How is treatment obtained?

There are a number of methods which individuals and their families can use to obtain treatment. The methods people use often differ depending on how troubling and disruptive symptoms are, and how familiar the person might be with the signs of a developing psychosis. In the prodromal (or early) phase, when behavioral changes are starting to appear, individuals and their families usually feel that 'something isn't right' but they may not know what the problem is. This is particularly true if an individual hasn't experienced a psychotic illness before. Other individuals and their families might recognize the early warning signs as those of a developing psychosis. During an acute phase, families usually know that there is a problem, but may be unsure of where to seek assistance. The following people will be helpful for the individual and/or their family to talk to:

A school psychologist or counselor.

Because the first episode of a psychosis usually occurs during young adulthood, many people will have psychologists or counselors at their school that they can talk to. These professionals can help to make a decision if specialist assistance is required, and can help make referrals to appropriate professionals.

The local or family doctor.

The local doctor will also be helpful to talk to. If the doctor believes that the individual is experiencing early warning signs or more obvious symptoms of a psychosis, they can assist by making a referral to a mental health professional (usually a psychiatrist).

The local mental health clinic, community hospital or mental health/psychiatric emergency teams.

These are also valuable resources if the individual, or the family, feels that 'something isn't right' but isn't sure what the problem is. They may also notice signs that they know from past experience, indicate that a psychosis is developing or is being experienced. Phone numbers for these clinics are available in the phone book and through telephone help-lines.

Mental health professionals such as psychiatrists or clinical psychologists.

If the individual is already seeing a mental health professional, then these individuals will be in a good position to assess if any troubling symptoms or changes in the person's behavior are signs of a developing psychosis or not. They will also know where to direct the person and their family for further assistance.

Telephone help lines.

The local telephone directory will have some telephone numbers for local telephone help lines that specialize in mental health or welfare issues. These help lines can be very useful in directing individuals and their families to appropriate services.

Sometimes it can take several contacts with the above professionals before a referral is made. Individuals and their families need to be patient and persistent. It is advisable to keep a diary of troubling behavior, and to write down the troubling behaviors in a clear and objective way. For example, the diary might contain the following information about the sufferer.

• What is the 'typical' day like, and is this different from usual?
• When did behavior begin to change?
• What is the state of such things as sleeping, eating and self-care?
• Are unusual things being said or done? If so, what?
• How is the sufferer managing their social, financial and work/study responsibilities?

A diary will help inform the health professional about important information relating to the development of the illness, and it will also help to determine what the next step, if any, might be.

What are the goals of treatment?

The goals of treatment during an acute psychotic episode are usually:

• to ensure the safety of the individual and others, and to decrease the risk to the individual and to those around them;
• to decrease psychotic symptoms such as hallucinations, delusions and thinking problems as a matter of urgency;
• to use appropriate medications and to minimize their side-effects;
• to engage the family as well as the patient in treatment, education and support; and
• to develop a management plan to promote recovery from the acute episode.

As the individual begins to recover, treatment goals also include:

• continuing to keep the individual, and those around, safe;
• reducing the occurrence of problems that can go hand-in-hand with a psychosis, such as depression or anxiety, or alcohol and other drug use;
• preventing relapse;
• enhancing the individual and his/her family's quality of life; and
• returning the individual to usual life including daily routines (rehabilitation).

Why is early intervention important?

Whether this is a first episode of a psychosis or not, or whether a person has experienced a psychosis before or not, it is imperative to seek assistance as soon as the person or the person's family notices the 'early warning signs'. The individual, the family and close friends can all play a part in becoming aware of these personal 'early warning signs' and encouraging the sufferer to seek treatment when they appear. Adopting a 'wait and see' approach is never a good idea, as a psychosis illness always requires treatment, and the earlier that treatment is obtained the better. Some of the reasons why early intervention is important are:

The earlier treatment is obtained the better the outcome will be for the individual with the illness.

If psychotic symptoms are left untreated, sufferers can start to feel very bad about themselves, and very worried about their future. This can result in lowered self-esteem and a loss of confidence.

The experience of psychotic symptoms greatly increases the likelihood of becoming depressed and anxious - sometimes severely so. Strange and distressing symptoms can lead a feeling of terror or great agitation, with added hopelessness, sadness, worry and pessimism. Signs of depression always need to be taken seriously because of the great suffering they induce in the patient and the ever-present danger of self-harm. People are at particular risk if they hear voices that command them to hurt themselves.

Experiencing psychotic symptoms puts one at greater risk of abusing alcohol and/or other drugs. Sometimes people use these substances to try to feel better, or in an attempt to block distressing symptoms.

Psychotic episodes can put great strain on family relationships and friendships. The earlier help is sought and the psychotic symptoms brought under control, the less disruption that will occur to important relationships.

Psychotic symptoms have a negative impact on the ability to function well at work or study. This puts people at risk of losing a job or of performing badly in studies.

Often the first episode of a psychosis occurs during young adulthood when the victim is just discovering where they belong in the world, with important social relationships in the process of being formed. An untreated psychosis will interfere greatly with these important tasks of young adulthood.

Similarly, if left untreated, symptoms of a psychosis will interfere with the process of developing parenting skills.

People are easier to manage in their usual environments. Failure to seek intervention at an early stage can lead to unnecessary hospitalization because symptoms become more severe and difficult as time progresses and this can happen quite quickly over a period of a day or so

What are some of the barriers to early intervention?

Clearly it is important to receive treatment as early as possible if a psychotic episode is developing. Unfortunately a number of factors arise that can interfere with getting urgent and appropriate help. It is important to be aware of some of these potential barriers to early intervention. Recognizing them is the first step to overcoming them and getting necessary help. Some barriers to early intervention are:

People are often worried about the stigma which may attach to seeing a mental health professional or about what it means to be experiencing psychosis. Fears of 'madness' abound. These notions frequently lead to severe delays in getting help.

People worry that a history of suffering from a psychosis, consulting a psychiatrist or being hospitalized for treatment of a psychotic illness will interfere with their jobs or with their studies or otherwise lead to their personal disgrace. In fact the earlier treatment is obtained the less will be the disruption that will occur in these aspects of life.

Family members, co-workers and friends of the person suffering from a psychotic illness may not understand the changes that are taking place in their loved one's behavior, and may believe that they are 'just going through a phase,' and that the symptoms will go away by themselves.

Frequently families are reluctant to seek help on their loved one's behalf because they feel that this is a betrayal of their confidence, or means they are being disloyal, or that they are doing things that will be hurtful to their loved one's feelings. These reactions are common and are well-intentioned, but they are contrary to the best interests of the ill family member. There is no doubt whatsoever, given the potentially serious consequences of untreated psychotic illness, that securing early and effective professional care is the single most important thing that a family can do to ensure the recovery and future wellbeing of the person they love.

Often the symptoms experienced by the individual make it unlikely that they will seek assistance for themselves. Some symptoms that present very real barriers in this connection include:

• feeling suspicious or afraid that others, including family, friends and health professionals, are 'out to get' them (paranoid conditions);
• lack of insight or awareness that anything is wrong(most psychotic conditions);
• lack of motivation and energy (especially in depressive psychoses);
• difficulties with concentration and remembering to do things;
• difficulty in thinking clearly and reasonably; and
• in some psychotic states feeling that one is perfectly and abundantly well and more intelligent than anyone else (mania or hypomania).

When these symptoms are present, families and loved ones have a particularly important role to play in assisting/supporting/persuading the individual to seek treatment as the patient is more likely to listen to family members than to strangers.

What are the treatment approaches?

The exact treatment that an individual will receive differs from person to person, and also differs according to the phase of the psychosis that is being experienced. In general, treatment will usually include the following steps.

1. Assessment.

The first step in any treatment plan must be accurate assessment and to accomplish this the patient will have a series of interviews with a mental health professional such as a psychiatrist, clinical psychologist or mental health nurse. The specialist will need to spend some time getting to know the person and his/her circumstances. A vital part of such assessment, especially so when the illness is a psychotic one, is for the professional to talk to talk to key family members at the earliest possible stage. This ensures they get as much accurate information as possible about what has been occurring and what symptoms have emerged and when. Often blood tests and x-rays will be ordered to rule out the possibility that the psychosis has occurred because of a physical illness.

The information that is obtained from the assessment usually leads to the development of a list of possible diagnoses as to the nature of the psychosis, what might have caused it, and how best to help the person experiencing the illness.

2. Medication

Medication is a fundamental part of the treatment of psychotic illness. The medications used to treat psychosis are called anti-psychotics because they help control the symptoms of psychoses such as hallucinations, delusions and thinking problems. There are a number of antipsychotic medications available and the amount and type of these taken varies from illness to illness and from person to person. The treating doctor will provide the patient and the family with information about how much and when to take the medication. The doctor may very well try several different medications or combinations of medications before the one most suitable for the individual is found. Injections may be used instead of tablets.

The anti-psychotics that have been in use the longest are called 'typical' anti-psychotics. Although they are very effective, they can cause troubling side effects, including problems with movement and posture. Some of these anti-psychotics include:

• Haloperidol;
• Thioridazine;
• Trifluoperazine; or
• Chlorpromazine.

It is becoming more common for doctors to prescribe newer, so called 'atypical' anti-psychotics, because they tend to have fewer side effects. These medications are called 'atypical' because they work in a different way from conventional anti-psychotics and are less likely to cause distressing side effects affecting movement. Some of the newer, atypical anti-psychotics available in Australia include:

• Risperidone;
• Quetiapine;
• Olanzapine; or
• Clozapine.

Regardless of which medication or combination of medications is decided on its use will be monitored and, if any side effects develop, the doctor may make changes to the amount or type of medication being taken. It is most important that the individual and his/her family report any side effects, real or imagined, to the doctor so that steps can be taken to eliminate or reduce these. It is common for people to stop taking their medication because of unpleasant side effects. Good communication with the doctor about side effects is vital to ensure that people don't stop taking the medication prematurely, or through stopping too abruptly, cause themselves further unnecessary and unpleasant withdrawal or discontinuation effects.

3. Psychological therapy or counseling.

While the individual is experiencing acute psychotic symptoms, therapy will normally involve simply trying to help the person to understand what is happening, and letting him/her know that there is somebody available to talk with who understands what he/she is experiencing. At this time the major therapeutic effort may well be with the closer family members. Supporting families and educating them about the illness, helping them understand its causes and the things that help it or don't help it, instructing them about medication, and explaining to them what to expect and what their role may be as caregivers, is an absolutely vital part of psychological therapy. Such family therapy, with or without the ill person, should start at the earliest point in time and should not wait for the sick person to have recovered.

With the unwell individual, when acute symptoms have subsided, therapy will often involve the following:

• dealing with the fear and stigma often associated with the experience of a psychosis;
• helping with feelings of depression or anxiety that usually arise;
• assisting with the identification of potential triggers for the illness, and identifying its early warning signs;
• making an 'action plan' that covers how future help can be obtained and who should be asked for help if early warning signs are experienced or observed;
• helping individuals to decide who to tell about their abnormal experiences and what precisely to tell them;
• assisting with the day-to-day management of specific symptoms; and
• teaching stress management and relaxation techniques.

4. Education

It is very important to educate the individual and the family about psychotic illness and about the treatment available for psychosis. This is essential for them to begin to make sense of what has happened, to take steps to prevent relapse, and to promote a return to normal routines. Mental health professionals will provide individuals and their families with information such as:

• what a psychosis is;
• what causes a psychosis;
• what is known of future outcomes and what determines these;
• the effects of non-prescribed drug use on psychotic illness;
• how a specified psychosis is treated;
• how relapse can be prevented; and
• how to work towards recovery.

The need for close ongoing care, with good communication, will be emphasized, and so to will be the vital importance of continuing to take medication, even after the symptoms have improved. This educational process will also include discussions on what individuals and families can expect, how individuals can help themselves, and how family members can help.

5. Day programs

Often treatment will also require the individual to participate in day programs. Day programs are small group programs that run for a number of days per week, for several weeks, usually under the guidance of an occupational or other therapist. Day programs are selected to meet the individual's particular set of needs and are very useful for assisting the return to normal daily routines, as well as providing activities that are fun and relaxing. For instance some day programs involve physical activities to 'get fit'; others involve creative activities such as painting, drawing or pottery; and other programs involve more work-related activities, such as using computers. Some day programs aim to help the individual get back to work or to study.

6. Practical assistance

Another aspect of treatment involves helping with practical things such as sorting out finances, claiming social security benefits, dealing with legal matters, or finding accommodation.

Where can treatment take place?

Most people who are experiencing a psychosis can be supported at home by their family or friends as long as they receive regular support and are in close and regular contact with mental health professionals. Sometimes it may be necessary for the person to receive treatment in hospital. Usually hospital treatment is reserved for situations where the psychotic symptoms that a person is experiencing puts them at risk of hurting himself/herself or other people as occurs when, for example, the sufferer is seriously considering suicide, or has tried to harm themselves. In these situations, hospitalization helps ensure that the person is properly assessed and treated so that they remain safe. However, hospitalization may also be essential in the early assessment and treatment of a psychotic state when no caring or close or functional family is available (For details about the professional treatment team involved in treatment refer to the brochures Treatment team or Inpatient admission.)

For local treatment, you may need to look for an appropriate service. If you live in Perth, WA, you be able to access treament at Sentiens and partake in our day program and avoid an inpatient admission.

What is an involuntary admission?

(For additional details about the involuntary patients refer to brochure Inpatient admission)

In some cases, admission to hospital may need to occur against the person's will or without them having given consent, at least for a short time. When a person is admitted to hospital against his/her will or without him/her having given consent, this is called involuntary admission. In these cases, treatment is resumed at home as soon as possible.

What is a crisis?

During an acute psychotic episode, when symptoms are at their most obvious, individuals and families can find themselves in severe crisis or emergency situations in which help is needed straight away. Remember that during an acute psychotic episode, individuals will often not recognize that they need assistance, and families will need to seek assistance on their loved one's behalf even against their will. Sometimes families are not sure if a situation is a crisis or an emergency. In these circumstances it is wise for the family to trust their feelings - if they are feeling overwhelmed, afraid, and unable to manage the person's behaviour, then prompt action should be taken. Some crisis situations are noted below.

The individual talks about or is trying to hurt or kill themselves, or hears voices directing them to hurt themselves. All threats or gestures of this type need to be taken very seriously, and help needs to be sought straight away.

The individual threatens or seems likely to harm others. If the person is behaving in a threatening or aggressive manner towards another person, or if the individual is hearing voices directing them to hurt somebody else, then this must be taken very seriously indeed and help needs to be obtained straight away. Sometimes people who are experiencing delusions believe that another person is trying to harm, poison or kill them or someone they love, and they may take violent action against someone to prevent this happening. However, it is important to remember that in general, people who are experiencing a psychosis are not necessarily more dangerous or violent than anyone else. Much depends on the type of disturbed thinking they are experiencing. Sometimes this can be concealed from the treating professional and it is vital that families, in such a situation, communicate their fears.

The individual may become verbally aggressive, abusive, and becomes angry easily.

The individual experiences very obvious symptoms of a psychotic state including hallucinations and delusions.

The individual behaves recklessly, such as walking alone at night, or engaging in dangerous or inappropriate sexual behaviour.

The individual has stopped eating or drinking.

Whom do I contact in a crisis?

In a crises or emergency situations such as those outlined above there are several agencies that can be contacted.

The emergency department of the local hospital.

Families should try to gain the sick person's cooperation to accompany them to the local hospital. However, if the sufferer is feeling suspicious or paranoid they may not agree. In such a case it is best for families not to try to coerce the person. Coercion can make the individual feel even more unsafe and suspicious. Persuasion, done gently and skilfully, is the approach that needs to be used.

Police.

It may be necessary to call the police when there is a risk that the individual will cause harm to self or somebody else. When this is judged to be the case no time should be wasted. In situations like this, the police will normally assist by escorting the person to hospital to be assessed by a specialist. The individual will then be able to get the help that is needed.

Emergency psychiatric teams.

The local telephone directory will list the number of local emergency psychiatric teams who can respond in a crisis. Like the police, this team will usually assist by escorting the individual to hospital where specialist assessment and treatment are available.

Ambulance.

Actual self-harm and attempted suicides are extreme emergencies. Call an ambulance immediately and ask for directions about what can be done while waiting for it to arrive.

Understandably, crisis situations can be extremely frightening and traumatic for the individual and for the family. It is important for family members to support one another at these times, and to establish good relationships with the mental health agencies that are assisting them. After the emergency situation has passed it is often helpful to talk through the emergency with the other family members or friends that were involved. Families can also ask to meet with a mental health professional to help them talk through these emergency situations. Especially after a crisis situation, families and friends need to ensure that they look after themselves properly, and this includes discussing what happened, discussing how the members of the family feel about what happened, and getting back into a normal routine (see also Information for caregivers brochure).

When the emergency is over, and the painful feelings that go hand-in-hand with these situations have eased, the time is then ripe to make a family plan for handling future emergencies of this type. The helpfulness of existing plans or planned actions need to be assessed. Mental health professionals can help individuals and their families make or amend these plans.