Focus: Psychosis

About 100,000 new cases of a documented psychosis are reported in the US every year, according to the National Institute of Mental Health (NIMH). Roughly 1-2%, give or take, of the general population might experience psychotic episodes at some point in their life. Although the most common age for a first-time psychotic breakdown is most prevalent in the early to mid-twenties (supposedly due to accumulating life-stress) it might happen at any other time during life as well.

The experience of a psychosis can be very dramatic and intense, for everyone involved. I myself have got to know the emotional struggle and devastating effects it has on the family, friends and first and foremost the life of the affected persons themselves, while supporting my ex-girlfriend and 4 other persons through such an experience. In my upcoming post “Psychosis: My own experience” I report on the experience I had with my ex-girlfriend, who herself had a psychotic phase for 6 months, which in retrospective view, we handled quite well in my personal opinion.

Unfortunately, there is not much accessible, often dispersed information on the web, which is very suboptimal when taking into account that statistically, at least 1 in every 100 individuals (and their family and friends) face that condition at least once during their life-time. With this extensive focus-topic, I want to help in filling that gap and attempt to provide a comprehensive overview from my experience and educational knowledge as a psychologist.

What is Psychosis?

Psychosis is when the brain takes a break from our consensual reality. It is like swinging the white flag in a war and calling defeat in the fight against a stressor which seems unbearable any more for our psyche. In that sense, it could be seen as a kind of mental breakdown, which prevents us from being further pressured by something the psyche can just not take any more and any longer. It is thus often traced back to either one specific, or an accumulation of stressors, which are called “triggers“. Those stressful triggers can be anything, from financial concerns, a break-up with a loved one, an overly intense drug-induced experience, nutritional deficiency, exposure to toxins, to having constant work-related stress or being the victim of a crime. Once triggered, the psychotic episode can begin either rapidly, within just one or two days, or slowly emerging, getting more obvious only over time, sometimes weeks, months or years after being triggered. Once fully developed, the affected person sees reality in a fundamentally different way. The duration of the psychosis can last from some days, up to one or two years (seldom longer), depending on the cause and type of psychosis and whether the person gets professional help and takes anti-psychotic medication in order to be better treatable.

Although psychotic episodes are also very typical for Schizophrenia Spectrum Disorders, and in fact share very similar psychodiagnostic characteristics, they should not be confused. While psychotic episodes can be part of schizophrenia, they do not necessarily need to be present. Moreover, schizophrenia is a rather life-long and enduring condition including the presence of negative symptoms (absence of emotion, facial expressions and motivation) and physical decline in brain-structure, while psychosis can be seen as an episode of loosing touch with reality. One should therefore be cautious in diagnosing schizophrenia in a psychotic-behaving person.

The Perception Perspective

The perception of a person experiencing psychosis is fundamentally shifted. The person experiences the world more intensely, sometimes with overwhelmingly over-flooded senses, which could remind of a trance-like state of awareness as experienced during certain drug-experiences, prolonged meditation or related disorders such as schizophrenia. Little details, which the normal consciousness usually filters out for the purpose of not being distracted and remain functional in our daily life, are perceived as very prominent. To generally speak, the filters which we all have in our normal state of consciousness in order to function, are turned down. The decrease, or even absence, of those protecting filters can result in hallucinations (either auditory or visionary), increased uptake of information from the surrounding, and leads to an overdrive, which the brain cannot fully process. Delusions occur, which unfold differently for every person, but interestingly, can be broadly categorized into distinct types of delusions (more on that later). Furthermore, common to all psychotic experiences is that they have a spiritual or religious flavour. While spiritual aspects of the person are increasingly coming to the forefront, the ego (which is our sense of self, sense of identification) is strongly decreased or even absent, which results in a kind of depersonalisation. This depersonalisation often creates the feeling, for relatives and friends, of not recognising the person any more. The affected individual seems like a completely different person to them. Affected people perceive (and present) themselves often as someone knowing something which others do not know or have not yet “realized”. This perceived knowledge often gives them the feeling of superiority over others. Sometimes, they think that others know about that “something” but just “act” as if they do not know. With this belief, and their evaluation if someone just “acts”, comes about a trust-issue. Trust is a very important key-point in treating and helping someone in a psychosis, to which we will refer back to later on. Another typical perceptual aspect of psychosis is to perceive “signs” which, for them, are absolutely clear and can only be interpreted in one meaningful way, which is the way they perceive it.

Delusional Beliefs

Delusional beliefs are irrational, fixed beliefs, which make an individual experiencing psychosis behave, think and talk in the way they do. Those beliefs are like a motor in a car, the drive for their psychotic experience. Delusional beliefs are irrational and fixed in the sense that even when presented with strong contrary evidence to their beliefs, the delusional person seems unable to be convinced. As mentioned earlier, although every person seems to have their unique content within those delusional beliefs, the delusions themselves often share a very common type of overarching theme. Moreover, multiple types of delusional beliefs can be present at the same time, or at different times during the psychotic experience, in one person. The main ones (but not all of them), commonly recognised in psychodiagnostics, are:

Delusions of reference: Believing that other people, specific circumstances, or seemingly unrelated constellations of things refer to the psychotic person themselves, giving them direct or indirect instructions or providing signs according to which the person should act or behave. For them, it is like getting new insights which bring them either to take another course of action, or to confirm them in their irrational thinking. Namely, they might talk about those references in an insightful way such as “Ohh, sure, now everything makes sense!” or confirming way “I knew that it is like that!”.

Examples: *leafs laying randomly on the ground which fell from a tree* where the delusional person thinks “Those leafs all have a specified order, they show a direction! That means I should go into that direction!”

*While listening to music on the radio in the car* the delusional person thinks “the singer knows about all of this, he wanted to warn us, he speaks to us! So, we must take another route!”

Paranoid / Persecutory delusions: Believing that other entities (other people, humans, organisations, animals or aliens) are chasing the person, want to do harm or even kill the delusional person or other people (friends, families, people involved in the situation). Within this delusion, people act very paranoid, look around very often, are afraid, and show bodily symptoms of being very nervous (shakiness, sleeplessness, carefulness). They might believe that their thoughts can be heard or read by a device or other entities. They often engage in preventative behaviour such as locking the doors and windows, compulsively looking out of the windows to watch out, ensuring that mobile phones and computers are shut-off or out of reach, or avoiding specific places or rooms.

Examples: *asking the delusional person why he/she is so shaky* the delusional person reacts with “Shhh! be quiet! Not so loud! Don’t you know that they hear us? We are all in big trouble if they know that we speak about that!”

*The phone of a person in the room rings* the delusional person says “Don’t take up that call! It is them! If you take up the phone call they know where we are, they will track your call and will kill us!”

Delusions of grandiosity: Believing that the delusional person is someone or something of superiority and grandiosity (a god, an “astral being”, a famous person) or having superior power (being rich, being able to fly, being able to read minds). While experiencing this type of delusion, the person may behave overly confident or acting/talking in the way of someone/something they associate with. They might display recurring movements or sayings which they believe can bring about a superpower or demonstrate their beliefs.

Examples: *reminding the delusional person that he/she must rest and go to sleep* the delusional person replies “haha, no, you know my beloved friend, that I, Shiva herself, the goddess of all eternity, must not go to sleep! Sleep is something for humans and other earth-like creatures!”

*reminding the delusional person that they are in depth and cannot walk into a store to buy all the products of that store* the person replies with “Oh yes, I can! I know that you don’t know, but I have stocks in Tesla & Microsoft which I did not told anyone. They are worth 3 million 300 thousand dollars. If you don’t come with me to the store, I will do it on my own and buy all of their watches and glasses to give them to other poor people. In fact, I just buy the whole building!”

Nihilistic delusions: Believing that something or someone has ceased to exist (their body-parts/organs, dear one’s, they themselves, the whole world). Commonly, due to the belief that something they actually need or like is not existing any more, depressive symptoms accompany this delusional belief.

Examples: *Asking what the delusional person’s parents would think of a certain thing* the delusional person replies “I wish they still existed… If they could only see me once again, but I myself am just a bodyless spirit, a shallow shadow of my own past…”

*Asking how the delusional person liked the food* the delusional person replies “I don’t really know. I do not have a stomach anymore. In fact, I cannot sense anything inside of me…”

Delusions of infidelity/Jealousy: Believing the partner cheated on the delusional person (for years long, once or still now). When having this belief, the delusional person might come with accusations towards their partner out of the blue, or first giving their partners small hints until they fully accuse them. Often, the delusional person starts to “realize” or see cues for infidelity, which might make them jealous towards the person the partner is seemingly cheating with.

Examples: *4 years in the past, the delusional person and the partner met with another couple to go for dinner* the delusional persons suddenly asks “You remember when we met with the other couple? You went on the toilet for a moment when this other guy wanted to go outside for a cigarette. I have the strong feeling you had sex with him on the toilette, right?!”

*The delusional person and the partner visit the delusional person’s mother for a week* the delusional person suddenly says “Well, I just knew it! You slept with my mother! My mother had that red underwear on, which she always wore for my dad. Even more so, there were weird spots on my parent’s bed!”

There are a multitude of delusional beliefs (not all of them were explained here), which often, but not always, can be distinctly categorized into one of the aforementioned ones. Moreover, some themes mix up or the delusional person switches between some of them. In my opinion, consistent with theories of other mental health practitioners, it is not random which delusion a psychotic person might experience. Often, they seem related to specific character-traits of a person or to certain unprocessed experiences or fears the person has had in their life. For instance, a generally fearful character who regularly takes illegal drugs or is involved in crimes and dislikes the police, might develop adverse reactions towards authorities from which, when experiencing a psychotic breakdown, a rather paranoid delusion might come about, instead of a quite unrelated nihilistic or infidelity delusion (which could still happen, but occurs less likely).

The Biological Perspective

Until now, not much is known about the biological patterns which underlay psychotic experiences, and we are far from understanding them fully. However, what we know from various brain scans and the way how certain antipsychotic medication work, is that Dopamine might play a big role in experiences of psychosis and schizophrenia.

The Dopamine Hypothesis: Coming from the insight that when Parkinson patients (whose dopamine-levels are chronically low, resulting in the condition-typical shakiness called tremors) received the amino acid L-Dopa (precursor of dopamine) as medication, suddenly developed psychotic symptoms. The idea that dopamine is involved in psychotic disorders and schizophrenia is further based on the fact that dopaminergic drugs such as cocaine and amphetamines can induce states of psychosis. Moreover, as long used in Indian traditions to treat schizophrenia, the snakeroot plant, containing reserpine (one of the first isolated antipsychotic medications after chlorpromazine in the 1950s) was observed to reduce dopamine levels, despite being quite toxic to the body and therefore not treated with any more. The dopamine hypothesis led to the finding that, without going into too much biopsychology, the Mesocortical & Mesolimbic pathway (the pathways between the frontal cortex, related to rational, logical thinking, executional functions and inhibition and the limbic system which is related to feelings & emotions) are overly attenuated and overly expressed, respectively. Those mechanisms could explain some phenomenons (irrational beliefs and inability to inhibit behaviour), but by far not all symptoms we see in people experiencing psychosis. Next to dopamine, researchers found that glutamate dysregulation precedes and dictates the regulation of dopamine mechanisms in those brain areas. In addition to those two specific neurotransmitters, actions of serotonin, which are intrinsically connected with actions of dopamine, could be traced back to specific biological actions of the disorder.

Due to those neurochemical insights, the first- (typical) and second-generation (Atypical) antipsychotics target the dopamine receptors (typical antipsychotics such as haloperidol or loxapine) or both, dopamine & serotonin receptors (Atypical antipsychotics such as risperidone, quetiapine or olanzapine).

Nevertheless, the sole actions of dopamine, glutamate or serotonin dysregulation cannot fully explain all observed phenomenons and aspects of schizophrenia or psychotic disorders and as so often, the underlaying biology seems way more complex than just having deregulated neurotransmitters.

Lastly, the overexpression of the involved pathways requires a high amount of glucose (fuel of the brain) which is then missing in other areas of the body, resulting in side effect symptoms of long-term psychosis such as overall weakness, switching between sensations of feeling hot & cold, and intensification of all kinds of given autoimmune diseases (neurodermitis, psoriasis, …).

The neurotransmitters involved are the same that are involved in effects of drugs such as LSD, Psilocybin, MDMA (Ecstasy) or related amphetamines, or cocaine. Therefore, people having psychotic episodes often show bodily symptoms of those drugs, such as dilated pupils, boosts of energy, insomnia or increased talkativeness.

The Jungian Perspective

Carl Gustav Jung, an early and nowadays famous but controversial psychotherapist, had his very own perspective on how psychosis and its phenomena could be explained.

To understand his stance on psychosis, we must first dive into his understanding of mental illness in general: “In therapy, the problem is always the whole person, never the symptom alone. We must ask questions which challenge the whole personality. […] paranoid ideas and hallucinations contain a germ of meaning. […] A personality, a life history, a pattern of hopes and desires lie behind the psychosis” (C. G. Jung: Memories, Dreams, Reflections, p.118). What Jung describes here basically is the need in therapy (and as I see it, generally in the pursuit of true well–being) to see things holistically, from the perspective of the person itself, not just their symptoms.

An important concept in understanding Jung’s approach towards psychosis is his division of the consciousness, the unconsciousness and the collective unconsciousness. In a wake-state, we all are within the frame of our consciousness, which is the “normal” and direct way we perceive our world. This consciousness is in constant contact with our unconsciousness though, lying “beneath” our consciousness, which we could picture as the observable tip of the iceberg. The unconsciousness would then lie below the tip, being usually barely accessible. The cut-off which determines how much of the iceberg peaks out of the water then is, what Jung would call the “threshold” of our consciousness. When taking his analogy, the unconscious could also be seen as a shelf in which our consciousness can put information into (experiences, feelings, emotions). Sometimes, this information comes out of the “shelf” into our consciousness where we can directly perceive it (such as fears, for example). During dream-states (such as during sleep or deep trance), we can experience the contents of our unconscious more purely (We dive into the water to see the rest of the iceberg).
A bit more tricky then is, what Jung calls the “collective unconscious”. For him, the consciousness and unconsciousness have unique content for every individual, depending on their experiences. Someone might fear dogs, because this person was bitten at some point, while another person is absolutely not anxious at all about dogs (unique content). However, there seem to be deeply-anchored emotions, drives or aspects of our unconscious, which are innate and common to all of us (sexual drives, instincts, or spirituality, for example). Those “shared” or “collective” aspects of our unconsciousness is what Jung called, the “collective unconsciousness”. Understanding those concepts is crucial to understand his approach towards psychosis.

The condition in which our sense of identification (the ego) is no longer the director, or master, of our unconscious and feelings, is called “neurosis” by Jung: “A neurosis is a relative dissociation, a conflict between the ego and a resistant force based upon unconscious contents. These contents have more or less lost their connection with the psychic totality. They form themselves into fragments, and the loss of them means a depotentiation of the conscious personality” (C. G. Jung). Nevertheless, what Jung called “neurosis” could be seen as a less intense form of a psychosis and differs much in extensiveness. While a person having neurosis is still able to uphold the ego to some degree, a psychotic person might completely surrender to the contents of the unconscious.

Similar to what I described in the beginning of this blog-post, Jung sees psychosis as including a kind of lowered thresholds of consciousness, in which it allows “normally inhibited contents of the unconscious to enter consciousness in the form of autonomous invasions” (C. G. Jung). He explains this by comparing psychosis to states of dreaming, in which the consciousness is lowered and so the content of our unconscious has the possibility to show up (the iceberg peaks out more than it is used to). In that sense, Jung describes psychotic experiences as a kind of wake-dreams. For Jung, it is the “threshold” of consciousness which lowers, not consciousness itself (which seems to be more or less in a fixed state for him). This threshold is what I would call “filters“, which are turned down, and then brings about an overstimulation and increased sensibility to the outer world, but also the inner, unconscious world.

The emergence of unconscious content within one’s inner world could be seen as the “unique” content the person experiences during a psychosis. While one person with delusions of grandiosity experiences him/herself as Shiva (a goddess within Hinduism), another person with the same theme of delusion, might experience him/herself to be a magician, capable of “reading minds”. Whereas both of them experience the same type of delusion, the content is unique. This unique content is thus telling something about the delusional person’s individual inner world (something that they locked away in their shelf but then suddenly pops out). According to Jung, the delusional experiences in general, arise from the collective unconsciousness and flood the affected person with its content, which would explain the commonality of those themes and its spiritual aspect (which is what lies, according to Jung, in the collective unconscious).

So, to make sense out of this, we could say that the spiritual and delusional beliefs from the collective unconscious, express themselves via the unique content of the unconscious, which (due to the lowered threshold) rise up into the consciousness of that person. This is, in a nutshell, how Jung sees and explains the condition of psychosis.

How to spot an Emerging Psychosis & What to watch out for

Diagnosing a psychosis in someone, or the emergence of it, should be done by mental health experts, such as Psychiatrist, Psychotherapists or Clinical Psychologists. They have the necessary training and expertise to clearly distinguish signs of a psychosis and if someone is having a psychotic episode, developing actual schizophrenia, bipolar disorder or merely shows subclinical delusions, delusional disorders or no mental health issues at all. With the signs that I will provide you now, I want to equip you with the necessary tools, to recognise solely if someone is behaving in a concerning way. Nothing more than that. Seeing all or most of the provided signs in a person could give hints for a developing psychosis, however, I want to make clear that if you are not a mental health expert, you should refrain from making any claims about the mental condition of another person.

First of all, seeing one, or two signs of the following might not be sufficient to worry about a developing psychosis. Some signs can be temporarily given, while they do not hint at an upcoming episode. If you clearly see all or most of the signs in a person, you should have enough cues to suggest that the person be evaluated by a (mental) health professional. Do not tell the person that you might spot a “developing psychosis” or anything alike. If you feel concerned, tell this person that you feel concerned and for the good of them, suggest a check-up by a GP or health practitioner.

1. The person has perceived a lot of stress lately.

It could be that you know that this person had a lot of financial stress, has lost their job or dear one, or had a very intense drug-experience which they tell you, they could not handle well. If you know about either one intense stressor, or multiple stressors in the recent times, that could be a sign of being very stressed out.

2. The person shows paranoid thinking or becomes increasingly irrational in their argumentation and beliefs

Sometimes, those irrational beliefs can be prevalent way ahead of an upcoming psychotic episode. Having and rapidly shaping new “weird” ideas could hint at confused thought-patterns. However, by far not everyone who thinks in irrational ways is on their way towards a mental health issue. See the examples of spiritual or religious people, of children or childish beliefs, or people who are just anxious about some aspects of their life’s, which we cannot really understand. Thus, having irrational beliefs is not a strong cue for a mental health issue and could mean many different things.

3. The person stops to care about their hygiene or basic needs

While every one of us might sometimes experience lethargy, having less energy and motivation to care about ourselves, the rapid change in lack of hygiene or not sleeping / eating correctly could hint at differences in our mental life.

4. Isolating from the outside world

When people, who are usually very extrovert, going outside very often and meet a lot of social contacts suddenly start to isolate themselves, this could be a hint for stressful times. Important here is to distinguish the deviance from the baseline. Some people very much like to be by themselves which does not mean that they could develop any concerning behaviour.

5. Talking a lot while being uneasy with others in a conversation

Again, some people are just naturally very talkative. If someone who is normally quite calm and introverted starts to talk in passively aggressive ways, is very excited when they speak and even interrupts others in a conversation frequently, this could be a sign of concern. With this cue, it is important to see if this behaviour lasts for a longer period, since every one of us can be excited when talking about our passions or frustrated at times.

6. Trouble concentrating and performing

If someone suddenly decreases in their performance in work, school or elsewhere, combined with troubles to concentrate in daily life, it could hint towards a concerning behaviour. Although this sign can also be of physical cause, such as sleep deprivation or poor diet, it certainly shows that the human-system (mind or body) is stressed somehow and does not function correctly.

7. Trouble to communicate and showing confused speech

When someone suddenly experiences difficulties to find words, speak in understandable terms, clearly or coherently, it could be a sign of concern. However, it can also show that the person is just nervous, anxious or overly excited.

8. Having rapid changes in mood or thinking

If someone gets triggered into negative or positive moods very easily, it could be a sign of being sensitive to the outside world. In and of itself, this does not show a strong hint for a concerning behaviour though. Our personalities differ, just as our tendency to be sensitive or insensitive to our inner and outer world.

Nevertheless, I want to mention that first, even if all of those cues are present, the person does not have to be on their way towards a mental health crisis. Second, those signs should be observed over a longer period of time and coming together, instead of separated. Third, the baseline is important: Only if the person is deviating from their usual behaviour, the signs can be interpreted as concerning. Moreover, those signs can sometimes lead to other disorders such as depressive disorders, personality disorders, or anxiety-related disorders. There are multiple explanations and reasons why a person might behave in those ways, from poor diet/nutritional deficits, to being sleep-deprived, being intoxicated by drugs or just having a hard time. So again, I want to stress that those signs are just to be considered as potential precursors for an underlying health-issue, whether it is about mental- or physical health, or at least being in a low-mood or stressful state. I would advise talking to the person about your concerns, but refrain from diagnosing or jumping to conclusions in any way.

How to Manage Psychosis as an Out-stander

Not experiencing the condition of psychosis itself, does not mean that one is not affected by it, when facing a person which experiences the psychosis. Especially when being emotionally close to the affected person (as friend, partner, or family-member), it can be very dramatic to go through this time with that person, often involving big emotional-struggle, uncertainties, fears and frustration.

In order to manage the situation and support the affected person in getting “back” to their “normal” self and being treated, I want to provide some tips and things to look out for. Moreover, I want to present insights I had during my own experience as out-stander of individuals experiencing psychosis.

What to Do & What to Avoid

First of all, one should always consult a mental health expert, if anyhow possible, about the situation.
Furthermore, the overall goal is to present the affected person to a mental health expert and not attempt to treat the condition on your own or by yourself.

The tips I will give you here, are supposed to guide you in that process and in reaching this overall goal. They are not meant to equip you with the expertise or skills needed to treat the person’s condition.

What to Do

In my opinion, the key towards supporting an affected person (and thus to make the person present themselves willingly to a mental health expert and take the necessary medication), is to build a trusting, loving & accepting environment for that person. Every communication with that person should be non-judgemental. Remind yourself, at all times, that the affected person is not being their “actual” or “unified” self. They are not in full conscious control of what they say to you or others, how they act, or behave. A person experiencing psychosis can seem extremely mean, say uncomfortable things, twist around your words or let you feel very negatively about yourself. It is, in the very most cases though, not their intent to make you feel that way. In my experience, the opposite is often actually true. They mostly mean it well:

• A paranoid-delusional person might not want you to answer a call to save you from being “killed”

• A person experiencing delusions of grandiosity might want to teach you to not be so “egoistic” and make you aware of your own “false beliefs” which limit you in your life, in order to live a better life

For the affected person, their experiences and beliefs are true and 100% real in their view. If you imagine that, in reality, there is a serial killer walking around your house, would you not freak out if someone just “unknowingly” opens the door and walks out to bring out the trash? For the purpose of explaining, we will stay within this example of the delusion of a serial killer walking around the house, since it can be well envisioned.

It is therefore important to understand, that judging the affected person in any way for their beliefs and acts, could make the person feel ridiculed, and not taken seriously, which often worsens the situation.

So, how should we then act, in order to support the person?
Firstly, accept the beliefs that the person has. This does not mean to reinforce them (“Yes, you are right! We should run away as fast as possible!”), or start to think yourself that there is really a “serial killer walking around the house to kill us”. Rather, we accept that they believe it, and although we think differently (i.e. that there is no serial killer walking around the house), we take them seriously in their belief. We can show them that we still like them, respect them, appreciate them, or love them, although they believe such irrational beliefs (like with a child who might think that thunders are actually elves who are arguing).

The most important aspect though is to gain trust from that person (which can be achieved by, among other things, accepting their beliefs). People within a psychosis often have a very thin line between trusting someone, seeing them as a “good” person who wants to help them, or mistrusting someone, seeing them as being malevolent or even harmful or a threat to them. It often occurs that they switch between those evaluations, where in one situation they trust you fully, and with one wrongly-perceived move or sentence, they suddenly mistrust you. However, you can gain the trust back in many cases as fast, as you lost it.

1. You could ask questions about their irrational beliefs to make them think about that, disclose and share their experience and emotions (Did you saw the Serial Killer? Do you know where he/she/it is at the moment? Do you think he/she/it wants to kill us, and why? Is there something I can do to help you at the moment?). Maybe, they even see themselves that something is not matching with their belief. Be aware though, that you should not drift into questioning their seriousness or them, as a person. Also, it might be that they give quite paradox answers, saying “yes, I saw the serial killer from our front window”, whereafter the question of “What did he wear?” could be replied with “I don’t know, I did not really saw him” or “I’m unsure”. Do then not dig too deep into this paradox, since it, again, questions them as a person which could make them feel like invalid observers or liars, resulting in stressful emotions for that person.

2. To an extent, follow their instructions. If you say “okey, I will go to the front-window to see if the serial killer is still there”, and the delusional person replies “Alright, but take that crystal-stone with you so that you are invisible to him”, then you should take the crystal-stone with you while going to the window. Again, this shows that you are accepting the person’s beliefs, and that builds trust. Be mindful though to not do all and everything the person wants you to do. If the person said “Call the police! We must run out of here, right now!” you should better not act upon their belief. In such situations, you should try to calm that person, give them alternative options to handle the situation, or at last, you can always say “No, I do not want to do that.”

3. Be a beacon of calmness, safety and support for them. Show them unconditional positive regard in the sense of smiling, being open and easy to talk to. Try to see the situation from a rational standpoint, which is exactly what the affected person is not able to at that moment. If they say there is a serial killer waiting on the front door to kill them, logically, we should attempt to gain control over the situation without much exaggeration (turning the lights on outside, asking if the person feels safer if you stay with them, asking them if they feel safer when you lock the front door). Without much exaggeration here means, to not fully engage in actions, you might normally make if that situation would be real (like calling the police, taking a weapon, screaming for help, etc.). Try to think in ways which calms the delusional person down, without inflicting too much unnecessary stress or reinforcing their beliefs too much.

4. Take the affected person to places and locations they like and where they have an emotional connection to. Many people who experience a psychosis might have the strong urge to seek those places by themselves, and you should allow them to go there (at best together). Moreover, psychosis, as explained in the biological perspective paragraph, often produces a boost of energy, similar to taking drugs like ecstasy or amphetamines. They might walk around the house and keep on talking, seemingly without getting tired. To take them for a walk (especially in nature or parks), might give them the opportunity to express this energy and calms them down a little. Psychologically, a shift in environment and the exposure to nature can have huge beneficial effects on a person, not only for (but including) people having a psychotic episode. This is, certainly, only a good idea if the affected person wants that and agrees with going outside the house. Another point to keep in mind is to be patient with them. They might get distracted by little details they see, do not want to move further or go home again. In such situations, you cannot force them to go home or go further. Give them the time they need and ask them, after some moments again, to go home with you.

5. That said, asking the person about every action you are about to do with them, and getting consent, is very important. Relating back to trust-building and acceptance, you should never force the person to do something or go somewhere, the person does not want to. Rather, convince the person to willingly do it, or at least, accept it. Only by asking “Are you okay with going for a walk in the park together?”, you know if the person is fine with doing that. Moreover, it saves you a lot of stress and unwanted situations, when going outside with that person. Furthermore, try to offer the person basic needs, such as going to sleep, having some food and drink water. Never pressure the person into something and keep the person deciding themselves, if they want to eat, drink or do something. Again, this is about building trust and showing respect and care to that person.

6. Care about their physical needs, such as sleep, healthy food and water-intake. Often, psychotically-affected people do not want to, or believe they don’t need to, care about their physical needs. However, not sleeping, eating or drinking will rapidly worsen the situation from a biological standpoint, since the body is already very stressed and taxed by the overdrive it experiences. Therefore, offer them a glass of water once in a while, make them food or convince them to go to sleep at some point. Remind them about those things and how important they are, but do not force or pressure them into doing that. It can be critical sometimes to offer affected individuals any type of goods, since they might not trust the good (water or food for example) and think that it was poisoned or will harm them. If that is the case, then give them the option to decide themselves what they want to drink or eat, or let them make their own food/drink. This gives them certainty that it is not harmful what they are about to ingest. Moreover, make those goods available and reachable at any time, so that they can drink, sleep or eat when they want to. Although healthy food and drinks should always be prioritized, sugar and sugary drinks might sometimes help the person to regain some energy (sugar & carbohydrates are the fastest source of energy for the body).

7. Another tip I want to give you is, to make them aware of not being themselves. This needs to be done in cautious ways, since it can easily switch into mistrust again when done wrongly. In the very beginning, the person who experiences the psychotic episode will not be able to de-attach from their view of reality. At that point, it does not make sense to tell them that they could be in a psychosis. However, with progress and some time and eventually prescribed medication, they could come to realize that something is not going the way it’s supposed to be in their mind. One way to make the person de-attach from the psychosis, is to give the psychotic-version of that person a name. That is often done in other disorders, such as tourette-syndrome, to depersonalize the disorder from the actual personality the person has. In this way, the affected person, and you yourself, are constantly reminded that the psychosis is a state of being, not a personality or “the way someone is”. It makes it easier to talk about those psychotic states and communicate about the effects it has on the affected person and the surrounding people. When calling the psychosis “Hans” or “Jeffrey” for example, it is much easier to say “Jeffrey hurts my feelings when he does it”, instead of saying “you hurt my feelings when you do this”. Furthermore, the affected person will feel much less stressed about critic or emotional disclosure when being able to refer to this “other version” which has an arbitrary name. You can think together with the affected person about a fitting name, so that they feel more comfortable talking about the psychosis.

8. Managing their life-matters and bureaucracy. While having a break from reality, the person is often not capable any more to manage their worldly duties. However, until relevant others do not know that the person is hindered for some unknown time, they will expect the affected person to function, come to work, go to uni-exams and pay their rent. Since this will in most cases not work out, it is the job of the supporting out-stander to care about those things and let relevant others (Boss of the affected person, Uni, school, landlord, municipality etc.) know about the hindrance. Do this with the least amount of detail possible, since unfortunately, there is still quite some stigma around mental health issues, especially psychosis. You could for example let others know, that the affected person had an accident and cannot function at the moment. Where more detail is necessary, you can explain the situation, but mention that this should not be disclosed to third parties. In the end, you may want the affected person to still have their job, their house etc. after the episode is over. In some cases, when insurance is available, you can get financial support for this time. For those matters, I would advise you to talk to a social worker, lawyer, or inform yourself about the possibilities you have.

9. Lastly, try to convince the person at some point to go visit a doctor / mental health expert. Framing is very important here, since the psychotic person might think the doctor wants to do harm to them or mistreats them (the trust-issue). Make clear to them, that a doctor can be of great help for them, offering solutions you and the affected person maybe did not think of yet. Also, always keep the doctor in a positive light and communicate that a doctor is truly interested in alleviating their suffer and issues. However, accept that it might take a while until you can convince the person and try it again at another point, if it does not work right away. Always make sure you yourself gained trust before you attempt to visit a doctor. It often helps to ask the person if you should come with them or if they want another person with them to feel safer when going to the doctor (I would not advise letting the delusional person go there alone).

What to do in Emergency Cases

Although most situations can be resolved calmly, it might very rarely still happen that the situation becomes actually dangerous for yourself, others, or the delusional person themselves. Opposed to the general societal thinking that psychotically affected people are dangerous (which was put into our heads by horror movies and news), that is actually only very rarely the case. In the very most cases, the affected individuals can be quite excited, nervous or frustrated, full of emotions, but will not harm you or themselves. However, if you evaluate the situation as seriously dangerous (the person threatens to kill themselves or another person, is about to jump out of a window, has a weapon and threatens to harm you, others or themselves etc.) you need to immediately call the police, and explain the situation with as many details as possible. Explaining the details is important here, since the emergency case of “jumping out the window” is very much different from “the person has a knife and tries to kill me”. Moreover, always mention that the person is delusional and in a state of psychosis. This detail makes a big difference, since in some cases, a psychiatrist/psychologist will be sent in addition who could eventually solve the situation by communication and medication. If you yourself feel that the delusional person is about to attack you, run away and seek a safe space first (the bathroom which you lock up, a neighbour’s house etc.) before you call the police. If however the person wants to jump out of the window, or is about to commit suicide, you should react in the exact opposite way: stay with that person, try to de-escalate the situation and calm the person down, physically hold the person if necessary, close and lock the window, if possible. Moreover, try to bring harmful items out of reach or even out of sight (knives, weapons, tools etc…).
Always try to resolve the situation by yourself and call the help of other, non-institutional persons (your friends, friends of the delusional person, neighbours, family-members) first, if that is possible and does not endanger them.

Calling the police or an emergency is the very last option you should take and should be reserved for the very case, of a serious threat. Calling the police for such an emergency will break loose a cascade of serious institutional mechanisms (A SWAT-team or similarly-trained special force will come and resolve the situation with brute-force. This will leave a deep trauma behind in the delusional person, which might become a condition to be treated in and of itself afterwards!)

So please, be careful what you do and how to react. Always make sure that you yourself are safe and choose the least intrusive, but still appropriate solution, possible!

Self-care

While managing and caring about a person who experiences psychotic episodes, you will, at some point, need the help of other people. Include other family members or close friends and ask them for their help and support. You should inform them with much detail about the situation and the state, in which the delusional person is in. Moreover, you could give them a brief introduction into the Do’s and Dont’s which I mention here, to not make it worse, if they offer their direct help in managing the affected person.

If the episode seems to hold on for a longer period of time, you will need to make breaks occasionally. Go for a walk, call a trusty friend or family member and explain them your situation and talk about the stress you experience. Talking with other people you trust is important. It gives your inner feelings and concerns expression and communicates to your close one’s that you are in a difficult situation. With that, they might offer advice or want to help themselves in the situation (even if it’s just going to the supermarket for you, so that you don’t need to care about groceries). You can, and should admit, that you have a difficult time and that is not a sign of weakness. As much as you care about helping the psychotic person, it does not help anyone of you two, when you yourself might develop stress-related disorders or physical conditions.

That said, try to still fulfil your own needs and duties. If possible, you could certainly arrange some free-time from work, uni, or school. However, that is not always the case, and you might need to fulfil those duties to be still able to pay your rent and have food in your fridge. That is, among various other reasons, why I would highly recommend you to include other trustful people in the situation, which might switch the supporter-role with you and give you time for those duties. In the end, the main goal is still to introduce the delusional person to a mental health expert or facility, so that you have time to rest and keep up with your normal life schedule. Remember that it is the job of a mental health expert, and the purpose of a mental health facility, to treat and care about, among others, psychotically-affected individuals. They have the expertise, the time and medication to help the person in the most effective way.

What to Avoid

Basically, avoid to behave in the opposite way which was mentioned in the “What to Do” paragraph.

Avoid to judge the person, avoid to make fun of the person and avoid overreacting or avoid leaving the person alone with their intrusive beliefs, if you truly want to help them. Do not exaggerate the situation by reinforcing their beliefs too much. Do not underestimate their condition by putting it off as “that will resolve itself by tomorrow”.

Do not force them physically into something (also not to visit a doctor) or even worse, harm or beat the person.

However, also avoid to do each and everything the affected person wants you to do. You should show them if you are unwilling to do something and give them a clear “No!” if the demand of the person is just not appropriate or has serious consequences (such as calling the police for a supposed serial killer outside the house, where none is, just because the delusional person wants you to do that).

Although it often seems beneficial in reaching the overall goal, and in making the situation more manageable, refrain from giving the person drugs or medications yourself (if you are not a licensed doctor, or the doctor did not ask you specifically to give a certain medication). You do not have the knowledge nor the (legal) right to give them any kind of drugs (whether it is sedatives, anti-psychotics or any other drug). Some drugs might worsen the condition, and you could get into serious (legal) trouble when doing so. Moreover, giving the person a pill or drug in general, often creates mistrust. Always consult a mental health expert for doing this, and do not do it on your own (and especially not without the consent of the affected person).

Furthermore, do not attempt to treat the person’s condition on your own. Even if you are a trained mental health expert, if the person is emotionally close to you, or you have an emotional bond to that person, let other professionals do that job.

Lastly, but not less importantly, avoid being too much involved with that person for very long periods. The situation can be very stressful for you as a supporting out-stander and after some time, you will need a break from that situation. Take a walk once in a while when the person is fine to be left alone for a moment (asleep or very calm) or when other people take care of the person. Try to get your head free for some time. Self-care is not to be completely dismissed as out-stander, since the situation can become increasingly taxing on your physical and mental health, as well!

How to Argue with Someone Who is Irrational

Changing the delusional belief of a person who experiences psychosis is by definition (since they are fixed), very difficult if not impossible. Although subclinical delusional beliefs might have a good chance of being changed in early stages of its emergence, they are nearly unchangeable when having developed into a full-fledged pathological belief, as within a psychosis. We should therefore accept the fact, that the chances of coming out of a conversation with a psychotic person with the result of having convinced them that their beliefs are false, go against zero.

Nevertheless, there are some guidelines in arguing with a person who has irrational delusional beliefs during a psychotic episode. Following those guidelines can eventually make the delusional person feel accepted, respected and listened to, which, as you may remember, are the most important factors when supporting a person with psychosis in presenting themselves to a health care facility or doctor.

The most important strategy in arguing with any kind of person, but especially individuals being in a psychotic and delusional state, is active listening.

Everyone wants to be listened to. This does not only relate to people being in a psychosis, but generally. You want to show and make clear to the person you are arguing with, that you understand what they say, although you may not agree with their beliefs. Once in a while during the conversation, you should say back to them what they told you, and ask them if you understood them correctly. This can be done by asking for example “So, you say that…?” or “Is it correct that you mean …?”.

As an example: if the delusional person says “I do not want to tell you that, because they are listening! Those aliens can hear us with their mind-reading devices!”, you could reply with “Okay, so is it right that the aliens are able to hear our conversations with their mind-reading devices?”

Another example: If the delusional person says “Don’t worry, if someone wants to harm me, I will just control his mind, so that he will think I am invisible!” you could reply with “So, do I understand you correctly that you are not vulnerable to the harm by others, because you can control the minds of other people to make them think you are invisible?”

Some good starters for those “saying-back” strategies could be:

• “So, you say that…?”
• “Is it correct that you mean…?”
• “Let me make sure I understand you, so …”
• “Is it right that …?”
• “Do you mean that …?”
• “Correct me if I’m wrong, but you say that…?”

While applying this technique, you should stay within the same wording and phrasing that the other person uses and do not much deviate from that. The closer you are to their wording, the more understood they will feel. Too much deviation could result in being accused to have listened incorrectly to what they said:

Example of too much deviation: The delusional person says “There are cameras in the room, which are set up by the CIA to observe every move I make. I feel that they want to spy on me and collect evidence against me!” you reply with “So, you say that you get recorded by the government?”.
Although this seems to be a valid rephrasing of the statement, it deviates much from what was said by the delusional person. It might not be the whole government which they feel is conspired against them, but specifically the CIA. Moreover, the delusional person did not say that they record them, but rather that the cameras are used to observe the delusional person (which could be done live, without recording anything).

The point here is, to make them feel as understood as possible, not to rephrase their content.

Furthermore, refrain from any emotion besides curiosity. Be a rational and logical conversation partner and do not laugh, or smile, or let yourself be driven by anger, frustration or aggressiveness. Try to put on a “poker-face” without showing too much of your actual feelings. The delusional person will most often think, that you are driven by those emotions, making them feel unheard, ridiculed or not listened to. Moreover, they might think that you act suspiciously if you start to smile or laugh (although you might mean it well and want to show positivity). Take their utterances and arguments seriously in your conversations, since they mean it in a serious way. Try to normalise the conversation, so that they feel comfortable in speaking with you about their beliefs.

After the saying-back technique, you could ask a follow-up question, to make things more clear.

Example: The delusional person says “There are cameras in the room, which are set up by the CIA to observe every move I make. I feel that they want to spy on me and collect evidence against me!” you could reply with “Correct me if I’m wrong, but you say that in this room, there are cameras used by the CIA to spy on you and collect evidence against you, is that right?” After the agreement of the delusional person, you may ask “What evidence could they collect against you? Did you do something wrong?” / “Why do you think they want to collect evidence against you?”

Another important point to understand is, that the delusional person (just as you yourself) have triggers, which when triggered, could shift the conversation into emotional and negative ways. Once being emotionally triggered, our Fight or Flight mode turns on, and we do not argue in rational ways any more. Not believing the person by saying “I think you are delusional” or “There must be another explanation to that!” could trigger the delusional person to be upset and become frustrated. On the other hand, be aware that you yourself might be triggered if the delusional person twists around your words when you for instance say “It could be that you are right, but research says that normally this is not the case” and the delusional person replies with “Research? You mean you want to research me? You do not really think that you can research me, or?”. Clearly, this is not what you wanted to say, and the delusional person twists around your argument against you in an irrational way, which could make you angry or frustrated yourself. Try to not take those twists seriously and rephrase what you said, for example by saying “No, I’m sorry if that came across like that. What I actually meant is, that maybe there could be another explanation to that”.
The point here is, to be aware of the other person’s triggers, but also those of your own. Do not let emotions control your arguments or the conversation and forgive the other person for twisting around your words.

Another more advanced technique is to express subtle doubt. Within this technique you could start with proposing an alternative solution to the explanations a person has, without disregarding their explanation. Often, you would start this alternative solution with the word “maybe…” to infer that they could still be right.

Example: The delusional person says “Everyone hates me! I have the feeling that everyone looks at me with disgust and shame” you could reply with “maybe the people are disgusted by something else, but look at you afterwards with their disgusted emotions?”

When offering alternative solutions, you should not refer to “how many people think that way”, such as “I guess that 99% of the people would not think that the CIA spies on us with cameras, don’t you think?”. This does not really matter for them, since if they have the feeling that they are spied on, they do not care about how many other people think this is not true. Moreover, their belief that they know “more” than others know, disregards this argument.

Furthermore, instead of proposing an alternative solution, you could ask directly what the person thinks why that is, or what evidence they may need, to doubt that belief: “What makes you think that those people are disgusted especially by you?” or “What evidence would make you feel differently?”
We often feel that we know what other people mean, but actually we do not. Especially with ambiguous utterances, it might be difficult to distil their true meaning. Therefore, we should not jump to conclusions and rather ask the person directly what they mean with that or how we can help them in finding a solution.

Lastly, leave them a win. Do not doubt everything they say and also show them, that yes, they might be correct. Maybe “there are aliens listening to us” or maybe “people are disgusted by the affected person”. When there is no way to convince them of the contrary, why should we argue with them about that? Give them a win once in a while, and admit that yes, the person could be right and you do not 100% know if there are aliens. This can give them the feeling of being respected and accepted. You do not need to agree with them, but let them feel “not doubted about” at least, and keep this possibility open, that they could be right. Nonetheless, you could give them a compliment in saying that “you are a smart person, so maybe it could be true that …” or “it was very interesting to talk to you about that, and although I am not fully convinced, I did not yet consider this possibility that …”.

You see that arguing with pathologically delusional people in a psychosis is very difficult and might need some training. Psychotically-affected people speak another language, that of total irrationality and emotional associations. It is absolutely okay, if you just stick to the “saying-back” technique and maybe ask some follow-up questions while keeping the conversation logical from your side. Anything more advanced can be left out and done by trained professionals. You also do not need to worry if you did something wrong here or made the other person upset. Learn from that and try it again the next time you say something back or have another conversation with that person.

Health-Care System Issues

If the psychotically-affected person is finally willing to visit a mental health professional, receives proper diagnosis and gets the recommendation to admit themselves to treatment in a mental health-care facility, there can still be some challenges and barriers popping up.

Firstly, if the affected person is considered an adult in your country and not willing to follow the recommendation of the mental health professional (namely, to be treated in a facility), this could be very problematic in some cases. It heavily depends on the laws in your country, but in most cases, there is no legal way to “force” the adult psychotic person into treatment. This means, that even though the professionals strongly advised the affected person to admit themselves to the mental-care hospital, take medication and gave a proper diagnosis, the psychotically affected person can just say “no, I don’t want that”. With that, there is no option (for now) besides convincing the person into willingly admitting themselves. However, there are 2 exceptions to that case: First, the person is evaluated by the professional to be suicidal, self-harming or other-harming. In this case, a Psychiatrist by law can legally force the person to be admitted. The second exception is, that there are laws in your country, which make exceptions, such as section 2 in the UK Mental Health Act (put into force in 1983).
This barrier is a strong one, since after all the hard work, good conversations and encouragement you and others did, the affected person (who is clearly not able to make the right decisions for themselves), is legally capable, to reject treatment and just go home again. Nevertheless, in most such cases, there are still positive things to not be dismissed here:
1. The affected person has a proper diagnosis and can be referred more easily to other doctors or facilities. Moreover, with the diagnosis, the evaluation step by professionals can be skipped next time and if the affected person is convinced, readily get a place in a hospital.
2. Often, appropriate medication is prescribed (Anti-psychotics, sedatives, sleeping-pills) and handed over to a responsible person (family members or partner) or the affected person themselves. Thus, medication can now be given to the person if advised by the professional. Under medication, the affected person might be less confused, better manageable and realizes that treatment is necessary and should be a worth attempt.
3. The affected person is known now at this facility and might get an arrangement to be readily admitted if convinced.

Nevertheless, it feels hard to come so far and be unsuccessful in receiving treatment for the person. Remind yourself that you did not lose, but that it might need some more time, medication and patience, until the affected person accepts professional help. From now on, it is important to remind the affected person every now and then, that they should go to the facility to receive treatment and to feel better.

Secondly, the mental-health care system is at full capacity. With overcrowding, there might come along further, system-related challenges. For example, the affected person cannot be admitted to the same hospital where they are evaluated, which means that extra effort needs to be done to transport the person into a hospital which has a free place. Another issue could be, that space is only free in an unrelated station (such as addiction, somatic or anxiety-related). With this unrelated station might come further challenges, such as untrained personnel for psychosis, co-patients which cannot understand or relate to the psychotic person and even mistreat that person (making fun of the person, sexually harassing the person, stealing from the person). Lastly, the unrelated professional doctors themselves might not know how to deal with a psychosis in proper ways and therefore cannot treat the psychosis in the most effective way.

Lastly, the admission into a mental health care facility can be traumatic for a person, depending on the way that is done, and how this person is treated there by nurses, professionals and co-patients. It could be that the affected person feels betrayed by their family members or friends, who actually want the best for that person. Another tip is, to bring the person entertaining goods (books to read, games to play, something creative to do). I would therefore advise keeping in contact with the affected person via mobile phones or regular visits (if allowed). This shows the affected person that their dear ones are still supporting and caring about them, and that if such mistreat happens, the supporting out-standers can communicate that to the hospital, or ask for a referral into another hospital. Be assured, that the staff in the hospital is normally aware of those cases and if mistreat happens, the malevolent person will be either suspended immediately from this hospital, put into another station or at least be observed very closely to not come close to the psychotically-affected person. Moreover, with mistreat there is always the right to take legal actions against the malevolent person. Only because they are in a mental-health care facility, this does not free them from law regulations.

The bottom-line is, that you should be prepared for those potential issues. They do not necessarily need to come up, but they could. Moreover, I do not want you to fear the hospital or professional help, since only there, the affected person can be helped effectively. In most cases, there will be a way to effectively receive treatment in the hospital and most of them keep some emergency rooms free, for such cases.

Reintegration into Life

With proper treatment and medication, the affected person will come back to a more-or-less normal state again. While regaining their actual personality, rationality and conscious thinking, they often realize their situation which can be just as hard to go through.

Depending on the length of the break from reality, a lot of things happened in the meanwhile. The person might have lost their job, lost their relationship partner or some friends, needs to restart university, search for another accommodation or take some medication for a while. Moreover, the “damage” done to others, and the stress they have put upon their dear-ones can be heartbreaking for them to realize.

Realizing that the person might basically need to start their life again, and the associated fear to get into another episode at some point, often results in a state of deeply negative feelings, sometimes depressive-like states including self-hate and generally miserable feelings.

Although the psychotic episode might be over at that point, the person needs the support and encouragement of their friends and family now more than ever. It is very important to care about the feelings of the person, ensuring them that they are still loved, liked and appreciated. Moreover, making clear to them that their dear ones do not relate the damage and stress to the person themselves, but to the condition they had (the psychosis), often gives them a much better feeling about themselves.

As a supporting out-stander who went through all of this with the person, this is an emotionally very intense time, as I know from my own experience… Important here is to let the affected person’s, and also your own feelings, give expression. Do not inhibit yourself or the other person to cry to process this. Show yourself and the other person love and affection after all this struggle. Let the other person some time to process their emotions and support them, whenever needed with good words and encouragement.

Another factor during this time is the physical condition of the affected person. Depending on the length of the psychosis, and medication they take, their neurotransmitters are in absolute imbalance. This means that the affected person may not be able to concentrate, feel happy, or access their usual qualities and talents. It needs some time and good nutrition to refill the emptied dopamine, serotonin and related storages in the body. During this time, the affected person should mainly recover, should not overestimate their abilities and care about proper sleep-hygiene.

In order to reintegrate the affected person into life, process their emotions and feelings, minimize the chance of relapses into psychosis, build up mental resilience and finally get back to their usual well-being, I highly encourage the affected person to search for a therapy place. It might take a while to get accepted for therapy and find a fitting therapist (up to 6 months or even a year or two!) and therefore strongly encourage enrolling the affected person very soon after the episode, if not immediately after the hospital release. A further benefit for having regular therapy sessions is the expert view from a person who was not involved in the process. Moreover, there is no emotional bonding between the therapist and the affected person (as it might be the case with you and the affected person).

In most cases, it is advisable to also enrol yourself for therapy sessions, or at least talk about your experiences with trustful friends, since the time of emotional struggle and stress you experienced also creates trauma and emotions in you yourself, which need to be expressed and processed and let go of.

In the end, medication should if possible be slowly decreased (although I know that some psychiatrists would advise taking them for a lifetime…). That is, since medication can attenuate the symptoms, but does not resolve the source of the psychosis, neither does it make the person come to true well-being. Side effects will become increasingly prevalent with longer time and there is no medication without those. To get to the source of the issue, which is often underlying emotional struggles and fears, I would recommend to work on those with the therapist. A little tip I got from someone who overcome his psychosis, and who now lives happily without any medication while giving lectures at universities and schools to educate about this condition, is holotropic breathwork. Created by Stanislav Grof (Renowned Psychotherapist, Psychiatrist and founder of Transpersonal Psychology), holotropic breathwork is focused on the upbringing and processing of deeply unconscious emotions through breathing techniques. I might make a blog-post in and of itself about that technique, so stay tuned if you are interested in this!

Conclusion, Final Words and Summary

The condition of a psychosis brings with it a multitude of concerns, struggles and emotional ups & downs. Facing such a condition as out-stander or as affected person oneself can be life-changing, in many ways. If you read until here, you should be equipped with more than “common knowledge” about this condition and how to handle it to support the affected person effectively. Take this blog-post as a manual and guideline if you face such situations in your life. You are also welcomed to share it with others who may face the condition at a given time. Personally, I would have wished for this blog-post when I was myself a supporting out-stander for over 6 months. I had to learn most of this myself, and it took me hours, if not days of research to come to this knowledge.

A last aspect to think about is a quote I got from the same person, who told me about the holotropic breathwork technique:

Find wisdom in madness

As much as the delusional content of psychosis seems bizarre, unreal, nearly unrelatable, it might have “a germ of meaning” as C. G. Jung put it. It tells us something about the deep inner world of a person and their hidden, unconscious feelings and deep desires. What you think of that, is up to you.

Lastly, if you are reading this because you are affected by psychosis, either as out-stander or affected person, I truly wish you all the best. It can be a hard time but be assured, that it can be managed. If you have any questions, concerns, or are currently facing this condition, you can send me an E-mail via the contact form at the bottom of the front-page, or leave a comment below this blog-post. I will reply to your request as soon as possible. Be aware though, that yet, I am still in my last bachelor year and neither a psychologist, psychotherapist, psychiatrist or actually any certified expert yet. At the end of 2024, I will finish my Clinical Psychology Master and therewith offer counselling sessions. If you want to apply for a place to talk about your experience and process your emotions and eventually resolve traumata under my guidance, you can do this here.

Summary Overview

What is Psychosis?

• Roughly 1-2% of people in our society statistically experience a psychotic episode once in their life
• The common age of a first episode is within the early to mid-twenties
• Psychosis = A break from our consensual reality
• Psychosis is often triggered by life-stressors (either one, or multiple ones accumulating)
• Psychosis is not the same as schizophrenia
• During psychosis, the affected person perceives the world more intensely (both inside & outside world)
• Often, spiritual content is embedded in the psychosis
• Delusional beliefs, which are irrational & fixed, can take many forms, and drive the psychosis
• Biologically, the neurotransmitters dopamine, serotonin & glutamate are playing a main role
• C. G. Jung sees psychosis as coming from the collective unconscious, bringing unique content from the unconscious into the consciousness, which happens through a lowered threshold of consciousness

How to Spot an Emerging Psychosis & What to watch out for

• Different cues must come together over a prolonged period of time
  • The person has perceived a lot of stress lately
  • The person shows paranoid thinking or becomes increasingly irrational in their argumentation and beliefs
  • The person stops to care about their hygiene or basic needs
  • Isolating from the outside world
  • Talking a lot while being uneasy with others in a conversation
  • Trouble concentrating and performing
  • Trouble to communicate and showing confused speech
  • having rapid changes in mood or thinking
• The cues are merely signs of concerning behaviour
• The cues do not replace a proper diagnose by a mental health practicioner
• Do not diagnose someone else and refrain from jumping to conclusions

How to Manage Psychosis as an Out-stander

• What to Do
  • Build a trusting, loving & accepting environment
  • Do not judge the person in any way
  • Accept the beliefs of the person and the person itself, although you do not agree with them
  • Gain trust
  • Ask rational questions about their irrational beliefs in a respective manner
  • To an extent, follow their instructions
  • Be a beacon of calmness, safety and support for them
  • Take the affected person to places and locations they have an emotional connection to
  • Asking the person for consent before doing or offering something
  • Care about their physical needs, such as sleep, healthy food and water-intake
  • Make them aware of not being themselves (carefully)
  • Managing their life-matters and bureaucracy
  • Convince the person at some point to go visit a doctor / mental health expert
• What to do in Emergency cases
  • In the very most cases, psychotic episodes are not dangerous for the affected person or others
  • In rare cases, they could be dangerous. If that is the case, then
    • Immediately call the police when the situation is life-threatening
    • Explain the details as much as possible
    • Distinguish between Suicide and Other-harm
    • In threat of suicide:
      • Stay with that person
      • De-escalate the situation and calm the person down
      • Physically hold the person if necessary
      • Close & lock the windows if possible
      • Bring harmful items out of reach and out of sight
    • In threat of yourself being harmed
      • Run away
      • Seek a safe place first
      • Call the police
      • Mention that the person is delusional and in a psychotic state
    • Try to call other people for help, if they are not getting endangered
    • Only as last option, you should call the police (leaves behind traumata)
• Self-Care
  • Do not dismiss your own mental and physical health
  • Call other people to help you in supporting the affected person
  • Take some rest and time for yourself
  • Take a walk once in a while
  • Communicate to trustful friends that you are in a difficult situation
  • Admitting that you have a hard time is not a weakness
  • Try to still fulfil your own needs and duties
• What to Avoid
  • Basically, avoid behaving in the opposite way of the “What to Do” part
  • Do not judge the person
  • Avoid to make fun of the person
  • Avoid to overreact
  • Avoid leaving the person alone
  • Do not exaggerate the situation
  • Do not underestimate the situation
  • Do not force them physically into something, harm them, or beat them
  • Avoid to do every little thing the person demands of you
  • Show them a clear “No!” if the demand of the person is not appropriate
  • Do not administer medication or drugs to the person by yourself
  • Do not attempt to treat the condition on your own
  • Avoid being too much involved with the person for very long periods

How to Argue with Someone Who is Irrational

• Changing a delusional belief in a psychosis is nearly impossible
• Accept the fact, that you will not win the argument
• Make the person feel accepted, respected and listened to
• Actively listen to the person
• Say back what the person explains to you in their own wordings and phrasings
• Ask follow-up questions
• Refrain from any emotion besides curiosity
• Be rational
• Be aware of their, and your own, triggers
• (Advanced) express subtle doubt
• (Advanced) offer alternative solutions
• Ask directly what the person thinks and why
• Leave them a win in the argument

Health-Care System Issues

• If the affected person is an adult, there is often no way to force them into treatment
  • Exception: The person is evaluated as suicidal, self- or other-harming
  • Exception: Your country has exception laws
• If the affected person rejects therapy, remind them once in a while about the benefits of treatment
• System-related issues
  • Overcrowding
  • Getting admitted into unrelated station
  • Being mistreated by professionals, nurses or co-patients
• Potential for traumata in the admission process
• Legal rights can be used in mistreat cases

Reintegration into Life

• When realizing the situation, the affected person often shows depressive symptoms
• Care & emotional support is needed
• It might be that the affected person needs to rebuild their life
• Seek therapy as soon as possible
• Also as supporting out-stander, seek therapy sessions or talk to trustful friends
• Physically and mentally, the affected person needs recovery
  • Healthy diet
  • Good sleep-hygiene
• Slowly decrease medication if possible and process emotions and trauma with therapist