Can you do therapy for this?

“Well, he only called the cops 3 times this week.”

“Oh that’s better than usual! Do you remember why he called?”

“Just the usual, the Navy is putting cocaine into the orange juice, that he’s a samurai in hiding from the CIA.”

“And he’s still taking all his meds?”

“He’s been doing good there. And he’s drinking less soda. He’s lost a few pounds so far.”

“That’s great! Well, overall it sounds like an improvement so maybe no medication changes this week?”

“Yes, that’s fine…. Oh…. And now he thinks he’s a vampire.”


Such is the conversation with the mom of my 40 something year old patient who struggled with severe, hard to treat schizophrenia.

Do you ever feel like you’re in over your head, Reader? I’ve felt like that plenty of times! This was only my second vampire-related psychotic patient. I definitely didn’t learn about this is residency!

What I did learn, is how to get comfortable with patients who are very sick. Because they’re really just people suffering in a reality we can’t appreciate.

I bring this up because a therapist recently asked about psychosis.

“Is there anything we can actually do to help? It’s just so hard. I never know the right thing to say.”

Although I didn’t get the typical info when talking to this patient, we had a pretty good relationship, considering he didn’t speak to his previous shrinks at all.

And you know what I did that was so special?

I listened and validated his feelings.

You are able to provide this gift to people who are suffering and you're really good at it!

So here’s the thing. We don’t know exactly what’s going on in a brain that’s experiencing psychosis but some of it seems to be related to a processing issue that causes internal sensations and thoughts to feel as if they are coming from outside the self; that they’re not being experienced internally as imaginary or self-produced.

Think about that for a second.

You have a sometimes negative, judgy inner voice that says nasty things about your choice of Cheetos for lunch or watching Bridgerton instead of reading something soul-inspiring by Brene Brown.

What if, instead of you knowing it’s just in your head, you heard that commentary as if someone else was saying it to you out loud. That you weren’t thinking it, but someone that you couldn’t see was in your house saying terrible things to and about you. That’s terrifying!

And that’s where I start from: What it might feel like if my reality was as solid as a pint of chunky monkey ice cream stuck between the couch cushions. Somewhere between not great and total meltdown.

But there are ways to help someone feel better and engage more, and it starts with building an alliance. Make way for the trust that some people can’t forge with anyone else they come in contact with.

First off, don’t do these things. I’m sure you don’t, but this is a strong reminder:

  • Don’t blatantly challenge someone’s ideas/delusions: they think it’s real. Which means all the evidence you present to the contrary will keep you from being able to help in a meaningful way
  • Don’t endorse all of their beliefs: you can’t just give in and say “yeah you’re right, those Navy guys poisoning your OJ are real a-holes. And I’ll keep your secret safe from the CIA.” Nope. Not the kind of alliance we’re building here.
  • Don’t go straight to calling 911, the cops, or the ER (unless there’s a specific medical or safety concern): because if they’re “just psychotic” that will almost never get them admitted to the hospital. And jail is not a great place for most mentally ill people (although that’s where you’ll find many of them).

So that’s not a very long list. Yay!

And the list for helping is super short!

  • Meet them where they’re at! Identify with the feelings of fear, the nature of suffering and confusion about what’s happening. Validate the feelings because THEY'RE TOTALLY REAL!
  • Genuinely care. As delusional as some patients may appear, they will ALWAYS be able to tell if you don’t care and just want them to go be someone else’s problem. Caring allows them to trust and for that alliance to form. Then you’re someone who can help long before it gets “this bad” next time. (Yes, unfortunately there will likely be a next time) And this can ripple out for a better treatment results (for meds too!) and greater stability.

If it seems like I’m making this too simple, I promise you that I’m not. What’s going on in the brain is complicated, and we don’t fully understand it, yet. You can watch more on psychosis and meds here.

Medications are often helpful in situations like this. But a B52 (ER speak for Benadryl, 5mg of Haldol, and 2mg Ativan, usually as shots) is not the real answer. And the more helpful, long-term meds are great for stabilizing but aren’t a “cure”. Like with my patient here who already had plenty of meds and we were just trying to figure out how not to make things worse.

But to provide comfort to someone struggling, who just happens to be psychotic? That’s what we do!

This is just a reminder that our humanity can help bond us together.

Now at no point am I asking you to risk harm, or put yourself in a dangerous position. But after a zillion hours in psych ERs in the wee hours of the morning, calmly listening and validating feelings and concerns (“It must be really scary to feel like people are after you”) I’ve been successfully unscathed.

So the next time you’re faced with a question of what to do with someone who’s paranoid or psychotic or doesn’t seem like they’re a good fit for therapy right now:

  • Start from a place of perspective. Feel what it would be like if your reality felt all outa wack and people kept telling you it was fine even though everything you felt and experienced was to the contrary: it's scary and disorienting!
  • Listen. Then ask questions that help you get a better understanding of the stakes here, what this person is really afraid of, and how you might be able to help mitigate that together or with help from family, case management, or psychiatry
  • Validate feelings, not delusions. Build an alliance so that once they stabilize, there’s a relationship providing a foundation for more work that can be done

The work you do makes a difference is so many ways for so many people and the people connected to them. And it all ripples out. Even if you think you’re a vampire.

Cheers to healthy brains,

Dr. B

Jessica Beachkofsky, MD

Your friendly, online psychiatrist!

P.S. Just to be clear, I am not making fun of the fact that this patient thought he was a vampire. It’s kind of a funny idea for me to imagine myself as a vampire but that’s because I can pretend and just imagine it. It’s funny that the mom told me in a totally flat, deadpan way. But it said a lot about what we were really dealing with and how I might help during this visit.

P.P.S. Kudos to all the cops and crisis teams out there that are good with people struggling with mental health issues. I’ve heard a lot of really great stories (and only a few less than stellar ones)! Psychotic people in crisis situations can be scary or feel threatening and I value the calm and kindness that these teams often bring. Thank you!

Welcome to Brain Bites with Dr. B!

Brain Bites is all about broadening your reach with easy-to-digest psych knowledge! Join me for quick, interesting medication and brain science tidbits! Elevate your therapy practice with insight and data from your friendly online psychiatrist!

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