Mental Illness: The Last Acceptable Stereotype?

A series of news stories about the failed mental health system in Massachusetts focused on the tragic loss of life that has occurred due to untreated mental health conditions. Many of the case examples featured young adults with serious mental health conditions.

The stories in The Boston Globe said the state system had led to a public safety crisis, including murders by disturbed people, police shootings, and embattled institutions from courts to hospitals confronting a tidal wave of mentally ill people.

We agree there is a crisis. But spotlighting “murders by disturbed people” feeds into prejudice, discrimination and stereotyping of millions of people who live with serious mental health conditions, who have also been failed by the mental health system and who are not dangerous. And, it adds more fear to an already frightening illness for both those who experience it and their families.

We want to highlight two additional points:

1. Most youth and adults who live with serious mental health conditions that include psychosis are not violent and dangerous
2. Stigma and the lack of a full continuum of quality care prevents people with mental health conditions and their families from getting the services and support they need.

Just as it is harmful to suggest all members of any socially constructed identity group possess a particular behavior or trait, it is harmful to suggest, overtly or covertly, that all individuals who live with serious mental health conditions are dangerous. Unfortunately, people who live with mental health conditions are one of the last groups today that it is socially acceptable to stereotype.

Society, including those closest to individuals with serious mental health conditions and those who are trained to help them, are often afraid when people manifest mental health symptoms, such as psychosis. A common paradox with psychosis is that it can be just when individuals need the most care, when they are actively psychotic, that they find themselves increasingly isolated. It is during these times that individuals need someone to stand in the gap for them — the vulnerable space between reality and psychosis.

Data suggest, however, that a tragic outcome is not the norm. The National Institute of Mental Health suggests that most people with schizophrenia are not violent. A 2015 study illustrates with epidemiological research that the large majority of people with serious mental illnesses are never violent. It would be a mistake to fuel fears that lead to further rejection of people who need more understanding and care.

The lack of a continuum of quality community-based services is part of the crisis, and it needs to be addressed nationwide.

In our research with youth in low-resourced communities, we hear individuals tell the story that they go to emergency rooms in crisis and receive a prescription for psychotropic medications, but no referral to therapeutic services, such as psychotherapy, case management or broader supports intended to increase stability, such as housing and employment supports. Medications are not enough. Government needs to invest in more community-based rehabilitation and recovery programs, which include holistic and innovative approaches to rebuilding lives and dealing with symptoms.

Youths with serious mental health conditions need more, not less, treatment within the community. State and federal governments can right that wrong by stepping up and moving forward with more programs within communities, such as recent efforts of ThriveNYC from the New York City mayor’s office.

The crisis in our mental health systems calls for increased capacity across the system, not just more crisis beds. Investment in less -intensive, supportive options such as psychotherapy, partial-hospitalization, drop-in centers, faith-based options and supportive housing programs can prevent some of these crisis episodes while improving the quality of life for youth who experience mental health symptoms.

Can we have a dual focus on caring for those who are dangerous in safe, high-quality institutions, while connecting and serving all those who are not dangerous in the community? This may, in the long run, lead to fewer lost lives.

So, how is this done? How do mental health professionals, parents, friends, doctors and police officers find concrete and effective ways to work with individuals experiencing challenging mental health symptoms, including psychosis?

There is no easy answer. But we suggest first that there is need for a shift in the way society views people who live with serious mental health conditions. This should include education and training that is deeply sensitive to the symptoms that individuals experience, the varied causal factors of these symptoms and an ability to be with a person who is experiencing psychosis, as opposed to fearing them.

Further, to battle the stigma and negative views of youth, organizations need to increase efforts to highlight the bravery and courage required of individuals with a mental health condition to continue to engage in society — a society that repeatedly stigmatizes and oppresses them. And to add insult to injury, this stigma and oppression is often unaddressed.

As a place to start, we can look to further develop specialty clinics in North America that have expertise in assessing and treating serious mental illness, including psychosis, and invest in developing more services to support youth and their families the first time symptoms manifest.

Youth who live with psychosis are experts in their own experiences, and through collaboration we can come up with specialized care to set them on a path to heal.

A common theme we hear among youth is that they don’t want to share their experiences because of the stigma that comes with disclosing that you hear voices, or believe “strange things.” Young people would rather keep their experiences to themselves than risk becoming a “social pariah.” And when young people are brave enough to share their experiences, they receive messages that what they are experiencing is “just a stage” or that they just need to shut their feelings off and focus on school or work. Some youth have told us that they are afraid to share their experiences because society “immediately assumes that you are going on a shooting spree.”

Engaging with this population is essential to providing better treatment. But it does not stop there. We need to engage providers who are meeting individuals in the ER to provide them with education, training and tools to ensure they are not fearful of clients with psychosis. We need to provide them with improved tools to assess suicidal or homicidal ideation and intention, and more time to assess and reach out to the family members of clients to gain a more complete picture of the person’s risk level and functioning.

We need to also engage with families, offering them psychoeducation and resources for family counseling, as well as their own individual counseling, to help them manage the difficulties that are part of living with loved ones who experience challenging symptoms. And, we need to provide them with a full range of supportive options for assisting their loved ones, not just crisis hospitalization.

We believe it would benefit society to broaden the spotlight and also recognize the millions of individuals who experience serious mental health symptoms, including psychosis, and do get better. The individuals who will never harm others.

The youth who, in fact, are oftentimes themselves victims of violence and abuse. In doing so, we can move toward realizing a developed continuum of care that is prepared to intervene early, that recognizes that symptoms of serious mental health conditions are nuanced, and that provides a full range of supportive services to better support recovery.

Michelle R. Munson, Ph.D., is an associate professor at New York University. Director of the Youth and Young Adult Mental Health Group at NYU, her research focuses on understanding how to engage and treat marginalized youth and young adults who live with mental health challenges. She has provided services in public mental health settings, including a large hospital emergency room and community-based settings.

Shelly Ben-David, MSW, is a doctoral candidate at the New York University Silver School of Social Work. Her research focuses on how adolescents and young adults with serious mental health challenges, in particular those in the early stages of psychosis, make decisions about seeking mental health services.

Andrea R. Cole, MSW, is a doctoral candidate at the New York University Silver School of Social Work. Her research focuses on the impact of trauma on young adults. She has practiced on a mobile crisis unit serving individuals experiencing a mental health emergency for the past eight years.

Sarah C. Narendorf, Ph.D., is an assistant professor at the University of Houston, Graduate College of Social Work. Her research focuses on developing services for young adults who experience homelessness, fragmented social supports and mental health problems. She has practiced as a psychiatric social worker across the continuum of care from an inpatient forensic state hospital to community-based prevention programs.