Helping Patients With Persecutory Delusions Find Safety

At the heart of a persecutory delusion is an incorrect perception of threat from others. This makes the person feel very unsafe. Overcoming such delusions therefore means establishing a sense of safety, and thus a realisation that there is no current threat. Discovering that one is safe functions as the counterweight to feeling unsafe. The counterweight shifts expectations and changes beliefs. In this article, we describe how safety may be learned. This includes how to engage patients, framing the finding of safety, switching from threat to safety mode, using experiential learning, and consideration of blocking beliefs that may prevent new learning. Key points are to: frame intervention as an opportunity to find greater safety in the world so that meaningful activities can be resumed; repeatedly measure the learning of safety; make new benign associations with the internal and external cues driving the delusions; keep the new learning to the present and future, suitably circumscribed for an individual, so that potential for discord is limited; carry out safety-establishing behavioral experiments that allow for the dropping of defense behaviors, the reframing of evidence for the delusion, and diminish the pervasiveness of the perceived threat; and help patients move from situation-specific instances of safety to more generalised belief change. Enabling patients to re-discover safety in their everyday lives-decisively tipping the scales in favor of the counterweight-is the most transformational element of successful psychological intervention for persecutory delusions.