Interesting question

[jaycola13]

Hello everyone,

I'm new to this board. The reason I came was because over at another forum somasimple.com some physical therapists were discussing placebo and their role in eliciting a response in patients and whether or not it's ok to go along with a patients ill-informed preconceptions of therapy. The discussion was kinda going in circles so I wanted to get a fresh perspective on the matter and you guys deal with it in your own profession.

So imagine a scenario like this... A disturbed patient comes in for counseling. He is vehemently claiming to be possessed by the devil and is in need of an exorcism to be cured (just pretend he'd come to you first and not a priest/exorcist). Now what's the protocol for treating something like this?

1) Do you go along with his delusion and have an exorcism performed knowing that it will elicit a strong placebo response and the patient will most likely get the relief he is seeking and paying for.

2) refer out to an exorcist

3) Do you not indulge such behavior and as well-educated experts do you explain to the patient that their is no scientific evidence showing possession from the devil is possible and that their problem is likely the result of some other psychological condition. However, does going about it this way, however scientifically sound it may be, work against the patients preconceived notions and diminish the likely hood of therapy working, especially in comparison to the first approach.  Remember, this guy very strongly believes he's possessed. He won't exactly listen to reason.

4) Do a little bit of both. Indulge his idea while at the same time explain a more rational complementary therapy that will deal with the actual problem at hand.

Just curious what you guys think or would do in this situation. Is it more important to give the patient what they think they want if you know it will most likely work (though not by the mechanisms they think) or is their a professional prerogative to educate the patient to your best ability even if theirs a chance of him not buying what you're trying to sell and as a result, little progress is made. What are the consequences of indulging a patient like this?

Looking forward to hearing your responses,
Jason

[pert -5]

Cool post.

In my opinion, I would enact the remedy that the person thinks will cure them (and hopefully does!).  Then, after they are no longer possessed, I would ascertain whether or not to divulge the truthfulness of this person's theories or not.  Alleviation is the trade, is it not?

[susie23]

i would do a bit of both perhaps under the assumption that you need to study the patients condition before you get the right (specialised) exorcist in to perform any placebo type experience the patient needs.

[maze]

if one can help the person by talking then that has the first pririty to me, otherwise medication and treatment
exorcisme??? never no not i am very much against that since i do not believe that a human is  a devil or has the devil in him, i believe that "devil" is just a way of saying..
and 'devil'is something all sins are casted to, i bet there an englsih word for that...

[voodoo scientist]

Of course you do not validate a patient's delusions. If you validate their delusion, all the information implied by that now-valid delusion becomes implicitly true, and you lose an opportunity to find out why the delusion appeared in the first place. Equally obviously, you don't just dismiss the patient's delusion, either, but that's for practical rather than ethical reasons - if you simply dismiss their delusions as delusional to their face without a proper therapeutic relationship first being established, you are very likely to lose the patient's trust.

One of your immediate goals in dealing with a delusional patient is therefore gaining their trust without validating their delusion or otherwise shooting yourself in the foot. The other immediate goal is determining if the delusion is an actual delusion (remembering that you can't be reasoned out of delusions) or a deep-seated wrong belief that coincided with extraordinary stimuli. If it is an actual delusion, the cause could be either psychological or neurological, which you also need to determine. Once you are through that, it should be possible to establish a diagnosis and begin treatment.

In conclusion, none of the listed approaches are good. Approach 1 is just plain evil, 2 is unscientific and irresponsible, 3 is uninformed (but better than the other 3 in that the patient will at least leave your office no worse off than when he came in) and 4 is basically 1 with a little 3 mixed in - essentially, slightly more competent evil.

Assuming you diagnose the delusion as purely psychological, rather than caused by neurological or medical reasons that won't be fixed with therapy, what you want to do is marginalize the delusion while observing the rules it plays by. Unlike schizophrenics with disorganized thoughts, delusions are rarely really random - they're more like an errornous formula in the great equation of perception. A psychodynamic approach is often effective for diagnosing delusions such as this.

Understanding this will give a considerable clue towards determining the real cause, and by not dealing directly with the delusion, you run no risk of making the patient worse or losing his trust until you possess the information you require to treat the patient. The only problem is, as always, maintaining patient compliance (which is, admittedly, not nearly as hard if you tell them what they want to hear) - but that's really where skill as a therapist shows.

[SWM]

So imagine a scenario like this... A disturbed patient comes in for counseling. He is vehemently claiming to be possessed by the devil and is in need of an exorcism to be cured (just pretend he'd come to you first and not a priest/exorcist). Now what's the protocol for treating something like this?

It is an interesting question and Voodoo Scientist answers it very well from a medical /science perspective.

My response would be much simpler. If the client is coming for counselling. I would be making clear that counselling is a talking therapy, and discussing with the client how talking therapy could help with their particular problem. If the patient is requesting an exorcism, I would point out that it is not within the role of a counsellor to provide exorcism and not appropriate to make a referral for an intervention that is not evidence based. 
 

[voodoo scientist]

Clients who are delusional may not be fit to rationally judge what "talking therapy" may or may not be able to do for them, irrespective of whether they know or understand what talking therapy even is based on at best a very limited amount of conversations. If the patient is requesting an exorcism and there are no extenuating circumstances for why he would reasonably believe in exorcisms (such as cultural or family influence), treating the patient as though they are a perfectly rational being is almost certainly not in the patient's best interest.

Edit: Italicized pet peeves!

[SWM]

Coming to a counsellor asking for an exorcism is like going into a church and asking for a lap dance, there is nothing rational in that. this does not mean he should be treated any different from any other patient that requests counselling. Until he asks me rationally to engage him as a counsellee then there is nothing that i could offer him. He will only be able to request that when he understand that counselling is not an exorcsim.  Whether the patient can understand what i am saying or not, the only position that I could reasonably take remaining true to my role would be to explain what counselling is about and how it works and to discuss with the patient if there was something within that which would benefit him.

[voodoo scientist]

Psychoeducation has no statistically significant effect as treatment for delusion (for reasons that should be fairly obvious), or at least I am not familiar with the given research. In more common sense terms, attempting to rationally educate or inform someone who has a malfunction in their perception is an inherently flawed approach.

Going to a counsellor and asking for an exorcism could indeed seem much like going to a church and asking for a lapdance, at least at first glance. However, it would be prudent to ask yourself as a psychologist: why is the patient coming to a counsellor instead of a church? Do they really want an exorcism? What caused the patient to go to the counsellor in the first place, then?

Unless the specific delusion is that counsellors, not priests, perform exorcisms, the church-lapdance metaphor does not hold water. Delusional patients act rationally, just according to a rule or set of rules that doesn't correspond with the real world. I have to maintain that appealing to a delusional patient from a strictly rational point of view and treating them as if they were not delusional is not in the patient's best interest.

I have respect for you as a counsellor, but to put it bluntly, your proposed treatment is either grossly oversimplified or you leave a very great deal of information implicit that makes it difficult to perceive the full meaning of your proposed treatment. You have an obligation to make your patient understand what you are saying to the best extent of your ability: psychologists never get to wash their hands and say "Well, he was being really irrational about it, so that's why I couldn't/wouldn't help him."

[SWM]

this is basically about informed choice. i cannot engage someone in counselling that is not asking for counselling or has no understanding of what counselling is.  

my position is also taken with the view to engagement. a patient is less likely to engage if the therapist takes the attitude that patient is delusional/irrational and is treated as irrational/ deluded. 

i make the distinction again between this position as a counsellor and the position that a medical practitioner (psychiatrist, GP) or psychologist would take.

[SWM]

just to clarify this is not a proposal of treatment. there would need to be a contract for treatment. based on the outcome of the above.

[voodoo scientist]

That's a rather extreme view of informed consent, and I'm not sure that the counsellor's ethics guidelines includes this particularly harsh version of IC. The patient only needs to understand that you are a tool they can use to help themselves, which you can infer simply by the patient being in your office - if the patient did not understand that a counsellor is a tool that can be used to solve their problem, they would never have gone to you in the first place.

Setting the barrier of entry above "showing up" thus seems arbitrary and unnecessary and almost certainly not in the best interest of our "possessed" patient. IC exists to serve the patient's best interest, not the other way around - too much information can be against the patient's best interest just as surely as too little, and gauging exactly what information the patient needs to make an informed choice as a non-expert, non-rational (but still non-random) agent is very important.

[SWM]

its hardly extreme. if an individual is coming into counselling asking for an exorcism, there is a basic level of information that needs to be exchanged.