Helpful Tips for Families

Disclosure: It is the intent of NAMI-Yolo to provide this information as possible strategies for families to follow in dealing with their mentally ill member.  These guides should not be used in lieu of any specific conflicting treatment advice given by an individual's personal physician unless discussed with the physician beforehand.

• Clear Communication
• Guidelines for Families with a Mentally Ill Member
• Helpful Family Attitudes and Skills
• Guidelines for Creating a Low Stress Home Environment for a Mentally Ill Person
• Living with a Mentally Ill Relative - Practical Advice
• Should My Ill Relative Live at Home?
• Guidelines for Persons Who Have Psychotic Symptoms
• More on Surviving Schizophrenia
• Responding to Delusions
• Predicting and Preventing Relapses
• Enhancing Compliance with Medication
• Motivation Toward Goals
• Preventing Violence
• Preventing Suicide

GUIDELINES FOR FAMILIES WITH A MENTALLY ILL MEMBER

This guide offers a pragmatic summary of the research on family factors and provides methods for presenting these global principles to families.

Of the thousands of studies of studies done on the etiology of schizophrenia only one (Goldstein Schizophrenia Bulletin 13,  pp 505-514) has shown any evidence of family factors in the cause of schizophrenia. Biology (including genetics) has proven to be the primary cause. Telling families that families do not cause schizophrenia is probably true and is a powerful positive intervention. The intervention reduces destructive and obstructive blame and guilt.

It is proven that once a person develops schizophrenia, family factors strongly influence the outcome. Family interventions should focus on helping families to understand and develop the factors associated with positive outcome. Some family factors that research has proved are related to patient outcome are described below...

Factors Proven To Promote Better Outcome For Schizophrenia

Accept the person as ill. This is simple to say but difficult to do. The grief over the dramatic reduction in functioning is never totally resolved. Both the patient and the family cling to old images and false hopes of what the ill person could have been if he had not been afflicted with schizophrenia. For the patient to truly be accepted as ill and to mobilize the energy for rehabilitation, the family must consistently send the message : "We love you just the way you are." The family must relate to the ill person as a person of worth. They must greet the patient where he is, love him as he is, and promote growth that is congruent with his current condition and current hopes and goals.

Attribute symptoms to the illness. One of the essential elements of psychotherapy is that the patient will act out his symptoms with the therapist. The therapist manages their own affect so that they don't feel personally threatened. They recognize the patient's behavior towards them as a symptom and help resolve the symptom. Ethical codes bar therapists from treating people that they know because this objectivity is impossible to achieve with friends or relatives. To be maximally helpful to their ill members, families must attempt the impossible task of being objective and therapeutic when their son says he hates them because they are poisoning him.

This particular point is best communicated to families via stories and examples. The therapist can use examples from their own experience of psychotic patients being angry or otherwise inappropriate with them. Analogies to Alzheimer's patients or babies with the stomach flu can validate the families experience of having negative affect or behavior projected towards them in circumstances in which the symptom is not a reflection of the patient's lack of love for them or desire to harm the family.

Include the person in the family. Families often don't initially understand  this concept of full membership in the family. They may be unaware of subtle ways in which they exclude the patient. Examples of subtle exclusion :

• Not discussing the patient with friends when they discuss their own children.
• Not inviting other people to their home when the patient is present or other ways hiding the patient.
• Not altering family gatherings so that the patient may be included in at least part of the event.
• Not including the patient in family portraits, and
• Not involving the patient in family decisions.

In deciding how to provide full membership for their ill person families must (1) take into account the patient's handicap and how it effects his level of functioning in a variety of situations, and (2) consider the needs of other family members, so that the family meets the needs of all of its members.

This principle is often well taught through a description of the cross cultural literature which may be summarized by:

• Schizophrenia occurs with roughly equal frequency in all cultures.
• The prognosis for persons with schizophrenia varies dramatically with culture.
• In cultures which accept and incorporate mentally ill persons into daily family and community life, they function much better. Tribal cultures which have important roles (gatherers of wood, for example) that the ill person can perform and which fully include the person in all elements of the community promote the best course for schizophrenia.

HELPFUL FAMILY ATTITUDES AND SKILLS

by Christopher Amenson, Ph.D.

HAVE REALISTIC HOPES

1. Accept your relative as he is:
1. Mourn the loss, but not in the presence of your relative.
2. Never discuss what he was or what he could have been.
3. Avoid comparisons to peers.
    
2. Demonstrate that he is a person of worth and dignity even if he can't do certain things.
   1. Treat him as an adult.
   2.  Include him in decisions.
   3. Ask him to help you do things.
       
3. Allow him to have his own dreams and goals.  No one  knows what the future will bring.
    
4. Translate long-term large goals into a step which is possible to do today.
    
5. Focus efforts on today's step.
    
6. Help him to attain his unique version of fulfillment

HEALING ENVIRONMENTS

• Recognize that the illness is no one's fault.
• Have clear and appropriate expectations, understanding the limits of the illness and the extent of the person's control over his behavior.
• Are simple and structured with predictable routines.
• Are quiet with calm voices and limited stimulation.
• Are consistent and change seldom and gradually.
• Include the patient  in life in ways that are not over stimulating.
• Offer opportunities to have major personal, social, activity, and competence needs met.
• Provide lots of praise and encouragement.
• Teach and reward the use of daily living, social, and vocational skills.
• Utilize medication and treatment programs as resources to help the ill person move toward his goals.
• Are prepared for and manage minor system worsening to minimize disruption and prevent major relapse.

KEEPING THE FAMILY STRONG

• Pay attention to the needs of each family member, including yourself, and create ways for those needs to be met.
• Stay involved with friends and community.
• Seek support from persons and families who understand.
• Learn and use skills which promote your health and the health of each member of the family.
• Direct your anger and energy to making life better for your relative and the mentally ill in general.
• Provide privacy and support for individual tastes and endeavors.

GUIDELINES FOR CREATING A LOW STRESS HOME ENVIRONMENT FOR A MENTALLY ILL PERSON

by Brian D. Eck, Ph.D.

1.   Go Slow!
      Recovery and growth take time. Rest is important.

2.   Keep It Cool.

Enthusiasm is normal. Disagreement is normal. Emotions are normal. Help your family members to keep thing in perspective and obtain some degree of balance.

3.   Give People Space.

Private time and space are important for everyone. It's okay to offer or to refuse and offer.

4.   Set Limits.

Everyone needs to know what the rules are. A few good rules that are consistently enforced will help keep things calm.

5.   Ignore What You Cannot Change.

Let some things slide. Do not ignore violence.

6.   Keep It Simple.

Say what you have to say clearly, calmly, and positively. When you address them, your family members will most likely respond only to the first couple sentences that you say to them at one time.

7.   Follow Doctor's Orders.

Encourage your family members to take their medications as prescribed and only those that are prescribed. If you can, have them sign a release of information so that you and the doctor can discuss your family member's treatment program.

8.   Carry On Business As Usual.

Reestablish routines as quickly as possible when they are disrupted. Encourage your family members to stay in touch with their supportive friends and relatives.

9.   No Street Drugs Or Alcohol.

Emphasize that illegal drugs and alcohol make symptoms worse. Help them find creative ways to avoid or limit the use of those substances in social situations.

10.  Recognize Early Signs Of Relapse.

Note changes in your family member's symptoms and behaviors, especially those which usually occur just before a relapse. Help your family members to recognize these changes and to make contact with their doctor.

11.  Solve Problems Step By Step.

Help your family members make changes gradually. Work on one thing at a time and be patient as they learn from the consequences of their behavior. Let them experience the non-dangerous consequences of their choices.

12.  Establish Personal Measures Of Success.

Help your family members set realistic goals, and then chart these personal goals from week to week and month to month. Remember that success for your relative is in comparison to how they were personally doing last month, not how they were doing before they got ill, or how others their age are doing.

LIVING WITH A MENTALLY ILL RELATIVE:  PRACTICAL ADVICE
from AMI Van Nuys Reference Book 

• Although hope is needed, the family must work on accepting the diagnosis and recognize that treatment does not guarantee success.
   
• It is essential to have realistic expectations of what your relative can accomplish. This is achieved through trial and error.
   
• Plan smaller units of time. Plan short-term goals rather than long-term.
   
• Handling anger is important. Recognize your typical angry response. Give yourself  time to cool down. Try to separate what has made you angry from the person who did it. Train yourself not to exaggerate the severity of events. When necessary, express mild anger appropriately when it occurs.
   
• Too much inconsistency can have a negative effect on your ill relative. It is important for family members to act consistently, although they may hold different opinions.
   
• Find creative ways of reducing your own stress.
   
• Hiding mental illness simply isolates the ill relative and family even more and helps maintain social stigma. There is a danger in allowing your relative to become increasingly isolated.
   
• It may be necessary to push your relative into treatment in spite of his angry response.
   
• Try to keep your criticisms to a minimum. Focus on one or two things at a time which are most important. Try to use positive reinforcement rather than nagging criticism.
   
• While you can and should empathize with your relative's fearfulness, you ought to encourage independent behavior. But again, move slowly.
   
• A supportive atmosphere should be accompanied by limit-setting and structure. A chronically ill individual is usually coping with confused thoughts and emotions. He needs a routine to add a degree of order and calm to an otherwise tumultuous state.
   
• Do not get into an argument about whether or not your relative's thoughts are true or false. Acknowledge the reality of your relative's subjective experiences.  Communicate that you understand what he believes and how he feels before you attempt to correct his perception.
   
• If your relative does unacceptable bizarre things, request in a simple and non-emotional way that he change this behavior and also make a statement about consequences of future similar behavior.
   
• Do not give in to a person's every demand in the hopes of preventing a crisis. Some limits are needed, particularly when your relative is acting impulsively or in a dangerous fashion.

Suggested Ways To Deal With Common Behavior Problems

• Develop a list of behaviors that you would like to help your relative change. Begin with the most dangerous or disturbing behaviors and focus your attention and energy on them. Take first things first.
   
• Develop a consistent and clear approach to the behaviors in question. Ideally, all family members should agree on how to respond to the problematic behaviors. If rewards and punishments are involved, make sure your relative knows exactly what is expected of him and is aware of the consequences you have specified. Be clearer and more specific than you think you need to be. Follow through.
   
• Do not waste energy arguing, threatening, or pleading. This only raises the level of anxiety.
   
• If the task is complicated, break it down into smaller units. Keep yourself and your relative going by acknowledging small steps forward.
   
• Do not become upset with yourself when you fail to follow these principles - you are bound to make mistakes.

SHOULD MY RELATIVE LIVE AT HOME?

by Christopher S. Amenson, Ph. D.

Whether your mentally relative should live in your home is a very difficult decision. It is also a very personal value decision. Only you must look in the mirror and be satisfied with the decision. You can get ideas and opinions from immediate and extended family, families in the Alliance for the Mentally Ill, knowledgeable friends, ministers, or professionals. Ultimately you must decide.

There are many factors to consider. You must not only consider the factors but decide how important each factor is to you. (For example: whether to live farther from work to have a nicer house depends not only how far and how nice but also on how valuable to you a nicer house is compared to how costly to you the extra time commuting is.) When considering the factors below give greater weight to those factors more important to you.

Patient Factors

Compare living with you to the realistic alternatives for the patient in terms of:

• Safety (drugs, sex, violence)
• Stability (medication compliance, running away)
• Rehabilitation (availability, effectiveness)
• Activity Level
• Involvement in the Community
• Comfort in Surroundings
• Breadth and Quality of Life
• Happiness/Self Esteem

Family Factors

Compare your home life with and without the patient living with you, in terms of:

• Safety of the Family
• Disrupting Symptoms (anger, up all night, rituals)
• Expanded or Constricted Life
• Added Burden (caretaker worry)
• Possession of the Requisite Caretaker Skills
• Availability of Energy to be a Caretaker
• Resulting Neglect of Other Persons, Roles, or Goals

Positive and Problematic Scenarios

Positive - Living at Home

• Few disruptive symptoms.
• Has activities outside the home.
• Comfortable with parents being away.
• Helps parents.
• Family is calm and skilled.
• Family is minimally disrupted.
• Family has lots of support.

Problematic - Living at Home

• Patient is in control.
• Patient seldom leaves home.
• Parents must restrict their lives.
• Patient creates chaos and damage.
• Family has no support.
• Family unable to support and direct patient.

GUIDELINES FOR PERSONS WHO HAVE PSYCHOTIC SYMPTOMS

by Christopher S. Amenson, Ph.D.

Understand your symptoms and their treatment:

• Ask your doctor or therapist for information about symptoms, medication, and other treatments.
• Keep a record of your symptoms and the treatment you have received.
• Do not blame yourself or others for your illness.

Get the best treatment for your symptoms:

• Find and stick with a psychiatrist you can trust.
• Take medication as prescribed.
• Tell your psychiatrist or family about the effects and side effects of medication.

Learn to manage your symptoms from a good therapist or program:

• Learn to control your own thoughts and feelings.
• Remove yourself from stress that feels overwhelming.
• Use alone time to quiet yourself.
• Learn to recognize the early signs of relapse.
• Ask for help when you need it.

Have and work toward realistic goals:

• Go slowly but steadily toward being what you want to be.
• Know your limits ( what you can't do now).

Do something constructive everyday, (help someone, make something, fix something, learn something).

Be with and talk to friends or family everyday:

• Dress and behave in a normal manner.
• Discuss important issues only when you are relaxed.
• Do not talk about odd ideas or experiences except to persons who understand.

Be physically active every day.

Be as independent as possible:

• Cherish your good days and the things that you can do.
• Live the most complete life that you can.
• Get out of your home every day.
• Be close, but not too close to your family.

Avoid street drugs and alcohol.

MORE ON SURVIVING SCHIZOPHRENIA

from "Surviving Schizophrenia, A Family Manual", by Doctor E. Fuller Torrey

Auditory hallucinations are by far the most common form of hallucination in schizophrenia. The brain makes up what it hears, feels, smells, or tastes. Such experiences may be very real for the person. A person who hallucinates voices talking to him may hear the voices just as clearly as, or even more clearly than, the voices of real people talking to him. There is a tendency for people close to the person to scoff at the "imaginary" voices, to minimize them and not believe the person is really hearing them. But they do, and in the sense that the brain hears them, they are real. The voices are but an extreme example of the malfunctioning of the sufferer's sensory apparatus.  

RESPONDING TO DELUSIONS

by Christopher S. Amenson, Ph.D.

Do not argue with strongly held delusional beliefs.
Logic or verbal arguments usually have the effect of further intensifying the patient's delusions. The delusions are caused by biochemical changes. The only effective way to reduce delusions is antipsychotic medications. Discussions of delusions are harmful for the patient and very frustrating for the family.

Do not agree with delusional statements.
Most patients have some degree of doubt about the truth of their delusional beliefs. If the patient asks "Is this true?" Respond accurately. Unless he explicitly asks, do not comment on whether you agree or not. If the patient holds his delusional beliefs very strongly and persists in trying to verify his beliefs, acknowledge that you know the patient truly believes what he is saying and that you accept this as the truth as he knows it. Ask the patient to be as respectful of your beliefs as he would like you to be of his.

Change the topic to a constructive issue.
Respond to the non-delusional aspects of what the patient is saying. Tactfully steer the conversation to other issues. (Remember to steer toward something else, not away from the delusion).

Assert your right to not discuss topics which trouble you.
Inform the patient of the limits of your willingness to discuss delusional beliefs. Remind him not to discuss these topics. End conversations which seem driven by delusions by stating that the topic troubles you and you are unwilling to continue. Invite the patient to talk to you at a later time when he can calmly discuss topics that you both enjoy.

Distinguish between having beliefs and acting on them.
If the beliefs result in bizarre or dangerous behaviors, manage those behaviors as indicated in the information on Managing Bizarre Behavior, Preventing Suicide, Preventing Violence, and Preventing Relapse.

Reduce the fear and dread than may accompany the delusion.
Most delusions are troubling to the patient. You may be very effective in calming or reassuring the patient by addressing the distressing emotional consequences rather than the belief itself.

PREDICTING AND PREVENTING RELAPSES

by Christopher S. Amenson, Ph.D.

Causes of Relapses

(In Order of Importance)

1.   The episodic nature of schizophrenia.
2.   Non-compliance with a therapeutic dose of medication.
3.   Substance abuse.
4.  Psychosocial stress.

Signs of Potential Relapses

Are different for each person. The most common signs in order of frequency are:

1.   Increased interpersonal sensitivity, suspiciousness, paranoia.
2.   Sleep disturbance worse than usual pattern.
3.   Anger or hostility of an unusual type or amount.
4.   Hallucinations of increased intensity or intrusiveness.
5.   Actions based on or preoccupation with delusions.
6.   Increased fearfulness, anxiety, or feeling threatened.
7.   Increased depression with withdrawal and eating less.
 

Identifying Early Signs of Relapse

For your ill relative, identify the specific signs which lead to a serious relapse. Differentiate between 1) behaviors which are troubling for the patient and problematic for the family, but which do not result in rehospitalization and 2) the specific behaviors whose presence uniquely predict or are the earliest signs of a relapse which may require rehospitalization. For example, plants may begin to talk to your son every day, but when they begin to tell him what to do he begins to get much worse and often engages in dangerous activities. Take time to sit down and write out the earliest warning signs of your relative's last few hospitalizations. Watch for these behaviors and test whether they truly predict relapses in the future. Often there are one to three key signs that are specific to each person. Over time, discover what these are and monitor them.

Most Relapses are Preventable

With the best efforts of everyone there will still be relapses. The best programs reduce the relapse rate to 8% per year. The nature of schizophrenia is for there to be two to eight exacerbations per year. These are biologically determined worsening of the symptoms.

An exacerbation with worsened symptoms and decline in functioning does not necessarily result in full relapse. Typically 50% of exacerbations result in hospitalization. Prompt medication and behavioral interventions result in only 8% of exacerbations leading to hospitalizations.

Preventing Relapses Through Medication Compliance

(See "Compliance with Medication)".

Preventing Relapse Through Managing Psychosocial Stress

Lowered tolerance for stress is one of the core symptoms of schizophrenia. Consider your relative as mentally and emotionally frail. As a physically frail person must deal with physical exertion, your relative must deal with stress. He should change slowly, not have too much stress at one time, and have frequent rest or respite to prevent his stress tolerance from becoming exhausted. To manage stress:

• Identify the chronic conditions, specific situations, and critical events which cause stress for your relative. Remember that supposedly positive events such as Christmas can be very stressful (e.g. the ill person feels compared to his peers, has no money, or doesn't know how to shop).
• Encourage your relative to avoid certain stressful situations which will overwhelm him, but be careful not to overprotect him and rob him of opportunities for growth.
• Reduce the stressful components of situations by helping your relative do things for shorter periods, with fewer people, or with support and assistance.
• Teach or get professionals to teach your relative to manage his stress response with relaxation skills, positive self talk or seeking reassurance.
• Teach or get professionals to teach your relative how to actively manage situations so that he can request the situation to change, leave the situation or seek assistance.

RESPONDING TO WARNING SIGNS OF AN IMPENDING RELAPSE

1.   Temporarily increase medication.

2.   Temporarily reduce stress by:
       a. lowering demands and activity level.
       b. keeping a routine (minimizing changes), and
       c. providing a safe, calm, predictable environment.

3.   Do the specific things which calm and reassure your relative. Alternatives include:
       a. low stress activities or hobbies,
       b. social support,
       c. allow alone time, and
       d. relaxation techniques.

4.   Remain calm and in control.

5.   Use your urgency and emergency plans as needed.

ENHANCING MEDICATION COMPLIANCE

by Christopher S. Amenson, Ph.D.

FACTORS CONTRIBUTING TO NON-COMPLIANCE

PATIENT CHARACTERISTICS

1.  Very young or very old.                                     7.   Poor judgment and insight.
2.  Low education.                                                  8.  Hostility and aggression.
3.  Living alone.                                                      9.  Fear and paranoia.
4.  Lack of transportation.                                      10. Personality disorder.
5.  Lack of knowledge of illness.                             11. Substance abuse.
6. Therapeutic effects not understood.

DRUG-RELATED FACTORS

1.   Presence of extra-pyramidal side effects (involuntary movements).
2.   Presence of dysphoric response (feels less alive).
3.   Presence of other side effects.
4.   Medication not very effective.
5.   Need to continue medication in absence of symptoms.
6.   Complicated drug regimes.
7.   Cost of medication.
8.   Inadequate information about how to take medication.
9.   Feels best when first stops medication; feels worst when first starts medication.
10. Possibility of tardive dyskenesia.

"PERSONAL THREAT" FACTORS

1.   Resistance to accepting the "sick" role.
2.   Paranoid delusions about content or effects of medication.
3.   Change in lifestyle or habits required.
4.   Prefers delusional sick life to depressing well life.
5.   Resistance to mind-controlling medication.

INTERPERSONAL FACTORS

1.   Patient-physician relationship.
2.   Family relationships.
3.   Peer influences.
4.   Resistant to authority.
5.   No alliance toward patient goals.

METHODS TO ENHANCE COMPLIANCE

1.   The goal is that the patient take his medication. The goal is not to wear a Scarlet S. This goal may involve many steps over time.

2.   Listen to how the patient feels about his situation and understands his symptoms given his goals, values and concerns.

      a. Identify factors contributing to his non-compliance.
      b. Identify patient's goals for himself.
      c. Identify which and how symptoms disturb him.

3.   Help the patient identify how symptoms interfere with goal achievement and cause negative social consequences.

4.   Help the patient to see medication as a way to avoid negative consequences, relieve troubling symptoms and remove barriers to goal achievement. Get data from:

     a. his own description of events,
     b. feedback from others, and
     c. videotapes or other evidence.

5.  Educate the patient about the illness and medication in a way that is congruent with his education, functional level, and values. Use the following sources:

     a. Family, if patient trusts and complies with them,
     b. Professionals,
     c. Other persons whom the patient trusts and are knowledgeable,
     d. Peer support group of similar or of recovered mentally ill persons, and
     e. Pamphlets, books, or videotapes.

6.  Involve the patient in medication and treatment decisions by:

     a. Tracking his own symptoms and side effects.
     b. Taking an experimental approach. (incorporate blood levels and symptom tracking
         by the patient and others).
     c. Helping him to learn to gain control over symptoms and side effects (medication and
         symptom management classes).
     d. Negotiating a shared treatment contract.
     e. Using the lowest possible dose of medication that the patient prefers (if appropriate).
     f. Helping the patient do a cost benefit analysis of therapeutic versus side effects.

7.   Help the patient minimize side effects by:

      a. Preparing patient for potential side effects.
      b. Contacting patient frequently by telephone when beginning a new medication.
      c. Selecting medications and dosages to minimize side effects.
      d. Teaching patient techniques to cope with side effects.

8.   Make it easy to comply by:

      a. Using long acting injectables.
      b. Using a weekly dose pill box.
      c. Putting in with vitamins.
      d. Making it routine (so it doesn't need a verbal reminder).
      e. Having it easy to remember and keep appointments.

IF ALL ELSE FAILS

The things that families often do when all else fails is to nag, criticize, and make empty threats which increase resistance, family conflict, and potential for violence. Items 9. and 10. below are the most powerful (like nuclear power). Before using either, be sure to:

      a. Thoroughly examine family values, tolerance for symptoms, and ability to sustain
          limit setting over time and in the face of danger to the patient or family.

      b. Do preplanning regarding all possible consequences for the patient and the family.

      c. Set up a safety net (access to treatment) in advance.

      d. Consult with a professional to help you plan the intervention and plan for the most likely responses from your ill relative.

9.   Make privileges dependent on taking medication. Be prepared:

      a. For the patient to be angry at you. Have a plan to deal with any anger, threats or violence.
      b. To need support to stick with the decision.
      c. To repeat this two or three times before success in gaining compliance.

10. Make living or visiting with you dependent on taking medication. Be prepared:

      a. To use the police to expel the person.
      b. For small possibility that patient may become estranged from you or be harmed.

MOTIVATION TOWARDS GOALS

by Christopher S. Amenson, Ph.D.

Motivating a Person with Schizophrenia

1.   Recognize that the negative symptoms of schizophrenia include apathy, loss of interest and enjoyment of activities, lack of motivation, and withdrawal.

*  NAMI NOTE: Older psychotropic medications do not help these symptoms. Newer medications do address the negative symptoms of schizophrenia.

2.   Recognize that the patient also may have a learned motivational deficit called "learned helplessness". Any mammal that experiences a sufficient number of repeated failures will give up because they believe they can't succeed. Not trying then confirms this belief.

3.   Remember that each person is ultimately in control and responsible for his own actions. Be a good influence but remember that "you can lead a horse to water, but you can't make him drink."

4.   Understand and work toward the patient's goals. He will try much harder to achieve what is important to him. He may also resist goals imposed by you. If you can't agree on the ultimate goal (e.g., being a rock star), you may be able to agree on subgoals such as improving concentration, getting along with people, sticking to tasks, etc.

5.   Use external motivators to get the patient started, then gradually shift to internal motivators.

6.   Use external motivators to teach internal motivation (e.g. reward the patient for remembering to do something, for acting independently or for sustaining effort).

Removing Barriers to Change

1.   For unrealistic goals:

• allow long term dream.
• redefine goals into smaller and smaller steps.
• have subgoals which can be done in less than one hour.

2.   For learned helplessness:

• do anything to get the person started.
• redefine success as something the person can do.
• reward the smallest effort.

3.   For the feeling the only things he can do are trivial:

• focus on steps toward larger goals.
• label as necessary for recovery.
• label as helpful to others.
• focus on changes that your relative can do today (all anyone can do is to be a little better every day).

4.   For anxieties and fears:

• do the activity with the person at first then gradually withdraw your support.
• teach or have professionals teach the patient anxiety management skills.

5.   For not being able to get started:

• start the project with the person and then leave.
• arrange for a routine structure or cues which prompt the patient to begin.

6.   For saying that he doesn't want to:

• if this is true, accept it and find an alternative.
• check to see if this is a cover for the person not being able to do it. If so, teach the requisite skills or get the required resources.

7.   For experiencing failure when he tries:

• praise effort.
• find any positive element and praise.
• delay criticism and ignore problems.
• shape behavior over time.
• make task simpler or less anxiety provoking.

Method for Motivating Anyone

Selective Attention - (catch the person doing something good).

• It is easy to expend effort to deal with problems and then relax when things go well, therefore, inadvertently teaching your relative to have problems in order to get your attention.
• One of the highest praises is simple to pay attention to someone.
• Let your relative notice when he does something which is improved behavior or a step towards a goal.

Reinforcing or Rewarding (as behaviors occur)

• Use intangible rewards like attention, praise, compliments, hugs, smiles, etc.
• Tell others about your relative's efforts and successes.
• Use rewards which are appropriate in size to the behavior.
• Use tangible rewards only in ways which are natural for adults ( e.g. you helped me so much today, I'll bake a pie for you).
• Beware of rewards which will be perceived as condescending (as treating an adult like a child).
• Do not give praise and criticism at the same time. If you wish the person to try again, you must only praise effort and the parts of the task that he did well. Any constructive criticism must wait. Before the next try you can provide helpful suggestions, but after
• the trial you must only praise.

Contingency Contracting (setting up a reward system)

• Love and certain things should continue to be given non-contingently.
• Social exchanges and earning things or privileges are a part of our culture.
• The contract can be unstated (e.g. to go to the grocery store, you must wear clothes), informal verbal (e.g. I'll cook dinner if you do the laundry) or more formal verbal or written agreements. The contract should use natural consequences (e.g. if you get up by 8:00, I'll make you breakfast or, if you drink, you can't use the car).
• Contracts involving monetary are only appropriate for activities for which people can be employed ( e.g. housework, gardening, baby-sitting, repairs, etc.). To offer money to someone for activities such as taking a shower is demeaning. To refuse to do an activity with someone unless he takes a shower would be a natural consequence
• Arrange contracts so the ill person can earn money or things (e.g. "You want a radio. I'll pay you $5.00 per hour to help me with the gardening so you can buy one.").

Asking for Help

Mentally ill persons seldom get opportunities to be in the helper role. For them it is also "More Blessed to Give Than to Receive." Arrange as many opportunities to need help from your relative as possible.

PREVENTING VIOLENCE

by Christopher S. Amenson, Ph.D.

Criminal Violence

Probability of Committing a Future Assault

Legal Status                                             Schizophrenic                        Not Schizophrenic
Never arrested                                                 3%                                            3%
Arrested for violence                                       23%                                          23%
Committed as dangerous                                75%                                           n/a

Predictors of all Types of Violence

(in order of importance)

1.   Past history of physical assaults
2.   Drug and/or alcohol abuse
3.   Non-compliance with medication
4.   Hallucinations commanding patient to kill
5.   Cornered paranoid patient who kills in "self-defense"

Violence by schizophrenics is more sensational because it arouses fear of unpredictability, challenges one's sense of control, and is more bizarre. This is analogous to ministers being no more likely to commit crimes, but when they do, it is more sensational.

Physical Aggression

Defined as threatening, breaking objects, shoving, hitting or beating someone:

• occurs among 30% of patients in the hospital.
• occurs among 30% of patients in the family home.
• can be caused by symptoms of the illness:
  • command hallucinations,
  • paranoid protection, and
  •  grossly disorganized behavior
• Prevent symptom-based violence with medication.
• Can be caused by great frustration and poor impulse control. The patient has so few skills to get his needs met that he uses physical aggression to:
  • Get what he needs,
  • combat the perceived source of frustration,
  • maintain a sense of status or power, and
  • respond to an environment perceived as hostile.
• Prevent frustrated, impulsive violence with:
  • external controls,
  • teaching internal control, and
  • making life more fulfilling and less frustrating.

Parents Response to Aggression

Method                                           % of Families Using It                             Effectiveness
Restrict own behavior                                    54%                                                Poor
Create distance                                            20%                                               Good
Calm patient                                                14%                                                 Best
Set limits                                                      6%                                                Good
Do nothing                                                    6%                                                 Poor
 

Steps to Prevent Physical Aggressions

1.   If your relative has a history of physical aggression, do not allow him to live at home unless he is compliant with medication and not using drugs or alcohol.

2.   Learn factors which predict physical aggression from your relative. Common predictors are:
      a. physical signs (red-faced, wide-eyed, trembling).
      b. paranoia, especially of imminent harm.
      c. angry remarks, arguments, confrontational attitude,
      d. disorientation, confusion, or
      e. withdrawal into a simmering silence.

3.   Do not pretend everything is fine; have a plan.

4.   Avoid the tempting responses of:
      a. restricting your own activities,
      b. backing down from the rules, or
      c. letting the violence control you. (You can inadvertently teach the patient to use
         violence to get his way and you can destroy the family in the long run).

5.   If your relative is imminently dangerous, attend to safety needs first. Leave, call the police, and activate your emergency plan.

6.    If your relative is less upset, adopt a calming attitude. Imagine that you are braking a runaway truck. The attitude you should assume:
      a. is calm and non-threatening,
      b. has slow speech with simple statements,
      c. is caring but confident,
      d. listens more than talks,
      e. empathizes with fear and pain,
      f. focuses on calming now,
      g. avoids discussing emotionally charged issues, and
      h. doesn't argue or criticize.

7.   Assist your relative with doing things that uniquely calm him. Convey the expectation that he can control his behavior. Help him to become more calm. Make it easy for him to cooperate and still save face.

8.   Once the crisis is passed and both the patient and family are calm, use the "wisdom of Solomon" to review the situation and apply natural consequences. Aggression tends to escalate over time, so it is very important to apply negative consequences to the first incidents.

9.   Involving the police is a very effective intervention which usually has positive short-term and long-term consequences. In the short term, police are able to control the situation. (Be sure to give the police as much information as possible about your relative, so that they can handle the situation with maximum safety for all). In the long term you create a record which can be used in future involuntary treatment proceedings.

10. Follow through with involuntary treatment and/or conservatorship, if appropriate.

11. Get professional help if;
      a. there is any physical violence,
      b. violence or threats control the family, or
      c. the family is afraid of the patient.

12. Make sure that you protect yourself. Your ill relative relies on your care. If he seriously injures or kills you, he'll be in jail and will have no one to help him.

Depending on the circumstances, you may need to:

     a. get a restraining order,
     b. lock up sharp objects or weapons,
     c. put a lock on your bedroom,
     d. install a security system with a panic alarm,
     e. change the locks on your house, or
     f. temporarily leave your house.

Handling Your Relative's Anger

Mentally ill people have more reasons to be angry but fewer resources for managing anger. Anger can have constructive features in signifying that something is wrong and activating that person to action.

Most mentally ill people cannot harness the constructive elements of anger because the anger exacerbates their thinking and problem solving deficits.

An important predictor of violence in hospitals is a staff response of anger or confrontation to an angry patient.

Understand which techniques work best to manage your relative's anger. Some useful techniques are:

• you remain calm. If you are not calm, leave the situation and return when you are calm.
• establish a plan when everyone is calm and remind patient to use the plan.
• allow patient to express anger in acceptable ways.
• teach or have someone teach anger control strategies. Remind patient to use the strategies.
• expect and reward appropriate behavior.
• don't argue or confront the patient when he is angry.
• set reasonable limits on and consequences for inappropriate expressions of anger.

PREVENTING SUICIDE

by Mary A. Rawlings, L.C.S.W.

Coping with suicide is one of the most difficult situations you will face. It raises a lot of strong feelings that can paralyze us. While none of us can prevent suicide 100% of the time, there are things we can do that can prevent suicide much of the time.

Most attempts are preceded by warning signs. Knowing what these are, knowing your unique situation, and having your own crisis plan can help you be prepared.

Remember that due to the complicated nature of suicidal behavior, obtaining professional consultation for your particular situation often can be very helpful.

Warning Signs

Some warning signs are considered to be more serious than others, however there are no absolute rules to follow so all warning signs should be taken seriously and responded to in some fashion.

1.   Most serious warning signs include:
      a. acute delusional or manic state involving beliefs that can cause harm such as a belief they can fly.
      b. discussion of a concrete specific plan for committing suicide.

2.   Additional warning signs include:
      a. going into or just coming out of a state of serious depression in which there is extreme hopelessness and an extreme sense of worthlessness.
     b. hallucinations commanding the person to suicide.
     c. getting one's affairs in order, i.e., giving away possessions, saying good-bye, writing a will.
     d. talking of wanting to die, especially if this is a new behavior.
     e. a history of previous attempts or gestures combined with any of the above.
     f. concurrent alcohol or drug abuse with any of the above.

Understanding Your Unique Situation

Each circumstance will be different and unique. The above warning signs provide you with some general guidelines, however your situation may have some unique characteristics which can help you plan your interventions. For example, your relative may have command hallucinations, but he only makes suicide attempts when he is also drinking alcohol. Thus, in this situation, drinking dramatically increases the seriousness of the situation. Or your relative has had chronic depression for a long time but without suicidal ideation. Suddenly he is talking about suicide. This shift is behavior is important to notice and to respond to in some way. Consider your situation. List any unique aspects or warning signs.

Developing a Crisis Plan

To develop a crisis plan, talk through each situation that may present itself, from your relative talking about suicide, all the way to finding your relative having just taken a bottle of pills. Plan interventions for each situation you may encounter. Although this is difficult, it will empower you to act effectively when you need to. Obtaining professional consultation might also be helpful with this if you find yourself having difficulty planning.

Reminders

(Adapted from When Someone You Love Has A Mental Illness by Rebecca Woolis)

1.   Familiarize yourself with local resources both daytime and after hours.

2.   If the person is severely depressed, do not ignore, minimize or deny his feelings, but rather empathize, offer support, and encourage as indicated.

3.   Encourage your relative to seek help, and seek help yourself.

4.   Try to determine if the person has a concrete plan for suicide. The closer he is to having one the more serious the situation.

5.   If the situation seems serious and you can elicit an agreement from the person not to harm themselves unless they contact you first, hide or confiscate dangerous items such as knives or medication, and seek assistance.

6.  Some suicides happen with no warning. Nothing anyone can do will prevent them.