Your Family Member Has Bipolar Disorder
and is Refusing Treatment

           
           Colleen Sullivan
           2000

Lack of insight is one of the reasons an individual with Bipolar Disorder may refuse treatment, even though they are very ill. This illness, at the same time may be painfully obvious to his family member/loved one. Another reason treatment may be refused is one common to many with long term chronic illnesses, and that is denial. It isn't easy or pleasant to admit (even to oneself much less to others) that one has a serious mental illness. Stigma, despite inroads being made in recent years to eradicate it, is still alive and well for those with mental illnesses. 

Denial is a coping mechanism and results in an inability to recognize symptoms, the inability to accept the ones that one does recognize, and the inability to seek help for an illness that doesn't exist. (at least in the bipolar individual's mind at the time) Other things like fear and mistrust play a part in some cases. While all of this denial and lack of insight is going on within the person diagnosed with bipolar disorder an acute episode of either mania or psychotic depression may occur. 

The responsibility for caring for the uncontrolled bipolar falls to you...the family member or loved one. What to do? How to help? The bottom line is that unless the person with bipolar disorder meets the criteria for involuntary committal procedures HE CAN NOT BE FORCED INTO TREATMENT

Dr. Phelps asked me to do some research into this and see what I could come up with as far as some good advice when, unfortunately, you find yourself in this position. I have bipolar disorder and also am a family member, and having "lived on both sides of the fence" finding some answers was of interest to me. To my dismay I found there is not nearly enough immediate help available to people in this situation but i am sharing what I have found out. 

1. Call 911 or your local police department in the case of an emergency. This can not be emphasized enough. If your loved one is in any way an immediate danger to himself or to others time is of the essence...do not hesitate. Waiting can result in tragedy. 

2. NAMI (National Institute for the Mentally Ill) has 1200 state and local affiliates in all 50 states, the District of Columbia, Puerto Rico, American Samoa and Canada. The folks at NAMI understand the situation you are dealing with...many of them have dealt with similar situations. NAMI offers Support, Education, Advocacy and Research. NAMI is I think the best source for immediate information. Contact your local chapter for help or use the information below to contact them to discuss your current situation and to get some advice and support. 

Helpline: 1-800-950-NAMI (6264) Mon-Fri 8 am - 9 pm Eastern 

or online at: http://www.nami.org 

NAMI holds the following beliefs: 8.1 Right to Treatment 

(8.1.1) NAMI believes that every person with a brain disorder is entitled to the same level of service afforded other physical illnesses. Every person is also entitled to be fully informed about specific medications and procedures and the risks, possible undesirable side effects of such medications and procedures, and other options. The risks and possible undesirable side effects of refusing treatment and what the alternatives are should also be a part of this information process. Every consumer has a right to be part of individual treatment planning. Every consumer has the right to be informed of all community services and supports. 

(8.1.2) With adequate professional consultation, every person with a brain disorder who has the capacity and competence to do so should be entitled to manage his or her own treatment. When an individual lacks capacity and competence because of his or her brain disorder, however, the substitute judgment of others--subject to sufficient safeguards with frequent review--may be justified in determining treatment and possible hospitalization. To read more go to the NAMI pages at 
http://www.nami.org/update/platform/legal.htm 

3.  In Canada, contact the Canadian Mental Health Association either locally in your community or at 
http://www.cmha.ca 
416-484-7750 

4. Your ill relatives psychiatrist or physician or both should be contacted. Sometimes you may be able to convince your relative to see his primary care physician for a purely medical reason - you get there first and let the doctor know what is happening! 

5. Local County Mental Health Agencies (Community Mental Health in Canada) can often offer insight and information and intervention when it is needed. Find them in the yellow pages of your telephone book and call them. 

6. Involuntary Commitment: If the situation is serious your relative meay have to be hospitalized against his will, either to protect himself or others. The laws for this differ in each state  
http://www.psychlaws.org/legalResources/index.htm 
for a summary of these laws) 
http://www.psychlaws.org/legalResources/ModelLaw.htm
 for excellent information about mental health law and terminology. 
In Canada contact the Canadian Mental Health Association. 

7. Your Attorney: to obtain temporary guardianship or power of attorney if the situation warrants it 

8. Your Bank: to make arrangements to limit your ill relative's access to bank accounts and credit cards. Many a bipolar family has faced bankruptcy in the aftermath of a manic wild spree! Protect yourself and your security. 

9. Your Doctor: Finally...and perhaps this should have been at the top of the list, arrange for some counseling and support for yourself. Living with a person with bipolar disorder may leave you feeling that you have "been run over with a Mack truck" ... you need support and time out for you as well. There...as I said a too short list. If you have other ways that have worked for you please let me know. 

 

Over the Longer Term 

The above suggestions are to be used mostly when you are in crises with your relative in an uncontrolled episode although many are useful in the longer term. I found many words of advice and suggestions for coping with a family member with bipolar disorder as well, and will share some of that advice with you.

 Education 

It is imperative that you seek out and learn all you possibly can about bipolar disorder. Like a general fighting a battle you are going to need all the ammunition you can garner at your disposal. There are many different sources of information...books, films, internet, support groups and others. Take from as many as you can and learn. 

One of the websites I recommend highly for relatives of individuals with bipolar disorder is: 

Bipolar Significant Others at http://www.bpso.org 

The Depression and Bipolar Support Alliance (DBSA) also offers information for both individuals with bipolar disorder and their loved ones. Their web site is at http://www.DBSAlliance.org 

There is also an excellent article on getting help for one who doesn't know or understand they are ill at http://www.schizophrenia.com/family/denialhelp.html The Schizophrenia Homepage. It is meant for family members of persons diagnosed with schizophrenia but much of the advice is applicable to those with bipolar disorder. 

Prepare yourself ahead of time by contacting experts and asking questions about such things as financial assistance, education, insurance, employment opportunities and other concerns that do have definite answers

Communication Do all you can to keep communication lines open between you and your ill relative. Assure him you are there for him and that you know he is sick but will get well again. Try to be a part of his wellness, but not a part of his illness. Encourage every effort to get better and go with him, rather than send him for help if he wishes. Try to project positive thoughts about his recovery. 

Network Lessen the burden on the family broadening the network of people who can help in a crises. Another person who has been through this, a concerned friend or professional may offer respite when you need it most. 

Live Your Own Life One of the hardest things for family members to do do sometimes, but one of the most important. It is imperative that you realize that your life doesn't stop to revolve around your ill relative. Take care of your own health and your own needs or you may not have the strength to cope. 

Know the Warning Signals Know the warning signals that may trigger an episode in your family member. Be prepared to act before they worsen and get out of control. Tragically suicide is an all too common result of bipolar disorder. Learn about it...and what you should watch for. Denying the possibility could end in tragedy. Be prepared. Educate yourself about suicide at http://www.metanoia.org/suicide/ 

Don't Expect Too Much of Yourself Surprise, surprise...You are not superman (or woman), and there are limits to what you can handle. It is natural for your emotions to vary...you are dealing with a serious situation. It's natural to feel angry, frustrated exhausted. These are valid feelings and ones shared by all families of bipolars. So cut a little kindness to yourself into the equation. 

Don't Blame Yourself In the throes of illness your relative may try to blame you for the way he is feeling. Don't listen. You have educated yourself and know that he has a chemical disorder. But neither will arguing with him at this point help much. Tell him that you will not accept what he is saying and that you know it is the illness talking. Don't let him hurt you. 

Talk About Your Situation It is hard sometimes to talk to others about how out of control things have become in your life. You don't want gossip or pity...you don't want lasting stigma...but you do need to talk to someone. Find a sef help group in your area if there is one...if there isn't start one...you'd be amazed at how many others face the same issue...or talk to a close friend. 

Seek Counseling If you are having trouble coping never be afraid or ashamed to seek help for yourself 

DON'T GIVE UP Don't give up too soon...recovery from an episode is not often a straight path...relapses are common...but wellness is achievable and has been achieved by many. 

NEXT TIME - I Know You Don't Want to Hear This! But chances are very good that there will be another episode. Try to be prepared. Have telephone numbers...doctor, emergency, admitting hospital, support, advice etc readily available. Ensure insurance is in place and the best that you can manage for psychiatric illness. Support others going through crises...as they will support you. The more prepared you are the easier it will be for you to get action and to cope.

Consider having advanced directives  in place prior to another episode.

 

RELEVANCE FOR EARLY INTERVENTION The study reported in this paper involved over 400 patients from around the country and showed, unequivocally, that poor insight into illness is common in psychotic disorders while being rare in other psychiatric disorders. Large proportions of patients with schizophrenia, schizoaffective disorder, psychotic mania and psychotic depression were generally unaware of having an illness. This study is the first to also evaluate whether patients with these disorders were aware of the signs and symptoms of illness that they personally suffered from. Again, a very large proportion of patients in each of these four groups had no insight into the signs of the illness that they had despite the fact that they had been hospitalized in order to receive treatment for the very same symptoms that they were unaware of. The results of this study make it clear that many patients with these disorders lack the ability to recognize that they are ill and in need of medical care. 

Amador XF, Flaum M, Andreasen NC, Strauss DH, Yale SA, Clark CC, & Gorman JM. (1994). Archives of General Psychiatry, (51): 826-836. http://www.psychlaws.org/MedicalResources/Insight1.htm

RON S. HONBERG is Director of Legal Affairs for the National Alliance for the Mentally Ill (NAMI) and earned his Juris Doctor degree from the University of Maryland School of Law in 1990. A member of the Maryland Bar, he also holds a Masters Degree in Counseling from the University of Maryland and is a former president of the Maryland Rehabilitation Counselor's Association. Reprinted with permission from the publisher from The JOURNAL of NAMI California, Volume 11 Number 3 "Mental Illness and the LAW"

 

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