Reinforcing a Perception of Reality

[Davey Do]

There was a Discussion here back some time ago on Feeding into a Patient's Delusion in order to decrease anxiety or de-esculate a Behavior. Although not Texbook, many Nurses have utilized this Technique successfully.

Take, for example, a Geriatric Patient who wakes in the Night, is Anxious, and wants to know "Where's my Mother?!" The Patient is informed that her Mother is "taken care of". This Perceptual Statement of Fact decreases the Patient's anxiety and allows her to go back to sleep.

Reality Orientation, for example, by telling the Patient that her Mother passed away long ago, would only serve to increase her Confusion and Anxiety. And, it would not be an Untruth to inform the Patient that her Mother is taken care of, for wherever her Mother may be, she is being taken care of.

At a Mandatory Inservice recently, a Co-Worker and I were in a Group together from our Gero-Psych Unit. All the Groups where asked to list Alternative Methods to Mechanical Restraints. Among other Techniques, I named "Feed into the Patient's Delusion". My Co-Worker asked me to Rephrase the Concept, so I said, "Reinforce the Patient's Perception of Reality". The Concept was Generally Accepted by those present.

Recently, on a MN Shift, I experienced yet another Situation to implement this Concept. A Patient would wake up, get out of her bed, stand at her door, and loudly Sling Insults. "You are Stupid!" she would shout. "I could be smarter", I replied. "You don't know your *** from a hole in the ground!" she said. "I have to admit, I don't", I said. You are a liar!" she accused. "I do tend to embellish and have been told I have a Gift for Fiction", I admitted. You are dirt!" she said. "I am less than dirt", I replied.

This approach gave the Patient no Defensive Comebacks, so the most she could do was to insult me until she ran out of Fuel. And run out of fuel she did. Her Behavior occurred at least Three Times that night and never esculated.

Ever have any Similar Experiences?

[TerpGal02, ASN]

What I've always been told and practiced is that with dementia pts, you never argue with them about their delusions., it will just agitate them. And with that said, they are never going to go back to "living in reality anyway". It's the acutely psychotic you do reality testing with them, but you have to finesse it. For an example, the pt states, "The CIA is coming to kill you" I would say, "It must be very scary to have those thoughts".

[Hygiene Queen]

I agree 100%.

I have told the story, here on AN, how I xeroxed money for a very agitated dementia pt who was looking for his paycheck.

Worked like a charm.

I also have said, to a lady who asked, "Does my mother know where I am?" by answering, "Of course, don't all good mothers know where their children are?"

And assuming this lady's mother was in heaven, looking down, well, I guess I didn't tell a lie and the pt was soothed by this response.

To tell a dementia pt their mother is dead would be cruel as it would be as though they are hearing this news for the first time.

Also, speaking of their reality, I have asked my pt's, "So... who is the President of The United States?"...

Number one answer, "Eisenhower".

Ah, so it is.... I guess I don't need a fancy machine to time travel... I just go along for the ride with my pt's!

[ClearBlueOctoberSky]

Validation is good, but I have no answer for my LOL that says "I have to go home. My mother died."

I will admit, I never thought about copying money for the paycheck routine, though. Thanks for the idea.

[LTCalznurse]

I use that approach every day on my Alzheimer care unit. Attempting to reorient patients will only increase behaviors when a simple answer will validate and calm them. And I keep some old blank checks in the nursing office for 'paychecks" and to pay for their meals, as they also seem to worry about paying for things all the time.

[twinmommy+2, ADN, BSN, MSN]

I've told a young delusional patient who saw bugs all over the walls in her room, screaming as she went, that "wait really? Let me look with you, I think someone just came by to take care of those critters". So I entered the room with her and was able to tell her then that I didn't see anything on the walls to which she agreed with me.

[Davey Do]

Thank you all for the Support and Creative Examples in dealing with Delusional or Demented Patients.

I agree that LTC's Xeroxed Checks and Hygiene Queen's Xeroxed Money really "Fit the Bill" (Pun intended.)

Often times, as in CBOS' example, a Therapeutic Response to some Demented Remarks are difficult to come up with. Luckily, since I work straight MN's, I can always reinforce their desire to be responsible, however, also advise them to take care of Business during Regular Business Hours. I often tell them that their Rest is the Most Important Thing, and they'll need their Rest in order to Adequately take Care of Business. This Approach has a High Success Rate.

I wanted to Address TerpGal's Excellent Example:

the pt states, "The CIA is coming to kill you" I would say, "It must be very scary to have those thoughts".

TerpGal not only lets the Patient know that she/he is being heard, but also Addresses the Meat of the Matter, which is the Patient's Feelings. In fact, TerpGal doess not Acknowledge whether the Patient's Belief is Real or Not, but instead Focuses on that which is Objectively Real. Good Job!

Originally, with my Example Patient, I attempted to Address her Delusion by focusing on her Viewpoint. In Essence, when the Patient said something like, "You're Stupid!" I would reply with something like, ""Well, you are entitled to Your Opinion". To which the Patient would reply, "You're G.D. Right I'm entitled to My Opinion!" and on she would go. I found out that if I Ageed with the Patient, that gave her No Obstacles or would not Fuel Her Fire. The Therapeutic Goal of De-esculation was attained.

I also want to mention that these Outbursts were Sporadic, i.e. the patient was labile. This Patient could be Sweet as Potato Pie or Mean as a Venomous Snake.

As always, we usually need to Adjust Our Approach to the Specific Patient and/or Situation.

Thanks again for your Posts!

[Davey Do]

Let me look with you, I think someone just came by to take care of those critters".

Good Approach! In a Way, in both your Statements and Actions, twinmommy, you're comforting the Patient in assisting them to Face Their Fears. And maybe even doing a little Reality Orientation in alluding to the Fact that the Bugs should no longer be there!

Thanks for your Example!

[ricksy]

I do that even when not a work! LOL...get's em every time! LOL

[Davey Do]

I do that even when not a work!

You know ricksy, you may have something there- If we treat the General Population with the same Amount of Understanding and with the same Type of Interventions that we do as Professionals, perhaps we could all live in Better Harmony.

That is, of course, if we want to Free-Lance being Therapeutic!

[Mandychelle79, ASN, RN]

With dementia patients I call it Jumping Realities. Ive told little old ladies their husband ( who I happened to know was an excellent mechanic back in the day) was out fixing my car. When they ask for their parent I normally say I havent seen them but if they show up I will make sure they find them.

As for non-dementia hallucinations I usually use, I know that it is real you, but I am not seeing ...

We have one patient right now who is very paranoid, but for some reason trusts me. And I do at times do things that feed into the delusion, but whatever it is I feel is not the hill to die on so to speak. After the explanation of why he wouldnt take certain meds, we worked out a compromise for the other meds... wont take the medications for DM, because BGM's are stable, closer monitoring of BGM's has been ordered and I explained that if they reached a certain level things would have to be ordered. And if legs begin to swell will take the lasix, etc.

[batgirl23]

I think it is important to be clear about the language we use.

It is never okay to "reinforce delusions" or to challenge them. As others have mentioned though, you can re-focus on what is most relevant - the feelings or the experience of the patient with those (often disturbing) beliefs. My experience working with folks living with delusions is that if you explore what it is like for them to have those beliefs, they get a sense of relief from the fear and anxiety. They don't feel challenged. Once there is a trust relationship built, they will often ask about your experience of their reality. If asked directly I always answer truthfully: that I am not experiencing whatever it is or I don't see it, believe it, etc. BUT I only do this if asked directly and I always re-iterate that I understand how real their beliefs / experiences are to them.

With Dementia patients, I see things a little differently. I do not see them as being "delusional" in the same way as people in psychosis. Rather, I see it as they are living in multiple realities simultaneously. They can be physically here with you and at the same time be a 5 year old child looking for their mother. The patient doesn't believe they have been sent back in time. They are just experiencing this moment as they did when they were a child. Going along with that is not reinforcing a delusion, it is merely being present with them in their current experience of reality.