Managing Suspiciousness and Paranoia

Definition

Suspiciousness can be defined as being unusually guarded and unwilling to reveal information. It includes suspicious thoughts or worries about other people’s motives.

This can lead suspicious service users to become hostile in response to questions, and/or making complaints or demands.

 

Who is suspicious and how?

See the ‘top tips’ section of the Personality Disorder Guidance for more information about personality traits.

Suspiciousness appears to be most commonly associated with paranoid personality disorder. However, it can also be evident in those with antisocial personality disorder, where there is an attitude of mistrust – particularly towards those in authority.

When someone has marked narcissistic traits, suspiciousness may be evident when there is a threat to the service user’s self esteem (that is, they fear being humiliated or belittled). In a somewhat similar fashion, those with schizoid traits are likely to respond with very prickly and guarded responses when attempts are made to develop a close relationship with them (either by a professional or a peer).

To complicate matters further, some service users may present with more extreme suspicious behaviour when they suffer from a psychotic illness (where someone has lost touch with external reality). One of the main distinctions between paranoid personality disorder and an illness such as schizophrenia is the presence of hallucinations (voices) in the latter.

This is why it is important to make sure that the service user is reviewed by mental health services.

 

Why be suspicious?

Generally, suspiciousness is a protection against forming close relationships for fear of being attacked or ridiculed, perhaps emerging as a strategy during childhood when trying to manage difficult experiences.

You can try and work out the meaning and function of suspiciousness from the list below:

  • A difficulty (biological) in reading other people’s states of mind
  • Dealing with anxiety by locating the problem outside of yourself – avoiding humiliation and shame
  • Gives permission for never having to feel weak by relying on others – ‘life is a jungle’
  • A belief that others will always exploit personal information about you
  • Understandable vigilance in light of life experiences

 

Impact on the practitioner

Service users who present as suspicious can be very difficult to engage. You might feel:

Suspicious – as well, because the service user’s guardedness results in you wondering what they are hiding from you

Fear – they become immediately hostile to any questions that are asked. It makes you nervous about asking further questions on that topic for fear of angering them.

Defensive – from being constantly questioned about your motives, dismissed or belittled

Angry– anything from irritable to enraged, when your attempts at being helpful are responded to defensively or with threats, particularly when the service user complains to your manager and requests a replacement staff member.

 

The two C’s – control and capitulate

The above feelings draw you into behaviours which fall on a spectrum from being controlling towards the service user, to capitulating (that is, letting things go which should really be challenged with the service user). Controlling behaviours include adding licence conditions, responding secretively to accusations, bringing two members of staff into the room for interviews and increasing the frequency of appointments. Everyone falls into the trap of trying to persuade the service user that his beliefs are wrong. Capitulation is something we all do when very busy, or demoralised; however suspicious service users are really exhausting, and often it doesn’t seem worth standing up to repeated complaints or demanding letters.

 

 The practitioner’s stance – do’s and don’ts

DO DON’T
Notice and talk in supervision about the distressing feelings which the incident provokes Focus on the explanation
Let the service user give his side of the story Imply disbelief or disagreement in your manner
Consider a range of explanations for the incident Dismiss the service user’s explanation for their behaviour the motivation
Aim to soothe the service user Expect a paranoid style to change
Ask permission before you ask for information about a topic Don’t make any promises about what you do with the information. Especially when you feel pressured to provide answers
Acknowledge that your comments may be interpreted as threatening Become defensive when confronted with being disloyal or threatened.
Focus on possible courses of action or ways forward Focus on the service user relinquishing his explanation
Offer short answers that are relaxed and jargon free. Try to embellish you responses to fill the awkward silences. You will get caught in knots.
Stick with it despite setbacks Give up at the first disappointing hurdle
Focus on the triggers in the environment, and try to reduce these Focus on therapy as the primary means of improving the situation

 

 Managing suspiciousness

The do’s and don’t’ suggestions outlined above are designed to minimise suspiciousness, paranoia and unnecessary complaints. Unlike other challenging behaviours, suspiciousness is particularly difficult to tackle directly. This is largely because the suspicious person does not believe that

  1. they are unduly paranoid
  2. their suspicions are unreasonable

It means that any distress is only as a result of the consequences of the beliefs.

The most successful interventions are those which focus as much (or more) on altering staff interventions and the social environment, to minimise the problems. See the figure below:

managing-suspiciousness