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Navigating Mental Health
Rebecca Turpin
Edge Employment Solutions (BA Psychology Honours) Conditionally registered psychologist
Aims of this seminar To provide information and education
about psychiatric disabilities To enable individuals to understand what
is needed to provide effective services to people with a psychiatric disability
To enhance individuals ability to work together between organisations, and to develop effective networks in working with people with a psychiatric disability.
Mental Illness – The basics
Mental health issues constitute one of the most serious and perplexing problems we face in today’s society.
Mental illnesses touches all of us at some time during our lives. If we are not the ones afflicted, then it will be a family member, a loved one, a friend and in our case, a client we are supporting within the agency.
Some famous and historically important people who claimed
they heard voices Socrates (philosopher) Charlemagne (Emperor) Moses (prophet) Caeser (Emperor) Jesus (prophet) Alexander the Great
(Emperor) Mohammed (prophet) Teresa of Avila (religious
mystic) Joan of Arc (martyr) Columbus (discoverer) Luther (religious leader) Calvin (religious leader) Swedenbourg (philosopher/politician) William Blake (artist) John Welsely (founder of Methodism) Jonathan Swift (writer) Carl Jung (psychologist) Ghandi (politician/ pacifist)
Evelyn Waugh(writer) Anthony Hopkins (actor) Malcolm Lowry (writer) Charles Dickens (writer) Zoe Wannamaker (actress) Sylvia Plath (poet) Philip K. Dick (writer) John Paul Sartre (writer) Beethoven (composer) Virginia Woolf (writer)
Abnormal Behaviour Society has explained and treated abnormal behaviour in
different ways in different times. How a particular society reacts to abnormality depends on
the society’s values and assumptions about human life and behaviour.
For example during the Middle Ages, when a religious point of view was predominant, abnormality was usually explained in terms of supernatural causes such as demons, and treatment involved prayers and various forms of exorcism.
Contrast this with current trends in Western society to which science is important and in which people have a great deal of faith in the miracles of modern medicine, abnormal behaviour is considered evidence of mental illness and is often treated with drugs.
Classification of abnormal behaviour
So what is the line between normality and mental illness?
There is no single definitive widely accepted truth about what constitutes psychological abnormality.
However there are guidelines for defining abnormality and practical standards for the formal diagnosis of disorders.
As you saw earlier, today’s definitions have evolved over the centuries and have changed even more so within the last few years with the recovery movement gaining momentum.
To examine the question of what defines abnormal behaviour let us pose a number of questions
Does infrequency define Abnormality?
Does Suffering Define Abnormality
Does Strangeness Define Abnormality?
Does the Behaviour Define Abnormality?
Is normality a guideline?
So what is defined as abnormal behaviour
Professionals generally use two practical guidelines to define abnormal behaviour.
Firstly they take into account the persons behaviour, the context in which it occurs, and the appropriateness for that context. In other words they consider whether the persons behaviour causes impaired functioning.
Secondly they consider whether the person displays a consistent set of maladaptive feelings or behaviours that have been defined by mental health professionals as constituting mental dysfunction.
Diagnostic Systems
There are two major classification systems of mental illness/disorders in use in Australia:
The current edition (DSM IV) is the most widely accepted system in the world for classifying psychological problems and disorders.
WHO (World Health Organisation) publishes another manual
worldwide, The International Classification of Diseases (ICD) which in many respects is similar to the DSM.
To be diagnosed with a disorder the person must exhibit multiple behaviours that fit a defined pattern, their behaviour must cause dysfunction, it must be present for a specific amount of time, and it must not be due to some other explanation or physical disorder.
So what are we to conclude?
Although most serious behaviour disorders are universally recognized many others are culture specific.
This is why there is no single, universally accepted definition of abnormal behaviour.
Instead we have some guidelines (DSM) which vary in their applicability depending on the case.
According to these guidelines abnormal behaviour is unusual, maladaptive, and causes distress.
It also typically violated social norms.
The Disease Analogy and Medical Model of Mental
Illness This analogy can help scientists
apply the scientific methods that have worked so well in medicine.
Yet the Illness analogy can obscure the social nature of much abnormal behaviour.
Criticisms of the DSM
Sometimes the personal and cultural points of view concerning what is abnormal come into conflict.
Some psychologists allege that if we take environmental circumstances into account then mental disorders are not medical illnesses.
David Rosenham’s study (1973)
Other criticisms have been made regarding the validity of diagnostic categories.
Diagnostic Labels also become a self-fulfilling
prophecy Once a person begins to behave abnormally a
second force comes into play, society’s reaction. People diagnosed as mentally ill are stigmatized
and socially disadvantaged. To adapt they withdraw from social contacts and
may behave violently or act out towards a society that has shunned them.
Eventually diagnostic labels even begin to affect how people think about themselves.
They may lose faith in their ability to control their own life and become dependent on mental health professionals. They may view themselves as nothing more than “a schizophrenic”.
Should mental health professionals be using the
DSM This does not mean that everything
contained in the DSMIV is uncritically accepted.
Mental health, psychology and psychiatry is a rapidly moving field in which there are still more questions than answers.
Neither the current DSM nor any DSMs in the foreseeable future can or will claim to be definitive.
New information on mental health is constantly being accumulated and no single research study is likely to be the last word on any issue.
What causes mental illness?
Most mental illnesses are caused by the interaction of a number of factors including:
Biological predisposition (genetic or acquired) Adverse early life experiences (eg abuse, neglect,
death of parents or other losses and traumas) Individual psychological factors (self-esteem,
thinking style) Current social circumstances (financial, work,
relationship or family stress, or adverse life events)
A “single” cause is highly unlikely. Rather an episode of illness appears to occur in a biologically and psychologically predisposed individual, under the trigger of social/environmental stress.
Depression The word depression is used in many different
ways.
Everyone can feel sad or blue when bad things happen. However everyday blues or sadness is not depression.
People with the blues may have a short-term depressed mood but they can manage to cope and soon recover without treatment.
The depression we are talking about is clinical depression which lasts for at least two weeks and affects a persons ability to carry out their work or to have satisfying personal relationships.
Clinical depression is a common but serious illness and is often recurrent (that is people recover but develop another episode later on).
Mental Status IndicatorsEmotions Sadness, anxiety, guilt anger, mood swings, lack of emotional
responsiveness, Anhedonia (e.g. lack of pleasure) helplessness, of unrelentless hopelessness (e.g., I can’t take one more day of this. I just cant do it. Things are never going to change, no matter what I do).
Thoughts Frequent self-criticism, self-blame, worry, pessimism, impaired
memory and concentration, indecisiveness and confusion, tendency to believe others see you in a negative light, suicidal ideation, idyllic thoughts of death as a release (e.g. I’ll be up in heaven, no-one will be able to hurt me anymore)
Behaviour Crying spells, withdrawal; from others, neglect of responsibilities,
loss of interest in personal appearance, loss of motivation
Physical Chronic fatigue, lack of energy, sleeping too much or too little,
overeating or loss of appetite, constipation, weight loss or gain, irregular menstrual cycle, loss of sexual desire, unexplained aches and pains.
What causes Depression
Depression has no single cause and often involves the interaction of many diverse biological, psychological and social factors
ANXIETY DISORDERS
Everybody experiences anxiety at some point in their lives
Anxiety can be quite useful in helping a person to avoid dangerous situations and motivate them to motivate them to solve everyday problems.
Anxiety can vary in severity form mild uneasiness through to a terrifying panic attack.
Anxiety can also vary in how long it lasts, from a few moments to many years.
An Anxiety Disorder differs from normal anxiety in the following ways:
It is more severe It is long lasting It interferes with the persons work or
relationships
General symptoms of Anxiety
Anxiety can show in a variety of ways: physical, psychological and behavioural
Physical Cardiovascular: palpitations, chest pain, rapid heartbeat, flushing Respiratory: hyperventilation, shortness of breath Neurological: dizziness, headache, sweating, tingling and
numbness Gastrointestinal: choking, dry mouth, nausea, vomiting, diarrhoea Musculoskeletal: muscle aches and pains (especially neck,
shoulders, and lower back), restlessness, tremor, and shaking
Psychological Unrealistic and/or excessive fear and worry (about past or future
events), mind racing or going blank, decreased concentration and memory, indecisiveness, irritability, impatience, anger, confusion, restlessness or feeling on edge or nervousness, tiredness, sleep disturbances, vivid dreams
Behavioural Avoidance of situations, obsessive or compulsive behaviour,
distress in social situations, phobic behaviour
Anxiety Disorders
Generalized Anxiety Disorder (GAD)
Panic Disorder
Phobic Disorders Agoraphobia Social Phobia Specific Phobia
Acute stress disorder and post-traumatic stress disorder (PTSD)
Obsessive Compulsive Disorder
Compulsive behaviours are repetitive behaviours or mental acts that the person feels driven to perform
in response to an obsession in order to reduce anxiety e.g. washing, counting, checking
PSYCHOSISWhat is psychosis? Psychosis is a general term to describe a
mental health problem in which a person has lost some contact with reality.
There are severe disturbances in thinking, emotion and behaviour. Psychosis severally disrupts a persons life. Relationships, work and self-care are difficult to initiate and/or maintain.
The main psychotic illnesses are schizophrenia, bipolar disorder, psychotic depression, schizoaffective disorder, and drug-induced psychosis.
Schizophrenia
Schizophrenia is nothing to do with split personality. This is a common misconception, which is often confused with dissociative identity disorder (formerly known as multiple personality disorder)
The term schizophrenia means fractured mind, and refers to changes in mental function where thoughts and perceptions become disordered. when first affected.
The major symptoms of schizophrenia are defined as either positive or negative.
Symptoms such as hearing voices no-one else can are positive as they are added to normal experience by the illness.
When the illness causes things to be missing from a persons normal experience and behaviour, this is called negative symptoms e.g. lack of motivation, withdrawing from people.
The symptoms of schizophrenia include:
Delusions These are false beliefs held by the
person, which is not held by others of the same cultural background. The person is so convinced of their delusion, that the most logical argument against it is useless.
Delusions take various forms:
Paranoid delusion - a belief that you are being watched and singled out for some harmful purpose
Grandiose delusion - a belief that you have special powers – that you are an important religious leader, politician, scientist
Depressive delusion – a belief that you are guilty of some terrible crime or responsible for horrific world events
Hallucinations These are false perceptions.
Hallucinations most commonly involve hearing voices, but can also involve seeing, feeling, tasting or smelling things. These are perceived as very real by the person with schizophrenia but are not actually there.
While the voices are unpleasant for some people for others they provide companionship or reassurance.
Visual hallucinations are less common however they most commonly occur when the psychosis is drug induced.
Hallucinations of taste and smell can also occur so that what seems to be the peculiar taste of food can cause someone who feels paranoid to believe they are being poisoned.
Confused thinking The everyday thoughts that let us lead our
daily lives become confused and don’t join up properly. Some even believe their thoughts are being interfered with or that they can influence the thoughts of others, or that everybody else can read their thoughts.
These disturbances in thinking mean that the person often has difficulty concentrating, following conversation or remembering things. Thoughts are all jumbles up
Thinking Difficulties There may be difficulties in concentration,
memory and ability to plan. These make it more difficult for the person to reason, communicate and complete daily tasks.
Loss of drive/motivation A secondary symptom often
associated with psychosis is low motivation. Sometimes we under-estimate or forget about this.
It can be genuinely difficult for the brain to translate a thought or wish into actual action.
Diagnosing Schizophrenia
Schizophrenia is only diagnosed if the symptoms last over 6 months.
A diagnosis of schizophreniform disorder is made if the psychotic symptoms last more than one month but less than 6 months.
Brief Reactive Psychosis is the diagnosis if symptoms last for less than one month and may be a temporary reaction by the brain to a very stressful event.
Bipolar DisorderPeople suffering from Bipolar Disorder have extreme mood swings, fluctuating
between periods of depression, mania and normal mood. Common symptoms in mania include:
Increased energy and overactivity Elated mood
The person will feel high, happy, full of energy, on top of the world, invincible
Need less sleep than usualThe person can go for days with little sleep
IrritabilityThis may occur if others disagree with a manic persons unrealistic plans or ideas
Rapid thinking and speechThe person may talk too much, too fast, and keep changing topics
Lack of inhibitionsThe person may disregard risks, spend money extravagantly or be very sexually active
Grandiose delusionsThese involve very inflated self esteem such as a belief that the person is superhuman, especially talented, or an important religious figure
Lack of insightThe person is so convinced that their manic delusions are real that they do not realise they are ill
Psychotic Depression Sometimes depression can be so intense it
causes psychotic symptoms. E.g. the person may have delusions involving guilt, severe physical illness or hopelessness.
Schizoaffective Disorder Sometimes its not possible to tell the difference
between schizophrenia and bipolar disorder as the person has symptoms of both illnesses. Schizoaffective disorder just means a form of psychosis which falls midway between diagnosis of schizophrenia and bipolar disorder.
Drug-induced Psychosis This is a psychosis brought on by the use of
drugs. The symptoms usually appear quickly and last a short time (from a few hours to a few days) until the effects of the drug wear off. The most common symptoms are visual hallucinations, disorientation, and memory problems. Drugs that can cause psychosis are marijuana, cocaine, ecstasy, amphetamines.
The jigsaw – you, your client and the system
Crisis Intervention
A crisis is a situation when a person feels completely overwhelmed or defeated by the problems they are facing.
Crisis intervention is immediate person to person assistance. It helps restore self-determination in people who have exhausted their usual coping resources.
The intervener aids in the search for solutions by encouraging the individual to consider and to clarify thoughts, feelings and options.
Relating to a person who is experiencing a crisis
Be warm, respectful and matter of fact.
The situation varies from one individual to another.
Recognise that the experience is real for this person at this time and that they may have difficulty paying attention to you.
Keep sentences short: stick to one thing at a time.
Be honest but not argumentative.
It can be useful to ask the person what they want right now
Ask about friends, relatives, therapists or psychiatrists
If the person is doing things which annoy or anger you ask them firmly to stop.
Don’t make generalised criticisms.
If the person is violent or if you feel unsafe, make it clear that you are not going to harm the person, but you will not tolerate violence.
If the person does not calm down, ring the police for your own protection.
Remember that not everyone who experiences active symptoms of mental illness will be in a state of crisis,
What to do for someone experiencing depression and
suicidal thoughts People often disclose information to employment
consultants that they would not disclose to even a spouse or family member due to the rapport built and the trust that has been instilled in the relationship. These disclosures may include feelings of hopelessness or despair or frank suicidal thoughts.
A suicidal patient may evoke significant strong emotions for an individual, such as anger toward the person or fear of losing the person, of personal failure in preventing suicide. However, despite these emotions, employment consultants have tremendous potential to respond to this call to action by arming themselves with the knowledge of risk factors for potential suicide
Risk Assessment
A number of suicide risk assessment tools have been devised.
Depression is a major risk factor for suicide, but there are others as listed below
(http://www.capefearpsych.org/documents/SADPERSONS-suiciderisk.pdf)
The SAD person’s risk assessment TOOL Sex: males kill themselves more than 4 times
more often than females Age: certain age groups are more at risk Depression: Depressed persons are more at risk Previous attempt: more likely to attempt in the
future Ethanol: alcohol abuse very often implicated in
suicide Rational thought: more prone to suicide if
psychotic Social network: the less social support, the
greater the risk Organised Plan: greater risk if suicide plans are
organised No spouse: greater risk of suicide if there is no
partner Sickness: a chronic physical illness makes suicide
more likely
The two most important risk factors to look for are:
1 Current Plan Does the person have a plan about how
they will kill themselves? Have they go the means to do it?
2 Previous attempt Has the person attempted to kill
themselves in the past? Another factor that may increase the risk that someone will choose suicide as a way to end their suffering is if a significant person in their life has chosen suicide
The presence of Warning Signs
Myth: People who commit suicide always give off some kind of clear warning sign or call for help
Warning signs
Expressions of wanting to die, not wanting to go on living, to put an end to their relentless suffering
An overwhelming sense of guilt Organizing their affairs Giving away possessions Sudden change (better or worse) of
appearance or behaviour No longer including themselves in plans
for the future Withdrawing into themselves
What to do immediatelyAsk the following questions Have you often thought of death or dying? Do you have a specific suicide plan? Have you made serious suicide attempts before? Can I be sure you will not act on suicidal ideas? What help could make it easier for you to cope with your
problems at the moment?
If the person is talking of committing suicide, listen to the persons expression of their feelings and take them seriously.
Contact the doctor or local mental health service (Ensure the person is not left alone – stay with the person if you consider the risk of suicide is high or try to arrange that someone be with them while they get through the immediate crisis
Seek immediate help: Phone the mental health crisis number in our
area Phone Emergency 000 or Take the person to a hospital emergency
department or Take the person to a GP
Preferably contact such services with the clients permission, but be aware of your duty of care.
It the person is consuming alcohol or drugs, try to stop them from consuming any more
Try to ensure the person does not have ready access to some means to take their life
What doesn’t help?
• There’s no point in just telling someone with depression to get better as they cannot “snap out of it” or “get over it.”
• You should not be hostile or sarcastic when the person attempts to be responsive but rather accept these responses as thebest the person has to offer at that time.
• Avoid speaking to the person with a patronising tone of voice and do not use overly-compassionate looks of concern.
• Resist the urge to try to cure the person’s depression or to come up with answers to their problems.
The person who threatens or attempts suicide again and
again…. And again
This is the type of person who is brought into emergency unit repeatedly. It is often easy to become frustrated with such a person because the suicide attempts are not dangerous.
However these people are not acting, their lives are unhappy and they need help.
Establishing Liaison with other Parties
Staff need to be familiar with community resources specifically deigned to meet the needs of people who have a psychiatric disability. This may include issues associated with housing and local treatment services. Frequently it is factors such as loss of housing or change in medication that impact on an individuals ability to maintain employment.
If the clients primary case worker is part of the mental health system, it is important for employment program staff to have a working knowledge of the language, philosophy and principles upon which the mental treatment is based.
The Mental Health Sector
There are many services available to clients which broadly fall under the heading of mental health provision. They include:
Psychiatric institutions, for residential and outpatient care Crisis Emergency Teams - which will assist in emergencies
and assess whether someone is unwell enough to warrant hospitalization
Psycho-social rehabilitation programs, which often provide assistance with daily living skills and leisure activities
Housing programs, which assist people to find suitable accommodation in the community
Mental health clinics, which may provide both counselling and medication services, along with various education programs
Support groups, which provide an opportunity for people to meet with other consumers, share experiences, and lobby for additional services
Private practitioners, including psychiatrists and psychologists
It is essential that you develop good working relationships with the staff of these other agencies.
It is simply not possible to assist someone with a serious illness in isolation from other resources – your client will need assistance beyond the boundaries of employment agency, and it is important that you are able to refer them to more appropriate services when necessary.
Mental Health Professionals
GP’s A GP can provide the following types of
help: Explaining a mental illness and how the
person can best be helped Prescribing medication if needed Referring the person to a counsellor,
clinical psychologist or psychiatrist
Counsellors and Clinical Psychologists
Counsellors and clinical psychologists specialise in the psychological treatment of mental health problems.
They are not medically qualified, so they cannot prescribe antidepressants or other drugs. A counsellor of clinical psychologist can provide a person with the following types of help:
An opportunity to talk about problems and to be listened to in an emotionally supportive and non-judgementally way
Specific methods for overcoming mental illness and preventing its recurrence. A counsellor will provide active listening techniques and an opportunity to discuss life problems, however a clinical psychologist is able to provide therapeutic intervention such as CBT
If a person wants help from a counsellor or clinical psychologist they can contact one themselves or get a recommendation form their GP.
Psychiatrists Psychiatrists are medical specialities
who treat mental health problems. Psychiatrists generally only treat
people who have severe or long lasting problems. They are experts on medication and can help people who are having side-effects from their medication or interactions with their other medications.
It is possible to see a psychiatrist only by getting a referral from a GP.
What if the person doesn’t want professional help?
The person may not want to seek professional help. You should find out if there are specific reasons why this is the case.
If the person still doesn’t want help after you have explored their reasons with them, let them know that if they change their mind in the future about seeking help they can contact you. You must respect the person’s right not to seek help at all times unless you believe that they are at risk of harming themselves or others.
Psychiatric TreatmentAdmission for Psychiatric Treatment Voluntary Admission This is normally on the grounds that the person is
exhibiting signs of mental disorder. It is recognised that it would be most appropriate place for them to be, and that they would not benefit from treatment at any other place.
Involuntary Admission This covers the following two separate criteria: That the person is suffering from mental illness to
a degree that warrants hospitalisation That they ought to be detained either in the
interests of the persons own welfare or with a view to the protection of other persons.
Stopping Medication Clients sometimes make decisions without
consulting their doctor, about stopping their own medication. They may do this because their job-seeking has been successful and they see it as a part of returning to the normal world, but it can be a disastrous step to make without close discussion with the doctor.
Some rules of thumb if your client wishes to cease taking medication:
Try not to be judgemental Advise your client of the possible repercussions Encourage your client to discuss their decision
with people they trust – their psychiatrist, doctor and rehabilitation consultant
Cyclical nature of psychiatric disability
A characteristic of many psychiatric conditions is their repetitive pattern of occurrence and the unpredictability of the course they take.
To deal with this support staff can help the client establish an illness pattern, by looking at when they became ill during their past work history.
Relapse and Crisis What needs to be considered closely
are the triggers for episodes or some particular idiosyncratic early warning signs which are components displayed by the client early in the episode.
Early negotiation with the client and relevant others e.g. close friends, family, psychiatrists and counsellors about an appropriate way to deal with a crisis.
Close collaboration with the treating psychiatrist, especially if they have known the client for some time is invaluable as long as the client is happy for this transfer of information to occur.
Dependency
Very often, a client who is highly dependent is suffering from the effects of institutionalisation, where they may have had a little power or control over their environment, and where every facet of their life was organised by others.
Discuss the issue with your client. They may be unaware that you have less time to spare than they either need or want. Set boundaries on the amount of time you can spend with them and define your role more clearly
Assist the person to gain assistance or support from somewhere other than the employment agency. Discuss rehabilitation, recreational and psychosocial rehabilitation programs run in the region if appropriate.
Self –Care
The social services sector is renown for being a tough place to work, and a place where burnout of workers is more common than we would like to believe.
Burnout is a very real risk in any human service field, but perhaps particularly when staff are working with people with psychiatric disabilities. The results of burnout can be serious for both staff members involved and the agency as a whole.
There is no question that working with people who at times are in need of substantial emotional support can be draining. Developing effective ways of dealing with this is essential
