Remote surveillance of the paranoid person is essential when these individuals are out of custody or committed to treatment. The therapeutic alliance must incorporate the patient's beliefs and feelings, and may require the assistance of a mental health professional. Patients are not likely to accept the necessity for mental health treatment if they perceive the treatment as an intrusion into the privacy of their home. Consequently, the therapist needs to be aware of these individuals' need to conceal and to be alone. When the patient is in treatment, the therapist must be aware of the need for self-soothing, which will be apparent during the course of the treatment. Although this phase is one of stabilization, it is often difficult to reach a compromise on the issue of the right to privacy versus the need for intervention by the mental health professional. With respect to the therapeutic alliance, the therapist must try to be tactful and sensitive to the patient's needs. The therapist should be aware of the possibility that such treatment may be viewed as a violation of the patient's right to privacy and should make this a point of discussion with the patient from the beginning. The therapist should take care not to act in a confrontational or threatening manner during such discussions, especially if the patient presents a threat to the therapist. There is a tendency for some patients to view the psychiatrist as a potential threat to their privacy. Patients may react with aggressive, threatening, or defensive behavior when they perceive such an intrusion. On the other hand, an open, empathic communication with the patient, along with a willingness to discuss the issue, can reduce the likelihood of patient aggression and defense. Brief psychotic reactions can lead to a high level of fear and anxiety in a person living alone. Family or community members should be informed of these changes. If the person exhibits a sudden reversal in beliefs or actions that would threaten the family safety, there should be immediate notification to the appropriate authorities. As in the case of many borderline patients, it is important to try to have the patient engage in some treatment voluntarily. Involuntary hospitalization should be viewed as a last resort when all other attempts to resolve the patient's problems are unsuccessful. Even when hospitalization is necessary, one should try to negotiate some period of voluntary treatment with the patients' consent before involuntary commitment. After a patient is hospitalized, the therapist must maintain constant communication with the patient. This is especially true when a medication change is made. In general, most paranoid patients are initially uncomfortable when they first become mentally ill. If treatment with them is to be successful, it is important to gain their cooperation from the beginning. The use of medication and/or a gradual transition in treatment are likely to be the most effective approaches. It is important to assess the patient's ability to withstand medication; to assess the need for and the timing of, increased doses and increased frequency of psychotherapy; and to maintain constant contact with the patient. Patients with a history of paranoid symptoms often have difficulty developing an alliance with their therapist. This is due to a combination of the intensity of their fears and the fear that they have that the therapist will discover them. Frequently, paranoid patients resist psychotherapy, but the intensity of their resistance can make it difficult to provide effective psychotherapy. To develop a productive relationship, it is important to listen to what they are saying. At the same time, the patient needs to be assured that it is not necessary to share all the details of his or her life. Once a relationship has been established, the patient needs to feel assured that his or her confidentiality will be protected. It is necessary to explain in some detail why certain information is necessary to determine treatment. The therapist may need to explain that some information will be necessary to insure the safety of the patient. In addition, the paranoid person is often hypervigilant, and is aware that he or she is being spied on and that the situation is out of control. To gain his or her cooperation, the therapist needs to let the patient know that he or she is not going to spy on him or her. The patient needs to know that the only person the therapist is there to see is him or her. In some instances, when the patient is experiencing a paranoid reaction, contact with a mental health professional can facilitate stabilization of the patient. Patients who are in mental health treatment often find it necessary to be seen by a mental health professional to receive medication, as well as therapy. Such contact can also help to allay a patient's fear of going outside. Contact with a mental health professional can facilitate the establishment of an alliance. For example, one woman who attempted to commit suicide was reluctant to use the medication prescribed for her. During the first few weeks, the therapist had no contact with the patient for a few days. When he resumed contact, the patient became agitated. The therapist waited another day. When the patient became agitated, the therapist informed her of the situation. The patient responded by saying, "This is crazy. I'm not crazy, you are." The patient continued to be agitated when she was contacted the following day, and she was brought into contact with a mental health professional. It is believed that the patient had been frightened by the therapist's phone call. Because it is important that patients trust the therapist, the therapist must be sensitive to this issue. This is especially true of paranoid patients. It is important that the therapist give a reassuring message and then allow the patient to share his or her feelings. It is essential to find an understanding and stable relationship with a primary support person who is not a member of the patient's family. With paranoid patients, family members are often either overly intrusive or overly distant. While some family members, when confronted with the patient's condition, may want to have the patient committed to a hospital, the other family members may find it necessary to withdraw from the patient. One patient who lived alone with a woman who was her daughter became increasingly agitated, verbally abusive, and suspicious of their relationship. The therapist believed that the patient's behavior was influenced by the patient's fears about the therapist, and by her own paranoid attitudes. It was difficult for the therapist to determine how much of the patient's behavior was influenced by these factors. The patient had an extensive history of using alcohol, and was also dependent on nicotine and caffeine. Her most recent medical history was a head injury and an incident involving possible choking by a dog. She had a history of suicidal attempts, both serious and less severe, and she had been in and out of treatment. She claimed that the therapist had not had adequate contact with her, and that she had not followed the therapist's treatment plan. However, when the patient was confronted with this information, the patient became agitated. In order for the patient's trust to be developed, the therapist needs to be flexible, and to try to do things that are not expected. The patient needs to be given the opportunity to test the therapist, so that the therapist's limits can be established. The therapist must allow the patient to test the therapist in a way that is not threatening. Often, the ability of the therapist to trust the patient is enhanced when the therapist is able to be supportive and encouraging, while maintaining a respectful, but firm distance. At times, the therapist may need to offer to spend some additional time with the patient, even if it is necessary for the patient to wait. When it becomes apparent that the patient will not be forthcoming, the therapist should accept this information in a nonconfrontational, and accepting, manner. If the patient cannot wait, or if there is some indication that the patient is a danger to others, the therapist must be prepared to leave the appointment immediately. It is not acceptable for the patient to be unresponsive. Many of the paranoid patients exhibit a mixture of the behaviors described previously, and some of these patients do not want to be treated with medication, and some do not want to be followed by a therapist. It is important to evaluate the patient's motivation for treatment in this way. A person's inability to understand why a medication is necessary does not necessarily mean that he or she is resistant to treatment. If this is not the case, the patient is not demonstrating paranoid tendencies at that point. It may be helpful to explain to the patient that, without medication, he or she will experience an increase in psychotic symptoms. The patient may have the need to understand why it is necessary to take medication, and this should be addressed. Patients are often reluctant to continue medications once it has been determined that they need them. It is important that patients understand the necessity of taking medication to control their symptoms. It is also important that the patient understand that they are not required to see the therapist every day, or even every week. A patient who has a psychotic reaction may be so fearful of losing control, that it is necessary to have contact with him or her once or twice a day. In the following example, it is illustrated how treatment should be structured for a paranoid patient. This patient exhibited a preoccupation with physical illness