Basic know-how Communication

I know from many relatives that thy rack their brains as to how they might handle the sick person „“better“, what they did “wrong“ in the past or perhaps even whether they themselves are at fault for the sickness of the family member. In the following initial exercise (in accordance with Wilms. i.a. 2005) I would like to invite you to answer the following questions:

Intense toothache cannot of course be compared with the complexity of psychological illnesses. However, this little experiment of thought perhaps helps you to think about your role in handling the sick family member. In my experience, relatives at some point no longer become simply relatives, buts also assume the role of nurse (“Have you taken your medicine today?“), the role of a social worker (“We have to fill in this form, otherwise you won’t receive any money!“), the role of the psychologist (“How are you today, you don’t look too well. Can you explain why things are getting worse again?“) or many other roles. 

By that I do not mean to say that such behavior is “wrong“. I would simply request you ask yourself whether this plethora of strenuous roles is not sometimes too much for you. And maybe these roles don’t make communication with your family member easier, since he may sometimes not know whether he’s facing his mother or the social worker.

Remember, psychological illnesses are complex disorders which

• are reflected in biology – and thus also in physical experience and feeling
• in thinking and
• in behavior and
• in interaction with the social and working environment.

Treatment of schizophrenia can initially start in one area – for example via medicine in the field of biology. However, it is usually helpful to start with therapy in all four sections coordinated in a time schedule. Experts exist in each field who “wear their hat“ at different times during therapy, and who should assume responsibility with the patient. Such experts are specifically qualified for such purposes, and it is not the responsibility of the relative to take on their function.

The main task of the relative may simply be to “cope with“ the illness together with the sick person, i.e. to get through it. An additional task which relatives may assume in consultation with the sick person is to support the person in sickness management so as to ensure that his “navigation in the support system“ is facilitated. However, responsibility for sickness management always remains with the sick person himself.

You have not studied Psychology, Medicine or Social Work and have not completed therapy training. Therefore you are behaving “correctly“ if you behave as you used to behave in the past e.g. as mother or father and how you met each other as partners – including compromises which you have agreed on together.

Even if you had studied Psychology, Medicine and Social Work and you had all knowledge at your disposal, would you want or be able to combine psychologist, doctor, social worker and relative in one person? Imagine the burden you would then have on your shoulders? The way you normally live together is the way your family member knows you, and that is the right way for you to  behave.

If you think you ought to change your behavior because of the illness, agree on this with the sick person. However, the most suitable moment for such decisions is not during an acute illness phase, but rather a phase during which your family member is feeling better. Ask him what he would like you to do the next time he appears to slip into an illness phase. Check whether you consider such wishes to be useful, whether you can or want to fulfill them. And, together, find an acceptable compromise.

You will find various ideas in this paper on how to keep up conversation and to communicate with each other. I have decided to term these techniques “basic know-how“ – not because it is essential to know, but because this involves techniques which can be helpful in general in conversation – i.e. not only with the sick family member.

“The better I’m in contact with myself and the clearer I convey my message, the more open I am for my conversation partner and can be sure to be correctly understood. Making contact doesn’t mean asserting your own view as convincingly as possible, but of finding a way which provides both partners with the opportunity of talking honestly to each other.“ (Satir, 1989)

Communication is the complex process of information transfer between people. We differentiate between the person who sends information (sender) and the person who hears the information (recipient). The words said in information transfer play a role (verbal shares), but we also receive information via gestures, facial expressions, tone of voice, posture, pitch of the voice, emphasis, etc. (nonverbal shares). In addition, aspects like the attitude to each other are also transferred, one develops assumptions on the inner at attitude of the conversation partner. Communication is never objective, but is always dependent on the persons who are in contact with each other.

When a message is sent, the following four information aspects are transported:

• Factual information: What factual information is transferred? What  am I informing about?
• Relationship information: What is my attitude to the other person? How good is my contact to him?
• Self-revelation: Which information about me and my feelings are included in the  message? How am I revealing my own attitude?
• Appeal: What am I trying to effect in the other person via my message? What do I want the other person to do or think?

And with which ear we hear something (the factual ear, the relationship era, the self-revelation ear or the appeal ear) also depends on your own mental state, your own interpretation of that which is said, and the relationship between the communication partners.

Communication with a sick family member is sometimes very strenuous and may lead to misunderstandings and to conflicts. In such a situation one often wants to change the other person, to shake him. But no-one can change another person, and that’s why it is always necessary not only to look at what the other person might do differently, but also to reflect on yourself. One “trap“ in communication involves our own appraisals and interpretations.

 
Certain interpretations and thoughts influence our feelings, our self-esteem, sometimes even our body. For example, anger may cause you to feel stomach ache or suffer palpitations. Our feelings tell us how we would like to behave and also determine the behavior we then choose. Our reaction then influences the behavior of the other person.

Since many of the variables which co-determine communication remain unknown for the other person, this communication model can be compared to an iceberg. From the outside, only the action and reaction of the two communication partners are to be seen – that which happens beneath the water surface mostly remains invisible. This means we should always consider that something is received in a different way than we meant it.

There is of course no patent recipe for successful communication. Stiff heeding of communication rules and techniques is bound to take the spontaneity and personal tone out of a conversation. Conflicts are part of analytical dispute and of negotiating respective points – the question is: are conflicts helpful in finding solutions.

However, observing some tips can help improve communication.

» » Typical communication situations

According to Hinsch and Pfingsten (1998) almost all social situations can be allocated to three different types. In their training program, the authors convey social skills, techniques and behavior which can be applied in the respective situations. The three different types involve:

• Asserting your right;
• Clarifying relationships;
• Seeking understanding.

Most situations in which you find yourself in communication with your family member belong to the type of ‘clarifying relationships‘. However, for better understanding I would like to present all three types.

• Asserting your right
  In these situations your ‘I’ is in the right to make justified demands of your conversation partner and to assert such rights. This includes situations in which you wish to make a claim for a product due to a manufacturing error. Rejecting a rep. at the door or looking around a shop and asking for advice without buying anything are also included in this group. In contact with your relative this would include situations in which you have to go to work early the next morning but your family member listens to extremely loud music until 2 o‘ clock in the morning.
• Clarifying relationships
  This type includes situations in which two equal partners have to negotiate differing interests with each other. This applies to partnerships as well as to parent-adult child relationships, and also to friendships and some contacts to colleagues and superiors. For example, a married couple has to negotiate how to arrange the evening event – despite different interests. This type also includes conveying unpleasant feelings, if the behavior of the other person has been perceived as disturbing. Addressing and clarifying conflicts also belongs to this category. In contact with your relative this would include situations in which you express your disappointment or anger about agreements not kept. It would also include situations in which you might have differing ideas about medicinal treatment than your family member and wish to talk about it with him. Preparing a crisis plan to handle future relapses is also part of this category.  
• Seeking understanding 
  This type comprises two forms of situations. It involves situations in which contact is made. This includes the attempt to try and get to know someone, a brief, non-committal conversation with a salesperson or a request to a passerby to give you small change. But this type also includes situations in which you have made a mistake and wish to alleviate the consequences. For example, you have parked your car incorrectly and try to convince the traffic warden to keep the fine low.

The common issue of all these situations is the aim of persuading the other person, who is basically in the right, to give up his right and to fulfill your own wishes and needs instead. 

In contact with relatives, the following examples of situations could be allocated to this type. The sick family member has withdrawn, but you would like to persuade him to support you in a task.

The greatest difficulty and resultant misunderstandings involves differentiating between situations which belong to the type “clarifying relationships” and the type “asserting your right“. Conflicts always emerge in relationships if one person is of the opinion he has to assert his right against the other person who, however, also sees himself to be in the right and, instead of looking for solutions, both partners seek only to represent their own position and do not budge from their position.

Understanding for the view and attitude of the other person can sometimes have a miraculous effect.

» » Helpful communication techniques

Irrespective of the communication situation, there are certain communication techniques which prevent misunderstandings and which contribute to a clarification of positions and concerns. It is helpful to consciously exercise these in role games – possibly in the scope of a relatives’ group.

Active listening

The aim of this technique is for the other person to feel he is understood, but that you as the relative also have the opportunity to enquire. This method is helpful to “slip inside the skin of the other person“for a brief moment and “to see the world with his eyes“. At the same time, active listening sometimes reduces the high speed existent in conversations. You don’t have to react to something immediately or justify yourself, but can first try to understand the position of the other person.

Active listening includes eye contact, making sure your conversation partner knows he has your full attention. Convey a signal by nodding, one-word responses ("Mhm", "Aha" ...) that you can follow what he is saying. Don’t bring any new topics into the conversation, but make simple enquiries and remain with that which the other person wants to tell you. Try not to interrupt the other person.

It is also important to withhold your own opinion for a short time and not to express any value judgments (“That’s nonsense!“) or open criticism. It can sometimes be helpful to summarize what has just been said (“Have I understood you correctly that you think I skipped our appointment deliberately?“).

 
I-messages

Sentences are often started by “Today you’ve got to…“. One consequence may be that the other person does not feel understood and feels patronized. Such sentences usually trigger objection since the other person would first like to show his opinion. Since it isn’t possible to change another person, it is more useful in communication to speak about yourself. You’re own feelings, needs and wishes should be clearly and directly addressed. These are some rules of thumb for how I-messages ought to be formulated:

• The sentence should begin with "I". Describe the feeling you are sensing at the moment, e.g. : "I’m disappointed / annoyed / sad / relieved / worried / ..."
• Describe clearly the behavior of the other person or an event which has triggered this feeling in you: "... because you did not attend our common meeting with the neurologist today."
• Avoid generalizations such as "always", "never", always", "yet again" ...
• Avoid global reproaches such as "You have yet again ...", "I can’t rely on you!"
• Describe the wish, the request or an improvement proposal for the future:  "Please call me next time you don’t come." Or: "Please let me know in good time next time, then I can do something else in that time."

You don’t have to use these formulations – even if that may be easier at the beginning. When you have more experience, it is better to apply your own style so that sentences don’t sound too mechanical.

 
It is always helpful to first practice new behaviors with someone or gain some security in applying such behavior. However, remember to look for former behavior and communication methods with which you are satisfied and that which don’t need to be modified!

Expressing feelings – both positive and negative

The expression of feelings plays a very special role in the relationship between people. Most people watch out for the reaction of others to derive information or guidelines for their own behavior. At the same time, feelings in everyday communication are often “swept under the carpet“. It is often assumed for positive feelings that the other person is aware of them, so that the other person is not told about such positive feelings. Negative feelings sometimes involve shame and fear. Some people simply swallow their negative feelings in order to avoid conflicts or because they fear about their relationship to the other person. This may lead to many negative feelings building up – and then  comes the final straw, and  breaks the camel’s back. Pent-up feelings burst out without control and the situation may escalate. In such situations both sides tend to treat the other disparagingly, constructive handling of the situation is almost impossible due to the mutual tension.

However, it is also often the case that people only convey things which they find disturbing about the other person at that moment – the view of things which are going well is lost. Getting on together appears to involve only problems and difficulties. To ensure this impression does not emerge, the ratio between appreciation and criticism should be roughly 7:1! Specify clearly what you like about the other person.

 
Expressing negative feelings can be important in order to discuss grievances and to bring about changes. However when expressing negative feelings it is also important to be careful about the formulation of I-messages:

• Your feelings should be directly addressed and relate to specific behavior of the other person, not to his person as a whole.
• Also address your negative feelings directly, such as anger, annoyance, disappointment, helplessness. Avoid commands, aggressive expressions, threats or reproaches.
• Pay attention to your facial expression, gestures and body posture. Try to say the same things as you do with your body language.

Criticism and paternalism also put your conversation partner under pressure and can raise mutual stress levels. Try to show a willingness to compromise where possible, but also to insist on clear agreements if you think this is important.

Avoid slipping into a problem trance. In the course of the conversation, try to talk about possible solutions. It is not helpful to be too careful to the other person or to underchallenge him. At the same time, it is also unhelpful to ‘shake‘ him or to overtax him!

» » Training in solving problems

 It occurs again and again in discussions, conflicts and disputes that it takes “hours“ to discuss how someone behaved, how someone did something wrong, how something was misunderstood, etc. This leads to a situation in which the problems are addressed but that the conversation partners no longer know what is to be changed or how to avoid such a dispute in future.

And sometimes you don’t just stay with one problem, but tell the other person what’s gone wrong “in the past 20 years“. You feel tired and frustrated after such a conversation, you’re annoyed about yourself and the other person, or feel misunderstood – which is a sure sign that you and your conversation partner have slipped into a “problem trance“, that you only speak about problems and not about possible solutions.

In such situations,  problem solving training is useful. The aim of this technique is to discuss difficult issues in a structured manner and above all with a solution-oriented approach. A solution should be there at the end of the conversation, which is acceptable and feasible for all involved.

Problem solution training comprises seven steps. It is assumed the aforementioned conversation techniques are already applied. A willingness to compromise is required as well as the ability to let go of your own ideas of an ideal solution.

Step 1: Describing the problem

Talk about the facts involved. Don’t address all issues at once, but define one topic. Give your conversation partner the opportunity to present his point of view, listen carefully, do not interrupt him. If anything is unclear, ask. At the end it should be possible to write down the problem actually involved.

This conversation  phase may take some time. It is important that all have understood which problem is to be discussed. Distracting from the topic can be stopped by saying for example: “That’s a different topic. Today we wanted to talk about….!“

Step 2: Writing down possible solutions

The aim here is to find as many proposals for solutions as possible. Each should put forward at least one proposal. Make sure you do not assess or play down solutions in this conversation phase. Allow all solutions to be written down – even unusual or crazy ones! Make a note of all solutions put forward.

Step 3: Discussing the possible solutions

Now discus all solution proposals one after the other with regard to their benefits and disadvantages. Don’t merely specify the advantages of your own proposal, but illustrate the other side. Sometimes something is of benefit to one person which is of a disadvantage to the other. Make sure you assess only the solution and not the person or his characteristics!

Step 4: Select the best possible solution(s)

Try to decide together on the best possible solution. In this phase there is often a power struggle since each person wants to cling to his own proposal. Show a willingness to compromise and, if necessary, remind your conversation partner that it will help no one if there is no mutual solution.

If conversation stagnates here, return to point 2 and try to find/discover other solutions.

Step 5: How can the best possible solution be put into practice?

Now think together about which steps are necessary to implement the solution. Try to specify these as exactly as possible. Also define who is to do what. Make a note of all steps, since this ensures more commitment.

Step 6: Checking implementation

In the following days, check that the steps agreed on are observed. Check your own tasks as well as those of your conversation partner. Express respect when your conversation partner observes the agreement. Remind him in a friendly way of the agreement if implementation has not taken place within the agreed time.

Step 7: Feedback

Sit down together again. Discuss what has happened and whether the problem solving training was successful. Look closely at the steps which were successful. These include many indications of what might also be successful in difficult situations in future.

Also discuss the obstacles which made implementation difficult, and what would need to be optimized next time. But don’t dwell on such discussion. Each conversation partner should be able to say what went well and what went not so well, and ensure that there is a positive message at the end of the feedback round.

This chapter focuses on how communication changes when a family member suffers from a psychosis. We differentiate between communication during a psychotic crisis and after a psychotic crisis! If you think about the communication you have with your family member, you will initially think of many things which are difficult or which do not function properly at the moment, Perhaps you were happy to receive tips on how to do things ‘correctly‘. And yet I am convinced - no matter how sick your relative is and no matter how difficult it is between family members – there are surely moments during communication with your family member in which communication works. So please spend a few minutes to look at what’s good about your communication!

» » Communication during a psychotic crisis

One of the difficulties is that it is difficult for both sides to clearly say during and after the crisis what they actually feel. A lot is only touched on vaguely, unspecifically or not at all. If a conversation does arise, so many thoughts have built up in the relative as well as the patient that it is easy to end in a “problem trance“.

The illness sometimes causes the sick person to withdraw – he seems to want to avoid any kind of communication. Especially questions from the relative relating to his health (“How are you, how are you feeling?“) go unanswered or are simply ignored. In some cases it is even difficult to start a conversation, since the patient physically turns away or leaves the room.

All family members are under stress and react differently than normal. Not only the sick person will behave differently, you as a relative will become different when under stress.

It cannot be expected that the sick family member is able to open himself to the wishes and expectations of a relative in an acute crisis situation. 

 
The aim should be to make sure the higher level of stress is not made worse by way of arguments. Try to convey clear, direct and simple messages. Avoid emotional outbursts and criticism of the sick person. This would lead to him feeling under pressure, his tension level would rise and the situation could escalate. In an acute phase it is very important that you, as a relative, remain calm – even though that can be difficult.

Positive or negative feelings should not be discussed with the patient during this period, he may feel overburdened. However, to ensure you don’t have to swallow all your feelings during this period it is helpful to talk to other relatives and to seek help and relief with friends or other family members or to write down the things you’re thinking about in a diary.

Communication is especially difficult with someone in an acute psychotic phase, since the interlocutors are in differentl realities. Imagine a bee and a dog on a field. The bee registers the different color patterns and the dog will mainly smell things. You can think about communication with a psychotic person as if a bee and a dog try to talk about a flower. One will not understand what the other means, since the realities and experience are completely different.

If your family member has psychotic experiences which do not comply with your reality (e.g. all people are watching me, there’s a conspiracy against me, my parents are in fact not my parents), try to leave the reality of the patient as it is. As awful as that may be, it is not possible to talk the patient out of his reality. On the contrary: trying to convince the patient of reality usually makes the situation worse, in two ways:

In their mind, psychotic patients often think that someone could injure them, pursue them or observe them. If relatives then “deny“ the event which the patient considers to be an absolute fact, he will feel confirmed in his psychotic assumption. In the worst case it could happen that the patient loses trust in the relative, since in his opinion this relative is now also turning against him.

And speaking against the patient may even make the distress of the patient worse. Psychotic experiences are very frightening and stressful for most sick persons, since their map is no longer in order, the feeling of not even being understand by people in their close environment may worsen such feelings of anxiety and loneliness.

Therefore, try to show understanding and acceptance for the present situation. Try to sympathise with feelings of the patient and not to focus the conversation only on the psychotically changed experience. Try to choose neutral conversation topics to try to carefully steer the patient to his healthy aspects.

Since people are very open for any kind of stimulus during acute psychosis (noises, colors, etc.), but cannot process them all, it is important to ensure a calm atmosphere and to avoid disturbing external stimuli (e.g. switch off the radio, don’t walk around yourself during the conversation, accept the withdrawal).  If the sick person wishes, physical contact (an embrace, a hand on his shoulder) and the clear message that you are there can be helpful and relieving for the patient. 

 
Crisis support does not mean that the person supporting shares or corrects the experience, but that he sees and understands the distress the sick person is experiencing.

» » Communication and aggression

It may be that your family member tends to be aggressive in acute phases. Sometimes there are warning signs before such aggressive outbursts, which you should not ignore. You can recognize internal agitation via physical tension, a threatening gesture, shorter physical distance and verbal threatening or abuse. Some sick persons are so tied up in their system of thoughts that they don’t recognize the person with them or suddenly see someone else in the familiar person, and feel threatened by that person.

The main principle in such an agitated condition is to reduce the risk potential for you and for the sick person. In case of serious aggression or physical violence you should leave the room and obtain help for yourself and the sick person. This may mean you have to call the attending physician, the social psychiatric service or the emergency doctor. It may, however, also mean that you inform the police and have the sick person taken to a psychiatric clinic against his will.

If there is a risk for others or for you, psychiatric treatment and professional support is essential!

Even though not every aggressive situation can be managed using de-escalation strategies, these may be applied in certain situations. This means you must not give any reason for provocation. Yes/no questions are to be avoided, since this often makes the sick person feel like being cornered. If necessary, make concessions. In situations where the agitation potential is already very high, it is irrelevant who is right and wrong. Power struggles are to be avoided at all costs. Your aim should be to control the situation, not the sick person. If it’s possible for you, continue to show attention and to be open.

Try to give the sick person the chance to make decisions, sometimes offering various solutions can defuse the situation, since the sick person has the feeling of being able to influence things himself. Sometimes this may overtax the sick person.

Your speech should be calm and not too loud. Even if the sick person is currently in a different reality, he should always have the feeling you take him seriously. 

 
Since hostile behavior to the other person can also bring about hostile behavior, you should be aware of your own behavior and limits. It is a sign of competence if you do not want to solve all situations alone, and obtain help in difficult moments.

» » Communication and passiveness

Concentration problems, lack of drive, loss in interest and an increase in the need to withdraw and to sleep occur in many psychological disorders.

These symptoms are not recognized or assessed as sick by many relatives. They interpret such behavior more as laziness, disinterest or ‘letting yourself go’, and therefore react with less compassion. But such symptoms are also a part of the illness and should be assessed as such. They may be an indication of being overtaxed or a consequence of medicinal treatment. After an acute phase, some sick persons require peace and quiet and a retreat in order to process what they have experienced. Therefore, the following should be observed when handling such situations:

Do not continuously compare the abilities of your family member, and not only with how they used to be. Many relatives have high expectations when the acute phase subsides, and such expectations may be disappointed, and this may lead to frustration on both sides! Adjust your requirements to the sick person and his current capacity.

It is helpful to arrange small daily or weekly targets together with the sick person and to give him specific tasks which he can handle. Due to the concentration disorder, some sick persons forget such agreements. Don’t talk about these indirectly and don‘t criticize the sick person. Sometimes it's useful to wait and see whether he completes the tasks. The sick person needs plenty of praise and attention. The sick family member also has to deal with the loss of abilities. Feedback on small successes can be encouraging and convey hope. Efficiency should be increased slowly, step by step. It may be possible to fall back on former hobbies and familiar tasks. 

 
The phase after a serious psychological crisis is a tightrope between overtaxing and under- challenging. Stress may overtax the sick person, too much care and a reduction of duties may under- challenge the sick person and indirectly give him the feeling he can’t do anything, and he is of no value. It is difficult, almost impossible, to read the level of stress in the eyes of the sick person. It is therefore important and necessary to remain in conversation with your family member and ask him what he thinks he could manage, or would like to try and which situations were too stressful for him and where he needs time for withdrawal and for breaks. Even if it sounds easy here, this is often a process over many years for the sick person and for you to find out how to cope with this tightrope situation the best!

» » Communication and suicidal tendency

Suicide thoughts or intentions are often a taboo subject. Perhaps you are in fear of the life and safety of the sick person, or maybe you feel blackmailed, threatened or put under pressure. Recognize your own limits. If necessary, find help for yourself if you feel overtaxed! Existing suicidal tendency cannot be intercepted in everyday life, and certainly not by a relative! The most important rules for handling suicidal tendency are:

• Always take the subject of suicide seriously – even if everything turned out right dozens of times in the past!
• Only a specialist can decide whether suicidal tendency exists.

There are still a lot of myths about suicide tendency which have nothing to do with reality or actual experiences:

He who acts doesn’t talk about it!

There are numerous sick persons who talk about the idea of suicide with others. Announcements of suicide are to be taken seriously. Many other sick persons don’t want to burden anyone with such distressful thoughts, but are relieved if they can talk about this distress with somebody. Talk about the subject calmly, even if this is difficult for you. Tell the sick person you think it is important to consult a specialist.

Suicide comes without advance warning!

Some kill themselves without anyone in their environment suspecting. Especially in acute psychotic phases, the experiences and thoughts of the sick person are often not plausible and therefore suicidal thoughts can also not always be foreseeable. However, normally there are indications and signs in the behavior and in conversations with family members. For relatives it is very difficult to differentiate whether this is a threat or a real intention. If you are worried or have the feeling that your family member is thinking about suicide, talk about it and obtain support from experts!

Talking about it makes people think about doing it!

Do not shy away from talking to the sick person about his suicide thoughts with open, carefully chosen questions. Helpful questions include: “Have you thought about taking your own life recently?“, “How often do you suffer from such thoughts?“, “Do you have specific ideas as to how you want to kill yourself?“ etc. Never play down the suicide thoughts. If you reach your own limits, tell the sick person that you will look for professional support for your own relief and for his safety.

For acute suicide tendency the main target is to prevent the actual act. Decisions of free will may be impaired for the sick person during an acute illness phase. Even though many sick persons do not like to receive help in acute phases, they are happy, when the symptoms have subsided, that they were prevented from committing suicide. Therefore, always consult a doctor and, if possible, do not leave the sick person alone.

After a crisis, there is no more risk!

An acute phase is sometimes followed by subsequent fluctuations in mood. There may be frequent suicidal thoughts during this period. It can be helpful to carefully ask the sick person what makes him cling to life. And an unusual question such as whom or what he would miss if he were to actually kill himself helps to shift his thoughts in a different direction. However, once again it is important to remember: you are not a doctor or a therapist? It is not your responsibility to assess how dangerous the situation is! Better to obtain professional support more often than is needed!

» » Communication after a crisis

After a crisis has been overcome, all involved may wish to forget about what has happened as quickly as possible. Perhaps you or your family member have experienced a lot of chaos in the foregoing episode, perhaps there were injuries or insults on one or both sides that you would prefer to push to one side. It could be that not only you are burdened by aspects or behavior from the acute phase (e.g. the sick person wanted to separate from the partner, mistook the parents). The sick person may also have experienced injury or disappointment during the acute phase (e.g. if compulsory hospitalization occurred, or a doctor was consulted against his will). It is understandable that all involved tend to seek to return to normal everyday life, although the unspoken may lead to fractures in  a relationship!

 
It is important that experiences be shown from the various perspectives. Both views are allowed and should be heard.

Tell each other what was difficult about the behavior of the other person. Again, it is necessary that both sides express cautious criticism. Ask your family member what was difficult for him in your behavior during the crisis. Don’t forget to look at the solution side, and clarify together what you might both do better in another crisis situation. Take note of the tips for active listening and formulation of criticism. And don’t only look at the deficits! Talk about what went well and which specific behavior of either side was helpful.

However difficult it may have been, you can always use a crisis in retrospect to learn what might develop differently in the next crisis, what was not so good and what should be repeated because it was helpful!

Make clear agreements, if possible in writing, how to deal with one another in case of a relapse. It is helpful if you prepare a crisis plan after the crisis – together with the sick person for the sick person, but also for yourself! It may be that you pushed your own limits in the past crisis and often felt overtaxed. In that case, you should now look for alternatives.

You should discuss the following points before preparing a crisis plan:

• Which early warning signs can be recognized in your family member?
• What is to be done in the case of early warning signs? Who is to do what?
• Which doctors are helpful, and when (e.g. GP for sick note, specialist physician for medicinal treatment, psychology for supportive talks)?
• When does the sick person enter a clinic? To which clinic does he want to go and to which clinic does he not want to go? When is a day-care hospital good, when is inpatient admission good?
• Who is to accompany the sick person?
• How often should visits take place? Who should come?
• How would the sick person like to be treated
  - if he becomes psychotic;
  - if he becomes aggressive;
  - if he talks about suicide?
• What is to be done in crisis situations, if close persons are not available due to vacation or at weekends?

It is best to prepare a plan on which all important telephone numbers (doctors, clinics, alternative facilities, and emergency phone numbers) are listed. Agreements cannot prevent a crisis, but they may alleviate the unpleasant consequences of a crisis!

If your family member does not wish to talk about the past crisis and rejects clear agreements or a crisis plan for a relapse, it is good to ask him again quite a few times, but should the sick person remain persistent in his opinion, then respect his opinion. Treatment remains the responsibility of the sick person.

That shouldn’t stop you finding out about the sickness and preparing a crisis plan yourself. Your own crisis plan should include the following points:

• How can you recognize your own feeling of being overtaxed (less desire, little sleep, feeling of fatigue, less activity, withdrawal from social environment)?
• How can you reduce your burdens? Which work has to be completed, which can remain unfinished? Who might be able to help you? Who can take smaller everyday tasks off your hands? Who could you ask for help in absolute emergencies?
• How can you relax? Where can you recharge your batteries? What is really relaxing for you?

It may be helpful to join a relatives’ group. This is a place where you can express your troubles and fears. Relatives are also frequently experts in their own field and can give you addresses of good physicians and therapists as well as tips on how to handle sick persons or help in handling your own overtaxed feelings. And it also provides a protected area where you can exercise useful communication techniques.