Research: Myths of the ‘Crazy’ Client

Myths of the ‘Crazy’ Client

Published in Journal of the Phillip’s Graduate Institute,

Progress: Family Systems Research and Therapy

Volume 9 – Summer 2000

By

Karalee L. Bechtol, M.A.

The study of schizophrenia represents a cornerstone on which much of family therapy has been built. Theorists such as Bowen, Haley and Whitaker based much of their research on work with this population and their families. Yet many Marriage and Family Therapists prefer to avoid working with this group, often stating that it is out of their “scope of practice.” Many desperate individuals and their family members are referred to others when they are most in need of the help that a caring clinician could provide.

An original qualitative study was conducted involving ten marriage and family interns and trainees, seven of whom were female and three male. These participants were interviewed using a semi-structured interview protocol regarding their desire to work with this population. How myths and the media impact their desire to work with chronically mentally ill clients was explored.

In examining the results, seven common myths emerged which are believed by many of the participants to be true. Unexpected results also emerged, as two of the participants had had close personal contact with someone diagnosed with a psychotic disorder. Their answers to the fifteen questions were vastly different than those who had never met someone in this population. It could be implied from these data, that the views of participants who had never met someone with a mental illness are based on myths that society at large hold to be true and upon the media’s interpretation of the mentally ill. 

     In studies of the four major ‘unacceptable’ groups in society—ex-convicts, alcoholics, the mentally retarded, and the mentally ill—the mentally ill are rated the most unacceptable. Schroder and Ehrlich (1968) demonstrate that mental health professionals share these attitudes as many believe that there are no rewards and there is no prestige in working with people who are mentally ill.

It is a common misconception that more enlightened and educated professionals will have less exclusionary attitudes than the general public. However, Rabkins’s (1974) comprehensive review of the literature on public attitudes toward the mentally ills suggests that while education may lead to correct identification and labeling of various mental illnesses, it does not prevent rejection or bias. It appears from this review that the public is less quick than mental health professionals to label odd or deviant behavior as mental illness. Rabkin (1974) states that once a label is assigned, the response is almost always rejecting.

Professional resistance to working with people with mental illnesses may be due to the fact that the resistance, as a problem, has been studied so little. One of the few studies on this topic specifically measured professionals attitudes toward people with mental illness. In this study, 85% of the respondents agreed that they would prefer not to treat this population. Fifty-five percent believed that most clinicians prefer to avoid them altogether, and 65% believed that there were no satisfying professional rewards in treating the chronically mentally ill, (Mirabi, Weinman, Magnetti & Keppler, 1985). In a similar study by Schwartz, Krieger and Sorenson (1981), therapists working with people who have a mental illness reported that the least satisfying aspect of their work was being devalued by their professional peers.

These negative attitudes are firmly instilled during professional training and are very difficult to change over time. Interns and trainees begin to adopt these attitudes early in their training and schooling. Minkoff (1987) believes that it is easier to develop positive attitudes in trainees who are still in their graduate programs, as they are more open to learning new ideas. It is much more difficult to try to teach established professionals to “unlearn” the negative attitudes they already have. Although it is easier to teach those who are early in their careers, a significant majority of students believe that their schooling and training does not prepare them adequately to successfully treat people with mental illness. Furthermore, much of the information available through many master’s programs is outdated and inaccurate.

The task force on families and mental illness of the California Allicance for the Mentally Ill conducted a survey of California graduate training programs in the core mental health disciplines. They found that 53% of all training programs surveyed still teach a theory of family causation for the serious mental illnesses. Eighty-two percent of the programs reported that they prepare their students only “somewhat” or “not at all” to work with families of people with mental illness (Amenson, 1998). This tendency for graduate programs to ignore this population adds to the strong stigma that they are not work working with.

Minkoff and Stern (1985) believe that when clinicians assume that clients cannot be helped, they, as a result become useless in helping them because they do not pursue the knowledge and skills they need to become successful in treating them. Minkoff (1987) believes that with regard to people with mental illness, supervisors are more likely to convey misinformation and pessimism, rather than positive attitudes, comprehensive skills, and successful treatment experiences. The purpose of this study was to explore and confront the assumptions and attitudes that are prevalent among mental health professionals, specifically Marriage and Family trainees and interns.

METHOD

This study explored existing myths and how the media’s portrayal of severe mental illness impacts Marriage and Family Therapists (MFT) trainees’ and interns’ desire to work with this population and their families. Effective treatment models that can help therapists overcome barriers they face in working with this population are examined.

The ten participants in this study were drawn from interns and trainees working toward licensure in marriage and family therapy. All participants were either in their third or fourth semester of their graduate program, or had recently graduated from Phillip’s Graduate Institute, California State University, Northridge, or Antioch University.

The people involved in this study were recruited primarily through word of mouth and solicitation at internship sites located in Los Angeles County. All participants were volunteers. Three men and seven women were interviewed. They ranged in age from mid twenties to mid fifties. All but two participants had never met or known anyone with a sever mental illness.

A qualitative approach was taken using a semi-structured interview format Answers to the questions were reviewed for common themes and beliefs among the participants regarding working with the mentally ill population, and the media’s impact on the participants. Through comparison of the ten interviews, patterns and themes were identified. Prevailing myths, as well as the interns’ and trainee’s views of mental illness were considered. Participants’ current preparation to work with the mentally ill population was noted.

RESULTS

Myth#1: There is little hope for this population

     When asked, “What do you perceive the outcome of therapy to be with this population?” most participants responded negatively. Andy stated the treatment is “most times, pretty dim…once they’re gone, they’re gone. Doing just the menial tasks of everyday life are very difficult for them.”

Sue stated that therapy “would be more toward behavior modification or token economy to facilitate them fitting in with our society.” Sally believes “A person who is severely mentally ill probably does better in an institution, where, if it’s a good institution, they can get modern help and they have a similar population to themselves.”

Dana replied that, “They don’t do therapy, and therefore there would be no outcome.” Holly said, “They will not recover…and some of them can, sort of, be on their own, but most of them do best in group homes.”

Myth #2: Out of Scope of Practice

     When asked “What would you do if someone with a mental illness came to you for help?” most stated that someone diagnosed with a mental illness was out of their scope of practice and/or they would refer them out, rather than explore what the nature of the problem was. Mary stated, “I think that it would be a population I wouldn’t ethically feel comfortable with.”

Dana answered, “It didn’t even dawn on me that marriage and family therapists would work with that or that they got any kind of therapy other than with a psychiatrist. I just didn’t even imagine that it would be something that I would deal with. I don’t think that MFTs have enough of the medical background to really work with that. A person with schizophrenia is beyond my scope of practice. Ethically, I would have to refer them out.”

Holly replied “That’s an expertise that we’re not really trained in nor is it within our scope of competence. I would refer them out.”

Joe stated, “Right now it’s perhaps beyond my scope of experience.”

Myth #3: Working with this population is unfulfilling, depressing and frustrating

When asked, “How would you feel about working with this type of client?” six of the ten participants used negative words in their response. Two participants stated that they would rather continue to work with the type of clients they are working with now.

Andy said that it would be “Too challenging and not rewarding enough. Too difficult…Frustrating as Hell. I would be frustrated and don’t think I would want to work with them.” Mary answered, “It would be really difficult for me. My countertransference would be so great, especially when you’re working with someone who has been so damaged.”

Jill stated, “I don’t anticipate working with the mentally ill. There is very little hope, and that, for me personally…I would get too depressed and I would feel really hopeless. It would be really hard.” Sue said, “I think it’s too much of a difficult population to work with and that there is very little positive outcome.”

Dawn answered, “I want to work with basically upscale, neurotic type clients, you know, basically high functioning.”

Joe said, “I love the clients that I have now because they’re very challenging, they’re high functioning clients. I like clients that are capable of having that ‘Aha’ moment, and being able to translate that moment into action. They have some awareness of their own responsibility. I guess that’s kind of important to me.”

When asked, “What type of opinion do you think your peers and teachers have about working with this population?” most responded that peers and teachers had negative opinions, or ignored the topic all together.

Andy stated, “I think most people don’t know much about them and I don’t think most people want to work with them.” Mary responded, “Most of my peers would rather not work with them. As far as my instructors, I think that they believe that it’s challenging, but I don’t think they present a very positive picture in working with that population.”

Sally replied, “It’s kind of ‘I don’t want to hear about it, it’s too crazy, it’s way out there,’ it’s ‘I just don’t want to be bothered with it.’” Dana stated, “I think that tearchers put it on the back burner and don’t really talk about it much. I don’t see that any of them do it on any kind of regular basis as part of their living, and so they don’t bring it into the curriculum. It’s pretty low on the totem pole.”

Joe responded, “There is fear. I mean, I’ve heard classmates talking about how uncomfortable it is when they see videotapes in class. Some classmates have expressed discomfort, so I know that some people are uncomfortable dealing with that.”

Myth #4: Violence

When asked, “What was the last thing you saw in the media relating to this population?” most mentioned a violent incident. Andy recalled “a reference to a diagnosis in a trial for a convicted felon. Like saying the killer was psychotic…He was schizophrenic. They use it as a defense and to kind of explain to the public on the news why this person did what they did.”

Jill replied that, “there was a show on stalkers, just last night. The only ones we really hear about are the ones trying to shoot the president.” Sue stated that she had recently seen the remake of the movie Psycho.

     Sally stated, “All I can remember is Son of Sam or that sort of thing, wehre they hear voices of Jesus or the Devil telling them to do things. That’s possibly why some people commit crimes, because they think that someone else is telling them to do that.” Dana recalled an episode of Law and Order, “Where this deranged, bearded crazy, filthy, dirty man, who kills some people, gets off due to using an insanity plea.”

Myth #5: The Media is Accurate

When asked, “How accurate do you think the portrayals in the media are?” most sated that they believed the media gives an accurate portrayal. Sue answered, “One aspect is usually elaborated to prove a point. If you look at all the instances of mental illness almost everything possible could have happened. So they may have been exaggerated to prove a point, but they probably did happen in one place or another.” Sally believed the media to be “fairly accurate.”

Dana said, “It’s got to be somewhat based in fact or actuality, it portrays someone’s experience.” Holly answered, “They put it accurate, sort of plain…they put the facts as best they can. It’s accurate and informative.”

Joe replied, “For the most part, I would say that it is fair, but maybe a little, maybe a slight distortion. It’s sympathetic…I feel that there is empathy. There is an attempt to somehow represent them from…represent what’s happening in the world from the perspective of the person that’s affected with mental illness.”

Myth #6: The media has had not impact on me

     When asked, “How do you feel the media has influenced your view of the mentally ill?” the majority of participants stated that the media has had either a positive impact, or little/no impact.

Mary answered, “Overall, I think it’s been pretty positive. It can really put a human face on what is going on. I think it’s natural for children to be afraid of people who are mentally ill. Children are so sensitive anyway, you know, when someone is off.” Jill said, “I thought they were people to be feared and have very little empathy for. The media had made me more callous and jaded.”

Dana stated, “In some ways it has made me more aware.” I don’t think it’s had a bad influence. I think that the news media and the magazine shows show what can be done and how they can be helped. I just think that there’s a lot of information out there and that as long as it’s handled responsibly, it’s been O.K. I don’t feel like I’ve had these huge negative opinions.”

Joe replied, “My experience of the media, and again, it’s very selective, has been that it’s been pretty empathetic of the population.

DISCUSSION

     While almost all of the respondents in the study believed that there was little or no hope for the chronically mentally ill population, there is actually much evidence of the contrary. In their book, Coping with Schizophrenia, Mueser and Gingerich (1994) state that one third of people with schizophrenia have a few episodes of the illness, but with treatment, are able to regain their former level of functioning after a period of recovery. Harding and Zahniser (1994) indicate that studies have consistently found that one-half to two-thirds of patients significantly improved or recovered, including some groups of very chronic cases.

Incorporated into this myth of no hope and no available treatment is the myth that the mentally ill have to be on their medications all their lives. The reality is that only a small percentage needs medication indefinitely. Harding and Zahniser (1994) report that a surprising number of mentally ill (at least twenty-five to fifty percent) were completely off their medications, suffered no further signs of symptoms of schizophrenia and were functioning well.

In contrast to the message of hopelessness tat was so often conveyed to patients and their families in the past, current mental health workers and therapists are able to offer genuine assistance and hope. Services have been expanded, and recovery rates for those diagnosed with a mental illness are high. There are many resources currently available to therapists and their mentally ill clients. Yet therapists continue to be resistant to working with this population believing that the work is too difficult and success unattainable.

In this study, most respondents recalled having seen something violent in the media involving someone with a mental illness. In his book Media Madness, Wahl (1995) writes that, “the occasional violence of some individuals with mental illness, however dramatic, tragic and frightening, does not warrant a blanket conclusion that people with a mental illness are dangerous or that any given individual with mental illness automatically has a high potential for violence” (p. 82).

Monahan (1992) found that violent or dangerous behavior occurs in only about ten percent (or less) of those with mental illness. This is comparable to the percentage of violent people in the general population. Gerbner (1993) suggests that the belief that the mentally ill are violent is due to the effects of the media. His studies not only show that mentally ill characters on television are more likely to be villians, but they are also more likely to be violent.

Mueswer and Gingerich (1994) believe crmes commited by non-patients often appear less sensational to the public, and consequently receive less media attention. This bias in reporting leads to the impression that schizophrenia is a violent illness. This bias in reporting leads to the impression that schizophrenia is a violent illness. The message conveyed is that those with mental illness are characteristically violent, dangerous and unpredictable. In truth, the opposite is more often the case. Mueser and Gingerich point out that rather than becoming more violent when their symptoms worsen, most people with schizophrenia withdraw from others and prefer to spend time alone.

Wahl (1995) states that it is also the case that those with mental illness are overall a greater danger to themselves than to others—owing to high rates of suicide and to illnesses and injury as a result of inadequate self-care. Involuntary hospitalizations are more likely to be a result of clients being a danger to themselves, rather than a danger to others.

People learn about mental illnesses from what they see and hear in the mass media. In his studies, Wahl (1995) shows that the public identifies the mass media as their primary source of information about mental illness. He further explains that consumers of mass media indicate that they tend to believe what they see and hear in the mass media about mental illness. The results from this study suggest that those in the mental health profession also rely on what they see and hear in the mass media for information regarding the mentally ill as their beliefs are closer to the image the media creates than reality.

Americans identify mass media as the source from which they get most of their knowledge about mental illness. It can be assumed that interns, trainees and licensed individuals are getting their information from the same sources, as they hold similar beliefs to the general population.

Wahl (1995) writes that the mass media do a poor job of depicting mental illness, with misinformation frequently being communicated unfavorable stereotypes of people with mental illnesses predominating, and psychiatric terms used in inaccurate and offensive ways. He is “quite certain that public knowledge of mental illness does not come from the professional journals through which mental health professionals share their research and ideas with one another” (p.2). It is more likely that the public’s knowledge of mental illnesses comes from sources closer to home, sources to which we all are exposed on a daily basis—namely the mass media, which includes television, movies, newspapers and literature.

Media portrayals are inaccurate. They depict people with mental illness as different, dangerous, and laughable. They misuse or casually use psychiatric terms. It is even more important that therapists, who may end up with mentally ill individuals or their family members in their care, understand how the media misinforms them and shapes their ideas. It appears that currently, many therapists are unaware of the impact the media has on them, and are therefore incapable of providing proper care.

The majority of the participants in this study stated that they were not affected by the media. Although many people may never have read a professional journal about mental illness or met any one who had a mental illness, they will have been exposed to a great deal of information about mental illness through the media from an early age, much of which is inaccurate information.

Gerbner (1985) reports that out of three hundred eighty-five programs watched during one month, thirty-five (approximately nine percent) were identified as depicting mental illness. He goes on to state that these mentally ill characters are, for the most part, portrayed inaccurately and negatively.

There is a tendency of mass media to treat mental illness as an object of ridicule, to use psychiatric terminology inaccurately, and to overuse slang and disrespectful terms for mental illness. What is even more significant in studies of public attitudes toward mental illness is that the rejection expressed by the public is based not on any real knowledge of the individual’s specific disorder or psychiatric symptoms. The rejection is based only on the knowledge that the person had an unspecified “mental illness,” or even that he or she had been to see a mental health professional about an unspecified problem.

CONCLUSION

A National Institute of Mental Health document describes stigma as the most debilitating handicap surrounding mental illness. Culwell (1992) writes that most mental health consumers he has spoken with agree that the stigma surrounding mental illness is worse than the illness itself. One of his clients reported “The discomfort of my nine months of hospitalization was not nearly as bad as dealing with the stigma for the last forty years” (p. 41).

Evidence from this research shows that stigma is still strong among mental health professionals and is being passed down from supervisors and teachers to interns and trainees. Nunnally (1961) described the findings of one study: “The mentally ill are regarded with fear, distrust, and dislike by the general public…old people and young people, highly educated people and people with no formal training—all tend to regard the mentally ill as relatively dangerous, dirty, unpredictable and worthless” (p. 50). These opinions are usually stated by people who have never before met someone with a psychotic disorder.

Almost none of the interns and trainees in this study had met or worked with someone with a chronic illness, yet described working with a mentally ill client as “not rewarding enough, too difficult, frustrating as Hell.” Participants stated that “there is very little positive outcome.” “I would get too depressed and I would feel really hopeless.” “There is very little positive outcome.” “They will not recover…and some of them can, sort of, be on their own, but most of them do best in group homes.” “Working with people diagnosed with mental illness is out of my scope of practice.” These beliefs are not correct and need to be challenged in graduate programs, by teachers and by supervisors. Accurate information regarding this population, and the treatment available to them, needs to be taught and instilled in the minds of interns and trainees during their training time.

Most of the participants stated that the media gives an accurate portrayal of the mentally ill. This is simply not true. As shown by the studies of Wahl and Gerbner, the media almost always gives an inaccurate and stigmatizing portrayal. The majority of participants stated that the media has not had a negative impact on their desire to work with the chronically mentally ill. Yet, although they have never before met someone with a mental illness, they have a negative picture in their minds of what this work would be like.

It is sad to think therapist are not available to empathize with these individuals’ feelings of anger, hurt, and self blame because of their own fear and tendency to avoid working with the mentally ill. It is sadder still to realize that therapists may add to these individuals’ hurt and feelings of rejection because of their inaccurate beliefs in the many myths.

It is important that graduate programs update their curricula and that supervisors become more informed, so that more accurate information can be relayed about the mentally ill population. Working with the mentally ill is not hopeless, depressing and unfulfilling On the contrary it can be very rewarding and exiting.

Throughout history, scientific myths have permeated society. The earth was once thought to be flat. Lepers were sent to an island to die, secluded from others. Blind and deaf people were thought to be useless and institutionalized. HIV/AIDS patients were feared and loathed, while being pushed into back rooms to waste away. The list could go on and on.

With time, effort and education, all these beliefs have, in fact, been proven mythical. Mental health professionals need to lead the way in the legitimacy of mental illness, not add to the confusion and perpetuation of myths and stigma.

REFERENCES

Amenson, C., (1998). Schizophrenia: Family Education Methods. Pasadena:  Pacific Clinics. 5-26.

Culwell, D., (1992). The national mental health consumer scene. Journal of the California Alliance for the Mentally Ill., 3, 40-42.

Gerbner, G., (1985). Dreams that hurt: Mental illness in the mass media. Proceedings of the First Annual Rosalynn Carter Symposium on Mental Health Policy (Atlanta, GA.: Carter Center, 1985), 8-13.

Harding, C., & Zahniswer, J., (1994). Empirical correction of seven myths about schizophrenia with implications for treatment. Acta Psychiatrica Scandanavica, 90, 140-146.

Minkoff, K., (1987). Resistance of mental health professionals to working with people with mental illness. Barriers in Treating the Chronic Mentally Ill, 33, 7-8.

Minkoff, K., & Stern, R., (1985). Paradoxes faced by residents being trained in the psychosocial treatment of people with chronic schizophrenia. Hospital and Community Psychiatry, 36, 859-864.

Mirabi, M., Weinman, M.L., Naginetti, S. M. & Keppler, R.V., (1985). Professional attitudes toward the chronic mentally ill. Hospital and Community Psychiatry, 36, 404-405.

Monahan, J., (1992). Mental disorder and violent behavior: Perceptions and evidence. American Psychologist, 47, 511-521.

Mueswer, K., & Gingerich, S., (1994). Coping with Schizophrenia: A Guide for Families. Oakland: New Harbinger Publications, Inc. 20-58.

Nunnally, J., (1961). Popular Conceptions of Mental Health. New York: Holt Rinehart & Winston. 46-51.

Rabkin, J., (1974). Public attitudes toward mental illness: A review of the literature. Schizophrenia Bulletin, 10, 9-33.

Schroder, D., & Ehrlich, D. (1968). Rejection by mental health professionals: A possible consequence of not seeking appropriate help for emotional disorders. Journal of Health and Social Behavior, 9, 222-232.

Schwartz, S., Kreiger, M., & Sorenson, J., (1981). Preliminary survey of therapists who work with chronic patients: Implications for training. Hospital and Community Psychiatry, 32, 799-800.

Wahl, C., (1995). Media Madness: Public Images of Mental Illness. Rutgers University Press, New Brunswick, New Jersey.

 

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