1. Navigating Mental Health
Discuss Programme Outline
Advise that in the handouts of the slide have also included section on Substance Use Disorders, deliberate self injury and Personality Disorders. Don’t have time to go through however can look at it when you have time
Handout Evaluation Questions
Ask them to rate whether they agree with statements or not and that we will be reviewing them at the end of the session

2. Rebecca Turpin
Edge Employment Solutions
(BA Psychology Honours)
Conditionally registered psychologist

3. 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.

4. 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.

5. 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)
Many highly intelligent creative and well functioning people who have enriched society have had periods of psychological disturbance

6. 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.

7. 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

8. Does infrequency define Abnormality?
If normality is what is typical then abnormality must be what is atypical or rare – right?
Yes and No. It is true that some of the disorders occur infrequently.
It is certainly true that if everyone had panic attacks then we might consider this experience to be normal.
Yet consider the following two rare qualities genius and sainthood?
Although only a few people like Albert Einstein or Mother Theresa or even Bernie Popuard may have ever possessed this quality, we do not consider their extraordinary intellectual ability as psychologically abnormal.
Therefore rarity can not serve as the sole basis for defining psychological abnormality.

9. Does Suffering Define Abnormality
If a person is miserable or feels persecuted or tormented by voices then there must be something psychologically abnormal about the persons life?
Indeed personal distress is one of the reasons that people define themselves as having a psychological problem and decide to seek treatment.
Yet distress alone is not a satisfactory criterion for defining abnormality.
Many persons who are considered mentally ill do not appear to suffer at all, such as an extremely euphoric manic person or a child molester who experiences no remorse

10. Does Strangeness Define Abnormality?
It is certainly true that seeing or hearing things that others do not may constitute what mental health professionals call a psychotic experience, however such experiences in and of themselves do not necessarily signal psychological abnormality.
Consider people who believe in ghosts, seeing deceased loved ones, or conversing with god. Rarely would any of these beliefs in themselves be considered abnormal or psychotic.
Conversely a great deal of what experts consider to be psychological abnormality is not at all strange or bizarre e.g. excessive fears, overwhelming sadness.
All of these conditions occur at least in mild forms , among the majority of people at some point.

11. Does the Behaviour Define Abnormality?
Some behaviour is so disgusting or shocking to human sensibilities that it might seem the behaviour is and of itself constitutes psychological abnormality.
But consider the act of murder. In most circumstances murder and mutilation represent abnormality and yet under conditions of combat such as WW1 and WW2 such acts are common and aggressiveness is expected and rewarded.
Thus the meaning of a behaviour depends on its context. Behaviours themselves cannot be judged abnormal apart from the situations and historical periods in which they occur.

12. Is normality a guideline?
Is psychological abnormality a departure from normality?
If we know how an ideal person is supposed to behave and feel, then deviations from such norms would help identify abnormality.
An auto mechanic knows how a car is supposed to run; when it doesn’t run right, the mechanic can generally find the defect and figure out how to repair it.
Unfortunately we do not have the same knowledge of human behaviour.
There are many theories, models and causes of human behaviour (e.g. psychodynamic, cognitive, behavioural, biological).
Arriving at a generally acceptable definition of abnormal behaviour is difficult as human beings are unique individuals.

13. 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.
An important factor to take into account also is the cultural context in which an individual comes from. When defining abnormal behaviour from the cultural point, attention is focused on the degree to which an individual deviates from cultural norms.
For example an individual who hallucinates will be defined as abnormal because most people do not hallucinate.
However it is relevant to note that what is normal in one culture may be abnormal in another culture e.g. in Aboriginal and Maori cultures hearing voices of deceased loved ones is considered a privileged experience.
Many people who are registered with DENS may not have a clear diagnosis or they may choose to use a more socially acceptable term such as nervous breakdown or stress condition to describe their disability.

14. 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.
As a general rule, people who come to an employment agency seeking assistance will have been advised of a diagnosis of their particular illness. Some people will agree with this diagnosis, and others will be questioning it. Either way, the impact of being labelled with one or other mental illness cannot be underestimated.

16. 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.

17. 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.

18. It is important to keep this in mind especially in today’s society in which medication is seen as the be all and end all to treating many mental illnesses. 18

19. 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.
Such a conflict occurred in the case of homosexuality.
For many years homosexuality was labelled as abnormal, however in 1987 the
panel of experts that prepares the DSM (Diagnostic and Statistical Manual) for
mental disorders reconsidered the issue and decided that homosexuality
should not be considered abnormal and was eliminated from the manual
completely. 19

20. David Rosenham’s study (1973)
Other criticisms have been made regarding the validity of diagnostic categories.
A researcher David Rosenham (1973) arranged for ‘pseudo patients’ (psychologists, physicians, a painter, a housewife and himself) to present themselves to psychiatric hospitals claiming to hear voices.
Apart from feigning this symptom and using false names and professions, the pseudo patients answered all questions honestly and made no attempt to appear abnormal. Nevertheless, nearly all were diagnosed “schizophrenic”.
Once they were admitted to a hospital, the pseudo patients task was to convince the medical staff that they were sane so they could be discharged. They stopped talking about their hallucinations and reported no symptoms. Nurses described the patients as friendly and cooperative. Yet pseudo patients spent 7 to 52 days in the hospital.
During that time not a singe one was unmasked by the hospital staff, because they could not tell the difference between real patients and those posing as patients.
After the last pseudo patient had been discharged, Rosenham informed the staff of one teaching hospital that sometime within a 3 month period that one or more pseudo patients would attempt to gain admission. He asked the hospital staff to try and guess the fake patients.
Forty-one of the 193 people admitted to the hospital during the 3-month period were alleged by staff with high confidence to be pseudo patients. This finding was embarrassing for the hospital as Rosenham had lied and had never sent any pseudo patients. 20

21. 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”.

22. 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.
Most often combinations of biological, behavioural and social factors best explain some of the mental health issues I will be discussing today.
It is both unhealthy and unproductive to attempt to diagnose you clients. 22

23. 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.
Biopsychosocial Model 23

24. 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).

25. Mental Status Indicators
Emotions
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.
Anxiety, Alcohol & Depression (Co-morbidity)
Anxiety
Often people will experience symptoms of both anxiety and depression. Some theories postulate that depression results from too much stress and anxiety.
Substance misuse
Also frequently occurs with depression and anxiety disorders. People may be trying to self medicate with alcohol to drown their sorrows or to chill out (relax). It is also now believed that ongoing alcohol misuse can cause depressive and anxiety disorders

26. What causes Depression
Depression has no single cause and often involves the interaction of many diverse biological, psychological and social factors
Distressing and uncontrollable events e.g. a break-up of a relationship, having a baby (post-natal depression), loss of job, having an accident which results in a long term disability, being a victim of crime,
Exposure to stressful life events – individual stressors often interact, resulting in additive effect
Persistent (ongoing) stress and anxiety
Illness which is life threatening, chronic or associated with pain
Recent childbirth
Some medical conditions (e.g. Parkinson’s Disease, dementia, stroke)
A side effect of some medications
Stress of having another mental illness
Pre-menstrual changes in hormone levels
Lack of exposure to bright light in winter (SAD)
Family history such as having a depressed family member
Having a previous episode of depression
Having a more sensitive emotional nature
Difficult childhood (e.g. abuse, neglect, abandonment)
Substance/drug misuse especially alcohol & tranquilisers
Chemical (neurotransmitter) imbalance

27. 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

28. 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

29. 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
The main symptom of generalized anxiety disorder is overwhelming, unfounded anxiety and worry (about things that may go wrong or one’s inability to cope) accompanied by multiple physical and psychological symptoms of anxiety or tension occurring more days than not, for at least 6 months.
People with GAD worry excessively about money, health, family & work, even when there are no signs of trouble. This anxiety appears difficult to control.
Physical symptoms include fast or pounding heart, headaches, stomach pains, tremors, muscle tensions, inability to relax, dizziness, sweating, dry mouth
Psychological symptoms include excessive worry, irritability, restlessness, feeling on edge, difficulty concentrating, mind going blank and sleep disturbances.
GAD can make it difficult for people to concentrate at work, function at home and generally get on with their lives.
A person with a panic disorder suffers from panic attacks and is afraid that a panic attack might occur
A panic attack is a sudden onset of intense apprehension, fear or terror. These attacks can begin suddenly and develop rapidly. This intense fear is inappropriate for the circumstances in which it is occurring.
The person experiencing a panic attack often feels there is impending doom or death. Many of the symptoms are physical ones such as dizziness, shaking, feeling sweaty, nausea, hyperventilating and rapid heartbeat. Many of the physical symptoms can appear similar to those of a heart attack.
One Canadian study has shown that one person out of 4 who goes to emergency for chest pains is having a panic attack.
Once a person has one of these attacks they often fear another attack and may avoid places where attacks have occurred.
People may also avoid exercise or other activities that may produce physical sensations similar to those if a panic attack.
A person with a phobia avoids or restricts activities because of fear. This fear appears persistent, excessive and unreasonable.
They may have an unreasonably strong fear of specific places or events and often avoid these situations completely. Commonly feared situations include leaving home, crowds, or public places, open spaces, speaking in public, travelling in buses, trains, planes, and social events
The following constitute phobic disorders:
Some people who suffer reoccurring panic attacks progressively develop a fear of going back to the places or repeating the activities associated of an attack, they avoid places and situations that would be hard to get out of quickly in the event of an attack, and adopt safe behaviours close to home.
When this type of fear and avoidance is present the panic disorder is complicated by agoraphobia, so contrary to popular belief agoraphobia is not simply a fear of open spaces.
Involves avoidance of situations because of the fear of a panic attack occurring. Some people avoid leaving their home for fear of a panic attack occurring. Other people avoid certain situations (for example shops, driving in a car) where a panic attack has occurred.
Is the fear of any situation where public scrutiny may be possible, usually with the fear of behaving in a way that is embarrassing or humiliating.
The key fear is that others will think badly of the person.
Example fear of spiders or fear of heights. Because they only involve specific situations, these phobias are less disabling than agoraphobia and social phobia.
Acute stress disorder and PTSD occur after a distressing or catastrophic event. This event may involve actual or threatened death, or serious injury. Alternatively it may involve witnessing such an event or learning about such an experience of a family member or close friend
In acute stress disorder the person gets over the event within a month, whereas in PTSD the distress lasts longer.
A person is more likely to develop PTSD if their response to the traumatic event involved intense fear, helplessness or horror. A study of Vietnam war veterans exposed to the traumatic events of war found that 20% of them developed PTSD
A major symptom is re-experiencing the trauma. This may be in the form of recurrent dreams of the event, flashbacks, intrusive memories or unrest in situations that bring back memories of the original trauma.
There is avoidance behaviour such as persistent avoidance of stimuli associated with the event, emotional numbing, which may continue for months or years, or reduced interest in others and the outside world.
Also persistent symptoms of increased arousal occur (hypervigilence, irritability, exaggerated startle response, outbursts of rage, insomnia).
This form of anxiety disorder is the least common however is extremely disabling.
Obsessional thoughts and compulsive behaviours accompany the feelings of anxiety. Obsessional thoughts are recurrent thoughts, impulses or images that are experienced as intrusive unwanted and inappropriate and that cause marked anxiety e.g. fears of contamination or harm

30. 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
Some people develop ways of reducing their anxiety that cause further problems.
For example, people with phobias avoid anxiety provoking situations.
This avoidance reduces their anxiety in the short term but can limit their lives in important ways.
Similarly people with compulsions reduce their anxiety by repetitive acts such as checking or washing hands.
The compulsions then become problems in themselves.

31. PSYCHOSIS What 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.
Like a lot of other medical terms the term psychosis has its origin in two Greek words psych meaning the mind and osis meaning a state of illness. 31

32. 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. 32

33. 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.

34. 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.
E.g. someone may be convinced by the way cars are parked outside their house that they are being watched by ASIO. Another person might be on a train and see a newspaper being folded by another passenger, and would suddenly know that this is a sign they have been chosen to give birth to a new Christ 34

35. 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
Delusions can lead to bizarre behaviour. Someone who seriously believes he’s being watched by aliens may stay up all night and become very secretive. Another person who’s convinced she’s on a mission to God to lead people into the Chosen Land may stop passers –by to recruit them and this could put her at great risk
For some people delusions may be quite harmless and even a source of comfort. For others though they can be serious and lead them into dangerous situations. Someone who feels constantly persecuted for example may become suicidal 35

36. 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.
The hallucinations can be very frightening, especially voices saying negative comments about the person. Because their delusions and hallucinations are so real for them, it is common for people with schizophrenia to be unaware they are ill.
The voices people hear can mock the person, be abusive or may be amusing. They may tell you to do certain things, comment (often critically) on what you are doing, or repeat your thoughts aloud. People often shout at their voices or giggle at the funny remarks they can hear. 36

37. 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.
Interestingly, a series of studies by our group and others has shown that during hallucinations there are regions of the brain that become active.
And those regions commonly involve the regions of the brain, the temporal lobe, that are associated with the processing of normal sounds.
So it's as if the brain is being tricked, or the person is being tricked into believing that these voices are actually occurring because there's spontaneous activation of these hearing regions of the brain. 37

38. Thinking Difficulties
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. 38

39. 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.
This means that all too often people withdraw form family, friends, workmates or neighbours. They may become very lethargic and sit around all day watching television. Everyday things like getting up in the morning, showering and doing the dishes may seem impossible.
This is very often a cause of irritation and distress to others. While encouraging someone to get up and do something we always need to keep in mind that this behaviour is due to the illness and not to laziness or lack of effort. 39

40. 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. 40

41. Bipolar Disorder
People 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 usual
The person can go for days with little sleep
Irritability
This may occur if others disagree with a manic persons unrealistic plans or ideas
Rapid thinking and speech
The person may talk too much, too fast, and keep changing topics
Lack of inhibitions
The person may disregard risks, spend money extravagantly or be very sexually active
Grandiose delusions
These involve very inflated self esteem such as a belief that the person is superhuman, especially talented, or an important religious figure
Lack of insight
The person is so convinced that their manic delusions are real that they do not realise they are ill 41

42. Schizoaffective Disorder
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. 42

43. The jigsaw – you, your client and the system
How do DEN’s support people through a crisis and when should a client be referred to external support services

44. 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.
A crisis is a situation when a person feels completely overwhelmed or defeated by the problems they are facing. What one person may see as a crisis would not necessarily be regarded as a crisis by someone else. Thus the definition of a crisis is based on the persons view of their situation and on how the situation has affected their ability to cope with the problems.

45. 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 warm, respectful and matter of fact. Don’t patronise the person – they are not a child or stupid. Even in a crisis, most people can process information
The situation varies from one individual to another. The person may be experiencing great or overwhelming fear, panic or anger. They may be experiencing hallucinations such as hearing voices, may be feeling fragmented or a loss of sense of reality.
Recognise that the experience is real for this person at this time and that they may have difficulty paying attention to you. Speak clearly, gently and calmly. Listen attentively.
Keep sentences short: stick to one thing at a time. Wait for a reply before moving on to the next thing. Check that they are following what you are saying. Tell the person if you don’t understand and help them to communicate so that you do understand.

46. 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.
Be honest but not argumentative. Say that you see things differently and encourage the person to check it out with someone they trust. Don’t agree with the implausible perceptions; this can cause greater distress later.
It can be useful to ask the person what they want right now (what would make them feel safe) in terms of physical distance/closeness to you, talking or silence, being alone or wanting someone with them, eating drinking, warmth and or/rest.
Ask about friends, relatives, therapists or psychiatrists and ring them, with the clients permission. Ask about accommodation tonight.
If the person is doing things which annoy or anger you ask them firmly to stop. Tell them how it is affecting you. Be flexible but don’t wait until you explode. Be specific about what you do not want to tolerate.
Don’t make generalised criticisms. If the persons behaviour is very noisy or demanding, stay calm, try to clarify what the person wants and try to limit distractions.

47. 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,
Remember that the person may be feeling confused, frightened or angry because of the way they are currently experiencing their situation (Don’t take it personally).
Remember that not everyone who experiences active symptoms of mental illness will be in a state of crisis, as many people learn management strategies e.g. people with schizophrenia may learn strategies to cope with their voices and become fully functional at work.
I will talk about two crisis situaitons in more detail Suicide and psychosis

48. 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

49. A number of suicide risk assessment tools have been devised.

50. The SAD person’s risk assessment TOOL
Depression is a major risk factor for suicide, but there are others as listed below (
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

51. 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

52. The presence of Warning Signs
Myth: People who commit suicide always give off some kind of clear warning sign or call for help
In fact there may be times when a person does not exhibit warning signs and there certainly have been cases in the media recently of people who have committed suicide without exhibiting warning signs. However there are a few signs which you might want to keep in the back of your mind when faced with a client who has expressed suicidal ideation.

53. 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
If you think someone may be at risk, ask the following question directly: “Are you thinking of killing yourself?” “Are you planning suicide?”
Take seriously any communication of distress. If you believe the person is at risk of harming themselves, seek professional help immediately.

54. What to do immediately Ask 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
An individual can assist a person to do this initially by
(1) to do all they can to keep the client alive long enough for this stable state to be achieved and referrals to be processed
Be aware that Clients are responsible for their own behaviour, and they may choose to commit suicide.

55. 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
People who are psychotic are at an increased risk of suicide this is important to also recognise
I will be providing a list of crisis numbers at the end of this seminar

57. 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 the
best 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.

58. The person who threatens or attempts suicide again and again…
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.
This help may take the form of counselling with the aim getting the person to react to unhappy events by means other than attempting suicide. The best way of helping them is referring to a counselling/psychiatric program to build up a trusting relationship so that, when upset or unhappy they can talk to a counsellor or psychologist rather than try to kill themselves.
Antidepressants, CBT and ECT have been found to be the most
However it is generally well recognised in the psychology profession that a combination of medication and psychotherapy is the most useful treatment strategy
Treatments for Depression

59. 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 development and maintenance of strong links with other service providers is also an important ingredient. Without active links, limited resources are utilised on non-employment activities and ongoing support. Without strong links a small agency can very rapidly become overwhelms by extra-ordinary demands. Through strong links referrals, resources, and information are exchanged. Those links provide support options for consumers and minimise their inappropriate and impossible involvement of employment service staff in general support activities
Graffam, J & Naccarella L. (1995)

60. 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

61. 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.
In this way you are resourcing the client whilst maintaining boundaries and encouraging independence.

62. 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

63. 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.
Counsellors and psychologists vary a lot in their training and in their experience of helping people with depression. 63

64. 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.

65. 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.
For example, the person might be concerned about finances, or about not having a doctor they like, or they might be worried they will be sent to hospital. These reasons may be based on mistaken beliefs, or you may be able to help the person overcome their worry about seeking help.
Then crisis emergency teams can be contacted and no confidentiality applies due to duty of care

66. Psychiatric Treatment
Admission 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.

67. 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
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 Encourge your client to disucss their decision with people they admire and trust – their partner, family, psychiatrist, doctore and rehabilitation consultant

68. 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.

69. 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.
The negotiation could take place as part of a discussion about triggers/stressors that may be associated with episode of illness.
A clear arrangement for dealing with crises provides something of a safety net for all concerned as the client encounters challenges associated with taking up employment again for the first time.

70. 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.
Speaking to the treating medical person about the intensity of therapy or review of medication

71. 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.
If you feel that your client is becoming overly dependent upon you (perhaps calling you several times per day, or asking you to make decisions about mtters such as job choice or assist with personal decisions) a number of strategies should be considered indlucing:

72. Discuss the issue with your client
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.

73. 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
Although work in mental health can serve as one of the most personally rewarding of professions, it can lead to burnout, e.g. long hours, 24 hour availability in emergencies. An acceptance of slow and sporadic progress, long periods of intense mental concentration. Should also consider the real possibility that a patient under their care may attempt or successfully commit suicide.
Myths
If I cam a good therapist I can help or save everyone – Such rescue fantasies literally can cripple otherwise competent therapists. Patients may have already have predetermined plans to commit suicide or engage in violent behaviour, and no therapist could prevent or predict behaviour. (How mabny times have we told clients about this and ignored it ourselves)
Because I am so aware of my own issues as a therapist, it is ok if I stretch the patient-therapist boundaries once in a while. The desire to violate patient-therapist boundaries can be strong, particularly in face of certain types of psychopathology.
There are a number of general staff support mechanisms that can be implemented by agencies to assist staff in preventing burnout.
Formal case reviews, to provide support relating to specific clients
Professional supervision
Employee Assistance Programs (Usually involve 6-8 sessions that are solution or outcome focussed, generally resulting in an individualised work stress management plan. If the particular issues are not resolved within this time period, EAP counsellors will often provide referrals to other appropriate services that are able to provide more long term care.
The agency response to critical incidents should be considered. High level stressors such as the suicide of a client, assault of a worker and other major incidents require immediate intervention in order to support the staff involved in both short and long term.

74. Discussion Contact Details rebecca.turpin@edge.org.au
Get People to look at their rating sheet they completed at the beginning of the presentation and see whether their answers have now changed.
Remind of the Psychological and Counselling Resource Files and the one kept in my locker that’s locked up