There is still a widespread myth that people with mental illnesses are dangerous, and psychosis especially so. The chap talking to himself at the bus stop freaks people out. What we fear is the different, the unknown, the irrationality that makes people confusing and difficult to predict. Having a mental illness myself does not make me immune to this. The first time that someone came to the voice hearer group I attend, Sound Minds, who was actively psychotic and clearly perceiving things we were not, (apart from the voices, obviously) I was spooked. I felt stressed and anxious and really unsure of how to interact with them. Fortunately, there were other people present much more experienced than I was, and I was able to learn from their excellent responses. I’ve since read a lot more and met a lot more people who experience all kinds of mental illnesses. Many of my good friends are dealing with psychosis and the whole area is a lot more familiar to me now.
The most useful thing I ever read about psychosis was about a shrink who had a miraculously calming effect on psychotic inpatients. He so was renowned for this in the hospital that the staff used to call him in for the most florid, hysterical, extreme examples of psychotic distress, only to marvel as the patients inevitably settled down and within a few minutes were conversing lucidly. His secret? He spoke to them kindly, respectfully, and as if they made sense. That was it.
It can be challenging to put ourselves in the shoes of someone who is psychotic, that is, experiencing hallucinations and/or delusions. One of the things it is difficult to appreciate is what it feels like to be perceiving things other people are not, and to be gripped by certainty about ideas and beliefs other people do not share. Attempting to communicate with other people is a terrifying, frustrating, shocking confrontation with their refusal to accept your reality. You are desperate to convince people of what they refuse to believe, and profoundly afraid that you are insane. Caught between terror and denial, you are incoherent, and people respond to you with fear, are dismissive of your perceptions, and treat you as if you are not worth engaging with. You spiral into a dark place where you are alone with your nightmares.
Having someone respond to you as if you are normal and still perfectly comprehensible reaches through that darkness. You may be caught up in an inner reality that no one else can see, but you are still human. The fear settles, and the imperative to convince other people of your beliefs is reduced when they don’t argue with you. This doesn’t stop you being psychotic, but it does mean that you can connect and engage and become more settled and lucid.
So, when I come across someone experiencing psychosis, I am not afraid of them. When they talk to people I can’t see, I ask them about them without fear or judgement. I try to have interest and compassion guide my responses. If they share about delusions that are frightening them, I am sympathetic to how distressing the situation is. I never lie about my own perceptions, if they trust me to help to reality check I certainly explain that I do not see or hear or believe what they do, but I do it pretty gently because working out that you are alone in your perceptions is pretty confronting. I simply treat them as if they are a normal person who happens to be experiencing things I am not. Most of the time this leads to increasingly coherent conversations.
The statistics clearly indicate that people with mental illnesses are no more likely to be violent than the general population. In fact, people with mental illnesses are more likely to be the victims of violence. Having a mental illness can make you more vulnerable to harm. The only indicator that has ever been shown to be reliable in predicting the likelihood of violence is previous violent behaviour. One of the most effective treatments for psychosis is the development of a close, supportive relationship with someone (therapist, partner, friend) whom the person trusts and regains the skills to reality check psychotic experiences with. That is, the two together work out what is dream and what is reality. One of the best descriptions of psychosis I have come across was by actor Alan Alda about his mother who had schizophrenia, that she was “dreaming while awake”. I’m not saying that is the science behind the experiences, but as a metaphor it works beautifully. The experiences of psychosis are often a tangle of deeply personally meaningful fears and desires mixed with the kind of random bizzareness that we are familiar with in our dreams and nightmares. There is both meaning and irrationality. Treating all the experiences as meaningful can be exhausting, confusing, and lead to delusions. Treating none of it as meaningful – which is generally the approach of mental health services that favour biological explanations, strips people of the ability to interact with the content in a useful way. Because they are dreams, they are written in the language of symbol and metaphor. People craving significance may have delusions that they are angels, come to save humanity in the end of times. A good therapist or friend will support the person to work their way through the ideas, cope with the painful crash back to earth, and find ways to meet that need for significance.
So what about the stories we hear on the news, where someone with psychosis has murdered or harmed another person? This does happen – at the same rates as all the people without mental illness murder and harm, but it certainly does happen and the incidents stick in our minds. What happened? Many things may have happened. There are some truly horrible people out there who also happen to have psychosis. Having a disability or mental illness doesn’t only happen to good people. The psychosis may have been completely irrelevant. They may not have even been psychotic at the time. In other cases, people can do terrible things when they become deeply lost in delusions. A parent who becomes deluded that their child is trying to harm them may become intensely preoccupied and distressed, and if no one intervenes, the outcome could be tragic. These cases are so deeply distressing because there is such terrible pain in having a good and caring person become so confused that they have harmed people they love.
This is very rare! Most people who experience psychosis are in no way dangerous or a risk to anyone. They are not struggling with the kind of delusions that are likely to lead to such tragic outcomes. There is also a range of degree in psychosis – in milder forms people may be having hallucinations but are able to reality check – they are completely aware that what they are seeing/hearing/feeling/smelling etc is not ‘real’. Even in more severe psychosis, most delusions are benign in that they are not of a kind to induce a violent response. Most psychotic people are either really scared and believe they are going to be hurt – they want to run, escape, or hide; or they are caught up in a complex grandiosity where they are Buddha, or Jesus, or a secret government agent, or an angel with a message of wonder for all people. These kinds of beliefs may certainly be strange to the rest of us, and interfere with daily life quite severely because when you believe you are the savour of the universe you are much too busy to worry about eating, sleeping, showering, or getting the kids to school, but they are not in any way likely to inspire violence. In fact, we have at times had a really good giggle in Sound Minds about how silly these kinds of beliefs seem when you’re no longer gripped by them.
One of my best friends experiences at times severe psychosis, and he is, even when psychotic, one of the kindest, most generous, peaceful, gentle people I have ever met. The fear and stigma that he faces breaks my heart. What has helped him work through his experiences (among many things) is having friends who accept him for who he is, who understand that at times he is caught up in his internal world, his internal reality, and who support him to work out where the internal and the external realities meet. Social support is one of the most crucial factors in the recovery and management of experiences like psychosis. When we are afraid and shun people with these experiences, we are the ones who set the stage for the possibility that some of them will become completely lost, walking labyrinths in their mind with no string to guide them home. The best way to reduce the risk of violence has always been to love. If you know someone who struggles with psychosis, don’t be afraid. Be loving, trustworthy, compassionate, and wise. You are at no greater risk of being harmed by a strange neighbour who rants at people you can’t see and wanders about barefoot in the small hours of the night than you are from your perfectly normal seeming neighbour on the other side. If you remember that and you behave that way, you are part of the work to reduce the stigma and help people with these experiences to still feel part of the human race. That can only ever be a good thing. If you’re serious about reducing the risk of violence, you will work to strengthen community and include people who experience psychosis.
A final point. Psychotic and psychopathic are frustratingly similar sounding words, and many members of the public use them interchangeably. They are descriptions of utterly different traits. Someone who is psychotic may be hallucinating, struggling with disordered thoughts (that is, all jumbled up and confused), or delusions (being convinced of things that are not logical to the rest of us). Psychopathy is not a mental illness. It is a description of a set of traits and behaviours. Psychopaths lack fear, empathy, and guilt, and therefore behave in ways that are manipulative, abusive and exploitative. To be perfectly fair, most psychopaths are not violent either, because most are capable of blending in and achieving their goals without the risk of the repercussions of violence. Despite the similar sounding names, the two conditions have absolutely nothing to do with each other.