HOW TO BEST SUPPORT SOMEONE WITH PSYCHOSIS
MELISSA WELBY, MD (PSYCHIATRIST)
THIS ARTICLE WAS FIRST PUBLISHED, ON THE BLOG OF DR. MELISSA WELBY. PUBLISHED ON AUGUST 21, 2018
Psychosis can be a terrifying experience for everyone. When a loved one has a psychotic episode, families, and friends are usually not prepared. The first step is figuring out “What is psychosis?” and getting a basic understanding of what might be happening. After that, plans can be made for how to deal with the psychosis.
People are often too scared to talk to the person because they don’t know how to respond to the psychotic thoughts. It is much easier to support them and stay connected if you know the best ways to communicate. Read this to learn how to help someone with psychosis.
I am not going to talk about the treatment options for psychosis or the importance of early intervention in this post.
• What is psychosis?
Psychosis is a symptom of an illness. It is a descriptive term rather than a specific diagnosis. It is associated with various diagnoses including schizophrenia, depression, bipolar, dementia, alcoholism, and many other medical conditions.
Here is how the National Institute of Mental Health describes psychosis:
The word psychosis is used to describe conditions that affect the mind, where there has been some loss of contact with reality. When someone becomes ill in this way it is called a psychotic episode. During a period of psychosis, a person’s thoughts and perceptions are disturbed and the individual may have difficulty understanding what is real and what is not. Symptoms of psychosis include delusions (false beliefs) and hallucinations (seeing or hearing things that others do not see or hear). Other symptoms include incoherent or nonsense speech, and behavior that is inappropriate for the situation. A person in a psychotic episode may also experience depression, anxiety, sleep problems, social withdrawal, lack of motivation, and difficulty functioning overall.
• What is a delusion?
A delusion is a fixed, false belief. A delusion is a symptom of psychosis. No matter what you say, the person believes the delusion. If you insist on correcting the delusion you risk ostracizing them from you and frustrating yourself.
• How to deal with psychosis:
How you respond to a loved one with psychosis can make a big difference in your ability to maintain a relationship with them. Bear with me while I try to explain:
Imagine (metaphorically) standing next to your loved one while communicating. Try to see what they are saying through their eyes and not your own. You are by their side listening and not challenging them head-on. Focus on the emotion of the conversation not whether the facts are plausible. When they speak, listen to the themes in what they are saying. There are usually “reality-based” themes sewn in and that is what you can focus on.
• Example of psychotic thoughts:
- There is a car parked on my street that is monitoring me. Every time I leave my house a car drives by marking down the times I left. They follow me around wherever I drive.
- I bought extra locks for my house because they came in the middle of the night and drugged me. All my doors are barricaded to keep them out. The police say they won’t do anything to help me.
- I stay up at night watching and waiting and set up traps in the yard to catch them. I bought a hearing amplification device so I can catch them before they get to my house.
• Different ways you can respond:
1. What are you talking about?! There is no one monitoring you on your street. No one broke into your house or drugged you. You aren’t making any sense.
2. That must be SO scary to feel like people are always watching you! You’re saying you can’t go anywhere without them following you? That must be terrible to constantly feel you are being monitored. How do you handle this stress? What are you doing to stay safe? So when do you sleep? And what do you do to get food? If you are always being followed I imagine I wouldn’t feel too safe leaving the house. Is there anything I can do to help?
• Which response will have a better outcome?
By listening and being supportive, you will better understand the depths of their psychosis. With this knowledge about what they are experiencing, you will get more information. This information will help you know if they are putting themselves or others safety in jeopardy because of their psychotic thoughts. You will be able to monitor if they are no longer able to care for themselves so that you can try to intervene in a timely manner. You will be able to give them the support.
Try to join with them in their feelings rather than focusing on the facts of what they believe is happening. If you can emphasize with their feelings you give them the opportunity to be heard and stay connected to you.
• How do you want people to treat you when you are upset?
Think about when you are upset and how you want others to treat you. It feels nice to have someone empathize with your feelings even if they don’t know all the facts or don’t agree with your conclusions. People don’t have to agree with you to validate your feelings. Have you heard the saying “feelings aren’t facts”?
It is comforting to have loved ones say they are sorry to hear what you are going through. They can offer their help or brainstorm with you about how to best handle the situation. Hopefully, you leave the interaction feeling heard and not alone.
• General guidelines for how to help someone with psychosis:
I’m going to list out some general do’s and donts. Obviously, every person and situation is different so these won’t apply to all interactions.
• What NOT to do when speaking with someone with psychotic thoughts:
1. Avoid criticizing or blaming the person for their psychosis or the actions related to their psychosis.
2. Avoid denying or arguing with them about their reality “That doesn’t make any sense! Of course, the government isn’t tapping our house!”
3. Don’t take what they say personally. Paranoia and psychosis can lead to mistrust and suspicion. All relationships can be called into question and be affected by delusions.
4. Do not directly confront them. If you want to be heard you may have to find a different way to communicate. Being heard isn’t always possible when someone is in the midst of a psychotic episode.
5. Don’t tell them they are psychotic. As much as I wish it would work, telling someone they are psychotic will not convince them to stop thinking that way.
6. Do not dismiss their concerns or laugh it off. Even if their concerns are bizarre or shocking they are not amusing to the person having a psychotic episode. Remember that their brain believes these things are going on.
7. Do not encourage their psychosis by confirming their delusions. Just because I am telling you not to argue with them about reality this doesn’t mean you have to agree with what they are saying. You don’t need to comment directly. Often a general, supportive statement will suffice. Some helpful things to say are “I don’t know what happened. It sounds very scary” or “There are lots of things that happen in this world that I can’t explain” or “I don’t know what to make of what you are saying. It’s so confusing and upsetting to hear everything you are telling me. How are you handling it?”
8. Do not focus on correcting the reality of delusions. Don’t waste time trying to prove the delusion can’t be true with reason and logic.
9. Don’t get angry. They are psychotic because their brain is playing tricks on them. They are not in control of what is happening in their mind.
• What to do instead:
1. Be gentle and calm.
2. Make them comfortable to share what is going on in their life.
3. Focus on what is troubling them.
4. Empathize with their situation “It must be SO scary to see those UPS trucks everywhere monitoring you!”
5. Focus on their feelings in what they say, not the actual facts of their story
6. Ask them if you can help in any way. “I know you are waiting for that letter with the million dollars. Are you managing to leave the house or are you too fearful you will miss it? Have you been able to get out and pick up your chocolate milk? Can I get you some?”
7. Ask about things you know they enjoy.
8. Emphasize strengths “Wow! You skipped your cigarette this morning? How did you do that?!”
9. Share love in a way they can tolerate. This may simply be by giving your full attention to their thoughts.
10. Don’t underestimate the power of human connection
11. Contact their treatment team to let them know what you are seeing, especially if it is concerning. If you think they are getting worse tell their providers. Even if you don’t have consent to speak with their treatment team you can always leave a message. Their team cannot acknowledge if the person is (or isn’t) their patient but they can listen to what information you have. I have found that providers sometimes refuse to speak due to confusion about HIPAA laws (laws about protection of patient confidentiality) and I’ve heard of office staff saying they can’t even take a message. This is not true. Find a way to communicate your concerns even if it involves sending a letter to the doctor. Tell the staff up front that you understand they cannot acknowledge if the person is a patient and you just need to leave a message.
12. Call for help if they are making unsafe decisions that are putting themselves or others safety in jeopardy. Someone having a psychotic episode won’t always willingly go with you to the Emergency Room. If you are concerned about safety, then you may need to call 911 to get them evaluated.
• How to help someone having a psychotic episode:
A person with psychosis has a medical condition and is in need of psychiatric treatment. Even if they get treatment, it takes time for psychotic thoughts to resolve. Unfortunately, people in a psychotic episode won’t always willingly get treatment. Until they are making decisions that put them or others in danger we cannot force them to get help. At that point, someone can be admitted to the hospital against their will.
The laws surrounding mandated treatment and hospitalizing against someones will are complicated and differ by state. What I can say in general, is that we (family members, friends, psychiatric providers) may KNOW someone is psychotic and needs help. But even if we know this fact, if they are not willing to get treatment, we are only able to intervene when they get worse. This is extremely difficult and frustrating for everyone involved. Obviously, there are good reasons these laws have passed, however, a consequence is that people can be ill for some time before they get help.
The goal of learning how to communicate with someone having a psychotic episode is so you can stay connected and support the person in whatever way possible. Ideally, by staying connected you will be able to encourage and help them get into treatment.
• A word of encouragement:
When someone is psychotic we may have to shift how we measure improvement. The immediate goal may be the maintenance of a relationship, building trust, and having the opportunity to listen. If you have a relationship with the person you can watch for early warning signs of relapse or worsening of the current psychotic episode. You can keep an eye on medication compliance, side effects, and their physical health. You can also alert the treatment team to any concerning changes.
It can take a village to help someone in a psychotic episode. Be kind to yourself and give yourself space if you need it. Get support and see a therapist. See a psychiatrist for a consult about your loved one. The psychiatrist can help educate about symptoms and treatment options, brainstorm with you, and coach you about ways to handle situations.
(See also https://www.earlypsychosis.ca/pages/resources/downloads/)