Negative Symptoms – Self help Skills
Self Help Skills for Negative Symptoms of Schizophrenia
Nowadays doctors tend to think of schizophrenia as having two kinds of symptoms. The positive symptoms include things like hallucinations such as hearing voices and delusions like paranoid thoughts whilst the negative symptoms include lack of motivation, social withdrawal and apathy. Whilst the positive symptoms tend to be more dramatic and will often prompt swift action by the Mental Health Service the negative symptoms are more insidious in their effect but can often be just as disabling, in some cases moreso, than the positive ones. There is more about negative symptoms on our advice sheet Understanding Negative Symptoms.
The first line of defence against positive symptoms is antipsychotic medication which is effective in about 70-80% of cases. Unfortunately we do not have such ready treatments for the negative symptoms. Although some of the newer antipsychotics and antidepressants are thought to give some relief, the evidence is not conclusive and certainly they do not have such a marked effect on the negative symptoms as the antipsychotics do on the positive ones. See our advice sheet on Treatments for Negative Symptoms for more on this.
So in the absence of really effective treatments from the medications we need to think about other ways in which people with schizophrenia can improve their lives when faced with the negative symptoms.
Tell Your Doctor
If you are having problems with negative symptoms it is really important that you speak to a psychiatrist about it as they may be able to help. It may be that the doctor can change the antipsychotic that you are on or change the dose in case the side effects of the medication are making things worse. It is also important to know whether your problems are due to the negative symptoms of schizophrenia or to depression and your GP will probably not be able to assess this. If your problems are due to depression rather than negative symptoms then they may respond well to one of the antidepressant medications or to talking therapies such as cognitive behavioural therapy. Before you see the psychiatrist it is a good idea to keep a diary of how your problems affect your daily life and how your thoughts and feelings have been.
Learn to deal with Loss
An episode of schizophrenia inevitably leaves the person with an overwhelming feeling of loss. You may have lost your job or had to give up your studies. You may have accumulated debts, have a poor credit record or been made bankrupt. There will also be a loss of reputation: you may have lost the trust and respect of many of those close to you who may not understand how schizophrenia affects people and what causes it. You may have come into contact with the criminal justice system and now have a criminal record.
These losses on such a large scale attack our feeling of self worth and make us feel that we cannot succeed in life. They eat away at our sense of our own capabilities and ruin our self esteem. They are in many ways one of the biggest psychological challenges to someone who has experienced an episode of psychosis.
People with schizophrenia experience loss in so many areas of their life that it is vital to learn to cope with it. Some losses can be restored, for instance you may be able to get back into studying, if not by going back to college then through the Open University. If you are in debt you could put together a plan with your creditors to pay off your debt over time in a way that wouldn’t leave you with a bad credit report and after a while be totally debt free.
However, some losses cannot be restored and we simply have to learn to live with them. This is nowhere more difficult than when we have close friends or relations who have rejected us because of our disturbed behaviour. However, even though this sort of loss can be immensely painful it is still important to try to make sense of it. This is where a good counsellor and support network can come in really useful as they can help you to work through all of the negative thoughts and feelings that go along with this kind of loss.
Remember that for the future it is vital to assemble around you a supportive circle of friends and family who will be there for you when you are in crisis and it may be that those people close to you who have rejected you now would not be able to play that constructive role in the future and that parting company from them is a necessary, if painful, part of the recovery journey.
In many ways the losses experienced by someone with schizophrenia are very similar to those losses experienced in bereavement and much of the advice available for those going through bereavement is very pertinent to people with schizophrenia. In particular it is important to give yourself time and permission to grieve for your losses. These things were important to you and losing them hurts.
Learn to Deal with Guilt
For most people who have experienced an episode of psychosis and come out the other side they will be really painfully aware of how their disturbed behaviour affected those people around them. Feelings of guilt, embarrassment and shame are perfectly normal at this time. However if we were to allow these feelings, however legitimate , to dominate our thinking then we would not be able to put the episode behind us and move forward. It is vital to understand that however much distress we may have caused other people this illness, which we call schizophrenia, was not our fault. We did not choose it or ask for it and we would give anything to be able to undo it.
Again this is where having a good counsellor to help us understand these feelings and thoughts and put them into some context can be extremely useful. But in any case we need to affirm that our schizophrenia was not our fault and that whatever we may have done while we were ill we are now going to move forward into a better life.
Learn to be strong
Reject passivity and accept responsibility. In the UK today it is very fashionable to describe people living with schizophrenia as “service-users”. This term is unfortunate as it implies a passive receiver of services provided by an organisation in which they play no role.
Of course there are times in an episode of schizophrenia when our insight is so poor and our capability to make decisions so badly impaired that we have to hand over that role to the doctors and our carers, but later when our crisis is behind us it is necessary to start to take responsibility: not for our illness, for that is not our fault, but to take responsibility for our recovery. To become, not passive users of services, but experts in our own condition who play a role in making decisions about our treatment and care.
It is necessary to understand that the doctors don’t have all the answers and we must become, to a large extent, our own case manager: identifying the problems in our lives, learning about them and then working out coping plans to help us manage them.
When you are in crisis “living one day at a time” is good advice but when your crisis has passed it is really necessary to start to set some goals in your life and try to work towards them. Initially these goals may be quite simple and straightforward such as keeping the house cleaner or the garden tidier. Later more ambitious goals such as getting back to study may be more appropriate.
But for someone suffering with the negative symptoms of poor motivation and lethargy goal setting is a very difficult skill to get right. If you set your sights too low you will under-achieve whereas if you set your sights too high and aim for goals that you cannot achieve you will risk failure which can be demoralising and bad for your self esteem. Furthermore repeated failure caused by constant over-ambitious goal setting will reinforce negative thinking patterns and make the problem of poor motivation even worse. It is sometimes necessary to accept that you can’t do as much as you used to do.
On the other hand if you establish a record of achieving your personal goals you will not only boost your self –esteem but you will also reinforce your sense of your own capabilities. So it is really important to get the skill of goal setting right. If you find that you have negative thoughts about your abilities try to plan less and do more. Constantly under-achieving on your plans will badly affect your self esteem and reinforce feelings and thoughts of failure. It is better to attempt a bit less but be more assured of succeeding.
Don’t forget to give yourself little treats as rewards when you achieve your goals. When you don’t manage to get to your goal don’t beat yourself up. We all fail at times and sometimes it isn’t always our fault. Circumstances may have just conspired to make the goal unachievable. Tell yourself that you will have another go at another time or re-visit your goal setting and ask whether the goal was really achievable or whether it was over-ambitious.
When you are having problems motivating yourself it is best not to think and plan too far ahead. One person with negative symptoms used what he called his “rule of threes”. Don’t try to think more than three things ahead. So if going into town he would plan to make sure he had the bus fare, get to the bus stop on time, then what he would do in town but wouldn’t think too much about what he was going to do later in the day.
Try to develop your own techniques for managing this problem and give them names so that you can refer back to them later. Here’s a technique that one person with negative symptoms came up with to help him get out of bed in the morning:
“Morning is my worst time. When I wake up I feel like my body is made of lead and I just can’t get out of bed for hours. Sometimes I use what I call my “bargaining” technique. I will tell myself that I am going to get up right now and go and have a cup of tea but that if I want to I will come back to bed afterwards. This makes it easier to get up by giving myself permission to change my mind later. In fact I never do go back to bed. Once I am up I tend to stay up. But I just have to trick myself into getting up.”
Structure Your Day
Even if you can’t do very much it is important to try to structure your day. Try to get up and go to bed at regular times. During the day set aside time for chores and time for relaxing. Try to keep to regular meal times and avoid snacking or dozing during the day.
(Image: Axente Vlad/Shutterstock)Drugs and Alcohol
Many people living with schizophrenia abuse alcohol or use street drugs. In fact over half of them do. Why this is so is not clear. Some claim that the drugs help to blunt their symptoms and that they are attempting to self medicate. However it may be that young people with schizophrenia (and most of them are young) use drugs for exactly the same reasons that young sane people use them: because it makes them feel good. It may also be that an episode of schizophrenia has such a devastating impact on a person’s morale and self esteem that anything that helps to relieve that distress is welcome.
Whatever the true reason it has to be said that abusing alcohol or using street drugs will not help to relieve the negative symptoms of schizophrenia and that they will make the problem worse. In addition the effects of drugs and alcohol on other issues in the person’s life such as debt, looking after themselves and getting back into study or work will inevitably be to make matters worse not better.
In short abusing alcohol or using street drugs has no place in a successful recovery form schizophrenia. Alcohol should be kept as an occasional treat whilst street drugs must be avoided altogether.
Get the Basics Right
Try to spend a bit of time each day looking after yourself. Make sure you are washed, shaved and well groomed and keep your house or flat clean and tidy. If you find that it is difficult to motivate yourself to do this don’t worry you are not alone. Most people who don’t have schizophrenia find it difficult to get excited about doing the housework but do try to do a little each day to keep on top of it. Don’ t try to do too much. Even if you only spend 20 minutes a day on looking after yourself it is better than nothing at all.
Keep sleeping for night times and try to allocate a reasonable time for sleeping. Most people need about eight hours. Set an alarm to wake you in the morning. If you can’t get out of bed straight away because you lack motivation try to do something in bed such as reading or listening to music. Don’t simply lie in bed doing nothing. If you have difficulty sleeping at night try our advice sheet on sleep problems for some useful advice.
Get Enough Exercise
There is some research evidence of a link between exercise and depression but it is not yet conclusive. However exercise will help to improve your mood. Going for a short walk around the block in the fresh air each day is good but if you can’t manage that try doing some home exercises such as sit ups and press ups. Again don’t try to do too much and risk failing . Even ten minutes of light exercise is better than nothing. In some areas there are schemes that enable GPs to refer you to local gyms where there are more strenuous exercise regimes.
Build a Support Network
After a prolonged period of serious illness it is really important to start to assemble around you a circle of people who can support you through your struggle. They may be people who will have practical skills that will help such as someone with a car who could help with lifts to appointments or they may simply be people who are understanding about your condition and can provide that all important moral support when you need someone to listen. It is important not to keep your troubles bottled up.
The skill of disclosing to other people around you about your schizophrenia becomes really important here and our advice sheet on Disclosure has some useful tips for this. Avoid negative people without ambition in their own lives and try to forge relationships with people who are successful. For instance if you have difficulty managing your finances look for friends who are good at managing their finances so that you can learn from them.
Your support network will be there for when things are not going well for you but don’t forget to let them know when things are going well. Telling other people about your successes will help to reinforce your own positive thinking about your abilities.
Schizophrenia represents such a massive threat to our well being that we cannot be expected to handle it alone. We need help. As well as your doctor and community psychiatric nurse many people with schizophrenia find that spending time each week with a good counsellor can help. Even if you are still living with your family sometimes talking things over with a complete stranger is better. A counsellor can help you to deal with the any residual symptoms that you may be having, with the ways that schizophrenia inevitably complicates your life and with dealing with the every day problems of relationships etc that we all have to cope with but for people with schizophrenia become much sharper.
In some areas counselling is available through your GP and that would be a good place to start. Some counselling services are free for people on certain benefits. However if you don’t qualify for free counselling think about engaging with one privately. Counsellors in private practice generally charge between £30 and £50 an hour for a session. Try to find one who has been well recommended and who is a member of the British Association for Counselling and Psychotherapy. If you find this difficult to afford try applying for the government’s Personal Independence Payment which may be able to help.
Define Your Role
Margaret Mead, an American anthropologist of great note, studied societies around the world and concluded that the greatest challenge for every society was defining the roles of the people in it. This is also true on a personal level for people living with schizophrenia. It may be that our psychotic breakdown has stripped us of our previous role in work or at college. It may be that our relationships with those close to us have changed for the worse. It may be hard to see any better future from this condition that seems to grind away at our will to survive year in and year out. We are in many ways left without a role in our family or society. And this problem is compounded by the way that the media sometimes stigmatises people with schizophrenia who are often portrayed as at best feckless and at worst dangerous. Is it any wonder then that people living with schizophrenia often see no role for themselves in our society.
But from this tangle of losses and complications that schizophrenia has left us with we must somehow find a role for ourselves. Could we work? Could we volunteer for a charity? Could we study? Could we have a closer relationship with our family? Could we tell others about our struggle? Or is it simply that our new role for the time being will be to beat schizophrenia and survive: sometimes this is the best that we can achieve.
Whatever the option that we choose it is vital to have a clear view of the role that we have chosen. At some point in their life everyone will ask the question “what am I here for?” For people with schizophrenia that question is all the more meaningful and important.
1.This advice sheet is based on the author’s personal experiences.
Lost and Then Found: Turning Life’s Disappointments into Hidden Treasures, Trevor Griffiths, Paternoster Press.