5.4 Long-term self-care strategies

A Family Guide to Concurrent Disorders - Part II: The impact on families

Outline - Chapter 5: Self-care

Challenges

There are many challenges in having a relative with concurrent disorders. Try to identify and prioritize these challenges. You may decide that some cannot be dealt with quickly or easily. Others can be addressed immediately and even resolved. It can be difficult for family members when a loved one:

refuses to take psychiatric medication
feels severely depressed and suicidal
lacks motivation and will not get out of bed
doesn't think it's necessary to go to appointments and groups to solve problems
uses alcohol or other drugs in your home
doesn't see the alcohol or other drug use as a problem and, in fact, may tell you that those substances improve the symptoms of the mental health problem
will not respond to your suggestions or offers for help
becomes angry, verbally abusive or aggressive toward you and other family members.

It can also be difficult when:

you or another family member become physically ill and are unable to attend to your relative
you feel overwhelmed, anxious or depressed yourself, and it begins to affect your ability to care for your loved one
you are afraid to leave your loved one at home alone, and yet you need to go to work
another family member develops a mental health or substance problem (or both).

Making a list of your options and possible solutions can help you develop an action plan. Some challenges may require help from other people, such as other family members, friends or health care professionals. You may decide to see a health professional who can help you with your own needs and concerns. You may join a family support group after this one, or even while this one is running. You can make a list of especially close and supportive relatives and friends for help in a crisis. Maybe you can hand over some responsibilities that can be carried out by others, so you can lighten your load in general (e.g., ask for help in car pools, have another family member shop for groceries, simplify the home cleaning schedule, teach everyone the miracle of the microwave!).

Sometimes you need to change the way you think about the problem. Perhaps you need to deal with it differently. For example, you might decide to set limits and clear boundaries with your loved one, so that you do not feel helpless, angry and manipulated. Setting limits also helps your relative because your expectations for his or her behaviour are clearly stated (see Chapter 10: Limit-setting). Then you must always follow through with the consequences, whatever you decide they will be. Feeling in control is an important part of a long-term self-care strategy.

Understanding problematic thought patterns

Trying to cope with emotions is challenging for many people at the best of times. When faced with severe and persistent stress, you can find it even harder to deal with anger, grief, loneliness, sadness, shame and guilt.

Remember that feelings are intertwined with thoughts, beliefs and behaviours. For example, if caregivers believe that they caused a family member's co-occurring mental health and substance use problems, then they are more likely to feel responsible for their family member's relapses. Such beliefs may then lead to feelings of sadness, guilt and remorse. If caregivers are not able to cope with these emotions constructively, they could avoid seeking help for their family members or for themselves. This may have serious repercussions for their family members and for their own health and well-being. All the self-care morning coffees in the world will not help if you let problematic thinking rule your thoughts.

In Feeling Good, David Burns discusses how errors in thoughts and beliefs may lead to negative emotions. Awareness of the types of problematic thinking often helps caregivers to recognize these types of thinking in themselves. They are then in a better position to work on strategies for changing problematic thoughts and beliefs.

Overgeneralization

This is a common distortion in thinking that leads people to conclude that things are worse than they really are. It occurs when a person exaggerates and therefore inaccurately appraises an event or situation. For example, a family member may think, “I failed to convince my daughter that she needs to take her medication, and she ended up being taken to emergency by the police. Since I failed to help her, that must mean I'm a failure as a person.” Mental filter bias is a type of overgeneralization in which a person focuses only on the negative aspects of an experience and downplays or ignores the positive aspects.

Magnification

Magnification, or catastrophizing, occurs when a negative event is blown out of proportion. For example, the father of a teenage son with concurrent depression and alcohol abuse thinks “Our neighbours looked at my wife and me in a funny way this morning and didn't even say hello. That must mean they think we're to blame for our son's illness and they want nothing to do with us because they think we're bad parents.” This brief encounter is interpreted as something catastrophic.

Minimization

Minimization occurs when people downplay the meaning and importance of a positive event. “It's great that I was hired for this job after almost 25 people applied for it. It pays more than any job I've ever had before and my new boss said he is looking forward to hearing more about my ideas. I'll get to talk about these ideas in the executive board room meetings . . . but all I can think about now is the increase in taxes I'll have to pay with the higher salary and all the extra meetings I'll have to go to. Besides, I probably won't last long anyway. Once my boss sees that I'm actually underqualified, I'll be fired and then I won't be able to pay any of my bills. And I really only got the job because my cousin worked here for years and put in a good word for me.”

Disqualifying the positive

Disqualifying the positive occurs when people do pay attention to positive information but then later find a reason to discount it. “It's great to have a friend like Barb call me all the time to talk, but she only calls me because her best friend got a new job now and is busy during the day. She really doesn't even like me.”

All-or-nothing thinking

All-or-nothing, or black-and-white, thinking occurs when a person's evaluation of an experience lies at one extreme or the other. For example, a person does not get a job that he or she really wanted. Instead of thinking, “Up until now, I've been hired for most of the jobs that I've ever applied for, so if I keep looking, a great job is bound to turn up,” the person thinks, “I was just turned down for the best job I've ever applied for. I'll never have an opportunity like that again—I'm a total failure.”

Jumping to conclusions

This occurs when people jump to (usually negative) conclusions that are not justified by the facts that they have about the situation. “It looks like this is going to be a good day to relax and watch television, but I just know that the minute I sit down, another family crisis will start up.”

Mind reading

Mind reading occurs when people assume, without any evidence, that someone is thinking something negative about them. They react based on this conclusion, which is often false. “Why should I bother trying to talk to my co-workers down the hall? They all hate me and think that I should be replaced by somebody who actually knows what they're doing.”

Should, must and ought beliefs

These thoughts and beliefs are often found in people who set unrealistic, often impossible demands on themselves. When they fail to meet these demands, they either punish themselves for their perceived failures or sink into low self-esteem and depression. “I should be a better father”; “I ought to try harder to stop my husband from drinking”; “I should be better looking. I'll never get ahead in this life being this ugly!”

Some people with perfectionistic tendencies may also hold others to unrealistically high standards. “My mother should learn a lot more about how to deal with my brother. She should kick him out of the house if he refuses to take his medication and clean himself up. And I can't understand why she doesn't demand that he go to a drug treatment centre. She lets him just sit around the house thinking about whether or not he's ready to get help. If he were my son instead of my brother, I'd have him whipped into shape in no time. Nobody in this family can do anything right.”

Personalizing and blaming

This happens when a person takes responsibility for something that in reality they had very little control over. “I wasn't paying enough attention to my son. If I hadn't been so busy working and doing other things, I would have known that he was planning to hurt himself and I could have stopped him. It's because of my negligence that he's back in the hospital.”

Similarly, a person might unfairly assign responsibility to someone else. “You would think my adult children would have noticed how stressed out I've been trying to take care of their father and work and manage the whole household at the same time. They can be so selfish and self-centred. If they had been more helpful, I could have paid more attention to my husband and he'd be off the drugs by now. It's really their fault that the whole situation is so out of control.”

Dealing with difficult emotions

Strategies that may help you to deal more effectively with difficult feelings include:

repeating positive affirmations over and over to yourself such as, “I am doing the best that I can and I am a good and decent person.”
being aware of yourself and any problematic thoughts you might be having about situations, events and other people that might be resulting in negative feelings
being aware of how you handle stress and what kinds of stressful situations leave you feeling most vulnerable
developing effective ways of coping with a family member who has concurrent disorders (e.g., finding out how to navigate the treatment system and get help (see Chapter 7)
setting limits and clear boundaries (see Chapter 10)
talking openly and honestly about how you feel, and examining those feelings, either with someone you trust or within a peer or professionally led support group
talking to other families about effective ways to deal with stress and difficult emotions
developing and following your own personalized self-care plan.

If you practise these strategies on a regular basis, you can cut down the frequency and intensity of distressing thoughts. They can help prevent negative moods from occurring in the first place, and also help prevent them from getting a lot worse.

In order for many of these strategies to work, it is better if you are calm and thinking logically and rationally. In a stressful situation, if you find that you are already experiencing intensely negative feelings, it might be better to first try calming and soothing yourself before you try to work on any problematic thoughts and beliefs.

Building social support

Family members often give up their own activities, and can become isolated from their friends and colleagues when caring for a family member with concurrent disorders. Social support is crucial to help you achieve and maintain emotional and even physical health.

Friends and colleagues

Some people find it helpful to have a large social network to draw on. Others prefer to have only a few supportive and understanding friends. Participating in a group activity you enjoy, such as a walking club, a sports team, a reading club or church group can help you retain your social network. Old friends and colleagues you've grown apart from may appreciate hearing from you. Being open about your situation will often bring support from the least likely places and people.

Self-help organizations

Many family members join family self-help / mutual aid support organizations such as the Schizophrenia Society of Ontario (SSO), the Mood Disorders Association of Ontario (MDAO) or the Family Association for Mental Health Everywhere (FAME). While these groups provide support, education and advocacy for family members of people with a mental illness, many of the participants have loved ones with both a mental health problem and a substance use problem.

Some of the groups are structured with educational programs or guest speakers from the mental health care system. Other groups are more informal and may involve small group discussions and peer support from other family members struggling with similar issues. Some families also choose to attend self-help groups for family members of people with alcohol or other drug problems. These groups include Al-Anon (for family members of people with alcohol problems), Alateen (for young adults who have siblings with substance use problems) and Nar-Anon (for families of people with substance use problems). (See Treatment approaches in Chapter 7)

Becoming informed

Information is power. Many family members seek both formal and informal opportunities to learn about concurrent mental health and substance use problems. They find it helpful to learn as much as they can about their loved one's particular mental health and substance use problems, including the causes, signs, symptoms and possible treatments.

Believing in yourself and your rights

You have a right to ask questions and to receive attention and respect from health care professionals. Some people with concurrent disorders want their family members to be very involved in their treatment plan, even if they're in hospital. Others may prefer not to involve their families and may want to keep their personal information confidential. Whether or not you are actively involved in the professional care of your family member, you have a right to: