Housing First programs prioritize highly vulnerable people with a serious mental illness who are coming out of extremely stressful circumstances. Considering these factors, it's expected that case managers will encounter some participants who experience psychosis. Psychosis refers to the presence of psychiatric symptoms involving a loss of contact with reality. These symptoms are the defining features of schizophrenia-spectrum disorders. But, these symptoms can be present for other reasons including: a mood disorder (most commonly bipolar disorder but also depression); substance use (e.g. hallucinogens or alcohol withdrawal); a physiological condition (e.g. head injury or migraines): or even just extreme deprivation caused by a lack of sleep, food, or water. Symptoms of psychosis include delusions, hallucinations, disorganized thoughts or behaviors including becoming catatonic, and negative symptoms (decreased motivation, limited emotional expressions, and decreased interest in pleasurable activities or social interaction).
It’s important to distinguish between delusions and hallucinations. Delusions are fixed false beliefs that may include the belief that a person has special powers (grandiose) or that someone is controlling or inserting thoughts into someone’s mind. Sometimes it can be hard to identify whether something is delusional because there may be degrees of truth. For instance, people may experience persecutory delusions (a belief that they are going to be harmed or harassed). In reality, many people we work with regularly encounter harassment and abuse related to their mental illness, lack of money, housing status, race, gender identity, or sexual orientation. Hallucinations are sensory experiences that occur without an external stimulus or outside input. A person may hear, see, smell, taste, or feel something that isn’t actually there. They may appear to be listening and responding to voices without anyone in view talking to them. Visual hallucinations tend to involve scenes with family members or animals (bugs crawling on your arm), seeing shadows, or visual distortion. To get an idea of what it’s like to experience auditory hallucinations check out this video and for an example of what visual distortion can feel like look at motion aftereffect illusions. Imagine how difficult these experiences can make going about your daily life.
Experiencing psychosis can be distressing and even harmful, regardless of the type and cause. Psychosis is associated with an increased risk of depression and suicide, impaired functioning in school or employment, and strained relationships resulting in a loss of supports. Symptoms of psychosis usually begin when people are between the ages of 16-30. Early intervention is important because the duration and severity of a psychotic episode can increase the likelihood of additional episodes and poor outcomes in the future. Coordinated Specialty Care (CSC) is a treatment program specifically developed to support people experiencing their first psychotic episode. CSC providers develop a personalized treatment plans that can incorporate medication, therapy, case management, education or employment, and family support to address a manage psychosis.
Because of the risks associated with psychosis, case managers and other helpers can use a harm reduction approach to support people. As with substance use, the focus should be on reducing the negative consequences of psychosis. Case managers should help participants learn to manage psychotic symptoms in a way that reduces their impact, instead of emphasizing the elimination of symptoms. The presence of psychosis does not have an inevitable result. It does not mean that a person can’t maintain housing and independence. As Sam Tsemberis, CEO and Founder of Pathways to Housing, explained in the @Home documentary segment on Housing First, “People have a functional ability and it’s quite separate from their diagnosis. You can believe that the government is after you or that there are people flying in from outer space and they’re going to take over the planet. And, leaving all that aside, you can still go get a ham and cheese sandwich and some French fries, have a meal, or go shopping.” Understanding that people who experience psychosis can and do successfully stay housed is essential for effectively using the Housing First Model. Below, are some things to keep in mind to support people experiencing psychosis.
people who experience psychosis can and do successfully stay housed...
Begin by assessing for safety. People with psychosis are at an increased risk of suicide. If a case manager thinks a person is at risk of hurting themselves, they should be direct and open about the topic. A case manager should try to figure out if the person has a specific plan, previously attempted suicide, and the likelihood that they will act on their suicidal thoughts. The risk of violence to others is also a possibility. However, it’s important to point out that people with a mental illness are not more likely to commit violent acts. Instead, they are over 10 times more likely to be the victims of violent crime than the general population. If there is a clear threat, consider assisting the participant with hospitalization or safety planning and contracting.
Don’t argue with psychosis. The nature of delusions is that they are fixed beliefs and unlikely to change based on conflicting evidence. Arguing with people about the validity of their idea will only encourage them to dig in their heels, find faults in your logic, and possibly even refuse to continue working with you. As with all harm reduction work, the quality of the relationship is essential. Case managers should align themselves with their participants and avoid being confrontational. Even casual statements like, “Don’t be silly” or “Get it together” can be dismissive and isolating. Remember that whatever they are experiencing is real to them and genuinely affects them. Help people explore their symptoms and speak in a calm, clear, and concise way. Don’t pretend to hear what the person hears or share in a false belief. Without feeding into a delusional thought, we can still identify with the feelings it creates in a person. For instance, a case manager might say, “It’s really scary to feel like you’re constantly being watched by others. That takes a lot of strength and courage. How do you manage to get through your day despite that?”
Help develop a list of options that can include personal coping strategies and professional support from a psychiatrist, therapist, or case management team. As we mentioned in a previous post, a participant has a right to choose whether or not to take medication. Although medication is considered a go-to response for the treatment of psychotic symptoms, there is some research showing that people may benefit from managing psychosis without medication. A recent study compared people with schizophrenia who were being treated with antipsychotic medications and those who were not. The study showed similar levels of symptoms but higher levels of general functioning among people not taking medication. Although medication may be most effective for some, we should explore strategies beyond medication with all of our participants to help them cope with psychosis. Don’t assume that someone needs medication in order to be successful in housing. At a recent training, one attendee mentioned a participant who was homeless for 25 years prior to being housed in their program, does not take medication, and maintains the cleanest apartment of anyone on their caseload!
Respect people’s right to use drugs. People may use illegal drugs or alcohol to self-medicate the symptoms of psychosis. For example, participants have reported using depressants like alcohol, heroin, or other opioid pain relievers to drown out voices and help them sleep. There might be therapeutic benefits to other substances as well. As researcher and journalist Helen Redmond explains, “Nicotine may even have specific properties that ‘treat’ symptoms of schizophrenia.” Consider the capacity for nicotine to improve mood, memory, and concentration and how that may balance the impact of psychosis. In a harm reduction program, helpers should never remove a helpful coping mechanism before finding substitutes. With substance use or psychosis the course of treatment is the same—to nonjudgmentally help people explore and understand the function, the potential consequences, and the alternative ways to manage it.
Some additional resources for information on psychosis include Mental Health First Aid, the National Alliance on Mental Illness (NAMI), and the Hearing Voices Movement.