Working with delusions

“I have a client with a delusion that others are harassing him (coughing at him, making noise to disturb him). This was triggered by the recent loss of a girlfriend who suddenly broke off the relationship. After revealing intimate details of the relationship, he appeared embarrassed so I asked him “what was it like to share this with me?” He said that he trusts me, and felt good talking here- like talking to a friend that he can trust. I went on to help him experientially deepen the felt-sense of the trust with me in the session.

Here’s the question: You said, “You have to work with delusions if the patient is going to have a realistic therapeutic alliance with you instead of a delusional misalliance” and “delusion is a defense that distorts the relationship with the therapist” In this example, it doesn’t seem that he is projecting his delusion in the transference with me, i.e., there is no overt misalliance, given his experience of trust in-session (contrasted to the mistrust w strangers in his neighborhood). Am I missing something here?” Thanks for this important question!

Let’s look at the triangle of conflict:

Stimulus: girlfriend leaves him

Feelings: anger, grief, love

Anxiety: cognitive/perceptual disruption

Defense: delusion/projection—others (not my girlfriend) are harassing and disturbing me. In fact, he is quite disturbed by his feelings; self-attack: embarrassment.

By focusing on other people through his delusion, he avoids the feelings he has toward her for leaving him. The fact that he equates his projections with reality means that this is a delusion and his reality testing is impaired. At this level of fragility, monitor very carefully any feelings the patient has with the therapist. Since the patient can tolerate only a small amount of feelings before he becomes delusional, help him with any feelings toward the therapist so he can integrate and experience them without having to get rid of them through projection.

In this case, the therapist very wisely checked in with the patient after he had shared some important material.

Th: What was it like to share this with me?

Pt: I can trust you and I feel good about sharing with you.

However, the patient had looked embarrassed. Thus, we know the patient is feeling more than just “good.” Unable to tolerate mixed emotions easily, these patients will split off negative feelings and project them elsewhere to maintain a positive connection with the therapist. But this prevents them from developing closer, more complex relationships with loved ones. So the therapist could continue as follows.

Th: I’m glad you feel you can trust me and that you feel good. However, since you’re also feeling embarrassed, I wonder what other feelings might also be coming up here toward me?

Pt: I like you.

Th: Of course you do. But if that was the only feeling you wouldn’t be feeling embarrassed too. So can we take a look to see what other feelings are coming up here toward me? [Always acknowledge the fact he likes you so he can acknowledge also his other mixed feelings. The fact he likes you is true. It’s just he uses this as a defense to avoid facing the other feelings that are also true.]
There is no evidence in this vignette that the patient is has a delusion regarding the therapist. However, the embarrassment shows that he has mixed feelings toward the therapist. Help the patient bear these mixed feelings here, so he can gain the ability to do so in other relationships.

Remember: whatever feeling he does not face toward the therapist will get projected onto others or onto the therapist. By helping him experience mixed feelings at higher levels, we reduce his need for projection and delusion, making it possible for him to navigate personal relationships successfully.

Let’s not forget the three forms of resistance:

Isolation of affect: I detach from you and from my mixed feelings

Repression: to protect you from my anger I turn it on myself and acknowledge my love and grief to you

Projection: I cannot tolerate mixed feelings within myself, so I project some aspect of myself onto others or you (my feelings, my anxiety, or my defense, e.g., self criticism)

Anytime a delusional patient has mixed feelings toward you, help him face those feelings toward you. That builds his affect tolerance, reducing his need to use projection. When he describes mistrust of others, he delusional patient invariably mistrusts you. Explore those mixed feelings and any mistrust with you. That will build his capacity to bear mixed feelings and improve his realistic alliance with you: one based on the inevitable mixed feelings that arise in any human relationship. Soon he learns that you can tolerate his mixed feelings toward you and that he does not have to protect you from them by having a delusion instead.


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