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SUMMARY: These guidelines are a general set of recommendations about how you can help someone who may be experiencing psychosis or a loss of touch with reality. Each individual is unique and it is important to tailor your support to that person's needs.

Responding to psychotic episodes

PSYCHOSIS FIRST AID GUIDELINES

The following guidelines are based on the expert opinions of a panel of clinicians, mental health consumers, and caregivers from Australia, Canada, the USA, New Zealand, the UK, and Ireland about how to help someone who may be experiencing a psychotic episode. They have been adapted for Canada. Details of the methodology can be found in: Langlands RL, Jorm AF, Kelly CM, Kitchener BA. First aid recommendations for psychosis: Using the Delphi method to gain consensus between mental health consumers, caregivers and clinicians. Schizophrenia Bulletin 2008; 34:435-443

Mental Health First Aid Canada is a program of the Mental Health Commission of Canada. To learn more about Mental Health First Aid Canada, go to www.mentalhealthfirstaid.ca.

Purpose of these guidelines

These guidelines are designed to help members of the public provide mental health first aid to someone who may be experiencing psychosis. The role of the mental health first aider is to assist the person until appropriate professional help is received or the crisis resolves.

How to use these guidelines

These guidelines are a general set of recommendations about how you can help someone who may be experiencing psychosis. Each individual is unique and it is important to tailor your support to that person's needs. These recommendations, therefore, will not be appropriate for every person who may have psychosis.

How do I know if someone is experiencing psychosis?

It is important to learn about the early warning signs of psychosis so you can recognize when someone may be developing psychosis. Although these signs may not be very dramatic on their own, when you consider them together, they may suggest something is not quite right. It is important not to ignore or dismiss such warning signs, even if they appear gradually and are unclear. Do not assume the person is just going through a phase or misusing alcohol or other drugs, or that the symptoms will go away on their own.

Common symptoms when psychosis is developing¹

  • Changes in emotion and motivation.
  • Depression, anxiety, irritability, suspiciousness, blunted, flat or inappropriate emotion, change in appetite, reduced energy and motivation.
  • Changes in thinking and perception.
  • Difficulties with concentration or attention, sense of alteration of self, others or the outside world (e.g. feeling that self or others have changed or are acting differently in some way), odd ideas, unusual perceptual experiences (e.g. a reduction or greater intensity of smell, sound or colour).
  • Changes in behaviour.
  • Sleep disturbance, social isolation or withdrawal, reduced ability to carry out work or social roles.

¹ Adapted from: Edwards, J & McGorry, PD (2002). Implementing Early Intervention in Psychosis. Martin Dunitz, London.

You should be aware the signs and/or symptoms of psychosis may vary from person to person and can change over time. You should also consider the spiritual and cultural context of the person's behaviours, as what is considered to be a symptom of psychosis in one culture may be considered normal in another.

How should I approach someone who may be experiencing psychotic symptoms?

People developing a psychotic disorder will often not reach out for help. Someone who is experiencing profound and frightening changes such as psychotic symptoms will often try to keep them a secret. If you are concerned about someone, approach the person in a caring and non-judgmental manner to discuss your concerns. The person you are trying to help might not trust you or might be afraid of being perceived as "different", and therefore may not be open with you. If possible, you should approach the person privately about their experiences in a place that is free of distractions.

Try to tailor your approach and interaction to the way the person is behaving (e.g. if the person is suspicious and is avoiding eye contact, be sensitive to this and give them the space they need). Do not touch the person without their permission. You should state the specific behaviours you are concerned about and should not speculate about the person's diagnosis. It is important to allow the person to talk about their experiences and beliefs if they want to. As far as possible, let the person set the pace and style of the interaction. You should recognize they may be frightened by their thoughts and feelings. Ask the person about what will help them to feel safe and in control. Reassure them you are there to help and support them, and you want to keep them safe. If possible, offer the person choices of how you can help them so they are in control. Convey a message of hope by assuring them help is available and things can get better.

If the person is unwilling to speak with you, do not try to force them to talk about their experiences. Rather, let them know you will be available if they would like to talk in the future.

How can I be supportive?

Treat the person with respect. You should try to empathize with how the person feels about their beliefs and experiences without stating any judgments about the content of those beliefs and experiences. The person may be behaving and talking differently due to psychotic symptoms. They may also find it difficult to distinguish between what is real from what is not real.

You should avoid confronting the person and should not criticize or blame them. Understand the symptoms for what they are and try not to take them personally. Do not use sarcasm and try to avoid using patronizing statements.

It is important for you to be honest when interacting with the person. Do not make any promises you cannot keep.

How do I deal with delusions (false beliefs) and hallucinations (perceiving things that are not real)?

It is important to recognize that the delusions and hallucinations are very real to the person. You should not dismiss, minimize or argue with the person about their delusions or hallucinations. Similarly, do not act alarmed, horrified or embarrassed by the person's delusions or hallucinations.

You should not laugh at the person's symptoms of psychosis. If the person exhibits paranoid behaviour, do not encourage or inflame the person's paranoia.

How do I deal with communication difficulties?

People experiencing symptoms of psychosis are often unable to think clearly. You should respond to disorganized speech by communicating in an uncomplicated and succinct manner, and should repeat things if necessary. After you say something, you should be patient and allow plenty of time for the person to process the information and respond. If the person is showing a limited range of feelings, you should be aware it does not mean that the person is not feeling anything. Likewise, you should not assume the person cannot understand what you are saying, even if their response is limited.

Should I encourage the person to seek professional help?

You should ask the person if they have felt this way before and if so, what they have done in the past that has been helpful. Try to find out what type of assistance they believe will help them. Also, try to determine whether the person has a supportive social network and if they do, encourage them to utilize these supports.

If the person decides to seek professional help, you should make sure they are supported both emotionally and practically in accessing services. If the person does seek help, and either they or you lack confidence in the medical advice they have received, they should seek a second opinion from another medical or mental health professional.

What if the person doesn't want help?

The person may refuse to seek help even if they realize they are unwell. Their confusion and fear about what is happening to them may lead them to deny anything is wrong. In this case you should encourage them to talk to someone they trust. It is also possible a person may refuse to seek help because they lack insight that they are unwell. They might actively resist your attempts to encourage them to seek help. In either case, your course of action should depend on the type and severity of the person's symptoms.

It is important to recognize that unless a person with psychosis meets the criteria for involuntary committal procedures, they cannot be forced into treatment. If they are not at risk of harming themselves or others, you should remain patient, as people experiencing psychosis often need time to develop insight regarding their illness. Never threaten the person with the mental health act or hospitalization. Instead remain friendly and open to the possibility that they may want your help in the future.

What should I do in a crisis situation?

It is important the first aider take appropriate action and arrange for professional help if someone is at risk of harming themselves or someone else, even if the person does not want help at that time. This may be a mental health professional, but include emergency medical services, the police or other professionals.

In a crisis situation, you should try to remain as calm as possible. Evaluate the situation by assessing the risks involved (e.g. whether there is any risk the person will harm themselves or others). It is important to assess whether the person is at risk of suicide [please see the MHFA Guidelines for Suicidal Behaviour]. If the person has an advance directive or relapse prevention plan, you should follow those instructions. Try to find out if the person has anyone s/he trusts (e.g. close friends, family) and try to enlist their help. You should also assess whether it is safe for the person to be alone and, if not, should ensure someone stays with him or her.

It is important to communicate to the person in a clear and concise manner and use short, simple sentences. Speak quietly in a non-threatening tone of voice at a moderate pace. If the person asks you questions, answer them calmly. You should comply with requests unless they are unsafe or unreasonable. This gives the person the opportunity to feel somewhat in control.

You should be aware the person might act upon a delusion or hallucination. Remember your primary task is to de-escalate the situation and therefore you should not do anything to further agitate the person. Try to maintain safety and protect the person, yourself and others around you from harm. Make sure you have access to an exit.

You must remain aware you may not be able to de-escalate the situation and if this is the case, you should be prepared to call for assistance. If the person is at risk of harming themselves or others, you should call for assistance (e.g. emergency services 911) to ensure they are evaluated by a medical or mental health professional as soon as possible. You should convey specific, concise observations about the severity of the person's behaviour and symptoms to the emergency services dispatcher and to emergency services personnel when they arrive at the scene. (Note: you should not assume the person is experiencing a psychotic episode but should rather outline any symptoms and immediate concerns.) You should tell the emergency services whether or not the person is armed. You should explain to the person you are helping who any unfamiliar people are, that they are there to help and how they are going to help.

What if the person becomes aggressive?

People with psychosis are not usually aggressive and are at a much higher risk of harming themselves than others. However, certain symptoms of psychosis (e.g. delusions or hallucinations) can cause people to become aggressive. You should know how to de-escalate the situation if the person you are trying to help becomes aggressive.

How to de-escalate the situation:

  • Do not respond in a hostile, disciplinary or challenging manner to the person.
  • Do not threaten them as this may increase fear or prompt aggressive behaviour.
  • Avoid raising your voice or talking too fast.
  • Stay calm and avoid nervous behaviour (e.g. shuffling your feet, fidgeting, making abrupt movements).
  • Do not restrict the person's movement (e.g. if he or she wants to pace up and down the room).
  • Remain aware the person's symptoms or fear causing their aggression might be exacerbated if you take certain steps (e.g. involve the police).

Take any threats or warnings seriously, particularly if the person believes they are being persecuted. If you are frightened, seek outside help immediately. You should never put yourself at risk. Similarly, if the person's aggression escalates out of control at any time, you should remove yourself from the situation and call emergency services.

Although these guidelines are copyrighted, they can be used for non-profit purposes provided the source is acknowledged. Please cite these guidelines as follows:

Mental Health First Aid Training and Research Program. Psychosis: first aid guidelines. Melbourne: Orygen Youth Health Research Centre, University of Melbourne; 2008.
Enquiries should be sent to:
Professor Tony Jorm, Orygen Youth Health Research Centre
Locked Bag 10, Parkville VIC 3052 Australia
email: ajorm@unimelb.edu.au