Working with delusions

“I had a client who was fragile and had a delusion that I was using her videotaped sessions to exploit her. She expressed what I believe was a delusion that a young woman at work was staring at her and was sexually interested in her. I gently explored what evidence there was for this woman being sexually interested. My client got very angry with me. She said I didn’t believe her and think she’s “crazy”. Then she said that I was going to tell her psychiatrist that she’s crazy and that I didn’t understand her at all. She raised her voice, started cursing, and stormed out of the session, saying that she wasn’t coming back.

When she said she was “frustrated” with me for not believing her, I asked her how she experienced the frustration physically. But she was not interested in exploring it with me because she was angry, convinced I thought she was crazy. I know I should go VERY slowly in exploring projections, but do you have any other suggestions?” Should I have persisted in exploring her anger toward me? Thanks for this important question!

When a patient has an irrational perception about you but realizes it is irrational, we call it a neurotic transference. When the patient cannot differentiate the reality of you from her fantasy, we call this a psychotic transference. She has lost her reality testing, relating to her projection, not to you. Thus, we have no reality-based alliance at that moment. So our first task is to re-establish reality testing.

When the patient relates to her projection, any exploration you do will confirm her projection. When you explore, she may take that as evidence you think she is crazy. If you explore her anger at you (really at the projection onto you), her anger and projection will only increase. That’s why we do not explore rage toward a projection. It will deepen the psychotic reaction.

Let’s examine the triangle of conflict. The patient believed a woman at work was sexually interested in her. This suggests that she has positive feelings toward someone at work, and she projects that this person has positive feelings toward her. These feelings are sexualized. In the transference, this suggests that she has positive feelings toward the therapist and thinks the therapist has positive feelings toward her. Those feelings are sexualized too. However, this poses a danger. As soon as she is in touch with her positive feelings, underlying complex feelings also are poised to rise.

These mixed feelings trigger a rapid rise of anxiety, leading her to use the defense of projection.


“You think I am crazy.” [She has an emerging awareness that she has irrational perceptions.”

“You are going to tell the psychiatrist that I am crazy.” [She is telling herself that she is crazy, but fears that the therapist will do this.”

“You don’t understand me.” [She does not understand herself. She also fears that the therapist will project onto her. Thus, viewing the therapist as a threat to her sanity, she curses at the therapist and runs out of the office. Now she completely equates the therapist with her projection.]


Pt: “You don’t believe me.”

Th: “Since I wasn’t there, I’ve never met her or talked to her, so I can’t know what is in her mind.” [Reminding the patient of reality.]

Pt: “Do you believe me?”

Th: “The question is whether I believe your thought. There is a thought that she was attracted to you. And then you believe your thought. Since I wasn’t there, I haven’t met her. So I can’t know if your thought fits her or not. It’s ok with me if you believe your thought. Is it ok with you if I don’t know?”

Help her differentiate herself from a thought and then point out her relationship to the thought. Then deactivate her paranoid transference that there is room for only one mind in the room (“Do you believe me or do I have to believe you?).

Pt: “You think I’m crazy.”

Th: “That’s a thought about me. But is there any evidence that I have that thought?”

Pt: I just feel it’s true.”

Th: “So let’s see if there is evidence that matches your feeling. Is there any evidence I am having that thought?”

Pt: “I think this woman is sexually attracted to me. I notice she was looking at me.” [Referential thinking: imagining that actions and words of others refer to oneself.]

Th: “Are there any other reasons she could have been looking at you?”







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