How to Manage Common Symptoms

“Compassion follows understanding. It is therefore incumbent on us to understand as best we can. The burden of disease will then become lighter for all.” – Dr. E. Fuller Torrey  

People with schizophrenia sometimes experience symptoms that are difficult for the individual, friends, family members, professionals and others to deal with.

The following techniques may be helpful in dealing with these issues.

Handling Paranoia – 6 Steps

•  Place yourself beside the person rather than face-to-face. Don’t stand directly in front of the person. It may be considered confrontational. The side-by-side position tends to deflect paranoid fears away from you. Instead, both you and the person who is ill are looking out at the (hostile) world together. Positioning techniques can improve your chances of forming a working bond with the person.

•  Avoid direct eye contact. Direct eye contact often makes a paranoid individual feel even more so. Look elsewhere.

•  Speak indirectly. Avoid speaking directly to the person. Avoid using “I” or “you” statements. Try to substitute pronouns such as it, he, she, or they for the words “I” and “you”. Much like body positioning, the purpose here is to deflect the ill person’s paranoid projections away from one-on-one interactions. Instead, paranoid symptoms are directed towards external and more general “real world” issues.

•  Identify with, rather than argue with, the person . Whenever possible, your attitudes and emotional expressions should parallel the person’s attitudes and expressions. The goal is to help the person feel understood. If they are angry or frustrated, you can also express anger and frustration with the difficult circumstances. Your own emotional expressions should be taken up to the point of  – or even perhaps slightly beyond – the person’s own emotional expression, to show you are on his or her side A paranoid individual is not thinking rationally , so attempts to encourage rationality will probably not be successful.

•  Don’t rationalize. Share mistrust. The intuitive approach with a paranoid person is to try to persuade him or her to be more trusting. But it’s often better to do exactly the opposite – that is, to join the ill person in their mistrust of the world. No attempt should be made to correct what is being said, or to test reality. Instead, the person’s account of reality is temporarily accepted. The assumption behind this technique is that, in the midst of a paranoid state, the person is overburdened and overwhelmed by a mixture of real-life stress and distress from psychotic symptoms. While carefully avoiding collusion with psychotic delusions, you should attempt to find certain believable or credible aspects of the paranoid belief system. This allows you to agree with the person on something. You then move on to a symptom area, attempt to substitute a less paranoid, more benign (and general) explanation for the highly personalized paranoid one. Exchanging malignant for more benign paranoid beliefs is best done in a step-wise fashion, where the alternate explanation is only a notch less paranoid than the previous one. The eventual goal is for the ill person to tell the person trying to help: ” Don’t be so paranoid .”

Ms. C. blames her last hospitalization on a police conspiracy to terrorize her. Rather than confront her with her own behaviour that led to her being arrested, her case manager agrees that the police cannot be trusted and goes on to talk about his own outrage at the Rodney King case. By the end of the conversation, Ms. C. tells the caseworker to stop treating the police so unfairly!

•  Postpone psychoeducation. A person in a paranoid state is often unable to acknowledge to others the existence of their psychosis. Rather, they will deny experiencing symptoms and blame others for their difficulties. Until the person is strengthened, and the paranoia lessened, no attempt should be made to identify, correct, or argue with them about paranoid or delusional symptoms. Until a sound alliance is formed, you should avoid the more traditional psycho-educational approach that teaches about symptoms of illness, benefits of medication, etc.

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Helping Overcome the Terror of Psychosis

People with psychotic symptoms are usually terrified when they discover they can no longer find or maintain coherent mental functioning. What often follows is a frantic search for “normal” mental functioning, and a desperate attempt to hide this struggle from other people. Be aware of how bad this terror can be, and how common it is. Recognizing fear depends upon a number of familiar signs. Because ill people often can’t or won’t verbalize their terror, it’s all too easy to ignore this issue, or to become indifferent about it. You need to look for indirect evidence of terror . Thoughts are scattered or dissociated; feelings are volatile, inappropriate or absent, and behaviour unpredictable or contradictory.

Management of Terror

Recognize. The goal is to decrease the sense of terror and despair that comes with the awareness of being psychotic. Treating this reaction to loss of regular mental functions requires supportive intervention. Ask the person if they are frightened. State that you too would be frightened under the same circumstances. The knowledge that someone else recognizes one’s sense of terror without it having to be explained can be tremendously reassuring. Perhaps the greatest difficulty facing you is to understand the extent of the person’s desperation while at the same time not being overwhelmed by it.

Reassure. While it may seem the most obvious, this simple measure is often overlooked. Help reassure the person that their fear is normal, and that the psychotic experience – although terrible – is temporary, and that things will get better. Avoid false cheerfulness, which will be picked up as feigned.

Provide Companionship . Even when verbal communication cannot be reciprocated, companionship can be very helpful in reassuring the person that he or she is not completely alone.

While in the presence of a terrified person, proper physical positioning is important. You should remain slightly to one side and avoid staring; one aims for an easy accompanying. An air of quiet confidence is also needed because anxiety is contagious. Little should be said except occasional reflections about what must be experienced by the consumer’s presumed state of mind. Words like wandering , aimless , frightened , bewildered , or vulnerable might be tried to see if the person can acknowledge any of these states.

These attempts to make contact with the withdrawn and frightened person are best done by combining these descriptions with short empathic statements such as ” How awful ” or ” It must be frightening .”

Leave the Person Alone . Paradoxically, at the same time as offering companionship, you need to be able to leave the person alone. The skill here is to know how to be able to sit with the person and, at the same time, give them enough physical and emotional space. It is important to avoid being intrusive. Most people experiencing psychosis cannot deal with normal physical gestures of reassurance. Some emotional distance should also be maintained because anxiety over excessive verbal interventions or interpersonal closeness can make psychotic symptoms worse. Too much activity, emotional reaching toward the person, or inquiring about symptoms can backfire by overstimulating the psychosis.

Many mental health professionals and family members have trouble with the notion of being alone with an ill person, feeling that by not talking they will be perceived as being indifferent or hostile. Actually, it is just the opposite. Just being there as a quiet companion is often very positive, and the ill person is able to sense the difference.

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Denial of Illness

If someone denies illness because they are suffering from an acute psychotic episode, the person should be treated with hospitalization and/or increased medication. If they are denying that they are ill, they may also deny the need for treatment. The only solution to help someone in this situation is involuntarily hospitalization. British Columbia does not have community treatment orders . Involuntarily hospitalization for treatment currently requires authorization from two doctors – one of whom is a psychiatrist. (More info on this option see the Guide to the BC Mental Health Act)

Avoid Overzealous Attack on Denial. When denial of illness is chronic and seems unrelated to relapse, the first step is to determine whether the denial should be addressed at all. Denial of illness may not be harmful as long as the person is otherwise doing well and is compliant with treatment. Indeed, several studies have shown that consumers who deny their illness see themselves as having more purpose in life, are more optimistic, and have fewer affective symptoms. This may be a difficult concept for families to accept. But denial of illness often only needs to be addressed if it is causing a problem.

Provide Alternative Explanations. If denial must be addressed, it should be addressed indirectly. Enlarge the person’s perspective by helping them acknowledge the existence of (or at least the possibility of) different points of view. There are 4 steps to help accomplish this.

Step 1. Recognize the ill person’s point of view. Assume their point of view is believed in, even cherished, highly learned, or at least, very determined. For example, if the person says ” I’m not sick, it’s others who are sick and making up these stories about me ” ­ – hold off from disagreeing. Instead, you should say to yourself: “Let me assume this statement is true. Now, in what way might this be true?” This can help you see that the denial is a reasonable response from the ill person’s point of view. In this context, you can acknowledge the person’s beliefs as being one point of view (even if delusional) without having to collude with them.

Step 2. Establish that the person’s view is only one point of view . Once you understand the ill person’s rationale for the denial, the goal is to establish the fact that people can have legitimate differences in viewpoints and opinions, and that people can “agree to disagree” without taking personal affront at the disagreements. Discuss non-threatening issues (e.g., recent political events, sports, music, food) and try to come to an agreement that different opinions are acceptable and a part of life. Then, you can bring up that it is o.k. to hold different points of view about the person’s own situation or need for treatment.

Step 3. Supply an alternative . This step marks the first time denial is directly addressed. You suggest alternative explanations in a way that leaves the person room to disagree without getting into a power struggle with you. Be respectful. Feel why it is necessary for the person to take the position of denying their symptoms. For example, you may broach a new topic with something like “Other people have found that…” and “Is it possible that this is true for you?”

Step 4. Anticipate setbacks after successfully addressing denial . When denial of illness abates, be prepared for trouble ahead. Demoralization – a terrible sense of failure or despair – often follows. A most striking example is the higher suicide risk for people who have suffered from psychosis and recently regained insight. Demoralization is often triggered by setbacks, such as repeated rejections in finding a romantic partner. Denial may have been protective, shielding the person from attributing setbacks to their symptoms. When they become aware of real-life defeats, it is necessary to show how apparent defeat sometimes represents real progress. Success and progress frequently go unnoticed by someone who is ill; and even their most striking success may be viewed as a failure. Often, people overlook their own very real success ¾ having the courage to keep on trying and not to give up.

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Help Overcome Stigma

Many people will not admit to stigma because it is tantamount to acknowledging that they suffer from a “mental” illness. Therefore, stigma’s presentation is often indirect, such as refusal to participate in treatment or programs. (Note: Refusal to participate may also be because the program is inappropriate, ineffective, or otherwise substandard.) Stigma can also lead to substance abuse, where having psychotic symptoms in the setting of getting high is seen as normal . Stigma may also be the underlying cause of unrealistic expectations, such as an attempt to over-reach vocational goals (for example, a very poorly functioning and symptomatic person who signs up for law exams.)

Stigma can explain the commonly seen paradox of a person who denies their illness but voluntarily takes antipsychotic medication. Stigma may be greatest in people who had good pre-illness functioning, who come from middle-class backgrounds, and among those whose families have trouble accepting a diagnosis. It is important to acknowledge that when hurtful stigma occurs it is due to ignorance about the physical causes of mental illness, to try and normalize the person’s experiences as much as possible, and to support their self-esteem.

People who are stigmatized tend to attribute all their struggles to being ill, an attitude that can foster even greater stigma and isolation. Normalizing the person’s experience as much as possible can be very helpful. Many people with schizophrenia idealize the lives of “normal” people. They will do much better if they know that many of the same trials and tribulations of life are experienced by so-called “normals”.

Talk about yourself. Talking about yourself is a way of normalizing the other person’s experience. It allows them to compare their frustrations with yours. Use concrete examples taken from your own life (trouble with authority, experiencing failure) to assure the person that not all his or her problems come from illness. But try not to patronize or trivialize real-life difficulties eg: getting a mediocre grade in a course is not a comparable setback to having to drop out of school because of mental illness. Avoid disclosing socially taboo or overstimulating topics (for example, sexual issues.)

Use Performative Speech. One technique that works well is the use of performative statements. Performative speech refers to statements that are powerful by being made by the right person under the right circumstances. Performative statements can be made by anyone with credentials that are acknowledged by the person i.e., by someone they like, admire, or someone they believe has authority.

Be Sensitive to Language. Blunt or direct use of emotionally laden psychiatric terms may backfire when used on people who have been stigmatized. Often, the ill person is confronted with psychoeducation before he or she is ready. Be tactful. You can always use descriptive rather than medical terms: psychotic symptoms instead of schizophrenia ; suspiciousness or sensitivity instead of paranoia . Find a face-saving way to explain humiliating events. For example, someone brought in in handcuffs after walking naked in the streets may accept an explanation like ” You know, being naked is upsetting to many people “, rather than ” You know, you were exhibiting bizarre psychotic symptoms.”

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Often, demoralization occurs after an acute psychotic phase. (This assumes the person does not have depression or neuroleptic-induced akinesia.) It is often due to not meeting social or family expectations (e.g., shame over not achieving higher education goals.) Not achieving expected goals may affect many other aspects of the person’s self-esteem. For example, someone who has to drop out of college because of schizophrenia may tend to devalue all of their remaining intellectual skills. Depression is very common and should be treated .

Self-deprecation can be recognized by a tendency to comment negatively on one’s own abilities. There is an accompanying tendency not to blame others. However, a central difficulty in assessing depression may be the person’s reluctance to disclose their feelings of stigma, embarrassment, unworthiness, or low self-esteem.

Maintain a Positive Attitude. A hopeless attitude is a major problem for many people with severe brain disorders and their family members. It is very important to maintain morale and a sense of hope. Otherwise, the ill person’s attitude may be a reflection of your own, leading to a vicious circle of demoralization.

Use Admiring and Approving Statements. Statements of admiration have special power when they are sincere. While this may seem obvious, in practice it is more common to see problems being stressed, rather than strengths being praised . One way to help is to consider, and to reflect to the ill person, the admirable inner strength and courage they have to keep on striving in life despite having disabilities.

The use of admiring or approving statements can backfire. There are two common traps. The first is insincerity and making patronizing remarks. Choose only admiring statements that are genuine and heartfelt . Some allegedly “admiring” statements are frequently delivered in a degrading or sarcastic tone, especially by professionals who are accustomed to focusing on psychopathology, not strengths.

The second trap is to let yourself get discouraged by the person rejecting an admiring statement you’ve made. Don’t be dismayed by initial rejection. In fact, if the person has trouble accepting honest approval, it suggests that you are “on target.”

Give/Get Education about Negative Symptoms. Negative symptoms of schizophrenia (apathy, inertia, etc.) can mimic or cause demoralization. When a person understands that these are symptoms of their illness, they may feel better. Use medical language in this case. Laziness becomes avolition , tiredness becomes apathy , and lack of appreciation becomes anhedonia .

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No two people  ill or otherwise are identical. Knowing the person is the first step towards helping. The above suggestions are provided because they have worked in some cases, but of course they will not work in all. Judgement and common sense must prevail when attempting to use them.

-Adapted from an article by Dr. Peter Weiden and Dr. Leston Havens

British Columbia Schizophrenia Society

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