inner world of many patients, so they need an external world which is coherent and predictable. They experience a life that is disrupted and disconnected; therefore planning for continuity in living situations and in their various support systems is indicated. Predictability of events is important to people who have experienced the events of their internal world as arbitrary and capricious. Reducing stimulation, maintaining appropriate expectations, and enhancing self-esteem are other ways to reduce stress and provide the best possible environment for recovery. 5. Learning generic problem solving skills. While we try to meet the immediate needs of families for solutions to their problems, effectiveness and efficiency dictate that we teach families to solve their own problems independently. This means families need to learn generic problem solving skills: Delimiting and defining problems, generating a range of possible solutions, selecting the most promising solution, trying out, and evaluating the results. This skill must be developed in a context where many examples are given and linkages are made with the home situation (Falloon, Boyd, and McGill 1985; Hatfield in press). 6. Planning for the long run. Mental illness may last for a long time, and families need to plan for the future. Providers can help families identify the range of considerations that they must make in order to accommodate the ill person's needs and those of the rest of the family. This means assessing the community for all of the resources that that it can provide: residential care, community rehabilitation services, case management, clinics, hospitals, social clubs, and so forth. Providers should be fully aware of what is available in their communities and how they can be accessed. In addition, the family needs to look at its own resources and how they are to be shared in the family. Families need to understand their medical insurance policies, if they have coverage for the ill person, and how the benefits can best be used. They need to consider other financial resources that they have and the importance of trusts and wills in insuring that the family's intentions are carried out. Models of Help to Families There are probably several ways to provide the kinds of help that we have described, each of them with advantages for certain kinds of situations. We will confine our discussion here to education, consultation, and support. 1. Education. The function of education is to develop longterm, organized bodies of knowledge and generic problem solving skills that will help the learner solve problems in their lives presently and in the future. Education does not presume dysfunction or pathology. It assumes the need for knowledge and skills and believes that most people do well when they understand how to deal with their situation (Guerney, Stollak, and Guerney 1971). Emphasis is on developing competence through facilitating the natural adaptive capacities of people (Maluccio 1981). Education usually takes place in in classes and workshops, although it may occur in many settings. It involves preplanning an orderly sequence of learning experiences so that a coherent body of knowledge is learned and stored for future use. It also involves teaching generic problem solving skills so that families become less dependent on the mental health system and more able to solve future problems on their own. Family educators need certain skills to be efficient and effective: They need to know how to sequence information and communicate it in a logical way. They need to understand the concept of transfer of learning and how to teach so that families apply their learning broadly in their own environments. Since most formal education is done in group settings, family educators need to have well developed leadership skills. 2. Consultation. Most families may want help on an individual basis from time to time. They may want to have this kind of help without taking on a patient role or entering into therapy. Recent clinical, political, and economic circumstances have emerged that suggest the need for alternatives to the role of "family therapist." An adequate alternative model has been lacking, but recently several professional providers have been attempting to conceptualize an alternative model which they are calling "family consultation" (Kanter 1985; Terkelsen 1988; Wynne, McDaniel and Weber 1986). What seems to be emerging is a model for relating with families that is non-judgmental, collaborative, and responsive to the immediate problems that the family feels need addressing. The focus is toward enhancement of healthy family functioning with focus on strengths rather than on pathology. Terkelsen (1988) depicted the role of the family consultant as being analogous to other consultative professionals--financial planners, tax advisors, and lawyers, for example. The consultee basically sets the agenda by identifying the problems needing solution. 3. Support. Once mental health professionals understand the consequences to families of having of their members become mentally ill, their need for support from practitioners becomes readily apparent. The work "support" appears frequently in professional and popular literature, but the word is rarely defined and it is used variously. In supportive relationships, we are there for people in need, we communicate an interest in them and a liking for them and a desire to be helpful. We reflect empathy for the painful dilemmas which they face, we offer reassurance and hope, and we express confidence in the person's strengths and competence in surmounting the present problems. In a recent recent book called Caring and Compassion in Clinical Practice, Sarason (1985) insists that "caring and compassion" are in short supply in the mental health profession. He analyzes this predicament and comes up with several explanations: too much emphasis on objectivity and too much worry about emotional involvement; inadequate process for selecting students; overemphasis on technical skill; and the large bureaucratic institutions in which many professionals work. Empathy and acceptance are probably the two most important elements in support. One is empathetic when one is able to step into the private world of another and lose all desire to evaluate are and judge it. Barriers to empathy, Sarason says, "parochialism," by which he means students' experiences with diverse families have been too limited and students do not use their own experiences creatively enough to help them understand others. The work of Rogers (1961) is helpful in defining the meaning of "acceptance." Acceptance means having a warm regard for the other person as a person of unconditional self-worth--of value no matter what his condition, his feelings, or his behavior. He is respected as a separate person, entitled to possess his own feelings in his own Genuine acceptance is antithetical to to judgmentalism and way. labeling. SUMMARY We are living in an age in which great changes are taking place in the treatment of the mentally ill. During the past couple of decades we have seen: the pace of deinstitutionalization greatly accelerating; great strides in the biological explanations of mental illness and increasing separation of mental illness from other mental health problems; changing attitudes toward parents of mentally ill offspring; and the emergence of family and consumer movements. It is critical that institutions training professionals to work with the mentally ill recognize the vast changes taking place and make the necessary curriculum modifications so that their graduates are fully competent for a new age in mental illness. REFERENCES Alvarez WC: Minds that Came Back. New York, J.P. Lippincott, 1961 Anderson CM, Reiss DJ, Hogarty GE: Schizophrenia and the Family. New York, Guilford, 1986 Anscome R: The disorder of consciousness in schizophrenia. Appley MH, Trumbull R: On the concept of psychological stress, in Stress and Coping: An Anthology. Edited by Monat A, Lazarus RS. New York, Columbia University Press, 1977 Arnoff FN: Social consequences of policy toward mental illness. Science 1975; 188:1277-1281 Bateson G, Jackson D, Haley J et al: Toward a theory of schizophrenia. Behav Science 1956; 1:251-264 Beels CC, McFarlane WR: Family treatments of schizophrenia: Background and state of the art. Hosp Community Psychiatry 1982; 33:541-549 Bernheim K: Family consumerism: Coping with the winds of change, in Families of the Mentally Ill: Coping and Adaptation. Edited by Hatfield A, Lefley HP. New York, Guilford, 1987 Bernheim K, Lehman A: Working with Families of the Mentally Ill. New York, Norton, 1985 Bernheim K, Lewine RRJ, Beale CT: The Caring Family. New York, Random, 1982 Bugen LA: Human grief: A model of prediction and intervention, in Role of the Family in Rehabilitation of the Physically Disabled. Edited by Powers PW, Del Orto AE. Baltimore, University Park Press, 1980 Caesar B: Preserving the family: A brief for limited commitment of non-dangerous mentally ill persons. J Marital Fam Ther 1980; 6:309-319 Clausen J, Yarrow MR: The impact of mental illness on the family. J Soc Issues 1955; 11:3-24 Coelho GV, Hamburg DA, Adams JE (eds): York, Basic Books, 1974 Coping and Adaptation. New London, Institute of Creer C, Wing J: Schizophrenia at Home. Psychiatry, 1974 Dearth N: Families Helping Families: New York, Norton, 1986 Living with Schizophrenia. Dewar TR: The professionalization of the client. Soc Policy 1978; 8:4-9 Doll W: Family coping with the mentally ill: An unanticipated problem of deinstitutionalization. Hosp Community Psychiatry 1976; 27:183-185 Falloon IRH, Boyd JL, Magill CW: Family Management of Schizophrenia. Baltimore, Johns Hopkins University Press, 1985 Figley CR, McCubbin HI (eds): Coping with Catastrophe. Volume II. New York, Brunner/Mazel, 1983 Freedman MA: Subjective experience of perceptual and cognitive disturbance in schizophrenia. Arch Gen Psychiatry 1974; 30:333-340 Fromm-Reichman F: Notes on the development of schizophrenics by psychoanalytic therapy. Garson S: Out of Our Minds. Buffalo, NY, Prometheus, 1986 1:544-547 Guerney B, Stollack G, Guerney L: The practicing psychologist as educator: An alternative to the medical practitioner model. Profess Psychol 1971; 3:276-282 Haley J: Leaving Home: the Therapy of Disturbed Young People. New York, McGraw Hill, 1980 Hansell H: The Person-in-Distress: On the Biosocial Dynamics of Adaptation. New York, Human Sciences Press, 1976 Hatfield A: Psychological costs of schizophrenia to the family. Soc Work 1978; 23:355-359 Hatfield A: The family as partner in the treatment of mental illness. Hosp Community Psychiatry 1979; 30:338-340 Hatfield A: What families want of family therapy, in Family Therapy in Schizophrenia. Edited by MacFarlane W. New York, Guilford, 1983 Hatfield A: The family consumer movement: A new force in service delivery, in Advances in Treating the Young Adult Chronic Patient. Edited by Pepper B, Ryglewicz H. New Directions for Mental Health Services. San Francisco, Jossey-Bass, 1984 Hatfield A: Coping and adaptation: A conceptual framework for understanding families, in Families of the Mentally Ill: Coping and Adaptation. Edited by Hatfield A, Lefley HP. New York, Guilford, 1987a Hatfield A: Systems resistance to effective family coping, in Edited by Barriers to Treating the Chronic Mentally Ill. San An Hatfield A: Helping Families Cope with Mentally Ill Relatives: Hirsch S, Leff J: Abnormalities in Parents of Schizophrenics. Hoenig J, Hamilton MW: The schizophrenic patient in the community and his effect on the household. Int J Soc Psychiatry 1966; 12:165-176 Howells JG, Guirguis WR: The Family and Schizophrenia. New York, Research and Johnson D: The needs of the chronically mentally ill: As seen by Kanter JS (ed): Clinical Issues in Treating the Chronic Mentally Ill. New Directions for Francisco, Jossey-Bass, 1985 Mental Health Services. San |