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STRATEGIES FOR WORKING WITH DELUSIONS Toni Rose G. Gimenez, RN 1. Establish a trusting, interpersonal relationship. Do not reason, argue, or challenge the delusion. Attempting to disprove the delusion is not helpful. Assure the person that it is safe and no harm will come. Do not leave the person alone, use openness and honesty at all times. Encourage the person to verbalize feelings of anxiety, fear and insecurity. Offer concern and protection to prevent injury to self and others. Convey acceptance of the need for the false belief. It is more helpful to talk about the experience that may have triggered the delusion. Center on the patient as a person, rather than on the need to control symptoms. Remain calm. 2. Identify the content or type of delusion. Assist in understanding the patient and the purpose of delusion. Clarify any confusion about the verbalization by asking what the patient is saying. If you do not attempt to clarify confusion, the result may be even greater confusion, anxiety and reaffirmed delusion. Identify the presence of a central topic. Identify the presence of a central feeling tone. 3. Investigate the meaning of the delusion. Assess areas in the persons life he can no longer manage, control or participate in. Assess the concrete ways the delusion interferes with functioning or may explain malfunctioning to the person. Ask whether the person has taken action based on the delusion. Without agreeing or arguing, question

the logic or reasoning behind the delusion. 4. Assess the intensity, frequency and duration of the delusion. Fleeting delusions are able to be worked with in a short time frame. Fixed delusions that have endured over a long time may have to be temporarily avoided in order to prevent them from becoming stumbling blocks in the relationship. Does the person always greet you with the delusion? If so, quietly listen and then give direction for the task at hand. If it appears the patient cannot stop talking about the delusion, ask gently if he recalls what you have been doing and that its time to resume that activity. If the patient is very intent on telling the delusion, just quietly listen until there is no need to discuss it any further. Remember, it is helpful to give the person reassurance during the delusion that he as a person is okay. 5. Identify what triggered the delusion. Assess for a change in the persons ability to manage activities of daily living, since delusions can be triggered by minor changes such as alterations in the daily schedule. Anything that is potentially disruptive to the person can trigger delusions. 6. Identify current major stresses. Assess if the person is under exaggerated stress (financial, family or job difficulties). 7. Correlate the onset of the delusion with the onset of the stress. Help the patient connect the false beliefs to time of increased anxiety; if the person is able to interrupt escalating anxiety, delusional thinking may be prevented.

Becoming anxious and avoiding the person. 8. If the patient asks you directly if you believ the delusion, respect that this is the patients experience. Always present reality to the patient who is delusional, without listening or invalidating his perceptions. Reinforce and focus on reality. Talk about real events and real people using real situations to divert the patient away from a long, rambling conversation. 9. Identify emotional needs the delusion may be meeting. Respond to the underlying feelings rather than the illogical nature of the delusion. This will encourage discussions of fears, anxieties, or anger without assuming the delusion is right. The person generally attaches the emotional tone of the first experience of the delusion to each successive experience with that particular delusion. Use the process of the conversation rather than the content by reflecting the feeling the feeling back to the patient. 10. Promote activities that require attention, physical skills, or action. When a persons energy is diverted, pathological thinking is interrupted, satisfying activities will help the person give up time used in delusional thinking. 11. Recognize healthy aspects of the patients personality. This will help the patient to doubt own delusional perceptions. 12. Structure situations so it is difficult to spend time in a delusional system, this encourages alternative methods of meeting needs. BARRIERS TO SUCCESSFUL INTERVENTION FOR DELUSION This leads to annoyance, anger, a sense of hopelessness and failure, feelings of inadequacy, and potential laughing at the patient. Reinforcing the delusion. Do not go along with the delusion, especially to get cooperation of the patient. Attempting to prove the person is wrong. Do not attempt a logical explanation. Setting unrealistic goals. Do not underestimate the power of a delusion and the patients need for it. Becoming incorporated into the delusional system. This will cause greater confusion for the person and make it possible to establish boundaries of the therapeutic relationship. Failing to clarify confusion surrounding the delusion. If the nurse does not clearly understand the complexity and many intricacies of the delusion, the delusion will become more elaborate. Being inconsistent in intervention. The intervention plan must be firmly adhered to. Try anything approaches lead to inconsistency and the person is less able to identify reality. Seeing the delusion first and the person second. Avoid saying the person who thinks hes being poisoned. STRATEGIES FOR WORKING WITH PATIENTS WITH HALLUCINATIONS 1. Establish a trusting, interpersonal relationship.

If you want the person to open up, you must express feelings in an open, honest and direct manner. You will elicit the behavior you emit- if you are frightened, the individual will be frightened. Have as consistent a routine as possible. Be patient, show acceptance, and listen. Always remember the individual is experiencing anxiety, fear, loneliness, and low self-esteem, and the brain is not processing stimuli accurately. 2. Assess for symptoms of hallucination. Look at and listen to the person for clues the hallucination is in the beginning level of intensity. Behavioral clues include grinning or laughing inappropriately, moving lips without speaking, rapid blinking, slow verbal responses, silence, or making frequent telephone calls. Be Patient and listen when the patient is ready to talk. 3. Focus on the symptom and ask the person to describe what is happening. The goal is to empower the person by helping understand the symptoms experienced or demonstrated. This helps the person gain control of the illness, seek help, and hopefully prevent the hallucination from reaching a greater level of intensity. Be patient and use active listening techniques.

manage symptom intensity. The combination of brain disease and drugs or alcohol may cause irreparable harm and promote a long relapse. 6. Help the person describe and compare the present and recently past hallucination. You need to find out what the person is seeing, hearing, tasting, touching, or smelling to begin to discover if a pattern exists. Encourage the person to remember when hallucinations first began. This process is similar to taking medical history regarding any other symptoms. It is nearly impossible to understand the present without a clear understanding of the past.

4. Identify if drugs and/or alcohol has been used. You need to find out if the person is using street drugs and/or alcohol. You need to teach that this is extremely dangerous and a general rule of thumb is that one beer will act like a six-pack. Many persons turn to illicit drugs or alcohol as a coping mechanism or as a quick means to

7. Encourage the person to observe and describe thoughts, feelings, and actions, both present and past, as they relate to the hallucination. Frequently, people with schizophrenia appear to be able to turn their symptoms on and off. Many have learned how to survive this illness by covering up symptoms to appear normal. It takes tremendous energy and concentration to control the illness. If you listen for at least 15 minutes, the person will usually be able to talk about their cognitive and perceptual symptoms and provide clues to the underlying psychosis. Remember not to imply blame, since everyone involved in patient care shares in the responsible management of this illness. 8. Help the person describe needs that may be reflected in the content of the hallucination. Emotional needs can be categorized into four: a. ability to express anger b. having power and control of decisions that affect daily life

c. feeling ego syntonic(attuned to) with sexuality d. experiencing positive self-esteem

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8. Help the person describe needs that may be reflected in the content of the hallucination. If one or more of these needs are not met for any of us(family members, consumers, providers) we also will experience emotional distress. Try to step into the shoes of an individual with brain disease who is already impaired in the ability to accurately interpret reality. Then add the effects of extra stress of unmet needs. For survival of the self, hallucinations may partially reflect these unmet needs.

11. Identify how other symptoms of psychosis have affected the persons ability to carry out activities of daily living. This means sharing your concerns and providing feedback regarding persons general behavioral responses. By assisting the person with the symptom identification and recognition of the effect of symptoms on ADL, self esteem will be increased, anger will be diffused, and the person will feel in control of the symptoms instead of feeling that the symptoms are in control.

9. Help the person identify if there is a correlation between the hallucination and the needs it may be reflecting. Focus on the unmet emotional need the person may be experiencing and discuss if there is a relationship with the appearance of hallucinations. Encourage the person to keep a chart or calendar of when hallucinations occur and how long they last in an effort to identify the trigger.

10 . Suggest and reinforce the use of interpersonal relationships in meeting the need. It is important to find one individual who will give honest feedback to help the person sort out reality from the hallucination. This individual must be readily accessible to the patient. Remember that anxiety reduction is the key intervention to interrupting hallucinations.