Dealing with unusual thoughts and behaviours

Common problems you may encounter from a relative with a mental illness include:

• Disordered thinking and speech

Disordered thinking and speech can be seen in a number of disorders but are most commonly associated with schizophrenia.

Normal communication and thought require us to place one idea after another in a logical order of related ideas. People with disordered thinking have difficulty maintaining this orderly flow of ideas, and so their thoughts and speech may be jumbled and disconnected. In disordered thinking, thoughts "jump" between completely unrelated topics or may be "blocked" altogether. The person may talk nonsense, make up words or replace words with sounds or rhymes.

Disordered thought in schizophrenia may be closely related to the impaired attention associated with this illness. People with schizophrenia seem to be unable to "filter out" distracting associations in their flow of ideas, and its believed their thoughts and speech may become fragmented as a result.

How can I help someone with disordered thought and speech?
Try to be patient and listen to the person. If they start drifting off onto unrelated subjects try to steer them back onto the subject. If you don't understand something that you think is important to the conversation, ask for them to clarify it.

• Delusions and paranoia

Like disordered thinking or speech; experiencing delusions and paranoia can affect people’s behaviour and the way they interact with others, such as through their conversations.

Delusions are false beliefs or thoughts with no basis in reality. For example, some patients may believe that mysterious forces are controlling their thoughts or that ideas are being inserted into their brains. Some people may believe that their minds are like radios, broadcasting their thoughts over long distances or through the television. To cope with delusions and in trying to make some sense of them, people often describe elaborate explanations, and so simpler delusions may become incorporated into a more complex belief system.

How to help someone with delusions and paranoia beliefs
It is important to avoid colluding with or humouring someone with delusions or paranoid beliefs by following them into their beliefs. Try to avoid -
confronting them about the thoughts they express
laughing at them
undermining them by telling them they are stupid or their thoughts are stupid
ignoring them by remaining silent

Instead it is better to reassure them clearly and calmly by letting them know that though you understand they see may see things in a particular way, you believe there is no problem or threat in the situation. Try to help them separate their emotional response to the situation by justifying with a rational explanation why they should not worry:

“You seem to be frightened that the police may be following you, but I don’t think this is true.
You have done nothing wrong, so the police would not be interested in you"

• Social withdrawal

Social withdrawal can be a ‘negative’ symptom of a psychotic illness such as schizophrenia, but it can also be a symptom of depression and other disorders. Social withdrawal can be a symptom of mental illness but it can also be as a consequence of the symptoms people are experiencing.

People may start to see themselves as different, feeling unable to ‘fit in’ with friends and family and so they may withdraw. It can start with staying at home and not socialising, to not speaking or even not showing emotions. It is important to remember that someone with severe mental illness has suffered a blow to their self-confidence and sense of identity. They may lack confidence in their ability to manage even ordinary day-to-day social situations and to cope with this may cut themselves off from them. Social contact both inside and outside the family is likely to decrease.

How can I help someone who is becoming socially isolated?
To reduce the effects of mental illness on social isolation it is important to:
understand their vulnerability in social settings
lower your expectation to a realistic level
provide uncomplicated and undemanding social activity to help rebuild their confidence - keep numbers to a minimum and keep conversations short and free of issues that generate high emotions
expect progress to be made in very small steps
reassure and encourage them by noting and praising each small success made

Ask the person with the mental illness where they would feel most comfortable. Often people with mental illness feel isolated by society because of stigma they may have experienced or think they will experience. Encouragement to socialise with similar experiences such as a day centre can be helpful in the short term.

• Depression

Depression is not limited to people with clinical depression, but can be experienced by people with many different mental and physical illnesses. It can be a symptom of mental illness, caused directly by the mental illness, or it can be caused by the situation the person finds themselves in, for instance, no longer working after a period of successful employment. Friends, family and carers can find depression in someone with a mental illness hard to deal with. No matter what you try, you cannot lift their mood and seems like the person is no longer the person you knew before.

How you can help someone with depression
Depression can be effectively treated as an illness in its own right and as a symptom of another mental illness. Medication such as antidepressants and antipsychotics that deal with the negative aspects of schizophrenia can make an initial difference. In the long term, many different talking therapies have been found to help relieve depression. The treatment of depression is discussed here.

Suggestions of things you can do or not do to help someone when they are depressed include:
offer them emotional support, patience, affection and encouragement
don't tell them you understand
invite them out on walks, outings, and gentle activities, encourage participation in activities that once gave them pleasure
help them feel good about themselves by praising daily achievements
encourage them to help themselves through self-help techniques
find out about self help or support groups open to them

• Self harm, suicidal feelings or actions

Self harm can be one of the most disturbing aspects of mental illness. It is a complex subject and for this reason is dealt with in greater detail in a separate section. Suicide & self harm

Often thought to be associated with self harm is suicide. Self harm does lead to a greater risk of suicide but often the reasons for self harm are very different from the reasons given by people who have attempted suicide.

It is important that all suicidal thoughts or actions that someone expresses are taken seriously and that you urge them to get specialist help as soon as possible, or if they are unwilling, possibly seek help for them.

• Aggression

Aggression is a result of anger. It can take several forms including verbal aggression (insults, threats) physical aggression or restriction.

Most people with mental illnesses are no more prone to violent behaviour than anyone else. However, there is a small group of people who experience problems with impulse control, aggression and paranoia, making them more likely to strike out violently if they are not receiving adequate treatment. Aggression is more commonly seen as a symptom of mental illness in children and in older people with dementia.

Aggressive behaviour may come on without warning and may make you feel very apprehensive. However, if you can figure out what situations trigger aggressive behaviour, (perhaps by keeping a diary) you may be able to work out ways of avoiding it. If not, you may still be able to find methods of dealing with the behaviour quickly and effectively when it occurs. It is important to realise that most of the anger and aggression directed against the carer is because you are the closest person, it is not necessarily a personal attack.

How to help to minimise or stop aggressive behaviour
try to minimise stress
distraction - if there are a few moments before an outburst when the person becomes increasingly agitated, you may be able to prevent an over-reaction by calming the person early
try not to argue with the person when they become upset because they no longer have the ability to be rational
try not to get upset or excited as well
never try to restrain a person
never put your own safety at risk

Medication can be used in some circumstances to reduce the likelihood of aggression and a person who is aggressive should be told that their behaviour is unacceptable and urged to seek treatment. If their behaviour escalates out of control at any time, you should be prepared to remove yourself from the situation and call your doctor or the police.

• Risky behaviour

People with a number of mental illnesses may engage in risky behaviour. This may be linked to self harm in which people seek to harm themselves or it may be in relation to suicide. It may also be as a consequence of increased impulsiveness, an emotional numbness leading to 'thrill seeking' or as a symptom of a mental illness as is the case in people experiencing a manic episode of bipolar disorder (manic depression).

Risky behaviour can take on a number of forms but usually includes an inability to see the consequences of an action, reduced boundaries and inhibitions, increased impulsivity and an as the name suggests, an increase in risk taking.

Risky behaviour can include:
Spending beyond means, increased drinking & drug taking, increased sexual activity and sexual practices.

In the light of the increase in sexually transmitted diseases and the spread of HIV, increased sexual activity, (in particular unprotected sex) has been the subject of many studies. A symptom of bipolar disorder can be an increase in sexual activity. This coupled with an increase in risky sexual practices in both people with mania and those experiencing the poor reasoning and cognitive skills of other mental illnesses, has been shown to lead to a higher risk of pregnancy and contracting sexually transmitted diseases than found in the general population.

How can I help someone who is engaging in risky behaviour?
Carers often discuss that finding the balance between protecting someone who is engaging in risky behaviour and taking control is difficult to achieve. Some of the suggestions in dealing with risky behaviour include:
try to help the person see the consequences of what they are doing
provide reassurance, the person needs to know that you will support them until they regain control over the situation
urge the person to seek help, engaging in risky behaviour is often a sign of deteriorating mental health in someone with mental health problems
try to understand the reason for a particular risky behaviour
if the person has little control over their behaviour, suggest ways in which they could increase their safety, for instance if their sexual drive is greatly increased, suggest they take precautions

If the behaviour is putting either you or them in direct danger it is important that you seek help. You may want to contact the persons GP or their mental health team. The factsheet 'Getting help in a crisis' may be useful in seeking help. This can be obtained from the Rethink National Advice Service.

• Becoming over-dependent

When someone you care about has mental illness you often feel the need to help them through difficult periods. This could be by listening, encouraging and supporting them; taking them to appointments, making sure they take their medication, pay their bills and eat properly. You may start out helping with small tasks and end up doing a lot more.

After a period of mental illness in which as person has been unable to cope alone, they may lack the confidence and self esteem to go back to coping the way they were before the illness. It is important both for yourself and for the person with the mental illness that they do not become over-dependent on you. Over-dependence can contribute to poor self-esteem and confidence of a person with mental illness. In addition, it can lead you to be a less effective carer if you are tired and cannot make time for yourself.

How can I stop someone becoming over-dependent?
Decide early on how much you can do and how much you want to do and set boundaries. Make sure you let the person with mental illness know these boundaries. If you find yourself having to do more than you want to do because the person is particularly unwell, contact social services for a carer assessment. They may be able to arrange additional help or a respite break for you and the person who is ill.

You can help to build up the person’s self-esteem and confidence by gradually building up their independence.