Working with Clients Who Exhibit Paranoia Symptoms
I have worked in Community Mental Health for a number of years, addressing the needs of some of the most vulnerable populations in our society, and paranoia symptoms are something with which with I’ve become rather familiar.
I’ve worked with folks who have refused to use computers and phones, donned disguises when going out in public, been convinced that entire blocks of random strangers are spying on them, and accused me of being an agent of some occult government order.
My Experience with a Paranoid Client
I once worked with a client, “George,” who had not seen a medical professional in almost 10 years because of his paranoia about hospitals and medical settings, and unassuageable fear that he would be detained for painful experiments and interrogation, that he would never be allowed to return home.
George had been suffering from gout for some time, and it had begun to impair his mobility, which also prohibited from working and engaging in many of the coping activities he enjoyed such as community walks and fishing. His insight into the nature and severity of the gout was very limited, and attempts to educate him were met with argument and dismissal.
In this way, his paranoia symptoms were beginning reduce his quality of life across many areas, and in doing so put his mental health recovery at risk. It was a powerful example of how severe mental illness can impact interlocking aspects of well-being from psychological to financial to medical.
For nearly a year, I noticed aloud how George’s health condition seemed to be impeding on his life, ceaselessly validated his feelings about hospitals and doctors, and in the brief and tiny moments where his paranoia lapsed, I gently affirmed my support for him to engage in healing services.
I couldn’t help but feel as though I wasn’t helping, that so many months of the same conversation appeared to be having no effect and ultimately this man would suffer increasing restrictions in his ability and wellbeing because I could not permeate his seemingly intractable paranoia. I did more independent research, sought supervision, and consulted my colleagues.
I took some time to move out of the rigor of trying to be the great problem-solver, and spent some time in my own reflection that in severe cases a person may not have the insight or capacity to join with efforts to help them reason out the paranoia symptoms. It began to occur to me to fall back on my foundational social work principles and attitudes and simply offer a committed compassionate presence while respecting George’s fundamental right to self-determine.
George Started Considering Something New
Until one day, he asked me “If we were to go to the clinic, what would they do?” I realized this was the moment those many months of listening, joining, and staying respectfully curious had lead up to. He was considering a new possibility. I told him I couldn’t know for certain because I wasn’t a medical professional, but that he and I would call them together to make the appointment.
During the call, which I put on speaker phone with George’s permission so he and I could collaborate, I helped him advocate for both his needs and understanding with the clinic nurse, the planned details of the visit, his hard boundaries (no needles, no medications, no radiation or x-ray).
When we had run the gamut of his interrogation and needs, just as we were about to hang up, he brought the question so crucial to his paranoia, looking up at me as he spoke into the phone “can you guarantee that I can leave whenever I want?” The nurse and I spoke almost in unison “Yes, of course,” and I followed, “George, you give me the word, and we will be on our way, together.” We called three different times, reviewing the same questions with the nurses before he agreed to schedule an appointment.Steering clear of hard promises, I committed to him that I would be there with him every moment of that first appointment and that when/if he chose to leave, I would honor, support, and advocate for him to do so.
Since then he has been back to the clinic three times in 6 months, and while he refuses to allow a needed surgery or take medication, he has had two other minor issues taken care of, completed his first full physical exams in a decade, and he has a team of providers helping him minimize the impact of his gout.
What I Learned from Clients with Paranoia Symptoms
Working with George was a major learning I came to understand that “psychological reactance is present when direct confrontation is used,” and that I had to reposition myself from being George’s adversary and trying to prove him wrong to being his patient ally and arriving at new understandings and possibilities, however long that would take.
Using a comprehensive approach to working with paranoia, I formulated a combined approach that involved not only some evidence-based Cognitive Behavioral Therapy skills, but also socialization opportunities, advocacy, and coping activities. I offered him almost unconditional positive regard, non-judgemental exploration, active listening, but perhaps most importantly, I never gave up on him.