If someone you love has a mental health condition with psychosis, then you likely already know that communication during psychosis is a particular challenge. Drawing from the research, we’ve put together a guide on how to communicate with someone in psychosis. Mental health conditions that involve psychosis include:
- Schizophrenia.
- Schizoaffective disorder.
- Bipolar with psychotic features.
- Major depressive disorder (MDD) with psychotic features.
What is Psychosis?
Psychosis is a medical condition driven by neurobiological dysregulation in the brain—specifically the frontal lobe—which affects how a person processes reality, manages emotions, and perceives their own illness. This lack of insight is known as anosognosia, a physiological deficit, rather than stubbornness or denial.
Communicating with Someone in Psychosis
To bridge the gap between your reality and theirs, communication must shift from convincing to connecting. By utilizing the following four pillars of de-escalation drawn in part from Dr. Xavier Amador’s LEAP (Listen-Empathize-Agree-Partner) method, you can bring tension down, preserve dignity, and move toward a shared goal of safety and treatment.
Pillar 1: Spatial Presence (The Non-Verbal Foundation)
Before you speak a single word, your physical presence sends a powerful message to a brain that may be struggling with sensory overload and paranoia. The primary goal of this pillar is to reduce threat perception and ensure physical safety.
- The two-arm rule: Maintain a physical distance of at least two arm’s lengths. This respects the individual’s personal space, reduces their sense of being crowded, and provides you with vital reaction time if the situation shifts.
- The angle: Never stand directly face-to-face, as this is often perceived as a confrontational or aggressive stance. Instead, position your body at a slight angle to appear less threatening.
- Open hands: Keep your hands visible and open at all times; avoid clenching your fists, crossing your arms, or concealing your hands, which can trigger suspicion or fear.
- The exit: Always ensure that both you and your loved one have a clear, unobstructed path to an exit. Trapping someone who is experiencing persecutory delusions can lead to a survival-driven physical attack.
Pillar 2: Linguistic Precision (The Mechanics of Speech)
Psychosis often impairs sensory gating, meaning the brain is flooded with unfiltered stimuli. To communicate effectively, you must reduce the cognitive load on your loved one.
- Tactical conciseness: Use short, simple, one-step sentences. Avoid complex, multi-step instructions or compound questions, which can increase confusion and agitation.
- The processing pause: Allow significant time for your loved one to process what you have said before expecting a response. Their brain is working overtime to navigate internal and external inputs.
- Permission-asking: Restore a sense of autonomy to someone who feels powerless by asking for permission before you speak or act. Simple phrases like, “Is it okay if I ask a question?” can immediately lower defensiveness.
- Terminology matching: Adopt the exact words your loved one uses to describe their experience. If they name a voice they hear, use that name rather than clinical terms like “hallucination.” This signals respect and minimizes linguistic barriers.
Pillar 3: Reflective Validation (The Bridge-Building Mindset)
Validation is not the same as agreeing with a delusion; it is about acknowledging the emotional reality of your loved one’s experience.
- Miller’s Law: This cognitive tool requires you to assume that what the person is saying is true in their reality. By imagining what their experience could be true of, you become less judgmental and more authentically curious.
- Emotional validation: Empathize exclusively with the feelings caused by the symptoms—such as the terror of being followed or the frustration of insomnia—rather than the facts of the delusion itself.
- The reflective loop: Use reflective listening to ensure they feel heard. Repeat back what they have said without adding your own opinion or corrections: “I hear you saying… Did I get that right?”
Pillar 4: The Collaborative Pivot (Navigating to a Goal)
The final stage of de-escalation moves the relationship from an adversarial “I’m right, you’re wrong” dynamic into a partnership.
- Ignoring the bait: If your loved one becomes provocative or insulting, recognize that this behavior is often a symptom of the illness. Bypass the bait (the attack) and respond directly to the underlying emotional need: “Of course I want to help you; let’s talk about what’s bothering you,” not, “I did not abandon you. I’ve been here with you all day.”
- Finding shared goals: You do not need to agree on a diagnosis to agree on a goal. Find common ground on outcomes you both want, such as improving sleep, reducing stress, or staying out of the hospital.
- Empowering choices: Offer simple, one-part choices to help them regain a sense of control, such as whether they would like a glass of water or a quiet place to sit.
- Setting respectful limits: Clearly and calmly state what behaviors are unacceptable, emphasizing that limits are in place to ensure everyone’s safety.
How does CooperRiis address psychosis?
We listen. Just like the guide outlines, we listen and validate feelings. Many people experiencing psychosis have been isolated for a long time, and listening can be as impactful as any treatment.
We make sure the person receives the right level of care. Generally, a person in active psychosis will do a brief inpatient stay to stabilize before coming (or returning) to one of our programs.
Many families do come to us in crisis, though, and our admissions clinicians often help move things in the direction of getting help by talking with the loved one who is experiencing psychosis. These conversations have the same focus on dignity and respect as is woven into our clinical programs.
Psychosis is a clinical event, and a person experiencing it is a whole human who deserves agency and opportunities for fulfillment, as we all do.
A Note on Safety
If a situation escalates beyond the reach of verbal de-escalation and poses an imminent threat, do not hesitate to seek professional help. When calling 911 or a crisis team, be specific that you are reporting a psychiatric emergency and describe the behavioral actions you are seeing (e.g., “She is lying in the middle of a busy street”) rather than using vague adjectives like “unstable.” Meet responders outside the home to brief them on your loved one’s history and triggers before they enter.
By leading with empathy and maintaining these four pillars, you can preserve the dignity of your loved one while navigating the complexities of their psychiatric crisis.