Changing Minds: The go-to Guide to Mental Health for Family and Friends

Dedication

For our children Arlo, Clem and Zoe, that they may have a future free of discrimination.

Contents

Dedication

Foreword

Introduction

How to use this book

1.   You’re not alone: Living with a mental illness

Confronting the myths

Removing the stigma

The code of silence – mental illness in the workplace

How you can make a difference to overcoming the stigma

2.   Where can I get help? Understanding the system

Who can help?

Getting help in the community

Getting help in hospital

Involuntary treatment – the Mental Health Acts

The Guardianship Act

3.   (How to) Just get over it: Depression

What causes depression?

How common is depression?

Symptoms of depression

Diagnosing depression

Special cases

Treating depression

Living with depression

What to do if you have depression

What to do if you think your loved one has depression

What to do if you would like to make a positive difference

4.   Not all fun and creativity: Bipolar disorder

Diagnosing bipolar disorder

When mania becomes extreme

Treatments for bipolar disorder

Managing bipolar disorder

What to do if you have bipolar disorder

What to do if your loved one has a manic episode or bipolar disorder

5.   I’m going to die: Anxiety disorders

What is anxiety?

What causes anxiety?

What is panic disorder?

Anxiety and depression

Treating anxiety

What to do if you have anxiety

What to do if your loved one has anxiety

6.   Not just for soldiers: Trauma and stress-related disorders

A normal response to trauma

How common is PTSD?

What traumatic events cause PTSD?

The symptoms of PTSD

PTSD and other disorders

Complex PTSD

Treating PTSD

Treating complex PTSD

What to do if you have PTSD

What to do if you think a friend or loved one has PTSD

7.   I can stop any time I want: Substance abuse

What is substance abuse?

Who is at risk of a substance abuse disorder?

How often do substance abuse and mental illness go together?

Alcohol abuse

Detoxing

Methamphetamines and mental illness

What to do if you think your loved one has methamphetamine psychosis

Cannabis and mental health

Treating people with a substance abuse disorder

What to do if you have a substance abuse disorder

What to do if someone you love has a substance abuse disorder

8.   Not split personality: Psychosis and schizophrenia

What is the different between psychosis and schizophrenia?

How common is schizophrenia?

Risk factors for psychotic illness

Symptoms of psychosis

Diagnosing psychotic illness

Managing schizophrenia and psychotic disorders

Living with schizophrenia and psychotic disorders

What to do if you have a psychotic disorder

What to do if your loved one has a psychotic disorder

9.   Baby I was born this way: Gender identity and sexual disorders

History of sexuality and psychiatry

Homosexuality and mental health

Gender identity

Sexual dysfunction

What to do if you are struggling with sexual or gender identity

What to do if a loved one is struggling with sexual or gender identity

10.   What is ‘normal’ anyway? Personality disorders

What is a personality disorder?

Different categories of personality disorder

How common are personality disorders?

Borderline personality disorder

What to do if you have a personality disorder

What to do if a loved one has a personality disorder

11.   ‘You don’t have to be thin to pull weight in the world’ – Eating disorders

What are eating disorders?

What are the risks of eating disorders?

What are the signs a loved one has an eating disorder?

Myths about eating disorders

Treating eating disorders

What to do if you have an eating disorder

What to do if your loved one has an eating disorder

12.   Not a coward’s way out: Suicide

History and culture of suicide

Myths about suicide

How common is suicide?

Who is at risk of suicide?

Assessing the risk of suicide

What to do if you feel like taking your own life

What to do if your loved one is contemplating suicide

Endnotes

Acknowledgements

Index

About the Authors

Copyright

WHAT REAL PEOPLE SAY ABOUT THIS BOOK

DEPRESSION

The prospect that depression will one day return to me is an unending concern. It’s a feeling akin to a young child’s fear of a monster being under the bed. If one day I must face that battle again, however, life experience tells me that ‘speaking out’ is my most powerful weapon.

Many of the solutions suggested by Dr. Cross resonate greatly with my own experience. The importance of listening and understanding cannot be underestimated. Contrary to what is often practiced, agreeing rather than debating with a depressed person on their outlook in life allows the sufferer to feel welcome and acknowledged.

Xavier Eales, 17-year-old Sydney student who revealed the years of pain he endured as a result of undiagnosed depression in a speech to his school community in 2015.

LIVING WITH A MENTAL ILLNESS

Many people in our society avoid facing up to mental illness, including treatment, because they fear the discrimination they will experience afterwards.

We need to be aware that mental illness is an ‘invisible disability’. A simple analogy is to liken mental illness to a condition such as Type one diabetes. You can’t see the chemical imbalance but it is nonetheless having a profound effect on the person who has it.

Kate Swaffer, psychologist and disability advocate

BIPOLAR DISORDER

The information on bipolar disorder is fantastic. It explains and fleshes out the key states of mania, hypo-mania, depression and psychosis. A great insight into the illness and I would recommend it to anyone who wants to broaden their knowledge on mental health issues.

Craig Hamilton, an ABC broadcaster who has bipolar disorder and advocates on mental health and lifestyle.

PSYCHOSIS

Psychosis is the most baffling, stigmatised and misunderstood area of mental illness and perhaps the area that causes the most distress to the patient and loved ones caring for the person.

The authors expresses that immediate treatment with medications as well as a solid support base following first episode psychosis is paramount in keeping the condition ‘managed’ and minimizing the recurrence of symptoms.

Just maybe, if my husband Jeremy had been presented with the knowledge, support and medications available now, his life may have taken a different path and he may not have had to suffer those long years of chaos, occasional homelessness, poor health, loneliness and despair. I urge every potential patient, family member and carer to read this chapter thoughtfully to try to gain an understanding of what psychosis can be like, and approach it with patience and with love.

Mary Oxley-Griffiths, registered nurse and wife of Sunnyboys frontman Jeremy Oxley.

SUICIDE

As a survivor of a suicide attempt, I found ‘Not A Coward’s Way Out: Suicide’ an honest, hard hitting, raw and emotionally gripping read. Suicide has been a taboo topic for many years so it is encouraging to hear people now continuing the conversation. Not only does this book raise awareness, but it also is educational on the topic. A great read.

Joe Williams, proud Wiradjuri Aboriginal man and former NRL player turned professional boxer.

GENDER AND SEXUALITY

There is a rainbow of different expressions of gender and sexuality and you are in safe hands with Dr Mark Cross as he navigates this complex and far too often misunderstood area of the human experience, and its impact on mental health.

Jason Ball, former AFL player and LGBTI and mental health advocate

Foreword

Like most of you, I first ‘met’ Mark through my television screen, where he comes across as a caring clinician who is genuinely interested in the welfare of his patients. Subsequently, I have got to know him via mutual colleagues and through chance encounters at meetings and functions. Recently I was guest speaker at the Annual Dinner of the Royal College of Psychiatrists where Mark received the NSW branch Meritorious Service Award for raising awareness of mental illness via the acclaimed ‘Changing Minds’ series on ABC. Some months prior to this I had the pleasure of spending a weekend with Mark at an educational conference where I also met his partner and informally gained some interesting insights into his views on life. I mention these events because it is important to realise and remember that psychiatrists like patients with mental illness, are just people; like you, like me, indeed like all of us. And that everyone ultimately wants the same thing namely, to make mental illness go away. The problem is we can’t achieve this fully, not yet anyway.

This is because by and large we don’t fully know what causes mental problems in the first place, and by this I mean the specific reasons for the emergence of psychiatric pathology.

What we do know is that certain patterns of activity or associations within the brain make mental illness more or less likely and that certain experiences, for example, prolonged heightened stress, can increase one’s vulnerability to mental problems. We also have many effective treatments at our disposal, which when administered appropriately, and at the correct time during the course of an illness, can meaningfully improve mental function. When expressed in this manner, such claims seem modest and almost inconsequential, but in reality, they reflect significant advances and are major achievements – given that the human brain is by far the most complicated and sophisticated entity in the universe. Hence, it should be no surprise that understanding how the brain works, and more importantly, why sometimes it doesn’t, remains one of the greatest challenges we face.

Therefore, in practice psychiatrists take a somewhat pragmatic approach – working with what they know and what they can ultimately change. They attempt to communicate this to their patients and try to demystify its workings. The ABC program ‘Changing Minds’ achieved this by presenting a window into the lives of individuals suffering from mental illness. This book attempts to do the same by translating the complex ideas and concepts that underpin our collective knowledge of psychiatric disorders into accessible language.

This is a truly formidable task – and one, which many have tried and failed. Partly, this is because the language of most doctors’ tends to be descriptive and convoluted, whereas others oversimplify concepts – dumbing them down to the point they become patronising and meaningless. Both approaches offer no real explanations. It is this delicate balance that the authors have achieved so masterfully. Their style of writing makes the book immediately user-friendly. The authors have provided essential information but have done so using a human voice, a voice of experience and most importantly one that can be trusted. The book also skilfully interweaves feelings and emotions into the clinical context. Thus, it is to be commended for many reasons but perhaps chief amongst these is it readiness to address difficult, controversial and stigmatising topics such as schizophrenia, sexuality and suicide.

For all of these reasons there is a need for yet another book on mental illness, especially because this is not just another book and certainly it is starkly different from most other texts on psychiatry. The language is simple and clear and the narrative is interesting and engaging. The parts that I particularly enjoyed were the anecdotes that illustrate and emphasise key points, and in doing so bring the people featured in the book to life. As a consequence it is easy to relate to their problems, and to put yourself in their shoes. I also admire the book (and the authors), because, apart from being candid about the illnesses and laying the truth bare, the authors also reveal themselves – their thoughts and vulnerabilities. In this manner the book surprises you with the whole gamut of emotions – sadness, joy, anger and even disgust.

When I began reading the book I was somewhat critical: as a scientist I was trying to intellectualise and find fault. I was also overly focused on the content, that is, what was being said rather than how or why. However, as I read on and was drawn in by the stories and explanations, I began to ‘feel’ the book, and this is what makes this book different and so very special. It not only provides knowledge but it also fills you with warmth – such that you feel you can trust what is being said. And believe me – you can. The book has authority, but at the same time the authors keep the conversation personal, and it is this that makes the messages both fresh and yet familiar. This is apt – because mental illness is a common and familiar problem and one, which touches all of us. It can only be conquered if we all make it our personal mission to achieve this goal, and this marvellous book will no doubt greatly assist in this endeavour. I therefore urge everyone to read the words of Drs Cross and Hanrahan, and to recommend this book to everyone you know – so that we can all change our minds and transform our thinking, together.

Professor Gin S. Malhi

Chair of Psychiatry

University of Sydney

Sydney, Australia

Introduction

The TV series ‘Changing Minds’ aired on the ABC in October 2014 as part of ‘Mental As’, the network’s mental health week coverage. After the broadcast, it became apparent that, for Australians, mental illness is still a dangerously misunderstood topic – stigma is still a real issue for people with mental illnesses, their carers and their families. Along with a second season of the program, with this book I aim to further undermine those misunderstandings, myths and prejudices, as well as provide a really clear guide to the different kinds of mental illness, their repercussions for individuals and the community, and how they are treated.

I have been a doctor for 25 years, working in mental health for nearly 24 years, in South Africa, in England and now in Australia. Perhaps I was drawn to the field for very personal reasons. One of my first cousins shot himself at home after leaving the army, and there were a few other cousins, generationally removed from me, who also suicided. I wasn’t sure whether to write about this aspect of my life, but I am writing this book to de-stigmatise, to normalise mental disorders – which nearly half of Australians may experience in their lifetimes – and it seems only right that I do so: it’s part of my story.

It is such a taboo, shrouded in something like mysticism and a widespread lack of knowledge; as one of the family members of a patient on the show so clearly articulated by saying, ‘It is as if no one talks about it. No one wants to talk about it.’

The people who put themselves out there on the show, the patients, want to talk about it. Rebecca, one of the patients featured, told me afterwards, ‘I just want people to know what I have to go through, I want them to understand.’

I had an email after ‘Changing Minds’ was aired from a mother of two sons with schizophrenia. She thanked me for pointing out that people with this illness don’t usually kill others, something I thought was widely acknowledged, but obviously not. It was then I realised we have a longer journey ahead if people don’t know the facts, and this book is about getting those facts out there in a format that will work.

Of course there are textbooks, journal articles and the internet with its myriad and often confusing facts and opinions. And people have written heartfelt and meaningful books about their own or their loved ones’ journeys with mental illness. But I wanted to write a book where mental illness and treatment are explained and demystified in a clear and forthright way.

This book will cover all the main categories of mental illness and touch on some of the causes. But the focus is really to understand what it means to have a particular mental illness and explode some of the myths around it. It will show people that they are not alone, where they can get help and what that help might look like.

One in four Australians will have some form of mental illness in his or her lifetime.

What was very clear to me after the series aired is that people welcome this sort of approach, which is: let’s just talk about how it is; let’s talk about mental health.

My patients often say they feel they are the only ones going through these experiences and that they look around and see everyone else being ‘normal’. My response to that, is that no one knows who is on medication, who is being treated and that the only definition of normal I use is what is normal for any specific person.

Australia has led the world in educating people about mental health – we are continuing to do so and hopefully will for a while to come. Mental illness is just that: an illness. It can be brought out into the open – it has been brought out into the open – and we can deal with it in a positive, life-affirming and rewarding way.

I don’t know about you, but I want to live in and bring my sons up in a society that cares for its people with mental illness, that deals with issues around mental illness in a compassionate, inclusive and open way and where we can learn from and include those with mental illness as being part of our normal everyday existence.

How to use this book

When we filmed ‘Changing Minds’ we quickly saw that not many people outside the system truly understand what it is we do in mental health. People often told me that seeing the series showed ‘another world’ – an interesting but very confronting one. Health professionals who saw it were glad that others, including their own families, could finally understand what their work involved, and the carers and patients/consumers said there is not enough information out there, and that what there is is hard to find at times and too often contradictory. So the main rationale for this book is to provide helpful, informative, up-to-date detail, for everyone.

I want this book to be a practical guide to mental health disorders for all the people affected by them – patients/consumers, carers, families, teachers, friends and employers. Of course I also hope that the general public will be curious about issues that affect people with mental health and their families. I can’t tell you how many times a new patient, when asked about their family history, will say something like, ‘We always thought Uncle Ed had issues’, or ‘My father has never been diagnosed, but he is very moody’.

With mental illness affecting one in four Australians, the next time you are at a meeting, a conference, on the train, on a plane, at a family BBQ or in the locker room after a game, you can be sure there are at least a couple of people there with you who either have been or are being treated for a mental illness. Chances are they are right next to you. Chances are you may be going through some tough times yourself. You might even crack a joke about someone with a disability, someone with mental illness, someone who may be confused about their identity, because isn’t it great to project emotion – tell yourself it belongs to that other person, and not you – rather than have to deal with it? You don’t notice the few who don’t laugh, or the ones who laugh that little bit too hard.

People will say: ‘Hold on, they’re just jokes, mate. I am not bowing down to PC bullshit!’ Well, this is not political correctness, this is acknowledging the reality of human emotional response, and doing that is the essence of being a compassionate person. Making jokes at the expense of those already downtrodden and discriminated against is not the true ‘mateship’ we Australians know and deserve.

I love a wicked sense of humour and I use humour in my work all the time. I crack jokes at my own expense – I use them as a tool of engagement, especially with my younger patients, and this comes across in the series ‘Changing Minds’. There is a fine line between being funny to defuse a difficult moment or laughing with someone and laughing at their expense, but it’s a line we have to find and navigate. Of course I make no bones about making jokes at the expense of racist or misogynistic or homophobic people, especially if they make jokes about people with disabilities, and especially if they run for high office. Using humour to put those sorts of people in their place is the Aussie way. And there is humour in this book too: dealing with mental illness is not all doom and gloom, and patients and carers need lightness and laughter just like everybody else.

I don’t want to overwhelm you with medical information, but nor do I want to hold back on the details of how people with mental health problems are treated in the twenty-first century as opposed to how they were treated in the last century.

This is not a self-help book. It aims to explain what common mental illnesses are, how they are treated based on evidence from clinical studies and where you can find help.

Unlike many other books on the subject of mental health, this one is distinctly Australian and is meant for those negotiating their way through the Australian health system.

I have included nine disorder chapters – depression, bipolar disorder, anxiety, traumatic stress, substance abuse, psychosis and schizophrenia, gender and sexual identity, personality disorders and eating disorders. These account for the vast majority of mental health problems, though of course there are other less common disorders I did not have space for.

The information is relevant for adults and young people aged around 16 and up; this is an age where many mental illnesses first become apparent. I have not covered any of the mental disorders that affect children, such as autism and attention-deficit hyperactivity disorder (ADHD) because childhood mental health is such a specialised branch of psychiatry.

Likewise, I have not talked about the disorders that specifically affect the aged, such as dementia. Psychogeriatrics is also a specialised branch of psychiatry and the care of older people with mental illness is often the domain of neurologists, geriatricians and psychogeriatricians. Nonetheless, much of the advice on conditions like depression and anxiety will be of use to older people.

I believe there’s a lot of benefit in bringing together information on a range of mental illnesses into one book for the simple reason that people are very often affected by more than one disorder. Depression and anxiety often occur together and substance abuse is associated with many mental illnesses. Personality changes can be associated with drugs, alcohol and psychotic illness as well as being a diagnosis in their own right. People with chronic medical illnesses such as multiple sclerosis or HIV can have a range of mental health issues and disorders and require mental health input and treatment. People who struggle with their sexuality and gender have a higher incidence of mental health problems than the general population.

You’ll see that I avoid the word ‘normal’. It just isn’t correct or appropriate to exclude atypical behaviours or feelings from our idea of what people should be. I use the term to denote what is normal for the individual concerned, when they feel normal in themselves – and so it becomes a useful indicator that they are on the road to recovery.

I have included case studies from clinical practice to demonstrate the range and complexities of treating mental illness and to show you that however you experience a mental health disorder, the chances are your doctor has seen another patient go through the same thing. In fact you can be assured that you are not the only one dealing with mental illness and that help is out there.

I did not want to write a textbook, there are enough of them out there, but hopefully this book will have enough information and detail for you, the non-mental health professional, to gain benefit from it.

You can use it like a reference book – you don’t have to read it cover to cover to make sense of it. At the end of each chapter there is advice about what to do if you have symptoms of the disorder or illness and where to get help, and there is also advice for carers and families on how to help a loved one.

I mention some organisations that can help in your neck of the woods, but I can’t cover every one. If I have missed any, it was not an intentional oversight.

I also acknowledge that some people may not agree with some of the sentiments expressed in this book, either past or present patients, carers or health professionals. As with everything we do in life, and especially in the practice of what I consider ethical medicine, the main ethos is ‘do no harm’ and I did not intentionally do so here.

This book is collaborative; it is meant to be informative, to break down stigma and stereotypes, to acknowledge past mistakes in the practice of psychiatry and to ensure those same errors do not get traction in the twenty-first century, and to promote all of us working together to make someone with mental illness know they are loved, they are still themselves, they are not alone and they are certainly not ‘abnormal’.

A consumer advocate friend of mine once said some wise words about the practice of mental health. ‘You work with us, not making decisions on our behalf because you think that is what you need to do. Even when we are not ourselves we still have enough of our personalities and awareness to deserve to be treated like the human beings we are. Our behaviours may need containment at times but our souls don’t.’

Many patients say, in response to me asking them what they think may be helpful to them, ‘You’re the expert, Doc.’

But I’m not. I am the facilitator, the guide, for you becoming you again. You and your loved ones know you far more intimately than I do and I could not do my job without you or them. And I can’t do my job properly and with compassion and care without you, somewhere along the line, working with me.

I have gained great knowledge and experience in my life and my aim is not to use this over my patients, but to share it with them so they can see we are working towards the same goal, getting them where they want to be in terms of their general health and function.

I hope this book smooths out that journey, and empowers you to get the right help for yourself or your loved ones.

CHAPTER 1

You’re not alone: Living with a mental illness

People with a mental illness can and do get well, but some will grapple with the reality of managing their illness for the rest of their lives. To be able to do that effectively, the whole of society – family, friendship networks, teachers, employers and landlords – has to develop awareness of what people with mental illnesses are dealing with and how to help them.

We as a country have come a long way in overcoming the appalling stigma that has historically been associated with mental illness. But still the research reveals some disturbing attitudes. When asked about the causes of depression in 1995, 50% of Australians said it was caused by a ‘weakness of character’.¹ That number dropped to 40% in 2011, but that is still far too high.

Confronting the myths

Here are some of the myths about mental illness that the National Mental Health Council says we as a society need to confront:²

Mental health is not my issue; it is something that happens to other people but not my family

Mental health is a mainstream issue that impacts everyone in some way – if not the individual, then