1. Self-Represented Litigants & Mental Disorders: The Legal System as an Agent of Healing The State-wide Conference on Self-Represented Litigants Friday March 17, 2006, San Francisco, California Lynn E. O’Connor, Ph.D. Darryl Inaba, Pharm.D Judith Hirsch, Psy.D.

2. Agenda:Agenda: The current crisis in medicine and mental health  Stigma and its effects  Clients/Customers who suffer from mental illnesses  The “difficult” customer  The “dangerous” customer  The “disorganized” customer  Major mental disorders are brain diseases  Disorders: Brief Overview  Mood Disorders:  Depression  Bipolar I & II  Anxiety Disorders (OCD)  Psychotic Disorders: Schizophrenia  Summary: The Take Home Message

3. A Crisis in Mental Health Care… Self-help Centers functioning in context of collapsing medical system Jails and prisons filled with the mentally ill who should be in treatment centers 80% to 90% are incarcerated directly or indirectly because of substance abuse Social and economic factors are contributing to rise of mental illness -- the prevalence of disorders rising Funding for research and treatment of mental illness is rapidly disappearing

4. Mental Disorders Share: STIGMA Mental Illness brings to sufferers and their families the dark cloud of STIGMA Blaming Guilt-inducing Shaming Lowering of status & social ranking “Secrets” even within the family Living with stigma may sometimes be as devastating as symptoms of the illness People avoiding the “mentally ill” Can’t get work People showing “fear” McGuire’s vervet monkeys

5. Stigma is always present… Those with mental illnesses and their families are stigmatized Despite the fact that: THERE IS MENTAL ILLNESS IN EVERY FAMILY It may be hidden A source of secrecy and shame But it is there

6. Effects of Stigma on Mental Health Professionals: A Case Study 170+ mental health professionals questioned about their own use of psychotherapy and medications (Godfredsen, 2004) 56% CURRENTLY using psychoactive medications Same rates in all professions: psychiatrists, psychologists, family counselors, social workers While many freely disclose use of psychotherapy to fellow professionals Few disclose their use of psychoactive medication 30% hid medication use from spouses Almost no one told their supervisors or fellow professionals And yet, this group is treating the “mentally ill” Saying “there is “nothing to feel ashamed of” “Nothing to feel guilty about” Don’t self-disclose because fear of harming their families

7. Clients, Patients, & Customers with Mental Illnesses: They live with the stigma of mental illness Are worried most of all about their families and loved ones, often without conscious awareness Shame and guilt embedded in stigma Shame about the self is secondary, and relates to: The fear of shaming or otherwise harming the family and loved ones Stigma prevents people from getting help Stigma depletes the sense of self-worth and confidence An Example: Our soldiers in Iraq are suffering from psychological problems at in escalating numbers The suicide rate is alarming Avoid getting help, because they are afraid of being stigmatized, and harming their families

8. Working with Self-litigating Customers with Mental Disorders: Customers frightened Used to being stigmatized Feel undeserving, feel toxic to others Professionals motivated to help Motivated by altruism Feel sorry for customers Feel survivor guilt, often below the surface The story of survivor guilt How it effects us Every day feeling, out of awareness May be defended against by anger, frustration, blaming the victim

9. New Paradigm of Human Nature: Its been assumed people are “self- centered” A review of cognitive neuroscience & our own research on depression and other problems supports a new paradigm of the mind, The new and highly social “non-conscious” People non-consciously driven to hold group and family together Non-conscious mind is organized, organizing, and prosocial towards the “ingroup”

10. The New Paradigm: Our Altruistic Human Nature Empathy: The Neural System Built on Mirror Neurons Highly developed neural system of empathy Built upon “mirror neurons” We feel others’ pain, seen in the brain And they feel ours Infants at 43 minutes imitate Babies (and chimps) trying to help Crying at other babies cries New research on helping In contrast to older theories, people profoundly “other-focused” Always worried about harming others, loved ones, families People who suffer from mental disorders also primarily “other-focused” Exceptions are rare: the true “psychopath”

11. Working with Mentally Ill Customers Difficult to manage the feelings of guilt at being better off than person you are helping People come for help, wanting to “get better” and to overcome their problems Unconscious plan for how to use their time with helpers In therapy, clients often test the therapist  Want to change beliefs, feeling they are harmful  Overly responsible, paralyzed with guilt Want to pursue normal goals in life Use the therapist to change They also use others who are helpers, for example people in the legal system

12. Problems in Helping: Customers who are “difficult” “You aren’t really helping me” “You don’t care at all, I’m just a number” “If I don’t get help soon -- you know I have a temper” “Nothing you’ve suggested has worked out at all” These are intended to make you feel responsible, and like a failure Imitation of what they felt in their families, and in life

13. The Difficult Customer: The difficult customer The person who you can’t please enough These are “tests” of the helper Call them “omnipotent responsibility tests” Intended to make you feel --briefly-- responsible, and like a failure Imitation of what she/he felt in family and in life, overly responsible, guilty Wants the helper to “BE DIFFERENT” To feel strong and helpful anyway, despite feelings of guilt, or shame, or fear To provide a model of another way of reacting  To the problems and stresses life presents  To feeling responsible for others

14. Customers who are Frightening: Pay attention to your feelings If frightened It might be a “test” If might be the person is going out of control with fear/guilt/anger It might be impulse control problem Brain damage from being beaten Drug effect DON’T TAKE A RISK Play it safe Take care of yourself first and foremost This is always most helpful

15. Disorganized Customers: Often biological reason Battered women study found over 85% suffered (at least) mild traumatic brain injury (Mercontoni, 2003) Symptoms of TBI include confusion Disorganization Failure at Planning Don’t make appointments, lose papers Recovering addicts may have similar problem Can’t make plans Don’t show up Disorganized and confused Get no help, no recognition of the problem Others may have ADD, ADHD, since childhood, unrecognized, felt like failures, never treated THINK BIOLOGY ALWAYS, FIRST AND FOREMOST

16. Common Mental Disorders Mood Disorders Unipolar Depression Bipolar I & II Mood Disorder So-called “Personality Disorders” may be milder versions of same (I.e., a person who is diagnosed with “borderline personality may in fact suffer from Bipolar II, depressive type Anxiety Disorders OCD, PTSD, Generalized Anxiety Psychotic Disorders Schizophrenia, Schizoaffective Substance Abuse Disorders Drug effects Addiction Withdrawal

17. Problems in Diagnosis Reisberg, Lecture in Psychiatry Hypomania?Depression?Schizophrenia? EuphoriaApathyEmotional bluntness RestlessnessInertiaUnconcern about own person/ personal hygiene ImpulsivityUnconcernMuteness Depressiveness

18. thosethose Copyright (c) Houghton Mifflin Company. All rights reserved. Unipolar Depressive Disorders Bipolar Disorders Psychotic Features? Single Episode or Recurrent? Melancholic Features? Seasonal Pattern? Major Depressive Disorder Dysthymic Disorder Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder Recurrent Major Depressive Episodes with Hypomania Mood Disorders Mood Disorders Single Manic Episode Most Recent Episode Hypomanic Most Recent Episode Manic Most Recent Episode Mixed Most Recent Episode Depressed Most Recent Episode Unspecified

19. Mood Disorders

20. From Current Online Research (O’Connor, Lewis & Berry, 20050

21. Cost of Mood Disorders Epidemic in countries using the greatest per capita resources, (in form of energy) These countries also have the lowest birth rates How do we explain this? Type of disabilityCost (in DALYs) Unipolar major depression 42,972 Tuberculosis19,673 Road traffic accidents19,625 Alcohol use14,848 Self-inflicted injuries14,645 Manic-depressive illness 13,189 War13,134

22. Why the Epidemic of Mood Disorders? Depression = Neuronal Death In hippocampus, in prefrontal cortex Shrinkage is visible Is depression sign of “Nature Deficiency?” Wired for hunter-gather life-style Today: Little exercise Poor Western diet Less than optimal social activity, connection BDNF (Brain-derived neurotrophic factor Most of us have the “low BDNF” alleles “high Neuroticism” alleles, V 66 /V 66 or V 66 /Met Met is new Higher levels of BDNF if Met/Met allele

23. Older Theory of SSRI Treatment: Low Serotonin

24. From Current Online Research O’Connor, L., Berry, J.W., & Lewis, T. (2005). Emotions & Personality, www.eparg.org

25. New Theories of SSRI Treatment SSRIs, MAO Inhibitors, Mood Stabilizers, ECT, Exercise, Diet: All function by turning on genes that begin a chain of events Leading to increased BDNF, a protein that produces new neurons NEUROGENESIS

26. Bipolar I & II Disorder It affects 1-3% of population About half untreated Abnormalities in: Brain biochemistry Structure or activity of certain brain circuits Both Serotonin & Dopamine “deficit” Results in: Extreme shifts in mood, energy and functioning Untreated bipolar illness results in suicide 10 to 15 percent commit suicide

27. Genetics of Mood Disorders FROM: Emily Pollard Identical twin bipolar: % chance of bipolar 75% chance depression 1 st degree relative (child, parent, sibling) bipolar : 8% chance bipolar 10% chance depression Two parents bipolar 30-75% chance bipolar 2 nd degree relative (aunt, uncle, cousin, grandparent) bipolar: 1% chance bipolar 5% chance depression No relatives bipolar 1% chance of bipolar 5% chance of depression 50-60

28. Mood Disorders in One Family Emily Pollard

29. Bipolar Genes: Positive & Negative GENEGENE EFFECT SMALL AMOUNT TOO MUCH AConnect unrelated ideas CreativityTangential, disorganized BSeek noveltyFascinated by change, curious Jumping from project to project CBe aware of others' opinions Socially polishedAnxious, suspicious, paranoid DHigh energy levelVery productiveCan't stop, slow down Racing thoughts Unable to focus Scattered activity ETake risksCourageousBad judgment about harm

30. Obsessive Compulsive Disorder Brain imaging shows increased activity within the frontal lobes, basal ganglia, and cingulated area of the brain. The main pathway involved in OCD patients (shown at right) indicates a miscommunication within the cortical-limbic-basal ganglia-thalamic circuit (Epstein 1995, p.136). With all this combined, the receiving, gathering, and processing of information in an OCD patient is inadequate essentially causing the behaviour rituals to continue to loop (Epstein 1995, p.137). Abnormal output from cognitive/ emotional sensory processing areas of the brain may cause compulsions (Nigg, 1994). Leucotomy operations target the detachment of the orbital and frontal cortex from the limbic circuit. Seventy-five percent of the seventeen cases reported decreasing anxiety and obsessions (Nigg, 1994).

31. OCD & Neurotransmitter Hypothesis On the left: Normal functions, serotonin through synapse On the right, OCD functioning -- far less serotonin passing through synapse Serotonin hypothesis Treat with Selective Serotonin Reuptake Blockers Our research shows some evidence that Dopamine may also be low though not as dramatically Co-morbidity with Bipolar “ocd.jpg ” “normal.jpg”

32. Obsessive Compulsive Disorder Pople with OCD use different brain circuitry in performing a cognitive task than people without the disorder ( ocd2.jpg)

33. Schizophrenia was once thought to be “caused” by the “schizophrenogenic mother”. This false belief lingers on… Schizophrenics have visible anatomical changes Loss of gray matter of brain (up to 25%) Enlarged ventricles Temporal and frontal lobes Same changes in people who have been treated, and those who haven’t Laboratory of Neuro Imaging, UCLA,

34. Although a heritable brain disease, with visible anatomical changes, it is not hopeless.

35. Cognitive and psychological abnormalities associated with anatomical changes Symptoms include: Cognitive deficits Executive function Short term memory Declarative memory Motor ability Hallucinations Delusions Bizarre thoughts Hearing voices Depression Flat affect Schizophrenic patients experience emotions as we do, but don’t express them normally.

36. Schizophrenia affects 1% of the population everywhere suggesting a positive function Brain shrinkage twice as fast as normal Normal process accelerated? There is some evidence damage occurs near to birth, before or after Schizophrenia is heritable Not due to the family, although it effects the family profoundly Like autism was believed to be the falt of the “iceberg” mother,

37. Grey matter loss in adolescents with schizophrenia. Warmer colors denote regions with the most significant losses © 2001 National Academy of Sciences, USA

38. Schizophenia & Bipolar may be Related When Seen on a Continuum

39. Schizophrenia & Bipolar May be Related:When Seen on a Continuum Continued

40. Phenomenological Approach

41. The “Odd” or “Difficult” Clients who are often Diagnosed as “Personality Disordered”: May be suffering from an Axis I, clinical disorder, I.e., a milder form of brain disease.

42. Copyright (c) Houghton Mifflin Company. All rights reserved. Unipolar Depressive Disorders Bipolar Disorders Psychotic Features? Single Episode or Recurrent? Melancholic Features? Seasonal Pattern? Major Depressive Disorder Dysthymic Disorder Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder Recurrent Major Depressive Episodes with Hypomania Mood Disorders Mood Disorders Single Manic Episode Most Recent Episode Hypomanic Most Recent Episode Manic Most Recent Episode Mixed Most Recent Episode Depressed Most Recent Episode Unspecified

43. Bipolar Disorder I & II Often misdiagnosed as “major (unipolar) depression” Wrong medications (e.g. SSRIs may set off manic episode Explains suicidal ideation associated with SSRIs (wrong diagnosis, not the drug per se) Bipolar I more severe in manic states, maybe be psychotic Bipolar II less “manic” or hypomanic Demonstrating symptoms of severe depression Suicide rate high iBipolar II, depressive type.

44. Mental Disorders: A Summary: Chronic Relapsing Disabling Stigmatized Frightening to person with disorder, to families, and friends Isolating Misunderstood Many are highly treatable Mental Disorders are Brain Diseases Complex polygenetic diseases Environmental factors With huge psychological ramifications

45. The Burden on the Legal System The Burden on the Legal System Staff of prisons, county and state jails, courts, self-help centers, and depleted community mental health agencies: Taking care of chronically mentally ill Taking care of drug addicted populations Taking care of those without resources What belongs in forensics, and what belongs in the realm of “the mental health clinic”? What to do with people who are in trouble, needing help, far beyond what the court has done traditionally Legal system has become the front line of mental health treatment

46. To Take Home: To Remember (1): Many of your customers have some form of severe, diagnosable, and treatable mental disorder Mood disorders Anxiety disorders “Personality disorders” Substance abuse disorders Psychotic disorders Most severe mental disorders are biological (genetic, neurotoxins etc.) in etiology, and in “basic nature” Most mental disorders are treatable with a combination of medication and psychotherapy Many of your customers need medication and psychotherapy Although mental disorder may be biological in origin Severe psychological ramifications: History of failures Poor social relationships Effects of stigmatization.

47. More To Take Home: To Remember (2): Your customers often treat you as “psychotherapists They suffer from pathogenic beliefs Pathogenic beliefs from family of origin Pathogenic beliefs from suffering from mental disorder They test you in order to change pathogenic beliefs, to overcome their problems They test you much as they test their therapists (when available) Test you by: 1) Acting as if you were the parent Doing TO you what they did to their parents that they believe caused their parents to behave in ways that deeply upset or even traumatized them 2) Imitating their parents Doing TO you what their parents did TO them, that was deeply upsetting or traumatizing

48. More To Take Home, To Remember (3): When customers are testing you By treating you as a parent For example acting as if you and you alone can “save them” Acting unrealistically “needy” By imitating a parent For example, throwing temper tantrums You need to: Remain calm Remain accepting Refuse to accept omnipotent responsibility for customer

49. More to Take Home, to Remember (4): This provides: A new “model” of how to be in the world How to be when they are faced with difficult people How to be when faced internally with memory of traumatizing parent And finally: Always pay attention to your own feelings This is how you know how your customer is testing you This informs you of how you should respond

50. More to Take Home, to Remember (5): Trust your feelings Trust your motivations Your “non-conscious” mind Is fundamentally altruistic Including when when you believe you are being “selfish” Is engaged in information processing What seems like magical “intuition” Is a manifestation of your highly adaptive and social non-conscious Your own responses, feelings Will not fail you Are like a guide book to what is going on

51. More to Take Home, to Remember (6): Whenever possible When working with difficult customers Talk to colleagues (in your office etc.)  To brain storm  To problem solve  To get support  To develop strategies of how to best respond  To work together instead of working in isolation You are working in difficult conditions, with very vulnerable and difficult customers

52. More to Take Home, to Remember (7): Because the people you are serving May often be difficult Present multiple problems If possible: Discuss setting up a regularly scheduled “support group” or group consultation for your office Discuss getting a consultant for your office If no one available locally, do it by conference calls In setting up consultation, once again trust your feelings If a “helper” or consultant makes you feel inadequate, guilty, angry, or ashamed, do not use that person as a consultant You help the most disadvantaged, stigmatized, and mistreated populations Therefore your job is very difficult You deserve all the support possible

53. More to Take Home, to Remember (8): Those working in the self-litigating court system deserve a thank you from those of us who benefit directly and indirectly from the work you do, on a daily basis To conclude: We thank you, lawyers, office workers, paralegal professionals, judges, and all the other court workers who are taking “legal care”of those who suffer from mental disorders and who by necessity are representing themselves, with your help, in our courts

54. Self-Represented Litigants & Mental Disorders : The Legal System as an Agent of Healing Self-Represented Litigants & Mental Disorders : The Legal System as an Agent of Healing The State-wide Conference on Self-Represented Litigants Friday March 17, 2006, San Francisco, California Lynn E. O’Connor, Ph.D. Professor, The Wright Institute Associate Clinical Professor, UC Berkeley Emotion, Personality & Altruism Research Group (EPARG): Emotion, Personality & Altruism Research Group (EPARG): www.eparg.orgwww.eparg.org Research, Evaluation, Assessment & Supervision, & Psychotherapy Consultation E-Mail: lynnoc@aol.comlynnoc@aol.com Phone: (415) 821-4760 California Psych Lic 13759,