1. Blue Roses and Jonquils: The Stigma of Mental Illness*
34th Annual I&R Training and Education Conference
New Orleans, Louisiana
Tuesday, May 22, 2012
2:15pm - 3:45pm
*With apologies to Tennessee Williams
John Plonski – Facilitator
Director of Online Supervisors
IMAlive National Hopeline Network
Paper-free
Workshop 1

2. Some questions to start…
What would you like to take away from today’s session?
What attitudes do we have
about those with mental health disabilities?
How do our attitudes affect those with
mental health disabilities with whom we interact?
What questions do you have?
Psst…Keep in mind not having an attitude is an attitude!

3. Let’s look at some numbers*.
Mental disorders are common in the United States
About 1 in 5 adult Americans ages 18 and older suffer from a diagnosable mental disorder in a given year.
This figure represents 20% of the population and translates to approximately 62 million people nationally.
Statistics show that only one-third of these individuals seek treatment.
* Statistics derived from:Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):

4. Some more numbers. 1 in 17 Americans suffer from a
serious mental illness.
45% of those with any mental
disorder meet criteria for 2 or more disorders, with severity related to comorbidity.
Mental disorders are the leading cause of disability in the U.S.
The cost of mental health services is approximately $69 billion* in the United States.
Indirect costs*, (lost productivity at the workplace, school, and home) is an estimated at $78.6 billion.
* According to the National Alliance for Research on Schizophrenia and Depression (NARSAD).

5. Some more numbers.

6. As it relates to I&R you need to realize…
The numbers indicate that you will at
some time, interact with a consumer with
a mental disorder…In fact, you may know
someone with a mental disorder
Mental illnesses are medical conditions. Just as diabetes is a disorder of the pancreas, mental illness is a medical condition affecting the brain making it difficult to cope with the ordinary demands of life.
They are biologically based brain disorders.  They cannot be overcome through "will power" and are not related to a person's "character" or intelligence. 6

7. Let’s stop for a moment and look at this list… Your thoughts…
Avoidance
Delusions
Denial
Displacement
Dissociation
Hallucinations
Intellectualization
Isolation
Projection
Rationalization
Reaction Formation
Repression
Somatization
Splitting
Suppression 7

8. While we may think it is, the list is not a list of mental disabilities.
It is actually a list of symptoms of various mental disabilities. And it is also… 8

9. Perhaps more importantly…It is a list of coping defenses we all use when confronted by stress.9

10. behaviors triggering stress. Stress is the brain’s response to a
In our “normal” lives what we think, feel, and the way we behave are in a homeostatic balance referred to as the “Normal State”.
In the Normal State there is a complimentary balance between a person’s thoughts, feelings and behaviors.
In the crisis state there is imbalance between a person’s thoughts, feeling and
behaviors triggering stress.
Stress is the brain’s response to a
stimulus (change) characterized by
a physical and psychological arousal
response. 10

11. Like this brain?
Close…
But not quite.

12. Confronted by stress we engage in basic physical and psychological responses.
When a disruption of the Normal State triggered by alarming experiences, real or imaginary. The body reacts releasing epinephrine (adrenaline), norepinephrine, cortisol and
cortisone. This leaves the
lower brain functions in control
inducing three possible
responses to the stressor…the
Primal Coping Defenses. 12

13. Primal Coping Defenses… Stressor induces one of three responses
Fight
Flight
Freeze 13

14. Then the brain engages in what we will term Autonomic Coping Defenses.
Autonomic Coping Defenses protect the individual from consciously experiencing anxiety and engage automatically when the homeostatic balance is upset. 14

15. The Autonomic Coping Defenses
Avoidance
Delusions
Denial
Displacement
Dissociation
Hallucinations
Intellectualization
Isolation
Projection
Rationalization
Reaction Formation
Repression
Somatization
Splitting
Suppression 15

16. Yet only 1/3 of those affected by mental illness seek and receive help
Yet only 1/3 of those affected by mental illness seek and receive help. How can this be?
Although there are other issues, stigma is the major factor preventing people from seeking the help available to them.

17. Stigma is a very real problem for people who have a mental illness.
Based on stereotypes, stigma is
a negative judgment based on a personal
trait and myths accepted as fact — in this case, having a mental health condition.
It is a common perception that having a mental illness is due to some kind of personal or moral weakness or the person is not “normal”.
Unfortunately stigma frequently blocks people from getting the help they need.

18. For the person with a mental illness stigma has several harmful effects including…
Trying to pretend nothing is wrong
Refusal to seek treatment
Rejection by family and friends
Work or school problems or discrimination
Difficulty finding housing
Being subjected to physical violence or harassment
Inadequate health insurance coverage of mental illnesses 18

19. However… We now know that mental health
disorders have a biological basis and
can be treated like any other health
condition.
Even so, we still have a long way to go to overcome the many misconceptions, fears and biases people have about mental health, and the stigma these attitudes create.
Let’s look at and debunk some of the myths contributing to the sigma surrounding mental disability.

20. Let’s do some myth/stigma busting!
Myth: Psychiatric disorders are not
true medical illnesses like heart disease
and diabetes. People who have a
mental illness are just "crazy.“
Reality: Brain disorders, like heart disease and diabetes, are legitimate medical illnesses. Research shows there are genetic, environmental and biological causes for psychiatric disorders, and they can be treated effectively.

21. Myth: People with a serious mental illness, such as schizophrenia, are usually dangerous and violent.
Reality: Statistically the incidence of violence in people with a brain disorder is not much higher than the general population’s. Those with a psychosis are more often frightened, confused and despairing than violent. In fact, people with mental illnesses are much more likely to be the victims of crime.
Myth: Mental illness is the result of bad parenting.
Reality: Experts agree that a genetic susceptibility, combined with other risk factors, leads to a psychiatric disorder. In other words, mental illnesses have a physiological cause.

22. Myth: Depression results from a personality weakness or character flaw
Myth: Depression results from a personality weakness or character flaw. People who are depressed should just snap out of it!
Reality: Depression has nothing to do with being lazy or weak. It results from changes in brain chemistry or brain function, and medication and/or psychotherapy often help people to recover.
Myth: Depression is a normal part of the aging process.
Reality: Depression is not part of the aging process. However, the elderly can have depression and seniors and their family members should seek professional help if they suspect depression.

23. Myth: Mental illnesses do not affect children or adolescents
Myth: Mental illnesses do not affect children or adolescents. Any problems they have are just a part of growing up.
Reality: Just like seniors, children and adolescents develop mental illnesses. One in ten youth has a mental disorder. However, only about 20 percent of these children receive needed treatment.
Myth: Addiction is a lifestyle choice. People with a substance abuse problem are morally weak or "bad“.
Reality: Addiction is a disease that generally results from changes in brain chemistry. It has nothing to do with being a "bad" person.

24. Myth: Schizophrenia means split personality, and there is no way to control it.
Reality: Often confused with multiple personality disorder schizophrenia is disorder that prevents clear and logical thinking. Symptoms range from social withdrawal to hallucinations and delusions. Medication helps many to lead fulfilling, productive lives.
Myth: If you have a mental illness, you can will it away. Being treated for a psychiatric disorder means you failed or are weak.
Reality: A serious mental illness cannot be willed away. Ignoring the problem does not make it go away, either. It takes courage to seek professional help.

25. Myth: People with mental illnesses cannot tolerate the stress of holding down a job.
Reality: All jobs are stressful to some extent. Anybody is more productive when there's a good match between the employee's needs and the working conditions, whether or not the worker has a mental health problem. Employers who have hired people with mental illnesses report good attendance and punctuality as well as motivation, good work, and job tenure on par with or greater than other employees.

26. Myth: Therapy and self-help are a waste of time
Myth: Therapy and self-help are a waste of time. Why bother when you can just take a pill?
Reality: Treatment varies depending on the individual. People work with therapists, counselors, friends, psychologists, psychiatrists, nurses, and social workers during the recovery process. They also use self-help strategies and community supports. Often they combine these with available medications available.
Myth: Mental illnesses don't affect me.
Reality: Mental illnesses are surprisingly common; they affect almost every family. Mental illnesses do not discriminate - they can affect anyone.

27. Myth: I can't do anything for a person with mental illness.
Reality: You can do a lot, starting with how you act and speak. You can create an environment that builds on people's strengths and promotes understanding. For example:
Don't label people with words like “crazy”, “nuts”, “wacko”, or “loony”.
Don’t define them by their diagnosis. Use “People First” language to separate the individual from their diagnosis. For example a person is not “a schizophrenic” they “have schizophrenia”.

28. In Addition…
Examine your own attitudes about mental illness and how they may affect your interactions.
Learn the facts about mental health and share them with others - don’t be a myth spreader.
Treat people with mental illnesses with the respect and dignity you would accord anyone else.
Respect the fact that just because some one has a mental disability it does not mean they have no abilities.
Respect the rights of people with mental illnesses. They have the same guaranteed rights to housing, employment, healthcare, or education as anyone else.

29. And to sum it all up…
Most people diagnosed with a serious mental illness can experience relief from their symptoms by actively participating in an individual treatment plan.
Mental illnesses are treatable! 70% - 90%
of those who receive pharmacological and/or
psychosocial treatment and support show a
major reduction of symptoms and an improved
quality of life.
Medication need not always be part of the treatment. Psychosocial treatment such as cognitive behavioral therapy, interpersonal therapy, peer support groups, and other community services can also be components of a treatment plan and that assist with recovery.
Early identification and treatment are of vital importance. 29

30. So do I have to know about all the different diagnoses
So do I have to know about all the different diagnoses!?! I need to be able to do differential diagnosis?!? 30

31. Not so much. But inquiring minds … A list of the basic disorders*.
Mood Disorders
Mood disorders include major depressive disorder, dysthymic disorder, and bipolar disorder.
Approximately 20.9 million American adults have a mood disorder.
The median age of onset for mood disorders is 30 years.
Depressive disorders often co-occur with anxiety disorders and substance abuse.
* Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):

32. Major Depressive Disorder
Mood Disorders
Major Depressive Disorder
It is characterized by an all-encompassing low mood and low self-esteem, and by a loss of interest or pleasure in normally enjoyable activities.
It is the leading cause of disability in the U.S. for ages
It affects approximately 14.8 million adults.
Occurs at any age and is more prevalent in women.

33. Mood Disorders Dysthymic Disorder
Characterized by a chronic, mild depression that persists for at least 2 years (1 year in children).
It affects approximately 3.3 million adults.
Bipolar Disorder
Characterized by dramatic shifts in mood, energy, and ability to function often with periods of normalcy in between. Unlike the normal ups and downs the majority of us experience, the symptoms of bipolar disorder are pronounced and severe.
Bipolar disorder affects 5.7 million adults.

34. Schizophrenia
Characterized by hallucinations, delusions, disordered thinking, movement disorders, flat affect,
social withdrawal, and cognitive deficits. Individuals are fearful and withdrawn and have difficulties when they try to have relationships with others. Affects 2.4 million adults.
Schizophrenia affects men and women with
equal frequency.
Schizophrenia often first appears in men in their late teens or early twenties. Women are generally affected in their twenties or early thirties.

35. Anxiety Disorders Anxiety disorders include panic disorder,
obsessive-compulsive disorder,
post-traumatic stress disorder, generalized anxiety disorder, and phobias (social phobia, agoraphobia, and specific phobia). Affects 40 million adults.
Anxiety disorders frequently co-occur with depressive disorders or substance abuse.
Most people with one anxiety disorder also have another anxiety disorder and nearly three-quarters of those with an anxiety disorder will have their first episode by age 21.

36. Anxiety Disorders Panic Disorder Characterized by repeated, unexpected
episodes of intense fear accompanied by physical symptoms that may include chest pain, heart palpitations, shortness of breath, dizziness, or abdominal distress. Affects 6 million adults.
Typically develops in early adulthood but the age of onset extends throughout adulthood.
About one in three people with panic disorder develops agoraphobia.

37. Anxiety Disorders Obsessive-Compulsive Disorder
Characterized by recurrent, unwanted
thoughts (obsessions) and/or repetitive behaviors (compulsions) affecting 2.2 million adults.
Symptoms often start in childhood or adolescence.
Social Phobia
Characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations affecting 15 million adults.
Social phobia begins in childhood or adolescence, typically around 13 years of age.

38. Generalized Anxiety Disorder (GAD)
Approximately 1.8 million American adults age 18 and over, or about 0.8 percent of people in this age group in a given year, have agoraphobia without a history of panic disorder.1
The median age of onset of agoraphobia is 20 years of age.5
Specific Phobia
Specific phobia involves marked and persistent fear and avoidance of a specific object or situation.
Approximately 19.2 million American adults age 18 and over, or about 8.7 percent of people in this age group in a given year, have some type of specific phobia.1
Specific phobia typically begins in childhood; the median age of onset is seven years.5
Anxiety Disorders
Generalized Anxiety Disorder (GAD)
Characterized by chronic anxiety,
exaggerated worry and tension, without little or nothing to provoke it.
Agoraphobia
Characterized by intense fear and anxiety of any place or situation leading to avoidance of situations such as being alone outside of the home; traveling in a car, bus, or airplane; or being in a crowded area.
Specific Phobias involve the persistent fear and avoidance of specific objects or situations.

39. Post-Traumatic Stress Disorder (PTSD)
Generalized Anxiety Disorder (GAD)
Approximately 6.8 million American adults, or about 3.1 percent of people age 18 and over, have GAD in a given year.1
GAD can begin across the life cycle, though the median age of onset is 31 years old.5
Social Phobia
Approximately 15 million American adults age 18 and over, or about 6.8 percent of people in this age group in a given year, have social phobia.1
Social phobia begins in childhood or adolescence, typically around 13 years of age.5
Agoraphobia
Agoraphobia involves intense fear and anxiety of any place or situation where escape might be difficult, leading to avoidance of situations such as being alone outside of the home; traveling in a car, bus, or airplane; or being in a crowded area.5
Approximately 1.8 million American adults age 18 and over, or about 0.8 percent of people in this age group in a given year, have agoraphobia without a history of panic disorder.1
The median age of onset of agoraphobia is 20 years of age.5
Specific Phobia
Specific phobia involves marked and persistent fear and avoidance of a specific object or situation.
Approximately 19.2 million American adults age 18 and over, or about 8.7 percent of people in this age group in a given year, have some type of specific phobia.1
Specific phobia typically begins in childhood; the median age of onset is seven years.5
Anxiety Disorders
Post-Traumatic Stress Disorder (PTSD)
Characterized by persistent frightening
thoughts and memories of a traumatic event. Individuals feel detached or emotionally numb, especially with people they were once close to. They may experience sleep problems, or be easily startled. Affects approximately 7.7 million adults.
PTSD can develop at any age, including childhood.
Frequently follows violent personal assaults, natural or human-caused disasters, accidents, or military combat.

40. Attention Deficit Hyperactivity Disorder
Attention Deficit Hyperactivity Disorder (ADHD)
ADHD, one of the most common
mental disorders in children and
adolescents,
It also affects an estimated 4.1%
of adults.
ADHD usually becomes evident in
preschool or early elementary years, although the disorder can persist into adolescence and occasionally into adulthood.

41. Autism Spectrum Disorders (ASD)
Autism Spectrum Disorders (ASDs) cause impairment in thinking, feeling, language, and the ability to relate to others. ASDs vary in severity, with autism being the most debilitating whilebother ASDs produce milder symptoms.
A recent study by the CDC reported the prevalence of autism among 8 year-olds to be about 1 in 110.
Autism and other ASDs develop in childhood and generally are diagnosed by age three.
Autism is about four times more common in males than females though females tend to have more severe symptoms and greater cognitive impairment.

42. Eating Disorders Anorexia Nervosa
Anorexia nervosa is characterized by emaciation, a relentless pursuit of thinness and unwillingness to maintain a normal or healthy weight, a distortion of body image and intense fear of gaining weight
The mortality rate among females with anorexia has been estimated to be about 12 times higher than the annual death rate due to all causes of death among females ages

43. Eating Disorders Bulimia Nervosa
Bulimia nervosa is characterized by recurrent and frequent episodes of eating unusually large amounts of food (e.g., binge-eating), and feeling a lack of control over the eating. This binge-eating is followed by a type of behavior that compensates for the binge, such as purging (e.g., vomiting, excessive use of laxatives or diuretics), fasting and/or excessive exercise.

44. Binge-eating Disorder
Eating Disorders
Binge-eating Disorder
Binge-eating disorder is characterized by recurrent binge-eating episodes during which a person feels a loss of control over their eating.
Episodes are not followed by purging, excessive exercise or fasting. As a result, people the disorder often are overweight and experience guilt, shame and distress leading to more binge-eating.
Obese people with binge-eating disorder often have coexisting psychological illnesses including anxiety, depression, and personality disorders.

45. Personality Disorders
Represent a pattern of behavior deviating from cultural norms but the individual perceives these patterns as appropriate affecting an about 9.1% of the population.
Antisocial Personality Disorder is a disregard for social rules and cultural norms, impulsive behavior, and indifference to the rights and feelings of others.
Avoidant Personality Disorder is characterized by extreme social inhibition, sensitivity to negative evaluation, and feelings of inadequacy.
Borderline Personality Disorder is a pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood.

46. Alzheimer's Disease
Affects an estimated 4.5 million Americans. Since 1980 the number of those affected has more than doubled.
It is the most common cause of dementia among people age 65 and older.
Increasing age is the greatest risk factor for Alzheimer’s. Usually symptoms first appear after age 65. One in 10 individuals over 65 and nearly half of those over 85 are affected. Rare, inherited forms of the disease can strike individuals as in their 30’s and 40’s.

47. Alzheimer's Disease
The disease is manifested by both the impaired ability to learn new or recall learned information and one or more of the following cognitive disturbances:
Aphasia (language disturbance)
Apraxia (impaired ability to carry out motor activities despite intact motor function)
Agnosia (failure to recognize or identify objects despite sensory function)
Disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)
People diagnosed with the disease survive about half as long as those of similar age without it.

48. Mental Disorders and Suicide
In 2008, 36,035 (approximately 12 per 100,000) people died by suicide in the U.S.
It is estimated the actual number of deaths by suicide exceeds the reported number by 5% to 25% (37,493 to 45,971 deaths for 2008).
More than 90 percent of people who kill themselves have a diagnosable mental disorder, most commonly a depressive disorder or a substance abuse disorder.
While a mental disorder is considered a risk factor in assessing suicide lethality not all persons affected by mental disorders are suicidal.

49. Signs of Mental Health Disorders Can Signal a Need for Help
A person is troubled by feeling:
Sad and hopeless for no reason, and these feelings do not go away.
Very angry most of the time and
crying a lot or overreacting to things.
Worthless or guilty often.
Anxious or worried often. 49

50. More Signs of Mental Health Disorders Can Signal a Need for Help
Unable to get over a loss or death
Extremely fearful or having unexplained fears
Constant concern about physical appearance or physical problems
Fear that their mind is out of control or being controlled 50

51. Clues can be changes, such as:
Declining performance at work or school.
Losing interest in things once enjoyed.
Experiencing unexplained changes in
sleeping or eating patterns.
Avoiding friends or family and wanting to
be alone all the time.
Daydreaming too much and not completing tasks.
Feeling life is too hard to handle.
Hearing voices that cannot be explained.
Experiencing suicidal thoughts. 51

52. If the person talks of experiencing
Poor concentration and is unable to think straight or make up their mind.
An inability to sit still or focus attention.
Worry about being harmed, hurting others, or doing something "bad".
A need to wash, clean things, or perform certain routines hundreds of times a day, in order to avoid an unsubstantiated danger.
Racing thoughts that are almost too fast to follow. 52

53. And … Persistent nightmares. Using alcohol or other drugs.
Eating large amounts of food and then purging, or abusing laxatives, to avoid weight gain.
Dieting and/or exercising obsessively.
Violating the rights of others or constantly breaking the law without regard for other people.
Setting fires.
Doing things that can be life threatening.
Killing animals. 53

54. So what does this mean to me and my work?
It is the stigma associated with mental illness that affects us in our interactions.
We tend to equate the individual with their illness. A person is not bipolar. They have bipolar disorder.
We sometimes assume a person with a mental health disorder will behave a certain way…the classic assumption being the person will be violent or dangerous because of their mental health diagnosis.
We have to overcome the many misconceptions, fears and biases people have about mental health. Our own and our consumers. 54

55. What is our role in working with people with mental illnesses?
Our role is to remember the
fundamentals we talked about today in an effort to overcome the stigma mental illness carries.
Listen actively to engage the person we
are interacting with
Be alert to the clues a person may need
help
Enable the person to recognize the
need for help and to empower them to know
that help is available AND effective! 55

56. Well that is all interesting but I do I&R…Unless someone asks me specifically for a mental health referral I can’t give them one.
Well we might think that is so but let’s look at the AIRS Standards For Professional Information and Referral And Quality Indicators…In particular Standard 4: Crisis Intervention.

57. Standard 4: Crisis Intervention
“The I&R service shall be prepared to assess and meet the immediate, short-term needs of inquirers who are experiencing a crisis and contact the I&R service for assistance. Included is assistance for individuals threatening suicide, homicide or assault; suicide survivors; victims of domestic abuse or other forms of violence, child abuse/neglect or elder/dependent adult abuse/neglect; sexual assault survivors; runaway youth; people experiencing a psychiatric emergency; chemically dependent people in crisis; survivors of a traumatic death; and others in distress.”

58. We started with a few questions…Anymore?