Perspectives - Vol. 5, No. 3 - Just One Mans PerspectiveThomas Cox, MS Updated: Jun 1st 2000 Neurotic people build castles in the sky,
Psychotic people live in them. That was an illustration used in my undergrad Abnormal Psychology class to distinguish between the two major types of mental illness. I can't say I was stigmatized by the illustration, but being a mental health professional for over 15 years, I have experienced stigma first hand. I hear it when my new client cautions me "I don't like talking to you people", or "Fred wouldn't come because he doesn't believe in you people". We'll save the discussion on "you people" for another time, but understandably I am sensitive to stigma, so it was with trepidation that I first began reading the Surgeon General's Report on Mental Health (SGR, 1999). I knew the Surgeon General (SG) had released the report, but I didn't feel compelled to read it until after I had read an article criticizing the SGR for further perpetuating stigma of mental health (Shulman, 2000). I was pleasantly surprised to find quite the contrary. I found the SGR to be a comprehensive, well balanced report that actually promotes itself as a tool to dispel stigma and myth associated with mental health, to make better informed consumers aware of available effective services. It provides a detailed history of mental illness as well as society's responses: From the etiology of much of the stigma, to societies efforts to provide mental health services. It explains the present system, existing services, problem areas, and recommendations for improvement, with lots of facts, figures, and statistics. The SGR envisions a bright future for mental health, and the benefits we can offer consumers. The mandate is clear, to realize our potential, stigma must be replaced by knowledge and understanding, and access and availability to services must be improved. Subsequently, I have read most of the SGR, portions many times, in great detail. You can't truly appreciate how long the SGR is until you're printing Chapter 2 off the internet, at the office, with your supervisor standing nearby, wanting to know why the printer won't stop printing. I view the SGR as a baseline, a detailed thumbnail of the current mental health system. For better or worse, it is the official consumer report on the Mental Health system as we enter this new millenium. I question how many consumers will ever read the SGR, or providers for that matter. It is not my purpose to summarize the entire report here, but instead I want to present a perspective: a response to the SGR's call for action. This new electronic medium allows for immediate, ongoing feedback, and that is what I seek. If I am missing the point please help me see more clearly. One Man's Perspective I have been providing mental health services since before I completed my Master in Counseling Psychology. I have worked in a variety of settings from Community Mental Health, to youth and family ministry, private practice, social service management, school services, and case management. I am presently a family therapist for a drug and alcohol treatment program. I have had an opportunity to experience many areas of our system in my quest to find my niche. As a mental health provider looking for a niche, I was thrilled with the overall message of the SGR: On the strength of these findings, the single, explicit recommendation of
the report is to seek help if you have a mental health problem or think
you have symptoms of a mental disorder. (SGR: Executive Summary) This was stressed because the SGR found that a majority of people with mental health problems do not seek treatment. In my experience that's a product of the biggest stigma that consumers hold: "Mental health services are for the mentally ill, and I'm not that bad". Identifiably, two major beliefs that perpetuate the stigma are; Mentally ill people are a violent threat to society, and/or they are simply morally weak people, who need to pull themselves up by their own bootstraps; "Stand up", "get over it", or "deal with it" are familiar refrains. They are also clear indicators of a lack of understanding, a stigma. The SGR differentiates between "Mental Illness" and "Mental Health Problems", identifying them as points on a continuum. Mental illness represents a diagnosable disorder, whereas, mental health problems are problems or symptoms of insufficient intensity or duration to meet criteria for a mental disorder diagnosis. Many people are not seeking help for mental health problems because they don't differentiate. As a result, in addition to a diminished quality of life, they also risk traveling along that continuum to more serious problems, dysfunction, or mental illness. Our task is to find an effective way of conveying that difference to our consumers. Consider this illustration: Mental Health Problems are as common as the cold. The common cold is something that everybody can relate to, everyone's had a cold. Sometime it goes away on its own, or you may use an over-the-counter medicine to address symptoms. If symptoms linger or get worse, you either continue to fight through it on your own, increase self medication efforts, or see your PCP for symptom relief. Your PCP tells you it's not a cold, it's the flu, you're then prescribed medication and given treatment recommendations. If you follow them it should improve in time. If you don't follow through, you stop taking the medication when you start feeling better, pull extra shifts, or work overtime to makeup for sick time, within a week your back feeling miserable. You go see the doc again and you get prescribed the same medication, with a more directed treatment recommendation. Or you may find out it's progressed to pneumonia requiring an even more intensive level of care. The cold, flu and pneumonia are all respiratory conditions. All three diminish your quality of life, but at distinctly different levels. You can catch a cold, the flu or pneumonia alone, it doesn't have to be progressive, and all three have specific, effective treatment protocols. How does this illustration relate to mental health? Consider the following comparison: Cold _______________________________FLU________________________________Pheumonia Mental Health Problems__________________________________________________Mental Illness Everyone has problems, issues or concerns. Sometime they go away on their own, or you take the effort to address them. Sometimes they linger and symptoms get worse, you continue to try to get through it on your own. When problems progress to the point that you go see someone, they have often reached the point that your willing to fight through any embarrassment or reluctance to divulge confidential information to a stranger. Now your seeking symptom relief. Upon evaluation it's found to be a more serious problem, issue or concern, it's become depression, or anxiety. Together with your mental health provider you develop a treatment plan with recommendations, if you follow them, it should improve in time. If you stop following the treatment recommendations when you start feeling better, pull extra shifts, or work overtime to makeup for sick or unproductive time, increase stress levels, return to negative behaviors or attitudes. Within weeks your back feeling miserable again. You go see whomever again, and you receive treatment recommendations, hopefully exploring the pattern of not following past treatment recommendations and the resulting consequences. The continuum includes levels where medication becomes appropriate, with an extreme that reaches a mental health equivalent of pneumonia, i.e., clinical depression, bipolar, schizophreniaetc. You can develop problems, issues or concerns; depression or anxiety; or bipolar or schizophrenia independently, they don't have to follow a continuum. All three diminish quality of life, but at distinctly, progressively different levels. Most importantly all three levels have specific, effective treatment protocols.
Does that make sense? Many may see this illustration as an aberration, an oversimplification of the complex processes involved in mental illness, and another example of Band-Aid therapy; Short term, problem-oriented therapy that doesn't address the underlying dynamics and unconscious forces. Please understand I am aware of those dynamics and forces, and I firmly believe there are times when a more long term, intensive treatment focusing on those aspects is appropriate. Very appropriate. By the same token I also believe that when problems, concerns or issues have reached a certain point, there can be a need for medical intervention to provide a balance. That ranges from short term use, to a lifetime of medication depending on the mental illness and the severity. Just like a lifetime of managing any illness. No trauma, no stigma, unless the consumers views people with medical conditions as weak, pitiful people. I realize that there are many points in the illustration that can be disputed. I'm trying to present a concept, an analogy that may help consumers better understand the distinction between having mental health problems, and being mentally ill. But more importantly I also want consumers to be aware that there is treatment at every stage along the continuum. The SGR identified a major barrier to people seeking treatment that has little to do with stigma but more with the reality that accessing mental health services is justifiably perceived as difficult to access; many not knowing where or when to access it. That was based on a study by Sussman, Robins, & Earls (1987), first reported over a decade ago. The same access problems exists as we enter the new millenium. As a beginning we can help consumers to differentiate between the common cold, the flu, and pneumonia. Next we'll address who provides what services for each. Many people suffer needlessly because they just don't know where to turn. Instead of making it easier to access the system, we perpetuate the confusion. The SGR was very clear that in order for the mental health field to achieve its potential we must improve public education of both mental health and available effective treatment. Changing perceptions is not an overnight process, but we must begin somewhere. I have presented one perspective, on one issue, a way to resolve one stigma. I'm not looking for a debate, the SGR is inclusive of most recognized traditional and nontraditional treatments that help consumers. I want to generate discussion, fruitful, constructive discussion, that begins building consensus that leads to action. After we discuss it what are we going to do about it? This forum, and our use of it, can provide a valuable public education tool to dispel stigma and create a mindset; A mindset that can replace existing stigma, and increase the consumers awareness of effective services. This electronic medium can provide the vehicle to spread the resulting mindset and potentially effect large scale change. What do you think? References Shulman, Richard (2000). The Surgeon General's New Clothes: How the press and the SG distort the truth about Mental Distress. [Online]. Perspectives. [2000, May ]. Surgeon General, (2000) Report on Mental Health, [Online]
Reference
Cox, Thomas (2000). One Man's Opinion. [Online]. Perspectives. [2000, July 1]. | 
