Uncovering Delusional Material

Mar 07, 2017

“It is in a dialogue with pain that many beautiful things acquire their value. Acquaintance with grief turns out to be one of the more unusual prerequisites of architectural appreciation. We might, quite aside from all other requirements,need to be a little sad before buildings can properly touch us.”

Alain de Botton
from The Architecture of Happiness (2006)

Uncovering Delusional Material

TISA Description of the Problem: One of the more difficult tasks in clinical interviewing is the fine art of uncovering psychotic process. For instance, helping clients to feel comfortable sharing delusional material can be a complicated task. In the following interviewing tip, Karl Smith, RN provides some sound advice on approaching this challenge.

Tip: Because of stigmatization and paranoid guardedness (as well as many other reasons), it can be hard for a patient to share delusional material. Obviously, the clinician cannot ask, “Do you have any delusions?” It is also problematic to ask the client whether he or she is “having strange, weird or bizarre thoughts (many delusional patients would, if they were answering truthfully, still answer negatively to this inquiry, for they do not feel that their delusions are strange, weird, or bizarre). In this regard, I have found the following question to be useful:

“Do you ever tell other people about your thoughts or ideas and they tell you that you are off the wall or that it is crazy talk?”

TISA Follow-up: This excellent tip from Karl Smith works, in my opinion, because it shifts the focus off the client, allowing the possibility, from the client’s perspective, that it is the other people “who just don’t get it.” Freed of this sense of being judged by the clinician, it makes it easier for the client to more openly share his or her delusional material.

If you are looking for some more practical and sophisticated techniques for uncovering psychotic process you might want to check out the outstanding article by the clinical interviewing innovator David Robinson called, “My Favorite Tips for Exploring Difficult Topics Such as Delusions and Substance Abuse.” In the article, tough situations such as what to say when a delusional client asks the interviewer, “Do you believe me?” are explored in detail with various responses nicely illustrated. I highly recommend the article, and it can be found in the June, 2007 issue of the Psychiatric Clinics of North America. Volume 30 (#2):239-244. I also highly recommend this entire issue of the Psychiatric Clinics of North America which is subtitled, Clinical Interviewing: Tips from Master Clinicians, for it includes many practical articles on clinical interviewing such as Talking with Patients About Spirituality and Worldview: Practical Interviewing Techniques and Strategies and the article, Practical Strategies for Building an Alliance with the Families of Patients who have Severe Mental Illness. There are also a handful of great articles on teaching clinical interviewing including an article on how to design clinical interviewing training courses for psych residents and grad students (including a course outline and a list of concrete educational goals).

Tip provided by:

Karl Smith, RN
Adolescent Psych In-Patient Unit
Alta Bates Summit Medical Center
Berkeley, California