Ask the psychologists...

My brother (34-years-old) has been getting worse in the last couple of years. He has frequent episodes of psychotic ranting, total loss of social awareness and many other symptoms to the point where I am seriously concerned for his safety (I am worried that he will decide everything is too much soon). He is normally very depressed, feels that he is genuinely cursed and everything does seem to go wrong for him. I suspect this could have something to do with his daily use of cannabis for more than 15 years. I would like to be able to guide him to the right help as soon as possible. Do you have any advice as to whether there is anything we can do for him?

I am afraid that it is quite hard to tell from your account whether your brother is currently in contact with any services or not – and getting help for him probably means getting some services involved.

If he is not in contact with mental health services, please discuss with his GP– make an appointment if necessary, and try to get your brother to go with you, but go on your own if not. You need to make it clear to his GP that you are worried about his depression and his suicide risk. You need to ask his GP to arrange to see him or to refer him to your local mental health team. It will help in this, if you are his next of kin. If you are not, please try to get the person who is to do this.

If your brother is in contact with a mental health team already, you should contact them and again say that you have concerns about him – be specific about his depression and his suicide risk. Has he actually said he wants to end it all for instance? You need to ask them to do a new assessment. 

Sharing your observations with his team will be very useful in helping them to understand the difficulties your brother has. For example, you may have noticed a pattern to his ‘ranting’. Do these tend to occur at particular times of the day? Are there specific things that he does or other people do that tends to calm your brother or make things worse?  Any thoughts that you have on his difficulties will be valuable.

You are right that his cannabis use is unlikely to be helping him. At the very least, it will be demotivating and there is some recent evidence that heavy persistent use makes concentration more difficult. However, your brother has to decide about this for himself. If this is a concern for him and it is getting in the way of other things he wants to do, then his team or his GP should be able to offer him help on where to access specialist advice about reducing or stopping his use.

Your brother may also not agree that he wants or needs help from the GP or a clinical team. But you could try asking him what, if anything, you can do that would be helpful for him. If he refuses, you are already being helpful in staying in touch with him and alerting services (as above). If his behaviour becomes risky enough to merit an emergency call out, if he becomes acutely suicidal or dangerous to others for instance, do try to take him to your local Accident and Emergency hospital department, or call the police. At that stage, you will be able to get some help, even if he does not want you to be involved.

It is not clear from your account what conversations you have had with your brother to date, but we know that it can be stressful to support someone with mental health difficulties similar to your brother’s, particularly if they don’t recognise they have difficulties or reject any offers of help. It can also be particularly difficult for a sibling because it is not always clear how much you can do.

My 25-year-old daughter, married with two children (20 months and 7 months) refused to let me in the house after two weeks of just texting me that her family were 'very busy'. On the phone she screamed 'how dare you come to my door unannounced'. She has had a reasonable relationship with me over the last two and half years during pregnancies etc. I helped with the deposit for the house and I have tried to be a supportive gran. She lives 25 miles away so I try to see the family every two weeks but she often refuses contact. She cannot drive, they have no television, she does not seem to have friends and does not take the children to mothers’ groups etc. She had very bad post-natal depression after baby one so had Prozac, which I believe she is off now. Her husband is a very quiet man. Last time I saw her she was high – very chatty, full of herself and her website. She has written a novel and lots of poems while at home with the babies. She and her husband are trained shamans, trying to make a business out of it (he has a full-time job too). She became a shaman four years ago after a psychotic episode when she needed psychiatric intervention. She refused long-term treatment then and went abroad. I am lost here and feel sad. Any comments?

This does sound very sad and very difficult for you. From your letter, it sounds like you are concerned about your daughter’s well being, which is understandable given your role as a grandmother and the circumstances you report.

Unfortunately, unless you have evidence that your grandchildren are at risk, particularly of physical harm, or your daughter is at risk of harming herself or them, your daughter is correct that she does not have to answer the door to you or to anyone else. Your contact with them is then going to have to rely on your ability to weather her shouting and her refusal to let you see the children. The fact that you have helped them financially in the past and wish to be helpful now is not going to guarantee that your daughter behaves well to you in the future. That will depend on how you manage this very upsetting scenario.

Is there some way of keeping contact with them all that would work better than turning up unannounced or phoning? It sounds as if you need to establish with her what would suit her in terms of visits and contact. Would she prefer monthly contact and weekly phone calls, for instance? With two very young children, lots of creative work to do and a husband working full-time, your daughter sounds as if she has a very busy life. She is probably in contact with lots of people via her website and this might feel to her like enough socialising at this stage. She might also feel that your unannounced visits are trying to ‘catch her out’, or imply that she is not coping well instead of being perceived as helpful, which is what you might intend. Is there a way of discussing with her, that you are sorry that you came when you were not expected? Could you suggest that you organise contact that would suit both you, her family commitments and her? Does your daughter respond better to an email or to a letter? You may wish to send a card with a brief note attached. In the note, it might be helpful to include a few lines about you and what you have been up to recently. This may reduce some of the pressure between you both and will gently give your daughter the message that your contact with her will not solely be focused on her and her parenting.

As I am sure you can appreciate, motherhood can be a very stressful time. Sometimes your confidence can be shaken, and you can become very sensitive to criticism, however slight or unintended it may be. It is also worth noting that your daughter does have a husband who would be likely to raise concerns about her health and their children, if there were any. While her situation does not sound ideal, and her lifestyle choices not ones you might have made, you may have to accept that your role at the moment is to be supportive in a way that suits her and this may be from a distance Your continuing contact with both her and your grandchildren will depend on your being able to negotiate this. If you do agree to meet, you may wish to go somewhere neutral in the beginning, for example a park nearby to her home.

My daughter has a diagnosis of paranoid schizophrenia and is often violent at home towards her sisters and brothers and to her mother and me, her father. I feel powerless to help her. Please do you have any advice?

It is worrying that you say you feel ‘powerless’ at home while your daughter is being violent to you and the rest of the family. Violence is not acceptable at home or in the street, and it is not helpful for your daughter and her future care to let it continue. You need to write down what is happening, and when, and to let your daughter’s GP and/or mental health team know the full extent of the difficulties. If the violence is acute, you need to call the police and make it clear that your daughter’s behaviour is putting the rest of the family and herself at risk. Even if not acute, any violence puts stress and pressure on you all and is not a sustainable long-term option. It may mean that you need to consider other care for her apart from in your home for instance. While this is a difficult decision, it might mean that she can get the help she needs.

It is not clear why your daughter is behaving like this. Is she responding to voices or does she feel threatened? Have you noticed any particularly triggers or things that tend to make it worse or stop the violence? What would your daughter find helpful? If there are things that your daughter could tell you about the situation, but without jeopardising your own safety in the process, it would be helpful to pass this information to her GP and/or her team.

As we have said in previous questions, any episodes of aggression and violence should not be ignored. It is always important to maintain the safety of all family members. Whatever the cause of your daughter’s behaviour, it is a clear sign that she needs more help and that you need to involve outside agencies. Her violence is not something that you need to be ashamed of. Please begin to take some action to prevent this continuing.

My son is a 34-year-old man who has had a diagnosis of schizophrenia since the age of 24. He lives at home with me, as a main carer. One year ago he commenced on clozapine. This was because his medical team felt he was not responding well to all his previous medication. In recent months, my son’s weight has increased from 69 to 88 kilograms. He complains of having an insatiable appetite and wants to stop the medication for fear of gaining more weight. I am very worried about this because this clozapine has really helped him and stabilised his mental state. Please advise me what I can do to help him.

Unfortunately, weight gain is a common side effect of some antipsychotic medication and an issue that concerns many relatives and service users. As you say, it is encouraging that your son’s mental state has improved, and this would have been the thinking from your son’s mental health team. However, weight gain is not a pleasant side effect, and is damaging to long-term physical health. It can also negatively affect an individual’s mood and self-esteem. It is usually caused by an increase in appetite as your son describes, and many people will often crave sugary, high fat foods, and carbohydrates. However, we know that consuming these food groups, in large amounts, and taking minimal exercise, can lead to considerable weight gain. It may also be that with more stability, your son has regained some of his former enthusiasm and interest, and this has now been focused on food.

The usual advice about weight gain is now based on a broader understanding about lifestyle, and the kind of changes that need to be made are likely to be long-term. The advice is not very complicated, but is often difficult to put into practice, and requires some planning beforehand. Your son needs help in not eating so much at each mealtime, having regular meals including breakfast, but avoiding sugary, high fat snacks between meals, cutting out fizzy drinks, which can be loaded with sugar, and trying to be more active. Do discuss with him how he might achieve this, but in small achievable steps. It might also involve you making plans together about the type of foods you purchase from the supermarket. Your son may find it helpful to keep a diary of his food intake. Food diaries can be a helpful reminder about exactly how much food we are eating every day. Diaries can also help to identify whether there are any particular patterns to our food intake. For example, does your son tend to consume more food when he is bored, lonely or sad?

In terms of efforts to increase his activity levels, it would be helpful to know whether your son enjoys a particular sport. For example, does he like walking, swimming, bowling, dancing or playing football? It is always best to start with an activity that he enjoys. Perhaps you could embark on it together, as often more than one member of a family can benefit from these kinds of changes. If there are available resources, your son may find it helpful to invest in a computer-based fitness programme (eg Wii Fit) or exercise equipment designed for the home (eg bike, rowing machine). This can be a good way of kick-starting a fitness programme, but in the comfort of your own home, and perhaps having fun with other people too. Similarly, you could suggest that your son uses a pedometer and sets daily and weekly targets for walking.

It is important that your son is encouraged to go back to the mental health team to discuss these side effects, and perhaps also ask for a referral to a dietitian, who would be able to make more detailed and tailored suggestions. It would also be helpful for your son to inform his mental health team worker about any plans to follow a new exercise regime.

My brother has schizophrenia and is ringing me all the time and threatening me. He thinks I am involved in some sort of plot against him and says he will get me before I get him. How should I handle these calls? We don’t live near each other and I rarely see him.

This is very unpleasant for you and we agree it is not easy to handle, as your brother will probably not believe any reassurance from you. The fact that he is making threats against you is the main problem. Do you have any evidence that he actually has a plan to harm you, or are these just vague threats? If he has told you about his plan, you should let the police know that this is happening, and log any calls with content, times and dates, as well as taking any reasonable precautions while the threat is realistic.

When he calls, you should say that you are sorry that he believes these things and is upset, but state clearly that this is not something that you are involved in. Say that you know that he finds this hard to believe, but from your side it is not what is happening. Say that until he stops threatening you, you will not accept his calls, and if he continues, that you have told the police about it. Do not accept any of his calls again, but you may wish to call him yourself, from a phone with a blocked number, to see how he is. Alternatively, you could find out how he is getting on through other family members. It might also be helpful to contact his mental health team, his psychiatrist or his GP, to tell them that he is threatening you. Be explicit about how often, how realistic and how upsetting this is. They need to know he is behaving like this and that he might need more support. He is unlikely to have reported this to them himself. Meanwhile, try to look after your own support and if things get worse, do not hesitate to get help.

My daughter has bipolar and recently had an episode of mania during which time she had increased sex drive and was very promiscuous. I am extremely worried about this behaviour. Can you give me some advice about how to deal with it and how I can talk to her about it to stop it happening again?

Increased sexual drive and resultant promiscuity can be a common component of a manic state. We agree it is very worrying and your daughter will be very vulnerable during that time. She may also be very upset and depressed about it subsequently, which can be part of the downturn in feelings of bipolar disorder.

You ask how to talk to her to stop it happening again, and unfortunately this latter may not be realistic. You can certainly talk to her about it and how to keep herself safe during sexual encounters, but if she is to stop it happening again, that will take a longer term approach about how to help her to prevent manic episodes. There is now some literature about this, which mainly relies on micro-management of mood – how to recognise daily changes in mood which precede manic upturns (or depressive episodes) and take action swiftly to bring mood back to more normal levels.

A typical precursor of manic episodes that is easy to spot is missing sleep: more than two nights without sleep means that your daughter should urgently seek help from her mental health team. If your daughter can get to know her own early signs of mood change, she may be able to begin to control them, together with medication, more effectively. Can you discuss these ideas with her and see if you can help her in day-to-day mood monitoring, if she would find this useful? It is possible that your daughter will not want to talk to you about her mood and/or her behaviour because she may feel embarrassed or self-conscious. If this is the case, you could encourage her to talk to someone from her mental health team.

Staying healthy plans are recommended as part of the NICE (National Institute for Health and Clinical Excellence) Guidance for Bipolar Disorder (2006). We have mentioned before that supporting a relative with bipolar affective disorder can be demanding, particularly when there have been episodes of mania with sexually disinhibited behaviour. You may find it helpful to attend a local support group for families affected by bipolar affective disorder where you will have an opportunity to be supported by other family members and exchange helpful coping strategies. Visit the website of MDF, The Bipolar Organisation to find a local group. In addition, you and your daughter may find a new report from The British Psychological Society (BPS) useful. It is called Understanding Bipolar Disorder; why some people experience extreme mood states and what can help helpful. You can contact the BPS for details on how to obtain a copy on 0116 254 9568 or via email: enquiries@bps.org.uk.