Speaking of Psychology - Treatment and recovery from serious mental illness, with Kim Mueser, PhD

Episode Date: November 22, 2023

Among the many challenges people with serious mental illness face is the stigma surrounding illnesses such as schizophrenia and bipolar disorder. Kim Mueser, PhD, of the Center for Psychiatric Rehabilitation at Boston University, talks about the progress psychology has made in treating serious mental illness; the role of both medication and psychosocial interventions; why meaningful work can play a critical role in recovery; and the truth about the connection between violence and mental illness.   For transcripts, links and more information, please visit the Speaking of Psychology Homepage. Learn more about your ad choices. Visit megaphone.fm/adchoices

Millions of people in the United States have experienced a serious mental illness such as schizophrenia, bipolar disorder, or major depressive disorder. Among the many challenges these people face are the stigma and misunderstanding surrounding these illnesses, including the idea that serious mental illness is untreatable and that recovery is impossible, as well as the stereotype that people with serious mental illness are violent or dangerous. But in reality, researchers have found that with the right, treatment, many people with serious mental illness can manage their symptoms, return to work or school, and recover and rebuild their lives. So how much progress have we made in recent decades in treating serious mental illness?

What are the biggest challenges in the field? What's the role of psychosocial interventions versus medication in treatment? What role can family support, work, and community play in people's recovery? How does stigma surrounding serious mental illness affect people's treatment and recovery? And finally, is there really a connection between violence and mental illness? Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association that examines the links between psychological science and everyday life. I'm Kim Mills.

My guest today is Dr. Kim Muser, a clinical psychologist and professor at the Center for Psychiatric Rehabilitation at Boston University. He's a clinician and researcher who studies treatment for serious mental illnesses, including illness management and recovery, specialty care programs for first episode psychosis, and vocational rehabilitation. He's the co-author of more than 10 books and treatment manuals and has published numerous peer-reviewed journal articles and book chapters. His work has been funded by grants from the National Institute of Mental Health and the Substance

Abuse and Mental Health Services Administration. Dr. Muser, thank you for joining me today. Thanks very much. I'm delighted to be here. Let's start by defining the term serious mental illness. illness, what disorders does the term encompass? How common are they and what makes them serious as compared with other mental illnesses? So a serious mental illness is defined as a mental illness in which the impact of the disorder on the person's life is profound and long term. When I say the

impact on their life is profound and long term, I'm talking about their ability to work or to go to school to fulfill other role obligations, such as being a parent, their ability to have good, ongoing and rewarding relationships with others, and their ability to take care of themselves. People who have a major mental illness that disrupts these areas of functioning for significant period of time are said to have a serious mental illness, sometimes also referred to as a severe mental illness. The most common of these different mental illnesses are schizophrenia and schizoaffective disorder, bipolar disorder, major depression, especially treatment refractory major depression that doesn't respond so well to medications.

And there are many other possible disorders such as post-traumatic stress disorder and obsessive compulsive disorder that may be serious mental illnesses for some people. So serious mental illness has been with us pretty much throughout human history. In the bad old days, we locked such people away, often for their entire lives. And not that long ago, treatment for SMIs, as we call them, might have included insulin comas, electroshock treatments, and lobotomies. How much progress have we made in recent decades in understanding how to treat serious mental illness? Because we don't do a lot of these things anymore.

Right. I'm glad you asked those questions, Kim. First, I forgot to mention that about 5% of the population has a serious mental illness. So these are pretty common disorders, and that often can lead to the need for disability entitlement, such as Social Security, disability income, and the like. You mentioned a number of treatments that have gone out of phase, such as lobotomy and insulin comat therapy. And in fact, there's been huge advances in both the pharmacological treatment of serious mental

illnesses, as well as the psychosocial treatment, the development of therapies and rehabilitation programs designed to help people manage their symptoms more effectively and get back to living life, including work and having rewarding relationships. I would like to mention one of the treatments that you described has made a huge amount of progress over the last 50 years, and is now actually a recommended treatment, and that is electroconvulsive therapy is, in fact, a recommended treatment generally for people who have treatment-resistant major depression. It is occasionally used for a number of other conditions that we don't need to go into a lot of detail now, but the research actually shows that

people who have treatment refractory major depression, by that, meaning that they have a case of major depression, which has not really responded well to pharmacological treatments, that for these individuals, ECT can be a lifesaver. It can lead to both a resolution and improvement in the depressive symptoms, and it's actually been found to prevent subsequent hospitalizations. And so it's important for people to recognize that there is a role to play for ECT, as well as to know that the methods for administering ECT, which are always done on a voluntary basis, make the procedure both very, very safe as well as not harmful in terms of causing pain and discomfort to individuals. So I do think it's important for people to recognize that there's a role for ECT to play now

and that the methods have improved very much, although there still is a problem. in terms of people lacking access to ECT for treatment, refractory depression. A lot of us have that searing image of electroshock therapy that was used in one flew over the cuckoo's nest, the film. Is it still like that? First of all, it's always voluntary. And of course, in one flew over the cuckoo's nest, it was used as a type of punishment. Second of all, the typical procedures involve providing the person with some anesthesia so that they're not actively conscious during the time that the electric shock is provided. In addition, extensive research on ECT has shown that it can be provided with really minimal cognitive side effects associated with it.

Sometimes there are some temporary side effects, but generally they go away pretty quickly. And often people's cognitive abilities actually improve after ECT because their depression lifts. And we know that when people are depressed, their thinking is often not. as logical and as fluid as it could be. 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? 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 could 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. 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. Can people with SMI recover completely, or do they have to continue medication and other therapeutics for the rest of their lives? Well, that's a very interesting question because it kind of 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 reconcernation. conceptualized 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. 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? 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 that, 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 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 can develop even after the age of 35, even into once four. 40s and 50s. But because it's not that common a disorder, the prevalence of schizophrenia is around 1% in the general population, it is 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 providing 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 for 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 equality of life of individuals. 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? Now, 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 self-esteem, in terms of improving, their financial standing. And we now know that helping people get jobs can actually offer them a certain protection against relapses and re-hospitalizations. 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. 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. 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 front line of recognizing when 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 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 client's treatment team and to work in concert with the treatment team in helping the client work towards and achieve personal goals. 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? 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 a 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. Now, you're a psychologist, as we have established, but some, people with serious mental illness never encounters 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? Well, you're right that psychologists, in fact, do not have as large a 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 health care 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. I want to talk for a minute about two things that are often interrelated. the stigma against people with serious mental illness and violence. One common stereotype is that people with serious mental illness are more likely to commit violent crimes, and this is only reinforced by events like the mass shooting that recently took place in Maine to give just one example. But advocates often point out that people with serious mental illness are more likely to be the victims than the perpetrators of crime. Where does the truth lie? First of all, just to make the connection with stigma, we do know that in the general population,

when you ask people questions about people who have a serious mental illness, 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 illness 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 illness, it turns out that the belief that people with serious mental illness are very prone to violence is the most important predictor of what they're. 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 illness. So somebody who's had a family member, a friend, a coworker with a serious mental illness,

those individuals by and large have much less stigmatizing attitudes about mental illness. So beliefs or concerns about violence in people with serious mental illness. illness really go to the core of the nature of stigma of mental illness. So you asked about, well, what is the truth about both violence and victimization in people with serious mental illness? 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 illness. And then we also know that after people develop a serious mental illness, 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. So now let's turn to the question of violence.

It turns out that the research shows that having a severe mental illness has a very small, but it does have a slight increase in the chances of the person engaging in some kind of a crime, including a possible violent crime. This increase is a relatively small increase, and it's something that is greatly reduced when a person is in treatment, because the medications that can be used, as well as psychosocial treatments, can lower the chances of a person being violent. So, although there is a slight increase in the chances of somebody being violent, the chances are still really quite low that a person with 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. There's been a lot of discussion recently around the issue of involuntary commitment or forcing people with mental illness 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 and a fact that? effective way to get people treatment, does it work? 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 is involuntary treatment for people who perhaps lack awareness into having a psychiatric illness, but are not necessarily presenting a psychiatric illness.

a grave threat to themselves or to other people. There is a clear role to play for involuntary commitment for people who are presenting a grave risk to themselves or to other people. And this is a practical necessity in terms of the protection of society as well as the protection of people against themselves. And the current laws essentially support

this type of involuntary treatment throughout the entire United and throughout most of the world as well. The question of whether involuntarily committing somebody, say, to outpatient treatment, in the absence of a history of presenting a grave danger to themselves or to other people, is a more complex one. 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 is a lack of evidence showing that involuntary outpatient treatment actually improves the long-term outcomes of individuals with a serious mental illness.

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 a court order or some type of a protective order. So at this point, the role 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 the serious mental illness. 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. 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 mental illness.

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 illness. I can take one particular practice as an example. This is 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 job 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 re-hospitalization. In addition, getting work can be destigmatizing because other people see that the individual with serious mental illness 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 U.S. 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 illness. Dr. Mucera, I want to thank you for joining me. I think you have dispelled some of the myths about people with serious mental illness. I really appreciate that. Kim, it's been a delight to be here. I have really enjoyed talking with you and to spread the good word about how much progress we have made in the treatment of serious mental illnesses. Absolutely. Thank you. You can find previous episodes of Speaking of Psychology on our website at www.combeckycology.org or on our website or on

Apple, Spotify, YouTube, or wherever you get your podcasts. And if you like what you've heard, please leave us a review. If you have comments or ideas for future podcasts, you can email us at Speaking of Psychology at APA.org. Speaking of Psychology is produced by Lee Wynerman. Our sound editor is Chris Kondyenne. Thank you for listening. For the American Psychological Association, I'm Kim Mills.