Sample
There was one female and five male psychiatrists. Their mean age was 41 years and the mean number of years working in mental health care since qualifying was 11 years.
Of the 16 patients who met the inclusion criteria during the study period and were asked to participate, 14 consented (8 female, 6 male) with a mean age of 40 years. Four of the patients were diagnosed with paranoid schizophrenia, four with other forms of schizophrenia, three with delusional disorder, two with acute psychosis, and one with depression. In nine patients, the delusions were persecutory in nature, and in the remaining patients they were hypochondriac, Cotard, thought sharing and mystic. There was no pre-existing outpatient therapeutic relationship between any of the psychiatrists and the patients in the study and for all psychiatrists, this was the first extended clinical meeting with the patient, although they may have met briefly before, during previous hospitalisations or during the current admission. Equally for the patients, this was the first extended clinical meeting during the current hospital admission, although they had reported their symptoms briefly before, e.g. during the admission process.
Eliciting the content and nature of the beliefs
The most frequent approach to address delusional beliefs was an attempt to elicit the content of the delusions. This was usually done in the form of simple questions. The questions aimed to understand the patient’s beliefs and encourage the patient to disclose their experience, without, however, challenging their beliefs:
PS: So, let’s say, you do not have anyone whom you can trust?
PA: No, at the end, I have realised that I cannot trust anyone…nobody….the others talk with each other….. and I am excluded, am I not?
(patient 1, psychiatrist 1)
PS: Where do these worms come from, can you tell me?
PA: They come from inside me.
(patient 3, psychiatrist 3)
PS: You always found him behind you?
PA: I always found him behind me. Of course, I now understand that I am wrong, I was worried that I would reject him and he would follow me to check my movements
PS: And that happened everyday?
PA: No, not everyday, no, every … every.. as if there were dates
PS: For example, what do you mean?
PA: As far as I know, every month, then every two months, then every three months, like this…
(patient 4, psychiatrist 2)
PS: Why did you feel at the centre of attention? What did you notice that gave you the impression that you were the centre of attention?
PA: Well, I felt like that for very long time, and now I understand
PS: What made you understand it?
PA: From the content of my thoughts
(patient 5, psychiatrist 2)
PS: That makes me think that you are saying that that theft of the motorbike did not occur by chance.
PA: … there is someone who is out to get me
(patient 7, psychiatrist 4)
PS: You told me even about crimes that happened during the night, about horrific situations, how can I say this, did you not
PA: in fact, we are full of blood and bruises, and talking about it with the police again…
PS: Did they confirm that situation?
PA: Yes, they said “we are all dead”
PS: also the carabinieri?
(patient 9, psychiatrist 3)
PS: they persecuted you, so do you want to tell me what happened?
PA: Eh… but it was all because of a group of people from a satanic sect…
(patient 11, psychiatrist 3)
PS: At the beginning you talked about your ability to cook
PA: Yes, I am a great chef
PS: You are a great chef?
PA: The greatest in the world
(patient 13, psychiatrist 2)
Understanding the impact
Discussing reasons for hospital admission
When delusions (and subsequent behaviours) were reported to be the main reason for hospitalisation, psychiatrists discussed to what extent patients were aware that they had been admitted to hospital because of an illness and their delusional beliefs. Most of the time, psychiatrists used direct questions aimed at exploring the patient’s explanation for the hospitalisation or provided their own explanation:
PS: Could you please tell me why are you here? What happened?
PA: Oh, well, I called the ambulance many times for months, and the police, and firemen and the centre for victims of violence against women… cause some people followed me to trouble me or damage things
(patient 9, psychiatrist 3)
PS: So… what happened?
PA: Ehm… something at work, as everybody says that I bring bad luck… and when things happen it is my fault… if someone get sick it’s my fault… and everybody looks at me
(patient 1, psychiatrist 1)
PS: (You were admitted) in a dramatic moment, because you were very upset, worried about serious things, and ……and felt persecuted…
(patient 11, psychiatrist 3)
Patients responded to such questions and explanations in different ways. In some meetings, patients appreciated that the behaviour that led to hospital admission may have been inappropriate, but did not explain this through an illness or delusional beliefs:
PS: Ok, but what is the reason why you have been hospitalised?
PA: oh… is that I stripped in public…I went out naked… I left my clothes on the gate and I went to the barber shop… naked…
PS: I see…
PA: Then I went to the family doctor… still naked… and he asked me: “What are you doing?
PS: I see…
PA: And… he called the police… and sent me here…
PS: And why do think this happened, why did you undress and do all this?
PA: Because I felt like induced… forced by external factors… by hoots of cars… and I was in the spotlight… then by television, radio and even satellite…
(patient 5, psychiatrist 2)
Patients sometimes actively avoided talking about the symptoms leading to hospital admission, at times linked to feelings of guilt or shame. Yet, they still talked about themselves:
PS: Did the doctor tell you why he admitted you?
PA: I have understood everything. I have understood that I have pushed for it … because there, where I work….you know, I'm a very good person, I would not hurt nobody…you see that this is right…
PS: Yes, of course!
PA: I have nothing against S, or against R, or against all the people I have met here. I am from the countryside.…
(patient 14, psychiatrist 2)
Exploring links with dysfunctional behaviour
Psychiatrists tried to explore how delusions were linked with the patient’s behaviour and functioning:
PS: How did you realize that you were decomposing?
PA: Because of the strong smell
PS: Ok, but if one is decomposing, parts of the flesh should be missing, shoud they not? Because when the worms enter a dead body, I don’t know, in a forest, and nobody finds it there, for three months, the worms….
PA: I put hydrochloric acid on it, the bleach kills them
PS: Where do you put it?
PA: On those parts where they grow
PS: Did you put hydrochloric acid on your skin?
PA: Yep.
(patient 3, psychiatrist 3)
PS: The thought that you have to hit someone, when does it come up? ….
PA: Ehm.. it comes when the satellite influences me, sends me signals… I give you an example: I have to go to the bloke and hurt him… the satellite makes me understand that I have to do this…
(patient 5, psychiatrist 2)
PS: We have been told… that you do not sleep in your bed, but sometimes in a cupboard, on a chair
PA: Yes, because my bed has been broken by those people
(patient 6, psychiatrist 1)
Identifying and exploring emotions
Frequently, psychiatrists addressed emotional aspects of the experience of delusions:
PS: … But how did you feel, were you relaxed, or was there something… because several times you rang the ambulance, also the police…I assume that you were alarmed ..no?
PA: Yes, because, I saw everything. I see here too, everything in a contaminated mess
(patient 9, psychiatrist 3)
PS: For example, do you think it might be useful – particularly during this admission - to try and understand the emotional components which are associated with your physical sensations? That the problems are not only due to anemia, but are possibly linked to difficulties that you have emotionally and not only physically?
PA: It is both …
PS: That is one of the reasons why it is not easy to discharge you right away. So that we understand how we can help you from a physical point of view, but also from a different perspective …
(patient 2, psychiatrist 2)
PS: Mmm. And… Does it happen that sometimes when you feel more relaxed, less stressed, that you have doubts about this belief and maybe at times when you feel more tense, more nervous …
AP: Yes, yes, When I feel stronger, … not exhausted, then I do not think about these things
PS: And you feel more relaxed
PA: More relaxed, yes
PS: I understand. Instead, when you are under stress, this belief is stronger
PA: Exactly, yes
(patient 5, psychiatrist 2)
PA: But the person has no intentions to help me ... but only to make it difficult for me, with my little project
PS: Ah, I understand, and you, how did you feel like seeing all these obstacles? Were you ever angry? Were you ever
PA: Desperate
(patient 8, psychiatrist 5)
Questioning the validity of the beliefs
Challenging the content
Psychiatrists did not just explore the content of the beliefs, but also challenged it through further questions which sometimes put patients into a position to defend their beliefs:
PS: So, they wanted to kill you and sell your organs?
PA Yes, and … sell the meat to restaurants where cannibals go…
PS: Are there restaurants for cannibals?
PA: Yes, these are secrets that the police do not know
PS: Really?
PS: This seems to be a bit difficult to believe, honestly…
(patient 11, psychiatrist 3)
Ps: Do you think there is any slightest chance that this is something you are exaggerating? Or that you are possibly wrong?
Pa: Nooo… I am not wrong at all.
(patient 1, psychiatrist 1)
PS: So… do these worms eat organs too?
PA: I think so
PS: How do you survive then, when these worms eat your organs?
PA: Well, how do I know?
(patient 3, psychiatrist 3)
However, in this consultation, a direct challenge makes the patient attempt to justify the belief:
PS: And if you were having thoughts, I could hear you?
PA: Yes
PS: How can this be possible? How can I hear your thoughts? I can hear only….
PA: I just don’t know, maybe because of the great burden of stress they’ve been laying on me since I was a little child
(patient 5, psychiatrist 2)
Exploring alternative explanations
Psychiatrists suggested and explored possible alternative explanations for the patients’ experiences. This was different from challenging the content as psychiatrists did not directly challenge the beliefs, but asked the patients only to consider the views of others or different explanations:
PS: You are describing this like a plot against you, in which at the end you were accused of having stolen a ring.
PA: Yes, but
PS: But it is not certain that this is what actually happened?
PA: But I have come to think they put me to work when I wasn’t good enough or experienced enough
(patient 7, psychiatrist 4)
PS: What do your parents say, given that they live with you?
(patient 6, psychiatrist 1)
This approach sometimes led to a defensive response of the patients too:
Ps: Did anyone tell that to your face that you bring bad luck, or is this just an interpretation you’re making of their expressions and gestures? Because there might be many reasons for example why someone can touch you…
Pa: No! Because they say “everything that has happened has been you!”
(patient 1, psychiatrist 1)
PS: Your parents, what do your parents for example say?
PA: They say that it is not true…
PS: Okay, they say that it is not true. And the fact that they say that it is not true, does not make you think that it is possible that it is not true, that it is perhaps rather your perception that you have worms in the body?
PA: I am decomposing
(patient 3, psychiatrist 3)
Contradictory evidence
Altogether, five more categories were identified, but featured in only four or fewer of the 14 meetings, so that they were not considered as common themes in the analysis:
1.
Tracing history (a total of 10 extracts in 4 meetings)
2.
Exploring links with previous stressful experiences (10/3)
3.
Exploring links between discontinuing medication and symptoms (6/4)
4.
Identifying coping behaviours (6/3)
5.
Explaining physical symptoms as a sign of psychological distress (3/1)