by avoiding things, and by not sleeping well. We applied a lot of learning from really good psychological therapy for anxiety and depression. And we say that it's relevant to people with psychosis, too.
Now there's added elements and there's adaptations one needs to do. But actually there's almost a core set of processes that good therapy across the board in mental health disorders, including for people with severe mental problems, that work.
What we really focus on in reducing paranoia is to shift the focus to helping the person build up new memories of safety. What's happened to people with paranoia is everyday situations— people being out on the streets or local shops—they're all associated with memories of threat and danger. What we have to do is help people get back into these situations, willing to engage in them anew and help enable learning of these new memories: that they're safe in these places.
These new memories of safety counteract the old threat memories. In essence, what we're doing is helping people get in the state to be able to make this learning, and that's by making them feel more confident, by getting their minds less focused on worry, by getting a good night's sleep and then going back into these situations, dropping all the defenses and really learning that actually, they're okay.
That takes courage because people get into these situations and they feel terrified, it feels horrible. I have amazing respect for the people in the Feeling Safe program who have gone and done these things. But we help explain that what they’re feeling is anxiety but it doesn't mean any harm is going to happen, and they need to find out what's going to happen. And it’s very freeing.
It reminds me a bit of exposure therapy, which I’ve done a fair bit of in treatment for OCD. It takes a situation or thing you’ve built up a lot of negative emotion around and says, let’s go do it.
For a long time in psychiatry there's been an idea that somehow psychotic experiences are "un-understandable," is the phrase used. And therefore, mysterious and separated off. Neuroses and psychosis is the classic divide in psychiatric classification systems. And neuroses, like anxiety, depression, are considered as things that are rather understandable and treatable psychologically. But psychosis was thought of as very, very different, and psychology didn't have a role. That's simply not the case.
There is large overlap and huge amounts of understanding from one condition to another. And it's very clear there is a large emotional component to psychotic experiences. And that's great because that opens up the door to powerful techniques.
This reflects a more global shift in how some clinicians are thinking about delusions. Before it was thought you shouldn't engage with them because they’re not real. The goal was to get a person not to believe the thing that's “wrong.” But now, we’ve seen great work from the Hearing Voices Network, for example, which doesn’t try to make voices go away, but is focused more on the appraisal of those voices. Do you feel like Feeling Safe is in line with this shift?
I think the brilliant thing about cognitive behavioral therapy for psychosis is it has certainly shown that it's absolutely safe to talk about delusions and voices, and actually you can get benefits from doing that. That's been one of its huge contributions.
If you want to change someone's mind about anything, for all of us, getting into an argument about it never changes the mind. None of us changes our beliefs like that. What we do in the Feeling Safe program is we focus just on building up the new experiences of safety. We don’t have to challenge the old beliefs. We don't know what happened in the past. We can only find about the here and now, and going forward.
We certainly saw people who were absolutely convinced; there was no margin of error for their being wrong. It's all about how you present the help. We're not saying we can treat your delusion. We are saying you feel really unsafe. How can we help you feel safe? It’s horrible having this experience, isn't it? And, you can't sleep at night? We can help you sleep at night. We're not trying to disprove them. It’s building up those new memories of safety, building up confidence, good sleep. It’s building up time where the person is thinking about what they want to think about, rather than all the worries.
How has your personal experience treating patients for many years informed what’s in the program?
Probably about 15 years ago, I set out on a journey to improve the [existing treatments], and did a lot of developing a better and more precise, clear understanding of delusions. This was not a therapy that popped out of thin air, this was built upon a sustained process of development.
We have wonderful groups of what's called a “lived experience advisory panel,” people who provided advice all along the way. That's been incredibly helpful. And of course, we've also done large scale surveys of patients, getting their views. There's no point having a brilliant therapy if patients don't want to use it.
But for me, the main crucible of learning has been the privilege of being a therapist and having time to listen, talk, and try things out with people. That is within a context of understanding the theory of psychological processes, and also within a philosophy of how you deal with complexity and causation as well—because single answer factors of mental problems seem, to me, unlikely.
We know there’s not a single cause of any mental problem, let alone delusions. So we worked out the key causes, developed treatments for each bit, and then worked to put them together. The result is a combination of both new theoretical understanding, but also a different way of doing things. One of the different ways of doing things is to be much more active, actually getting out of the clinic rooms. We try not to do so much sitting in the room talking because mental health problems play out in everyday environments. We actually go out with patients. Sometimes we meet two or three times a week, or do phone calls or texts, if people want. This is a group, at least in the initial stages, that really benefit from having that.
All the sleep stuff is interesting because that was something for a number of years I just did in therapy because people would say, "I have a sleep problem," so we would treat it. Helping people sleep better is a very powerful thing because when you're worried, it means you don't sleep so well. It's great to have a therapist helping you deal directly with a problem like that. It dawned on me a while ago that actually nothing was written or talked about in doing this in psychosis. So that became a strand of research.
Our approach has been to offer these different types of interventions, personalize it for the ones that are relevant to the person, then add in also patient choice. That seems a powerful combination. You've got to acknowledge this complexity. You've got to provide options in treatment, and you've got to give choice and control to the people who could benefit.
We continue to find ourselves in a climate in which people are debating the biological or social causes for mental illness. Some argue the social or trauma-based explanations are being ignored, and accuse psychiatry of being too biologically reductive. The Feeling Safe program is a psychological intervention rather than a medication-based intervention. Does that have any implications to you, when it comes to understanding the genesis of mental illness like psychosis?
The patients in the trial are pretty much all on anti-psychotic medication. The group we worked with were people who haven't responded to current treatments. It means most patients are on medications which are not working sufficiently or at all, but that some patients are definitely benefiting from medication. To me, it’s not about the modality. It's about what works.
If medication works, great. There’s a very interesting area about whether you can get synergy—are there moments where you can get the timing right of medication and psychological therapy, so that you get additional benefits? Are there ways you can use doses at the right time to help people make certain steps? I think there's a lot of work to be done there.
But the reality is in services, those kinds of nuances are seldom possible because there isn't enough provision of psychological therapy. My view is that biology and psychology are just different levels of explanation. There's nothing that's done in Feeling Safe that's biologically implausible. We use established cognitive ideas about how the mind works, and obviously they're going to have correlates on a biological level.
There's complexity in mental health. There are no single answers most of the time, unfortunately, and we're going to need a range of responses and treatment options for people. For people with psychosis, there are just too few psychological options available. That is a clear problem. But of course, most psychiatrists want that changed, too. In everyday settings, psychiatrists and psychologists can work together very well, and do, in mutual respect.
What are your thoughts on implementing this therapy? It’s often the case that we read about an amazing trial, and think, so what? How can this help me, or my family member, or friend who can't access it?
This is the absolute crucial issue now. And you're right that in effect, this treatment is available in Oxford in my team, and that's pretty much it. And therefore, there is a huge issue. We developed the treatment in a way that we think that's going to make it more implementable. It's modular and there are booklets. We think in terms of training clinicians, those are going to be advantages. But it is absolutely the case that for us to do the training now, there aren’t that many of us in my team that even could do it. There's the whole issue of capacity while we're doing everything else.
Looking at the future, are there ways we can blend it with technology so that we can enable it to be a bit more self directed whilst retaining the key features? Can we make it deliverable by more staff members than just clinical psychologists? This is the crucial next focus. At the moment I'm writing proposals to try and deal with this.
We've shown that we can deliver this treatment really well in Oxford. But we're going to have to show that this is possible for many others to provide too. The job is half done, in a way.
It does mean that there is potential optimism here for what's been considered a serious mental health problem; actually people can do really well if you provide good psychological therapy. But we now have to try and get that to all the people who need it, and that's going to be a huge challenge.
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