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.
You Need To:
trouble with reality
|are over stimulated
input, don't force discussion
|easily become agitated
recognize agitation, allow escape
|have poor judgment
expect rational discussion
|have changing emotions
|have changing plans
little empathy for you
recognize as a symptom
|have low self-esteem
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
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
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
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
- Not including the patient in
family portraits, and
- Not involving the patient in
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
- 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.
by Christopher Amenson, Ph.D.
HAVE REALISTIC HOPES
- Accept your relative as he
Mourn the loss, but not
in the presence of your relative.
Never discuss what he was or what
he could have been.
Avoid comparisons to peers.
- Demonstrate that he is a
person of worth and dignity even if he can't do certain things.
- Treat him as an adult.
Include him in decisions.
Ask him to help you do things.
- Allow him to have his own
dreams and goals. No one knows what the future will bring.
- Translate long-term large
goals into a step which is possible to do today.
- Focus efforts on today's
- Help him to attain his
unique version of fulfillment
- 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
- 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
- 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
- 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
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
Let some things slide. Do not
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
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
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
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
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.
- 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
- 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
- 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
- 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
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
- 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
by Christopher S. Amenson, Ph.
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
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.
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,
- Activity Level
- Involvement in the Community
- Comfort in Surroundings
- Breadth and Quality of Life
- Happiness/Self Esteem
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
- Possession of the Requisite
- Availability of Energy to be
- Resulting Neglect of Other
Persons, Roles, or Goals
Positive and Problematic
Positive - Living at Home
- Few disruptive symptoms.
- Has activities outside the
- Comfortable with parents
- Helps parents.
- Family is calm and skilled.
- Family is minimally
- Family has lots of support.
Problematic - Living at Home
- Patient is in control.
- Patient seldom leaves home.
- Parents must restrict their
- Patient creates chaos and
- Family has no support.
- Family unable to support and
by Christopher S. Amenson,
Understand your symptoms and
- 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
- Find and stick with a
psychiatrist you can trust.
- Take medication as
- 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
- Learn to recognize the early
signs of relapse.
- Ask for help when you need
Have and work toward
- 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
- 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
Be as independent as
- 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
- Be close, but not too close
to your family.
Avoid street drugs and
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.
by Christopher S. Amenson,
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
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
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
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
by Christopher S. Amenson,
Causes of Relapses
(In Order of Importance)
1. The episodic nature of
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
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
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
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
2. Temporarily reduce stress
a. lowering demands and
b. keeping a routine
(minimizing changes), and
c. providing a safe, calm,
3. Do the specific things
which calm and reassure your relative. Alternatives include:
a. low stress activities or
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.
by Christopher S. Amenson,
FACTORS CONTRIBUTING TO
1. Very young or very
old. 7. Poor judgment and insight.
education. 8. Hostility
alone. 9. Fear and
4. Lack of
transportation. 10. Personality
5. Lack of knowledge of
illness. 11. Substance abuse.
6. Therapeutic effects not
1. Presence of extra-pyramidal
side effects (involuntary movements).
2. Presence of dysphoric response
(feels less alive).
3. Presence of other side
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
"PERSONAL THREAT" FACTORS
1. Resistance to accepting the
2. Paranoid delusions about
content or effects of medication.
3. Change in lifestyle or habits
4. Prefers delusional sick life
to depressing well life.
5. Resistance to mind-controlling
2. Family relationships.
3. Peer influences.
4. Resistant to authority.
5. No alliance toward patient
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
c. Identify which and how
symptoms disturb him.
3. Help the patient identify
how symptoms interfere with goal achievement and cause negative social
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
b. feedback from others, and
c. videotapes or other
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,
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
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
c. Helping him to learn to
gain control over symptoms and side effects (medication and
d. Negotiating a shared
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
b. Using a weekly dose pill
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.
by Christopher S. Amenson,
Motivating a Person with
1. Recognize that the negative
symptoms of schizophrenia include apathy, loss of interest and enjoyment
of activities, lack of motivation, and withdrawal.
NOTE: Older psychotropic medications do not help these
symptoms. Newer medications do address the negative symptoms of
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
- 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
- label as necessary for
- 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
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
- 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
- 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
- delay criticism and ignore
- shape behavior over time.
- make task simpler or less
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
- 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
- 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
Contingency Contracting (setting up a
- 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.
by Christopher S. Amenson,
Probability of Committing a Future
Schizophrenic Not Schizophrenic
Predictors of all Types of Violence
(in order of importance)
1. Past history of physical
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
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
- command hallucinations,
- paranoid protection, and
- grossly disorganized
- 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
- maintain a sense of status
or power, and
- respond to an environment
perceived as hostile.
- Prevent frustrated, impulsive
- external controls,
- teaching internal control,
- making life more fulfilling
and less frustrating.
Parents Response to Aggression
Method % of Families Using
Steps to Prevent Physical
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,
b. paranoia, especially of
c. angry remarks, arguments,
d. disorientation, confusion,
e. withdrawal into a
3. Do not pretend everything
is fine; have a plan.
4. Avoid the tempting
a. restricting your own
b. backing down from the
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
b. has slow speech with
c. is caring but confident,
d. listens more than talks,
e. empathizes with fear and
f. focuses on calming now,
g. avoids discussing
emotionally charged issues, and
h. doesn't argue or
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
b. violence or threats
control the family, or
c. the family is afraid of
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
c. put a lock on your bedroom,
d. install a security system
with a panic alarm,
e. change the locks on your
f. temporarily leave your
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
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
- don't argue or confront the
patient when he is angry.
- set reasonable limits on and
consequences for inappropriate expressions of anger.
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
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.
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
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
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
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.
(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.