How to Interact with Mentally Ill People

Mental illness is universal, its prevalence is vastly underestimated, its etiology poorly understood, and its perception covered in stigma. As if it weren’t enough, awareness campaigns tend to make things even worse by depicting it as something one catches like the flu, which couldn’t be further from the truth. No social progress can be made without tackling the problem because it seems to be either the cause or consequence of all ills. And there’s no avoiding it; even if you shun human beings and live in a cabin in the woods, you might be the next patient yourself, if only because extreme solitude is known to cause it.

So you have to handle an encounter with someone who’s manic, depressed, demented, delusional, or psychotic. How to proceed? Well, there’s no good approach, only bad ones, so don’t be too hard on yourself if you “fail” by having unrealistic expectations of such interventions. If you’ve got training on the topic, forget it, it’s wrong; the mentally ill will never follow the script, so you have to start from scratch in every case.

Remember I just said mental illness isn’t something one catches like the flu? It’s important, because the exact cause of the problem is often key to reading the patient and coming up with a strategy. There is always a biological cause behind the patient’s ill behaviour and tackling the problem from an analytical standpoint is usually the way forward. Feeling guilty about it is counterproductive; just turn off the moral corner of your brain that tells you labelling and diagnosing people is wrong, because it’s getting in the way of a positive resolution. Which of course doesn’t mean leaning toward prejudice. Just accept the person in front of you as is, forgetting any conception of what is normal, and try to think like they do, without worrying about making any sense of it (at first).

Just like the brain is compartmentalised, so is mental illness, which means it follows patterns; try to think of what is being affected:

Memory:

Both dementia and brain damage are common causes of memory loss, which tends to be either retrograde (forgetting distant memories) or anterograde (forgetting recent events). In the former case, the patient may live in the present, such that in extreme cases everyone seems to be a stranger to them; in the latter case, the patient lives in the past, and may even fail to register what’s around them.

Watch out for retrograde memory loss in one respect: it may not be plain amnesia, but rather memories being jumbled up, to the point that the patient’s recollections may be a patchwork of their own experiences mixed with snippets of whatever they’ve been exposed to, which makes them look like pathological liars. Challenging people with such memory loss is usually a blunder; I prefer playing along if possible. Likewise with anterograde memory loss patients; if they’re reliving the past, it’s better to become a part of it than try to bring them back to the present.

Mood:

Mood disorders lie on both ends of a spectrum, defined as depression (feeling down) and mania (being overexcited). Either way, keep in mind this isn’t a rational process, so arguing and lecturing may be counterproductive. While these people may be aware that something is off with them, they usually don’t understand what’s going on and they can’t help it.

Trying to put a good spin on a depressed person’s account may seem natural but it’s bound to backfire. Sometimes being vaguely supportive is the best one can come up with in the circumstances. Of course the most important thing to watch out for is risk of imminent suicide, in which case it may be best to call upon the help of professionals. Self-injury is another common issue with depression and may require restraining the patient while calling for help if you witness it; otherwise it’s best not to be judgemental. Overall neglect, such as extremely poor hygiene or diet, is another indicator, and may require constant encouragement—and patience—in order to overcome.

Mania evokes hyperactivity, but it can take multiple forms. Sometimes it comes with anxiety, and can devolve into outright paranoia. Sometimes it leads to compulsive behaviour, which is usually harmless. It may also lead to megalomania, in which case patients may become a real danger to themselves; imagine if one tries to jump off a building thinking they can fly, for example. Otherwise they may only look overexcited somehow, and interacting with them can be difficult or awkward, especially if they exhibit pressure of speech—but often the best is to either just listen to them or ignore them outright.

What’s really going to make your head spin is dealing with bipolar patients, because there’s no predicting how they’re going to feel from day to day—or even from hour to hour.

Cognition:

Don’t confuse a cognitive deficit with a developmental deficit; the former aren’t systematically exhibiting mental retardation, and treating them as such is likely to cause offence. Often the cognitive deficit is very specific, especially if it’s due to a stroke or some other kind of brain damage, and interventions shouldn’t exceed that scope. Even people with clinically low intelligence make take exception to being treated like children—or worse. And even in cognitive areas where they’re actually challenged, it may be best to be patient and attentive rather than try to get ahead of them; what one means as a benevolent intervention can instead be perceived as exasperation.

Language:

One common condition is aphasia, which may be caused by dementia. It’s very challenging to keep up with people who start rambling about something, only to forget what they meant to say by the end of their sentences. If in an argument, it may be best to ask them afterwards what their point is, which will either bring the conversation back on track or shut them up in confusion—without having to be rude about it.

Perception:

Hallucinations and paranoia are two common symptoms of mental illness—and they often come together, which can be a sign of cannabis overdose.

How to interact with someone who’s hallucinating depends on the nature of the hallucinations and how the patient behaves. If they come along cognitive impairment then it may be best to just go with the flow and play along. If you can feel a bubble forming around them, it may likewise be best not to burst it, unless they become a danger to themselves. If they hear voices it may be difficult to reach them at all because they may not be able to hear you. The most challenging of all are those who may get violent; fortunately, most psychotic patients are too messed up to mount an effective assault so then they’re not all that dangerous, but the paranoid ones who look otherwise lucid are another issue and may require restraining altogether.

When paranoia is the dominant trait, avoid projecting airs of authority because that’s just pouring fuel on the fire (and obviously calling the police is the single worst thing to do). If they’re any receptive to dialogue, going with the flow by making an irrational argument may work, such as: “Look, how about you give me that cudgel, and if the zombies show up I’ll beat them up with it for you.” The zombies part isn’t a joke by the way: meth addicts are notoriously prone to seeing them everywhere so keep a few lines like this at the ready.

Speaking of meth, people using stimulants like cocaine or amphetamines may be hypersensitive to light or sound (especially loud or high-pitch noise). On one hand, having them withdraw to a quiet space with low stimuli may be the best way to calm them down in the event of an emotional crisis; on the other hand, these may constitute outright weapons in the event they need to be restrained (although I would use that only in last resort, otherwise it’s just plain cruel).

Personality:

If they sound like: “I hate you, don’t leave me” then they’re most likely afflicted by Borderline Personality Disorder. Borderline patients make the worst relationship partners and are extremely challenging to interact with in any context. In a crisis, it may be best to just stonewall them until the outbreak passes.

Narcissism is arguably the most common personality trait to devolve into the pathological. It may look like the subject is aggressively reaching out for an audience, or on the contrary that they’re so self-centred they’re happy to just contemplate their own reflection in a mirror. Those of greatest concern are the vindictive narcissists, whom share a lot with psychopaths, with the notable difference that the former are also susceptible to flattery. Another clear sign is pathological lying, which may require outright confrontation.

Empathy:

Psychopathy is way more common than most people realise, and in many cases the unsuspecting needs look no further than the mirror to find one. Simply put, the subject lacks empathy, whether it’s partial or total, and whether or not they realise it. It may be blatant, as in violent offenders, or as subtle as an aversion to all cute things. It may go all the way back to childhood, be triggered by a recent ordeal in adulthood, or even vanish altogether with age. It can be discreet and manipulative, or accompanied by bombastic megalomania. There can be all kinds of causes, like drug use, brain damage, trauma, or genetics. So there isn’t a comprehensive set of stereotypical psychopaths, and the worst are often those who hide it best by avoiding the said stereotypes.

The most important thing to remember is that psychopaths feed on weakness and can hardly resist exploiting it. The worst of them are wolves: they understand only force, and only respect a fellow predator. Even milder cases require setting boundaries and pushing back when being encroached upon. In my experience, it’s possible for those with empathy to get psychopaths to acknowledge them, both by showing strength and, ironically, by respecting them; pushing too far in retaliating against them may easily be counterproductive. Just look for a balanced relationship between you and them.

We must respect evil, and we must make evil respect us.

The Old Man, Millennium

Development:

Regression is a common sign of dementia, although it can also be the result of trauma. If the patient behaves like a child, the least bad approach may be to treat them as such, however distasteful this may be. For once I would invite you to lecture them if nothing else seems to work. This doesn’t imply being judgemental, of course, but it may mean being firm.

Autistic patients may require a similar approach, but I would advise first trying to understand them. If nothing else, keep in mind that autists are extremely introverted people surrounded by extraverts, evolving in an environment that makes extraversion outright compulsory, which can amount to a pervasive form of aggression. Introverts tend to fare poorly in group activities and prefer one-on-one engagement. They may also communicate much better in writing and struggle to come up with a reply on the fly. And they may also resent being compelled to look at someone in the eye. Autists in particular may struggle to read facial expressions, and even more so to answer in kind. See if being patient and giving them their own space works better than lecturing them, and they’ll often give you the answers you seek—especially if they prove to be way smarter than you after all.

Concentration:

ADHD patients may prove difficult to manage, but often that just means it’s the wrong approach. Sometimes there’s nothing particularly wrong with people being labelled with the disorder, but they need a supportive environment. Consider harnessing their characteristics instead of addressing them. For example, someone who struggles with focusing on a single task may be a natural multitasker who excels in contexts too challenging for most people. Likewise, they may be unusually creative and thrive in artistic undertakings. Look for something they display interest in, instead of fitting them into a given mould, and the problem shall solve itself.

Sexuality:

Let’s wrap this up with hypersexuality, which can notoriously stem from low self-esteem, itself commonly caused by trauma. If you encounter someone who seeks to hook up with anyone featuring a complementary set of genitals in a blatantly pathological fashion, how about being supportive in a way that improves their self-esteem instead of lecturing them? That might just do the trick.

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On a concluding note, some basic outreach notions are particularly important when dealing with the mentally ill. Always be mindful of your body language, starting with your stance. For example, staring down at someone may be perceived as condescending or intimidating. Likewise for facing someone, especially if that person is introverted; sitting or standing beside them may avoid looking confrontational. Of course that advice has to be turned on its head when trying to project authority, but even then one should avoid overdoing it.