Dr. Peter Weiden of St. Luke's Roosevelt Hospital wrote an article with Dr. Leston Havens that appeared in the May'95 issue of Hospital and Community Psychiatry. Following is a much abbreviated version of that article edited by D.J. Jaffe to be of use to family members.

6 steps to handling paranoia

1. Place yourself beside the consumer rather than face-to-face. The side-by-side position tends to deflect the paranoid fears away from you. Instead, both you and the consumer are looking out at the (hostile) world together. This positioning technique may improve the chances that you will form a working therapeutic relationship with the consumer early on. Don't stand directly in front of the individual. That may be considered confrontational.

2. Avoid direct eye contact. Direct eye contact often makes a paranoid individual feel even more so. Look elsewhere.

3. Speak Indirectly. Avoid speaking directly to the consumer. Substitute pronouns such as "it", "he", "she" or "they" for the words "I" and "you". Like the body positioning, the purpose is to deflect the consumer's paranoid projections away from one-on-one interactions with the case worker. Instead, paranoid symptoms are directed towards external and more general "real world" issues.

4. Identify with, rather than fight, the consumer. Whenever possible, your attitudes and emotional expressions should parallel the consumer's attitudes and expressions. The goal is to help the consumer feel understood. Meet anger with reciprocal anger, frustration with frustration (i.e., you also express anger and frustration with the difficult circumstances). Your own emotional expressions should be taken up to the point of, and perhaps slightly beyond, the consumer's own emotional expression to show your on his/her side A paranoid individual is not thinking rationally and your attempts to rationalize will not likely be successful.

5. Don't rationalize. Share mistrust. The intuitive approach with a paranoid person is to try to persuade him or her to be more trusting. It is often better to do the opposite; that is, for you - along with the consumer - to mistrust the world together. No attempt is made to correct or contradict the consumer, or to test reality. Temporarily, the consumer's account of reality is accepted as reality. The assumption behind this technique is that, in the midst of a paranoid state, the consumer is overburdened and overwhelmed by a mixture of real-life stresses and distress from psychotic symptoms. While carefully avoiding collusion with the psychotic symptoms, you should attempt to find certain believable or credible aspects of the paranoid belief system. This allows you to agree with the consumer on something. You then move on to a symptom area, attempt to substitute a less paranoid, more benign (and general) explanation for the more highly personalized paranoid one. The process of exchanging more malignant to benign paranoid beliefs is best done in a step-wise fashion, where the alternate explanation is only a notch less paranoid than the previous one. The eventual goal is for the consumer to tell the case worker, "Don't be so paranoid." Ms. C. blames her last hospitalization on a police conspiracy to terrorize her. Rather than confront her with her own behavior that led to her being arrested, her case manager agrees that the police cannot be trusted and goes on to talk about his own outrage at the Rodney King case. By the end of the conversation, Ms. C. tells the case worker to stop treating the police so unfairly!

6. Postpone Psychoeducation.

A consumer in the midst of a paranoid state often cannot tolerate psychoeducation, as he or she is unable to acknowledge to others the existence of a psychotic illness. Rather, the consumer will deny the illness and blame others for his or her difficulties. Until the consumer is strengthened, and the paranoia lessened, no attempt should be made to identify, correct, or argue with the consumer about paranoid or delusional symptoms. Until a sound alliance is formed, you should avoid the more traditional psychoeducational approach that teaches about illness and benefits of medication.

How to help with denial of illness

If psychotic, treat the individual: If the denial represents a symptom of an acute psychotic episode, the consumer should be managed as an acute relapse with hospitalization and/or increased medication. If they are denying that they are sick, they will also most probably deny treatment. The only way to treat someone over objection is to get them involuntarily commited to an inpatient unit (NYS does not offer involuntary outpatient treatment). The only way to have someone committed to an inpatient unit is to have them declared a "danger to self or others". This is not easy to do. AMI/FAMI is working on changing the laws to make it easier to get treatment to those who need it before they become a danger to self or others. Your help is appreciated.

Avoid Overzealous Attack on Denial

When the denial of illness is chronic and seems unrelated to relapse, the first step is to determine whether the denial should be addressed at all. Denial of illness may not be harmful as long as the consumer is otherwise doing well and is compliant with treatment. Indeed, several studies have shown that consumers who deny their illness see themselves as having more purpose in life, are more optimistic and have fewer affective symptoms. This is a difficult concept for families to accept. But denial of illness often only needs to be addressed if it is causing a problem.

Provide Alternative Explanations.

If denial has to be addressed, it should be addressed indirectly. Enlarge the consumer's perspective by helping the consumer acknowledge the existence (or at least the possibility of) different points of view. There are 4 steps to accomplish this.

Step 1. Recognize the consumer's point of view. Assume the consumer's point of view is believed in, even cherished, highly learned, or overdetermined. For example, if the consumer says "I'm not sick, its others who are sick and making up these stories about me" , hold off from disagreeing. Instead, you should think (but not say to the consumer) 'let me assume this statement is true. Now, in what way can this be true?' This kind of thinking can assist you with the task of assuming that the denial is a reasonable response from the consumer's point of view. In this context, you can acknowledge the consumer's beliefs as being one "point of view" - even if delusional - without having to collude with them.

Step 2. Establish that the consumer's view is only one point of view. After you have comprehended the consumers rationalization of the denial, the goal here is to establish with the consumer that people can have legitimate differences in viewpoints and opinions, and that people can "agree to disagree" without taking personal affront at the disagreements. Discuss nonthreatening issues (e.g., recent political events, sports, music) and come to an understanding that different opinions are acceptable and a part of life. Then, you can bring up that it is acceptable to hold different points of view about the consumer's own situation or need for treatment.

Step 3. Supply an alternative. This step marks the first time denial is directly addressed. You suggest alternative explanations in a way that leaves the consumer a way to disagree without getting into a power struggle with you. Be respectful: Feel why it is necessary for the consumer to take the position of denying the symptoms. For example, you may broach a new topic with something like "Other people have found that ... is it possible that this is true for you."

Step 4. Anticipate setbacks after successfully addressing denial. When denial of illness abates, be prepared for trouble ahead. Demoralization, sense of failure, or despair often follow. The most striking example is development of suicidal despair during the period when the recently-psychotic consumer is regaining insight. This is often triggered by setbacks, such as repeated rejections in finding a romantic partner. Denial may have been protective, shielding the consumer from attributing the setbacks to his or her symptoms. When the consumer becomes aware of his real-life defeats, show how apparent defeat sometimes represents real progress. Success and progress frequently go unnoticed; even the most striking success can be viewed (by the consumer or you) as a failure. Often, the hidden success is the willingness and courage to make an attempt.

How to help overcome stigma

Many consumers will not admit to stigma because an admission is equated to acknowledging that they suffer from a "mental" illness. Therefore, stigma's presentation is often indirect: A refusal to participate in treatment or programs. (Note: refusal to participate may also come about because the program is inappropriate, ineffective, or otherwise substandard-ed.). Stigma may also lead to substance abuse, where having psychotic symptoms in the setting of "getting high" is seen as "normal". Stigma may also be the underlying cause of unrealistic expectations such as an seemingly foolish attempt to overreach vocational goals (for example, a very poorly functioning and symptomatic consumer signed up for pre-law exams). Stigma can explain the commonly seen paradoxical situation of when the consumer seems to deny illness but voluntarily takes antipsychotic medication.

Stigma may be greatest in consumers who had good pre-sickness functioning, who come from higher socioeconomic backgrounds, and among consumers whose families have trouble accepting the person's diagnosis. Acknowledge the stigma, normalize the consumer's experiences, support self-esteem, and help save face. Help the consumer recognize how normal he/she is. Stigmatized consumers tend to attribute all of their struggles to being ill, an attitude that fosters greater stigma and isolation. Normalizing the consumer's experience, as much as possible, can be very helpful. Many consumers idealize the lives of "normal" people. These consumers do much better if they know that many of the "trials and tribulations" of life are experienced by so-called "normals".

Talk about yourself.

Talking about yourself is a way of normalizing the consumer's experience. It allows the consumer to compare his or her frustrations with yours. Use concrete examples taken from your own life (e.g., trouble with authority, experiencing failure) to assure the consumer that not all of his or her difficulties come from illness. You should not patronize or trivialize the consumer's real-life difficulties (for example, getting a mediocre grade in a course is not a comparable setback to dropping out of school because of mental illness). Avoid disclosing socially taboo or overstimulating topics (for example, sexual issues).

Use Performative Speech.

One technique that works very well is the use of performative statements. Performative speech refers to statements that derive their power simply from being made, providing that they are made by the right person under the right circumstances. Should the consumer not acknowledge the authority of you, then the performative statement can be given by someone else with credentials that are acknowledged by the consumer. Help consumer 'save face'. Blunt or direct use of emotionally-laden psychiatric terms may backfire when used on stigmatized consumers. Often, the consumer is confronted with "psychoeducation" before he or she is ready. Be tactful. Use descriptors rather than medical terms. Ex. "psychotic symptoms" instead of "schizophrenia," and "suspiciousness" or "sensitivity" instead of "paranoia". Find a face-saving way to explain humiliating events. For example, someone brought in in handcuffs after walking naked in the streets may accept an explanation like "you know, being naked is upsetting to many people" rather than "you know, you were exhibiting bizarre psychotic symptoms".

What to do about demoralization

Often, demoralization occurs after the psychotic phase. This paper will assume that the consumer does not have a depression or neuroleptic-induced akinesia which is causing it. Demoralization often is a function of failing to meet societal or familial expectations (e.g., shame over not achieving higher education goals). Not achieving these expected goals then affects all other aspects of the consumer's self-esteem. For example, a consumer who has to drop out of college because of schizophrenia may go on to depreciate all of his or her remaining intellectual gifts. Depression is common. Self-deprecating trends can be recognized by a tendency to comment negatively on one's performances. There is an accompanying tendency not to blame others. A central difficulty of this assessment is consumer's frequent reluctance to disclose any feeling of stigma, low self-esteem, or self-deprecation.

Maintain a Positive Attitude

A hopeless attitude is a major problem for many family members and people with severe neurobiological disorders. It is very important to maintain morale and hope; otherwise, the consumer's attitude will be a reflection of your's, leading to a vicious circle of demoralization.

Use Admiring and Approving Statements

Statements of admiration have special power when used sincerely. While this may seem obvious, in practice it is common to see problems stressed at the expense of strengths. One way to assist in sincerity of admiration is to consider, and reflect to the consumer, the inner strengths needed to keep on going with life despite having disabilities. The use of admiring or approving statements can backfire. There are two common traps: the first is insincerity and making patronizing remarks. Choose only admiring statements that are genuine and sincere; allegedly "admiring" statements are frequently said in a degrading or sarcastic tone, especially by professionals who are accustomed to focusing on psychopathology, not strengths. The second trap is to be discouraged by the subsequent rejection of the admiring statement. Expect initial rejection; in fact, the consumer's disowning of approval suggests that you are "on target".

Give/Get Education about Negative Symptoms

Negative Symptoms of schizophrenia (apathy, inertia, etc.) can mimic or cause demoralization. When a consumer understands that these are symptoms of the disorder, they may feel better. Use medical language in this case. Laziness becomes avolition, tiredness becomes apathy, and lack of appreciation becomes anhedonia. How to help someone overcome the terror of being psychotic Many consumers are terrified that they can no longer find or maintain coherent mental functioning. What often follows is a desperate search for normal mental functioning combined with an attempt to hide this struggle from other people. Be aware of how bad the terror can be and how common it is. Recognizing terror depends upon a number of familiar signs. Because consumers often can't or won't verbalize their terror; it is all too easy to ignore this problem, or become indifferent to it. You need to look for indirect evidence of terror. Thoughts are scattered or dissociated; feelings are volatile, inappropriate or absent, and behavior unpredictable or contradictory. Management of Terror: The goal is to decrease the sense of terror and despair that comes with awareness of being psychotic. Treating the reaction to loss of normal mental functions requires an intervention that, in some respects, is not easily described. Ask the consumer about being frightened, and state that you would be frightened under the same circumstances. The knowledge that someone else can recognize the sense of terror without it having to be explained can be tremendously reassuring. Perhaps the greatest difficulty facing you is to understand the extent of the consumer's desperation while, at the same time, not to become overwhelmed by it.

Reassure

While obvious, this simple measure is often overlooked. Help reassure the consumer that the fear is normal, and that the psychotic experience - although terrible - will improve. Avoid false cheerfulness, which will be picked up as feigned.

Provide Companionship.

Even when verbal communication cannot be reciprocated, companionship can be very helpful in reassuring the consumer that he or she is not completely alone. While in the presence of the terrified consumer, proper physical positioning is important. You should remain slightly to one side and avoid staring; one aims for an easy accompanying. An air of quiet confidence is also needed because anxiety is contagious. Little should be said except occasional reflections about what must be experienced by the consumer's presumed state of mind. Words like "wandering", "aimless", "frightened", "bewildered", or "vulnerable" might be tried to see if the consumer can acknowledge any of these states. These attempts to make contact with the withdrawn and frightened consumer are best rendered by combining these descriptions with short empathic statements such as; "How awful." or "It must by frightening."

Leave the Consumer Alone.

Paradoxically, at the same time as offering companionship, you need to be able to leave the consumer alone. The skill here is to know how to be able to sit with the consumer and, at the same time, give the consumer enough emotional space. It is important to avoid being intrusive. Some emotional distance should be maintained because anxiety over excessive verbal interventions or interpersonal closeness can exacerbate psychotic symptoms. Too much activity, emotional reaching toward the consumer, or inquiring about symptoms can backfire by overstimulating the psychosis. Many mental health professionals and family members have trouble with the notion of being alone with a consumer, feeling that being quiet together means that they are experienced as indifferent or hostile. Actually, being alone with the consumer doesn't feel like that at all, and the consumer is able to sense the difference. Everyone is an individual No two individuals, consumers or otherwise are identical. Knowing the consumer is the first step towards helping.

This article is meant to provide suggestions that have worked in some cases, but will not work in all. Apply common-sense when attempting to use them. Thank you for your support of AMI/FAMI which makes reproducing this report by Dr. Weiden possible. For more info, call AMI/FAMI at (212) 684-3264. (Edited for families by D.J. Jaffe) PLEASE JOIN AMI/FAMI TO HELP US HELP YOU