A quick & dirty guide to helping someone who's dealing with active psychosis
Before we begin, context: I have cPTSD and Bipolar type I (mania) that I've been in treatment for since the age of five. Part of my lifelong treatment of my distressing symptoms led me to spend three years at a peer-led recovery project that specifically was for people who experience hallucinations, delusions, and other symptoms of psychosis. My time at this program is what informs me the most for the content of this post.
I am NOT a mental health professional! I am instead speaking from a position of long experience with my own and others' hallucinations and delusions and psychosis. Please carefully consider carefully what advice here is relevant to the situation you're dealing with as every person is different, especially when it comes to ways people develop to deal with their distressing symptoms.
The things in this guide are not the only ways to help with psychotic people! Every person is unique and I ask that you please let the needs of the person who is suffering be your guide rather than any dogmatic ideas of what help has to look like. If they are able to communicate their boundaries, you must respect those boundaries.
If you're not ready to respect the affected person's boundaries, you're not ready to help.
What is psychosis?
What psychosis looks like is very specific to the episode and the person experiencing it, but it means that you lose the ability to tell what is real and what is not in a profound, non-momentary way. Psychosis can look wildly different person to person, depending on what someone's brain and normal reality look like.
Impact-wise, psychosis means your delusions/hallucinations and delusions have gotten to a point where they are causing you significant distress and thereby preventing you from engaging in your usual daily activities. Psychotic episodes interrupt your life rather than being a normal shape of your life.
Loss of reality is the biggest key component of psychosis. It can be important when you are dealing with psychotic friends to figure out exactly what reality has been lost to know how to not hurt them further. Psychosis does not typically present as someone acting acutely agitated all the time. More often it's subtle and requires knowing the person in order to actually tell if what you're seeing is the normal level of symptoms for them.
This will probably come as a shock, but delusions and hallucinations are not necessarily an indicator of psychosis!
They can be, but it varies wildly by what your normal symptoms are. Some schizo-affective people have constant hallucinations and the thing that changes when they get psychotic is the nature of the hallucinations (kind voices turn mean and new, crueler people show up) and the loss of the ability to reality check along with the ability to resist the accompanying compulsions.
Psychosis inherently always involves the current symptoms being at a level which is distressing to the person's experience. If someone is having a Tuesday full of their usual affable hallucinations, they're not experiencing psychosis.
Most of my psychotic episodes involved a specific thing that my brain fixated on, which after too much time fixating causes me to lose the connection to reality and start having hallucinations and delusions related to the original psychosis topic that scare me. This pattern is one of the very classic bipolar methods of delusion related to psychosis.
Different disorders present differently, but the constant with true psychosis is that loss of reality and the loss of ability to exist comfortably. You can't shut up about how Black Mirror is coming to get everyone for long enough to pack for a cross-country move. You don't know that you're talking to a hallucination and not some asshole who decided to sit with you, since you aren't allowed to sit indoors in a more controlled environment thanks to the fact that your normal symptoms frighten people. And so on, and so on.
Most distressingly for me, even if I notice that something is wrong I typically can't stop myself from engaging with the delusion/hallucination. It's compulsive, which adds to the discomfort/distress.
That's psychosis: a place where your brain disconnects you from your everyday world. A place where you've lost reality and can't stop yourself from doing what you're doing even if you want to & recognize that you're not interacting with reality anymore. A place where your normal comfortable symptoms of whatever illness you have can get scary.
It's a terrifying and isolating experience, and it often leaves us vulnerable to being taken advantage of because we're in a state of constant fear that reinforces the reality break that started the whole psychotic episode.
All of that said: you can help! In fact, it is very important to help people when they are in psychosis. A big part of the reason is that due to the brain's plasticity, the longer someone stays in acute psychosis, the more their brain gets re-wired to exist only in a state of constant terror/reality break and it gets harder for that person to live a life where they feel comfortable on a regular basis.
So, help if you can. No, it's not easy, so if you don't have the bandwidth, it is okay to not help.
Again, because it's important: If you don't have the bandwidth, it is okay to not help. You are not a bad person, you are just managing your own resources the best you can.
Helping people is always a "put your own oxygen mask on first" situation; if you don't have the ability to help, don't do it. No harm, no foul. Educate yourself, and educate others, as these are more passive methods of helping, but please make sure you're in a safe place where you can follow through helping someone who may be difficult to help.
The number one thing I will say about materially helping delusional/hallucinating people is that you should not confront the delusion directly, as the delusion is more likely to fade if you distract someone than if you make them focus on it by trying to challenge the psychotic thought patterns.
There is significant evidence that this sort of forced reality checking from the outside actually drives delusions in deeper because it reinforces that the hallucination/delusion is real enough that other people see it. This might seem weird, but it's best to ignore the specific hallucination/delusion than to try to orient someone to the reality they've lost. Being oriented from the outside will reinforce the lost reality as a distressing situation and make them believe the delusion more.
There are a lot of different studies that have proven this, but the one that sticks in my mind was a study done on several men who all thought they were Jesus, which included the men living and interacting with one another. Rather than breaking the delusion by seeing other people also thought they were Jesus, the experiment drove the delusion in deeper and many of the nurses and doctors came to regret having performed the experiment.
Please understand: you are not going to break the delusion/hallucination. You can't and you won't. Your goal is to support someone through the distressing symptoms they're experiencing, not to fix anything.
Again, your task (should you judge you are willing & able to take it on) is to support someone experiencing psychosis, not to fix them. They're not broken, they are just experiencing a difficult time that is also a regular part of their life. Your job is to trust that they know best what helps and what hurts.
Situation one
Someone that you have never met before is having what seems to be psychosis difficulties in a public area. The key aspects of this situation are that you do not know the person and that they are in a very public setting where other people are around and may take actions of their own if you don't take action.
This is probably the one that most people are imagining so I'm going to spend the most time on it.
Talk to the affected person like a real person. Ask if you can sit down and talk with them, and respect their boundaries if they say no. Don't talk to them in that high pitched voice we use for animals and small children--that's dehumanizing. Talk to them the same way you would anybody else.
Introduce yourself and ask what they go by. See if they are oriented to person, place, and time; this means finding out if they know who they are, where they are, and what the general date/time is. This is called being oriented x3. Possibly surprisingly, most people in psychosis are pretty oriented. If they are not well oriented, you need to elevate care because what's going on is not within your scope*.
* in this particular case I am talking about your medical scope of practice, which is the things you are qualified for based on your real-life education, training, or experience. Recognizing when things are beyond your scope of care is an essential part of being healthy about helping others. Bear in mind that due to what I discussed earlier it takes specific training to know how to help people who are not oriented without causing unintentional harm; this is why we elevate care for everyone's safety when someone is not well oriented.
Speak to them, human to human. Share a real vulnerability; show that you trust them. Ask what they care about; tell them what you care about. Let them be human with you and not just someone dealing with upsetting symptoms beyond their means to cope.
Talk to them about the symptoms they're having right now. Use as many softeners as possible, like seem, might be, could, maybe, and so on; make sure they have plenty of opening to correct you if you are wrong, and heed their corrections.
Ask them if they are aware that they seem like they might be having some distressing symptoms.
If they are: ask how they normally deal with these symptoms. Try to identify ways you can help them engage their normal coping mechanisms.
If they aren't: say that you think they may be having some. Do not suggest that you know better than them, because again, they may be having a normal Tuesday even if it seems extreme to your eyes. Only the person dealing with a symptom can decide if it's distressing to them.
Ask them if you can help connect them with their network. Most people who deal with psychosis have a history of dealing with it, so we often have support systems in place. Try to connect them with theirs, whether it's partners, peer support, therapists, religious leaders, mentors, family--it varies by the person. They may not have a phone, or money for a trip to someone's house, or whatever, and that can be all they need to get on the right track.
If they are not well-oriented, don't leave the person without connecting them to their network or another professional for help. Doesn't matter if it's peer support or therapist or EMS if they decide they want to do inpatient. It is dangerous to let people who are not well-oriented be without care because they can be (and often are) very easily taken advantage of and hurt mentally and physically. Try not to call 911, but do not leave until they are safe in the care of someone who is qualified to help without hurting them.
Before you go, leave them with a way to contact you. I usually write something like "Lugarn - [something related to the conversation we had]! Call me!" that indicates my name & what kind of support I'm offering in the same place where my number is. Remembering things that happened when you were psychotic is an absolute shitshow, so don't be surprised if they forget who you are.
Situation two
A friend has started acting out of the ordinary and you're worried they might be experiencing psychosis.
Offer support if they are able to articulate what they need. As with above, connecting them to their existing network should be the number one priority. Most psychotic episodes don't need hospitalization and can be treated without inpatient care, because again, most episodes don't involve loss of orientation.
If they are not able to articulate what they need, ask them if they are okay with the things you do before doing them. Don't try to do things for them unless they've said that is what they need.
They will probably have normal ways for dealing with it if they have an illness that includes psychosis. In this case, it is best to just help them get into their normal system for coping with psychosis.
Don't disclose details of their illness to other people in your mutual friends group. Just don't do it! If they want to tell your friends then that's up to them and not you.
Above all, remember that you are equals with this person even if they experience psychotic episodes from time to time and don't treat them differently afterward any more than you would someone insensible from any other injury or illness.
Who you gonna call?
In most places in America, it is dangerous to call 911 on someone having a psychotic episode. Most dispatches for someone who is agitated/experiencing mental health issues include cops along with EMS. There are a few places that have succeeded in changing how police are dispatched for some mental illness related calls (shout out to Denver/Aurora, who have the best crisis system I've been through), but for the most part it's very likely to end up with police and EMS rather than just EMS. If you can avoid calling 911 on someone experiencing a psychotic episode, please do so.
How to find places to call/people to help instead of 911:
Their usual support friend/family member/partner
Their therapist/psych (bear in mind they won't be able to confirm or deny that the person is their client, but they will put things into motion on their end to extend care)
Search "[Your town name] public safety" or "[Your county name] public safety"
EMS = ambulance to the hospital, make sure they're okay with this!
This will give you the non-emergency numbers for EMS, which means it might take longer but you are less likely for cops to show up.
Search "[Your town name] mental health" or "[Your county name] mental health"
Some places have well-funded mental health departments and you'll get a great listing of all the resources, and some places don't have very good websites.
This is where you will find out if your city has specific community response teams or specific efforts for mentally ill people and people dealing with addiction. If you can't find this information on your city's webpage, you should see if the local mental health center has a list of these resources instead.
Be prepared to end up making calls in order to connect to resources, especially if you're in rural/underfunded areas.
If you have any questions, especially about what to do in more specific situations, please don't hesitate to ask. This is not a comprehensive guide and I'm 100% positive I've left things out.
Thank you for reading! Please spread the knowledge if you can and help save a life 🙏
