Psychosis, Paranoia and ABI: Safe Support Without Over-Restriction
Psychosis and paranoid thinking present significant challenges in acquired brain injury services, particularly where cognitive impairment affects insight, reasoning and emotional regulation. These experiences can emerge directly from neurological injury or coexist with pre-existing mental health conditions. Without careful support, services risk escalating fear, mistrust and restriction. This article builds on mental health and dual diagnosis in ABI and aligns with established ABI service models and care pathways.
Supporting psychosis in ABI requires a balance between safety and autonomy. Overly defensive responses may temporarily reduce risk but often worsen long-term outcomes.
How psychosis presents in ABI contexts
Psychosis following ABI may include delusional beliefs, paranoia, hallucinations or fixed mistrust of others. Brain injury can reduce an individual’s ability to reality-test, increasing distress and fear-based behaviour.
Staff must recognise that confrontation or correction often escalates risk. Effective support focuses on emotional reassurance, consistency and proportional risk management.
Operational example 1: Paranoia and staff mistrust
A man with ABI believed staff were conspiring against him, leading to refusal of care and verbal aggression. Early responses involved increased monitoring and restrictions.
A revised approach prioritised relationship-building, consistent staffing and non-confrontational communication. Staff were trained to acknowledge feelings without reinforcing beliefs. Incidents reduced, and engagement improved, evidenced through care notes and supervision records.
Operational example 2: Psychosis and safeguarding risk
A woman experiencing hallucinations attempted to leave her placement at night due to perceived threats. Initial responses focused on physical barriers.
The service introduced emotional safety strategies, night-time reassurance routines and joint working with mental health professionals. Safeguarding risk reduced, demonstrated through incident trends and improved sleep patterns.
Operational example 3: Medication, consent and ABI
A provider supporting a man with ABI and psychosis faced challenges around medication refusal. Capacity fluctuated, creating legal and ethical complexity.
The service implemented regular capacity assessments, best interest decision-making and clear documentation. Effectiveness was evidenced through stable mental state, reduced crisis use and defensible governance records.
Governance and legal oversight
Psychosis in ABI services requires robust governance, particularly around capacity, consent and restrictive practice. Providers must ensure decisions are lawful, proportionate and regularly reviewed.
Supervision and incident review processes should test whether responses remain person-centred rather than fear-driven.
Commissioner expectation
Commissioners expect ABI services to manage psychosis safely without defaulting to exclusion or inappropriate restriction. Evidence of partnership working, crisis reduction and placement stability is central to ongoing commissioning confidence.
Regulator expectation (CQC)
CQC expects providers to demonstrate understanding of mental health needs under Safe, Effective and Caring domains. Inspectors will scrutinise restrictive practice, capacity assessments and safeguarding responses closely.
Supporting recovery and stability
When psychosis is managed with skill and proportionality, individuals experience greater stability and trust. Services benefit from reduced incidents, stronger assurance and improved regulatory outcomes.