Tag Archives: schizophrenia

Challenging the inevitability of inherited mental illness

By Lindsey Phillips August 29, 2019

With a family history that famously includes depression, addiction, eating disorders and seven suicides — including her grandfather Ernest Hemingway and her sister Margaux — actress and writer Mariel Hemingway doesn’t try to deny that mental health issues run in her family. She repeatedly shares her family history to advocate for mental health and to help others affected by mental illness feel less alone.

And, of course, they aren’t alone. Mental health issues are prevalent in many families, making it natural for some individuals to wonder or worry about the inherited risks of developing mental health problems. Take the common mental health issue of depression, for example. The Stanford University School of Medicine estimates that about 10% of people in the United States will experience major depression at some point during their lifetime. People with a family history of depression have a two to three times greater risk of developing depression than does the average person, however.

A 2014 meta-analysis of 33 studies (all published by December 2012) examined the familial health risk of severe mental illness. The results, published in the journal Schizophrenia Bulletin, found that offspring of parents with schizophrenia, bipolar disorder or major depressive disorder had a 1 in 3 chance of developing one of those illnesses by adulthood — more than twice the risk for the control offspring of parents without severe mental illness.

Jennifer Behm, a licensed professional counselor (LPC) at MindSpring Counseling and Consultation in Virginia, finds that clients who are worried about family mental health history often come to counseling already feeling defeated. These clients tend to think there is little or nothing they can do about it because it “runs in the family,” she says.

Theresa Shuck is an LPC at Baeten Counseling and Consultation Team and part of the genetics team at a community hospital in Wisconsin. She says family mental health history can be a touchy subject for many clients because of the stigma and shame associated with it. In her practice, she has noticed that individuals often do not disclose family history out of their own fear. “Then, when a younger generation person develops the illness and the family history comes out, there’s a lot of blame and anger about why the family didn’t tell them, how they would have wanted to know that, and how they could have done something about it,” she notes.

Sarra Everett, an LPC in private practice in Georgia, says she has clients whose families have kept their history of mental illness a secret to protect the family image. “So much of what feeds mental illness and takes it to an extreme is shame. Feeling like there’s something wrong with you or not knowing what is wrong with you, feeling alone and isolated,” Everett says. Talking openly and honestly about family mental health history with a counselor can serve to destigmatize mental health problems and help people stop feeling ashamed about that history, she emphasizes.

Is mental illness hereditary?

Some diseases such as cystic fibrosis and Huntington’s disease are caused by a single defective gene and are thus easily predicted by a genetic test. Mental illness, however, is not so cut and dry. A combination of genetic changes and environmental factors determines if someone will develop a disorder.

In her 2012 VISTAS article “Rogers Revisited: The Genetic Impact of the Counseling Relationship,” Behm notes that research in cellular biology has shown that about 5% of diseases are genetically determined, whereas the remaining 95% are environmentally based.

The history of the so-called “depression gene” perfectly illustrates the complexity of psychiatric genetics. In the 1990s, researchers showed that people with shorter alleles of the 5-HTTLPR (a serotonin transporter gene) had a higher chance of developing depression. However, in 2003, another study found that the effects of this gene were moderated by a gene-by-environment interaction, which means the genotype would result in depression if people were subjected to specific environmental conditions (i.e., stressful life events). More recently, two studies have disproved the statistical evidence for a relation between this genotype and depression and a gene-by-environment interaction with this genotype.

Even so, researchers keeps searching for disorders that are more likely to “run in the family.” A 2013 study by the Cross-Disorder Group of the Psychiatric Genomic Consortium found that five major mental disorders — autism, attention deficit/hyperactivity disorder (ADHD), bipolar disorder, major depressive disorder and schizophrenia — appear to share some common genetic risk factors.

In 2018, a Bustle article listed 10 mental health issues “that are more likely to run in families”: schizophrenia, anxiety disorders, depression, bipolar disorder, obsessive-compulsive disorder (OCD), ADHD, eating disorders, postpartum depression, addictions and phobias.

Adding to the complexity, Kathryn Douthit, a professor in the counseling and human development program at the University of Rochester, points out that studies on mental disorders are done on categories such as major depression and anxiety that are often based on descriptive terms, not biological markers. The cluster of symptoms produces a “disorder” that may have multiple causes — ones not caused by the same particular genes, she explains.

Thus, thinking about mental health as being purely genetic is problematic, she says. In other words, people don’t simply “inherit” mental illness. A number of biological and environmental factors are at play in gene expression.

Regardless of the genetic link, family history does serve as an indicator of possible risk for certain mental health issues, so counselors need to ask about it. As a genetic counselor, Shuck, a member of the American Counseling Association, admits that she may handle family history intake differently. Genetic counseling, as defined by the National Society of Genetic Counselors, is “the process of helping people understand and adapt to the medical, psychological and familial implications of genetic contributions to disease.” It blends education and counseling, including discussing one’s emotional reactions (e.g., guilt, shame) to the cause of an illness and strategies to improve and protect one’s mental health.

Thus, Shuck’s own interests often lead her to ask follow-up questions about family history rather than sticking to a general question about whether anyone in a client’s family struggles with a certain disorder. If, for example, she learns a client has a family history of depression, she may ask, “Who has depression, or who do you think has depression?” After the client names the family members, Shuck might say, “Tell me about your experiences with those family members. How much has their mental health gotten in the way? How aware were you of their mental health?”

These questions serve as a natural segue to discussing how some disorders have a stronger predisposition in families, so it is good to be aware and mindful of them, she explains. Discussing family history in this way helps to normalize it, she adds.   

Everett, who specializes in psychotherapy for adults who were raised by parents with mental illness, initially avoids asking too many questions. Instead, she lets the conversation unfold, and if a client mentions alcohol use, she’ll ask if any of the client’s family members drink alcohol. Inserting those questions into the discussion often opens up a productive conversation about family mental health history, she says.

Environmental factors

Mental disorders are “really not at all about genetic testing where you’re testing genes or blood samples because there are no specific genetic tests that can predict or rule out whether someone may develop mental illness,” Shuck notes. “That’s not how mental illness works.”

Shuck says that having a family history of mental illness can be thought of along the same lines as having a family history of high blood pressure or diabetes. Yes, having a family history does increase one’s risk for a particular health issue, but it is not destiny, she stresses.

For that reason, when someone with a family history of mental disorders walks into counseling, it is important to educate them that mental health is more than just biology and genetics, Shuck says. In fact, genetics, environment, lifestyle and self-care (or lack thereof) all work together to determine if someone will develop a mental disorder, she explains.

One of Shuck’s favorite visual tools to help illustrate this for clients is the mental illness jar analogy (from Holly Peay and Jehannine Austin’s How to Talk With Families About Genetics and Psychiatric Illness). Shuck tells clients to imagine a glass jar with marbles in it. The marbles represent the genes (genetic factors) they receive from both sides of their family. The marbles also represent one’s susceptibility to mental illness; some people have two marbles in their jar, while others have a few handfuls of marbles.

Next, Shuck explains how one’s lifestyle and environment also fill the jar. To illustrate this point, she has clients imagine adding leaves, grass, pebbles and twigs (representing environmental factors) until the jar is at capacity. “We only develop mental illness if the jar overflows,” she says.

Behm, an ACA member, also uses a simple analogy (from developmental biologist Bruce Lipton) to help explain this complex issue to clients. She tells clients to think of a gene as an overhead light in a room. When they walk into the room, that light (or gene) is present but inactive. They have to change their environment by walking over and flipping on a switch to activate the light.

As Everett points out, “Our experiences, drug use, traumas, these things can turn genes on, especially at a young age.” On the other hand, if someone with a pervasive family history of mental disorders had caregivers who were aware and sought help, the child could grow up to be relatively well-adjusted and healthy in terms of mental health, she says.

In utero epigenetics is another area that illustrates how environment affects our genes and mental health, Douthit notes. The Dutch Hongerwinter (hunger winter) offers an example. In 1944-1945, people living in a Nazi-occupied part of the Netherlands endured starvation and brutal cold because they were cut off from food and fuel supplies. Scientists followed a group who were in utero during this period and found that the harsh environment caused changes in gene expression that resulted in their developing physical and mental health problems across the life span. In particular, they experienced higher rates of depression, anxiety disorders, schizophrenia, schizotypal disorder and various dementias.

Why is this important to the work of counselors? If, Douthit says, counselors are aware of an environmental risk to young children, such as the altered gene expression coming from the chronic stress and trauma associated with poverty, then they can work with parents and use appropriate therapeutic techniques such as touch therapy interventions in young infants and child-parent psychotherapy to reverse the impact of the harmful
gene expression.

Behm uses the Rogerian approach of unconditional positive regard and “prizing” the client (showing clients they are worth striving for) to create a different environment for clients — one that is ripe for change.

Counseling interventions that change clients’ behaviors and thoughts long term have the potential to also change brain structure and help clients learn new ways of doing and being, Behm continues. “It’s the external factors that are making people anxious or depressed,” she says. “If you get yourself out of that situation, your experience can be different. If you can’t get yourself out of it, the way you perceive it — how you make meaning of it — makes it different in your brain.”

The hope of epigenetics

Historically, genes have been considered sovereign, but genetics don’t tell the entire story, Behm points out. For her, epigenetics is a hopeful way to approach the issue of familial mental illness.

Epigenetics contains the Greek prefix epi, which means “on top of,” “above” or “outside of.” Thus, epigenetics includes the factors outside of the genes. This term can describe a wide range of biological mechanisms that switch genes on and off (evoking the prior analogy of the overhead light). Epigenetics focuses on the expression of one’s genes — what is shaped by environmental influences and life experiences such as chronic
stress or trauma.

Douthit has written and presented on the relationship between counseling and psychiatric genetics, including her 2006 article “The Convergence of Counseling and Psychiatric Genetics: An Essential Role for Counselors” in the Journal of Counseling & Development and a 2015 article on epigenetics for the “Neurocounseling: Bridging Brain and Behavior” column in Counseling Today. In her chapter on the biology of marginality in the 2017 ACA book Neurocounseling: Brain-Based Clinical Approaches, she explains epigenetics as the way that aspects of the environment control how genes are expressed. Epigenetic changes can help people adapt to new and challenging environments, she adds.

This is where counseling comes in. Clients often come to counseling after they have struggled on their own for a while, Behm notes. The repetition of their reactions to their external environment has resulted in a certain neuropathway being created, she explains.

Clients are inundated with messages of diseases being genetic or heritable, but they rarely hear the counternarrative that they can make changes in their lives that will provide relief from their struggle, Behm notes. “Through consistent application of these changes, [clients] can change the structure and function of [their] brain,” she adds. This process is known as neuroplasticity.

Behm explains neuroplasticity to her clients by literally connecting the dots for them. She puts a bunch of dots on a blank piece of paper to represent neurons in the brain. Then, for simplicity, she connects two dots with a line to represent the neuropathway that develops when someone acts or thinks the same way repeatedly. She then asks, “What do you think will happen if I continue to connect these two dots over and over?” Clients acknowledge that this action will wear a hole in the paper. To which she responds, “When I create a hole, then I don’t have to look at the paper to connect the dots. I can do it automatically without looking because I have created a groove. That’s a neuropathway. That’s a habit.”

Even though clients often come in to counseling with unhealthy or undesirable habits (such as responding to an event in an anxious way), Behm provides them with hope. She explains how counseling can help them create new neuropathways, which she illustrates by connecting the original dot on the paper with a new dot.

Of course, the real process is not as simple as connecting one dot to another, but the illustration helps clients grasp that they can choose another path and establish a new way of being and doing, Behm says. The realization of this choice provides clients — including those with family histories of mental illness — a sense of freedom, hope and empowerment, she adds.

At the same time, Behm reminds clients of the power exerted by previously well-worn neuropathways and reassures them that continuing down an old pathway is normal. If that happens, she advises clients to journal about the experience, recording their thoughts and feelings about making the undesirable choice and what they wish they had done or thought differently.

“The very act of writing that out strengthens the [new] neuropathway,” she explains. “Not only did you pause and think about it … you wrote about it. That strengthened it as well.”

In addition, professional clinical counselors can help bring clients’ subconscious thoughts to consciousness. By doing this, clients can process harmful thoughts, make meaning out of the situation, and create a new narrative, Behm explains. The healthy thoughts from the new narrative can positively affect genes, she says.

Protective factors

When patients are confronted with a physical health risk such as diabetes or high blood pressure, they are typically encouraged by health professionals to adjust their behavior in response. Shuck, a member of the National Society of Genetic Counselors and its psychiatric disorders special interest group, approaches her clients’ increased risk of mental health problems in a similar fashion: by helping them change their behaviors.

Returning to the mental illness jar analogy, Shuck informs clients that they can increase the size of their jars by adding rings to the top so that the “contents” (the genetic and environmental factors) don’t spill over. These “rings” are protective factors that help improve one’s mental health, Shuck explains. “Sleep, exercise, social connection, psychotherapy, physical health maintenance — all of those protective factors that we have control of and we can do something about — [are] what make the jar have more capacity,” she says. “And so, it doesn’t really matter how many marbles we’re born with; it’s also important what else gets put in the jar and how many protective factors we add to it to increase the capacity.”

Techniques that involve a calming sympathetic-parasympathetic shift (as proposed by Herbert Benson, a pioneer of mind-body medicine) may also be effective, Douthit asserts. Activities such as meditation, knitting, therapeutic massage, creative arts, being in nature, and breathwork help cause this shift and calm the nervous system, she explains. Some of these techniques can involve basic behavioral changes that help clients “become aware of when [they’re] becoming agitated and to be able to recognize that and pull back from it and get engaged in things that are going to help [them] feel more baseline calm,”
she explains.

In addition, counseling can help clients relearn a better response or coping strategy for their respective environmental situations, Behm says. For example, a client might have grown up watching a parent respond to external events in an anxious way and subconsciously learned this was an appropriate response. In the safe setting of counseling, this client can learn new, healthy coping methods and, through repetition (which is one way that change happens), create new neuropathways.

At the same time, Shuck and Douthit caution counselors against implying that as long as clients do all the rights things — get appropriate sleep, maintain good hygiene, eat healthy foods, exercise, reduce stress, see a therapist, maintain a medicine regime — that they won’t struggle, won’t develop a mental disorder, or can ignore symptoms of psychosis.

“You can do all of the right things and still develop depression. It doesn’t mean that somebody’s doing something wrong. … It just means there happened to have been more marbles in the jar in the first place,” Shuck says. “It’s [about] giving people the idea that there’s some mastery over some of these factors, that they’re not just sitting helplessly waiting for their destiny to occur.”

Shuck often translates this message to other areas of health care. For example, someone with a family history of diabetes may or may not develop it eventually, but the person can engage in protective factors such as maintaining a healthy body weight and diet, going to the doctor, and getting screened to help minimize the risk. “If we normalize [mental health] and make it very much a part of what we do with our physical health, it’s really not so different,” she says.

Bridging the gap

Shuck started off her career strictly as a genetic counselor. As she made referrals for her genetics clients and those dealing with perinatal loss to see mental health therapists, however, several clients came back to her saying the psychotherapist wasn’t a good fit. Over time, this happened consistently.

This experience opened Shuck’s eyes to the existing gap between the medical and therapeutic professions for people who have chronic medical or genetic conditions. Medical training isn’t typically part of the counseling curriculum, often because there isn’t room or a need for such specialized training, she points out.

Shuck decided to become part of the solution by obtaining another master’s degree, this time in professional counseling. She now works as a genetic counselor and as a psychotherapist at separate agencies. She says some clients are drawn to her because of her science background and her knowledge of the health care setting.

Behm also notes a disconnect between genetics and counseling. “I see these two distinct pillars: One is the pillar of genetic determinism, and the other is the pillar of epigenetics. And with respect to case conceptualization and treatment, there aren’t many places where the two are communicating,” she says.

Douthit, a former biologist and immunologist, acknowledges that some genetic questions such as the life decisions related to psychiatric genetics are outside the scope of practice for professional clinical counselors. However, helping clients to change their unhealthy behaviors and though patterns, deal with family discord or their own reactions (e.g., grief, loss, anxiety) to genetically mediated diseases, and create a sympathetic-parasympathetic shift are all areas within counselors’ realm of expertise, she points out.

An interprofessional approach is also beneficial when addressing familial mental health disorders. If Behm finds herself “stuck” with a client, she will conduct motivational interviewing and then often include a referral to a medical doctor or other medical professional. For example, she points out, depression can be related to a vitamin D deficiency. She has had clients whose vitamin D levels were dangerously low, and after she referred them to a medical doctor to fix the vitamin deficiency, their therapeutic work improved as well.

Another example is the association between addiction and an amino acid deficiency. Behm notes that consulting with a physician who can test and treat this type of deficiency has been shown to reduce clients’ desires to use substances. Even though counselors are not physicians, knowing when to make physicians a part of the treatment team can help improve client outcomes,
she says. 

Another way to bridge the gap between psychotherapy and the science of genetics is to make mental health a natural part of the dialogue about one’s overall health. “Mental illness lives in the organ of the brain, but we somehow don’t equate the brain as an organ that’s of equality with our kidneys, heart or liver,” Shuck says. When there is a dysfunction in the brain, clients deserve the opportunity to make their brains work better because that is important for their overall well-being,
she asserts.

Facing one’s fears

Having a family history of mental illness may result in fear — fear of developing a disorder, fear of passing a disorder on to a child, fear of being a bad parent or spouse because of a disorder.

“Fear is paralyzing,” Shuck notes. “When people are fearful of something … they don’t talk about it and they don’t do anything about it.” The aim in counseling is to help clients move away from feeling afraid — like they’re waiting for the disorder to “happen” — to feeling more in control, she explains.

Some clients have confessed to Everett that they have doubts about whether they want or should have children for several reasons. For instance, they fear passing on a mental health disorder, had a negative childhood themselves because of a parent who suffered from an untreated disorder, or currently struggle with their own mental health. For these clients, Everett explains that having a mental health issue or a family history of mental illness doesn’t mean that they will go on to neglect or abuse their children. “With parents who have the support and are willing to be open and ask for help … [mental illness] can be a part of their life but doesn’t have to completely devastate their children or family,” she says.

Shuck reminds clients who fear that their children could inherit a mental illness that most of the factors that determine whether people develop a mental disorder are nongenetic. In addition, she tells clients their experience with their own mental health is the best tool to help their child if concerns arise because they already know what signs to look for and how to get help.

Even if a child comes from a family with a history of mental illness, the child’s environment will be different from the previous generations, so the manifestations of mental illness could be less or more severe or might not appear at all, Douthit adds.

The potential risk of mental illness may also produce anger in some clients, but as Shuck points out, this can sometimes serve as motivation. One of her clients has a family history that includes substance abuse, addiction, hoarding, anxiety, bipolar disorder, OCD, depression and suicide. The client also experienced mental health problems and had a genetic disorder, but unlike her family, she advocated for herself. When Shuck asked her why she was different from the rest of her family, the client confessed she was angry that she had grown up with family members who wouldn’t admit that they had a mental illness and instead used unhealthy behaviors such as drinking to cope. She knew she wanted a different life for herself and her future children.

Defining their own destiny

Everett doesn’t focus too heavily on client genetics because she can’t do anything about them. Instead, her goal is to encourage clients to believe that they can change and get better themselves. She wants clients to move past their defeated positions and realize that a family history of mental illness doesn’t have to define them.

Likewise, Behm thinks counselors should instill hope and optimism into sessions and carry those things for clients until they are able to carry them for themselves. To do this, counselors should be well-versed in the science of epigenetics and unafraid of clients’ family histories, she says. Practitioners must believe that counseling can truly make a difference and should attempt to grow in their understanding of how the process can alter a client’s genes, she adds.

From the first session, Behm is building hope. She has found that activities that connect the mind and body can calm clients quickly and make them optimistic about future sessions. For example, she may have clients engage in diaphragmatic breathing and ask them what they want to take into their bodies. If their answer is a calming feeling, she tells them to imagine calm traveling into every single cell of their bodies when they breath in. Alternately, clients can imagine inhaling a color that represents calm. Next, Behm asks clients what they want to let go of — stress or anxiety, for example — and has them imagine that leaving the body as they exhale.

Hope and optimism played a large role in how Mariel Hemingway approached her family’s history of mental illness. She recognized that her history made her more vulnerable. Determined not to become another tragic story, Hemingway exerted control over her environment, thoughts and behaviors. Today, she continues to eat well, exercise, meditate and practice stress reduction.

Hemingway’s story illustrates the complexity of familial history and serves as a good model for counselors and clients, Douthit says. “Whether it’s genetic or not, it’s being passed along from generation to generation,” Douthit says. “And that could be through behaviors. It could be through other environmental issues. It could be any number of modifications that occur when genes are expressed.”

Shuck says she often hears other mental health professionals place too great an emphasis on the inheritance of mental illness. A family history of mental illness alone does not determine one’s destiny, she says. Instead, counselors and clients should focus on the things they do have control over, such as environmental factors and lifestyle.

“We have to emphasize wellness [and protective factors] much more than the idea that ‘it’s in my family, so it’s going to happen to me,’” she says. “We have to look at those things we can do as an individual to enhance those aspects of our well-being to make [the capacity of the mental illness] jar bigger.”

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Study: Genetic wiring as a ‘morning person’ associated with better mental health

By Bethany Bray February 11, 2019

Are you a morning person or a night owl?
Most people consider themselves to be one or the other, with a natural inclination for productivity either in the morning or after sunset.

Not only are these tendencies wired into our genes, but they have a correlation to mental well-being, according to a study published Jan. 29 in the journal Nature. A cohort of researchers found that the genetic tendency toward being a morning person is “positively correlated with well-being” and less associated with depression and schizophrenia.

“There are clear epidemiological associations reported in the literature between mental health traits and chronotype [a person’s ‘circadian preference,’ or tendency toward rising early or staying up late], with mental health disorders typically being overrepresented in evening types. … We show that being a morning person is causally associated with better mental health but does not affect body mass index (BMI) or risk of Type 2 diabetes,” the researchers wrote.

A person’s tendency toward what the researchers refer to as “morningness” is wired into the genes that regulate our circadian rhythm. In addition to sleep patterns, the body’s circadian rhythm affects hormone levels, body temperature and other processes.

Using data from more than 85,000 people, the researchers found that the sleep timing of those in the top 5 percent of morning persons was an average of 25 minutes earlier than those with the fewest genetic tendencies toward morningness.

The study also highlights the connection, reported by previous research, between schizophrenia and circadian dysregulation and misalignment, as well as the increased frequency of obesity, Type 2 diabetes and depression in people who are night owls.

“One possibility which future studies should investigate is whether circadian misalignment, rather than chronotype itself, is more strongly associated with disease outcomes,” wrote the researchers. “For example, are individuals who are genetically evening people but have to wake early because of work commitments particularly susceptible to obesity and diabetes?”

 

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Read the full study in the journal Nature: nature.com/articles/s41467-018-08259-7

 

From the Australian Broadcasting Corporation: “Early birds have a lower risk of mental illness than night owls, genes show

 

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Related reading from Counseling Today:

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Reads recommended by counselors: Psychotic Rage!: A True Story of Mental Illness, Murder and Reconciliation

Review by Judith A. Nelson & Richard E. Watts December 27, 2015

Psychotic Rage!: A True Story of Mental Illness, Murder and Reconciliation is the gut-wrenching, yet fascinating, account of the Malone family and their struggle with severe mental illness. The author, Benny Malone, now retired, was a mental health professional in schools and in the community throughout her career. In this book, she provides readers with a detailed account of living with a mentally ill family member and the journey through the medical, mental health and judicial systems as she and her husband tried desperately to help their son overcome a severe mental illness.

At age 14, Benny’s son, Chris, was diagnosed with bipolar disorder. By the time Chris was 21, his diagnosis had expanded to include schizoaffective disorder. The book details the roller coaster ride of Chris’ 18 hospitalizations due to self-harm or suicidal ideation between the ages of 14 and 24. During this 10-year period, Chris had relationships as a patient with nine different psychiatrists, PsychoticRageworked with two therapists and was prescribed 25 different medications. He was hospitalized for a total of 295 days during these years.

In Benny’s words, “Psychosis became our new family member following the schizoaffective diagnosis, and my son’s health significantly deteriorated despite continual psychiatric treatment.” Despite Benny and her husband’s dedication to their son’s psychiatric treatment, Chris’ health deteriorated until the situation spiraled into an unbelievably tragic event.

In their quiet suburban neighborhood on a warm summer day in 2005, Benny and her husband were chatting at their kitchen table when Chris, now 24, had a major psychotic break, attacking Benny and killing his father. In spite of all the help they had provided Chris and the years of ups and downs with his illness, nothing could have predicted such a tragic outcome.

Benny details the entire account of the murder, including the 911 call, the sirens, the ambulance and the police cars. The scene at the house was chaotic, and even Benny’s visit to the hospital for her injuries is disturbing given the compassionless treatment of the emergency room personnel.

Chris was arrested the same day as the murder. In November 2011, following 6 1/2 years awaiting trial for murder, he was ultimately found not guilty of murder by reason of insanity. Benny recounts this long span of time prior to the trial in which Chris was transferred back and forth four times between a county jail and a state hospital, resulting in his spending a total of 39 months in jail and 38 months in the state hospital. These delays occurred because he was deemed not competent to stand trial for most of this time period.

After years of trying to manage Chris’ severe mental illness, Benny and her family didn’t anticipate the many additional years of burden they would experience struggling to navigate the criminal justice system. Readers are given a vivid sense of how the struggles of families dealing with severe mental illness seem unending.

Benny ends her story by explaining her understanding of her son’s inability to control his illness and her ability to forgive him for his erratic behavior that resulted in her husband’s murder.

This well-written account of living with a family member with a severe mental illness is intended for a variety of audiences. Psychotic Rage provides hope and encouragement to families such as Benny’s. She makes it clear that severe mental illness happens to all kinds of families, even those with a mother who is a mental health professional. Mental illness crosses all economic, social, racial, ethnic and faith lines and often attacks youth first.

The book is also meant for mental health professionals and those in training. It will help them better understand the complexity of severe mental illness and the ramifications for affected family members.

Psychotic Rage is also for policymakers and mental health advocates who need this important information to make informed decisions about the difficult legal aspects of patients and families facing serious mental illness.

To conclude, Psychotic Rage is a must-read for anyone who is interested in a compassionate understanding of the struggles of families who have a member with severe mental illness.

Benny Malone was the recipient of the Professional Writing Award at the most recent Texas Counseling Association Annual Professional Growth Conference.

 

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Have a book that you’d like to recommend to other counselors? Contact us at ct@counseling.org.

 

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Judith A. Nelson is associate professor of counselor education (retired) at Sam Houston State University in Texas and a past president of the Texas Counseling Association. She and Bunny Malone, the author of the book being reviewed, were former colleagues in a suburban Houston school district.

Richard E. Watts is a Sam Houston State University distinguished professor of counseling, the immediate past president of the North American Society for Adlerian Psychology and a fellow of the American Counseling Association.

What counselors need to know about schizophrenia

By Bethany Bray August 22, 2014

The adjective “schizophrenic” needs to be removed from counselors’ vocabulary, says Elizabeth Prosek, a counselor and assistant professor at the University of North Texas (UNT).

Schizophrenia has a great deal of stigma and negative connotations associated with it, and referring to clients in the first person can lessen these, she says.

“I encourage counselors to advocate for what clients with schizophrenia can do rather than [focusing on] the limitations of experiencing psychosis,” says Prosek, who has counseled clients with severe mental health disorders and served on a support team for individuals with schizophrenia living independently. “I once heard someone discuss the ‘aggressive nature’ of those diagnosed with schizophrenia. I could not help but wonder where that perception evolved. In my experience, clients did not demonstrate aggressive behavior or language.”

Counselors, as part of a multidisciplinary treatment team of helping professionals, can play a critical role in the lives of people diagnosed with schizophrenia, say Prosek and Kara Hurt, a puzzlelicensed professional counselor who works with clients with schizophrenia at an inpatient psychiatric hospital.

Prosek and Hurt, who is also a doctoral student at UNT, recently collaborated to write a practice brief on schizophrenia for the American Counseling Association’s Center for Counseling Practice, Policy and Research (see sidebar below).

In the brief, the duo describes schizophrenia as a lifelong illness characterized by negative symptoms, including “delusions, hallucinations (most commonly auditory), disorganized thinking or speech and disorganized or abnormal motor behavior.” The estimated prevalence rate for schizophrenia is 1 percent of the population in Western, developed countries.

For counselors, empathy should play a big part in therapy – from knowing the many side effects of schizophrenia medications to fully understanding what it is like to live with hallucinations and psychosis, say Prosek and Hurt. Special training and workshops can help counselors understand the nuances of the disorder, as can materials from mental health agencies (see “for more information” below).

Prosek once attended a seminar at which participants sat through the experience – virtually – of living with hallucinations, experiencing paranoia and hearing voices intertwined with the dialogue of another person.

Prosek and Hurt led a course this past year in which they showed videos of clients with schizophrenia explaining their own experiences.

“When the students in the class debriefed after the video, many confirmed that hearing firsthand from a client decreased their misperceptions about the disorder,” says Prosek. “Watching a video of a client with schizophrenia who was articulate and successful in a career reduced stigma of the disorder. Also, I noticed that when person-first language is used when discussing clients with schizophrenia [as opposed to using the term “schizophrenic”], negative connotations are immediately lessened.”

 

What do counselors need to know about schizophrenia?

Elizabeth Prosek: Living with psychosis can be scary and challenging. When working with those diagnosed with schizophrenia, demonstrating empathic concern is essential to build a therapeutic relationship. In my experience, clients appreciated my willingness to embrace their perspective of psychosis. I think all of the clients I worked with experienced their psychosis uniquely, and it was imperative that I understood their lived experience.

Kara Hurt: Schizophrenia affects the client’s support system, not just the client. In my experience, it is just as important to provide counseling and support to family members and loved ones of people diagnosed with schizophrenia as it is to provide support and counseling to clients with schizophrenia. All of us counselors can help provide services in some way that help clients diagnosed with schizophrenia and those that love them.

EP: Counselors may provide family members and friends with psychoeducation on the symptoms and treatment options for schizophrenia. Furthermore, counselors may assist family members and friends to build empathy for the experiences of those diagnosed with schizophrenia. There are support groups for family members through the National Alliance on Mental Illness (NAMI). Find a local NAMI support group through nami.org.

For those clients who do not have a familial support system, encouraging the development of a community support network may be essential for the social and emotional well-being of clients diagnosed with schizophrenia. Regardless of diagnosis, humans in general seek “belongingness” in their community, and those diagnosed with schizophrenia are no different.

 

What advice would you give about working with clients diagnosed with schizophrenia?

EP: Recognizing strengths can be a great first step to creating an appropriate treatment plan. Several of the clients I counseled had creative interests, such as art and music, and we developed interventions to promote participation in those activities.

Also, I recommend communication with all professionals working with the client. In my experience, collaborating with the client’s psychiatrist and case manager allowed for a holistic approach when addressing current therapeutic needs. Having a multidisciplinary team also allows for clients to more easily transition in and out of inpatient psychiatric hospitalization when necessary. With the appropriate releases of information, all professionals involved can be aware of how the client’s psychosis presented, any medication changes and any changes in treatment recommendations after an inpatient hospitalization stay.

It did not take long after beginning my work with clients diagnosed with schizophrenia for me to recognize the need for socialization. Several of my clients lived in isolation but longed for social relationships. In collaboration with case managers, I organized social outings for clients, which allowed for a more genuine community-living experience. There are several community resources for clients diagnosed with serious mental health disorders, such as supported-work programs. Having knowledge of such programs in the community will serve as great referral sources for clients diagnosed with schizophrenia.

 

With what other types of issues can clients diagnosed with schizophrenia present?

KH: One of the presenting issues that I had not expected when I started working with clients diagnosed with schizophrenia was substance abuse. One client in particular stands out in my mind because of the extent of his illicit drug use, which worsened his paranoia and other delusions. When working with clients with schizophrenia, you may need to reconsider your assumptions to appreciate that these clients have many of the same kinds of problems as other clients.

EP: I agree. Substance misuse was prevalent among the clients diagnosed with schizophrenia that I worked with as well. I also observed many secondary diagnoses, including anxiety and depression. I connect the anxiety and depressive symptoms back to the potential isolation clients experienced. Furthermore, it seems to me hearing voices and feeling out of touch from reality would lead to feelings of anxiety. Helping my clients accurately explain symptoms to their psychiatrists allowed for more precise medication prescriptions.

 

What are some common misperceptions about schizophrenia?

EP: One of the common misperceptions I hear frequently when describing a client with schizophrenia is the term “medication noncompliance.” I advocate for this phrase to be removed from counselor language. From my observations, when clients did not take medications regularly or as prescribed, it was not with intentional noncompliance, but rather there was confusion when medication regimens became complex or changed with frequency. Moreover, several antipsychotic medications have uncomfortable side effects. On a bad day, when a client is not feeling well, he or she might not feel inclined to perpetuate the experience by taking medications that may worsen physical symptoms. In counseling sessions, taking time to hear clients’ concerns or complaints about side effects may help clients feel validated in their experience.

 

What challenges do counselors face in this area?

EP: I think there may be a perception that clients with schizophrenia only need a case manager and psychiatrist. From my perspective, counselors can play a vital role in the treatment team. Never underestimate the power of a space in which a client’s experience is heard and valued.

KH: I think it is absolutely critical to have good supervision when working with a client diagnosed with schizophrenia. I have felt frustrated with my perceptions of clients’ lack of progress or insight, but with supportive supervision, I have been able to be more flexible with my therapeutic expectations and shift my perspective to be a better counselor for my clients. I cannot underestimate the value of good supervision. It can help you gain awareness of potential burnout and the need for regular self-care.

EP: Supervision is helpful. I often felt frustrated with the mental health care system and how clients with schizophrenia became victims of gaps in continuity of care. I agree with Kara that there is a greater potential for burnout when working with clients in and out of crisis.

Another challenge for counselors might be understanding the differences in antipsychotic medications most commonly prescribed for clients with schizophrenia. Actually, Kara introduced me to an app (named Epocrates) that provides names, descriptions and side effects for medications. I remember when I first started working with this population, I had a hard time differentiating the medications the clients were prescribed. There are several research studies published outlining effectiveness and common side effects of antipsychotic medications which may be helpful to read.

Going back to one of Kara’s original statements about the importance of family supports, it may be challenging to help family understand the experience of schizophrenia. Counselors can serve as a good source of information to help educate and support family members. Consequently, family members can better support the client diagnosed with schizophrenia.

 

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For more information

 

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ACA Center for Counseling Practice, Policy and Research practice briefs

Prosek and Hurt’s information sheet on schizophrenia is one of 30 practice briefs available to American Counseling Association members through the Center for Counseling Practice, Policy and Research.

The briefs, which range from working with victims of domestic violence to animal-assisted therapy to posttraumatic stress disorder, are written by ACA members who are experts on that particular topic. New practice briefs are being added regularly.

The practice briefs are designed to be practical, evidence-based resources for ACA members, says Victoria Kress, executive editor of the ACA center’s practice briefs project and a professor at Youngstown State University in Ohio.

Counselors can use the practice briefs as a refresher on topics they may not encounter very often, such as schizophrenia, or as a jumping-off point for further research. Each brief contains links to in-depth sources and data on a topic, as well as therapy models and other tools.

Kress says each practice brief is written and edited to be practical and succinct, with focused bursts of information on topics that counselors in all works settings may encounter, from divorce and autism to perfectionism and suicide prevention.

The plan is to post 15 to 20 new briefs each year, Kress says, including on each of the new disorders added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Kress began soliciting practice briefs from ACA members, then editing and posting the briefs on the ACA website, close to two years ago. The idea grew out of ACA past president Bradley Erford’s focus on counselor use of evidence-based practices, Kress says.

“Counselors don’t always have access to, or the time to read, journal articles,” she says. “We wanted to provide an outlet for ACA members to sit down and get a quick overview. … It was really born out of this idea that counselors should be using evidence-based practices. We know that counselors are busy and have competing demands. … The ultimate idea is that it will improve their practice. It’s better for their clients and the profession.”

 

 

 

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Bethany Bray is a staff writer for Counseling Today. Contact her at bbray@counseling.org

 

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