The following document is a reproduction of materials distributed in a course called Mutual Education, Support and Advocacy (MESA) for family members of persons with bipolar disorder or schizophrenia. The 12 week course was sponsored by NAMI (National Alliance for the Mentally Ill). One of bpso's members attended this workshop, and has obtained the permission of the course instructor to make these materials available here.

MESA - FAMILY WORKSHOPS

Mutual Education, Support and Advocacy

TABLE OF CONTENTS

MESA KEY CONCEPTS AND GUIDELINES

PART 1: INFORMATION AND SUPPORT

SESSION I - What is Mental Illness?

SESSION II - Impact on the Family

SESSION III - Symptoms of Mental Illness: Schizophrenia

SESSION IV - Symptoms of Mental Illness: Mood Disorders

SESSION V - Impact of Mental Illness on Sense of Self

Special Concerns: Substance Abuse, Suicide Risk

SESSION VI - The Diagnostic Process and Theories on Causes

SESSION VII - Impact of Stress

PART II: SKILLS BUILDING

SESSION VIII - Communication 1

SESSION IX - Communication 2

SESSION X - Communication 3

SESSION XI - Problem Solving

SESSION XII - Applying the Guidelines

Post Test

Pre/Post Test

M E S A

Mutual Education, Support, and Advocacy

FAMILY WORKSHOPS

KEY CONCEPTS AND GUIDELINES

1. MENTAL ILLNESSES, LIKE OTHER LONG TERM ILLNESSES, PRESENT THEMSELVES IN DIFFERENT WAYS AT DIFFERENT TIMES IN A PERSON'S LIFE.
   1. The degree of intervention and support needs to vary depending on the stage of the illness.
      1. During a stage when symptoms are most severe (acute episodes):
         1. families need to be more accessible and supportive.
         2. medication and hospitalization may be the most effective treatment
      2. During recuperative/stable periods:
         1. families need to continue support
         2. while gradually increasing expectations and levels of responsibility.
   2. The illness is not the person: Recognize that people who have a mental illness also have their own unique personalities with strengths and contributions to make.
   
   
2. THE STRESS OF MENTAL ILLNESS AFFECTS ALL THE FAMILY MEMBERS.
   1. A. Feelings of anger, hurt, resentment, despair are typical responses for family members.
   2. Adjusting to a relative's mental illness is a painful process similar to grief and mourning.
   3. Blaming oneself or others is non-productive.
   4. Support from others in a like situation helps relieve the stress imposed by mental illness.
   5. Outside activities and time for oneself are necessary in order to maintain health.
   6. Education about mental illnesses and resources helps families understand and cope.
   7. Educating others helps to combat the stigma of mental illness and to overcome the isolation that families experience.
   8. Families need to resume their own lives as they cope with and adapt to the illness.
   9. Joining with other families to advocate for the needs of people who have mental illness can be rewarding and productive.
   
   
3. MENTAL ILLNESSES ARE BIOLOGICAL ILLNESSES WHICH IMPAIR INTERNAL CONTROL OVER THOUGHT AND MOOD PROCESSES.
   1. Order and structure in the environment help to provide external controls (for the person who has a mental illness).
   2. Expectations and life goals may need to be reevaluated.
   3. Maintenance of a calm mood (as much as possible) increases control over the situation.
   4. Clear and simple communications increase ability to understand and be understood.
   5. Reinforcement of reality can be reassuring to a person with mental illness when thoughts become distorted or delusional.
   
   
4. MENTAL ILLNESSES INTERRUPT NORMAL DEVELOPMENT OF A SENSE OF IDENTITY AND SELF ESTEEM.
   1. Family members, the person with the mental illness, and professionals need to work together to develop and support a rehabilitation plan.
   2. Families need to encourage the establishment of appropriate and attainable roles within the home and community.
   3. Families need to look for "health" and reward small gains.
   
   
5. PEOPLE WITH MENTAL ILLNESSES TOLERATE STRESS POORLY.
   1. An environment which is neither over stimulating nor under stimulating helps reduce stress.
   2. Change, positive or negative, creates stress.
      1. Plan ahead, when possible, in order to minimize stress.
      2. Avoid making more than one change at a time.
   3. Identification of stressors and individualized reactions to stress can help prevent relapse.
   
   
6. MENTAL ILLNESSES INTERFERE WITH COMMUNICATION BECAUSE THOUGHTS AND MOODS BECOME DISORDERED.
   1. Communication needs to be clear, specific, and focused.
   2. Verbal communication needs to be consistent with nonverbal communication.
   3. Communication of anger, hurt or disappointment should be done in a clear, non threatening manner. (Suppression may foster resentment and the accumulated anger may resurface as hostility at a later point.)
   4. Emphasis in communication should be on acknowledging or praising positive actions or behavior.
   
   
7. THE COMPLEX NATURE OF MENTAL ILLNESSES REQUIRES SPECIAL GUIDELINES FOR THE WHOLE FAMILY.
   1. The needs and rights. of all family members must be considered.
   2. Overdoing for a person who has mental illness decreases his ability to do for himself and increases the burden on the family.
   3. The member who has mental illness should not be allowed to dominate the whole family.
   4. The family needs to act as a unit. A consistent approach among family members and follow-through in dealing with behavioral issues prevent manipulation.
   5. Hope and determination lead to solutions.

Return to Table of Contents

SESSION I - What Is Mental Illness?

Mental illness is portrayed in different ways on television and in newspapers. Families often experience many other behaviors and have many feelings about mental illness.

REFLECTION

What is mental illness? What have you experienced?

Mental illness affects people in different ways. Symptoms are not the same for everyone. Some symptoms like hallucinations are more apparent in the active stage. Others like social isolation and low motivation may continue after the active symptoms are under control.

REFLECTION

What does mental illness look like? What have you seen in your family member?

The course of any mental illness is highly variable. It is sometimes hard for both families and professionals to maintain realistic expectations regarding personal, social, and occupational behaviors. Expectations which are too high may increase the individual's symptoms. Expectations which are too low do little for symptoms such as isolation and low motivation.

Homework

Catch a person pleasing you.

Use the "Catch a Person Pleasing You" sheet on the next page to document as many as possible expressions of positive feelings each day during your week. At the bottom of the sheet are several examples of small behaviors that anyone may do all the time but fail to get recognized. A positive attitude is based on perceiving and responding to such everyday behaviors.

Return to Table of Contents

SESSION II - IMPACT on the Family

Family members are affected by a relative who has mental illness just as they would be with any catastrophic illness.

REFLECTION

How have you been affected by your relative's illness?

REFLECTION

How has your life changed since having a family member develop a mental illness?

EXERCISE

There is a form called "Impact List". Fill out, marking any of the statements that apply to your situation. Do you see any similarities between the symptoms marked on the form and the statements that you listed in the above exercises?

IMPACT LIST

• I feel guilty that I may be the cause of this mental illness.
• I blame myself by feeling: "If I had done this or that......
• I feel embarrassed by his/her behavior.
• This bizarre behavior is a reflection on me as a person.
• I'm afraid he/she may hurt me or someone else.
• I resent this intrusion in my life. (Why me, Lord?)
• I neglect my other family members to look after this person.
• I get angry at this person because I feel he/she could do better if he tried.
• I get angry when I respond to this person in a way that is not helpful.
• I worry about what would happen if my parents were not around.
• I now see many mistakes I have made in the past.
• There are times when I dislike this person.
• I get so blue about this situation we are in.
• I'm so afraid he/she will get sick again.
• I feel helpless about being able to change what is happening. I find myself taking out my frustrations on other family members.
• I often wonder what it would be like if my brother/sister were not ill.
• I really want an easy answer -- some "magic dust".
• The mental health professionals should have an answer by now.
• I feel I should be willing to sacrifice myself for this person.
• I have no time for myself. I don't go out and do things that I like to do.
• I'm afraid to point out a wrongdoing because it might cause some craziness. I spend a lot of time "walking on eggs".
• I wish things were different.
• Sometimes I am afraid that I too will become ill.
• I'm afraid to leave this person alone. He/she may burn the house down. What if he/she doesn't take his medication?. I worry a lot.
• I have left the mental health center really disagreeing with the professionals. Mental health professionals ignore what I feel about this illness.
• It has taken so much of our hard earned money to take care of this person. I find myself pulling back from friends and acquaintances.
• My wife/husband is too hard/soft on this person who has mental illness. We fight over this.
• My parents are too hard/soft on my brother/sister who has mental illness.
• I feel such a loss.
• I am physically, spiritually, emotionally tired and depleted.
• I seem to be visiting my family physician's office more frequently.
• I worry about whether or not my children will get a mental illness.
• I feel sad about his/her losses.
• I have hope for the future that things will be better.

REFLECTION

Read Guideline II. How does it apply to your situation? Which statement is the most helpful?

While the impact of mental illness on families continues to be heavy, there are some very hopeful, positive developments taking place. Research into the biological causes of mental illness is advancing. Community support services are improving and better rehabilitation methods are being created. More collaboration is taking place between families and professionals. National Alliance f or the Mentally III families have joined together to provide support for each other and are strong advocates for research, services, and education.

Mental illness is very stressful on both the consumers and family members. Education and support help in many ways.

Return to Table of Contents

SESSION III - Symptoms of Schizophrenia

The Diagnostic and Statistical Manual of Mental Disorders (DSM IV), is used by professionals to provide clear descriptions of symptoms and diagnostic categories. The information on Schizophrenia and Mood Disorders is taken from this book.

Sometimes a person may receive different diagnoses at differentiates A comparison of Schizophrenia to Bipolar Disorder is listed below. These are "classic' examples of how these disorders differ. However in Individual cases the division may not be so clear. History is important when making a diagnosis. A person in the- height of a manic stage may be disorganized, agitated and delusional and appear to have Schizophrenia.

Approximately one to two percent of the United States population develop Schizophrenia during their lifetime. The onset is usually between the ages of 16 and 25. Men develop the illness earlier than women. Symptoms can be controlled but a cure is not known at this time. Research is progressing rapidly into the biological causes of the illness.

SYMPTOMS OF SCHIZOPHRENIA

No single symptom is always present or seen only in schizophrenia.

POSITIVE SYMPTOMS (The presence of perceptions, beliefs & behaviors that are not present in people who do not have Schizophrenia).

1. Delusions.
   Delusions are fixed beliefs which have no possible basis in fact and cannot be changed even when presented with evidence to the contrary.

   Types of delusions include:

   • Simple Persecutory - believes others are spying, plotting against him.
   • Delusions of Reference - objects, events, or other people are given unusual significance (TV or radio talking about them).
   • Thought Broadcasting - believes his thoughts are broadcast to others so they can hear them.
   • Thought Insertion - believes thoughts which are not his own are inserted into his mind.
   • Thought Withdrawal - believes his thoughts are being taken from his mind.
   • Being Controlled - believes that her feelings, impulses, thoughts and actions are not her own, but are imposed by some other force.
   • Grandiose - a delusion of inflated worth, power, knowledge, identity of special relationship to a deity or famous person.

   REFLECTION

   What have you experienced with your relative? How have you responded to these symptoms?

   Tips on Dealing with Delusions:

   • Recognize that the ideas are real to the person.
   • Do not take delusional ideas personally.
   • It is not helpful to argue or to agree.
   • Reflect reality. Provide support.
   • Base your response on the strength of the delusion.
   • Realize that the person may be asking for help assessing reality.
   • Delusions are target symptoms of medications. A medication adjustment may be needed.
   • 70%-80% of people with Schizophrenia respond to traditional antipsychotic medications.
   • Newer antipsychotic medications are helping people who have not responded to traditional medication.
   
   
2. Hallucinations

   Hallucinations are sensory perceptions in the absence of the appropriate external stimuli. The person may hear, see, smell, taste or feel something that others do not hear, see, smell, taste or feel

   .
   Types of hallucinations include:
   
   • Auditory - hearing sounds (most common type of hallucination), usually voices. Tactile - feeling a tingling, burning sensation.
   • Visual - seeing things.
   • Gustatory - misperception in taste.
   • Olfactory - misperception in smell.
   
   

   REFLECTION

   What have you experienced with your relative? How have you responded to these symptoms?

   Tips on dealing with hallucinations

   • Realize that hallucinations are real to the person.
   • Realize the hallucinations may be terrifying.
   • Express support to the person and give assurance that the voices etc. are not real Antipsychotic medication can control hallucinations.
   • Stay calm. Be reassuring.
   
   
3. Disorganized Speech (previously known as disorganized thought processes)
   
   • Confusion in thinking
   • Poor ability to concentrate or organize thoughts.
   • Poor ability to organize thoughts toward a goal.
   • Loosening of associations
   • Ideas shifting from one subject to another unrelated one;speaker does not show awareness that subjects are unrelated.
   • Tangentiality. Answers to questions- may be completely unrelated or only vaguely related.
   
   REFLECTION
   What have you experienced with your relative? How have you responded to these symptoms?
   Tips on dealing with disorganized speech:
   • Keep communication clear, specific and direct.
   • Avoid processing and excessive details.
   • Provide structure in daily activities.
   • Give one instruction at a time.
   • Consider completion of a job a success, no matter how small or well done.
   • Be patient.
   
   
4. Grossly Disorganized Behavior
   
   • Childlike silliness to unpredictable agitation.
   • Problems with goal directed behavior, e.g. organizing meals, maintaining hygiene. Disheveled appearance or unusual manner of dressing.
   • Inappropriate sexual behavior.
   
   
5. Catatonic Motor Behaviors (Stupor, Rigidity, Negativism, Posturing, Excitement).

NEGATIVE SYMPTOMS (The absence of behavior or feelings that are ordinarily present in persons with no mental illness)

Families often find it more difficult to cope with negative symptoms than positive symptoms. Negative symptoms sometimes cause the family to feel that the person is lazy or not trying to help himself.

1. Flat Affect
   Affect is an immediate expressed and observed emotion. A feeling state becomes an affect when it is observable. Facial appearance or tone of voice -may change. The person may have a flat or inappropriate affect.
   A flat affect occurs when there are no signs of affective expression. The voice may be monotonous and the face immobile.
   [Another type of affect disturbance (which is not a "Negative Symptom") is inappropriate affect. This occurs when the expressed emotion is different from the individual's feelings, such as: laughing while describing a sad experience. Sudden changes in affect involving unexplainable outbursts of anger or crying may also occur.]
   REFLECTION
   What have you experienced with your relative? How have you responded to these symptoms?
   Tips on dealing with affect disturbances:
   • Recognize that affect disturbance is a symptom of the illness.
   • Don't be offended by inappropriate affect.
   • Don't take the affect personally.
   
   
2. Poverty of Speech
   Brief empty replies Decreased speech
   REFLECTION
   What have you experienced with your relative? How have you responded to these symptoms?
   Tips on dealing with Poverty of speech
   • Poor response can be a symptom.
   • Don't blame yourself.
   • Try not to feel uncomfortable or angry. Be supportive.
   • Continue to try to engage relative but don't overdo.
   
   
3. Impaired Motivation - Avolition
   The person may have low interest and drive and or may have inadequate ability to make plans and initiate activity to reach a goal.
   The person with schizophrenia often seems to be poorly motivated and not interested in helping himself. He may be seen as lazy. Poor motivation seems to be closely related with disturbed sense of self.
   REFLECTION
   What have you experienced with your relative? How have you responded to these symptoms?
   Tips on dealing with impaired motivation - Avolition:
   • Realize that low motivation is a symptom of the illness.
   • It is not a character defect or reason to put shame or blame on the person. It could be fear.
   • Help develop a rehabilitation plan with clear goals.
   • Provide support for family member to stay on tasks.
   • Recognize the need to take small steps.
   • Provide positive reinforcement for small gains.
   
   
4. Social Withdrawal
   The person may withdraw and avoid involvement with others. He may become preoccupied with fantasies and illogical ideas. Social withdrawal is one of the most common symptoms of persons with schizophrenia. It may be the first symptom families notice. There may be several reasons for withdrawing including: confusion in thinking; poor sense of self; high vulnerability to stress; fear of relationships; and too much stimulation.
   REFLECTION
   What have you experienced with your relative? How have you responded to these symptoms?
   Tips on helping with social withdrawal:
   • Recognize difference between alone time and isolation.
   • Everyone needs time to himself.
   • Extended withdrawal may signal need for medication consultation.
   • Consider the length of time the relative is apart and alone, activity during these times and the extent it interferes with daily activities.
   • Encourage the relative to participate.
   • Participation in activities should be gradual.
   • Subtypes of Schizophrenia:
     1. Paranoid type
     2. Disorganized type
     3. Catatonic type
     4. Undifferentiated type
     5. Residual type
   
   REFLECTION
   Read Guideline III. How does it apply to your situation? Which statement is the most helpful?

Return to Table of Contents

SESSION IV - Symptoms of Mental Illness: Mood Disorders

There are four classifications of Mood Disorders: Mood Episode, Depressive Disorders, Bipolar Disorders, Other Mood Disorders.

A mood is a prolonged emotion that colors the whole psychic life of the person and generally involves depression or mania. The person's energy level is usually affected. Everyone has moods, but moods are considered disordered when they interfere with a person's ability to perform usual roles involving work, family relations, self care, etc., and over a long period of time such as every day for two weeks.

Many people have the impression that persons with Bipolar Disorders constantly have severe mood swings from high to low. However many people may have only the manic phase of the illness. Below are the symptoms of mania and depression.

Symptoms of Mania:

• Mood - elated, euphoric, cheerful, or high, inflated self esteem, irritable or agitated when questioned.
• Appearance - Appearance is out of character and may be disorganized, flamboyant or bizarre in quality.
• Speech - Excessive amount, loud, rapid, may use jokes and puns, may be theatrical with dramatic mannerisms and singing. May also be verbally critical and hostile.
• Behavior - Displays a lot of activity, excessive planning and participation in multiple activities. Increased sociability. Decreased need for sleep or food. Buying sprees, reckless driving.
• Thoughts - May have rapid, racing thoughts. A nearly continuous flow of speech abruptly changing from one subject to another. Ideas may shift to unrelated ideas without the speaker being aware.
• Delusions or Hallucinations - Do not necessarily occur, but when they do, they are consistent with the person's mood. For example, he may feel he has special powers and abilities when in a manic state.

All these symptoms may not be present at the same time in the person.

REFLECTION

What have you experienced with your relative? How have you responded to these symptoms?

Tips on Dealing with Mania:

• Lithium and other medications have proven effective in stabilizing mood. Education about medication and the illness is essential in preventing relapse. Many people with Bipolar Disorders function well as long as they take medication, participate in a rehabilitation plan and don't expose themselves to excessive stress. Stay calm. The high mood may be contagious.
• Our own mood and level of control affect our relative's mood.
• Superior attitudes and patronizing advice are symptoms.
• Don't take behaviors personally.
• Efforts to reason are usually not effective.
• Medication or hospitalization may be the only effective treatment at this time. Learn to distinguish between a good mood and early signs of relapse.

Symptoms of depression:

• Mood - Depressed and hopeless, not caring anymore, loss of interest or pleasure, guilt feelings, feelings of worthlessness.
• Speech - Slowed speech, increased pauses before answering. Low or monotonous and decreased amount of speech.
• Appearance - Sad facial expression, tearfulness, may neglect grooming, hygiene and dress.
• Behavior - Withdraws from family and friends. Withdraws from usual activities. Difficulty performing responsibilities. Decreased or increased sleep and appetite. Body movements are slowed down. May have pacing or wringing hands. Extreme fatigue and decreased energy. Changes in sexual habits or bowel habits.
• Increase in physical complaints.
• Thoughts - Self depreciation, slowed thinking, poor concentration, indecisive, memory difficulties, easily distracted, preoccupied with death and fear of dying. Suicidal thoughts.
• Delusions or Hallucinations - Do not necessarily occur, but when they do, they are consistent with the person's mood.For example, they may feel persecuted because they are worthless and sinful.

REFLECTION

What have you experienced with your relative?

How have you responded to these symptoms?

Tips on dealing with depressive symptoms

• Medication can be helpful in elevating mood.
• Maintain hope and optimism.
• Don't buy into the relative's negative opinion of himself.Recognize that the relative truly feels worthless, guilty, and hopeless.
• Provide education on the illness and treatment.Be alert to suicide risk and seek medical consultation. Encourage activity and give reassurance.

SCHIZOAFFECTIVE DISORDERS

Some families state that their relatives have been given diagnosis of Schizoaffective Disorder, sometimes after having first a diagnosis of Schizophrenia or Bipolar Disorder.It is difficult at times to distinguish Schizoaffective Disorder from Schizophrenia because the symptoms of a mood disorder can overlap with those of Schizophrenia. Also, if significant mood symptoms are identified, it is difficult to determine how long they have been present and whether this time period would be consider 'substantial".

Symptoms of Schizoaffective Disorder

1. The occurrence of a mood episode (Major Depressive Episode or Manic Episode) concurrent with the symptoms of Schizophrenia.
2. The Mood Episode has been present for a substantial portion of time since the onset of this illness, but not all the time.
3. There must be at least a two week period in which the symptoms of Schizophrenia have been present without the depression or mania.
4. Currently there are two types of Schizoaffective Disorders:
   1. Bipolar Type: if the disturbance includes a Manic or a Mixed Episode (or a Manic or Mixed Episode and Major Depression Episode).
   2. Depressed Type: if the disturbance only includes Major Depressive Episode.

Return to Table of Contents

SESSION V - IMPACT of Mental Illness on Sense of Self

Throughout life, a person continues to develop a sense of who he is. At each stage of development one learns more about his abilities and where he fits into the world. Mental illnesses often occur at the point where a young person is struggling to realize his identity. Mental illnesses often affect a person's ability to organize and to pay attention to his experiences. Being able to organize and synthesize information is necessary for developing one's identity. When unable to do this, it becomes very difficult for a person to develop a sense of who he is and to adapt to new roles and expectations. A person may lose confidence in his abilities. Because mental illness usually occurs in a person's teens or early twenties, it is easy to understand how devastating it is to one's sense of self. It is helpful to read accounts of persons who have experienced these illnesses to better understand the effects of the illnesses on the person's sense of self.

REFLECTION

When did your family member first develop his mental illness? How do you think it affected the way he thought about himself and his abilities, plans and hopes for the future?

Points to remember regarding your relative's sense of self:

• Encourage your family member to participate in a rehabilitation program. Encourage goals which are realistic.
• Recognize gains, however small they seem.
• Having responsibilities helps re-establish roles and a sense of self. Clubhouse programs can help a person establish roles for himself. Re-establishing a sense of self is hard work, but worth it.

Substance Abuse

Families often report that their relative was using drugs/alcohol during the time that he first showed symptoms. Usually symptoms which are caused by drug/alcohol use will clear up in 5 days. Untreated symptoms of mental illness last much longer. The effects of some drugs can cause symptoms which are similar to mental illness. Repeated use of drugs/alcohol can damage the brain and impair intellectual functioning, but there is no evidence that drugs actually cause mental illness.

Many people with mental illness use drugs/alcohol. They may be attempting to selfmedicate or fit into a peer group that does not emphasize achievement. Drugs/alcohol may increase a person's symptoms and further decrease motivation and goal setting.

Both substance abuse and mental illness are thought to be at least partially due to biochemical causes. The incidence and use of drugs/alcohol among people who have mental illness is a growing problem. 47% of people with Schizophrenia and 32% of people with Mood Disorders have a substance use disorder in their life time.

Mental health and substance abuse professionals have recognized the need to treat the coexisting disorders simultaneously. Specialized treatment programs that integrate substance abuse and mental health programs have been developed. Families can help by learning the signs of substance abuse, and insisting on treatment. Specialized "dual diagnosis" educational/support groups are helpful to many families.

REFLECTION

Has your family member been involved in abusing alcohol/drugs? What is your biggest concern about this?

Suicide Risk

Many family members live with the fear that their relative might take his own life. Sharing concerns with others help families "get it out in the open" and give and receive support from others with like concerns. It is helpful to become aware of information on suicide and take reasonable precautions when needed.

Suicide and Schizophrenia

Ten to thirteen percent of persons with Schizophrenia complete suicide. Studies indicate that it is the young, white male with chronic relapsing Schizophrenia who is at high risk for suicide. Other factors include good educational background, high performance expectations, painful awareness of the illness, fear of mental disintegration, prior suicidal behavior and change in treatment status ' The risk may be especially high during the non-psychotic depressed phase of the illness. Hopelessness about the future is often present. One study shows that suicides by persons with Schizophrenia are frequently preceded by interpersonal disruption. Fifty percent had experienced loss of support or contact with family within three months prior to death.

Suicide and Bipolar Disorder

Fifteen to seventeen percent of persons with Bipolar Disorders complete suicide. At highest risk are depressed persons who are constantly and compulsively preoccupied with suicide and who have made plans on how to carry it out. Particularly dangerous periods are during the early stages of depression and when the person has improved and seems to be free of symptoms most of the time. Suicide risk is not high during the manic stage, but the person may injure himself through reckless behavior. Alcohol/drug use increases the risk of suicide.

Common Suicide Warning Signs:

• Feelings of worthlessness or hopelessness.
• Preoccupation with morbid topics or death.
• Withdrawal from previous activities or relationships.
• Increased risk taking behavior.
• Sudden brightening of mood or increased activity in someone who has been seriously depressed.
• Putting one's affairs in order.
• Feelings of anguish or desperation.
• Hallucinations that are very critical of the person or who command the person to hurt himself.
• Sleeplessness, loss of appetite and other "vegetative" symptoms of depression. A concrete plan for suicide.

REFLECTION

Have you worried that your relative may hurt himself? What have you experienced?

Tips on dealing with suicide:

• Assume that suicidal thoughts are present in most, if not all, moderately to severely depressed persons.
• Take all threats of suicide seriously. It is not true that people who talk about suicide do not attempt it.
• Talk with your relative if there is reason to believe that he may be suicidal. Try t increase hope. Above all, seek immediate professional help if there is any concern about suicide.
• Urge treatment for relative's suicidal thoughts.
• Maintain contact with relative's therapist. Hospitalization may be necessary. Maintain support and contact with relative even if he is not at home.
• Avoid suddenly withdrawing support and contact with relative.

REFLECTION

Read Guideline IV. How does it apply to your situation? Which statement is the most helpful?

Homework

Write down what you believe to be your relative's treatment plan, including short term and long term goals. Do you think these are realistic? How can you help your relative and the professionals working with him to achieve these goals?

Return to Table of Contents

Session VI - The Diagnostic Process and Theories on Causes

The Diagnostic Process

REFLECTION

What is your family member's diagnosis? How did you find out?

The Diagnostic and Statistical Manual of Mental Disorders, (DSM-IV) is the guideline used to diagnose mental illness. The DSM-IV describes behaviors and symptoms. A diagnosis provides a common basis for communication among professionals, patients and families. There are five axes which provide a holistic view of the person and his environment.

DIAGNOSTIC AXES

Axis I is where the mental illness diagnosis is placed and usually the primary focus of treatment.

Axis II looks at personality disorders and mental retardation.

Axis III lists any medical conditions the person has. These may impact on the person's mental illness.

Axis IV lists any stressful events which may have occurred during the last year.

Axis V lists the highest level of functioning the person has achieved over the past year and where he is functioning now. If stressors have been high and functioning has been good over the past year, there is hope of a better outcome. If stressors are few and functioning is low, then it is more likely that the episode will be harder to control.

Each diagnosis has a five digit number which describes the specific diagnosis. Thereis a basic three digit number for each disorder. For example in Schizophrenia the # is 295. Following this number will be a 2 digit number for the subtype. The "course specifiers" are noted after the appropriate subtype.

DSM IV NUMBERING SYSTEM

295. Schizophrenia

• 10 Disorganized
• 20 Catatonic
• 30 Paranoid
• 90 Undifferentiated
• 60 Residual

Longitudinal Course:

• Episodic With lnterepisode Residual Symptoms (specify if: With Prominent Negative Symptoms)/Episodic
• With No lnterepisode Residual Symptoms
• Continuous (specify if: With Prominent Negative Symptoms)
• Single Episode In Partial Remission (specify if: With Prominent Negative Symptoms)/Single Episode in Full Remission
• Other or Unspecified Pattern

So 295.30 = Schizophrenia, Paranoid Type, Episodic With lnterepisode Residual Symptoms, With Prominent Negative Symptoms

BIPOLAR DISORDERS

The following specifiers apply (for current or most recent episode) to Mood Disorders as noted above:

1. Severity/Psychotic/Remission specifiers
2. Chronic
3. With Catatonic Features
4. With Melancholic Features
5. With Atypical Features
6. With Postpartum onset
7. With or Without Full Interepisode Recovery
8. With Seasonal Pattern
9. With Rapid Cycling

So 296.54 - Bipolar I Disorder, Most Recent Episode Depressed, Severe With Psychotic Features, Mood Congruent, With Melancholic Features, With Rapid Cycling

Exercise

Read the following vignette and list questions that you would want to possibly ask in order to make a good diagnosis.

A 26 year old young man comes into a crisis center with his parents. He is dressed in a leisure suit with one pierced earring, chains around his neck, and a large watch on his wrist. He appears very unhappy. He is restless, agitated, talking constantly and loudly in the waiting room, talking to all who will respond or listen to him. He looks very tired. Once in the office, he insists that he does not need to be there. He has important things to do for his business. When asked to explain his business, he is vague and guarded. Suddenly, he begins talking about his parent's marriage and then mentions he is hungry and asks to leave to go and get some lunch. He states he has a road construction company and builds highways. His equipment is unguarded in his backyard and he needs to leave. He then lashes out at his parents, saying that they have never supported his business ventures. He says they have caused him to go bankrupt and he sneers angrily at them. There is a loud sound from another part of the building and the young man jerks his head sharply and begins to talk more rapidly about the police coming and taking his equipment....

What questions would you want to ask to make a diagnosis of this young man? What would your tentative diagnosis be? (Some sample questions are at the end of this session).

Theories on Causes

REFLECTION

What do you feel are the causes of mental illness? What do you think caused your family member's illness?

The theories of causes of mental illness are complex, varied and continually being expanded. In times past, mental illness was thought to be the result of sin, bad living, or an imbalance in body fluids. In recent past, family theories suggested that the families were the cause of mental illnesses based on their child rearing patterns or patterns of communicating. Families often felt frustrated and blamed. There is no evidence that any of these theories are valid. Families do not cause mental illness any more than they cause diabetes. The idea that mental illness is caused by faulty family relationships is false.

Current research focuses on biological causes of mental illnesses. Recently - developed technology has revolutionized the way researchers investigate mental illnesses. Brain imaging methods make it possible to study the structure as well as the functioning of the brain. Research is- advancing rapidly!

Research on Causes of Schizophrenia

Schizophrenia is classified as a brain disease. Structural brain abnormalities have been found in some people who have Schizophrenia such as: enlarged ventricles, loss of brain tissue and abnormalities in the size of various parts of the brain. Research on the brains' limbic system has shown abnormal structural changes and abnormal electrical impulses in some people who have Schizophrenia. Abnormalities in the limbic system may produce hallucinations, paranoia and distortion of perceptions.

Functional brain abnormalities found in Schizophrenia include, decreased blood flow to the frontal lobes and decreased metabolism of glucose in regions of the prefrontal cortex. The latter is associated with more positive and negative symptoms and with attention problems. Other research findings show an imbalance in the dopamine/dopamine receptors in the brain. Dopamine is one of the many neurotransmitters or chemicals which transmit messages to the brain. There are at least 6 dopamine receptors; some are overly active and some are under active in Schizophrenia. Other neurotransmitters which are studied in relation to Schizophrenia are norepinephrine and serotonin. Another theory on causes of Schizophrenia is that it may be caused by a brain virus in the pre-or post-natal periods.

Genetics play some role; the person may inherit a predisposition to develop the illness. Schizophrenia is not thought to be 1 00% genetic. If one parent has Schizophrenia their child has a 10% chance of developing the illness. If both parents have Schizophrenia, their child has a 28% chance of developing the illness. Identical twins (those with same genetic material) have a 30% chance of developing the illness. In the general population, 1.5% will have Schizophrenia in their lifetime.

Theoretical Causes of Mood Disorders

Two neurotransmitters, norepinephrine and serotonin, have been linked to mood disorders. These neurotransmitter networks reach many parts of the brain that are responsible for a variety of functions disturbed in depression and mania: mood, sleep, appetite and sexual activity. Antidepressants have specific effects on these neurotransmitters.

Enlarged lateral ventricles have also been found in the brain of persons with Bipolar Disorders. (but less prominent than in Schizophrenia).

Genetic factors clearly play a larger role in the development of mood disorders than in Schizophrenia. If a parent has a mood disorder, the child has a 27% chance of developing a mood disorder. A sibling has a 10% chance of developing a mood disorder if his brother or sister has the illness. Identical twins have a 60% to 80% chance of developing a mood disorder if their twin sibling has the illness. Depression affects 8%-20% of the population. Mania affects 0.5% to 1 % of the population.

Theories Regarding Stress as a Cause

Whether stress causes mental illness has been considered over the years. Studies show that a person who develops mental illness has no more stressful events preceding the onset of his illness than the general population. It appears that the person who has a predisposition to mental illness also has an innate vulnerability to stress. In a person who is highly sensitive to stress, physiological or psychological stress may play a role in the onset of the illness. Once the illness emerges, stress may affect the course of mental illness just as stress influences the course of other long term physical disorders like cancer, diabetes, and multiple sclerosis.

The Biopsychosocial Model

The Biopsychosocial model is one explanation relating to causes of mental illness. It states that a combination of factors is probably responsible. The total physical makeup (biological, neurological, inherited and acquired), psychological influences on the personality, and social factors (such as the society and culture in which a person grows up), affect the development of mental illness. Each of these components influences the other and determines a person's vulnerability to an illness of any kind. The Biopsychosocial model represents the understanding that the illness resides within a unique person, who resides in a unique social network. Each aspect affects the way the illness expresses itself.

REFLECTION

How does learning about the biological nature of mental illness help your understanding of how to help your loved-one?

DIAGNOSTIC VIGNETTE QUESTIONS

• How long has this behavior been going on?
• Is there any history of being on medication?
• What has been happening around him lately?
• Are there any stressors which have been affecting him or his family lately?
• Can he track the conversation in. the room (attend to what is being said and stay focused?)
• What have been his sleeping and eating habits recently?
• How different is his behavior from last year?
• To what extent is his functioning impaired?
• Is there any history of mental illness in the extended family?
• Does he feel like people have been talking about him?
• Has he been able to manage his money?

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Session VII - Impact of Stress

Stress is present in our daily lives. There are many types of stress. Both positive and negative events can be stressful. One definition of stress is that it is an imbalance between perceived demand and ability to cope. What is stressful for one person may not be stressful for another. The accumulation of little everyday hassles can be as damaging as a major life crisis. Each person responds to stress differently and these reactions influence how stress affects him.

People who have a mental illness are thought to tolerate stress very poorly. Stress affects how the person functions during the course of every chronic illness (heart disease, diabetes) and can lead to an increase in symptoms. Families usually experience considerable stress when a family member develops a mental illness. How well the person functions affects the stress level for the whole family. If a person with mental illness can learn to identify personal stressors and his personal reactions to stress, he may be able to learn to deal with stress better and possibly prevent relapse.

Dealing with Stress:

1. In dealing with stress we need to recognize our own personal reactions to it. Examples: tight shoulder muscles, insomnia, keyed up feeling, fear, feeling unhappy, tired.
2. Identify the stressor or stressful situation. Examples: too many responsibilities, untidy house, deadlines, mealtime, speeding ticket, car problems.
3. Evaluate the importance of the stressor. What does it mean to you? How important is it in relation to the rest of your life?
4. Decide to...
   1. Deal with the stressor/situation directly;
   2. Avoid the stressor insofar as possible in the future; or
   3. Learn to react differently to the situation that created the stress by changing habits or reactions to daily events.
5. Practice new habits until you become comfortable with them.

Exercise

Take time now to use these steps to identify your stressors.

1. Identify one personally stressful situation (stressor) during the past week.
2. Why was it stressful to you? What were you thinking/feeling?
3. What symptoms of stress did you have?
4. How did you deal with the stressful situation?
5. Were you satisfied with the way you handled the situation? If not, what would be a more constructive way to deal with a similar situation in the future?

Common Stressors for Persons with Mental Illness

There are four major stressors which pose a problem for a person with a mental illness. There are many more. Families cannot be expected to control the person's environment, but recognizing possible stressors can help maintain the difficult balance that is helpful for a person recovering from a mental illness. These four are listed along with guidelines for making these situations less stressful. You may have many ideas of your own to add.

1. Overstimulation: noisy surroundings, excessive activity, too many and too varied responsibilities, unstructured social events.
   Guidelines:
   • Make a quiet place available in living space.
   • Provide structure in daily routine.
   • Make responsibilities and expectations simple and specific.
   • Give "permission" to withdraw from social events.
2. Understimulation: social isolation, extended withdrawals, no responsibilities, no expectations.
   Guidelines:
   • Encourage participation.
   • Maintain emotionally "neutral" communication.
   • Maintain clear expectations.
   • Assist in developing a daily routine with daily activity.
3. Change: new job, new living situation, new roommate, different therapist, new emotional involvements.
   Guidelines:
   • Plan ahead to decrease stress. Discuss the new development prior to its happening when possible.
   • Recognize that all change, good or bad, creates some stress.
   • Change usually involves new roles and responsibilities in relation to other events.
   • Provide additional support during a change.
   • Only make one change at a time if possible.
4. Communication: unclear, general, hostile, loud, critical communication.
   Guidelines:
   • Be clear and focused when communicating.
   • Give only one direction at a time.
   • Make sure communications are verbally and emotionally consistent.
   • Don't process or give a lot of unnecessary information.
   • Be brief.
   • Look for positives and be specific with positive feedback.
   • Avoid being critical or hostile.

REFLECTION

Which of the above stressors are especially stressful for you or your family member? What events might be coming up during the next week that may create stress? Which guidelines could be helpful?

Preventing relapse: Recognizing Early Warning Signs (Common)

Studies have shown that family members often detect early warning signs of relapse more than a week before a full relapse occurs. In many situations, there is enough time for emergency intervention (medication or relief of stressful situation) between nearly signs" and a full relapse and/or hospitalization. If we can learn to identify the person's individualized early warning signs, a full relapse may be prevented.

Review the "Changes Noted Before Relapse" sheet at the end of this session. These are common early warning signs. Mark off three to five changes you have noticed in your family member prior to relapse. Rank them according to the most frequent to the least frequently noticed symptom.

Preventing Relapse: Recognizing Early Warning Signs (idiosyncratic)

Many people experience early warning signs which are not common. These are unique to the individual; sometimes called idiosyncratic. Some examples might be: preoccupation with a special diet, complaining of an old leg injury, wearing lots of make up and jewelry etc. The behavior is usually out-of-character for that person.

REFLECTION

Think back to the time when you first noticed that something was going wrong with your relative before he became ill or had a relapse. What early warning signs did you notice. Have these signs occurred more than once? Have you discussed early warning signs with your relative?

Preventing Relapse: Responding to Early Warning Signs:

Preventing relapse works best if your relative with mental illness is aware of his early warning signs and has agreed to a plan of action should they occur.

Should Early Warning Signs Occur:

• Initiate discussion with relative to explore concerns. Keep an open non-judgmental atmosphere.
• Evaluate (with relative) medication compliance. Evaluate (with relative) stress level.
• Consult mental health provider.

The reduction of stress may not be sufficient to prevent relapse and sometimes the usual dosage of medication is not sufficient.Monitor the early warning signs, along with your relative, until the problem has cleared.

Support for Families

Families often find that the support they receive from each other in these workshops and support groups is highly beneficial in reducing their own stress. Giving and receiving support is an important way to relieve stress. We don't know exactly how support works, but when someone shows understanding and caring, we feel better. When we are able to help someone else, we also feel better. When we feel better, our competence and coping skills increase.

Other Important Factors in Reducing Stress

• Regular exercise
• Healthful diet
• Sufficient sleep
• Quiet time
• Recreation
• Constructive activity
• Balance between work, play and rest.

REFLECTION

Read MESA Guideline V. How does it apply to your situation? Which statement is the most helpful? How can you carry out each guideline and make it work in your life?

CHANGES NOTED BEFORE RELAPSE

Often family members are able to recognize the signs of a possible relapse more than a week in advance. Mark each item with a Yes, No or Maybe beside relapse signs that you have seen in your family member.

• Felt more tense or nervous
• Felt more depressed
• Had more trouble sleeping
• Felt more restless
• Had more trouble concentrating
• Lost interest in things he/she usually liked to do
• Saw friends less
• Felt that people were talking about him/her
• Ate less
• Had more religious ideas
• Preoccupied with one or two ideas
• Had trouble making sense when talking
• Felt as though he/she were forgetting things more
• Felt worthless
• Felt as though he/she were going crazy
• Heard voices or saw things
• Felt that something was controlling him/her
• Felt badly for no apparent reason
• Stopped caring how he/she looked
• Had more nightmares or bad dreams
• Felt more angry over little things
• Thought about hurting himself/herself
• Felt more aggressive or pushy
• Felt too excited or overactive
• Had trouble relating to family
• Had frequent aches and pains
• Drank more alcohol
• Used more drugs (uppers, downers, marijuana, LSD)
• Thought about hurting someone else
• Other

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Session VIII - Communication 1

REFLECTION

Complex communication can increase tension and stress. How does it feel when you cannot understand information or cannot get your point across to another person?

Communication is the sending and receiving of information and the way you interact to get things done. Interactions include words, facial expressions, body movements, voice, tone, and writing. People usually respond more to the nonverbal cues they "hear" than the words the person says. Even persons without a thought disorder or problems with attention can feel confused when communication is unclear. Complex communication can be difficult to follow and leads to frustration, anger, and withdrawal when feedback cannot be given, questions asked, no eye contact given, etc.

Because the attention mechanism in the brain of a person with mental illness may not be working effectively, it is important that communication be clear, focused, and simple. One directive at a time needs to be given and ample opportunity to ask for clarification is necessary. It is also important to ask for feedback to see if you were heard correctly. This process takes time, but is time well spent and may head off frustration, resentment, anger, etc. Be careful not to be patronizing. Keep in mind that you are dealing with an adult individual deserving of respect.

REFLECTION

Read MESA Guideline VI. How does it apply to your situation? Which statement isthe most helpful? How can you carry out each guideline and make it work in your life?

Return to Table of Contents

Session IX - Communication 2

Clear, focused, simple communications are necessary, especially when interacting with persons with mental illness. General statements and assumptions are confusing and frustrating for a person with mental illness because they have difficulty processing abstract information.

Guidelines for Clear Communication:

• Be specific and clear.
• Be descriptive. Focus on what you see at the moment.
• Do not make assumptions about motives or attitudes.
• Do not judge the person. Be non-critical.
• Do not make general statements. Keep it simple.
• Clear communication involves active listening, expressing positive feelings, and making positive requests.

Active Listening

Though it is difficult to be a good active listener, communication is only possible when you listen and understand what is said to you. Active listening involves hearing not just the words a person says but also "hearing" their nonverbal communication (body language). Hearing both words as well as body language reduces misunderstanding and tension and assists in problem solving.

How to Listen Actively:

• Look at the person.
• Look interested - lean toward the speaker.
• Nod your head or give some other verbal expression that lets the speaker know you are attentive and hearing him.
• Ask questions to clarify what is being said.
• Check out what you heard the speaker say.
• Example: 'I hear you saying .... is that correct?"

REFLECTION

What is the most difficult problem you have in actively listening to another person? How can you overcome this?

Exercise

Practice this idea. Pair up with a person you do not know very well. Make what you believe to be a true statement about some aspect of your life. It can be as complex as you wish. Have your partner repeat it verbatim, mimicking your words, voice tone, inflection, facial expression, body position and movement. Check your partner for accuracy. If it fits say so. If it doesn't, provide specific evidence and feedback to your partner and have them repeat until the mirror image is correct. Reverse roles and do it again.

Was this difficult to do? What was the most difficult? What was the easiest?

Expressing Positive Feelings:

Mental illnesses are affected not only by brain functioning, but also by the environment. An increase in stress/tension in the environment can precipitate symptoms. People, especially family and friends, are the most influential part of our environment. Relatives and friends can help a person with mental illness cope better with his world and influence his family in positive ways. Together problems can be shared, understood, and solved.

Effective problem solving requires clear communication of information as well as clear communication of feelings. One of the most important and most effective communication skills is the expression of positive feelings.

When giving positive feedback, praise or acknowledge specific behaviors, statements or changes the person has made. Don't wait for major changes, give praise for small accomplishments. This will help the person work gradually towards major goals. Positive feedback works best when given right after the pleasing behavior. Avoid discounting or critical praise. Example: "I'm glad you did that, but..." It is important to give reinforcement and praise for each and every positive behavior. By thinking how the positive action made you feel, you will be able to express your appreciation in a genuine and sincere manner. Patronizing or discounting attitudes should be avoided.

How to Express Positive Feelings:

• Look at the person.
• Be in close proximity to the person.
• Say exactly what they did that pleased you.
• Tell him how it made you feel.
• Use positive/friendly facial expressions and gestures.
• Praise small accomplishments.
• Avoid discounting or critical praise.

REFLECTION

What has your family member done that has pleased you over the last few days? What did you say to him?

Making Positive Requests:

Making positive requests in a direct, pleasant and honest way helps people get what they want and need from others. A request feels better and is different from a demand. Demands annoy people and may put people on the defensive. Requests made in a positive way help build cooperative relationships in which each person's contributions are respected and valued.

How to Make a Positive Request:

• Look at the person.
• Say exactly what you would like him to do.
• Tell how it would make you feel.

Examples:

• "I would really like you to..."
• "I would really appreciate it if you would..."
• "it would make me feel good if you would..."
• "It's very important to me that you help with..."

REFLECTION

Have you experienced demands from other people? How did you feel about those demands? How would you have preferred to be asked?

CATCH A PERSON PLEASING YOU

Examples:

(From Fagoon, I.; Boyd, J.; & McGill, C.; Family Care of Schizophrenia. Used with permission)

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Session X - Communication 3

REFLECTION

What do you do with your negative feelings? Do you blow up? Feel guilty? Become silent? Are you afraid you will worry someone?

Expressing Negative Feelings

Our communication skills must be at their best in order to solve problems effectively. Most problems evoke some sort of negative feelings. Negative feelings are no more or less important than positive ones. They are part of life.

It is even more difficult to express anger at someone who is disabled. However, feeling sorry for someone is not productive. Negative feelings include more than just anger. Anxiety, fear, and sadness are also feelings that may be difficult to express. See next page for a list of feeling words.

How to Express Negative Feelings:

• Look at the person.
• Speak firmly.
• Say exactly what he did that upset, displeased you. Tell him how it made you feel.
• Suggest how he might prevent this in the future.
• Example: When you .... I feel..... in the future could you..."

By using this approach to express negative feelings your clarity will maximize your being heard and comprehended. You will not be getting as agitated as before. You will be treating your family member as an adult with respect, just as you would want to be treated. You will be less likely to explode and the environment will be stressful.

Your family member may not respond beneficially at first, but you will be calmer and in better control of yourself. Over time you may see a difference. By following these guidelines, you set a more productive example for others to follow.

***** FEELINGS SHEET ******

1 - NEGATIVE FEELINGS

A

1. LONELINESS
2. EMBARRASSMENT
3. DEPRESSION
4. ANGER
5. ANXIETY
6. SELFISH
7. INDECISIVE
8. DOMINATING
9. COMPULSIVE
10. JUDGEMENT

B

1. GUILT
2. REGRET
3. INADEQUACY
4. APATHY
5. BOREDOM
6. GREEDY
7. RUTHLESS
8. HATEFUL
9. GIVING
10. CRITICAL

C

1. DESPAIR
2. SELF-PITY
3. GRIEF
4. REMORSE
5. REJECTION
6. REJECTING
7. DOUBTFUL
8. DISHONEST
9. OBSESSIVE
10. CYNICAL

D

1. DEAD
2. SHAME
3. IMPATIENCE
4. PERSECUTED
5. ENVY
6. RESIGNED
7. SPITEFUL
8. FRUSTRATED
9. OBSESSIVE
10. WORRIED

E

1. IRRITATED
2. JEALOUSY
3. POWERLESSNESS
4. RESENTMENT
5. HURT
6. UPSET
7. PRIDE
8. VULNERABLE
9. KILL
10. DEATH

F

1. FEAR
2. UNLOVED
3. ABANDONED
4. ABUSED
5. SUBMISSIVE
6. DESTRUCTION
7. AFFAIR
8. GRUDGE
9. BITTERNESS
10. SUSPICION

G

1. INFIDELITY
2. HUNGER
3. CONTRADICT
4. ARGUMENTATIVE
5. FIGHT
6. PARANOIA
7. SEX
8. RIDICULE
9. DEMANDING
10. REPULSIVE

2 - POSITIVE FEELINGS

A

1. CREATIVE
2. SENSITIVE
3. INSPIRED
4. IMAGINATIVE
5. FAITHFUL
6. LOVE
7. JOY
8. PEACE
9. SERENITY
10. COMPASSION

B

1. HOPEFUL
2. ENTHUSIASTIC
3. CONTENTED
4. ACCEPTING
5. EXPECTANCY
6. SINCERITY
7. HARMONY
8. COMPATIBILITY
9. CONSISTENCY
10. FAITHFULNESS

C

1. PLEASURABLE
2. BLISS
3. ELATION
4. SATISFIED
5. PLEASED
6. GRACIOUS
7. LOYAL
8. TRUE
9. DEDICATED
10. CAREFUL

D

1. AGREEABLE
2. GLAD
3. GRATIFIED
4. SATISFIED
5. PLEASED
6. UNWAVERING
7. FIRM
8. CONSCIENTIOUS
9. STABLE
10. CAREFUL

E

1. JOVIAL
2. ADORE
3. DEVOTION
4. BIRTH
5. WARMTH
6. RELIABLE
7. TRUST
8. GOOD
9. DEPENDABLE
10. HONEST

F

1. CHERISH
2. INTIMACY
3. FRIENDSHIP
4. PASSION
5. BENEVOLENT
6. TRUTHFUL
7. MORAL
8. VIRTUOUS
9. ACCURATE
10. EXACT

G

1. TRANQUILITY
2. QUIETNESS
3. CALM
4. COMPOSURE
5. DESIRE
6. DELIGHT
7. RIGHT
8. PERFECTION
9. SEX
10. HAPPINESS

Homework

Expressing Unpleasant Feelings:

Use the sheet on the next page to keep track of any unpleasant feelings you have towards another person during the following week. What exactly did the person do? How did you feel? What did you suggest he could do in the future?- _

*** EXPRESSING UNPLEASANT FEELINGS ***

MONDAY

PERSON WHO DISPLEASED YOU:

WHAT EXACTLY DID HE DO THAT DISPLEASED YOU?:

HOW DID YOU FEEL? (angry, sad, etc):

WHAT DID YOU ASK HIM TO DO IN THE FUTURE?:

TUESDAY

PERSON WHO DISPLEASED YOU:

WHAT EXACTLY DID HE DO THAT DISPLEASED YOU?:

HOW DID YOU FEEL? (angry, sad, etc):

WHAT DID YOU ASK HIM TO DO IN THE FUTURE?:

WEDNESDAY

PERSON WHO DISPLEASED YOU:

WHAT EXACTLY DID HE DO THAT DISPLEASED YOU?:

HOW DID YOU FEEL? (angry, sad, etc):

WHAT DID YOU ASK HIM TO DO IN THE FUTURE?:

THURSDAY

PERSON WHO DISPLEASED YOU:

WHAT EXACTLY DID HE DO THAT DISPLEASED YOU?:

HOW DID YOU FEEL? (angry, sad, etc):

WHAT DID YOU ASK HIM TO DO IN THE FUTURE?:

FRIDAY

PERSON WHO DISPLEASED YOU:

WHAT EXACTLY DID HE DO THAT DISPLEASED YOU?:

HOW DID YOU FEEL? (angry, sad, etc):

WHAT DID YOU ASK HIM TO DO IN THE FUTURE?:

SATURDAY

PERSON WHO DISPLEASED YOU:

WHAT EXACTLY DID HE DO THAT DISPLEASED YOU?:

HOW DID YOU FEEL? (angry, sad, etc):

WHAT DID YOU ASK HIM TO DO IN THE FUTURE?:

SUNDAY

PERSON WHO DISPLEASED YOU:

WHAT EXACTLY DID HE DO THAT DISPLEASED YOU?:

HOW DID YOU FEEL? (angry, sad, etc):

WHAT DID YOU ASK HIM TO DO IN THE FUTURE?:

EXPRESSING UNPLEASANT FEELINGS

• Say exactly what displeased you.
• Tell the person how It made you feel.
• Suggest a way this could be avoided in the future.

Examples:

• I feel angry that you shouted at me Tom. I'd like it if you spoke quieter next time.
• I am very sad that you did not got the job. I'd like to sit down and discuss some other possibilities with you after dinner.
• I feel very anxious when you tell me I should get a job. It would help me a lot If you didn't nag me about it.

(From FaRoon, I.; Boyd, J.; & McGill, C.; Family Care of Schizophrenia. Used with permission)

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Session XI - Problem Solving

REFLECTION

What gets in the way of solving problems in your life? Does everyone get too emotional? Can't agree or figure out the problem? Is everyone too negative? Can't get others to help?

There are several problem solving steps which are helpful in creating solutions. In the steps below, it is best to accept any solution suggested in Step b ... even if it is absurd. This is the basis for creative problem solving. If anyone offers an absurd solution, it will be accepted as a viable suggestion, and the person will not feel discounted. Also, it may generate another more useful solution. Later during Step c the practicality of each suggestion can be discussed.

Problem Solving Steps:

1. Clearly define the problem.
2. Suggest several possible solutions.
3. Discuss the pros and cons of each solution and decide on the best one.
4. Plan and carry out the best solution.
5. Praise all efforts.
6. Review effectiveness after following the plan for a week or so.
7. If necessary, go back to (a) and begin again.

Exercise

With family members or friends at home, use the Solving Problems sheet at the end of this session to decide on a problem and proceed through the steps.

The Need for Consistency:

It is important for people to be able to talk with each other effectively, honestly and predictably. Difficulties arise in any situation when people do not follow through with consequences. Consistency in communication is important to everyone and essential for someone who is trying to manage a mental illness. If you do not follow through with what you say, you become inconsistent, vulnerable and open to manipulation. The recipient of your behavior becomes confused, unstructured and maybe resentful. It is important to say what you mean and mean what you say.

• Say what you mean...
• Make direct, clear statements as to what behavior you expect and the consequences.
• Mean what you say...
• Follow through to see the behavior is carried out.
• Apply the consequences or rewards as indicated.

Exercise

• List a behavior you would like to have your relative change. You might want to choose one that is easy to change or one that is most disturbing to your family.
• Develop a consistent and clear approach to the behavior in question.
• Say what you mean. How will you express your expectation to your relative?
• Mean what you say. What will you need to do to follow through? How will you monitor compliance?

SOLVING PROBLEMS

STEP 1: WHAT IS THE PROBLEM?

Talk about the problem, listen carefully, ask questions, get everyone's opinion. Then write down exactly what the problem is.

STEP 2: LIST ALL POSSIBLE SOLUTIONS (BRAINSTORM).

Put down all ideas, even absurd ones. Get everybody to come up with at least one possible solution. Do not discuss possible solutions at this point.

1)

2)

3)

4)

5)

STEP 3: DISCUSS EACH POSSIBLE SOLUTION.

Go down the list of possible solutions and discuss the advantages and disadvantages of each one.

STEP 4: CHOOSE THE BEST SOLUTION OR COMBINATION OF SOLUTIONS.

STEP 5: PLAN HOW TO CARRY OUT THE BEST SOLUTION.

Step 1)

Step 2)

Step 3)

STEP 6: EVALUATE (AFTER A SPECIFIED TIME PERIOD) THE ATTEMPTED SOLUTION.

Decide to keep or modify. If you modify, use the problem solving strategy again.

[From Falloon, 1; Boyd, J; & McGill, C. Family Care of Schizophrenia 1984. Used with permission.]

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Session XII - Applying the Guidelines

The Key Concepts & Guidelines of the MESA Family Workshops were developed to provide the material in a brief, useful way. They provide:

• CONNECTION: Between the information on mental illness and how to make use of it.
• DIRECTION: For making educated decisions on dealing with issues and problems.
• CONTROL: Helping families increase control over their own lives.
• COMPETENCE: Helping families feel more confident in their ability to cope.

Exercise

Read the case situations on the next 2 pages and decide which of the guidelines apply in each of the situations.

REFLECTION

Think of a situation over the past week. Which of the guidelines applies to your situation?

CASE SITUATIONS

1. Mr. & Mrs. T want suggestions for dealing with the smoking habits of their 27-year-old daughter, Sue, who has a diagnosis of Schizophrenia. Sue lives in a supervised apartment and works part time. She visits the family every Sunday and seems to look forward to her visits. However, Sue smokes constantly and no one else in the family smokes. They are bothered by the smoke as well as the overflowing ashtrays and the mess she makes. They do not want to hurt her feelings but there are many arguments surrounding her smoking habits.
   
2. Mr. & Mrs. J want to comply with the wishes of their 26-year-old daughter, Mary, to move out of their home. Mary has been ill for five years and has had three hospitalizations. She becomes upset easily and has not learned the skills necessary for independent living. Her presence in the home is very stressful to the parents, due to her unstable mood. However, they want to do whatever will be most beneficial to Mary.
   
3. Bill, aged 35, was first hospitalized with a diagnosis of Schizophrenia 1 5 years ago. Due to his aggressive behavior and verbal abuse, he is not allowed to visit home. His parents visit him in his apartment and are supportive of him--taking him places and doing things for him when possible. Bill telephones his mother frequently and speaks in a loud and angry voice making threats and demands. Later he apologizes. His mother wants to be helpful but would like the abusive phone calls to stop.
   
4. Mr. & Mrs. G have a 28-year-old daughter, Jane, who is currently in a hospital in another state. This is her sixth hospitalization due to Manic Episodes. Jane wants to return to live with her parents when she is released. However, in the past she has immediately discontinued her medication upon returning home, refused all treatment, and soon has become manic again. The parents have experienced the pain and frustration of many commitment hearings. They would like to allow Jane to return home but are afraid of what will happen. The hospital has offered to place her in supervised housing in the state where she is hospitalized.
   
5. Mr. & Mrs. R want to go alone on a much-needed vacation. However, they are afraid that something will happen to their 31 -year-old daughter, Susan, who has been out of the hospital for six months. Susan lives with her parents, attends a pre-vocational day program, and is showing good progress, although she continues to be very dependent on her parents. There are two siblings who live in the same city but Mr. & Mrs. R are reluctant to ask them for assistance. They have about decided to delay their trip.
   
6. Ann is resentful of her brother, Mark, aged 2 1, who became ill three years ago. He is constantly going into her room, playing her stereo, and leaving a mess behind. There are many arguments because Mark has no responsibilities in the home and Ann has quite a few. Mark stays at home most of the time and sleeps or watches T.V. Ann believes that her parents cater to Mark. She wants to know how to deal with this situation.
   
7. Mr. & Mrs. C are concerned about the number of hours their 19-year-old son, Joe, works and whether to insist that he cut back. Joe has been hospitalized several times since age 16. His most recent diagnosis was Schizophrenia. he has been living at home for the past year and compliant with his treatment plan. He began working in a fast food restaurant six weeks ago and has shown no signs of being overly stressed, although he sometimes works 40 to 50 hours a week.
   
8. Mrs. M, aged 70, is a widow and her 42-year-old son, James, lives with her. James had one psychiatric hospitalization about 20 years ago. He worked for several years following the onset of his illness, but has been unable to work for the past ten years. He sees his doctor regularly for medication but refuses to participate in any type of counseling or rehabilitative services. He is highly sensitive to stress. He stays at home nearly all of the time. He spends most of his time reading or sleeping. He has no responsibilities. Mrs. M feels responsible for seeing that James begins to move toward more constructive activities.
   
9. John, aged 30, finished college before he had his first psychiatric episode at age 21. he has had six hospitalizations with a diagnosis of Bipolar Disorder. He has been unable to hold a job for more than two months. He has difficulty concentrating and staying on focus during conversations. He is sporadic in medication compliance. His parents have continued to support him in his own apartment, which has been a financial burden to them. John wants to return to college for a second degree.
   
10. Mr. K, a 72-year-old retired school principal, attends the family workshops alone because he and his wife feel that one of them must be with their 45-year-old son Robert. Robert became psychiatrically ill during his senior year of college and has a diagnosis of Schizophrenia. He has tried various rehabilitation and treatment programs but has not been involved in any outside activities for several years now. He does see a private psychiatrist and takes medication as prescribed. His mental status is unstable; he is delusional and at times aggressive toward his parents. They try to do things that would make him feel better and to keep him from getting upset. Robert's psychiatrist refuses to talk with Mr. & Mrs. K due to confidentiality issues. They seem to be resigned to continue as they are, but the group members believe that Mr. & Mrs. K are entitled to some peace of mind.

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Post Test

Please decide which is the best answer and circle the letter.

1. The symptoms of mental illness are basically the same for everyone.
2. Symptoms of mental illness vary from severe episodes to more stable periods.
3. Severe mental illness affects the person's whole personality.
4. All family-members are affected by the stress of having a family member with mental illness.
5. Feelings of anger, hurt, and resentment towards the member who has mental illness are unusual and need to be ignored if present.
6. Adjusting to a relative's mental illness is a painful process similar to grief and mourning.
7. It is helpful for families to find who is to blame for the illness.
8. Family members need to find outside activities and time for themselves in order to maintain their health.
9. Education about mental illnesses and resources helps families understand and cope.
10. It is important to keep expectations and life goals the same even though a person develops a mental illness.
11. Most people with mental illness can control their thoughts and moods when they want to.
12. In most cases, family members should agree with a person who is delusional or hallucinating so they don't get more upset.
13. Having order and structure in the environment is helpful for a person with mental illness.
14. Family members and professionals need to decide on a rehabilitation plan for the person with mental illness.
15. Families need to be acutely aware of symptoms of mental illness and only reward the person when a large goal is accomplished.
16. Families need to help the person establish attainable roles within the home and community so the person can maintain his/her identity.
17. People with mental illness tolerate stress poorly.
18. Families should provide lots of activities and conversations for persons with mental illness to participate in so their minds will stay busy.
19. Families and persons with mental illness can learn to identify early symptoms of a relapse.
20. When you're angry or upset about something, it is best to keep it to yourself since it would only upset the person if you were honest with him/her.
21. Non-verbal communication is as important as verbal communication.
22. By emphasizing what is wrong with a person's actions or behavior, the family can help the person with mental illness overcome his/her disabilities.
23. The needs and wants of the person who has a mental illness should be considered first in a family since he/she is the one who is ill.
24. Talking with other family members can improve consistency and prevent manipulation.
25. Hope and determination lead to solutions.

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Pre/Post-Test

Please decide if the following questions are true or false.

1. The symptoms of mental illness are basically the same for everyone.
2. Symptoms of mental illness vary from severe episodes to more stable periods.
3. Severe mental illness affects the person's whole personality.
4. All family members are affected by the stress of having a family member with mental illness.
5. Feelings of anger, hurt, and resentment towards a person who has mental illness are unusual and need to be ignored if present.
6. Adjusting to a relative's mental illness is a painful process similar to grief and mourning.
7. It is helpful for families to find who is to blame f or the illness.
8. Family members need to find outside activities and time for themselves in order to maintain their health.
9. Education about mental illnesses and resources helps families understand and cope.
10. It is important to keep expectations and life goals the same even though a person develops a mental illness.
11. Most people with mental illness can control their thoughts and moods when they want to.
12. In most cases, family members should agree with a person who is delusional or hallucinating so they don't get more upset.
13. Having order and structure in the environment is helpful for a person with mental illness.
14. Family members and professionals need to decide on a rehabilitation plan for the person with mental illness.
15. Families need to be acutely aware of symptoms of mental illness and only reward the person when a large goal is accomplished.
16. Families need to help the person establish attainable roles within the home and community so the person can maintain his/her identity.
17. People with mental illness tolerate stress poorly.
18. Families should provide lots of activities and conversations for persons with mental illness to participate in so their minds will stay busy.
19. Families and persons with mental illness can learn to identify early symptoms of a relapse.
20. When you're angry or upset about something, it is best to keep it to yourself since it would only upset the person if you were honest with him/her.
21. Non-verbal communication is as important as verbal communication.
22. By emphasizing what is wrong with a person's actions or behavior, the family can help the person with mental illness overcome his/her disabilities.
23. The needs and wants of a person who has a mental illness should be considered first in a family since he is the one who is ill.
24. Talking with other family members can improve consistency and prevent manipulation.
25. Hope and determination lead to solutions.

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