Reactions of Family Members and Friends

When mental illness strikes, family members are often overwhelmed by feelings of bewilderment, guilt, and denial.  Exhaustion from being on call 24 hours a day may be coupled with frustration and anger when professionals are unable to accomplish what the family sees as basic, prompt diagnosis and treatment and after assistance to help their relative regain a productive life. 

It is not “unloving” to feel resentment in response to the behavior of the relative with a mental illness.  Realizing the person is ill does not always overcome the hurt, dismay and anger felt by those trying to help.  He or she may rebuff attempts to reach them, and may be fearful or accusatory toward those trying to help.  Understandably, families, friends, and coworkers have problems with these symptoms, yet a hostile reaction will almost certainly intensify or lengthen an episode.

It is natural and necessary to grieve for the person who used to be, but strength and determination are needed to meet the coming challenges.  Caring, supportive family members can play a vital role in helping their relative to regain the confidence and skills needed for rehabilitation.  

Keep in mind:

• Avoid placing blame and guilt.  The family did not cause the illness.  Self-blame and blame leveled by others are destructive.  Focus instead on the future and on what can be done to develop supportive living arrangements that will enhance the possibility if rehabilitation and recovery for your family member or friend. 
• Remember other family members (siblings, grandparents) are affected too, and they probably are experiencing depression, denial, and guilt just as you may be.  Keep communication open by talking with them about this.
• Both you and your relative / friend should learn all you can about the illness.  Find out about benefits and support systems when things are going well; don’t wait for a crisis.
• It is also important to address physical health problems as these exacerbate or become a considerable part of the mental health problem.  The approach to care should be holistic.

BEHAVIORAL ISSUES

Some suggestions for coping with problem behavior

• Plan ahead for situations when acute symptoms may recur.  Discuss this with the primary therapist or treatment team.

• Learn to recognize signs of relapse, such as withdrawal or changes in sleeping and eating habits.  The individual may be able to identify early signs of relapse (and should be encouraged to do so).  He or she may also be able to tell you what method has worked in the past to relieve stress and gain control of symptoms.  A visit to a psychiatrist or other therapist may help prevent a full-blown relapse, particularly when the person needs an adjustment of medications.

• Anticipate troublesome situations.  If Aunt Tessie can’t handle the relationship, do not invite her when you ill family member is present. 

• ·Do not agree with stropping medications because the condition is “cured” or because the medication “makes me feel sick.”  Refer these decisions to the doctor who prescribed the medication.

• ·Set reasonable rules and limits and stick to them.  It may help to ask the patient’s doctor, or a counselor he or she has suggested, to help you do this.

• Do not suggest that a person in crisis “pull themselves together.”  If possible, he or she would.  Not being able to do this is part of the illness.  Remember, the suffering and distress of the person with mental illness is even greater then your own.

• Do not expect and insist that all disturbing habits be corrected at once.  Focus on what is accomplished, not what is going wrong. 

• At times, people with mental illness suffer from memory loss or inability to concentrate; just repeat the information in a nonjudgmental way.

• Neither support nor be critical of delusional thinking.  The person with mental illness needs to be able to depend on a person who is objective, aware of what is really happening and able to kindly work with the truth.

Your family member may hallucinate; that is, see, feel, hear, or otherwise perceive things not perceived by others.  Be honest.  Accept his or her perceptions as his or her own.  If asked, point out that you are not experiencing the hallucinations.  A discussion of how to respond to hallucinations and to other symptoms is an important part of family support and education sessions that are offered by local NAMI affiliates, hospitals, or community mental health agencies and other behavioral health settings. 

SUPPORT & ADVOCACY GROUPS

Your local NAMI group provides support programs for families and friends as well as for individuals who are living with a mental illness.  Providing this assistance is part of the primary mission of NAMI affiliates.  It is important to share information about mental illness with others and to understand the serious long-term mental illness is not caused by something the individual has done.  “We thought it was our fault,” is said too many times.  Family members and friends, because of their lack of information, may not be able to provide the support that is needed.   

Unless they have lived with a family member or friend who is mentally ill, it is difficult for most people, sometimes even physicians, to understand the everyday trials and concerns of the rest of the family. It is comforting to know that other people deal with almost exactly the same issues and understand.  Sometimes they have suggestions and answers; at other times they can only say “Yes, I know”, and they do. 

In support groups, information is shared about housing, sleeping, and eating problems, available social services, medications, the ill individual’s lack of friends and loneliness, grief and loss, and fear of taking vacations.

Many people drop in at support group meetings for a few months, get answers and support for the hard times, and then move on.  Other people may move from support groups into committee work.  Often people make lifelong friends.  May people say, “I want to help.  I don’t want other people to go through what I went through.”  Some work at making real changes by becoming advocates for better services and care.  NAMI’s assist in all these ways. 

VOLUNTARY & INVOLUNTARY HOSPITALIZATION (BAKER ACT)

Statutes governing the treatment of mental illness in Florida date back to 1874.  in 1971, the Legislature enacted the Florida Mental Health Act, better known as the Baker Act, named for a state representative from Miami.  The Act has been amended many times since it was implemented, with extensive revisions made in 1996. Some key definitions used in Baker Act hospitalization include: 

Voluntary Admission: An adult may apply for voluntary admission if found to show evidence of mental illness, to be competent to provide express and informed consent, and to be suitable for treatment.  A child must not only be willing to be admitted, but must have his or her guardian apply for the admission.  

Mental Illness: An impairment of the emotional processes that exercise conscious control of one’s actions or of the ability to perceive or understand reality, which impairment substantially interferes with a person’s ability to meet the ordinary demands of living, regardless of etiology.  A biological brain disorder. 

Express and Inform Consent: Consent that is voluntarily given in writing, by a competent person, after full disclosure to enable the person to make a knowing and willful decision without any element of force, fraud, deceit, duress, or other form of constraint or coercion. 

Incompetent to Consent to Treatment: Refers to a person whose judgment is so affected by the illness that he or she lacks the capacity to make a well reasoned, willful, and knowing decision concerning medical or mental health treatment.

A physician must evaluate any person admitted voluntarily within 24 hours after arrival at a receiving facility to confirm the person’s competence to provide express and informed consent for admission.  If not competent, the person must be discharged or involuntary placement must be initiated. 

Persons on voluntary status who request discharge or who refuse or revoke consent to treatment must be discharged from the facility within 24 hours, unless the facility administrators files a petition for the patient’s involuntary placement with the circuit court. 

INVOLUNTARY EXAMINATION & TREATMENT

A person may be taken to a receiving facility for involuntary examination if there is a reason to believe that he or she is mentally ill and because of his or her mental illness:

• The person has refused voluntary examination or is unable to determine whether examination is necessary;
• Without care or treatment, the person is likely to suffer from neglect resulting in real and present threat of substantial harm that can’t be avoided through the help of others; and
• There is a substantial likelihood that without care or treatment. The person will cause serious bodily harm to self or others in the near future, as evidence by recent behavior.

An involuntary examination may be initiated by any one of the following means:

• A court may enter an order, based upon sworn testimony.
• A law enforcement officer, who has reason to believe the criteria is met.
• A physician, clinical psychologist, psychiatric nurse, or clinical social worker, based on their examination of the person within the preceding 48 hours.

Regardless of the way the involuntary examination is initiated, law enforcement must take the person to the nearest receiving facility, and the facility must accept (not necessarily admit) the person.  If appropriate under state and federal law, the person may later be transferred to another facility. 

Upon arrival at a receiving facility, a physician or clinical psychologist must examine a patient.  The patient can’t be released by the receiving facility without the documented approval of a psychiatrist or clinical psychologist. 

A person may be held in a receiving facility for involuntary examination longer than 72 hours.  With the 72 hour examination period, one of the following must take place:

• The individual must be released unless charged with a crime.
• The individual must be asked to give express and informed consent to voluntary placement.
• A petition for involuntary placement must be filed with the court by the facility administrator.

If a petition for involuntary placement is filed, a public defender will be appointed by the court to represent the person and a hearing will be scheduled within a few days.  If the court finds that the person meets the criteria, he or she can be involuntarily hospitalized for a period of up to six months.  However, facilities are required to discharge persons at any time they no longer meet the criteria for involuntary placement, unless the person has transferred to voluntary status. 

INVOLUNTARY OUTPATIENT PLACEMENT

The 2004 Florida Legislature revised the Baker Act to add provisions for involuntary outpatient placement effective January 1, 2005.  This will allow court-ordered outpatient treatment for selected adults who have serious mental illness and meet the criteria established by the law. 

A petition for involuntary outpatient placement can only be filed by administrators of community-based receiving facilities or state hospitals and only if the services proposed are currently available and funded for the person.  The criteria that must be met by clear and convincing evidence including that the individual:

• Has a history of non-compliance with treatment and is unlikely to survive safely in the community without supervision, based on clinical determination;
• Has either at least twice within 36 months been involuntarily admitted to a receiving or treatment facility or received mental health services in a forensic or correctional facility; or engaged in one or more acts of serious violent behavior towards self or others, or attempted serious bodily harm to self or others, within the preceding 36 months;
• Is unlikely to voluntarily participate in the recommended treatment plan and has either refused voluntary placement or is unable to determine whether placement is necessary;
• In view of the person’s treatment history and current behavior, the individual is in need of involuntary outpatient placement in order to prevent a relapse or deterioration that would be likely to result in serious harm to self or others;
• Is likely the individual will benefit from involuntary outpatient placement; and
• All available less-restrictive alternatives that would offer an opportunity for improvement of his or her condition have been judged to be inappropriate or unavailable.

The person must meet all criteria and a service provider must agree to provide the services before the court can order the treatment.  Court-ordered treatment can be for a period of up to six months, but the court can consider periods of continued treatment if all the criteria listed above are still met.

MARCHMAN ACT:
Substance Abuse

The Marchman Act provides individuals in need of substance abuse services with emergency services and temporary detention for substance abuse evaluation and treatment when required.

Marchman Act petitions that may be filed in Probate Court Records:

• An Ex Parte Petition for Involuntary Assessment and Stabilization
  or
• An Ex Parte Petition for Involuntary Treatment

A Petition for Involuntary Assessment and Stabilization may be filed:

When there is reason to believe that a person is substance abuse impaired and:

1. Because of the impairment, he or she has lost the power of self control with respect to substance use.
2. The person’s judgment is impaired because of substance abuse and he/she is incapable of appreciating the need for, and is unable to make a rational decision in regards to, substance abuse services.
3. He or she has either inflicted, attempted or threatened to inflict, or unless admitted, is likely to inflict, physical harm on himself or herself or another.
4. The petition may only be filed by:

The person’s spouse or guardian, any relative of the person, a director of a licensed service provider, a private practitioner, or any three adults who have personal knowledge of the person’s substance abuse impairment.

In the case of a minor, only the parents, legal guardian/custodian or licensed service provider can file a petition.

Unlike the Baker Act, there is a filing fee required. Refer to the Schedule of Service Charges for current fees. The petitioner must also make arrangements for an available bed in a designated facility prior to submitting the petition for filing.

What happens after the petition is filed:

If the Court finds that the criteria have been met, an Order for Involuntary Assessment and Stabilization will be issued by the Court. The Court may set the case for a hearing, or the Sheriff may ordered to transport the person to the designated facility. The facility then has 5 days to do an assessment. After the assessment has been completed at the facility, the petitioner may file a Petition for Involuntary Treatment of Subtance Abuse for the patient.

A hearing date is set for the determination of the need for treatment. The assessment results are subpoenaed as evidence for the hearing, and a summons to appear at the hearing is issued and served on the patient.  

At the hearing the court will hear all the evidence and determine if the Order for Involuntary Treatment for Substance Abuse is warranted.