Working with People with Mental Illness

A Person's Resistance to a Referral

• Denial
• Misconceptions About Symptoms
• Mental Health Treatment
• Psychopathology
• Psychosomatic symptoms
• Diminished Self-Esteem
• Loss of Control
• Stigma
• Loss of Role and Status
• A Changed Future
• Fear of Abandonment or Rejection by the Minister

1. Denial: Very often denial happens after the first hospitalization for a mental illness. The experience may have been very upsetting. Both the family and the person who is ill want to forget the abhorrent behavior that led to the hospitalization, and the pain it caused the person, the family and others. Many times all involved are relieved that the problem is taken care of and do not want to revisit the situation

   In this situation people with mental illness and their families, behave much the same as people with other illnesses. For example, some people with diabetes attempt to deny the seriousness of their illness and do not follow a prescribed diet or exercise. Some people with life threatening heart conditions will continue to smoke, refuse to exercise or change their eating habits. Change is not easy. A person must reorganize his/her way of thinking, reacting and carrying out his/her daily routine. It is far easier, once a person is stabilized, to disregard the need to make changes and to return to the "normal" routine of one's life.

   Denial can lead to reduced participation in treatment and a reduced level of recovery. It can prevent a person accepting his/her illness and taking responsibility for managing it. People are frightened about what is happening to them in the present and what may happen in the future. They are angry and distraught about the changes occurring in their lives. All of this underlies much of why the person who is ill and the family may deny or avoid facing reality and finding ways to manage the illness.

2. Misconceptions About Symptoms: Many people believe that physical symptoms must have physical causes, a view that is part of our cultural focus on disease. What they do not recognize is that the brain is part of the body. It, too, can be attacked by disease. "I am feeling very tired," or "I can't sleep" or "I just don't feel able to get through my ordinary working day," may indicate a mental health problem. If someone has a thorough medical examination and there are no obvious causes for these feelings, there may be a mental health explanation. The emotional behaviors that the person is displaying are those "physical symptoms" that have been brought about by the illness, a mental illness. The brain is not physically functioning in a normal way.

3. Mental Health Treatment: The person's understanding of mental health treatment is equally important. Many people believe that mental illness is incurable and unalterable. This is not so. The literature clearly shows that the majority of people with a mental health problem are helped a great deal. In most cases they are able to function normally after receiving medication, therapy or a combination of both treatments.

   If the person has had treatment in the past, the person may have had an unsuccessful, or even hurtful, experience with a mental health professional, an agency or rehabilitation program. It is important to know the array of services in the community, so that the person can be referred to a resource that is an appropriate alternative.

   The person may be unable to access mental health services, because he/she does not have health insurance that adequately covers mental health treatment. In this situation, the pastor can help the person to identify resources to overcome this barrier.

4. Psychopathology: Negative reactions to a referral do not necessarily imply a mental health problem. However, people may have specific objections to seeing a mental health professional that arise from the symptoms of the illness. Depression, as an example, diminishes the sense of one's own worth. Often people believe that punishment is deserved. Depressed people may refuse a mental health referral because they feel they do not deserve to feel better and are not worth treating. Schizophrenia can distort a person's sense of reality because of paranoia, delusions or hallucinations or a combination of these symptoms. Consequently, the person may completely deny there is a problem and refuse any help or treatment.

5. Psychosomatic symptoms: People with this difficulty distract themselves from emotional distress by focusing on physical symptoms. They substitute physical discomfort for emotional discomfort. A mental health referral implies that the suffering is emotional, which is precisely what these people are trying to avoid. The person reacts to this threat by denying the need for the remedy, i.e., by refusing the referral. Finally, persons who are especially private, shy, mistrustful, or hypersensitive may perceive a mental health referral as particularly threatening. Mental health professionals or member of a support group may be thought to pry into personal matters and to ask intrusive questions.

6. Diminished Self-Esteem: Many people believe that mental health problems, psychological problems, emotional problems, psychiatric disorders, etc., are a sign of personal or moral weakness or failure. There is little understanding that having the good sense to recognize that you have a mental health problem that may need the help of a trained clinician, shows very good judgement. Unfortunately, far too many people believe that if you are unable to "pull yourself up by the bootstraps" and get on with your life, that you are deficient in some way. Having to rely on a professional to help with one's emotions when one feels one should be able to manage such problems on one's own, can be a major blow to self-esteem. This results in a sense of inadequacy, of being a malingerer, or even of being morally deficient.

   In this context one can see that denial of mental illness is very understandable. Mental illness is so disturbing and degrading that one can easily see why people are unwilling to openly admit that they have the illness or focus on it all day long. It is less painful to deny it and not think about it. People generally go on denying the illness and how the illness has altered their lives unless and until they can see other possibilities and alternatives to the "what might have been." Certainly a pastor and a congregation can assist a person in such a situation by being supportive and helping the person with the spiritual journey he/she is taking. People are more likely to comply with their medication therapy or participate in psychotherapy if there is hope for the future. If people know a fulfilling life is possible, provided the person complies with the treatment plan, they will have an incentive to accept their illness and learn to control and manage it.

7. Loss of Control: When a person is acutely ill, he/she may have lost control over his/her actions and thoughts. When the person has recovered, he/she may fear losing control once again. Some people falsely believe that one way of maintaining control is to deny that this could ever happen again, and to go on with life as if nothing ever happened. Actually, this is often the surest way to lose control. They may fear having their freedom taken away if they must enter the hospital. Another concern may center around receiving medication which changes their behavior and which may have side effects. For example, if a person is the accountant for a company, he/she may deny the need for electroconvulsive therapy (ECT) for fear of the side effect of temporary loss of memory. This loss of memory prevents the person from carrying out his/her job for a period of time. This is disturbing in any circumstance, but is particularly so if it is tax time, or the end of the fiscal year, etc. This can lead a person to deny what may be happening to him/her, or it may prompt the person to leave the area for fear of the consequences if the person stays.

8. Stigma: There is a great deal of stigma associated with having a mental illness. People with mental illness are often feared, distrusted and marginalized. According to the U.S. Department of Health and Human Services (publication #ADM 86-1407) the two worst things that can happen to a person are leprosy and mental illness. In American society, ex-prisoners stand higher on the ladder of acceptance than people with mental illness. When asked to rank twenty-one categories of disabilities from the least offensive to the most, mental illness was placed at the bottom of the list. Mental illness, unlike other forms of illness, is viewed by society as being socially unacceptable, embarrassing and not to be discussed or acknowledged.

9. Loss of Role and Status: A person, very realistically, may be concerned about the loss of status and his/her ongoing role in the community or in the family. In working with people with mental illness a pastor should attempt to understand their concerns. Imagine how you would feel if you were a good student or employee and suddenly you could not concentrate because of intrusive voices or because so many thoughts flood your mind that you cannot sort them all out. Imagine how you would feel if all your friends were moving along through the years going to school, university, graduate school, getting jobs and starting families and you are unable to complete high school, technical school or junior college. You even find it difficult to hold a menial job at a fast food restaurant, and yet once you were at the top of your class with a seemingly unlimited future. Perhaps you have worked as hard as you could at a job and failed, because of whispering voices that no one else can hear. What if members of your congregation would rather not interact with you in any way because of your disjointed speech, mannerisms and dress. It is difficult to keep up your self-esteem or attempt to go out in public if you are constantly rejected and misunderstood by others.

10. A Changed Future: The person and his/her family may have to accommodate themselves to a drastic change in the person's future goals and the possibility of reduced academic or vocational achievement. Obviously this is depressing, discouraging and, at times, can lead the person to believe that he/she will never achieve at an acceptable level achievement. A pastor and the congregation can be very affirming by recognizing what the person is able to achieve and not dwelling on what is not possible at the present time.

11. Fear of Abandonment or Rejection by the Minister: A referral to a mental health professional can be perceived as a rejection or dismissal. For some people, buried in the referral is the implicit message that one has not connected. The person may believe that his/her story was not understood or accepted. This may lead to a feeling that the person is being "dumped," because the person is not worthy of the pastor's involvement and support.

    At times the person's sense of rejection may be fueled by the pastor's attitude and behavior. The pastor may be frustrated by an inability to help. Furthermore, people with a mental health problem sometimes can seem remote, combative or overly demanding. Being unable to successfully manage the situation, the pastor may see no reason to continue the interaction. Frustration and impatience with a difficult person sometimes combine to deepen that person's sense of rejection. The person views the referral as a way of denying the spiritual assistance that is needed.