Behind Closed Doors
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Behind Closed Doors



Attendees will gain insight and understanding into the unique challenges and needs of families who have a relative with a mental illness from a family system’s perspective. With this knowledge ...

Attendees will gain insight and understanding into the unique challenges and needs of families who have a relative with a mental illness from a family system’s perspective. With this knowledge those in attendance will learn ways to help family members to get the knowledge and supports they need to help themselves and their ill relative.



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  • Families identified a strong connection between hope for the future and loss in the present, whether this was loss of what the ill person had once been, loss of their potential, or loss of the shared relationshipFamily bonds and commitments-family members join forces to cope with the mental illness and it’s consequences to their family. Often find that their concerted action reinforces the bonds that link them together.Family strengths and resources-access and utilize resources to struggle to adapt to this unwelcome event and maintain the integrity of the family system.Family growth and development-acquire essential information about mental illness and community resources, develop effective coping skills and often change in constructive ways.Family contributions-reach out to needs of other families, move into roles of effective advocates for a more human and responsive system of care.Family gratifications-sense of pride in accomplishments of self or relatives. Fulfilling role as an advocate and family member.
  • Clarify roles. Professionals can be open to negotiating and clarifyingwith families the varied roles which they play. These roles can change overtime for the same family. Professionals can be observant of the changingneeds, abilities, and willingness of families, and be assertive in suggestingand encouraging their assumption of new roles.Work as a team. Consider developing a team approach to working withfamilies. Utilize families as collaborative adjuncts to your practice. Mostfamilies want to work cooperatively with you. As you build relationshipswith families and work with them to structure a legitimate place for themas team members, both you and the family member will discover valuablebenefits from a collaborative relationship (Lefley & Johnson, 1990).Use educational approaches. Families often feel comfortable in the roleof “learner” and are anxious to assimilate all of the information and adviceprofessionals have to offer them. Their development as an educator forpeers, professionals, and their own family member with a psychiatric disabilitywill support families in new roles and provide great benefit to thesystem.Include families in planning and system monitoring groups. Invitingfamily members to assume roles that have power can be valuable. Familymembers can provide input into program evaluation, system planning,human rights, and monitoring. Inviting family members to assume thesepositions and supporting their roles at this level will be very helpful to boththe family and the mental health systems.Learn to respond to intense feelings. Families often report a long historyof frustration and even abuse by mental health professionals. Their feelingsare deeply felt and may be expressed at unexpected times or with greatintensity. Professionals can learn to listen to what families are saying withunderstanding and compassion, rather than defensiveness. These are thekinds of responses that families need.Meet local support groups. Professionals can get to know families intheir area by visiting their meetings and finding out what their concernsand their strengths are. These groups are a great resource for recruitingfamily members who are interested in new roles. Some professionals havemade lists of family groups in their area which they have distributed toother professionals. If you are part of an agency, you may want to consideran agency liaison person for the family groups. This person can help toupdate other professionals in the agency on the needs, concerns, and availabilityof family members. Make yourself available as a resource to a localfamily group. Volunteer to share your information through formal presentationsor group discussion. Invite family members to talk to your staff. Askfor their comments on your program and how it might better serve theirneeds. Join the NAMI as a professional member.Acknowledge diverse beliefs. Learn to acknowledge that there is a widevariety of beliefs and needs that exist in the mental health field. Familiesmay often disagree with you (as other mental health professionals oftendo!). The professional’s learned assumptions, allegiances, and loyaltiesmay be regularly challenged as he or she begins to get more involved withfamilies. Learning to accept this is an important part of supporting familiesin new roles.Point out family strengths. Families have significant strengths that canbe noted. A major part of supporting families in new roles is letting themknow that they have a great deal to offer. Be specific in acknowledgingtheir abilities and in describing how these competencies will support themin new roles.

Behind Closed Doors Behind Closed Doors Presentation Transcript

  • Behind Closed Doors: An Inside Look at Families that have a Relative with Mental Illness.
    Kimmie Jordan, M.S. , CPRP, CLC
    “Is Anyone Listening?”
    PSRANM 19th Annual Conference
  • Mental Illness affects the family system in many different aspects: personally, economically, socially, and systemically.
    “Mental illness is, by its very nature, a familial experience. A single family member may exhibit symptoms, receive a diagnosis, and undergo treatment, but because of the interdependence that exists within a family system, each and every family member is affected in some specific way. “(Kinsella, 1996)
  • The Family’s First Experience With Mental Illness
    “Almost always, the ill person is taken to medical experts for help and usually placed in a hospital. Examinations are carried out sometimes members of the family are interviewed, medication is prescribed and other treatments may be recommended. After a few days the patient is released. Most often the family has been told nothing.” “In short, the professional staff has ignored the family until it is time for the patient to return home, and then it is assumed that the family will know what to do.” (Johnson, 2005)
  • Possible Disruptions to the Family System Include:
    Prolonging of early family developments stages, such as the “care of young children stage”, due to required care needed by the family member.
    Adult children remaining in the home during the normative “empty nest” stage of development.
    Siblings, spouses or other family members assuming the role of caregiver.
    (Corring 2002; Stein, 2001; Mannion, 1996)
  • Objective Burden to Families(Readily Verifiable Behavior Phenomena)
    Financial Stress
    Disruption of Family Routine
    Impairment of the health of other family members
    Social isolation
    Employment difficulties
    Family Conflict
    Possible breakup of the family
    Culture specific themes
    (Karp, 1999; Thara 1994; Marsh 1996; Kung, 2003)
  • Subjective Burden to Families(Emotional Reactions)
    Emotions such as: sorrow, disappointment, resentment, anger, worry, and guilt.
    Sense of loss of control over their lives
    Concern for continuity of care
    Feeling “left out” by other family members
    Social stigma and rejection
    Difficulty sleeping
    Uncertainty for the future
    (Karp, 1999; Thara 1994; Marsh 1996; Kung 2003)
  • Common experiences of Caregivers
    Fear and vulnerability
    Loss and grief
    Dissatisfaction with professional services
    Piling up of demands
    Confusion as to whether relative’s behavior is due to illness or personality and circumstances
    Concerned with their own mortality and continuity of care for ill relative
    (Stern, 1999, Heru 2000)
  • Stages of Family Recovery
    Personal/political advocacy
    (Spaniol, Zipple, Marsh, Finley, 2000)
  • Family Resilience
    Family ”readily recovering from a setback”
    Hope is a crucial part of the process
    Types of Resilience
    Family bonds and commitments
    Family strengths and resources
    Family growth and development
    Family contributions
    Family gratifications
    (Bland, 2002; Marsh, 1996, Schwartz, 2002)
    Family pride over their accomplishments and those of their relative
    Growth of the family as a unit and of individual family members.
  • Factors Affecting Family Resilience
    Other stressful events confronting the family, such as unemployment or chronic medical problems
    Family characteristics, including composition, social class, ethnic group, and religious affiliation;
    Family strengths, limitations, resources, and coping strategies
    The meaning of the psychiatric disability for the family
    The nature and quality of family relationships.
    (Spaniol, Zipple, Marsh, Finley, 2000)
  • Where are the Cocoa Puffs Book Trailer
    PresentationMoviesWhere Are The Cocoa Puffs.flv- Created by Jake Weinheimer
  • How to Help Families
    Clarify Roles
    Work as a team
    Use educational approaches
    Include families in planning and system monitoring groups
    Learn to respond to intense feelings
    Meet local support groups
    Acknowledge diverse beliefs
    Point out family strengths
    Develop your own supports
    Be clear about your limitations
    (Spaniol, Zipple, Marsh, Finley, 2000)
  • Family Needs
  • Family Needs – Information
    Psychiatric diagnosis
    Etiology of psychiatric disability
    Treatment of psychiatric disability
    Prognosis of psychiatric disability
    Reasons for an acute decompensation
    Knowledge of the hospital setting
    Ideas on how to prevent a relapse
    Recovery from psychiatric disability
    Meaning and causes of symptoms
    Availability of resources and supports
    Sources of personal stress and burden
    Family recovery process
    Availability and utility of family/ consumer self-help/advocacy groups
    Legal issues, e.g., patient rights, trusts, commitment laws
    (Spaniol, Zipple, Marsh, Finley, 2000)
  • Family Needs - Skills
    Survival skills
    Crisis response skills
    Negotiating skills
    Personal stress management skills
    Symptom/problem behavior management skills
    Advocacy and organizational skills
    Educational skills
    (Spaniol, Zipple, Marsh, Finley, 2000)
  • Family Needs - Supports
    Listening by other families and professionals
    Continued involvement with a supportive practitioner
    Sharing and expression of feelings
    A role in mental health policy
    Encouragement to join NAMI
    A role in NAMI or other family support / advocacy organizations
    (Spaniol, Zipple, Marsh, Finley, 2000)
  • Practical Concerns for Family Members
    Bizarre or unusual behavior
    Violent or aggressive behavior
    Self-destructive or suicidal behavior
    Social withdrawal
    Hygiene and appearance
    Collaboration with treatment
    Sit down and talk calmly with family
    member about concerns
    Be firm, without threats, about behavior that you do not like.
    Be clear about behaviors that you do like.
    Remind family member clearly and firmly about what is OK and what is not OK.
    Confront the unreality of a behavior by telling family member that what he/she is experiencing is not real but a part of the psychiatric disability.
    Tolerate behaviors that may appear a little different but that are not dangerous or harmful.
    Avoid physical contact
    Directly disagree with the paranoia, for example, and refuse to discuss it because it is unreal.
    Distract family member from his/her behavior by involving him/her in other activities such as a ride in the car.
    Offer humor or reassurance to allay family member’s fears.
    Solicit information and support from case manager.
    Arrange for teaching about symptom management strategies.
    Coordinate strategies with professional treatment person.
    Talk directly with your family
    member about his/her behavior
    Keep calm and speak in a normal voice.
    Be clear and firm about what you do not like and what you would like your family member to do.
    Let your family member know the effect he/she is having on you and other people. Let them know how you and others feel when they act this way.
    Call on outside help, such as a crisis clinic.
    Call on police if behavior is dangerous.
    Learn to understand and cope with your own fear.
    Identify early signs of a problem.
    Listen sympathetically to your relative’s concerns. What is happening that is causing him/her to feel so bad that he/she wants to hurt him/herself?
    Gently confront your relative by telling him/her that life is a gift and not one’s own to take.
    Sit quietly with relative to keep him/her company.
    If a threat of self-destructive or suicidal behavior does not subside, talk to your relative about where to get immediate help.
    Call a crisis team.
    If a threat has already been acted on, stop or interrupt the behavior, even physically if necessary. Your relative may need immediate help, such as a stomach pumping or hospitalization.
    If medical attention is refused, call the police or take legal action to force the issue of medical help.
    Remind relative to “put on a clean shirt,” “comb his/her hair,” and “wear different clothes.”
    Acknowledge what relative is already doing well.
    Be actively involved in buying new clothes.
    Lay out clean clothes at the beginning of each day.
    Share your feelings with family member about his/her appearance.
    Acknowledge the range of styles that are acceptable among relative’s peers.
    Arrange for teaching or instruction in hair care, make-up, personal styles.
    Understand relative’s medication and its side effects.
    Help relative to understand and to manage his/her medication and its side effects.
    Remind relative to take the medication.
    Discuss with relative the importance of the medication in reducing the symptoms and staying in the community.
    Require relative to take the medication to remain at home or to visit the home.
    Rely on professional assistance for medication management.
    Encourage relative to assume his/her own responsibility and to live the consequences of finding his/her own balance in his/her drug regime.
    Physical contact and touching.
    Share your own feelings about the medication issue.
    Involve relative in family social activities
    Acknowledge that relative needs to be alone at times.
    Encourage relative to become involved in a social rehabilitation program.
    Encourage relative’s friends to do things with him/her.
    Suggest activities for relative and his/her friends to do.
    Advocate for case manager to become more involved in planning for social activities for relative.
    Do not push too hard on withdrawal. Relative needs “down time” for sorting out his/her experiences.
    Become involved in activities that have nothing to do with psychiatric disability.
    Find meaningful work away from the home.
    Maintain a normal life style.
    Maintain a life of your own.
    Share your experiences and feelings in a family support group.
    Create a greater balance in your life.
    Achieve and maintain physical fitness through regular exercise and good nutrition.
    Acknowledge that you are not the only one who can make a difference.
    Be able to feel the pain, move through it, and move on to other feelings.
    Be prepared for the upset your limits may cause and get support.
    Advocate for the services your family member needs.
    Become active in changing the mental health system.
    Be selective in your helping.
    Know your limits and don’t wait until you are over the edge.
    Distance yourself from what is not possible and focus on what is possible.
    Distance yourself from behaviors that you cannot or need not be trying to change.
    Pay attention to the lives of other family members.
    Know that structure can communicate caring.
    Take one step at a time.
    Accept that whatever you are doing is the best that you can do at this time.
    Become involved in a group or process that supports the exploration and deepening of your beliefs and values.
    Identify options.
    Schedule time with friends.
    Celebrate small victories.
    Maintain a realistic hope.
    Join a local NAMI group.
  • Family Programs and Resources
    Support And Family Education (SAFE) Program: Mental Health Facts for Families
    Developed by Michelle Sherman, Ph.D. at the Oklahoma City VA Medical Center
    18-session curriculum of monthly workshops
    Applicable to all severe mental illnesses
    Specific session on post-traumatic stress disorder (PTSD)
    Sherman, M.D. (2003). Support And Family Education (SAFE) Program: Mental Health Facts for Families. Oklahoma City VA Medical Center. 2nd edition.
  • Family Programs and Resources
    NAMI’s Family to Family Education Program
    12-week course for family caregivers
    Taught by trained family members
    Course and materials are free
    NAMI Support groups
    NAMI Website
  • Family Programs and Resources
    Family Connections Program
    12-week course for family members with a relative with borderline personality disorder (BPD)
    based on the strategies of standard Dialectical Behavior Therapy (DBT) and DBT for families
    Modeled after Family-to-Family
    Suggested donation is $50 or more if possible.
  • Family Programs and Resources
    Dialectical Behavior Therapy-Family Skills Training (DBT-FST)
    6-month (24-week) series that meets for an hour and a half on a weekly basis with a group of from 6 to 9 families
    Presents the biosocial model to patients and family members in a non-blaming manner
    Offers support and education to family members in the form of teaching DBT skills
    Reinforces skillful behavior though empathy and validation in the family
  • “All family members are affected by a loved one’s mental illness. The entire family system needs to be addressed. To assure us that we are not to blame and the situation is not hopeless. To point us to people and places that can help our loved one. I was not informed by anyone what my mother actually suffered from. I endured a lot of unnecessary emotional pain. The impact still lingers on.”
  • Provider Family Education
    The Role of the Family in Psychiatric Rehabilitation: A Workbook (on CD) Edited by LeRoySpaniol, Anthony M. Zipple, Diane T. Marsh, & Laurene Y. Finley The Role of the Family in Psychiatric RehabilitationRoleFamilyCD.pdf
    Table of Contents
    Chapter 1: The Family Experience of Psychiatric Disability
    Chapter 2: Changing Family Roles
    Chapter 3: The Recovery Process of Family Members
    Chapter 4: Family Needs
    Chapter 5: Meeting the Needs of Young Family Members
    Chapter 6: Practical Coping Strategies for Families
    Chapter 7: Helping Families to Manage Personal Stress and Burn-out
    Chapter 8: Confidentiality and the Family
    Chapter 9: The Cultural Context: Families Coping with Psychiatric Disability
    Chapter 10: Family-Professional Collaboration
  • Provider Family Education
    What Professionals Need to Know about Families (on CD) LeRoySpaniol & the Massachusetts NAMI/DMH Curriculum, Training, and Practice Consortium
    Table of Contents
    Module 1: The Family Experience of a Family Member with a Psychiatric Disability What Professionals Need to Know when working with FamiliesM1.FamilyExperienceM1PM.FamilyExperience.pdf
    Module 2: Changing Family Role
    Module 3: Family and Practitioner Needs for Information, Skills, and Support
    Module 4: Family/Professional/Consumer Collaboration
  • Kimmie Jordan Mental Health Rehabilitation Services