Lecture 2

Questions to be Answered in this lecture:

Review:

MENTAL ILLNESS IS A WIDESPREAD PHENOMENON THAT OCCURS IN MANY DEGREES AND FORMS. MOST INDIVIDUALS WILL EXPERIENCE MENTAL ILLNESS PERSONALLY EITHER INDIRECTLY OR DIRECTLY AT SOME POINT IN THEIR LIVES. IT IS NOT LIMITED TO ADULTS BUT CAN OCCUR AT ANY AGE.

Confused thinking.

Prolonged depression.

Feelings of extreme highs and lows.

Excessive fears, worries, and anxieties.

Social withdrawal.

Dramatic changes in eating or sleeping habits.

Strong feelings of anger.

Delusions or hallucinations

Growing inability to cope with daily problems and activities.

Suicidal thoughts.

Denial of obvious problems.

Numerous unexplained physical ailments.

Substance abuse.

Changes in school performance.

Poor grades despite strong efforts.

Excessive worry or anxiety.

Hyperactivity.

Persistent nightmares.

Persistent disobedience or aggression.

Frequent temper tantrums.

Substance abuse.

Inability to cope with problems and daily activities.

Change in sleeping and/or eating habits.

Excessive complaints of physical ailments.

Defiance of authority, truancy, theft, and/or vandalism.

Intense fear of weight gain.

Prolonged negative mood, often accompanied by poor appetite or

thoughts of death.

Frequent outbursts of anger.

MOVING ALONG........

Even though most members of our society have experienced or will experience some form of mental illness in degrees which might at times be severe, it is important to understand that not all individuals with severe mental illness would be considered to be experiencing a "disability". Those of us in service providing agencies see only those individuals whose diagnoses and functional levels meet certain criteria defined by the regulations effecting the agency. For instance, consider the story below:

Margaret carries a diagnosis of "paranoid schizophrenia". The onset of her symptoms occurred when she was seventeen. At that time, Margaret had been a pretty and popular high school senior. Prior to that time she had been experiencing episodes of depression which were interpreted by her parents as a normal part of the moodiness of teenagers. Gradually she began withdrawing more and more from her friends and family, retreating into the world of loud music, video games and computers which were all accessible to her in her own room. She particularly enjoyed afternoon soap operas which occupied most her conversation. Gradually she seemed to be less and less able to separate the stories she was watching and reliving through the chats and websites she visited from the reality of the world her parents pushed her into each day. School officials became more and more concerned as her grades plummeted and her class attendance became less and less frequent. Margaret would come to school and retreat to the girls room where she stayed in the stalls until everyone went to class. She would then emerge singing loudly or talking to herself in the mirror. Hall monitors and teachers would try to corner her from time to time but that would result in her smiling compliantly, promising to return to class, but finding other places to hide in the school building. Eventually, her behaviors resulted in her expulsion from school. One afternoon, Margaret's mother opened the door to her bedroom and found Margaret huddled on the floor of the bathroom, rocking and crying, muttering incoherently about a warlock who she believed was going to destroy her.

Margaret's course of treatment was long and difficult for her family who remembered their beautiful talented daughter of the family albums. The medication seemed to work at first, but the changes were far from dramatic. Margaret was stiff and rigid in her speech and motor activity. She smiled and laughed at voices no one else was able to hear. On the days when she was at her best, her parents would find that she would respond to some directives and conversation but there was little spontaneity or normal interactions.

When Margaret was twenty six, her Doctor approached her parents with a miracle.

"There is a new medication which has been shown to be highly successful in treating individual's like Margaret. For many individuals, this drug has allowed them to return to near normal functioning. The results are absolutely incredible. But it is not without problems. Not everyone can take this drug and regular monitoring of blood levels is an absolute must. I would recommend that we give this a try. I can't promise that Margaret will be able to take it and I can't promise that she will be one of the miracles, but it is certainly worth the effort to try it."

Margaret's parents reluctantly agreed fearing the risks but silently hoping that the miracle would happen.

At age twenty-nine, Margaret was again a part of the world. She laughed and cried at the right times, initiated conversations, looked forward to social events, and had dreams of returning to work. She was one of the miracles!

Her parents began to pursue efforts to get Margaret back to school where she could finish her high school requirements and go onto a technical college to pursue an Associate's Degree in Computer Technology. But their budget was strained. Years of hospitalizations and paying for medications and visits to numerous doctors in search of the "miracle" had taken its toll. Margaret and her mother sat together filling out the papers for application to the Ohio State Vocational agency. The answered the questions about Margaret's functional limitations honestly, reporting her present abilities, the diagnosis which would follow her all her life, and their belief that Margaret could handle the rigors of college life.

The response that Margaret was not eligible for services was based on the "moderate level of impairment" Margaret was experiencing and had been experiencing for a significant period of time. Her diagnosis would have qualified her had she been experiencing more functional difficulties.

Severe, long term mental illness is a combination of physical symptoms, psychosocial factors, and legal or bureacratic criteria. This week we will be looking a severe and persistent mental illness from all three viewpoints.

What is the criteria in your agency which would be used to determine Margaret's eligibility for services?

Both Margaret and Roger (last week's case study) have a severe mental illness. Imagine that both of these individuals have reported to your agency for assistance in re-entering the workplace. What objective criteria would be used to determine their eligibility? What would the outcome of that determination likely be? Why?

Now consider the Case Study of Dottie (labeled "Case Study" in the Reference Room). Suppose Dottie applied for services in your agency? How would her eligibility be considered, and what would the outcome be? Would it be different than the other two case studies, and if so, how and why.

 

A Legal View of Severe and Persistent Mental Illness

Note: The term "chronic mental illness" and "severe, long term mental illness" basically denote the same thing. Please note that "chronic mental illness" is seen as a highly stigmatized phrase. Current acceptable language for this condition is "severe, long term or persistent mental illness".

A standard definition of Chronic Mental Illness is likely to look something like the one below.

… One of several diseases resulting from unknown or multiple factors which affect the brain causing the individual to experience a significant impairment in routine functioning for an indefinite period of time.

Diagnosis: Agencies will typically designate a list of diagnoses which initially qualify an individual for services. These diagnoses are typically medical in nature and come from a prescribed list of diagnoses published by either the American Medical Association or the American Psychological Association. We will be discussing a medical model view of mental illness later in the lecture.

Disability: In addition to a qualifying diagnosis, individuals must typically experience a significant level of impairment in their ability to function normally. Federal laws have established priorities for the provision of services to the most severely impaired individuals. These laws forbid the exclusion of individuals with severe levels of impairment by agencies that receive Federal dollars. However, states are permitted to establish their own criteria for defining and identifying "severe" levels of impairment. These state level definitions have created a very non-uniform standard of eligibility. If Margaret lived in another state, her diagnosis and current near-normal level of functioning may have produced a different outcome.

Duration: In order for a specific condition to be considered a "disability", it must, by most definitions, be expected to be lifelong in nature. This simply means that even though treatment may allow for improvement, the nature of the disabling condition must be such that it will never completely go away. For instance, a person who breaks two legs may temporarily experience the same mobility limitations as someone who is a paraplegic. This individual is definitely experiencing a disabling condition . But it is likely that the legs will heal and he will be able to return to normal functioning in a matter of months. In order for individuals to receive services designated for individuals with disabilities, the condition must be expected to continue permanently. Agencies again have the option of determining how long an individual must experience the condition before they can receive services and how long the disability must be expected to last if services are to be delivered. It is easy to see how a combination of factors in the "legal model" could present challenges for people with a severe, long term mental illness.

It is significant to note that agencies which provide services to people with disabilities are overseen by a number of state and federal agencies: education, welfare and human services, mental health, medicine, vocational, Social Security, insurance companies, etc. Each of these entities has its own definition of severe mental illness, chronicity, and disability. One may be "disabled enough" for some and "too normal" for others.

Food for Thought:

How inclusive is your agency in regards to providing services to people with mental illness?

What systemic issues might have effected the criteria your agency uses to determine eligibility?

 

A Medical View of Mental illness:

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association,1994) offers the following caveat:

" ....although this manual provides a classification of mental disorders, it must be admitted that no definition adequately specificies precise boundaries for the concept of "mental disorder". The concept of mental disorder, like many other concepts in medicine and science, lacks a consistent operational definition that covers all situations. All medical conditions are defined on various levels of abstraction - for example structural pathology, symptom presentation, deviance from a physiological norm, and etiology. Mental disorders have also been defined by a variety of concepts (e.g., distress, dyscontrol, disadvantage, disability, inflexibility, irrationality, syndromal pattern, etiology, and statistical deviation. Each is a useful indicator for a mental disorder, but none is equivalent to the concept, and different situations call for different definitions."

In spite of the insistence that no definition of mental disorder is really terribly accurate or reflective of all that is known about these conditions, the medical model of viewing mental illness is the one which is primarily used and has the greatest influence on the kinds and amounts of services which will be provided and the amounts in which those services will be provided. The move in our country toward a managed care health system has canonized the medical model of diagnosis even more. In order for a payor (primarily private insurance companies at this time) to cover a treatment or service, the DSM-IV diagnosis (given by a qualified medical provider specifically physician, psychiatrist, or psychologist) must qualify and the proposed treatment must be follow a regime (typically medical in nature and based on treatment plans from a less than holistic period) seen as the "Standard of Care" (a purely medical construct ). The following paragraph describes the concept of mental disorder used by the American Psychiatric Association, the medical profession, and is therefore the standard acceptable definition serving as the pivotal point (diagnosis) around which all other definitions hang.

".....a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (painful symptom) or disability (impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely and expectable and culturally sanctioned response to a particular event. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g. political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above. "

You will note some similar language to that discussed earlier. However, words such as "significant" and "distressed" are more clearly defined. We will be discussing the concept of "differential diagnoses" utilized in the APA classification system later.