Both parents need to nurture children. Healthy parenting helps the grown child be his or her own best mother and father. A child must not only feel loved, but also that he or she is understood and valued by both parents as a separate, unique individual and that both parents want a relationship with him or her. Although we have many needs, I’m focusing on nurturing emotional needs.

Emotional Needs

In addition to physical nourishment, including gentle touch, care, and food, emotional nurturing consists of meeting a child’s emotional needs. These include:

• Love
• Play
• Respect
• Encouragement
• Understanding
• Acceptance
• Empathy
• Comfort
• Reliability
• Guidance
• The importance of empathy

A child’s thoughts and feelings need to be taken seriously and listened to with respect and understanding. One way of communicating this is by mirroring or reflecting back what he or she is saying. “You’re angry that it’s time to stop playing now.” Instead of judgment (“you shouldn’t be jealous of Cindy’s new friend”), a child needs acceptance and empathic understanding, such as: “I know you’re hurt and feel left out by Cindy and her friend.”

Empathy is deeper than intellectual understanding. It’s identification at an emotional level with what the child feels and needs. Of course, it’s equally important that a parent appropriately meets those needs, including giving comfort in moments of distress.

Accurate empathy is important for children to feel understood and accepted. Otherwise, they may feel alone, abandoned, and not loved for who they are, but only for what their parents want to see. Many parents unwittingly harm their children by denying, ignoring, or shaming their child’s needs, actions, and expressions of thoughts or feelings. Simply saying, “How could you do that?” may be felt as shaming or humiliating. Responding to a child’s tears with laughter, or “That’s nothing to cry about,” or “You shouldn’t be (or ‘Don’t be’) sad,” are forms of denying and shaming a child’s natural feelings.

Even parents who have sympathetic intentions may be preoccupied or misunderstand and misattuned to their child. With enough repetitions, a child learns to deny and dishonor natural feelings and needs and to believe that he or she is unloved or inadequate.

Good parents are also reliable and protective. They keep promises and commitments, provide nourishing food and medical and dental care. They protect their child from anyone who threatens or harms him or her.

Tips for Self-Love & Self-Nurturing

Once grown, you still have these emotional needs. Self-love means meeting them. If fact, it’s each person’s responsibility to be his or her own parent and meet these emotional needs, irrespective of whether you’re in a relationship. Of course, there are times you need support, touch, understanding, and encouragement from others. However, the more you practice self-nurturing, the better your relationships will be.

All of the things a good mother does, you have the superior capacity to do, for who knows your deepest feelings and needs better than you?

Here are some steps you can take:

• When you have uncomfortable feelings, put your hand on your chest, and say aloud, “You’re (or I’m) ____.” (e.g., angry, sad, afraid, lonely). This accepts and honors your feelings.
• If you have difficulty identifying your feelings, pay attention to your inner dialogue. Notice your thoughts. Do they express worry, judgment, despair, resentment, envy, hurt, or wishing? Notice your moods. Are you irritable, anxious, or blue? Try to name your specific feelings. (“Upset” isn’t a specific feeling.) Do this several times a day to increase your feeling recognition. You can find lists of hundreds of feelings online.
• Think or write about the cause or trigger for your feeling and what you need that will make you feel better. Meeting needs is good parenting.
• If you’re angry or anxious, practice yoga or martial arts, meditation, or simple breathing exercises. Slowing your breath slows your brain and calms your nervous system. Exhale 10 times making a hissing (“sss”) sound with your tongue behind your teeth. Doing something active is also ideal for releasing anger.
• Practice giving yourself comfort: Write a supportive letter to yourself, expressing what an ideal parent would say. Have a warm drink. Studies show this actually elevates your mood. Swaddle your body in a blanket or sheet like a baby. This is soothing and comforting to your body.
• Do something pleasurable, e.g., read or watch comedy, look at beauty, walk in nature, sing or dance, create something, or stroke your skin. Pleasure releases chemicals in the brain that counterbalance pain, stress, and negative emotions. Discover what pleasures you. (To read more about the neuroscience of pleasure, read my article, “The Healing Power of Pleasure”.)
• Adults also need to play. This means doing something purposeless that fully engages you and is enjoyable for its own sake. The more active the better, i.e., play with your dog vs. walking him, sing or collect seashells vs. watching television. Play brings you into the pleasure of the moment. Doing something creative is a great way to play, but be cautious not to judge yourself. Remember the goal is enjoyment – not the finished product.
• Practice complimenting and encouraging yourself – especially when you don’t think you’re doing enough. Notice this self-judgment for what it is, and be a positive coach. Remind yourself of what you have done and allow yourself time to rest and rejuvenate.
• Forgive yourself. Good parents don’t punish children for mistakes or constantly remind them, and they don’t punish willful wrongs repeatedly. Instead, learn from mistakes and make amends when necessary.
• Keep commitments to yourself as you would anyone else. When you don’t, you’re in effect abandoning yourself. How would you feel if your parent repeatedly broke promises to you? Love yourself by demonstrating that you’re important enough to keep commitments to yourself.

A Word of Caution

Beware of self-judgment. Remember that feelings aren’t rational. Whatever you feel is okay and it’s okay if you don’t know why you feel the way you do. What is important is acceptance of your feelings and the positive actions you take to nurture yourself. Many people think, “I shouldn’t be angry (sad, afraid, depressed, etc.). This may reflect judgment they received as a child. Often it’s this unconscious self-judgment that is the cause of irritability and depression. Learn how to combat self-criticism in my ebook, “10 Steps to Self-Esteem,” available in online bookstores.

It follows a mom through her day with a little boy who appears to have some kind of developmental delay. The voice-over tells us he was in the neonatal intensive care unit for over 100 days. Now he looks somewhere between 3 and 4 years old. She makes him a peanut butter sandwich and laughs when he spills the milk. She plays with him and keeps a watchful eye while she goes about daily chores. She washes his hair as he kicks and squirms. She struggles to brush his teeth. Then there’s story time and a kiss good night. All the while, she is the epitome of patience and all smiles.

Then the ad gets real. Having tucked her little boy in, having said she wouldn’t trade him for any other kid, she has a moment alone on the front porch. In that moment we see “the look.”

Anyone who has been there knows what it means. To see it cross another’s face is to feel it in the gut. It’s the shadow that passes through in a moment of exhaustion. It’s the small piece inside that does wish, if only for a moment, that she did have another kid; one who didn’t need her every single minute of every single day.

Then she does what loving parents do: She takes a breath, remembers the blessings of being a mom to this special child, and goes in to get ready for another day and another round of constant care.

Moms, and dads with kids who are disabled or chronically ill know that look and the feelings that create it. They also know the moment that comes next: the moment of renewed commitment that is born of love and hope and determination. Raising a disabled or chronically ill child is not for sissies. If parents weren’t strong before this special child became theirs, they’ve developed strength they never knew they had in them.

Mother’s Day is almost here. Let’s all take a moment to appreciate the mothers who do everything every other mom does plus a whole lot more.

They are the moms for whom the first months of sleeplessness extend into years. They are the moms who become experts on their child’s diagnosis and therapies and education plans. They have learned to manage endless appointments with medical specialists and endless meetings with educational experts. They have learned an awesome vocabulary of medical terminology, education jargon and insurance codes.

Complicated schedules and routines and star charts have become second nature. Those who have kids with special diets know how to spot dangerous ingredients in a cupcake from a hundred yards away. Those with behaviorally challenging kids can handle a tantrum while folding laundry and planning dinner. Many even find the energy to organize support groups, get involved with agencies that offer activities for their kids, and advocate for other families as well as their own.

Contrary to conventional wisdom, most of their marriages are strong. Sure, the demands on these couples are many and constant. But most do better than just cope. They succeed as partners and as parents and develop positive feelings and values about raising a child who is challenged and challenging. The birth or adoption of a child with special needs has taken their lives in unexpected directions that aren’t always pleasant but are nonetheless meaningful and important. When asked, most will say that parenting their child has made them better people.

That strength and love and commitment extends to their nondisabled kids as well. If they thought about it, they could take enormous pride in their success in raising compassionate, competent kids whose experience with their brother or sister with a difference has made them sensitive to the needs of others. Most moms don’t think about it. They are just doing what feels right and good for their families.

For mothers of children with special needs, Mother’s Day rarely means a dinner out or diamonds. A qualified babysitter is hard to find. Money is more likely to go to bills than jewelry. Often the child who made her a mother can’t understand a holiday, can’t carry a tray to give her breakfast in bed and won’t be bringing her a bunch of violets or a card made all by himself. These moms celebrate their day with their different child in a different way.

And celebrate they do. They find joy in the knowledge that they are nurturing a child’s spirit as well as her health. They take satisfaction in knowing that each accomplishment, however small it may look to others, is a major victory. Each of her child’s achievements is at least partly her own. She knows the value of her efforts and the importance of keeping a positive attitude and counting the blessings of every day.

Still, it never hurts to hear all this acknowledged. Loving words of appreciation from a partner, spouse, friend or extended family members do mean a lot. If you know such a mom, reach out this Mother’s Day and let her know that you see her for the amazing person she is. A phone call or visit or card may seem like a small thing but for a mom in the special needs trenches, it can really make her day. The support of others added to her own commitment is what makes it possible for her to take that breath and get ready for another day.

The aptly-titled Things I Wish I’d Known: Cancer Caregivers Speak Out, by Deborah J. Cornwall, is a welcome resource for those struggling to help the people they love who have cancer.

My grandmother, mother, father, and wife all had cancer. My mother was a caregiver for both her mother and my dad; I helped with all four. My parents and wife recovered, though my dad was housebound and disabled for the remaining nine years of his life. 

Cornwall, meanwhile, has had her own experiences with cancer. Her mother-in-law died of breast cancer at a young age, and the author herself was diagnosed with breast cancer 33 years to the day after her mother-in-law’s death. Cornwall recovered. Her experience, she says, including extensive volunteer and consulting work with the American Cancer Society, led her to write this book. She contacted and interviewed many caregivers of persons with cancer, and created this guide to help them.

Cornwall does a good job describing what caregivers, as well as patients, go through, and what one can do to stay afloat during the grueling process. The caregivers in her book mention a void after death — but there is also a void after a successful outcome. You spend all your time and energy in the fight to overcome cancer and it becomes your center. When that fight is done, you are left seeking a new center. The people in this book share ways to do that, and to commit to living life to the fullest. Hearing it in the voices of the caregivers themselves is particularly powerful.

After old age and dementia, cancer is the third leading reason for caregiving. To that end, Cornwall quotes Rosalyn Carter: “There are only four kinds of people in this world: Those who have been caregivers, those who are currently caregivers, those who will be caregivers, and those who will need caregivers.”  No two experiences are the same, either—I know this from my own caregiving, and Cornwall knows it, too. “There are over 100 different types of cancer that can arise in nearly any part of the body,” she writes. Even people with the same type of cancer getting the same treatment may react very differently.

What can make things especially hard for both the patient and the caregiver is that many of those with cancer had no history of the illness in their family, Cornwall reports. Being diagnosed with the disease seems to be some kind of random event that hits out of nowhere. The caregivers she interviews include children, spouses/domestic partners, relatives, siblings, and friends. Those with cancer range in age from two to 90, with 40 different types of cancer, and the different caregiving paths Cornwall writes about last from a short four days to a long 23 years. About half of the patients of the caregivers she interviews had a successful remission and went on to live a cancer-free life.

The book approaches the daunting, unpredictable task of caregiving in a step-by-step way, with each step clearly explained and most often in the words of caregivers themselves. It covers all aspects of the journey, beginning with getting a clear diagnosis, which may not be easy. Problems can occur because of symptoms, such as fatigue, being attributed to other causes. This can be especially true when the person has no family history of cancer and also does not have any behaviors associated with increased risk. Many of the patients in this book never smoked and had been athletic. Cancer was just not something anyone would suspect.

Cornwall also writes about the person who may have a rare cancer that local physicians have not seen before. At times, she tells us, caregivers had to work hard and really push to get a correct diagnosis. “Working through the diagnostic tests and waiting for results was the hardest part for many caregivers,” she writes.

The book also provides testimony from caregivers on how they gathered information to help make informed decisions about treatment. This is crucial. There may be times when the patient is so distraught that they have difficulty making those decisions and need someone they love and trust to help. Choosing your treatment team is crucial, and Cornwall goes into detail. There are many factors to consider: experience with the type of cancer and outcomes, the chemistry you have with the medical staff, whether to go with a local hospital or a major cancer center, whether to get second opinions, and whether it is time to change physicians. Every decision potentially has life or death consequences. As Cornwall writes, caregivers learn the ins and outs of the medical system including privacy issues, legal issues in decision making, and especially how to advocate in a way that will be heard among medical staff.

For those who need resources, Cornwall lists them extensively. She cites patient navigators in hospitals, as well as many websites that give information on such things as free lodging when a treatment center is far away from home. Financial issues are covered as well, including insurance, prescription drugs, employment, and important record keeping. Cornwall also talks about creating a healing environment. A person does not need to be defined by their cancer. She provides guidance about what to say and how to be when you are with people with cancer and those who care for them. Since cancer can strike at any age, there is an extensive section on children and cancer—both when children are the patient and when they are in the family of a person with cancer.

A very important and sometimes overlooked aspect of caregiving is taking care of oneself. Caregiving stress can potentially take as many as ten years off the life of a caregiver, according to a study at the University of California. The people Cornwall interviews speak of many ways to self care. They also share how they dealt with the aftermath of the cancer, regardless of the outcome. If your loved one dies, there is the void, the grief, and sometimes visions of the one lost. But, again, there is a void even if the outcome is that the patient is cancer-free.

No matter what, being a caregiver means going on a very rocky journey — and Cornwall’s book is a thoughtful and excellent travel guide. It will give you ideas of how to cope and how, even in the darkest most frightening moments, to find your way to grace and resilience.

Things I Wish I’d Known: Cancer Caregivers Speak Out
Bardolf & Company, October, 2012
Paperback, 258 pages
$19.95

Somebody, somewhere, declared April to be Autism Awareness Month. I’m all for it. We need to be more aware of it so that children are diagnosed early and accurately to make sure that they get the treatment they need.

What is Autism?

Autism is a neurological disorder that usually becomes apparent by the age of 3 if people know what to look for. Part of the problem in diagnosing autism is the wide range of possible behaviors and abilities. However, there is usually a distinct pattern of significant impairment in three major areas:

• Impairment in reciprocal social interaction. Children who are on the autism spectrum don’t get the give and take of conversation and sharing of experience. Even when very little, neurotypical kids will point to things that interest them so that others will see it too. They will babble back and forth, imitating conversation. Autistic kids seem to be in their own world, uninterested in sharing it with others or unable to understand that other people aren’t as interested as they are in their obsession of the moment. Higher-functioning kids with autism may come off as rude, clueless, or self-centered because of their apparent inability to read what is socially appropriate at any given time.
• Impairment in communication skills. Their language may be unusual, stilted, or limited. High-functioning kids on the spectrum may have large vocabularies but may use words incorrectly or idiosyncratically. Lower-functioning kids may not speak at all.
• Presence of stereotyped behaviors, interests, and activities.Spinning, flapping, and finger-flicking are common in young kids and even in some autistic adults. Many rock to comfort themselves. Children may develop an intense obsessive interest in just about anything. I’ve known kids who are walking encyclopedias about pirates or fishing or who know every detail of every one of the Star Wars movies. They can talk for hours about their “thing” but are unable to have even a brief conversation about almost anything else.Some of the more disabled kids with autism I’ve known have been obsessed with things such as different kinds of tires, ceiling fans or string. They are happiest when they can watch or play with their particular interest. High-functioning autistic adults may become experts in arcane academic or technical areas, again to the exclusion of almost everything else.

  In addition, many of these children show sensory processing disorders. They can be intensely over- or under-sensitive to sensory stimulation (lights, sounds, smells, or touch). Some are unable to stand the buzz of fluorescent lights or the smell of certain foods, the sensation of certain fabrics or changes in temperature, to name only a few examples. Some have a very high tolerance for pain. (A school program called me recently because a teenaged girl seemed to feel no pain when she pulled off fingernails.) Some can’t manage any discomfort at all. I know one preschooler who walks on tip-toe whenever he is barefoot because he can’t tolerate how grit feels on his feet.

Autism is associated with a known medical condition in only 10 to 20 percent of cases. It is thought to be genetic since 60 to 90 percent of identical twins both have it while in fraternal twins it is less than 5 percent. As yet, there is no genetic test or brain scan or medical test to use for diagnosis. We rely on observation and the experience of professionals.

Why Does the Prevalence Rate Keep Growing?

In my professional lifetime, the odds of a child having autism have kept growing. In the 1970s, the statistic worldwide was 4 in 10,000. Between 1985-1995, the number tripled to 12 in 10,000. The rate was estimated to be 1 in 155 by 2002; 1 in 110 in 2006 and 1 in 88 in 2008. Some studies are now suggesting that it afflicts 1 in 50 kids in the U.S.

What happened? Partly it’s about a change in the acceptance of autism as a genuine, distinct disorder. Partly it’s due to a change over time in the description of criteria and the number of criteria that need to be met to make a diagnosis.

When I was in graduate school in the early 1970s, we were using the DSM-II. Autism isn’t mentioned except as a subset of childhood schizophrenia. Frankly, back then, I’d never heard of it. When DSM-III came along in 1980, a section on infantile autism was added and the first effort was made to delineate criteria. It took until the DSM-IIIR in 1987 for autism disorder to appear with a well-articulated set of 16 criteria, 8 of which had to be present to warrant a diagnosis. By the time the DSM-IV (1994) and DSM-IVR (2000) came out, the number of criteria had been reduced to 12, with 6 being needed for a diagnosis. With each succeeding edition, mental health professionals became more aware of autism as a possible diagnosis.

At least some of the increase in prevalence is due to that awareness on the part of professionals. Some of it is probably because kids who at one time might have been diagnosed with psychosis or retardation or hyperactivity are now being assigned the diagnosis of autism. And some of it is due to the fact that parents and teachers have become much more attuned to the possibility that a child is on the autism spectrum, so evaluations are occurring at a much earlier age. Finally, it’s possible that there is something going on in our environment or in genetics that is causing an increase in the disorder. That last one remains a mystery.

What if You Suspect Your Child Has Autism?

With the increase in autism prevalence and awareness has come an increased sophistication in screening. A diagnosis of autism is rarely assigned before 15 to 18 months of age. If by then you suspect that your child isn’t developing as he or she should, you can first go to one of the many websites that have quizzes and checklists for the symptoms of autism for the age of your child. But please don’t go on the results of those websites alone. There are many reasons why a child may not be keeping up with peers. It’s just a good, if crude, first effort.

The next step is to ask your pediatrician to take a look at your web-based checklists and to decide if a referral to an autism screening team is advisable. There are early childhood interventions (EI) teams all over the U.S. who can make a more refined diagnosis and who can offer treatment if it is needed. If there is no EI team nearby, there is probably a diagnostic team in a mental health clinic or children’s hospital near you. An accurate diagnosis is essential. Diagnosis is what determines what types of treat may be the most helpful for your child.

Early Intervention Matters

There is no cure for autism but when children get intense and appropriate treatment early on, preferably before age 3, many can and do learn compensatory skills. Excellent programs provide physical, occupational and speech therapy as well as coaching in social and language skills for the child. They also provide coaching and support for parents so they can reinforce and continue the treatment at home. If there is no comprehensive program nearby, there is often a resource center connected with a school or with a medical center that can help families get the services the child needs.

I’m just getting to know Michelle. She had her first baby 3 weeks ago and has been sad and irritable ever since. Her pediatrician was worried about her at the well-baby visit this week and sent her to me. She’d had a tough pregnancy (morning sickness that wouldn’t quit for what felt to her like forever), made tougher by the financial stress that came from her husband being out of work for several months. The doctor is worried that she and her baby aren’t getting off to a good start.

Sadly, moms like Michelle often feel alone and guilty. Not feeling what they think they are supposed to feel, they are embarrassed to admit to themselves and others that things aren’t going well. Just when they need help the most, many don’t reach out. Some start to resent their babies and begrudge them time and attention. They force themselves to do what needs to be done but don’t provide their newborns with the nurturing they need.

Still others give up on nursing, or holding their babies when bottle feeding, depriving themselves and their babies with the closeness that comes with the quiet feeding times. Propping a bottle is the best they can do. Overtired, irritable, and sinking into depression, life after birth isn’t at all what they expected.

As hormones shift and settle, it’s absolutely normal to feel what is commonly known as the baby blues in the weeks following birth. One of my clients described the first couple of weeks after her first child was born as PMS times ten. Others feel more emotionally fragile than usual and maybe a little weepy. Still others are surprised that they are on an emotional roller coaster, feeling great one minute and set off into tears by something that normally wouldn’t bother them the next. It’s all because the endorphins from delivery are leaving the new mother’s system and the body is resetting itself.

Different women react differently but normal baby blues are usually accompanied by moments of joy and wonder and happiness about the baby and motherhood. The emotions settle down after a couple of weeks and the routines and rhythms of new parenting get established.

But when those up and downs last more than a few weeks, and especially if they get worse, it may indicate that the new mom is developing postpartum depression (PPD). This happens to between 11 and 18 percent of new mothers, according to a 2010 survey by the Centers for Disease Control (CDC). Surprisingly, it can last anywhere from a couple of months to a couple of years.

Symptoms of Postpartum Depression

Postpartum depression looks like any major depression. Things that once gave the mother pleasure are no longer fun or interesting. She has trouble concentrating and making decisions. There are disturbances in sleep, appetite, and sexual interest. In some cases, there are thoughts of suicide. Many report feeling disconnected from their baby and some worry that they will hurt their baby. Feelings of hopelessness, helplessness and worthlessness immobilize them. Many feel guilty that they can’t love their child, which makes them feel even more inadequate.

In some cases, women develop psychotic delusions, thinking their baby is possessed or has special and frightening powers. Sadly, in some cases, the psychosis includes command hallucinations to kill the child.

Who Develops Postpartum Depression?

There are a number of issues that contribute to a woman’s risk of developing PPD:

• A prior diagnosis of major depression. Up to 30 percent of women who have had an episode of major depression also develop PPD.
• Having a relative who has ever had major depression or PDD seems to be a contributing factor.
• Lack of education about what to realistically expect of herself or the baby. Teen mothers who idealized what it would mean to have a baby to love with little appreciation for the work involved are especially vulnerable.
• Lack of an adequate support system. Unable to turn to someone for practical help or emotional support, a vulnerable new mom can become easily overwhelmed.
• A pregnancy or birth that had complications, especially if mother and baby had to be separated after the birth in order for one or the other to recover. This can get in the way of normal mother-child bonding.
• Being under unusual stress already. New mothers who are also dealing with financial stress, a shaky relationship with the baby’s dad, family problems, or isolation are more vulnerable.
• Multiple births. The demands of multiple babies are overwhelming even with substantial support.
• Having a miscarriage or stillbirth. The normal grieving of loss is made worse by the shifting hormones.

What to Do

In cases of the normal “baby blues,” often all a new mom needs is reassurance and some more practical help. Engaging the dad to be more helpful, joining a support group for new parents, or finding other sources of support so the mom can get some rest and develop more confidence in her mothering instincts and skills can put things back on track. As with any other stressful or demanding situation, new parenthood goes better when the parents are eating right, getting enough sleep, and getting some exercise. Friends and family can help by bringing some dinners, offering to take over with the baby for an hour or so so that the parents can get a nap, or by babysitting siblings to give the parents time to focus on the infant without feeling guilty or pulled in multiple directions.

Postpartum depression, however, is a serious condition that requires more than naps and caring attention. If the problem has persisted beyond a few weeks and has been unresponsive to support and help, the mother should first be evaluated for a medical condition. Sometimes a vitamin deficiency or another undiagnosed problem is a contributing factor.

If she is medically okay, those who care about her and her baby need to encourage her to get some counseling, both for the emotional support counseling offers and for some practical advice. Cognitive-behavioral treatment seems to be especially helpful. Since women who have experienced postpartum depression are vulnerable to having another episode of depression in their lives, it is wise to establish a relationship with a mental health counselor to make it easier to seek help if it is needed in the future. If the mom has had thoughts of suicide or infanticide, the therapist can help the family learn how to protect them both. If the birthing center or hospital offers a PPD support group, the new mom and dad should be encouraged to try it. Finally, sometimes psychotropic medications are indicated to alleviate the depression.

The baby blues are uncomfortable. Postpartum depression is serious. In either case, a new mom deserves to get practical help from family and friends. When that alone doesn’t help a new mom adjust, it’s time to seek out professional help as well.

Other factors, including cultural context and faith, play an enormous role in implementing crisis interventions. This paper will compare and contrast some of these elements and models to examine how crisis interventions can be best handled now and in the future.

Crisis Intervention

Crisis management after a natural disaster is critical. Going about it properly is key to the success of crisis aversion.

There are many elements to examine when looking at a natural disaster. These include: disaster type; disaster zone environment; available resources; and delivery of resources to the area in which the disaster occurred.

Psychological First Aid

It is important to consider psychological first aid when talking about crisis management for natural disasters. This model examines the needs of the first responders and those involved with crisis recovery and management. Such people can include rescue workers, police officers, firefighters, humanitarian relief workers and any others who are in a position to help out during a natural disaster. This model includes key aspects such as education, providing support of peers, speedy recovery, mental health accessibility and a continuum of care (Castellano & Plionis, 2006).

As Castellano and Plionis (2006) discuss, first responders view themselves as having to be strong for others. Showing emotion is considered a type of weakness. This often develops into a hesitancy to seek help, which ican lead to worsening mental health. This creates a domino effect. The first responder needs to be psychologically and physically healthy enough to assist others. However, if their own physical and psychological health is ignored, the person in need may not be taken care of either (Kronenberg, Osofsky, Osofsky, Many, Hardy, & Arey, 2008).

However, psychological first aid is not applicable only to the first responder. It also is a model of how the first responder is able to help those in need. Providing compassionate engagement is key to helping those who are faced with a natural disaster, as well as allowing those in need to know that the first responder’s purpose is to provide safety and emotional comfort (Vernberg, Steinberg, Jacobs, Brymer, Watson, Osofsky, et al., 2008).

The first responder also must be able to collect information pertinent to disaster victims’ immediate needs. The first responder must be clear-headed enough to recognize the population’s needs and resources available to meet those needs. This requires the first responder to maintain psychological steadiness (Vernberg, Steinberg, Jacobs, Brymer, Watson, Osofsky, et al., 2008).

Stabilization is another key to psychological first aid. A first responder must be able to calm those who are in crisis due to a recently experienced trauma. This is applicable to those who are helping the first responders as well. However, the level and immediacy of stabilization may be different according to the different scenarios and to the needs of a crisis victim vs. those of a first responder. (Vernberg, Steinberg, Jacobs, Brymer, Watson, Osofsky, et al., 2008).

Cultural Considerations

As with most other topics, cultural considerations come into play when looking at crisis management for natural disasters. For instance, within an Asian setting, emphasis may be placed in different areas of a crisis intervention model than it would in a Western one (Udomratn, 2008).

In India, the Nitte Rural Psychiatric Project was adapted for those with limited access to resources. This project offers free care. Its goal is to overcome the stigma of mental health care by utilizing respected community members of, such as religious leaders and local doctors. Education, lectures and awareness are components to mental health care and crisis management. (Akiyama, Chandra, Chen, Ganesan, Koyama, Kua et al., 2008).

However, in another part of Asia, Senior Peer Counseling may be viewed as important in crisis intervention. In Singapore, the respect given to elders may play a valuable role in developing models of overcoming crises after a natural disaster (Akiyama, Chandra, Chen, Ganesan, Koyam, Ku., et al., 2008). In Korea, the Seoul Mental Health 2020 project offers a review of key components of the community mental health resources available to those in the area. This includes looking at adequate coverage, diversifying services in particular areas and also an integration of services. This model is looks at the overall structure of mental health and crisis intervention and aims to improve it (Akiyama, Chandra, Chen, Ganesan, Koyam, Ku., et al., 2008).

Holistic support also may be an important consideration in crisis intervention needs within an Asian population, as discussed in the Yuli psychiatric rehabilitation model for Taiwan.

Faith-based Interventions

Faith-based models also may be considered when dealing with crisis intervention following natural disasters. One model in particular, called the Camp Noah model, focuses mainly on children who have been affected by natural disasters. It is a week-long camp that allows children to express their trauma and be in an environment that supports their faith. It also relies on fun activities to provide therapeutic relief of trauma for these children (Zotti, Graham, Whitt, Anand, & Replogle, 2006).

The Camp Noah model is similar to some of the culturally-based Asian models in that it takes the context of the individual and community to heart. However, its format differs. It does not take on the viewpoint of therapy, but of a therapeutic means of expression. The Camp Noah model is more of a strategy, whereas the Asian-based models are more of an implementation. The Camp Noah model utilizes Bible study, therapist consultation, music, games and crafts. It also has the elements of low participant ratios for quality care and highly trained staff to provide adequate care for children (Zotti, Graham, Whitt, Anand, & Replogle, 2006).

Camp Noah seeks to improve disaster trauma processing and coping skills related to natural disasters. Most of the Asian-based models focus on reducing the stigma of seeking mental health care when a natural disaster does occur. There also are similarities between these models: the community setting is taken into account, and the community and its available resources are included.

Integrative Reviews

An examination of the purpose, sample, method, procedure and results of differing models is a good means of conducting an integrative review for crisis intervention models. Walsh (2009) examined different means of cultural crisis interventions for relief workers after natural disasters had occurred. A cross-cultural sample was examined in-depth to see what governmental and non-governmental agencies could do to intervene.

Walsh (2009) focused primarily on the incidence of reducing post-traumatic stress disorder and how each model worked within the context of cultures such as New Zealand, Germany, the United States, Australia, Turkey, Taiwan, Israel and Iran. Walsh found that three key elements in the data reduction model were relevant to each culture. These three elements included: debriefing, team building and preparation. These elements were different according to the cultural context; however, each proved effective in each of the cultures (Walsh, 2009). Walsh notes that long-term effects on relief workers should be further researched for future crisis intervention models (Walsh, 2009).

Conclusion

Crisis intervention has many elements in the context of a natural disaster. There are the considerations toward the population involved in the natural disaster and the aftercare of not only this population, but the relief workers as well. Models based on cultural contexts are necessary to provide effective intervention and treatment to particular populations. There is also the element of faith when developing crisis intervention models, so as to look at ways of coping with and overcoming trauma. And finally, there is the relevance of examining a model within the cross-cultural context that integrates key elements so as to be globally applicable and efficient in reducing such traumas as post-traumatic stress disorder and other mental health concerns.

References

Akiyama, T., Chandra, N., Chen, C., Ganesan, M., Koyama, A., Kua, E., et al. (2008). Asian models of excellence in psychiatric care and rehabilitation. International Review of Psychiatry, 20(5), 445-451. doi:10.1080/09540260802397537.

Castellano, Cherie, and Elizabeth Plionis. 2006. “Comparative analysis of three crisis intervention models applied to law enforcement first responders during 9/11 and Hurricane Katrina.” Brief Treatment and Crisis Intervention 6, no. 4: 326-336. PsycINFO, EBSCOhost.

Kronenberg, M., Osofsky, H., Osofsky, J., Many, M., Hardy, M., & Arey, J. (2008). First responder culture: Implications for mental health professionals providing services following a natural disaster. Psychiatric Annals, 38(2), 114-118. doi:10.3928/00485713-20080201-05.

Udomratn, P. (2008). Mental health and the psychosocial consequences of natural disasters in Asia. International Review of Psychiatry, 20(5), 441-444. doi:10.1080/09540260802397487.

Vernberg, E., Steinberg, A., Jacobs, A., Brymer, M., Watson, P., Osofsky, J., et al. (2008). Innovations in disaster mental health: Psychological first aid. Professional Psychology: Research and Practice, 39(4), 381-388. doi:10.1037/a0012663.

Walsh, D. (2009). Interventions to reduce psychosocial disturbance following humanitarian relief efforts involving natural disasters: An integrative review. International Journal of Nursing Practice, 15(4), 231-240. doi:10.1111/j.1440-172X.2009.01766.x.

Zotti, M., Graham, J., Whitt, A., Anand, S., & Replogle, W. (2006). Evaluation of a Multistate Faith-based Program for Children Affected by Natural Disaster. Public Health Nursing, 23(5), 400-409. doi:10.1111/j.1525-1446.2006.00579.x.

Managing Depression and Suicidality

It is common for clients with schizophrenia to feel grief and loss due to the myriad life changes that it triggers (Wittmann & Keshavan, 2007). In this sense, during treatment, it is essential for clinicians to help clients navigate through the grieving process. According to Tait, Birchwood, and Trower (as cited in Wittmann & Keshavan, 2007), depression has been found to lead to the abandonment of treatment by clients due to the isolating characteristics of the disorder. Abandonment of treatment poses serious drawbacks for clients.

Wittmann and Keshavan (2007) assert that the grieving process is a necessary component to coming to terms with a new diagnosis of schizophrenia. Due to the sense of loss experienced by individuals newly diagnosed with schizophrenia, it is essential for them to navigate and work through the grieving process (Wittmann & Keshavan, 2007). According to Lewis (as cited in Wittmann & Keshavan, 2007), by doing so, clients will learn to mourn the life and identity changes that have occurred, along with establishing the ability to integrate such change into their lives. It has been shown that counseling can be beneficial in such a situation.

Grief and mourning are a common component in clients diagnosed with schizophrenia (Wittmann & Keshavan, 2007). This is because the diagnosis of a serious, permanent mental disorder is a major life crisis for most. The disorder affects the mind in very serious ways (Wittmann & Keshavan, 2007). In some cases, clients might spiral into psychosis as a means of dissociating, or defending against facing, the losses their disorder has caused (Wittmann & Keshavan, 2007). Clinicians have a major hand in helping clients manage this crisis.

Numerous models exist to explain grief and mourning, and can also help professionals guide grieving individuals. Elizabeth Kubler-Ross (1969) proposed five stages of grief that individuals can experience while grieving. They include denial, anger, bargaining, depression, and acceptance. In contrast, Worden (2002) proposes four tasks, as opposed to stages of grief. These include accepting the reality that loss has occurred, feeling the pain and emotional responses to the loss that has occurred, readjusting to life after the loss, and finding ways to remember the lost individual. Although these models are meant to aid in grieving a person, individuals diagnosed with schizophrenia are, in fact, grieving the loss of the person they once were and will potentially no longer be. In this sense, these models offer a framework that can be used in counseling to help a client adjust to life after their loss of self.

A Safety Plan for the Newly Diagnosed

Clinicians should develop a safety plan for use in the event that a client presents with suicidal intent or depressive symptoms, as these are both common in newly diagnosed clients. One of the first issues to address is the onset of depressive symptoms or suicidal thoughts. A safety plan can involve listing symptoms characteristic of depression, including those characteristic to the client, as well as those that the client has not felt before, but could potentially feel in the future. This would help foster the client’s awareness of their own symptoms.

Along with such a list, clinicians can help clients determine the course of action to be taken if suicidal thoughts or feelings occur. Action plans can include emergency contact numbers, such as a suicide hotline and that of the primary therapist, the psychiatrist and other medical doctors, and family members or other individuals who serve as the client’s support system. One of these individuals could sit with the client and support them through the situation while attempting to contact appropriate clinicians. If the client has no close friends or relatives, suggest that they join an in-person or online support group.

Clients should be asked to keep a list of depressive or suicidal triggers. During sessions, the counselor and client could develop and implement ways for such triggers to be managed.

Clinicians should urge clients to remove from his or her home any items that could be used to self-harm. Making access difficult reduces the temptation to use them. This might be especially useful for clients who have already made attempts, and would also potentially increase the likelihood of them seeking some form of support or following an appropriate plan of action, rather than engaging in self-injurious behavior.

Clients can be encouraged to keep an up-to-date medication list with them at all times. This will help them if they need to seek out emergency services. During a crisis, it might be difficult for them to recall each of the medications they take, as their minds will be preoccupied.

Clinician should keep a current list of service providers to which clients can be referred. For example, if the client’s symptoms become more intense and overwhelming for them, and more in-depth treatment is required, the clinician should be able to make an appropriate referral or direct the client to an appropriate provider. This could further ensure the client’s safety, as he or she would receive the necessary services, especially if more in-depth treatment is required.

Conclusion

A diagnosis of schizophrenia presents serious implications for newly diagnosed individuals in particular. Those with schizophrenia have a vast series of challenges to face, including overcoming and grieving the loss of a sense of self, experiencing a loss of hope for the future, accepting the diagnosis, facing the fact that social, occupational, educational, familial, and romantic arenas might undergo marked change, and integrating new insights, coping strategies, and processes learned on their journey into their life.

Because the diagnosis of a serious mental illness can cause a major life crisis (Wittmann & Keshavan, 2007), clinician support is critical. This is especially true because depression and suicidal ideation are common in the newly diagnosed (Addington et al., 2004). Along with helping the client manage their diagnosis and helping to facilitate his or her grieving process, clinicians can help ensure client safety by establishing and agreeing upon a safety plan for use in the event that the client is experiencing depressive symptoms or suicidal ideations. Not only will this help clients to feel supported and cared for, but it will also potentially help save a life in the event of an emergency or crisis.

References

Addington, J., Williams, J., Young, J., & Addington, D. (2004). Suicidal behaviour in early psychosis. Acta Psychiatrica Scandinavica, 109(2), 116-120.

Kubler-Ross, E. (1969). On death and dying. New York: Scribner.

Wittmann, D. & Keshavan, M. (2007). Grief and mourning in schizophrenia. Psychiatry, 70(2), 154-166.

Worden, J.W. (2002). Grief counseling and grief therapy: A handbook for the mental health practitioner (3rd ed.). New York: Springer Publishing Company.

This is something that I see periodically in the population of Alzheimer’s Disease and Related Dementia (ADRD) patients I work with as director of care for a home care agency. Named for Joseph Capgras, the French psychiatrist who first described it, this delusion also sometimes is seen in people who have schizophrenia or bipolar disorder, or where there has been some type of brain injury or disease. Regardless of its source, it is likely less rare than is typically believed by psychiatrists and psychologists (Dohn and Crews, 1986), and therefore deserves more public and professional awareness.

It can be highly perplexing and upsetting for both the person experiencing Capgras, as well as for their caregivers and those who are the misidentified “imposters” (Moore, 2009). There are more effective ways to help manage someone suffering from Capgras and dementia, as well as methods that likely will increase management difficulties. Unfortunately, the approaches that are likely to increase difficult behaviors are the very ones to which family and professional caregivers instinctively gravitate (Moore, 2009). However, we find effective guidance in all aspects of dementia behavior management — including Capgras — when we turn to Habilitation Therapy, the compressive behavioral approach to ADRD that the Alzheimer’s Association finds to be a best practice (Alzheimer’s Association, 2001, n.d.).

Three core concepts found within Habilitation Therapy can be most helpful in dealing with Capgras Syndrome (Moore, 2009). They are to:

• Enter the reality of the person with dementia
• Never argue or correct
• Focus on creating positive emotional experiences to address challenging behaviors

Let’s explore each in more depth…

1. Enter into their reality. Imagine for a moment what it must be like to truly believe that a person or place you care about is an imposter. Someone you count on and feel close to, the comfort and safety of your own home is all some weird, unfathomable charade. As if the world wasn’t already topsy-turvy with having dementia, now this trusted person or beloved place is somehow involved in a fraud with an identical imposter! How horrifying and upsetting such a situation must be. Who and what can you trust? What is safe? Real? Seeing the world through the experiencer’s eyes is the first step to understanding their needs (Alzheimer’s Association, n.d.).
2. Never argue or correct.Focusing on correcting a dementia patient’s constantly twisted information and misguided understandings creates a never-ending struggle. A person with dementia cannot keep “facts” straight, and correcting them will not help for more than a minute or two. Arguing that they are wrong and trying to prove it to them is unlikely to yield anything but resentment, discouragement, and hurt feelings. Habilitation Therapy says to stop arguing and correcting immediately and in all cases. Care partners need to let go of having the objective “facts” set right – it just cannot be done. Trying to do so can seriously damage the relationship with the person with dementia, and feelings of love and connection can quickly be replaced by resentment and anger that go both ways. This is particularly true with Capgras, where the very nature of care partners’ relationships are called into question.Having Capgras Syndrome is not the dementia patient’s fault. It is not the care partner’s fault either, and they must stop taking the problem as a personal insult, and trying to correct its misguided conclusions. The confusion is just the disease at work. (Alzheimer’s Association 2011, n.d., Snow, n.d., Moore, 2010, n.d.).
3. Create positive emotional experiences. In this situation, where your ability to think through and solve problems is seriously impaired, what would your needs be if suddenly faced with an imposter? I’d bet on needing reassurance, love and connectedness, and feeling safe. It is up to a dementia patient’s care partners to help create an environment where such emotions can thrive. (Alzheimer’s Association 2011, n.d., Snow, n.d., Moore, 2010, n.d.).

Putting it All Together

Here are elements of an Habilitation Therapy-consistent response to an episode of Capgras Syndrome (Alzheimer’s Association 2011, n.d., Snow, n.d., Moore, 2010, n.d.):

• Acknowledge their feelings. “Of course this is upsetting. Are you OK? I’m so sorry this is happening to you.”
• Get and stay emotionally connected. Connect to the emotional aspect of the dementia patient. “I care about you. You are safe with me.” Or “[Name of person with the imposter] loves you. I love you too. She or he sent me while she or he can’t be here. You are safe with me.” However it can be done, a warm emotional connection must be made and maintained.
• Send the imposter away. If another person is present, that person can shoo away the imposter and say to the dementia patient, “I sent them away. You are safe with me.” In a while, have the loved one return, and engage immediately on an emotionally positive level. Have the other person recognize them as who they are, also engaging warmly and emotionally.
• Connect through the ears. Have the person with the imposter connect through sound only. For example, come home and shout from outside the sight of the dementia patient, For example: “Hi, honey, it’s your husband Bob, I’m home! I can’t wait to tell you about my day! How are you?” – or whatever makes a connection to the warm emotions in the relationship. Keep talking as he or she comes into sight, connecting emotionally. “You look so great in that color shirt. I love you, and I just saw our uncle Bob who also sends his love. Dinner smells great! What’s cooking?” This may help make a positive identification of the “real” person more possible (Ramachandran, 2007).

Connecting emotionally and warmly to the person with dementia is key to successful management. Arguing and proving through logic and fact that the person with dementia is wrong will not work. Each person’s malfunction is unique and each needs a unique intervention in the moment; creativity by care partners will be needed to find the most effective approach. But the basic underlying Habilitation concepts for successfully managing Capgras remain the same case to case (Alzheimer’s Association 2011, n.d., Snow, n.d., Moore, 2010, n.d.).

References

Alzheimer’s Association, Massachusetts/New Hampshire Chapter. (n.d.) Caring for People with Alzheimer’s Disease: A Habilitation Training Curriculum. (Watertown, MA). p. 68.

Alzheimer’s Association, Massachusetts/New Hampshire Chapter. (August 2, 2011) Caring for People with Alzheimer’s Disease: A Habilitation Training Curriculum [Training Course]. (Lawrence, MA)

Ellis, H., Lewis, M. (2001). Capgras delusion: a window on face recognition. TRENDS in Cognitive Sciences Vol. 5 No. 4.

Hirstein, W., Ramachandran, V.S. (1997) Capgras Syndrome: A Novel Probe for Understanding the Neural Representation of the Identity and Familiarity of Persons. Proceedings, Biological Sciences, Vol. 264, Issue 1380, Mar. 22, 1997), 437-444.

Dohn, H., Crews, E. (1986). Capgras syndrome: a literature review and case series. Hillside J. Clin Psychiatry. 1986; 8 (1): 56-74. Retrieved January 23, 2013 from www.ncbi.nlm.nih.gov/pubmed/3744300.

Moore, B. L. (2009). Matters of the Mind and the Heart: Meeting the Challenges of Alzheimer Care. New York: Strategic Book Publishing.

Moore, B. L. (Nov. 20, 2010) StilMee™ Certification for Professionals: Working respectfully and effectively with people with Memory Loss [Training Course] Burlington, MA.

Ramachandran, V.S. (2007). V.S. Ramachandran: 3 clues to understanding your brain. TED Talks. www.ted.com/talks/vilayanur_ramachandran_on_your_mind.html.

Silva, J., Leong, G., Weinstock, R., Boyer, C. (1989). Capgras Syndrome and Dangerousness. Bull Am Acad Psychiatry Law, Vol. 17, No. 1, 1989 (13).

Snow, T. (n.d.) The Art of Caregiving. [Video] Florida: Pines Education Institute of Southwest Florida.

The Boy On The Lake: He Faced Down the Biggest Bully of His Life and Inspired Trevor’s Law tells the true story of Trevor Smith Schaefer, his fight to survive cancer, and his determination to find answers concerning the much higher than average rate of childhood cancer around the town of McCall. Penned by writer Susan Rosser with help from Trevor and his mother, Charlie Smith, the book chronicles the the pair’s battles with disease, with an emotionally abusive father and husband, and, finally, with the government’s lack of attention to environment problems.

When her twelve-year-old son’s malignant medullablastoma was discovered, Charlie Smith was trying to deal with a divorce. During Trevor’s surgery and chemotherapy, the author tells us, Charlie felt she practically lived in the hospital’s cancer unit. As she got to know the other mothers and cancer patients, she developed a sinking feeling that something wasn’t quite right in her town. She began her search to find out why so many children in the area were suffering from cancer. Through extensive research, good friends, nerves of steel, and the drive and optimism to keep going, Charlie came across shocking information about McCall and the surrounding area. The beautiful place she called home was actually a chemical cocktail, and the government seemed less than willing to help.

Along with the cancer, Trevor had to fight off a bully who should have been his most steady support through the whole ordeal: his own father. Ballard Smith was there for his son only when it was convenient, and often stood him up as he suffered through the effects of chemotherapy. Ballard’s lack of emotional support eventually led to emotional abuse, in the form of ridicule for walking funny (an effect of the chemo). Charlie and Trevor were finally able to escape from Ballard’s emotional abuse and control issues to team up for their next obstacle.

Once Trevor had beaten cancer, he and his mother embarked on a mission to raise awareness of the chemicals that infest many towns, with the goal of making the government do something about them. Through years of research, networking with the right people, and the unwavering courage to face down the people who attempted to belittle their quest, Charlie and Trevor were able to make extensive progress in discovering the secrets their town held. The calls began pouring in from all over the country from those suffering in towns like McCall, and Trevor’s Law was born.

The law, if passed, would direct federal funds to areas where the cancer level is particularly high among children so that testing can be done to find possible environmental influences. To help create the law, Trevor and Charlie worked to gain the backing of politicians in Idaho, including numerous state senators. They also worked with parents of children with cancer, people in other cancer clusters across the country, and even the famous Erin Brockovich. Their message gained momentum, eventually leading Trevor to Washington, D.C., to encourage lawmakers to support Trevor’s Law. While there, he pleaded with Congress to see that more effort needs to be made to figure out what’s going on in areas with high childhood cancer rates.

It must have taken Trevor and Charlie tremendous amounts of optimism and courage to not only get through cancer but then campaign to help others with similar problems. Trevor faced the prospect of death before he had the chance to become an adult, yet managed to turn his experience into something positive — something that still may affect the entire country. Charlie, meanwhile, helped the cause even at a time when her family life was falling apart. This perseverance, shown by both mother and son, makes “The Boy on the Lake” an inspiring read.

The Boy On The Lake: He Faced Down the Biggest Bully of His Life and Inspired Trevor’s Law
Morgan James Publishing, October, 2012
Paperback, 300 pages
$21.95

A 65-year-old woman diagnosed with early-onset Alzheimer’s Disease had what had become a typical spat with her spouse of 40 years. He argued, furious and insulted, “I’m your husband! Don’t you know me?!” “You look exactly like him,” she said quietly, “but I know that you’re not him.” Nothing could convince her otherwise, though the man told her many things only her husband would know. “You are one of the two imposters that come around here, not my husband,” she insisted.

Are these the plots of psycho-thriller movies? Scary stories told around a campfire? Disturbing dreams? No – they are two examples of a neuropsychological condition called Capgras Delusion or Capgras Syndrome, also known as the “Imposter Syndrome” (Hirstein and Ramachandran, 1997).

Capgras Syndrome, named for Joseph Capgras, the French psychiatrist who first described it, also can be seen occasionally in people who are psychotic (typically schizophrenic), or where there has been some type of brain injury or disease (Hirstein and Ramachandran, 1997). Regardless of its source, it can be equally perplexing and upsetting for the person experiencing it as it is for those around him or her to encounter it.

Within psychiatry and psychology, Capgras is considered extremely rare (Ellis and Lewis, 2001, Hirstein and Ramachandran, 1997). There is evidence, however, that it is not as rare as most clinicians believe. It is “uncommon,” but often overlooked (Dohn and Crews, 1986). From my own experience as the director of care for a home care agency, I concur: I see it often enough within my population of people with Alzheimer’s and other related dementias (ADRD) that it is likely not extremely rare.

While Capgras may not be typical, it certainly deserves to be better known both by the general public and among helping professionals. For those of us who love or work with such patients, we need to know how to manage the challenging behaviors that arise from it. Assessment of such patients’ potential danger to others needs to be performed (Silva, Leong, Weinstock, and Boyer, 1989). Awareness of the presence of Capgras also will help caregivers and families know how to better manage their own behavior around and feelings about its symptoms, particularly for the sake of those who are deemed “imposters.”

What Causes Capgras Syndrome?

It’s not known for certain what causes Capgras, but researchers have evolved several credible theories. One is from neurologist V.S. Ramachandran (Ramachandran, 2007). Ramachandran believes that a malfunction between the brain’s visual cortex and the emotional feeling of “familiarity” causes the sufferer to think he or she is seeing a perfect duplicate, not the real thing. The eyes are reporting correctly, but emotions of familiarity aren’t present. The conclusion: here’s an exact imposter.

Ramachandran also reports that a brain injury patient with Capgras was able to correctly identify his mother when he heard her on the phone, but not when he saw her. He hypothesizes that sounds may be correctly connected to the feelings of familiarity in some cases (Ramachandran, 2007).

There are several features particular to Capgras:

1. The patient has a brain injury or disease.
2. He or she recognizes that a person or place is exactly like the “real” one, but insists it is not.
3. The imposter always is a person or place with which the patient is familiar, not a stranger, vague acquaintance, or a new place.
4. The problem does not fruitfully yield to psychological analysis or interpretation; it is a biological disorder.

Prosopagnosia, a better-known form of facial misidentification, differs from Capgras in that it causes a total inability to recognize previously familiar faces (Ellis and Lewis, 2001). Capgras includes easy recognition of the face, but disagreement about the person’s true identity.

Are Capgras Sufferers Potentially Dangerous?

There are some reported cases where those suffering from Capgras delusion have become dangerous to others, with violent behavior resulting in injury and even death. There is very little research on this subject and not much information with which to reliably predict violence — which is striking given that great hostility and resentment are typical of how sufferers of Capgras view “imposters.”

In a paper by Silva, Leong, Weinstock, and Boyer (1989), they stated that at that time there was little published on the subject of danger and Capgras. A further search in the literature for this article found no papers published later than that date. It should be noted, however, that no cases have been found in the literature of danger paired with dementia; all cases were connected to diagnoses of schizophrenia or bipolar disorder.

Silva, Leong, Weinstock, and Boyer (1989) report several important factors to take into account when assessing danger:

1. Those “…suffering from multiple coexisting types of delusions of doubles may present with significant dangerous behavior…”
2. Where there is unabated hostility toward the misidentified person, “… the slightest
   perceived provocation that the misidentified persons are in some way harming the affected individual may serve as a necessary and sufficient psychosocial stressor that may upset this delicate equilibrium.” Violent behavior could potentially be the outcome.
3. “…[T]he dangerous behavior… related to the specific delusional content in each case” can be vital. If the delusion points to great danger or evil on the part of the “imposter,” this may increase the potential for violence.
4. Accessibility to the people involved in the delusion should also be part of the assessment. Is the “imposter” living with the person who holds the delusion, thereby increasing likelihood for opportunity for triggers for violence?
5. Pre-existing emotional, psychodynamic factors that increase the potential for violence need to be assessed. For example, does the relationship before the delusion between the Capgras sufferer and the misidentified person include high levels of hostility, hatred, or even abuse or assault, thereby increasing the likelihood of future violence?

Violence aside, managing the day-to-day difficult behaviors and emotions around Capgras and dementia takes some specific skills. These will be discussed in Part 2 of this article.

References

Ellis, H., Lewis, M. (2001). Capgras delusion: a window on face recognition. TRENDS in Cognitive Sciences Vol. 5 No. 4.

Hirstein, W., Ramachandran, V.S. (1997) Capgras Syndrome: A Novel Probe for Understanding the Neural Representation of the Identity and Familiarity of Persons. Proceedings, Biological Sciences, Vol. 264, Issue 1380, Mar. 22, 1997), 437-444.

Dohn, H., Crews., E (1986). Capgras syndrome: a literature review and case series. Hillside J. Clin Psychiatry. 1986; 8 (1): 56-74. Retrieved January 23, 2013 from www.ncbi.nlm.nih.gov/pubmed/3744300.

Ramachandran, V.S. (2007). V.S. Ramachandran: 3 clues to understanding your brain. TED Talks. www.ted.com/talks/vilayanur_ramachandran_on_your_mind.html

Silva, J., Leong, G., Weinstock, R., Boyer, C. (1989). Capgras Syndrome and Dangerousness. Bull Am Acad Psychiatry Law, Vol. 17, No. 1, 1989 (13).

Occupational therapy often is misunderstood in this process. According to the American Occupational Therapy Association, the primary goal of occupational therapy is to support and enable each person’s “health and participation in life through engagement in occupation.”

“Occupation” does not solely mean work. Some examples of occupations include time spent on personal hygiene, preparing a meal, managing finances, painting a picture, attending a community leisure course, and socializing with others. Occupational therapists enhance people’s ability to live meaningful and satisfying lives.

The purpose of occupational therapy can best be described by the profession’s motto, “Occupational therapy: living life to its fullest.” All individuals have a right to live life to its fullest. An occupational therapist can help people consider not only their needs, strengths, abilities, and interests, but also their physical, social, and cultural environment.

Origins of Occupational Therapy

While many commonly think of occupational therapy as physical rehabilitation after injury or illness, it actually has roots in mental health.

Occupational therapy’s emergence can be found as far back as eighteenth-century Europe. At a time when mentally ill people were treated like prisoners, a “moral treatment movement” began to evolve. While the previous treatment model was associated with punishment, brutality and idleness, the moral treatment movement sought to encourage kindness and the therapeutic value of engagement in purposeful activities.

The first occupational therapy treatment model, called Habit Training, began at Johns Hopkins in the early twentieth century. This approach proposed that in mentally ill people, occupational activities such as work, rest and play had become unbalanced. Early occupational therapists introduced therapeutic occupations such as weaving, art, and bookbinding. These goal-directed activities were used to help individuals learn new skills to be productive, and derive therapeutic benefits of a balanced daily schedule.

The occupational therapy profession grew as wounded soldiers returned from World War II, and then surged again in the 1970s with the medical field’s increase in specialized skills and knowledge.

Occupational therapists always have believed in treating the whole person, whether the primary problem relates to physical or mental health. They practice in diverse settings, including hospitals, outpatient clinics, skilled nursing facilities, intermediate care facilities, home health, neonatal intensive care units, community programs and the workplace. Those who work in mental health can do so in residential hospitals, community-based mental health settings and outpatient private practice clinics.

Assessments and Treatments

When working with someone with a mental health condition, occupational therapists employ a variety of assessments. Once the necessary information has been obtained, the therapist creates a personalized occupational profile. This profile is used for goal-setting and treatment planning.

Common areas of assessment include:

• Activities of daily living (e.g., bathing, dressing, eating)
• Instrumental activities of daily living (e.g., driving, money management, shopping)
• Education
• Work (paid and volunteer)
• Play
• Leisure
• Social participation
• Motor processing skills
• Mental and cognitive processing skills
• Communication and interaction skills
• Habits, roles and routines
• Performance contexts (e.g., cultural, physical, spiritual)
• Activity demands
• Client factors (e.g., difficulties due to body structures or functions)
• Occupational self-assessment

For example, an occupational therapist may assess a client with schizophrenia who is living in a residential hospital in order to help to determine the best placement in the community. The assessment may include standardized evaluation tools, individual interview, and observation to determine ability to function and live alone safely, and identify important roles and occupations. This information is then used to determine the skills, supports, and environmental modifications the person may need to live as independently as possible.

Occupational therapy can be vitally important in the overall mental health treatment process. Following are some common interventions:

• Life skills training
• Cognitive rehabilitation
• Supported employment
• Supported education
• Social and interpersonal skills training
• Life balance intervention
• Modalities such as biofeedback and mindfulness-enhanced therapy

Part of Collaborative Process

As noted in the beginning of this article, occupational therapists collaborate with many other professionals to help individuals on their road to recovery. While the role of the occupational therapist may overlap with other team members, the occupational therapist provides a unique theoretical and clinical contribution to the recovery and treatment team; thus, occupational therapy should be considered a vital part of a comprehensive and integrated treatment program.

In The Attachment Therapy Companion: Key Practices for Treating Children & Families, attachment experts Arthur Becker-Weidman, Lois Ehrmann, and Denise H. LeBow seek to create a foundational text. Though they suggest that the book might be useful for caregivers as well, it is designed as a manual for clinicians, outlining the existing best practices in attachment therapy and organizing the field for the way forward. The text has an unfortunate tendency to repeat itself and some of the later chapters feel insubstantial; still, the authors have crafted a strong case for attachment therapy as an exciting theory deserving of further research.

Attachment therapy is new enough that it does not yet have a fixed terminology, so the authors wisely begin with a discussion of key definitions and concepts. The book is careful to distinguish what it terms “attachment-focused therapy” from more heavily “touch-reliant” techniques, explaining that, though touch may be involved in some successful attachment-focused strategies, the focus of the therapy is building an emotional understanding and trust between the child and caregiver. There is also an emphasis on the importance of reciprocity: The child must not only feel the effects of the caregiver’s love and support but also feel that the caregiver is affected by the child in turn. A major theme is that the caregiver’s place in the therapeutic process is equally significant to the child’s, whereas the clinician “takes more of a coaching or consultant role.”

The book argues that attachment is already the basis for many trauma-focused therapies, though it may not always be explicitly labeled. By making attachment the specific target of therapy for children who have experienced lasting trauma, the authors believe that clinicians will be able to avoid frequently used but insufficient diagnoses such as PTSD or bipolar disorder. The authors devote significant time to discussing the particular difficulties of diagnosing and treating children, and claim that attachment-focused therapy is especially suited to the developing minds of the young. They emphasize the necessity of a flexible, individualized treatment plan and rely more on case studies and examples to guide readers in working with their own clients than on step-by-step methodologies.

The Attachment Therapy Companion seems to do a fine job of consolidating current knowledge in the field and paving the way for future developments. The chosen examples are presented in a dialogue format that effectively demonstrates ways in which the clinician can strengthen the child-caregiver relationship. The emphasis on careful listening and avoiding blame for disruptive behavior, with the clinician playing the role of facilitator, provides a convincing image; it is easy to picture the children in the chosen examples making significant progress.

However, it is a bit difficult to imagine a clinician reading this book and successfully implementing its ideas without significant further research, as the text tends to be vague on the beginning stages of the therapy. The book states that a prerequisite for these techniques is a comprehensive assessment of the suitability of both child and caregiver, including “an assessment of the child and the caregiver’s capacity to be insightful, responsive, sensitive, reflective, and committed, and their state of mind with respect to attachment.” Yet it does not offer advice on how to locate and enlist such a qualified caregiver. The book addresses the fact that many traumatized children have difficult family situations when discussing behavior management and treatment logistics but does not address the seemingly larger question of how an attachment therapist would find a suitable caregiver in the lives of these children. As the book argues that attachment-focused therapy is the best way to treat these children and that the role of the caregiver is essential, the lack of strategies offered to find such a caregiver is glaring.

Ultimately, the book seems a useful resource for clinicians interested in working with child victims of lasting trauma—but it is not quite the foundational text it seeks to be. It is by no means comprehensive, and its weaknesses call out for further research and further writings. Considering the integral role of the caregiver and the significant emotional qualifications required of him or her, it seems like the logical next book would be a primer for the caregivers themselves. (Attachment-focused therapy puts an uncommon amount of responsibility on the parent figure, so he or she deserves to be provided with an uncommon amount of clinical information.) What The Attachment Therapy Companion does, however, is outline a new therapeutic model that requires more psychological knowledge from the client. Though it does not solve all of the problems of such a model, it proves the worth of its field.

The Attachment Therapy Companion: Key Practices for Treating Children & Families
W. W. Norton & Company, September, 2012
Paperback: 240 pages
$27.95

Whoever made up that rhyme is just plain wrong. Consider these comments from letters to Psych Central’s “Ask the Therapist” column:

• “My folks just tell me that I’m fat and stupid. They’re always telling me I’m no good.” –14-year-old girl
• “No matter what I do, my parents criticize me. I get good grades. I help out at home. My girlfriend is polite to them. But I can never do things enough right for them.” –17-year-old boy
• “Both my parents yell at me all the time. I try to stand up for myself but it only makes it worse. They say they wish I’d never been born.” – 11-year-old girl
• “I think my mom is depressed. She stays in bed all the time. She expects me to clean house, cook dinner every night, take care of my little sister, and bring her whatever she wants. She’s not a bit grateful. Actually, she complains about me to my grandmother and to my dad. Then they yell at me too. I don’t think I can take it much longer.” – 16-year-old boy

The anguish and bewilderment in these kids’ voices is heartbreaking. Some of the letters are laced with anger. Most are testaments to the pain of feeling unloved by the very people who the whole world tells you should love you — your parents and extended family.

The teens who write are essentially good kids who are doing all they can to do okay in school and contribute at home. They try to please their folks. They often do far more in the way of housework and child care than is reasonable to expect. All they want is for their folks to love them but all indications are they don’t. These kids want an explanation. They want to make it right. They wish and hope and dream that there is something they can do to make it different.

Sadly, there’s probably not a thing they can do to make loving parents out of angry and inadequate adults. Their parents are too caught up in their personal pain or too unloved themselves to comfort and nurture their kids.

If you relate to the kids in the beginning of this article, know that you are not alone. It’s not fair that you need to take charge of your own life so young. But constantly thinking about the unfairness will only keep you stuck and hurting. A better use of the energy that is born of anger and disappointment is to use it to fuel efforts to move on. The teen years do not last forever and there is much you can do to set yourself up for a happier present and more promising future.

Don’t add self-abuse to your parents’ abuse.

Cutting, isolating, failing in everything you do, abusing drugs and alcohol and attempting suicide may seem like reasonable responses to pain. But none of these tactics are likely to make you feel better or impress unloving parents. Although hurting yourself may provide a temporary distraction or relief, it won’t make your life better. Not loving yourself won’t help you find love.

Take it seriously but not personally.

It’s really hard not to take things personally when you’re the person being attacked. But when parents don’t love their kids, it’s usually not about the kids. Usually the parents have mental health issues of their own. Sometimes there is a family secret around the child’s birth (like a rape or grandparents’ disapproval) and the child gets scapegoated. Sometimes parents got so little nurturing themselves as children they haven’t a clue how to be good parents.

Whatever the case, it’s important that you refuse to accept your parents’ opinions. They are not an accurate assessment of your worth, lovability, intelligence, appearance, or potential. They are a reflection of your parents’ inadequacy.

Drop your end of the tug of war.

When parents are inadequate, yelling, arguing, debating, and defending yourself go nowhere. It only frustrates you and makes your parents more angry. In some cases, it fans the flames to the point where the parent gets violent. Give it up. You’re not going to change who they are or how they treat you. You don’t need to hear whatever they say when you get into a fight with them.

Develop a life outside of your home.

When home isn’t a place you want to go home to, it’s essential to find other places where you feel safe, supported, and seen for who you are. Join up with an organization, team or cause or get an evening and weekend job where you can hang out, where you can make a contribution, and where you can find friends and adult mentors who appreciate you. The best antidote for feeling bad about yourself at home is to feel very good about yourself in the larger world.

Be open to other older people who are ready to love you.

Some people aren’t born to the right family. They have to make one. When an older relative, a teacher, a friend’s parents, or a coach offer to mentor you, follow up. Invest some time in getting to know them. These people can give you some of the wisdom and support your own parents can’t give you. Some of these relationships can evolve into lifelong friendships.

Prepare for independence.

It may not be fair, but it’s important to be real. Unloving parents aren’t going to prepare you for independence. They’re just going to be glad when you move out. It falls on you to learn the skills you need to know to survive out there on your own. Make a list of what you need to know how to do, from doing your own laundry to managing money, and set out to learn how to do it. Get a job and start putting money away so you can rent a place of your own the day you graduate from high school. Get good grades and ask your school counselor to help you identify scholarships so you can go away to college.

Report.

If your parents move beyond criticism and belittling words to physical or sexual abuse, report to the local authorities and get yourself out of there. Talk to your school counselor or your doctor or the local children’s services department. Yes, it’s hard to give up on your family. But it can take years to recover from chronic abuse. You deserve better — even if your parents don’t think you do.

This month we had the pleasure of talking to Christina Hibbert, PsyD, a clinical psychologist and expert in women’s emotional health across the lifespan; pregnancy and postpartum mental health; grief and loss; and parenting.

Hibbert is the founder of the Arizona Postpartum Wellness Coalition and author of the upcoming memoir This is How We Grow. A frequent speaker, she’s been called “The Singing Psychologist,” and often shares an original song or two when she speaks.

Hibbert is the mother of six energetic kids and has a private practice in Flagstaff, AZ. Get to know Christina Hibbert by visiting her website at www.drchristinahibbert.com.

1. What’s surprised you the most about being a therapist?
How similar we all are on the inside, despite how we appear on the outside. Deep down, we all just want acceptance and love.

2. What’s the latest and greatest book you’ve read related to mental health, psychology or psychotherapy?
My all-time favorite “greatest” book is Bonds That Make Us Free: Healing Our Relationships, Coming to Ourselves, by C. Terry Warner (I’ve read it 3 times!). Warner shows us how we “betray ourselves” in relationships by failing to act on impulses to do the “right” thing. Then, we end up fighting to protect our self-betrayal and this blocks out love.

For instance, if a dad hears his newborn cry and thinks “I should feed him so my wife can sleep,” but then falls asleep instead, he has betrayed himself. He then has to tell her all the “reasons why” he didn’t wake up (“I work all day, you know!”); she feels hurt, so does he, and the love has vanished. Understanding these principles has changed my world, and now it helps me change others’ worlds too!

3. What’s the biggest myth about therapy?
That the therapist is going to “fix” you. That’s not it at all. Therapy is a partnership, and when both parties do their part, change is the result. The therapist offers insights, suggestions, and tools, and the client implements them in his or her life. That’s what therapy is all about.

4. What seems to be the biggest obstacle for clients in therapy?
Implementing the insight gained from therapy into real life. One of the most common questions I get as a psychologist is: “What stops us (human beings) from making the change we know we need to make?”

And all I can say to that is that making change is tough business. But it’s also simpler than we think. It can take just an instant to choose to change — just an instant to make up your mind and do it.

Instead, we are our own worst enemies, standing in the way of the change we desire. My job is to not only help clients see and understand the need for change, but to help them “get out of their own way,” and let change happen.

5. What’s the most challenging part about being a therapist?
The emotional drain. It’s lovely to get to know clients on such a deep level — to be there with them in their most intimate moments. But it can take a lot out of you if you’re not careful.

I have to consciously choose to leave it all behind when I go home, and I have to set limits on how much I can give to clients so I still have enough to give to my family and myself. (For instance, at this time I only see clients one day a week. I spend the other days being a “stay-at-home-mom” while also blogging for my website and working on my upcoming book!)

6. What do you love about being a therapist?
The deep connection with clients. There’s nothing like feeling someone’s heart and helping them heal it. It bonds you for life. I also love being a psychologist for the opportunities it provides for other types of connections; through speaking, teaching, and writing I also connect with people. It’s wonderful to have a career with so many options.

7. What’s the best advice you can offer to readers on leading a meaningful life?
Make “space” to check in with yourself each day. Even 5-10 minutes to be still, meditate, ponder, or pray will make a huge difference in creating a meaningful life, for it will allow you to “unplug” and instead “tune in” to what really matters.

Ask yourself, “What matters most to me?” Then listen, and write it down. Compare everything you do each day to your list of “what matters most.” Pay attention to the things that do matter, and get rid of all that doesn’t. Repeat this process often, and your life will be full of love, joy, and meaning.

(Hibbert has written more on these topics in her posts “What Matters Most,” and “Joy is in the Moments: 3 Tips for Discovering & Appreciating the Joy in Life.”)

8. If you had your schooling and career choice to do all over again, would you choose the same professional path? If not, what would you do differently and why?
I would absolutely choose the same path. I love what I do. The only thing I might do differently is add a minor in music and songwriting. It’s a favorite hobby of mine I often incorporate into my talks and seminars, and I’d love to have more expertise in that area!

9. If there’s one thing you wished your clients or patients knew about treatment or mental illness, what would it be?
That’s there’s so much more to life than just “feeling better.” Many of us are simply hoping to overcome mental illness—to just “feel better.” But we’re shooting far too low. That’s why my tagline is “Overcoming, Becoming, Flourishing.”

I want everyone to know that life isn’t just about overcoming challenges—it’s about becoming who we’re meant to be and even living a life that’s flourishing!

Don’t settle for just “being better.” Keep with it until you’re “better than better”!

10. What do you do to cope with stress in your life?
I put myself to bed early as often as I can so I can be up early and feel rested the next day. I take an “hour of power” each morning, including exercise, meditation, prayer, and scripture study before getting the kids ready and out the door. This gets me centered and focused on what really matters for my day. I strive to give my family my full attention when I’m with them, so I’m very careful about taking on new projects that can’t be done in the few hours when everyone’s at school.

I take a little time each afternoon to rest, read, nap or relax before my kids get home and my “night shift” begins. I also know I need time alone to de-stress and I love to travel, so I try to get away for a night or two as often as I can (with six kids, leaving the house is often the only chance I get to just “be me”!).

I also take baths, walks, talk with my husband, and get a massage at least once a month. And music is a great stress-reliever! If I’m really needing help, I’ll sit down at the piano or guitar and write a new song or sing!

“Oh, she sees funny things,” said the daughter. “She has Charles Bonnet Syndrome.”

I was in an intake interview with the pair before placing a caregiver in the home of this delightful 95-year-old woman with macular degeneration. We had been talking for about 40 minutes before she mentioned her “visitors.” It was already clear that she was fully oriented, sound-minded, intelligent, witty, and sharp. “When this first started, I thought I had gone crazy, but I know now I haven’t,” she said. “Now I just sit back and watch the show. Having Charles Bonnet Syndrome is like seeing a little movie, though it is quite strange.”

Hallucinations of vividly clear, complex patterns, people, faces, buildings, cartoons, children and animals – often in amazing detail – would be understandably disturbing and frightening. But this woman had learned that this trick of the mind happens to some people who have had vision loss. Hers was the healthiest reaction to Charles Bonnet Syndrome (CBS) I had ever seen.

CBS – named for the Swiss naturalist who first described it in 1760 (Bellows) – is little discussed and not widely known. Because I work with many elderly people, I know it because there is so much macular degeneration among the aged. It is the leading cause of blindness in those over 60 (National Institutes of Health and the National Library of Medicine). It is not thought to be rare, though it is likely vastly underreported: those who experience it are terribly frightened they have become crazy or demented, so they don’t dare mention their visions. (Menon, Rahman, Menon, and Dutton, 2003). However, it may occur in as many as one-third of visually impaired people (Light House International).

Such silence and fear are not entirely unreasonable. CBS can be misdiagnosed and often goes unrecognized by medical professionals (Menon, G., Rahman, I., Menon, S., and Dutton, G., 2003). Families often panic. Patients reporting such symptoms should be checked medically against the possibility of other causes, such as neurological diseases or medication side effects. CBS also can occur where damage or disease affects the area of the visual cortex of the brain. Those who experience it without known visual impairment should be checked for other conditions. (Royal National Institute of Blind People).

15 Tips for Managing Charles Bonnet Syndrome

There is no cure for Charles Bonnet Syndrome, so patients need to learn to live with and manage it — all too often on their own and in silence. Some patients can develop depression or anxiety as a response to CBS. There are, however, a variety of steps that can be taken to support low vision patients at risk for CBS, and to minimize its negative emotional effects:

1. Every health care practitioner, person with low vision, their family and caregivers should be educated about CBS.
2. Medical personnel need to learn how to correctly screen for and diagnose CBS (Menon, G., Rahman, I., Menon, S., and Dutton, G., 2003).
3. An approach to screening that makes it easy for patients to admit their symptoms must be in every physician, nurse and nurse practitioner’s toolkit. (Menon, G., Rahman, I., Menon, S., and Dutton, G., 2003). “You know, many people who have vision loss see things that aren’t there. It’s called Charles Bonnet Syndrome. These are nothing to worry about, but they can be upsetting if you don’t know that. Have you ever experienced anything like this?”
4. Any depression or anxiety should be treated appropriately with medication, counseling or some other applicable therapy (Light House International; Roberts, 2004).
5. “Normalizing” the experience is absolutely vital, but without being dismissive of any upset the visions may cause the person. “Yes, lots of people have CBS, and they think they’re going crazy or have dementia, but they’re not… who wouldn’t think at first that they’ve lost their mind?” (Royal National Institute for the Blind)
6. CBS patients should be encouraged to talk about their visions rather than remain silent about them. (RNIB; Menon, G., Rahman, I., Menon, S., and Dutton, G., 2003)
7. CBS usually stops within 12 to 18 months. Reminding the patient of this every so often can be helpful. “Oh, did you have one of your Charles Bonnet episodes again? What did you see? I hope it didn’t upset you too much. You know, it should go away in time.”
8. A good sense of humor can help in adjusting well to CBS (Roberts, 2004). Family and health care professionals can affirm lightheartedly how strange and bizarre the visions can be. Jokes about what is seen can be made, but only if the patient finds them amusing.
9. Fascination for the images and the wonders of the brain can help reframe CBS from a problem to an “experience.” “Isn’t it amazing how the brain is stimulating itself by making all those amazing images! Did you know you had all of these tucked away in your head? Your brain is just so remarkable!” “Butterflies flying out of your toaster? School buses driving down your hallway? What creativity!”
10. Refrain from psychoanalyzing the images to look for their deeper meaning – they do not yield productively to psychological interpretation. They are not the product of past trauma or unresolved feelings (Saks in Kiume, 2009).
11. Remind the experiencer that they have from the start had the wisdom to recognize that these visions are not real, though at first they may have had some doubts. When meeting moments where they may not be certain, examining the clarity and detail is often telling; hallucinations might be sharper than the person’s remaining eyesight allows (RNIB).
12. Since CBS episodes happen more often during “down time” than when the person is actively engaged in activities or with other people, decreasing their incidence may require finding ways to reduce social isolation, boredom, lack of stimulation, and low activity (Roberts, 2004; Murphy, 2012; Menon, Rahman, Menon, and Dutton, 2003).
13. Sometimes, eye exercises — such as looking from left to right without moving one’s head for 15 to 30 seconds — can help stop a hallucination.
14. Increased room lighting can sometimes prevent an episode of CBS visions if they commonly take place in low light (Murphy, 2012; RNIB).
15. Some report that stress and fatigue can exacerbate CBS. Reducing causes of and increasing coping skills around stress, and getting enough rest can sometimes help (RNIB).

While CBS can be frightening and stressful, there can also be positive outcomes. American author, humorist and cartoonist James Thurber lost vision in one eye as a child due to an accident. He reported many visions of strange things afterwards. It is suspected that he had CBS, and that these hallucinations fueled his amazing imagination. His hilarious stories and cartoons may have been a direct result of Charles Bonnet Syndrome (New World Encyclopedia).

References

Bellows, A. Chuck Bonnet and the Hallucinations. Retrieved September 5, 2012 from http://www.damninteresting.com.

Light House International. Charles Bonnet Syndrome. Retrieved September 5, 2012 from http://www.lighthouse.org/.

Menon, G., Rahman, I., Menon, S., and Dutton, G. (January-February 2003). Complex visual hallucinations in the visually impaired: the Charles Bonnet Syndrome, abstract. Surv Ophthalmol 48 (1): 58-72. Retrieved September 5, 2012 from http://www.pubmed.gov.

Murphy, C. When Seeing Isn’t Believing: Charles Bonnet Syndrome. (August 9, 2012) Scientific American. Retrieved on September 5, 2012 from http://www.scientificamerican.com/.

National Institutes of Health and the National Library of Medicine. Leading Causes of Blindness. NIH Medline Plus. Retrieved September 5, 2012 from http://www.nlm.nih.gov.

New World Encyclopedia. James Thurber. Retrieved September 5, 2012 from http://www.newworldencyclopedia.org/.

Royal National Institute of Blind People (RNIB). Retrieved on September 5, 2012 from http://www.rnib.org.uk/.

Saks, O., in Kiume, S. (2009). Seeing Hallucinations While Blind. Psych Central. Retrieved on September 4, 2012, from http://www.psychcentral.com.