September 17, 2007

Recommended First Aid for Schizophrenia and Psychosis

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 (see early treatment centers here)

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.


I wish that I had had the information in this site while I was married to a paranoid schizophrenic who had all the symptoms and even went into schizophrenic jargon. Do they continue to believe their hallucinations after they get professional help. Is it true the condition becomes less problematic when they get old.

Posted by: Pat at February 12, 2008 08:28 PM

Pat, I have paranoid type sz. It's my experience that really, It has taken me a long time, but I realize now that many things were not real that I once believed. However, there are subjects I really stick to and try to keep as they are viewed as 'part of who I am'. I hope this helped! :D

Posted by: Kellie at March 13, 2008 08:22 AM

I'm 34 age. I live in Indonesia, Bandung, West Java.
I'm sick from 2000 year until 2004-2005. I'm now working in school as administration. I'm still looking for the meaning of spirit. Can you help me?

Posted by: Dindin Rus'adin at March 18, 2008 03:52 AM

Hello, my name is Linda. I have a 28 year son who has schizophrenia. My son does not live with me, I live in another town and I want to go take care of my son but my husband my sons step day does not want me to. My so has his dad their but I feel the need for helping my son. I feel like a bad mother for not being their with him, please help me to decide what it is I need to do. Thank you have a blessed day. Linda

Posted by: Linda at April 8, 2008 10:57 AM

Go to your son, no matter what. i have the same situation with a 40 year old son, everyone else has pretty much written him off. his father goes to take him shopping and other everyday tasks once a week and that's it. if anything happens between that time, oh well. he has also tried to turn my son against me because i am the only one horrified that he has been left alone in this state for so long. (he was released from a home in 2006 and immediately stopped taking meds. after his father placed him in a small apt. miles from both of us. I stay on his father's case and constantly drive by, go by, whatever i can manage in between the time when i am working to check on him because i know no one else does. His father doesn't want me in the picture because i stay on his case about my son being alone. Him & my other kids have pretty much turned their backs because it is too much trouble, they are ashamed etc. etc. So i have turned my backs on them and don't speak to any of them. you do not turn your back on your family because they become ill or it is inconvenient or whatever other reason you might have. I cannot live with myself and have to check on him even when he doesn't want to see me and hangs the phone up on me, slams the door, tells me to get lost, calls me names etc. he is very ill and psyschotic and that is all i can do beside calling the police and i am afraid they will shoot him. i live with this everyday but i know that i am the only one that goes to check on him except his father once a week sometimes every two weeks for about an hour. in other words he does what he has to do and leaves and goes back to his own life, wife, other family etc. don't forget about your son he doesn't realize that he is ill and needs someone to check on him and keep an eye on him. if not you then who? Don't let other people including a husband live your life for you, they don't care because it is not their blood. if it were, you can bet he would be their to see him. Mary

Posted by: mary at April 26, 2008 09:54 PM

hi. im a male 25 yrs old from india.

from the last yr or so i have been experiencing symptoms of Schizophrenia and IED.

some symptoms as i read in the last page , i have copied here..:

in the early stages, people with schizophrenia may find themselves losing the ability to relax, concentrate or sleep
work or school, as well as personal appearance begins to suffer
the person may start to shut out long time friends
may be one or more episodes where the person talks in ways that may be difficult to understand and/or start having unusual perceptions
once it has appeared, schizophrenia tends to appear in cycles of remission and relapse
people with schizophrenia may experience
delusions — false beliefs that have no basis in reality

ambivalence — the inability to make decisions because of conflicting feelings
lack of motivation, interest or energy
social withdrawal
thought disorders
disorganized thinking resulting in jumping randomly from one unrelated topic to another in conversation
depression and anxiety ...

i seem to have everything except hallucinations...

i dont know wats wrong with me...

i need some help URGENTLY...

if possible (everyone) PLEASE send some advice to me on my email...


Posted by: ahmed at May 8, 2008 01:06 AM

Please, don't be afraid. I will answer any question you might have. My son and daughter are both ZS. He is 18 and she is 20 will turn 21 may 27. I am crushed with pain but have a great hope that God will restore both their minds. Please write back

Posted by: yanira at May 9, 2008 08:10 AM

I have a brother who has paranoid schizophrenia since he turned 20; he is 49 now. It has been a long and painful journey; The length of stabilization of the disease has increased but he still has psychotic episodes which are usually traumatic to all of us. At present, he is in a hospital by court order for his latest episode where he hit a police officer; He has been in numerous hospitals, programs, and has had success and heartbreak depending on the medication he was on and whether he was taking it. He looks much older than 49 and is currently on Haldol which seems to help him for awhile anyway. Sometimes he is ok and it is beautiful to see him again; to see him smile and laugh and be happy. But relapses are part of the illness and I try to give any extra cash I have to org.s that do research. I am lucky I have a wonderful brother who advocates for his sick brother as the rest of the family is so burnt out on it. It can literally consume you. So, we found he was best being cared for in an adult home with supervision and with people like himself. We still love and support him but he doesn't live with any of us for the last 25 years or so. None of us were successful taking him in. Medicine and a program are key and visit them. Be an advocate for them. Read about the medications; talk to them; let em know you are there for them. Donate if you can and just don't let the illness cripple you. You must keep distance or detach emotionally sometimes to get things done. It is a very sad illness and easy to get depressed about being there is no cure. I just keep handing it up to God, donating when I can and just being really nice to him whenever I see him. I can say in the early days, it was necessary to get the cops involved at times to get him hospitalized. Sometimes, like presently, he gets them involved all by himself..:-) A good relationship with a doctor can help. I think it takes two phsychiatrists to come to the house and declare him a danger to himself or others and then they can involuntarily get him to a hospital. It's traumatic to go through it, but necessary when they are psychotic to a point of not taking their meds, not taking care of themselves, not in reality, etc. Just keep the faith, try a support group (NAMI is good) and read all you can on it. If it's affecting you emotionally and devestating your own life, please seek support for yourself. And of course, I always pray. I am more optomistic and less sad about it than I was 20 years ago. Maybe cause you feel the worst is in the past. It is also so cool to see all of these sites dedicated to the disease. We knew nothing about it way back when; it's been a long struggle but there are still tons of good memories in that time. I concentrate on those times and just hang in there and never give up. Love and hugs to all of you.

Posted by: Kay at May 9, 2008 06:53 PM

Schizophrenia is just like any other disease when our system fails to keep upto the factors of environment. The only difference is ppl dont believe in patients of schizophrenia and ppl feel that they are doing some sort of drama and there is nothing wrong with them. Eventually when they get violent, they are thrown in some lunatic hospital where the relatives are given huge bills and the patients are treated like pigs. What a schizophrenic patient requires is lots of milk, lots of physical exercise and keeping himself busy and taking the medicines prescribed by pschiatrist and not caring what the ppl do and say. The hallucinations and other related symptons can come for even those ppl who are not schizophrenic if they dont sleep for extended period. The patient should try to get proper sleep and should tire himself everyday and then see how a schizophrenic patient will be better able to cope with his illness. I was diagnosed as schizophrenic and lost many years and was in and out of hospitals and trashed by my own ppl who believed that i am lazy and dont want to work. I was expected to work as a clerk who can just do repetitive work and here i am teaching their sons and daughters a subject which is not easy to understand. I teach mathematics to higher classes and earn a decent living and now dont giv a damn about the ppl who used to laugh at me. I dont tell any new person i meet about my illness and the ppl who know still feel that i am mad and avoid me. In a way it is a boon to me. After one stabilizes from the disease and is able to manage the day to day affairs, it is always better to change the place of residence because ppl will talk and what is the use and need to stay in the same locality. A change is always better in these cases and I may be wrong but, i have seen that people who are schizophrenic do lots of things which an ordinary person cant do. But its a disease and i hope a cure comes eventually for it.

Posted by: Deepa at June 1, 2008 07:27 PM

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