I've been thinking a lot this last year about how to approach someone with paranoid delusions, as unfortunately I had a delusional friend. I don't have any medical authority over my friend, but I took a similar line. I quickly realised direct confrontation of facts wouldn't work, so I tried to take an agree-to-disagree type approach. In the end I expressed too much doubt about some thing (whether some public figure had really been assassinated) and when my friend went stopped taking antipsychotics and the delusions worsened, my name got plastered on social media as a secret agent engaged in spying.
I'm not really sure there was a way to avoid that and also still be friends. Obviously the approach most people take is to consign people like this to institutional oblivion, but everyone needs a friend.
I'm sorry this happened to your friend and to your relationship with him. Your friend sounds like they are very lucky to have someone who cares so much about them, even if they are unable to realize it at the moment. It is hard for us as humans to show caring and tolerate the angry and often hateful rejection of our attempts at connection, especially when we do not know if anything will come of it. One day, I hope your friend comes to realize what you are offering them and can accept it.
This post was quite emotionally difficult for me to read and process. I don't mean that as an indictment. I read it when you originally posted it, and came back today to see if it landed differently, or if I could work out for myself why it had such a strong effect. It hit softer on the second read, but wasn't much different in quality. I've come to identify two initial registers of feeling and two initial conclusions about this experience.
First, the aspects your post that related to questioning patients' trans identity felt alarming to me in relation to my experiences as a trans person who has gone through and received treatment for a temporary period of psychosis (in which the stress of gender dysphoria and denying my own trans identity to myself seems to have been a significant factor). "Trans=delusional" is already such a common and damaging stereotype, and it's even nastier to deal with if you've actually had or have delusions. While I really, really hope that psychiatric professionals are in fact able to ethically discern gender from gender-related delusions in a way that makes them worthy of their patients' trust, I also can't ignore how quick members of the general public are to use their equivocation of transness and delusion to try to put you in your place. Choosing to believe that a given medical professional won't do the same (which I want to do, in at least some situations)--in order to do that, I have to actively suppress strong and experientially well-founded instincts for the preservation of my safety and dignity. I know not everybody in our demographics will have the same experiences or instincts. More that I feel taken aback by just how brightly those alarm lights started flashing when I got to those parts of your post.
Second, you post felt quite uncanny to me for another reason: the strategies you recommend for interacting with delusional patients are pretty much a carbon copy of the ones I've worked out on my own, as a trans person, for dealing with the wide range of precious misconceptions that cis people entertain about trans people (I won't even call them prejudices because half the time, it ain't even "pre" the "judice", it's just bad "judice", eyes wide open.) But, yeah. Reflexive collusion with those precious misconceptions will only make things worse for you and others down the road. Collaborate only when you are under threat and only to the extent necessary to de-escalate to an acceptable risk level. Validate their feelings as feelings, not as facts (and don't expect them to consider your feelings). If engaging seems beneficial, redirect their attention to the factual exigencies of the situation with a factually grounded and confidently delivered explanation, and don't pretend to have answers you don't. Pick your battles, know your own tendencies and energy and when not to engage at all.
Thanks for sharing your thoughts! Making patients feel comfortable enough to, as you put it, "suppress strong and experientially well-founded instincts for the preservation of my safety and dignity" (in other words, to trust us!) is perhaps one of the most fundamental parts of our work.
Thank you so much for this beautiful narrative. You articulated the issue of political and non-medical influencers on care of patients well and I appreciated your rational and medically founded proposed treatment strategy.
If there was serious empirical evidence showing that doctors pretending to believe a patients delusion would lead to better outcomes would you change your approach then?
This may be a question that has no answer. Trump really seems to believe a lot of things that are not true. Could he be psychotic? And many of Trump's followers seem to be in the same place.
Psychosis encompasses much more than just delusional thinking - it is just one part of a collection of symptoms that make up the clinical syndrome. I would discourage trying to apply psychiatric labels to those whose ideas we believe to be discordant with reality without considering other reasons first.
As a cautionary example, I see from your profile that you're very familiar with Christian belief and theology; as an atheist, I might observe that the Pope seems to believe a lot of things that are not true, and many of his followers seem to be in the same place! I certainly don't think Christians are psychotic though.
Why don't I think Christians are psychotic? It's a fair question.
I already mentioned this in the comment you're replying to, but psychosis is a clinical syndrome (i.e. a collection of symptoms). Delusional beliefs are just a piece of that syndrome, which typically includes other ways in which people are untethered from reality (e.g. hallucinations) and obvious problems in their thinking (e.g. tangential speech, derailments, thought blocking). In schizophrenia-spectrum illnesses, we also see other signs of reduced psychological functioning (we call these "negative symptoms") like flattening of affect, social withdrawal, poverty of speech, etc.
Christians might have a very strongly held set of beliefs, but as a class don't have the rest of the characteristics of psychosis.
I've been thinking a lot this last year about how to approach someone with paranoid delusions, as unfortunately I had a delusional friend. I don't have any medical authority over my friend, but I took a similar line. I quickly realised direct confrontation of facts wouldn't work, so I tried to take an agree-to-disagree type approach. In the end I expressed too much doubt about some thing (whether some public figure had really been assassinated) and when my friend went stopped taking antipsychotics and the delusions worsened, my name got plastered on social media as a secret agent engaged in spying.
I'm not really sure there was a way to avoid that and also still be friends. Obviously the approach most people take is to consign people like this to institutional oblivion, but everyone needs a friend.
I'm sorry this happened to your friend and to your relationship with him. Your friend sounds like they are very lucky to have someone who cares so much about them, even if they are unable to realize it at the moment. It is hard for us as humans to show caring and tolerate the angry and often hateful rejection of our attempts at connection, especially when we do not know if anything will come of it. One day, I hope your friend comes to realize what you are offering them and can accept it.
This post was quite emotionally difficult for me to read and process. I don't mean that as an indictment. I read it when you originally posted it, and came back today to see if it landed differently, or if I could work out for myself why it had such a strong effect. It hit softer on the second read, but wasn't much different in quality. I've come to identify two initial registers of feeling and two initial conclusions about this experience.
First, the aspects your post that related to questioning patients' trans identity felt alarming to me in relation to my experiences as a trans person who has gone through and received treatment for a temporary period of psychosis (in which the stress of gender dysphoria and denying my own trans identity to myself seems to have been a significant factor). "Trans=delusional" is already such a common and damaging stereotype, and it's even nastier to deal with if you've actually had or have delusions. While I really, really hope that psychiatric professionals are in fact able to ethically discern gender from gender-related delusions in a way that makes them worthy of their patients' trust, I also can't ignore how quick members of the general public are to use their equivocation of transness and delusion to try to put you in your place. Choosing to believe that a given medical professional won't do the same (which I want to do, in at least some situations)--in order to do that, I have to actively suppress strong and experientially well-founded instincts for the preservation of my safety and dignity. I know not everybody in our demographics will have the same experiences or instincts. More that I feel taken aback by just how brightly those alarm lights started flashing when I got to those parts of your post.
Second, you post felt quite uncanny to me for another reason: the strategies you recommend for interacting with delusional patients are pretty much a carbon copy of the ones I've worked out on my own, as a trans person, for dealing with the wide range of precious misconceptions that cis people entertain about trans people (I won't even call them prejudices because half the time, it ain't even "pre" the "judice", it's just bad "judice", eyes wide open.) But, yeah. Reflexive collusion with those precious misconceptions will only make things worse for you and others down the road. Collaborate only when you are under threat and only to the extent necessary to de-escalate to an acceptable risk level. Validate their feelings as feelings, not as facts (and don't expect them to consider your feelings). If engaging seems beneficial, redirect their attention to the factual exigencies of the situation with a factually grounded and confidently delivered explanation, and don't pretend to have answers you don't. Pick your battles, know your own tendencies and energy and when not to engage at all.
Funny stuff, huh.
Thanks for sharing your thoughts! Making patients feel comfortable enough to, as you put it, "suppress strong and experientially well-founded instincts for the preservation of my safety and dignity" (in other words, to trust us!) is perhaps one of the most fundamental parts of our work.
Thank you so much for this beautiful narrative. You articulated the issue of political and non-medical influencers on care of patients well and I appreciated your rational and medically founded proposed treatment strategy.
If there was serious empirical evidence showing that doctors pretending to believe a patients delusion would lead to better outcomes would you change your approach then?
Yes, I would. Probably not without some difficulty, though!
This may be a question that has no answer. Trump really seems to believe a lot of things that are not true. Could he be psychotic? And many of Trump's followers seem to be in the same place.
Psychosis encompasses much more than just delusional thinking - it is just one part of a collection of symptoms that make up the clinical syndrome. I would discourage trying to apply psychiatric labels to those whose ideas we believe to be discordant with reality without considering other reasons first.
As a cautionary example, I see from your profile that you're very familiar with Christian belief and theology; as an atheist, I might observe that the Pope seems to believe a lot of things that are not true, and many of his followers seem to be in the same place! I certainly don't think Christians are psychotic though.
Why not?
Why don't I think Christians are psychotic? It's a fair question.
I already mentioned this in the comment you're replying to, but psychosis is a clinical syndrome (i.e. a collection of symptoms). Delusional beliefs are just a piece of that syndrome, which typically includes other ways in which people are untethered from reality (e.g. hallucinations) and obvious problems in their thinking (e.g. tangential speech, derailments, thought blocking). In schizophrenia-spectrum illnesses, we also see other signs of reduced psychological functioning (we call these "negative symptoms") like flattening of affect, social withdrawal, poverty of speech, etc.
Christians might have a very strongly held set of beliefs, but as a class don't have the rest of the characteristics of psychosis.
There you stand, as Pilate, mocking, laughing, "quid est veritas?" Then washing your hands, onto the next.
Have you encountered a lot of floridly psychotic patients?
Noo, but a good friend of mine was inappropriately IVC'd last year, so I have certainly seen that side of things