Your Brain Needs a Sick Day: 4% and the AP Group

by Catherine Morin
mentalhealthAPgroup@yahoo.com

The 4%
Americans do not like talking about mental illness. We certainly would never admit to having a mental
illness ourselves. Those mentally ill people they are in jails, or homeless, or are heavily medicated.
The person who walks into a movie theatre, church, or a school and fires a gun killing innocent people is
mentally ill. In America we have this all or nothing view: either you are mentally healthy or you are
mentally ill. With the mentally ill always being someone else. After all, I have a job and a family; I cant
have a mental illness.
Some mental illness conditions are commonly diagnosed prior to adulthood. For this article, I am
focusing only on adult mental health and leaving the mental health of minors for another time.
According to the National Institute of Mental Health (NIMH), approximately 1 in 25 adults in the U.S.
(13.6 million or 4.1%), live with a serious or severe mental illness (SMI) such as schizophrenia, major
depression or bipolar disorder. The NIMH data does not cover persons who, for the entire year were
homeless; were on active military duty; or who resided in institutional group quarters (e.g., correctional
facilities, nursing homes, mental institutions, long-term hospitals). Some people in these excluded
categories have SMI, but they are not accounted for in the 1 in 25 adults estimate resulting in a low
estimate. Serious mental illness is defined as:

A mental, behavioral, or emotional disorder;

Diagnosable currently or within the past year;
Of sufficient duration to meet diagnostic criteria specified within the 4th edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV); and
Resulting in serious functional impairment, which substantially interferes with or limits one or more
major life activities.

I will refer to this group with serious mental illness as the 4%. Lets look at this statistic within the
framework of our all or nothing attitude:

I feel pretty good looking at this. You and I are clearly in the Mentally Healthy category and those other
people who have a mental illness are all the way to the far right on the bar chart. The majority of
American adults have good mental health. There is safety in numbers.

Today, the 4% are the focus of a growing and spirited debate in our country. While the raw number of
seriously mentally ill individuals who grab our attention is relatively low, their actions create sensational
headlines especially when combined with one of Americas most protected Constitutional Amendments
- the right to keep and bear arms. The expected reaction after a theatre, church, or school shooting is
to fight for more gun control, but we are slowly seeing that ineffective argument shift to a fight for
improved mental health services. I fully support this ongoing debate about the amount of access the 4%
have to guns but will not be focused on it in this article.
You see the 4%, while not always helped effectively, do have a large amount of law and support programs
already on the books to assist them. There is Administrative Law under the Social Security
Administration that provides aid for individuals meeting the mental disability definitions and
requirements of both Social Security Disability Insurance and Supplemental Security Insurance. The
Mental Health Parity Act of 1996 and the Mental Health Parity and Addiction Equity Act (MHPAEA) of
2008 are two laws that focus on the 4%. The MHPAEA requires insurance groups that offer coverage for
mental health or substance use disorders to provide the same level of benefits that they provide for
general medical treatment. Finally, in the sphere of criminal law, we have developed laws providing
instruction on how to deal with a mentally ill defendant. We use mental capacity as a factor related to
the capacity to stand trial and the capacity to reach the mental state required by the element of a
particular crime. Although this is not a comprehensive list of laws that affect the 4%, it gives you a brief
overview of what exists today and sheds light on how much we make an effort to help them.
To be clear, there is a lot of opportunity to improve the existing laws and resources to more effectively
support the 4%. Our country has undergone a dramatic shift over the last fifty years in how the mentally
ill are treated. In 1959 the majority of mentally ill patients were housed in state run psychiatric hospitals.
President Kennedys Community Mental Health Act of 1963 attempted to provide a bold new approach
to treating the mentally ill. At that time the national institutions held close to 600,000 mentally ill
patients. The goal of Kennedys reforms was to create community facilities which would be designed to
allow people to stay closer to their home, family, church, and employers while they received treatment.
In reality the reforms were not funded and we saw a shift to deinstitutionalize mentally ill people so that
by the late 1990s only 70,000 people were housed in state run psychiatric hospitals. Unfortunately this
drastic decrease did not equate to fewer people suffering from serious mental illness. Many mentally ill
people ended up falling through the cracks to homelessness or tangled within the criminal justice system.
According to the National Alliance on Mental Illness (NAMI), the consequences of ineffective mental
health services in America have had devastating effects:

An estimated 26% of homeless adults staying in shelters live with serious mental illness and an
estimated 46% live with severe mental illness and/or substance use disorders
1.2 million mentally ill adults are incarcerated
10% of homicides are committed each year by adults suffering from severe mental illness
50% of mass killings are committed by individuals with severe mental illness
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Your Brain Needs a Sick Day: 4% and the AP Group by Catherine Morin

You can see from these numbers why we think of the mentally ill as being criminals, or homeless, or
heavily medicated. The ongoing debate around the 4% is crucial to our societys growth. However, I
believe there is a change that could be made simultaneously to such work that would have a significant
impact on improving how our society copes with mental illness. Before I share this change, lets look at
the reasons for our fear of mental illness and make sure we are talking about the same thing.
Root Cause of Fear
Americans are afraid of mental illness. I believe this fear has two fundamental root causes. First, the
law in America focuses around severe mental illness the 4%. Mental health runs along a continuum:
on one end is perfect mental health and sanity, while on the other end is mental illness that is complete,
permanent, mental incapacity or insanity. As I mentioned earlier, we have a lot of laws that affect the
4%. The percentage of people who fall into the severe end of the spectrum is minor, yet the number of
laws that regulate this group are extensive. Compare this to the large percentage of people who are at
the sane end of the spectrum yet have episodes of mental health troubles periodically throughout their
life. Ill refer to this group as the Average Person Group or AP Group. The number of laws regulating
the AP Group are almost nonexistent. I should note, I am not advocating for an increase in laws for the
AP Group. I am only pointing out the amount of laws that exist for the 4% versus the AP Group to
highlight where our focus lies and that all of this focus on the severe side of the spectrum scares people.
It perpetuates a strong social stigma that is attached to mental illness. Society in general has stereotyped
views about mental illness and how it affects people. Many people believe the mentally ill are violent
and dangerous or are more likely to behave in bizarre ways. We associate mental illnesses with the
criminally insane who are not held accountable for their actions or the mentally disabled who need
government aid or a hand out.
Part of our resistance to associating with the 4% is the moral judgment we attach to this group. Placing
a moral judgment is not uncommon when dealing with a person who needs assistance beyond
themselves. We see this judgment a lot for people living in poverty who seek public benefits such as
food stamps or welfare programs. There is an unspoken assessment of deserving versus undeserving
when it comes to government handouts. The deserving poor are seen as respectable, virtuous people
who are poor through no fault of their own (and would never ask for government aid) while the
undeserving poor are lazy, dishonest, and unmotivated (and live continuously on government handouts
as a burden to society). According to Mark R. Rank in Toward a New Understanding of American Poverty,
this is despite the poors behavior differing little from that of more economically fortunate people.
The 4% experience a similar moral judgment within our society. The moral judgment and stigma can be
seen clearly with how freely we share our physical weakness while hiding from our mental weakness.
Suffering a physical illness occasionally is taken for granted as part of being human. We are not afraid
to tell our family and friends about how bad we had the flu. We call our boss and tell her we will not be
at work today because we are sick. In contrast, I would not tell you that I expect to experience a mental
illness once or twice over the next three years. And I cannot imagine a situation where I would just as
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Your Brain Needs a Sick Day: 4% and the AP Group by Catherine Morin

freely tell my boss I am taking a few days off to seek mental health help. We are scared that such an
admission would mean we are becoming part of the 4%.
The second fundamental root cause of our fear is the myth in America that mental health is an all or
nothing proposition. If you are not at the severe end of the spectrum - the 4%, then you are normal and
sane. The myth does not allow for a sane individual to experience episodes of mental illness the AP
Group. There is no grey area when it comes to mental health under this proposition. Compare this to
how we readily accept that our physical selves will run into obstacles over the course of our lives. We
fully expect to catch a cold, have the flu, experience a cavity and we know it is possible we might break
a bone, suffer from arthritis, or develop cancer. Comparing our belief that our mental selves will always
be healthy with our acceptance of the weakness of our physical selves, illuminates the disconnect in the
all or nothing proposition. I believe it is useful to compare our attitudes about physical health to our
attitudes of mental health. You will see these comparisons throughout this article.
The fear of mental illness is entrenched in our society. We see it in how those with mental illnesses are
portrayed in the media and even our vocabulary gives away our fear. We say the mentally ill not
people with mental health issues. Try adding the to the description of other groups and you will
start to see the problem: equal coverage for the women, crime and the blacks. It sounds offensive,
doesnt it? Regrettably you do not see a lot of people-first language related to mental health. Again,
compare that to how we use people-first language all the time to describe physical health: people with
diabetes, he has hypertension, she has a broken leg. Could you imagine saying the broken legged
woman? Words are a reflection of our level of respect and how comfortable we are with a topic. Our
words show we are not comfortable with mental weakness. We are afraid to admit we are anything but
mentally healthy because of the moral judgment and stigma, our excessive focus on the 4%, and our
insistence on an all or nothing view of mental health. Now that we have looked at what is feeding our
fear, do we know what mental illness is?
Mental Illness Defined
A mental illness is a medical condition that disrupts a persons thinking, feeling, or mood, or disrupts
their ability to relate to others or disrupts their daily functioning. Mental illness can range in impact
from no or mild impairment to a significantly disabling impairment that results in a diminished capacity
for coping with the ordinary demands of life. What's the difference between mental health and mental
illness? Sometimes the answer seems clear. For instance, a person who hears voices in his or her head
could have schizophrenia. A person who goes on a frenzied shopping spree or starts an ambitious project
such as remodeling the bathroom without any plans, might be having a manic episode caused by
bipolar disorder. Many times the difference is not clear especially in the way a broken bone or a tumor
on an x-ray is clear. Mental health issues are given names to help distinguish one group of symptoms
from another and to develop distinct treatment paths. Despite our resistance to discussing mental
illness, most of us can easily name at least some of the specific conditions:
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Your Brain Needs a Sick Day: 4% and the AP Group by Catherine Morin

Anxiety Disorders
Autism Spectrum Disorders
Attention-Deficit/Hyperactivity
Disorder (ADD/ADHD)
Bipolar Disorder
Borderline Personality Disorder
Depression

Dissociative Disorders
Schizoaffective Disorder
Dual Diagnosis:
Substance Schizophrenia
Abuse and Mental Illness
Eating Disorders
Seasonal Affective Disorder
Obsessive-Compulsive Disorder Tourettes Syndrome
(OCD)
Panic Disorder
Posttraumatic Stress Disorder

Some number of these conditions is familiar to us yet we are afraid to associate too closely with any of
them due to our all or nothing attitude and excessive focus on people who make up the 4%. But not
everything in our all or nothing perspective is missing the mark. The 4% of American adults we saw in
our first graph who suffer from a mental illness suffer from one or more serious mental illnesses. This
typically means a mental illness that is long term. That leaves 96% of us not subject to long term mental
illness. I continue to feel pretty good looking at that chart.
The AP Group
If you find yourself agreeing with me so far about the safety in numbers of 96% of us with unwavering
mental health, you might be surprised when I tell you that according to NAMI and NIMH, one in five
adults, or approximately 43.8 million Americans, experiences a mental illness in a given year and 44%
will experience a mental illness in their lifetime. One in five adults in America. In a given year. Were
you surprised? My AP Group reference from earlier is made up of this one in five in a given year group
and the 44% in their lifetime group. Our graph still shows the 4% at the far end of the mental health
spectrum. But now we can see how our lives are much more likely to be touched by mental illness than
we thought with our all or nothing perspective.

The Ebb and Flow of Mental Health

The reality of mental health is that it changes throughout your life. It is not all or nothing, there is an
ebb and flow to it. Lets look at how this works. Take George, he is 35 years old, has a wife and two
children - a one year old daughter and a six year old son. George works as a sales rep for a payroll
company. Life is good. George and his wife own a home and two cars. He makes enough money to
allow her to stay home with the children. Their marriage is average. They have the typical struggles one
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Your Brain Needs a Sick Day: 4% and the AP Group by Catherine Morin

would expect raising two children in America. George has struggled with low self-esteem at times and
has not always figured out the best ways to relieve stress. He indulges in smoking marijuana occasionally
to help him relax and drives his sports car faster than he should when he is frustrated. But overall, he is
able to meet his responsibilities at work and home. George is considered mentally healthy.

A few months ago George and his wife started fighting more than they ever have. Whatever patience
he had seems to have evaporated. George is not sure why they have hit this rough patch in their
marriage but he is feeling stressed a lot. He is having a hard time concentrating at work. He has been
drinking more which is causing him not to sleep well. George is still mentally healthy but he has slid a
little further along on the continuum. A professional mental health checkup might provide George with
better tools to deal with stress and improve communication within his marriage. But without exposure
to using mental health resources proactively, George can only push forward hoping for the best.

A few months pass. George and his wife learn their daughter has a rare heart condition. Instead of
unifying them, this news has added more stress to Georges marriage. He misses a fourth sales goal at
work and is no longer being considered for a promotion. George has now slid into the AP Group. His
low self-esteem has grown into depression. He needs help but he is a proud man and he thinks it is
better not to talk about how he is struggling.

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Your Brain Needs a Sick Day: 4% and the AP Group by Catherine Morin

When Georges wife tells him she wants a divorce, he is devastated. He knew they were having problems
but never expected she would leave. His work performance is suffering. He is sad, angry, worried about
his children, and worried about the finances. He feels his life is spiraling out of his control. A few turn
of events of life and George finds himself squarely in the AP Group.

Georges story is common. This is how life works. You build a life, you are thrown curve balls, and at
some point you are thrown enough of them and you struggle. George might get stuck in the AP Group
for years; resulting in a less productive employee, a less effective father, and an individual who is
suffering. On the other hand, George might get help formally from a professional or informally from
people who have experienced similar struggles. He might learn how to improve his mental health and
return to his mentally healthy position on our continuum.
Georges example illustrates how the ebb and flow of mental health is normal. It happens to all of us to
varying degrees. Until we embrace the fact that we will endure mental weakness at some point during
our lifetime, our language will highlight a them versus us mentality exposing our continued fears. As I
said earlier, I find it useful to compare how we accept physical illness to how we do not accept mental
illness in our country. Physical illness can cover a lot of ground so I would like to narrow it to focus only
on dental health. Stay with me as I explore the basic structure of dental health to illustrate what our
views on mental health could develop into.

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Your Brain Needs a Sick Day: 4% and the AP Group by Catherine Morin

Genetics, Personal Responsibility, and Professional Intervention

According to the National Institutes of Health, dental health has three main components: genetics,
personal responsibility, and professional intervention. The genetic component is luck of the draw. We
have no control over who our parents are or what genetic traits they pass on to us. Some people will
have genetically strong teeth that resist cavities, inflammation, and disease. Others will inherit teeth
which start to decay just at the sight of sugar. Under the personal responsibility component we are
taught at an early age to take actions every day to maintain the health of our teeth. Generally speaking,
our parents supervise us as children to ensure we learn good daily habits. Brush and floss our teeth in
the morning and before we go to bed. Floss after meals when we eat food that lodges in our teeth.
Rinse with some form of mouth wash to kill bacteria in places our brushing and flossing cannot reach.
Our personal responsibility extends to choosing our foods wisely, like having a diet high in calcium and
vitamin D and low in sugar. The key to the personal responsibility component is the frequency: daily.
The professional intervention component of dental health involves proactive and reactive activities.
Proactively we have our teeth cleaned twice a year and x-rays once a year. Reactively, if a problem arises
such as a cavity we rely on a dentist to fix it with a filling. We also engage professionals to straighten our
teeth with braces and whiten our teeth with chemicals. The interaction of these three components helps
to determine how healthy our mouths will be during our lifetime. Each component has a positive and a
negative. You are either lucky or not with your genetics. The success of executing the personal
responsibility varies from failure to perfection. Not all dental professionals are created equal, sometimes
the professional intervention leaves you worse off than when you started. But the bottom line is that as
a general rule we each know how to maintain the health of our mouth through a combination of
proactive routines and reactive fixes.
I see mental health as being composed of similar components. Your mental health has a genetic
component. Some mental illnesses have been traced to inherited genetic variations. You are either
lucky or you are not when it comes to genetics. Daily habits impact your mental health and are part of
the personal responsibility component. Habits such as valuing yourself, taking care of your body,
surrounding yourself with good people, learning how to deal with stress, developing coping skills,
quieting your mind, getting enough sleep, setting realistic goals, staying productive, keeping alcohol use
to a minimum and avoiding other drugs. For the professional intervention component, having a
proactive checkup once or twice a year can uncover things we are not able to see on our own and
engaging professionals reactively when a problem arises can facilitate a more successful recovery.
As I said earlier, I believe there is a change that could be made simultaneously to improving the resources
for the 4%, which would have a significant impact on improving how our society copes with mental
illness. This change is to approach mental health in a similar way to how we approach dental health.
Unlike dental health where most people understand they have a responsibility to maintain daily habits
and seek professional intervention proactively and reactively to maintain the health of their mouth,
many people do not understand the habits they can adopt to maintain their mental health. We know
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Your Brain Needs a Sick Day: 4% and the AP Group by Catherine Morin

the basics for physical health: nutritious food, adequate shelter and sleep, exercise, immunizations, and
a healthy living environment. But how many of us know the basics for mental health: unconditional love
from a family unit, self-confidence, self-esteem, opportunity to interact with other people who share
common interests, safe and secure surroundings, and appropriate guidance and discipline. Almost no
one seeks proactive professional help for mental health checkups. Those that seek reactive professional
help tend to do so long after it was needed and usually only when forced into it. They also tend to hide
the fact that they sought out reactive professional help. The reason for this limited knowledge of
personal responsibility in maintaining daily habits for mental health and the apprehension of involving
professionals, stems from our fear of mental illness, our irrational focus on the 4%, and our all or nothing
attitude.
My approach includes proactive daily actions on the part of the individual, annual proactive checkups
with professionals, and seeking professional help reactively when problems arise. This approach will not
eliminate mental illness. We will still have the consequences of unlucky genetics, poor personal
execution, and lower quality professional care. Despite these challenges, adopting an approach to
mental health similar to how we handle dental health would result in a healthier society. So how do we
do it?
I would love to say it is as simple as realizing we are all human beings with flaws both physical and mental;
we are trying to find our way through life with acceptance, safety, and love. But I realize it is not that
simple. So how do we improve our attitudes about mental health? I believe we need awareness and
education to explain that the AP Group exists, to show how mental health naturally ebbs and flows over
the course of a lifetime, and provide tools similar to the types provided for dental health to optimize our
mental health. In keeping with the dental health comparison, we could provide children with a
foundation of supporting their mental health. We could help new parents teach their children about
personal responsibility and professional intervention. The parental awareness and training could then
be supported by programs in formal school settings just as dental hygiene programs are handled today.
Besides providing children with a foundation of tools and knowledge about mental health, we could have
awareness campaigns for professionals who are either likely to be personally effected by mental illness
or have customers with mental illness. For example, a lawyer is one such profession because of the
likelihood of mental illness among lawyers and among their clients in combination with the fact that for
the most part the lawyers are the law makers. According to Martin E. P. Seligman in Why are Lawyers
so Unhappy? lawyers are in remarkably poor mental health. They are at a much greater risk than the
general population for depression. Lawyers also suffer from divorce, alcoholism, and illegal drug use at
rates far higher than non-lawyers.
Now lets look at their clients. Consider why people hire lawyers. Obviously they need legal help with
something going on in their lives. Maybe they are getting a divorce and are fighting for custody of their
children. Maybe their business is failing and they are facing bankruptcy. Maybe their father who they
have unresolved issues with passed away and they need help probating his estate. Many of the reasons
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Your Brain Needs a Sick Day: 4% and the AP Group by Catherine Morin

lawyers are hired are to resolve a stressful situation that the individual is unable to resolve on their own.
Depending on how many curve balls life is throwing the client, they could be right where George found
himself in our earlier example. With clients and lawyers more likely to experience mental troubles,
lawyers make a solid choice for leading the charge on a new approach to mental illness. My final reason
for suggesting lawyers is that many of the countrys lawmakers are lawyers or at least have a legal
education. Providing a basic foundation of understanding and acceptance of the ebb and flow of mental
health to lawyers will result in more effective laws. Okay, you are not buying that for a minute. I may
have overestimated the effects of increasing mental health knowledge in lawyers, but it is reasonable to
believe exposure and training on mental health would better equip lawyers in their lawmaking roles.
Aside from parental and education programs for children or programs targeted at professionals with a
greater likelihood of exposure to mental illness, public service campaigns could be utilized to increase
awareness of the AP Group and offer the dental health model of personal responsibility and professional
intervention as a new approach to maintaining mental health. According to the Advertising Council,
their public service advertising campaigns have increased awareness for some of the most important
social issues facing our country during the last sixty years. The familiarity of these slogans highlights the
effectiveness of such awareness campaigns: Only You Can Prevent Forest Fires, A Mind is a Terrible
Thing to Waste, and Friends Dont Let Friends Drive Drunk.
As you can see there are different ways to foster a change in attitude about mental health, mental illness,
and the AP Group. I expect we need all of them in combination and more. We will also need even more
mental health service providers under this idea of changing our view of mental health to mirror our view
of dental health. If people are going to take proactive steps to get mental health checkups one or twice
a year and reactively seek professional help when they have an issue, they need easy access to services.
As it stands today, we have a nationwide shortage of mental health professionals in our country.
According to the Substance Abuse and Mental Health Services Administration, fifty-five percent of the
nations 3,100 counties have no practicing psychiatrists, psychologists, or social workers. Relying on
governments to establish the needed mental health services is not the answer. We need new ideas and
creativity to help solve the shortages. In addition to access, we need a financial structure that works for
all income levels. This means improving the way private insurance deals with mental health treatments.
There is much work to be done on both the demand and supply sides of this issue. We need to increase
awareness of the AP Group, promote acceptance of the ebb and flow nature of mental health, increase
the number of professional mental health services, and create affordable options.
It is clear why we are inclined to deny our mental weaknesses. We are driven by fears feeding off of our
hyper-focus on the 4% and our all or nothing attitude. But there is hope. Our approach to dental health
provides a glimpse of an improved approach to mental health in our society. If we leverage numerous
mental health awareness programs, we will be in a much stronger position to effectively help the AP
Group remember this is the Average Person Group. We know people will continue to experience
mental troubles on and off throughout their lives. We need a new approach beyond the stigma and
fears. After all, we are very likely to find ourselves part of the AP Group at some point during our lifetime.
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Your Brain Needs a Sick Day: 4% and the AP Group by Catherine Morin

As awareness grows so will acceptance. Today my challenge to you is to start thinking about mental
health in the way you think of dental health: incorporate proactive daily actions in your life, consider
annual proactive checkups with professionals, and seek professional help reactively when problems
arise. Lets embrace our part in the AP Group.

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Your Brain Needs a Sick Day: 4% and the AP Group by Catherine Morin