2023- A U.S. Psychologist gives a personal view- Begins describing Mental Health Challenges- a term we BROUGHT INTO COMMON ACCEPTED Worldwide USAGE but with interviewer’s prompts, etc. falls back into the Old Words…Mills: What do we know about the role of medication versus some of these other types of treatments for serious mental illness are both necessary? Or can medication alone, for example, treat SMI?

Mueser: Probably for most people, medication alone is insufficient for treating a serious mental illness. There certainly may be some individuals where medication is really all they need to get back to living their day-to-day lives. But for the larger majority of individuals with a serious mental illness, medication can reduce the burden of symptoms and it can also reduce the chances of a person having a relapse of symptoms, but it can’t help them relearn life skills or help them reconnect with jobs, school and other kinds of important functions that perhaps they were playing before in their lives. And so that’s where the role of psychosocial treatment comes in, which is helping people whose symptoms are under control. It could be that the symptoms are either in remission or that they are less severe than in an exacerbated state. Learn new skills and get on with the business of living, whether it’s going to school or work or parenting and just enjoying good social relationships.

Mills: Can people with SMI recover completely or do they have to continue medication and other therapeutics for the rest of their lives?

Mueser: Well, that’s a very interesting question because it gets to what do we mean by recovery? It used to be that recovery was very conventionally defined in medical terms, meaning that a person was recovered if they didn’t have any symptoms of the illness anymore, or related impairments. But over the last 20 to 30 years, the concept of recovery has really been redefined to make it something more personally meaningful to individuals who have a serious mental illness. And so recovery now refers to getting on with the process of living one’s life and being able to live and participate in one’s communities, being able to work, to have social relationships and the like despite potentially having ongoing symptoms or challenges related to a mental illness. So the idea of recovery has been reconceptualized to refer to recovery in terms of living a meaningful and rewarding life for the individual, even if they may have some continued challenges related to the mental illness.

So from that perspective, recovery is possible even though a person may continue to have symptoms or take medication for a mental illness at the same time, to get back to the medical definition of recovery, like not having any more symptoms or any more impairments, it certainly is possible. In fact, we know that people do recover from mental illnesses across the lifespan. For some people it takes many, many years. For other people, it can happen after just a few years or even a single episode or two. And so there are people who may end up stopping taking medication, not needing it anymore, and no longer having any symptoms revisit them. And this can happen either earlier in the course of the illness or later on in the course of the illness. So medical recovery is also possible.

Mills: Now, one of your main areas of research is treatment for first episode psychosis, especially using something called coordinated specialty care. Why is early treatment like this so important and what does it involve?

Mueser: So early treatment of psychosis or early treatment of schizophrenia refers to when you try to provide treatment as soon as possible after the characteristic symptoms of psychosis have been identified. This is often referred to as first episode psychosis. And to be specific, it really means first episode, non-affective psychosis. When I say non affective psychosis, we’re talking about when the first symptoms of psychosis, such as hearing voices or having delusions, occur in the absence of the person having a significant mood disorder or mood symptoms such as major depression or such as a manic episode when people have a major depression, thoughts of worthlessness feeling like life is not worth living, depression, loss of appetite, or things like, or when a person is in the midst of a manic episode in which they may have a great decreased need for sleep, they may have grandiosity, they may pursue things relentlessly without really thinking them through during the height of one of these mood episodes. It’s very common for people to have psychotic symptoms. And so if the mood episode is treated, either major depression or bipolar disorder, those psychotic symptoms usually go into remission.

When we’re talking about first episode of psychosis, we’re talking about people who experience psychotic symptoms like hearing voices and delusions, but they’re not experiencing these symptoms in the midst of a mood episode like mania or depression. So first episode psychosis usually reflects the beginning of the illness of schizophrenia when it’s in the first six months of a person developing the symptoms and becoming impaired. The name of the disorder is called schizophreniform disorder. It’s considered a schizophrenia spectrum of disorder. And then after six months, if symptoms continue and to some extent impairments continue, then the person may meet criteria for either schizophrenia or the related disorder of schizoaffective disorder. Schizoaffective disorder is a little bit like schizophrenia, but it means the person also has significant episodes of either mania or depression in addition to the other schizophrenia symptoms.

So the reason why it’s so important to intervene early and comprehensively in people who develop a first episode of psychosis is that the disorder tends to develop relatively early, in either late adolescence or early adulthood. Typical onset occurs sometime between the ages of 16 and 17 up to around say 35, although it certainly could develop even after the age of 35, even into one’s forties and fifties. But because it’s not that common a disorder, the prevalence of schizophrenia is around 1% in the general population, it’s often missed by clinicians and by family members and by people in the medical profession because they don’t understand what psychosis is and they don’t recognize when a person is having psychotic symptoms. Interestingly, this can occur even for people who are receiving mental health treatment from a mental health professional because the mental health professional may not be aware that they have developed psychotic symptoms if they haven’t done the appropriate screening.

So what happens is that people sometimes go for extended periods of time before their psychotic symptoms are recognized and before they’re treated. And the problem with this is that the longer you go before treatment for a first episode of psychosis, the more difficult it is to treat it once the person comes into treatment and the more problematic outcomes there may be before the person gets into treatment. So for example, it’s possible for people to commit suicide before they ever get into treatment for a first episode of psychosis, and in that case, suicide could have been prevented. Or sometimes what happens is that a person may become delusional and they may become paranoid, for example, and they may do harm to other people because of their psychotic symptoms. And that harm could be prevented if the first episode of these symptoms were detected and treated. So in addition to preventing the harm from occurring when the symptoms of psychosis are not treated, the other thing is that we know for many people, schizophrenia can last a significant period of time, sometimes a lifetime.

And so the earlier we can provide effective and comprehensive treatment, the more opportunity we have for helping people develop coping skills, skills from preventing relapses, the more we can help them develop the kind of skills for having good, rewarding interpersonal relationships, for providing the supports for returning to school and work, and in effect getting on with a business of living. So the first episode of psychosis represents an opportunity to intervene early in the long-term course of schizophrenia with the potential of improving the long-term trajectory of the disorder in terms of both disability as well as improving the quality of life of individuals.

Mills: You mentioned employment a moment ago, and I know you’ve written about the importance of helping people with serious mental illness find employment. What role does meaningful work play in recovery?

Mueser: That is one of my favorite questions because meaningful work is potentially one of the most important parts of the recovery process. People used to think that everything else needed to be under control and in perfect shape before you could help a person get a job or perhaps return to school. But now we realize that first of all, people are capable of working, and in fact, that work has beneficial effects even if they may continue to have particular symptoms or cognitive challenges. And that working provides a sense of meaning and integration into one’s community and occupies people’s time in a meaningful and purposeful fashion that is both beneficial in terms of the person’s improving their financial standing. And we now know that helping people get jobs can actually offer them a certain protection against relapses and rehospitalizations. And the reason is that, or one of the reasons is that when people work, it structures their time in a meaningful sort of way. And we know that lack of structure can be stressful for everyone, and especially somebody with a major mental illness. The lack of structure can play havoc in terms of contributing to a worsening of symptoms. So helping people occupy their time in meaningful ways can actually reduce that sort of stress.

Mills: Let’s talk for a minute about family. I’d like to know what you believe the role of family is when a relative or a spouse develops a serious mental illness. What should a family member do if they see someone who seems to be developing a serious mental illness?

Mueser: Family members have an absolutely critical role to play both in the identification of mental illnesses as well as helping a loved one cope with and live a fulfilling life after they’ve developed mental illness. If we go to the beginning, family members are usually the first person to recognize when a person is experiencing mental health challenges. And in fact, we know if we talk about first episode of psychosis that about 70% of the people brought in for treatment for a first episode of psychosis are brought in by family members. So family members are on the frontline of recognizing when a loved one is having a difficulty. Sometimes mental illnesses involve a loss of insight or awareness that one is not functioning as well, or that one has a condition that may in fact be treatable. And so family members often play a role in helping a loved one get into treatment and can have an important role to play in supporting their involvement in treatment as well.

That’s one of the reasons why treatments for people with serious mental illness frequently involve a family component. Sometimes this is referred to as family psychoeducation, and it refers to when a mental health professional, usually a member of the client’s treatment team engages and works with the family, including the client with the mental illness to help them understand more about the nature of the mental illness, and it’s the principles of its treatment as well as to reduce stress in the family, such as by teaching or improving communication and problem solving skills. This enables family members to be allies of the clients a treatment team, and to work in concert with the treatment team in helping the client work towards and achieve personal goals.

Mills: It would appear that many people who are living with serious mental illness are living in poverty. Those of us who live in major cities often encounter homeless people who seem to be suffering from some kind of delusion or other serious mental illness. What is the relationship between poverty and SMI?

Mueser: There’s an important and a complex relationship between poverty and serious mental illness. First of all, we know that before a person develops a serious mental illness, higher levels of poverty contribute to or increase the vulnerability of an individual to developing a mental illness. So for example, we know that an individual who was brought up in a household in which there was a lack of economic means, and in addition, where there are higher rates of trauma, poor living conditions and the like are more prone to developing mental illnesses in the first place. So some of the poverty that comes from mental illness may actually be the contribution of poverty to developing a mental health condition. Second of all, we know that one of the defining characteristics of a serious mental illness is the difficulty or inability to work, and therefore to have an income to support oneself. And that leads people to become dependent upon disability programs to cover basic living. But these disability programs rarely provide sufficient funds for a person to really be able to have a decent quality of life. And for that reason, people with serious mental illness often live in poverty. Other factors can contribute to problems related to homelessness, such as the loss of social support and factors such as that, which are all contributing factors to the high rate of people with serious mental illness who are homeless.

Mills: And now you’re a psychologist, as we have established, but some people with serious mental illness never encounter psychologists in their treatment. They’re mostly treated by psychiatrists, social workers, and others. Do you want to see more psychologists involved in this aspect of the field? And if so, why? How would that help?

Mueser: Well, you’re right that psychologists in fact, do not have as larger role as they could play in the treatment of people with serious mental illness. In typical community mental health centers, there usually are at least some master’s level psychologists who like master’s level social workers provide many of the psychosocial treatments that have been shown to be effective for people with serious mental illness. This could be intervention such as social skills training, cognitive behavior therapy for psychosis or training in illness management and recovery. But psychologists as a profession typically have a relatively limited role to play in the treatment of people with serious mental illness and yet have potential to play a much bigger role and to be part of the solution of bringing more effective treatments to the SMI population. This is because the training of psychologists uniquely prepares them for working with complex cases of individuals as people with serious mental illness often are, and who are living in both complex social situations involving family members, communities, and multiple healthcare providers. So the training of psychologists puts them in a unique position both to lead treatment teams and in particular, to coordinate effective psychosocial services to help people with serious mental illness live a more productive and rewarding lives.

Mueser: First of all, just to make the connection with a stigma. We do know that in the general population, when you ask people questions about people who have a serious mental, many people have negative attitudes and attitudes such as beliefs that the person is incapable of working, incapable of having good social relationships and of taking care of oneself. And there is a great deal of stigma and even prejudice against people with serious mental when it comes to things such as housing, hiring for jobs and things like that. Now, if you want to understand what factors are most strongly predictive of stigma towards people with a mental, it turns out that the belief that people with serious mental are very prone to violence is the most important predictor of whether a person has stigmatizing attitudes. We also know that the most important protective factor against people having stigma is having a relationship with a person who has a serious mental.

So somebody who’s had a family member, a friend, a coworker with a serious mental…, those individuals, by and large have much less stigmatizing attitudes about mental… You asked about, well, what is the truth about both violence and victimization in people with serious mental…? So let’s talk about victimization first. Victimization is very, very common. We know that childhood victimization, such as physical and sexual abuse has a significant effect on increasing the risk of an individual developing a serious mental… And then we also know that after people develop a serious mental, they continue to be more at risk for victimization, for a variety of reasons. They may live in bad neighborhoods where they’re more likely to be victims of crime.

They may lack social judgment in terms of being able to identify situations where they’re more likely to be victimized. And because they have a mental illness, if they are victimized, they may be less likely to be believed when they report problems such as to police or people in the medical profession. So we know that victimization is very, very high among people with serious mental illness, the chances are still really quite low that a person with a serious mental illness will be violent. And if you look at their lifetime history, the chances are in fact much greater that they will have experienced or do experience ongoing victimization.

Mills: There’s been a lot of discussion recently around the issue of involuntary commitment or forcing people with mental… into treatment, especially people who are unhoused. And this has been in the news recently in California and New York City. What does the research say on this, if anything? Is involuntary commitment an effective way to get people treatment? Does it work?

Mueser: So the question of involuntary treatment needs to be broken down into two levels of involuntary treatment. There is involuntary treatment when the person is presenting a grave risk to themselves or to other people. And then there’s involuntary treatment for people who perhaps lack awareness into having a psychiatric…, but are not necessarily presenting a grave threat to themselves or to other people.

There is research that does not show that involuntary outpatient treatment helps. And in fact, it is a highly controversial approach because essentially it involves taking away the civil rights of an individual to choose what kind of treatments and what kind of lives they want to live. There’s a lack of evidence showing that involuntary outpatient treatment actually improves the long-term outcomes of individuals with a serious mental… It also has the problem of turning the treatment providers into guardians, or in effect, having to monitor an individual’s participation in treatment not for their own good, but rather because of a kind of court order or some type of a protective order. So at this point, the role of out of involuntary outpatient treatment remains to be established empirically. In fact, you can argue that the research indicates that it does not work, and therefore efforts to increase involuntary outpatient commitment are problematic in that they interfere with the basic civil rights of people with a serious mental.., those civil rights being to make their own decisions regarding their own treatment in the absence of presenting a grave danger to themselves or to other people.

Mills: So I just want to wrap up by asking what we could be doing on a policy level to improve the treatment and care for people with serious…

Mueser: Well, there’s a variety of different kinds of policy improvements, certainly that could be done. One way of improving long-term outcomes would be to make the funding of a broader range of evidence-based practices, more routinely available to individuals with a serious mental. I can take one particular practice as an example. This the individual placement and support called IPS Model of supported employment.  Supported employment is an approach to helping people get and keep competitive jobs that places a priority on rapid jobs search to help people find jobs related to their areas of interest, and then providing the ongoing supports in order to keep these jobs. There are over 25 randomized controlled trials showing that supported employment programs based on the IPS model are more effective than any other vocational rehabilitation approach to helping people get and keep competitive jobs. And we’ve already discussed how getting and keeping competitive work can both improve financial standing and reduce risk of relapse and rehospitalization.

In addition, getting work can be destigmatizing because other people see that the individual with serious mental is capable of working and contributing to society. And yet despite this throughout the United States, most states lack a central funding mechanism for funding IPS supported employment. And in fact, the funding difficulties with this intervention continue in the majority of states in the US today. And so this is an example of where there’s a need for review or revision of policies supporting mental health services in order to support the wide scale implementation of an evidence-based practice for improving employment outcomes in people with serious mental