Mental Health First Aid
Springfield School of Social Work
MSSW 612 Policy II
People with mental illness are discriminated against resulting from both personal and public stigma associated with mental disorders (Cummings, Lucas & Druss, 2013). This was demonstrated by a group of participants from a Mental Health First Aid Training class when asked to develop an “A to Z” list of adjectives describing mental illness. The following is the list they composed: agitated, ballistic, crazy, depressed, extreme, frantic, grandiose, homicidal, insane, jumpy, killer, lunatic, manic, neurotic, oppressed, paranoid, quirky, resistant, scary, traumatized, unstable, violent, withdrawn, extreme, yo-yo and zany (personal communication, 2014). None of the attributes are positive or conducive to improving the perception of mental illness and treatment.
The purpose of this paper is to illuminate the stigma surrounding mental illness. The intent of the Mental Health First Aid Act 2013 is an effort to educate, inform and activate the general public toward eliminating bias and barriers to humane care for mentally ill individuals. While some components of stigma may reach beyond the scope of federal legislation, augmenting previous legislation aimed at eliminating discrimination of the mentally anticipates breaking down stereotypes and prejudices that prevent just provision for this growing population.
According to issue five, the latest of the Diagnostic Statistical Manual (DSM), there is more than a 50 percent chance that you’ll have a mental disorder within your lifetime. The previous version, DSM-IV, put the approximate numbers of Americans being diagnosed with a mental disorder at 46.4% based on a study from 2005. The new manual will likely make getting a diagnosis even simpler and include more of the population. (Rosenberg, 2013).
There are several reasons for the increasing numbers. The swelling epidemic can be attributed to better detection of mental illness. Also, more of us are becoming mentally ill than in previous generations and with earlier onset in our lives. Another rationalization for amplified incidence of mental disorder is reflected in our culture. Some behaviors once considered within normal range of human practice are currently regarded as pathological in the continuum of mental health care. Essentially, the definition for mental illness now encompasses more people (Rosenberg, 2013).
The National Institute of Mental Health (NIMH) states that:
• 61.5 million people; 1 in 4 adults, experience mental illness is a year
• 13.6 million live with a serious mental disorder
• 20 percent of youth experience a severe mental disorder in a year
Substance abuse – like alcoholism – are not in the estimates despite being in the DSM-V.
It may be argued that with the most current data, nearly 1 in 3 Americans suffer from a mental illness, which translates to over 75 million people (Grohol, 2010).
The Centers for Disease Control (CDC) reports there is still stigma surrounding mental illness despite the widespread affliction of mental disorders affecting Americans. A 2007 survey reported that only 57% of Americans considered people to be sympathetic and considerate toward persons with mental illness. More importantly, only 25% of people with mental illness believed that people were concerned and supportive of them (“Burden of mental,” 2013).
It is no secret that what makes headlines and floods social media is what influences public opinion. With the rash of mass shootings in the U. S. over the last few years, the mental health of the shooters is what has drawn mental health into the spotlight and as a result, has been the focus of public opinion and new legislation. As recently as the first week of April 2014, mental health deliberation continues. There has been great attention and legislative action in our nation’s capital. Under comprehensive legislation, Medicare reimbursement for mental health physicians passed both the House and Senate and is pending the President’s signature. An eight-state “pilot-program” intended to streamline services by community mental health clinics is one component of the bill. The second approves a “demonstration program” of federal grants for outpatient treatment of people suffering from mental illness who are not participating in treatment and have experienced significant adversity such as incarceration, repeated hospitalizations or homelessness. (Carolla, 2014).
At the National Press Club, Virginia Senator Creigh Deeds, whose son died from suicide last year, spoke about the continued need for extensive mental health reform. A hearing that focused on the shortage of psychiatric hospital beds supported Deed’s perspective.
Mary Gilberti, Executive Director of the National Alliance of Mental Illness (NAMI), also acknowledged that in addition to there not being enough beds to meet the needs of people living with mental illness, other services are severely lacking. Those services involve:
• Early intervention mental health screening
• Crisis response and stabilization programs
• Discharge planning
• Outpatient services
• Peer Support
• Assertive Community Treatment (ACT)
• Supportive Housing
• Jail Diversion
Additionally, a hearing for the Helping Families in Mental Health Crisis Act was scheduled for early April 2014 (Carolla, 2014).
On April 2, 2014 the debate concerning mental health and gun control was reignited after another shooting at Fort Hood in Texas. The shooter was identified as having behavioral and mental health issues and was being assessed for Posttraumatic stress disorder (PTSD). Issues of security and gun restrictions at Fort Hood were raised. Rules about carrying firearms on bases were highlighted. Soldiers are unarmed while on post and are prohibited from carrying privately owned guns. After the 2009 massacre at Fort Hood there was a rash of suicides on post and consequently only law enforcement and security personnel have weapons while on post (Krayewski, 2014).
There is no shortage of pundits criticizing the mental health crisis, pushing for gun control while opponents insist responsible gun owners aren’t the cause of violence. Unfortunately, mass media gives these incidents the most attention and by doing so link mental illness with gun violence.
Nonetheless, diagnosable and treatable mental health illnesses such as anorexia, depression, PTSD, substance abuse, suicidal ideation and more are the leading cause of disability in the United States according to the National Institute of Health (“The numbers count,” 2012). All across America individuals and families struggle. Someone has a parent with depression or a friend who is bipolar. Someone else has a neighbor who returned from war with PTSD or knows a co-worker who is suicidal. Or someone has a sibling trying to get sober. These are real threats to our well being as a nation yet many people suffer in silence and don’t seek treatment because of the stigma associated with mental illness. Others remain aloof and detached from those who are afflicted with mental illness rather than speak up or to offer help. Some reluctance is due to ignorance. Some is due to ambiguity; not knowing what to say or do. And in the case of those with severe mental illness, they are unrepresented unless advocated for by others on their behalf.
HISTORY OF CARE FOR MENTALLY ILL
In 1843 Dorothea Dix submitted her Memorial to the legislature of Massachusetts imploring those in leadership and authority, to advocate for the inhumane conditions that brought unjust suffering to the mentally ill. Dix’s efforts were in stark contrast to Social Darwinism and survival of the fittest. She appealed to their honor and humanity, begging them to “put off the armor of local strife and political opposition” and to “raise up the fallen; succor the desolate; restore the outcast; defend the helpless…” (Parry, 2006).
Unfortunately, not many strides have been made with regard to the social welfare of the mentally ill since the mid nineteenth century. In David Gil’s essay in which he outlines his understanding of social justice on the levels of individual human relations, social institutions and global human relations, it can be argued that the plight of the mentally ill has remained paralyzed. In Dix’s era, ignorance was largely responsible for the callous treatment the mentally ill suffered. Psychology and pharmacology had not developed to comprehend or respond to mental illness and consequently mentally ill people were regarded as incurable (Vinney & Zorich, 1982). That lack of knowledge may explain society’s ignorance in not knowing what to do with the mentally ill, however, ignorance doesn’t justify or excuse inhumane treatment. The responsibility of how to treat fellow human beings lies to individual, societal and cultural character, integrity and morality.
There is a saying that a person’s character is reflected in how one treats those who can do nothing for you. Aside from those who would debate whether or not morality could be legislated, this moral imperative is what Gil alludes to in defining social justice and a society’s response in meeting its member’s intrinsic needs. What a society values is reflected in its social, cultural and technological development. The outcomes determine people’s quality of life (Gil, 2004), thus a social system’s policy is equivalent to humanity’s core values and choices to either address or ignore them. Finally in the U.S. mental health parity is now law, yet mental health care is in crisis.
Article 5 of the Universal Declaration of Human Rights, guarantees that ‘no one be subjected to torture or to cruel, inhuman or degrading treatment or punishment (“The universal declaration,”). Deinstitutionalization of the mentally ill was well intended to uphold human rights by closing mental hospitals and transferring patients to community-based mental health agencies; however, the lack of forethought and provision for patients once released can be reasoned as a societal failure. The consequences of such moved many mentally ill people out of mental institutions and into jails, subjecting many to repeat hospitalizations and homelessness (Torrey, 2014).
The CDC’s findings in their Mental Illness and Stigma study from 2007 highlighted the need to educate the public about how to support people with mental illness and the need to reduce barriers for people seeking or receiving treatment for mental illness (“Burden of mental,”). Actress Glenn Close stated, “The mentally ill frighten us and embarrass us. And so we marginalize the people who most need our acceptance. What mental health needs is more sunlight, more candor, more unashamed conversation “ (Close, 2009). With discussion and education the stigma surrounding mental illness can be dissipated and impediments to treatment minimized.
In President Obama’s Now Is The Time report, he called for Mental Health First Aid Training to enable educators and school staff to recognize the symptoms of mental health disorders in young people and find resources for their care. U.S. Representative Ron Barber of Arizona originated a Mental Health First Aid bill after the Tucson mass shooting in January 2011 in effort to decrease gun violence. It received strong bipartisan support. The gunman was diagnosed with mental illness, however Barber has stressed that over 95 percent of people living with mental illness are not violent. In fact, they are more likely to be victims of violence, not perpetrators (U. S. rep, 2014).
Barber contends that 60 percent of people with mental illness are not receiving treatment in part because people are uncertain about how to respond to a person with mental illness (U.S. rep, 2014). Broadening public awareness about mental illness symptoms by training educators, fire fighters and police officers, emergency service workers and members of the public sector about mental health services is the objective of the Mental Health First Aid Act of 2013 (Mental health first, 2013). The Act provides $20 million in grants, which fund Mental Health First Aid training programs throughout the nation. The training aims to teach participants how to recognize the symptoms of common substance abuse and mental health disorders. The program instruction also includes de-escalating crisis situations and introducing appropriate referral to available resources (Mental health first, 2013).
American Psychosis by Dr. E. Fuller Torrey
Dr. Torrey is a psychiatrist who believes the federal government is responsible for ruining treatment for the mentally ill. He traces the history of deinstitutionalization and gives critical analysis of the results. He contends that the development of Thorazine, a drug to treat delusions, hallucinations and manic symptoms of severe mental illness, gave misguided though well intentioned hope to decision makers. He contests that relying on drugs as a panacea for treating the mentally ill has proven to be insufficient and damaging to the mentally ill and society at large. The errors he charges, are in closing mental hospitals, misunderstanding what is involved in community treatment and federal financing of mental health care (Torrey, 2014).
He condemns the change in the American Psychological Association’s original intent from treating mental illness to mainly functioning as a lobby to protect economic investments of psychiatrists. He asserts that the mentally ill have been abandoned. While there may be agreement on what services should look like, there is no consensus on how to organize care or how to fairly fund it. Torrey argues that federal programs prohibit improving mental health care because of conflicting political interests striving to maintain the status quo of a capitalist economic society. He cites the Nursing Home and Home Care industry’s motivation for profit as a major impediment to properly caring for the mentally ill (Torrey, 2014).
Torrey goes further to point out that the public has a mistrust of psychiatry that is further compounded by society’s misunderstanding of the civil rights of mentally ill people. Those that claim the mentally ill homeless have a right to live without an address on park benches, under bridges or in jail are missing the mark. People whose mental capacity is compromised are not living by their free will. Their actions are commanded by delusions. Mental illness is the only illness where the brain can distort reality and prevent the patient from knowing he or she is ill (Torrey, 2014).
Much like the paradoxes Deborah Stone speaks of, when it comes to mental illness there is no clear distinction of how to best meet the needs of the mentally ill and the general public. There is a trade off between a market model and a political model (Stone, 2012). Both populations need protection and provision. As quoted by Torrey, (2014) Psychiatrist Gary Maier has said, “When the personal freedom of the mentally ill is given priority over all other considerations the tyranny of some will jeopardize all.” This illustrates negative liberty where mentally ill persons have freedom to – live according to their free will and positive liberty where the public wants freedom from – security pertaining to the mentally ill (Stone, 2012). As a society we are faced with the dilemma of how to protect the rights of all our citizens.
Nonetheless, failure to provide appropriate treatment to people with severe mental illness is perpetuated by society’s lack of understanding. Torrey emphasizes that much of the public believes mental illness is psychological and not biological in origin, however, schizophrenia, bi-polar disorder and severe depression are brain diseases, as are Multiple Sclerosis and Alzheimer’s disease (Torrey, 2014). Therefore, public education is a vital component in providing comprehensive care to the mentally ill which may in turn reduce the stigma surrounding the predicament.
National Public Radio
A First Aid Kit for Mental Health Emergencies
October 18, 2011
Host: Neal Conan
Guests: Bryan Gibb – Director of Public Education, National Council for Community Behavioral HealthCare
Clare Miller – Director, Partnerships for Workplace Mental Health
The Talk of the Nation program featured two guests who provided information and education for the program entitled: A First Aid Kit for Mental Health Emergencies.
Mental health is a distinct issue separate from gun violence as evidenced by this public radio program. It is important to recognize this interview took place before the influx of the more recent mass shootings linking mental health to gun violence. The key points taken from this episode are important in educating the public and shifting the ambiguity many people feel when it comes to dealing with people experiencing mental health challenges.
Bringing training to the workplace is instrumental for eliminating stigma. Many human resource departments welcome and provide training for traditional physical health emergencies such as CPR for heart attacks and the Heimlich Maneuver for choking, but when it comes to emotional first aid there a void. Co-workers need to know how to respond to mental health crisis as well because there is more chance for a mental health issue arising in the workplace than a heart attack or choking incident (“A first aid,” 2011).
The mental health first aid course prepares the participants to be aware of subtle changes in a person and how to respond to them. The human resources department has responsibility to protect its valuable resources, its employees. If a person were to develop symptoms of diabetes, he or she would be directed to services in an effort to help maintain the employee’s viability and productivity. The same model needs to be applied to employees with mental health concerns. The employee needs to have intervention which includes addressing what is observed and if necessary directing them toward resources. Often this is in the context of employee assistance programs (EAP’s) (“A first aid,” 2011, “National survey on,” 2013).
The mental health first aid program doesn’t impart diagnosis or treatment methods. It teaches participants to recognize, confront and refer the same way a supervisor observes, informs and recommends. In the workplace privacy can be a concern. The program doesn’t deter from legal or professional obligations. In a definitive emergency when someone is at risk for harm to self or others, standard emergency protocol prevails (“A first aid,” 2011).
Job security is an issue for employees who are reluctant to seek help for fear of being fired if they reach out for help. The double standard between physical and mental illness needs to be eradicated. If diagnosed with a mental illness, job security, hospitality and support from co-workers are usually hard to come by. A listener who called in to comment illustrated this. She had experienced mild psychosis over a two-day period because her meds had been altered. She was fired. If she had experienced a heart attack, she would have been welcomed back and probably had casseroles delivered for a few weeks after the incident. Firing an accomplished employee for a treatable mental health issue is an injustice that must be corrected (“A first aid,” 2011).
Employers and business owners of the free market can be considered penny wise and pound-foolish when their highest priority is their profit margin and at the expense of their employees health. Depression costs $50 billion in lost productivity every year while substance abuse costs $200 billion a year in lost productivity. Employers need to work smarter and invest in their employees by funding mental health care and preventing unnecessary loss (Impact & cost, 2013).
The New York Times
Sunday Review Op-Ed Columnist Nicholas Kristof
Inside a Mental Hospital Called Jail
Mr. Kristof highlights the irony of the truth; that the same society that detested locking up the mentally ill in mental hospitals now locks them up in jails. He summarizes sobering statistics from the National Sheriff’s Association and the Treatment Advocacy Center: three times as many mentally ill people are housed in jails as opposed to hospitals. Forty percent of people with severe mental illness have been arrested. They aren’t incarcerated because of their psychiatric issues directly, rather indirectly. They end up getting arrested because their violations stem from offenses that result from their mental illness The Justice department reports mentally ill inmates are preyed upon and receive more injuries than those without mental challenges (Kristof, 2014).
Kristof points out that incarceration of mentally ill inmates costs American taxpayers between $300 and $400 a day. Often the mentally ill will stabilize and be released, and once back into the community without supports, they go off their medications and their symptoms escalate. They eventually re-offend and break the law again and the cycle repeats. He argues that fiscally it doesn’t make sense to incarcerate because it would be more cost effective to manage their mental health care in the community and maintain their stability with caseworkers and other community supports (Kristof, 2014).
The National Association of Social Workers Code of Ethics focus is to improve
the well being of humans by meeting their basic needs and enabling the vulnerable, oppressed and impoverished (“Code of ethics,” 1999). Social workers are distinctively prepared to advocate for the dignity of every human being by upholding basic civic and political freedoms at the micro, mezzo and macro levels.
Being agents of change, social workers commit to work on the behalf of vulnerable and oppressed populations, particularly toward fostering social justice. The construct and implementation of the Mental Health First Aid Act promotes this objective as well. Educating about mental health by providing information, directives and resources for the public to recognize symptoms, intervene and refer compromised individuals to professionals is critical for the benefit of everyone in society.
The implementation of the Mental Health First Aid Act is foundational toward affecting positive change toward the mental health crisis in America. Shifting the focus from sensationalized media reports linking the mentally ill with gun violence to promoting factual information to the public is the first step of many in combatting the personal and public structural stigma of mental illness. Engaging the general public to aid the mentally ill serves both populations. Given the anticipation of the numbers of persons who will develop a mental illness in a given year, the demand for mental health care will be staggering. This legislation addresses early intervention, crisis response and peer support, but doesn’t impact the present problems of stabilization programs, discharge planning, out patient services, supportive housing or jail diversion.
Momentous federal legislation has made headway in defeating discrimination of the mentally ill within the areas of healthcare, education and employment. The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) targeted the health insurance industry to provide equal coverage for mental health and substance abuse disorders treatment. Where the MHPAEA lacked, the Patient Protection and Affordable Care Act of 2010 (PPACA) filled in gaps by requiring inclusive coverage for substance abuse and mental health disorders within benefit package plans by insurance companies and with coordination betwee Medicaid plans (Cummings, Lucas & Druss, 2014). Building on these landmark pieces of legislation, the Mental Health First Aid Act may serve as an impetus for radical change toward refurbishing the present complications that resulted from deinstitutionalization of the mentally ill.
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