How to Coach Yourself and Others Coaching and Counseling in Difficult Circumstances | Page 89

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woman living in the flat below, that she was making noises that were ‘threatening to him or sexual
towards him’, and the nurse explored what contact the patient had with her, and asked what was the
likelihood he was going to act on those beliefs and in what ways that might be. The second example
was of a patient who believed he was on a mission that meant he should jump out of a third story
window, and the nurse explored how important the mission was, and whether the patient was
making any plans about beginning the mission.
Monitor delusions for incorporation (9/28)
Occasionally nurses get incorporated into patients’ delusion systems in a negative way, becoming
part of the conspiracy against them in some way. This could result in patients becoming hostile and
antagonistic towards the nurse concerned, and when this did occur, care had to be swapped to other
nurses who were not incorporated in the delusional system in this way, because contact could lead
to the patient becoming distressed, or in extreme circumstances, violent. Nurses suggested this
could be averted by ‘constantly checking’ with the patient, ‘being mindful’ and evaluating ‘how you
are perceived, how you are seen’. Sometimes it was necessary to explain in great detail why you
wanted to ask certain questions before asking them, or maybe even checking with the patient first
whether you could ask them, so as to minimise and feeling of threat or loss of control. Staying
‘neutral, professional and appropriate’ was important, as was not insistently arguing with them that
their delusions were false.
Don’t deny or dismiss (23/28)
The nurses were generally agreed that it was not helpful or successful to deny the delusion, ‘shout at
the patient saying it was not real’, or disrespectfully dismiss it, ‘belittling’ them: ‘oh don’t be so
stupid, that’s not true’, ‘that’s total rubbish’ or ‘it’s just your mental illness’. Doing this was said to
‘completely break down any sort of relationship’, sometimes make the patient angry, turns the nurse
into an ‘adversary’ and ‘can make the person stop communicating’. Alternatively, with someone
who is ‘fragile and vulnerable or where the delusion is particularly sensitive or protective of
patients’ emotions, a denial can ‘shatter’ them, make them ‘distressed’ or precipitate ‘depression
and possible self-harm attempts’. In addition not listening ‘doesn’t really take you anywhere’,
prevents proper understanding of the person, and a correct assessment of the level of risk.
Gently question, cast doubt (18/26)
Introducing questions or doubts about the delusional beliefs could be done and might be helpful.
However the nurses indicated that you first needed to have a good, trusting relationship with the
patient concerned, and that the strongest and most central parts of the delusional system should be
left alone whilst doubt is introduced around the edges, with less strongly held and perhaps less
emotive beliefs. This work could not, therefore, easily be done early in the patient’s admission
before confidence in the staff had been established, the delusional system was thoroughly known
and good relationships formed. At this point, slightly challenging questions (not direct
contradictions) could be introduced, say thro Vv