Guest post: The Power of a Delusion

by Betty Morningstar, clinical social worker in private practice in Newton, Massachusetts, former pastoral care associate at Hebrew SeniorLife, and former Continuing Education Faculty at the Smith College School for Social Work.

Meet Peg

Peg sits on her bed surrounded by papers, mostly junk mail, when I arrive. Religious pictures, crosses, and little statues of saints cover the walls and every flat surface. The bed covers have been pulled up hastily. The hair at the back of her grey head stands up in all directions, its unruliness mimicking her surroundings. She’s on the phone. “I’ve gotta go. That lady is here. The one who comes to check on me and talk about stuff. She’s a chaplain, I think. Love you too. Wait! Don’t forget to bring the rest of the photo albums when you come.”

“How are you today?” Peg asks, as I make a spot for myself on the mustard-colored vinyl covered chair next to her bed. I brush the newspapers to one side and sit on the edge.

“I’m fine, thanks. I hope I didn’t interrupt an important conversation.”

“No, no, it’s okay, but what are you doing here? Why do you come to see me? There’s nothing to talk about. This place is terrible and I want to leave as soon as I can get into the Catholic home in my town.” Her face turns rigid, and I take an extra moment to come up with a response.

“I know you aren’t happy about being here, but maybe we can talk about what would make it easier to be here while you’re waiting for a new place to live.”  I am trying to balance hope with reality. It is unlikely that a new place will be available in the foreseeable future.

Relaxing a bit, Peg says, “I guess you can stay. You seem to understand. But everyone else wants to punish me. They all think they know what I did. If they found out the whole story I would be put in jail.” She looks away from me toward a plastic Madonna and child on the window sill.

Peg’s photos

“Really? Can you tell me what you think they know? I’m confused but I would like to help you.”  I am being drawn in to the drama.

“You know. The pictures. I stole them.” She pulls at some loose curls above her forehead.

“Oh. So where are they now?”

“Shhh. Is the door closed? Okay, take out the briefcase that’s under the bed.” She continues in a whisper that I can’t make out. I reach under the bed and take out the briefcase, putting it on the bed in front of her. The case is held together with thin rope and looks like an overnight bag for a 1940’s train trip. It is so tightly packed that when Peg unties the knot a bunch of photos slide out onto the bed and the floor.

“Look at these.” With a finger, Peg caresses the face on one of the pictures. “These are from a trip with my daughters to England. My aunt took them and made copies for all of us. It was a great trip. I loved my aunt.” I lean in from my perch on the edge of the seat.

“These are of my sisters and me.” Peg points to a blonde, middle-aged woman in a light blue shirt-waist dress. “This one is my mother. She wasn’t really my mother. She was my grandmother, but I wasn’t supposed to know. My mother wasn’t married when I was born. I’m not supposed to have these pictures. If they find out I will definitely go to jail. Do you think they’ll find me guilty?” She finally takes a breath.

“You know, Peg I am looking at these pictures and I can see that you are in them, and you’ve told me they are from trips and other family occasions. So that means they do belong to you and you didn’t steal them.”

Her eyes grow big. “Really? Are you sure? How do you know for sure? Will you go to court and tell them?”

“Yes, I would go to court, but I don’t think it will come to that. Look, this one says, ‘To Peg, Love, Aunt Mary.’ You own the pictures and you can’t steal what is already yours.”

“Oh my god. You are an angel. You are the only one who understands me, and I know that God must have sent you.”

I feel a quick glow from her adulation, then let it go. “I’m glad you are able to see that you did nothing wrong. God knows you did nothing wrong too. He knows that you pray and you love him and he knows that you are a good person and that you don’t steal.”

“Oh. I am so relieved. I was so scared. I hate this place, but jail would be worse. At least you understand me. Do you believe in Jesus? You are Jewish aren’t you?”

“Yes, I am Jewish. And I can appreciate what Jesus means to you. I believe we all come from the same God and I am very interested in how you feel about God and Jesus.” The crinkly lines on Peg’s face seem to smooth out a bit, and she continues to rifle through the photographs, suddenly oblivious to my presence.

Peg is not alone

Dementia affects over five million people in the United States today. That number will increase by an estimated forty percent by 2025. There is no cure and no prevention. One way of helping improve the quality of life for elderly people is through pastoral care. Long-term care facilities often provide chaplains to help patients cope with spiritual, religious, and existential crises. Pastoral care for patients with dementia, however, is not a high priority in many settings, because these patients are considered incapable of making use of such services.

My work in long-term care convinced me that some patients with dementia can benefit from pastoral care. Peg’s dementia caused paranoid delusions. In the opening vignette, her delusion was related to the guilt she bore for most of her life. It had much to do with her strict Catholic upbringing. Despite evidence of some harm done by the church, her embrace of Catholicism gave her life meaning to the end.

Peg’s disordered thinking made sense on multiple levels. The photos were concrete evidence of her family memories. She had indeed been raised by her grandmother, with her birth mother as her “sister.” She often spoke of the guilt she felt about being born of an unmarried mother. Her Catholic upbringing made sure of that. Underneath the guilt, she experienced shame. Guilt came, by association with her mother, from a sinful act. Shame came from her perception of her very being. But despite these strikes against her, Peg maintained a faith that helped her as much as it hurt her. Add dementia to the mix and you find the paranoid delusions that tormented her in her old age.

Think of what might have happened to Peg if she had reported her fears to someone who didn’t know what her religion meant to her. She would probably have been ignored and an opportunity would have been lost. Or worse. By engaging in a short exchange about her beliefs, using her language, I tried to help her let go of the problem. Until the next time.

Pastoral care for all

It is easy to think of dementia sufferers as psychologically empty, without real thoughts, feelings, or beliefs. Despite her cognitive decline, Peg maintained her belief that Jesus saves and that God forgives. I have seen other severely impaired people recite or chant prayers from liturgy. Peg herself once told me she had observed a fellow patient at a concert of Jewish music. That patient had been completely unresponsive for months. As her aide began singing and moving to the rhythm, Peg noticed a tear in the corner of the patient’s eye. She said it looked like a diamond and she was enthralled by the vision. She knew God was present.

Spiritual matters, like emotions, are outside of the rule of everyday logic—to say nothing of paranoid delusions. But the thoughts, beliefs, and delusions that Peg harbored had a logic of their own. I have no idea whether Peg held onto any of the reassurances I gave her on that one day. I do know that I was affected by her story. And her report of the tear/diamond experience transformed my own belief in the power of faith to foster resilience in those with cognitive and psychological impairments.

Such are the little miracles that allow me to believe.