Seriously Mentally Ill (SMI), by N.N.

My experience is based on working with the SMI population in a behavioral health outpatient clinic and through personal experience with a spouse with a SMI diagnosis as well as a parent with an SMI diagnosis. The types of individuals that are in the SMI population vary wildly and can been acutely symptomatic and asymptomatic depending on their diagnosis. This is NOT a complete guide on mental illness; it’s only an experienced perspective on mental illness.

Acute symptoms

Acute symptoms are often easy to identify; they include talking to self, responding to internal stimuli, depression, aggression, or suicide.

  • Common symptoms to look for when assessing whether or not an individual is mentally unstable can include: laughing/giggling at internal stimuli, talking to self, inability to control emotions, verbal/physical aggression, unrealistic delusions, paranoia, or attempt to complete suicide.
  • There are generally two categories of the SMI population– those who have drug induced psychosis, and those who are legitimately SMI because of genetic reasons or trauma related reasons.
  • Drug induced psychosis generally pertains to the use of substances like alcohol, caffeine, cocaine/methamphetamine, hallucinogens, nicotine, opioids, and sedatives. The use of these substances in some cases will likely never lead to a psychosis related incident, however, used in quantity or excessively over time they can cause psychosis. The biggest problem with drug related psychosis is that there is significant damage done to the brain that can be irreversible.
  • Legitimate cases of a person having an SMI diagnosis are quite common. Some common diagnosis can include anxiety disorders (social issues, phobias), mood disorders (depression), schizophrenia/psychotic disorders (delusions, aggression, and hallucinations), and schizoaffective type (dementia).
  • I will use delusions as an example, because they can often lead to aggression due to the altered state of reality for the individual. Delusions can take many forms. They can include paranoia (believing someone is trying to kill them or you are trying to kill them), belief that they are an alien, or believing that they are the richest person in the world and all they needs is you to sign for them at the bank to get their money. The reason why delusions can be dangerous is that, while seemingly harmless to the non-SMI person, to the person with the delusion it can turn into a violent situation is they believe someone is preventing them from acting on what they see as reality. That is the key factor; these types of individuals believe to their core that this is reality and that your reality is not valid.
  • Mood disorders are another dangerous SMI diagnosis. The danger is not always to the non-SMI individual but often to the SMI individual because of the depression that is often associated with a mood disorder diagnosis. Individuals with a mood disorder often have a chemical imbalance that prevents them from being able to regulate their moods based on their environment (like being happy when you should be happy and angry when you should be angry). In these cases, it is dangerous because, without access to medication, mood regulation can swing violently from extremely depressed and a danger for suicide to extremely angry and a danger for homicide.
  • Schizophrenic/psychotic related disorder can be the most dangerous. These individuals, without medication management, can be unpredictable, violent, and deadly.

Individual Reactions

When interacting with these types of individuals, it is important to note that while what is listed above can be common, it is not a definitive guide to SMI individuals. Each person will react to medications, environmental stimulation, and trauma in many different ways. That is why two people with identical diagnosis can be on completely different medications.

  • Some simple skills to use in a situation where an individual is struggling with some of the non-violent symptoms, like depression, suicidal ideation, or anxiety, can be the difference between life and death for some.
  • Skills, like active listening, which can be very difficult when you as the listener are in a stressful situation, can be essential. Often people experiencing these symptoms just want to be heard, either as a requirement to fulfill a need as part of their diagnosis or because of previous trauma they need to be heard because they were not heard when it mattered to prevent the trauma. Active listening is simple; it is listening to someone without interjecting your opinion, asking simple unobtrusive questions (how are you feeling, what can I do to help), and following through if you agree to something. Follow through can determine whether or not that person feels like they can trust you in the future (establishing a rapport).
  • Another skill that many struggle with in daily life is knowing when and how to speak calmly, particularly in a less-than-calm situation. Pausing between sentences to think before you speak will not only prevent you from saying the wrong thing but it also lengthens the time someone is listening; the length of time you can speak with someone calmly can greatly help with their ability to calm down and may deescalate a situation.
  • Redirection works well with individuals that are experiencing anxiety or are having difficulty understanding a situation. Changing the subject of a conversation is often simple, but changing the topic to something that can prevent a return to the original reason for the redirection can be difficult. Redirecting to a topic that would require active thinking, such as redirecting to work that needs to be done and explaining how to do it; or physical redirection, like getting someone to actively engage in a physical activity can help. Just asking someone to walk with you can be a useful redirection or doing chores together can be a useful redirection.
  • Avoidance of SMI individuals is dependent on your situation; it could be someone in your group/home (family), or it could be a neighbor. Clearly we are asked to love thy neighbor; however, we can love them and respect them from afar. In the case of someone in your group or family, we are committed to their protection either from themselves or their environment. When traveling, it is provident to avoid people experiencing some of the symptoms that have been noted, primarily because of safety and unpredictability.
  • Dangerous SMI individuals can and should be avoided if possible, but what is more likely to happen is that they either randomly or specifically target you for some reason only known to them. Many times these dangerous individuals can start out as being charming but are easily agitated and can become verbally abusive in an instant. These individuals also can be violent. In cases where you suspect that an individual is SMI, you should utilize all of your skill set to avoid conflict and remove yourself from the situation immediately, but you should also be prepared to defend yourself as necessary.

Loved Ones Can Be Most Difficult To Help

Loved ones with an SMI diagnosis can be the hardest for those of us who do not have to deal with the symptoms and management of the diagnosis to understand and help. In a situation where a family member utilizes medication to manage the severity and occurrence of their symptoms and access to that medication is limited or exhausted, understanding how to proceed is important to your family’s safety and to the safety of your loved one.

  • Tapering off medication is always the best course of action should that medication not be available in the future. This is because there are some medications such as Clozaril that, if stopped abruptly, can cause a resurgence of symptoms that were worse than prior to the medication but can also cause flu-like symptoms or seizures.
  • Stress management is an issue, if your loved one has a mood disorder related diagnosis. In this case, it will be important to limit the amount of stress that they are exposed to. Utilizing them for simple tasks, such as cleaning, cooking, or possibly taking care of children can help prevent them from experiencing some symptoms.
  • Understanding that there are some alternatives to medication management, like meditation, homeopathic type remedies, and stress management can help (not stop) the occurrence of symptoms.
  • It should be noted that homeopathic methods should only be used if the person has a full understanding of them as well as the risks associated with using them over medication management and stress reliving methods. Please encourage your loved one to have a dialogue with their prescriber discussing access to medication and alternatives to medication where appropriate.
  • There are, however, risks associated with any type of disruption to medication for those that are SMI. Becoming psychotic is a possibility, but the most likely risk, particularly with the excessive use of antidepressants in the U.S., is suicide.
  • Being able to talk to someone about thinking about suicide can be extremely difficult. It has been for millennia a taboo and in many cultures is not spoken about at all. If you suspect that someone is contemplating suicide, you should ask them. The simple act of asking someone if they are thinking about suicide can open the door to prevention. Think of the things that can convince them to live and use them. Play on their emotion for an individual, and get them to commit to safety for a set period of time.
  • The realities of the SMI population are that death is only preventable as long as it can be prevented. In cases where it cannot be, those left should understand that the person who completed suicide was not doing it for themselves. In their mind, they believed they were helping you or their family. While this does little to comfort someone or justify it, it is a perspective rarely looked at.

Broadening your understanding of what it is to have a serious mental illness can be difficult, because of the stigma that is often associated to those who are ill. It can be done, and if mental illness is present in your life it is another thing we should be prepared to handle.