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rules and restrictions may apply

1:44

millions of people in the united

1:46

states have experienced a serious

1:48

mental illness such as schizophrenia

1:50

bipolar disorder or major depressive

1:53

disorder

1:53

among the many challenges

1:55

these people face or the stigma

1:57

and misunderstanding surroundings illnesses,

2:00

including the idea that serious mental illness

2:03

is untreatable and that recovery is impossible,

2:05

as well as the stereotype that people with

2:08

serious mental illness are violent or

2:10

dangerous. But in reality, researchers

2:13

have found that with the right treatment, many

2:15

people with serious mental illness can manage

2:17

their symptoms, return to work or school,

2:20

and recover and rebuild their lives. So

2:23

how much progress have we made in recent decades

2:25

in treating serious mental illness? What

2:27

are the biggest challenges in the field? What's

2:30

the role of psychosocial interventions

2:32

versus medication in treatment? What

2:34

role can family support, work and

2:37

community play in people's recovery? How

2:39

does stigma surrounding serious mental

2:42

illness affect people's treatment and recovery? And

2:44

finally, is there really a connection

2:47

between violence and mental illness? Welcome

2:53

to Speaking of Psychology, the flagship

2:55

podcast of the American Psychological Association

2:58

that examines the links between psychological

3:00

science and everyday life. I'm

3:02

Kim Mills.

3:06

Our guest today is Dr. Kim Musur, a

3:08

clinical psychologist and professor at the

3:10

Center for Psychiatric Rehabilitation at

3:12

Boston University. He is a clinician

3:15

and researcher who studies treatment for serious

3:17

mental illnesses including illness management

3:19

and recovery, specialty care programs

3:22

for first episode psychosis, and

3:24

avocational rehabilitation. He's

3:26

the co-author of more than 10 books and treatment

3:28

manuals and has published numerous

3:31

peer-reviewed journal articles and book chapters.

3:34

His work has been funded by grants from the National

3:36

Institute of Mental Health and the Substance

3:38

Abuse and Mental Health Services Administration.

3:41

Dr. Musur, thank you for joining me today. Dr. Musur Thanks

3:44

very much. I'm delighted to be here. Dr. Musur

3:46

Let's start by defining the term serious mental

3:48

illness. What disorders does the

3:50

term encompass? How common are they

3:53

and what makes them serious as compared

3:55

with other mental illnesses? Dr. Musur

3:57

So a serious mental illness is defined

3:59

as a mental illness in

4:01

which the impact of the disorder

4:05

on the person's life is profound

4:07

and long-term. When I say

4:09

the impact on their life is profound and long-term,

4:12

I'm talking about their ability to work

4:14

or to go to school to fulfill other

4:16

role obligations such as being a parent,

4:20

their ability to have good ongoing

4:22

and rewarding relationships with others

4:24

and their ability to take care of themselves. People

4:27

who have a major mental illness

4:29

that disrupts these areas of functioning

4:32

for a significant period of time are

4:34

said to have a serious mental illness,

4:37

sometimes also referred to as a

4:39

severe mental illness. The

4:41

most common of these different mental

4:43

illnesses are schizophrenia

4:45

and schizoaffective disorder, bipolar

4:48

disorder, major depression,

4:51

especially treatment refractory major depression

4:53

that doesn't respond so well

4:56

to medications. And

4:58

there are many other possible disorders such

5:00

as post-traumatic stress disorder and

5:02

obsessive compulsive disorder that may

5:04

be serious mental illnesses for some people.

5:07

So serious mental illness has been with us pretty

5:10

much throughout human history. In

5:12

the bad old days, we locked such

5:14

people away, often for their

5:17

entire lives and not that long ago

5:20

treatment for SMIs as we call

5:22

them might have included insulin, colas,

5:24

electroshock treatments and lobotomies.

5:27

How much progress have we made in recent

5:30

decades in understanding how

5:32

to treat serious mental illness because we don't

5:34

do a lot of these things anymore? Right.

5:36

I'm glad you asked those questions, Kim.

5:39

First, I forgot to mention that about

5:42

5% of the population has a serious mental

5:45

illness. So these are pretty common

5:47

disorders and that often can lead

5:49

to the need for disability

5:52

entitlements such as Social Security, disability

5:55

income and the like. You

5:58

mentioned a number of treatments that have

6:00

have gone out of phase such

6:02

as lobotomy and insulin coma

6:04

therapy. And in fact, there's

6:07

been huge advances in both

6:09

the pharmacological treatment of serious mental

6:12

illnesses as well as the psychosocial

6:14

treatment, the development of therapies and rehabilitation

6:17

programs designed to help people manage

6:19

their symptoms more effectively and get

6:22

back to living a life including work

6:24

and having rewarding relationships. I

6:27

would like to mention one of the treatments

6:29

that you described has

6:31

made a huge amount of progress

6:34

over the last 50 years and is

6:36

now actually recommended

6:38

treatment and that is electroconvulsive

6:40

therapy is in fact a recommended

6:43

treatment generally for people who

6:45

have treatment resistant major

6:48

depression. It is occasionally

6:50

used for a number of other conditions that we

6:52

don't need to go into a lot of detail now

6:54

but the research actually shows that people

6:57

who have treatment refractory major depression

7:00

by that meaning that they have a case

7:03

of major depression which has not really

7:05

responded well to pharmacological

7:07

treatments. That for these individuals

7:10

ECT can be a lifesaver.

7:12

It can lead to both a resolution

7:15

and improvement in the depressive

7:17

symptoms and it's actually been found

7:19

to prevent subsequent hospitalizations.

7:23

It's important for people to recognize that

7:26

there is a role to play for ECT as

7:28

well as to know that the

7:30

methods for administering ECT

7:32

which are always done on a voluntary basis

7:37

make the procedure both

7:39

very, very safe as

7:41

well as not harmful in terms

7:44

of causing pain and discomfort

7:46

to individuals. I do

7:48

think it's important for people to recognize that there is a role

7:50

for ECT to play now

7:53

and that the methods have improved very

7:56

much although there still is a problem in

7:58

terms of people lacking access. access

8:00

to ECT for treatment

8:03

refractory depression. A lot of

8:05

us have that searing image of electroshock

8:08

therapy that was used in One Flew Over the Cuckoo's

8:10

Nest, the film. Is it still

8:12

like that? First of all, it's always voluntary

8:15

and of course in One Flew Over the Cuckoo's Nest it

8:17

was used as a type of punishment. Second

8:20

of all, the typical procedures involve

8:23

providing the person with some

8:25

anesthesia so that they're not actively

8:28

conscious during the time that the electroshock

8:30

is provided. In addition, extensive

8:33

research on ECT has

8:35

shown that it can be provided with

8:37

really minimal cognitive side

8:39

effects associated with it. Sometimes

8:42

there are some temporary side effects

8:44

but generally they go away pretty quickly.

8:47

And often people's cognitive abilities

8:49

actually improve after ECT

8:52

because their depression lifts. So

8:54

that when people are depressed, their thinking

8:56

is often not as logical and

8:59

as fluid as it could be. What do we

9:01

know about the role of medication versus

9:03

some of these other types of treatments for

9:05

serious mental illness? Are both necessary

9:09

or can medication alone

9:11

for example treat SMI? Probably

9:13

for most people, medication alone

9:16

is insufficient for treating a serious

9:18

mental illness. There certainly may be

9:21

some individuals where medication

9:23

is really all they need to get back

9:25

to living their day to day lives. But

9:28

for the larger majority of individuals

9:30

with the serious mental illness, medication

9:33

can reduce the burden of symptoms and

9:35

it could also reduce the chances of

9:37

a person having a relapse of symptoms. But

9:40

it can't help them relearn life skills

9:43

or help them reconnect with

9:46

jobs, school and other kinds

9:49

of important functions that perhaps

9:51

they were playing before in their lives.

9:53

And so that's where the role of psychosocial

9:56

treatment comes in which is

9:58

helping people whose symptoms are under attack. under control,

10:01

it could be that the symptoms are either in remission

10:03

or that they are less severe than

10:06

in an exacerbated state. Learn

10:11

new skills and get on with the business

10:13

of living, whether it's going to school or work

10:15

or parenting and just enjoying good

10:18

social relationships. Can

10:20

people with SMI recover

10:22

completely or do they have

10:24

to continue medication and

10:26

other therapeutics for the rest of their lives? Well,

10:29

that's a very interesting question because it

10:31

kind of gets to what do we mean

10:33

by recovery. It used to

10:35

be that recovery was very conventionally

10:38

defined in medical terms, meaning

10:41

that a person was recovered if they

10:43

didn't have any symptoms of the illness

10:45

anymore or related impairments.

10:48

But over the last 20 to 30 years, the

10:51

concept of recovery has really

10:53

been redefined to make it

10:55

something more personally meaningful

10:58

to individuals who have a serious mental illness.

11:01

And so recovery now refers to

11:04

getting on with the process of living one's

11:06

life and being able to live

11:09

and participate in one's communities, being

11:11

able to work, to have social relationships

11:13

and the like, despite potentially

11:16

having ongoing symptoms or

11:18

challenges related to a mental illness. So

11:21

the idea of recovery has been

11:23

reconceptualized to refer

11:26

to recovery in terms of

11:28

living a meaningful and rewarding

11:30

life for the individual, even

11:33

if they may have some continued challenges

11:35

related to the mental illness. So

11:38

from that perspective, recovery is possible

11:41

even though a person may continue to

11:43

have symptoms or take

11:45

medication for a mental illness. At

11:48

the same time, to get back to the medical

11:50

definition of recovery, like not having any

11:52

more symptoms or any more impairments, it

11:54

certainly is possible. In fact, we know that

11:57

people do recover from mental illnesses

11:59

across either

14:00

major depression or bipolar disorder,

14:03

those psychotic symptoms usually go into remission.

14:06

When we're talking about first episode

14:08

of psychosis, we're talking about

14:10

people who experience psychotic

14:12

symptoms like hearing voices and delusions,

14:15

but they're not experiencing these symptoms in

14:18

the midst of a mood episode

14:20

like mania or depression. So

14:22

first episode psychosis usually

14:26

reflects the beginning of

14:28

the illness of schizophrenia. When

14:31

it's in the first six months of

14:34

a person developing the symptoms and becoming

14:36

impaired, the name of the disorder is

14:38

called Schizophreniform Disorder. It's

14:40

considered a schizophrenia

14:42

spectrum disorder. And then

14:45

after six months, if symptoms

14:47

continue and to some extent impairments

14:49

continue, then the person may

14:51

meet criteria for either schizophrenia

14:54

or the related disorder of schizoaffective

14:57

disorder. Schizoaffective disorder is

14:59

a little bit like schizophrenia, but

15:01

it means the person also has significant

15:04

episodes of either mania or

15:06

depression in addition to the

15:09

other schizophrenia symptoms.

15:11

So the reason why it's so important to

15:13

intervene early and comprehensively

15:16

in people who develop a first episode of psychosis

15:19

is that the disorder tends to develop

15:22

relatively early in either

15:25

late adolescence or early adulthood.

15:28

Typical onset occurs sometime

15:30

between the ages of 16 and 17 up to around say 35, although

15:36

it certainly could develop even after the age of 35, even

15:38

into ones 40s and 50s. But

15:43

because it's not that common

15:45

a disorder, the prevalence of schizophrenia

15:48

is around 1% in the general population,

15:51

it is often missed by

15:53

clinicians and by family members and

15:56

by people in the medical profession because

15:58

they don't understand what's psychotic. is

16:01

and they don't recognize when a person

16:03

is having psychotic symptoms. Interestingly,

16:06

this can occur even

16:08

for people who are receiving mental health treatment

16:10

from a mental health professional because

16:13

the mental health professional may not

16:15

be aware that they have developed psychotic

16:17

symptoms if they haven't done the appropriate screening.

16:21

So what happens is that people sometimes

16:23

go for extended periods of time

16:25

before their psychotic symptoms

16:28

are recognized and before

16:30

they're treated. And the problem with

16:32

this is that the longer you go before

16:34

providing treatment for a first episode

16:37

of psychosis, the more difficult

16:39

it is to treat it once the person comes

16:41

into treatment and the

16:43

more problematic outcomes there

16:46

may be before the person gets into treatment.

16:49

So for example, it's possible

16:51

for people to commit suicide

16:54

before they ever get into treatment for

16:56

a first episode of psychosis and

16:58

that case of suicide could have been prevented. Or

17:01

sometimes what happens is that a person

17:03

may become delusional and

17:06

they may become paranoid

17:08

for example and they may do harm

17:10

to other people because of their psychotic

17:13

symptoms and that harm could be prevented if

17:16

the first episode of

17:18

these symptoms were detected and treated. So

17:21

in addition to preventing the harm from

17:23

occurring when the symptoms

17:25

of psychosis are not treated, the

17:28

other thing is that we know for many people

17:30

schizophrenia can last a

17:33

significant period of time, sometimes a lifetime.

17:36

And so the earlier we can provide

17:38

effective and comprehensive treatment, the

17:41

more opportunity we have for

17:43

helping people develop coping skills, skills

17:46

for preventing relapses, the

17:48

more we can help them develop the kind

17:50

of skills for having good, rewarding interpersonal

17:53

relationships, for providing the

17:55

supports for returning to school and

17:57

work and in effect getting...

18:00

on with the business of living. So

18:02

the first episode of psychosis represents

18:05

an opportunity to intervene

18:08

early in the long-term course of

18:10

schizophrenia with the potential

18:12

of improving the long-term trajectory

18:15

of the disorder in terms of both disability

18:18

as well as improving the quality

18:20

of life of individuals. You

18:22

mentioned employment a moment ago and I

18:25

know you've written about the importance of helping

18:27

people with serious mental illness find employment.

18:30

What role does meaningful work play

18:32

in recovery? Now that is

18:35

one of my favorite questions because meaningful

18:37

work is potentially

18:40

one of the most important parts of

18:42

the recovery process. People

18:45

used to think that everything

18:47

else needed to be under control and

18:49

in perfect shape before you could help a person

18:51

get a job or perhaps return

18:53

to school. But now we realize

18:56

that first of all, people are capable

18:59

of working and in fact that

19:01

work has beneficial effects even

19:04

if they may continue to have particular symptoms

19:06

or cognitive challenges and that

19:08

working provides a sense of meaning and

19:11

integration into one's community and

19:14

occupies people's time in

19:16

a meaningful and purposeful fashion

19:18

that is both beneficial in terms of

19:21

the person's self-esteem, in

19:23

terms of improving their financial

19:25

standing and we now

19:27

know that helping people get jobs can

19:30

actually offer them a certain protection

19:33

against relapses and rehospitalizations.

19:36

And the reason is that or one of the reasons is

19:38

that when people work, it

19:41

structures their time in a meaningful

19:43

sort of way and we know that

19:45

lack of structure can be stressful for

19:48

everyone and especially somebody

19:50

with a major mental illness, the

19:53

lack of structure can play

19:55

havoc in terms of contributing

19:57

to a worsening of symptoms. Helping

20:00

people occupy their time

20:02

in meaningful ways can actually

20:04

reduce that sort of stress. Let's

20:07

talk for a minute about family. I'd

20:09

like to know what you believe the role of family

20:12

is when a relative or a spouse develops

20:15

a serious mental illness. What should a

20:17

family member do if they see

20:19

someone who seems to

20:21

be developing serious mental illness? Family

20:24

members have an absolutely critical

20:27

role to play both in the identification

20:29

of mental illnesses

20:33

as well as helping a loved one cope

20:36

with and live a fulfilling life

20:39

after they've developed mental illness. If

20:41

we go to the beginning, family members

20:44

are usually the first person to recognize

20:47

when a person is experiencing mental health

20:49

challenges. In fact, we know if

20:51

we talk about first episode of psychosis

20:54

that about 70% of the people brought

20:57

in for treatment for a first episode of psychosis

21:00

are brought in by family members. So,

21:02

family members are on the front line of

21:05

recognizing when a loved one is having a difficulty.

21:09

Sometimes mental illnesses involve

21:12

a loss of insight or awareness

21:15

that one is not functioning as

21:17

well or that one has a condition

21:19

that may in fact be treatable. So,

21:22

family members often play a role in

21:24

helping a loved one get into treatment

21:27

and can have an important role to play in

21:30

supporting their involvement in treatment as well.

21:33

That's one of the reasons why treatments

21:36

for people with serious mental illness frequently

21:39

involve a family component. Sometimes

21:42

this is referred to as family psychoeducation

21:46

and it refers to when a mental

21:48

health professional, usually a member

21:50

of the client's treatment team, engages

21:53

and works with the family, including

21:56

the client with the mental illness, to

21:58

help them understand more about their health. about the nature

22:00

of the mental illness and the principles

22:02

of its treatment as well as

22:05

to reduce stress in the family such

22:07

as by teaching or improving

22:09

communication and problem solving skills.

22:12

This enables family members to

22:15

be allies of the

22:18

client's treatment team and

22:20

to work in concert with

22:22

the treatment team in helping the

22:24

client work towards and achieve

22:27

personal goals. It would appear

22:29

that many people who are living with serious

22:31

mental illness are living in poverty.

22:34

Those of us who live in major cities often

22:36

encounter homeless people who

22:39

seem to be suffering from some kind

22:41

of delusion or other serious mental illness.

22:44

What is the relationship between poverty

22:47

and SMI? There's an important

22:49

and a complex relationship between poverty

22:52

and serious mental illness. First

22:54

of all, we know that before

22:57

a person develops a serious mental illness, higher

23:00

levels of poverty contribute

23:02

to or increase the vulnerability

23:05

of an individual to developing a mental

23:07

illness. For example,

23:09

we know that an individual who

23:11

was brought up in

23:14

a household in which there was a lack

23:17

of economic means and

23:19

in addition where there are higher rates of

23:21

trauma for living conditions and

23:24

the like are more prone to developing

23:26

mental illnesses in the first place. So

23:29

some of the poverty that comes from mental

23:31

illness may actually be

23:33

the contribution of poverty to

23:35

developing a mental health condition. Second

23:38

of all, we know that one of the

23:41

defining characteristics of a serious mental

23:43

illness is the difficulty or

23:45

inability to work and therefore

23:48

to have an income to support oneself

23:51

and that leads people to become

23:53

dependent upon a disability

23:56

programs to cover basic

23:58

living. programs

24:01

rarely provide sufficient funds

24:03

for a person to really be able to have a

24:05

decent quality of life. And

24:07

for that reason, people with serious

24:10

mental illness often live in

24:12

poverty. Other factors

24:15

can contribute to problems related

24:18

to homelessness such as

24:20

the loss of social support and

24:24

factors such as that which

24:27

are all contributing factors to

24:29

the high rate of people

24:31

with serious mental illness who are homeless.

24:34

And now you're a psychologist as we have

24:36

established but

24:37

some people with serious mental illness never

24:39

encounter psychologists in their treatment.

24:42

They're mostly treated by psychiatrists,

24:44

social workers and others. Do

24:46

you want to see more psychologists involved

24:49

in this aspect of the field? And if so, why?

24:51

How would that help? Well,

24:53

you're right that psychologists in fact

24:56

do not have as large a role

24:58

as they could play in the treatment of

25:00

people with serious mental illness. In

25:03

typical community mental health centers, there

25:06

usually are at least some master's

25:08

level psychologists who like

25:11

master's level social workers provide

25:14

many of the psychosocial treatments that

25:16

have been shown to be effective for people with

25:19

serious mental illness. This could

25:21

be intervention such as social

25:23

skills training, cognitive behavior

25:25

therapy for psychosis

25:28

or training in illness management

25:30

and recovery. But psychologists

25:32

as a profession typically have

25:35

a relatively limited role to

25:37

play in the treatment of people with serious mental

25:39

illness and yet have

25:41

potential to play a much bigger

25:43

role and to be part of the

25:46

solution of bringing more effective treatments

25:49

to the SMI population. This

25:51

is because the training of psychologists

25:55

uniquely prepares them for working

25:57

with complex cases

26:00

of individuals as people with serious

26:02

mental illness often are

26:05

and who are living in both complex

26:08

social situations involving family

26:10

members, communities and

26:12

multiple healthcare providers. So

26:15

the training of psychologists puts them in

26:17

a unique position both to

26:19

lead a treatment teams and in

26:21

particular to coordinate effective

26:24

psychosocial services to help

26:26

people with serious mental illness live a

26:29

more productive and rewarding lives. I

26:31

want to talk for a minute about two things that

26:33

are often interrelated, the stigma

26:36

against people with serious mental illness and

26:38

violence. One common stereotype

26:41

is that people with serious mental illness are more

26:43

likely to commit violent crimes and

26:46

this is only reinforced by

26:48

events like the mass shooting that recently

26:50

took place in Maine to give just one example.

26:53

But advocates often point out that people with

26:55

serious mental illness are more likely to be the

26:58

victims than the perpetrators of crime.

27:01

Where does the truth lie? First

27:03

of all, just to make the connection with stigma,

27:06

we do know that in the general

27:09

population when you ask people

27:11

questions about people who have

27:13

a serious mental illness, many

27:17

people have negative attitudes and

27:19

attitudes such as beliefs that

27:21

the person is incapable of working, incapable

27:24

of having good social relationships

27:27

and of taking care of oneself. And

27:29

there is a great deal of stigma and

27:32

even prejudice against people with serious mental

27:34

illness when it comes to things such

27:36

as housing, hiring for jobs

27:38

and things like that. Now if

27:40

you want to understand what factors

27:43

are most strongly predictive

27:46

of stigma towards people with a mental illness,

27:48

it turns out that the belief

27:51

that people with serious mental illness are

27:53

very prone to violence is

27:56

the most important predictor

27:58

of whether a person has stigma. attitudes.

28:02

We also know that the most important protective

28:04

factor against people having stigma

28:07

is having a relationship with a

28:09

person who has a serious mental illness. So

28:12

somebody who's had a family member, a friend,

28:15

a co-worker with a serious mental

28:17

illness, those individuals by

28:19

and large have much less stigmatizing

28:22

attitudes about mental illness. So

28:25

beliefs or concerns about violence

28:27

in people with serious mental illness really

28:29

go to the core of the nature

28:32

of stigma of mental illness. So

28:35

you asked about, well, what is the truth about

28:37

both violence and victimization

28:40

in people with serious mental illness? So

28:42

let's talk about victimization first. Victimization

28:46

is very, very common. We know

28:48

that childhood victimization, such

28:51

as physical and sexual abuse, has

28:53

a significant effect on increasing the

28:55

risk of an individual developing

28:57

a serious mental illness. And then

28:59

we also know that after people develop

29:02

a serious mental illness, they continue

29:04

to be more at risk for victimization

29:07

for a variety of reasons. They may live

29:09

in bad neighborhoods where they're more likely to be victims

29:12

of crime. They may lack

29:14

social judgment in terms of being able

29:16

to identify situations where they're more likely

29:18

to be victimized. And

29:21

because they have a mental illness, if

29:23

they are victimized, they may be less

29:26

likely to be believed when they report

29:28

problems such as to police or

29:31

people in the medical profession. So

29:33

we know that victimization is

29:35

very, very high among people with serious

29:37

mental illness. So now

29:40

let's turn to the question of violence. It

29:42

turns out that the research shows that

29:45

having a severe mental illness has

29:48

a very small, but it does have

29:50

a slight increase in the chances

29:53

of the person engaging

29:55

in some kind of a crime, including a possible

29:57

violent crime. This increase

30:00

is a relatively small increase

30:03

and it's something that is greatly reduced

30:05

when a person is in treatment because the medications

30:08

that can be used as well as psychosocial treatments

30:11

can lower the chances of a person

30:14

being violent. So although

30:17

there is a slight increase in the chances

30:19

of somebody being violent, the

30:21

chances are still really quite low

30:24

that a person with serious mental illness will be violent

30:27

and if you look at their lifetime history, the

30:29

chances are in fact much greater that

30:31

they will have experienced or do

30:34

experience ongoing victimization.

30:37

There's been a lot of discussion recently around

30:39

the issue of involuntary commitment or

30:41

forcing people with mental illness into

30:44

treatment, especially people who

30:46

are unhoused and this has been in

30:48

the news recently in California and

30:50

New York City. What does the research

30:52

say on this if anything is involuntary

30:55

commitment and effective way to get

30:57

people treatment, does it work? So

31:00

the question of involuntary treatment needs

31:03

to be broken down into two levels

31:05

of involuntary treatment. There

31:08

is involuntary treatment when

31:10

the person is presenting a grave

31:13

risk to themselves or to other people

31:16

and then there is involuntary treatment for

31:18

people who perhaps lack awareness

31:21

into having a psychiatric illness but

31:24

are not necessarily presenting a

31:26

grave threat to themselves or to other

31:28

people. There

31:31

is a clear role to play for involuntary

31:34

commitment for people who are presenting a grave

31:37

risk to themselves or to other people

31:40

and this is a practical

31:42

necessity in terms of the protection

31:44

of society as well as the protection of people

31:47

against themselves and

31:49

the current laws essentially

31:51

support this type of involuntary

31:54

treatment throughout the entire United

31:56

States and throughout most of the world

31:58

as well.

31:59

well.

32:00

The question of whether involuntarily

32:04

committing somebody say to outpatient

32:06

treatment in the absence of a

32:09

history of presenting a grave danger

32:11

to themselves or to other people is

32:14

a more complex one. There is

32:16

research that does not show

32:19

that involuntary outpatient treatment

32:22

helps and in fact it is a highly

32:24

controversial approach because

32:27

essentially it involves taking

32:29

away the civil rights of an individual

32:32

to choose what kinds of treatments

32:34

and what kind of lives they want to live.

32:37

There is a lack of evidence showing that involuntary

32:40

outpatient treatment actually improves

32:43

long-term outcomes of individuals

32:45

with a serious mental illness. It

32:47

also has the problem of turning the

32:50

treatment providers into guardians

32:53

or in effect having to monitor

32:55

an individual's participation

32:58

in treatment not for their own good

33:01

but rather because of a kind of a court

33:04

order or some type of a protective

33:06

order. So at this point

33:09

the role of out

33:11

of involuntary outpatient treatment remains

33:15

to be established empirically.

33:17

In fact you could you can argue that the

33:20

research indicates that does not work

33:23

and therefore efforts

33:25

to increase

33:28

involuntary outpatient commitment

33:31

are problematic in that they interfere with

33:33

the basic civil rights of people

33:35

with a serious mental illness. Those civil rights

33:37

being to make their own decisions

33:40

regarding their own treatment in the

33:42

absence of presenting a grave danger

33:44

to themselves or to other people. So

33:47

I just want to wrap up by asking what

33:50

we could be doing on a policy

33:52

level to improve the treatment

33:54

and care for people with serious mental illness?

33:57

Well there's a variety of different kinds

33:59

of of policy improvements, certainly

34:02

that could be done. One

34:05

way of improving long-term

34:07

outcomes would be to make the

34:10

funding of a broader range

34:12

of evidence-based practices more

34:15

routinely available to individuals

34:17

with a serious mental illness. I

34:19

can take one particular practice as an example.

34:22

This is the individual placement

34:25

and support called IPS

34:28

model of supported employment. Supported

34:31

employment is an approach to helping people

34:34

get and keep competitive jobs

34:36

that places a priority on rapid

34:39

job search to

34:41

help people find jobs related to

34:43

their areas of interest, and then

34:45

providing the ongoing supports

34:48

in order to keep these jobs. There

34:51

are over 25 randomized

34:53

control trials showing that

34:55

supported employment programs based

34:58

on the IPS model are more

35:00

effective than any other vocational rehabilitation

35:03

approach to helping people get

35:06

and keep competitive jobs. We've

35:08

already discussed how getting and

35:10

keeping competitive work

35:13

can both improve financial standing

35:16

and reduce risk of relapse and

35:18

rehospitalization. In addition,

35:20

getting work can be de-stigmatizing

35:23

because other people see that the individual

35:26

with serious mental illness is capable

35:28

of working and contributing to society. Yet

35:31

despite this, throughout the United States,

35:34

most states lack a

35:37

central funding mechanism for

35:40

funding IPS-supported

35:43

employment. In fact, the

35:45

funding difficulties with this intervention

35:48

continue in the majority of states

35:51

in the US today. This

35:54

is an example of where there's a need for

35:57

review or revision of policies.

36:00

supporting mental health services in

36:02

order to support the wide-scale

36:06

implementation of an evidence-based

36:08

practice for improving employment

36:11

outcomes in people with serious mental illness. Dr.

36:14

Musso, I want to thank you for joining me. I

36:17

think you have dispelled some of the myths

36:19

about people with serious mental illness. I really

36:21

appreciate that. Kim, it's been a

36:23

delight to be here. I have really enjoyed

36:26

talking with you and to spread

36:28

the good word about how much progress we

36:30

have made in the treatment of serious mental

36:32

illnesses. Absolutely. Thank

36:34

you. You can find previous

36:37

episodes of Speaking of Psychology on our

36:39

website at www.speakingofpsychology.org

36:43

or on Apple, Spotify, YouTube,

36:45

or wherever you get your podcasts. And

36:47

if you like what you've heard, please leave us a review.

36:51

If you have comments or ideas for future podcasts,

36:53

you can email us at speakingofpsychology.org.

36:58

Speaking of Psychology is produced by Lee Weinerman. Our

37:01

sound editor is Chris Condayan. Thank

37:03

you for listening. For the American Psychological

37:05

Association, I'm Kim

37:07

Meech. Thank

37:51

you.