Patient is a 66 year old Caucasian male, physically healthy, who presented at our initial consultation complaining of severe anxiety, insomnia, and panic attacks related to his belief that unnamed government officials were conspiring to form "death panels" with the intent of murdering not only patient, but patient's grandmother as well (Patient's grandmother is deceased).
During the session, patient elaborated numerous additional paranoid fantasies, each centering on his belief that the federal government has been subverted by an agent of a foreign country for the purpose of undermining patient's values, stripping away his rights and ultimately enslaving him in a dystopian system variously described as communist, fascist, or Jihadist. As evidence in support of his theories, patient provided therapist with a Photoshopped Kenyan birth certificate, a "tweet" from Sarah Palin, and a campaign poster of the President on which patient had scribbled in a Hitler mustache.
Initial sessions were dedicated to fully elaborating and cataloguing the rich imaginative world of patient's persecution complex, which ranged widely over subjects as diverse and seemingly unrelated as the Census, homosexuality, the movie Avatar, National Service, George Soros, the Gold Standard, and the Law Of The Seas treaty. A complete catalog of these (admittedly fascinating) delusions is beyond the scope of this note, and in any case new and astonishing accusations continue to emerge almost weekly, abetted by patient's sessions of internet "research," which appear to be compulsive in nature, and during which he typically interacts with several online communities of similarly delusional enablers.
At first, no attempts were made to confront patient with the plainly delusional nature of his beliefs. To have done so would surely have doomed the therapy to failure, given patient's deep-seated suspicion of therapist, the psychotherapeutic process, science as a discipline and, indeed, facts in general.
Rather, therapy in this critical beginning stage focused primarily on establishing trust.
Unfortunately, this has proved difficult for several reasons, but primarily due to the fact that patient views therapist as part of a vast worldwide conspiracy of scientists, educators, and policy makers intent on destroying capitalism through the promotion of a bogus theory in which human carbon emissions are implicated in the warming of the earth's climate. Patient counts himself among a small band of contrarians who alone possess the truth about this conspiracy, and makes frequent reference to his pride in his possession and use of a vehicle that gets poor gas mileage.
Additionally, patient's susceptibility to factual persuasion is hampered by his astonishing ability to maintain plainly contradictory beliefs with apparent equanimity. He, to list but a few examples, rails against government while lauding the Medicare that pays for his sessions; believes the government to be simultaneously incapable of any competent action and yet skilled enough to remake a foreign country or stop a gushing oil well a mile beneath the ocean's surface; insists that the President is alternately the dupe of foreign countries and the mastermind of a vast globalist conspiracy. When these contradictions are brought to his attention, patient reverts to hostile accusations of bias directed against the therapist or he changes the subject. In either case, the chance for real progress slips away.
On several occasions, therapist has attempted to draw patient's attention to the Oedipal origin of his disorder: the freedom-threatening government as symbolic of a castrating mother, the virile young president representing the punishing father; his own externalized infantile rage. Patient, however, clings tenaciously to his projections and refuses to admit the possibility of error. Indeed, it has become all too clear that patient has no interest in alleviating his symptoms and, indeed, nurtures and cherishes them as evidence of his superiority.
All paths to a cure thus appear effectively blocked, and our sessions themselves have become little more than opportunities for patient to reinforce his own entrenched belief structure, with therapist serving as a captive audience before whom patient may elaborate his grievances and practice his self-deceptions, in exchange for an hourly fee.
It appears that, apart from shock therapy, to which patient is unlikely to agree, no further progress is possible. However, this therapist remains committed to the possibility of effective change through the psychotherapeudic process, and is reluctant to admit defeat, even in the face of such tenacious resistance. Therefore he is reaching out to colleagues or interested lay people who may have experience or advice to offer. Our field has effectively treated schizophrenics, addicts, sociopaths and psychotics. Surely we can find a way to help a Republican.