Working with People with Mental Illness

Symptomatic Behavior and the Appropriate Responses

• Hopelessness
• Apprehension and fear of failure or rejection
• Low self-esteem and the resulting lack of motivation
• Withdrawn behavior
• Relapse
• Difficulty in processing information
• Anxiety, agitation or aggression
• Regressive behavior
• Bizarre behavior
• Hallucinations
• Delusions
• Feelings of depression
• Disorganized thinking and slow responses

When working with someone who has a mental illness the pastor should try to think of what the person may be experiencing that may account for these symptoms. If the pastor has some history with the person, he/she should try to identify what happens when the person becomes ill. Then the pastor should structure limits, behaviors and responses in an appropriate way. He/she should try to avoid focusing on the details of the person's behavior. He/she should try to keep the interaction as normal as possible. The pastor should use statements that give his/her perspective rather than imposing perceived behavior on the person. For example instead of saying "You are not interested," try "I am concerned because you seem disinterested."

The pastor should use an open, caring, accepting manner that is genuine. People with these illnesses pick up on false behavior that can be demeaning or threatening to them. When the pastor listens to the person, it should be true listening that encompasses both verbal and nonverbal responses. The pastor should try to understand what is being said and what is not being said from the person's perspective. Remember that the pastor's concern and interest is very important to the person, even if he/she is unable to show it. The pastor should remind the person that God cares for him/her. If the person expresses an interest in the illness and its consequences, the pastor can work with the person to learn about it. The pastor should be a resource for information and referral. If the person wants to have a serious discussion, the pastor should attempt to do it remembering that many severely ill people are rational as much of the time as they are symptomatic or psychotic.

For example, Wagner (1985, 83-86) describes his work with a severely depressed woman. She was a pastor's wife who gave the repeated message to all who came in contact with her of "Woe is me, I don't know why things are so terrible for me."

Wagner engaged her in dialogue. The conversation not only involved listening to her "woe is me," but also listening for what was uniquely hers as a person. She expressed it particularly in relationship to her husband. Wagner indicated to her that she had been heard. He also offered her other possibilities and ways of handling her anger as alternatives to internalizing it and allowing the anger to devour her and make her feel worthless. Her recovery was slow and painful. In the end this chaplain reports he learned what it meant to be patient, while the pastor's wife learned what it meant to be more fully human and that God accepted her in her humanness.

Hopelessness: For both the person who is ill and the family, visual representations of how the illness affects the brain can be very freeing. It becomes very clear to all involved that these illnesses do change the way the brain looks and functions. Matching the person with others who have recovered and are going on with their lives is also helpful. Seeing a videotape, such as those listed in the bibliography, can be very helpful in illustrating these points.

Apprehension and fear of failure or rejection: In describing this type of concern a consumer says: "I had fears. I am scared to death that I'm going to do something out of line." The pastor should convey an accepting, friendly, understanding and genuine manner and not be judgmental. He/she can give an understanding response to the person's concern. After all, the concern is reasonable, since the person may have failed may times in the past. For example, "I know it is hard to live with. Fear of being inappropriate, failing, being hurt or being rejected happens to all of us."

If the person has difficulty forming and maintaining relationships, the pastor can help the person use appropriate behaviors and set limits on bizarre and odd behavior. The pastor should affirm the person when he/she uses appropriate behavior and acknowledge that this takes a good deal of work, concentration and self-control. The person should be allowed to discuss unusual and disturbing perceptions and should be cautioned that it may not be appropriate to share these perceptions with others, except for his/her therapist. The person may be unable to give up these unusual perceptions. However, he/she can begin to learn to manage them.

If the person decides to participate in congregational activities or to volunteer to do a task, it is helpful to develop a structure with the person. Simple, structured tasks are less threatening as first steps toward resuming responsibilities. It is very helpful for the pastor to go over an outline and schedule for what will be happening and what is expected and then give the outline to the person. The interaction should be as predictable as possible and mutually agreed upon. Time should be allowed for the person to "ease into" the project. It is unreasonable to expect regular participation all at once. The pastor needs to support the person in what he/she is able to do. Focusing on what the person does do, not on what he/she does not do is most helpful. The pastor should learn when to apply gentle pressure and when to "back off."

Low self-esteem and the resulting lack of motivation: A former Air Force officer describes his feelings: "There is a sense of loss when I see others doing well. I feel a social disparity between us." The pastor can affirm the person's value. Honest compliments and encouragement are very important to anyone struggling to regain their self-worth and dignity. It is very supportive when the pastor spends time with the person, just for the sake of being with him/her, or matches the person with someone in the congregation who is willing to be a supportive, nonjudgmental friend. Those interacting with the person should focus on the person's strengths and what the person has accomplished and treat this in a positive way. Dwelling on past failures or inappropriate behaviors or expectations is not helpful. If the person exaggerates his failures or weaknesses, the person should be assisted in solving the problem or changing the behavior if this offer of assistance is well received. The person should be reassured that the healing process takes time. Small accomplishments, such as going to worship, or keeping an appointment to see the pastor, are progress. For that person getting out of bed, organizing him/herself to get dressed, having breakfast (often having to make it him/herself) and finding a way to travel to see the pastor or to attend worship is a major accomplishment. This is particularly so when the person has recently returned to the community.

People with mental illness often lack the motivation or courage to make decisions. When helping a person with this difficulty, the pastor should keep the session structured, consistent, simple and focused. If the decision is a small one and seems to be causing unwarranted anxiety, the pastor might suggest a decision. For example, if the person cannot decide whether to attend the coffee hour after services, the pastor can suggest that the person try it for fifteen minutes, rather than the entire hour.

Withdrawn Behavior: The pastor should not interpret withdrawal as rejection. It is often a normal response to more stimulation than the person can handle at that moment. A consumer notes, "It may not be withdrawing from social contact but from a confusing or terrifying experience." The person may need "time out" from the situation. It is helpful to find a quiet place for the person to be alone. The person should know that place is always available and be encouraged to use it if the need arises. This could well be the pastor's study or the sanctuary when services are not being held. The person should be left alone and allowed to rest and have time to cope with the confused thoughts and sensations the he/she may be experiencing. Demands should not be made of the person at this time. Perhaps a quiet, restful setting is all the person can handle. For example do not say, "Do you think you would be better off at home, so should I call you a cab so you can go there?" Instead, say, "Stay here as long as you want. I'm available for you, if you want me." The pastor should not view this as a step backwards. He/she should realize that some days are simply better than others in any recovery process.

If the person does not need a quiet time alone, he/she may simply need the pastor to acknowledge the inability to interact with ease. For example, "I am glad you kept this appointment, I know it is not always easy getting yourself over here to talk with me." If the person has trouble getting started, the pastor can try to initiate conversation by focusing on something that is relevant to the person. If the person has difficulty in making contact, the pastor should make direct contact and keep the initiative in the interaction.

The pastor and the congregation should understand that when the person is first home from the hospital, the person will need more rest and lower levels of activity and personal interactions than usual. This diminishes over time. If the person cannot see the pastor or resume activities within the congregation, this should be recognized as an often temporary situation. The pastor should let the person know that he/she is available when the person is ready. The pastor can check in with the person regularly by sending a note, giving a message to a family member, or by telephone, if the person is up to receiving calls. Members of the congregation should be reminded that the person is not shutting them out, but is simply unable to handle a great deal of stimuli, activity and interactions with a number of people during this recovery time. Encourage them to send a card or note, telephone the person and leave a message if the person is unable to come to the phone, or let the person know he/she is in their prayers.

Relapse: Relapses are temporary. Recovery has happened before and it can happen again. Many illnesses, including mental illness, have remissions and then flare up again due to changes in body chemistry, or when medications are not taken or have adverse reactions over time, or when the living situation changes.

Memory loss and processing information: With some mental disorders there may be a temporary memory loss or a slower ability to process information that is a result of the illness, treatment or medication. A consumer says:

I have difficulty with working memory. It's difficult sometimes in school when I will have to go over and repeat and repeat and repeat things like logic and algebra. They were a forte of mine. It's difficult now. I keep getting grades on my consults saying my judgment and insight are wonderful, but that doesn't help processing that information or an interaction between you and me. Understanding is really tough.

People suffering from dementia may experience permanent memory loss. The same sense of bewilderment, confusion, and loss is operative in this situation. People working with the person should accept what the person is able to remember. For example, if the person cannot remember that it is April 10, but does remember that it is Sunday, that level of functioning should be accepted in a positive, relaxed manner.

In all cases, people interacting with the person should slow down their speech and interactive responses. At times the pastor may need to repeat what has been said. It is helpful to use short, simple, uncomplicated word structures and sentences.

Difficulty in processing information: This can be a result of too much internal or external stimuli. As noted in the previous section, it can also be a result of medications which can slow down the person's ability to respond. The pastor should slow down his/her delivery and use sentences and words that are short, simple and uncomplicated. Some things may need to be repeated. Opening more than one topic at a time should be avoided. The discussion should be concrete, simple and devoid of excessive details.

Sometimes the person displays a very ordinary demeanor, which often masks all kinds of stimulation problems such as an acute sensitivity to noise, light, odors or temperature. People with these difficulties need a quiet, tranquil setting in order to interact with others. When the pastor has an appointment with the person it would be helpful to hold all telephone calls, and eliminate outside noise, activity, or the odors of a meal being prepared. For a person with an intense sensitivity to sensory stimulation, this decrease in receiving any stimuli can be very helpful and allow the person to be as calm and focused as possible.

The person should be assisted to avoid situations where there may be too much going on for him/her to handle. For example doing a task in a high activity setting rather than in a room where the person can close the door and draw the blinds, may be asking too much of him/her. The pastor might schedule appointments, when there is very little activity going on in the building. And, if the person should arrive early for the appointment, a quiet, restful place to wait is most helpful.

Anxiety, agitation or aggression: Direct contact should be in a quiet, supportive way. If the person is severely disturbed, the pastor should stay calm, keep eye contact and retain a calm facial expression and body manner. For example, it is quite obvious that a pastor is fearful or worried, if he/she has a calm facial expression, but is clutching the arms of the chair and is sitting rigidly. This behavior can easily exacerbate the situation. Using simple, calm, quiet speech and keeping the interaction relaxed is very helpful. The pastor should not attempt to force the person to make a decision if the person is highly agitated, aggressive or anxious.

The pastor can slow down and ask the person to slow down. The pastor can offer reasonable reassurances such as, "We have plenty of time." However, the pastor should not become condescending or give responses he/she may not believe at the moment such as, "everything will be okay." The person may pick up on this and become more distressed. The pastor should not demand answers or a response. The person should be given plenty of space. The person may be having very disturbing sensory perceptions. Therefore the pastor should not reach out to touch the person or make any sudden moves toward him/her. The pastor may perceive physically reaching out to the person as a loving gesture of reassurance. The person may not see it that way. Sensory stimulation should be decreased at such a time. For example, if the person is in bible class or service, it might be advisable to help the person to a safe, quiet place to give the person a chance to calm down.

If the person is becoming increasingly aggressive, limits should be set in a calm, non-threatening way. Past violent behavior is the single best predictor of future violence. If the person gives a warning such as, "I'm going to get those people, before they get me," it should be taken seriously. The pastor should get professional help for the person, if it seems warranted.

Regressive Behavior: Sometimes an anxious or agitated person will display regressive behavior. The person may be returning to a lower level of functioning in an attempt to reduce his/her distress. At such a time the pastor should be empathetic. It is helpful to use a clear, concise delivery and be realistic about what can be accomplished during this time.

The person needs reassurance about what is going on and why. This is especially true if the person is just returning from the hospital to the community, or seems to be degenerating into an acute episode. Remember that the person is more fragile when the illness flares up or right before or after that happens. The pastor should realize that regression, withdrawal or acting out can be an attempt to stabilize perceptions, or a reaction to overloaded sensory impulses.

The pastor should realize that this person is struggling to regain his/her balance and control. His/her fears, anxieties and concerns are very strong. Consider the way you would want help if you were terrified. In such a situation one may misinterpret others' intentions, believe they do not understand, and acutely feel other people's irritation and impatience. At such times people tend to exaggerate other people's tension, resistance, denial and anger.

Bizarre behavior: The pastor should set firm limits. In setting limits and distance, the pastor should do this in a supportive, non-rejecting way. The pastor can explain to the person how his/her actions make the pastor and members of the congregation feel. The person can be encouraged to limit these behaviors to private situations. In general, one must set limits on unreasonable and bizarre behavior before tension builds. Expectations should be clear, simple and realistic. If the person seems overstimulated, the pastor should limit input and not force discussion. If the person is displaying unsound judgement, the pastor should remain rational and reinforce common sense.

Very often bizarre behavior involves hallucinations and delusions. Hallucinations are inaccurate perceptions that impact the senses and delusions are inaccurate beliefs.

Hallucinations: In dealing with hallucinations, one can agree that these are special experiences that the person may see, hear, taste, touch or smell. And, that these experiences may be shared by nobody else. If the person says: "I see demons in this room," the pastor should not make a flat statement that is a complete denial such as "There are no demons in this room!" If the person says he or she sees David with his harp sitting next to him, the pastor can agree that he/she may actually see David, but that the pastor and others in the area do not. A consumer who is a peer counselor advises:

We can't play into what a person with a mental illness is experiencing or describing. At the same time we can acknowledge, "Yes, I understand that is your reality and that's what you're experiencing. However, it is not what I'm dealing with, so it's hard for me. Can you tell me about that?

Delusions: In dealing with a delusion the pastor should not argue with the person about the delusion, as it will not change the person's perception and may be perceived as threatening or unsympathetic.

It is helpful to understand and closely listen to the person's fears. The pastor can empathize with the delusional thinking. He/she should not attempt to dissuade the person or to show the faulty logic of this symptom. He/she should reinforce reality. For example the pastor might say: "I don't find or see anything that shows me this is happening, but I understand how frightening it might be to feel the devil is watching you and directing everything you say and do." The pastor should never make light of, or make fun of, the delusion. It is unreal to the pastor, but very real to the person who has it.

If the person seems extremely agitated, fearful or aggressive the focus should be shifted from the delusion. The pastor can do this by suggesting he/she needs some assistance with a task. Or, the pastor can talk about music or sports, or guide the conversation toward a subject the person enjoys.

The pastor can suggest that fixed ideas and preoccupations, such as "I can't move, or they will destroy me" or "I must help the Pope," or "I must drive out the devil from this place," may be changed if he/she and the person can start writing down facts together. Talking about ways to change the delusion or preoccupation often may include assistance from a mental health professional. The pastor might say: "What exactly is troubling you about this situation? What is certain, what is probable, and what is only a possibility? What rank of importance is this trouble or feeling? What can you do to change this? What can I or others do to resolve this problem?"

Feelings of depression: If the person displays depression, frustration, loneliness and/or feelings of guilt he/she should be allowed to ventilate these feelings. This can be done verbally or nonverbally. The pastor should listen and accept what is said. The person should be allowed to cry. It is very supportive when the pastor spends time with the person, even if it is spent in silence. The pastor should avoid attempting to cheer the person up and should understand at this moment, the person is feeling very low. Platitudes and biblical references may make the situation worse. Just as the pastor should not argue with delusions, he/she should not argue with depressions. If the person could "pull himself or herself out of it," the person would not be clinically depressed. Instead, the pastor can acknowledge the person's pain and let the person know that there is understanding of what a difficult experience it must be to have this pain. When the person is feeling somewhat better, the psalms that express anger, frustration and despair may be of help.

Disorganized thinking and slow responses: If the person is clearly not grounded in reality, the pastor can listen for kernels of truth, or wait for a better time to discuss the situation with the person. The pastor should not encourage the person to express accelerated, illogical thoughts. This can quickly degenerate into disconnected, unintelligible speech. It is helpful to look directly at the person and communicate in a simple, clear, practical way. The pastor should avoid focusing on more than one topic at a time and use a calm, quiet delivery and calm body language.

The person may be having difficulty in processing information. The pastor should not display impatience or annoyance, as this can agitate the person. The person may require extra time to respond to what has been said, as other thoughts or sensations may be interrupting the ability to process what has transpired. If there are other people involved in the interchange, the pastor can act as a buffer for the person. For example the pastor can suggest the person leave the room for a quieter setting.

The pastor can decrease stimuli, by turning off any music or closing a window to reduce outside noise and activity. The session should be kept structured, consistent and not free wheeling.