Expert answer:Article critque 3 Schizophrenia
Solved by verified expert:After reading Schizophrenia: A Sibling’s Tale, write a paper of 500-750 words in which you address the following questions:What did you think of the article?How did the article relate to topics presented in the textbook?What interesting questions did the article raise for you?Identify the positive and negative symptoms of schizophrenia and give an example of each.Describe the types of therapy discussed in Schizophrenia: A Sibling’s Tale. include a minimum of two outside references or other resources to highlight and support your viewpoint.Prepare this assignment according to the APA guidelines
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Feature
SCHIZOPHRENIA:
a sibling’s tale
A diagnosis of psychosis can have a devastating effect on close family members
of the person concerned. Stephan Kirby introduces Leanne Bowman’s account
of living with a brother who was diagnosed with schizophrenia five years ago
Summary
Stephan Kirby suggests that mental health
professionals need a greater insight into the effects
a diagnosis of serious mental illness has on family
members. Leanne Bowman’s account explains how
her brother’s diagnosis was received and how living
with him since then has introduced new challenges
to her life.
Keywords
Serious mental illness, schizophrenia, siblings,
advocacy
As an occasional user of mental health services,
and a mental health nurse of many years’ standing,
I have some insight into the needs, requirements
and problems facing mental health professionals
and the users and carers we come into contact
with. But the one thing I have never given much
thought to over the years, apart from as an
academic or professional requirement, was how my
own mental health issues were affecting and had
affected loved ones around me.
As professionals, we know it makes sense to
foster relationships with service users, based on
listening and understanding. But from political
and common-sense points of view it is vital to
remember to listen to our patients’ carers, their
parents, siblings, children and other loved ones, and
understand what the experience of mental illness is
like for them, as well as for the patient in our care.
I met Leanne, a mental health nursing student,
when she was embarking on her final year of study.
18 September 2009 | Volume 13 | Number 1
When preparing some work for me, Leanne was
open and honest when discussing her brother’s
major mental illness and the effect it had and was
having on her family life and her training.
We hope this paper offers readers an insight into
the trials and tribulations faced when a close family
member has a serious mental illness. We hope
readers will gain an understanding of what it is like
to have a sibling diagnosed with schizophrenia.
In what follows there is a discussion about
the feelings, isolation and stigma encountered
by Leanne when she learnt that her brother ‘was
schizophrenic’, a term we accept is not politically
correct. It shows the importance of appropriate
support from mental health services and
professionals to enable families to cope effectively
with the situation.
Leanne Bowman’s story
‘I am a third-year mental health nursing student
and by no means an expert on schizophrenia. But
I can explain how the condition affects the family
because my brother Jamie (not his real name) was
diagnosed with this severe and enduring mental
illness when he was 18 years old. Our mother is his
primary caregiver and I am the secondary, but no
less involved, carer.
‘When Jamie was diagnosed in 2003 I experienced
a mixture of feelings and emotions. First, I felt a
great sense of loss, almost like a bereavement. In
a sense it was a bereavement because, while Jamie
looked the same, he acted very differently from the
brother I knew. This process is described by Kuipers
et al (2002) who identify two types of loss: the loss
MENTAL HEALTH PRACTICE
Jim Varney
Feature
‘I felt that because I was the older sibling
I had the responsibility to protect my brother
from suffering, but I had somehow failed him’
Leanne Bowman
MENTAL HEALTH PRACTICE
September 2009 | Volume 13 | Number 1 19
Feature
of the person we knew and the loss of the hopes
and aspirations we had for them. I also experienced
“survivor’s guilt” (Kuipers et al 2002) because I was
the “normal one” and had managed to escape the
suffering of being mentally ill. I felt that because
I was the older sibling I had a responsibility to protect
my brother from suffering, but I had somehow failed
him. I also felt frustrated because my mother and
I seemed to be doing everything we possibly could to
help Jamie, but it was never enough.’
Stigmatisation ‘I had a basic understanding of the
term schizophrenia, but probably like many others
I had misconceptions and was even scared of the
term and its connotations. In society in general there
is a stereotyped view of people with mental health
problems, especially in the case of schizophrenia.
The common misperception is that these people are
violent, exhibit sexually inappropriate behaviour and
have a split personality (Kuipers et al 2002). Corrigan
and Watson (2002) refer to this stigmatisation as
“the double misfortune of the mentally ill”. It occurs
because of discrimination in areas such as work and
independent living and, second, due to the effect
of a culture steeped in stigmatising images that are
exacerbated by headlines in the national media, such
as “Schizophrenic man chops off his mother’s head”
(Anon 2004) or “Schizo cabbie knifed six” (Moult
2005).
‘In the five years since my brother was diagnosed
we have encountered our share of stigmatisation and
isolation. When Jamie first came out of hospital the
positive symptoms of his illness (Box 1) appeared
to be under control but he was suffering with the
negative symptoms and often stated that he felt
depressed. As a result, he would often use socially
inappropriate coping strategies to lift his depressive
state, which more often than not involved taking
illicit substances.
‘When Jamie was taking them he became violent
and aggressive towards our mother, towards me
and his friends. At first, we turned a blind eye and
tried to deal with it ourselves because we wanted to
protect him and did not want him to get into trouble.
Box 1 Positive and negative symptoms
As a general rule, positive symptoms are an additional experience, whereas
negative symptoms are a reduction in normal experiences:
Positive symptoms
■■ Hallucinations.
■■ Delusions.
■■ Thought disorder.
■■ Catatonia.
(Brennan G (2009))
20 September 2009 | Volume 13 | Number 1
Negative symptoms
■■ Lack of volition.
■■ Lack of excitement.
■■ Poverty of thought.
■■ Poverty of speech.
But the violence and aggression escalated until it
reached the point where we had to call outside help
every week to have him removed from the house.
‘This sort of behaviour does nothing to promote
a positive image of people with schizophrenia, but
I understand that Jamie acted this way because of
the substances he was taking. When he is not taking
anything, he is a gentle and loving human being, but
I do not think our neighbours understood that.
‘Schizophrenia can be devastating not only for
the person who is ill, but also the entire family.
Among the most vulnerable and most affected are
siblings (Friedrich et al 2008), as the unremitting
stress affects many aspects of their lives, including
relationships, roles and health. I can relate to this
because my life has changed dramatically since
Jamie’s diagnosis. As a result of his changeable
moods and unpredictable behaviour, I stopped
inviting friends over because I often felt embarrassed
because I did not know what sort of mood he
would be in from one minute to the next.
‘I was lucky because my friends understood when
I had to cancel plans or if I was late. They knew it
was because Jamie’s needs had to come first. On the
rare occasions when I managed to meet friends it
was hard to focus on the conversation because I was
worried something might be happening at home.
At times my friends’ problems, such as boyfriend
troubles, seemed unimportant compared with what
was happening to our family. Chapman (2004), a carer
herself, says she was reluctant to mix socially because
her son’s illness was always uppermost in her mind.’
Carer experience ‘The relationship with my mother
also changed. We had always been close and in some
ways we became even closer. But there were times
when we would disagree about the best way to deal
with a situation. For example, if my mother and
I had arranged to go shopping, but Jamie wanted
to go somewhere different, his needs came first. If
I disagreed with my mother and said we should do
as we had planned, neither of us would have been
able to enjoy the shopping because we would have
worried about how Jamie had reacted to taking
second place, so we would cancel our arrangements.
‘The National Service Framework (NSF) for Mental
Health Standard 6 states that “carers play a vital
role in helping to look after service users of mental
health services particularly those with severe mental
illness” (Department of Health (DH) 1999).
‘The National Institute for Health and Clinical
Excellence (NICE) (2002) also acknowledges that
“carers of someone suffering with schizophrenia
have an integral role in community mental health
care”. Their experiences need to be taken into
MENTAL HEALTH PRACTICE
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account for their own wellbeing and to ensure
they can give their loved ones relevant community
support. NICE makes it clear that intelligible
information about schizophrenia and the possible
role families can have in promoting recovery and
preventing relapse should be made available to
service users and their families.
‘But as a carer I feel let down by mental health
services. After Jamie was first admitted to a
psychiatric unit under the Mental Health Act 1983,
where he spent 28 days, I kept asking to speak to the
mental health nurses on the ward to find out how he
had been or if they were any closer to a diagnosis,
but they always seemed to be too busy to talk to
us. On the last day of Jamie’s detention, my mother
and I were to our surprise invited to the ward to
discuss Jamie’s progress and plans. But the mental
health professionals seemed to be talking among
themselves and the only time they made eye contact
or paid us any attention was when they told us that
Jamie’s diagnosis was schizophrenia, that we could
take him home and that we would get some support
from a mental health team specialising in psychosis.
‘I wanted to shout: “What does that mean?”, “Why
did this happen?”, “What can we do to help?” But we
were not given the opportunity to ask any questions.
‘The Mental Health Policy and Implementation
Guide (DH 2001) states that early intervention in
psychosis teams (EIP) are there to support people
aged 14-35 years with a first presentation of
psychosis and to offer support for the first three
years. The guidelines also state that EIP teams
should involve families and carers in the assessment
and treatment process, as well as offering family
therapy and maintaining regular contact with carers.
‘The EIP team did give us some useful information
about schizophrenia and had regular contact with
Jamie. But I felt that I was disregarded as a carer
because I was not the parent or the primary carer. It is
important to recognise that the bond between siblings
is distinct and can be the longest lasting relationship
in some families (Barnable et al 2006). Even if they
are not involved in care, siblings can still experience
stress by being part of the same household and
because of the chronicity of the illness.’
Expressed emotion ‘Despite initial promises, my
mother and I were not offered any family therapy.
There were times when my brother and I were
constantly arguing and being hostile towards one
another, due to his unpredictable behaviour. At
these points, it would have been useful to have had
some knowledge of the stress-vulnerability model
(Zubin and Spring 1977), which the EIP teams use
to underpin care. But I had not heard of it – or the
MENTAL HEALTH PRACTICE
I wanted to shout: ‘What does that mean?’,
‘What can we do to help?’ But we were not
given the opportunity to ask any questions
concept of expressed emotion (EE) (Brewin et al
1991) – until I started nurse training.
‘The theory of EE (Thomas et al 2004) correlates
certain family communication patterns with an
increase in symptoms and relapse in patients with
schizophrenia. I support the idea of EE, but in
practice, it is difficult not to make negative comments
and to be critical when your sibling is constantly
being demanding, and is hostile and aggressive
towards you, especially when there has been no
offer of support or family interventions to help deal
with the situation more positively.
‘My brother too received little help, and was
offered only antipsychotic medication. We were told
by the mental health professionals that as long as
he continued to take his medication he would be
“under control”. The drug Jamie was prescribed,
amisulpride, is an atypical antipsychotic drug that
is a first-line treatment in people newly diagnosed
with schizophrenia (NICE 2002). I do not dispute
its effectiveness in alleviating some of the positive
symptoms of his illness, but he still has auditory
hallucinations – even though he will deny this to
his mental health worker – and he continues to
suffer with the negative symptoms of schizophrenia,
particularly a lack of motivation.
‘Jamie’s lack of motivation has a major impact on
the family because we constantly have to prompt him
to attend to even simple things such as self-care, or to
make doctor’s appointments to get his prescriptions,
and then remind him to take his medication twice a
day, every day. I feel that badgering him to take his
medication takes away his freedom of choice. When
I am at home my role as a sister is over-ridden by a
nursing role, so it feels that I never get a break from
mental health and mental illness and the professional
caring role I am training for.
‘I think it would have been beneficial for Jamie to
have tried interventions such as cognitive behaviour
therapy (CBT), which can work in conjunction with
medication to try to normalise his experiences of
hallucinations. Evidence suggests that therapies
such as CBT can be part of treatment to reduce the
impact of the positive symptoms of schizophrenia
(Turkington et al 2006).
‘Another thing never mentioned by the
professionals who have worked with us is the word
“recovery”, which the US National Institute of Mental
Health (NIMH) (Darton 2002) defines as the “act of
September 2009 | Volume 13 | Number 1 21
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Implications for practice
■■ Staff caring for a person with schizophrenia must
be aware not only of the patient’s experiences
but also that of family members, who have to live
with the crisis phase of the illness.
■■ Staff should seek and acknowledge family
members’ accounts, recognising that they are
as much experts on the illness as the patient,
especially in terms of relapse triggers and
coping strategies.
■■ It should be remembered that true collaborative
working necessitates the involvement and
experience of the family.
claiming and gaining the capacity to take control of
life that is personally meaningful and satisfying…”
despite “…the limitations and challenges invited and
imposed by distress, its treatment and the personal
and environmental understandings made of them”.
‘But, despite the lack of support from services,
Jamie has always had and will always have our
support. It is almost five years since his diagnosis.
He has not been hostile or aggressive for at least a
year since he gave up taking illicit substances. He is
demanding at times and does not always understand
that I cannot drop everything because he says so.
‘Jamie has a long-term girlfriend with whom he
is very happy and he feels mentally well enough to
find employment. He is an intelligent, thoughtful,
insightful and creative young man. And he has had
recognition for his talents as a budding DJ.
‘At times I lost sight of what it must be like for
Jamie. He still hears voices when he is particularly
stressed; he has lost friends and being labelled “a
schizophrenic” has affected his self-confidence. But
no matter how difficult it is for his carers, it is worth
to reminding ourselves now and again that we are
not the ones with schizophrenia.
‘My mother has been a tower of strength and she
has kept me strong. I have the utmost respect for
her: she is a fantastic role model. I am not sure what
the future holds for me as a carer and I think there
are likely to be more difficult times ahead, but we
will face them as a family.’
Nurse training ‘Three years ago, I started my mental
health nurse training because I wanted to help other
people with mental illnesses and to be able to pass
on my negative and positive experiences to other
professionals, academics, carers, fellow students
and, most importantly, service users. During clinical
placements I have had the opportunity to work with
people with a variety of mental health problems.
‘I find myself drawn to working with young men:
I find in them the qualities I see in my brother.
They do not usually open up immediately about
their fears and it takes time to build a therapeutic
relationship and gain their trust, whereas the women
I have worked with generally find it easier to express
their feelings and are more willing to “engage”.
‘One thing I find difficult about being a nursing
student is how my experiences and viewpoints are
frequently challenged, albeit unconsciously. I often
hear staff nurses saying things such as “there is so
much high EE in that family, no wonder he is back in
hospital”. But I don’t think I am judgemental and I will
always make time to speak to service users’ families,
offering as much support, information and, perhaps
more importantly, hope for the future, which I believe
is an integral part of the nursing role. We need to walk
a mile in their shoes to appreciate fully what it is like
to have a family member with a serious mental illness.
‘Now that I work in mental health services
I am more positive about the future. Services have
improved since 2003, with more nurses being
trained in psychosocial interventions and putting
them into practice. I hear the word “recovery” a lot
more than I did five years ago. I have worked with
some excellent nurses during my training. I hope
that when I am qualified I will never to be too
busy to talk to a carer as I know only too well the
unrelenting stress of being a carer of someone
with a mental illness.’
This article has been subject
to double-blind review.
For author guidelines
visit the Mental Health
Practice home page at www.
mentalhealthpractice.co.uk. For
related articles visit our online
archive and search using the
keywords
Leanne Bowman was a nursing
student at the University of
Teesside at the time of writing
this article. She is now a staff
nurse working on an acute
inpatient unit at Tees, Esk
and Wear Valley’s NHS Trust
Stephan Kirby is a senior
lecturer in forensic mental
health at the University of
Teesside
Ms Bowman’s brother has
consented to this article being
published
References
Anon (2004) Man decapitated mum. The Sun
March 26 2004. London.
Barnable A, Gaudine A, Bennett L et al (2006)
Having a sibling with schizophrenia: a
phenomenological Study. Research and Theory
for Nursing Practice. 20, 3, 247-265.
Brennan G (2009) The person with a perceptual
disorder. In Norman I, Ryrie I (Eds) The Art
and Science of Mental Health Nursing. Second
Edition. Open University Press, Milton Keynes.
Brewin C R, MacCarthy B, Duda K et al (1991)
Attribution and expressed emotion in the
relatives of the patients with schizophrenia.
Journal of Abnormal Psychology. 100, 546-554.
Chapman V (2004) Carer issues in mental
health. In Kirby S, Cross D, Hart D (Eds) Mental
Health Nursing: Competencies for Practice.
Palgrave Macmillan, Hampshire.
Corrigan P, Watson A (2002) The paradox
of self-stigma and mental illness. Clinical
Psychology: Science and Practice. 9, 1, 35-53.
Darton K (2002) Recovery. Openmind. 115, May/
June. www.mind.org.uk/Shopping/Openmind/
Extracts/ExtractfromOpenmindIssue115
Recovery.htm (Last accessed: April 29 2009.)
Department of Health (1999) The National
Service Framework for Mental Health: Modern
Standards and Service Model …
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