clinical social work with clients having delusions of persecution

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This article was downloaded by: [University of Ulster Library] On: 13 November 2014, At: 06:07 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Practice: Social Work in Action Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/cpra20 Clinical social work with clients having delusions of persecution Joseph Walsh Published online: 01 Feb 2008. To cite this article: Joseph Walsh (1997) Clinical social work with clients having delusions of persecution, Practice: Social Work in Action, 9:4, 23-34, DOI: 10.1080/09503159708411660 To link to this article: http://dx.doi.org/10.1080/09503159708411660 PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions

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Page 1: Clinical social work with clients having delusions of persecution

This article was downloaded by: [University of Ulster Library]On: 13 November 2014, At: 06:07Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Practice: Social Work in ActionPublication details, including instructions for authors andsubscription information:http://www.tandfonline.com/loi/cpra20

Clinical social work with clientshaving delusions of persecutionJoseph WalshPublished online: 01 Feb 2008.

To cite this article: Joseph Walsh (1997) Clinical social work with clients having delusions ofpersecution, Practice: Social Work in Action, 9:4, 23-34, DOI: 10.1080/09503159708411660

To link to this article: http://dx.doi.org/10.1080/09503159708411660

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information(the “Content”) contained in the publications on our platform. However, Taylor& Francis, our agents, and our licensors make no representations or warrantieswhatsoever as to the accuracy, completeness, or suitability for any purpose of theContent. Any opinions and views expressed in this publication are the opinions andviews of the authors, and are not the views of or endorsed by Taylor & Francis. Theaccuracy of the Content should not be relied upon and should be independentlyverified with primary sources of information. Taylor and Francis shall not be liablefor any losses, actions, claims, proceedings, demands, costs, expenses, damages,and other liabilities whatsoever or howsoever caused arising directly or indirectly inconnection with, in relation to or arising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Anysubstantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,systematic supply, or distribution in any form to anyone is expressly forbidden.Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Page 2: Clinical social work with clients having delusions of persecution

Clinical social work having delusions of

with clients persecution

Joseph Walsh

People with a persecutory orientation to their environment present a treatment challenge for

clinical social workers because of their negative orientation to the helping process. Such persons do not typically seek counseling services but may be referred by others who perceive their need for improved coping mechanisms. The purposes of this article are to apply social work's biopsychosocial perspective to an understanding of delusions of persecution and present guide- lines for clinical intervention. The author emphasizes the utility of symbolic interactionist theory for formulating interventions.

delusion is a false belief that is firmly maintained even A though contradicted by social reality (American Psychiatric Association, 1994). Delusions of persecution include beliefs that certain people or forces are attempting to bring one harm. There is an adaptive function of vigilance, particularly among immigrants and minority groups who endure acts of prejudice (Meissner, 198 l), but persecutory delusions are characterized by the inability to consider alternative interpretations of situations (Kheshgi- Genovese, 1996). The purposes of this article are to discuss caus- es of persecutory delusions and provide guidelines for clinical social work intervention.

Sources of persecutory delusions

Delusions of persecution may result from metabolic, endocrine, neurologic, and infectious disorders which produce perception or memory problems (Stoudemire & Riether, 1987). A variety of street and prescription drugs can foster delusional ideation (Block & Pristach, 1992). Sensory loss, particularly visual and hearing impairment, is associated with persecutory delusions in elderly persons (Munro, 1991).

Freud (1966) asserted that the defense of projection is key to the development of persecutory delusions. A person may repress an undesired emotion and, to protect the ego, unconsciously project a self-reproach onto another. Meissner (1981) states that the

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parents of the person with persecutory delusions tended to act out patterns of aggressor and victim with each other, and the child internalized these characteristics. The child as victim assumes that others are acting against him or her, and the child as aggressor learns to project negative impulses.

The sense of persecution develops from learning to externalize responsibility for significant events (Candido & Romney, 1990). An adolescent may develop delusions of persecution as a result of failures in early efforts at intimacy without adequate emotional support from primary caregivers (Swanson, Bohnert, & Smith, 1970). Major life transitions such as childbirth can create levels of stress which produce transient delusions of per- secution (Retterstol & Opjordsmoen, 1991).

The theory of symbolic interactionism asserts that personality is shaped by role expectations in social situations (Charon, 1992; Hewitt, 1994). In social interaction, most people develop a broad repertoire of responses to situations, and select from among them those most suitable to goal achievement. The cognitive style of the person with persecutory delusions features rigid categories for organizing perceptions, all of which are distorted to fit this schema (Magaro, 1981). In one’s need to be alert to threats, any element of an interpersonal situation which confirms expectations is generalized to the entire relationship. These meanings develop from experience with previous rela- tionships. The person with persecutory delusions lacks adaptive flexibility and restricts his or her social interactions so that the opportunity to develop alternative definitions of situations is minimized.

Clinical intervention

The goal of intervention with clients having delusions of perse- cution is to help them become less self-centered and expand their range of interpretations of situations. After a relationship of trust between the worker and client is developed, change can occur through cognitive-behavioural methods (Granvold, 1995; Ritzler, 1981). These methods intrude less into details of the client’s life than is typical of analytic methods. They are also consistent with the symbolic interactionist principle of persons constructing the meanings of their social situations. The client must be able to think abstractly and not require an emotional encounter with the worker (Burbach, Borduin, & Peake, 1988). Change may be modest due to the client’s rigidity and negative attitudes about the utility of therapy.

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Joseph Walsh

The author now presents a clinical intervention approach con- sisting of four phases, each including subphases of social work activity.

Phase one: introduction to the setting

Consistency in worker presentation. The client with persecutory delusions cannot tolerate unstruc- tured relationships, and thus the worker encourages trust with a formal, matter of fact personal style. This may include consis- tency in meeting times, use of the same office, and concreteness in communication. Facial expressions, body posture, and physical movement should remain as non-intrusive as possible. The worker may also schedule meetings less frequently than usual to allow more ‘space’ for the client during this early phase. The worker should be open about his or her emotional responses when challenged, because the client will otherwise make distorted assumptions about them.

Explanation of the clinical process. The client will be suspicious of the social worker’s thoughts, particularly if the worker tends to be abstract or insufficiently verbal. The worker should outline the intervention process and his or her role parameters, so that the client will know what worker behaviour to expect. The client may be dissatisfied with the amount of information that is provided, because no amount will suffice. But the client wilI begin to develop a frame of reference from which to negotiate a shared definition of the clinical situation.

Acceptance of the client’s perspective (Fraser, 1983). The social worker should communicate concern for problems from the perspective of the client by encouraging the client’s sharing, asking for details about situations, and acknowledging the client’s perceptions as plausible hypotheses. This may be difficult if the client asks for the worker’s opinions about the delusional ideas. Pretending to agree is not appropriate, as the client will eventually realize this deception and have his or her initial mistrust confirmed. The content of the delusion is not validated. but the client’s emotions can be affirmed.

Acknowledging that trust must be earned. The worker acknowledges that the client is justified in being suspicious of any new acquaintance, including the worker. In

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this way the clinician accepts and reinforces a basic premise of the client and demonstrates an empathy which may become a point of engagement.

This introduction phase is not preliminary to, but a central component of, intervention. It facilitates relationship develop- ment and the client’s ability to collaborate with the social worker. If successfully managed, the client will begin to learn that not all persons are antagonists. The client’s self-concept may incorporate the possibility of positive external regard.

Case illustration. Ronald, age 42 and unemployed, had a delusional disorder. He lived with his mother and came to the mental health centre at her insistence. Ronald believed that people in his neighbourhood were talking about him behind his back, accusing him of being useless, and saying that he should be killed or put in jail. Ronald lived and had grown up in an urban setting, and his ideas were partly supported by neighbourhood norms. He was frightened and occasionally confronted his neighbours for making such remarks, threatening them with physical harm.

Ronald was vigilant of the social worker’s every physical movement, and confronted him regularly.

‘Why are you looking at me that way?’ ‘Why did you move your hand over to the desk just then?’ ‘Why do you always nod when I’m talking ? ’

Ronald shared his distrust of the worker’s motives. ‘Are you going to talk to my ex-wife about this?’ ‘Have my neighbours been on the phone to you with their lies?’ ‘Do you have friends on the police force to call i f I turn out to be trouble?’

For several months their weekly meetings returned to these themes. The worker’s questions were perceived as intrusive, and as Ronald said, ‘I don’t want information about my personal life getting out. ’ The social worker, while feeling somewhat defensive, acknowledged the plausibility of some of Ronald’s concerns. He explained his own nonverbal habits when chal- lenged (and, in fact, became much more aware of them in doing so), including why he sat in the chair the way he did, what kind of room lighting made him comfortable, etc. He reviewed the agency mission, confidentiality policies, paperwork require- ments, legal issues around worker/client relationships, and the limits of what he could do in trying to help Ronald.

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Phase two: defining the clinical situation

Negotiation. By now, the worker has produced a tolerable environment for the client. Next, the worker promotes a shared definition of the clinical situation; a mutual understanding of purpose. There needs to be agreement on goals which will preserve a comfort- able interpersonal distance for the client. One generally agreeable goal is the client’s learning new coping strategies to reduce stress in response to perceived external aggression.

Speaking from the perspective of the generalized other. The worker can keep the focus off him or herself as a source of the client’s suspicions when challenging delusional thinking by sharing concerns as they might be expressed by third parties (Weiden & Havens, 1994). For example, the worker can share the same thought as

‘Are you sure that your boss is bugging your car? It just doesn’t seem likely’

and ‘Some people might have a hard time accepting that your boss bugs your cal: Do you worry about their reaction? ’

Both questions address the same issue, but the first places the worker in the role of skeptic while the second joins the worker and client as allies in considering how those unfamiliar with the situation might assess it.

With the above strategies, a shared definition of the clinical situation may emerge. The worker understands the client’s point of view and its impact on relationships, and the client perceives the worker as an empathetic individual who wants to assist in resolving problems. The client may still doubt that the worker’s contributions will be substantive and not entirely trust the worker’s motives.

Case illustration. Shelita was a 37-year-old single unemployed college student, living alone in an apartment, who had a pervasive tendency to interpret the actions of others as threatening. She came to coun- seling because she was concerned about failing in school. She was not ambivalent about entering the clinical situation (she had a positive experience with a social worker in adolescence) but was so rigid that it was difficult for the social worker to negotiate goals with her. Shelita believed that it was the cruelty

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of all people at the university that caused her to fail, and her problems would only be solved if she moved to another part of the country. Shelita’s desire was that the worker listen to updates on her life events each week and advise her on how to more suc- cessfully avoid other people. The worker, in contrast, perceived that Shelita’s pervasive negative attitudes about others was the source of her interpersonal problems.

The social worker did not initially challenge the reality of Shelita’s persecutory delusions, but eventually began to confront her thinking patterns. The success of this strategy was facilitated by his use of the third person in speaking. For example, Shelita had difficulty in her classes because of her negative feelings about classmates and professors. The worker said

‘You’ve told me what yourfirst impressions of your class- mates were, Shelita. They certainly seem unpleasant. Now, I’m not in the class, so I don’t know what those people are like. Do you think that everyone else looks at their classmates the same way? Do you suppose that some of them feel opti- mistic about making friends there? Have you noticed anyone getting along well with the professor? How can they do this if he is so arrogant? ’

With this line of questioning the worker took the imagined per- spective of a third party (classmates), rather than saying

‘ I would never walk into the classroom with the expectation that people will be diflcult, Shelita. I have always considered that the professor has a lot to teach me ’.

These confrontations gradually moved Shelita to consider other ways to approach situations. She eventually accepted that the worker would challenge her interpretations of situations and agreed to consider his thoughts about approaching them differ- ently. Shelita and the worker had clear expectations of each other.

Phase three: alternative hypothesis testing

Following the development of a shared definition of the situation, the social worker can intervene to modify the client’s perspectives on relationships. The worker helps the client increase the range of conceptual categories in which to organize perceptions, and thus expand the range of behavioural responses (Magaro, 1980). The social worker maintains a focus on current situations and builds on the client’s strengths in this process.

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Formulate a hierarchy of situations. The clinician and client should construct a list, and then a hierarchy, of situations which are the most troublesome to the client’s quality of life (Hepworth, Rooney, & Larsen, 1997). They can work with the least distressing situation or that which the client is most eager to address. The worker looks for specific stressors in the client’s life which contribute to the persistence of the delusions.

Reframing. As the client shares interpretations of specific situations, the social worker offers alternative explanations for the behaviour of others. The worker does not endorse an alternative, but asks the client to react to each of them. The worker and client can role play situations with the client attempting to act from an alternative definition of a situation.

Prescribing new behaviours. The worker suggests how the client might alter behaviour in a situation to test out the plausibility of a new definition, and in so doing approach the relationship differently. Because clients with persecutory delusions are more sensitive to persons than envi- ronments, the worker asks the client to investigate environ- mental variables which might influence the outcome of an inter- action. These strategies can be implemented as assigned tasks to be discussed at subsequent sessions. The worker must not prescribe any behaviour that might be destructive to the client’s role functioning; for example risking job loss through a major confrontation with a co-worker.

Case illustration. Tracy was a 26-year-old single woman, living with her parents, who came to the agency at the suggestion of a relative. She always expected people in the social environment to reject her, and when under stress developed delusions of persecution. She spent most of her time at home and had no friends. Tracy had recently lost a job due to arguments with coworkers, in which she confronted and even filed grievances against them for con- spiring to get her fired. Despite her presentation, Tracy wanted to feel close to other people. She was lonely.

Tracy kept her appointments, but was suspicious of the social worker’s motives and was not shy about confronting any perceived mistakes he made. She ridiculed him at times, and one particularly angry outburst occurred when he was five minutes

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late for a session. The social worker met with Tracy weekly for several months, with little apparent progress, until the relation- ship improved and Tracy came to trust the worker’s positive intentions.

Tracy had begun working again as a secretary. As they listed her priorities for clinical work, the issue of job success came first, followed by meeting new peers. During each weekly session Tracy described what had happened at work with co-workers and supervisors. Invariably these interactions were reported as unpleasant and featured their efforts to reject Tracy as a colleague, criticise her work, and get her fired. Tracy suspected that the other staff were jealous of her work skills.

The worker challenged Tracy to defend these conclusions and consider other interpretations of situations.

‘What exactly did the receptionist say to you? How did you conclude from that that she was being malicious? What was her body language? Could she have meant something else than what she said? LRc me suggest what she might have meant. ’ ‘ Why do you think that people are so attentive to you? Don’t they have plenty to worry about without focusing on you?’

The worker was able to use the relationship to encourage Tracy to consider alternatives without alienating her. Tracy considered the worker’s ideas and tried to implement them. Positive outcomes were evidenced by the fact that she kept her job.

The worker occasionally made visits to Tracy’s place of employ- ment. They met during Tracy’s breaks so that he could become familiar with the physical environment and have a better frame of reference from which to problem-solve with her. They went to a nearby restaurant to complete the sessions. The social worker hoped that getting Tracy into the habit of taking breaks away from the office might help her meet other working persons from the neighbourhood. This was successful, as Tracy became friendly with a man from a nearby small business.

Phase four: consolidation of gains

By the ending phase, if intervention has been successful, the client trusts the worker well enough to tolerate confrontation without misinterpreting the worker’s motives. The client’s sense of self may incorporate the possibility of responsibility for the outcomes of some interpersonal events. The client has achieved some gains and the worker now focuses on generalizing them.

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Stress reduction activities (Hepworth et al., 1997). These behavioural activities take on added significance with the client who has persecutory delusions. They imply that the client, who is accustomed to projecting blame, must assume responsi- bility for his or her stress. The client may not feel responsible for the origins of stress, but can learn to influence its emotional outcomes. Relaxation activities may help the client utilize foresight in managing stressful situations. For some clients, the worker may suggest strategies for avoiding certain situations which increase tension. Particular strategies depend on the client’s interpersonal style, level of anxiety, and sense of initiative.

Social network intervention. Networks refer to persons in a client’s environment who can be counted on to provide material or emotional support (Walsh, 1994). The social worker has helped the client learn that there are some others who are trustworthy, and the client can be helped to identify ongoing supports in light of the expanded repertoire of behaviors. These may include family members, neighbours, friends, co-workers, or casual community contacts. Such persons may be brought to the agency for joint meetings, although in most cases they should be identified, discussed, and left to the client to seek out for assistance.

Case illustration. Nancy was a 25-year-old married and pregnant woman. Her husband was out of town on business several days per week. Nancy had a delusional disorder in which she episodically expe- rienced fears of molestation by nonspecific others. The delusions became more pronounced as Nancy’s anxiety level increased and became most severe during her pregnancy. It was clear that both her physical changes and anxieties about mother- hood contributed to her persecutory delusions. When alone she would not leave her house or even go upstairs by herself, fearing that she might be assaulted. At this time she came to the mental health centre with her husband. The social worker was able to engage the client in treatment quickly due to her desperation for help. He looked for patterns in Nancy’s delusions to see where intervention might be focused. Because she was most delusional when alone, he helped structure a daily routine in which she was regularly in contact with others, even though many of these rela- tionships were superficial. Nancy’s delusions persisted but became less incapacitating.

Five months later Nancy’s daughter was born. Nancy enjoyed motherhood but her fears of being alone persisted. She called

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her husband at work several times per day, and when he was out of town called and visited with relatives who lived in a nearby town. The social worker had concerns about the rescue behaviours of the family system (mother, sister, aunts, and husband) and devoted their final sessions to this theme. Her family members might eventually resent spending so much time with Nancy. The worker made a list with Nancy and her husband of those stressors which seemed most troublesome (shopping and driving a car), and outlined behavioural strategies for reducing them. Provisions for family member availability were included in all of these. The social worker agreed to consult in person or by phone about Nancy’s progress if the family wished. The positive relationship that the social worker had with Nancy enabled him to make these suggestions without being seen as pushing her with unrealistic expectations.

Summary

Clients in a variety of social service agencies may exhibit delusions of persecution. These persons are difficult to treat because of an unwillingness to accept responsibility for change. However, they can be helped to broaden their definitions of social situations and response repertoires with the assistance of an empathic, patient social worker who attends carefully to rela- tionship development. The social worker can offer a sensitivity to the biopsychosocial influences on persecutory ideation and a variety of intervention strategies through a four-phase process.

References

American Psychiatric Association (1994). Diagnostic and sta- tistical manual of mental disorders (4th ed.) Washington, D.C.: Author.

Block, B. & Pristach, C. A. (1992). ‘Diagnosis and management of the paranoid patient’ American Family Physician, 45(6), 2634-2640.

Burbach, D. J., Borduin, C. M., & Peake, T. H. (1988). ‘Cognitive approaches to brief psychotherapy’ In Peake, T. H., Borduin, C. M., & Archer, R. P. (Eds.), Brief psychotherapies: Changing frames of mind (57-84). Newbury Park, CA: Sage.

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Candido, C. L. & Romney, D. M. (1990). ‘Attributional style in paranoid vs. depressed patients’ British Journal of Medical Psychology, 63, 355-363.

Charon, J M. (1992). Symbolic interactionism: An introdw- tion, interpretation, and integration (4th ed.). Englewood Cliffs, New Jersey: Prentice-Hall.

Fraser, J. S. (1983) ‘Paranoia: Interactional views on evolution and intervention’ Journal of Marital and Family Therapy, 9(4), 383-391.

Freud, S. (1966). Introductory lectures on psychoanalysis. New York: Norton.

Granvold, D.K. (Ed.). (1994). Cognitive and behavioral treatment: Methods and applications. Pacific Grove, CA.: Brooks/Cole.

Hepworth, D.H., Rooney, R. & Larsen, J. (1997). Direct social work practice: Theory and skills (5th ed.). Pacific Grove, CA.: Brooks/Cole.

Hewitt, J .P. (1994). Self and society: A symbolic interactionist social psychology (6th ed). Boston: Allyn and Bacon.

Kheshgi-Genovese, Z. (1996). ‘The crystallization of a paranoid symptom: Three theories’ Clinical Social Work Journal, 24( l), 49-63.

Magaro, P.A. (1981). ‘The paranoid and the schizophrenic: The case for distinctive cognitive style’ Schizophrenia Bulletin, 7(4), 632-661.

Magaro, P.A. (1980). Cognition in schizophrenia and paranoia: The integration of cognitive process. Hillsdale, NJ: Lawrence Erlbaum.

Meissner, W. W. (1981). ‘The schizophrenia and the paranoid process’ Schizophrenia Bulletin, 7(4), 61 1-631.

Munro, A. (1991). ‘A plea for paraphrenia’ Canadian Journal of Psychiatry, 36(4), 667-672.

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Retterstol, N. & Opjordsmoen, S. (1991). ‘Fatherhood, impending or newly established, precipitating delusional disorders: Long-term course and outcome’ Psychopathology, 24,232-237.

Ritzler, B. A. (1981). ‘Paranoia-prognosis and treatment: A review’ Schizophrenia Bulletin, 7(4), 710-728.

Stoudemire, A. & Riether, A. M. (1987). ‘Evaluation and treatment of paranoid syndromes in the elderly: A Review.’ General Hospital Psychiatry, 9, 267-274.

Swanson, D.W., Bohnert, P.J. & Smith, J.A. (1970). The paranoid. New York: Little, Brown.

Walsh, J. (1994). ‘Social support outcomes for the clients of two community treatment teams’ Research in Social Work Practice, 4,448-463.

Weiden, P. & Havens, L. (1994). ‘Psychotherapeutic manage- ment techniques in the treatment of outpatients with schizo- phrenia’ Hospital and Community Psychiatry, 45(6), 549-555.

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