The public’s guide to dealing with psychosis

I was speaking to a friend recently. She said that she was accosted by someone while walking on the greenbelt. He was delusional and feverishly trying to engage her in a grand scheme. She felt uncomfortable and was unsure of how to deal with him.

A patient of mine works in a bank. She dreads when a particular client comes in because he always demands to speak to her outside, “where the cameras aren’t watching”. She too feels uncomfortable and is unsure how to respond.

One of my medical colleagues was giving a talk at a restaurant which opened onto a sidewalk. A Bergie came in asking for money from those present and then got loud and abusive when rebuffed. Since he was hosting the talk, my colleague felt that he had to deal with it, but had no clue as to how to do this.

Much of our uncertainty when dealing with people who are psychotic is that we don’t know what psychosis is. People who are psychotic are strange and unpredictable, and this makes us uncertain and fearful.

To get a handle on psychosis we must realise that it is not an illness, but a symptom. It can be a symptom of serious mental illnesses such as schizophrenia, bipolar mood disorder, major depression or delusional disorder.It can be a symptom of illegal drug abuse or misuse of steroids, stimulants or benzodiazepines. Physical illnesses such as endocrine disorders or delirium can also present with psychosis.

Psychosis means being out of touch with reality, which can present with hallucinations – your senses picking up information which is not there, such as hearing things, seeing or smelling something which does not exist. It can present with delusions, which are firm, fixed, false beliefs. Often psychosis is accompanied with thought disorder, where the thoughts are disorganised, illogical and all over the place.

The Bergie who argues with unseen tormentors on the street corner might be the poster child for untreated schizophrenia, but the reality is that three percent of us will experience psychosis at some time in our lives (more if we include drug abuse). Psychosis does not make socioeconomic distinctions.

Another reason why dealing with psychotic people is scary is because we fear violence. It is a fear fuelled by the media – violence perpetrated by a mentally ill person gets huge airtime. The reality is that psychotic people are only slightly more likely to commit violence than the general population. Other factors, such as substance abuse, being young and male, and a history of violence, are far more predictive of potential violence than psychosis. Sadly, psychotic people are far more likely to be victims of violence. They are a vulnerable population group.

When accosted by a psychotic person, it is an opportunity to see the world a little differently.

  • Be respectful

Psychotic people might be talking rubbish, but they are very aware of nonverbal cues and tone. Psychosis is interesting in that you can slip in and out of it. It is not an on/off switch. So, if you relate to someone “normally” they will start acting more normal. Psychosis has nothing to do with IQ, so don’t talk to them as if they are idiots.

  • But you can’t talk someone “out” of their delusions

Be honest with where you are at. You can acknowledge their mental state by saying, “I don’t believe someone is watching us, but I can see that you are worried about it”. It is more effective relating on an emotional level than on a content level.

  • Keep Calm

Keep calm, keep your voice quiet. Give more body space than usual and keep your movements predictable. Try and reduce extra distractions (turn off the radio, for example).

  • Keep yourself safe

Move towards help if you are feeling unsafe.

  • Set boundaries

Set boundaries just as you would for any other person: “I have two minutes to listen to you, then I have to go.”; “It is not banking policy to help clients outside the bank.”

It is a tricky question whether to involve the police for someone who is a public nuisance. My (perhaps biased) feeling as a psychiatrist is that police should be called only if someone needs arresting. Most other situations can be dealt with firmness and compassion.

In the case of my colleague in the restaurant, I would have called the manager. Restaurateurs usually know the people around the restaurant and have a way of giving a meal and sending them on their way (I hope that the days of heavy-handed managers are mostly over).

Caregivers of people with serious mental illnesses like schizophrenia will see warning signs of pending psychosis, such as increased withdrawal, a decline in hygiene, a haunted look in their eyes. They usually then access help and recovery can start. In an ideal world, all people with psychosis would be able to get the help they need. Unfortunately, the very nature of the illness makes it hard for these patients to access help from medicine or loved ones. By engaging with them kindly, the world is a little less scary for a few moments.



  1. Last week I met the sweetest girl for what felt like the first time, although she told me we had met before in the same venue. She was with her mom, who did not contradict her, so I believe her. Like me she is bipolar. Unlike me when I was manic and had some delusions of grandeur, she has delusions of infamy. Her mom told us of a recent trip to the beach with her daughter. She believed that all the people in the cars around her knew her and knew terrible and dark things about her.

    She has suffered humiliation as the hands of a state psychiatrist or registrar that I won’t go into but I believe that now she is suffering in a worse way from another one in private practice. I know the type – when presented with a difficult patient, keep them sedated and the problem behaviour will go away. Besides prescribing the most expensive anti-psychotic (even more expensive than Zyprexa) which her mom can’t afford, this girl is so heavily sedated all day that her mental fog only lifts after 5pm, by which time the day is almost over.

    Before her troubles started she used to be a hotel manager, so she is no fool. In fact she was highly responsible and reliable. Now she is basically a zombie all day and not fit for employment. How can the system have failed her so roundly? Bipolar disorder is very amenable to treatment if you have a willing patient, and I’m guessing that if she can get that under control the delusions will diminish of their own accord.

    I’m sorry if this sounds like a rant but it really makes my blood boil when I hear from someone how they are being mistreated by people who should know better. Psychosis as you say is only a symptom, it’s not an evil in and of itself.

  2. Sad but hopeful. They have agreed to see a more caring psychiatrist (and our group has several to recommend, including of course yourself), one who will focus on treating her primary diagnosis and not one who is hell-bent on extinguishing her psychosis at all costs (both in terms of Rands and cents and quality of life.)

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