Paranoia is not pretty.

January 4, 2007 9:49 AM

How can I talk rationally to someone amazingly paranoid without further agitating them?

My brother is currently having classic paranoid delusions. He has a history of this, but I speculate that this specific episode is the result of several months of stress. He's convinced that someone is out to kill or harm him: he has accused various people of monitoring the phone and internet, bribing him, snooping around his yard, stalking him while he's out and so on. His theory as to why all of this is occurring continually morphs, but he insists that some sort of shadowy organization is behind it all. His paranoia directly relates to the reason behind the stress he's experienced in the past months. The most important thing is: he truly believes that all of this is happening and absolutely refuses to consider otherwise.

Living with him recently has been hectic, and his little conspiracy theory is getting more elaborate and absurd every day. He's able to warp nearly anything - completely explainable, mundane occurrences such as getting a stomach ache after overeating - to fit in with it. He is having enormous difficulty functioning like he did before all of this. He's having difficulty functioning at all, for that matter.

His paranoia has started to encompass anyone who is even mildly critical of his theory; he's beginning to craft special parts in all this for each family member. I am the only one left who he vaguely trusts. However, conflict between us is eroding that. I am losing patience with him; these past few weeks have been some of the most surreal and agonizing of my life. I hate watching him hang himself like this and I'm losing the ability to remain calm while talking to him. Consequently, I've been being more vocal in my criticism of his theory. When he presents me with yet another aspect of it, I make the mistake of trying to discount it and he gets ferocious. Due to a lack of control on my part, conversations between us frequently degenerate into yelling at each other.

I feel like I'm walking a fine line here. Playing along with his paranoia is surely dangerous, but it's extremely difficult to rationalize with him without making him angry. I initially tried to be tactful and meek in my attempts at logic, but as this situation gets more insane it's getting hard to stay calm. Alternatively, I have also tried rationalizing normal behavior within his bizarre worldview - in a "don't let them get the best of you" sort of way. I realize that his paranoia is at the level that it cannot be resolved without some sort of intervention. Regardless of what I say, he is not going to snap out of it. I know that I can’t fix this, but I certainly don’t want to inadvertently contribute to it.

I don't want to break the trust he has in me. I imagine he's feeling pretty lonely right now. My goal is to provide comfort without giving credit to his delusions. What I’m asking is: How can one talk to someone paranoid without furthering their delusions, or buying into them? What is the appropriate approach here? Is there a certain way psychologists/psychiatrists/nurses communicate with patients of this kind? Is this completely impossible?

posted by anonymous to human relations (28 comments total)

"My goal is to provide comfort without giving credit to his delusions."

You're goal should be to get him help. Immediately.
posted by matty at 10:00 AM on January 4, 2007

Does your brother have a psychiatrist or psychologist? If so, I would call that doctor and explain what's going on and ask her/him what you should do. S/he won't be able to tell you anything about your brother's care or about what he's said to him/her, but s/he will be able to give you general advice about how to take care of him and avoid making the situation worse.

If your brother does not have a mental health provider, I would suggest calling one who specializes in paranoia/delusions (any major medical center should be able to give you a recommendation) and asking about how to get treatment for your brother. If he poses a danger to himself or others, you may be able to do this against his will. If not, there may be techniques that a doctor can suggest to help convince him to seek treatment.

IANAPsychiatrist, but from what I understand about paranoid conditions, your response to him is unlikely to have any meaningful effect on his thinking. That is, there's nothing you can say that will convince him he's not being followed/threatened/poisoned/etc., and you validating or playing along with his delusions is unlikely to make them worse or prolong them. At this point, I would focus on making sure that he continues to trust you, even if that means agreeing with him when he says delusional things, because him believing that you are his ally gives you the best chance of convincing him to seek treatment from a qualified mental health professional.
posted by decathecting at 10:02 AM on January 4, 2007

God damn, get professional help.
posted by boo_radley at 10:03 AM on January 4, 2007

I remember reading something useful about how to interact and communicate with someone with paranoia. Let me google ... hmm, can't find. I can probably find it at work.

But as I remember the recommendation/idea is that you don't directly challenge the delusions or get into a power struggle about the reality/truth of the delusions. Instead, the idea is to focus on what is he going to do to deal with his [delusional] situation, ala: "I would find it stressful to be followed, too. Is there something you can do to feel less stressful?" "I wouldn't like my emails to be read, either. What's your plan, then? Do you want to go talk to Mary in person?"

And as to not endorsing the reality of the delusion, you can use "I" statements like: "It's hard for me to believe that [you are being followed] [Mary is trying to kill you], because that's so different from anything I have seen and experienced. But I agree that it would be stressful to be [followed] [the target of a murder plot]."

All of this is easier said than done, and living with someone is completely different from an occasional interaction by a social service provider (the advice I am remembering was directed toward social service and mental health providers). You may not be able to play this sort of role consistently, and you may need to take steps to care for yourself and the stress you are experiencing.

On preview: I'm sure the OP knows that his brother requires professional help. That wasn't the question, the question was how to interact with his brother around delusions. Finding a decent therapist/psychiatrist, getting a person with delusions to participate in the mental health system and to trust a therapist/psychiatrist, takes some time. And it doesn't always work. In the meantime, the OP has a brother to interact with.
posted by ClaudiaCenter at 10:19 AM on January 4, 2007 [1 favorite]

Get him into treatment if he's not already. Delaying treatment will make the condition worse.
posted by footnote at 10:21 AM on January 4, 2007

"My brother is currently having classic paranoid delusions. He has a history of this, but I speculate that this specific episode is the result of several months of stress"

Nowhere do you state that your brother has had any professional treatment of any type. For all we know neither of you have insurance.

Regardless of the well-intentioned advice from the some on here, advice from the internet on how to talk to and deal with someone with repeated and escalating occurences of paranoia is inappropriate, and downright dangerous, regardless of your relationship to them.

decathecting said it best, and it ALREADY bears repeating:

If your brother does not have a mental health provider, I would suggest calling one who specializes in paranoia/delusions (any major medical center should be able to give you a recommendation) and asking about how to get treatment for your brother. If he poses a danger to himself or others, you may be able to do this against his will. If not, there may be techniques that a doctor can suggest to help convince him to seek treatment.
posted by matty at 10:28 AM on January 4, 2007

"You're goal should be to get him help. Immediately."

Seconded.

The fact is, you CAN'T provide comfort to someone in his situation without throwing more fuel on the fire. The only thing he will find comfort in is you validating his delusions (which he already KNOWS are true).

He is already past the point of no return. His delusions will keep feeding themselves, and they will grow exponentially until you get him professional help.

Call a psychiatrist. Get him institutionalized if you must. But whatever you do, do it now.
posted by tipthepizzaguy at 10:30 AM on January 4, 2007

Get help yesterday. This is a life-threatening emergency situation. There is nothing you can do on your own for this. If he has a doc, call his doc now. If he doesn't, take him to the nearest psych emergency room.
posted by gokart4xmas at 10:45 AM on January 4, 2007

This sounds a lot like schizophrenia, though I'm certainly not qualified to make that diagnosis.

Delaying treatment will make it worse. The earlier he gets treatment, the more likely that his symptoms will not continue to take over his life and the more likely that he will be able to live as a normal member of society. Schizophrenia is one of the most tragic mental illnesses I've encountered, and men with the disease are more likely to die young than men without the disease, for a number of reasons. Please get him help.
posted by croutonsupafreak at 10:59 AM on January 4, 2007

follow up form the OP:

"My brother is currently seeing a psychiatrist. He is on sedatives and antipsychotics, both of which he takes regularly. He has a history of (involuntary) hospitalization. He has refused (and will refuse) to admit himself voluntarily. I'm not very familiar with involuntary hospitalization (I am in my teens now and was quite young when he was previously hospitalized), but my understanding is that one has to either act out in some capacity or be suicidal. At this point, I don't think my family could make a case for either. Even if he is hospitalized against his will, he will not abandon his delusions: he still to this day believes in the delusions that got him in the hospital in the past. My question is how to deal with him at home."
posted by jessamyn at 11:02 AM on January 4, 2007

Oh man - do I feel for you. I have an idea what it's like. Given the expanded information, others will offer advice on what you should do or say - to which I will add 'when he tries to bring it up, change the subject'. XBoX works wonders in this regard.

That being said - you need someone to talk to professionally as well to help you find a way to deal with all of this, if you haven't already. If you haven't, start asking around... a guidance counseler, family doctor, your brother's previous psychologists, etc.

Just promise yourself you won't let things escalate past the thresholds (those little flashpoints) you've already seen before without exploring the more drastic measures again.
posted by matty at 11:14 AM on January 4, 2007

That clarification makes a big difference, jessamyn.

I really think OP needs professional input about how to deal with his/her brother in a way that will

1) not make his brother's situation worse (frankly it sounds unlikely that there is anything that will make it better) and

2) will not force OP to deal with any more emotionally charged negative feedback from the brother than necessary (as, I would imagine, taking a hard line against the brother's delusions would probably result in).

If there are any qualified mental health professionals or people who have truly dealt with this specific situation, advise away, but otherwise please take all the unqualified advice likely to show up here (including mine) with a massive grain of salt. Would it be possible for you to talk to the Dr. caring for your brother about how to deal with these issues?

My final thought is, I hope OP is getting support (including perhaps professional) for what s/he is dealing with emotionally. This just sounds like such a tough thing for a teen to deal with. As a person who is very emotionally connected to my family, and has dealt with substance abuse/mental health stuff in that context (nothing anyway near like this) my heart really goes out to you. But this is the wrong place to get good advice about this.
posted by nanojath at 11:24 AM on January 4, 2007

I read the follow up. Have you or your parents called your brother's doctor? Are you sure your brother is taking his meds? If he is, they are clearly not working, and his doctor needs to know that so he can try something else. Find out what it takes to get someone involuntarily hospitalized in your area, and make a plan (preferably with his doc) to do this as soon as it becomes possible. Try to figure out a way to get him to go into the hospital voluntarily. I know it seems like your brother doesn't want to go in the hospital or get help, and doesn't want to give up his delusions, but he is not in control of his thoughts and wants right now. This is a dangerous situation, for your brother, for your family, and for anyone he comes in contact with. Good luck to you and your family.
posted by gokart4xmas at 11:37 AM on January 4, 2007

you need someone to talk to professionally as well to help you find a way to deal with all of this

Yes. It's natural for you to focus on wanting to help your brother, but as others have said, realistically nothing you can do or say will make much difference. What you can do is try to help yourself through it. Good luck; that's a tough row to hoe, and we all sympathize.
posted by languagehat at 12:15 PM on January 4, 2007

Therapists learn very early in their training to not argue with delusions. It's pointless, increases stress, strains relationships, and does nothing productive, regardless of how illogical a delusion may be.

One of my psychopathology instructors told us about a patient who had the delusion of being dead. Being young, the therapist got into a discussion about what it would take to logically prove that the patient *wasn't* dead. After long discussion, they both agreed that if the patient bled when he was cut, that would prove he wasn't dead. So they did a little pinprick on the guy's finger, he bled, and then said that he'd have to write about this to a medical journal, as it was big news that dead people can bleed!

Moral of the story - don't argue with delusions.

What can you do? Stay grounded. Speak truthfully from your experience. If he wants you to be upset about the people following him, tell him that you love him and want him to feel better, but you don't share his point of view that people are out to get him. Then don't get into an argument with him about it - just let him know that you can love him and still disagree with him about that.

When you feel the timing is right, by all means, tell him that you worry about him when he talks about the people out to get him because you love him and don't know what to do to help him. Let him know that you're concerned that he's going to start mistrusting you. Tell him that he looks stressed and lonely. If he starts going into the whole delusional content, just gently stop him and say that you don't know how to make sense about any of that, and that you'd rather talk about more immediate, concrete things he can do to feel less stressed, like taking a walk, or getting lunch, or something.

Does your brother feel the psychiatrist who is prescribing the meds? Is he just getting meds but no relationship/ talking type therapy? If that's true, it might be nice for your brother if the psychiatrist can help facilitate some structured day activities for your brother. If you can talk to the psychiatrist, by all means do so, but ask for your brother's permission first. Chances are the therapist won't talk with you unless he gets permission because of patient privacy laws. If you're worried that he's imminently suicidal, call 911 or whatever emergency service number there is.

Finally, many family members of people with severe mental illness have been helped by reading books like Surviving Schizophrenia, or have been helped by getting support from groups for family members such as NAMI has.

Also, as you're learning, having a family member with mental illness is quite stressful - you might want to consider visiting with a therapist to try to take care of yourself.

Good luck to you. Feel free to email if you like - my email address is in my profile.
posted by jasper411 at 12:45 PM on January 4, 2007

Sorry this is so long. Hope it's helpful in some respects.

I am not a professional. I am a nursing student who recently finished a psychiatric rotation at a county mental hospital. I am also an individual with a family member who for years has suffered from delusional thinking that involves paranoia and conspiracies. We are close and I see her daily. She is distrustful of most professional assistance so much of her care falls on me and the rest of our immediate family. After almost 20 years of various approaches to dealing with this family member I found many of the conversational techniques I learned in my mental health class and clinical rotation to be infinitely helpful.

I'll try to list those for you in a moment. Before that let me say that nanojath makes a good point about how much of this advice, including mine, should be taken with a grain of salt. The sad and tricky part of mental illness is how diverse the issues are and how relatively new we are as a culture in dealing successfully with them. Also bear in mind that my advice revolves around my personal experiences with my family member and the people I've worked with at my job in healthcare and my clinical rotation in a mental health facility.

Here are some of the techniques that nurses may use in similar situations:

1. Accept the person's need for the false belief, but indicate you do not share the belief. They must understand you do not view the idea as real.

2. Do not argue or deny the belief. Say things like: "I find that hard to believe," if you say anything directly about the delusion at all. Arguing the delusional ideas serves no useful purpose and impedes any trust in the relationship.

3. Reinforce and focus on reality. Discourage long ruminations about the irrational thinking. Talk about real events and real people. Discussions that focus on the false ideas are purposeless and useless and may aggravate any psychosis.

4. If the person is highly suspicious, promote trust by being honest and keeping any promises you make about anything. Don't ever promise something that may not be able to be fulfilled. Say you don't know if you don't know. Avoid any behavior that might seem threatening. Examples may be physical contact, laughing loudly, whispering to others in the room or competitive activities.

5. Keep stimulus to a minimum. Turn off noisy tv's, talk radio, have relatives that make excessive noise leave. Stress needs to be kept to a minimum when possible.


Basically when my family member goes into one of these phases, there is some triggering event that has happened that is upsetting to her. If I can get her to tell me that event and we can address that, then the delusions subside somewhat. I don't challenge the delusion. I don't ask her to tell me more about the delusion. They're fascinating and tragic, but digging around in them just solidifies them more the next time that delusion comes up. I try to remain calm regardless of what she says - sometimes the delusions is me doing something awful and for years this pained me greatly to hear her say such things. But it is absolutely not about me at all.

For instance, one day she told me after seeing tortillas in her yard that someone else in our family was issuing a death threat to her. It didn't matter that the tortillas had probably been dropped or littered by some random person who was probably walking down her street. She thought it was specific to her. At one time she had a friend that fed his dog tortillas as a snack. That dog died. Even though it had nothing to do with tortillas I think that's where she connected the two. Without denying this threat that she saw as actively real, I asked her to tell me more about what had been happening earlier before she noticed the tortillas. I'm asking her to focus on what we both know is real. Eventually I was able to get out of her that an acquaintance she liked had died a few days earlier. It had nothing to do with tortillas or death threats. It was about her sadness of the loss of someone she knew and her fears of death. We were then able to talk about that.

Distraction is also a huge tool I use when dealing with this family member. I'll ask her to go for a walk with me. The physical activity calms her. The stimulus of the walk distracts her from whatever current problem is creating her need for delusional thinking.

My nursing text book was especially helpful if you want to check it out. It was an easy read, clearly explaining current nursing approaches to mental health: Psychiatric Mental Health Nursing by Mary C. Townsend 5th ed. It's expensive - go to your local medical library or nursing school/med school text book store if you just want to thumb through it.

Perhaps most important: know what your own limits are. You are not responsible for any of this. I know that sounds so simple, but it is so easy to try and take over for someone that is ill. To try and think for them, feel pain for them. And you cannot do that. It takes some personal strength that can seem cruel at times. Nursing school is the most stressful thing I've ever done in my life and often my family member has asked me to sacrifice my time when it was not available. I simply have to tell her: "I'm sorry, but I can't deal with this now." Sometimes this demand that she depend on herself, that I need her to do that, is what she indirectly needs from me to do that.

It is a puzzle. Good luck to both of you and your family. I'm glad he is getting professional support. Don't ignore your own needs. Email is in my profile if my story is at all familiar and we can talk some more.

Take care.
posted by dog food sugar at 1:05 PM on January 4, 2007 [6 favorites]

I sympathize with you. What you're going through - providing support to someone struggling with the most severe mental illness - is relentlessly difficult. The fact that you are there for him and have not abandoned him - regardless of what he says - is the best thing that you can possibly do for him, and probably more than anyone has a right to expect of you.

Since you have taken this on, you will also have to focus on protecting yourself from his words and ideas, some of which will be baffling or hurtful to you. Spend some time thinking about what he says, thickening your skin against it. Try to remember that it's not personal - it's the disease - even when it feels the most personal of all.

Finally, as others have noted, the situation you describe is beyond what you're expected to deal with. You should be talking to your brother's psychiatrist. The situation you describe sounds like what is euphemistically called a "decompensation;" you're going to need professional help in dealing with it.
posted by ikkyu2 at 1:12 PM on January 4, 2007

Alternatively, I have also tried rationalizing normal behavior within his bizarre worldview

This is a bad idea. His brain should be spending as little time as possible going over his irrational delusions. When they come up, redirect the topic to a different one.
posted by ikkyu2 at 1:15 PM on January 4, 2007

Paranoids, because they perceive this enormous level of danger and threat, behave like a person who is in danger and threatened. Can you imagine where this goes?

My aunt had her daughters up on the roof, trying to disconnect the electricity, so that her ex-husband and parents couldn't send mind-controlling messages through the wires.

A paranoid is not someone who has simply a bad idea that can be disproven. It isn't as if they are missing certain facts about the world, it's that when these facts add up, it all spells DANGER to them. Any additional evidence you supply to the contrary just makes it look as if They are trying to separate him from people who might believe him, so that They can get on with Their plot. You're either deceived by Them or you're actually one of Them.
posted by adipocere at 2:00 PM on January 4, 2007

I don't think this has been mentioned yet. Try to get him in touch with someone who has had similar experiences and gotten over it and/or learned to live with it. There is a chat room on schizophrenia.com
posted by srs at 4:37 PM on January 4, 2007 [1 favorite]

I am the only one left who he vaguely trusts.

Maintain his trust. Be careful with your tone of voice and try to maintain your calm. If he needs professional help, do not make yourself the one who commits him. Let your parents claim responsibility. Be a beacon for him, eye of the storm thing. This is important.
posted by srs at 4:45 PM on January 4, 2007

I had to deal with something similar with my step-father in the last couple of years before he died. I was living abroad and only saw him once in a while when I visited Canada, but it was hard. I can only imagine how hard for my mom.

For my part, I didn't try to argue with him about his fears, or convince him they were groundless -- I just listened (expressing gently through body language that I was dubious but that I supported him without qualification, regardless), and tried to avoid subjects that would set him off (lawyers, real estate, oil -- long story).

I don't know what we'd have done, or what would have happened to him, if he hadn't died of a massive heart attack in his sleep.

(For what it's worth, I was convinced at the time and remain convinced that it was unexpected drug interactions from the rainbow cocktail of chemicals his small-town Northern BC doctors had him on that made him go loopy, and possibly killed him.)
posted by stavrosthewonderchicken at 5:00 PM on January 4, 2007

Try to get him in touch with someone who has had similar experiences and gotten over it and/or learned to live with it.

I think this is an extraordinarily bad idea. Psychotic delusions are a terrible disability; having them, or having had them, does not in itself qualify you to become a counselor for others. In fact, I'd argue that in most cases the reverse is true.
posted by ikkyu2 at 5:30 PM on January 4, 2007

I have no psych training, but I've been mad and I've had mad friends and housemates.

I think the best things that you, as somebody also without psych training, can do for a mentally ill person who trusts you and already has a psych worker are these:

1. Make sure he's getting enough sleep. Remind him that he needs his sleep to keep him strong.

2. Make sure he's eating nutritious food and drinking enough water.

3. Discourage him from taking drugs (alcohol, smoke etc) that weren't prescribed by his psych worker. Encourage him to keep taking those that were. If he complains about side effects (muscle tightness, grogginess etc.), make sure his psych worker is aware that these are happening so that appropriate countermeasures can be put in place.

4. If he wants to talk about his delusions, make it clear that you love him and wish this wasn't happening to him (leave the nature of "this" carefully unspecified) and leave it at that. Do your level best to avoid engaging with the delusion itself; focus on the person.

The best thing you can do for yourself is to keep your own identity-as-you separate from your identity-as-carer. Your brother's mind may well be a trainwreck, but it's not a train you're driving. If you're going to be of use to your brother, your own mental health must come first.

This is incredibly hard stuff to deal with, and you have all my sympathy.
posted by flabdablet at 6:06 PM on January 4, 2007 [2 favorites]

On lack of preview: if ikkyu2 disagrees with any of my advice, listen to him, not to me.
posted by flabdablet at 6:07 PM on January 4, 2007

I think this is an extraordinarily bad idea. Psychotic delusions are a terrible disability; having them, or having had them, does not in itself qualify you to become a counselor for others. In fact, I'd argue that in most cases the reverse is true.

I suggested it, and still do, because it is particularly helpful in treatment-resistant cases, and with people who refuse to take their medicine. Schizophrenia is a lonely illness. People are helped out a lot when they no longer feel alone. It helps to talk to someone who has been though the same thing, makes them feel like less of an alien. If someone who suffers from the same thing goes into great detail on how treatment and medicine helped them, it could convince.
posted by srs at 6:20 PM on January 4, 2007

Is there a support group for the family of mentally ill people you could attend? Your brother's psychiatrist might be able to help you out with this if you're unable to find one on your own.
posted by sarahw at 6:40 PM on January 4, 2007

The problem with people who are paranoid is that they think anybody trying to prevent them from being paranoid (pointing out reality, trying to get them to take meds, etc) must be in on the plot. It's a dilemma, because anything that really helps a paranoid person can potentially be seen as a threat. I will not go into how I know this; just take my word that you cannot reason with someone who is that mentally ill.

I Nth getting professional help now, any way you can get it. He needs medication NOW. Not a little talking to, not explaining how silly it is to think that dad sent the stuffed toys to spy on him, meds. NOW. And if he has to be hospitalized to get him to take the meds (be prepared for this because of course it could all be seen as a plot to poison him), so be it.
posted by ilsa at 6:44 PM on January 4, 2007