Managing symptoms of psychosis

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Table 32 presents some strategies for managing acute psychotic symptoms. Some clients may be aware that they are unwell and will voluntarily seek help; others may lack insight into their symptoms and refuse help. Active-phase psychosis can put both the client and others at risk of harm and therefore mental health services should be contacted, whether the client wants such a referral to be made or not.

It should also be remembered that there is much stigma and discrimination associated with both psychotic spectrum disorders and AOD use, and some people may attempt to conceal either one or both of their conditions. Many people with comorbid psychosis and AOD use are frightened of being imprisoned, forcibly medicated or having their children removed. Take the time to engage the person, developing a respectful, non-judgemental relationship with hope and optimism. Use a direct approach, but be flexible and motivational [431].

Table 32: Dos and don’ts of managing a client with symptoms of psychosis

DO:

  • Ensure the environment is well lit to prevent perceptual ambiguities.
  • Ensure discussions take place in settings where privacy, confidentiality, and dignity can be maintained.
  • Try to reduce noise, human traffic, or other stimulation within the person’s immediate environment (e.g., reduce clutter).
  • Ensure the safety of the client, yourself, and others.
  • Allow the person as much personal space as possible.
  • Be aware of your body language – keep your arms by your sides, visible to the client.
  • Ignore strange or embarrassing behaviour if you can, especially if it is not serious.
  • Listen attentively and respectfully.
  • Appear confident, even if you are anxious inside – this will increase the client’s confidence in your ability to manage the situation.
  • Speak clearly and calmly, asking only one question or giving only one direction at a time.
  • Use a consistently even tone of voice, even if the person becomes aggressive.
  • Limit eye contact as this can imply a personal challenge and might prompt a hostile, protective response.
  • Point out the consequences of the client’s behaviour. Be specific.
  • Ensure both you and the client can access exits – if there is only one exit, ensure that you are closest to the exit.
  • Have emergency alarms/mobile phones, and have crisis teams/police on speed dial.
  • If psychosis is severe, arrange transfer to an emergency department for assessment and treatment by calling an ambulance on 000.

DON'T:

  • Get visibly upset or angry with the client.
  • Confuse and increase the client’s level of stress by having too many workers attempting to communicate with him/her.
  • Argue with the client’s unusual beliefs or agree with or support unusual beliefs – it is better to simply say ‘I can see you are afraid, how can I help you?’
  • Use ‘no’ language, as it may provoke hostility and aggression. Statements like ‘I’m sorry, we’re not allowed to do___but I can offer you other help, assessment, referral…’ may help to calm the client whilst retaining communication.
  • Use overly clinical language without clear explanations.
  • Crowd the client or make any sudden movements.
  • Leave dangerous items around that could be used as a weapon or thrown.

Adapted from NSW Department of Health [277], Jenner et al. [123], and UK NICE Guidelines [431].

Some clients with psychotic disorders may present to treatment when stable on antipsychotic medication and thus may not be displaying any active symptoms. These clients should be encouraged to take any medication as prescribed, and ensure they receive an adequate diet, relaxation, and sleep because stress can trigger some psychotic symptoms [522].

Despite the risk of further psychotic episodes, some people decide to keep using substances that mayinduce psychosis. In such cases the following strategies may be helpful [123]: 

• Educate the client about ‘reverse tolerance’ (i.e., increased sensitivity to a drug after a period of abstinence) and the increased chance of future psychotic episodes.

• Encourage the client to avoid high doses of drugs and riskier administration methods (e.g., injecting in the case of methamphetamine).

• Encourage the client to take regular breaks from using and to avoid using multiple drugs.

• Teach the client to recognise early warning signs that psychotic symptoms might be returning (e.g., feeling more anxious, stressed or fearful than usual, hearing things, seeing things, feeling ‘strange’), and encourage them to immediately stop drug use and seek help to reduce the risk of a full-blown episode.

• Inform the client that the use of AOD can make prescribed medications for psychosis ineffective.

Social stressors can be an added pressure for clients with psychotic conditions and the client may require assistance with a range of other services including accommodation, finances, legal problems, child care, or social support. With the client’s consent, it can be helpful to consult with the person’s family or carers, and provide them with details of other services that can assist in these areas. Family members and carer smay also require reassurance, education, and support. See Chapter B4 for strategies on how to incorporate other service providers in a coordinated response to clients’ care.