Strategies of family activity in various disease stages

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Functional strategies at the first psychosis and the first hospitalisation.

The first hospitalisation is one of the most difficult periods in life of the family with a schizophrenic person. It is a time of anxiety and uncertainty and diagnosis of schizophrenia is often received as a nonappealable verdict. The goal of patient's stay in hospital is to obtain diagnosis - determine the medical condition - and to plan therapy, i.e. apply proper treatment regimen. It is not always possible to obtain reliable diagnosis during the first psychotic episode.

Useless strategies (often destructive) Useful (constructive) strategies
trying to find upbringing errors and looking for the guilty a contact with the therapist and gaining knowledge about the disease by participation in psychoeducational activities, making use of information sources, the internet
undertaking premature decisions, concerning radical changes in life, such as changes in residence place, employment, etc. maintenance of to-date's occupational activities, social contacts, a constant daily rhythm
„gloom and doom” and the sense of helplessness, causing eventual neurotic symptoms, such as sleep and concentration disorders, vegetative symptoms, decreased mood maintenance of to-date's activities, acquisition of a broad knowledge about the disease, contacts with therapists
excessive protectiveness or emotional rejection, which may result from blaming oneself for the disease psychoeducation and contacts with therapists
attempts to persuade delusions during visits at hospital the acceptance of the patient's identity, building the climate of empathy and closeness, patience, collaboration with therapists: communicating the information which is needed / useful to obtain diagnosis, discussing the guidelines how to deal with the patient during hospitalisation and after discharge

A school of independence at a day-care war after hospitalisation

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Stock photo. Posed by model.

Therapy at a day-care ward may be a continuation of hospital therapy, when the patient does not yet reveal acute symptoms but still has functional problems and difficulties with daily activities. Activities at a day-care ward take place every day before noon time, so that occupationally active caregivers can work in normal working hours. Various forms of therapy are conducted at the day-care ward, including:

  • pharmacotherapy,
  • individual and group therapy,
  • trainings in life and social skills and competences.

The patients make up a community, in which they play various roles and are included in various activities, such as preparation of meals, cleaning or joint organisation of activities.

Remember!

This is a period, during which, the patient after hospitalisation learns again how to be independent. It is important the continue the independence building process also after return home. Excessive assistance and taking away daily problems is an improper approach.

The ill person should be let free to undertake attempts and make mistakes. For example, the patient should arrive to scheduled activities independently and on times, as well as to keep order at his/her room.

The scale of difficulty should gradually be increased with the patient's health improvement. Certainly, the patient should not be overloaded with tasks, taking into account the possibility of being tired, mood variations and even depressive states. When the patient's state improves, the disease symptoms will be radically weaker and the patients will begin to socialise normally as before - and discharge from the ward is possible.

The medication doses are usually decreased vs. those which were administered in hospital. An administration of an antipsychotic agent in injections of sustained release is a safe solution, as it allows medication every 2-4 weeks.

What to avoid in the case of a person discharged from a psychiatric hospital?

Many people discharged from hospital with a diagnosis of schizophrenia are confronted after discharge with excessive expectations of relatives and friends who want them to "make up for the lost time." This applies especially to people after falling ill for the first time and those in the first years of illness.

When the ill family member returns home, the family members and close persons often express their expectations of the patient's very good functional state (even better than that of his/her healthy peers), to catch up in all areas and undertake many activities and do many things, e.g. like return to studies, the best as he/she could catch up with the lost year or start working as before, as well as quickly and simultaneously settles all issues. Such a situation poses, however, new problems, since:

  • such perfect functioning is not possible immediately after a schizophrenic episode and hospital stay,
  • excessive expectations may become a serious stress for the patient - and be one of the risk factors of subsequent mental state deterioration.

Let us imagine such a situation:

Someone broke his leg, was in a plaster cast for several weeks and then he had the plaster removed. Will he be able to immediately move well? Will he be able to run at once? No, the leg will not be fully fit immediately. Such a person requires some time in which the leg will slowly go back to the previous condition. You can think similarly about a person discharged from hospital with a diagnosis of schizophrenia.

Remember!

A psychosis episode and hospital stay are serious events in a person's life. Psychosis results in less efficient operation of the brain for some time. Hospital stay is often a source of serious stress and a great effort for the ill person.

Do you know that...

Is it possible to become fully fit immediately after such events? No. The ability to function (learn, work, contact other people) will gradually be improving However, full ability will not return directly after discharge from hospital.

How to then deal with a schizophrenic?

The following fundamental rules of management are relevant:

  • Different goals should be proposed to such person gradually, step by step.
  • Requirements should be adjusted to the current capabilities of the discharged person.
  • Such a person should also set his/her own goals which, in a given period of time, are possible for him/her to pursue.

Immediately after falling ill and hospital stay, the patient is often able to only something which does not require any bigger effort. Yet, even simple activities may demand a significant effort from such a person. This person simply cannot be burdened at that time with severe stress, anxiety and fears.

This does not mean that the achievement of ambitious goals is completely precluded. Many goals are likely to be achieved, but gradually, as time passes by from hospital discharge and along with improvement of the patient's mental state.

Remember!

Refrain from excessive expectations impossible to fulfil at a given time.

In the period after the onset of the illness and hospitalization there must be time for recuperation, time for a gradual improvement – only after this time will it become evident how the ill person is able to function. Such time may be very different, sometimes it takes several months.

It is worth knowing that...

Excessive "urging" of the ill person may not, in most cases, bring positive effects. And the point here is not to have requirements or expectations at all, only that the expectations were not excessive during this period.

If we give the ill person too difficult tasks – he or she may be unable to fulfil them, may feel "useless and hopeless" and then may resign from further efforts to get better because everything would seem too difficult (as he or she did not manage to do something).

If expectations towards the ill person are suitable and such a person manages to do something (even something seemingly small), it will be an incentive to take further action. The person may then think: "if I managed to do this, I will manage to do something else."

Remember!

Follow the "step by step" rule, and do not apply the "all at once" rule.

It is worth knowing that...

The idea is to set realistic goals and have expectations feasible for a given period of time. Such an approach may pay off in the future but you have sometimes to wait and it is not worth hurrying too much.

At home with disease

Even if all the symptoms have disappeared, the patient immediately after discharge is not yet a fully healthy person. Schizophrenia usually requires therapy throughout the whole life. Similarly as with patients with diabetes or after thyroidectomy, people with schizophrenia require continuous medication. Its goal in convalescence is to prevent psychosis relapses which injure the patient's brain.

The task of caregivers is to help the patient to regain full health and remain in the state of remission. The patient should slowly be returning to independence, taking the opportunity of all accessible forms of therapy and support. Medical care over the patient is taken over by an outpatient doctor or a doctor from the environmental care system.

However, pharmacotherapy alone is not enough. Nursing homes, patient clubs and other forms of therapy should be sought for in the local environment; the best way is to enquire a psychiatrist at an outpatient clinic.

It is worth knowing that...

At this time, complex therapy, supoorted by collaboration of the patient's family, brings bery good effects.

If it is implemented early enough, optimally from the onset of disease, it opens perspectives of return to university, gainful employment or having a family. The first five years make the most important period of disease course. It is good to take adavantage of any form of support not to allow relapse of psychosis. The doctor may advise medication form from daily tablets to long-lasting formulations, what may relieve the pressure on the patient but also on the caregiver, involved in everyday care and control of pharmacotherapy.

The doctor may advise medication form from daily tablets to long-lasting formulations, what may relieve the pressure on the patient but also on the caregiver, involved in everyday care and control of pharmacotherapy.

Remember!

Living with an ill person brings many problems and sets more and more challenges before caregivers.

In order to cope effectively with these strains, care givers should not only take care of the patient but also of themselves. It is important that a caregiver continues work and maintains contacts with family and friends.

It is worth knowing that...

A hobby, rest, sometimes a trip without the ill person, give a chance to maintain their own health and obtain new energy, so needed in everyday struggle.

Functional strategies during prodromes of psychosis relapse and during relapses.

How to help a person with a relapse of psychosis? This is what you should do:

  • help the person get to a psychiatrist – psychiatrists are "first contact" physicians – you do not need to have a referral; also, all services related to the treatment of psychosis in health service units (hospitals, psychiatric wards, mental health centres) that have contracts with the National Health Fund (NFZ) do not charge for their services;
  • strengthen the patient at the time of a nervous breakdown because of exacerbation of schizophrenia, or when during the first episode of schizophrenia the person is not aware that he or she should be treated;
  • you will learn as much as possible about schizophrenia – you will take part in psychoeducational sessions;
  • you may encourage the patient to take medicines or to consult a doctor in case of doubt associated with the therapy;
  • you will notice the warning signs of relapse – do not ignore them;
  • try to notice the warning signs of suicide – the majority of patients talk about their suicidal thoughts, do not ignore them; at the same time remember that even as many as one in ten schizophrenia patients may commit suicide; suicidal tendencies are the result of relapse of schizophrenia and disappear with the resolution of symptoms of schizophrenia; make the schizophrenic person aware that suicide is a loss for everyone, and not a solution for their and your problems; in case of strong suicidal tendencies call an ambulance (dial 999), instead of looking for the psychiatrist who is in charge of the ill person;
  • negotiate with the ill person the ways to deal with crises – both those, associated with schizophrenia, and those which are not connected with ill;
  • do not expect too rapid improvement, but do not treat schizophrenia as an incurable disease – do not isolate the ill person but at the same time do not be overprotective; during remission most patients can function as normal, active people in different life roles (family member, friend, employee, pupil, student);
  • if you only can, participate in self-help groups for people with schizophrenia and their families – at meetings of such groups you will learn how others have coped with your current problems.

When psychosis returns...

It is worth knowing that...

A number if young persons after their first psychotic episode believe that it was an exceptional experience which will never return. While for other patients, the experienced hallucinations and delusions were so much real that even after their regression and discharge from hospital, they are not able to approach that experience critically and remain in their own world, replacing the truth of their being ill.  Both approaches are associated with quick treatment withdrawal after discharge from hospital.

In data from the Finish register of patients, published in 2013, it appears that almost half of the patients, hospitalised for the first psychosis, ends up their pharmacotherapy already in the first month after discharge. Almost 8, out of 10 discharged patients, return to hospital within a year with symptom relapse.

Remember!

Ensured continuation of antipsychotic therapy is the most reliable method to prevent from psychosis, thus the focus now is shifted towards continuation of pharmacotherapy plus all other forms of therapy which support compliance with medication regimen.

Unfortunately, persons with schizophrenia demonstrate hypersensitiveness to stress and thus any, highly emotional situation - both negative and positive - may lead to relapse. Observation of the patient and picking up the first symptoms of relapse may prevent from progressive deterioration and another hospitalisation.

Sometimes, however, despite the best efforts, psychosis returns. Usually, subsequent hospitalisation is longer and the patient is not able to return to the functional level before psychosis. Some of the symptoms may stay with the patient. What to do then?

Remember!

Collaboration among the patient, the caregiver and the therapist is still important. Complex therapy and various forms of rehabilitation may significantly improve the patient's health status.

Strategies for family behaviour during prodromal periods of upcoming psychosis relapse.

Useless strategies (often destructive) Useful (constructive) strategies
a quarrel: „Sometime ago you stopped medication and it was a catastrophy. You will be ill again. Why do you want to do it again to yourself?” showing understanding: "I understand that you may feel adverse effects after the medicines but what will happen when you again stop the therapy. It depends on you, but recall how it was the last time”
anger, malice: „I told you yesterday you must go to a doctor. It is your problem that you forget about the visits. I cannot remember everything for you!” a peaceful discussion: „Let's talk about how to make it that you remember about your visits to the doctor”
criticising: „You are lazy. Do something. You are lying down and smoking the whole day” constructive exchange of statements: „Let's talk how to set up the plan of activities for today”
lecturing: „Move a litlle bit, go out to people, tou know you cannot drink alcohol, you will find yourself in hospital again” listening and asking of encouraging questions: „You were out with friends yesterday. How was it? How did it happen you had some booze? What could you do instead?”
a change of topic: „I do not see any problem. What would you like for dinner?” listening and asking of encouraging questions. „I understand you have a problem. How would you like to solve it?”

Strategies for the family behaviour during psychosis relapse (psychotic period)

Useless strategies (often destructive) Useful (constructive) strategies
being an enemy: „Move your ass from the bed, do something with yourself!” being an ally, understanding, listening: „Listen, I'm really worried about you, can I help you somehow?”
alienation: „I'll not be talking with you, if you behave like that, you are hopeless!” offering time and space: „I see you are sad, maybe you need some piece? I'll go to another room and give you some time”
frightening: „If you behave like that, I'll put you into hospital!” finding reasonable limits: „I guess you should take another look on such behaviour as messin' around the park at night”
escalation of situation: „It makes no sense, why should I add a poison to the meal? What a stupid idea, stop fooling around and it your dinner!” problem mitigation: „Do you really thing the food is poisoned? You must really be scared. Let's go the kitchen, perhaps you will find something safe over there”
problem perception as soething personal: „How can you say such things, my only child is accusing me!” being objective: „I can see you are upset and broken up and you tell me such things you never tell. Let's try calm down and we'll talk about it later on”
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