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Social & Policy Environment & Mental Health

Issues Related to the Social & Policy Environment

The following statement from The President’s New Freedom Initiative Commission on Mental Health summarizes the distinctive impact of the attitudinal barriers toward people with mental health disorders:

"Stigma refers to a cluster of negative attitudes and beliefs that motivate the general public to fear, reject, avoid, and discriminate against people with mental illnesses. Stigma is widespread in the United States and other Western nations. Stigma leads others to avoid living, socializing, or working with, renting to, or employing people with mental disorders —especially severe disorders, such as schizophrenia. It leads to low self-esteem, isolation, and hopelessness. It deters the public from seeking and wanting to pay for care. Responding to stigma, people with mental health problems internalize public attitudes and become so embarrassed or ashamed that they often conceal symptoms and fail to seek treatment." ¹

Stigma

Survivors with mental health disorders may be unwilling to reveal directly that they have a mental health condition. Telling a provider about a history of mental health problems may feel like too high a risk to take. Her perception of risks may include:

risk that she will not be deemed credible
risk that she will be perceived as someone who is unable to pursue self-determination, including living on her own, working, raising children, and otherwise participating in everyday life
risk that she will be targeted because it is generally known that she is not likely to be believed
risk that others will perceive that her symptoms are unmanageable or routinely out-of-control
risk that others will use the information to gain access to therapist’s records
risk that courts will remove children from her custody
risk that she may or may not get a supportive response - a potentially re-traumatizing experience
risk that decisions about her treatment will be taken away from her
risk that others of her culture will respond in particular ways to her condition
risk that she will lose her job through discrimination

Policy

Survivors with mental health disorders are often discriminated against in policy. It has been common practice among most private insurers to discriminate against people with mental health disorders. Most limit benefits and treat mental health fundamentally different than physical disorders in terms of annual and lifetime spending caps. A national campaign to change this practice has resulted in 34 states passing legislation to establish a policy of mental health “parity” that requires equal access to healthcare for physical and mental disorders.² But the policy is commonly limited to people with the most serious conditions like schizophrenia and bi-polar disorders.

It has also been common across much of the country for domestic violence and sexual assault provider agencies to establish policies that prohibit accepting women with mental health diagnoses. Sometimes those policies are surprisingly overt and literal and sometimes staff and volunteers are trained in the techniques to screen out women with histories of mental health diagnoses.

Substance Abuse

Another issue common to people with mental health limitations is the use of substances to self-medicate. Mental health issues and substance abuse issues may co-occur. Yet, survivors who use substances may be unwilling to reveal directly that they do. Telling a provider about a past or current history with substance use may feel like too high a risk to take. For background information and strategies for creating welcoming environments for women who use substances, who abuse substances or who have addictions, please see Getting Safe and Sober: Real Tools You Can Use, ©Alaska Network on Domestic Violence & Sexual Assault. It is "An Advocacy Teaching Kit For Working With Women Coping with Substance Abuse and Interpersonal Violence".

Safety Issues

“The ADA expressly provides that a public accommodation may exclude an individual, if that individual poses a direct threat to the health or safety of others that cannot be mitigated by appropriate modifications in the public accommodation's policies or procedures, or by the provision of auxiliary aids. A public accommodation will be permitted to establish objective safety criteria for the operation of its business; however, any safety standard must be based on objective requirements rather than stereotypes or generalizations about the ability of persons with disabilities to participate in an activity.” ³

Examples of Problems

A woman finds out at the end of a screening call that she is not eligible for services. The provider cannot accommodate her mental health condition because the shelter has a policy of not accepting survivors with mental health conditions.
A sexual assault counselor at a university suspects that the woman she is counseling has a significant mental health issue that may be increasing her risk of sexual assault. She is not even sure that anything the woman is telling her is true. She feels like she has no training to help her.
A survivor has been asked to testify in criminal charges against her perpetrator. The provider is encouraging the survivor to participate in the proceedings because the case is relatively strong. The survivor refuses without explanation. What the provider does not know is that the survivor has a significant mental health issue and she is afraid to reveal it because the agency has a policy that screens out people with mental health issues.
A survivor of sexual assault is moaning and rocking back and forth while the intake staff attempts to comfort her. The staff member is afraid and isn’t sure what to do.
A volunteer criticizes a survivor’s approach to managing her mental health because she feels that it is self-evident that the woman’s treatment is not working.
Upon intake, a survivor is asked if she is on any medications. When she explains that she is supposed to take Depacote and Paxil but she does not like the way they affect her, she is told she cannot enter shelter until she has filled her prescription and has been on her medication for one week.

Possible Solutions

Sally Mason of Phoenix, Arizona, a respected provider with extensive expertise in providing safety to women with mental health disorders, explains: “Not all programs and shelters have a ‘no-screen-out’ policy, nor is it a straightforward policy to have. Yet, when a shelter does have criteria, it would be helpful for those criteria to be made known at the beginning of the call, rather than after all of the questions have been completed – only to be disqualified in the end.” Survivors need to know that it is safe to disclose honest information.
A woman’s coping mechanisms may be designed to protect her from having to disclose her mental health problem. Her way of coping under new stressors may fail her. A survivor may lose control of her emotions and behavior rather than be able to explain her situation and self-advocate. This can appear as disruptive, inexplicable, confusing or even angry. They may violate rules when overwhelmed – not deliberately so much as it is a maladaptive coping mechanism. People need support rather than discipline to the whatever extent possible without putting other people at risk. If you can help to establish trust, there is a high likelihood that a survivor will benefit from your programs and services and make progress toward improved safety. See Confusing or Disruptive Behaviors.
Differences in functional ability need context in order to interpret them. Cross-cultural differences in emotional expression or accompanying behaviors can be misinterpreted as mental health problems. See Disability & Culture.
Staff and volunteers need to know the importance of diffusing situations rather than controlling them. And they need to know how to self-monitor in order to learn their personal limits in order to competently deal with these potentially intense encounters.
Staff and volunteers need to be empowered to understand anger and using anger management or conflict resolution skills in ways that do not exacerbate seemingly out-of-control situations. The goal is to diffuse them in order that real dialogue can proceed that is recovery-focused.
Each person who uses your services should be asked for any known behavioral or emotional tendencies when in crisis. Ask for the person’s own advice about what works to alleviate her response to crisis. Create an accommodation plan for de-escalation of symptoms when in crisis and also take any preventative measures that are learned. Allow flexibility in any activities, like support groups, where the person may want a particular chair and location, or like chores, that may take longer to complete when symptoms are escalated.
Staff and volunteers can learn to recognize signs of relapse, such as changes in sleeping or eating habits, withdrawal, etc. by asking during check-in sessions with survivors. A person with a mental health condition may be able to identify early signals of relapse and may also be able to tell you what method she has used successfully in the past to gain control of symptoms and to relieve stress.
If you know that a woman has labile emotions (sudden expression of emotions that are out of synch with the intensity of the moment or out of synch with the person’s mood, such as laughing uncontrollably or crying when something is only moderately sad, or laughing when angry or frustrated) here are some pointers:

Adopt a posture that is the opposite of the one associated with crying to help relieve a crying episode.
If an individual tends to tilt the head back and look at the ceiling while crying, try bringing the head down and/or leaning forward. Alternatively, if the person tends to bend the head toward the floor, try looking up and bringing the shoulders back.
Ask the person to try blowing air out of the lungs, and then taking a slow, deep breath. Hold the breath for a beat; slowly exhale; and take another slow, deep breath. Do this three times, or until the person begins to experience control over the crying episode.
Distraction might help. Silently counting the objects on a shelf, recalling the food she ate at the last meal, commenting on the items of clothing someone is wearing, etc.
When she is comfortable again, you can return to the topic at hand.

Some women may not know how discredited they might be when they make formal sexual assault or abuse claims. Advise her of the precautions she needs to take when in contact with other service providers. Ask her about precautions that you yourself need to take with other service providers with whom she has experience.
You may have to prepare her for the pressures she will encounter and assure her that you will believe her, even if her story changes.
Learn about self-harming and how to distinguish it from suicidal tendencies. People who self-injure can become suicidal if they are forced to stop self-injuring. Self-help ideas for this purpose are included in a separate document and you may want an expert to speak to staff and volunteers. For more on self-injury, please see the following links:

Understanding and Responding to Women Who Live with Self-Injury [Note: this link will download a PDF File]

Note: Some of the resources listed in this section are available as PDF files. In order to view PDFs you must have Adobe Acrobat Reader installed on your computer. If you do not have this software installed, you can download Acrobat Reader for free on Adobe's web site.