Supporting People With Altered Perceptions
The use of drugs can sometimes result in altered perceptions, including delusions and hallucinations. These are when someone believes something that is clearly untrue according to consensus reality, such as that they are dead, that they can fly, that they are a deity or that they are covered in spiders. Altered perceptions are often the intended goal of taking drugs, and usually end as the effects of the drug(s) wear off. However, they have the potential to become extremely distressing and overwhelming. Even if the person is not distressed, the nature of the altered perceptions could also pose a risk to themselves or others.
It is best to avoid using the term ‘psychosis’ or other diagnostic language. Use of these terms can trigger unnecessary concern and overreactions among care space staff, security, medics and event organisers. Instead, it is best to talk about altered states of perception, delusions or hallucinations to more accurately label what is happening until further information is available. The only exception to this is if someone has a known history of psychosis, and they are experiencing a relapse.
If someone becomes highly agitated, aggressive or is at significant risk of harming themselves or others, contact security, a mental health crisis team, a medic, and police immediately while continuing to provide support. Do not leave the person alone, in so far as it is safe to do so.
Providing Support
People experiencing altered perceptions may not always want the support of a care space. They should be given choice in how to engage with the service, and not be followed, chased, or pressured to accept support as feeling monitored or watched can increase anxiety and distress.
If people do not want to come to the care space, notify medics, security and other care teams so that they can keep an eye out for the individual and be aware of the context if the situation worsens.
If someone becomes highly agitated, aggressive or is at significant risk of harming themselves or others, the care team may need to act against the person’s wishes. Contact security, a mental health crisis team, a medic, and police immediately, and clearly explain to the person what's happening and why. It is best practice to make the event management team aware of the situation as well.
Reassure the person and those around them to help everyone feel calm and empowered whilst also removing environmental risk factors (e.g. remove chairs from the area if they are likely to be thrown).
Keep the person safe and comfortable until the effects of the drug(s) wear off or they feel ready to rejoin the event (and are deemed safe to do so by the care space team).
Try to get a sense of ‘how far out’ they are: Do they know where they are? The time of day? Their name? That they’ve ingested a psychoactive drug? Be careful not to confuse them by repeatedly asking them questions they can't answer.
Try to identify what drugs they’ve taken, get information from either the individual or their friends to have more accurate expectations of the duration of the experience and presentation of the drug’s effects.
Be as calm as possible while talking to them (even if you’re feeling anxious yourself!), remember to breathe and relax your body, and use a normal tone of voice to reassure them that they are safe and that you’re there to support them. It can be difficult, but regulating yourself can make a huge difference. Keep in mind that if they’re feeling afraid, they may also be afraid of you and they will pick up on fear in others.
Use a non-judgemental approach that encourages an active exploration of what they are thinking or feeling through open-ended questions about their experience.
Remind them to breathe and relax, and, if appropriate to their distress, let them know that spiritual crises are normal.
Explore activities based on what the person wants to do and can do safely, such as looking at beautiful things, smelling things, singing simple songs, recalling good memories, naming the things around them (e.g. 5 blue things), or dancing. Sometimes people find it helpful to assist with simple tasks in the space to regain a sense of normalcy, such as folding blankets or tidying up. However, avoid complex physical activities and be mindful of their risk of falling.
Drinking water and eating can be helpful (especially berries, fruit, candy etc), but be mindful of potential food allergies.
People experiencing an altered state should still be given agency and autonomy, provide options to choose from, transparency around actions being taken, and do not lie or trick them in an effort to manage the situation.
It is important to keep in mind that what they’re experiencing is their truth and lived experience of reality in that moment. It is helpful to have the mindset that you believe they are really experiencing these delusions while knowing that you do not believe in them also, and thus avoid feeding into the delusions. Therefore, it is best to avoid directly challenging them on their beliefs while also avoiding reinforcing them.
However, if someone is in significant distress due to a belief that they’ve lost their mind or that the experience will never end, it is usually helpful to remind them that they’ve taken drugs, that it is an experience that other people have had, that it will end and that what they’re going through is temporary. It can be helpful to also give rough timelines around duration if you’re familiar with the drugs they have taken.
Prolonged Altered Perceptions
Sometimes people can continue to experience altered perceptions for longer than expected after the effects of a drug(s) should have worn off. This could be hours, days, and sometimes longer. This can look like ongoing delusions, hallucinations, paranoia, aggression or other significant behavioural changes. Keep in mind that they may not always be distressing for the person, but can still pose a risk to themselves or others.
If this happens, it is necessary to monitor the person and determine their level of risk with the support of other care services, especially medics. If it occurs at a multi-day event, a person experiencing mild symptoms may be able to be monitored within the care space or by sober, supportive friends to see if their condition improves. If not, they will need to be assessed by mental health support services who can make recommendations about what to do next.
Most prolonged drug-induced delusions and hallucinations resolve after several days. However, there are instances of them continuing for weeks, months and even years. Therefore, it is important that a person receives appropriate ongoing support to ensure the best possible outcome. Avoid scaring people by telling them this information if it is not relevant.
Care spaces should have agreed criteria with other medical and mental health services for involving external support.
Cultural Considerations For Altered Perceptions
This section is intended to raise awareness of potential cultural differences and requirements in order to promote cultural safety. For it to accurately represent the experiences and needs of Māori, consultation with tangata whenua and kaupapa Māori organisations is required. However, we feel it's important to have an interim resource available as a means of drawing awareness to an important part of safe care space practice. It is imperative that meaningful consultation with relevant people and organisations is also a part of its development and implementation into care space practice.
The below is a brief overview on one cultural understanding, but it is important to consider the diversity of an event community and the various other different cultural perspectives it may be important to educate yourself on in the interest of performing safe care space work. The below link is a resource which begins to demonstrate the beliefs different cultures have towards hearing voices, as one possible starting point - https://www.hearingvoices.org.nz/index.php/en/different-perspectives
“The way my experience was viewed by my whānau was very, very different from the way it was viewed by the psychiatrists and the nurses. What people call mental distress is what we call Wairangi or Pōrangi, which means existing in another worldly way. A psychiatrist from Switzerland will believe I’m hearing voices and have schizophrenic tendencies, but to a Māori I’m hearing my tupuna talk to me”. (Tania, cited in Fenton, 2000)
When working with people experiencing altered perceptions, it is important to remember that Western biomedical frameworks are only one among many. Various indigenous cultures around the world conceptualise altered perceptions and mental distress in very different ways, particularly those involving spiritual concepts and concerns. However, these differences have been frequently marginalised in health policy and practice by the dominance of Western frameworks (Ngata, 2014). Therefore, non-Western perspectives need to be acknowledged, respected, and celebrated through a process of cultural humility in order to ensure safety for all within a care space.
There is a history of discrimination towards Māori within mental health services, which is exacerbated by a lack of recognition of cultural heritage and background (Bell & Maraku, 2022). It is therefore of utmost importance that care spaces do not perpetuate this history, but instead offer an alternative experience of inclusion and respect.
For many Māori, the terms ‘mental illness’ and ‘mental distress’ are associated with discrimination, judgement and stigma (Bell & Maraku, 2022). Instead, some Māori prefer terms such as Mauri Ora, Pai, Hinengaro Mamae, Taimaha, Ngaro and other kupu Māori (Bell & Maraku, 2022). If they do use Western terms, they are usually utilised within Māori models of health such as Te Whare Tapa Whā to encompass a “continuum of wellbeing, that takes into account energy, physical wellbeing, emotional wellbeing, environmental conditions, spirituality, and connection to self, others, wairua, and nature” (Bell & Maraku, 2022, p. 10).
Māori spirituality and culture is innately relational, emphasising connectedness to people and places in past, present, and future contexts (Bell & Maraku, 2022). This can involve Matakite, a Māori cultural experience of heightened intuition which can be experienced through all the senses as well as different dimensions, like cosmic visions and dreams, framed within the Māori worldview and derived from Māori cultural concepts (Ngata, 2014). It can also include Mākutu (witchcraft, magic, sorcery, spell) or Mate Māori (psychosomatic illnesses attributed to transgressions of tapu or to mākutu), representing spiritual dimensions and perspectives about balance and imbalances (Bell & Maraku, 2022).
For Māori, the things a person may see, hear or feel, either sober or under the influence of a drug may represent a genuine matakite or wairua experience rather than delusions or hallucinations. Care spaces should consider how to ensure that these experiences are respected and celebrated, as well as how to uphold cultural values such as tikanga and manaakitanga. It is also important that care space staff do not assume that all Māori will resonate with these concepts, and therefore it is best to respectfully hold space for what each individual tangata whenua is experiencing, rather than imposing ideas based on either the Western biomedical framework or Māori cultural beliefs.
Some Māori with these lived experiences have benefited from Matauranga Māori healing approaches such as karakia, whaikōrero, whakawātea, whanaungatanga, waiata, mirimiri and rongoa, as well as accessing Tohunga (Bell & Maraku, 2022). However, it is important to remember that not all Māori are receptive to these healing approaches. While there is potential for care space providers to integrate some of these techniques into their practice, this should only be explored through careful, meaningful consultation with kaupapa Māori organisations and conducted by, or under the strict guidance of, someone who is trained, qualified and experienced with their use.
Resources
Zendo Project: How to Work with Difficult Psychedelic Experiences
Erowid: Psychedelic Crisis FAQ
Hearing Voices Aotearoa: Different Perspectives
NZ Early Intervention Psychosis Society: Matakite and Wairua Experiences
References
Bell, C. & Maraku, L. (2022). Noku Te Ao Education for Social Change Series 1. Māori Lived Experiences of Discrimination. Te Kete Pounamu & Te Rau Ora.
Fenton, L. (2000). Four Māori Kōrero about Their Experience of Mental Distress. Mental Health Commission.
Ngata, R. S. (2014). UNDERSTANDING MATAKITE:A Kaupapa Māori Study on the Impact of Matakite/Intuitive Experiences on Wellbeing [Doctoral dissertation, Massey University]. Massey Research Online.