Psychosis is a mental state in which individuals may experience hallucinations or delusions that distort their sense of reality.

These symptoms can make ordinary conversations frightening, threatening, and overwhelming for both the patient and their caregiver.

When working with patients experiencing psychotic symptoms, it is important to use a structured communication approach that emphasizes clarity and empathy.

Build trust first

Trust lays the groundwork for every therapeutic relationship. Patients experiencing psychosis may feel suspicious or fearful, so rapport must be built slowly. You can:

• Start the session with neutral, non-threatening topics (ex. “How has your sleep been?” instead of “Why do you think people are after you?”). 
• Maintain calm body language and tone of voice. Therapy will be the patient’s safe space, so your presence needs to be calming. For example, you can sit at their level (rather than standing over them), avoid sudden movements, and respect their personal space.
• Use the patient’s name regularly in order to foster recognition and respect.
• Allow for silence to happen. Some people may need extra time to process information and respond without feeling pressured. For example, a patient who is hesitant to speak may feel safer and become more open if you allow pauses and gently prompt them with “take your time, I’m listening.”

Listen without confronting delusions

Directly challenging a psychotic patient’s beliefs can lead to mistrust and resistance. Instead, the focus should be on validating their emotions and finding common ground, with a major emphasis on listening.

A lot of patients’ psychosis symptoms actually have a larger meaning behind them, giving you a clue as to what you can work on. Some practical steps include:

• Acknowledging the feeling without challenging the delusion (ex. “That sounds frightening”, instead of “No, they are not watching you”).  
• Ask about the impact their belief has instead of chasing the truth (ex. “How does it affect your day to feel watched?”). 
• Redirect attention towards current coping strategies (ex. “What helps you feel calmer when that happens?”).

Communicate clearly and simply

Disorganized thinking can make complex language hard to follow. Simplicity and repetition can help patients process information more easily. For example:

• Use of short, easy to understand sentences: “Take this medication twice a day” instead of “This medication should be administered twice daily”.
• Give one instruction at a time and confirm if it has been fully understood.
• Repeat or rephrase if the patient feels confused.
• Avoid clinical jargon and metaphors.

Maintain a patient-centered approach

People experiencing psychosis often feel disempowered and controlled by their symptoms.

Your role in providing care is to counteract this by inviting them to collaborate with you, and by respecting their autonomy.

You can:

• Offer small, realistic choices to provide patients with some sense of control over their lives. For example, if you have a client who is supposed to start group therapy, but seems unsure, you could ask if they would feel more comfortable starting with a shorter session or meeting one-on-one with you first.
• Ask the patient for input on the topic of their goals (“What’s most important for you to work on right now?”).
• Reinforce the patient’s autonomy by respecting their decisions as much as possible.

Stay calm and regulated

Psychotic patients may enter into a session already in distress, or something during the conversation might trigger negative emotions inside them. In these situations, it’s important for clinicians to stay calm, maintain composure, and de-escalate the situation.

Therapy should be the patient’s safe space, where they can feel free to express any emotion without feeling ashamed or guilty, and in providing care, clinicians can model stable behaviors.

This could look like:

• Keeping your tone steady and volume low, even if the patient becomes agitated.
• Using slow, deliberate movements to avoid escalating paranoia.
• Setting boundaries calmly if the patient becomes verbally aggressive. For example: “I want to continue talking with you, but I need you to lower your voice so we can communicate effectively.”

It’s important to note that in case you feel the situation has become unsafe for you, the patient, or others, you should disengage and follow your institution’s safety protocols.

Additionally, if the situation doesn’t seem physically dangerous, but the emotional pressure feels overwhelming for you, take a step back, seek supervision, and use team-based approaches rather than continuing alone.

Provide consistency and structure

Predictability can lower anxiety and foster security in schizophrenic patients. You can provide this by keeping appointments consistent in timing and setting, and giving brief explanations of what will be discussed in the next session.

In case changes are necessary, you should give gentle warnings. For example, if the session needs to be shorter, you could say “today we only have 40 minutes instead of an hour, but I will make sure to cover all the main points and continue the next time we see each other.”

Humanize the patient beyond the diagnosis

The last but most important aspect of communicating with psychotic patients is humanizing them.

People experiencing psychosis often feel reduced to just their symptoms, rather than being seen as individuals. This leads to feelings of mistrust, isolation, and stigma.

It’s critical to have empathy and approach patients as people—not just a set of symptoms that needs to be “fixed”. Try to engage in topics about their life and show genuine curiosity about their interests, goals, and relationships.

Additionally, a patient’s psychosis symptoms can stand out to the world and people around them, making them feel isolated, so it’s important to acknowledge the person’s strengths and resilience, not just their difficulties. Truly caring for people and their interests can build therapeutic rapport and make them feel validated and recognized, reinforcing hope, and helping with the recovery process.

Further resources

• American Psychiatric Association (APA) – Practice Guideline for the Treatment of Patients With Schizophrenia, Third Edition.
• Early Psychosis Intervention Network (EPINET) – Articles of Interest.
• Schizophrenia and Psychosis Action Alliance (S&PAA, formerly known as SARDAA) – Provider Resources.
• National Institute of Mental Health (NIMH) – Recovery After an Initial Schizophrenia Episode (RAISE).