Managing Depression and Anxiety

Families who have one or more members with severe, persistent mental illness face unique challenges. Complex family dynamics, social isolation and often unpredictable behavior can take their toll. Other ways that mental health issues impact families include:

  • The family may change its rules or patterns.  The ill person may no longer do chores, and the family may withdraw from social situations.
  • Friends may withdraw from the family.
  • Everyone is walking on eggshells around the person.
  • Family members vent their frustration on non-ill family members.
  • Parents may be stricter with non-struggling children.
  • Family members may blame themselves.
  • Family members may become resentful of the ill person for the disruption the illness has caused.
  • Family members may be ashamed of the ill person’s struggle.

Under these circumstances, the primary caregiver or other family members may develop depression and anxiety. This also impacts the entire family. In fact, the additional stress can be overwhelming. But there is hope. The ideas below come from people who have lived experience, as well as NAMI, Mental Health America and the Veterans Administration.

When You Are Struggling

Learn all you can. If you develop depression or anxiety, learn all you can about the illnesses. Taking good care of yourself is critical to caring for your loved ones. Connect with other people experiencing these issues in support groups or meetings. Attend local mental health conferences and conventions. Build a personal library of useful websites and helpful books. Learning is an active thing you can do that gives you a feeling of control where control is possible. Ideally, you should learn about your loved one’s illness as well as depression and anxiety.

Recognize early symptoms. Identify possible warning signs and triggers that may aggravate your depression or anxiety symptoms. With this knowledge, you can recognize an emerging episode and get the help you need as soon as possible. Don’t be afraid to ask your friends and family for help—they can help you monitor your symptoms and behavior.

Partner with your health care providers. Give your health care provider all the information he or she needs to help you recover—including any reactions to medications, your symptoms or any triggers you notice. Develop trust and communicate openly.

Know what to do in a crisis. Be familiar with your community’s crisis hotline or emergency walk-in center. Know how to contact them and keep the information handy.

Avoid drugs and alcohol. These substances can disturb emotional balance and interact with medications. You may think using alcohol or drugs will help you “perk up,” but using them can hinder your recovery or make symptoms worse.

Eat well and exercise. To relieve stress, try activities like centering prayer, meditation, yoga or Tai Chi.

Deal with unresolved grief.  Do you have a mixture of persistent feelings of sadness, anger and frustration about your loved one’s mental illness?  Seek more help if you know that you are still grieving over the illness.

Helping Another Family Member  

In these circumstances, some family members may develop depression or anxiety. This is a heavy load for a caregiver dealing with another loved one with mental illness. Getting support is essential for you to continue be helpful. Some suggestions include:

Be proactive in keeping the family as strong as possible.

  • Eat, sleep, connect with other people and turn to God.
  • Take a break when needed.
  • Go places as a family even if the ill person does not go.
  • Encourage all family members to continue with regular activities.
  • Know some days are better than others, and all things pass.
  • Consider family therapy.

Learn more about your loved one’s condition. Learning about depression and anxiety will help you better understand and support your loved one.  They do not need to “hit bottom” to get better. In many cases, hitting bottom means suicide.

Communicate.  Speak kindly and honestly. Don’t scold or blame people with depression or urge them to “try harder” to “just be happy.” Instead, make specific offers of help and follow through with those offers. Tell the person you care about them. Ask them how they feel and truly listen.

React calmly and rationally. You can’t fix the person, but you can walk with them through this time. Even if your family member or friend is in a crisis, it’s important to remain calm. Listen to their concerns and make them feel understood—then take the next step toward getting help.

Find emotional support from others. Share your thoughts, fears and questions with other people who have loved ones with similar conditions. If they won’t get help, you should.

Schedule pleasant events and encourage an increased activity level.  Assist your loved one in making plans at specific times and dates to do something pleasant … a walk in the park, a movie, etc.

Correct unhelpful thinking. Help your loved one challenge thoughts about how things “should” be.  You need to learn about cognitive distortions and how to gently help a loved one to understand them.   I recommend reading  “Feeling Good: The New Mood Therapy” or “The Feeling Good Handbook,” both by David D. Burns.

Dealing With Anxiety

Note: The information in this post comes from NAMI, Mental Health America and the Veterans Administration.

Anxiety is the most common form of mental illness in the U.S., affecting 14% of the population before the pandemic. The KFF Health Tracking Poll from June 2020 reported that the number had risen to 40% of adults during 2020. Typically, the National Institutes of Health reports that 18% of adults and 8% of children and teenagers have anxiety.

Anxiety disorders are a group of related conditions, each with unique symptoms. All the types of anxiety disorders do have three major things in common:

  1. Extreme fear and dread, even when there is nothing to provoke it
  2. Emotional distress that affects daily life
  3. A tendency to avoid situations that bring on anxiety

Anxiety also can be an early warning sign of a relapse in other forms of mental illness, including schizophrenia.

Symptoms

People suffering from anxiety disorders typically experience one or more of the following symptoms:

  • Mood and thinking:  Worry or concern, fear, irritability, or difficulty concentrating.
  • Behavior:  Avoidance of feared situations, escape from unpleasant situations, trembling, and agitation (such as pacing)
  • Increased arousal: Perspiration, heart palpitations, muscular tension, butterflies in stomach, mild nausea, dizziness, shortness of breath, headaches, sweating, tremors or twitches, frequent urination, diarrhea, insomnia and fatigue

The most common types of anxiety disorders include:

Generalized Anxiety Disorder (GAD)

GAD produces chronic, exaggerated worrying about everyday life. This worrying can consume hours each day, making it hard to concentrate or finish daily tasks. A person with GAD may become exhausted by worry and experience headaches, tension or nausea.

Social Anxiety Disorder

More than shyness, this disorder causes intense fear about social interaction, often driven by irrational worries about humiliation (e.g. saying something stupid or not knowing what to say). Someone with social anxiety disorder may not take part in conversations, contribute to class discussions or offer their ideas, and may become isolated. Panic attacks are a common reaction to anticipated or forced social interaction.

Panic Disorder

This disorder is characterized by panic attacks and sudden feelings of terror sometimes striking repeatedly and without warning. Often mistaken for a heart attack, a panic attack causes powerful physical symptoms including chest pain, heart palpitations, dizziness, shortness of breath and stomach upset.

Phobias

We all tend to avoid certain things or situations that make us uncomfortable or even fearful. But for someone with a phobia, certain places, events or objects create powerful reactions of strong, irrational fear. Most people with specific phobias have several things that can trigger those reactions. To avoid panic, they will work hard to avoid their triggers. Depending on the type and number of triggers, attempts to control fear can take over a person’s life.

Causes of Anxiety Disorders

Scientists believe that many factors combine to cause anxiety disorders:

  • Genetics.  Studies support the evidence that anxiety disorders “run in families,” as some families have a higher-than-average amount of anxiety disorders among relatives.
  • Environment. A stressful or traumatic event such as abuse, death of a loved one, violence or prolonged illness is often linked to the development of an anxiety disorder.

Diagnosis

Physical symptoms of an anxiety disorder can be easily confused with other medical conditions, like heart disease or hyperthyroidism. Therefore, a doctor will likely perform an evaluation involving a physical examination, an interview and lab tests. After ruling out an underlying physical illness, a doctor may refer a person to a mental health professional for evaluation.

Treatment

Because different anxiety disorders have their own distinct symptoms, each type has its own treatment plan. Common types of treatment include:

Helping Ourselves

Leading a balanced lifestyle helps us manage symptoms. The suggestions from people who have lived experience with anxiety are similar to those who live with depression:

Learn all you can. Learn about your loved one’s mental illness, our own anxiety, and the many treatment options available. Connect with other people experiencing anxiety in support groups or meetings. Attend local conferences and conventions. Build a personal library of useful websites and helpful books. Learning is an active thing we can do that gives us a feeling of control.

Recognize early symptoms. Identify possible warning signs and triggers that may aggravate your symptoms.

Partner with your health care providers. Give your health care provider all the information he or she needs to help you recover—including any reactions to medications, your symptoms or any triggers you notice. Develop trust and communicate openly.

Avoid drugs and alcohol.

Get physically healthy.

Anxiety is common. Especially in difficult times. As a caregiver of a person with a mental illness, you are likely to experience it occasionally. Be sure to take it seriously. You have to help yourself first before you can help the people you love.

hand coming up from water

Dealing With Depression

Depression and anxiety are now wide-spread problems stemming from the coronavirus pandemic. But caregivers of people with mental illness have often suffered from these issues.

On February 21, 2021, the New York Times published an American Psychological Association poll that said 74 percent of psychologists are seeing more patients with anxiety disorders than before pandemic. Sixty percent were seeing more people with depression. Time Magazine also published this on the increase in depression.

First the good news.

Almost all depression and anxiety conditions are treatable.  But there is no magic fix. These are very complex conditions.  Depression and increased anxiety also can be signs that a person with a more severe diagnosis, such as bipolar disorder or schizophrenia, is heading into an episode. Let’s take a look at depression first.

Depression … what it is and who gets it

Depression can result from a combination of genetic, biological, environmental, and psychological factors, the Veterans Administration website reports. Trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger depression, but depression can also occur without an obvious trigger.

According to the National Alliance on Mental Illness, an estimated 16 million American adults—almost 7% of the population—had at least one major depressive episode in a non-pandemic year. Women are 70% more likely than men to experience depression. And young adults aged 18–25 are 60% more likely to have depression than people aged 50 or older.

Depression is frequently under-diagnosed, however. Psychologists estimate that only about one-third (35%) of people with depression ever see a mental health professional.

The Veterans Administration reports that military personnel are prone to depression, at least partially as a result of exposure to traumatic experiences, including witnessing combat and separation from family during deployment or military trainings. Data shows it is five time higher among active duty soldiers and even higher among the previously deployed solders.

Some will only experience one depressive episode in a lifetime, but for most, depressive disorder recurs.

Without treatment, episodes may last a few months to several years.

Symptoms of Depression

Depression can present different symptoms, depending on the person. But for most people, depressive disorder changes how they function day-to-day, and typically for more than two weeks. Common symptoms include:

  • Changes in sleep
  • Changes in appetite
  • Lack of concentration
  • Loss of energy
  • Lack of interest in activities
  • Hopelessness or guilty thoughts
  • Changes in movement (less activity or agitation)
  • Physical aches and pains
  • Suicidal thoughts

We are not capable of diagnosing depression, but we can use the SIGECAPS diagnostic tool to determine whether someone should see a doctor. If a person has five or more of these 8 symptoms every day for two weeks, they are likely struggling with a major depression.

SIGECAPS Diagnostic Tool

  • SADNESS / SLEEP INTERRUPTION
  • INTERESTS … lost interest in things that used to enjoy
  • GUILT … ruminating over past perceived failures, character flaws, mistakes
  • ENERGY … noticeable lack of it
  • CONCENTRATION … inability to
  • APPETITE … could be eating more or eating less
  • PSYCHOMOTOR ABNORMALITIES … retardation (slowed speech, slowed movement, shuffling gait, collapsed posture, low voice volume, monotone speech, lack of facial expressions) or agitation (pacing, wringing hands, removing and putting on clothing over and over,
  • SUICIDAL … actively (with a plan), passively (stopped caring whether they live or die) and para (cutting or overdoses that the person knows won’t kill them … a cry for help)

Causes of Depression

Depression does not have a single cause. It can be triggered by a life crisis, physical illness or something else. But it can also occur spontaneously. Scientists believe several factors can contribute to depression:

  • Trauma. When people experience trauma at an early age, it can cause long-term changes in how their brains respond to fear and stress. These changes may lead to depression.
  • Genetics. Mood disorders, such as depression, tend to run in families.
  • Life circumstances. Marital status, relationship changes, financial standing and where a person lives influence whether a person develops depression.
  • Brain changes. Imaging studies have shown that the frontal lobe of the brain becomes less active when a person is depressed. Depression is also associated with changes in how the pituitary gland and hypothalamus respond to hormone stimulation.
  • Other medical conditions. People who have a history of sleep disturbances, medical illness, chronic pain, anxiety and attention-deficit hyperactivity disorder (ADHD) are more likely to develop depression. Some medical syndromes (like hypothyroidism) can mimic depressive disorder. Some medications can also cause symptoms of depression.
  • Drug and alcohol abuse.  About one-third of people with substance abuse problems also have depression. This requires coordinated treatment for both conditions, as alcohol can worsen symptoms.

Treatments for Depression

After an assessment rules out medical and other possible causes, a patient-centered treatment plans can include any or a combination of the following:

  • Psychotherapy including cognitive behavioral therapy, family-focused therapy and interpersonal therapy.
    • Cognitive behavioral therapy (CBT) has a strong research base to show it helps with symptoms of depression. This therapy helps assess and change negative thinking patterns associated with depression. The goal of this structured therapy is to recognize negative thoughts and to teach coping strategies. CBT is often time-limited and may be limited to 8–16 sessions in some instances. 
    • Interpersonal therapy (IPT) focuses on improving problems in personal relationships and other changes in life that may be contributing to depressive disorder. Therapists teach individuals to evaluate their interactions and to improve how they relate to others. IPT is often time-limited like CBT.
    • Psychodynamic therapy is a therapeutic approach rooted in recognizing and understanding negative patterns of behavior and feelings that are rooted in past experiences and working to resolve them. Looking at a person’s unconscious processes is another component of this psychotherapy. It can be done in short-term or longer-term modes. 
  • Medications including antidepressants, mood stabilizers and antipsychotic medications.
  • Exercise can help with prevention and mild-to-moderate symptoms.
  • Psychoeducation and support groups
  • Brain stimulation therapies can be tried if psychotherapy and/or medication are not effective. These include electroconvulsive therapy (ECT) for depressive disorder with psychosis or repetitive transcranial magnetic stimulation (rTMS) for severe depression.
    • Electroconvulsive Therapy (ECT) involves transmitting short electrical impulses into the brain. ECT does cause some side effects, including memory loss. Individuals should understand the risks and benefits of this intervention before beginning a treatment trial.
    • Repetitive Transcranial Magnetic Stimulation (rTMS) is a relatively new type of brain stimulation that uses a magnet instead of an electrical current to activate the brain. It is not effective as a maintenance treatment.
  • Light therapy, which uses a light box to expose a person to full spectrum light in an effort to regulate the hormone melatonin.
  • Alternative approaches including acupuncture, meditation and nutrition can be part of a comprehensive treatment plan, but do not yet have strong scientific backing.

Major Depressive Disorder with a Seasonal Pattern

Major Depressive Disorder with a Seasonal Pattern (formerly known as seasonal affective disorder, or SAD) is characterized by recurrent episodes of depression in late fall and winter, alternating with periods of normal mood the rest of the year.

Researchers at the National Institute of Mental Health were the first to suggest this condition was a response to decreased light and experimented with the use of bright light to address the symptoms. Scientists have identified that the neurotransmitter serotonin may not be working optimally in many people who experience this disorder.

The prevalence of this condition appears to vary with latitude, age and sex:

  • Prevalence increases among people living in higher/northern latitudes.
  • Younger persons are at higher risk.
  • Women are more likely than men to experience this condition.

Symptoms

This disorder’s most common presentation is of an atypical depression. With classic depression, people tend to lose weight and sleep less. This condition is the kind of atypical depression often seen in bipolar disorder—people tend to gain weight and sleep more.

Although not everyone experiences all the following symptoms, the classic characteristics of Major Depressive Disorder with a Seasonal Pattern include:

  • Hypersomnia (or oversleeping)
  • Daytime fatigue
  • Overeating
  • Weight gain
  • Craving carbohydrates

Many people may experience other symptoms as well, including:

  • Decreased sexual interest
  • Lethargy
  • Hopelessness
  • Suicidal thoughts
  • Lack of interest in usual activities and decreased socialization

Diagnosis

The key to an accurate diagnose of this condition is recognizing its pattern. Symptoms usually begin in October/November and subside in March/April. Some people begin to experience a “slump” as early as August, while others remain well until January. Regardless of the time of onset, most people don’t feel fully “back to normal” until early May.

For a diagnosis to be made, this pattern of onset and remission must have occurred during at least a two-year period, without the occurrence of any non-seasonal episodes during that same period.

This means you will not receive this diagnosis the first time you experience symptoms. If you believe you may have a seasonal depressive pattern, it’s important to pay attention to the pattern. Track your symptoms, noting when they begin and when they subside. This self-awareness can help. Mental health professionals will ask you about your observations and also your family history since mood disorders tend to run in families.

Treatment

As with most depressive disorders, the best treatment includes a combination of antidepressant medications, cognitive behavioral therapy and exercise. Unlike other depressive disorders, this condition can also be treated with light therapy. Light therapy consists of regular, daily exposure to a “light box,” which artificially simulates high-intensity sunlight.

If you know you have a seasonal pattern, ask yourself “How can I plan for this?” Because this disorder has a specific pattern, those who experience it can prepare for its arrival in the following ways, for example:

  • Exercise more toward the end of summer
  • Get into therapy around September
  • Start your lightbox in October
  • Plan a vacation to a sunny spot in January

Where Should We Set Boundaries?

Caring for a loved one with mental illness creates life burdens. Here are just a few:

  • Helping the loved one in a crisis while trying to meet the needs of other family members
  • Dealing with family disagreements about what to do
  • Dealing with family members in various states of acceptance of the illness
  • Finding the best ways to deal with “negative symptoms” or residual symptoms, such withdrawal, silence, inability to have a conversation, irritability, resistance to treatment
  • Trying to get information you need from providers
  • Serving as the “real” case manager for the loved one
  • Staying alert to signs of decompensation and relapse
  • Dealing with your own anxiety about relapse and other horrible things that could happen
  • Balancing earning a living with caring for your loved one
  • Managing the impact of your loved one on your marriage and other family relationships
  • Dealing with financial issues and plans for future care

Setting boundaries, as we’ve said before, is for your own good and your loved one’s good in this challenging life circumstance. Here are some possible areas where you may need to set them:

  • Financial support
  • Whether or not you are willing to co-sign documents
  • Your loved one’s ability to live in your home
  • How much practical help you can provide (meals, budgeting or handling money, grocery shopping, transportation, etc.)
  • Household chores you expect your loved one to do
  • Personal hygiene requirements
  • Disruptive behaviors (refusing to follow house rules, playing music or videos too loudly, etc.)
  • Use of tobacco, alcohol and/or street drugs in your home
  • Gambling
  • Attending medical appointments
  • Taking prescribed medications

Establishing boundaries is one of the most thoughtful things you do. It is also one of the most difficult.

The best way I’ve found is to pick out one or two of the most troublesome behaviors. Assign consequences for violations of these boundaries. Clearly communicate this to your loved one. Be consistent in enforcing them.

no trespassing signs indicating boundaries

Yes, You Are Allowed to Set Boundaries

Note: The material below is based on information in Chapter 8 of “When You’re the Caregiver: 12 Things To Do If Someone You Care For Is Ill Or Incapacitated” by James. E. Miller. (Courtesy VA/AMI)

When you are helping to care for a loved one who has a life-limiting disability, including mental illness, you still need boundaries. The three principles for those boundaries are:

  1. You have a right to be safe and comfortable in your own home.

Violence and aggressive behavior, whether it is a symptom of mental illness or not, is never acceptable.

2. You need to establish boundaries for your own good.

Yes, it’s true – the other needs you. Yes, you can help, and yes, you may find meaning in doing that. But, no, you don’t have to do it all. And, no, you don’t have to do it to your own detriment. If you’re not careful, you’ll soon be on your way to exhaustion and burnout.

Some boundaries for you to set are physical. Some things are simply too strenuous for you. Some hours are too long for you to keep. Some chores you cannot continue to perform without relief.

Other boundaries are emotional. If you identify too completely with the other’s pain, fear or other strong emotions, you are in danger of making them your own. Your responsibility is to handle only one person’s feelings: your own.

Setting limits to your caregiving will make room for other caregivers. Family members and friends may wish to share in these duties. It’s one way they can cope with what has happened, and one way they can show their love.

Setting boundaries eliminates the need for arguments and criticism. It also makes dealing with issues easier and settles your mind. You have made the decision already. You don’t have to think it through every time.

3. You need to establish boundaries for the other person’s good. One way you can respect the other is to give them their own space. They need their privacy just as before – perhaps to read or meditate or write or just look out the window. If you do not provide for this solitary time, the one in your care may not have the strength or the heart to seek it.

The other person needs the freedom to do things on their own as a matter of self- esteem, and perhaps for continued recovery. If you insist on doing too much, the other has too little opportunity to flex their muscles. And there are several kinds of muscles they may need to flex.

Good boundaries give the other this added benefit: you can be a more objective presence in their life. Your insight can be more accurate and your feedback can be more useful.

All in all, establishing boundaries is one of the most thoughtful things you can do. It can even draw you closer together. And it is one of the most difficult things to do.

Use LEAP to Help Your Loved One Get Treatment

How to get a loved one with mental illness to accept treatment? One path has the research to prove itself reliable: the LEAP method developed by Dr. Xavier Amador.

So many people with mental illness have a brain-based inability to understand that they are sick. Dr. Amador, whose brother had schizophrenia, developed the LEAP method to overcome this.

LEAP stands for:

  • Listen
  • Empathize
  • Agree
  • Partner

Listening begins with dealing with your own fears.

If you know what you are afraid of hearing, it can help you to stay on the LEAP path and not become reactive.

Instead concentrate on what your loved one says. Do not try to follow your own agenda for the conversation. Instead, repeat to the person what you think they are saying. Ask questions instead of making statements in response. Be open to having your loved one correct you.

If your loved one asks for your opinion, delay answering three times. One way to delay is to say: “I’m more interested in what you think about this” or “What I think doesn’t matter as much as what you think.”

Once you have delayed three times, you can answer the question. Start by apologizing, as in “I hope this doesn’t upset you.” Tell them that you could be wrong and that you want to agree to disagree, if necessary.

Good examples of this are found on the LEAP Foundations video page here.

Empathize with your loved one’s feelings.

You don’t have to agree with a delusion. But arguing against it is pointless. It’s all real to your loved one.

So response by normalizing. When they tell you that they are terrified by the voices or the delusions, say: “I think I would feel that way, too.”

It’s not hard to feel empathy for a person who is in torment. So allow yourself to do so.

Let your loved one set the pace of the discussion. Don’t push them.

Agree, and agree to disagree.

What you have heard gives you information that you can use to move into discussing treatment. Your loved one may not think that they have a mental illness. But they may want to sleep better. Or to feel less anxious. Or to be less afraid.

Approach treatment from this perspective: Offer to partner with them to deal with the problems that your loved one thinks they DO have. They don’t want to see a psychiatrist because you think they have schizophrenia. They may be willing to see a doctor to get help sleeping better.

You can agree to disagree. “I don’t you don’t want to go to a doctor. But that’s the only way we can get the medicine to help you sleep.” You can also suggest peer groups, therapy and community services as next steps.

You also can try to correct misinformation gently and with love.

Partner by helping your loved one feel safe and in control.

Move from agreement on a goal to partnering to get the help needed. You may need to cycle through the LEAP steps more than once.

Phases that help your loved one feel safe and in control include:

  • Would you mind if I …
  • I can see why you feel that way.
  • Would this be all right?
  • Can we make this call together?
  • I’d be happy to go with you.

Dr. Amador’s book – “I’m Not Sick. I Don’t Need Help!” — has been a lifesaver, literally, for many families. A link to a PDF is here. I highly recommend reading it and watching the videos linked above.

cup with words "be strong"

How to Avoid Becoming Codependent

“It does not do to leave a live dragon out of your calculations, if you live near him.”

J.R.R. Tolkien

This is true.  Caregiving for a beloved person who has a mental illness is so tough.  It’s easy for the situation to consume your life. You do need to take the issues of your loved one into your calculations about how you live your life.

This can make you codependent and a little crazy, or it can make you stronger and closer to God than you imagined.  Life will be better for your loved one if you avoid codependency.

Need to take your life back?

One of the best books of practical advice I’ve read is “Stop Walking on Eggshells” by Paul T. Mason and Randi Kreger.  It’s written for people who have a loved one with Borderline Personality Disorder, but the advice is good for anyone who is feeling overwhelmed by another person’s behavior. I’ve also used “Codependent No More” by Melodie Beattie.

These books and my own experiences are reflected in this post.

Caretaking is different from caregiving.  Caregiving includes the recognition that we have to take care of ourselves first.

Caretaking develops when the caregiver’s life has become unmanageable as a result of a close relationship with another person. The caretaker makes sacrifices that are unhealthy and unbalanced. When someone asks how you are, you tell them how your loved one is. You are trying (and failing) to control your loved one’s behavior. You think about your loved one obsessively. 

The truth comes down to two basic facts:

  • You are not able to control your loved one.
  • You do control yourself.

True Christian sacrificial love means that the sacrifice comes out of life, not fear or need. Take care not to spiral into another person’s distorted world. Yet you can still listen carefully to find out what the person is really upset about.

What they say may not make sense to you, but it makes sense to them. Using your listening skills, you can find places where you both agree. Not sleeping at night is hard. Hearing voices is scary. Being worried about being followed by the FBI and space aliens is also scary.

More information about the LEAP method of communications that, research shows, works best with people with mental illness is here.

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.

 

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.