Resources for working with conspiracy theorists?

[Seven_Costanza]

Happy Friday! If anybody has any resources for treating people with PTSD who also believe in conspiracy theories (9/11, 12/21/2012, Q, etc), I would sincerely appreciate it! My main concern is that the PTSD symptoms and conspiracy beliefs seem to be pretty intertwined and influencing each other. Rigidity when comes to religiosity is also a factor.

Any resources? I imagine we’ll all be seeing a lot more of this in the coming years.

---

Members don't see this ad.

 

[Fan_of_Meehl]

Happy Friday! If anybody has any resources for treating people with PTSD who also believe in conspiracy theories (9/11, 12/21/2012, Q, etc), I would sincerely appreciate it! My main concern is that the PTSD symptoms and conspiracy beliefs seem to be pretty intertwined and influencing each other. Rigidity when comes to religiosity is also a factor.

Any resources? I imagine we’ll all be seeing a lot more of this in the coming years.

Socratic questions?

I know that there was some literature out there on CBT with psychosis/delusions where the importance of alliance building and judicious use of Socratic questioning (open-ended) were emphasized. I'm also going to have to wonder about the definition of a 'conspiracy theory' when conspiracies do, in fact, occur. I know there are some wild ones but I wouldn't just automatically be quick to use that label (this may be a controversial position among MH providers, however). For one thing, it has a tendency to be automatically dismissive of what the client is saying and may impair the therapeutic alliance if we label things like that or we immediately jump into that frame. Also, it occurs to me that it is a form of a 'thought-terminating-cliche' that shuts down discussion/investigation.

I have found myself often having the discussion of, 'Okay, so even if this were true...(and I'm not saying it is), what would it mean to you in terms of how you need to act in the world (today and going forward)? I mean, if the person believes, for example, that we're going to be facing serious food shortages this winter (or at least, hyperinflation and price spikes), the person may just say that they plan to stock up on storable food (do some prepping). Okay, so what's the harm in that (you can examine pros/cons of that action with them, for example. If, however, their belief system leads them into territory involving dangerous/violent behavior, that's another issue.

 

[Seven_Costanza]

Socratic questions?

I know that there was some literature out there on CBT with psychosis/delusions where the importance of alliance building and judicious use of Socratic questioning (open-ended) were emphasized. I'm also going to have to wonder about the definition of a 'conspiracy theory' when conspiracies do, in fact, occur. I know there are some wild ones but I wouldn't just automatically be quick to use that label (this may be a controversial position among MH providers, however). For one thing, it has a tendency to be automatically dismissive of what the client is saying and may impair the therapeutic alliance if we label things like that or we immediately jump into that frame. Also, it occurs to me that it is a form of a 'thought-terminating-cliche' that shuts down discussion/investigation.

I have found myself often having the discussion of, 'Okay, so even if this were true...(and I'm not saying it is), what would it mean to you in terms of how you need to act in the world (today and going forward)? I mean, if the person believes, for example, that we're going to be facing serious food shortages this winter (or at least, hyperinflation and price spikes), the person may just say that they plan to stock up on storable food (do some prepping). Okay, so what's the harm in that (you can examine pros/cons of that action with them, for example. If, however, their belief system leads them into territory involving dangerous/violent behavior, that's another issue.

Thank you so much for your helpful response. I definitely do not frame them as conspiracies, and use the more general “beliefs”. I haven’t given my opinion on them or tried to challenge them (at least until I can figure out if there’s an effective way). My experience is that trying to challenge those beliefs tends to make people shut down and be more defensive, while viewing me as the ignorant one with my head in the sand. So definitely not the direction I’d want to take. And I think that’s where a lot of my concern comes in, as yes, this is leading them into more violent territory (no imminent plans, though). And the more traditional strategies we’d use like challenging thoughts, or acting according to their values, etc, could possible have the opposite effect I want (especially considering all the alternative facts online).

 

[JeyRo]

Can't go wrong with a skilled socratic approach

 

[Fan_of_Meehl]

Thank you so much for your helpful response. I definitely do not frame them as conspiracies, and use the more general “beliefs”. I haven’t given my opinion on them or tried to challenge them (at least until I can figure out if there’s an effective way). My experience is that trying to challenge those beliefs tends to make people shut down and be more defensive, while viewing me as the ignorant one with my head in the sand. So definitely not the direction I’d want to take. And I think that’s where a lot of my concern comes in, as yes, this is leading them into more violent territory (no imminent plans, though). And the more traditional strategies we’d use like challenging thoughts, or acting according to their values, etc, could possible have the opposite effect I want (especially considering all the alternative facts online).

Yeah, I hear ya...and, for the more 'extreme' beliefs (especially those that would maybe set them up for more interpersonal conflict/aggression), I'd just fall back on some of the CBT literature for how to deal with delusions / psychosis / personality disorders. I think that a non-judgmental, curious, Socratic approach is best. And try to preferentially focus more on what the IMPACT (interpersonally, intra-personally (e.g., symptoms/suffering), practically (do they lose jobs because of their beliefs?)) of having the beliefs is upon their life and functioning (and their life goals) rather than trying to debate or rationally refute the specific beliefs--I tend to get more therapeutic mileage out of such an approach. Also, it could be a real window into their value systems (and network of beliefs) if you could take a deep dive into why such beliefs are so important to them...for example, do they value individual liberty, autonomy, truth, hard work, transparency, whatever? And then, again, use a Socratic approach to help them realistically assess how their cognitive/affective/behavioral patterns (which may be fuelled by their 'conspiracy' beliefs) are actually impacting their valued outcomes and life goals. For example, are they alienating their wives/friends/family through engaging in conversations about these beliefs trying to convince them? What motivates them to do so? Okay, so now we identify a value that you want to look out for the safety of your family because it is important to you. Is there an alternative, socially-skilled, and more tolerable (to the family member) way of trying to better look out for their safety that they would agree is a good idea? (e.g., installing a home security system, if they agree that it's a good idea). The client could identify 'safety to family because I love them' as an important value or life goal and be asked if his current preoccupation with whatever 'theory' is actually, in fact, operating successfully in service to that goal or not. Then he could be encouraged to consider different ways of finding 'common ground' with his loved ones (they probably want to be safe, too...they just probably don't buy into the specific 'conspiracy theory' type belief that the client happens to be preoccupied with).

 

[Seven_Costanza]

Can't go wrong with a skilled socratic approach

Right, and I guess my concern is that it could go wrong with the mountain of misinformation and “evidence” online that validates their beliefs. And the belief that actual valid sources are bought and paid for by the government who has their own nefarious motivations. Am I overestimating this concern when it comes to Socratic questioning?

 

[Fan_of_Meehl]

Right, and I guess my concern is that it could go wrong with the mountain of misinformation and “evidence” online that validates their beliefs. And the belief that actual valid sources are bought and paid for by the government who has their own nefarious motivations. Am I overestimating this concern when it comes to Socratic questioning?

Yes.

I don't see any risk associated with engaging in Socratic questioning. Except, maybe, having to admit that you don't have all the answers. Again, I'd tend to sidestep the debate over whether their 'conspiracy theory' (CT) is TRUE or FALSE or the mountains of evidence they believe support it. I would gently but persistently strive to pivot away from that and more into, 'What are your values/priorities in YOUR life right now and are your cognitive/emotional/and behavioral responses actually moving you forward toward satisfaction of those goals? By using Socratic questions, you can uncover WHY the CT is SO IMPORTANT to the person and why they are so emotionally invested in others believing it. Once their goals are established, you can help them pivot into a more practical approach of getting those needs met or those goals realized. To the extent that they (and they will) try to bring goals into the session of 'waking the world up to the XXXXXXX', just gently redirect them to the fact that therapy is about changing themselves, and not the world.

 

[JeyRo]

Right, and I guess my concern is that it could go wrong with the mountain of misinformation and “evidence” online that validates their beliefs. And the belief that actual valid sources are bought and paid for by the government who has their own nefarious motivations. Am I overestimating this concern when it comes to Socratic questioning?

You can only do what you can do. You know the limitations of trying to be overly and/or improperly directive when working w/ a patient with distorted belief systems. Can cause power struggles, blowback, poison the therapeutic relationship, etc.

You can lead a horse to water - but you can't force them to drink. Besides, our role isn't to teach critical thinking skills with patients, as much as we would like to.

 

[Seven_Costanza]

Yeah, I hear ya...and, for the more 'extreme' beliefs (especially those that would maybe set them up for more interpersonal conflict/aggression), I'd just fall back on some of the CBT literature for how to deal with delusions / psychosis / personality disorders. I think that a non-judgmental, curious, Socratic approach is best. And try to preferentially focus more on what the IMPACT (interpersonally, intra-personally (e.g., symptoms/suffering), practically (do they lose jobs because of their beliefs?)) of having the beliefs is upon their life and functioning (and their life goals) rather than trying to debate or rationally refute the specific beliefs--I tend to get more therapeutic mileage out of such an approach. Also, it could be a real window into their value systems (and network of beliefs) if you could take a deep dive into why such beliefs are so important to them...for example, do they value individual liberty, autonomy, truth, hard work, transparency, whatever? And then, again, use a Socratic approach to help them realistically assess how their cognitive/affective/behavioral patterns (which may be fuelled by their 'conspiracy' beliefs) are actually impacting their valued outcomes and life goals. For example, are they alienating their wives/friends/family through engaging in conversations about these beliefs trying to convince them? What motivates them to do so? Okay, so now we identify a value that you want to look out for the safety of your family because it is important to you. Is there an alternative, socially-skilled, and more tolerable (to the family member) way of trying to better look out for their safety that they would agree is a good idea? (e.g., installing a home security system, if they agree that it's a good idea). The client could identify 'safety to family because I love them' as an important value or life goal and be asked if his current preoccupation with whatever 'theory' is actually, in fact, operating successfully in service to that goal or not. Then he could be encouraged to consider different ways of finding 'common ground' with his loved ones (they probably want to be safe, too...they just probably don't buy into the specific 'conspiracy theory' type belief that the client happens to be preoccupied with).

Thanks again for a very helpful response. I do think the issue of their personal values and identity may exacerbate the issue. Like, placing more value on being a protector of the people than personal relationships. I definitely think I need to seek more targeted consultation. Unfortunately, nobody at my job feels well equipped.

 

[summerbabe]

Happy Friday! If anybody has any resources for treating people with PTSD who also believe in conspiracy theories (9/11, 12/21/2012, Q, etc), I would sincerely appreciate it! My main concern is that the PTSD symptoms and conspiracy beliefs seem to be pretty intertwined and influencing each other. Rigidity when comes to religiosity is also a factor.

Any resources? I imagine we’ll all be seeing a lot more of this in the coming years.

Spitballing a bit…… if the conspiracy theory piece wasn’t present, what treatment would you ideally like to complete with this patient? Would you take a cognitive/CPT approach, an exposure based approach, or something less common (eg., ACT)? And what might the biggest barriers be to this ideal approach?

Did they present to treatment to address trauma specifically? General mental health distress?

I do a lot of work with DBT patients who also really need trauma focused treatment. Targeted assessment and collaboration on current goals helps me to stay focused on a lane that feels like it can accomplish something (e.g., building up distress tolerance prior to doing PTSD work after DBT is over).

 

[erg923]

Happy Friday! If anybody has any resources for treating people with PTSD who also believe in conspiracy theories (9/11, 12/21/2012, Q, etc), I would sincerely appreciate it! My main concern is that the PTSD symptoms and conspiracy beliefs seem to be pretty intertwined and influencing each other. Rigidity when comes to religiosity is also a factor.

Any resources? I imagine we’ll all be seeing a lot more of this in the coming years.

Alot of this stuff (but not all of course) is bizarre delusion at this point/degree. I'm not sure how much confrontation, Socratic Questioning, or CBT logic work will actually be effective (or desired?) for many of these people. I guess it depends on how severe/bizarre it is, how many layers there are to it, how open to other points of view they are, and what the specific conspiracy belief is? The fact is that alot of these Q types are mentally ill and/or are genetic probands of such and are prone to magical thinking, strange beliefs, mania/hypomania, etc.

Further, and while I am certainly generalizing alot here, many of these people are of low educational achievement or just plain dullards. Ok?

Education about how science works over time, and more importantly, statistics and formal logic, are at the heart of alot of this nonsense. It was ABSOLUTELY outstanding to me how many grown adults had no clue about the basic science behind medical immunization during the height of COVID-19 (even as almost all of them had the Polio vaccine scare on their arm and never got ****ing Polio). That is something I learned by attending...."gasp"... college/university (if not actually well before that).

Add in the narcissism of: "I know something that you idiots don't..."and I'm not sure how much we can really do in the outpatient therapy office?

As an aside, I and my family are lifelong, devout Catholics. I am not sure there is any connection between this and government conspiracy theory in-and of-itself. That said, again, we tend to be around relatively educated and successful families. I think this comes about more in disaffected persons and families, and may be more prominent in the "born-again" and "evangelical" converts? I am actually fairly ignorant of how Christianity is taught outside the Roman Catholic tradition.

 

[deleted1100659]

Im not trying to be a debbie downer with this point of view/question, but how often do people with these "interesting" views become more flexible about them? Honest question, not being sarcastic. Every q anon believer I have ever encountered believes in trump/democrat conspiracies more hardcore than anything I have ever seen.

 

[Fan_of_Meehl]

Im not trying to be a debbie downer with this point of view/question, but how often do people with these "interesting" views become more flexible about them? Honest question, not being sarcastic. Every q anon believer I have ever encountered believes in trump/democrat conspiracies more hardcore than anything I have ever seen.

I know that a lot of folks spend a lot of time on the internet 'researching' (sometimes they refer to it as 'reading the news' or keeping up with the news) and they get sucked into some of these domains. One thing that HAS happened with a few of my veterans is we've been able to examine their habit of going online and reading the news from more of a functional perspective--i.e., what impact is this having on your quality of life?--and we HAVE been able to successfully encourage them to spend less time in this activity with quite beneficial reductions in their overall levels of negative affect. There seems to be a widespread problem related to exposure to (and significant cognitive/emotional/behavioral disturbance in relation to) online content of a partisan political nature. I would also observe that this phenomenon is not strictly limited to one pole of a polarized political spectrum. It's all over the place.

 

[Seven_Costanza]

J

I know that a lot of folks spend a lot of time on the internet 'researching' (sometimes they refer to it as 'reading the news' or keeping up with the news) and they get sucked into some of these domains. One thing that HAS happened with a few of my veterans is we've been able to examine their habit of going online and reading the news from more of a functional perspective--i.e., what impact is this having on your quality of life?--and we HAVE been able to successfully encourage them to spend less time in this activity with quite beneficial reductions in their overall levels of negative affect. There seems to be a widespread problem related to exposure to (and significant cognitive/emotional/behavioral disturbance in relation to) online content of a partisan political nature. I would also observe that this phenomenon is not strictly limited to one pole of a polarized political spectrum. It's all over the place.

Just doing a quick reply in between sessions, and not ignoring everybody else’s helpful responses! I wonder about examining the effects on quality of life when the individual sees themselves as a protector who is uniquely skilled to be at the tip of the spear should it be needed. My sense (only met a couple times) is that they believe the usual “quality of life” things like family, partners, are things that get in the way of their larger purpose.

 

[Fan_of_Meehl]

J

Just doing a quick reply in between sessions, and not ignoring everybody else’s helpful responses! I wonder about examining the effects on quality of life when the individual sees themselves as a protector who is uniquely skilled to be at the tip of the spear should it be needed. My sense (only met a couple times) is that they believe the usual “quality of life” things like family, partners, are things that get in the way of their larger purpose.

Better to know than not know (I'd say).

Then try to help them examine whatever values/beliefs you collaboratively uncover with them. I won't say "make the unconscious conscious" but, it kinda is...prompt them to identify, attend to, and clearly articulate their beliefs to you no matter how irrational you anticipate that they may be.

 

[Fan_of_Meehl]

J

Just doing a quick reply in between sessions, and not ignoring everybody else’s helpful responses! I wonder about examining the effects on quality of life when the individual sees themselves as a protector who is uniquely skilled to be at the tip of the spear should it be needed. My sense (only met a couple times) is that they believe the usual “quality of life” things like family, partners, are things that get in the way of their larger purpose.

Sorry to double-post but I just remembered that Aaron T. Beck published a book -- 'Prisoners of Hate: The Cognitive Basis of Anger, Hostility, and Violence' in 1999 that could be helpful for this issue.

 

[erg923]

Just doing a quick reply in between sessions, and not ignoring everybody else’s helpful responses! I wonder about examining the effects on quality of life when the individual sees themselves as a protector who is uniquely skilled to be at the tip of the spear should it be needed. My sense (only met a couple times) is that they believe the usual “quality of life” things like family, partners, are things that get in the way of their larger purpose.

"Tip of the spear?" Did they say that with a straight face?

That's called narcissism!

"I am a warrior for X cause.... and all you idiots don't know WHAT I KNOW" is narcissistic investment.... by textbook.

That said, I would again caution against ruling out hypomania and other psychiatric disturbances too, here.

 

[BuckeyeLove]

This stuff is not quite delusional disorder level rigidity (i.e., no amount of flexibility even in the face of great countering evidence), but it's real fkin close I've seen. People just LOVE getting ensconced in their own beliefs, especially with how polarized things have become.

 

[Fan_of_Meehl]

This stuff is not quite delusional disorder level rigidity (i.e., no amount of flexibility even in the face of great countering evidence), but it's real fkin close I've seen. People just LOVE getting ensconced in their own beliefs, especially with how polarized things have become.

Yeah, more like 'overvalued ideation' (if we still use that term)

 

[R. Matey]

Im not trying to be a debbie downer with this point of view/question, but how often do people with these "interesting" views become more flexible about them? Honest question, not being sarcastic. Every q anon believer I have ever encountered believes in trump/democrat conspiracies more hardcore than anything I have ever seen.

I've worked with people who legitimately believed they were angels and have found that SQ has been helpful in a least adapting their thinking to the environment (e.g., maybe God doesn't want you to shout at the police or at cars on the highway). It doesn't cure the delusion, but at least has helped a few people live with it.

 

[borne_before]

"Tip of the spear?" Did they say that with a straight face?

That's called narcissism!

"I am a warrior for X cause.... and all you idiots don't know WHAT I KNOW" is narcissistic investment.... by textbook.

That said, I would again caution against ruling out hypomania and other psychiatric disturbances too, here.

I’ve got a very wealthy brother with a phd in a hard science who def has some narcissistic traits if not full blown narcissism - who has adopted a very hardcore conspiracy theory mindset about the 2020 election.

We’re not talking after he called me a little a “little [homosexual slur], kept “accidentally” sending me dubious links about fraud in group texts after I told him not too, left a family skiing vacation to go to the January 6th unite the right, and had the audacity to lecture my wife when she said that she didn’t want to be included in political texts about how “you used to be able to be friendly but have political differences.”

I’m probably done with a that fool - you don’t lecture my wife. He refuses to think he did anything wrong.

He’s eight years older than me, too. His path to radicalization was openess to conspiracy theories (researching ufos, above top secret, etc when young), contradicting personalities, hating paying taxes, spending too much time online (especially r/the_donald), and hanging out too much with the “disabled” vets who he let’s hunt his ranch for tax breaks. That took him from an Obama voter to full on Trumphole who loves owning the libs in less than 8 years….

It’s a hell of a mind virus.

 

[deleted106747]

I’ve got a very wealthy brother with a phd in a hard science who def has some narcissistic traits if not full blown narcissism - who has adopted a very hardcore conspiracy theory mindset about the 2020 election.

We’re not talking after he called me a little a “little [homosexual slur], kept “accidentally” sending me dubious links about fraud in group texts after I told him not too, left a family skiing vacation to go to the January 6th unite the right, and had the audacity to lecture my wife when she said that she didn’t want to be included in political texts about how “you used to be able to be friendly but have political differences.”

I’m probably done with a that fool - you don’t lecture my wife. He refuses to think he did anything wrong.

He’s eight years older than me, too. His path to radicalization was openess to conspiracy theories (researching ufos, above top secret, etc when young), contradicting personalities, hating paying taxes, spending too much time online (especially r/the_donald), and hanging out too much with the “disabled” vets who he let’s hunt his ranch for tax breaks. That took him from an Obama voter to full on Trumphole who loves owning the libs in less than 8 years….

It’s a hell of a mind virus.

It reminds me of working with people who insist that they have a girlfriend or boyfriend who always needs money to pay for a plane ticket and lives in Europe or Africa. These people are typically lower IQ, but I wonder if there’s research out there on some sort of delusional disorder that’s fed by (flimsy) outside confirmation.

 

[smalltownpsych]

If they aren’t delusional and just kind of ignorant, then I don’t waste too much time with it and just redirect the conversation to topics that are relevant to their life. If they are delusional, then maybe medications would help. Either way, talking about beliefs is reinforcing so don’t do that. If these beliefs are impairing functioning, which to be a problem they would have to be otherwise it is just us having a problem with his beliefs, then focus on functioning and why he is coming for treatment. I would surmise that his beliefs would be less prominent and problematic if he had more productive areas to focus on in his life.

 

[cara susanna]

I would probably focus on functioning and the helpfulness of the beliefs, rather than the accuracy. It's a bit tricker if doing CPT, but even then you have some wiggle room.

 

[PsyDr]

IIRC, there is some correlation between conspiracy mindedness and parental hypocrisy or neglect or something.

 

[msc545]

One important characteristic of the sort of "conspiracy-minded" people you are talking about is the inability to tolerate ambiguity and the need for closure - any closure - objectively right or wrong.

 

[smalltownpsych]

Just wanted to clarify that when I said talking about beliefs is reinforcing I was meaning trying to argue, debate, or logic someone out of beliefs. It is important for clinicians to know this point because I get students puzzled by how to deal with this one. The finesse of a good therapist is how to help a patient challenge their own beliefs and whether or not those beliefs work for them as opposed to challenge them directly because I don’t think they work for them. It doesn’t really matter what I think.

Sometimes I’ll tell a student that it doesn’t matter what they think, what matters is what the patient thinks. Some get frustrated because what the patient thinks is wrong. It may well be and that is exactly why it matters what they think, not what you think. I’m not worried about your thinking, you’re a grad student and fairly rational and functional.

 

[Fan_of_Meehl]

Just wanted to clarify that when I said talking about beliefs is reinforcing I was meaning trying to argue, debate, or logic someone out of beliefs. It is important for clinicians to know this point because I get students puzzled by how to deal with this one. The finesse of a good therapist is how to help a patient challenge their own beliefs and whether or not those beliefs work for them as opposed to challenge them directly because I don’t think they work for them. It doesn’t really matter what I think.

Sometimes I’ll tell a student that it doesn’t matter what they think, what matters is what the patient thinks. Some get frustrated because what the patient thinks is wrong. It may well be and that is exactly why it matters what they think, not what you think. I’m not worried about your thinking, you’re a grad student and fairly rational and functional.

Good points.

I also find it interesting that, as professional psychotherapists, we are--by definition--in the business of having conversations with people 'whose beliefs are (very often) wrong' since if they were people 'whose beliefs are right/functional' they wouldn't be having such serious psychosocial problems and wouldn't be in our office in the first place.

When the particular 'wrong' beliefs of particular patients really grind my gears and I start to take it personally or get especially upset by them (either by the content of the beliefs themselves or the difficulty the patients are having in altering these beliefs), I know I need to take a step back and reflect. Why am I getting personally upset or extremely frustrated by this patient and his/her beliefs. Do *I* (gasp) possibly have my *own* unique background and learning history that (gasp again) may indicate that *I* am not being perfectly rational about responding to my patient's belief system? Is it possible that *I* have been conditioned via my learning history and/or popular culture and media to exhibit negative thoughts and emotions about this particular patient because they hold certain beliefs with which I disagree? Is there some counter-transferential stuff going on here (possibly)? Does my own field (professional psychology) and its own history, revered theories/writings, and professional institutional motives 'see the world with complete rationality/objectivity/accuracy' or are there biases and blind spots that psychologists tend to have just as there are biases and blind spots that ANY profession or group of people tend to have? Just because we are psychologists doesn't mean that we, as individuals, are somehow completely immune to all sorts of blind spots, cultural biases, or all manner of non-conscious filters that alter our perceptions (we should know that). This is yet another reason that the approach of Socratic dialogue with my patient has utility...the back and forth can illuminate ME as well as my patient and if I am not open to the possibility (indeed, likelihood) that *I* am just as likely to learn something that I didn't realize before by virtue of the exchange then I am not, technically, engaging in Socratic questioning or dialogue. Asking ostensibly 'Socratic' questions when you think you already know the answer is more akin to 'rhetorical' and cynical cross-examination of a patient...not Socratic investigation.

I also think it's instructive to consider how it has become much more mainstream practice in the area of substance abuse to adopt more of a motivational interviewing approach to the problem (even in cases of severe substance abuse) rather than an authoritarian/prescriptive ('you're wrong and here's why') approach and that utilizing MI principles to address, say, certain 'wrong/dysfunctional' beliefs that the substance abuser may have (e.g., 'I can drink a 12 pack of beer every night and still function just fine, I'm not harming anyone') has become a standard approach.

Why wouldn't such an approach be standard toward any particular belief that the provider believes may be 'wrong' or 'dysfunctional' or harmful? If you engage in guided discovery, collaborative empiricism, and Socratic questioning around a 'conspiracy theory' (depending on your operational definition of this term) type set of beliefs, is this 'endorsing/condoning or promoting' said beliefs? Of course not. I do think, of course--as smalltownpsych has aptly noted--it is VERY easy to find yourself in a non-productive (and even reinforcing) dynamic when exploring these areas, so you best be on your toes and persistently steering the conversation back to therapeutically relevant goals and functions. But isn't it important that you, as the person's therapist, assess what those beliefs actually are, how they impact the person's cognitive/behavioral/emotional functioning as well as any implications that there may be for their safety or others? Is it really a good idea to immediately 'shut them down' when they start disclosing their beliefs and provide 'corrective education' to them or would it be a better idea to explore these areas with them?

 

[smalltownpsych]

Good points.

I also find it interesting that, as professional psychotherapists, we are--by definition--in the business of having conversations with people 'whose beliefs are (very often) wrong' since if they were people 'whose beliefs are right/functional' they wouldn't be having such serious psychosocial problems and wouldn't be in our office in the first place.

When the particular 'wrong' beliefs of particular patients really grind my gears and I start to take it personally or get especially upset by them (either by the content of the beliefs themselves or the difficulty the patients are having in altering these beliefs), I know I need to take a step back and reflect. Why am I getting personally upset or extremely frustrated by this patient and his/her beliefs. Do *I* (gasp) possibly have my *own* unique background and learning history that (gasp again) may indicate that *I* am not being perfectly rational about responding to my patient's belief system? Is it possible that *I* have been conditioned via my learning history and/or popular culture and media to exhibit negative thoughts and emotions about this particular patient because they hold certain beliefs with which I disagree? Is there some counter-transferential stuff going on here (possibly)? Does my own field (professional psychology) and its own history, revered theories/writings, and professional institutional motives 'see the world with complete rationality/objectivity/accuracy' or are there biases and blind spots that psychologists tend to have just as there are biases and blind spots that ANY profession or group of people tend to have? Just because we are psychologists doesn't mean that we, as individuals, are somehow completely immune to all sorts of blind spots, cultural biases, or all manner of non-conscious filters that alter our perceptions (we should know that). This is yet another reason that the approach of Socratic dialogue with my patient has utility...the back and forth can illuminate ME as well as my patient and if I am not open to the possibility (indeed, likelihood) that *I* am just as likely to learn something that I didn't realize before by virtue of the exchange then I am not, technically, engaging in Socratic questioning or dialogue. Asking ostensibly 'Socratic' questions when you think you already know the answer is more akin to 'rhetorical' and cynical cross-examination of a patient...not Socratic investigation.

I also think it's instructive to consider how it has become much more mainstream practice in the area of substance abuse to adopt more of a motivational interviewing approach to the problem (even in cases of severe substance abuse) rather than an authoritarian/prescriptive ('you're wrong and here's why') approach and that utilizing MI principles to address, say, certain 'wrong/dysfunctional' beliefs that the substance abuser may have (e.g., 'I can drink a 12 pack of beer every night and still function just fine, I'm not harming anyone') has become a standard approach.

Why wouldn't such an approach be standard toward any particular belief that the provider believes may be 'wrong' or 'dysfunctional' or harmful? If you engage in guided discovery, collaborative empiricism, and Socratic questioning around a 'conspiracy theory' (depending on your operational definition of this term) type set of beliefs, is this 'endorsing/condoning or promoting' said beliefs? Of course not. I do think, of course--as smalltownpsych has aptly noted--it is VERY easy to find yourself in a non-productive (and even reinforcing) dynamic when exploring these areas, so you best be on your toes and persistently steering the conversation back to therapeutically relevant goals and functions. But isn't it important that you, as the person's therapist, assess what those beliefs actually are, how they impact the person's cognitive/behavioral/emotional functioning as well as any implications that there may be for their safety or others? Is it really a good idea to immediately 'shut them down' when they start disclosing their beliefs and provide 'corrective education' to them or would it be a better idea to explore these areas with them?

Glad you got my point. One reason I like Linehan is her embracing of the dialectic at the heart of psychotherapy. If we don’t accept the patient exactly as they are and try to change them, then we won’t be very effective. At the same time they are coming to us for help because they need to change. The 12-step programs get this and likely why they say a group prayer that states this pretty explicitly. This acceptance of a negative state or fact can be hard for people.

NSSI is a great example. I will often tell my patients with self-harm that I am not going to tell them to stop self-harming. I explain that I understand why they do it and how it is of benefit and that I would hope that with our work together they won’t need to do it anymore as we find more effective ways of coping with emotional distress. I also say we aren’t going to talk about the self harm, we are going to talk about whatever is going on that made you feel distress that led to it (aka, painstaking chain analysis). I am stunned by how quickly most of them stop Typically, many people have been telling them to stop or trying to make them stop for years and the problem kept getting worse.

Good therapy is like judo, counterintuitive. If we do what comes naturally we will do the same as what everyone else does and that didn’t work for our patients, that’s why they are seeing us. I am preaching to the choir a bit probably as most of the people on this site have a pretty good grasp on this, but when I am supervising the midlevel folk, they typically have little to no grasp of these ideas and its often the first time they have heard any of it.

 

[quickpsych]

As others have said, Socratic questioning is a good approach to these types of patients. I've seen my share in various settings over the years. While some therapists might jump to reality test or therapeutically confront the conspiracy thoughts, IMO many do it too quickly and it ruins any chance of rapport building and thus a chance to actually help the patient improve.

Socratic questioning therefore isn't seen as directly challenging the paranoid beliefs or misinformed beliefs, rather many patients may see it as you trying to learn more about their beliefs aka joining and rapport building. You're not agreeing or disagreeing with them. You challenge them or reality test them too quickly you risk becoming part of the conspiracy in their minds.

Great example. Had a colleague many years ago who was a psychoanalyst through and through. Had an extremely paranoid patient who believed people were following and recording him everywhere in every room, every place he went. He was very anxious, very adamant, very uncomfortable in most settings. Colleague used a lot of socratic questioning (why would they bug this room, how would they know you're here, what if others use this room too, does this happen in other rooms, why might they do this?) and tying into his psychoanalytic approach the blank slate concept. But did it cautiously, the blank slate therapist could have become part of the conspiracy after all in the patient's mind. Finally after a while, the colleague figured the patient kept coming back, rapport and trust was there. But the patient couldn't focus on much else other than fixating on the room being bugged. Rather than simply confronting him, the colleague finally went around the room with the patient and let him open drawers, closets, look behind framed paintings, etc. The patient finally relaxed enough to be able to actually go beyond this one paranoid fixation and into other aspects of his life which led to more therapeutic progress. Had my colleague simply told him the room wasn't bugged or that there's no reason it would be, this patient likely would have been stuck in this circular loop of paranoia much longer and would not have shared or talked for fear of being in a "bugged" room. It was closure for the patient to move past , at least in the therapy room itself, worries and paranoia about a bugged room. Which allowed for more in depth therapeutic work to happen.

 

[smalltownpsych]

As others have said, Socratic questioning is a good approach to these types of patients. I've seen my share in various settings over the years. While some therapists might jump to reality test or therapeutically confront the conspiracy thoughts, IMO many do it too quickly and it ruins any chance of rapport building and thus a chance to actually help the patient improve.

Socratic questioning therefore isn't seen as directly challenging the paranoid beliefs or misinformed beliefs, rather many patients may see it as you trying to learn more about their beliefs aka joining and rapport building. You're not agreeing or disagreeing with them. You challenge them or reality test them too quickly you risk becoming part of the conspiracy in their minds.

Great example. Had a colleague many years ago who was a psychoanalyst through and through. Had an extremely paranoid patient who believed people were following and recording him everywhere in every room, every place he went. He was very anxious, very adamant, very uncomfortable in most settings. Colleague used a lot of socratic questioning (why would they bug this room, how would they know you're here, what if others use this room too, does this happen in other rooms, why might they do this?) and tying into his psychoanalytic approach the blank slate concept. But did it cautiously, the blank slate therapist could have become part of the conspiracy after all in the patient's mind. Finally after a while, the colleague figured the patient kept coming back, rapport and trust was there. But the patient couldn't focus on much else other than fixating on the room being bugged. Rather than simply confronting him, the colleague finally went around the room with the patient and let him open drawers, closets, look behind framed paintings, etc. The patient finally relaxed enough to be able to actually go beyond this one paranoid fixation and into other aspects of his life which led to more therapeutic progress. Had my colleague simply told him the room wasn't bugged or that there's no reason it would be, this patient likely would have been stuck in this circular loop of paranoia much longer and would not have shared or talked for fear of being in a "bugged" room. It was closure for the patient to move past , at least in the therapy room itself, worries and paranoia about a bugged room. Which allowed for more in depth therapeutic work to happen.

That is a great example. We get a lot further when we go slow. I have a current patient with schizophrenia who has been in a couple of residential treatments and multiple psychiatric settings for several years. I actually supervised his prior therapist for a couple of years. Little progress was made in helping him develop insight into his condition and need for treatment whether that is medication or therapy and especially not psychiatric hospitals. He has been seeing me for the last couple months and yesterday I opened up some dialogue about his symptoms and experiences and perceptions of those. He has a tough time talking for more than ten minutes at a time, I think because the internal stimuli is so strong and hiding it from everyone takes a lot of effort. He has been told in the past that he goes to the hospital because of his voices so he won’t tell anyone about them now. If I can get him to open up and actually talk about the voices in a year or so while maintaining rapport and keeping him out of the hospital, that will be a huge victory. I think a big part of what I am doing is cleaning up others messes as people tried to logic/argue him out of his illness and logic/argue/coerce him to take medications.

 

[Fan_of_Meehl]

That is a great example. We gpet a lot further when we go slow. I have a current patient with schizophrenia who has been in a couple of residential treatments and multiple psychiatric settings for several years. I actually supervised his prior therapist for a couple of years. Little progress was made in helping him develop insight into his condition and need for treatment whether that is medication or therapy and especially not psychiatric hospitals. He has been seeing me for the last couple months and yesterday I opened up some dialogue about his symptoms and experiences and perceptions of those. He has a tough time talking for more than ten minutes at a time, I think because the internal stimuli is so strong and hiding it from everyone takes a lot of effort. He has been told in the past that he goes to the hospital because of his voices so he won’t tell anyone about them now. If I can get him to open up and actually talk about the voices in a year or so while maintaining rapport and keeping him out of the hospital, that will be a huge victory. I think a big part of what I am doing is cleaning up others messes as people tried to logic/argue him out of his illness and logic/argue/coerce him to take medications.

The protocol-for-syndromes / manualized treatment movement in the field was beneficial to the field in many ways. However, one of the ways it was detrimental was somehow reshaping the field's expectations that X therapy should only be Y sessions long and that if you go over that number of sessions in any individual case (no matter what the particulars of the case are) you are taking 'too long' and must do a deep dive into investigating how incompetent or lazy you must be as a therapist for not curing them in Y sessions.

 

[quickpsych]

That is a great example. We get a lot further when we go slow. I have a current patient with schizophrenia who has been in a couple of residential treatments and multiple psychiatric settings for several years. I actually supervised his prior therapist for a couple of years. Little progress was made in helping him develop insight into his condition and need for treatment whether that is medication or therapy and especially not psychiatric hospitals. He has been seeing me for the last couple months and yesterday I opened up some dialogue about his symptoms and experiences and perceptions of those. He has a tough time talking for more than ten minutes at a time, I think because the internal stimuli is so strong and hiding it from everyone takes a lot of effort. He has been told in the past that he goes to the hospital because of his voices so he won’t tell anyone about them now. If I can get him to open up and actually talk about the voices in a year or so while maintaining rapport and keeping him out of the hospital, that will be a huge victory. I think a big part of what I am doing is cleaning up others messes as people tried to logic/argue him out of his illness and logic/argue/coerce him to take medications.

Well said , longer term therapy alongside medication management really has a lot of benefits for treating patients with schizophrenia. A lot of the origins of the practice of psychiatry and psychology stem from work with schizophrenia after all.

 

[borne_before]

Process comment: this type of stuff is why I love this forum and find it to be one of the most constructive online psychology spaces. We are having a frank and open discussion, without any defensiveness, talking about what has helped people become successful in various situations and applied settings. I’m impressed by y’all.