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A group that is a leader in the identification, treatment and prevention of schizophrenia (ORYGEN Research Centre, Department of Psychiatry, University of Melbourne, Australia) has recently come out with a list of "First Aid" actions to be taken by parents and family members, counselors, police officers, etc.
For people who are beginning to experience psychosis (loss of touch with reality) and schizophrenia.
Research strongly indicates that early treatment at the first signs of psychosis or schizophrenia is very important for the best long term outcome. As soon as possible a person suffering from psychosis should get treatment by professional psychologists or psychiatrists.
The action list below is based on the input from 157 experts in the field. The Orygen group has also set up a Mental Health First Aid web site for people to refer to. They have developed a series of mental health first aid classes that we hope will be used as a model around the world to help people in other countries who suffer from mental health problems.
We encourage you to pass on this list, and the research paper, to interested groups and people in universities and schools (i.e. school counselors or psychologists) as well as leaders in police forces world wide, and to support groups, to educate family members and key members of the public.
These new First Aid for Psychosis guidelines are covered in a research paper that was published recently in Schizophrenia Bulletin - and the full research paper is available for your viewing here (pdf file for download). The following list is from Table 1 of the research document. We also have a section on our site on schizophrenia recovery tips.
First aid recommendations for psychosis and schizophrenia
Schizophrenia as well as Psychosis (a description of a key symptom of schizophrenia) is the mental state when a person experiences hallucinations, unusual beliefs, paranoia, mixed emotions, muddled thoughts, unusual or puzzling behaviors. If someone seems distressed or impaired by their experiences, even if they're quite subtle at first, it's best not to ignore them and hope they'll go away. It's good to give the person the opportunity to discuss the situation.
You should realize that although warning signs and/or symptoms of psychosis are often not very dramatic on their own, taken together they may suggest that something is not quite right.
You should not ignore or dismiss warning signs and/or symptoms if they appear gradually and are unclear.
You should not assume that the person exhibiting warning signs and/or symptoms is just going through a phase or misusing substances.
You should not assume that the warning signs and/or symptoms of psychosis will go away on their own.
You should be aware that the warning signs and/or symptoms of psychosis may vary from person to person and can change over time.
You should take into consideration the spiritual and/or cultural context of the person’s behaviors.
You should be understand that people developing a psychotic disorder will often not reach out for help. If the first aider is concerned about someone, they should approach the person in a caring and nonjudgmental manner to discuss their concerns.
You should understand that someone who is experiencing profound and frightening changes such as psychotic symptoms will often try to keep them a secret. The first aider should be aware that the person they are trying to help might not trust them or might be afraid of being perceived as ‘‘different’’ and, therefore, may not be open with them.
You should make sure to approach the person privately about their experiences, in a place that is free of distractions.
You should try to tailor your approach and interaction to the way the person is behaving (eg if the person is suspicious and is avoiding eye contact, the first aider should be sensitive to this and give the person the space they need).
You should not touch the person without their permission. The first aider should state, in specific behavioral terms, why she/he is concerned about the person and should not speculate about their diagnosis. (For example - "I'm concerned about you not being able to get out of the house and do the things you want to do")
You should allow the person to talk about their experiences and beliefs if they want to.
As far as possible, you should let the person set the pace and style of the interaction.
You should recognize that the person may be frightened by their thoughts and feelings.
You should ask the person about what will help them to feel safe and in control.
You should reassure the person that she/he is there to help the person and wants to keep them safe.
You should let the person know that she/he is there to support them.
You should allow the person to stay in control by offering choices of how she/he can help them where possible.
You should convey a message of hope to the person by assuring them that help is available and things can get better.
If the person is unwilling to talk with the first aider, the first aider should not try to force them to talk about their experiences.
If the person is unwilling to talk, you should let them know that she/he will be available if they would like to talk in the future.
How the first aider can be supportive
You should always treat the person with respect.
You should try to empathize with how the person feels about their beliefs and experiences, without stating any judgments about the content of those beliefs and experiences.
You should understand that the person may be behaving and talking differently due to psychotic symptoms.
You should recognize that the person who may be experiencing psychosis may find it difficult to tell what is real from what is not real.
You should avoid confronting the person and should not criticize or blame them.
You should understand the symptoms for what they are and should try not to take them personally.
You should not use sarcasm when interacting with a person who may be experiencing psychosis.
You should avoid using patronizing statements when interacting with a person who may be experiencing psychosis.
You should be honest when interacting with the person and should not make them any promises that cannot be kept.
How the first aider should deal with delusions (false beliefs) and hallucinations (perceiving things that are not real)
You should recognize that the delusions and/or hallucinations are very real to the person.
You should not dismiss, minimize, or argue with the person about their delusions and/or hallucinations.
You should not act alarmed, horrified, or embarrassed by the person’s hallucinations or delusions.
You should not laugh at the person’s symptoms of psychosis.
If the person exhibits paranoid behavior, the first aider should not encourage or inflame the person’s paranoia.
How the first aider should deal with communication difficulties
People experiencing symptoms of psychosis are often unable to think clearly. You should respond to disorganized speech by communicating in an uncomplicated and succinct manner and should repeat things if necessary.
After you speak, you should be patient and allow plenty of time for the person to digest the information and respond.
If the person is showing a limited range of feelings, You should be aware that it does not mean that the person is not feeling anything.
You should not assume that the person cannot understand what they are saying, even if the person’s response is limited.
Whether the first aider should encourage the person to seek professional help
You should ask the person if they have felt this way before, and if so, what they have done in the past that has been helpful.
You should try to find out what type of assistance the person believes will help them.
You should try to determine whether the person has a supportive social network and if they do, the first aider should encourage them to utilize these supports.
If the person decides to seek professional help, you should make sure that the person is supported both emotionally and practically in accessing services.
If either the person experiencing psychosis or the first aider lacks confidence in the medical advice they have received, they should seek a second opinion from another medical or mental health professional.
What the first aider should do if the person does not want help
You should recognize that even if the person does realize that they are unwell, their confusion and fear about what is happening to them may lead them to deny that there is anything wrong.
If the person refuses to seek help, the you should encourage them to talk to someone they trust.
You should be aware that the person who is experiencing psychotic symptoms may lack insight that they are unwell.
If the person does lack insight, you should be aware that they might actively resist the first aider’s attempts to encourage them to seek help.
When someone who is experiencing symptoms of psychosis denies that they are unwell, the first aider’s course of action should depend on the type and severity of the person’s symptoms.
You need to understand that unless a person with psychosis meets the criteria for involuntary committal procedures, they cannot be forced into treatment.
You should remain patient, as people experiencing psychosis often need time to develop insight regarding their illness.
You should never threaten the person with the mental health act or hospitalization.
If the person refuses to get help, You should remain friendly and open to the possibility that they may want the first aider’s help in the future.
What the first aider should do in a crisis situation when the person has become acutely unwell
It is very rare that people with even severe psychosis become aggressive. They are much more likely to be a risk to themselves. The exception is if the person is abusing drugs or alcohol, or has a history of violence - in this case the risk that the person will be violent is higher.
In the event of a crisis, when the person experiencing psychosis has become acutely unwell:
You should try to remain as calm as possible.
You should evaluate the situation by assessing the risks involved (eg whether there is any risk that the person will harm themselves or others).
You should assess whether the person is at risk of suicide.
If the person has an advance directive/relapse prevention plan, You should follow the guidelines set out in the plan.
You should try to find out if the person has anyone s/he still trusts (eg close friends, family) and should try to enlist their help.
You should assess whether it is safe for the person to be alone and if not, should ensure that someone stays with the person.
You should communicate in a clear and concise manner and use short, simple sentences.
You should use a moderate, nonthreatening tone of voice.
You should speak quietly at a moderate pace and should answer all the person’s questions calmly.
You should comply with requests that are not endangering or unreasonable. This gives the person the opportunity to feel somewhat in control.
You should be aware that the person might act upon a hallucination or delusion.
You should remember that their primary task is to de-escalate the situation and therefore should not do anything to further agitate the person.
You should try to maintain safety and protect the person, themselves, and others around them from harm.
the first aider should have access to an exit.
the first aider should remain aware that they may not be able to de-escalate the situation, and if this is the case, they should be prepared to call for assistance.
If the person is a danger to themselves or others, the first aider should make sure they are evaluated by a medical or mental health professional immediately.
if the first aider’s concerns about the person are dismissed by the services they contact, they should persevere in trying to seek support for the person.
if crisis staff arrive, the first aider should convey specific, concise observations about the severity of the person’s behavior and symptoms to the crisis staff.
if other people arrive, the first aider should explain to the person experiencing psychosis who the people are, that they are there to help, and how they are going to help.
What the first aider should do if the person becomes aggressive
The first aider should be aware that people with psychosis are not usually aggressive and are at a much higher risk of harming themselves than others.
You need to recognize that certain symptoms of psychosis (eg, visual or auditory hallucinations) can cause people to become aggressive.
You should know how to de-escalate the situation if the person they are trying to help becomes aggressive.
You should not respond in a hostile, disciplinary, or challenging manner to the person who is being aggressive.
You should not threaten the person as this may increase fear or prompt aggressive behavior.
If the person is showing aggression, the first aider should avoid raising their voice and should not talk too fast.
If the person is showing aggression, the first aider should stay calm and avoid nervous behavior (eg, shuffling their feet, fidgeting, making abrupt movements).
You should not try to restrict the person’s movement (eg, if the person wants to pace up and down the room).
If the person becomes aggressive, the first aider should remain aware that the person’s symptoms or fear causing the aggression may be exacerbated by the first aider taking certain steps (eg, involving the police).
You should take any threats or warnings seriously, particularly if the person believes they are being persecuted.
If the first aider is frightened, they should seek outside help immediately as they should never put themselves at risk.
If the person’s aggression escalates out of control at any time, the first aider should remove themselves from the situation and call the crisis team.
When contacting the appropriate service, the first aider should not assume the person is experiencing a psychotic episode but should outline any symptoms and immediate concerns.
If the police are called, the first aider should tell them that the person is experiencing a psychotic episode and that the first aider needs the help of the police to obtain medical treatment and to control the person’s aggressive behavior.
The first aider should let the police know whether or not the person is armed.
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