holding hands

Create a Healing Environment

Creating a low-stress, healing environment can help our loved ones with mental illness.  This post contains information from “Helpful Family Attitudes and Skills” by Dr. Christopher Anderson and “Guidelines for Creating a Low-Stress Home Environment for a Mentally Ill Person” by Dr. Brian D. Eck.

Three Key Principles 

Accept the person as ill. This is simple to say but difficult to do. The grief over a 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 the illness. To be helpful, families should greet patients where they are, love them as they are, and promote growth that is in line with their current condition. Specifically:

  1. Mourn the loss, but not in the presence of your relative.
  2. Never discuss what he was or what he could have been in front of him.
  3. Avoid comparisons to peers.

Attribute symptoms to the illness. It’s an impossible task, but families must attempt to be objective and calm when the loved one’s brain is causing bad behavior.  This includes times when the loved one is screaming that he hates you because you are poisoning him. Our culture is more likely to attribute behavior to an illness when the person has Alzheimer’s or brain cancer.  Even when the behavior is completely unacceptable and must be restrained, such as violence, it is likely due to the illness.

Include the person in the family. Families often subtly exclude loved ones with mental illness from the family.  Examples include:

  • Not discussing the loved one with friends when they discuss their other children.
  • Not inviting other people to their home when the loved one is present.
  • Not altering family gatherings so the loved one may be included for at least part of the event.
  • Not including the loved one in family portraits.
  • Not asking the loved one to help you do things.

Creating a Healing Environment

Recognize that the illness is no one’s fault.

Understand the limits of the illness and the extent of the person’s control over his behavior.

Go slow! Recovery and growth take time. Rest is important.

Keep it simple and structured. People with mental illness do better with structure and predictable routines. Home life should have a consistent rhythm with change as seldom and gradual as possible.

Keep it calm. For the most part, try to keep the environment quiet with calm voices and limited stimulation.

Give people space. Private time and space are important for everyone.

Set limits. Have clear and appropriate expectations. Everyone needs to know what the rules are. A few good rules that are consistently enforced will help keep things calm.

Ignore what you cannot change. Let some things slide. Do not ignore violence.

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

Offer praise and encouragement. Try to be sure that you have at least a ratio of four positive interactions to one negative or challenging interaction.

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.

Carry on your business as usual. Reestablish routines as quickly as possible when they are disrupted.

No street drugs or alcohol. Emphasize that illegal drugs and alcohol make symptoms worse.

Recognize early signs of relapse. Learn what changes you will see in your family member’s symptoms and behaviors, especially those which usually occur just before a relapse. Contact their care team when you see the changes.

Find a way for the person to learn life skills.

Solve problems step by step. 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.

Offer opportunities to meet their needs Offer opportunities to have major personal, social, activity, and competence needs met.

It’s National Minority Mental Health Awareness Month

The pandemic and systemic racism has caused so much angst this summer.  So it’s important to talk about National Minority Mental Health Awareness Month.

The House of Representatives started this annual observation in 2008 in honor of mental health advocate and writer Bebe Moore Campbell.

The Department of Health and Human Services is highlighting its free and accredited e-learning program: Improving Cultural Competency for Behavioral Health Professionals. This program is part of the Office of Mental Health’s Think Cultural Health E-learning courses.

Despite advances in health equity, disparities in mental health care persist. The Agency for Healthcare Research and Quality reports that racial and ethnic minority groups in the United States are:

  • Less likely to have access to mental health services.
  • Less likely to use community mental health services.
  • More likely to use emergency departments.
  • More likely to receive lower quality care.

All this adds up to poor mental health outcomes, including suicide. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) and the CDC:

  • In 2017, 10.5% (3.5 million) of young adults age 18 to 25 had serious thoughts of suicide including 8.3% of non-Hispanic blacks and 9.2% of Hispanics.
  • In 2017, 7.5% (2.5 million) of young adults age 18 to 25 had a serious mental illness including 7.6% of non-Hispanic Asians, 5.7% of Hispanics and 4.6% of non-Hispanic blacks.
  • Feelings of anxiety and other signs of stress may become more pronounced during a global pandemic.
  • People in some racial and ethnic minority groups may respond more strongly to the stress of a pandemic or crisis.

 

A Dozen Ways to Love Someone With Mental Illness

It takes enormous courage and determination to live positively with a serious mental illness. But it can happen.  And we can help.  We can respect and protect our loved one’s deep vulnerability.

Here are a dozen ways to offer that support, based on material from NAMI’s Family-to-Family program.

  1. Don’t nag or criticize.  People who have a mental illness are unable to defend themselves against a direct personal attack.  Despite irritation, try to be supportive. Keep negative and nagging remarks to a minimum.
  2. Don’t push or punish.  It doesn’t work.  It will be hard on both of you.  And it is highly correlated to decompensation and relapse.
  3. Praise positive behavior and ignore negative behavior. This is the best way to influence your loved one’s behavior is to praise the positive.  Studies show your loved one will want to perform the behaviors that earn them recognition and approval.
  4. Learn to recognize and accept symptoms.  We wouldn’t get furious if a person with epilepsy had a seizure.  So we need to accept that some behaviors are the direct result of the illness.  Don’t argue with delusions.  Don’t try to talk someone out of a clinic depression.  Also, help your loved one understand that symptoms are not their fault, but part of the illness.  Some symptoms can be controlled with treatment, including medications.
  5. Stand up to the stigma.  People with mental illness are not bad people.  They are people with a bad disease.  They are not trying to embarrass or anger us.
  6. Lower your expectations for your relationship.  Then lower them again. People with mental illness do not have the capacity to provide emotional support to us. Get help from other places.
  7. Treat them like other people.  At the same time, set basic rules and limits for the whole family.  Structure is almost always helpful.
  8. Encourage steps toward independence.  When your loved one is ready, encourage them to take small steps toward being more independent.  But keep your expectations reasonable.
  9. Don’t dwell on “what might have been.”  Accept the illness.  Still, don’t give up hope.  We need to tell our loved ones that the illness can make things difficult.  But a happy life is still possible.  People do adapt.  Some people actually get much better.
  10. Be patient in health, as well as in sickness. When our loved ones improve, stay patient and loving. It takes time to develop a lifestyle that protects them from becoming ill again.
  11. Be gentle with yourself and others in the family.  This is a marathon, not a sprint. Mental illness is often cyclical, so things will get better, then worse and then better again.
  12. Pray for grace.  Ask for tolerance, compassion, endurance and self-control.  Sometimes only God can give you the attitude you need.

Understand the Inner Life of a Loved One With Mental Illness

Have you ever gone 24 hours without sleep? 48 hours? How did you feel?  How did you look?

Dozed off for a second, awakened with a start and didn’t know where you were?  Lost your sunglasses or car keys and no matter what you did, you couldn’t find them?   Gone driving down a road when your sense of direction got mixed up? Had a song stuck in your head that would not go away? How would you feel if that song stayed for a month or more?

Now let’s put three or more of these items together.  Say you’d hadn’t slept for three days, you heard the same music going on and on in your head, and you couldn‘t find your keys.  How would you feel?

That thought experiment gives you just a hint of the inner life of a person with mental illness. Even in remission and even when properly medicated, chronic mental illness leaves its sufferers in a devastating limbo.

Many people with mental illness are effectively cut off from the predictable, rewarding, self-fulfilling live involvements that make existence meaningful.  They suffer deeply from their inability to be competent and successful in their daily lives.

This threatens our loved ones’ psychological integrity.  It sets up a process where they feel they must protect their “core self” at all cost.

Many behaviors that result – refusing medication, rejecting family support and community programs and disrupting family life, for example – don’t make sense to us. Yet they are directly related to their struggle to maintain some dignity and self-respect in the face of stigma, failure and shame.

Psychological traumas are associated with any serious chronic illness.

 Whenever a person has a serious chronic illness …. COPD, emphysema, chronic heart disease, or a mental illness … two things happen to the sense of self.

First, they lose their protective belief that they are exempt from harm. Much of our sense of safety and willingness to take risks rests on a belief that serious harm or real trouble will never happen to us.  Young people especially still have this sense. Second, they lose their sense of a predictable, dependable future.

This results in some common defensive coping strategies.

These are self-management techniques that are basically maladaptive.  They don’t help people get what they really want, but they do provide temporary psychological refuge when confidence and self-image are taking a nose-dive.

  • Abusive criticism of others
  • Anger and attack
  • Apathy
  • Bargaining
  • Blaming others
  • Controlling or manipulative behavior
  • Defensiveness
  • Denial
  • Dependency
  • Doing nothing
  • Drug and alcohol abuse
  • Envy
  • Excessive sleeping
  • Haughtiness
  • Irritability
  • Quitting a job
  • Refusing help or services
  • Refusing medication
  • Rejection of family and friends
  • Resistance to change
  • Running away
  • Self-absorption
  • Suspicion
  • Withdrawal

From time to time in daily life, all of us will use one or more of these behaviors.  If we are criticized at work … snubbed by someone we thought was a friend … having a fight at home … we may use one of these behaviors if we feel momentarily crushed.  We complain or attack.  We “need a drink.” We get fed up and call in sick.

For us, these responses happen when we feel temporarily defeated.  We normally pull out of them quickly.  We turn to our social and personal life structure, finding comfort and reassurance.

The situation for people with mental illness is drastically different. Their social and personal life is vastly diminished. They often face poverty, stigma, disability, joblessness and social rejection. They are trapped in a runaway train going the wrong way.

The negative coping strategies become a familiar and reliable way to protect themselves from becoming even more diminished.

 

Mental Illness: Chronic Illness Has Predictable Reactions

Mental illness is a chronic illness with life changing impact. Even when a person is properly medicated, in treatment and in remission, mental illness puts its sufferers in a devastating limbo.  Let’s consider what it could be like:

  • Have you ever gone without sleep for one night? 48 hours? Longer?
  • Have you ever woken up, startled and not sure where you were?
  • Have you lost your keys or your glasses and couldn’t find them?
  • Has a song been running through your head for a couple of hours?  A day? A week?

Remember how you felt in these circumstances.  Irritable, frantic or close to screaming? What if it all happened at once?

Thinking about this can give us some empathy for people with mental illness.  Furthermore, many people who have brain-based mental illness are effectively cut off from predictable and rewarding life experiences.  They suffer from their inability to competently do things that they could do before.

This life-constriction threatens our loved ones’ psychological integrity.  This sets up a process where people with mental illnesses feel they must protect themselves at all costs.  They struggle to maintain some dignity and self-respect in the face of stigma, failure and shame. Still, the behaviors that result — refusing medication, rejecting family and community support, and disrupting family life — do not make sense to us.

Whenever a person has a serious chronic illness, such as COPD, emphysema, chronic heart disease or mental illness, two things happen to their sense of self:

  1. They lose their protective belief that they are exempt from harm.  Much of our sense of safety and our willingness to take risks rests on this belief, especially among younger people.
  2. They lose their sense of a predictable, dependable future.  This results in the use of defensive coping strategies.  These self-management techniques are basically maladaptive.  They don’t help people get what they really want, but they do provide temporary psychological refuge when confidence and self-image take a nose-dive.

In the next post, we will look at typical defensive coping strategies and the empathetic guidelines to help families deal with loved ones who exhibit them.

 

 

 

How to Navigate HIPPA

Note: Ken and I attended a NAMI Franklin County workshop on February 8, 2020, that included a presentation on Navigating HIPAA for Families and Caregivers.  We learned some good information that, in addition to info we had or have found out the hard way,  we’d like to share with you. 

The Health Insurance Portability and Accountability Act (HIPPA), which went into effect in 2003, has been a major barrier for many families dealing with a loved one with mental health issues.  Sometimes this is because the law is being used correctly.  And sometimes because health care providers are over-interpreting or misinterpreting it.

Here’s one example:  My cat, Chester, needed medicine that the vet didn’t have. So she wrote me a prescription to take to the pharmacy.  Once there, the pharmacist looked at the prescription for Chester Twinem (feline) and asked me how old he was.  I said, “16.”  The pharmacist said, “That’s good.  That means you can sign his HIPPA form for him.”

I was thankful that he wasn’t older because he would not like going to the pharmacy to sign the form for himself with his little paw.

That’s how it can be.  Systems are set up based on HIPPA that actually not in the best interest of all patients. There are the true HIPAA regulations, and then there are the interpretations of those regulations by hospitals, doctors, pharmacists, etc. Here’s a look at the truth:

Who has to comply with HIPAA?

  • Most health care providers (physical, mental health, addiction services providers)
  • Health plans (private insurance companies, such as Anthem
  • Public benefit payers, such as ADAMH boards

These people and organizations are called “covered entities.”

What is protected information under HIPAA?

Basically, it’s any information that a covered entity has in its records about a person who has received health care services, including demographic information. The rule is that HIPPA covers:

  • Information that relates to the individual’s physical or mental health or condition,
  • That a HIPAA covered entity created, received or transmitted in the provision of health care or payment for health care services AND
  • Which either identifies the individual or can be used to identify the individual.

Covered entities must obtain written authorization to disclosed protected information unless HIPPA contains an exception that applies to the disclosure. One exception is sharing between treatment providers.

What disclosures are permitted to families and caregivers? 

 Information can be disclosed to a Personal Representative, an individual who has the authority to make health care decisions under Ohio law.  Other states have different laws on this. Under Ohio law, covered entities (providers) must disclose information to the individual, the personal representative or both.

The people who have legal authority to make health care decisions for another person under Ohio law are:

  • Those with a Health Care Power of Attorney
  • Those identified in a Declaration for Mental Health Treatment
  • A court-appointed legal guardian
  • The parent or guardian of a minor child

What is a Health Care Power of Attorney?

This authorizes a second person to make health care decisions when a person can no longer make them. Two health care professionals have to agree that the person can no longer make decisions for themselves. When that happens, the second person becomes a Personal Representative.

The Health Care Power of Attorney document can also authorize the designated second person to obtain health care information for and on behalf of the individual at any time. It must say specifically: “I specifically authorize my agent to obtain my protected health care information immediately and at any future time.”

 What is a Declaration for Mental Health Treatment?

This document authorizes a proxy to make mental health treatment decisions when the individual does not have capacity to consent to treatment decisions. When the declaration goes into effect, the designee becomes the personal representative. (Note: This form is long and can be difficult for a mental illness person to fill out.)

Unless limited in the declaration, the proxy has the right to obtain personal health information regarding the proposed mental health treatment of the person and to receive, review and consent to disclosure of records relating to that treatment.

 What about court-appointed legal guardians?

The court-appointed legal guardian of an incompetent person is a personal representative. An incompetent person is incapable of taking proper care of themselves and their family as a result of a mental or physical illness/disability, intellectually disability and chronic substance abuse. The process of obtaining legal guardianship takes many months.

What are the rights of parents and guardians of minors regarding information?

The parent, legal guardian or other person acting in loco parentis with legal authority to make health care decisions is a personal representative.

Exceptions include when the minor is receiving confidential mental health services and the parent/guardian has agreed to a confidentiality agreement between the provider and the minor.

The covered entity may decide not to treat a parent, etc. as a personal representative if the covered entity has a reasonable belief that the parent has abused or neglected the child. Or if treating the parent of the personal representative could endanger the individual and the covered entity decides it’s not in the child’s best interest to treat the parent as a personal representative.

What information can be given to persons involved in care?

Health-care or payment-related information can be disclosed to a family member, other relative, close personal friend or other person identified by individual. The information must be directly relevant to the person’s involvement with the health care or payment of health care.

An organization’s policies may supersede and be more restrictive than HIPAA.

Covered entities can notify family members, personal representatives and other people responsible for an individual’s care of the person’s location, general condition or death.

If a person is present in the room and has the capacity to make health care decisions, the covered entity must obtain agreement to disclose personal health information, give the ill person the opportunity to agree or object, or reasonably infer using professional judgment that, based on the circumstances, the ill person would not object.

If a person is not present, or if the opportunity to agree or object cannot happen due to incapacity or emergency circumstances, the covered entity must use its professional judgment to determine whether disclosure is in the best interests of the person.

How do you get written authorization?

The form to obtain written authorization, in which the individual authorizes the Covered Entity to disclose personal health information, has many names:

  • Release of Information
  • Written Authorization
  • Consent to Disclose
  • Standard Authorization form

The form must contain some specific elements from the HIPAA law. Generally, the covered entity is not required to disclose the information.

Ohio’s Standard Authorization Form, which is a national example, says the covered entity is REQUIRED to disclose the information.

So what should you do to get access to the information you need to help your loved one? 

First, you need to act before there’s an issue.  Make sure that your loved one’s health care providers know that you are involved in the person’s care.

Get Health Care Power of Attorney, a Declaration for Mental Health Treatment and, if in Ohio, the Ohio Standard Authorization Form signed and given to the providers.  Do this when your loved one is well enough to discuss and sign to provide you with updates or notifications in the event of an emergency.


Tips to Reduce Anxiety About the Coronavirus

Scary dreams and worries can kick off an overwhelming level of anxiety during this pandemic.  While it’s bad for everyone, it’s worse for people who have mental illness.

Those who have existing issues with panic disorder, depression and generalized anxiety are almost certain to have more intense symptoms unless we take preventive measures. The symptoms can include digestive problems, dizziness, elevated heart rate, fatigue and insomnia, among other things.

I got the idea for this list from an article by Noma Nazish in ForbesLifeand have adapted for my website mindfulchristianyear.com

Control what you can control. And that means you. Wash your hands. Stay six-feet away from people. Still, it helps to smile and be friendly when you pass people from this distance. We also can pray for each person we pass on the street or in the park.

Schedule times for prayer and quiet. If you don’t already have a routine for regular prayer during the day, it’s a great time to start. An alarm on my phone reminds me to stop about every three hours to pray or read Christian materials. Sarah Young’s books, starting with Jesus Calling, are excellent. Her app is very good as well. I also use materials in apps like Pray-As-You-Go, the NIV Bible, Ending Your Day Right, Centering Prayer and the Divine Office.

Make this a good time for your children or grandchildren. Our attitudes will decide how the kids remember this time. Model faith, calm and self-care. Let your kids talk through their fears and concerns. Listen for increases in symptoms.  Determine whether you need to make a call to your child’s psychiatrist to provide information. Make sure you also find some ways to have fun together.

Use block scheduling to set up a routine. Setting up a routine will help to keep you and your family focused on the good. Block scheduling – setting aside an hour or two for each major kind of activity – has been very useful. Activities can include: reading, homeschooling, housework, paperwork, making things, exercise, shopping online, etc.

Reduce your exposure to news and social media. I look at my social media channels once a day. I also read the COVID-19 round-up on my Associated Press app and one local news app in the morning and at night. We do watch the PBS NewsHour as well. Other than that, I try to concentrate on my own life. I think the most reliable sources of information are the Centers for Disease Control and Prevention (CDC), WebMD, the Weather Channel’s COVID-19 section, the World Health Organization (WHO) and the John Hopkins’ Coronavirus Resource Center.

Stay connected to family and friends. This is the era of FaceTime calls and Zoom/Skype meetings. There’s also the good old-fashioned phone call and new-fashioned texting. Check in with your loved one with mental illness on a regular basis without seeming too anxious yourself. Make an effort to cheer your friends and family up. It will cheer you up, too.

Do a daily stress-reduction exercise. My isolation gift to myself was a subscription to the Breethe app, which is offering specific relaxation exercises regarding coronavirus anxieties. I also use Calm, Meditation Oasis and the Cleveland Clinic’s Stress Meditation. The relaxation exercise is on my block schedule for a specific time in the afternoon.

Eat well. Stress eating is one of my problems, but I do know that mindfully choosing to eat a nutritious meal before I can have my salty/sweet treat is cutting down on the overeating.

Get out in the fresh air and sunshine. Take a daily walk. Set up your patio furniture early or sit out on your porch to read.

Be the hands and feet of Christ. Get involved in helping other people during this time. Your church may have ideas. You also can call a humanitarian organization to see if you can help. Many people are helping from home by calling others to see how they are doing.

Like everything in life, this crisis is offering opportunities to grow as Christians.

Know Your Meds: Long-Acting Injectables

NOTE:  This information came from NAMI and other sources, as well as my own experiences.

Long-acting injectables (LAIs) can be helpful when an individual with mental illness either refuses or is not compliant with medication, often with very unfortunate results.  Most of the people I’ve met who are using LAIs got started in a hospitalization or a situation in which they had regularly become a danger to themselves.

LAIs slowly release medicine into the blood. Injectable medications used for individuals living with mental illness include: Abilify Maintena®, Aristada®, Haldol decanoate®, Invega Sustenna®, Invega Trinza®, fluphenazine decanoate, Risperdal Consta®, and Zyprexa Relprevv®. The LAIs can last anywhere from 2-12 weeks with just one dose, which helps to control symptoms of mental illness.

What do LAIs do?

LAIs treat psychosis (hallucinations or delusions) in individuals with schizophrenia. Some LAIs may be used as mood stabilizers in individuals with bipolar disorder.

How can an LAI help?

Living with active psychosis causes many people to make very bad decisions, which can result in arrests and involuntary commitments.  LAIs can help individuals stick to a medication plan.

When comparing LAIs to pill medications, LAIs may lower the chances of someone going to the hospital. LAIs allow for a steady level of medicine in the blood. These steady levels help lower the chance of side effects. The LAIs may also help improve quality of life and satisfaction with medicine.

How are LAIs given?

LAIs are given as an injection in the muscles of the arm or bottom. When starting a LAI for the first time, individuals may also have to take pill medication for a few weeks. The pill allows the injection to have time to start working. Injections are given every two to 12 weeks depending on the medication.

What if I’m interested in an LAI?

If interested in a LAI, talk to a doctor. A LAI may not be right for every person with a mental illness. The main side effect of a LAI is pain at the injection site.

When talking to a doctor, ask:

  • How will a LAI help?
  • What symptoms will a LAI control?
  • What side effects may occur?
  • What blood work will need to be done?

How can I pay for an LAI?

LAIs are usually expensive.  Many insurance plans should help cover the cost of one of the LAIs. The drug company for each medicine may also be able to help.

Know Your Meds: Mood Stabilizers

Mood stabilizers are typically used to treat intense, repeated shifts in a person’s mood, which may be common for those experiencing bipolar, schizophrenia, or borderline personality.

Many mood stabilizer drugs are also commonly categorized as anticonvulsant medications.

The oldest of them, lithium, has been in use for over 50 years and has proven very effective, particularly for bipolar disorder, type I. However, regular blood tests are required when taking lithium because of potential serious side effects to the kidneys and thyroid.

Newer mood stabilizers, many of which were originally used to treat seizure disorders, may work better than lithium for some people. Mood stabilizers can prevent manic or hypomanic episodes and depressive episodes. but also have side effects to know about and monitor.

Common mood stabilizers include:

Know Your Meds: Anti-Anxiety Medications

The next class of medication are anti-anxiety medicines, which reduce the emotional and physical symptoms of anxiety.  Benzodiazepines such as alprazolam (Xanax) can treat social phobia, generalized anxiety disorder and panic disorder. This information comes from NAMI and goodtherapy.org

These medicines work quickly and are very effective in the short-term. However, people prone to substance abuse may become dependent on them.

Because the body can become used to the meds, doctors may need to increase the dosage over time to get the same therapeutic effect. People who stop taking benzodiazepines suddenly may experience unpleasant withdrawal symptoms. Other potential side effects include:

  • Low blood pressure
  • Decreased sex drive
  • Nausea
  • Lack of coordination
  • Depression
  • Unusual emotional dysfunction, including anger and violence
  • Memory loss
  • Difficulty thinking

Antianxiety and antipanic medications on the market include:

Know Your Meds: Antidepressants 101

Antidepressants improve symptoms of depression by affecting the brain chemicals associated with emotion, such as serotonin, norepinephrine and dopamine. The following information comes from NAMI, goodtherapy.org and other sources.

Selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs) are newer antidepressants with fewer side effects than older drugs, but no medication is entirely free of side effects. Potential side effects of SSRIs and SNRIs include:

  • Nausea
  • Nervousness, agitation or restlessness
  • Dizziness
  • Reduced sexual desire/difficulty reaching orgasm/inability to maintain an erection
  • Insomnia, drowsiness
  • Weight gain or loss
  • Headache
  • Dry mouth
  • Vomiting
  • Diarrhea

One antidepressant (Bupropion) affects mostly the brain chemical dopamine and is in a category of its own.

Meanwhile, older types of antidepressants, including tricyclics and monoamine oxidase inhibitors (MAOIs), may be prescribed by a mental health professional if newer medications do not seem to be effective. Common side effects of tricyclics include:

  • Dry mouth
  • Blurred vision
  • Constipation
  • Urine retention
  • Drowsiness
  • Increased appetite, leading to weight gain
  • Drop in blood pressure when moving from sitting to standing, which can cause lightheadedness
  • Increased sweating

MAOIs are the least-prescribed of all antidepressants because they can cause dangerously high blood pressure when combined with certain foods or medications. People taking MAOIs must watch their diets carefully to avoid potentially life-threatening complications. Off-limits foods typically include aged cheese, sauerkraut, cured meats, draft beer and fermented soy products such as miso, tofu or soy sauce. Some people may have to avoid wine and all forms of beer.

Some antidepressants may be useful for post-traumatic stress disorder, generalized anxiety disorder and obsessive-compulsive disorder but may require higher doses. Symptoms of depression that are part of a bipolar disorder need more careful assessment because antidepressants may worsen the risk of mania and provide little relief from depressive symptoms. As always, ask your doctor about what treatment options are right for you.

When will the medication work?

In the first few days, the person may have better sleeping and eating habits. In the first 1-3 weeks, the person may have better memory, sex drive, and self-care habits. They may also feel like they have more energy and start to have less anxiety.

After 2-4 weeks, the person may start to have a better mood, less feelings of hopelessness, and less suicidal thoughts. They may also start to feel interested in hobbies again. It may take 6-8 weeks for the medication to fully work.

What are the common side effects?
These are most common in the beginning, and usually get better within 1-2 weeks.

  • Headache
  • Upset stomach, diarrhea
  • Sleepiness or feeling more awake

Some antidepressants can cause sexual problems, such as a decrease in sex drive or problems with ejaculation.

How long do people need to take this medication?
Some people need to take medicine for up to 1 year after they feel better. Others need to take medicine long-term to prevent their symptoms of depression or anxiety from coming back. The length of time depends on how bad the depression or anxiety was, how long they had it, and how many times they have had depression or anxiety in the past.

Here are some of the medication names and their types, with some links to their descriptions in goodtherapy.org

Know the Meds: Antipsychotics 101

Note: This information came from the websites of NAMI, goodtherapy.org and other sources, as well as my own experience. 

Antipsychotics come in two major categories: typical and atypical. Occasionally they are called first and second generation.

The antipsychotics developed in the mid-20th century are the typical and first generation class.  Atypical or second generation were developed more recently. These medications reduce or eliminate the symptoms of psychosis, such as delusions and hallucinations, by affecting the brain chemical dopamine.

Both types of antipsychotics are used to treat schizophrenia and schizoaffective disorder.  The atypical also are used to treat acute mania, bipolar disorder and treatment-resistant depression.  Both kinds work, but they have different side effects.

What are the names of these medications? 

What are the side effects?

Side effects are most common at the beginning, and most get better over time.  The most common are:

  • Sleepiness
  • Dizziness
  • Upset stomach
  • Increased appetite

First generation antipsychotics are more likely to cause movement issues, such as tardive dyskinesia (a condition in which the brain misfires resulting in random, uncontrollable muscle movements and tics.)

The second generation can cause weight gain.

How long does it take to produce results? 

It often takes four to six weeks for the medication to fully work.  However, in the first three days, the person may feel less upset and angry.

After one or two weeks, the person may have a better mood and improved self care habits.  You may see clearer thinking, with fewer hallucinations and delusions.

How long do people take this medication? 

It depends on the situation: how bad the problems were, how long the illness lasted before treatment, and how many times they have had episodes.  Some people only need it for one or two years, while others need it for a lifetime.

 

 

Know the Meds, Part 1

The treatments for mental illness conditions vary from person to person, which doesn’t make things any easier.  People with the same diagnosis can have vastly different experiences with treatments and medications.

Of course, your loved one’s mental health provider is the best source for information about treatment.  Getting a HIPPA release so you can discuss the situation with them is very useful.  The articles in this series, based on information from NAMI and my experience, are general information to help you understand the treatment options when they are discussed.

Psychotropic, or psychiatric, medications influence the chemicals in the brain that regulate thinking and emotions.  While they can be more effective when combined with therapy, often a person needs the medication first to reduce symptoms to allow them to participate in the therapy.

Predicting what works is a challenge.  One field of research called pharmacogenetics does genetic testing to help determine how medications will interact with a person’s genes.  Some people I know have taken these tests, so it’s worth discussing it with the doctor. It’s also helpful to tell the doctor if a medication has worked well for someone else in the immediate family.

Another major challenge is that the medications rarely work instantly.  A person may need to take medication for as long as a few months to see a difference, which becomes even more irritating if side effects are causing issues.

To try to stop that, physicians usually start with small doses and build up to get to the point where the symptoms are better.  It’s important that your loved one does not stop medicine at once.  Usually, it’s better to taper off to avoid unpleasant effects.

The main categories of psychotropic medicine are:

  • Antipsychotics
  • Antidepressants
  • Anti-anxiety medicine
  • Mood stabilizers

We will look at each in this series.

15 Ways to Abide With Jesus

Want to enjoy the presence of Jesus in your life as a caregiver?  Here’s 15 steps to help you get there.

  1. Try a daily prayer of surrender. “Today, this is Your day… Today, I am Yours… May Your Spirit lead, guide and prompt me throughout my day… May I be sensitive to Your prompting and respond accordingly… Today, I surrender my life to You…
  2. Read a short section of Scripture or a devotional book as often as you eat.
  3. Pray Bible verses. Even if it’s just a few verses, pray the Bible back to God.  This is easier if you put up Bible verses around the house. That can be in framed calligraphy, a perpetual calendar of Biblical thoughts or simple Post-it notes.
  4. Be in the day with a plan and the willingness to disregard the plan to respond to what God allows.
  5. Keep focused on what you are doing. When you walk with Jesus, everything you do can be a prayer. This is where the practice of Christian mindfulness comes in.
  6. Listen to yourself and be compassionate. Overcoming restlessness and the need to focus on the trivial to avoid the pain of grief is a problem that I have, and I think many others who are caregivers of people with mental illness have as well. The Three Things exercise can help you to focus your attention, reduce restlessness and add calm: Stretch or drink some water. Note three things you see, three thinks you hear and three feelings you have. 
  7. Refocus during transitions. Try to center yourself as you move from place to place, from event to event. You can say:  I am calm, peaceful and aware of the presence of God as I enter this home/door/time/event.
  8. Carry on a conversation with God and try to make it continual.
  9. When you run out of words, say the Jesus prayer. Using a “Jesus” prayer when you need to calm down or you are in a situation in which you would just look at your phone helps. You can pray “Jesus, Jesus, Jesus” over and over.  I use “Come Holy Spirit.”  It’s also a nice way to go to sleep at night.
  10. Stop to praise God
  11. Be a “yes” to all that is in God and to each circumstance and person who comes into our lives. Have faith that God is at work even in horrible circumstances. We should look at all circumstances, environments, and even all persons as coming through God’s hands so we can serve Him. This is the “good” that all things work for as mentioned in Romans 8:28: 28 And we know that in all things God works for the good of those who love him, who have been called according to his purpose. Acceptance of this kind makes caregiving less depleting and exhausting.It’s so challenging, but you can accept the reality of the circumstance and not argue in your mind that it should be different.  Second, you also need listen to yourself rather than taking a treat (food, a drink or a nap). Acceptance is not the same as being happy in sad circumstances. You cannot pretend everything is fine, because your mind knows it’s not. Accepting that everything is not fine, but it is impossible for you to change allows you to offer more empathy without draining excessive energy. We are not in heaven yet, and bad things happen in a fallen world.  God is still present and wants to abide in you.  The joy of the Lord is your strength.  Follow an energy draining situation with an energy builder such as reading, meditation, pray, eating something healthy and tasty.
  12. In everything give thanks
  13. Think on these things. Philippians 4:8:Finally, brothers and sisters, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable – if anything is excellent or praiseworthy – think about such things. I made up a phrase to help me remember this: The normal real person likes an excellent pizza. (true, noble, right, pure, lovely, admirable, excellent, praiseworthy).  This helps me to do a thought check when I seem to be on the wrong track.
  14. Give yourself a GIFT list.The GIFT list idea originated with Pam Young and Peggy Jones, and I adapted it to give myself something else to think about. I keep the daily list with my to-dos. GIFT stands for: Grace, Imagination, Focus and Thanksgiving.  I ask for a Grace from the list of the fruits of the Holy Spirit (love, joy, peace, patients, kindness, goodness, righteousness, gentleness and self-control). For Imagination, I pick a virtue and image how I could incorporate that virtue into my day.  Focus is the day’s predominate activities.  (Attending meetings, writing, planning, cleaning, making things, running errands, enjoying the family, taking a Sabbath, etc.)  And Thanksgiving is a gratitude list I fill out as the day goes on.  When my mind goes on a tear, I deliberately turn it back to the Grace, Imagination or Focus of the day.
  15. Summon up your courage and pray the welcoming prayer. This is the scariest prayer I’ve ever prayed: Welcome, welcome, welcome. I welcome everything that comes to me today because I know it’s for my healing. I welcome all thoughts, feelings, emotions, persons, situations and conditions. I let go of my desire for power and control.  I let go of my desire for affection, esteem, approval and pleasure. I let go of my desire for survival and security. I let go of my desire to change any situation, condition, person or myself.  I open t the love and presence of God and God’s action within. 

This practice of the presence of God, somewhat difficult in the beginning, when practiced faithfully, secretly brings about marvelous effects in the soul, draws down the abundance of God’s grace upon it, and leads it imperceptibly to this simple awareness, to this loving view of God present everywhere, which is the holiest, the surest, the easiest, and the most efficacious form of prayer. People who lean on Jesus know things that other people don’t know.

 

The Aim of Christian Meditation and Mindfulness

The prayer of the presence of Jesus and Christian mindfulness are two parts of a whole:  the experience of abiding in Jesus.

In their book “Practicing the Prayer of Presence,”  Adrian van Kaan and Susan Muto wrote:  “The best way to cope with suffering is not stoic indifference or pessimistic complaints, but constant conversation with God in all matters, great or small, at all times and in all places.

“A deeper way of learning to pray is to try to live in the presence of God. This is the beginning of always praying as the Gospels and St. Paul recommend. We try in a relaxed way to become aware of His Presence all the time we are awake. We need the grace of quiet concentration and perseverance to develop this habit.

“If we practice the prayer of Presence, we will be better able to check our speech.  Is it agitated, restless, disquieted?  Or is it calm, deliberate and quietly rooted in Christ, who is our Way, Truth and Life?”

What they are talking about has similarities to secular meditation and mindfulness.  But it is quite different.  What the world calls meditation is just a preliminary step that Christians call “recollection” exercises.  It is necessary to bring our spirit together again in inner stillness if we want to be fully present to the Lord.

The aim of Christian mindfulness meditation is:

  • To make our minds familiar with the truths of God.
  • To dwell on those truths.
  • To apply the insights we receive to our lives.

One of the reasons that mindfulness is a popular today is that research shows that it helps to reduce stress and even pain.  Mindfulness can release the mind from an overgeneralized state.  It relieves the automatic brooding, avoidant mind.  Loving kindness meditation and kindness to one’s self also help to decrease the fears that come from feeling responsible when anything goes wrong.  Being overly responsible is an issue I have.

Abiding in the Lord has elements of this mindfulness: seeking to concentrate on the present moment.  “The day’s own trouble is sufficient for the day,” as Jesus said. But it goes beyond that to recognize that God is present in the here and now.  God is here.  God is now.

The condition to receive the presence of God is emptiness.  We must empty ourselves inwardly of all that is not God, including distraction, agitation, fear and nervous tension.  All must give way to the flow of quiet presence.

The person who is experienced with this kind of effort is not a person whose mind does not wander.  Everyone’s mind wanders.  The experienced person is someone who gets very used to beginning again and again and again.

Why Low Expectations Are a Good Thing

How do you feel when you expect a $100 tax refund and the IRS finds a mistake in your favor, so you get $1,000 instead?

How about when you expect to wait for 10 minutes and you end up waiting an hour?

The way that things turn out compared to how we expected them to turn has a lot to do with how we feel.  Understanding the impact of our expectations can help us deal with the pain and frustration of loving someone with a brain-based (mental) illness.

For example, living with a person who has clinical depression is hard.  We want to help, but we don’t know how. Sometimes our efforts make things worse.  The same is true when you live with a person who suffers from anxiety disorders, bipolar disorder or the spectrum that is schizophrenia.

All of them have an intense need for love, but they often have trouble being loving in return.

What would an expert in the psychological community expect from a person with clinical depression?  Low energy, for one thing.  The depressed have so little energy that they rarely can think about other people.  So they seem self-centered.  The depressed person can feel an inner anger that life isn’t fair.  Yet, getting in arguments to try to talk them out of their hopelessness doesn’t work.

A person with bipolar disorder is expected to show signs of the illness.  The mood swings between mania and depression, with long or short periods in between, may seem as if they don’t have a rhyme or reason.  The reason is chemical, and it needs treatment.

Living alongside someone with borderline personality disorder is a true roller coaster ride.  One minute you are the best, and the next you are seen as a monster. “Walking around on eggshells” is a common description of daily life in that household.  People with this illness are in emotional pain almost all the time, and they project issues on others.

In short, people with mental illness are expected to behave in ways you don’t like.  They can no longer meet many simple expectations that we had for them before the illness.  One of the toughest issues family members have is deciding what the new expectations should be:  Can he work?  Can she do chores?  Can he join us for family dinner?  Can she take a shower without prompting?

This change has more impact on us that we want it to have.  We experience deep pain as we try to adjust,  as one thing after another becomes too much for them to do.  Grieving this loss is tough at the beginning, and it’s just as tough as time goes on.

You can measure stress by the difference between what is happening and what you think should be happening.  So your stress will be intense, unless you change your thinking about “what should be.”

At the beginning of a loved one’s mental illness, a psychologist suggested to us, “Why don’t you try not having any expectations at all?”  Easier said than done, and hard to hear.

But we learned to keep our expectations as low as possible.  To fill in the gap,  it’s wise to turn to God’s promises.  God is both sufficient and faithful,  walking with us through this valley of the shadow of death.  Abiding with the Lord can give you expectations of peace and comfort.

 

 

 

 

 

It Gets Better: The Emotional Stages of Mental Health Caregiving

Just as Elizabeth Kubler-Ross developed a stage-of-grief model, several sociologists have created a model for the emotional stages of loving someone with mental illness.

Dr. Joyce Burland, a psychologist, spent two decades of helping her mother and her daughter deal with schizophrenia.  She found no model for the experience, so she created the family education curriculum Family to Family for NAMI.  (My husband and I have taken this course and recommend it to many families in our support group.)

The Burland model has three stages:

  1. Heads Out of the Sand – The family knows their loved one has a mental illness.  They may still be in denial about how severe the illness is. The family needs education (especially about the prognosis for the illness), crisis intervention and emotional support.
  2. Learning To Cope – The family accepts the illness while still experiencing emotions like grief, anger and guilt. They need education about self-care and coping skills for their loved one, as well as peer support.
  3. Moving Into Advocacy – Some families eventually become advocates to help others struggling with these issues.

Dr. David Karp, a sociologist at Boston College, proposed a second model with four stages:

  1. Emotional Anomie – This stage comes before a firm diagnosis.  It can include fear, confusion, bewilderment and questioning of one’s possible “guilt” in the situation.  (“What did I do wrong to cause this?”) It also contain the fervent hope that the problem will “just go away.”
  2. Hope and Compassion – This occurs when the diagnosis is provided.  Fear and confusion directed at the loved one turn to compassion.  The family starts to learn about the illness and to understand they need to be caregivers.  While still hoping that the illness will be resolved quickly, some caregivers may feel that they are willing to do anything to make things better for their loved one.
  3. Loss of Dreams and Resentment –  Now the family understands that the illness may be a permanent condition.  Some experience anger and resentment because it is a problem that they cannot fix.  The resentments also arise from realizing that the illness will have a long-term impact on their own plans.  Some, such as adult children dealing with an ill parent, find themselves in a role reversal situation.  Many rethink their expectations for the ill loved one, struggling to understand what is realistic.  The struggle to decide what behaviors the loved one can control and what they can’t becomes a daily reality.  Families begin the process of trying to love the person and hate the illness. As the demands of caregiving continue, some families become isolated from friends and other family members.
  4. Acceptance –  The family realizes that it can’t control the loved one’s illness.  They feel somewhat relieved that they are not responsible for fixing the issue.  Karp was the person who created the “4 Cs”:  “I did not cause it. I cannot control it. I cannot cure it.  All I can do it cope with it.”   At the same time, the family more easily sees their loved one’s strength and courage in the struggle.  This may led to more respect and even admiration for that person.

Where you do think you fall in these scales?  Have you experiences the differences between having a loved one with a “physical” illness, such as cancer or heart disease, and having a loved one with a brain-based disease?

When the Worst Happens

Help Wanted

Needed immediately: a person to work 24 hours a day, 7 days a week, 365 days a year. Work gets tougher on holidays and trips. No salary.  No benefits. You may spend significant amounts of your own money out-of-pocket. No training. Learn by trial and error, although  what works one day might not work the next.  Be prepared for days that break your heart and times when you will be mistreated on the job.

If you are a caregiver for a person with mental illness, this is your job description. The shock and horror of getting this job has a seismic impact on the family.  Having a family member with any kind of serious illness is devastating.  Dealing with a mental illness … so often a brain-based physical illness … has extra components that make it even more grueling.

Factors Influencing the Family’s Response

A training put together by Michelle D. Sherman, Ph.D, for the Department of Veteran Affairs to help families impacted by post-traumatic stress disorder, clinical depression and other illnesses common to veterans noted that some families have an easier time responding to this situation than others.

The factors that impact the situation in any health crisis include:

  • The family’s support system.
  • Previous experience with or knowledge of the illness.
  • The family’s coping pattern in times of great stress.
  • Access to health care and the quality of that care.
  • Financial status.
  • Type of onset of the illness (sudden vs. gradual, public vs. private).
  • Nature of the symptoms.
  • Other demands on the family.
  • The loved one’s compliance or refusal to participate in care.
  • Prognosis of the illness.

Other factors are specific to mental illness:

  • Reactions by others are unpredictable and even hurtful.
  • Family members feel guilt that they somehow caused the illness, could have prevented the illness or did not detect it early enough. It’s typical to feel guilty about your reaction to previous behavior caused by the illness that you felt were intentional actions.
  • The prognosis and course of treatment are less concrete than with other physical illnesses.
  • The loved one can have embarrassing behaviors that could even result in arrest.
  • The loved one (as well as some family members) can refuse to accept the diagnosis.  This can result in failure to comply with treatment, lying about that, anger toward the family and total lack of appreciation for the family’s efforts.

As a result, families feel isolated. When they turn to their social and religious support, some get no help. Many fear telling others about the illness and do not ask for help.  Tension within the family can get very tough, especially when one or more family members refuse to believe that the loved one has a mental illness.

Families do tend to go through stages as they deal with the situation.  Next time, we will look at the patterns involved in this.

 

 

My Loved One Is Showing Signs of Mental Illness. What Do I Do?

Step One: Trust your instincts. This is especially true if you are very close to this person …. it’s your spouse or your child or your best friend. If their behavior seems unusual and demonstrates one or more of the warning signs of mental illness, you need to pay attention. The worst thing you can do is to ignore it.

If the person is a teenager, you may be tempted to dismiss this as a stage. Yes, many teenagers have episodes of sadness, anxiety, frustration and feelings of being overwhelmed. The episodes should not last more than a few days at most.

If the feelings last for weeks or months, speak to your child about your concerns and consult your family doctor. Teenagers who have stopped participating in activities, no longer connect with friends, and are chronically disconnected, angry and sad are exhibiting abnormal behavior and need help.

Likewise, it is never normal to have a psychotic episode. Even if someone appears to go back to normal, they need a professional assessment.  It won’t hurt anything to check into the situation. Go along with the delusion to get the person to a doctor.

What to Say and How to Say It

So what kind of conversation should you have with them? Here are some tips:

  • Speak in a calm voice.
  • Say what you mean and listen. “I am concerned about you because …” “How are you feeling about this?”
  • Try not to interrupt the person.
  • Avoid sarcasm, whining, threats or yelling.
  • Don’t criticize or call names.
  • Try not to use the words “always” or “never.”
  • Deal with the now.
  • Remember: This has nothing to do with you.  It’s a brain condition.
  • Acknowledge that you are in this together.
  • If things get heated, take a break and come back to the discussion later.

If you are seeing behavior or hearing language that indicate the person is a threat to themselves or others, take them to the emergency room. Tell the staff at the check-in what is going on immediately. If you have a specialized system for dealing with people in psychiatric emergencies in your town, you can call that organization (Netcare in Columbus, Ohio, for example) instead.

Otherwise, make a doctor’s appointment. Some psychiatrists who do not take regular insurance may be able to see you more quickly. Your loved mental health organization may have some names you can call.

While you are waiting for the appointment, help the person take steps to reduce their stress. Encourage them to do something relaxing. Try to help them keep a regular routine of sleep, activity, meals and medication. Again, trust your instincts. Go to the emergency room if you suspect psychosis or suicidal thoughts.

Early Warning Signs of Mental Illness

The warning signs of mental illness often come early in life. Fifty percent of cases of mental illness begin by age 14, and three-quarters begin by age 24.

Looking for warning signs will help you, your loved one and his or her treatment providers get a head start on managing the illness. Generally speaking, it’s hard for the people with the illness to fully recognize the warning signs. So often his friends and family will start to see problems first.  Here are some typical signs:

  • Increased irritability.
  • More noticeable tension, anxiousness or worries.
  • Increased sleep disturbances (such as hearing your loved one being up all night and sleeping through the day OR  not sleeping for more than 24 hours)
  • Depression.
  • Social withdrawal in more extreme forms, such as refusing to leave his or her room even to eat, spending most of the time alone.
  • Deterioration of school or job performance.
  • Concentration problems (taking longer to do tasks, have trouble finding tasks, having trouble following a conversation or a TV show).
  • Decreasing or stopping medication or treatment (such as, refusing to go to the doctor or the case manager appointment, skipping the vocational program).
  • Eating less or eating more.
  • Excessively high or low energy.
  • Lost interest in doing things.
  • Poor hygiene or lost interest in the way he or she looks.
  • Saying that he or she is afraid that he or she is “going crazy.” 
  • Becoming excessive in religious practices.
  • Feeling bothered by thoughts that he or she can’t get rid of.
  • Mistrustfulness or suspiciousness.
  • Showing emotions that do not fit the situation.
  • Vague speech.
  • Speech that doesn’t make sense.
  • Making up words.
  • Inappropriate responses … laughing or smiling when talking of a sad event, making irrational statements.
  • Unusual idea or beliefs.
  • Feeling completely overwhelmed. 
  • Leaving bizarre voice mail messages, outgoing messages or writings.
  • A blank vacant facial expression.
  • Rapidly changing mood … from happy to sad to angry for no apparent reason.

Warning Signs of Mental Illness in Children

  • Severe and recurring depression … feeling very sad or withdrawn for more than two weeks.
  • Explosive, destructive or lengthy rages, especially after the age of four.
  • Extreme sadness or lack of interest in play.
  • Severe separation anxiety.
  • Talk of wanting to die or kill themselves or others.
  • Dangerous behaviors, such as trying to jump from a fast moving car or a roof.
  • Grandiose belief in own abilities that defy the laws of logic (possessing ability to fly).
  • Sexualized behavior unusual for the child’s age.
  • Impulsive aggression.
  • Delusional beliefs and hallucinations.
  • Extreme hostility.
  • Extreme or persistent irritability.
  • Telling teachers how to teach the class, bossing adults around.
  • Creativity that seems driven or compulsive.
  • Excessive involvement in multiple projects and activities.
  • Compulsive craving for certain objects or food.
  • Hearing voices telling them to take harmful action.
  • Racing thoughts, pressure to keep talking.
  • Sleep disturbances, including gory nightmares or not sleeping very much.
  • Drawings or stories with extremely graphic violence.

Trust Your Instincts

If the person is a family member … a child or husband … and their behavior seems unusual to you, trust your instincts.

If your teenager is not engaging in activities or with friends and is chronically disconnected, angry and sad, the behavior is abnormal and needs intervention.

Many teenagers have episodes of sadness, anxiety, frustration and feelings of being overwhelmed.  The episodes should not last more than a few days at most.  If the feelings are continual and your teen is chronically anxious, speak to your child about your concerns and consult your family doctor.

Don’t ignore. Don’t accept other people saying it’s just a stage. Trust your instincts that something is wrong.

Mental Illness: Brain-Based, Common and Episodic

Mental illness is a difficult phrase: It implies that this kind of illness is different from all other kinds of illness. It’s not. It’s a brain-based illness, for the most part. I use the phrase because it is widely understood, not because it is appropriate.

Mental illness is common, and it’s generally episodic. Things get better and then things get worse and then things get better again. 

Illness or Individuality?

There are plenty of people who are very shy, or believe in government conspiracies, or are sure that they talked to the dead, or heard directly from God.  Does that mean they are mentally ill?  Not necessarily.

To one degree or another, many people hold views that are unusual or eccentric. To qualify as mental illness, the behavior must do these things:

  1. The symptoms must interfere with the person’s ability to have social relationships, go to school or hold down a job, or take care of himself.
  2. The most severe symptoms must last for at least a month, unless the period is cut short with successful treatment.
  3. The symptoms are not explained by drug abuse, the side effects of another medication or the impact of another illness.

Is Mental Illness Really Common, Though?

Yes. It may not seem common because it is so often hidden. Here are the facts from NAMI and the World Health Organization:

  • About 1 in 5 adults in the U.S. – 43.8 million or 18.5% experience a mental illness in any given year.
  • About 1 in 25 adults in the U.S. – 9.8 million or 4% – experiences a serious mental illness in any given year that substantially interferes with or limited one or more major life activities.
  • About 1 in 5 children aged 13-18 (21.4%) experiences a severe mental disorder at some point.  For children aged 8-15, the estimate is 13%.
  • 1.1% of adults in the U.S. are on the schizophrenia spectrum.
  • 2.6% of adults in the U.S. have bipolar disorder.
  • 6.9% of adults in the U.S. – 16 million – had at least one major depressive episode in the past year.
  • 18.1% of U.S. adults have an anxiety disorder such as posttraumatic stress disorder, obsessive-compulsive disorder and specific phobias.
  • About the 20.2 million adults with a substance use disorder, 50.5% – 10.2 million adults – have a co-occurring mental illness.
  • About 26% of homeless adults staying in shelters have a serious mental illness.
  • About 20% of state prisoners and 21% of local jail prisoners have a recent history of mental illness.
  • 70% of youth in juvenile justice systems have at least one mental health conditions and at least 20% have a major mental illness.
  • More than 90 percent of children who commit suicide have a mental illness.
  • Only 41% of adults with a mental health condition received medical services for it.
  • Only half of the children with mental health conditions get help.
  • African Americans and Hispanic American use mental health services at about half the rate as Caucasian Americans.  Asian Americans get services at about one-third the rate.
  • Percentage of people with mental illness that Jesus cared enough about to die for:  100%

Are You a Sponge or a Mirror?

Need to take your life back? One of the best books of practical advice I’ve found is “Stop Walking on Eggshells” by Paul T. Mason and Randi Kreger. The authors focus on Borderline Personality Disorder, but the advice is good for ANYONE who is feeling overwhelmed by another person’s behavior.

You start by asking yourself:  Are you a sponge (soaking up the other person’s pain) or a mirror (reflecting reality back to the person)?  The advice about improving communication is particularly good.

You must not spiral into another person’s distorted world, but you still can listen carefully to detect what the person is really upset about. It’s hard to be verbally attacked for a delusion, but the pain and fear underneath that attack are real.

While the person’s feelings may not make any sense to you, they make sense to them. Don’t judge. Don’t trivialize. Don’t be condescending. Use active listening skills to validate the feelings.

Still you must know your boundaries … what you will and will not tolerate.  Stay consistent, no matter what. Research shows that inconsistent response to a behavior actually makes that behavior more persistent than even rewarding the behavior every time does.

When things need to change, make specific requests in simple language, as in: “I want you to stop hanging up on me and then immediately calling me back when we are talking on the phone” rather than “Stop being so disrespectful.”

If you feel helpless, get some help yourself from a counselor.  Together you can work out responses to difficult situations. When my daughter was very ill with juvenile bipolar disorder, I had my own therapist. She was a great gift in my life because she understood that my daughter’s illness and could see difficult situations with a compassionate outsider’s viewpoint.  That gave me insights and ideas I would not have had otherwise.

In effect, you are learning to love the person while still being loving to yourself.  It will make both of you better.

My Life as a Lighthouse

Once I asked God for an image of my life’s meaning. What I saw was a lighthouse.

That won’t seem unusual to those who’ve been to my house in summer when lighthouses become a decorative item.  We’ve always been drawn to them, and we generally buy an image of each lighthouse we visit.  Only my husband has been brave enough to climb the scariest of old spiral staircases to the top. But we both love them.

Being a lighthouse is also an image of the difference between being loving to someone who is experiencing a storm of mental illness and being codependent.  The lighthouse shines its light to guide the ships to safety.  It does not drag itself off its rock and wade into the storm in an attempt to grab the ship and drag it to safety.  It sounds the foghorn, it’s true, but it doesn’t engage in a lengthy argument about why the ship should head in its direction.

Fortunately, the lighthouse is attached to its rock, just I am attached to my Rock. So we allow the ship to use us as a guide or to ignore all our sound advice. We look strong, maybe even stronger than we feel, and we shine our light so that all can see it.

You’d Be Fine If You Just Took Your Medicine


I take my medicine.  Do you?  Probably.  So why is it so hard for our loved ones with mental illness to take their meds? You probably have heard all the reasons:

  1. They hate the side effects.
  2. They feel good now so they hope that the illness is over.
  3. It’s too hard to get the medicine. 
  4. The medicine takes aways the “highs,” leaving them flat and uncreative.
  5. They just don’t like the idea of taking drugs for mental illness, athough they often medicate it themselves with alcohol and street drugs.
  6. The medicine is too expensive. (That’s certainly true.)

The No. 1 responsibility that we have as caregivers is to make sure that our loved ones get and take their medication. That’s difficult, to say the least. I have had a variety of experiences.  I’ve had loved ones actively refuse to take the medicine, spitting it out into the glass of water.  I’ve had loved ones pretend to take the medicine and later throw it into the toilet.  And I’ve had loved ones faithfully take the medicine.

This last came as a result of refusing to provide any money to the loved one and then offering to trade compliance for cigarettes.  Yes, I know the American Lung Association would be proud of me. But it worked.  And, since up to 80 percent of people with schizophrenia smoke, it is an option. Once he had been on the medicine for a while, he became faithful about taking it because, he said, “I remember what it’s like when I don’t take my medicine.”

Frankly that’s what we all wish for.  Of course, the classic strategies to encourage compliance include:

  • Talking up the benefits of taking the medicine, including pointing out that it will help them to stay out of the hospital. A locked psych ward isn’t a pleasant memory for anyone.  Pointing out that the medicine will help them move forward to better days is also important. 
  • Building the medicine into a routine that’s as simple as possible.  We do a weekly pill box.  I fill it each Sunday and check it intermittently. My loved one also takes all the medicine once a day, even though he is supposed to take it in 12-hour periods.  He was never able to remember taking it in the morning, but could remember to take it before bed. Better all at once than not at all.  
  • Using incentives, like money, movie tickets, keys to the car and other things.

If they still won’t take the medicine, you need to maintain as positive and pleasant a relationship as you can so the tension of the medicine doesn’t destroy your rapport.  At the same time, you need to allow the loved one to experience the consequences of not taking the medicine. And that can be the most difficult step of all.

Bringing God’s Grace to Your (Sad and Scary) Situation

Do not look forward to the changes and chances of this life in fear; rather look to them with hope that, as they arise, God, whose you are, will deliver you out of them … the same everlasting God who cares for you today, will take care of you tomorrow, and every day, either by shielding you from suffering, or by giving you strength to bear it. Be at peace, then, and put aside all anxious thoughts.

I don’t think I’ve ever met anyone who has achieved this advice from Francis de Sales.  But it is a goal for me, like it is for many who love people with mental illness.

First, falling apart under a burden of worrying and anxiety will not help your loved one.  Your stability is a bedrock for them, and you need to try to keep yourself at peace as best you can.

So how? Only with God’s grace is any of this possible.  The best way to open myself up to that grace is to realize that I need to ask for forgiveness for the sin of worry … yes, it actually is a sin … and ask for grace.  I certainly can’t do it by myself.

I was listening to a sermon from Tim Keller of Redeemer Presbyterian Church, a great church in New York. He pointed out that worry actually comes out of pride and even arrogance.  We think we know what SHOULD be happening and are distraught that it’s not. So we worry.

Has God allowed something to get past Him? No. God is sovereign, and He can make even the suffering that comes from the illness … and ultimately from the fallen world … and make good come out of it for those who love Him. If we repent and reach out for grace, step by step the peace will come.

When They Don’t Think They Are Mentally Ill

One symptom of having a mental illness is … not knowing that you have a mental illness. Really.

This symptom is anosognosia … pronounced uh-no-sog-NOH-zee-uh.  It means being unaware of one’s disease, disability or defect. This is common, as many who have tried to help a loved one can tell you.

Some people who have brain-based or “mental” illness have insight.  They know they have a mental disturbance that could be an illness. They recognize they have  experiences, including beliefs and perceptions, that don’t match reality.  Because they can see this, they are much more likely to accept treatment.

People with anosognosia often don’t accept treatment simply because they don’t think they are sick.

Anosognosia affects 50 percent of people with schizophrenia and 40 percent of people with bipolar disorder.  It also can be a symptom of major depression with psychotic features.

What Causes This?

The symptom can vary over time. Sometimes people understand they are ill, and sometimes they don’t. They are not being stubborn or difficult. The same brain dysfunction that causes hallucinations and voices also causes anosognosia.

People constantly update their own mental images of themselves.  You remember that you have a sunburn or a bruise or a runny nose, so you are not surprised when you see it again. The updating process takes place in the frontal lobe.

Unfortunately schizophrenia, bipolar disorder and dementia damage the frontal lobe.  So our loved ones can lose the ability to update their self-images.

Without an update, they have an old self-image from before the illness. Since our perceptions feel accurate, they believe they are well.  They decide that our families are lying or making a mistake.  When families insist that they are right, the person with the illness may get frustrated or angry.  They may begin to avoid family and friends.

Why Is Insight Important?

Lack of insight not only causes conflict. It usually causes a person to avoid treatment. It is also the most common reason that people with mental illness stop taking their medications.  When combined with psychosis or mania, lack of insight can cause dangerous behavior.

How Can You Tell If It’s Anosognosia or Denial?

It’s likely to be anosognosia if:

  • The lack of insight is severe and persistent (lasting for months or years).
  • The beliefs (I am not sick, etc.) are fixed. They don’t change when you confront the person with overwhelming evidence.
  • You hear illogical explanations or elaborate statements that attempt to explain away the evidence of the illness.

How Can You Help Your Loved One?

Anosognosia is a delusion. We can’t talk people out of delusions.  (That’s what a delusion is: a belief in the face of contrary evidence.) So stop arguing about it.

The alternative that experts stress is listening to the person.  The LEAP method, developed by Dr. Xavier Amador, has proven quite effective in research in helping people to accept that need for treatment.

In summary, the LEAP method is:

  • Listen to your loved one. If they don’t think they are sick, find out what problems they think they do have.  Lack of sleep, for example.
  • Empathize. Let them know you understand how difficult things are.
  • Agree with the loved one on some point. Example:  Lack of sleep makes things hard.
  • Partner with the loved one, starting with solving the problem that they recognize.

The method is detailed in Dr. Amador’s book, “I’m Not Sick. I Don’t Need Help.”  Details on also available in the videos here.  They are worth watching.