Trying to Make Sense of the Delusions

Family
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An older lady who’s been dealing with her son’s illness for years told me to never spend my energy trying to figure out what’s going on inside my son’s head because there’s never any way to know. But, as usual, I’m not so good at following what I know to be good advice.

My son, both on & off meds, had been stable for a very long time up until about a year an a half ago. He didn’t follow doctors orders exactly, but he had insight, recognized when symptoms were getting outside of his control & would either start taking his meds again or increase what he was taking. The doctor knew he was doing this, and instead of giving him a lecture, asked to be called if he made a big change or started to have big problems.

I keep thinking back to what happened back then. One thing that happened is he must have recognized that something was going very badly because he wanted to see a therapist in the worst kind of way - and we found one.

She was more for substance abuse than anything (he was on large amounts of suboxone & klonopin - all prescribed, plus he would drink with it to enhance the high). Soon after starting to see her, he became pretty obsessed with her and developed this whole fantasy that included hearing her say things she didn’t say when he was in visits, believing they were intimate, seeing visions of her when he was at home that he’s rationalized into being psychic or having ESP, and thinking they were planning a long-term relationship (he knows she’s married) including children (he believes she was pregnant, then he had to watch one of his visions where she forced herself to lose the baby - this is the most hurtful one for him.)

So, now he hasn’t seen or spoken to her in about 7 months, although he will still call her number when he’s very symptomatic and leave messages. Sometimes, he’ll call & just leave the phone off the hook because he thinks she can see through the phone.

However, these last few days to a week, he’s started talking about how he just hurts. When I ask what hurts, he says his heart.

So, I get it. He’s heartbroken. And, he keeps saying he should have married her. That she said “I do”, but it was when he asked her if she hated him.

Yesterday, we had a long talk & I told him that everyone gets their heart broken, that it’s part of life and absolutely everyone has either had, or will have, their heart broken. He wouldn’t be normal if it didn’t happen, he’ll probably get his heart broken many more times, and marriage was no shield against it. He asked me if his dad had ever broken my heart - and I said yes, many, many times over the years, because it’s very true.

I didn’t mention that he, my son, breaks my heart without even trying all the time.

I also told him that the difference was he can’t seem to get over it when it happens to him, and that he can’t let this drag out for years. He needs to put it out of his mind, move on, and there will be other people. Some will break his heart, and for others, he’ll be the one to break their heart.

He took a nap a couple hours later, and when he woke up, he said he spoke to someone in his dreams, a favorite actor from a sitcom, and he put it in a way my son could understand, and now he felt better.

So, as psychotic as that last part sounds, I’m very hopeful that he’s put this little bit of pain away because I’m thinking this is what started his massive decline and is also why the meds seem to be so effective in the hospital and then slowly seem to stop working. In the hospital, he’s distracted, and he makes friends, and he forgets about it for a little while. At home, he isolates, and eventually his mind goes back to the therapist, then he gets racing thoughts & feels the heartbreak again.

This also might be why the delusions are different this time. Before, it was always government conspiracies, time machines, etc. Now, it’s about things that would make him important in someone else’s mind - having special powers, knowing famous people, having lots of money, etc - very little about anything that would, in his mind, get him killed.

Sorry for writing a book, but I can’t help but want to bounce this off someone & see if anyone else thinks they’ve came up with what’s behind some of their family member’s delusions.

Somewhere, behind it all, there has to be some kind of logic - even if it’s a twisted logic with some false ideas.

The good thing is, because there’s always something good, he is not really abusing anything right now. Right before his first hospitalization, he quit the suboxone & klonopin cold turkey and hasn’t went back on them. There’s none to take anyway. He smokes like crazy, but don’t most people with MI? He does crave alcohol at times because he says it gives him some relief, but most days, he’ll be happy with a tall beer and right now he likes the Chelada’s that are only 3.5% alcohol, so that really amounts to one really strong beer, but it takes him longer to drink the extra volume so it makes him happier. I think to go from enough drugs & alcohol to kill some people to a little beer each night in less than a year is definite progress.

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I’m reading a book right now by Ira Steinman, M.D. He is a psychotherapist who believes that all delusions come from somewhere along the lines of underlying feelings that cannot be coped with. His theories and practice are more complex than that, but yes, your son sounds heartbroken and the genetic and physiological vulnerability to disordered thought makes delusions easier to enter as an alternative coping strategy that has many downsides.

Steinman writes, “There have to be reasons – loneliness, fear, impulsiveness, for example – to give up generally agreed reality…Had reality been kinder, had they coped better in adolescence, such a return to an inner world peopled with their own creations might not have been unnecessary.”

According to his theory, the difficulties underlying delusions are so great that the person sub- or unconsciously makes a delusional way to cope, with the help of genetic vulnerability to psychosis.

His practice attempts to bring people to awareness of the symbolism of each person’s delusions and their functional necessity. He writes that it usually takes years and years with a person willing to stay in psychotherapy, an excellent therapist. He does not mention the incredible financial resources needed to attend psychotherapy twice a week for five to ten years.

I don’t know whether the overwhelming heartbreaks and terrors of this life could be better described than by people in delusional states. I am sorry for the pain of everyone with a broken heart, especially young men who cannot withdraw projection from a “love object.” It’s almost like they do not see the woman (or women in general) as fully subjective with her own experiences, needs, and preferences. Such projection removes their own internal sense of self and agency as well, maybe a chicken and egg question.

Personally, as a family member, I think it’s good to try to understand delusions, but I personally would not try to disrupt or bring awareness. We are the caregiving friends – parents and spouses and siblings, etc. all equals – not sources of therapy because we cannot have the vital distances and containment of therapeutic relationships with our family members.

I read that 80 - 90% of people with SMI smoke cigarettes. And it’s really good he’s cutting down on alcohol.

Happy Mother’s Day @slw

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I don’t think it hurts to ask and talk to him and you gave some really honest advice. Too often, I think we take the position to leave well enough alone. I honor you for trying to understand. Happy Mother’s Day

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@slw, I think your advice and observations with your son are 100% solid love and friendship.

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Can you share the title of the book, just in case that doctor has written more than one?

It sounds like something I should read.

The case manager/therapist he’s assigned to has kind of implied he would go down that road with my son, if he could gain his trust, but my son’s having nothing to do with it. They’ve also implied that his recovery will be limited without going through that process. They can convince me, but that’s not worth a lot.

I keep saying implied because they seem to talk to me almost as gently as they talk to him - and I probably take just as long to get their meaning as he does. I get more out of them when I push them to the point of frustration - theirs, not mine. I really wish they’d just be blunt when they’re talking to me.

EDIT: By the way, he’s still talking about ESP, astral projection & famous people he knows today, but he’s only mentioned that old therapist once today and he’s much calmer - he’s taking a nap now. I’m not kidding myself that it will last, I’ll take whatever I can get.

Tomorrow will be 3 weeks into his shot, and he’s usually ticking up in symptoms & sleeping less, so maybe we’re turning a corner.

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The book is called “Treating the ‘Untreatable’: Healing in the Realms of Madness”

And I quote a quotation from the book: “‘Many patients in the public sector, probably the majority, have become ‘untreatable’ because they have not experienced treatment adequate to their needs.’”

The basic idea of the book is that the way in to delusional thought is also the way out. Steinman observes that delusions are intractable and cannot be “cut through” by reality testing, logic, or rationale, that these sorts of attempts usually strengthen the delusions. So his approach is to let the person reveal their delusions without being questioned from a shared reality point of view, but accepting and exploring the delusions (something family members really can’t do because we are there all the time and agreeing with delusions could make them worse or more harmful). Then after awhile he moves dynamically to get the person to understand their origin in real circumstances of external events or internal feelings and their symbolic nature in navigating what is overwhelming and has not been processed.

It takes a really long time, usually 9 months to more than a year for someone to even reveal their delusions or hallucinations to a therapist (according to a professional I know, not the book). In the book, a person may reveal a minor one and keep their main delusions for years. Building trust and a therapeutic relationship is a long-term process. The book says two years is not long enough for most people, though some have improvement in that time.

I also believe that delusions are meaningful, that dreams are meaningful, that actions are communication. If we believe that someone is doing something that makes absolutely no sense and comes from nowhere, that their world is without internal logic, what are we saying about our ability to value one another and to relate?

Also that harmful behavior is communication, but that safety is the number one priority for all involved. If a person is hurting themselves or others, there is no more interpreting, only fast action for safety and intactness. The police or involuntary admits add a whole new layer to most delusions. We family members are often blamed for having to reach out for help and, to me, this blame is really understandable from the delusionary point of view that does not see the self as the source of danger or difficulty, but things outside and external, because both the inner and outer world are out of the control of the person.

I think all the mean and terrible things my family member did and said were and are part of them, though not the parts they would choose to enact if they were not ill, just like I have terrible feelings and thoughts, but am able not to act on them most of the time. I think the anger and rage are very real and need to be integrated into awareness so there can be control of behavior and perspective on negative emotions. As long as the delusions are there, the self in all its goodness and not-so-goodness will not have to be known and psychosis will continue to one degree or another.

Knowing oneself is painful for any person who is forced to self-knowledge. People with these illnesses are already in more pain and experience more suffering, so I see why most therapists act strictly in support roles and do not attempt to resolve aspects of psychosis or understand the origins of delusions. It would take way more time than most professionals have, even if they had the training and experience to treat psychosis this way. The system is so full of patients and still, almost half of people with these illnesses are not treated at all. There are tragic consequences when people are not treated. Stopping death, homelessness, and incarceration have to be the priorities, so only the very wealthy, voluntary patient will receive the book’s type of therapy. I would estimate an infinitely small percentage, far less than 1% of patients will receive the book’s type of therapy.

It’s the fine line between relating openly and honestly and contributing to delusions that I personally have to navigate. I am genuinely interested in my family member’s inner world, but I don’t want to add stress or reinforce delusions.

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I have a pretty good idea where some of my son’s delusions come from - others, I’m clueless about.

i can see where this approach would be very beneficial.

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Yes, and I can see where it would take a lot of time. I have started to ask “I wonder what triggered you?” Or wonder what that meant when he said he had bad dream and I always said " I bet that was scary. Who know it might make him ask himself that very question.

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I’ve started saying that something would scare me - then ask if it scares him.
Sometimes he says yes - sometimes no.

It’s one of the things I’ve picked up from I’m not sick, I don’t need help - I’ll never get it all, but I’m slowly using more & more.

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Mine is leading, your way is questioning. Thanks, I better read that again.

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I think of it as letting him know it’s OK to say some of the things scare him.

I’m hoping it’ll help him see he needs help - and then maybe he’ll even accept it.

Right now, I think a big part of the problem is that he things nothing & no one can help him - even if they tried.

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We shouldn’t try to make sense of their delusions if this means walking on eggs shels.
But your analysis does make sense

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I’m not walking on egg shells, and I usually just say “I’ll take your word for it” or “that sounds nice” or something to that effect.

But, even though the relationship wasn’t real, his emotions and heartbreak are very real. So, I gave him the same advice I’d have given him if he’d broke up with a real girlfriend.

I haven’t shared any of my theories with him - and I won’t.

But, this kind of clarity and connecting of the dots for me, means I really do need to see a therapist of my own to bounce ideas off. I’m not going to try to play therapist or anything like that with him, because I know I’m not qualified, but I can think of several things that could have triggered him over the years.

It does give me a lot of hope though. This happened yesterday & now he’s sleeping a lot. They warned me that he could start sleeping too much due to this month’s increase in both the Invega & the Trileptal, but the opposite happened - his racing thoughts can fight off a tremendous amount of medication.

Maybe, the meds will have a chance to do their job now.

I know it’s a tiny change, but I look every day for the tiniest changes every day. Anything to tell me we’re headed in the right direction.

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I completely disagree with the advice of never trying to understand. If only we had known what was going on in his head, there were many times we could have prepared before the storm hit. Kind of like they board windows near the coast when a hurricane hits.
Have you ever read A Blueprint for Recovery by *Milt Greek? He says that people with schizophrenia need an understanding mentor and a consensus realist. The mentor’s role is to become a confidant who understands the person’s viewpoint.***I highly recommend this book. It’s easy to read and has advice from a person who has experienced psychosis first hand.

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Yes, I have read Milt Greek’s book and really like it. Thank you for reminding me about it.

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