Recently on the delusional disorder forum, a poster shared an experience where a woman was sick with delusions and hallucinations, and the passenger felt helpless in the situation. He felt he should have “done something” to help. His post asked for advice, and I’m sharing a response as someone who has been in the grips of intense psychosis, and come through with treatment to recovery and living in treatment. Here is my advice.

“How do you respond to a person suffering from delusions and hallucinations on the subway/trolley?” The answer probably depends on where you live and the laws governing the treatment of people who are experiencing mental illness.

In the United States, there is nothing anyone can do to "help" someone in a mental health crisis until they pose a threat to themselves or others. If the s/he was threatening the other passengers or to harm herself, that would be the appropriate time to call the police and clearly say you believe the person is having a mental health crisis and is a threat to himself or others. But if the person is not a threat, and is feeling persecuted, let him/her be. You may make the situation worse if you try to intervene without experience or knowledge of this person in a mental health crisis. In general, if you are not experienced interacting with a person, and do not know them, I would not recommend directly involving yourself with a person in a mental health crisis. It takes a special skill set, and training to be helpful.

When it is someone you know or love there is an effective strategy called LEAP developed by Dr. Amador. Listen, Empathize, Agree, and Partner. This strategy is the best strategy I know if you are in a situation with someone suffering from delusions and hallucinations. Trying to build trust to help is the key. I would not recommend you do anything if you didn't know the person who is showing signs of illness. The weight of the world is not on your shoulders. The person was ill, and will likely gain access to care through the people in their life who know them. If you want to understand better how to empathize with what it is like to have a mental illness there are many books that describe mental illness through personal narratives, like the book I wrote. It may give insight into what the experience is like.

As for how to behave when someone is having a psychotic break and you're on the subway?

1. If they are acting out: I'd recommend staying as you were. Don't turn your back. But don't make direct eye contact or stare. Direct eye contact may seem aggressive, whereas turning your back may make the person feel isolated.

2. If it makes you uncomfortable: Change subway cars at the next station, or wait for another train.

3. Be present: Don't ignore the person, but don't pay special attention to them either. In New York I've seen people who are skilled at dealing with unusual subway behavior. Keep to yourself as best as you can. Keep your head down, eyes averted from the individual acting out if they start to pester / direct their attention to you. Cross your arms and legs. Do all the nonverbal cuing that you don't want to engage with them, without isolating them. If they start to ask questions that are based in delusions you can shake your head back and forth and keep a low profile, or if they are checking in about their surroundings, asking if you see what they see, or something like that, keep it real. Be gently honest. For example, "Sorry, I don't understand." or "Sorry, I don't know." or "Sorry, I don't see anything like you described." Remember, you are talking to a person with feelings. Please be respectful and sensitive to their beliefs/feelings, but try to disengage if you don't have the experience and skills to know how to support an individual in crisis.

Sunny