For Families, Allies, and Young Adults

Tips for Communication and Family Living

Understand the Symptoms

Since most of the symptoms of psychosis have to do with perception and information processing, they are usually observed by others as behavior. One reason why it is important for friends and family members to become more educated about the symptoms of psychosis is that without this education, they are likely to misinterpret the behavior they see. For example, a parent may notice their child getting more and more angry, but not understand why. Below are a couple of typical examples:

  • "My son kept getting angrier and angrier at me. Sometimes he'd yell at me and tell me to leave him alone. What I didn't learn until later was that he was experiencing "thought insertion"- He believed I was putting thoughts in his head. No wonder he acted so defensive! I thought he was just upset that I was telling him to get a job."
  • "My daughter just wouldn't leave her room. We tried to get her to join the family, but she'd only stay for fifteen minutes, then would run from the room and wouldn't come out for hours. We thought she was upset at us for some reason. Later we found out that the stimulation of having a group of people was just too much for her, plus she was hearing voices telling her we were trying to hurt her."

Since psychosis directly affects a person's ability to perceive, interpret and communicate information, family members have to learn new communication skills.

A few key tips in communicating with a person who has psychosis:

  • Psychosis generally makes people much more sensitive to emotional tones and stimulation. It will help to keep the environment as low-key as possible, and to speak to the person with a kind, matter-of-fact voice.
  • Use short sentences. don't try to go into long explanations.
  • Be concrete and specific. Avoid abstractions and generalities.
  • Be careful about word choice to avoid communicating negative judgment.
  • Provide consistent, sincere praise and positive feedback.
  • After you speak, give the person plenty of time to digest the information and respond.
  • If there is something particularly important you are trying to communicate, use simple words and repeat the same language rather than using different language.
  • don't argue with people about delusional beliefs. Remember that their perception of reality is just that to them: reality. Directly confronting delusions usually causes people to become defensive and less prepared to consider alternatives.
  • don't "go along with" or agree to delusions, either. Learn reflective listening techniques. Agree to disagree. Approach delusions in a spirit of shared inquiry. don't push if the person starts to get upset.

Reflective Listening

No matter how hard it is to understand what a person is saying, there is ALWAYS a grain of truth. When a person is experiencing psychosis, their communication gets mixed up, but through reflective listening you can find a common ground.

The steps in reflective listening with a person who has a psychosis:

  • Listen to what they're saying. Look for elements of reality. Ask yourself what they are feeling, or how you would feel in the situation.
  • Ask clarifying questions only. Comment about the feeling, without stating any judgments about the content.
  • Give the person time to respond.
  • Comment about feeling again, and maybe gently begin to reframe/create a shared context.
  • Give the person time to respond.
  • Begin to identify "common ground"- reality you can agree on, or a way of addressing the feelings the person is having.

Here are a couple of examples:

Example 1

Person with psychosis: "God told me he doesn't want me to take my medicine."

Family member: "How did God tell you that?"

Person with psychosis: "God created the world in seven days, and on the seventh day He rested, and I can't rest on this medicine".

Family member: "Wow, resting is so important. You must be totally exhausted if you can't rest."

Person with psychosis: "Yeah, they put me on this really high dose."

Family member: "How about if we talk to the doctor about doing something to help you rest."

Person with psychosis: "Can you talk to him for me?"

Example 2

Person with psychosis: "Everybody in town is after me."

Family member: "That sounds terrifying to think everybody's after you."

Person with psychosis: "It IS terrifying."

Family member: "No wonder you're so upset. What led you to feel that everybody's after you?"

Person with psychosis: "There are all these cars outside."

Family member: "Hmm, that's interesting (going to look at the cars). Gee, there's a shopping center across the street. Do you think that might be part of why there are so many cars?"

Person with psychosis: "Well, maybe... but I still think people are after me."

Family member: "It sounds like you're feeling really scared. What can we do to help you feel safe?"

Learning to solve problems in a straight-forward, systematic way is very helpful:

  • don't put all your energy into problems. Give yourself a time and place for problem solving, and a time and place for enjoying life.
  • When selecting where to focus, always prioritize safety and well-being.
  • Focus on only one problem at a time. If multiple people are involved, try to create a shared understanding what the problem you are addressing.
  • Articulate the problem in terms of the person or people who identified the problem, and no one else (for example, if you are upset that your relative won't leave his room, don't define the problem as "John won't leave his room", but in terms of what you can do. Why is a problem to you? Are you afraid he's not safe? Perhaps the problem would be, "How can I feel reassured that John is safe?" Is it that you want him to pay his way? Then the problem might be, "How can I get out of the role of paying all of John's expenses?" Or perhaps you think he needs to move out- Then it might be, "What can I do to encourage John to move to another place?" The key in defining the problem is to define the problem in terms of your own feelings or choices, and never in terms of what someone else is doing or chooses.
  • It is helpful to do this process in a group. Multi-family groups are especially helpful, because they include both you and your loved one and can facilitate identifying a shared problem. NAMI Family-to-Family support groups also use a similar structure. By bringing a group into the process, you get a variety of ideas and resources you might not have considered.
  • Identify the problem in as behavioral, specific and concrete way as possible. Try to narrow it down: why is this a problem, when is it a problem, is there an aspect of the problem which is more important than others.
  • Brainstorm possible alternatives. At this stage, there is no right or wrong answer. Write down all ideas, including wild or impossible alternatives. These may help generate creative ideas.
  • Think about similar situations in the past and what worked then.
  • Choose which alternative you think is most likely to work and is most feasible for you.
  • Make a specific plan for how you will implement the alternative (who, what, where and when).
  • Identify 2-3 additional alternatives and work them through, either to do concurrently or as a back-up plan.

Setting boundaries and establishing rules:

No matter how ill a person is, they still are able to control their behavior to a certain degree. It is important to maintain certain limits and to encourage responsibility to the degree the person is able.

EASA recommends the use of the Family Guidelines. These guidelines, developed by Carol Anderson and built upon by Dr. William McFarlane at the University of Maine, are based on the experience of families and what is necessary to maintain stability.

A few good rules can help create a more livable situation and increases the person's level of independence.

It is helpful to have a family agreement which everyone knows about, and, hopefully, has agreed to.

Some tips in developing a family agreement:

  • There is a baseline of behavior with no exceptions (example: no threats of violence, no weapons in the house).
  • Supportive does not mean permissive.
  • Before a family meeting, make sure heads of household agree on baseline behavior and priority issues to address.
  • Choose no more than one to two key issues to address at a time. Before selecting the issue, assess your family member's ability to address it. For example, if you want the person to begin paying rent, they may or may not be in a place where they are able to work. It is important to provide alternatives.
  • Accept that your family member will not like the agreements.
  • A draft copy should be given to all willing to participate, with all parties giving feedback and ultimately agreeing to follow it.
  • Everyone's needs should be addressed.