Effective workplace communication with employees with psychiatric disability
- Implementation guide
- Psychiatric disability
- Talking about talking and listening
- Talking about learning
- Talking about the job
- Talking about tools
- Talking about safety
- Talking about quality and quantity
- Talking about teams and workmates
- Talking about problems
- Talking about changes
- Talking about futures
An introduction to psychiatric disability
- Let's talk about terms
- Mental illness
- What is mental illness?
- Treatments for mental illness
- The major mental disorders
- Effects of mental illness
- The issues for employment services
- Key points
Two important terms are used this resource.
- Mental illness: When we say someone has a mental illness we mean they have a disorder of the mind that results in disruption of the person's thinking, feeling, moods, and ability to relate to others.
Just as a physical illness affects our bodily functioning in some way, a mental illness affects the functioning of the mind. A medical doctor looks for bodily symptoms in a patient suffering something physical. (Does he have fever? A rash? Pain when swallowing?). In diagnosing a mental illness a psychiatrist will consider how the patient's mental functioning relates to the norm. (Is she alert to what is happening around her? Does she see things that are not in fact there? Is her conversation 'on track'?) Just as there are relatively clear criteria for defining a healthy body, enough is known about how the mind works to determine if it is functioning properly.
Both physical and mental illnesses are classified by the category of disorder into which they fall(cardio-vascular disorders, mood disorders), and each of these major categories is then broken down into further categories (for example, arrhythmia, aortic aneurysm, depression, bipolar disorder), each getting more and more definitive regarding the specific symptoms related to a particular disorder or condition.
- Psychiatric disability: We say someone has a psychiatric disability when the effects of a mental illness cause disruption or difficulty in their ordinary daily functioning. Mental illness can impair someone's ability to carry out daily activities such as working, learning and caring for themselves during periods of the illness. For example, a person experiencing an episode of psychosis may have severe problems concentrating on tasks.
A psychiatric disability is a problem or problems that people experience because they have, or have had, some sort of mental illness or disorder.
The information in this section is very general. It aims to give you a basic understanding of the nature of mental illness, the way it can impact on people and some of the issues that can arise for you in your work.
The term 'mental illness' describes a very broad range of mental and emotional conditions. Accurately determining the cause and predicting the outcomes of mental illness is almost impossible.
Mental illness affects many people in the community. At any one time around 15 per cent to 20 per cent of the population demonstrates symptoms of mental illness warranting further investigation. Another 15 per cent to 20 per cent of people are unhappy or psychologically distressed in some way. Many of these people can work through these problems; others will require support.
For some, psychiatric disorders will lead to serious impairment of their functioning – their ability to interact with others, learn efficiently, work, transact business, negotiate their way through everyday tasks and activities. They are therefore experiencing psychiatric disability.
- Mental illness is caused by a complex combination of biological, psychological and social factors.
- There is growing evidence about the role, in mental illness, of the structure of the brain, the fundtion of the brain and chemical activity in the brain and the nervous system.
- Mental illness results in emotional and behavioural difficulties and may cause a person to engage in behaviour that may be considered unusual and/or unacceptable, or 'abnormal'.
- Mental illness can be diagnosed by a psychiatrist or psychologist.
- Mental illness can be episodic.
Written records of the search for cures and the practice of treating people with mental illness go back at least 3,000 years.
In the middle ages, mental disturbance was considered evidence of possession by evil spirits.
In later ages, people who were mentally ill were generally cared for in institutions. Mental illness was viewed as shameful, a stigma that was best hidden. By the 19th century most large cities around the world, including Australian state capitals, had at least one institution, often called something like a 'lunatic asylum', built in an isolated part of the city to house people with mental illness well away from the rest of the population.
Institutionalised care often produced adverse effects in addition to those caused by the disorder. Patients, separated from family and mainstream society, often regressed to levels where they required almost total care.
In the 1960s and 70s the development of a group of drugs (phenothiazines or 'anti-psychotics'), led to profound changes in the treatment of mental illness, enabling people to spend much shorter periods of time in hospital. The concept of psychosocial rehabilitation grew to include the development of planned support systems and an integrated community approach to mental health care.
Today, people with mental illness can be assisted through one or a combination of three forms of assistance or 'treatment'. Mental illness can be episodic and the different forms of assistance or 'treatment' reflect this changing nature of an individual's illness.
1 Drug therapy (psychoactive medication)
Many employment service employees with psychiatric disability will be taking some form of medication, which may have side effects associated with it. Four categories of medication are commonly used in the treatment of mental illness:
- anti-psychotic drugs
- anti-anxiety drugs
- mood stabilisers.
2 Psychotherapy (counselling)
There are hundreds of types of psychotherapies. Cognitive behavioural therapy, for example, is a relatively short-term and focused way of treating types of emotional, behavioural and mental health problems. It helps people identify unhelpful thoughts and behaviours and to learn (or relearn) healthier ones.
3 Psychosocial approaches
This approach involves assembling a 'package' of support services to assist people with mental illness live as normally as possible in their communities. Employment services play a vital role in this support.
Community support systems have a key role in the alleviation of isolation, vulnerability and feelings of rejection in people with a mental illness, and in their learning and relearning of crucial social and interpersonal skills.
Medicine has identified more than 200 forms of mental illness. The most common forms of mental illness fall into three categories: anxiety disorders, mood disorders, and schizophrenia and psychotic disorders.
This is the most common group of mental illnesses. Anxiety disorders are characterised by severe fear or anxiety associated with particular objects and situations. Anxiety is marked by negative feelings and tension because a person feels apprehensive about something that might happen in the future.
Everyone gets anxious and nobody likes the feeling much but it is a normal part of experience, and helpful in keeping us alert. However, too much anxiety can be extremely harmful and, in some people, becomes a controlling feature in their lives. Severe anxiety usually doesn't go away and people can go for long periods not accepting that there may really be nothing to fear.
Anxiety disorders can include the following.
- Panic disorder. 'Panic attacks' are abrupt experiences of intense fear or discomfort with physical symptoms including heart palpitations, chest pain, shortness of breath and dizziness.
- Generalised anxiety disorder is excessive anxiety and worry occurring as a general response to most situations. As it is not due to any particular cause, the person has great difficulty controlling the worry.
- Specific phobia is an irrational fear of a specific object or situation (snakes, heights, flying, darkness) that interferes with the person's ability to function. Claustrophobia – a fear of enclosed spaces – is an example of a specific phobia.
- Post-traumatic stress disorder (PTSD) is a psychological syndrome characterised by specific symptoms that result from the person having experienced, or been exposed to, a terrifying life threatening situation – such as an act of violence, natural disaster, war, etc.
- Obsessive-compulsive disorder (OCD) is the most complex and debilitating of the anxiety disorders. People with OCD often experience some of the other anxiety conditions as well. A person with OCD has obsessions – thoughts, images or urges – that interfere with their thinking. These obsessions may make no sense but the person cannot overcome them. At the same time, they will also have compulsions to think or say or do something. These compulsive behaviours and thoughts are designed to suppress the obsessive thoughts – for example, walking in very small steps in a set pattern to curb some obsession.
Most people, most of the time, can regulate their moods and make them 'fit' with the circumstances. People who suffer mood disorders have great difficulty monitoring and regulating the moods they experience and their moods may often seem unrelated and out of touch with the context in which they occur. Two types of mood experience – depression and mania – contribute to a mood disorder.
Depression is when the clinically-depressed person perceives a world in which everything is hopeless and negative, and beyond any control on their part.
Mania is a period of abnormally marked elation, joy or euphoria. When in a manic state, a person will derive immense pleasure from everything and have enormous energy, requiring little sleep. Sometimes the mania can lead people into behaviours and activities that are completely alien to their usual patterns of life, such as wild extravagance (often based on unfounded optimism) or sexual promiscuity.
It is important to appreciate that some people experience depression or mania singly, some have both at different times (bipolar mood disorder – previously called manic depression), while a few even have both at the same time (elation and energy, but depression or anxiety as well). Each person is likely to have different patterns in terms of the timing of episodes, what (if anything) seems to bring them on, whether they actually recover fully between episodes and how much their normal, day-to-day functioning is affected.
A psychosis is a severe mental disorder characterised by disorganisation of the thought processes, disturbances in emotions, disorientation to time, space and person, and, in some cases, hallucinations and delusions. Schizophrenia is one of the disorders that involves psychotic behaviours and is by far the most common. Every year an estimated three to four thousand people enter public hospitals in Australia with a diagnosis of schizophrenia. Around one in a hundred people will experience schizophrenia, usually starting in early adulthood.
Schizophrenia is an extremely complex disorder. The symptoms can include:
- Disorganised thinking. Thinking becomes disorganised as the ability to make associations between ideas and events is disturbed by the psychotic condition.
- Emotional effects. Schizophrenia frequently disturbs the individual's awareness of and ability to monitor their emotional expression. Frequently there is a shallowness or blunting of emotion.
- Perceptual disturbance. Schizophrenia often produces perceptual disturbances in the form of hallucinations – perceptions of things that others do not perceive. The most common hallucinations experienced by people with schizophrenia are auditory – usually in the form of voices.
- Delusions (false beliefs) develop out of distorted perceptions. Common delusions are beliefs about persecution (my house has been bugged by ASIO), and grandeur (the prime minister asks for my advice).
- Contact with reality is likely to be disturbed by the condition as people become disoriented in time and place and lose their sense of personal self.
- Disturbed motor behaviour (movement) may also be evident. There may be significant reduction of spontaneous activity or stereotyped movements. Mannerisms, grimacing, pacing, rocking or immobility may occur.
As with any condition, the effects of a mental illness differ from person to person, even those diagnosed with the same condition.
- Difficulties relating to others – People with mental illness may find it hard to trust people as a direct effect of their illness. For example, the experience of paranoia (delusions of persecution or grandeur that may accompany psychotic disorders) will often make the person extremely suspicious of others. Similarly, they may see life as unpredictable and insecure, making them appear very pessimistic and 'disbelieving' in response to what others say or do.
- Dependency and helplessness – The nature of a mental illness can make a person feel helpless and dependent on others. They feel powerless to do anything themselves and want and expect others to do it for them.
- Loss of self-esteem – Very often, mental illness is accompanied by feelings of low self-worth which can be expressed in a number of ways including depression, over-timidness, flat emotional expression, lack of interest in personal care, low eye contact, lack of confidence when talking to others. It can also be disguised in over-confidence, aggression and attention-seeking behaviour.
- Stress – A mental illness may make a person less immune to stress and less able to cope with stressful situations.
- Agitation – Symptoms of mental illness are often displayed in varying degrees of agitation which can take both physical (for example, pacing, hand-wringing) and emotional ('racing' thoughts, rapid speech) forms of expression.
- Anxiety – People with a mental illness (of any kind) are more likely to feel anxious.
- Amnesia – Short or long-term loss of memory is often experienced as part of a mental illness.
- Problems with routine – People with mental illness can have problems following routines, or get very stressed if there is any change to routines.
- Self-care and appearance – A very common effect of mental illness is that people cease to care properly for themselves (washing, grooming, dressing). In some cases, bizarre behaviours might become part of self-care – wearing unusual clothes, dressing up as another person or character.
- Lack of motivation – Many forms of mental illness affect a person's motivational levels. Mood and anxiety disorders and psychotic conditions may all have low motivation as a symptom.
- Passivity and withdrawal – Extremely withdrawn and passive behaviour may be part of a mental illness for some people. The affected person may agree to anything, do anything they're told to do, or simply fail to interact and engage with others.
- Depression and suicidal thoughts – Typical signs that someone is suffering a major depression are fatigue, low interest, poor concentration, changes in sleep and eating patterns, feelings of hopelessness and isolation, and thoughts of death and suicide.
- Anger and aggression – Anger and aggressive behaviour can stem from an altered mental state. It is also commonly a product of strong fears, frustration or a sense of powerlessness.
Any service that aims to assist people with psychiatric disability build their work skills is involved in assisting them to learn, and some people with psychiatric disability may face significant communication and learning problems.
Individual functioning in employment is also likely to be affected by some specific characteristics of psychiatric disability, which include:
- The irregular nature of mental illness – Many forms of mental illness are episodic. Symptoms may be present for a few weeks or months, then disappear or lessen significantly, for a period of time. This can create problems in establishing and maintaining work patterns and with the person's work performance.
- Stress associated with disclosure of mental illness and symptoms – There is still a lot of stigma associated with mental illness. People with mental illness often feel compelled to try to hide their illness and its symptoms, particularly at work.
- Side effects of medication – Medications can have side effects that create difficulties at work. These include:
- dry mouth
- tremor (shakiness)
- weight gain.
- Interrupted education or training – Many people develop the first symptoms of mental illnesses between the ages of 15 and 25. This often causes a major interruption to their education and/or vocational training.
- More than one issue – Around 30 per cent of adults with mental illness have been diagnosed with an alcohol and/or drug or substance abuse issue during their lives.
When working with people with psychiatric disability it is useful to remember the following.
- You will get the best understanding of a person's psychiatric disability from working, listening, talking, observing, interacting and understanding things from their point of view.
- The impacts of psychiatric disability vary from person to person and can change over time, so as you get to know the person and the effects of the disability you will get a better idea of how best to support the individual.
- The effects of mental illness have the same dominating effect on the lives of people with it as a physical illness does. When you experience a physical illness it is likely that you will get a bit of sympathy and understanding from friends or workmates – often because they have had a similar experience. The same understanding and care is not always given to people with mental illness; they may have to deal with friends or workmates who think that mental illness is not 'real'.
- You need to be aware of the specific impacts of psychiatric disability on the individual you are working with. It is helpful to be aware of:
- the major effects of the condition that are leading to psychiatric disability – working with the employee's case manager may be the best way to gather this information
- recommended learning and communication strategies
- other services the employee is receiving and/or can access
- other support sources available to the employee
- what employment support the employee wants from you.