Thursday, August 31, 2006

Trying To Reason With the Paranoid

On my 13-bed acute involuntary unit seven of the current patients are paranoid, an unusually high percentage. I have therefore spent a lot of the last week trying to reason with paranoid people, and I am wondering whether there is any insight to be gained for use in reasoning with paranoid governments or leaders. It is difficult to separate out the obsessions and misinterpretations by victim cultures from true paranoia; in unstable countries, it is also hard to tell what actions by leaders are actually paranoid, as it is true that some people are plotting against them and want to kill them. Most importantly, paranoia of the schizophrenic variety is a brain illness, not a cultural or personal expression, and it may not illuminate the cultural paranoia of nations in any way.

Still, I will follow the trail and see where it leads.

It’s easiest if one doesn’t have to deal with them at all, of course, and it is best not to go looking for extra arguments solely for the purpose of telling them their world-view is wrong. But the nature of hospital commitments – as well as life in general – is that they must be approached to have various rights explained to them, questions asked of them, signatures sought, and life-tasks to accomplish (like getting up, eating, hygiene). I am heavily involved in the first three of those. Do you want an appeal hearing? Can we call your parents?

Simple questions provoke angry tangents. “Why the f- am I here? Do you think it’s fair for the police to break in without knocking and drag me to the ER where I didn’t see a doctor, just a b- nurse who lied to me…” Fierce anger may be apparent even under the attempt to appear calm. “I’d prefer that you not call anyone. I’ve decided that those relationships are toxic for me. My mother has been very interfering.” Suppressed rage, voice dripping with polite venom, can be worn as a badge of honor – supposed proof that the speaker is in control and gentle, surrounded by angry, out-of-control others. This is more common in women, but I won’t guess whether that is biological or socially conditioned.

Interviewing a patient for information may elicit anger, but the interviewer can adopt a pliant or accepting posture to deflect confrontation. Others are not so lucky. When the law requires not only that a patient must have his rights explained fully, but signatures and permissions acquired, the sidestepping of anger can go on endlessly, until a halt must be called. “You may have valid complaints, but that’s not what we’re discussing now. I need you to decide if you want an appeal or not. You can change your mind later. There is no wrong answer. It’s entirely your choice…” Non-decisions must at some point be declared decisions, and then that has to be explained to them. There are some stalemates that cannot go on forever. You must move from here or we will move you.

Paranoid patients are not the only ones to present this difficulty, but the intensity is greater at the point of conflict. It is also more surprising, because it can surface after a pleasant conversation on other subjects. Especially in late-onset paranoid schizophrenics, much of the personality has been formed competently before the intrusion of the voices or delusions, and the patient can rattle on with easy animation about sports, literature, or humor.

The fury proceeds from some issue that is of overriding importance to the patient. The police really are beaming infrared rays into their apartment. Other people really must hear those voices, but pretend not to. Mites really do infest all the clothing, and must be sealed off. A personality disordered patient may grudgingly acknowledge that his father is merely stupid and selfish rather than vindictive. People with depression can understand that there may be another way to look at things, even if they cannot bring themselves to it. But a person with paranoia will have none of that. There is a fierce insistence on a single interpretation of the issue – there is no other way to understand events. The rest of the world may not believe that satellites are beaming messages into some people’s brains, but it is true nonetheless.

To person in the grip of paranoia, this issue must be dealt with and acknowledged by others before any discussion can proceed. The things the doctors and nurses want to talk about are considered merely derivative issues. I was only violent because I was falsely accused and mistreated by the police. Of course everyone should eat, but I refuse to eat the flesh of babies. If the exterminator had done their job right and gotten rid of the bugs, I wouldn’t have had to set the floor on fire. If the priest had preached on the prophecy I wrote to him, I wouldn’t have said that God should strike him dead.

If this is sounding a bit like Iran or North Korea to you at this point, I am wondering that myself.

To try and prove themselves right on this key issue, people of many diagnoses, but especially those with paranoia, will fasten on the most amazing details as evidence, rapidly twisting them out of recognition. You’re saying that what I put into my body isn’t important… (No, I’m saying that side effects that you don’t have aren’t important to discuss) You won’t let me meet with my attorney… (You may meet with your attorney when she comes here. You cannot go there.) The replies in parentheses are more hypothetical than the complaints, because you usually don’t get to complete your sentence. Those are the types of things I am usually trying to say.

This sounds more like Hamas and Hezbollah than Iran, actually.

Next up, a look at what strategies work, or more usually, don’t work.


jw said...

Yes, I see your point and it's a good one.

My concern is and has always been when the therapist is seriously wrong on a point of fact. Martha Mitchell error I believe it is called, from her saying that there's been a break-in and it is serious while the therapist says she's being paranoid ... all the while she is quite right and later proven so.

As I've been down that road it is of major concern to me. Worse, to me, is the general attitude in the therapeutic community of "that doesn't matter."

The therapeutic community is still very loud and vociferous in their demand that women do not hurt men and that the law would never allow for discrimination against a male and ... blah blah blah. Needless to say, Martha Mitchell error abounds.

Some means of checking for serious error is clearly needed. I see no effort going in that direction and that worries me.

Anonymous said...

I think you make a superb comparison between the paranoid mindset of Islamofascist regimes/terrorist groups and the paranoid beliefs/behaviours of your patients.

Just a question: Do you negate the false beliefs of your patients to their faces, ie. do you explain to them that aliens really aren't beaming rays into their minds? Or do you just ignore those claims and focus on information gathering/emotional validation?

I have a client who suffers from paranoid schizophrenia. He has fixed delusions. He calls the Crisis Line service at my work anywhere from once to seven times a day to report on impossible things he believes are happening (which are part of his delusions). I've tried many times to challenge his beliefs in a gentle, logical way, but this just makes him VERY angry. And yet, I feel that if I don't challenge the delusions, I'm feeding into his illness. What do you think?

Assistant Village Idiot said...

There is an almost zero success rate either way. I have not seen any direct confrontation, even of the "I understand it seems that way to you, but a)I don't share that impression, b)other people find that implausible, c)let's agree to disagree work in the short term.

OTOH, lack of pressure on the beliefs does seem like tacit agreement and encouragement.

One common strategy is to focus not at all on statements and to stick with actions. "What do you think you should do about that?" "What do you think the outcome will be?" "What we happen if you do nothing?"

But as I note in the later post, the long pressure of the environment only works on mild to moderate paranoia, and even that incompletely.

Mark said...

My uncle also a Bible thumping NH conservative worked at your mental hospital in Concord during his CO days during WWII. He had the good sense to leave though and pursue other things. That you haven't is telling, but I suppose you both would buy into the same "Joe Wilson lied crapola." What part of no nuke program or yellowcake can't you people get? I think the part that says there isn't any and wasn't despite a feeble attempt to potrentially get some that Wilson reported as not coming to fruition.

I se epolitics as this: when people ignore reality in favor of a politial belief they're around the bend. Maybe there's a bed there for you?

Assistant Village Idiot said...

Gee Mark, it would be a powerful argument, except that Joe Wilson did lie, there was a nuke program, and Iraq did try to buy yellowcake from Niger. You should catch up with the news since 2003.

Assistant Village Idiot said...

Correction: They've found 700 chemical weapons, and a nuke program.