On the last track, we discussed four steps to cope with a raging bipolar child client, which were Creating a safe environment; disengaging the child; knowing your comfort zone; and rechanneling. We also included techniques parents can use when their child begins to rage at home.
As you know, paranoia and fearfulness go hand-in-hand with bipolar disorder. Often, paranoia incites irrational fear and anxiety or vise versa.
On this track, we will examine techniques to cope with a paranoid or fearful bipolar child client. The three Techniques for treating a paranoid client that I have found are Waiting It Out; Reality Check; and Staying on Guard. The two techniques I have found for treating a fearful client are: Breathing Exercises; and Counting.
3 Techniques for Treating a Paranoid Client
Technique: Waiting It Out
The first technique for coping with a paranoid client is Waiting it Out. Have you, like I, found that paranoia is actually a symptom of a severe psychotic episode? In such cases, similar to when a child client rages, he or she cannot be reasoned with. Their reality has become so skewed that any reasoning could be misinterpreted or lost on the client and usually arguing or contradicting the paranoia will get me nowhere.
Clive, an 11 year old client of mine, was convinced that the mailman was engaging in germ warfare because Clive had seen him pick his nose. I tried to explain to Clive the intricacies of true germ warfare and how the mail man could not possibly be involved with such activities, but, expectedly, Clive was in such a psychotic state, he could not be reached. When a client is so far removed from reality, I find it more beneficial to wait out the psychosis until the client has come back to a more rational state. Of course, during this time, I watch the client carefully to ensure that he or she does not do anything to harm themselves or others.
Technique: Reality Check - "No, he just wants to kill me, I know it."
The second technique I find useful for coping with a paranoid client is Reality Check once the client is slowly emerging from their psychosis. Only when the client has already started to come out of psychosis can such a tactic be effective. I use empirical data, logic, and examples to try to help the client realize the absurdity of their conjectures.
Ultimately, the convincing will have to come from within the client, and this might not come right away. Clive had slowly started to emerge from his psychosis after a few days of therapy. Once I had decided that Clive was indeed in a more rational state of mind, I put these questions to him, "Clive? Do you know what germ warfare is?" He responded, "When terrorists use germs to kill other people." I asked him, "And why would the mailman want to kill you? Did you do anything bad to him?" Clive stated, "No, he just wants to kill me, I know it."
I stated, "Do people kill other people for no reason? Who do you know who does that?" Clive was silent for a while then stated, "Nobody I know. Unless they want to steal something from them." I asked him, "Is there anything that an 11 year old boy has that a grown mail man would want?" Clive stated, "No. He doesn’t play video games and stuff." As you can see, through this line of questioning, Clive had answered his own paranoia through logic. Think of your "Clive". Could he or she benefit from a reality check?
Technique: Staying on Guard
In addition to Waiting it Out and Reality Check, a third technique I use for coping with paranoid clients is Staying on Guard. Although most paranoia is harmless, if a bipolar child client truly believes that someone is out to get him or her, he or she may take measures to protect themselves. For instance, Clive was caught by his mother putting trip wires all over their sidewalk to catch the mailman. I interview each of my clients who I believe is in a state of psychosis about their recent activities.
For instance, before Clive had begun to reason with me, I asked him, "So what have you done to protect yourself against the mailman?" Clive stated, "I tried to make a trap for him, but Mom caught me." I then asked, "What else have you done because you thought the mailman was out to get you?" He stated, "I keep a screwdriver for when I see him." I asked, "What are you going to do with the screwdriver?" Clive said, "I will stab his leg when I see him." Concerned about the extent to which Clive had taken his paranoia, I recommended that he be kept at a relative’s house until his psychosis has passed.
2 Techniques for Treating a Fearful Client
Technique: Breathing Exercises
As you know, extreme fearfulness also comes with paranoia. Luanne, a mother of thirteen year old Brandon, described her sons many fears. Luanne stated, "At thirteen and a half, he’s afraid of the dark, abandonment, being ignored, "bad guys", not being popular or accepted. I feel that he is more fearful than a normal child. When he has a nightmare, he still crawls into my bed for comfort. He wants to be cuddled on my lap all the time. I don’t really mind, except that he is bigger than I am, and heavy." For clients like Brandon, I teach them Breathing Exercises to use when they become overwrought with fear. During one of our sessions, I asked Brandon to take deep breaths from the pit of his stomach.
I had him lie down on the floor... and fold both hands over his chest. I asked him to watch his hands move up and down as he breathed in through his nose and slowly exhaled through his mouth. I explained that the oxygen cleansed the blood and nourished every cell in his body. When Brandon again felt overcome by fear, he tried this technique.
He later stated to me, "It really helped. Although I was still really scared, I didn’t feel as much panic as I once did. I didn’t run to my mom to hold me. I could manage it myself." As you can see, for older clients, teaching them ways to cope with their fears is an effective tool outside of therapy sessions as well. Think of your "Brandon" who is overly fearful. Could he or she benefit from breathing techniques?
Technique: Counting - Beaded Bracelet
In addition to Breathing Exercises, a second technique I use for fearful bipolar children is Counting. Gwen was a 9 year old bipolar client of mine who was constantly scared during inappropriate moments. Gwen stated, "When I’m at school, my breath gets fast and I’m really, really afraid. My mom is not there to hold me, so I get even more scared. One time, I even screamed. I don’t know why. I thought if I didn’t, whatever I was scared of wouldn’t go away." I told Gwen that the next time she was frightened to count something in the room. Some clients count ceiling tiles or sheep.
I gave Gwen a beaded bracelet... with over a hundred beads on it. When she became frightened, she counted the beads. Once she found sturdy rhythm, she felt less tense and her mood subsided. Although this may sound like a simple technique, I have found that it has helped several bipolar child clients.
On this track, we discussed techniques to cope with a paranoid or fearful bipolar child client. Three Techniques for treating a paranoid client were Waiting It Out; Reality Check; and Staying on Guard. Two Techniques for treating a fearful client were: Breathing Exercises; and Counting.
On the next track, we will examine three characteristics of mixed states which include irritability; distractibility; and boiling point. We will also include three techniques for children who experience mixed states: Define your Emotions; Sensory Focus; and Contract to Avoid Conflict.
Peer-Reviewed Journal Article References:
Allen, D. N., Randall, C., Bello, D., Armstrong, C., Frantom, L., Cross, C., & Kinney, J. (2010). Are working memory deficits in bipolar disorder markers for psychosis? Neuropsychology, 24(2), 244–254.
Grassi-Oliveira, R., Daruy-Filho, L., & Brietzke, E. (2010). New perspectives on coping in bipolar disorder. Psychology & Neuroscience, 3(2), 161–165.
Hardin, T. (2010). Review of Treatment of bipolar disorder in children and adolescents [Review of the book Treatment of bipolar disorder in children and adolescents, by B. Geller & M. P. DelBello, Eds.]. Psychiatric Rehabilitation Journal, 33(4), 335–336.
Malouf, J. (1996). Review of Cognitive-behavioral therapy for bipolar disorder and Cognitive therapy for delusions, voices, and paranoia [Review of the books Cognitive-Behavioral therapy for bipolar disorder, & Cognitive therapy for delusions, voices, and paranoia, by M. R. Basco, A. J. Russo, P. Chadwick, M. Birchwood & P. Trower]. Psychotherapy: Theory, Research, Practice, Training, 33(4), 636–637.
Online Continuing Education QUESTION 8
What are three techniques for treating a paranoid client?
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