Serious About Serious Series: What Every Mental Health Provider Should Know About Serious Mental Illness

This is the second of a series of posts on Serious Mental Illness, “Serious About Serious Series: What Every ____ Should Know About Serious Mental Illness”. In case you missed it, here’s the link to my first post on What Every Pastor Should Know About Serious Mental Illness.

Herein, I address Serious Mental Illness (SMI) in the context of the broken menagerie of the US Mental Healthcare system.

Mental healthcare professionals are next to those on the frontlines for these kinds of issues. It is crucial to educate those who serve the mentally ill population so that they are able to treat their clients better.

Mental health providers (MHPs) usually have extensive training to deal with those with SMI/SBDs (Serious Brain Disorders) in these situations. But I find that there are also gaps in knowledge of what might be hard to communicate from someone in the throes of an episode.

Especially in the wake of Covid’s circumstances, the matters of the mind have risen to a more visible level. This is good for generating awareness of mental health and education. However, it has not changed the significance nor moved the needle of treatment for those with SMI/SBDs. These are matters that a qualified MHP may even need to brush up on, or be newly introduced to.

What is Serious Mental Illness?

As I stated in my first post of this series, Serious Mental Illness (SMI) is not the same thing as mental health. Mental health conditions can be SMI, but not all of them are. The most vulnerable, most severe cases are ‘Serious’ in name and nature. These need to be addressed and distinguished differently from milder “mental health” cases.

Schizophrenia, schizo-affective disorder, bipolar disorder, major depressive disorder and any other mood disorder with psychotic features are serious brain illnesses, or SBDs. The brain with an SMI is at risk of actually having neurological damage done to it. This can eventually cause them to regress in cognition to the potential degree of not even realizing they’re sick.

Depending on their diagnosis, different symptoms present during episodes. I’m framing these descriptions within the context of clinician-based misconceptions and will then suggest medically appropriate solutions. These are descriptions of someone with an untreated condition. Those who are treated with medication and therapy are typically stable.

What are misconceptions of those with SMI?

Treatment Resistance:

The person with SMI is not consistent with their treatment plan because they can’t help themselves. So much of our mental healthcare system is broken, but that doesn’t have to be the case. In multiple states, there are programs that work for those who are suffering with SMI/SBDs to avert their behaviors and tendencies to fall through the cracks of care. Those coming out of the inpatient hospitalizations who are admitted into programs like AOT (Assisted Outpatient Treatment) and CCBHCs (Certified Community Behavioral Health Clinics) can enter a routine level of care on outpatient status. Since AOT can be directed by a court-order from a judge, the person with SMI is more likely to adhere to the requirements for treatment plan. This has proven a high success rate by the following numbers according to MentalIllnessPolicy.org

• AOT – Helps the mentally ill by reducing homelessness (74%); suicide attempts (55%); and substance abuse (48%)
• Keeps the public safer by reducing physical harm to others (47%) and property destruction (46%)
• Saves money by reducing hospitalization (77%); arrests (83%); and incarceration (87%)

Read more at: https://mentalillnesspolicy.org/aot/overview.html% in multiple states that employ the program.

Anosognosia:

About half of those with these diagnoses are unrecognizable persons to ourselves and others because of a lack of insight. This is not denial. Anosognosia, a symptom of the illness itself, can be debilitating and is often the main reason why so many people with SMI are incarcerated, homeless, or dead. As a case manager employed by a behavioral outpatient clinic for three years, I’m surprised by how many other colleagues were not educated about this condition. It’s a sad reality that so many with schizophrenia and bipolar disorder are subject to this absence of awareness to realize they’re sick. This must be communicated to MHPs in the base-level curriculum in education and training.

HIPAA Interference:

HIPAA laws protect personal health information, but if we treated SMI/SBDs like we treat those in care for dementia conditions, we would respond in their best interest and for their wellbeing. We need to legally and legislatively loosen the handcuffs that HIPAA unjustly restrains families and loved ones from leveraging their help. 

Read more at: https://mentalillnesspolicy.org/national-studies/how-hipaa-prevents-seriously-mentally-ill-from-getting-good-care-and-what-to-do-about-it-pdf.html

Trappings of Talk Therapy:

Utilizing talk therapy with those with SMI/SBDs like cognitive behavioral therapy and dialectical behavioral therapy is a helpful tool that can make significant improvements in one’s perspective and beliefs. I’ve learned while it is helpful to validate those with delusions or simply errant thinking, the popular client-centered approach is not without its own errors. In theory, centering the client’s treatment plan to work through their pain may empower them to feel like they are the center of their world, their feelings are truth, and they can cut off any relationships with those who disagree with them. 

Mental Health Provider beware – a client that is validated in their feelings must not be validated in their actions on their feelings if they are unethical. But that is the errant ways of a client-centered approach. Clients need moral absolutes to remind them of who they are – created in the image of God with significant and specific genders, roles, and abilities. Pampering a client to feel they are owed reparations or to encourage them down a path of philosophical idiotic worldviews is dangerous to them, you, and society in general. There must be ethical, God-honoring barriers and guardrails on the journey. To ignore such is to invite folly.

Especially for those with SMI, base their treatment plan on what they would like to accomplish in their strengths and abilities, but don’t stray too far from sound counsel. They may want to start a business, try out for American Idol, let their child sleep all day and be up all night (these were all actual cases of clients or myself). Find the common ground of common sense and encourage them toward sound solutions. Those solutions will be realistic and not too far-fetched, and decisions they make that wouldn’t embarrass them or harm them in the future.

The Law That Still Stands (IMD Exclusion):

Clinician, did you know that one of the biggest deterrents of your clients receiving adequate care is an outdated law known as the IMD (Institutions for Mental Diseases) Exclusion? This law was implemented in the 1960s in the era of deinstitutionalization and continues to bar the least of these from appropriate and medically necessary treatment. Because of fear of the pendulum swinging back toward asylum-like life-terms, and for idiotic politically-driven reasons (some quoting a disillusioned $50-60 Billion in cost), the law continues.

In most states, when someone with an SMI needs inpatient care at a psychiatric facility with more than 16 beds and are on Medicaid, they are refused. This shameful and asinine reality could be solved by repealing this law federally. By eliminating the IMD exclusion, the Treatment Advocacy Center estimates that the country would eliminate 50% of mass killings, 29% of family homicides, 10% of all homicides, 20% of law enforcement fatalities, and over 40,000 suicides.

To learn more about writing to your state representatives to encourage their duty to vote against this archaic standing, visit Resources for Advocates – Treatment Advocacy Center.

How do I handle someone with SMI?

Depending on the degree of stability, the person with SMI may or may not be able to comprehend, cooperate, or cope with your intervention. Here is what to do clinically and medically to handle these situations:

Dealing with Someone in Depression:

Those who have episodes of depression and exhibit sabotaging behaviors in their treatment journey can be pushed toward believing they will fail. For example, in my case management profession, we were basically trained with the mantra, “expect relapse” – something I disagree with entirely. When we believe the person we are seeing is going to relapse regardless of our efforts and their attitudes, we are setting them up for failure. 

It may be many cases that those with SMI have recurrent episodes or relapse into self-medicating substance use. However, to approach the person with the belief that they can relapse is holding out on hope. Hope inspires someone to find themself back to a place of healing and recovery. That’s the key ingredient to a success story – instilling hope into someone. Otherwise, you mislead them to errantly believe they hold no power within themselves to hope. 

Once hope is realized, they can close the door on depression. The temptation then is to fall into another depression. If they relinquish hope, they may see another depressed episode. They must never give up on the potential of a bright and beautiful future, so neither should you. Once they come through a depression episode, they’re then that much stronger and resilient to make it through another. As seasons of life change and time moves on, they should be able to reinforce their thought patterns of hope and recovery, especially with the help of medication, and in certain cases treatment-resistant alternatives such as the aforementioned AOT.

Dealing with Someone in Mania:

A person in mania may appear to be alright, but their energy levels and vibes they send out will be above average in frequency and tone. If you’re clued into the manic symptoms, you will find it can be deceiving if you don’t know the person very well. I had a therapist who thought I had adjustment disorder rather than bipolar disorder because she never knew me before that period in my life. 

If you have someone who walks like a duck, talks like a duck, looks like a duck, they’re likely a duck, as they say. Someone with untreated bipolar disorder will, in a manic state, be harder to reason with and may say one thing but believe another. It would behoove you as an MHP to get a second opinion from a loved one and encourage the client to return to their next appointment with someone they trust to join them. That way you have their story and their loved one’s perspective.

As mania in some cases can morph into a psychotic mixed-state, and mania can be erratic per se, beware of the person’s instability. Mania, left untreated, can be a risky and costly episode. Encouraging strong boundary setting within the patient’s family and within your own therapy setting is wise. 

Dealing with Someone within Psychosis:

I’ll repeat my advice to the first post toward pastors because it’s advice I would want everyone to know and take heed:

Always be sensitive to their perspective that it is real to them, however unreal it is to you.

Medically speaking, someone in an acute, active psychotic state needs medical attention. If you are a psychiatrist prescribing their meds, and they are still not stable, consider sending them inpatient. Collaborate with their care team and encourage them to spend some time in the hospital where there is help to get them better. 

You may, depending on the person and your relationship, want to preface the inpatient directive with something like: “I see and treat many people in similar situations to yours. There are usually two outcomes: the one result is they end up in jail, the other is they decide to get help from the hospital. It is in your best interest to work with me and your care team to get you the best help we can give. Let me get you to the hospital.”

The sooner these cases are treated, the better the outcome and prognosis.

De-escalation and handling crises is also imperative to be versed in. For those types of situations, I want to refer you to the Treatment Advocacy Center and National Alliance on Mental Illness sites on crisis intervention.

Disclaimer and Conclusion

As always, this information provided on my site and in the content that I post is never meant to diagnose, treat, or otherwise be responsible for anything you may apply and the results that happen therein. I am sharing from personal experience and clinical background, but this is not to be taken as professional advice. Please refer to a licensed, trained mental health professional for personalized care and treatment. As always, consult a psychiatrist before taking or changing medications/doses.

I hope this helps you understand and better address these situations and issues that may arise in the mental healthcare setting. If I missed something, please comment below to add your thoughts and I’ll connect with you there.

Stay bold, brave, and real,

Katie