Paranoia and Psychosis: Insights from Relational Frame Theory

I am excited to introduce Dr. Corinna Stewart, a post-doctoral researcher at the University of Glasgow’s (Scotland) Institute of Health and Well-being. Corinna is a gifted young researcher with a great facility for seeing the utility in paradigms and methods developed in cognitive approaches to mental health to potentially be more usefully adapted for a functional behavioral science understanding and conceptualization. She researches a wide variety of complex mental health and wellbeing concerns including paranoia, psychosis, and suicide. At conferences Corinna is an excellent and assured disseminator of behavioral science, and a great role model for all young budding psychologists and researchers. She is a new mum and currently enjoying the delights of motherhood! Enjoy this wonderful, sophisticated, and thought-provoking blog on paranoia and psychosis. – Dr Ian Tyndall, University of Chichester, UK

“I just think people are evil.”

– “How do you know they’re evil?”

“They just are.”

– “What is it that tells you that they’re evil? Like, is it something that they say or do?”

“Just like, if I see a group of lads hanging around when I’m out walking… I just think they might be… Like they might do something.”

– “And what do you do in those circumstances?”

“Well I just stare at them and give them a [menacing] look.”

This exchange is from an interview I had several years ago with John*, who had a diagnosis of psychosis. John had experienced physical and psychological abuse as a child. He now lived in a deprived neighborhood, struggled to trust others, and experienced paranoia and depression. A few things struck me as John and I talked. Firstly, I thought “If these were my early experiences and my circumstances now, I’d feel paranoid too.” John’s belief that people are “evil” was deeply ingrained and held with strong conviction, with little room for elaboration or nuance. Furthermore, he seemed unaware of how his hostility towards others, motivated by efforts to protect himself, might elicit unpleasant reactions from others, further reinforcing this belief.

My conversation with John had a real impact on me, and in hindsight, it planted the seed that ultimately flourished into my PhD program on paranoia. Briefly, paranoia involves the belief that harm is occurring or will occur and that a perceived persecutor is deliberately trying to cause that harm. It can be exceptionally debilitating and is often associated with other mental health difficulties (e.g., depression) and poor social functioning. To date, paranoia has mainly been studied by researchers operating from the cognitive clinical perspective. This research has greatly improved our understanding of paranoia and led to the development of helpful treatments. However, I believe that Contextual Behavioral Science (CBS) and Relational Frame Theory (RFT) can also provide important inroads for conceptualizing, studying, and ultimately influencing paranoia.  My research has involved bringing the two approaches together for this purpose.

One of the main reasons I personally gravitated towards a CBS perspective, is that there is something inherently compassionate about adopting a functional approach to mental health difficulties such as paranoia. If we start from the perspective that paranoia is a (set or class of) behavior and seek to explain that behavior in terms of the learning history that gave rise to it, and features of the current context that trigger and sustain it, then a whole new vista is openened. When dealing with sufferers the focus shifts from “What’s wrong with you?” to “What happened to you?” and such a stance offers a whole host of new insights into how we can predict-and-influence paranoia.

Cognitive researchers have long recognized the importance of exploring the impact that trauma has on the development of paranoia. Many propose that paranoid beliefs are likely to form if the individual already believes that they are vulnerable, or because they view the world as hostile and threatening, perhaps based on previous traumatic experiences. In my research, I used an experimental approach to better understand the impact that environmental factors have on paranoia. For example, I exposed participants to an aversive experience: social exclusion. Results consistently showed that events like these are followed by a rise in paranoia, especially for people who experience more distress with respect to paranoid ideas and beliefs.

While paranoia may be initially established by direct adverse experiences, paranoid beliefs can develop towards people who we’ve not even encountered before. For instance, John was fearful of strangers. Thus, from a CBS perspective, the question becomes: how do people come to fear and avoid others when they have not had any direct aversive experiences with them? RFT might provide an answer. In a recent study, we asked participants to imagine that they were a street performer. They were trained to form two equivalence classes each comprised of three men (e.g., Bob-Paul-Peter; Sean-Mike-Tim). They were approached by one member of each class, one of whom robbed the participant (Paul), the other did nothing (Mike). We found that 44% of participants avoided Bob and Peter, even though they did not directly experience threat with these two individuals. We labeled this sub-sample of participants ‘generalizers’ and the rest of the sample as ‘non-generalizers’ (we did so because the former ‘symbolically generalized’ what they learned about one individual to others who were part of the same ‘group’ [equivalence class]). Interestingly, the generalizers reported higher threat anticipation for Bob and Peter than the non-generalizers, while the non-generalizers also showed reductions in threat anticipation for Bob and Peter. Put simply, exposure to Bob and Peter in the absence of threat led the non-generalizers to re-evaluate and modify how they evaluated these individuals. These findings demonstrate that people can come to fear or avoid stimuli not based on direct experiences with them, but due to how they are related to other stimuli that have threatening functions (e.g., Bob and Peter were related to Paul, who was threatening).

There are two things I want to highlight here. Firstly, many people who experience paranoia engage in safety behaviors (typically avoidance). When someone engages in avoidance and the feared outcome does not occur, they may (incorrectly) conclude the safety behavior actually protected them from harm. In other words, their behavior can increasingly come under the control of verbal ‘rules’, such as “Other would hurt me if given a chance so I should avoid them”, rather than other contingencies in the environment (e.g., people would typically not hurt them if given the chance). And these rules are technically correct and coherent from the person’s perspective (“I stayed inside away from others and I didn’t get hurt”). This may help explain why paranoia is so resistant to extinction. If we think back to our study, the generalizers may have decided that Bob and Peter were a threat and should be avoided. They avoided Bob and Peter and weren’t robbed and so may have concluded that their avoidance protected them from harm. However, if they’d encountered Bob and Peter directly, like the non-generalizers did, they would have learned that Bob and Peter weren’t threatening at all and would have modified their beliefs. The problem is rule-governed behavior like that mentioned above, comes to limit the person’s behavioral repertoire so that they may even eventually stop engaging in meaningful activities (e.g., rewarding relationships) and focus almost exclusively on avoiding perceived danger.

CBS research on paranoia is still in its infancy, but this suggests a promising new avenue for future research; examining factors that undermine (rule-governed) avoidance and promote contact with other contingencies not specified in the rule. This could have important clinical applications: it would help identify variables that enable individuals who experience paranoia to discriminate whether threat is actually present or not and to respond accordingly.

Bringing together empirical insights from RFT research with psychotherapies such as Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT) may open up exciting new avenues for effective interventions that can help those who struggle with paranoia. These therapies involve teaching people who experience paranoia to monitor their paranoid thoughts and identify ‘triggers’, assess their environment and modify their behavior accordingly, as well as help sufferers develop useful coping strategies. The ultimate goal is to alleviate suffering and support people like John to live vital and fulfilling lives and combining these diverse approaches may help achieve this.