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.
- Don’t
fight back, verbally or physically. This will simply make the
situation worse.
- Be
assertive – stand up but don’t fight.
- Try
to gain understanding – seek first to understand….
- Listen
- Try
to get the person to sit down
- Try
to get between the hostile patient and the door
- 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
