siblings speak to social workers

FAMIUES OF CHRONICAU.Y MENTALLY ILL PEOPLE: SIBLINGS SPEAK TO SOCIAL WORKERS JOANNE L. RIEBSCHLEGER Twenty siblings of chronically mentally ill people discussed their emotional responses to the mental illness of their brother or sister. The findings were drawn from a study that was part of the author's practice experience as a social worker in a community mental health setting. The findings also paralleled the author's life experiences as a sibling of a chronically mentally ill person. Sibling emotional responses were categorized into grief and loss phases of denial, anger, bargaining, depression, relief/respite, and acceptance. Siblings believed that their expressions of grief and loss were impaired by characteristics of mental illness and by mixed messages from the mental health system. The siblings recommended inclusion of siblings in client treatment; support and education for siblings; clear communication between social worker and family; a social worker focus on family strengths; and, most of all, effective client intervention. The sibling perspective points out the salient need for social workers to use their ecological, person-inenvironment training to facilitate healthier family support networks for chronically mentally ill people.

Family members of chronically mentally ill people often are described as key players in the essential social support network that acts as a buffer against a client's illness (Bulow, Sweeney, Shear, Friedman, & Plowe, 1987; Crotty & Kulys, 1985; O'Connell & Mayo, 1988). Social workers who are. professionally trained in ecological assessment (that is, person-in-environment) have an opportunity to engage these family members in positive ways (Libassi, 1988). 94

Hollis and Woods (1981) described the personsituation reflection as a major social work principle in assessment and intervention processes. The psychosocial frame of reference, which is emphasized in social work education, provides a means for social workers to help chronically mentally ill people interact effectivelywith the external environment. An important component of that environment is the client's family system, and social workers are in a unique position to

CCC Code: 0360-7283/91 $1.00 © 1991, National Association of Social Workers, Inc.

strengthen family members and to facilitate strong social support networks for their clients. Social workers also can assist family members in expressing grief and loss feelings about the fact that a family member has a mental illness. Despite emphasis on environmental training, social work practice with mentally ill people and their families is too often targeted only to the individual client. The needs of familiesfrequently are ignored. In addition, socialworkers often give families conflicting and double-bind messages. This kind of communication replicates the mixed messages that are characteristic of dysfunctional family systems (Davis, 1987; Janzen & Harris, 1986); thus, communication patterns between social workers and families can increase stress in families and further jeopardize the socialsupport network of the chronically mentally ill client (Ferris & Marshall, 1987; Torrey, 1983). Siblings of chronically mentally ill people are an especially ignored component of underused family systems. The practice literature has reported client and parent or spouse interaction (Iodice & Wodarski, 1987; Walsh, 1989) and client and child interactions (DeChillo, Matorin, & Hallahan, 1987; Sargent, 1985). However, little attention has focused on siblings of adult chronically mentally ill persons, and siblings, particularly as adults, often become caretakers of the identified client. Although social workers acknowledge siblings as significant members of family systems, the needs of siblings often are unexplored and unmet in practice with families of chronically mentally ill people.

RESEARCH METHODS This analysis was drawn from semistructured interviews of 20 adult siblings of chronically mentally ill people. The author conducted the interviews on-site at a community mental health center in northern Michigan (n = 16) and by telephone (n = 4) from July 1985 to October 1986. Participation of the interviewees was elicited during the initial intake phase (n = 2) and the interdisciplinary treatment team planning phase (n = 12) of mental health casework services to 14 chronically mentally ill people. The author contacted siblings, with the written consent of the client, to participate in the intake

and treatment team planning procedures for the mentally ill person. Twenty-one siblings initially were contacted by telephone to provide input to the treatment of their ill sibling. One sibling of a chronically mentally ill agency client declined to participate, citing an estranged relationship with the ill sibling. The remaining 20 siblings were interviewed; six of them also attended interdisciplinary treatment team meetings at the community mental health center. Therefore, the sample was a selected (nonrandom) population of 20 adult siblings of 14 chronically mentally ill people. The sibling group consisted of 11 females and nine males, ranging in age from 21 to 65, with a mean age of 35 years. They participated in an average of 2.7 interviews. Four siblings were part of multiple sibling groups involved in the study. Thirteen of the 20 siblings lived within a half-hour drive of the agency client. Eight siblings described themselves as a primary caretaker of the mentally ill person. The diagnoses of the chronically mentally ill siblings of the study participants included 10 .agency clients with schizophrenia, three with bipolar affectivedisorders, and one with organic impairment resulting in mental illness. The client group included three femalesand 11 males ranging in age from 25 to 59, with a mean age of29 years. Every client had a history of multiple inpatient psychiatric hospitalizations and adult-phase onset of the psychiatric disorder. The study used qualitative research methods. In the initial phase, data were collected on the functioning of the agency client from the siblings' perspective and then used in client assessment and treatment planning. In the second phase, the siblings were interviewed to update client information and to examine their historical and current experiences as siblings of a chronically mentally ill person. Interview questions solicited information from the participant regarding eight issues: (1) initial onset of the client's mental illness and family members' responses, including the sibling's first realization that the brother or sister was mentally ill; (2) sibling's perceived emotional responses and coping strategies throughout the course of his or her relative's illness; (3) effect of the chronic mental illness on the life of the participant; (4) historical

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and current interactions of the sibling with the mental health system; (5) sibling definition of mental illness and sources of information about mental illness; (6) reactions offriends, family, and acquaintances to the sharing ofinformation by the participant about the mentally ill sibling; (7) sibling viewpoint of the mental illness prognosis for the agency client and of family planning related to the identified client's long-term care needs; and (8) siblingrecommendations of mental health service responses that would facilitate personal and family adjustment to the mental illness. The author coded the descriptive information from this sequence of questions for significant themes. For additional feedback, the themes were reviewed by three social workers who also were siblings of chronically mentally ill people. However, the interviews were not audiotaped, which precluded an interrater reliability check for the coding of data. A nonrandom, small sample and the lack of an interrater coding system form the major research limitations of this study. Generalizability to all siblings of chronically mentally ill people cannot be verified, and more systematic research on this topic is clearly warranted. Despite the difficulties, this analysis of semistructured interviews of siblings of chronically mentally ill people offers ideas for clinical assessment and intervention for social workers in mental health settings. It also offers a guide for future research on siblings of mentally ill people. This article also draws on the author's life experiences as a sibling of a chronically mentally ill person and the author's practice experience as a social worker in mental health settings. The poignant messages of these sibling interviews call for clarification of the social work knowledge base and active change in social work practice.

GRIEF AND LOSS Siblings of mentally ill clients enter into a grief and loss process similar to that families experience in confronting other traumatic events such as death, disability, or serious physical illness (Hatfield & Lefley, 1987; Sturges, 1977). The emotional continuum of denial, anger, bargaining, depression, and acceptance was devised by Kubler-Ross (1969) to describe five response 96

stages of individuals facing death. All sibling respondents reported that they experienced similarly intense grief reactions to the painful realization that their sister or brother was mentally ill. Siblings reported that they grieved the loss of the formerly healthy person who would perhaps never be the same as before the onset of the mental illness. Siblings of chronically mentally ill people described their feelings of the grief and loss process on Kubler-Ross's continuum of emotional phases-with the addition of the relief/respite phase-as they attempted to cope with the mental illnessof a brother or sister (Table 1). It is important to note that the process was not a linear progression from one of the six phases to another. Siblings could remain in one phase for a long time or vacillate between any number of phases. Sometimes phases aligned with fluctuations in the illness condition of the client. A common emotional pattern was to move circularly through the four emotions of anger, bargaining, depression, and relieflrespite (the second through fifth phases in Table 1). Siblings might briefly or partially enter a phase of grieving. For example, a sibling might partially accept the illness of the brother or sister (acceptance) but have unresolved feelings of sorrow and shame (depression). Siblings might be involved in different phases of the grief and loss process at the same time and experience mixed emotions. Finally, siblings might move forward or backward in the grief and loss process at a given point. Over many years, siblings tended to move through the phases of denial, anger, bargaining, depression, and relief/respite. Some of them reached the final stage of acceptance. Thus, the grief and loss process was a lengthy and complex phenomenon for the study participants, who reported four major impact areas, or significant themes: Siblings experienced the illness of their brother or sister as acutely traumatic because of (1) mixed negative emotions, (2) the special difficulties of adult-phase onset, (3) the cyclical illness pattern, and (4) mixed messages from the mental health system. Social workers can use knowledge of the themes of grief and loss to assist the family, including siblings, to become strong, healthy units that provide social support for chronically mentally ill people.

HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 2/MAY 1991

Table 1. Feeling Responses in the Grief and Loss Process of Siblings of Mentally III People

Phase

Social Worker Description of Phase

Sibling Response in Phase

Denial

In early case history, sibling downplays concern and negative emotions about the worsening condition of a brother or sister.

He or she is under a lot of stress. There's nothing wrong.

Anger

Sibling is aware of illness. Anger is pervasive.

Why doesn't he or she snap out of it? Why do I need to be involved? I'm not a parent. My sibling is getting all the attention. What about me? My mentally ill sibling is ungrateful for what I do for him or her. Why can't other people in my family see that my sibling is ill? Don't treat me like a client! Why don't my parents or other siblings stop this from happening? Why don't they tell me what is going on? I have enough problems of my own to deal with. This is not my fault.

Rivalry stories are often reviewed. Guilt is pervasive.

What did I do to cause or contribute to my sibling's deterioration? I shouldn't feel angry at him or her because this is an illness. Why didn't this happen to me?

Bargaining

Sibling often sees intensificiation of childhood roles including dependency and helplessness.

Why can't my parents or siblings or I stop this? Why doesn't anything work? Why aren't there enough resources? What if I just do this or that? Will it go away? This has genetic tendencies and I feel a little crazy when he or she gets worse. His or her behavior is embarrassing to me. What will people think of this, us, me? It has to stop.

Depression

With a brother or sister's long-term illness, sibling feels chronic sorrow and grieves the loss of the formerly healthy person. Embarrassment felt in early illness phases becomes enduring shame.

Who is this joyless shell of a person who used to be so full of life? It is sad and painful to see my brother or sister turn out to be like this.

Identity and self-esteem issues are evident.

This mentally ill person is my sibling; we're a crazy, degenerate family. Therefore, I may be a crazy, degenerate person. What will happen to my sibling's children or spouse? What if he or she never gets better? My sibling is vulnerable to exploitation by others. What harm will my sibling do to self or others?

As the illness cycle of the mentally ill brother or sister shows improvement, often paired with client medication stabilization, sibling feels a temporary reprieve from stress or negative emotions.

Thank goodness it's over. We got through this. I'm glad the illness didn't affect me. Now I can get on with my own life.

Relief/Respite


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Table 1. (continued)

Phase

Social Worker Description of Phase

Sibling Response in Phase

However, fear of recurrence of illness is a constant response of siblings and other family members, even during relief phase.

Acceptance

Before acceptance, sibling experiences simultaneous mixed emotions and a cyclical intensity of grief that parallels the illness cycles of the brother or sister. After acceptance, with education and support, some siblings achieve a personal acceptance of their sister or brother's chronic mental illness.

Mixed Negative Emotions Siblings experienced a plethora of negative emotions, which often occurred at the same time. Anger, guilt, fear, shame, and sorrow were pervasive sibling emotions that varied in intensity. Torrey (1983) reported that siblings experienced a "survivor's syndrome" in which they blamed themselves for being free of the devastating illness that affected their brother or sister. They blamed themselves for the situation, yet simultaneously felt certain that it was not their fault. They felt drawn to help the ill family member and at the same time were repulsed by their brother or sister's bizarre behavior and lack of impulse control. They hoped for a cure but feared there was none. They worried about their own sanity but assured themselves that they were sane. The normal ambivalence of sibling rivalry might have been exacerbated when family energy and resources flowed to the mentally ill member of the family (Cole & Cole, 1987). A social worker dealing with multiple sibling groups even within the same family might find that one sibling handled the situation in a different way from another sibling. Individual siblings might report feelings that changed depending on their progression in the grief process, their personal inclusion or exclusion in the client delusion system, the degree of stressors in their own environment, or the level of mental illness of the sibling at a specific time. 98

What if the illness gets worse again? When will it get worse? Will I go crazy too? Will my children inherit this? What if the medication has side effects? I or we will take it one day at a time. My sibling has an illness. An illness is not shameful. My sibling will not ever be the person he or she was before. It's OK to express grief and loss about my mentally ill sibling. I am not alone. Many others are dealing with this also.

Denial. Initial sibling responses were focused on denial and disbeliefof the illnessof the brother or sister. Siblings in this phase tended to rationalize, minimize, or ignore the illness. A common response was to avoid the ill relative. Social workers might perceive these siblings as difficult to contact and emotionally unconcerned. Knowledge of denial as a part of the grieving process can shift the worker's view from one of labeling siblings' behaviors as resistant to intervention to one of empathic understanding of siblings' pain. Anger. When siblings acknowledged that their brother or sister was mentally ill, they experienced intense anger, which could be directed at the social worker, the ill sibling, other family members, or themselves. Siblings alternately blamed themselves for and felt cheated because of the mental illness. Sometimes they were angry at the ill sibling for continuing to be ill. Sometimes the anger was expressed indirectly in the form of overconcern for the ill sibling. The siblings might be mistakenly labeled as controlling or hostile. Siblings also might be correctly identified as feeling angry over the loss of the healthy person and guilty because of the anger. This anger phase was often of long duration. A first inpatient hospitalization of the chronically mentally ill person might elicit anger because the mental illness, at that point, became difficult to deny. Social workers can use these times to help siblings become aware of their grief.


Bargaining. Many respondents reported that they sometimes entered a bargaining phase in the grief and loss process when they felt overwhelmed by a sense of helplessness and a lack of control over the resolution of the illness. They began to test out various individual activities in an attempt to cure the ill sibling. Siblings reported that this phase was relatively short but recurred in combination with the anger, depression, or relief phase. Social workers might find that siblings in this phase are cooperative treatment team members. However, the sibling might not understand the prognosis for the client or recognize the bargaining response as part of the grieving process. Depression. Depression was reported to be a very long phase characterized by profound feelings of sadness. The sibling faced the fact that the brother or sister had a chronic illness. The sibling experienced the illness as acutely painful and as a loss and simultaneously reported an awareness of shame and social stigma associated with the illness. Social workers often encountered intense shame when siblings described the reactions of others to their mentally ill brother or sister. If this topic was explored, siblings often shared a repertoire of shame experiences in social interactions where they were stigmatized because of the illness of their family member. These shame experiences increased the depressive condition. Siblings reported that the depression phase might alternate with a regeneration of the anger phase. Social workers can assist siblings in the depression phase by encouraging them to share their feelings in a nonthreatening, supportive environment.

Relief. In contrast to the Kubler-Ross model of grief and loss, siblings of chronically mentally ill people reported brief periods of relief and respite. Feelings of relief occurred during periods of stabilization of the sibling's chronic mental illness; siblings hoped that their brother or sister's illness was gone. At the same time, they reported a nagging fear that the illness would return. In contrast to death, the mental illness cycles of improvement and subsequent relapse interfered with grief resolution. Relief phases often were followed by a return to anger and FAMILIES OF CHRONICALLY MENTALLY ILL PEOPLE

depressive phases. Social workers can help siblings understand that relapses in their mentally ill brother or sister are possible and anticipate their emotional reactions if relapses occur. Acceptance. Although the acceptance phase was difficult to achieve, three respondents reported significant grief resolution. The siblings recognized the mental illness as a nonblameable condition that was likely to affect their brother or sister for the rest of their lives. Siblings understood that the illness created negative feelings that required working through. This phase was usually achieved with education and support, which social workers can provide.

The Special Difficulties of Adult-Phase Onset The adult-phase onset of mental illnesscreated special difficulties for the siblings, who watched the debilitation of the brother or sister. One adult sibling reported watching his brother" go from the promising young man to this ghost-this shell of a person-in 18 months." Unlike siblings of people with congenital abnormalities, 19 study participants (95 percent) knew the mentally ill brother or sister as a formerly healthy person. The sibling must, albeit reluctantly, accept the' 'new" ill person as reality. The sibling must learn to adjust to the rapid deterioration of their brother or sister, who is still alive, but ill. For siblings of chronically mentally ill people, acceptance was a more difficult emotional plateau to achieve.

The Cyclical Illness Pattern The cyclical nature of a chronic mental illness created further barriers to grief resolution for siblings; the loss occurred over and over. As the intensity of illness rose and fell, seven siblings (35 percent) reported they sometimes experienced rising and falling levels of emotional responses that mirrored the illness pattern (DeChillo, Matorin, & Hallahan, 1987). Siblings reported "feeling crazy" or "wondering if I'm crazy" around the time period of client deterioration, particularly just before client inpatient psychiatric hospitalization. They also reported increased levels of guilt, anger, and 99

shame. Five siblings (25 percent) stated that childhood relationship patterns or roles resurfaced in illness phases, and they felt more dependent and helpless. This regressive behavioral response was likelyto occur at times when siblings were assisting with family interaction in the crisis state of the illness. The response often is a normal reaction to a stressful environment, and it may not be unique to siblings of chronically mentally ill people.

Mixed Messages from the Mental Health System Messages from the mental health system were mixed in content and impaired grief and loss resolution. Thirteen siblings (65 percent) said they were very aware that the illness of the brother or sister was perceived by others, including mental health personnel, as a failure of the family due to heredity or child-rearing patterns. Treatment intervention with chronically mentally ill people has tended to focus on medical model methodologies that are pathologically based and targeted toward individual treatment (Bulow et al., 1987; Ferris & Marshall, 1987). Although many programs purported to follow a person-in-environment approach, including interdisciplinary planning, siblings reported that they were largely excluded from real participation in caregiving planning. Sixteen of the 20 interview respondents (80 percent) indicated they had not been previously contacted for treatment team inclusion. However, 12 siblings (60 percent) reported that they were sometimes called in emergencies to help with difficult tasks, such as crisis residential placement, financial assistance, transportation, and witness reports for involuntary inpatient petitions. Eleven siblings (55 percent) reported that they were not adequately assisted by the mental health system in dealing with their own trauma or the pain caused by participation in a family system that provided care to an acutely mentally ill person. Further, 18 siblings(90 percent) reported genuine concern over the lack of community resources available to provide quality-of-life care for the client. Iodice and Wodarski (1987) labeled families as unprepared "dumping grounds" that provide 100

home care to clients. Spaniol, Zipple, and FitzGerald (1984) pointed out that the majority of clients returned to family care, resulting in stress and disruption to the family. Yet the mental health system provided little support, information, or services to these overburdened caretakers. Fifteen of the 20 adult siblings (75 percent) said they had provided inhome care at least once for their mentally ill brother or sister. Parks and Pilisuk (1984) found that even if clients resided in other settings, siblings provided instrumental support (that is, assistance in daily living needs) as well as emotional support. The practice of involving siblings in crisis situations but not in treatment planning relayed conflicting messages to the sibling such as "stay involvedgo away," "we see you but you don't exist," "professionals know what's best," and "there are few resources professionals can provide." These double-bind messages left siblings with little understanding of their roles regarding their ill brother or sister, attention to their own needs, or recognition of their personal struggle or trauma. They also increased the intensity of sibling grieving emotions such as anger, shame, fear, helplessness, and guilt. Another mixed message from the mental health system, according to 12 of the siblings (60 percent), occurred when social workers searched for family pathology, which implied blame, while assuring siblings that the illness condition was biologically determined and that no one was to blame. This message was, "it is and is not your fault." Further,' the model of biological etiology provided little comfort for siblings, who were reminded of the hereditary effectsof schizophrenic, affective, and depressive illnesses. Most siblings reported that these concerns were not typically addressed by social workers in mental health settings. Siblings often did not understand the difficulties that social workers experienced in attempting to increase client self-determination, safeguard confidentiality, and support adultphase client development, which are often the bases for individual intervention methods with chronically mentally ill adults. Because sibling interactions with social workers were crisis based only, the lack of well-developed communication often precluded an explanation of this treatment


phenomenon. The confused sibling might have presumed that social workers withheld information with the shield of client confidentiality for unknown or purposefully antagonistic reasons. This lack of clarity also created increased anxiety in the siblings. Multiple and conflicting messages abounded for siblings of chronically mentally ill people, resulting in negative experiences and increased stress for siblings who interacted with the mental health system. These effects led siblings to avoid the system and be labeled family resistant in a downward spiral of relationship with social workers. This double-bind communication pattern between the treatment system and the sibling or family system was similar to the mixed-message communication family theorists describe in families of chronically mentally ill people.

SIBLING RECOMMENDATIONS Siblings recommended that social workers provide assistance in five major ways: (1) include siblings in the treatment team, (2) provide support and education, (3) model clear communication, (4) focus on family strengths, and (5) provide effective intervention for the ill sibling.

Inclusion in Team Thirteen siblings (65 percent) believed that they should be a member of the client's family treatment team and involved in tasks such as family assessment, intervention planning, and treatment phases. Siblings also should be included in social work research on families of chronically mentally ill people. Siblings can provide a wealth of information about client history, daily living activities, medication usage, and available resources (Spaniol & ZippIe, 1986). Involved siblings experienced a reduction in feelings of helplessness and of an external locus of control. Active social work outreach can be a helpful strategy to facilitate relationships. Therefore, social workers can engage siblings as useful members of the treatment team, which is consistent with the ecological approach. FAMILIES OF CHRONICALLY MENTALLY ILL PEOPLE

Support and Education Ten siblings (50 percent) requested educational and supportive intervention for various times, including transitions in family life, client crisis points, early case identification, and first client inpatient hospitalization. Social workers also should address caretaking disputes within the family (Pilisuk & Parks, 1988) and make referrals to or develop a support group for siblings to help them realize they are not alone in their pain and to facilitate healthy grieving. Some chapters of the National Alliance for the Mentally Ill, an organization of families with mentally ill members, sponsor support groups for siblings (State Alliance for the Mentally III of Michigan, 1988). Family educational workshops also were recommended (DeChillo, Matorin, & Hallahan, 1987). Support group topics could include sibling communication with a mentally ill brother or sister (for example, avoiding trigger words that increase client stress or paranoia and resisting arguments about the client's delusional statements). Other topics might be sibling grief and loss, client treatment approaches (for example, medication usage and purpose), and community resources.

Clear Communication Nineteen siblings (95 percent) recommended that social workers assist family members by modeling clear communication in the workerfamily relationship. Siblings should receivedirect information that is free of professional jargon and, as one sibling described, "diagnostic double-talk. " The social worker should listen to and provide feedback to siblings to model twoway communication, to develop a trusting relationship, and to facilitate the healthy expression of grief and loss. A simple but important request of sibling respondents was that the worker openly use the words "crazy" and "mentally ill" to give the message that mental illness is not too shameful to talk about. Three siblings (15 percent) indicated that their social workers avoided using these terms, which they believed reinforced the social stigma of labeling. Healthy communication and a worker-family relationship developed during the course of client treatment can be 101

positive alternatives to the previous mixed communications of the mental health system.

CONCLUSION

Eight siblings (40 percent) said they wanted social workers to balance crisis-based interactions with family members with a focus on family strengths, such as sharing with siblings "the good times" (for example, discussing client improvement). A social worker assessment of family strengths moves beyond the traditional search for family pathology and includes assessment of the cultural contexts of families, which requires worker flexibility and understanding (Malgady, RogIer, & Constantino, 1987; Williams, 1986). Finally, social workers should work to resolve their own discomfort with mental illness so that families receive fully supportive assistance and a positive mental health system response.

Social workers have a unique opportunity to use their training and skills in the ecological model (that is, the person-in-environment) to help families of chronically mentally ill people form healthier networks of social support for the client and for the family as a whole. Social workers must engage these systemic skills in clinical practice in mental health settings. The needs of siblings as full-fledged members of the family system must be met if families are to function better. As the study participants indicated, siblings experience the mental illness of their brother or sister as a personal trauma that elicits many negative emotional experiences consistent with grief and loss. The messages of these grieving siblings offer a beginning base of know1edge for future social work intervention and research.

Effective Intervention

About the Author

Eighteen siblings (90 percent) stated that they expected the mental health system and social workers to prioritize the needs of the ill sibling and to make available a range of resources to help the ill person become an independent, healthy adult. Siblings expected the worker to ensure client self-determination and to advocate for more resources within the mental health system, including preventive treatment. Siblings reported that they needed concrete assistance, especially in linking the mentally ill brother or sister to necessary services such as food, housing, finances, medical care, and transportation (Freddolino, Moxley, & Fleishman, 1988; Test, 1981). Siblings who provide caretaker functions may need respite opportunities, which the worker can facilitate by using community resources. Five siblings (25 percent) indicated that social workers sometimes overburdened family members in resource procurement and hospitalization admission. They recommended, for example, that workers interact with family members for involuntary client hospitalization so that the workers could deal with the difficultiesand emotions of guilt and anger that follow in the client and family relationship.

Joanne L. Riebschleger, MSW, CSW, is Outpatient Services Supervisor, North Central Community Mental Health Services, 2715 Townline Road, Houghton Lake, MI 48629.

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Implications for advocacy. Psychosocial RehabilitationJournal, 11(4),33-46. Hatfield, A., & Lefley, H. (Eds.). (1987). Families of thementally ill: Coping and adoption. New York: Guilford. Hollis, F., & Woods, M. E. (1981). Casework: A psychosocial therapy. New York: Random House. Iodice, J., & Wodarski, J. (1987). Aftercare treatment for schizophrenics living at home. Social Work, 32, 122-128. Janzen, C., & Harris, O. (1986). Family treatment in social work practice. Itasca, IL: F. E. Peacock Publishers. Kubler-Ross, E. (1969). On death and dying. New York: Macmillan. Libassi, M. F. (1988). The chronically mentally ill: A practice approach. Social Casework, 69, 88-96. Malgady, R., RogIer, L., & Constantino, G. (1987). Ethnocultural and linguistic bias in mental health evaluation of Hispanics. American Psychologist, 42(8), 228-234. O'Connell, R., & Mayo, J. (1988). The role of social factors in affective disorders: A review. Hospital and Community Psychiatry, 39, 842-851. Parks, S. H., & Pilisuk, M. (1984). Personal support systems of former mental patients residing in board-and-care facilities. Journal of Community Psychology, 12, 230-243. Pilisuk, M., & Parks, S. H. (1988). Caregiving: Where families need help. Social Work, 33, 436-440. Sargent, K. (1985). Helping children cope with parental mental illness through use of children's literature. Child Welfare, 64, 617-628.

Spaniol, L., & Zipple, A. (1986). Families with a chronically mentally ill member: A review of the research findings. In J. Bowker & A. Rubins, (Eds.), Studies onchronic mentalillness: New horizons for social work researchers (pp. 52-82). Washington: Council on Social Work Education. Spaniol, L., Zipple, A., & FitzGerald, S. (1984). How professionals can share power with families: Practical approaches to working with families of the mentally ill. Psychosocial RehabilitationJournal, 8(2), 77-84. State Alliance for the Mentally III of Michigan. (1988). Mental illness: A jamily resource guide. (Available from State-AMI Office, 24133 Northwestern Highway, Suite 103, Southfield, MI 48075.) Sturges, J. (1977). Talking with children about mental illness in the family. Health andSocial Work, 2, 87-109. Test, M. A. (1981). Effective community treatment of the chronically mentally ill: What is necessary? Journal of Social Issues, 37, 71-85. Torrey, E. F. (1983). Surviving schizophrenia: Ajamily manual. New York: Harper & Row. Walsh, J. (1989). Engaging the family of the schizophrenic client. Social Casework, 70(2), 106-113. Williams, D. (1986). The epidemiology of mental illness in Afro-Americans. Hospital and Community Psychiatry, 37, 42-49. Accepted November 20, 1990

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