A counterweight model for understanding and treating persecutory delusions.

Direct challenge seldom leads to change in strongly held beliefs such as persecutory delusions. A better route is to develop an alternative belief that can coexist with the delusion. The best such beliefs function as counterweights to the delusion. Over time, the scales shift. The alternative belief becomes more powerful than the delusion. In this paper, we set out such a model of persecutory delusions (or severe paranoia) and describe how it inherently translates theoretical understanding into treatment routes. Severe paranoia occurs when the adaptive cognitive processes of deciding whether to trust become overly weighted to mistrust. An inaccurate threat belief is formed, and the person feels very unsafe. Hence, overcoming the delusion means developing a counterweighting belief. It means building the alternative view that the world is safe enough for the person now and going forward. This, in turn, is done by experiencing safety. However, the pull of paranoia is strong due to multiple factors such as past history, anxious arousal, hallucinations, feelings of vulnerability, use of defenses, withdrawal, worry, difficulties distancing from fears, and a sense of defeat. These factors can prevent the person from feeling safe in even the most benign environments. Therefore, counterweights must be developed for these factors. For instance, feeling vulnerable can be counterweighted by developing self-confidence. Excessive time spent worrying can be counterweighted by devoting more time to thinking about meaningful activities. The counterweight approach provides a non-confrontational, empathic, personalized way to lift the burden of paranoia from a patient with persecutory delusions.