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Mental Health Information

Pathway Homes takes a closer look at mental illness

Mental illness affects more than five million Americans. Over the years, progress has been made in reducing the stigma and discrimination that has followed these individuals. The development of organizations such as NAMI (National Alliance for the Mentally Ill) provides a forum for society to both learn about and understand serious mental illnesses. One of the biggest obstacles facing an individual with serious mental illness and their family members is overcoming the negative and inhibiting societal views of mental illnesses. Education and understanding in the community are the keys to helping individuals cope with their illness and then learn to be productive members in society.

Over the years, InRoads, Pathway Homes' newsletter, has printed a series of articles written by staff members taking "A Closer Look at" major mental illnesses and related topics. They are reprinted here.

A note on the terminology and classifications used: Mental illnesses are classified in the DSM-IV, (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) the primary tool used by psychiatrists and other mental health professionals to recognize, diagnose and treat.

A Closer Look at Schizophrenia

by Amy Spiker, M.A.

Schizophrenia is one of the most recognized and common mental illnesses affecting approximately two million Americans each year. Unfortunately, for all its prevalence, there is a low level of understanding regarding its origins, symptoms and treatments.

One of the widespread misconceptions about schizophrenia is that is it synonymous with a "split personality" or multiple personality disorder, which is a rare condition compared with schizophrenia. This incorrect understanding was most likely derived from a literal interpretation of the definition of schizophrenia. The Greek root word "skhizein" means to split. In schizophrenia, it is within the individual's single personality that thought content and emotion are divided and distorted.

A recent surge in research has shown that schizophrenia is primarily a medical or a biological disorder. There continue to be many theories about what causes schizophrenia. It has, however, been established that the cause of many of the illness' symptoms such as the auditory hallucinations and unrealistic perceptions of people, events and feelings, is the result of a chemical imbalance in the complex brain system that controls thought, mood and behavior. Research has indicated that there is an excess of dopamine, a neurotransmitter that communicates information between nerve cells. This excess seems to result in overstimulation of these cells, causing confusion.

New research is continuing to investigate the physical, genetic and biological factors of schizophrenia. For example, some research has indicated that certain people, such as those with a parent with schizophrenia, may inherit a susceptibility to the illness. The statistics show that children of a schizophrenic have a 1 in 10 chance of developing the illness whereas the general population has a risk of about 1 in 100.

The development of symptoms of schizophrenia can be terrifying and confusing for both the individual and their family. The manifestation and severity of the symptoms varies from person to person. Most individuals begin to develop symptoms in their late teens or early twenties.

The treatment of schizophrenia is most often a combination of medication and psychosocial rehabilitation. Medications primarily target the symptoms resulting from the chemical imbalance in the brain. New drugs such as olanzapine and clozapine can effect both positive (hallucinations, delusions, etc.) and negative (depressed or withdrawn emotional appearance) symptoms. The benefit of many of the newer medications is the decrease of side effects that commonly accompanied early "anti-psychotic" medications.

Successful medications help control the symptoms that inhibit the individual's ability to function independently. Medication may allow an individual to participate in and benefit from other treatments such as psychosocial rehabilitation and supportive housing programs. Therapy can also help the individual and the family handle the emotional aspects of the disorder by providing understanding, reassurance, and insight.

The emergence of community support and therapeutic housing programs helps those suffering from schizophrenia and other mental illnesses to become more productive members of the community. The pride and self-confidence that comes from such acceptance are very important in helping an individual cope with a mental illness.

A Closer Look at Depression

Depression is sometimes called the "common cold" of the mental illnesses because so many people feel minor effects of it at some point in their lives. However, major depression is not common in terms of its severity and the devastating impact it can have on the individual and those close to him or her.

Clinical depression, which is more than a case of "the blues" or "feeling down," is characterized by symptoms that have affected an individual's emotional, physical, and mental health over a long period of time. Often people who suffer from depression describe feelings of hopelessness, helplessness, and worthlessness. This sadness is perhaps the most salient emotional symptom of depression. Some individuals feel so overwhelmed by these emotions that they find themselves crying uncontrollably for no apparent reason.

Other symptoms of depression include a feeling of numbness toward living. Some people lose interest and motivation in doing normal day-to-day tasks, such as getting out of bed, eating, and getting dressed. This may lead to physical symptoms, such as a change in appetite, weight gain or loss, change in sleeping habits, and a general physical deterioration. Additionally, there is a loss of gratification from activities that once brought pleasure and recreation. These symptoms are very painful for the individual with depression and his or her family and friends. Many people often wonder "why is this happening to me?"

Depression also has a large impact on a person's thoughts or cognitive health. One of the characteristics of depression is a negative view of the self. Many people believe that they have caused their failures, such as a job loss, loss of a loved one, etc. This belief contributes to already low self- esteem and self-worth. A difficult cycle emerges. The person who believes they have caused their present situation and feels increasingly powerless to change it then begins to view all aspects of his or her life negatively. They may not see success in an accomplishment, noticing only what could have been improved. As these thoughts continue, the person usually feels more worthless, helpless and hopeless.

For many years, depression was not viewed as a clinical mental illness. The prevailing attitude was that an individual with depression would be able to just "get over it." In recent years, however, a number of studies have indicated a relationship between abnormalities in the chemical construction of the brain and depressive symptoms. Studies show that depression is caused by biological, psychological and social factors. The extent to which each factor affects each individual varies from person to person, however, all three aspects must be incorporated in order to properly recognize and treat the illness.

Treatment for depression can take many forms. Medication is used in many cases, but is often combined with therapy. Effective therapy can help an individual change his or her negative self- view. As with other mental illnesses, therapy can also provide the information needed for the individual and their family to understand the illness.

Many people who suffer from depression are able to continue to be productive members of society with support from friends, family and the community. Through education, understanding and compassion, society can help these individuals lead more productive and healthy lives.

A Closer Look at Bipolar Disorder

Many people know bipolar disorder as manic-depression, a term which reflects that individuals with this diagnosis experience extreme variance in affect, or expression of their emotions. Bipolar disorders often involve swings between manic and depressive episodes.

A manic episode is characterized by "abnormal and persistently elevated, expansive or irritable mood that lasts for at least one week." Other symptoms evident during this period are an inflated sense of self-esteem, increased need to talk, pressured speech, flight of ideas or the sensation that one's thoughts are "racing," and excessive involvement in pleasurable activities that may have a potential for harm (gambling, shopping sprees, or unsafe sexual activity). Depressive episodes are marked with feelings of extreme sadness, hopelessness, helplessness and often, suicidal thoughts and behaviors. The difficulty of bipolar depression is the extreme and unpredictable nature of these episodes and the sometimes rapid cycling between them.

The onset of bipolar depression is sudden and is often unrelated to any precipitating event. The severity of the onset, the length of time each episode lasts, and the type of behaviors that are exhibited are used to diagnose the type of bipolar depressions and subsequently used to determine how best to treat the individual. Bipolar depressions tend to develop early in life, the first episode often between the ages of 20 and 30. The episodes can be either depressive or manic and last for days or months.

The cause of bipolar depression is still unknown. However, as with many other psychiatric conditions, it is being investigated from several perspectives. The most common treatment for bipolar depressions is lithium salts, which often end the manic episodes. This, however, sometimes leads to difficulty in treating individuals with bipolar disorders. Often the experience of a manic episode is so pleasurable, exhilarating and exciting that the individual does not want to end these feelings by taking medication. However, it is the extreme depression which follows the mania that often motivates the individual to seek treatment. Often taking the medication may be a choice between life and death because of the suicidal feelings that often accompany the depressive episode.

It is important to note that not all individuals with manic-depression engage in harmful behaviors while experiencing a manic episode. Many individuals, such as writers and artists, report they experience their greatest "creative flow" during a manic episode. These individuals are able to channel this excess energy into constructive ideas and projects. It has been hypothesized that important leaders such as Abraham Lincoln, Winston Churchill and Theodore Roosevelt were all manic-depressive.

Bipolar disorder is a difficult illness to understand and treat. As with most mental illnesses, understanding comes from education and an open mind.

Author's note: For readers interested in learning more about the experience of bipolar disorder, I highly recommend An Unquiet Mind by Kay Redfield Jamison. It is a wonderfully written memoir of one woman's experience of manic- depression. Dr. Jamison is a Professor of Psychiatry at Johns Hopkins University. It provides a human and insightful view of this illness.

A Closer Look at Personality Disorders

The study of personality is in some ways the most fascinating aspect of psychology because it concerns what is most human about us. But its personal and human qualities make personality a subject highly resistant to systematic description and explanation. How personality is formed remains in many ways a mystery. The definition of personality, the classification of personality traits or types, and even the distinction between healthy and disordered personalities have been elusive and intriguing.

Individual personality is defined by attitudes and behavior which persist in many situations over long periods of time. A personality type is regarded as disordered when traits are inflexible, maladaptive, and causes serious distress or impairment. According to DSM-IV, a personality disorder is identified by a pervasive pattern of experience and behavior that is abnormal in at least two of the following ways: thinking, mood, personal relations, and impulse control.

The rate of personality disorders in the general population has been estimated to be as low as five percent and high as 15 percent. One third to one half of psychiatric patients have been diagnosed with personality disorders.

Personality disorders can be grouped into three clusters:

• Cluster A (personalities which appear odd or eccentric) -- paranoid, schizoid, and schizotypal personality disorders.
• Cluster B (personalities which appear dramatic, emotional, or unpredictable) -- antisocial, borderline, histrionic, and narcissistic personality disorders.
• Cluster C (personalities which appear anxious and fearful) -- avoidant, dependent, obsessive compulsive, and passive aggressive personality disorders.

The use of anti-psychotic medications has proven effective in alleviating temporary psychotic episodes and the use of anti- depressants has been helpful in managing anger and depression. Although medication therapy has proven beneficial in temporarily modifying behavior, underlying attitudes and personality patterns can be very resistant to change. There remains a need for more controlled research in the use of drug therapy in personality disorders.

Because personality disorders are long-lasting, relationships with individuals with personality disorders can seem challenging. Setting limits and understanding boundaries help maintain and demonstrate the love, support and patience necessary to such a relationship. Individuals with personality disorders are assisted in recognizing and changing the pattern of maladaptive reactions and coping strategies that interfere with day-to-day functioning. Consistent limit-setting and role modeling can be helpful in developing healthy responses to life's stressors. Learning healthy coping and interaction styles serves to promote dignity, self-esteem and the ability to develop positive, meaningful relationships.

A Closer Look at Medications

The history of mental illness is filled with misunderstandings about its cause and treatment. Although the origins of the various types of mental illness are still being researched, our knowledge of medications to treat the symptoms has expanded greatly over the past 50 years. Due to new medications and other factors the treatment success rate for schizophrenia is 60 percent, 65 percent for major depression and 80 percent for bipolar disorder, according to the National Alliance for the Mentally Ill (NAMI). Whether you are a professional in the field of mental health, or yourself have or know someone who has a mental illness, it is important to be well informed about medications — their names, uses and potential side effects.

Like most medicines, psychiatric medications are often known both by brand name as well as generic, which can be confusing. Brand names are registered trademarks of the particular drug manufacturers. Generic terms are the substitutes often used in lieu of brand names and are usually less expensive. Examples of antipsychotic medications which treat psychotic symptoms include haloperidol (Haldol), fluphenazine (Prolixin), and chlorpromazine (Thorazine). Atypical antipsychotics include clozapine (Clozaril), risperidone (Risperdal), quetiapine (Seroquel) and olanzapine (Zyprexa). Mood Stabilizers used to treat manic symptoms include lithium, valproate (Depakote), and carbamazepine (Tegretol). Antianxiety agents include lorazepam (Ativan), clonazepam (Klonopin), and buspirone (BuSpar). Antidepressants include imipramine (Tofranil), sertraline (Zoloft) and the well-known fluoxetine (Prozac).

Some medications have been around for quite some time. Lithium was introduced in 1949, chlorpromazine was introduced in the early 1950s, and haloperidol was produced in 1958 by Jansen. These and other early drugs are still in use and effective for many clients. But just as mental illness manifests itself differently in each individual, medications have varying levels of effectiveness for each individual using them.

Each medication has its own strengths and weaknesses. The older antipsychotics primarily effect psychotic symptoms (hallucinations and delusions) but are less beneficial for the negative symptoms (apathy, withdrawal, lack of emotion and function), cognitive functioning (comprehension, judgment, memory, and reasoning), and mood symptoms of psychotic disorders. They may also have side effects including slowing of voluntary movement, expressionless face or facial grimacing, rigidity and tremor, difficulty swallowing and tardive dyskinesia (involuntary movements of lips, tongue, jaw, and extremities).

Some of the most recent drugs introduced, the atypical antipsychotics, have been effective in treating clients who did not respond well to medications previously available. The atypicals treat more of the symptoms of schizophrenia, and appear to produce fewer motor side effects. Because of the amount of research currently being conducted, the number of atypical antipsychotic drugs available should expand rapidly in the coming years.

Finding what medication or combination of medications will work best for an individual can be a complicated process, combining the knowledge of an experienced psychiatrist and careful monitoring and reporting of symptoms and side effects by a client. It is important to build a partnership between a client and his or her doctor, as well as family members, therapist and case manager. Drug treatment is based on the patient's past history, current clinical state, and the treatment plan.

The process of finding the best medication treatment can require patience, as many medications take time to reach full effect. Also, medications are often started at low doses, and titrated, or raised gradually, until the optimal results are achieved. Again, the partnership between the physician and client is important, so that the client understands the kind of improvement he or she should look for, and communicates his or her status as it changes.

As research into to the causes and treatments of mental illness continues, it is likely that new and better medications will continue to be made available.

Everyone's talking about stress these days. Newspapers and magazines are full of reports about how stress affects us. Serious health problems such as heart disease, ulcers and high blood pressure have direct links to stress. It can contribute to insomnia, errors in judgement, personality changes, and depress our body's ability to heal itself. Stress has been estimated to cost the country's businesses from $50 to $80 billion per year in lost productivity and related illness.

Because stress heightens the symptoms of mental illness, one of the important services that Pathway Homes provides to residents is to help them deal with the stresses of everyday life in the community. Counselors help residents build support networks in order to appropriately respond to challenges.

Not all stress is bad, however. Some stressful situations are happy events, such as birth, marriage, a new home or a job promotion. Sometimes stress challenges us to live up to our greatest abilities, it energizes us and keeps life exciting. Our modern and sophisticated society seems to be overloaded with stressful situations, however. Negative stress is the result when pressures upon us exceed our perceived ability to cope with those pressures. Our mental health is directly influenced by stress and how we handle it.

It is important to understand that stress is different for each person. A situation that is "no problem" for one person can be a major crisis for another. Also, the impact of stress varies because some people have learned skills which give them the ability and confidence to deal with difficult situations. Various skills and techniques work better for some people then others. Here's a list of ideas which you can try out.

1. Stay healthy. Give your body a chance to deal with the physical aspects of stress. Eat at least one hot, balanced meal a day. Get enough sleep. Exercise regularly.
2. Don't add stressors to your body. Alcohol, caffeine, sugar, fats and tobacco all put a strain on your body's ability to cope with stress.
3. Practice time management. Keep an updated "To Do" list. Prioritize your activities and do the most important ones first. Don't leave loose ends to worry about.
4. Manage how much you do. Evaluate new projects and ideas before you take them on and say "no" if your plate is already full. Ask for help when needed. Set small, doable goals. Learn what times of day you are most productive, and schedule the toughest tasks at that time.
5. Talk with others. Talk with friends, professional counselors, support groups or relatives about what is bothering you. Reach out and make new friends.
6. Help someone else. Taking time to focus on others in need can make you feel good about yourself as well as provide a sense of proportion for your own problems.
7. Give yourself a little break. During stressful time, take a five minute break and do some deep breathing exercises from your abdomen, or consciously squeeze and relax muscles progressively through your body. Try turning on some relaxing music, closing your eyes, and picturing a restful scene. Take a brisk five-minute walk.
8. Give yourself a big break. Time off from your regular routine isn't always a luxury, sometimes it's a necessity. Take a vacation or pursue a new interest to give yourself a break from worries and provide new perspectives.
9. Deal with nagging worries. Is there something you've been putting off? Decide whether it really needs to be done, and if so, schedule a time for it and do it. Often the actual task is easier than you imagined. Deal with problem relationships and work toward a resolution. Let go of negative thoughts, relationships and feelings.
10. Be good to yourself. Practice positive self-talk and encourage yourself. Realize you will never please everyone, that the most important opinion of you is your own. Pamper yourself when things are difficult. A relaxing bath by candlelight, a special meal, or an outing can be a well-deserved reward for dealing with stressful situations.

Seasonal Affective Disorder, commonly known by the acronym SAD, describes a depressive illness related to increased sensitivity to seasonal changes in some individuals. In DSM-IV, (Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition) SAD is classified as a subtype of major depression and is characterized by symptoms including deceased energy, anxiety, irritability, increased need for sleep, lethergy, overeating and/or cravings for sweets, weight gain, and difficulty concentrating. A diagnosis of SAD is based on suffering from these symptoms for at least two consecutive winters followed by an absence of such symptoms in the spring and summer. In addition, there must be no other condition to which the change in behavior could be attributed.

SAD affects over 10 million Americans. Seventy to eighty percent of those diagnosed are women. The typical onset of this illness begins in the early thirties. Symptoms usually begin in the fall, manifest in winter and resolve in spring. However, many individuals who work in poorly lit environments or live or work in buildings without windows suffer from these symptoms all year around.

Until recently it was believed that humans did not respond to the seasonal changes in day- lengths as other mammals do. In 1980, however, researchers at the National Institute of Mental Health (NIMH) demonstrated that high-intensity light affects the natural release of melatonin by the pineal gland in the brain. As a result of this research it was determined that human physiology is influenced by seasons, and more specifically by light. The alterations in brain chemistry induced by the changing seasons result in unconscious adaptations in behavior and activity. So how are these changes in day length registered? A biological clock, of course. This biological clock is located in the brain and signals alterations in body chemistry.

Each human has an internal body clock. In other mammals, we see that their body clock regulates behaviors such as eating, sleeping, socialization, and sexual activity. Mammals typically tend to eat more as the days get shorter, resulting in weight gain to help them survive harsh winters and conditions where food is limited. Energy is conserved by increased sleep and a reduction in activity. The most obvious body clock regulator is evidenced in animals who hibernate throughout the winter.

Humans are affected by seasonal changes as well, the degree to which this occurs increasing with latitude. Such brain chemistry changes affect the part of the brain that influences mood. The result in many people is a feeling of depression. In other mammals, this situation is helpful, but unfortunately these seasonal behaviors are not productive for the modern human mammal.

Individuals suffering from symptoms of SAD or noticing that mood changes seem to be seasonally connected should consult with their doctor.

A popular treatment for SAD recommended by the American Psychiatric Association and the National Institutes of Health is light therapy. While there are some disadvantages to this treatment such as headaches and hazards to eye sight, other more conventional treatments such as outdoor light, exercise, medication treatment, and therapy are available as well.

During the summer months, we tend to be more relaxed and spend more time outdoors with seasonal work, recreational pursuits and leisure time activities with family and friends. Everyone should take precautions in the sun and heat to stay healthy, but individuals with mental illness, especially those on medications, are a greater risk for medical difficulties.

Dehydration is a concern for everyone in hot, humid weather. The loss of body fluids can occur because of insufficient fluid intake or from excessive perspiration/sweating. Prolonged vomiting and/or diarrhea can also cause dehydration. Symptoms include dry mouth and thirst, anxiety, weakness and confusion; urine may be concentrated (dark) or decreased in volume. Severe dehydration can lead to changes in the body's chemistry and become life threatening if not treated.

Medications used in the treatment of mental illness, such as antipsychotics, antihistamines, antiparkinsonians ("side effect meds"), and antidepressants, may increase the risk for dehydration. Frequently these medications are used in combination, further increasing the potential for dehydration. Additionally, the medications have similar side effects which can increase during summer months unless adequate fluid intake is maintained. The side effects of these prescribed medications can mimic symptoms of dehydration such as dry mouth, nausea, anxiety, lethargy or drowsiness and therefore it is very important to consult the physician regarding any unusual symptoms or discomfort especially during the summer.

Lithium is used to treat bipolar disorder, or to augment efficacy of other medications used in the treatment of different mental illnesses. There is a narrow margin between therapeutic and toxic lithium levels; dehydration can cause therapeutic lithium levels to rise and become toxic. It is important to be aware of side effects and symptoms associated with toxicity. The physician should be notified with the occurrence of persistent vomiting, loose stools, increased weakness or tremulousness, or mental confusion. Increased fluids and adequate salt intake are essential to maintain stability.

Heat stroke is another danger from exposure to extreme heat. This medical emergency occurs when the body's temperature regulation system breaks down and the individual cannot sweat, causing a rise in the internal body temperature. Antipsychotic and antiparkinsonian drugs can decrease the body's ability to cool itself, therefore presenting a greater health risk during extreme temperatures. Warning signs include nausea, headache, weakness, anxiety, vomiting or loose stools; the skin is dry, warm or even hot. Heatstroke can be life-threatening and warrants immediate medical attention.

Antipsychotic medications, especially the older drugs (such as Thorazine, Haldol, Trilafon), can cause phototoxicity. This extreme sensitivity of the skin to sunlight can cause sunburn with even brief exposure. It is important to wear sunblock and protective clothing when in the sun. Allergies and insect bites can be problematic during the summer. Remember, do not use over-the-counter medications without medical advice because of the potential for dangerous drug interactions.

Schizophrenia, a thought disorder, can cause misinterpretation of the environment and at times guidance is needed with activities of daily living, including appropriate dress for the season. A cuddly, warm winter jacket may give a sense of comfort and security, but worn in the middle of summer, it can also lead to excessive fluid loss from sweating. Also at risk are individuals living alone because they may not recognize warning signs and may not seek treatment. Sadly, all too often individuals with chronic and persistent mental illness spend prolonged periods outdoors due to unstable living conditions. They may be resistant to medical intervention, and are at greatest risk.

Prevention is the best way to have a healthy summer. Avoid prolonged exposure to the sun; drink plenty of fluids (at least 8 to 10 tall glasses daily); avoid caffeine, sugar and alcoholic beverages which promote fluid loss; do not engage in strenuous exercise during warm conditions; wear light-colored summer clothing; and stay in an air-conditioned environment as much as possible. It is important to take medications as prescribed and consult with a physician with any vomiting, diarrhea or unusual symptoms. Family and friends should check on those living alone, especially during extremely hot weather.

Stable housing is an essential component of success for the treatment and recovery of mental illness. People who suffer from severe and persistent mental illness often find themselves without stable housing. Often this is due to the unstable nature of transitional housing, and the cyclical nature of some mental illnesses, which can result in hospitalizations or the need for an increased level of care. One unique aspect of Pathway Homes is that all of its programs are permanent or non-time-limited housing, which means that program residents can stay in any of the programs as long as they wish to, or need to.

While the non-time-limited housing component is one part of Pathways' services, the support service component helps residents to live to their maximum potential, and maintain their success living in the community. While the support services that Pathway Homes offers are designed around the individual needs of each resident, there are several areas of support services that are available to each resident. These areas are case management services, teaching and role modeling independent living skills, and counseling and crisis intervention.

Case management is the ongoing assessment of resident needs. These needs may include all aspects of residents' lives. For some residents, this means ensuring that a dental checkup is scheduled every six months or advocating for pro bono dental services. For others, it may mean helping to assess a resident's readiness for volunteer work or a more independent living environment. A residential case manager does not work alone. They work in tandem with all the resident's other care providers such as day program counselors, psychiatrists, therapists, and family members. The flexible nature of case management allows it to meet the individual needs of each resident.

Teaching and role modeling independent living skills covers all areas of independent living. These are skills that those who do not have a mental illness often take for granted. The mental health counselors who work in Pathway Homes' programs spend much of their time in the homes working with each resident on their individualized service plan goals. An example for a service plan goal for a resident might be to learn to cook spaghetti independently or to open a bank account. For another resident, a goal might be to take all of his or her medications as prescribed. The counselors have opportunities to role model for residents throughout their work day. Pathway Homes' counselors may use participation in social activities and outings or eating meals with residents as a tool to teach appropriate social interactions.

Counseling and crisis intervention is the third area of support services that Pathway Homes provides for residents. Pathway Homes' counselors do not provide psycho-dynamic therapy, but they do provide day-to-day problem-solving counseling for residents. There are times when some residents need encouragement to complete some activities of daily living, such as putting on clean clothes, or getting up in the morning. A resident may be having an exceptionally difficult day, struggling with increased symptoms of his or her disease or a problem at their day program or at work, and this is where the day-to-day counseling comes in. Often, it is a short, supportive conversation with a resident that can turn an overwhelming problem into a learning experience.

Counselors know the residents they work with quite well, so more often that not, the counselor can anticipate a difficult time or a problem, and in turn, offer supportive counseling or advocate for a timely appointment with the resident's psychiatrist or therapist to fend off a potential crisis for a resident. There are times, however, that the counselors or a resident cannot anticipate a potential crisis and the resident finds him or herself in a situation that needs immediate attention. The mental health counselors at Pathway Homes also provide crisis intervention as part of their services. This means assessing a resident for risk of imminent danger or harm to him or herself or others. Sometimes, this means helping get a resident to Woodburn Emergency Services for a psychiatric evaluation for inpatient services. In other cases, it may mean going to the urgent care center for immediate attention to a medical issue.

Pathway Homes has been providing permanent housing and support services for people who suffer from mental illness for more than 20 years, and the counselors have experienced first hand, time and time again, how residential support services can make a world of difference in the quality of life for residents and their families.

Advocacy is defined as a person or organization that speaks or writes in support of something. Advocates make an incredible difference in serving the population of adults with mental illness. Without advocates including family members and mental health professionals who understood the need for the need for housing for this population, Pathway Homes would have never been founded. Without the support of members from the Northern Virginia Alliance for the Mentally Ill (NVAMI), our first set of Semi-Independent Houses would have never been opened and our name may not have become Pathway Homes. Without continued advocacy, the Semi-Independent Program, SHOP, and Stevenson Place would not have been opened. Pathway Homes continues to remain connected with NVAMI through family members of residents and board members of Pathway Homes who are members of NVAMI.

Here at Pathway Homes, the Consumer Advisory Council has defined one of its main objectives to be researching ongoing legislation and advocating through letter writing. Consumers of services for mental illness are among the most passionate and effective advocates for their own needs. There are many organizations that advocate for the mentally ill including the National Alliance for the Mentally Ill (NAMI), the Coalition for Mentally Disabled Citizens of Virginia, the National Empowerment Center, the Parent Advocate Network, and the Treatment Advocacy Center.

As mentioned earlier, without advocacy Pathway Homes may have never been opened. Being an advocate can be a very rewarding process. Being an advocate is an important role. When you advocate to your local government officials, your voice joins that of others who share your opinion. When enough people express the same concerns, and issue gains greater attention and usually action at a higher level. As more advocates speak out, the issue becomes heard by more people and the likelihood it will be addressed is greater. Effective advocacy involves educating yourselves on issues that are of interest to you. Once you have found an issue that interests you there are several ways you can be an advocate, including:

• Call your local government officials involved in the issues.
• Write letters to your local government officials involved in the issues.
• Do volunteer work for an advocacy organization.

If you are interested in being an advocate for adults with mental illness, please feel free to contact any of the organizations mentioned above or explore their internet sites to learn more about them.

It started quietly.

The word was heard once, maybe twice. But as time has passed, the word "Recovery" is being chorused loudly by mental health consumers and professionals alike, in virtually every venue of discussion related to mental illness.

The mental health recovery model has been around since 1991. It proposes, "hope and restoration of a meaningful life are possible, despite serious mental illness," according to Pat Deegan, a leader in the recovery field. The model is unique in its view of mental illness because unlike the medical model, it focuses on the whole person not just the cause or symptoms of the illness.

Recovery literally means the act of restoring. Mental health recovery is defined by Pat Deegan as "a personal process of overcoming the negative impact of psychiatric disability despite its continued presence." The concept of recovery in mental health therefore refers to a process, not an end result. Put another way, recovery is something that an individual experiences on an ongoing basis.

The recovery model, among other things, proposes that people can recover from severe mental illness even though they may not be completely free of symptoms. It also stresses the rights of mental health consumers and the importance of changing how people view mental illnesses. In short, this model proposes that consumers should be able to make informed choices about the kind of treatment they receive within the health care system.

People working in the mental health field who believe in the recovery model allow consumers to make their own choices, good or bad. They do so while creating opportunities for them to take responsibility for these choices. As a result, mental health workers and consumers have a collaborative relationship that puts the consumer at the center of the recovery plan.

So what exactly is a recovery plan? The key concepts of recovery-based plans are: Hope, Personal Responsibility, Self Advocacy, Education and Support. In effect, a recovery plan empowers the consumer. It works under the belief that consumers are truly empowered only when they believe that they can experience long periods of wellness during which their symptoms are well managed. It is a plan that identifies how consumers can take action to do those things that keep them well. It educates consumers so that they have the power to make decisions that impact their treatment in a positive way. In addition, a recovery plan includes a strong personal network identified by the consumer.

At Pathway Homes we believe in the recovery model. We believe that people's experiences are more alike than different. We also believe that consumers can and do get better when they have all the necessary supports in place and are treated with dignity and respect. Staff members across the agency are committed to building strong collaborative relationships with consumers based on trust and respect for individual choice and self-determination. We continue to work on building even stronger recovery-based models of care by providing opportunities for staff and consumers to participate in ongoing training within and outside the agency. Our goal is to embrace recovery into all aspects of agency life as a day-to-day working model.

Everyone can become more recovery focused in their dealings with consumers. A good place to start is to learn more about mental illness in order to treat it like any other type of illness. This helps us become more informed about the way we view and treat people with mental illness. It makes us more aware of the stigma attached to mental illness and the unfortunate stereotypes assigned to consumers. As we become more informed, we begin to understand that a consumer is like any other person with an illness that affects many areas of their life but in no way defines who they are. Also, this helps us realize that mental health consumers, like people receiving other healthcare services, can and should be fully involved in their treatment to the extent that they are able.

The recovery model is not a fad. It is a positive change in the way mental health services are developed and provided. It is a movement that is influenced by consumers taking a more active role in their treatment, and mental health workers continually providing opportunities for them to do so. This model, more than any other treatment model, shows that recovery from severe mental illness is possible and that reoccurrence of symptoms does not prevent recovery. The staff of Pathway Homes hopes that more consumers, families, and treatment providers in the mental health and medical fields will embrace this model, its message of hope, and the possibility of change and improvement.

The following resources may be helpful in learning more about the mental illness recovery model:

Online Resources:

• www.mentalhealthrecovery.com
• www.recovery-inc.com
• www.MindFreedom.org

Books:

• Wellness Recovery Action Plan and Peer Support, by Mary Ellen Copeland and Sherry Mead. (Available at www.mentalhealthrecovery.com/shop/index.php)

Organizations:

• CONTAC (Consumer Organizational National Technical Assistance Center). Address: 1036 Quarrier St., Suite 208A, Charleston, WV, 25301. Telephone: 800-598-8847. Provides technical assistance to adults with psychiatric disability throughout the United States.
• National Empowerment Center (NEC), Address: 599 Canal Street, 5th Floor East, Lawrence, MA, 01840. Telephone: (800)POWER-2-U (800-769-3728). Web Site: http://www.power2u.org. Award-winning provider of consumer health information, programs and materials, with a focus on recovery. NEC can refer callers to a local support group or provide assistance to set up a new group.

In January, 2005, Pathway Homes introduced the Wellness Recovery Action Plan. Commonly abbreviated to WRAP, the program was created by Mary Ellen Copeland, an accomplished writer and herself a product of recovery. Through her program she addresses a number of topics on recovery including: daily maintenance, triggers (external), early warning signals (internal), breakdown, and a crisis plan, or, as she likes to call them, "The Wellness Toolbox."

Pathways' WRAP group was conducted Thursday afternoons from 1 to 3 p.m. from January to March, 2005, and included anywhere from three to nine participants.

The group was led and facilitated by Lauren Spiro, MA, and Rob Green, MEd. Class rules were arranged by the group at the start of the training and these rules were used throughout the WRAP process. The group decided that a spirit of cooperation and encouragement would be used in the trainings and that any participant could take a pass on any question if he or she chose.

Sessions began with open discussion and review of past sessions. Snacks of fruit and chips were passed around the group while going over the WRAP booklet. Exercises such as focusing, peer counseling and relaxation techniques were used. A large amount of time was devoted to peer counseling. Members found it useful to pair up and give each other their unlimited attention, listening and sharing. Members found it especially useful to compare WRAP book answers to learn how each person deals with their feelings and situation.

"The idea of WRAP is useful in putting ideas and coping skills on paper," says Mark Roudybush, WRAP participant. "I have gotten some new tools to use and have been exposed to new ideas. The peer counseling and focusing have been helpful."

While there were differing levels of participation by members of the group, a supportive and educational atmosphere was present at Pathways' WRAP training sessions. All members of the group were encouraged to share and participate in the recovery process, to use coping skills and all who participated seemed to find value in the process.

"WRAP has helped to organize our thinking step by step," says Sue Zywokarte. "It helps concretely look at and focus on solutions."

Wellness behaviors such as journal writing, diet, light exposure, exercise and sleep were covered as well as recovery topics including self-esteem, changing negative thoughts to positive ones, peer support, work related issues, and motivation.

"I learned how to handle my symptoms in many ways to feel better," says group member Vicki Wolfrey.

Each member who completed the course received a certificate and in the end had a finished product which they may now use as needed.

The WRAP program was selected by a state committee that felt WRAP best suited the mental health needs of those in recovery in Virginia. The facilitator training for WRAP was held in Richmond, Virginia, for a week in October, 2004, and included fourteen participants. WRAP trainings run by members of this WRAP facilitator team are now occurring throughout the state in seven regions of Virginia. These trainers continue to work together, conversing through e-mail. They hold WRAP trainings in clubhouses, drop-in centers, PRS centers, libraries, and other public meeting areas.

The Facilitator Training Manual for Virginia included a curriculum demonstrating how to take care of oneself, working with individuals and working with groups. A large set of 200 transparencies emphasizing the key concepts of hope, personal responsibility, education, self-advocacy and support were included in the program.

Pathway Homes expects that another WRAP group may be started in several months. A number of the participants from the first group are interested in taking the program again.

In this time of emphasis on recovery, the WRAP group and self-empowerment are an important part of the picture. WRAP will hopefully further the goals of recovery.

Dialectical Behavior Therapy, otherwise known as DBT, is an integrative cognitive behavioral treatment approach that was initially developed for use with suicidal women diagnosed with Borderline Personality Disorder. DBT is the brainchild of Dr. Marsha M. Linehan, who developed this approach in the 1980s while working as a clinician at the University of Washington. DBT has received international recognition because of its strong empirical basis (grounded in observation and experiment) and effectiveness with consumers of mental health services suffering from a variety of mental disorders in addition to Borderline Personality Disorder.

DBT is based on the theoretical assumption that an individual and his environment have a continuous and reciprocal influence on each other and that this transaction between individual and environment leads to dysfunctional behavior. DBT is also based on a logical and dialectical worldview which posits that there are no right or wrong answers but many possibly effective answers. Treatment then becomes a balance between accepting or validating behaviors with changing behaviors.

Standard DBT has four primary modes of treatment. First, each consumer participates in a psycho-social skills training group that meets weekly. In addition, the consumer has a primary therapist who helps with inhibiting maladaptive behaviors and also monitors motivation and commitment to therapy. Furthermore, the primary therapist is available for crisis intervention with the consumer via telephone consultations. The fourth component of treatment is case consultation available to the primary therapist as a means of support.

DBT treatment is structured to target specific behaviors in a hierarchical but overlapping format. During the pretreatment phase, the primary therapist's goal is to orient the consumer to treatment and obtain commitment to treatment. Stage One of DBT focuses on decreasing suicidal and other life-threatening behaviors. Therapy-interfering behaviors and major quality of life issues are also addressed during Stage One. Finally, behavioral coping skills in mindfulness, interpersonal effectiveness, emotion regulation, distress tolerance and self management are also taught. Stage Two of DBT treatment focuses on reducing post-traumatic stress. The Third and final Stage of DBT focuses on developing an individual's ability to trust and validate him or herself independent of the therapist. Work on individual goals also occurs during Stage Three.

The overall goal of DBT is to assist consumers in leading a life worth living, based on each individual's value system. Therapists practicing DBT believe that the consumer has a desire to improve and that the consumer cannot fail in therapy.

Self-determination is a broadly defined concept that encompasses the notion of freedom of choice as a basic human right. For individuals with disabilities, the road to self-determination can be difficult to navigate with even well-meaning individuals creating challenges. Sometimes people think that people with disabilities cannot think for themselves. Even family members or counselors sometimes try to "protect" individuals with disabilities by making decisions for them. Self-determination in the mental health system refers to individuals' rights to direct their own services and to make the decisions concerning their health and well-being, with help from others of their choice, if desired.

The mental health system has been undergoing a steady transformation from a medical model of service delivery to a recovery model. This new way of looking at mental illness, a vision that focuses on recovery and self-determination, aims to increase a person's ability to successfully cope with the challenges in life and build resilience, not just manage symptoms. Key to recovery is the concept of self-determination. Simply put, people succeed when they become empowered to determine their own destiny. Through making their own choices, people learn to solve problems and take responsibility for their lives. Stigma, however, remains a major barrier to an individual's recovery process as it erodes confidence that mental illnesses are real and treatable health conditions.

Self-determination allows a person to counter such stigma and an imposed sense of helplessness that creates social, systemic, and financial barriers to effective treatment and recovery. Principles of recovery emphasize the importance of a person's support system. The recovery model is not advocating that parents not be parents or that friends not give honest feedback and advice to a loved one. A self-determined person is recognized as someone who can set goals for themselves and realize the importance of partnering with family, friends and professionals to achieve success.

One in seventeen people have a serious mental illness. It is estimated that mental illness affects one in five families in America. Too many people are impacted for this issue not to rise to the forefront of the public consciousness. Self-determination allows individuals to step out from the shadows of their disability – to be a person, not a statistic or diagnostic code. The labeling of groups of people and the application of generic treatment modalities impose barriers to a person's recovery. When people are empowered to express their individual needs, make decisions, and assert their right to self-determination, the barriers will come down.