Important Context for Counselling People With Mental Health Disorders

Mental health disorders can affect thought, mood, perception, orientation, or memory. A person with a mental health disorder can be described in a respectful way as a person with a mental illness, a person with a psychiatric disability, or a person being treated for a mental disorder.

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Counselling People With Disabilities

Explore these articles to discover important context, effective practices, and ways to collaborate with employers when providing career counselling to people with disabilities and disorders.

Be aware of terms that demean people with mental health disorders. Words such as crazy, lunatic, psycho, mad, maniac, demented, mental, and loony are derogatory. Do not use them to describe a client—or any other person. Using terms like these in daily conversation perpetuates negative ideas about people with these disorders.

In general, avoid using a term that describes any disability or disorder as a way to describe the whole person. For example, in the case of mental health disorders, do not say, “She’s a schizophrenic” or “He’s a psychotic.”

Also avoid terms that suggest pity or victimhood, such as “He suffers from depression” or “She’s a victim of schizophrenia.” “He lives with depression” or “She has schizophrenia” are more appropriate.

If you use medical terms in conversation, be sure to use them correctly. Terms like psychotic, neurotic, manic, and OCD are inaccurately used in everyday language. This trivializes the people who live with these disorders. Avoid using medical terms outside the correct medical context.

Never use the terms insane and insanity outside a legal context.

Except in legal use, the terms insane and insanity are derogatory.

Types of mental health disorders

Clients with mental health disorders may have trouble with major life activities. These include working, going to school, and taking care of themselves. Mental health disorders often begin during adolescence or young adulthood but they can start at any age. The symptoms are often hidden except during acute phases.

The standard criteria for classifying mental disorders can be found in the Diagnostics and Statistical Manual of Mental Disorders (DSM-5). Published by the American Psychiatric Association, the DSM reviews and updates terminology, definitions, and diagnostic criteria every few years. In the DSM-5, published in 2016, some disorders were added and others removed. The criteria for some disorders were changed. The following sections share information on mental health disorders from the DSM-5.

Anxiety disorders

Anxiety disorders relate to distress or fear. They may include anxiety or panic attacks. Focused anxieties are called phobias. Anxiety disorders are the most common psychological disorders. Examples of anxiety disorders include:

• Social anxiety disorder. This is a fear of public performance, such as speaking in front of people or participating in public events.
• Panic disorders. These are described as repeated, unpredictable panic attacks. They may involve sweating, shortness of breath, and a sense of choking or fainting. The fear that a panic attack may happen is called anticipatory anxiety.
• Agoraphobia. This is a fear of open, public places.
• Separation anxiety disorder. This is excessive fear or distress when separated from home or a specific attachment figure. It is most common in children but can also occur in adults.

Antidepressants or anti-anxiety drugs can help clients handle anxiety. Cognitive behaviour therapy can also help. Drowsiness is often a side effect of drug treatment. It may affect the counselling process.

Trauma- and stressor-related disorders

This a new category in the DSM-5 grew out of increasing information about post-traumatic stress disorder (PTSD). It is now understood as a spectrum disorder. Treatments for mild and severe versions of the disorder vary widely. Some other disorders have been regrouped into this category:

• Post-traumatic stress disorder (PTSD) can arise from exposure to threatened death, serious injury, or sexual violence. It can arise whether the person experiences the stressor directly, witnesses it, or is in close relationship to the survivor. It can also arise among first responders and counselling professionals who are repeatedly exposed to other people’s trauma. PTSD can result in intrusive thoughts, dissociative episodes (such as flashbacks), persistent negative emotions, irritable or aggressive behaviour, and feelings of alienation. It can manifest differently in children and adults.
• Acute stress disorder (ASD) is similar to PTSD but occurs within the first month after a traumatic event. Early treatment can prevent PTSD from developing.
• Adjustment disorder (AD) is characterized by emotional or behavioural symptoms that are out of proportion to the severity of a stressor that occurred 1 to 3 months earlier. Symptoms vary but often include depression and anxiety.
• Disinhibited social engagement disorder (DSED) and Reactive attachment disorder (RAD) develop in children. DSED is characterized by children being quickly and extremely familiar with adults they don’t know. RAD involves complete emotional withdrawal from adults, no matter how caring they are. Both disorders develop in response to ongoing neglect or inconsistent care.

Eating disorders

Eating disorders are serious disturbances in eating patterns. A person might eat too much or too little. Eating disorders have psychological, social, and biological causes. The most common eating disorders include:

• Anorexia nervosa. Characterized by self-starvation, anorexia is driven by an intense fear of getting fat. People with anorexia may binge eat like people with bulimia. In spite of this, they remain dangerously underweight over time.
• Bulimia nervosa. People with bulimia alternate extremely low-calorie diets with binge/purge cycles. They binge on high-calorie foods, then purge by vomiting, using laxatives, or exercising to extreme excess. These cycles occur at least weekly. People tend not to notice a problem because the person’s weight remains average or above-average over time. They may even be obese.
• Binge eating disorder. People with this disorder have episodes of binge eating without purging. They eat very large amounts of food very quickly. They will do this even when they’re not hungry and take it to the point of physical discomfort.

In all these disorders, the urge to eat or not is too strong to resist. Periods of shame, guilt, and embarrassment follow every binge. All eating disorders can cause lifelong health issues, such as kidney or heart disease. In the worst cases, they can be fatal.

Eating disorders affect up to 5% of the population. People with these disorders may struggle with anxiety, depression, or substance abuse. Most people diagnosed with anorexia or bulimia are females between 12 and 35 years. However, eating disorders can affect people of any age or gender.

Counselling professionals should support clients to correct their behaviour first. Cognitive behavioural therapy (CBT) on an outpatient basis has proven effective, though advanced anorexia may call for hospitalization. Underlying psychological issues should only be addressed once the client is safe from physical harm.

Mood disorders

Depression and bipolar disorder are the most common mood disorders. Also called affective disorders, they colour a person’s worldview and experience of life.

Depression, also called major depressive disorder, may cause feelings of sadness and tearfulness. But it is more than normal sadness or low energy. It can cause:

• Loss of interest in activities the person has always enjoyed
• Disproportionate outbursts of anger, irritability, or frustration
• Sleep disturbances, including insomnia and oversleeping
• Appetite disturbances, including loss of appetite and weight loss, or increased appetite and weight gain
• Ongoing exhaustion—even small tasks seem tiring
• Withdrawal from others, even close loved ones
• Trouble with concentrating, decision making, and memory
• Feelings of hopelessness, worthlessness, guilt, and shame
• Unexplained pain, such as back pain or headaches
• Thoughts of suicide; attempts at suicide

Bipolar disorder causes mood swings. The main types of this disorder are bipolar 1 and bipolar 2. Both involve cycling between depressive and manic phases, although the term manic depression is no longer used. In bipolar 2, the manic phase is called hypomania. It is less severe than the mania of bipolar 1, which may trigger psychotic or grandiose behaviours. In these phases, the patient can endanger themselves and others. They must stay in hospital until their mood stabilizes.

The manic or hypomanic episodes of bipolar 1 and 2 share similarities. The client may:

• Be abnormally upbeat or jumpy
• Show increased energy or agitation
• Have an exaggerated sense of well-being or self-confidence
• Need much less sleep
• Have racing thoughts
• Be unusually talkative and distractible
• Indulge in risky behaviours like drunk driving
• Indulge in impulsive decisions, like charging tens of thousands of dollars to a credit card that they will never be able to pay off

After an episode or mania or hypomania, the client “crashes” into a depressive phase. The depressive phases of bipolar 2 tend to be longer, deeper, and more frequent.

Bipolar disorder can be treated with medicines, education, and counselling. Medication can have adverse effects such as drowsiness and weight gain. Clients may stop taking the medication to avoid these effects, or it may need to be changed or adjusted.

It can take time for clients to stabilize. This can be discouraging. An important role for employment counsellors is to help clients stay focused on long-term goals.

Personality disorders

Personality is made up of a set of enduring behavioural and mental traits that distinguish one person from another. Personality disorders are patterns of behaviour that deviate from social norms. They begin in childhood or adolescence and do not change over time or in different situations.

People with personality disorders tend to:

• Have trouble getting along with other people
• Be irritable, demanding, hostile, fearful, or manipulative
• Have disturbed thoughts or emotions
• Have poor impulse control

These issues can give rise to a pervasive negative view of life and maladaptive coping skills. This can lead to depression, anxiety, and other co-occurring mental health issues.

Up to 60% of psychiatric patients have personality disorders, making them the most common mental health issues. A person may have traits of 2 or more disorders.

People with personality disorders tend not to see problems in themselves. Some struggle in the workplace and turn to substance use to cope. They may be the most likely to be diagnosed and treated. Others use traits such as superficial charm, lack of empathy, manipulation, and perfectionism to achieve professional success, sometimes at the cost of relationships. They often go undiagnosed and untreated.

Treatments for personality disorders may include intensive personal counselling, group training in techniques such as dialectical behavioural therapy (DBT), and psychiatric drugs for depression and anxiety. Family and community support is important.

Schizophrenia

People with schizophrenia show disturbances in language, communication, thought, perception, and behaviour. These people may have:

• Deficits with attention and memory
• Deficits with planning, organization, and problem-solving
• Disorganized thinking and behaviour
• Limited, jumbled, or irrelevant speech
• Limited experience and restricted emotions
• Unpredictable or inappropriate emotional responses
• Hallucinations, delusions, and extreme agitation

Schizophrenia affects less than half a percent of people worldwide, but it can cause distress across every area of life. There is much stigma against people with schizophrenia, who often experience human rights violations. This stigma can limit their access to health care, education, housing, and work.

Schizophrenia usually requires intense treatment. This may combine medication, education, primary care services, and hospital care. It may also involve community services to ensure adequate housing and employment.

The most common form of treatment is therapy with antipsychotic drugs. These can have adverse effects including drowsiness, blurred vision, and weight gain. Patients may not be able to do certain activities, such as driving and using machinery. Despite adverse effects, can drugs help patients control symptoms and hold a place in society.

Substance abuse and gambling disorders

Substance abuse is the continued use of substances despite negative effects in major life areas. Progressive dependence on a substance may trigger other mental health disorders. If a person stops using the substance, it causes withdrawal.

Long-term heavy alcohol use can lead to stomach ulcers, sexual problems, liver disease, brain damage, and cancer. Inhalant abuse damages the central nervous system and can trigger behaviours much like those caused by psychotic disorders.

The first step in treatment is detoxification (quitting the substance). This may be followed by psychotherapy, counselling, continuing education, and 12-step recovery programs.

Gambling disorder stimulates the same reward centre in the brain as substance use disorder. Formerly called problem gambling or pathological gambling, this disorder used to be grouped with impulse control disorders. It’s now called gambling disorder and grouped with substance abuse disorders because of the many similarities.

In both disorders, the person’s need for reward increases over time: they need more of the substance or to gamble with larger amounts, to achieve the same sense of euphoria. They take increasing risks in their pursuit of that euphoria.

To be diagnosed with gambling disorder, a person must show at least 4 of the following problems within a 12-month period:

• Needs to bet increasing amounts of money to get the desired excitement
• Repeatedly tries (and fails) to control or stop gambling
• Feels restless or irritable when trying to control gambling
• Frequently thinks about gambling (past experiences, future plans)
• Uses gambling as an antidote for depression, guilt, or anxiety
• Tries to win back gambling losses
• Lies to cover up the extent of gambling
• Loses relationships, jobs, or career opportunities to gambling
• Starts depending on others to provide money to deal with financial problems caused by gambling

Comorbid disorders

In medicine, when two conditions coexist, they’re known as comorbid disorders:

• A physical illness can coexist with another physical illness. For example, it’s common for heart disease and diabetes to be comorbid.
• A physical illness can coexist with a mental illness. It’s not uncommon for a person with cancer to also struggle with depression.
• Two mental health issues can coexist. Depression and anxiety quite often occur in the same person at the same time.

Comorbid disorders raise questions such as:

• Which problem came first and is underlying the others?
• Is it the problem that should be treated first?
• Can the comorbid issues be separated or are they so fully intertwined that they must be treated at the same time?

Co-occurring disorders

Formerly called dual diagnosis, co-occurring disorders refer to substance use issues that are comorbid with mental health issues. Working with clients with co-occurring disorders can be particularly complex. Keep the following in mind:

• Mental illness increases the risk of developing an addiction.
• Addiction affects psychiatric treatment plans.
• Though the conditions are separate, they interact in ways that make diagnosis, treatment, and recovery more complex.
• Symptoms of mental illnesses may affect addictions treatment. For example, stimulant abusers will experience an emotional crash as part of withdrawal.
• Symptoms of mental illnesses may result from addictions. For example, depression or anxiety may result from the loss of a job or a marriage related to substance abuse or gambling.
• Untreated addiction problems can contribute to a relapse of the mental illness. Likewise, untreated psychiatric problems can contribute to a relapse of the substance use disorder.
• Mood disorders often accompany anxiety and personality disorders.
• People with depression are more likely to develop chronic diseases, such as diabetes.
• Personality disorders often co-occur with substance abuse, sexual dysfunction, anxiety disorders, eating disorders, and depression.
• Over time, symptoms may become hard to tell apart.
• Disorders can develop independently at different times.

Barriers and challenges

Complexity of treatment and recovery

Treatment for mental health disorders must reflect their complex origins. A variety of treatment strategies can improve a person’s functioning and quality of life. Examples include psychotherapy, CBT, medicine, and occupational therapy.

People with mental health disorders play an important part in their own recovery. However, they can’t simply “snap out of it” or “pull themselves together.” They may have cyclical periods of wellness and illness. Many develop successful strategies for their periods of illness. Supports such as workplace accommodations help them do so.

Responses to medication

It is not always possible to tell if the traits exhibited by a person with a mental health disorder are caused by the disorder or its treatment. The adverse effects of psychiatric drugs are important in the counselling process. They often present major barriers to career and employment options. These include both overt and subtle adverse effects, such as mood swings, decreased psychomotor control, and trouble concentrating.

Stress

People with mental health disorders respond to stress in highly individual ways, just as people without them do. Stress can come from many sources: struggling with basic self-care, managing finances, or dealing with relationships. People do not always understand what triggers stress. You can help clients determine what causes stress for them and help them find practical coping strategies.

Suicidal thoughts and behaviour

Suicidal thoughts and behaviour are highly correlated with certain mental health disorders. Most notable are major depressive disorder (MDD), bipolar disorder (BP), and borderline personality disorder (BPD). People with MDD or in the depressive phase of BP are at 25–30 times greater risk for suicide than the general population. People with BPD are at a 50 times greater risk for suicide than the general population. This may be because BPD is often comorbid with depression or for other reasons.

The following are categories of factors associated with suicidal behaviour:

• Predisposing factors are enduring factors that make one vulnerable to suicidal behaviour. Examples include a recent mental health diagnosis, a history of abuse, a family history of suicide, and trouble with peer relationships.
• Precipitating factors are specific events or triggers that create an acute crisis. Examples include the suicide of a friend or the sudden onset of financial difficulties, personal conflicts, or rejection.
• Contributing factors increase the effect of either predisposing factors or precipitating factors. Examples include risk-taking behaviour, ongoing substance abuse, physical illness, and a history of unstable family relationships.
• Protective factors decrease the risk of suicidal behaviour. Examples include resiliency, a sense of humour, tolerance for frustration, adaptive coping skills, healthy family relationships, and a strong network of support.

Treatment seeks to address the factors that influence suicidal thoughts and behaviour. This can include psychotherapy to deal with family and personal history. It can include CBT, DBT, and other ways to provide people with tools to deal with difficult thoughts and habits. It can also include medication for depression, bipolar disorder, or other issues that respond to drug therapies.

Stigma

People with serious mental health disorders may face more stigma at work than people with other disorders and disabilities. Stigma may cause anger and avoidance behaviours, affecting employment options, career advancement, and quality of work life.

Though awareness and understanding of mental health disorders is growing, false beliefs persist. Perhaps the most damaging is the belief that people with mental health disorders pose a danger to society. Yet research shows they are no more likely than the general public to commit crimes or act violently.

Another myth is that people with mental health issues cannot keep a job because they are less intelligent and have trouble learning. Some people also falsely believe that mental health disorders are caused by personal weakness.

Try to deal directly with the myths and stigma your clients encounter. For example:

• Play an advocacy role in the community.
• Help clients develop or enhance appropriate social skills.
• Encourage clients to join self-help groups.
• Help clients learn more about mental health disorders and treatments.