CHRONIC/SERIOUS MENTAL ILLNESS

Who is this population?

. . . individuals who, through no fault of their own or their families, suffer from one of several diseases affecting the brain, the most complex of human organs. The causes remain unknown, but are probably multiple. There is no cure, but we do have effective treatment. In addition to having a brain disease, people with serious mental illness are (by definition) significantly functionally impaired by the illness for an indefinite period of time (diagnosis, disability, duration). At least 1% of the population are seriously mentally ill. The problems of victims and their families are compounded by stigma, one of the cruelest and most prevalent forms of bigotry that exists.

Symptoms of chronic/serious mental illness:

Acute, "positive" symptoms (at least one of these usually present, at least during an exacerbation of illness):

• Distorted perceptions; loss of contact with reality;
  • Delusions.
  • Hallucinations.
• Disordered, disorganized and confused thinking.
• Unstable and inappropriate emotions.
• Bizarre behavior; impaired judgment.

Residual ("negative") or deficit symptoms (several of these usually present most of the time):

• Vulnerability to certain kinds of stress.
• Extreme dependency (sometimes combined with hostility).
• Difficulty with interpersonal relationships.
• Deficient coping skills.
• Poor transfer of learning; fear of new situations.
• Restricted emotional response and lack of enjoyment.
• Reduced speech and impaired abstract thinking.
• Reduced ability to pay attention; slowness.
• Apathy; lack of motivation; phobic avoidance of situations.
• Sensitivity to over- (and under-) stimulation.

(Rule out depression, demoralization, social breakdown syndrome, medication side effects, or alcohol/drug abuse).

"Normal" reactions to serious illness:

These reactions are common in anyone who realizes they have a serious, chronic (incurable) illness, and may progress through stages (like the mourning process). Some of these characteristics are often present and can be mis-diagnosed as positive or negative symptoms.

• General stress response ("fight, flight, fright").
• Grief; denial and impatience (lack of acceptance).
• Anger and striking out.
• Guilt and self-blame.
• Depression; hopeless, helpless feelings; demoralization.
• Regression to earlier levels of functioning.
• .Preoccupation with "self" (apparent disinterest in others).
• .Interruption of normal development (immaturity).

Social breakdown syndrome:

This includes loss of normal role functioning and varying degrees of extrusion (or exclusion) from normal family/community functioning. Characteristics are similar to the negative symptoms and also resemble institutionalization syndrome. Social breakdown syndrome can be a side effect of any treatment that removes the client/patient from his/her usual social environment (or excuses him from usual role expectations) (e.g., prolonged hospitalization or too much "overprotection" on the part of clinical staff and/or family members).

Coping and adaptation:

This is the hoped for and very possible outcome of treatment, rehabilitation, family support and self-help.

• Acceptance and hope; curiosity about the illness and its treatment, and/or efforts to be "like everyone else."
• "Responsible patienthood" and active collaboration with treatment and rehabilitation.
• Compensatory changes; lifestyle modifications (including more realistic goals and expectations).
• Full participation in life ("love" and "work").

GENERAL TREATMENT/REHABILITATION CONDITIONS:

IN GENERAL, patients/clients need:

• INDIVIDUALIZED treatment.
• CONTINUITY of care (includes continuity of relationships with staff as well as smooth transition between, and coordination among, programs and treatment components).
• .Patient EDUCATION about the illness and its treatment (leading to informed consent; responsible patient role).
• Safe and comfortable SURROUNDINGS with adequate privacy and desired amount of contact with others.
• Contingency PLANS for crises (to avoid "walking on eggshells").
• INVOLVEMENT, support and education of family and/or significant others (with elimination of guilt!).
• An approach which identifies and builds on STRENGTHS.
• OUTREACH - help and support provided in "natural" settings.
• A gradual, realistic, "step-wise", LONG TERM approach, recognizing various phases and stages of illness and recovery.
• To deal constructively and positively with STIGMA (starting with self-stigmatization, then family stigma, and finally stigma from broader social network). This often involves working through grief and mourning process.

THE BIO-PSYCHO-SOCIAL APPROACH TO TREATMENT AND REHABILITATION:

BIOLOGICAL needs:

• Psychiatric care with appropriate MEDICATION by a physician (and treatment team) who understands the illness and its treatment.
• Careful MONITORING of intended effects and side effects.
• Identification of NEW physical and mental/emotional problems as they emerge.
• Attention to BOTH active (positive) and deficit (negative) symptoms.
• ELIMINATION OF TOXIC CHEMICALS and unnecessary drugs (alcohol, caffeine, marijuana, "cold" medicine, etc.).
• EARLY DETECTION of "danger signals"--symptom monitoring by patient and others.
• Adequate REST and regular, planned, aerobic EXERCISE.
• A balanced, nutritional DIET.

PSYCHOLOGICAL needs:

• A therapeutic ALLIANCE with a person (or "team") which involves "titrated" support (varying degree of support depending on need), respect, reality orientation.
• Dealing with "NORMAL" REACTIONS to serious illness (listed above).
• Being actively, comfortably and USEFULLY BUSY.
• A BALANCE between over- and under-stimulation (everyone has a "window" of optimal stimulation; this tends to be constricted in serious mental illness).
• A RELAXED (non-"rat race") atmosphere.
• A regular daily ROUTINE (including evenings, weekends and holidays).
• Substitution of RESPONSIBLE ADULT BEHAVIOR for inappropriate behavior (behavioral approach using natural consequences, with some similarity to "tough love" concept. This should be done in an empathic and supportive way).
• Minimization of handicap; emphasis on strengths; INDEPENDENCE AS TOLERATED.
• If alcohol/drug use a problem, appropriate attention to dependencies should be integrated with other treatment.

SOCIAL needs:

• Learning "SURVIVAL SKILLS"; psychosocial and occupational rehabilitation.
• COMMUNICATION and PROBLEM SOLVING skills for patient and significant others.
• Construction of supportive SOCIAL NETWORK; prevent or reverse social breakdown syndrome.
• Instrumental help with daily living (money management, transportation, housing, etc.)

This handout developed by Charles R. Goldman, M.D. (revised 7/30/98)

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