As a therapist with a focus on holistic healing, one of the fundamental questions I am often asked is how to help a loved one who is going through a psychotic process without going to a hospital setting. As someone who has worked for a number of years in an inpatient setting I am very familiar with the issues people have with hospital stays. In this article I want to outline some of the tools people can use to assist someone through a crisis without having to go to a hospital.
Psychosis can include profound mania, hearing voices, becoming confused by bizarre thoughts, delusional thinking, odd somatic experiences such as feeling disconnected from the body, sensations of feeling “telepathic”, psychic, becoming extremely talkative, not sleeping for many days, paranoia, or many other types of extreme experience.
There are numerous theories as to why these experiences are taking place. In the medical model, there is an emphasis on the likelihood of an inherent disease due to genetic factors. If this psychosis persists and one can rule out medical factors or adverse reactions to recreational drugs, an individual who experiences these states is often labeled with Bipolar, Schizophrenia or Schizoaffective Disorder. In the medical model, these illnesses are thought to be pervasive for life, though there is the possibility of remission. The medical model includes the idea that life stressors can trigger the disease process.
Those who have problems with the medical theory of “madness” tend to think that psychiatric labels tend to be very poor descriptions of a person and not based in scientific evidence. The idea of labeling someone who experiences a psychotic state with a diagnosis such as schizophrenia or bipolar has gained in popularity over the past 60 years since psychiatrists created a book to differentiate different psychiatric disorders known as the DSM (Diagnostic and Statistic Manual.) The DSM defines disorders as emotional distress that have on some level incapacitating to normal human functioning. They define each disorder with a constellation of symptoms that psychiatrists have agreed meet a threshold of illness.
For example, here is a link to the DSM definition of Schizophrenia. One of the main critiques of the medical model of mental illness is that definitions of mental illness are not based in any objective scientific test. They are simply sets of symptoms that a group of psychiatrists have decided constitute an illness. Unlike diabetes or cancer which has biological markers, schizophrenia does not have any biological markers that can be easily measured for a diagnosis. Doctors simply note symptoms and decide on a diagnosis. These diagnoses are often very fluid and someone can be diagnosed as bipolar by one doctor and as having schizophrenia by another.
Alternative Explanations for Psychosis:
There are other models for explaining “first-break” psychosis. One main alternative model is that stress plus underlying childhood and early adulthood emotional trauma is the main contributor to the present psychotic state. In essence, toxic family of origin issues, poverty, emotional, physical and sexual abuse are main underlying factors for psychosis. There is an increasing body of evidence that links trauma and psychosis.
There is also a fair bit of evidence that nutrition and lifestyle patterns contribute to the potential for extreme states. If someone is susceptible to altered states, a diet high in processed and refined foods, sugar, caffeine, alcohol and drugs can contribute to destabilizing an individual and can lead to a psychotic break. There have been some remarkable studies here and here that show that diets high in vegetables and meat and low in carbohydrates and sugars.
Finally, one of the main reasons people experience psychosis is because they have stopped taking the medications that have quelled their symptoms and the withdrawal effect off these meds is inducing a shock to the nervous system and is iatrogenically creating a psychotic state.
Hospitalization and Antipsychotics
Those who experience psychosis and come to a hospital setting are almost always prescribed antipsychotics. These include the newer “atypical antipsychotics” such as risperdal, zyprexa, abilify, and geodon. They may also be prescribed older “typical” antipsychotics such as haldol. Antipsychotics in general tend to be sedating and tranquilizing. The atypicals were developed and marketed in the 90’s and thought to be far superior to the older typicals because of a smaller side effect profile and less potential for long term health problems. The older antipsychotics were specifically seen as dangerous due to the potential for “Tardive dyskinesia., a form of irreversible muscle twitching that can be quite severe. In the 90’s I worked with a man labeled with schizophrenia who had been prescribed thorazine (an old school typical antipsychotic) for a decade and he had developed incontrollable rocking, shaking and spastic arm movements. This was very sad because he was a painter and he had tremendous difficulty using his brush for his artwork.
Though the newer atypicals have been heralded as a godsend for those experiencing ongoing psychosis, they tend to come with a wide variety of problems as well. On a short term basis they can cause such symptoms as dry eyes and mouth, blurring of vision, strong sedation, hypersomnia, libido loss, as well as extrapyramidal side effects such as akathisia and parkinsonian like tremors and shaking. It is common for people that experience these EPS symptoms to be prescribed an anticholinergic anti-parkinsonian drug such as cogentin as well as the atypical.
On a long term basis, they tend to cause disorders such as obesity, diabetes, high cholesterol and heart disease, though there are some variations in their long term side effect profile. Those with a serious mental illness label such as Bipolar I and Schizophrenia die up to 25 years earlier than normal. Though socio-economic factors certainly play a role, there is a likelihood the long term health effects of the drugs are contributing to this early mortality rate.
Antipsychotics can be incredibly challenging to withdraw from as well. This class of drugs tend to work by blocking dopamine absorption. Dopamine is a neurotransmitter responsible for sending signals between neurons. On a crude level, it has been postulated that too much dopamine might cause some of the psychotic symptoms and therefore a drug that reduces available dopamine could reduce mania and psychosis. The longer a person takes one of these antipsychotics, the more habituated the body becomes to a drug that reduces available dopamine. If a person stops taking one of these drugs cold turkey, the body suddenly becomes flooded by dopamine and is likely to experience florid psychosis. Though some medical professionals will point to the underlying disease as the cause for the reoccurrence of psychosis, it is highly likely that the withdrawal effect off these drugs is playing a large role.
The longer one stays on these drugs, the larger the dose and the larger the prescription (polypharmacy) the harder it is to wean off of them. For many people, it becomes literally impossible as each attempt leads to a psychotic process. There is mounting evidence that taken over long periods of time, these antipsychotics can actually increase the susceptibility to psychosis, as well as cause tremendous health problems. This is a very clear article about the ongoing mounting evidence presented by Robert Whitaker.
In this article, Whitaker points to longitudinal studies done by scientists who examined how people fared when taking long term courses of antipsychotics verseus those who did not. Essentially, for those who took antipsychotics long term, there is a far greater chance of disability, hospitalizations and psychosis long term. This is an article about these longitudinal studies by Harrow and Wunderink. The evidence is clear that people who have discontinued antipsychotics or have never started them have a far better chance of recovery from initial psychosis.
Because of this, there are a number of people in the field who are now presenting an alternative model for managing crisis known as a “selective use model”. In this model, the best plan for initial psychosis is to avoid using the drugs altogether and see if the psychosis naturally dissipates. After that the next best plan is to try a low dose and then to try and taper the person off as quickly as possible. The selective use model is much more “evidence based” when taking into account the long term outcomes of the effect of antipsychotics.
Unfortunately, this is not what mainstream psychiatry believes is the best course and evidence based medicine. In hospitals and outpatient clinics, most still posit that early break psychosis is a sign of a chemical imbalance and a long term illness such as schizophrenia or bipolar disorder that will require a lifetime use of antipsychotics.
On a basic level, it is important to note that the theory that psychiatric drugs correct a chemical imbalance is simply false. To understand why this myth continues, please take a look at this great article by Chris Kresser. Essentially, this idea was presented as a way to establish the medical efficacy of these drugs for mental illness. However, no true scientific research has ever determined the exact nature of a chemical imbalance for mental illnesses, nor have they scientifically proved the idea that psychiatric drugs correct any imbalance.
Because of this it is essential that those who are experiencing a “first-break”, as well as their family members, take a long look at the pros and cons of starting one of these drugs. As tranquilizers, they can often be effective at reducing psychotic symptoms such as mania and hallucinations. For those who are experiencing extremely disturbing voices, sometimes commanding suicide or violence, any relief may seem worth the potential health risks. I believe we need to start seeing these antipsychotic medications for what they are, very potent tranquilizing drugs. They indeed work to quell “extreme state” symptoms such as florid psychotic mania, but long term they come at quite a cost.
This is all to say that due to the information about the long term effect of antipsychotics, making the decision to start these drugs should be very carefully examined. In a hospital setting, someone in the throes of severe psychosis may not understand the ramifications of starting one of these drugs. Often a doctor prescribes this class of medication with little conversation due to the altered state of the patient. There is often little in the way of informed consent about the side effects, long term health effects and problems with withdrawal.
For those labeled with Schizophrenia/Schizoaffective Disorder/Bipolar I in crisis
Complexity arises if a person has already started a course of antipsychotics and/or mood stabilizers and has been on them for an extended period of time and then goes into crisis. Probably the most common reason people with these diagnoses go into crisis is because they have gone off the psychiatric drugs. As I noted before, the body becomes habituated to the artificial changes in neurochemistry and the nervous system can easily go into shock when these drugs are removed, especially if they are stopped quickly or cold turkey. Those prone to extreme states and psychosis can then easily experience a recurrence of these psychotic symptoms that can lead to hospitalization. In this state, probably the smartest thing to do would be to reinstate the psychiatric drugs. Sadly, even though the drugs themselves may be causing quite a few side effects and health problems, a quick and sudden taper can create havoc on an already sensitive nervous system.
In general, if someone has been given a serious mental illness label and is on a number of psychiatric drugs, health complications will likely mount as the years roll by. It also becomes increasingly difficult to wean off the drugs, especially if the dosages are high and they are on
multiple drugs (polypharmacy). Quick tapers and cold turkey easily leads to new symptoms of sever anxiety, panic, insomnia, confusion, disorganization and psychosis. Reinstating the medications can sometimes be helpful for stopping the psychotic process and retiring stability. However, family members and the labeled individual should take great care of how a psychiatrist intervenes at this point. Some doctors will decide that previous prescriptions were unwarranted and will quickly change meds, add meds or change and often augment dosages. Generally, these sudden changes can cause further stress on the nervous system and one should be very careful with making lots of changes without doing a great deal of research on the medication changes.
If a person has been labeled and is on a long term course of antispychotics and mood stabilizers, and health problems mount, the best time to wean off the drugs is in a setting with lots of emotional support and good nutrition. It is deeply important that the person tapers slooooowly as to avoid a relapse in psychotic symptoms. Most doctors do not advocate a slow taper but anecdotal evidence points to slow tapering being a much more effective and safe way of getting off meds if a person has decided to do that. The best guide to coming off meds can be found by look at the guide the “Harm Reduction Guide to Coming off Psychiatric Drugs” (Click here.) Some other resources include Beyondmeds.com, survivingantidepressants.com and benzobuddies.com.
Managing Psychotic States in a holistic manner. Low-Stim, High Support
An individual going through a profound psychotic process can experience a wide variety of experiences including severe disorgnaization in thoughts, confusion, agitation, hearing voices, synesthesia, tactile and visual hallucinations, delusional thoughts, mania and bizarre, distorted and intrusive thoughts. Managing this experience in a non-hospital setting is paramount for many people who do not want to engage in the medical model, are worried about the health effects of psychiatric drugs or feel that a hospital environment is not conducive to long term healing.
As I said above, if the psychosis is related to quickly coming off psych drugs, and is essentially due to the iatrogenic effects of the quick taper of antispyahotics/mood stabilizers, the best course would be to reinstate the drugs and try to taper the medicine much slower. One rule of thumb is to try and lower doses by no more than 10 percent at a time. Skipping doses is not a good plan but instead slow and steady drops every 2-4 weeks has a much greater chance of being successful. At the same time, supporting the person who is tapering is really key. This is a very precarious time and that person needs as much nutritional and emotional support as possible. The best case scenario would be to take at least 6 months off to slowly taper off the drugs in a deeply supportive “low-stim” environment. That means reducing artifical lighting, encouraging an early bed time (9 pm), avoiding negative and violent media, spending time bathing, taking walks in nature and avoiding too much social contact while the nervous system heals. At the same time the best case scenario would include dramatically improving nutrition through eating a whole foods diet, eliminating processed foods, caffeine, alcohol, cigarettes and other drugs.
This is a very tall order for many people who are interested in discontinuing their meds but even a lesser modification of this plan is better than the usual course of simply stopping meds quickly and seeing what happens.
For those in the throes of a psychotic process who have not been taking meds (often younger people who are going through an initial experience of psychosis) the best course of action is what I call the “Low-Stim, High Support” model. In this model, the best case scenario is to create a comfortable home based environment where a person is allowed to act in odd and unusual ways without being judged or critiqued. In this setting the person should again be offered the best and most nutritious nutrient dense diet. Warm, nourishing and grounding soups and stews are really wonderful at this time. Wild fish, lots of greens, sweet potatoes, squashes and vegetables are also really helpful, and more important than any supplements or herbs you can offer. Try and remove “trigger” foods such as colas, processed high carb snacks, candies, etc.
Gentle relaxing teas such as linden, chamomile, lemon balm and holy basil can be really useful if the one going through the extreme state will take them. If the person is taking no meds, stronger herbs such as skullcap, passionflower, valerian and kava can sometimes help the person relax and get some sleep. Sometimes a stronger drug will be helpful, especially if mani and sleeplessness is a component. An over the counter antihistamine like benadryl or a sleep aid like melatonin can sometimes be useful. Another option is to get a doctor’s prescription for a benzodiazapene tranquilizer such as valium or klonopin for very limited use. (Regular use of these drugs can quickly lead to habituation and many more complexities and should be avoided.) Some may choose to get a prescription for an antispychotic such as seroquel. Again, this may be helpful when used intermittently and not on a long term basis.
In general, creating a warm and comfortable, non-judgmental home environment is key to helping someone move through a psychotic state. Sometimes, there is conflict with family members and it can be very helpful to hire someone who will act as a coach and assistant to come to the home environment to interact with the individual who is going through a psychosis. That person can not only provide human contact, non-judgmental reassurance but also can help cook and promote healthy activities (walking, cleaning, eating regularly, avoiding slef-injury, etc.) Generally, I also promote activities that help the person going through this profound experience to gain strength and increase calmness. Gentle yoga, tai chi, nature walks and gardening are all ways to ground strengthen wellness in this state.
If possible, It is also essential to build a support team of therapists, coaches, family members, friends and peers who can spend time with that person and walk through that road with that individual. In these initial states of psychosis- when psychiatric drugs are not involved, the process tends to burn itself out after a natural period of time- sometimes days sometimes months. Being willing to walk that road of being supportive for a person in that state can be deeply challenging, and expensive (if you need to take time off from work). But the expense is much worse if a person ends up repeatedly going back and forth to hospital over many decades. Spending the time to deeply support a person in crisis over a period of weeks and months is as important as helping a person who has been given a diagnosis of cancer.
Supporting a person who is experiencing psychosis in a holistic manner that is non primarily based on psychiatric drugs and the medical model can be challenging. But now more than ever, we need to create better models for helping people in crisis. The evidence is out that the long term use of psychiatric antipsychotics is actually more deleterious to the health and well being of those taking them long term. They are actually increasing the likelihood of disability and alternatives to this course of action are desperately needed. Creating models and paradigms that allow for people to be gently supported through a psychotic episode without medication (or with a selective and “low-dose” model) is key to supporting healthy recovery. The good news is that with time, patience, good nutritional and emotional support and lots of love, healing is not only possible, it is probable.