Psychosis: Early Warning Signs and Staying Alongside

A support worker arrives for an evening shift. The lights are off, and the person they support is standing at the window, telling the worker there are people in the car park who have been sent to watch him. He is genuinely frightened and asks the worker what they are going to do about it. There is no good answer to that question, and trying to supply one, by arguing, by agreeing, or by going outside to check, is not actually the job. Staying, being honest, and making a call are.

What does psychosis actually look like on shift?

Psychosis is not a diagnosis in its own right. It is a word for experiences other people do not share, and thinking that is hard to follow, and it turns up in several different conditions, in some physical illnesses, with some substances or medicines, and sometimes after childbirth. Some people call it "my voices", or "when I go unwell". Use the words the person uses about themselves, and never describe someone as "a psychotic" or say "he is psychotic" as though it were a character trait.

Many people who have been through it before know their own run-up, sometimes called a relapse signature: cleaning the kitchen at three in the morning, wearing a coat inside, one song on repeat. That pattern belongs to the person, and patterns change over a lifetime. Some people have none anyone can see, and some episodes arrive with no visible run-up at all, which is exactly why there is no checklist that reliably catches it. Research pooling 72 studies found that warning-sign checklists picked up around 71 per cent of episodes, so roughly three in ten arrived with nothing to see, and when nothing was happening the same signs said so correctly only about 64 per cent of the time, so a third of ordinary quiet weeks would set a checklist off. A worker being funny, in love, or genuinely angry about something unfair is not evidence of anything. What actually matters is a change from how this particular person usually is, reported in either direction, without a conclusion attached.

Why does the same word mean something different for Aboriginal and Torres Strait Islander people?

Aboriginal and Torres Strait Islander people often do not use the words "mental health" at all. The term is social and emotional wellbeing, and it is not a softer version of the same idea. It holds a person's wellbeing across several connections: to body, mind and emotions; to family and kinship; to community; and to culture, Country, spirituality and ancestors. A change can sit in one of those connections rather than in anything that looks like a symptom, and a person cut off from family or unable to get to Country can show real distress that no symptom checklist will explain. There is no single Aboriginal or Torres Strait Islander culture, and what is true for one person may not be true for the next. Ask what wellbeing means to this person, and record their own words, not a worker's.

Whose job is it to notice, and whose job is it to decide?

In roughly this order: the person themselves, who has often been through it before and can describe their own pattern; family, who have watched it before and often notice first, where the person wants them involved; the support worker, who might see someone in their own kitchen every week while a psychiatrist sees them for twenty minutes every few months; and the treating team, who hold the history and the plan. Being placed to notice is not the same as being qualified to conclude. A support worker's job is notice, record, report, never decide, and that is worth more than any checklist, because a worker is often the only person who sees the ordinary version of someone often enough to notice when it changes.

When is a sudden change a medical question first?

Confusion, disorientation, or someone becoming very different fast, especially if it comes on quickly or comes and goes through the day, can be a physical health situation rather than a mental health one. Infection, dehydration, constipation, pain, a head injury, a new or changed medicine, withdrawal, low blood sugar and fever can all produce exactly this picture. Say the words "this is a physical health concern" when you hand it over, so it does not get filed away as behaviour. If a colleague says "that's just his psychosis", treat that as a flag to push on, not an answer. One cause is rare and fast-moving enough to need its own rule: a sudden change in the weeks after someone has had a baby is treated as a medical emergency, ring 000, not as something to watch and wait on.

Some of the medicines used for psychosis can also cause a rare but fast-moving reaction. A worker does not need to know its name, only what it looks like: a high temperature, muscles gone stiff or rigid, confusion or being hard to rouse, heavy sweating and a racing heart. This combination needs an ambulance. Ring 000, describe exactly what you can see, and then follow your organisation's policy. Do not wait to see whether it passes.

A plan is not a permission slip

If there is a plan, it belongs to the person, and it usually sets out what they want done, who to ring, and what makes things worse. Having a plan and having actually read it are different things, and a plan sitting in a locked office is not much use at nine on a Sunday night. A line in a plan like "likes quiet time in his room when he is unwell" does not authorise anyone to put him in his room. If he is not free to leave, that is seclusion, whatever the plan says and whatever it is called.

Some people also have an advance statement, a record made while they were well of what they want to happen if they experience psychosis again. Very few people have one, and what it is called and what weight it carries differs by state and territory, so find out whether this person has one rather than assuming. Nowhere in Australia does an advance statement override lawful compulsory treatment, and it is not permission to restrict anyone either. If an ambulance, a crisis service or a hospital gets involved, say that the statement or plan exists and where it is kept. That takes seconds and it routinely does not happen.

How should a worker respond in the moment?

There is a third option between arguing and agreeing. Someone says people in the roof are watching them. A worker who argues becomes one more person who does not believe them. A worker who agrees tells a lie the person may work out later. The better move answers the feeling honestly: "that sounds frightening, do you want to come and sit with me? I'm going to ring the on-call now, and I'll tell you exactly what I say" meets the fear, stays honest, and tells someone, straight away.

Staying alongside someone in the room looks like slowing down, using fewer words, longer gaps, one person talking even if two workers are present, saying what you are about to do before you do it, turning one thing off, sitting down, and leaving the door open. The practical offer, a drink, a chair, somewhere quieter, often does more than any particular phrase. Stay, if it is safe to stay, until the person you rang takes over.

When does this go beyond what a support worker can manage?

Almost every unauthorised restriction in a disability service happens in the five minutes when someone is genuinely frightened, applied by a worker who is also frightened and trying to help. None of the following look like restraint and all of them are: giving someone "one to settle him down" when nobody can say what it is actually for, standing in a doorway so someone cannot leave, taking a phone (which also cuts off family and the treating team), or sending someone to their room while a worker waits outside. Chemical, environmental, physical and mechanical restraint and seclusion are the five regulated restrictive practices under the NDIS rules, and none of them needs a lock or a bad intention to count. A worker does not decide whether something is a restrictive practice. Write down what was done, by whom, at what time, and what was said about why, and report it.

People with these diagnoses are far more likely to be harmed than to harm anyone else, and workers are sometimes genuinely frightened at work. Both of those things are true at once. If it is not safe, leaving is not abandoning someone: say you are going and that you are getting help, never lock the person in, and ring, stay nearby if it is safe, and tell your supervisor what happened and why.

Who does a worker ring, and in what order?

Ring 000 first, always, for a life-threatening emergency. Then the organisation's own policy and escalation contact, and the named clinical contact in the person's plan. Poisons Information on 13 11 26 covers anything taken, with 000 as well if the person is unwell, and Healthdirect on 1800 022 222 is there for health advice that is not an emergency. Acute mental health services are run state by state, Victoria has no single statewide line, so find out your own pathway before you need it, not from memory on the night.

How CORA's course fits into this

CORA's course Psychosis: Early Warning Signs and Staying Alongside, part of the Mental Health & Wellbeing stream in the course library, covers what change can look like and whose knowledge it is, the person's own plan and what a worker actually does, and who to ring and what not to do while you wait, including recognising a restriction in the moment and leaving safely when it is needed. It is not de-escalation training. It builds understanding and judgement. It is not a substitute for clinical training, and CORA does not certify a worker's competence, that assessment sits with your organisation.

If you are mapping this alongside the rest of the Mental Health & Wellbeing stream for your whole team, the Free tools page has a free tool that maps it out, no sign-up required. Or enquire if you would rather talk it through.

Sources and further reading

• Psychosis, SANE Australia
• Orygen: early psychosis and youth mental health
• Behaviour support and restrictive practices, NDIS Quality and Safeguards Commission
• What a capable NDIS workforce actually looks like, CORA Workforce

This page is general information for support workers and providers, not clinical or mental health advice. Always follow the person's individual support plan, their treating team, and your organisation's policies.