Compassion Strengths

Workshops, consultations, education and support for care givers.

Article 10

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Psycho-educational Family Support


Family members of people who have severe and persistent mental illness are often the unidentified client and are far too often ignored in the treatment process. The following is a brief description of some simple approaches that families may find helpful in working with their loved one.

Low in expressed emotion.

Low "EE" families tend to show a casual, easy going, relaxed attitude towards the consumer and the symptoms of the illness. They are not prone to quick or severe reactions, they are not overly positive or critical. They take the ups and downs of the illness in stride. They remain balanced despite the consumers at times severe behavior.

Well structured.

These families have clear roles and expectations of each other. They are able to communicate clearly and in a timely fashion. They do not "bottle up" their emotions and explode or act out. They are able to perform consistently in their roles i.e., as husband, father, wager earner, etc. They also maintain consistent outside activities with friends, clubs, churches - they do not get overly involved or caught up in the consumer’s illness.

Able to set limits.

Families that cope well with consumers are empowered to set and keep consistent boundaries and limits. While these boundaries and limits are flexible, they are also firm. Certain specific expectations of the consumer are made clearly and consistently: both expected behavior as well as those behaviors that are unacceptable. If the limits are broken, defined and anticipated consequences follow. What is said is followed through with action.

Accepts that chronic mental illness is a medical disorder.

This empowers the family in two ways. First it takes away the mistaken notion that the family somehow caused the illness. This frees the family to see and respond the consumer objectively, responsibly and effectively. Second, it reminds the family, that as an illness medication is a requirement. The healthy family accepts, encourages and actively participates in the consumer complying to medication, i.e. taking, following the side effects and keeping appointments with medical personnel as needed.

Able to differentiate responsibility and blame.

The responsive family is able to accept its responsibility to but not for the consumer. Ultimately every adult individual is responsible for themselves. However, the responsive family accepts that it should do what it can do. Since the family does not feel to blame for the mental illness, it is free and able to respond appropriately.

The responsive family has a low level of expressed emotion. they are generally easy-going. They have a clear and consistent structure with well defined boundaries and expectations. They accept the illness and are able to set boundaries. They accept the need for medication and actively participate in the consumers compliance. They have a high degree of responsibility to the consumer and do not blame themselves for the illness.

The following outline is a guideline to help families deal more effectively with their loved one.

Revise Expectations.

Our image of others as well as ourselves are surprisingly resistant to change. Families tend to view their family member as they remember them before the illness. It will be necessary to adjust your image and expectations of your family member.

Consumers have an increased need for sleep, rest, social withdrawal and limited activity. They cannot be as active and involved as they were before the illness. Families should resist comparing their member's behavior with when he/she was well or with other people. Since the illness, a new baseline for behavior needs to be drawn.

Create Barriers to Over-stimulation.

Because of the disorganization and internal distraction inherent in chronic mental illness, even "normal" amounts of stimulation may be too much to handle. It is important for the family to develop an attitude of "benign indifference." Minimize nagging, negative, conflicting behaviors, allow the need for "time out." Also don't over-do the positive, strike a balance. Negative or less helpful behaviors to avoid include:
  • Conflict and criticism between family members in general and with the consumer in particular.

  • Extreme, or over-involvement, positive or negative with the consumer.

  • Decreased involvement with each family member's own social network or other potential supports beyond the immediate family.

Set Limits.

Again, because of the lack of internal boundaries as well as disorganization and distraction, precise, predictable, consistent boundaries or limits need to be set and kept. Do not confuse low stimulation with lack of boundaries. Keep a low key predictable family environment.
  • Decide on minimal conditions or rules necessary for the consumer to live at home with the family.

  • Set limit clearly without detailed discussion with the consumer.

  • Keep requests for limits specific - instead of "you should help out more," make the request in definable behaviors, - "take out the garbage."

  • Set limits before tension builds - be active not reactive. Don't wait for things to blow-up.

  • Don't be fooled by a person's age.

  • Avoid threats. Try not to set a limit you are not prepared to follow through on.

  • Expect to be tested.

Selectively Ignore.

Families may tend to either over-react to the consumer’s unusual behavior or (finally) ignore it - and them, altogether. Families should try not to be overloaded by the number of changes that need to be made. Also try not to overload the consumer.
  • There are of course some key exceptions to this guideline. Never ignore violent behavior.

  • The incidence of violent behavior is generally not any greater in consumers than the general population.

  • Violence, out of control behavior can be avoided by setting limits early, gently and firmly, keeping expressed emotions low, keeping a predictable structure.

  • If violence does occur, get immediate help - call the authorities. Express to them that the person out of control has a history of mental illness and requires immediate assistance.

  • Suicidal threats gestures and/or attempts require immediate attention. The incidence of suicide is much greater among the chronic mentally ill population. Refer to the mental status examination to make a thorough assessment of suicidal ideation, intent and plan.

Keep Communication Simple.

With the high level of distraction, difficulty attending and concentrating consumers tend to experience, keep communication clear, direct and simple. Avoid over-stimulating or overtaxing. Avoid long drawn out explanations or abstractions. Be clear, concise and concrete.
  • Acknowledge the statements made by others accepting responsibility for one's own communication. Keep assumptions to a minimum.

  • Avoid excessive detail or excessive abstraction. Do not "entertain" the consumers psychotic, delusional ideas or talk. Ask for clarification when unsure about what is said.

  • Express and emphasize positive messages and supportive comments.

Support the Medication Regime.

As previously stated, one of the most important behavior the family can support is that of regularly, and consistently taking prescribed medication. Also to support regular, scheduled and monitored follow-up with a psychiatrist who can make necessary, periodic changes in dose and type of medication. It is also a good idea for the family to try to maintain some kind of relationship with the clinic. This will demonstrate active interest on the family's part and will help generate interest and care on the part of the medical clinic.

Normalize Family Routine.

The ability to care for another begins with the ability to care for ourselves. There are dangers when becoming over-involved. The family loses it's own sense of balance. Over-involvement leads to "burnout," finally resulting in apathy. The very behavior intended to "save" the consumer results in further deterioration.
  • Maintain contacts outside of the family.
  • Social contacts are good distraction from the constant pain of dealing with the consumer’s illness.

  • Social contacts counteract the tendency to get overly involved with the consumer’s illness.

  • Families need to prepare themselves for and accept the "long haul" of dealing with chronic mental illness.

Learn to Recognize the Signals for Help.

These signals are specific behaviors unique for each individual. The family can learn only through experience and over time which of the consumer’s behaviors are "adaptive" and which are not.

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