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Section 3
Track #3 - Using a 'Trust List' with Delusional Thoughts,
Hallucinations, and Paranoia

CEU Question 3 | CEU Answer Booklet | Table of Contents | Bipolar
Counselor CEUs, Social Worker CEUs, Psychologist CEs, MFT CEUs

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On the last track, we discussed three types of resistant adult bipolar clients.  Those were clients who reject diagnosis; the underidentifying; and the over-generalizing client.

Generally, when a client hears the words, "psychotic symptoms" a variety of unrealistic thoughts come tomy wrists cut and bleeding Treating the Highs and Lows of Bipolar counselor CEU mind.  Often, the term "psychosis" conjures up images of raving lunatics unable to control their murderous impulses.  This image has been perpetuated by pop literature, the media, and a societal interpretation.  When a client has a clear misinterpretation of psychosis, I explain to them that psychosis is merely a break with reality during which everyday occurrences may seem strange and confusing.

On this track, we will examine characteristics of adult bipolar clients who come under the influence of psychosis:  delusional thoughts; hallucinations; and paranoia.

3 Characteristics of Psychosis

Share on Facebook 1. Delusional Thoughts
The first characteristic of a client during a psychotic break is delusional thoughts.  These delusions include a grandiose image of themselves such as the client believing he or she is a messenger of god or is in fact a deity. Often, this kind of augmented-purpose delusion occurs during mania.  Clients under depression, however, may exhibit somatic delusions in which they believe that their body is rotting away. 

During delusions, as you know,  a client becomes utterly unreasonable and very difficult to communicate with so convinced are they of their delusions.  During a delusional episode and especially during a depressive delusional episode, the client’s potential for suicidal or self-harming behavior increases.  I ask family members or loved ones to monitor the client’s behavior carefully and to understand that he or she has no control over what they say or believe.  If the client has no one to look after them and they are an extreme risk to themselves or to others, hospitalization may be necessary.

Darcy was a 23 year old bipolar client I was treating.  During her mania, Darcy would often believe herself to be cursed by the devil, who, she claimed, made bad things happen.  If she dropped a mug and it broke, Darcy believed that this was the work of Satan.  While under the influence of this delusion, Darcy became increasingly more at risk for suicidal tendencies. Because she was living with her mother, Cecilia, I asked that she be kept in sight of family members at all times and her behaviors watched.  I also told Cecilia to give Darcy as much a feeling of security as possible.  With the support of her mother and medication, Darcy was able to come through her delusions relatively unscathed.

Share on Facebook 2. Hallucinations
The second characteristic of psychosis manifested in bipolar clients is hallucination, as you are aware. Generally in bipolar clients, these hallucinations are auditory and internal resulting in negative self-talk. Occasionally, clients’ hallucinations may also become visual as well. Most of the time, clients know they are hallucinating, but still react to the hallucinations because they have lost the ability to appreciate the unreality of such experiences.

Chris’s hallucinations were chronic and extremely vivid. Chris stated, "I have many different types of hallucinations.  I often see myself being bitten by a dog or hit by a car.  I see my body fly in the air and land on the ground in front of me.  I have looked down and seen my wrists cut and bleeding.  I smell things more strongly and hear voices that tell me I should not be where I am or that I’m a failure and should die.  It scares the shit out of me every time." 

Understandably, Chris’s hallucinations were accompanied by a great deal of anxiety which threatened his help. Although I could not prevent the hallucinations without medication, I gave Chris a breathing exercise to practice when he became overwhelmed by his hallucinations.

Share on Facebook Technique:  5-to-1 Count
The breathing technique I recommended Chris try is called the 5-to-1 Count. I asked Chris to follow these directions whenever he felt anxious when he was experiencing a particularly frightening hallucination.
1. Say the number 5 to yourself, and as you focus on the number take a deep, full, slow breath.  Exhale fully and completely, making sure to get the last bit of air out of your lungs. 
2. Mentally count 4 and inhale.  As you begin the exhalation, tell yourself:  'I am more relaxed now than I was at number 5.'  Be sure not to rush the thought. 
3. Inhale, mentally counting 3.  Tell yourself:  "I am more relaxed now than I was at number 4," as you exhale fully and completely. 
4. Count number 2 and then number 1, mentally repeating the phrase:  "I am more relaxed now than I was at number 2."  Allow yourself to feel the deepening relaxation. 
5. As you approach number 1, you should feel calmer and more relaxed.
I recorded this exercise onto a tape so Chris could easily play it to himself without having to memorize the entire exercise.  I also find the 5-to-1 count helps clients to hear their therapist’s voice when there are especially anxious.

Share on Facebook 3. Paranoia
In addition to delusions and hallucinations, a third characteristic of psychosis common in bipolar clients is paranoia.  Paranoia involves a heightened sense of danger and alertness within a client resulting in suspicion of people that they may have trusted their entire life.  Often this is coupled with accusations against family members and spouses who I remind that the client is experiencing paranoia and in no way is basing their contentions in reality. 

Carol, age 34, has damaged several of her relationships.  Carol stated, "I’ve lost so many friends because of paranoia.  I can feel that they’re saying things about me and I have to tell them what I feel.  It’s as though I’m just sitting there and suddenly I have the idea that my friends don’t want to be with me and that they’re avoiding me.  When I ask them why they are treating me this way, they truly have no idea what I’m talking about.  They then think I’m totally weird and the friendship is over."

Share on Facebook Technique: The  Trust List
To help Carol during her paranoid stages, I asked her to make a "Trust List". I told her to divide  a sheet of paper into two columns.  At the top of one column, I asked her to write "Name" and the other to title it "Why I trust them".  Under "Name", Carol wrote the names of all the loved ones she trusted.  She wrote, "Mom, Dad, Aunt Bernice, Shelly, Tom, Pastor Davis". In the column "Why I trust them", I asked her to write in detail an incident in which each person proved beyond a doubt their trustworthiness. 

For example, for the name "Pastor Davis", Carol wrote "Invited me over to his house for dinner to meet his family, even when several families in the parish thought I was dangerous.  He let me talk and play with his young children and his wife listened to me without judgment." 

During a paranoid episode, I asked Carol to pull out her list and think on the times in the past that people have proven themselves trustworthy.  Many times, Carol reported that this list calmed her paranoia. 

Think of your client with chronic paranoia.  Would he or she benefit from a "Trust List"?

On this track we presented characteristics of clients who exhibit a psychosis.  These Characteristics are delusional thoughts; hallucinations; and paranoia.

On the next track, we will examine techniques to predict manic and depressive states and to aid clients through these cycles we will discuss Listing Symptoms According to Category; Preventative Maintenance Plan; and Three-Part Breathing Exercise.

Online Continuing Education QUESTION 3
What are three characteristics of clients under exhibiting symptoms of a psychosis? To select and enter your answer go to CEU Answer Booklet.

 
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