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NAMI Family-to-Family
A NAMI peer education program for family members of adults with mental illness
Participant Manual 2020
Developed by Joyce Burland, Ph.D. © 1997
Sixth Edition Revision Coordinated by Suzanne Robinson, MSW
Class 5
NAMI Family-to-Family 2020 Class 5 5.30
Class 5: Treatment Options Agenda
• Navigating systems
• Comprehensive approaches
• Collaborative care
• HIPAA: Health Insurance Portability and Accountability Act
• Treatment options
• Treatment settings
• Psychotherapeutic interventions
• Treatment providers
• Medication
• Hospitalization and Assisted Outpatient Treatment (AOT)
• Warning signs of relapse
• Biomedical approaches
• Complementary health approaches
NAMI Family-to-Family 2020 Class 5 5.32
Worksheet 2: Bio-Psycho-Social Aspects of Mental Health Conditions
The three dimensions of mental health conditions — “bio-psycho-social” — are interdependent.
• No one dimension can ignore the knowledge base of the other two. • Focusing on one dimension alone is not sufficient for recovery.
Biological/Physical (Medical Dimension)
Science-based knowledge Course Focus: Medical aspects of illness Symptoms, diagnosis Recognizing mental health conditions Predicting what the condition may be in the future (prognosis) Intensive care when needed Best medical strategies to maximize recovery Current brain research Treatment options Treatment providers Medications (side effects, taking medication as prescribed) Recognizing early warning signs of relapse Impact of mental illness on overall health Insight into clinical realities of brain disorders
Psychological/Emotional (Personal Dimension)
Psychology-based knowledge
Course Focus: Subjective emotions and feelings How the condition feels to the person experiencing it Handling anger, frustration, and hopelessness Accepting the “new normal” Typical family responses to mental illness Impact on the family Self-care skills Value of peer understanding and support Recognizing personal strengths Challenges of different relative roles in the family
Social/Occupational (Rehabilitation Dimension)
Recovery-based knowledge
Course Focus: Self-renewal; Re-entry into community Problem solving skills Communication skills Support from systems and community Mental health system Making or restoring social connections Definition and testimonials of recovery Maximizing self-determination, personal fulfillment and quality of life Principles of rehabilitation Rebuilding after transitions (hospitalization, education, employment) Challenging negative stereotypes Long-term care and planning Advocacy for better services and fair policies Celebrating our progress
NAMI Family-to-Family 2020 Class 5 5.34
Worksheet 4: Health Insurance Portability and Accountability Act (HIPAA)
Health care information that could be used to identify an individual person is called “protected health information,” or PHI. The HIPAA Privacy Rule created national standards to protect both the patients’ personal information and PHI. The HIPAA Privacy Rule limits the situations in which personal information and PHI can be used or shared by insurers, providers, and others involved in a person’s health care like hospitals and medical records companies. In order for a doctor, therapist, hospital or other health care provider to share any PHI, there must be a written authorization giving them permission to do so. This includes even confirming that someone is receiving services at a facility. When anyone goes to a health care provider, they are given HIPAA rules to read and a release form to sign. This form gives the provider permission to share medical tests with other providers if needed. It also allows the provider to share information with insurers for payment processing and to contact the person of our choice in an emergency.
Notes:
NAMI Family-to-Family 2020 Class 5 5.37
Worksheet 7: Psychotherapeutic Interventions
Intervention Description Behavior Therapy Helps the person change negative behaviors and improve
behaviors through a reward and consequences system. In behavior therapy, goals are set and small predetermined rewards are earned to reinforce positive behavior.
Cognitive Behavioral Therapy (CBT)
Teaches people how to notice, take account of, and ultimately change their thinking and behaviors that impact their feelings. In CBT, the person examines and interrupts automatic negative thoughts that they may have that make them draw negative and inappropriate conclusions about themselves and others. CBT helps the person learn that thoughts cause feelings, which often influence behavior.
Cognitive Enhancement Therapy (CET)
Cognitive rehabilitation training program for adults with schizophrenia or schizoaffective disorder who are stabilized and maintained on antipsychotic medication and not abusing substances. CET is designed to provide cognitive training to help improve impairments related to neurocognition (including poor memory and problem-solving abilities), cognitive style (including impoverished, disorganized or rigid cognitive style), social cognition (including lack of perspective taking, foresight and social context appraisal), and social adjustment (including social, vocational and family functioning), which characterize these mental disorders and limit functional recovery and adjustment to community living. Participants learn to shift their thinking from rigid serial processing to a more generalized processing of the core essence or gist of a social situation and a spontaneous abstraction of social themes.
Dialectical Behavior Therapy (DBT)
A CBT-based approach with two key characteristics: a behavioral, problem-solving focus blended with acceptance-based strategies, and an emphasis on dialectical processes. "Dialectical" refers to the issues involved in treating patients with multiple disorders and to the type of thought processes and behavioral styles used in the treatment strategies. DBT has five components: (1) capability enhancement (skills training); (2) motivational enhancement (individual behavioral treatment plans); (3) generalization (access to therapist outside clinical setting, homework, and inclusion of family in treatment); (4) structuring of the environment (programmatic emphasis on reinforcement of adaptive behaviors); and (5) capability and motivational enhancement of therapists (therapist team consultation group). DBT emphasizes balancing behavioral change, problem solving, and emotional regulation with validation, mindfulness, and acceptance of patients. Therapists follow a detailed procedural manual.
Exposure Therapy Educates and teaches people about how to manage fears and worries to reduce their distress. The person is gradually exposed to threatening situations, thoughts, or memories that make him/her excessively anxious or worried.
NAMI Family-to-Family 2020 Class 5 5.38
Intervention Description Eye Movement Desensitization and Reprocessing (EMDR)
A nontraditional type of psychotherapy. It's growing in popularity, particularly for treating post-traumatic stress disorder (PTSD). PTSD often occurs after experiences such as military combat, physical assault, sexual assault, or car accidents. EMDR does not rely on traditional talk therapy or medications. Instead, EMDR uses the individual’s own rapid, rhythmic eye movements and exposure to the traumatic events. These eye movements dampen the power of emotionally charged memories of past traumatic events. The premise is that EMDR weakens the effect of negative emotions and that disturbing memories will become less disabling.
Family Education and Support
Evidence-based practice in adult mental health. Designed to achieve improved outcomes for people living with mental illnesses by building partnerships among people, families, providers and others supporting the person and family. May be led by clinicians or by other family members. NAMI Family-to-Family is an example of this.
Interpersonal Therapy (IPT)
Designed for treatment of symptoms of depression. Examines relationships and transitions, and how they affect a person’s thinking and feeling. Focuses on the person and helps them manage major changes in their lives, such as divorce and significant loss, including the death of a loved one.
Psycho-educational Multifamily Groups (PMFG)
Treatment modality designed to help people with mental health conditions attain as rich and full participation in the usual life of the community as possible. The intervention focuses on informing families and support people about the illness, developing coping skills, solving problems, creating social supports, and developing an alliance between people with mental health conditions, practitioners, and their families or other support people. Practitioners invite five to six people and their families to participate in a psycho-education group that typically meets every other week for at least 6 months. "Family" is defined as anyone committed to the care and support of the person with mental illness. People usually choose a family member or close friend to be their support person in the group. Group meetings are structured to help people develop the skills needed to handle problems and to serve as problem solving consultants to each other.
NAMI Family-to-Family 2020 Class 5 5.39
Intensive Home and Community-Based Interventions Intervention Description Average Length of
Treatment Multisystemic therapy (MST)
Short-term and intensive home-based, family focused therapy for children and adolescents. MST therapists have small caseloads, designed to meet the immediate needs of families. The MST team is available 24 hours a day, seven days a week to work with families.
4 months with approximately 60 hours of contact with the MST Team
Mental Health Intensive Case Manager (MHICM), a servicer through the VA for veterans
Generally, relies on a single case manager assigned to work closely with the family and other professionals to develop an individualized comprehensive service plan for the veteran and family.
Long-term (no limit)
Wrap Around Services
A philosophy of care that includes a definable planning process involving the person and family that results in a unique set of community services and natural supports individualized for that particular person and family to achieve a positive set of outcomes.
Long-term (no limit)
NAMI Family-to-Family 2020 Class 5 5.40
Worksheet 8: Supportive Psychotherapy
Supportive psychotherapy refers to a variety of types of therapy. Supportive psychotherapies acknowledge the environmental factors that affect a person’s mental health, including systemic oppression and poverty. They aim to create a feeling of safety and trust between the person experiencing symptoms and the provider and often use positive reinforcement. The goals include:
• Helping the person improve their self-esteem • Developing the ability to have a realistic view of their experiences • Learning to cope with stress and anxiety
Some supportive psychotherapies include cognitive-behavioral and interpersonal models and techniques. A Psychology Today article defined Supportive psychotherapy as “…the attempt by a therapist by any practical means whatever to help patients deal with their emotional distress and problems in living.”
There are basic traits of how providers of supportive psychotherapy should approach their work, although there are variations depending on the person. Providers offer practical help and advice that supports people in managing their condition. In this approach, they listen empathetically and often comfort and reassure the person seeking treatment while helping them learn new skills. They may also help them advocate for services and treatments.
People receiving supportive psychotherapy don’t need to be highly motivated to engage in this treatment. It recognizes that mental health challenges often demoralize people and make them skeptical or reluctant about treatments. Providers should be willing to help persuade clients to accept and continue treatment, partly by being patient and trustworthy.
Common focuses of supportive therapies
• Education The client learns about their condition, their symptoms, treatment options, signs of overload, stress and relapse. They learn concrete problem solving around family and other relationships.
• Self-esteem The impact of mental health conditions have on daily life and relationships can deeply destabilize self-esteem. Supportive therapies help the person manage disappointment, rebuild their sense of self, and take gradual, steps towards progress.
• Mentoring Providers partly serve as mentors, helping the person become empowered to advocate for themselves in the health care system and in their community. It’s a collaborative partnership between the person and provider.
• Dynamic change Providers recognizes that their clients go through natural cycles of stability, relapse and remission. They shift therapeutic strategies to address these cycles as needed.
• Networks of support This approach recognizes that families, partners and friends can be invaluable allies in the treatment process. If the client wants to, the
NAMI Family-to-Family 2020 Class 5 5.41
provider can share information and suggest ways to support the client. With close collaboration between the person, the therapist and the important people in the client’s life, this can be a key part of the approach.
If your loved one is interested in therapy, they should look for a credentialed behavioral health professional such as a psychologist, licensed professional counselor, licensed clinical social workers or other licensed providers. Sources: NAMI Provider; Psychology Today; Psychiatric Times; see References for full citations
NAM
I Fam
ily-to
-Fam
ily 2
020
Cla
ss 5
5.
42
Wor
kshe
et 9
: Diff
eren
t Typ
es o
f Men
tal H
ealth
Clin
icia
ns
Prof
essi
onal
D
escr
iptio
n D
egre
e R
equi
rem
ents
Li
cens
ure
Cou
nsel
or
Clin
icia
n
Ther
apis
t
• M
enta
l hea
lth e
valu
atio
ns
• Va
rious
ther
apeu
tic te
chni
ques
de
pend
ent o
n th
eir t
rain
ing
• U
sual
ly s
erve
as
a m
embe
r of t
he
treat
men
t tea
m
• O
ften
the
prim
ary
cont
act f
or th
e fa
mily
Usu
ally
requ
ires
a m
inim
um o
f a
mas
ter’s
deg
ree
(MS
or M
A)
in a
men
tal h
ealth
rela
ted
field
Exam
ples
of l
icen
sure
to lo
ok
for a
re:
• LP
C—
Lice
nsed
Pr
ofes
sion
al C
ouns
elor
•
LMFT
—Li
cens
ed M
arria
ge
and
Fam
ily T
hera
pist
Clin
ical
Soc
ial W
orke
r D
utie
s ve
ry s
imila
r to
thos
e de
scrib
ed a
bove
M
aste
r’s in
Soc
ial W
ork
(MSW
) •
LCSW
—Li
cens
ed C
linic
al
Soci
al W
orke
r •
LISW
—Li
cens
ed In
depe
nden
t So
cial
Wor
ker
• AC
SW—
Acad
emy
of C
ertif
ied
Soci
al W
orke
rs
Psyc
holo
gist
(m
ay b
e cl
inic
al,
coun
selin
g,
educ
atio
nal,
or
othe
r spe
cial
ty
area
s)
• M
enta
l hea
lth e
valu
atio
ns in
clud
ing
psyc
holo
gica
l eva
luat
ions
and
te
stin
g •
Vario
us th
erap
eutic
tech
niqu
es
• W
hen
avai
labl
e, s
erve
as
a m
embe
r of
the
treat
men
t tea
m
• In
pub
lic s
ecto
r the
psy
chol
ogis
t is
ofte
n a
cons
ulta
nt ra
ther
than
a
prim
ary
ther
apis
t
Doc
tor o
f Phi
loso
phy—
Ph.D
. In
one
of t
he p
sych
olog
y fie
lds
Or
Doc
tor o
f Psy
chol
ogy—
Psy.
D.
Lice
nsed
psy
chol
ogis
t in
the
stat
e in
whi
ch y
ou li
ve
Psyc
hiat
rist
A ps
ychi
atris
t can
per
form
all
of th
e ta
sks
liste
d ab
ove,
and
can
als
o pr
escr
ibe
med
icat
ion
Doc
tor o
f Med
icin
e—M
D, o
r D
octo
r of O
steo
path
ic
Med
icin
e—D
O
Com
plet
ed re
side
ncy
train
ing
in p
sych
iatry
Lice
nsed
phy
sici
an w
ithin
the
stat
e M
ay a
lso
be b
oard
cer
tifie
d by
the
Boar
d of
Neu
rolo
gy a
nd P
sych
iatry
Nur
se P
ract
ition
er (N
P)
Perfo
rm c
ompr
ehen
sive
phy
sica
l exa
ms,
di
agno
se a
nd tr
eat c
omm
on il
lnes
ses;
re
gula
ted
by th
e in
divi
dual
sta
tes
Adva
nced
Pra
ctic
e R
egis
tere
d N
urse
FN
P—Fa
mily
Nur
se P
ract
ition
er
PMH
NP—
Psyc
hiat
ric/M
enta
l H
ealth
Nur
se P
ract
ition
er
Lice
nsed
NP
with
in th
e st
ate;
N
Ps c
an p
resc
ribe
med
s in
all
50
stat
es u
nder
the
supe
rvis
ion
of a
ph
ysic
ian,
and
can
pra
ctic
e in
depe
nden
tly in
26
stat
es
NAM
I Fam
ily-to
-Fam
ily 2
020
Cla
ss 5
5.
43
Wor
kshe
et 1
0: H
ow M
essa
ges
Trav
el T
hrou
gh th
e B
rain
The
brai
n is
a c
ompl
icat
ed s
yste
m w
ith o
ver
100
billio
n ne
rve
cells
affe
cted
by
elec
trica
l, ch
emic
al, e
nviro
nmen
tal a
nd b
iolo
gica
l ch
ange
s.
The
brai
n is
mad
e up
prim
arily
of n
euro
ns
whi
ch a
re c
ells
that
can
com
mun
icat
e w
ith
each
oth
er.
Also
pre
sent
are
Glia
l cel
ls th
at s
uppo
rt an
d pr
otec
t the
neu
rons
.
Each
neu
ron
is m
ade
up o
f a c
ell b
ody
with
long
ext
ensi
ons,
muc
h lik
e th
e br
anch
es o
f a tr
ee, c
alle
d de
ndrit
es.
Den
drite
s ca
n re
ceiv
e m
essa
ges.
Pr
ojec
ting
out o
f the
cel
l bod
y is
a s
ingl
e ax
on. A
xons
sen
d th
e el
ectri
cal m
essa
ges
to th
e de
ndrit
es —
the
rece
ivin
g pa
rt —
of
othe
r cel
ls. T
here
is a
fatty
whi
te ti
ssue
ca
lled
mye
lin th
at s
urro
unds
the
axon
and
im
prov
es it
s ab
ility
to s
end
mes
sage
s. It
is
like
insu
latio
n on
an
elec
trica
l cor
d. A
t the
en
d of
the
axon
are
mor
e br
anch
es, e
ach
of w
hich
end
s w
ith a
n ar
ea c
alle
d th
e te
rmin
al.
For a
mes
sage
to g
et fr
om th
e ax
on
term
inal
of o
ne c
ell t
o a
dend
rite
rece
ptor
of a
noth
er c
ell,
it m
ust c
ross
a
mic
rosc
opic
gap
cal
led
the
syna
pse.
Stor
ed in
side
eac
h ax
on te
rmin
al a
re
chem
ical
s ca
lled
neur
otra
nsm
itter
s, s
uch
as d
opam
ine
and
sero
toni
n. T
hese
ch
emic
als
are
need
ed to
del
iver
the
elec
trica
l mes
sage
acr
oss
the
syna
pse.
NAM
I Fam
ily-to
-Fam
ily 2
020
Cla
ss 5
5.
44
As
an
elec
trica
l mes
sage
trav
els
dow
n th
e ax
on it
stim
ulat
es th
e te
rmin
al to
rele
ase
the
stor
ed n
euro
trans
mitt
ers
into
the
syna
pse.
Onc
e re
leas
ed, t
he
neur
otra
nsm
itter
s at
tach
to m
atch
ing
rece
ptor
s on
a n
earb
y de
ndrit
e. T
his
crea
tes
a ch
emic
al b
ridge
and
the
mes
sage
can
then
cro
ss th
e sy
naps
e in
to
the
next
neu
ron.
Diff
eren
t typ
es o
f m
essa
ges
need
diff
eren
t ne
urot
rans
mitt
ers.
As s
oon
as a
mes
sage
is d
eliv
ered
, the
ne
urot
rans
mitt
ers
deta
ch a
nd a
re
rem
oved
from
the
syna
pse
to p
repa
re
for t
he n
ext m
essa
ge. S
ome
neur
otra
nsm
itter
s ar
e ab
sorb
ed b
ack
into
the
axon
term
inal
to b
e us
ed a
gain
. Th
is is
cal
led
re-u
ptak
e. O
ther
s ar
e ch
emic
ally
dis
solv
ed, o
r met
abol
ized
, in
the
syna
pse.
Med
icat
ions
can
impa
ct h
ow th
e di
ffere
nt n
euro
trans
mitt
ers
are
rele
ased
, abs
orbe
d or
met
abol
ized
. Th
is a
ffect
s bo
th th
e nu
mbe
r of
mes
sage
s tra
nsm
itted
and
the
qual
ity o
f ea
ch m
essa
ge.
Afte
r suc
cess
fully
cro
ssin
g th
e sy
naps
e,
an e
lect
rical
mes
sage
trav
els
to th
e nu
cleu
s of
the
new
cel
l whe
re it
is e
ither
se
nt fo
rwar
d to
ano
ther
neu
ron
or th
e m
essa
ge is
sto
pped
from
trav
elin
g an
y fa
rther
. Th
e br
ain
cont
inuo
usly
act
ivat
es o
r de
activ
ates
neu
rons
usi
ng th
is p
roce
ss.
NAM
I Fam
ily-to
-Fam
ily 2
020
Cla
ss 5
5.
45
Wor
kshe
et 1
1: H
ow P
sych
otro
pic
Med
icat
ions
Wor
k
Med
icat
ion
can
be a
n im
porta
nt p
art o
f tre
atm
ent f
or a
ny p
hysi
cal c
ondi
tion
incl
udin
g m
enta
l hea
lth.
Neu
rotra
nsm
itter
s st
ored
in th
e ax
on
term
inal
trav
el to
a n
earb
y de
ndrit
e an
d cr
eate
a c
hem
ical
brid
ge s
o th
at
elec
troni
c m
essa
ges
can
trave
l ac
ross
the
gap.
The
type
and
qua
ntity
of
neur
otra
nsm
itter
s pr
esen
t in
the
syna
pse
impa
cts
the
way
mes
sage
s ar
e se
nt a
nd re
ceiv
ed. A
nd th
e w
ay
the
mes
sage
s ar
e se
nt a
nd re
ceiv
ed
influ
ence
s ho
w a
per
son
thin
ks, f
eels
an
d be
have
s.
M
edic
atio
ns c
hang
e th
e pr
oces
s so
th
at e
ither
mor
e, o
r les
s, o
f a
parti
cula
r neu
rotra
nsm
itter
is
avai
labl
e in
the
syna
pse
for t
he
mes
sage
tran
smis
sion
.
Thin
k of
the
shap
es, w
hich
repr
esen
t th
e ne
urot
rans
mitt
ers,
as
cars
. Im
agin
e th
at th
e ca
rs a
re d
rivin
g fro
m
one
stor
e to
ano
ther
and
they
nee
d to
pa
rk in
a p
arki
ng s
pace
whe
n th
ey g
et
ther
e. T
he c
ars
are
leav
ing
the
first
st
ore,
at t
he a
xon,
and
tryi
ng to
par
k in
a s
pace
on
the
dend
rite.
The
med
icat
ions
can
kee
p th
e ca
rs
from
par
king
in o
ne o
f thr
ee w
ays:
•
They
can
blo
ck th
e en
tranc
e to
th
e pa
rkin
g sp
ace
NAM
I Fam
ily-to
-Fam
ily 2
020
Cla
ss 5
5.
46
•
They
can
blo
ck th
e en
tranc
e ba
ck
into
the
first
axo
n an
d pr
even
t re-
upta
ke
• O
r, th
ey c
an d
estro
y th
e ca
r and
ke
ep it
from
goi
ng a
nyw
here
Sc
ient
ists
hav
e le
arne
d th
at c
hang
ing
the
amou
nt o
f neu
rotra
nsm
itter
s in
the
syna
pse
star
ts a
ser
ies
of c
hem
ical
ev
ents
that
hap
pen
insi
de th
e ce
ll bo
dy
and
nucl
eus
of th
e re
ceiv
ing
neur
on.
Thes
e ch
emic
al p
roce
sses
eve
ntua
lly
prod
uce
sign
ifica
nt c
hang
es in
the
way
th
e se
ndin
g an
d re
ceiv
ing
neur
ons
func
tion.
Thi
s m
ay e
xpla
in w
hy
psyc
hotro
pic
med
icat
ions
nee
d to
be
take
n fo
r sev
eral
wee
ks to
feel
the
full
effe
cts.
M
edic
atio
ns m
ay w
ork
grea
t for
one
pe
rson
and
not
at a
ll fo
r ano
ther
—
even
if b
oth
have
the
sam
e di
agno
sis.
It is
diff
icul
t to
pred
ict
exac
tly w
ho w
ill re
spon
d to
wha
t m
edic
atio
n.
A nu
mbe
r of l
arge
-sca
le re
sear
ch
stud
ies
have
det
erm
ined
“firs
t-lin
e”
and
“sec
ond-
line”
med
icat
ions
bas
ed
on w
hich
med
icin
es o
ffer t
he b
est
sym
ptom
relie
f with
the
few
est s
ide
effe
cts.
Unf
ortu
nate
ly, m
any
rese
arch
st
udie
s on
med
icat
ions
and
oth
er
treat
men
t stra
tegi
es h
ave
faile
d to
in
clud
e ad
equa
te re
pres
enta
tion
from
raci
ally
and
eth
nica
lly d
iver
se
com
mun
ities
.
NAM
I Fam
ily-to
-Fam
ily 2
020
Cla
ss 5
5.
47
Why
are
ther
e so
man
y si
de e
ffect
s an
d ca
n an
ythi
ng b
e do
ne a
bout
them
?
Th
ese
med
icat
ions
are
mor
e lik
e bu
cksh
ot; t
hey
hit t
he ta
rget
and
ev
eryt
hing
els
e ar
ound
it. I
n so
me
case
s, c
ells
out
side
of t
he b
rain
use
th
e sa
me
neur
otra
nsm
itter
s to
tra
nsm
it si
gnal
s; s
o th
ese
med
icat
ions
als
o di
rect
ly a
ffect
oth
er
parts
of t
he b
ody.
For e
xam
ple,
the
dige
stiv
e sy
stem
us
es s
erot
onin
to c
omm
unic
ate
betw
een
cells
whi
ch is
why
m
edic
atio
ns th
at a
lter s
erot
onin
le
vels
can
als
o ca
use
naus
ea o
r di
arrh
ea.
Just
like
with
any
oth
er m
edic
atio
n,
ever
yone
con
side
ring
usin
g ps
ycho
tropi
c m
edic
atio
ns fa
ces
a co
st/b
enef
it di
lem
ma.
Ofte
n sw
itchi
ng m
edic
atio
n, c
hang
ing
the
dosa
ge o
r add
ing
on a
sec
ond
med
icat
ion
can
coun
tera
ct d
iffic
ult s
ide
effe
cts.
Whi
le u
nder
stan
ding
how
med
icat
ions
wor
k in
the
body
is im
porta
nt, t
he m
ain
issu
es
man
y fa
milie
s st
rugg
le w
ith a
re e
mot
iona
l. It’
s di
fficu
lt w
atch
ing
a lo
ved
one
begi
n to
ex
perie
nce
the
sym
ptom
s of
men
tal i
llnes
s ag
ain
afte
r a p
erio
d of
reco
very
.
Keep
ask
ing
ques
tions
and
look
ing
for a
nsw
ers
in o
rder
to b
e su
ppor
tive
of y
our l
oved
one
as
they
mak
e de
cisi
ons
abou
t the
ir tre
atm
ent.
NAM
I Fam
ily-to
-Fam
ily 2
020
Cla
ss 5
5.
48
Wor
kshe
et 1
2: S
peci
fic M
edic
atio
ns
DEP
RES
SIO
N
Sele
ctiv
e Se
roto
nin
Reu
ptak
e In
hibi
tors
(SSR
I) an
d Se
lect
ive
Nor
epin
ephr
ine
Reu
ptak
e In
hibi
tors
(S
NR
I)
It’s
not u
ncom
mon
for s
omeo
ne w
ith a
men
tal
heal
th c
ondi
tion
to b
e pr
escr
ibed
a v
arie
ty o
f m
edic
atio
ns th
roug
hout
thei
r life
time.
It
frequ
ently
take
s a
com
bina
tion
of m
edic
ines
to
treat
the
sym
ptom
s an
d si
de e
ffect
s.
Fortu
nate
ly, t
here
are
a v
arie
ty o
f effe
ctiv
e m
edic
atio
ns a
vaila
ble.
Typi
cally
, the
firs
t cla
ss o
f med
icat
ions
us
ed to
trea
t dep
ress
ion
are
Sele
ctiv
e Se
roto
nin
Reu
ptak
e In
hibi
tors
(SSR
Is)
and
Sele
ctiv
e N
orep
inep
hrin
e R
eupt
ake
Inhi
bito
rs (S
NR
Is).
Onc
e th
e m
essa
ge h
as p
asse
d th
roug
h,
the
neur
otra
nsm
itter
s ar
e ei
ther
re
abso
rbed
by
the
send
ing
cell,
cal
led
reup
take
, or d
isso
lved
in th
e sy
naps
e,
calle
d m
etab
oliz
atio
n.
SSR
Is a
nd S
NR
Is b
lock
the
reup
take
of
parti
cula
r neu
rotra
nsm
itter
s. D
epen
ding
on
the
med
icat
ion
take
n, d
iffer
ent
neur
otra
nsm
itter
s ar
e st
oppe
d fro
m tr
avel
ing
back
into
the
axon
term
inal
. Thi
s in
crea
ses
the
leve
ls o
f the
se n
euro
trans
mitt
ers
in th
e sy
naps
es s
o m
essa
ges
can
pass
thro
ugh.
NAM
I Fam
ily-to
-Fam
ily 2
020
Cla
ss 5
5.
49
A pr
ovid
er w
ill st
art b
y pr
escr
ibin
g a
low
do
se a
nd s
low
ly in
crea
se d
osag
es to
a
leve
l tha
t is
effe
ctiv
e. F
ollo
win
g th
ese
inst
ruct
ions
will
redu
ce s
ide
effe
cts.
Side
effe
cts
can
incl
ude
naus
ea,
nerv
ousn
ess
or a
gita
tion,
diz
zine
ss, r
educ
ed
sexu
al d
esire
or s
exua
l per
form
ance
, dr
owsi
ness
, ins
omni
a, w
eigh
t gai
n or
loss
, he
adac
he, d
ry m
outh
, vom
iting
and
dia
rrhea
. Th
ese
unw
ante
d sy
mpt
oms
may
go
away
af
ter t
akin
g th
e dr
ug fo
r a fe
w w
eeks
.
Whe
neve
r sto
ppin
g an
SSR
I or S
NR
I m
edic
atio
n, it
’s n
eces
sary
to w
ork
with
the
pres
crib
er to
tape
r off
the
dosa
ge w
hile
br
ain
chem
ical
s ge
t use
d to
the
chan
ge.
Tric
yclic
s (T
CA
s)
Tr
icyc
lics,
or T
CAs
, wer
e fir
st d
evel
oped
in
the
1960
s to
trea
t dep
ress
ive
diso
rder
s. T
hey
are
still
used
toda
y w
hen
SSR
Is a
nd S
NR
Is fa
il to
wor
k.
Tric
yclic
ant
idep
ress
ants
blo
ck th
e re
upta
ke o
f the
neu
rotra
nsm
itter
s se
roto
nin
and
nore
pine
phrin
e, in
crea
sing
th
e le
vels
of t
hese
two
neur
otra
nsm
itter
s in
the
brai
n.
NAM
I Fam
ily-to
-Fam
ily 2
020
Cla
ss 5
5.
50
Mon
oam
ine
Oxi
dase
Inhi
bito
rs (M
AO
I)
Com
mon
sid
e ef
fect
s of
TC
As a
re th
e sa
me
as th
ose
of S
SRIs
and
SN
RIs
plu
s bl
urre
d vi
sion
, urin
ary
rete
ntio
n, d
rop
in b
lood
pr
essu
re a
nd in
crea
sed
swea
ting.
The
bi
gges
t ris
k of
TC
As w
hen
pres
crib
ed fo
r de
pres
sion
is th
eir p
oten
tial t
o be
use
d to
at
tem
pt s
uici
de. O
verd
oses
of T
CAs
can
be
dead
ly.
M
AOIs
, or M
onoa
min
e O
xida
se In
hibi
tors
ha
ve a
long
his
tory
of u
se a
s a
treat
men
t fo
r dep
ress
ion.
M
AOIs
, or M
onoa
min
e O
xida
se In
hibi
tors
, st
op th
e br
eakd
own
of n
euro
trans
mitt
ers
in
the
syna
pse.
Thi
s m
akes
mor
e ne
urot
rans
mitt
ers
avai
labl
e in
the
syna
pse
whi
ch in
crea
ses
the
trans
mis
sion
of
mes
sage
s.
Thes
e m
edic
atio
ns h
ave
few
sid
e ef
fect
s,
but t
hey
have
ano
ther
ser
ious
pro
blem
all
thei
r ow
n. If
peo
ple
taki
ng th
ese
drug
s ea
t fo
ods
cont
aini
ng c
erta
in “a
min
es”,
They
m
ay h
ave
a se
vere
spi
ke in
blo
od
pres
sure
.
Ove
rdos
es u
sing
MAO
Is a
re a
lso
dead
ly. D
ue to
thes
e da
nger
s,
pres
crib
ers
only
reco
mm
end
MAO
Is
whe
n ot
her a
ntid
epre
ssan
ts h
ave
faile
d.
NAM
I Fam
ily-to
-Fam
ily 2
020
Cla
ss 5
5.
51
O
ne m
etho
d of
del
iver
ing
MAO
I m
edic
atio
n is
thro
ugh
a tra
nsde
rmal
pa
tch.
App
lyin
g a
daily
pat
ch d
oesn
’t ap
pear
to c
ause
the
spik
e in
blo
od
pres
sure
and
doe
sn’t
requ
ire a
ny d
ieta
ry
rest
rictio
ns w
hen
used
at t
he
reco
mm
ende
d do
sage
.
Star
ting
a ne
w a
ntid
epre
ssan
t m
edic
atio
n m
ay tr
igge
r a m
anic
epi
sode
in
som
eone
who
has
und
iagn
osed
bi
pola
r dis
orde
r. In
thes
e ca
ses,
gu
idel
ines
gen
eral
ly re
com
men
d st
artin
g a
moo
d-st
abiliz
ing
med
icat
ion
befo
re
pres
crib
ing
an a
ntid
epre
ssan
t.
Som
e de
pres
sion
is tr
eatm
ent-r
esis
tant
, m
eani
ng it
doe
sn’t
resp
ond
to fi
rst-l
ine
antid
epre
ssan
t med
icat
ion.
Psy
chia
trist
s m
ay
choo
se to
pre
scrib
e an
othe
r ant
idep
ress
ant i
n ad
ditio
n to
an
SSR
I or a
n SN
RI.
Som
e ne
wer
an
tidep
ress
ants
wor
k to
incr
ease
oth
er
neur
otra
nsm
itter
s. A
com
bina
tion
of
antid
epre
ssan
t med
icat
ions
ofte
n ef
fect
ivel
y tre
ats
depr
essi
on.
PSYC
HO
SIS
A
ntip
sych
otic
Med
icat
ion
An
tipsy
chot
ic m
edic
atio
n re
duce
s or
el
imin
ates
del
usio
ns a
nd h
allu
cina
tions
. An
tipsy
chot
ics
play
an
impo
rtant
role
in
treat
ing
schi
zoph
reni
a, s
chiz
oaffe
ctiv
e di
sord
er o
r any
of t
he o
ther
dis
orde
rs th
at
are
caus
ing
sym
ptom
s of
psy
chos
is.
NAM
I Fam
ily-to
-Fam
ily 2
020
Cla
ss 5
5.
52
D
elus
ions
and
hal
luci
natio
ns re
sult
whe
n th
ere
is to
o m
uch
dopa
min
e in
the
syna
pses
. Ant
ipsy
chot
ic d
rugs
pre
vent
do
pam
ine
from
bin
ding
to th
e re
ceiv
ing
dend
rite.
The
y do
this
by
occu
pyin
g th
e do
pam
ine
rece
ptor
site
s so
that
tra
nsm
issi
on is
blo
cked
.
The
term
use
d to
refe
r to
the
olde
r an
tipsy
chot
ic m
edic
atio
ns is
“firs
t ge
nera
tion.
” The
y ar
e hi
gh p
oten
cy,
mea
ning
they
blo
ck m
ore
dopa
min
e re
cept
ors,
are
less
sed
atin
g, a
nd a
re
avai
labl
e as
long
act
ing
inje
ctab
le (L
AI)
form
s th
at c
an b
e gi
ven
ever
y tw
o to
four
w
eeks
.
One
of t
he c
halle
nges
with
the
pow
erfu
l do
pam
ine
bloc
kade
of h
igh-
pote
ncy
antip
sych
otic
s is
that
they
can
affe
ct n
euro
ns
outs
ide
the
brai
n th
at m
ove
mus
cles
. Thi
s ca
n ca
use
mov
emen
t dis
orde
rs, s
uch
as T
ardi
ve
dysk
ines
ia w
hich
is a
n un
com
forta
ble,
ofte
n em
barra
ssin
g co
nditi
on in
whi
ch th
e br
ain
mis
fires
and
cau
ses
rand
om, u
ncon
trolla
ble
mus
cle
mov
emen
ts o
r tic
s in
the
arm
s, fi
nger
s,
legs
, toe
s or
faci
al m
uscl
es.
BIP
OLA
R D
ISO
RD
ER
New
er, s
econ
d-ge
nera
tion
“Aty
pica
l” an
tipsy
chot
ic m
edic
atio
ns s
elec
tivel
y bl
ock
neur
otra
nsm
itter
rece
ptor
s in
the
brai
n to
pr
oduc
e sp
ecifi
c be
nefit
s. T
hese
sec
ond-
gene
ratio
n m
edic
atio
ns a
ren’
t nec
essa
rily
bette
r or w
orse
than
firs
t-gen
erat
ion,
but
they
do
hav
e di
ffere
nt s
ide
effe
cts.
Seco
nd-g
ener
atio
n an
tipsy
chot
ics,
un
fortu
nate
ly, a
re m
ore
likel
y to
resu
lt in
w
eigh
t gai
n. In
divi
dual
s on
thes
e m
edic
atio
ns p
ut o
n w
eigh
t due
to
seda
tion,
app
etite
stim
ulat
ion,
and
an
inab
ility
to “f
eel f
ull.”
NAM
I Fam
ily-to
-Fam
ily 2
020
Cla
ss 5
5.
53
Moo
d St
abili
zers
M
ood
stab
ilizer
s ar
e th
e m
ost c
omm
on
med
icat
ions
for t
reat
ing
the
moo
d sw
ings
as
soci
ated
with
bip
olar
dis
orde
r.
The
olde
st o
f the
m, L
ithiu
m, h
as b
een
in u
se fo
r ove
r 50
year
s an
d ha
s pr
oven
to b
e ve
ry e
ffect
ive,
par
ticul
arly
fo
r bip
olar
I di
sord
er. H
owev
er, r
egul
ar
bloo
d te
sts
are
a re
quire
men
t for
an
yone
taki
ng L
ithiu
m, w
hich
has
po
tent
ial s
erio
us s
ide
effe
cts
to th
e ki
dney
s an
d th
yroi
d.
A
NXI
ETY
Ant
i-Anx
iety
Med
icat
ion
Ther
e ar
e al
so m
edic
atio
ns n
ow a
ppro
ved
for u
se a
s m
ood
stab
ilizer
s th
at w
ere
orig
inal
ly c
reat
ed to
trea
t sei
zure
dis
orde
rs.
Thes
e ar
e kn
own
as a
ntic
onvu
lsan
ts a
nd
ofte
n w
ork
bette
r tha
n Li
thiu
m fo
r som
e pe
ople
. Moo
d st
abiliz
ers
can
prev
ent t
he
high
s of
bot
h m
anic
and
hyp
oman
ic
epis
odes
, and
als
o pr
even
t low
s or
de
pres
sive
epi
sode
s.
NAM
I Fam
ily-to
-Fam
ily 2
020
Cla
ss 5
5.
54
NEW
MED
ICA
TIO
NS
Ther
e is
one
mor
e ca
tego
ry to
tell
you
abou
t, an
d th
at is
ant
i-anx
iety
m
edic
atio
n. T
hese
wor
k to
redu
ce th
e em
otio
nal a
nd p
hysi
cal s
ympt
oms
of
anxi
ety.
Benz
odia
zepi
nes
can
treat
pan
ic d
isor
der,
soci
al p
hobi
a an
d ge
nera
lized
anx
iety
di
sord
er. H
eart
med
icat
ions
kno
wn
as b
eta
bloc
kers
are
als
o ef
fect
ive
at tr
eatin
g th
e ph
ysic
al tr
embl
ing,
sw
eatin
g an
d ot
her
phys
ical
sym
ptom
s ex
perie
nced
by
peop
le
with
pho
bias
or p
anic
dis
orde
r. An
ti-an
xiet
y m
edic
atio
n w
orks
qui
ckly
and
is v
ery
effe
ctiv
e in
the
shor
t-ter
m. H
owev
er, p
eopl
e pr
one
to
subs
tanc
e ab
use
may
bec
ome
depe
nden
t on
benz
odia
zepi
nes.
GEN
ERIC
MED
ICA
TIO
NS
The
Food
and
Dru
g Ad
min
istra
tion,
or
FDA,
regu
late
s al
l pre
scrip
tion
med
icat
ions
ava
ilabl
e in
the
U.S
. The
pr
oces
s of
get
ting
FDA
appr
oval
for a
ne
w m
edic
atio
n or
for a
n ol
d m
edic
atio
n to
be
used
for a
new
pur
pose
is v
ery
long
— it
can
take
yea
rs.
Phys
icia
ns o
ften
find
that
alth
ough
a
med
icat
ion
hasn
’t be
en a
ppro
ved
by th
e FD
A fo
r use
with
a p
artic
ular
con
ditio
n, o
r for
a
parti
cula
r gro
up o
f peo
ple,
it h
as b
een
show
n to
be
effe
ctiv
e in
clin
ical
pra
ctic
e. R
athe
r tha
n w
ait f
or F
DA
appr
oval
, the
phy
sici
an h
as th
e au
thor
ity to
pre
scrib
e th
at m
edic
atio
n an
yway
. Thi
s is
cal
led
“off-
labe
l” pr
escr
ibin
g.
NAM
I Fam
ily-to
-Fam
ily 2
020
Cla
ss 5
5.
55
BLA
CK
BO
X W
AR
NIN
G
The
FDA
requ
ires
that
gen
eric
m
edic
atio
ns c
onta
in th
e ex
act s
ame
activ
e ch
emic
als
as th
ose
in b
rand
or
trade
nam
e m
edic
atio
ns a
nd th
at th
e ro
ute
of a
dmin
istra
tion
whe
ther
it’s
av
aila
ble
as ta
blet
s, c
apsu
les,
pat
ches
or
inje
ctio
ns —
be
iden
tical
.
Oth
er c
hara
cter
istic
s ar
e al
low
ed to
be
diffe
rent
, spe
cific
ally
inac
tive
ingr
edie
nts
such
as
colo
r, fla
vor,
fille
rs a
nd b
inde
rs.
Thes
e in
activ
e in
gred
ient
s us
ually
var
y be
twee
n dr
ug c
ompa
nies
and
can
in
fluen
ce th
e w
ay a
med
icat
ion
wor
ks fo
r di
ffere
nt p
eopl
e.
N
ot a
ll m
edic
atio
ns a
ppro
ved
by th
e FD
A to
trea
t men
tal h
ealth
con
ditio
ns in
ad
ults
are
als
o ap
prov
ed b
y th
e FD
A fo
r us
e in
the
treat
men
t of t
hose
sam
e co
nditi
ons
in c
hild
ren
and
adol
esce
nts.
Som
e ps
ycho
tropi
c m
edic
atio
ns fo
r chi
ldre
n an
d ad
oles
cent
s co
me
with
wha
t’s k
now
n as
a
“bla
ck b
ox” w
arni
ng. T
his
war
ning
app
ears
on
pres
crip
tion
drug
s th
at m
ay c
ause
sev
ere
adve
rse
effe
cts.
The
term
bla
ck b
ox re
fers
to
the
heav
y bl
ack
bord
er u
sed
to d
raw
atte
ntio
n to
thes
e w
arni
ngs.
Thes
e w
arni
ngs
are
requ
ired
on a
ny ty
pe
of m
edic
atio
n th
at th
e FD
A th
inks
nee
ds
it, n
ot ju
st th
e on
es u
sed
to tr
eat m
enta
l he
alth
con
ditio
ns.
NAM
I Fam
ily-to
-Fam
ily 2
020
Cla
ss 5
5.
56
THE
FUTU
RE
OF
TREA
TMEN
T
In 2
004,
the
FDA
bega
n re
quiri
ng th
at
phar
mac
eutic
al c
ompa
nies
add
bla
ck b
ox
war
ning
s on
all
antid
epre
ssan
t med
icat
ions
st
atin
g th
at: t
he ri
sk o
f sui
cida
l ten
denc
ies
may
incr
ease
in c
hild
ren,
ado
lesc
ents
, yo
ung
adul
ts a
ged
18-2
4 us
ing
thes
e m
edic
atio
ns. T
his
requ
irem
ent w
as b
ased
on
repo
rts o
f inc
reas
ed ra
tes
of s
uici
de
atte
mpt
s an
d de
ath
by s
uici
de in
chi
ldre
n an
d ad
oles
cent
s w
ho w
ere
taki
ng a
n an
tidep
ress
ant.
The
blac
k bo
x w
arni
ng d
oes
not m
ean
that
th
e an
tidep
ress
ant m
edic
atio
ns c
ause
d th
e su
icid
al b
ehav
iors
. It j
ust m
eans
ther
e w
as b
elie
ved
to b
e a
conn
ectio
n, a
nd
phys
icia
ns p
resc
ribin
g th
ose
med
icat
ions
sh
ould
clo
sely
mon
itor c
hild
ren
taki
ng
them
.
The
futu
re o
f tre
atm
ent f
or m
enta
l hea
lth
sym
ptom
s is
act
ually
ver
y ho
pefu
l. R
esea
rch
is n
ow c
once
ntra
ting
on
unde
rsta
ndin
g th
ose
chan
ges
that
hap
pen
with
in th
e ce
ll, b
elie
ving
a m
ore
effe
ctiv
e ta
rget
for d
rug
actio
n m
ay b
e re
veal
ed.
You
may
wan
t to
do s
ome
rese
arch
yo
urse
lf an
d re
ad a
bout
oth
er n
ew
disc
over
ies
that
may
cha
nge
the
futu
re o
f ps
ycho
tropi
c m
edic
atio
n op
tions
. NAM
I’s
web
site
is a
gre
at p
lace
to s
tart.
NAMI Family-to-Family 2020 Class 5 5.57
Worksheet 13: Side Effects of Psychotropic Medications Anti-Cholinergic Side Effects (blocking action of acetylcholine):
• Blurred vision • Dizziness • Urinary retention • Confusion or delirium • Dry mouth • Orgasmic and erectile dysfunction • Drowsiness • Gastrointestinal disturbances (nausea/diarrhea/constipation) • Increased heart rate • Reduced sweating or elevated body temperature
Anti-Adrenergic Side Effects (blocking action of adrenaline):
• Dizziness • Decreased blood pressure • Tachycardia (rapid heartbeat) • Sedation • Weight gain
Antihistamine Side Effects:
• Substantial weight gain • Drowsiness
Serotonergic Side Effects:
• Diminished libido • Orgasmic and erectile dysfunction • Gastrointestinal disturbances (nausea/diarrhea/constipation)
Dopaminergic Side Effects:
• Parkinsonian symptoms (decreased facial movement, stiffness, rigidity) • Acute dystonia (involuntary muscle movement) • Akathisia (restlessness or discomfort when not moving) • Tardive dyskinesia (late onset, involuntary movements) • Sexual dysfunctions
Glucose Dysregulation:
• Increased risk for new onset Type II diabetes • Increased risk for cardiovascular disorder
NAMI Family-to-Family 2020 Class 5 5.58
Worksheet 14: Cost and Benefits of Taking Medication
Have you ever:
• Felt disoriented by a medication you were taking? • Felt sick because of a medication? • Stopped taking a medication when the symptoms you were originally taking it for
went away or got better? Do you:
• Usually finish all of the pills you were prescribed? • Still have expired medication at home?
What would you do if you had to take a medication that made you feel sleepy, gain 45 pounds, gave you tremors and blocked your sexual responses?
NAMI Family-to-Family 2020 Class 5 5.59
Worksheet 15: Common Emotional Experiences that Affect Treatment
Lacking insight into the condition: “I’m not ill”
Lack of insight is a phenomenon where someone with a mental health condition doesn’t perceive that something problematic is happening with their health. This happens when a person is genuinely disconnected from the perceptions and beliefs shared by a wider community. A person lacking insight is unable to see the validity of other points of view. Because they don’t sense that anything is unusual, they don’t think there’s a reason to consider treatment.
This is called “anosognosia.” It’s especially common in schizophrenia and in episodes of mania. It’s so common that it’s considered one reliable sign of these conditions when making a diagnosis. People with depression also may not recognize when their condition is serious.
When people lack insight into their condition, they may continue to believe nothing is wrong, even if their symptoms improve with treatment. Many of the people who go voluntarily to the hospital go because someone has urged them to, but do not believe they need to. Using denial as a protective coping strategy: “I don’t need treatment”
When a person is overwhelmed or unequipped to address what’s happening, they may deny that the problem exists or ignore it, hoping it will go away. They may recognize that something is wrong but find it too painful to acknowledge to themselves or to others. As we’ve reiterated, people use denial to cope with many upsetting events and medical crises, not just mental health conditions. Being in denial temporarily protects the person. When someone is in denial, choosing treatment would be admitting that something is medically wrong. If they are in denial and do take medication anyway, they may be unlikely to tolerate side effects when they don’t see the benefits.
NAMI Family-to-Family 2020 Class 5 5.60
Missing the thrill of mania: “I’d rather feel pain than be numb or bored”
Some mental health treatments reduce the intensity of your emotions. Some people report not having emotions at all when taking certain medications. When a person’s emotional baseline changes, they must develop a new sense of what is normal, which can be frustrating and demoralizing. A person may prefer to tolerate the ups and downs of their condition rather than give up feelings they’re used to having or not feeling at all. When that’s the case, it’s understandable that someone might experiment with stopping and starting medication. Wishing to be seen as a person, not an illness: “I don’t want to be seen as broken”
People who choose to seek treatment and experience it as beneficial may decide not to continue long-term, even if they’re receiving benefits from it. Many people don’t like the idea of having a chronic condition that involves going to therapy or taking a medication indefinitely. People often say they feel they’re seen or treated as “just” their diagnosis, rather than as a full person with a variety of traits, needs and hopes.
This experience is true of people with many health conditions, not only mental illness. Being involved in treatment or taking medications long-term can seem like admitting you’ll never return to how you used to be. That can be extremely difficult to accept. When people start improving, they may stop treatment or stop taking medication because it seems, and they hope, that their need for treatment has gone away. Being reluctant to accept things as they are, or partial acceptance
When a person is unable to accept a situation or condition, it’s often because their experience feels too painful to tolerate. It may seem easier to disregard the problem even if there are negative consequences in the future.
Notes:
NAMI Family-to-Family 2020 Class 5 5.61
Worksheet 16: Assisted Outpatient Treatment (AOT) Overview
Introduction to AOT
When people are not being treated for their mental health symptoms, this is sometimes called “non-engagement,” meaning that they are not participating in or receiving mental health treatment. There are many reasons why someone might not participant in treatment. A few include:
• Insufficient community resources (agencies, social services, long waitlist, etc.) • Not having health insurance or coverage for services • Not being able to afford treatment (copays, sliding-scale fees, etc.) • Not enough providers or providers are too far away • Not having access to transportation to reach providers • Not being able to take time off work to access treatment • Substance use (interfering or making a person ineligible for services) • Discouraged by bad side effects of medications • Difficulty with executive functioning (making decisions, completing tasks, etc.) • Not trusting doctors/medical staff because of symptoms or bad past experiences • Feeling reluctant or ashamed because of stigma • Being unable to follow treatment plan consistently because of memory issues,
etc. • Anosognosia/lack of insight
Anosognosia is a symptom of a mental health condition that causes the person to not sense or believe that they’re experiencing symptoms. While the person’s personality, beliefs and behaviors may appear to be a mental health condition to others, it is not clear to the person with anosognosia. Anosognosia is not denial. It’s not a choice. It’s a biological, brain-based symptom that the person cannot control. Consequently, if a person does not believe he or she is ill, engaging with treatment would be illogical.
In some cases, not being treated for symptoms can put the person at risk of harm. It can also put other people at risk of harm. One way of helping to ensure that such individuals get treatment when they are not willing to do so voluntarily is called Assisted Outpatient Treatment (AOT). A person in AOT is required, by a civil court, to receive treatment. AOT is also called court-ordered outpatient treatment or outpatient civil commitment.
NAMI Family-to-Family 2020 Class 5 5.62
How AOT works
AOT works differently in each state (visit treatmentadvocacycenter.org, search “browse by state”). However, most state laws have some things in common. Most include these requirements:
• Someone files a petition (also called an affidavit or application) in the civil (or probate) court
o The petitioner describes in writing why he or she believes the person meets the legal criteria for AOT
o State laws vary on who may file the petition. In some states, family members are allowed to do so
• The court holds a hearing • The person described in the petition is legally entitled to “due process
protections,” such as a court-appointed lawyer • The person described in the petition is assumed to not need AOT until and
unless the petitioner convinces the court that the person does (“the burden of proof” is on the petitioner)
• Experts, including psychiatrists and other mental health professionals, provide testimony in support or opposition to the petition
• If the evidence that AOT is needed is clear and convincing, the judge (or a person representing the judge) may order the person to receive involuntary treatment
o AOT often begins with involuntary inpatient treatment and transitions to involuntary outpatient treatment
The ultimate goal of AOT is to encourage the development of an ongoing positive relationship between the treatment team and the participant so that in time the person voluntarily engages in treatment. The treatment team often uses evidenced based interventions such as shared decision making and motivational interviewing to increase the participant’s success.
Differences between mental health court and AOT
Mental health court is a criminal court process and is for individuals who have committed a crime. The purpose of mental health court is to reduce the number of people with mental illness in jails and prisons and to help prevent them from committing crimes in the future. The goal is to link the person to treatment services, provide him or her with intensive supervision by the court, and hold the person accountable for sticking to the court ordered treatment. If a person in mental health court does not follow through with treatment, a judge may order him or her to go to jail. A person who
NAMI Family-to-Family 2020 Class 5 5.63
successfully completes mental health court generally has his or her criminal case dismissed.
AOT is a civil court process and is for individuals who have not committed a crime. The purpose of AOT is to address treatment non-engagement by leveraging the power of the court to influence behavior. A judge can order a person in AOT to follow a treatment plan, but the person cannot be placed in jail for not following through with court ordered treatment. However, there are consequences that may be imposed by the judge. These include:
• Being ordered to appear in front of the judge • Increasing the length of time the person is on AOT • Being ordered to receive a mental health evaluation to determine if the person is
a danger to self or others • Being placed in the hospital if the evaluation determines that the person meets
the criteria for inpatient treatment
When to file an AOT petition
The best time to begin the AOT process is as the person is leaving a hospital, jail or prison. At this point, the person should have received care that has stabilized his or her mental health condition and is better able to understand the court’s expectations. In some states, a family member is allowed to file the AOT petition. However, the best person to file the petition is usually the doctor who’s been overseeing the person’s care, because the doctor has the information and expertise to explain to the court why AOT is necessary.
Paying for AOT
Often, people who meet criteria for AOT are on Medicaid or are eligible to receive subsidized services provided by the public mental health system. In that situation, Medicaid or the public mental health system covers the cost of treatment. If the person has private insurance, his or her insurance company would be billed for the costs.
Learning more
For more information on AOT, including how to get a program started in your community if one doesn’t exist, contact the Treatment Advocacy Center at treatmentadvocacycenter.org. Source: Treatment Advocacy Center, 2019
NAMI Family-to-Family 2020 Class 5 5.64
Worksheet 17: Supporting Your Loved One During Treatment
• If your loved one with the mental health condition is willing to discuss treatment, help them to understand how medications and talk therapy work and how they can help.
• You need to have a workable plan for monitoring medications (for treatment and safety).
• All medication issues need to be discussed openly.
• Sometimes adherence increases by avoiding the “mental illness” connotation of these medications (addressing the impact of the treatment on the symptoms that are causing distress rather than the diagnosis itself).
• It’s helpful to keep written records of the medications your loved one has taken, the dosages and the side effects that have been troublesome.
• Confidentiality will not be a barrier to communication with a treatment provider if your loved one gives permission. If permission isn’t granted, you may speak to the provider but the provider cannot give you information in return.
• If your loved one refuses treatment, it’s a good idea to prepare yourself for the possibility of a crisis.
NAMI Family-to-Family 2020 Class 5 5.65
Worksheet 18: Warning Signs of Relapse
• Feeling more tense or nervous*
• Having more trouble sleeping*
• Feeling that people are talking about them*
• Change in level of activity*
• Having more trouble concentrating*
• Having more nightmares or bad dreams
• Hearing voices or seeing things
• Feeling more depressed
• Feeling that someone else is controlling them
• Not taking care of personal hygiene
• Feeling badly for no apparent reason
• Losing interest in things they like doing
• Feeling angrier over little things
• Spending less time with friends
• Thinking about hurting themselves
• Enjoying things less
• Feeling more aggressive or pushy
• Feeling too excited or overactive
• Eating less
• Having trouble relating to family
• Having more religious ideas
• Having frequent aches and pains
• Preoccupied with one or two ideas
• Having trouble making sense when talking
• Increased substance use (alcohol or other drugs)
• Feeling like they are forgetting things
• Feeling worthless
• Thinking about hurting someone else
• Fear they are losing control of their mind or thoughts
(*) Universal Warning Signs McFarlane, W., Terkelson, K., “New Approaches to Families Living With Schizophrenia.” Institute, 62nd Annual Ortho-Psychiatric Meeting. N.Y.
NAMI Family-to-Family 2020 Class 5 5.66
Worksheet 19: Psychiatric Advance Directives (PAD)
What is a psychiatric advance directive (PAD)?
It is a legal document that allows people with mental illness to state their preferences for treatment in advance of a crisis. They can even consent to or refuse treatment during such a crisis. There are two kinds of legal documents in a PAD: (1) “Advance Instructions” to list treatment preferences and (2) “Health Care Power of Attorney” to appoint a trusted person to make decisions.
How are they used?
If a person is in crisis, and not capable of speaking for him or herself, medical professionals can refer to the PAD to get a clear description of the person’s preferences for treatment and if there is a trusted person who can help make decisions. PADs are only used temporarily, and only when the person is incapable of making or communicating treatment decisions.
What are the benefits of PADs?
PADs help people clarify their preferences and plan for crises — including having conversations that can sometimes help to prevent crises from occurring.
In research studies, PADs have been found to reduce the need for involuntary commitment and help people get the treatment they prefer.
What is a health care power of attorney?
A person can legally appoint another person to represent their interests when incapacitated by giving them power of attorney for healthcare decisions. The person in this role is called a health care agent, and only speaks for the person when the person is incapacitated — that is, unable to make or communicate healthcare decisions.
Notes: Source: Crisis Navigation Project at Southern Regional Area Health Education Center and Duke University Medical Center crisisnavigationproject.org
NAMI Family-to-Family 2020 Class 5 5.67
Worksheet 20: Guide to Psychiatric Advance Directives
Do you want more say in your mental health treatment? If you are someone who is in psychiatric treatment, you might be interested in finding out how to have more say in your treatment, especially when you are in crisis. This guide will help you understand how a psychiatric advance directive (PAD) might be useful to you.
It’s always a good idea to start with your psychiatrist or other mental health treatment provider if you are interested in creating your own PAD. Ask if they know about PADs, and if they can help you create one. If they don’t know about them, you can share this brochure with them so they can learn more, too. There are also volunteers in your community who will help you create a PAD.
What is a psychiatric advance directive? A psychiatric advance directive is a legal document that tells treatment providers your preferences for treatment in a crisis. It goes into effect if you are incapacitated — that means if you are in a state of mind where you cannot speak for yourself. An example of being incapacitated would be if you were unconscious, or couldn’t speak, or were experiencing significant confusion.
If you have a Wellness Recovery Action Plan, or WRAP Plan, or a Crisis Plan, there are some similarities with a PAD. A PAD is different because it is a legal document. To make it official, it must be signed in front of a notary public and two witnesses.
Treatment providers are required to follow your wishes stated in the PAD, unless those wishes include something they cannot do (like send you to a hospital in another state, or to a hospital that has no beds available), or it’s an emergency and they need to preserve your safety or the safety of others.
Where did the idea for PADs come from? Medical advance directives have been used in medical settings for years for people who wanted more control over their medical care at times when they had a serious medical illness and knew they would not be able to express their wishes on their own — like if someone was at the end of life. They were created as the result of the Patient Self-Determination Act of 1990, a federal law designed to give all patients more say in healthcare decisions.
NAMI Family-to-Family 2020 Class 5 5.68
Are PADs always respected? We hear from some people that their PAD was not followed during a crisis. They are not used often, and medical providers are just starting to learn more about them. By getting more PADs out there, we hope to strengthen the voice of people who live with mental illness and to encourage more shared decision making with their treatment providers.
Do you have a trusted person who will help you in a crisis? A PAD can include a health care power of attorney (HCPA). The HCPA is a legal document that lets you put someone in charge of communicating your wishes to medical providers if you are not able to. The person appointed by the HCPA is called your health care agent. That person can speak for you in a crisis. It’s your choice to have a health care agent or not. Sometimes family members are in this role, and sometimes friends or another person you trust and who can help you in a crisis.
Are there other benefits to having a PAD? The process of creating a PAD helps you think through what you can do to prevent a crisis, what to do during a crisis, and how best to recover from a crisis. The conversations with your treatment providers, your family and friends, can help you take control of your mental health and improve communication.
What do I need to think about before I create a PAD? What kind of treatment is helpful to you? What medications work for you? What medications don’t work for you? Is there a hospital that you prefer? Who should be contacted if you are in a mental health crisis? What practical matters in your life — like childcare, pet care, contacting your employer or paying your rent — need to be tended to if you are not able? You can include additional instructions tailored to what support you need in your PAD.
Where can I get more information about PADs?
National Resource Center on Psychiatric Advance Directives:
http://www.nrc-pad.org/ For information about PADs nationwide.
https://www.youtube.com/watch?v=eBSZ4ooRoZ8
Crisis Navigation Project: http://www.crisisnavigationproject.org/
A project to promote the use of PADs. Go to the link for North Carolina resources.
Source: The Crisis Navigation Project is a collaborative project to promote the use of psychiatric advance directives. It is based at the NC Evidence Based Practices Center at Southern Regional Area Health Education Center, in affiliation with Duke University Medical Center. Funding for the project is provided by The Duke Endowment. NAMI North Carolina is a key partner in the initiative.
NAMI Family-to-Family 2020 Class 5 5.69
Worksheet 21: Biomedical Approaches Electroconvulsive Therapy, or ECT, is a procedure where controlled electric currents are passed through the brain while the person is under general anesthesia. The currents cause a brief, controlled seizure that affects neurons and chemicals in the brain. ECT is usually used to treat severe depression, including depression with psychosis, that has not responded to other treatments. Some people report loss of memory as a side effect of ECT.
Transcranial Magnetic Stimulation, or TMS, involves placing an electromagnetic coil on a person’s scalp, near the forehead and directing short pulses into an area of the brain that’s believed to control moods. TMS was cleared by the FDA in 2008 for treatment resistant depression and more recently for OCD.
Vagus Nerve Stimulation, or VNS, uses a small implant in the upper chest to stimulate the vagus nerve with electrical impulses. The vagus nerve manages communication between your brain and the organs in your body. VNS can be used for treatment resistant depression and other medical conditions, including epilepsy.
Deep Brain Stimulation, or DBS, was originally developed to reduce tremors from Parkinson’s disease. The FDA cleared DBS as a treatment for OCD. This is usually used when other treatments such as medication and exposure response therapy are unsuccessful. DBS uses a small implant in the upper chest to send electrical impulses to electrodes attached directly to the brain.
Like other treatments, brain stimulation therapies can have side effects. It’s important to talk with a doctor about the risks and benefits of these treatments if your loved one is considering them.
NAMI Family-to-Family 2020 Class 5 5.70
Worksheet 22: Complementary Treatments
Some examples of complementary approaches are:
• Supplements, like vitamins and minerals. It’s important to know the ingredients of any supplement you consider and to review them with your prescriber.
• Omega-3 fatty acids which are groups of chemicals found in different foods, including fish and nuts that may help in the management of both medical and mental illnesses
• Folate, a vitamin required for the human body to perform many essential processes on a day-to-day basis. Also called folic acid or vitamin B9, folate is a compound that the human body is unable to make on its own.
• Medical foods, which are made with or without specific nutrients and aim to treat a health condition
• CBD oil • Exercise, yoga and Tai Chi • Meditation • Animal-assisted therapy
o Trained service animals (recognized by the Americans with Disabilities Act or ADA)
o Equine-Assisted Therapy, or EAP, which teaches individuals how to groom, care for and ride horses
o Therapy animals o Emotional support animals
• Art therapy
The National Center for Complementary and Alternative Medicine, or NCCAM, describes three types of approaches:
1. Complementary methods where non-traditional treatments are given in addition to standard medical procedures
2. Alternative methods of treatment used instead of established treatment
3. Integrative methods that combine traditional and non-traditional as part of a treatment plan
Remember: It’s critical that you discuss any over-the-counter medications or supplements with a doctor and pharmacist. Even vitamins can interact with medication. Certain substances can be safe to use with one prescription medication but make another medication less effective or dangerous.
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