Serving Consumers with Psychiatric Disabilities

Introduction

This resource guide is intended to provide helpful strategies for people who work with individuals with psychiatric disabilities in independent living centers and other consumer- oriented agencies. We seek to provide an informative yet brief and user-friendly source of information regarding common psychiatric disabilities, potential accommodations, and strategies that may enhance the collaboration between consumer and provider. This publication is not a guide to psychiatric treatments or crisis situations. Our goal is to provide information that will assist service providers in better understanding and communicating with the consumers they serve. This manual is only a starting point; obviously each individual has unique strengths and needs. We encourage you to use the information provided here to generate innovative and individualized strategies.

We have attempted to avoid unnecessary technical terms and professional jargon wherever possible. However, some technical terminology is used in order to communicate in a manner that is clear and in line with common usage. For instance, we chose to organize our guide around the psychiatric disorders that may be the focus of an individual’s need to seek services. In doing so we used diagnostic labels because this is most likely to be the language used by and understood by consumers and service providers alike.

Finally, we would like to thank the consumers and independent living center staff who assisted us in preparing this manual. Your suggestions and insight were invaluable.

Melisa Rempfer, Research and Training Center on Independent Living, and Libby Smith and Shawna Wendt, Department of Occupational Therapy, University of Kansas Medical Center,

Kansas City, Kansas

Schizophrenia

People with schizophrenia experience a range of symptoms that can involve difficulty with thinking, language, and perception. No single symptom is characteristic of schizophrenia, but individuals usually have some of the following symptoms: communication difficulty, trouble concentrating, trouble with motivation, delusions (a strongly held belief that is considered false or impossible to others in the person’s culture), and/or hallucinations (the perception of sights, sounds, smells, tastes or feelings that are not real).

Possible Challenges

Hallucinations

Strategy: Assist the person in focusing on the immediate task. The person may be distracted by a hallucination and may need prompts in order to get back to the task at hand. Emphasize reality but do not deny that the experience seems real to the person. (e.g., “I can’t hear anything, but I know the voices are real to you”)

Delusional or odd thinking

Strategy: While not endorsing false beliefs the person might have, attend to his/her reactions to these beliefs. In other words, do not reinforce such errors in thinking but recognize that these thoughts seem real to the person. These thoughts can be confusing and/or frightening and the person may need reassurances about safety, etc. Sometimes, the individual may not be sure whether his/her thoughts are real and might need help sorting through events. This “reality testing” should not be done in a demeaning or forceful nature. In other words, this should be done only when the person expresses doubts about beliefs or asks for feedback about them. Do not argue with a person’s delusional thinking or try to “talk him out of it.”

Cognitive difficulties

Strategy: Accommodate the person’s difficulties with memory or attention if necessary. For example, provide written reminders of appointments, present information so the person can see it visually as well as listen to it, reduce distractions in the environment, keep appointments short.

Ask the person what works best for him/her and work together to come up with new strategies that facilitate learning, remembering, etc. Adjust to the person’s tempo when interacting. For instance, do not rush through important information and ask the person for feedback about whether your pace is appropriate. Some people may have particular difficulty with problem solving. It can be helpful to go step-by-step through the problem-solving process: help define the problem, brainstorm various solutions, evaluate the solutions, choose and then implement the solution.

Communication difficulties

Strategy: Some people may not be very expressive in their facial expressions or voice tone. In these cases, it can be helpful to ask the person directly what they are thinking, feeling, etc. Be direct and clear when communicating. Be aware of your own non-verbal signs (such as facial expressions), and keep them appropriate to the topic/situation.

Fatigue or motivation difficulties

Strategy: Schedule appointments at times when the person is most able to function well. Take frequent breaks if necessary. Help the person pinpoint even the slightest areas of interest, and work from there.

Physical discomfort

Strategy: The person may experience medication side effects that produce physical discomfort. Be willing to recognize and accommodate such issues. For instance, the person may experience physical restlessness and need to walk about the room during appointments or the person may need to drink plenty of liquids to combat mouth dryness.

Depression

Depression describes a period of time when an individual’s mood is sad, hopeless, or blue and/or the person has lost interest or pleasure in most activities. The person also may experiences symptoms like sleep disturbance, weight changes, decreased energy, trouble thinking or making decisions.

Possible Challenges

Mood difficulty (feeling sad, blue, etc.)

Strategy: Use effective listening skills. Be supportive and encouraging. Do not expect person to “snap out of it.” Recognize that sadness, dread, or other negative emotions are a part of the person’s difficulty. Although you should not judge the person or try to talk him/her out of these feelings, be careful not to “buy into” the sadness yourself. Maintain a friendly, optimistic tone.

Crying spells

Strategy: Recognize that this is a common symptom of depression. Try not to feel overwhelmed by the person’s expression of emotion. Allow the person to express his/her feelings; listen and be supportive. However, you may find that the person’s crying is so frequent that it interferes with getting important things done. If this is the case, talk to the person about setting limits on his/her crying. For instance, some people may find it helpful to set up specific “crying periods” in which they may spend the first few minutes of an appointment crying or expressing feelings, then focusing on something else without crying, and leaving a few minutes at the end of the session to talk about feelings and cry some more if needed.

Low motivation or hopelessness

Strategy: Work with the person to pinpoint areas of interest/strength and build upon them. Set specific (and attainable) goals for each meeting and help the person record his/her progress on a task. Use a calendar or notebook so that the person can track and review his/her progress.

Remind him/her of the successes you have seen. Be specific and accurate—in other words, do not give general or patronizing praise. Help the person structure his/her time and schedule activities. If the person is having difficulty at certain times of the day, schedule tasks and appointments during times that she/he functions best. Avoid judging or blaming the person.

Recognize that even small tasks may seem overwhelming to the person, and encourage and praise the person for making efforts.

Difficulty with concentration and memory

Strategy: Help the person focus on the task at hand, and reduce distractions and noise. Break tasks into steps that are more easily followed and take them one step at a time.

Indecisiveness

Strategy: Many people dealing with depression have extreme difficulty making decisions. The challenge is to encourage the person to make his/her own decisions, while not blaming or forcing. Help the person recognize and write down the pros and cons of a decision and list the alternatives he/she has. Remember that the person may be easily overwhelmed by too many choices, so help him/her keep choices focused.

Negative thinking

Strategy: Recognize that the person may be viewing his/her life in a negative light that seems unrealistic or exaggerated to others. For instance, the person’s thinking may seem “black and white” (“if I can’t do this task, my life is a total failure”). The challenge is to empathize but gently encourage the person to recognize other, less negative, ways of viewing his/her situation. Model an optimistic and hopeful approach, but be careful not to be phony or dismissive of the person’s problems. Take the problems seriously but show the person through your example that there IS a way out.

Activity level

Strategy: The person may seem slowed-down in his/her activity level. If this is the case, be careful not to rush or ridicule the person. If the person has an increased activity level, it may be helpful to take a walk or do some other activity that will help burn the energy. For instance, play ping-pong while meeting, or let the person bounce a ball. Allow breaks when necessary, or cut a meeting short if the person feels too agitated. Keep the environment calm and try relaxation techniques like deep breathing or imagining a pleasant, calming scene.

Bipolar Disorder (“Manic Depression”)

Bipolar disorder is described as a condition in which a person experiences episodes of depression as well as separate periods of “mania.” According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV) a manic episode is defined by a distinct period in which a person’s mood is “abnormally and persistently elevated, expansive or irritable.” People who are experiencing mania might be described by others as hyper, over the top, high, or overly cheerful. Often, the person’s mood fluctuates between these “highs” and periods of depression. During periods of depression, see the “Depression” section for strategies. This section will focus on strategies relevant to periods when the person is experiencing a manic state.

Possible Challenges

Pressured speech, excessive activity

Strategy: Help keep the person focused on the task at hand. Limit distractions in the environment. Set small periods of time to focus on an activity, and take frequent breaks if the person is having difficulty staying focused. Be willing to reschedule appointments as necessary. Keep your tone and pace calm and neutral. In other words, do not get caught up in or reinforce the person’s manic pace.

Behavior changes

Strategy: Sometimes, while in a manic state, people do things they would not do otherwise. For instance, the may make impulsive purchases or decisions, or they may engage in risky activities. If possible, discuss this with the person when he/she is not experiencing a manic episode. It may be possible to identify potential problem areas in advance and come up with a plan for how the person wants to deal with this.

Irritability/Anger

Strategy: Encourage the person to use relaxation techniques or other methods to cool down. For instance, some people find it helpful to take a “time-out” from situations that agitate or upset them. It may be helpful to discuss this issue with the person during a calmer period and make a plan of what to do the next time he/she begins to get irritated. Of course, recognize that the person’s anger might very well be legitimate and address it. Give the person the same right to be angry that anyone else has. Unfortunately, people all too often disregard even the slightest expressions of anger as a “symptom.”

Anxiety Disorders

Anxiety can be defined as an overwhelming sense of apprehension, uneasiness or fear. It is often accompanied by physical signs of tension such as shortness of breath, increased pulse rate, or stomach pains. There are various diagnostic labels that fall under the category of “Anxiety Disorders”:

Generalized anxiety is frequent and persistent anxiety and worry that the person has difficulty controlling. The anxiety is accompanied by physical symptoms such as fatigue, muscle tension, sleep disturbances, etc.

Obsessive-Compulsive Disorder is characterized by recurrent obsessions (persistent and excessive distressing thoughts) and/or compulsions (repetitive behaviors the person feels driven to perform). The person recognizes that these obsessions and compulsions are excessive or irrational and is usually quite distressed by them.

Panic Disorder is when a person experiences frequent and unexpected panic attacks.

Panic attacks are periods of intense fear and discomfort where the person experiences the sudden occurrence of symptoms such as chest pain, dizziness, sweating, trembling, choking sensations, fears of dying or “going crazy,” etc. Because these attacks seem to come out of the blue, the person may be extremely worried or fearful about having another panic attack. Sometimes this results in a significant change in the person’s behavior. For instance, she/he might rarely leave home because of the fear that another panic attack might happen.

Posttraumatic Stress Disorder refers to recurrent distress, thoughts about, or dreams about a traumatic event the person has previously experienced. The person experiences increased levels of arousal, such as difficulty sleeping, irritability, difficulty concentrating, or startling easily.

Specific phobia is a fear of a clearly identified object or situation (snakes, flying, etc.).

When exposed to the feared object or situation, the person experiences intense anxiety and distress.

Many of the challenges associated with these diagnoses overlap with one another.

Therefore, they will be presented together. It is recommended that you talk to the person with whom you are working to determine what strategies will be most helpful based on the particular nature of his/her disability.

Possible Challenges

Discomfort in particular situations

Strategy: Be willing to recognize and accommodate the person’s discomfort in certain situations. Be flexible about when and where you will meet. Do not judge his/her discomfort or fears and be careful not to ridicule or demean.

Physical symptoms of anxiety/tension

Strategy: Again, recognize and accommodate these experiences. For instance, if the person begins to feel dizzy, find a place for him/her to relax.  Be supportive and calm.

Distractibility, concentration problems

Strategy: Help the person stay focused on the task at hand. Do not overwhelm the person with too much information at once. Break tasks and information into small pieces or steps.

General Strategies

Remember that the strategies presented in this booklet overlap and may be relevant beyond the specific diagnostic labels presented here. Work with the person to recognize his/her individual strengths and challenges and use this booklet as one method of generating strategies. Talk these over with the person and remember that he/she will have many insights into the strategies that are most helpful.

Be flexible. Accept that you may have to alter policies, schedules, etc. in order to accommodate the person’s needs.

Be aware of the way in which you communicate. Take care to be respectful, honest, clear, and as specific as possible.