Our mental health crisis

John F. Kennedy was one of our most visionary presidents. He set a ten-year goal for landing on the moon and, although he didn’t live to see it, the goal was met. He envisioned an agency, separate from the State Department, that would give American citizens the opportunity to live and serve as volunteers in developing countries around the world; and the Peace Corps became a reality. He envisioned, and provided funding for, a national mental health system, made up of local mental health centers, to replace the system where most mental health treatment was provided in large, centralized state institutions.

For most of my career as a psychologist, I was employed at community mental health centers (CMHCs). Little did I know when I started out in 1976, working for a CMHC in rural Alabama, that these were the halcyon days of our national mental health system. Mental health agencies had adequate funding to meet community needs. The plan was to decrease reliance on expensive (and often unnecessary) inpatient treatment in state “mental hospitals,” by providing outpatient mental health services at the local level. Almost all of the initial funding was federal dollars, with the understanding that the federal funds would gradually decrease, and states would allocate a portion of the money saved, to replace the federal funding for community outpatient treatment. The goal of the well-intentioned plan was called “de-instititutionalization.”

All across the country, states made plans to eventually shut down the massive institutions that often “warehoused” patients with chronic. severe mental disorders. This saved the states a lot of money over time, but the state legislatures failed to carry out their part of the plan and replace lost federal funding for community mental health treatment with state dollars. Instead, the money saved went straight into state general funds, and funding for community treatment gradually diminished, year after year. The range of services provided shrank over time. Community outreach and support services programs closed down and CMHCs became understaffed. Clinicians (like me) initially hired to provide individual, family and group therapy found themselves doing less therapy, and more and more bare-bones case management services for their ever-increasing caseloads of underserved clients. A lot of seriously mentally ill people received only occasional fifteen-minute medication management sessions with a psychiatrist.

With the big, centralized institutions shut down or downsized, and with the inability of most CMHCs to adequately meet community needs, across the country more and more people with mental illnesses and substance abuse problems have joined the ranks of the homeless. In many cities, hospital emergency departments stay backed-up because of all of the severely mentally ill people who need treatment and can’t get it elsewhere. Jails and prisons have become primary providers of (often inadequate) mental health services. Often, police officers are the first point of contact with people who are psychotic and out of control, sometimes with tragic results.

Few police officers are adequately trained to do effective interventions with manic and psychotic people. If the states had done their part and adequately funded community-based treatment, and we had the national mental health system that Kennedy envisioned, the first responder in a psychiatric crisis situation would be a social worker or a psychologist, not a cop. Police have enough responsibilities, without having to respond to psychiatric emergencies. Jails and prisons have enough problems to deal with, without having to be de facto mental health centers. Jails and prisons are obviously not environments conducive to stability and recovery.

Mental illness and substance abuse are some of the root causes of the rise in homelessness, and too many Americans are more judgmental than compassionate when they encounter homeless people. There remains in our society a stigma that brands mentally ill people as the Other, not as individuals whose impairments should be recognized and addressed on a societal level. Our national mental health system is a disgrace, partly due to stigma and the consequent marginalization of people with mental illnesses and substance abuse problems. We need to elevate our compassion for these people to the level of our compassion for people suffering from cancer and other physical diseases – maladies that have ad campaigns promoting awareness and compassion We need to treat substance abuse as more a public health issue than as a criminal issue.

Prevention is a vital part of medicine, and gets a lot of attention when it comes to physical illnesses. Kennedy’s plan emphasized prevention, and we need to develop a national model that puts the treatment of mental illness and substance abuse on a par with the treatment of physical injuries and diseases.

Why I write

Those of you who follow my blog may have wondered what’s happened to me, since I haven’t posted anything for months. I’m back, and I owe you an explanation. I plan to resume posting on a regular basis, but time will tell how frequently. I haven’t succumbed to the Plague. My only excuse is that in late May I injured my left knee in a fall, and required surgery. I realize that recovery from a knee injury doesn’t explain my silence as a writer; but it’s been part of a confluence of events that I’m trying to make sense of.

I knew from an early age that I wanted to be a writer, even though I didn’t know what I wanted to write about. It wasn’t just a fantasy about achieving fame or making money; I just knew that I had things to say. I read a lot and admired good writers.

I started out as a political science major in college, but discovered that my favorite classes were English literature courses. It didn’t take me long to switch majors. As a boy and as a teenager I’d mostly read adventure (including all of the Tarzan novels) and science fiction but, awed by the brilliance of such literary masters as Milton, Shakespeare and Goethe, I fell in love with literature. My first short story (science fiction) was published in The Citadel’s literary magazine, The Shako, and I served as poetry editor during my senior year. (Pat Conroy, The Citadel’s best-known alumnus author, held that job my freshman year.) It would be years before I wrote my next short story, but my brain was brimming with ideas.

Most of my fiction remains unpublished, but I hope that will change. I’ve written over a dozen short stories that I’m still proud of, as well as a crime novella and a speculative fiction novel. My two published books are non-fiction. Two years in Kingston Town is a memoir of my Peace Corps service in Jamaica (1991-93), with my wife Maria. Ad Nauseam: How Advertising and Public Relations Changed Everything, an examination of how we became a Propaganda Society, was the result of much research, and received several favorable reviews – including one in Kirkus Reviews. I had hoped it would be used as a textbook in high school and college social science and English classes, as an aid to teaching students about propaganda. But that didn’t happen.

Most writers — even good ones — have to get used to rejection and to persist in their efforts to get published. I’ve come to understand that what distinguishes true writers from dilettantes and people who write, motivated by fantasies of fame and money: we write because we must. I’ve said for years that writing is my therapy and, sure enough, now that I’ve had several unproductive months, I ‘ve been feeling that there’s something missing from my life. Writing is part of who I am. Whether it’s fiction or non-fiction, it’s like I get an idea in my head, and it wants to get out. So I start to put it into words, usually on paper for the first draft.

As I re-read and re-read the first draft, I make changes until I’m satisfied with it as a first draft. (Bestselling author James Michener said that he wasn’t a good writer, but was a very good re-writer.) I write my second draft on WORD, editing as I go, and print it out. As I read it over and over again, I continue to make improvements, polishing my prose until it says what I set out to say. Writing fiction, I continue to edit on WORD until I achieve what I consider a “final draft.” Blogging, as I type out my latest post on my WordPress blog site, I continue to find things to improve upon. So, what you read is a polished third draft.

At various times during my career as a psychologist, I wrote “You and Mental Health” columns for local newspapers. In them, I tried to de-mystify esoteric psychological concepts, and to educate readers about psychotherapy. While my father enjoyed my fiction, he told me that he most liked my mental health columns. He said that I had a gift for explaining complex things in layman’s terms. This praise and encouragement is part of what got me to start blogging.

Everyone is adapting — or trying to adapt –in their own way to this strange parenthesis in our lives that is the pandemic. I consider myself fortunate that I haven’t been significantly anxious or depressed, or afflicted by “cabin fever.” But that doesn’t mean that I haven’t been affected. The confluence of socially-distanced living and my knee injury seems to have temporarily sapped me of my creative momentum. I feel like I haven’t been fully myself lately. Until today, having written these words. It’s good to be back.

Models of Madness

In prior posts I’ve written about the pros and cons of the medical model (psychiatry) as the predominant model for the treatment of mental illness, and about what I call “the model muddle.” Models are ways of organizing and framing ideas in a way that serves as a guide. A good model is like a good map: it helps you to get where you want to go. The map is not the territory, but merely a helpful representation. No model is perfect and complete, or demonstrably superior to all other models, in all situations. Each one has its flaws and limitations.

Psychiatry is the medical model’s methodology for treating mental illnesses – primarily with medications. In a nutshell, the model starts with the identification of symptoms, which leads to an appropriate diagnosis, which in turn leads to an appropriate treatment.  The medical model is very good at what it’s good at, such as mending broken bones, doing surgery, and treating many physical ailments. But psychiatry is built more on theory than on scientific evidence.

One limitation of the medical model is that it’s mainly focused on what you do after you have symptoms, not so much on wellness and prevention. A distinct limitation of the medical model as regards mental disorders is that, unlike most common physical disorders, there are no identifiable biological markers to distinguish (for instance) what we call “schizophrenia” from “schizoaffective disorder” or “bipolar, manic.” Psychodiagnosis is not rocket science, because mental illness isn’t measurable in the way that many physical illnesses are (i.e. medical science can distinguish between asthma and pneumonia). At best it’s educated guesses, and many people with an extensive history of psychiatric treatment have been diagnosed with – and treated for – a variety of diagnoses.

Critics of psychiatry have argued that mental illness is a social construct and not a medical condition, and that psychiatry is a process of coercive social control. The negative side effects of some psychotropic medications and mood stabilizers outweigh the benefits for many patients. The term iatrogenic effects refers to treatments that do harm. Unfortunately, contemporary psychiatry is wedded to the pharmaceutical industry. That having been said, psychopharmacology has its place in the treatment of what we call mental illnesses. I believe that in some instances there’s no effective substitute for the right dose of the right medication at the right time. But I also believe that other interventions can mitigate the need for primary reliance on drugs as the default treatment for psychopathologies.

The biopsychosocial model takes into account such factors as physical health, heredity, stress, social stigma, social support system, mental habits, chemical dependency,  economic status, nutrition, and homelessness. We need to embrace a more holistic treatment model for what we call mental illness, and to provide a range of services that gives people who’ve been labeled as mentally ill more autonomy and more options for resolving problems related to their mental health. Unfortunately, the national mental health system is severely underfunded, and many people in need of help are underserved. This is a national disgrace.

The recovery model is an alternative to the medical model. A lot of mental health professionals initially scoffed at the idea of people “in recovery” from chronic psychiatric disorders. Recovery made sense as a helpful model for “recovering” substance abusers, but did it apply to the mentally ill? Many mental health professionals have come to recognize the merits of the recovery model, and there are now recovery centers/programs in some cities, that aren’t run on the medical model. Such programs don’t necessarily preclude psychiatric interventions, but also offer educational resources to empower patients, professional and peer support, and access to community resources, to reduce the stressors that exacerbate symptoms of mental illness.. The concept of recovery from mental illness doesn’t mean full and permanent remission of symptoms, but suggests that psychiatric treatment isn’t the only route to symptom remission and control of one’s life. To find out more about the recovery movement and alternatives to traditional psychiatric treatment, check out madinamerica.com.

Hatred is not a mental illness

For the most part I’ve avoided political topics in this blog, and I don’t intend to change that. However, our President has crossed a line that I can’t, as an advocate for mentally ill folks, ignore. This week he distanced himself from his promises to do something meaningful about advocating for tougher gun laws when he described mass murderers as “mentally ill” and suggested  that improved care for the mentally ill would prevent mass shootings. We may be sickened by the violence of these hateful acts, but that doesn’t mean that the perpetrators are sick, in the sense of being mentally ill. It’s an insult to all mentally ill people to conflate hatred with psychopathology. People with diagnoses of mental illnesses are  no more likely to be dangerous to others than people without mental illnesses, and are more likely to be of danger to themselves than to others.

I know what I’m talking about. Throughout most of my career in the mental health system, I was certified as a Designated Examiner in the Probate Court. That meant that I routinely assessed people and testified in the Probate Court as to whether they met the criteria for involuntary commitment to psychiatric facilities. The two primary criteria are that the person is credibly diagnosed with a mental illness, and that he or she is at risk for harm to self or others. I was proud to play a part in a system that protects the civil rights of mentally ill persons, and assures that their right to due process is honored.

Xenophobia and race hatred aren’t symptoms of mental illness. They are learned prejudices, not psychopathologies. The President would have us believe that lethal hatred is a symptom of mental illness, not a product of hatred for “the Other.” Our national mental health system is a disgrace and needs to be adequately funded. But even if we had a system that provided adequate treatment for all of our mentally ill citizens, the impact on our national crisis of mass shootings would be negligible. It’s domestic terrorists that we need to worry about, not mentally ill people.

I was raised with guns. My father, an Army officer, was a world class expert on small arms and an avid NRA member. He saw to it that his sons learned to shoot at an early age, in NRA gun clubs – first with bb guns, then with .22 caliber rifles. I own guns, and I taught my wife to shoot them. A reasonable interpretation of the Second Amendment would protect the right of most citizens to own handguns, hunting and target rifles, and shotguns; but we’ve got to draw the line somewhere. You can’t buy or own hand grenades, flame throwers, bombs, or tanks – and that’s how it should be. We need to re-instate the ban on military-style semi-automatic assault weapons, such as the M-16 (AR-15). We also need to ban clips and magazines that hold ten or more rounds. Until we do this, the body count from mass shootings will continue to rise.

The signers of the Constitution couldn’t have envisioned our modern military weapons, or the mass shootings we see all too often these days, The rifles of the eighteenth century weren’t as accurate as modern rifles, and had to be re-loaded after every shot fired. Today we have semi-automatic rifles, which fire one round each time the trigger is pulled. Fully automatic rifles, which fire rapidly as long as the trigger is held down, are rightfully banned; but some semi-automatic rifles can be easily modified to be fully automatic. With clips that hold from a dozen to a hundred rounds, such rifles are weapons of war, designed for rapid slaughter. They should not be for sale to civilians.

A ban on the manufacture and sale of assault weapons won’t completely solve the problem, as there are already millions of them out there. However, the overwhelming majority are in the hands of responsible gun owners, who will never use them for mass murder. As long as they’re not allowed to be traded or sold, most of them don’t present a threat  to public safety. But an absolute ban on sales would make it harder for people who decide they want to kill people to acquire an assault rifle. A massive public relations campaign promoting a national, voluntary buy-back program would gradually reduce the number of assault weapons over time.

We also need to have a national dialogue about the “Otherizing” of racial and ethnic minorities by hate groups – the “Us vs. Them”mentality. School children need to be educated about the stereotypes that are being used to indoctrinate people to fear and hate people who don’t look like them or believe in all the things they believe in. They need to be able to recognize the lies that are told to recruit domestic terrorists. Part of the reform of our mental health system needs to be a public education program, to try to end the stigma about mental illness that is so prevalent in our society. Mentally ill people have enough problems with stigma as it is, without being blamed for mass murder.

 

 

Who is a psychologist?

I have a masters degree in psychology, and was trained in the profession by doctoral psychologists. I worked for over thirty years as a clinical psychologist in the public sector, but there are psychologists with PhDs and PsyD degrees who would have you believe that I’m not a “real” clinical psychologist. That’s because I can’t be licensed as a clinical psychologist in South Carolina – as in most states – with a masters degree.

I’m thankful to the American Psychological Association (APA) because I got my first job as a mental health counselor as a result of  a job interview at an APA convention. (I was subsequently certified by the state of Alabama as a psychometrist – qualified to administer, score and interpret certain psychological tests.) But I’ve since come to view the APA as a professional guild, as well as a professional association. It serves to protect private practice psychologists with doctoral degrees from competition by masters-level psychologists. There’s no established scientific basis for excluding masters-level psychologists from licensure, if they can meet the other requirements.

The central issue is demonstrated competency, but the APA contends that a doctoral degree is the established educational standard for licensure. No body of scientific evidence exists which demonstrates that doctoral-level psychologists achieve better outcomes in the provision of psychological services than masters-level psychologists. But the APA doesn’t want the competition, and has opposed all efforts in various states to allow masters-level psychologists to be licensed. In South Carolina, a hard core of doctoral psychologists even tried to “trademark” the prefix psycho (as in psychotherapy, psychological testing, etc.) for the exclusive use of doctoral psychologists.

I know this because I was the acting chairperson of the South Carolina Association of Masters in Psychology (SCAMP), a state chapter of the North-American Association of Masters in Psychology (NAMP), when the licensed psychology establishment proposed legislation that would exclude any psychologist without a doctoral degree from the possibility of professional licensure in the field. To insure passage of their “practice act,” it was written for them by one of South Carolina’s most prestigious law firms, and they hired a lobbyist to promote it in the state legislature. SCAMP didn’t stand a chance.

But it didn’t stop us from trying. We did research on the availability of psychological services throughout the state, indicating that South Carolina was underserved, and that masters licensure would make psychological services available to more people. We argued that only those masters-level psychologists who could achieve the same scores on licensing exams as the doctoral-level psychologists should be eligible for licensure. We were even open to an initial period of supervision by licensed psychologists, leading to eventual licensure for independent practice. Perpetual supervision of masters-level psychologists in private practice would have been a new revenue stream for licensed psychologists, but a period of supervision leading to independent practice was unacceptable. The psychology practice act only affected private sector psychologists. In the public sector, masters-level psychologists routinely did things that they’d been deemed unqualified to do in private practice, by the practice act.

SCAMP had some significant support when testimony was presented in legislative subcommittee hearings. A publisher of certain widely-used psychological tests testified that masters-level psychologists were competent, with appropriate training,  to administer, score and interpret their tests. Dr. Logan Wright, a former president of the APA, testified in support of masters-level psychologists being eligible for licensure as psychologists. In spite of this, the South Carolina Psychological Association got the legislation they wanted. The law didn’t  prohibit appropriately -trained masters-level clinicians in private practice from doing any testing; you just couldn’t call the service “psychological testing.”

For years I worked as a mental health counselor, but routinely did psychological testing as part of my job. I eventually got licensed as a professional counselor; but for most of my career, I was hired as, and performed as, a clinical psychologist. My colleagues who were licensed psychologists always treated those of us with masters degrees as peers; and although we couldn’t be licensed as clinical psychologists, we did essentially the same work as the licensed psychologists. For legal reasons, our psychological evaluations were co-signed by licensed psychologists; but in all my years of doing testing, I never needed to have my work corrected, and never got critical feedback from my licensed colleagues. Whenever I was hired by a psychologist, I was supervised by licensed psychologists, and always got excellent performance evaluations from them.

So, although I “work like a clinical psychologist, talk like a clinical psychologist, and have frequently been seen in the presence of known clinical psychologists,” I can’t be licensed as what I am: a competent, experienced clinical psychologist. I never regretted not getting a PhD, as I was able to do all of the things I was trained to do, as a public sector psychologist. My last clinical supervisor – a licensed clinical psychologist –  explicitly told me that I knew as much about psycho-diagnosis and psychotherapy as any licensed psychologist he’s ever known. Shortly before I retired, he nominated me for an award honoring the outstanding clinical service provider in the state of South Carolina.

Although SCAMP is just a footnote in the history of psychological practice in SC, NAMP is still going strong, advocating for the licensure of qualified masters-level psychologists. Nine states now allow masters-level psychologists to practice independently in the private sector, although usually with a qualifier like “Psychological Associate” in the title. All this to say that you don’t have to get a PhD or PsyD in psychology to be a “real psychologist.” The central issue in determining who is a psychologist is demonstrated competency in the profession, not one’s academic degree.

Psychiatry: pro and con

I write this as someone who had a career as a psychologist in the mental health system, working within the scientific/medical model of psychiatric treatment. So, I’m not writing to reject psychiatry outright, but to examine its efficacy. I’ve written about the value and limitations of models in previous posts, and about what I call the “model muddle.” Models are just maps, helpful only to the degree that they’re accurate. No one model is demonstrably superior to all other models, in all situations. Every model has its limitations.

First, I’d like to distinguish between psychology, psychiatry and psychoanalysis. Psychology is the study of human behavior, and provides the basic theoretical structure for psychotherapy. Sigmund Freud came up with the concept of “the talking cure,” the notion that dialogue with a caring professional could help to resolve symptoms and treat psychopathology. Psychiatry is a branch of medical science, based on the concept that the accurate assessment of symptoms of mental illness can lead to an accurate diagnosis, which will result in an appropriate treatment. Psychiatrists are medical doctors who specialize in the treatment of mental illness. Freud was a psychiatrist, and psychiatrists who are trained in the system of Freudian psychotherapy are called psychoanalysts.

While I believe that psychiatric (medical model) treatment has helped a lot of people with debilitating metal and emotional symptoms, like any model, it has its limitations. Since the 1960s, the efficacy of psychiatric treatment has been questioned – with good reason. A primary critic was psychiatrist Thomas Szasz, who wrote The Myth of Mental Illness. Another psychiatric rebel was R.D. Laing, and yet another psychiatrist, David Cooper, coined the term “antipsychiatry.” Critics of psychiatry argue that mental illness/madness is a social construct and not a medical condition, and that psychiatry is a process of coercive social control. This core of criticism has led to the current antipsychiatry (alt. recovery) movement.

A primary criticism of psychiatry is that psycho-diagnosis isn’t rocket science. It’s imprecise relative to the diagnostic precision for most common physical medical conditions, and can be selective and subjective in its diagnostic criteria. Unlike with physical medical conditions that can be diagnosed by tests and procedures that reveal “markers” of a specific condition (i.e. pneumonia vs. tuberculosis), there are no such markers that distinguish schizophrenia from schizoaffective disorder or bipolar disorder. I’ve known many people with chronic mental and emotional disorders who have gotten a wide range of psychiatric diagnoses, over years of treatment. Ideally in the medical model, an accurate diagnosis results in appropriate and effective treatment. This is less often the case in psychiatry, because there’s more “educated guesswork” involved.

Proponents of the antipsychiatry movement contend that psychiatric treatment is all too often more damaging than helpful to patients. Extreme treatments such as prefrontal lobotomies haven’t proven to be effective; and the negative side effects of some psychotropic medications and mood stabilizers seem to outweigh the benefits for some patients. The term “iatrogenic effects” refers to treatments that do harm.

Another valid criticism of psychiatry is that it’s over-reliant on pharmaceuticals, and that the psychiatric profession has had incestuous ties to Big Pharma. I believe that, as a culture, we’re too dependent on medications as a panacea for health problems related to bad lifestyle choices. Drug company ads suggest that we can eat whatever we want and take pills to control any gastro-intestinal symptoms that result from a poor diet.

Having said that, psychopharmacology has its place in the treatment of what we call mental illnesses. I believe that in some instances there’s no effective substitute for the right dose of the right medication at the right time. But I also believe that other interventions can mitigate the need to rely primarily on drugs as the default treatment for psychopathologies.

The concept of recovery from mental illness doesn’t necessarily mean full and permanent remission of symptoms, but suggests that psychiatric treatment isn’t the only route to symptom control or remission. There are recovery centers in cities around the country that offer alternatives to traditional psychiatric treatment, recognizing that community and peer support can be important components of treatment. Such programs don’t preclude psychiatric interventions, but don’t rely on them as the default mode.

Factors such as physical health, stress, social stigma, chemical dependency, poverty, homelessness and nutrition can all play a role in mental health and mental illness. We need to embrace a more holistic treatment model for what we call mental illness, and to provide a range of services that give people who have been labeled as mentally ill more autonomy and more options for resolving their problems.

You can find out more about the antipsychiatry movement, the recovery model, and alternatives to traditional psychiatric treatment at <madinamerica.com>.

 

 

Involuntary commitment

Throughout the years I worked in the Alabama and South Carolina mental health systems, one of my responsibilities was to serve as a Designated Examiner (DE) in the Probate Court. Both states reviewed my clinical qualifications and certified me to examine people and give testimony in the Probate Court as to whether they met the legal criteria to be involuntarily committed to a psychiatric hospital. This commitment process was established nationwide to safeguard the rights of mentally ill persons, insuring that they couldn’t be “railroaded” into involuntary treatment, without due process. With only a few exceptions that I’ve witnessed over the years, the system worked.

You’ve probably heard the term “certifiably mentally ill.” Well, I was a certified certifier.  In most (all?) states a person that someone has petitioned the court to assess for possible involuntary commitment has to be independently interviewed by two DEs, one of whom has to be an MD. The two criteria were that the person had a diagnosable mental illness (based on the judgment of the DEs) and that he presented a credible threat of harm to self or others. Both DEs had to agree that the criteria had been met, in order for the person they’d examined to be deprived of their liberty. That person couldn’t be hospitalized indefinitely, but had to be re-certified at specified intervals.

The commitment process went like this: someone – usually a family member or medical professional or  law enforcement officer – had to petition the court for a hearing. Both DEs independently interviewed the individual, wrote reports on their findings, and made a recommendation for or against involuntary commitment. If both DEs agreed that that the person met the criteria for commitment, a Probate Court hearing was held. The hearing was recorded so that there would be a transcript, and if the person didn’t have his own attorney present, they were represented by a court-appointed attorney. Sometimes the person agreed that he needed hospitalization and the hearing was just a formality; but if he disagreed, the lawyer made sure that his point-of-view was represented in testimony.

Once the voice recorder was turned on, the court was declared to be in session and both DEs were sworn in. After they read their reports and recommendations, the attorney could consult with her client and ask follow-up questions, or have the client speak for himself. After hearing all the testimony, the Probate Judge could either dismiss the petition or order the person to be involuntarily committed. If both DEs had recommended commitment, the judge almost always went along with their recommendations.

The deprivation of liberty is no small matter, and the Probate Court hearing is an important safeguard, to insure that the commitment laws aren’t abused. Many people with severe, chronic mental illnesses have gone through the process multiple times and accept that they’re going to spend some time in the hospital. A few physically resist and have to be sedated. Yet others resist treatment in  a variety of ways, once they get on their assigned ward.

I spent the last nine years of my career as a treatment team psychologist on a locked ward at South Carolina’s largest psychiatric hospital, and had to deal with every kind of resistance imaginable. Some patients reasoned incorrectly that their refusal to speak or answer questions in treatment team would somehow shorten their stay. I remember an instance when I recognized an intelligent young man ( I’ll call him John) who’d been assigned to the treatment team I served on during a previous commitment, years earlier. At his treatment team initial assessment he was surly, but at least minimally cooperative. I asked if he remembered me, and he said he did. “You’re the one who told me that it’s impossible not to communicate.” I’m pretty sure I smiled at him, recalling our first encounter.

It had been John’s first commitment, and he must have reasoned that giving the treatment team the Silent Treatment (or elective mutism, as we call it) would lead to an early discharge. We’d tried to get him to open up, but he’d refused to answer a single question. So I said something like this: “John, it’s impossible not to communicate, and even though you’re not speaking, you’re communicating right now. What you’re communicating is, ‘You can’t make me talk,’ and you’re absolutely right. We can’t. We know you don’t want to be here, but we can’t discharge you until we know what’s going on with you, and that you’re safe.

“Let me tell you one thing that everybody on this team has in common with you. None of us wants you to stay here even one day longer than you have to. We plan for discharge from Day One. The best thing you can do to shorten your stay is to let us know what you think is going on. Work with us and I promise we’ll get you back home as fast as we can.” My intervention worked and John started answering our questions.

Sometimes people are so angry about their commitment that they get violent, so all employees who have contact with patients are trained to work with other staff to take down combative patients without anyone coming to harm. However most patients on locked wards understand that violent acts would be evidence of the “harm to others” criterion of commitment, and try to control their tempers.

 

 

Mood, disposition and disorder

In a previous post I referred to suicide as a “mood-specific” behavior, and I feel the need to clarify this statement. I wrote that nobody suicides when they’re in a happy mood, suggesting that if people in a depressed mood can “ride out” the mood without doing something lethal, the urge to end their lives will pass when their mood changes. Moods are transient emotional states that can be prolonged by irrational thinking and by ruminating.

Thoughts such as “My life is my problem; the only way to solve my problem is to end my life” can seem logical to a person in a depressed mood. When the mood passes, the person will likely recognize the thought as irrational – or at least as one that doesn’t have to be acted on immediately. Suicide hotlines have prevented many impulsive (mood specific) suicides by helping people to not act on suicidal impulses and to ride out the depressed mood – or to sober up. This principle doesn’t apply to suicidal people who experience chronic depression.

While moods aren’t enduring emotional states, dispositions are. We each have a unique disposition or set of dispositions. For instance, we’re each disposed to be somewhere on the continuum between optimism and pessimism – glass half full vs. glass half empty. I don’t know whether one’s disposition is a result of nature or nurture, or some combination of the two. Other adjectives I’ve heard used to describe disposition include gloomy, chipper, pushy, cranky, generous, stingy, passive and aggressive. They are a component of our personality. As a psychological construct, disposition has so many variables that it’s hard to precisely define or to measure, so these are just my opinions. Dispositions tend to be enduring traits, but that’s not to say that they can’t change over the course of one’s life. For instance, I think that people who’ve tended to be distrustful of others can learn to be more trusting, given enough positive experiences with trustworthy people.

When anxiety and depression are chronic emotional states that seriously affect our functioning, they’re diagnosable as psychiatric disorders. There’s considerable scientific evidence that there’s a biological basis for such disorders, although irrational thinking patterns can exacerbate them. The key to distinguishing  pathological states of anxiety and depression is impairment. Even during the saddest times in my life, my sleep and appetite weren’t seriously affected, and I was able to function adequately. I cried but didn’t have crying spells, and have never come close to attempting suicide. (I’m  not taking credit for this; I consider myself very fortunate.) During my year-long employment in an extremely stressful job, I suffered sleep loss; but my sleep improved immediately after I quit the job.

People who suffer from chronic anxiety and depression often get blamed for their symptoms, because they’re not understood as the symptoms of a chronic mental disorder. Because of the widespread stigma attached to mental illness, many people don’t feel the empathy they might feel for someone with a debilitating physical disorder. And people who suffer from these mental illnesses often blame themselves, telling themselves they “should be” able to control their symptoms. Others self-medicate with alcohol and other drugs that might give them short-term symptom relief, but only add drug dependency to their list of problems.

It’s hard enough to have a mental illness and to have to deal with societal stigma; but in addition, mentally ill persons are increasingly neglected in this country. The mental health system is shamefully under-funded, which explains why so many people with mental illnesses are homeless, why hospital Emergency Departments all over the country are swamped with people who are experiencing a psychiatric crisis, and why jails and prisons have become major providers of mental health services.

Everybody experiences anxiety and depression, and most of us learn how to cope with these transient conditions, because they’re not overwhelming or disabling. But some people with chronic anxiety and/or depression can’t cope without help from social support systems, whether in the form of professional services or community resources – family and otherwise – that recognize mental illnesses as treatable conditions, and provide needed help.

I’m taking a break for a couple of weeks, but will be back with a new post in early June. In the meantime, you can access other things I’ve written at my website: jeffkoob.com. It features links to my books, samples of my artwork, and a short story, “Demon Radio.”

On supervision and treatment teams

Throughout most of my career as a public sector psychologist, working in a variety of settings, I was blessed with good supervision. The few times I either didn’t have a clinical supervisor (as in Jamaica) or didn’t get adequate supervision, I felt like I was walking a tightrope without a net. A good supervisor will listen to you as carefully as you listen to your clients, and give you feedback on how you’re doing.  Positive feedback validates your work and increases your confidence that you’re on the right track, and negative feedback teaches you humility and provides valuable instruction.

As in therapy, a good supervisor asks the right questions. (When the person you’re talking to asks spot-on follow-up questions, you know she’s listening and understands you, whether it’s a friend, therapist, or supervisor.) As your supervisor gets to know you, he will validate your competencies and strengths, be part of your continuing education as a clinician, and insure that you know the appropriate scope of your practice. He will offer constructive criticism when necessary, and may suggest resources for your professional development. He will alert you to possible ethical issues.

At  the beginning of individual supervision, the therapist being supervised might have to staff each case in some detail, until the supervisor gets to know her strengths and limitations. Later in supervision, the therapist might provide brief updates on the progress in cases already staffed and spend more time on new, or challenging, cases. In group supervision, participating clinicians may be asked to prepare case presentations, usually on their most challenging cases.

The other group setting where clinicians might be asked to present cases is in treatment team, which is a kind of group supervision. In community mental health centers (CMHCs) and other treatment facilities, each new case has to be staffed,  and the treatment plan has to be approved by a multidisciplinary treatment team. Not only do treatment teams insure that all treatment is reviewed by colleagues on an ongoing basis, they also serve a professional development function. The ideal treatment team consists of one-or-more psychiatrists, psychiatric nurses (or nurse practitioners), psychologists, social workers, counselors, and possibly specialists such as art therapists or activity therapists. Each discipline represented on a treatment team brings a different area of expertise to the table. In the best treatment teams a kind of cross-pollination of ideas occurs, as treatment plans are generated and reviewed.

I’ve been a treatment team member at CMHCs, juvenile and adult prisons, and hospitals. The smallest, at a rural satellite office of a CMHC, consisted of only a psychiatrist, a psychiatric nurse (my supervisor), and me. The largest consisted of something like fifteen members, with people from all or most of the helping professions listed above. Some treatment teams might give assignments to its members, such as  asking a psychologist to do some psychological testing for a client on someone else’s caseload. In facilities run on the medical model, treatment teams are headed by psychiatrists. In a well-run treatment team, everybody has a voice.

I’ve not only appreciated, but enjoyed most of my treatment team experiences. Working with colleagues from a variety of disciplines has broadened my knowledge and increased my appreciation of the unique contributions offered by each profession. The highest goal of both clinical supervision and treatment team staffing is to insure that clients receive effective treatment, tailored to their unique needs. I have fond memories of interactions I’ve had with a number of my clinical supervisors over the years and – full disclosure – I fell in love with one of them. We’ve been married for almost thirty years.

Maria, a psychiatric nurse, was my third clinical supervisor, and I admired her before I fell in love with her. I had the silly notion – grounded in my own insecurities as a young therapist – that group therapy wasn’t effective with chronically mentally ill clients. She set me straight, telling me that I’d be leading  a weekly group with some of my most challenging clients, and offering to co-lead the group with me until I felt competent to lead it on my own. She was my first role model for doing group therapy.

We felt awkward at first when we started dating, but Maria did the right thing and talked to her supervisor about it. He reassured her: These things happen. You know what you’re doing.

The rest is history.

 

Mental illness and stigma

I’ve worked as a case manager and therapist with people who have chronic mental illnesses for over thirty years, and have learned a lot from them about the varieties of human experience. I’ve learned not to be quick to judge. I’ve observed over the years that many folks tend to stereotype mentally ill people, not realizing that each of them is as unique a human being as they themselves are. Some mentally ill people are of below-average intelligence, most have normal intelligence, and others are brilliant. Some are insightful about their need for treatment, others are in deep denial. Some are kind and some are mean-spirited. Some are potentially dangerous to others, most are not. In my experience mentally ill people are more likely to be of danger to themselves  than to others.

The cumulative effect of this widespread stereotyping is stigma – society-wide prejudice and discrimination. I’ve seen it in persons and in policies. I think this stigma is one of the reasons for the deterioration of the mental health system, as described in my last post. We now have federal legislation that supposedly establishes parity of treatment for mental illness with physical illness, but I haven’t seen that result in any significant improvement in mental health treatment. Addiction to opioids has become a public health epidemic, but some people have no compassion for addicts, due to stigma. They thinks addicts are bad, or morally weak, individuals who don’t deserve help.

Writers who should know better -notably book reviewers and film critics – still don’t seem to know the difference between schizophrenia and “split personality” (now known as dissociative identity disorder). Schizophrenia is characterized  by a disorganization or distortion of thought processes, not by the development of separate identities. I think that fear is at the root of the stigma attached to mental illness. At some level all of us fear losing control, because we know that if we were to lose control of our minds, anything could happen to us. So we tend to avoid looking at mental illness too closely. It’s too disturbing.

Another basis for the widespread fear and resulting stigma comes from media depictions of “insanity.” From Alfred Hitchcock’s classic horror film to the books and films about Hannibal Lector, the term psycho – a prefix that has come to be used both as a noun and an adjective – has taken on an aura of threat. Many people don’t know the difference between psychosis (being out of touch with consensus reality) and psychopathy, also know as sociopathy.  A sociopath commits antisocial acts and has no sense of conscience about the harm done. When psychopathic people do horrible things, many people think of them as “crazy” or “sick,” rather than simply evil. While psychosis is recognized as a medical condition, psychopathy doesn’t appear to be one.

One of the forms stigma takes is the attitude, “I want mentally ill people to get the treatment they need, but not in my neighborhood.” The acronym NIMBY is well known in the mental health community: Not In My Back Yard. I remember some years ago reading a letter to the editor in a local newspaper from a man warning readers to beware of allowing people in their neighborhoods to become “mentor families.” Mentor families are families who are willing to take in a mentally ill boarder – someone they’ve already gotten to know and trust. The letter writer apparently didn’t like the idea of having mentally ill neighbors, or wanted to know who they might be and where they lived. I wrote a reply in which I told the silly man that if he lived in a neighborhood of any size, he already has mentally ill neighbors. And that’s no reason to be scared. Mental illness isn’t  a rare thing, and most mentally ill people aren’t a threat to anyone.

Speaking to the House Education and Labor Committee in 2007 about her 35 years of mental health advocacy, Rosalynn Carter observed, “When I began, no one understood the brain or how to treat mental illness. Today everything has changed – except stigma, of course, which holds back progress in the field.” Progress in the field is exactly what we need. We need to systematically address stigma as a part of the problem, and restore community services that not only prevent more expensive episodes of inpatient treatment, but improve the quality of life for people with mental illnesses.