Q & A: Leaving Delusions Behind

Q:What is the motivation for a delusional person to get better when their delusional world is so much more pleasurable than their real one?

A patient in a mental hospital is mostly catatonic and dreams that he is living a normal life. In reality, he has many of the symptoms of schizophrenia.

A:Well, there isn't a motivation for him to get better, to be honest, in that scenario. Though delusions are often not pleasant -- what you're describing sounds more like the defense mechanism of fantasy taken to a psychotic extreme. (Delusions are only ideas, not images or dreams.) Some people escape into psychotic fantasy to get away from their real lives. This would also fit the idea that your character may have schizophrenia -- people with schizophrenia can engage in psychotic fantasy.

Psychiatrist Thomas Szasz argues that medicating and treating people who are like your character is a form of societal control. In other words, he believes that as long as someone is happy to be in the state they're in, we should leave him alone. But what happens instead is that people with mental illness freak us out, so we drug them up or stick them in institutions so we don't have to deal with them. (You can read more about Szaz on his website.

In one oft-quoted article he says

Because psychiatrists have power over persons denominated as patients, their descriptive statements typically function as covert prescriptions. For instance, psychiatrists may describe a man who asserts that he hears God's voice telling him to kill his wife as schizophrenic. This "diagnosis" functions as a prescription--for example, to hospitalize the patient involuntarily (lest he kill his wife) or, after he has killed her, to acquit him as not guilty by reason of insanity and again hospitalize him against his will...Regardless of psychiatric diagnosis, the typical mental patient is entitled to liberty, unless convicted of a crime punishable by imprisonment. If that patient breaks the law and is convicted, then he or she ought to be punished for it as prescribed by the criminal law. In a free society, a person ought not to profit from psychiatric excuses or suffer from psychiatric coercions.

I'm not suggesting Szasz is right, but he does have some very good points, and ones that are relevant to your character's situation.

Also note that an adult can be be forced to accept treatment under only 3 conditions in the US:

1. They are an immediate danger to themselves (ie they're going to commit suicide)
2. They are an immediate danger to someone else (ie they're going to commit homicide)
3. They're unable to care for their basic needs and are therefore an immediate danger to themselves. (ie they can't take care of food, basic hygiene, etc. because, for example, they're so lost in their fantasy world.)

Unless one of these things is true, nobody can make your character leave his delusional world.

You don't say whether you're looking for a way to convince the person to want to get better, but if you do, you'll need to introduce something that will force him to come out of his fantasy world because he can't solve the problem there. In other words, you'll have to create motivation to get better. Some people will fight to get well even though they're perfectly comfortable with their symptoms if someone is going to take away their children, for example.

Other than the approach above (giving the character some motivation), the best way for someone to try to force (or help) your character out of a psychotic fantasy is to give him antipsychotic medicine. In the movies, antipsychotic drugs are often just used to dope people up and make them control-able, but what they really do is reduce the amount of dopamine in the brain -- and dopamine is what causes psychotic symptoms. So the meds would reduce the psychosis and make the psychotic fantasy world less real. In other words, the meds would pull your character back toward reality.