• Support And Family Education: Session Five - Limit setting and boundaries with family members
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    Session Five - Limit setting and boundaries with family members

    Materials Needed:
    Handout J: "Coping with Mental Illness"
    Books: When I Say No, I Feel Guilty. M. Smith
    Your Perfect Right: A Guide to Assertive Living. R. Alberti & M. Emmons

    1. Introduction

      1. Maintaining a balance between taking care of your loved one and setting boundaries to take care of yourself can be very challenging. Family members may feel guilty for setting limits, so this skill is very important to discuss and practice.

      2. Listen to this description of a situation between a married couple, Joe and Helen. Think about how each person may be thinking and feeling in this scenario and what they could do.

        Read the following scenario aloud:
        "One Sunday Joe wanted to take the hour-long drive to his daughter's home to visit with her and her family. He was particularly eager to see his grandchildren who had called the previous day, begging them both to visit. Joe knew that Helen was once again deeply depressed. Whenever she was that down, she wanted nothing more than to stay in the bedroom watching tv. Experience had taught them both that if Helen forced herself to go out when she was depressed, she felt even more engulfed in the depression. When she felt this way, she did not want to be around her daughter, her son-in-law, or her grandchildren. Helen and Joe both knew that if she agreed to go, she would feel more miserable and useless than she already did.

        Joe had a dilemma about what to do." (Rosen & Amador, 1996, p. 134)

      3. Depending on the number of participants, break into groups of three or four people. Write the following discussion questions on the board and allow the groups 10 minutes to discuss these issues. Then, return to the large group and discuss the groups' responses.

            Discussion Questions:

      1. What might Joe have been thinking in this scenario?
        • I really want to visit my grandchildren today, but I just cannot leave Helen like this. I know Helen wants me to go, but I'd feel so guilty leaving her alone.
        • I sure wish Helen would go, as I think she'd feel better if she saw the grandchildren.
        • I worry that I'll start to feel depressed if I don't go see my family. Then I won't be able to support Helen.

      2. How might Joe have been feeling?
        • ambivalent, torn, confused, frustrated, disappointed, guilty, worried, resentful, etc.

      3. What might Helen have been thinking?
        • I don't want to disappoint Joe and the children, but I just cannot go today.
        • I'm sick and tired of feeling so depressed. I sure wish I felt better.
        • I don't want to be a burden for Joe, and I know he really needs to see the grandkids.

      4. How might Helen have been feeling?
        • afraid of being alone, lonely, depressed, isolated, angry at being left, etc.

      5. What are Joe's options in this situation?
        1. Stay home and resent Helen
        2. Stay home and take pride in his decision to support his wife
        3. Go, but call Helen several times to check in
        4. Go and try to forget about Helen
        5. Go, but feel guilty and struggle to enjoy the visit
        6. Invite the daughter's family to come to their house
        7. Discuss with Helen his desire to see the grandchildren and problem-solve as a couple

      6. Have you faced similar situations? How have you dealt with them?

    2. Remembering your own needs

            Discussion Question:

      • How can paying attention to your own needs be difficult?

      1. Discomfort with expressing your needs
        1. You may feel awkward or uncomfortable in asking for what you want.
        2. In stating your need, you become vulnerable to the possibility that the listener may say no.
         
      2. Fear of being selfish
        1. You may be uncertain as to if your request is "reasonable." You may convince yourself that your needs are somehow less important than those of your family member.
        2. You may be tempted to give all of your energy (resources, time, money, etc.) to the family member. In so doing, you can lose yourself, and that strategy will eventually backfire. You may even forget that you have personal needs that you are neglecting.

      3. Guilt can drive you to ignore your own needs
        1. The consequences of ignoring your own needs over time usually are anger and resentment. These emotions can be expressed in one or more of the following manners:

        1. May be directly expressed to the patient.
        2. May be displaced onto the children, co-workers, other family members, the family dog, etc.
        3. May be passive aggressively expressed to the family member (e.g., coming home late with no explanation; making meals that you know he/she dislikes).
        4. May be turned inward on yourself, which can result in depression or self-destructive behavior.


    3. Tips on how to strike a healthy balance between caring for your loved one and paying attention to your own needs (parts adapted from Rosen & Amador, 1996):

      1. In addition to helping your loved one, remember that your needs are equally important. Strike a balance as often as possible.
        1. If you immediately think, "I'm just being selfish," you miss the opportunity to find a way of getting your need met.
        2. It's not always bad to be selfish! Your own needs are just as important as those of your loved one. Take time to "refuel."
        3. Give yourself time to think it out.

      2. Talk about your needs constructively.
        1. Ask for your loved one's help in getting what you want.
        2. Weigh your needs carefully against those of your loved one. Work together to discuss all of the issues openly.

      3. Look for ways in which your family member can help you.
        1. All people need opportunities to be useful and helpful. Doing even small tasks for another person can enhance self-esteem and strengthen relationships.

      4. Don't be afraid to disappoint your loved one occasionally.
        1. No one can meet another's needs all the time or perfectly.
        2. Patients are usually strong enough to bounce back.

      5. Continue to devote time and energy to your other relationships. The fact that other family members or friends are well makes them no less deserving and needy of your time and energy.

    4. Negotiating compromises

      1. Living with family members can be difficult, and compromise is often important for the household to function well. The situation can be even more difficult when your loved one has a mental illness. Certain behaviors may be especially difficult to negotiate (e.g., poor hygiene, excessive use of nicotine, lack of involvement in household chores, excessive sleeping).

      2. Family members often face the challenge of differentiating between an annoyance and a real problem. Caregivers can become consumed with the mundane annoyances of daily living (e.g., leaving clothes on the floor), leaving less energy for the more significant problems.

      3. If you decide that the issue warrants a frank discussion, the following tips can be helpful:
        1. Focus on one specific behavior at a time.
        2. Prioritize what is most important to you at that time.
        3. Ask for more of what you'd like rather than criticizing the person's behavior.
        4. Example:

          Let's say that your husband showers only once per week, smokes 2 packs of cigarettes per day, sleeps until noon every day, and recently discontinued his psychiatric medications. You haven't said anything for a long time. Finally one day you are very frustrated and decide that things have to change. You angrily tell him that he has to get up every day at 8am and take a shower. He must cut back to 3 cigarettes per day, re-start his medications, and get a part-time job to fill up all his spare time.


          1. What would be the outcome?
            • He would feel overwhelmed and angry and probably wouldn't do any of your demands. He would likely feel pressured and badly about himself.

          2. What could you do instead?
          • You as caregiver could sort through your own frustrations, possibly with the help of a trusted friend or support group. In doing so, you would likely decide that the medication issue is most important at this time. You may still feel irritated about the other behaviors, but could choose to focus your energy on the more serious issue.

          • You could sit down with your family member at a calm time and discuss your concerns about his decision to discontinue the medications. You could seek to understand the reasons for this choice.

          • Together you could explore some options about how to deal with this situation, perhaps in coordination with his psychiatrist. All people respond better to requests for change when they feel included in the decision making process (rather than being told what to do).


    5. Financial issues

      1. Managing finances can be quite stressful for families. Patients may have difficulty obtaining income to which they are entitled due to their disability. Patients may also struggle with financial management, which can create significant distress for the family.

      2. In general, patients should retain as much control over their finances and decision-making as they are able to manage competently.

      3. Social workers are important contacts for dealing with financial matters. Several options exist, including court-appointed conservators, payees, legal guardians, power of attorney (etc.) in which family members or other court-appointed individuals can obtain control of decision making of the estate, health care, and/or finances.

      4. Provide local contacts for assistance with financial issues (e.g., social workers).

    6. Where to put your energy?

      1. There are many things that you as family members can do - but there are also things that you cannot do. Unfortunately, some people spend a great deal of energy trying to change things that cannot be changed.

      2. Distribute and discuss Handout J: "Coping with Mental Illness," originally written by Rex Dickens of NAMI.

    7. Personal Examples

            Discussion Questions:

      • Would you like to share any personal examples of times when:
        • You set a limit that had a positive outcome?
        • You set a boundary but struggled to enforce it consistently?
        • You set a limit and it was difficult?
          • During difficult times, how did you get the strength and support to set the limit?
      • Are you currently facing any situations with your family member that you'd like input from other group members on how to handle?

    8. Show recommended bibliotherapy on setting limits and assertiveness:
      • When I Say No, I Feel Guilty. (1979). M. Smith
      • Your Perfect Right: A Guide to Assertive Living. (1995). R. Alberti & M. Emmons