Efficacy of an emotion-oriented cognitive behavior therapy for delusions (CBTd-E) compared to waitlist in a single-blinded randomized-controlled trial

Why Feelings Matter in Unusual Beliefs

People living with psychosis often struggle with fixed, disturbing beliefs—called delusions—that do not easily shift, even with medication or standard talk therapy. Many of these individuals say what troubles them most is not just the strange thoughts, but the powerful emotions that come with them: anxiety, shame, sleeplessness, and low self-worth. This study tested whether a new form of psychotherapy that focuses directly on emotions and self-esteem, rather than on debating unusual beliefs themselves, could ease delusions and improve overall well-being.

A New Emotion-Focused Therapy Approach

The researchers developed an emotion-oriented version of cognitive behavioral therapy for delusions, called CBTd-E. Instead of primarily challenging the content of delusional beliefs, CBTd-E helps people notice and understand their feelings, regulate intense emotions, improve sleep, and work on negative views of themselves and others. The treatment is divided into two modules over six months: the first targets emotion awareness, coping skills, worry, and daily routines that support emotional stability, including sleep; the second focuses on deep-rooted self-beliefs, encouraging self-acceptance and healthier self-esteem through exercises like guided reflection, role-play, and behavioral experiments.

How the Study Was Carried Out

The team ran a randomized controlled trial across three outpatient clinics in Germany. Ninety-four adults with psychotic disorders and ongoing delusions took part. All continued their usual psychiatric care, including medication, but half were randomly assigned to receive 25 individual CBTd-E sessions over six months, while the other half were placed on a waitlist and received only standard care during that period. Participants completed interviews and questionnaires at the start of the study, after three months, and after six months. These covered delusional symptoms, other psychotic symptoms, mood, everyday functioning, sleep problems, worry, emotion regulation skills, and self-esteem.

What Improved and What Did Not

At the end of six months, CBTd-E did not show a clear statistical advantage over the waitlist in reducing the main measure of delusions, although there were hints of a small-to-medium benefit. In other words, the strength and impact of people’s unusual beliefs did not reliably drop more in the therapy group than in those who waited. However, the therapy did lead to measurable improvements in several important areas. People receiving CBTd-E showed better overall psychiatric health, less worry, better sleep, more frequent use of helpful emotion regulation strategies such as cognitive reappraisal, and higher self-esteem compared with those on the waitlist. These gains tended to appear in line with the therapy modules: changes in emotion skills, worry, and sleep emerged after the first three months, while improvements in self-esteem followed the later schema-focused work.

What This Means for Patients and Therapists

Even though CBTd-E did not substantially reduce delusions within the six-month window, it did help people feel emotionally steadier and better about themselves. Many patients say that feeling less overwhelmed, worrying less, sleeping better, and being kinder to themselves are central goals in their own right, sometimes more important than changing their beliefs. The study suggests that a therapy focused on emotional life can be a valuable option for people with psychosis who prioritize well-being and coping over directly confronting their delusions. It may also plant seeds for longer-term change in distress related to psychotic symptoms.

Next Steps Toward More Personalized Help

The authors conclude that CBTd-E, on its own, cannot yet be recommended as a stand-alone, evidence-based treatment specifically for reducing delusions. However, because it clearly improved emotion regulation, sleep, and self-esteem, it could serve as an important building block in broader, more tailored treatment programs. Future work may combine CBTd-E with other focused approaches—for example, therapies that target reasoning styles or safety behaviors—and allow patients to select modules that best fit their personal difficulties. Such personalized, modular care may ultimately offer stronger and more lasting relief from both the emotional burden and the unusual beliefs that define psychosis.

Citation: Mehl, S., Hautmann, C., Schlier, B. et al. Efficacy of an emotion-oriented cognitive behavior therapy for delusions (CBTd-E) compared to waitlist in a single-blinded randomized-controlled trial. Schizophr 12, 29 (2026). https://doi.org/10.1038/s41537-026-00737-y

Keywords: psychosis, cognitive behavioral therapy, emotion regulation, delusions, self-esteem