Magical Thinking: Delusions, Reality, and Treatment.

Credit: Kevin Foley. Flickr. License: Creative Commons.
Credit: Kevin Foley. Flickr. License: Creative Commons.

Pop quiz time!

A social worker is doing an intake assessment at an inpatient psychiatric unit with a 45 year-old male client, who states he is Godzilla. The client has no known history of substance abuse, which resulted negative during toxicology. Medical rule out for any other neurological conditions is also negative. What is the social worker’s FIRST appropriate approach?

  1. Reality-test client’s feelings about his identity by using confrontation techniques.
  2. Ignore the client’s verbalization and continue with the rest of the intake assessment.
  3. Reflect and validate client’s verbalization.
  4. Include Godzilla movie as part of the treatment plan during recreational time in the psychiatric ward.

So okay, I totally made up the Godzilla part; however, using social work principles, and testing principles the exam is testing, the correct answer would be C. Why? Confronting defenses amplifies defenses (A), (B) would not get you very far since the client may be a poor informant, (D) might be colluding with the delusion, and (C) is starting where the client is at, from a curious stance.

Delusions and bizarre ideations are probably some of the most interesting, and to newcomers to the field, possibly frightening areas of psychiatry, psychology, and social work.

While we have gone far in removing the stigma from mental illness and emotional struggles, delusional thinking and any of the other positive symptoms of psychotic disorders tap into one of the most palpable human fears: complete or near disconnection from reality.

However, if Freud and any of his successors (inside and even beyond psychodynamic theory) taught us anything, EVERYTHING has meaning and can make psychotic symptoms more meaningful to work with, if only as a function of a disorganized id and unconscious. Of course, this depends on your view of psychic determinism, and doesn’t discount the helpfulness of medication when managing risk.

In one of Harville Hendrix’s books (pioneer of Imago Relationship Therapy, which I am reading right now, for a friend, for totally clinical reasons) he talks about a psychologist in a psychiatric ward who engages with a patient who felt he was Jesus. Initially he is resistant to the idea, until he curiously starts to engage the patient with his view of reality.

The result was surprising, because one day, the patient corrects him, telling him to call him by his real name. Was he playing mind tricks? Not likely. In feeling safe and validated by the therapist, the client was unable to dismantle the defense (due to earlier pain) and engage in the real therapeutic work.

Stay safe out there and Happy Halloween!

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