The Psychological Cost of Letting Go of Grandiose Delusions

In most instances, the first episodes of psychosis occur in adolescence and young adulthood, a crucial period in psychological development.

In the ordinary course of growing up, from age 14 to 21, people become increasingly independent of their families and begin to take up their place in the larger community. During adolescence, young men and women consolidate their individual personal identities and establish social roles for themselves that can support self-esteem. Friendships and first loves bloom in adolescence, and when they do not endure for a lifetime, they are important practice for relationships to come.

Chronic psychosis, in most instances, wreaks havoc with this crucial developmental period. Expected developmental milestones are not achieved, and the affected person falls farther and farther behind his or her peers.

In some instances, people recover from a first psychotic episode and return to their prior level of functioning, but more commonly people experience residual psychotic symptoms. McGlashan, Levy, and Carpenter (1975) describe two patterns of adaptation to having had a psychotic episode, one in which individuals try to “seal over” by aiming to put the distressing psychosis behind them, and a second approach where others want to “integrate” the psychotic experience into their life, trying to understand what lessons the psychosis might have to teach them.

I want to focus here on individuals who neither seal over nor integrate, but where the psychosis leads to a persistent grandiose delusion, the clear psychological purpose of which is to maintain self-esteem. Unable to achieve ordinary successes in love and work, they resort to delusional narratives in lieu of more expectable markers of self-esteem.

Psychotherapists trying to help individuals with grandiose delusions face a concerning dilemma. Should the therapist aim to eventually challenge the patient’s delusion, hoping to help the patient return to reality, or should the therapist consider the grandiose patient’s self-esteem as too fragile to encourage any doubts? If the therapist maintains a purely supportive role that never attempts to lead the patient back to reality, patients who have lived in a delusional world may continue to do so as precious days, months, and years of their lives tick away as they remain devoted to an illusion.

Consider a man (James) in his late twenties who suffered his first psychotic episode as a sophomore in college, who subsequently developed a chronic psychosis. He maintained that he had invented a formula for turning seawater into freshwater at minimal cost. He believed his formula would relieve droughts worldwide, inevitably leading to his winning a Nobel Prize. He claimed that businessmen jealous of his invention tried to copy his formula from his computer, then delete his files, but their attempt to steal his invention only succeeded halfway. Half of his formula was stolen and deleted, but the other half remained on his computer, creating a stalemate in which neither the thieves nor he could capitalize on his invention. It seemed not a consideration for him that he could reconstruct his formula, but rather his achievement was a thing of the past unless he could recover it from the thieves.

From a psychological point of view, unable to finish college and perhaps find a job with a company developing a desalination process, he maintains self-esteem by claiming to have single-handedly solved a difficult engineering problem, which would redound to the good of many people in drought-stricken areas across the globe. Unable to reconstruct the missing part of his formula himself, he spent most of his waking hours trying to recruit family members and clinicians to participate in a “class action lawsuit” against several companies he believed to be the thieves. His mind was stuck in a recitation of indignant complaints. In the meantime, his life was on hold. His grandiose delusion maintained his self-esteem, allowing him to claim, “I am a genius who would receive widespread public recognition were it not for my persecutors, the thieves, who robbed me of my success.” But his life did not move forward.

James imagines a fulfilling life when eventually the thieves are brought to account. In the meantime, he devotes his life to an illusory pursuit. He does not imagine his future as a difficult journey of recovery from severe mental illness where he struggles to find a functional place for himself in the community. He doesn’t consciously understand how ill-prepared he is to achieve self-esteem in the real world. How can persons like James endure the realization that they have wasted much of their adult lives chasing a fantasy? This realization would kindle an ocean of grief, terror, and a sudden revelation of one’s social isolation and relative insignificance. It makes sense that people would prefer a grandiose delusion to this psychological pain.

How can mental health professionals help people like James make a transition from grandiose delusion to a sobering reality? Although medication can for some people be helpful in ameliorating certain symptoms of psychosis, medication alone is no antidote to a wasted adult life. It would be daft to imagine that if the psychiatrist were to just recommend the right medication and the patient agree to take it, all will be well. No. Grief and terror born of the reality of one’s life require other remedies.

For patients who have preferred a delusion to reality for many years, the therapist cannot assume that patients will inevitably take up the task of returning to the real world on their own in their own due time. Delusions, if unchallenged, may last a lifetime.

Clinical experience suggests that persons with psychosis who must face having spent years of their lives absorbed with an illusion can be assisted in their transition to more realistic living by the supportive presence of a psychotherapist. Patients struggling to find self-esteem from real-world sources, without recourse to a grandiose delusion, may discover their value as a person in the course of their relationship with the therapist.

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The therapist’s devotion of time and attention to the patient makes the implicit statement, “You are worth the attention and concern of other people without the trappings of delusional fame.” This stance provides a foundation for self-esteem that can serve as a base camp from which the patient can undertake the difficult journey that returns the patient to reality. One of the more difficult judgments a psychotherapist must make when trying to help a patient with a grandiose delusion is if, and when, and how to help the person undertake that journey.