talking with psychotic patients
psychosis, hallucinations
thought disorders
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Talking with Psychotic Patients

 by Stuart Sorensen - RMN.

As with anything else in life it’s useful to know what you want to achieve before you begin. This may be simply a social interaction or may have assessment or therapy implications. It’s important to know what you want as the patient may be far too thought disordered or distracted by hallucinosis to maintain any sort of logical stream of thought. In many ways you will need to help guide the psychotic person through the interaction and help them keep their thoughts on track.

Always keep in mind that the psychotic experience is real to the patient. As a rule they will be as convinced of their perception of reality as you are of yours. That’s why direct statements of fact such as "It’s not real" tend to be irritating and can provoke aggression. They certainly will be more likely to de-rail the conversation than enhance it. It’s usually more helpful to make comments such as these from a perspective of ‘opinion’ or personal experience whilst acknowledging the patient’s own standpoint:

"I know the voices are real to you but I just can’t hear them. I wonder if it might be another hallucination."

Follow this up with a question to get them to think about what you said:

"What do you think? Could it be an hallucination?"

It’s extremely important never to ‘enter the delusion’. This means never agreeing with the delusion or behaving in ways which imply agreement. For example if a person is complaining of rats around their bed don’t ‘sweep them away’ in order to reassure the patient. This just confirms their reality to the patient and makes it much harder for other staff to get them to acknowledge the possibility of psychosis.

This acknowledgement is the beginnings of what we call ‘insight’ which is extremely useful to develop. Insight is the term we use for ‘patient awareness’ and without insight patients are much more likely to relapse, refuse medication and have difficulty dealing appropriately with symptoms when they do arise.

Now you have an idea what not to do here are some useful pointers you can use in conversation. First try to find some common ground. Discover some shared perception and comment on that. It may seem quite innocuous at first but you’re task here is often simply to put the person at their ease. All interactions depend upon trust in order to be therapeutic and getting agreement over trivial matters is often instrumental in building rapport.

You can comment upon something obvious like the temperature, the weather or even the ‘boredom’ of hospitalization. Try to stick to observations likely to get agreement from the patient. Incidentally commenting upon and acknowledging the patient’s emotional state is known as validation and is a simple yet extremely powerful way to increase trust empathy and rapport.

Once you’ve established a reasonable rapport with the patient try to direct their thoughts back to reality by involving them in problem solving. For more information on the techniques involved in therapeutic problem solving see the handout ‘problem solving’ in this series. Problem solving is not only therapeutic on a practical level it also demonstrates and teaches a useful skill and encourages the patient to direct their attention away from hallucinosis. Unless of course the problem to be solved is how to stop the voices for example. Even then it’s therapeutic as it encourages the patient to think about their hallucinatory experience as a symptom of illness rather than reality.

Be careful to avoid arguing with the patient about their hallucinations or attempting to disprove their perceptions as this will almost certainly fail. The patient can only use their senses to make sense of the world and if their ears tell them the voices are real any form of reality testing is likely to confirm their experience. Remember that agreement is the thing.

None of this means that you can’t express a difference of opinion. In fact very often you will find yourself obliged to disagree with the psychotic patient. Just get agreement as often as you can so that your relationship will be strong enough to withstand the inevitable differences of opinion over serious or delusional issues. It’s often useful to state that you understand why the patient thinks the way they do before going on to posit an alternative interpretation. This statement of understanding implies respect and reassures the patient that they are being listened to.

Dr. Stephen Covey in his book The Seven Habits of Highly Effective People (Covey, S.) uses the phrase:

"Seek first to understand – then to be understood". This is an incredibly effective way to build trust and rapport and also is a useful and practical way to calm down angry patients. Incidentally whenever possible get potentially hostile patients to sit down – it’s just harder to fly off the handle when you’re relaxed and obviously being listened to.

Often it’s necessary to ‘negotiate’ agreement with psychotic patients either over medication or a range of other situations. There are a range of ways in which you can bring a patient to give their agreement which is sometimes known as getting closure. The word ‘closure’ is important as it means exactly what it says. Once the patient agrees change the subject. A common mistake is to carry on persuading which often results in a change of mind. The appropriate thing to do is confirm and accept the agreement and then leave the subject – or even the room. That way you have a good bargaining position should you need it later by reminding the patient of their word to you.

Another useful negotiating tool is to do with opening successive ‘files’ or ‘memory stores’ in the mind of the patient. This helps focus their thinking and also avoids ‘overloading’ the patient with too broad a question or subject area. For example if you ask a patient what are the pros and cons of staying in hospital you’re likely to set their mind off on a whistle stop tour of opposing thoughts and opinions which ultimately confuse and frustrate them. Not terribly helpful.

A better way would be to ask them to think about being at home (the ‘home file opens)

Secondly remind them of being ill at home (home illness file opens)

Thirdly remind them of feeling frightened when ill and at home (fear file opens)

Make a statement about hospital being a safe environment (positive hospital file opens). Be aware that there will also be a negative hospital file, which you do not want to open.

Ask them what is best when they’re ill frightened and at home. They’re likely to say admission to hospital.

Finally ask them to stay and change the subject as soon as they’ve agreed. This is a negotiating model devised by Peter Thomson in his audio program entitled conversation – the power of persuasion (Thomson P.)

Should you make any statements or give instructions these are better made in a positive context rather than a negative one. For example asking a thought disordered person ‘not to’ go outside may prompt them to go outside. It’s better to ask for what you do want instead of mentioning what you don’t. Try asking them to ‘stay on the ward’ instead. This phenomenon is well recognized as a core concept in a number of psychological interventions – notably Neuro Linguistic Programming. It’s to do with the mental ‘files’ the request opens. You can’t think about not going out until you’ve first thought about going out itself to establish what you’re being asked not to do. Asking the patient to stay in bypasses the ‘going out’ file altogether.

If you are faced with a hostile or aggressive patient, be they psychotic or otherwise, the appropriate course of action for any student is to get out of the situation calmly and quickly. Then report it to more experienced staff who will deal with the situation. However, if you cannot get away here are a few guidelines.

  1. Don’t fight back, verbally or physically. This will simply make the situation worse.
  2. Be assertive – stand up but don’t fight.
  3. Try to gain understanding – seek first to understand….
  4. Listen
  5. Try to get the person to sit down
  6. Try to get between the hostile patient and the door
  7. Don’t make promises you can’t keep – you’ll probably regret it later if you do.

I hope this handout has been of some use. There are of course many techniques for negotiating with psychotic patients and this handout barely scratches the surface. If it gives you an idea of the issues and a little confidence to draw upon then that is enough. For more specific questions please feel free to speak to your mentor.

Compliments of Stuart Sorensen – RMN

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