What is a caregiver?

Caregivers are those people who act as support for someone with a mental illness, be it a spouse, parent, sibling, friend, work colleague or relative. Being a caregiver is important because you not only provide love, care and support in the most difficult moments of a loved one's life, you also give feedback, act as a reality check, motivate and encourage, and ultimately, offer a window to a world of hope and normality.

How do I care for a person with bipolar disorder?

People with bipolar disorder should not be under the care of a caregiver alone. They require supervision and regular monitoring by a person experienced in treating the condition (e.g. a psychiatrist, or skilled general practitioner), as well as additional treatment from other mental health professionals, such as psychologists.

As a caregiver, however, you will be able to provide much needed support and practical assistance, and can help in the early detection of a manic or depressive episode.

Manic episode

At the beginning of a manic episode, your friend or family member will appear to be happy, energetic and optimistic. He or she will be drawn to social events or engage in deep discussions, and will love being the centre of attention. Because of this 'good feeling', the person will usually deny that there is anything wrong, even though you will be able to notice behavior that is out of character. If left to escalate, the person may become abusive, hostile or suspicious.

The onset of a manic episode is variable: sometimes it can develop over hours, and sometimes days. It may be possible, however, to decrease the severity of an episode if it is caught early enough. A caregiver can assist in the identification of early signs of relapse. Some early warning signs to keep an eye out for are as follows:

• increased physical and mental activity;
• reduced need for sleep;
• related mood;
• unrealistic plans;
• irritability or rage when plans are not realized;
• reckless spending;
• increased social activity; and
• less inhibited sexual behavior.

During a manic episode, the person generally has poor insight and is unlikely to be cooperative. He or she may resist any form of intervention from doctors, or assistance and support from you. It is important to remember that insight will slowly return as the mania is brought under control. It is at this stage that the doctor will attempt to gain more cooperation, and when you as a caregiver, should become more involved in the recovery process. Some tips to help you with follow.

• Try to remain relaxed, and be a calming influence on your family member or friend.
• Try to keep things uncompetitive and relaxing, avoiding games and group activities.
• Try to slow things down by example. That is, walk more slowly, talk more slowly.
• Try to ignore silly jokes or comments that they make.
• Do not laugh at their behavior, or join in their excitement.
• Set clear limits for their behavior, showing calm disapproval when necessary.
  

Effective treatment of mania may require hospitalization. An admission to hospital will probably be necessary if the person with mania is at risk of, or demonstrating, any of the behaviours listed below.

• Is he or she at risk of serious physical harm?
• Excessive alcohol or other drug use
• Unsafe sex
• Irresponsible or dangerous behavior, e.g. driving dangerously
• Is he or she at risk of serious financial harm?
• Extravagant purchases he/she cannot afford
• Making poor business decisions
• Is he or she at risk of causing serious damage to his or her reputation?
• Hostile, overconfident or thoughtless behavior that is out of character for the person
• Improper work or social decisions due to poor insight
• Inappropriate sexual behavior
• Other inappropriate behaviors, e.g. accosting strangers in the street

Depressive episode

During a depressive episode, the person you are caring for will withdraw from social activities, stop doing the activities they used to do, and keep to themselves a lot of the time. They may also become more emotional, reacting to situations, comments, and even movies, with more intensity than they used to. You may notice the person experiencing the following symptoms:

• consistent, low mood;
• significantly decreased levels of energy and motivation;
• lack of interest in previously enjoyable activities (including sex);
• disturbed sleep; and
• loss of appetite.

Being a caregiver for someone with depression frequently means being exposed to a grim world of hopelessness, unhappiness and negativity. Often, you may feel exhausted, 'dragged down' and helpless. It is also common to start feeling angry and traumatized when the loved one attempts suicide, or does not appear to be getting better.

You may be unsure of what to say because everything you say seems to be interpreted negatively. Your suggestions and advice may be rejected, leaving you confused and unsure about what the person wants. It is likely you will feel that your support is unwanted, even though he/she may not be able to cope without you. The most you can do at these times is to be as understanding and patient as possible.

Your practical help is most important. You could make sure that your friend or family member is safe and looking after himself/herself by ensuring that the person is eating, drinking and maintaining personal hygiene. If he/she is seriously neglecting personal care, you should seek professional help. Professional help should also be obtained immediately if there is any talk of self-harm or suicide.

Why am I feeling guilty?

It is common to start feeling guilty when the person you are supporting is not improving. Often, the caregiver agonizes over past mistakes and events, wondering what should, or shouldn't, have been done. Parents are particularly prone to these feelings and might think that "if only we had been better parents" their son or daughter would not have developed this mental illness. A caregiver, however, is not responsible for improvement or recovery. The reality is that although environmental factors can certainly have an impact, there are significant genetic and biological factors that make people prone to developing particular mental illnesses. Just as Type 2 diabetes can run in families, so too can mental illnesses.

Guilt can be a corrosive agent that saps your energy and motivation, ultimately destroying the relationship between you and the one you are supporting. It is important to be honest with yourself regarding the issue of guilt. If you are feeling guilty, make sure you talk it through with a trusted friend or doctor. There is little to feel guilty about, because most causes for mental illness are outside a caregiver's control. You can, however, offer important and much-needed support to the person, and help them on the road to recovery.

Do I keep secrets?

Issues of confidentiality can often arise when dealing with someone with a mental illness. You may be placed in an ethical bind when the person shares 'secret' information about suicide or harming others. This process can put enormous emotional strain on you as you decide between maintaining confidentiality and looking after your friend or loved one's best interests.

Though each case is different, as a rule of thumb, any information that suggests that the person is at risk of harming himself/herself or somebody else must be passed on to a doctor, community nurse or other health professional. In this situation, it is best to get the person to see a health professional as soon as possible.

Although he or she may be angry or feel betrayed, there is a clear duty of care that overrides any suicide pacts or plans. Simply be careful not to enter into any promises you cannot or should not keep. Be supportive and compassionate, but firm about where 'confidentiality' end.

Important things to remember

Mental illnesses are genuine disorders. A person with a mental illness is not 'pretending' or 'weak' or 'selfish'. It is important to realize that they are struggling with a condition that has a number of possible causes.

Realize that you can only do so much. You cannot talk a person out of a mental illness and you cannot cure their condition by yourself. Although you have a very important role to play, the healing process will need to involve other people, including health professionals.

Be careful of being the 'rescuer'. In the short term, this can seem like a solution, but in the long run, no single person can rescue another individual. The responsibility can result in burnout and 'compassion fatigue'.

Remember, recovery is a gradual process. Even with the right medication and professional support, recovery from a mental illness can be a slow and gradual process. It takes time and patience.

Suicidal talk is serious. If a person is suicidal, you must not be the only one to take on the burden of this knowledge. Anyone with suicidal ideas or plans must see a professional. This may be a GP, mental health professional, or the emergency department at your local hospital.

You could say…

"I would like to help you."
"I cannot imagine what you are going through, but I am ready to listen."
"I care about you and I would suggest you talk things over with your doctor."
"I would like to be a caregiver for you, however, you need to tell me how I could best fulfil this role."
"I cannot keep your suicide plan to myself. I would like to organize for us to go and see a doctor together."

Do not say…

"You need to pull your self together and snap out of it."
"Let me tell you about my problems, which I am sure will make you feel better."
"Taking medication is a sign of weakness in your personality."
These comments are unsupportive and unhelpful.

How can I help the children if their parent has bipolar disorder?

If you are caring for someone who is a parent, it is important to consider how the child may be affected. Try to minimize disruption to the children's daily routine. This may mean planning meals they are used to, making sure they have their shower or bath every day, and encouraging them to go to bed at the regular time each night. You may also need to arrange other practical issues such as childcare and transport to and from school.

It is natural for the children to feel confused and anxious when their parent is ill and someone else is caring for them. It helps to respond to any distressed behavior in a calm and understanding manner. You may need to explain to them why their parent's behavior has changed and why they seem sick, answering any questions factually and appropriate to their level of understanding.

If the child is older, they may need to be reassured that they are not to blame for their parent's illness. It may also help to encourage them to take part in the care of the parent, showing them what to do to assist.

How do I look after myself?

Supporting a person with a mental illness can be tiring work. In order to provide the best support, it is essential that you look after yourself.

1. Create a support team for yourself. Visit with people you can talk to, debrief with and who can lift your mood.
2. Take time for yourself, e.g. meet a friend or watch a movie.
3. Exercise regularly because this is will help you manage stress.
4. If you are feeling stressed and low, minimize your use of alcohol or other drugs. For example, alcohol decreases people's ability to cope with stress.
5. Follow through on your own activities and plans. The role of caregiver is important, however, you must look after your own life or risk burnout and being unable to help yourself and others