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CLINICAL PSYCHIATRY

Is the content of delusions and hallucinations important?

Yasmin Aschebrock, Nicola Gavey, Tim McCreanor and Lynette Tippett

Objective:

To explore the level of interest among researchers and cliniciansin the content of delusions and hallucinations.

Methods:

A survey of 58 mental health practitioners and researchers wasconducted. The questionnaire included closed and open-ended questionsabout participants’ views concerning the value of attending to the content ofdelusions and hallucinations.

Results:

Participants identified benefits (e.g. heightened understanding ofclients’ difficulties, enhanced therapeutic relationship, improved risk assess-ment) and drawbacks (e.g. waste of time, exacerbation of clients’ distress,reinforcement of content, blurred distinction between reality and non-reality) associated with attending to content. Half of the participants sug-gested that their work would be enhanced, while approximately one-fifth feltthat their work would be affected adversely, should they attend to content.

Conclusions:

Taken together, the data suggest that there is ambivalencetowards the practice of attending to content. Participants identified deter-rents to this practice that were not only pragmatic but were also related to thecustomary way in which delusions and hallucinations are conceptualized inthe mental health field.

Key words:

delusions, hallucinations, psychiatric symptoms.

INTRODUCTION

n psychiatric clinical practice, scarce attention is often paid to thecontent of delusions and hallucinations.

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It has been customary forclinicians to place more importance on establishing a diagnosis.

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Even some psychological approaches to the treatment of psychosis, suchas cognitive behavioural therapy (CBT),

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have tended to be more process-orientated than content-orientated. Researchers have seemed largelydisinterested in the content of delusions and hallucinations,

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as evi-denced by the paucity of literature on the topic.

It has been claimed that ‘the prevailing [biomedical] paradigm judges thecontent [of delusions and hallucinations] to be irrelevant’.

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Tradition-ally, delusions have been characterized as ‘incomprehensible, unreal andbeyond our understanding’,

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as merely surface expressions of an under-lying biological illness.

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Form has been regarded as more worthy ofstudy than content because it is more amenable to systematic researchorientated towards the scientific goal of identifying universal laws.

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Bydefinition, delusions are beliefs that are not shared within the person’simmediate cultural context, and hence are unintelligible.

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It has evenbeen suggested that ‘to pay too much attention to content might beprofessionally damaging’.

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The current paper presents the findings of an international survey ofmental health practitioners and researchers, exploring their views con-cerning the importance of attending to the content of delusions andhallucinations.

Yasmin Aschebrock

PhD candidate, Department of Psychology, University of Auckland, Auckland and Assistant Psychologist with the Adult Psychology Service, Northland Health, Kaitaia, New Zealand.

Nicola Gavey

Senior Lecturer, Department of Psychology, University of Auckland, Auckland, New Zealand.

Tim McCreanor

Lecturer, Department of Psychology, University of Auckland, Auckland, New Zealand.

Lynette Tippett

Senior Lecturer, Department of Psychology, University of Auckland, Auckland, New Zealand.

Correspondence

: Yasmin Aschebrock, 29 Henderson Bay Road, Henderson Bay, RD 4, Kaitaia, New Zealand.Email: yasmin@ihug.co.nz

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METHOD

Instrument

A questionnaire was constructed to investigate clini-cians’ and researchers’ beliefs about (i) the costs andbenefits of attending to the content of delusions andhallucinations; (ii) the possible effects on clinicalpractice of attending to content; (iii) the extent towhich persons currently attend to content; (iv) theirtraining regarding content; and (v) their familiaritywith the literature concerning content. The question-naire included both closed (e.g. using Likert scale)and open-ended questions, to allow for the collectionof both quantitative and qualitative data.

Procedure

Potential participants were identified as follows.A PsycLit search was conducted to locate articlesrelating to both psychosis and gender (because thissurvey was part of a larger project interested in genderin relation to delusions and hallucinations) publishedin the preceding 5 years. All authors of these articleswere contacted by email (except in cases in which itwas not possible to find their email addresses). Pub-licly available lists of members of professional associ-ations (e.g. American Psychological Association,international associations for mental health nurses,psychiatrists etc.) were also sought via the Internet,and emails were then sent to these members. We alsovisited as many websites of psychology, psychiatry,behavioural science, nursing, and social work depart-ments of universities throughout the world as wecould find on the Internet (including Australasia,North America, South America, Europe, Africe, Scan-dinavia, Asia etc.), and identified staff members ofthese departments whose interests seemed relevant tothis research project. Other participants includedcolleagues at Northland Health, former colleagues atAuckland Healthcare, and mental health practitionerswho belonged to a psychosis interest group in Auck-land. Following the initial contact, some respondentsrequested that information about the study and thequestionnaire form be posted to them. Others whowished to participate in the study accessed identicalversions of these documents, available on the Inter-net, and submitted their completed questionnaireforms, online. In total, 142 questionnaires were dis-tributed by post, including 46 when the survey waspiloted.

We received 58 completed questionnaires (21 onlinequestionnaires and 37 hard copy questionnaires),which constituted an overall response rate of 26% forthe hard copy questionnaires. There was a 15%response rate for the pilot survey and a 31% responserate for the survey proper; there were no differencesin the wording of these questions in the pilot surveyand the actual survey.

RESULTS

Sample

A total of 58 people participated in the survey. Res-pondents ranged from 30 to 71 years of age, with themean age being 44 years. Thirty-eight per cent ofparticipants were women. Respondents were primarilyfrom New Zealand (33%); the UK (24%); USA (12%);Australia (10%); Canada (9%); and South Africa (5%).

Nearly half of all participants (47%) were mentalhealth nurses, just over one-fifth (22%) were psy-chiatrists, and 19% were clinical psychologists. Theremaining respondents identified themselves asbelonging to other disciplines (e.g. occupational ther-apists). Thirty-six per cent of participants were identi-fied primarily as clinicians and 26% were identifiedprimarily as academics; while 38% identified as both.Most respondents indicated that their clinical orien-tation was either eclectic (50%) or CBT (22%). Lesscommon paradigms were biomedical (10%), psycho-dynamic (5%), or other paradigms.

As a group, the participants were highly experiencedin working with clients who had been diagnosed withpsychosis, 35 (60%) having had 10 or more yearsexperience, of whom three had more than 30 yearsexperience.

Responses to the Likert scale items did not differ fordiscipline, professional identification, chosen para-digm, or gender (Wilcoxon signed ranks). Likewise,qualitative analysis of the results did not suggest thatthere were any differences in participants’ responsesto the open-ended questions, based upon their groupmembership (i.e. their discipline, professional identi-fication, paradigm or gender).

Perceived benefits and drawbacks of attending to the specific content of delusions and hallucinations

In order to begin exploring the level of interestamong researchers and clinicians in the content ofdelusions and hallucinations, respondents were askedto indicate what they saw as potential benefits anddrawbacks of attending to the specific content ofthese experiences. While a small number of respond-ents saw little or no benefit in this practice, most(84%) listed both benefits and drawbacks, and theseare discussed here.

Benefits

The potential benefits identified by participants gen-erally fell into three main categories: heightenedunderstanding of clients’ difficulties; improvementsin the nature of the therapeutic relationship; andenhanced ability to assess risk and/or address safetyissues. The most frequently reported benefit ofattending to content (identified by 41 participants(71%)) was that it provided useful informationwith which to understand and formulate clients’

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difficulties. This enhanced understanding and, inturn, informed treatment interventions:

This is absolutely basic. While delusions/hallucina-tions may assist diagnosis, treatment decisions andformulation of risk assessment/management plansare determined by a content analysis of the illness.No competent care can proceed without it.

A common theme among these kinds of responses(evident for 28 of these 41 participants) was that thecontent of hallucinations and delusions were ‘under-standable’ within the particular contexts of clients’lives:

I can often find a lot of sense and ‘meaning’ behindpeople’s psychotic experiences – and the contentbegins to make a lot of sense when you begin toexplore the psychotic’s [sic] life experiences enough.

Twenty-two participants (38%) suggested that payingattention to content could be regarded as a strategicact to facilitate the development of good rapport withtheir clients. These respondents tended to suggestthat exploring the content of hallucinations anddelusions enhances the therapeutic relationship bysignalling to clients that clinicians are ‘taking themseriously’ and ‘taking an interest in [them] ratherthan dismissing them’:

Patients don’t really open up to you until you’rewilling to actually talk about the specific content oftheir psychotic experiences.

In addition, nine participants (16%) proposed thatattending to content facilitates risk assessment.

Drawbacks

Participants’ responses concerning the potentialdrawbacks of attending to content fell into four maincategories: concern about being distracted fromother, more useful, topics; the potential to inadvert-ently reinforce the content of hallucinations anddelusions; fear of causing clients further distress; andthe possibility of clinicians themselves losing touchwith ‘reality’. Thirty-eight per cent of respondentsindicated that focusing on content could mean thatclinicians become ‘too caught in the details’ and soare distracted from other areas, such as the form ofpsychotic experiences, which may be more importanttherapeutically. These participants raised concernthat such attention might be ‘problem-focused’,unfruitful, and unmanageable. It was common forthese respondents to suggest that attending to con-tent distracted clinicians from a solution focus (e.g.by ‘unduly focusing on [clients’] deficits’).

Paying attention to the content of delusions andhallucinations was sometimes represented as a ‘timewaster’ that might ‘lead [clinicians] in the wrongdirection’. Others felt that clinicians might becomeoverwhelmed by excessive detail, leading them tobecome ‘bogged down’ and ‘lost’.

Sixteen participants (28%) were concerned thatattending to the specific content may result in the‘reinforcing of psychotic experiences’, and ‘handledpoorly, can seem to be colluding with the patient’.Another concern, raised by (four) participants (7%),was that discussing the content of delusions andhallucinations ‘may be distressing’ or ‘traumatic’ forclients:

Patients feel ‘out of control’ when they are allowed toroam freely in their psychosis.

Three further respondents cautioned that when clini-cians attend to content, they may lose their ‘ownexperiential reality’:

You might ‘understand’ the psychosis so well that youmiss the fact that the patient is psychotic.

Respondents were asked to indicate how importantit is, in their eyes, to attend to the specific content ofclients’ hallucinations and delusions, respectively, onLikert scales ranging from 1 (‘not at all important’)to 7 (‘extremely important’). Although the medianresponse was higher for delusions (median = 6) thanfor hallucinations (median = 5), the modal responsewas higher for hallucinations (i.e. median = 7) thanfor delusions (median = 6). A Wilcoxon signed rankstest failed to reveal any statistically significant dif-ference, (

χ

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(1,n = 57) = –1.524, p = 0.128). Responsesranged from 2 to 7 for both hallucinations anddelusions. Yet, responses were skewed toward the‘important’ end of the scale, with few participantsindicating that the content of delusions and halluci-nations was unimportant (Figure 1).

Potential effects on clinical practice

When respondents were asked how aspects of theirwork would be affected if they were to attend to thespecific content of clients’ delusions and hallucina-tions, their responses coalesced with the costs andbenefits they had identified earlier. Thirty partici-pants (52%) responded that information about con-tent would enhance their formulations of clients’difficulties and facilitate appropriate decision-makingregarding treatment interventions. Interestingly,approximately one-fifth of the respondents (21%)suggested that their work would be affected adverselyshould they attend to the content of clients’ delu-sions and hallucinations. Some of these participantsfelt that they would ‘lose the[ir] sense of job satisfac-tion’, that they might have difficulty maintaining aclear distinction between ‘what is psychotic and whatis reality’, or that they would suffer ‘ridicule fromother professionals’.

Extent to which the specific content of delusions and hallucinations receives attention in current clinical practice

Participants were asked to indicate, on a Likert scale,the proportion of clients experiencing delusions andhallucinations, with whom they attend to specific

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content. Responses ranged from 1 (‘none’) to 7(‘every patient’); the median (and modal) responsewas 7 because responses were skewed toward this endof the scale (Figure 2).

When asked how much of their work with a givenclient would involve attending to the specific contentof her/his delusions and hallucinations, the medianresponse was 4 (midway on a scale ranging from 1(‘none’) to 7 (‘all’)), and the modal response to thisitem was 5 (Figure 3).

Respondents identified a number of factors thatmight influence the extent to which they attend tothe specific content of clients’ delusions and halluci-nations. The most frequent response (given by 27participants; 47%) was that this would depend uponclinicians’ judgements ‘as to [the] utility or efficacy of

any such attention’ for individual clients (i.e. clini-cian-driven). Another common response (given by17 respondents; 30%) was that this decision wouldbe influenced by each client’s own wishes, goalsand level of distress (i.e. client-driven). Participantstended to identify factors that were either exclusivelyclinician-driven or exclusively client-driven giventhat only six respondents suggested factors that fellwithin both categories. Twelve participants (21%)indicated that the ‘risk of self harm or harm to others’would influence the degree to which they attendto the content of delusions and hallucinations. Theamount of time available and current workload werealso cited by four respondents (7%) as importantdetermining factors.

Clinicians’ training regarding the content of delusions and hallucinations

Participants were surveyed about the training theyhad received (both in their initial training as clini-cians and in their ongoing professional development)regarding the content of delusions and hallucina-tions. Twenty-two respondents (38%) indicated thatthey had received little or no training in this area(five of these noted that they had to seek outinformation themselves, to enhance their practice).

Among those who indicated that they had receivedlittle or no training concerning content, were partic-ipants from each professional discipline. In thisgroup of 22 respondents, there were 12 mental healthnurses (44% of all mental health nurses in thesurvey), six clinical psychologists (55% of all clinicalpsychologists), two psychiatrists (15% of their group),and an occupational therapist. In contrast, threeparticipants reported that they had ‘extensive’training in this area. This group consisted of twopsychiatrists and one clinical psychologist.

Figure 2: Distribution of participants’ ratings of theproportion of clients (experiencing hallucinations anddelusions) with whom they attend to the specific content

of these experiences.

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Figure 1: Distribution of participants’ ratings of theperceived importance of attending to the content of hal-

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Figure 3: Distribution of participants’ ratings of howmuch of their work with a given client (e.g. the time spent)would involve attending to the specific content of her/his

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Participants’ familiarity with literature pertaining to the content of delusions and hallucinations

Participants were asked to indicate their level offamiliarity with the available literature relating to thecontent of delusions and hallucinations. Approxi-mately one-third of participants (31%) either indi-cated that they had little or no knowledge of thisbody of literature or left the question unanswered.

DISCUSSION

Our data suggest that mental health workers holdrather mixed views with regard to the importance ofattending to the specific content of delusions andhallucinations, insofar as they listed both benefits anddrawbacks to this practice. While a small number ofrespondents appeared to have unambiguously positiveor negative views concerning the value of attending tocontent, most participants seemed to be somewhatambivalent. Some respondents suggested that attend-ing to content might heighten clinicians’ understand-ing of clients’ difficulties, enhance the therapeuticrelationship, and improve practitioners’ ability toassess risk and/or address safety issues. Others raisedconcerns that attending to content might be distract-ing and a time waster that might cause further distressto clients and might even reinforce the content ofclients’ hallucinations and delusions. Overall, therewas no significant difference between delusions andhallucinations in terms of the perceived importance ofattending to their specific content.

While half of the participants indicated that aspectsof their work (e.g. formulation, treatment planning)would be enhanced by attending to the content ofdelusions and hallucinations, approximately one-fifth suggested that their work would be affectedadversely. Members of this latter group proposed thatthey would be ridiculed by their coworkers, their self-care would be compromised, and the distinctionbetween reality and non-reality would becomeblurred for them should they attend to content.

Despite ambivalence about attending to content,most participants indicated that they do routinelyattend to content with every client, and indicatedthat they spend a moderate amount of time attendingto the specific content of clients’ delusions andhallucinations. These findings are inconsistent withclaims that content tends to be ignored in clinicalpractice.

2

Participants suggested that the extent towhich they choose to attend to content is influencedby their own judgement as to the benefits of suchattention and also by clients’ goals and wishes. Riskmanagement and pragmatic considerations (e.g.workload) were also identified as important influ-ences affecting decision-making in this regard.

Although participants had high levels of experiencein working with clients diagnosed with psychosis, ingeneral they appeared to have received little formal

training relating specifically to the content of delu-sions and hallucinations, and a large number wereunfamiliar with the literature published on this topic.These findings are not inconsistent with reports thatthere has been little propensity to address the contentof delusions and hallucinations within research andclinical training.

9

Interestingly, three participants remarked on whatthey regarded as the paucity of research pertaining tocontent. One of these respondents suggested thatthe lack of interest in content may be due to thepersisting belief that delusions and hallucinations aresimply meaningless expressions of an underlyingbiological illness. This view adheres to the traditionalKraepelinian model, which characterizes delusionsand hallucinations as part of a syndrome, as beingsurface ‘symptoms’ with an underlying, presumablybiological, cause.

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Bentall has critiqued this way of construing delusionsand hallucinations,

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noting that it involves whatRyle identified as a ‘category error’.

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For instance,instead of ‘positive syndrome’ being regarded simplyas the term used to refer to a particular group of‘symptoms’, the ‘positive syndrome’ is taken to be theunderlying, hidden, cause of these ‘symptoms’. Thiscategory error is avoided if a ‘symptom approach’

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isadopted, for example, if the focus is on psychologicalphenomena (e.g. delusions and hallucinations per se)rather than on syndromes (e.g. diagnoses such asschizophrenia). However, it is important to recognizethat this approach is not without problems either,because the retention of the word ‘symptom’ carriesthe implication that an underlying (biological) illnessgives rise to these phenomena. Perhaps this difficultymight be lessened, at least to a degree, by referring todelusions and hallucinations as ‘phenomena’ ratherthan as (biomedical) ‘symptoms’.

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A consequence of continuing to adhere to a syn-drome approach is that the content of delusions andhallucinations is conceptualized as being beyond ourunderstanding,

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as being merely a manifestation of abiological process. Yet, many participants in thecurrent study indicated that, based on their experi-ence, delusions and hallucinations are ‘understand-able’, and when content is taken into consideration,rather than ignored, this can have considerable bene-fits for therapeutic work.

CONCLUSIONS

Despite the limitations of the current study (a rela-tively small number of respondents and low responserate), our survey has enabled us to begin exploringthe level of interest in the content of delusions andhallucinations among contemporary clinicians andresearchers, and the reasoning involved in clinicians’decision-making concerning whether or not to attendto content. From our findings it would seem that the

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paucity of research on this topic belies the frequencywith which content is actually addressed in currentclinical practice. Yet, participants identified a numberof factors that may contribute to a reluctance toattend to content. Some of these deterrents werepragmatic in nature (e.g. workload, limited provisionof supervision) while others seemed to stem from the(traditional) way in which delusions and hallucina-tions are conceptualized (e.g. as meaningless phe-nomena, and the view that attending to them couldcompromise a clinician’s professionalism (in the eyesof colleagues) and perhaps even imperil her/his ownsense of reality).

Further research is needed to gain a more detailedunderstanding of clinicians’ and researchers’ viewsconcerning the utility of attending to delusional andhallucinatory content. Given the lack of literatureaddressing content,

4

there are numerous opportuni-ties for further research in this area. Of particularimportance would be an investigation of the impli-cations for clients when practitioners attend, or failto attend, to the content of their delusions andhallucinations.

ACKNOWLEDGEMENTS

We wish to thank all those who participated in the study. We are also grateful toMargaret Francis and Jeffrey Burke for the technical assistance with the online versionof our survey, and Raymond Nairn for providing helpful comments on an earlier versionof this paper. The present study was partly supported by a University of Auckland PhDscholarship to Yasmin Aschebrock.

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