Supporting people perceiving a different reality to you protocol

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This protocol is a draft. It has not yet been accepted as protocol and may be incorrect or poorly cited. Please do not use this in your work until it has been accepted.

Please see #protocols on Slack to discuss this protocol further.

Note regarding COVID: This page is not specifically relating to the COVID-19 pandemic pandemic, but includes information that will be useful for dealing with the pandemic.

When you are doing mental healthcare in the community you will frequently come across people in distress who are perceiving a different reality to you. They may be hearing, seeing, tasting, smelling or feeling the touch of something that you and/or others are not perceiving. They may have strong beliefs which they don't usually have or which you don't share.

This protocol should be used as part of the Acute mental health intervention protocol or in general day-to-day life. This protocol does not contain an in-depth discussion of Risks, as this is discussed in the acronym RAISED in the above protocol.

The most important thing to remember when supporting someone who is perceiving a different reality to you is that you should always work with their consent and avoid projecting your own ideas about what you think would 'be best' on to them. It is useful to have discussions with people you care for and spend time around as to how they would like you to respond if they are perceiving different kinds of reality. As with all types of mental health intervention, what helps one person could have the opposite effect on another.

Be aware that people who perceive different realities use a range of words to describe these experiences. A few ways that someone may understand their perceptions of reality are:

  • As part of how they understand and cope with the world
  • As part of who they are as a person
  • As religious, spiritual or magical experiences
  • As trauma responses
  • As symptoms of or developments from a mental illness
  • As symptoms of or developments from a physical illness or injury
  • As part of a diagnosis
  • As a result of taking medication
  • As a result of using drugs or alcohol
  • As part of a creative process
  • As something commonplace and everyday
  • As something distressing and upsetting

People's understanding of the realities they perceive often changes depending on their life circumstances. For an introduction to how people who hear voices experience, understand and live with their voices you can see this video from Hearing the Voice.

Your role is to support someone to cope with their reality and the emotions their experiences are causing.

How to Support Someone Perceiving a Different Reality to You

You should ask people what they find helpful and unhelpful and base your support around this. If you care for or otherwise spend time with people who experience different realities, particularly different realities that cause them distress, it is useful to have a discussion in advance of periods of distress about what they find helpful, what they want you to do and what decisions they want you to make.

It is not good practice to tell someone that what they are experiencing is not real or not happening, unless they have specifically told you in advance that they want you to do this.

Instead, you should ask clarifying questions to help you understand what someone is experiencing and how this is making them feel. Some examples of questions you could ask are 'Can you help me understand how you are feeling?', 'It seems like that's making you feel really X, is that right?' and 'Can you describe what you're seeing?' Even if you can't understand what someone you are supporting is perceiving, you may be able to better understand how this is making them feel and support them based on those emotions.

If someone is nonverbal and/or experiencing feelings of panic, depression, suicidality or sudden emotional swings you should deal with this as described in the Acute mental health intervention protocol.

You must not make assumptions about what reality someone is experiencing or how they are reacting to it. You must not use judgmental or shameful language and you should appear calm and reassuring, even if someone is acting in a way that seems out of character for them.

The only situations in which it is appropriate to contradict someone's understanding of reality is if they have given you explicit permission to do so or if there is a direct threat to life or limb (for example, if they are about to walk into a busy road and can't see that it's there). Losing someone's trust will fundamentally make it impossible for you to continue supporting them effectively, and in contradicting them, always bear in mind you may yourself be experiencing a reality which is not useful to them for decision making.

If someone has asked you to contradict their experience of reality, make sure to be compassionate and understanding and don't dismiss what they are perceiving or how that is making them feel. For example, you can calmly tell them "I'm not seeing [something the person you're supporting has said they are perceiving], I can see [XYZ]." Even though they have previously asked you to, it is often still distressing and confusing for someone to have their reality contradicted. You should stay with the person you are supporting and follow Acute mental health intervention protocol.

Further Resources and Ideas

If the person you are supporting has recently started experiencing different realities and/or is looking for more information on coping strategies you should work with them to find strategies that work for them.

A range of coping strategies and information on different types of support for people who hear voices can be found on this page of the Understanding Voices website.

You can use what the person you are supporting enjoys doing to help you think of ideas for both virtual and in-person ways you can support them. For example, if someone likes listening to music and experiences periods of feeling as if they have travelled into their past and/or periods of forgetting who they are and the experiences they have had, they may find it helpful to make a playlist with music they have heard only recently or music which has positive or neutral associations in their life to listen to when they are having these experiences.