- Being tense and nervous
- Eating less
- Trouble concentrating
- Trouble sleeping
- Enjoying things less
- Not able to remember things
- Depression
- Being preoccupied by one or two
things
- Seeing friends less
- Feeling of being laughed at, talked
about
'Managing' the symptoms of relapse
generally means taking these symptoms seriously, increasing supports
to our working individual and connecting them to the doctor for
medical or medication evaluation.. Symptoms such as these may not lead
immediately to the loss of employment, but they do make work more
difficult and certainly make the lives of our participants extremely
uncomfortable and usually when untreated lead to hospitalization.
In preparing for this session I
surveyed several employment providers who serve people with longterm
mental illness. Here are some frank and revealing comments from
employment service providers about the importance of this issue:
- We review personal warning signs.
- We spend time with the person to get
an idea what to look for
- We encourage the person to talk
about their symptomotology. Do they have enough insight? What would
they need? We make a plan, which relies on the person.
- We do symptom review, getting people
to know their diagnosis.
- When possible we have the case
manager participate in our meetings so they know what we are doing.
- We watch for any types of noticeable
changes in behavior, even good changes, can mean decompensation, or
non-compliance.
- Make sure the medication is right
when you start.
- We set clear parameters for each
client so they know what the deal is-this doesn't change.
In summary, it is very important to
monitor and manage the signs which signal a resurgence of illness.
A second type of symptorn includes those which stand out, cause
embarrassment and may be frightening to others. These behaviors
might also be considered bizarre or socially unacceptable and may lead
to job loss. A good example, are the so-called positive symptoms of
Schizophrenia such as talking about delusions and hallucinations or
having thought disorders. People say things, for example, which are
obviously not true ( "I am king of the invisible universe") or they
make little sense or have 'loose associations', or ideas of reference.
They may suddenly find it significant that a license plate on a car
contains the same number as the day of their birthday. Or if the
person is suffering from Bipolar disorder they may talk
uncontrollably, which is called 'pressured speech'.
Studies have shown that of all the
therapeutic methods for treating these symptoms, particularly with
illnesses like Schizophrenia and Bipolar Disorder, medication,is
usually the most essential component. Realistically, then, managing
these symptoms is a matter of forming a close alliance with the
doctor, nurse, or case manager who have specific roles in helping a
person with a mental illness manage their medication.
People who experience the return of
these more serious symptoms of mental illness may have stopped taking
their medication, may require more medication than they are receiving,
or may require a change of medication. Unfortunately, medications do
not affect everyone the same way and effective medication and dosage
are usually only found by trial and error. In addition an effective
dosage in a given month may not be the correct dosage at another time.
If doctors, nurses and case managers
are to be of assistance in managing m~dication in a way which supports
successful employment, these personnel need to be informed and
sometimes educated about the importance of work to the consumer and
the requirements of the work setting. We need doctors to make
decisions which are consistent with the desires of the consumer who
chooses to work. Some actions doctors can take which may improve work
performance and the use of medication are:
- Simplify the medication regime
- Review the timing of appointment,
med changes and the time medication is taken with regard to work
schedules.
- Make sure transitions through all
major changes of living situations, work, and medications are
handled in a seamless manner.
A third type of symptom isolates
people with mental illness, makes it difficult to communicate and have
relationships and reduces their quality of life. For people with
schizophrenia these are the so-called 'negative' symptoms. . These
symptoms are called 'negative' because something is lacking which
should be there. These are symptoms such as apathy, social withdrawal,
poverty of thoughts, blunting of emotions. These symptoms seem to
say," I don't care, I don't want to be around people, I haven't much
to say and I don't feel anything in particular". While some of the
newer medications like Clozaril can improve these areas of a person's
life, we must remember that the same medications do not work for
everyone. Having friends, having activities, and having places where
we are needed and recognized may improve the outlook for individuals
with serious mental illness. Many people with mental illnesses try to
'self-medicate' these feelings with alcohol and often feel more
accepted in tavern atmospheres. I think there is a special importance
to the social aspect of Clubhouse programs, to job clubs and to the
special support circles, which can be created by person-centered
planning. Activities and connections to a caring community can help.
What is especially helpful is to have not one, but many such supports.
A fourth issue is the medication
side effect. just as medications can be extremely helpful, their
side effects can cause discomfort and may occur suddenly during
medication changes. Some effects are blurred vision, drowsiness,
slowed movement, stiffness, and restlessness. These side effects can
be uncomfortable and may make it difficult for good work performance.
Many of these side effects can be controlled by special medication. In
addition we need to appreciate the role of the doctor in prescribing
just enough medication to control the illness, but not so much that
side effects are troublesome. To be fair, historical studies of people
with mental illness have shown that many symptoms attributed to
medications occurred in people prior to the advent of psychotropic
medication and may be an effect of the illness. Some medications such
as Clozaril must be managed carefully and be followed by testing of
the blood because of its possible fatal effects on white blood cells.
Employment managers need to familiarize themselves with medications
their effects and side effects and to try to be informed of possible
changes. As one provider put it, " We study the PDR (Physicians Desk
Reference)". Medication is best studied in partnership with the nurse
or doctor. Again your participant also needs to know what to look for
and to be encouraged to consult when necessary with medical staff.
A fifth symptom to manage are those
of a secondary condition or illness. This condition may not have
been your main focus to begin with but without good management could
have very serious results. For example, when a person with a major
mental illness also has asecondary illness or condition such as
alcoholism, diabetes, or a personality disorder we must understand and
manage these symptoms as well. Those who use AA groups may need to
educate their peers that the medication they use is necessary for
health and is not an addiction. We need to be able to separate the
symptoms of one illness from the other. We need to know when confusion
is caused by diabetes and when it is caused by mental illness.
Some symptoms are best described as
a disruptive, odd or ineffective behavior pattern. Some
personality disorders such as anti-social, dependent and borderline
personality are usually not improved through the use of medication.
These can be especially troubling because by their very nature they
appear as inflexible and usually ineffective or destructive ways of
relating to other people. Good job matching is all the more important
here. Understanding how to relate to people with these disorders, how
to have boundaries and how to set limits can be extremely important.
Where we cannot control these symptoms we sometimes need to provide
extra emotional support to those who are struggling to work with the
personality- disordered participant. Counselors who regularly work
with personality disordered clients usually create some provision to
maintain their own sense of well being. When you spend time with these
people you often feel what they feel. If they feel angry and anxious,
you end up feeling the same way. It often helps to get support
yourself to get your bearings. In the same way employers who work with
people who have these disorders can greatly benefit from the support
and understanding shown to them by a knowledgeable job coach.
We have discussed six types of
symptoms, which need to be managed because of their potential
interference with good employment outcomes. But there are many
different work situations, many different people to work with ... what
are some principles to guide us through this maze?
First, good job matching can
minimize the symptoms, which interfere with work. I used to manage
a lawn crew, which mowed the congressional cemetery. One of my best
workers would yell, scream and sing as he pushed the lawn mower. In
the middle of the cemetery ... this was not an issue. However, if we
had been mowing the fairways at the local golf course, these symptoms
might have been quite disturbing to people on the putting greens. So
the first, principle is good job matching.
Second, remember that medication is
usually the essential, not the only, but the essential ingredient.
Third, like Socrates who said "Know
thyself "..Know your relapse; know your warning signs. Know the
pattern of your worker's illness; know it together. But remember that
you also need to know what helps to improve your worker's outlook.
When you or someone else is down in the dumps-what helps-do you go
shopping, read a good book, does exercise help, do you feel better
belonging to some group or club. When you are anxious, does it help to
take a break (or like me-eat a donut)?
Fourth, use a 'village' approach.
I remember the old joke about the people who were concerned about
their health. So they bought a sanitary drinking cup-and they all
drank out of it. Everyone needs a variety of supports, not just from
one person, not just one thing.
Fifth, create an awareness; of the
regard your participant has for being employed and use this to educate
case managers, doctors and nurses, so that their decisions take
the work setting into account. You need to know more about medication
and medical issues and the doctor needs to know more about the process
of rehabilitation.
Sixth, pay attention to secondary
issues like alcohol-these need to -be addressed in your plan as
well.
Seventh, support the supporters.
If your employer is to be helpful he or she also needs your support
for any extra effort. People who treat those who have severe
personality disorders know that they must also get support themselves
for the difficulties these disorders create in relationships. We need
some support to stay grounded.
Finally, If limits need to be set,
set firm limits. There is nothing more frightening to all of us
than not knowing where the boundaries are.
