Recently I read a quote from a celebrity, I think on Facebook, saying that he has been "struggling" with anxiety and depression for at least 7 years. I was puzzled by this, because there's no reason for anyone to struggle with anxiety or depression for that length of time. There are numerous treatments for depression and for anxiety disorders. Most people with depressive or anxiety disorders are able to resolve their symptoms or at least tolerate them, if they get the appropriate treatment.
I wondered whether the celebrity had really been diagnosed with bipolar disorder or borderline personality disorder, but was afraid to say so, because these conditions are far more serious and he thought it would be too stigmatizing to admit he had them. It's also possible that his treatment professionals told him that he had "anxiety and depression" when in reality they had diagnosed him with borderline personality disorder or possibly even with bipolar disorder, without telling him. In other words, it's possible his treatment professionals lied to him, to avoid upsetting him (and potentially losing a high-paying patient). It's also possible the celebrity was misdiagnosed or was receiving inappropriate or inadequate treatment, or that he has been noncompliant with treatment. All I know is that something was missing from the picture.
This scenario and its possible behind-the-scenes factors illustrate some of the pitfalls of our "Information Age" in which people are inundated with "information" from the internet and especially from social media. It also may illustrate the continuing stigma relating to mental health conditions, as well as the general difficulties people may encounter getting correct diagnoses, information and treatment for their conditions.
I have learned that it is important to tell people what their diagnoses are. When I was in graduate school, some of my professors minimized this educative component of treatment. Many colleagues I've had believe that patients can fixate on diagnosis, or that diagnoses are controversial or often inaccurate. Although I agree with those colleagues that there are many potential problems involved in telling patients that they have a condition such as borderline personality disorder, antisocial personality disorder, or another stigmatizing condition, I now believe patients have a right to know and I feel comfortable making such diagnoses when I have the required evidence.
I saw numerous comments on the actor's Facebook page from fans stating they too had been struggling with depression or anxiety and depression for years. I didn't see any comments from people speaking about how they recovered from their conditions. No one seemed to be questioning whether they had been given the correct diagnosis or the right treatment. This is sad. With only a couple of exceptions that I can think of, every patient I've worked with who had a depressive disorder or an anxiety disorder as their primary diagnosis got much better, sometimes with therapy alone and sometimes with a combination of therapy and medication. In the two cases that spring to mind in which the person did not get better, I strongly suspected the patients were not compliant with their medication and in one case, the person was using drugs. I also had one patient who didn't recover from severe depression until she had treatment with a brain stimulation method that at the time was only available in Canada ( I believe it is now approved in the US). The medications she'd previously tried had been ineffective. It may take some time to find the correct treatment regimen for someone's condition. But there is no question that depression and anxiety can usually be resolved. The treatment of a condition such as borderline personality disorder is far more difficult and perhaps I'll discuss this in a later post. Bipolar disorder is incurable but can be managed with medication.
I commend public figures for speaking about their personal problems in an attempt to destigmatize those problems, but this is only useful if what they are saying is the truth. It's sad that both patients and their treatment professionals are still sometimes victims of the fear of stigmatization. Perhaps one day our society will acknowledge that there's no such thing as perfect mental health and that we all have problems.
Tuesday, September 1, 2015
Sunday, July 26, 2015
What You Can Do To Improve Your Mental Health
There are many factors that influence mental health. Most emotional disorders are created by a combination of "nature" and "nurture"--genetics and environment. When clinicians do assessments, they evaluate the patient's family background and stressors and often make a decision as to whether symptoms have a mostly biological background or are mostly due to environment. Rarely, if ever, is an emotional disorder created only by biology or only by environment. What's most important for the patient to remember, however, is that current environment, behaviors and choices have an impact on mental health. Although the past can't be changed and neither can one's genes, people make many choices in their lives that affect their mental health.
The worst decisions that people make affecting their mental health include decisions to avoid treatment for emotional problems, decisions to continue using drugs or alcohol despite problems with these substances, and decisions to stay in bad relationships. People can also make bad career and financial decisions that often have very negative effects on their mental health later in life (see my previous post http://notesonsanity.blogspot.com/2015/01/do-therapists-give-advice.html.)
But let's reframe this question in a more positive way: What are the good decisions people make that can enhance their mental health?
In addition to promptly seeking help for emotional and behavioral problems, limiting or eliminating substance abuse and other dangerous behaviors and leaving abusive relationships, smaller decisions can have a big impact. Here are some healthy habits:
1. Exercise regularly see my previous post http://notesonsanity.blogspot.com/2014/08/run-for-your-life.html
2. Pursue your dreams while maintaining realism in your career choices (not so easy in practice, which is why it's good to get advice from others whom you trust).
3. Write in a journal. Writing down feelings and thoughts helps people gain a sense of control over their feelings and thoughts.
4. Pursue a hobby. Learning and gaining competence in a field unrelated to your job makes you less dependent on your career for your self esteem and means you can never be bored. Play a musical instrument, take up photography or painting, engage in creative writing, study foreign languages...etc. A hobby can also turn into a second career or at least something to add to your resume.
5. Develop a life philosophy and try to find a group of people who share it. There's a reason why religion continues to be popular despite the Scientific Revolution--people need a sense of meaning, purpose and belonging, in life. But there are many philosophies that don't require belief in a deity or practices that are thousands of years old. These include political philosophies and movements, alternative religions, 12-step programs, and various modern philosophies.
6. Associate with different types of people. Perspectives can become narrow when one only associates with people from one's own socioeconomic class and nationality. Associating with different types of people can lead to insight about expectations and pressures from one's social circle that aren't necessarily helpful but are based on tradition or culture.
7. Become a fan. This may sound like strange advice, as the word "fan" comes from the word "fanatic." But there's been some research indicating sports fans have better overall mental health than people who aren't sports fans, and it stands to reason that other types of fandom may have a similar effect. There is a human need to look to icons, which is another reason why religion survived the Scientific Revolution.
8. Neither ruminate on the past, remain stuck in the present, nor worry excessively about the future. Thinking about the past can be beneficial for two reason: One, to determine a chain of events that led to bad decisions, and two, to reflect on one's accomplishments, which is beneficial for increasing self-esteem. Dwelling on past traumas is not healthy, although talking about them with a therapist might be. People who only exist in the present lose perspective. It's important to remember the past to know who you are, and it's important to visualize and to even fantasize about the future, because this helps you to set goals. Worrying about the future, on the other hand, serves no purpose unless you have legitimate worries that require immediate action.
The worst decisions that people make affecting their mental health include decisions to avoid treatment for emotional problems, decisions to continue using drugs or alcohol despite problems with these substances, and decisions to stay in bad relationships. People can also make bad career and financial decisions that often have very negative effects on their mental health later in life (see my previous post http://notesonsanity.blogspot.com/2015/01/do-therapists-give-advice.html.)
But let's reframe this question in a more positive way: What are the good decisions people make that can enhance their mental health?
In addition to promptly seeking help for emotional and behavioral problems, limiting or eliminating substance abuse and other dangerous behaviors and leaving abusive relationships, smaller decisions can have a big impact. Here are some healthy habits:
1. Exercise regularly see my previous post http://notesonsanity.blogspot.com/2014/08/run-for-your-life.html
2. Pursue your dreams while maintaining realism in your career choices (not so easy in practice, which is why it's good to get advice from others whom you trust).
3. Write in a journal. Writing down feelings and thoughts helps people gain a sense of control over their feelings and thoughts.
4. Pursue a hobby. Learning and gaining competence in a field unrelated to your job makes you less dependent on your career for your self esteem and means you can never be bored. Play a musical instrument, take up photography or painting, engage in creative writing, study foreign languages...etc. A hobby can also turn into a second career or at least something to add to your resume.
5. Develop a life philosophy and try to find a group of people who share it. There's a reason why religion continues to be popular despite the Scientific Revolution--people need a sense of meaning, purpose and belonging, in life. But there are many philosophies that don't require belief in a deity or practices that are thousands of years old. These include political philosophies and movements, alternative religions, 12-step programs, and various modern philosophies.
6. Associate with different types of people. Perspectives can become narrow when one only associates with people from one's own socioeconomic class and nationality. Associating with different types of people can lead to insight about expectations and pressures from one's social circle that aren't necessarily helpful but are based on tradition or culture.
7. Become a fan. This may sound like strange advice, as the word "fan" comes from the word "fanatic." But there's been some research indicating sports fans have better overall mental health than people who aren't sports fans, and it stands to reason that other types of fandom may have a similar effect. There is a human need to look to icons, which is another reason why religion survived the Scientific Revolution.
8. Neither ruminate on the past, remain stuck in the present, nor worry excessively about the future. Thinking about the past can be beneficial for two reason: One, to determine a chain of events that led to bad decisions, and two, to reflect on one's accomplishments, which is beneficial for increasing self-esteem. Dwelling on past traumas is not healthy, although talking about them with a therapist might be. People who only exist in the present lose perspective. It's important to remember the past to know who you are, and it's important to visualize and to even fantasize about the future, because this helps you to set goals. Worrying about the future, on the other hand, serves no purpose unless you have legitimate worries that require immediate action.
Saturday, June 20, 2015
Is Racism a Mental Illness?
Many clinicians have long believed that racism is a type of Delusional Disorder. According to the Diagnostic and Statistical Manual of Mental Disorders, delusions are "fixed beliefs that are not amenable to change in light of conflicting evidence."(I find the DSM's definition of delusions somewhat humorous,
since many people stick to beliefs that are cultural or religious
despite overwhelming data indicating a lack of scientific evidence for
these beliefs. Most of these beliefs are not dangerous, however; whereas
some delusions can be dangerous).The DSM categorizes delusions by whether or not they are
bizarre (not possible) and according to type, e.g. Erotomanic,
Grandiose, Jealous, Persecutory or Somatic. Jealous, Persecutory and
Erotomanic delusions can be dangerous. Some racist beliefs could be
categorized as persecutory delusions.
After reading reports of the recent shooting in Charleston, South Carolina, I wondered if the perpetrator's thought content might qualify as delusional and persecutory. According to reports, the perpetrator, Dylann Roof, expressed thoughts that black people were "taking over" and were responsible for raping white women. There is no evidence in reality for these beliefs. Rapists tend to pick victims from their own racial group, and the percentage of black people in the US is not growing. Of course, people can have erroneous beliefs based on misinformation or ignorance rather than paranoia. I suppose it's possible Roof subscribed to websites or other sources of misinformation that promoted these erroneous beliefs. It's also possible they were simply inventions of his own mind, in which case they could be classified as persecutory delusions.
Some may find this discussion irrelevant in light of the fact that Roof apparently committed murder and his emotional problems aren't the point. Others might fear that examination of the perpetrator's mental state could lead to a conclusion of lesser responsibility. I disagree with these points of view. Before any incident, there is a chain of events. To prevent crimes and disasters, it's important to analyze the factors that led up to the event. Moreover, having a mental illness does not preclude responsibility for a crime. To be found Not Guilty By Reason of Insanity (NGRI), a person has to be shown to be unaware of the difference between right and wrong at the time of the crime. A rationalization for the crime does not count as a lack of awareness of right and wrong.
What, if anything, could have prevented the murders in South Carolina? Sadly, psychotherapy does not have a good track record in treating delusional disorder. The delusional person doesn't necessarily think that anything is wrong with him or her. Sometimes feelings of paranoia respond to anti-psychotic medications, but this treatment is only possible if the patient agrees to take the medication. What we do know is that most mental conditions can be exacerbated by stress. Unemployment or financial problems, or lack of social support, could exacerbate paranoid and delusional beliefs. According to reports Roof was occasionally living in his car, prior to the incident.
Roof was also voicing violent thoughts to his friends and some were aware that he had a gun. Yet, no one took action to prevent what in hindsight seems like the inevitable. I believe that a gun license should require psychological testing, which almost certainly would have revealed pathological and dangerous thought content in the case of Roof. One of Roof's friends reportedly removed his gun, but then put it back after fearing he himself could get in trouble for owning a gun. It's easy to see that some creativity on the part of Roof's friends might have averted the incident, but we can't rely on lay people who may have their own problems to intervene in these circumstances. We need to screen out the paranoid and delusional from gun ownership.
After reading reports of the recent shooting in Charleston, South Carolina, I wondered if the perpetrator's thought content might qualify as delusional and persecutory. According to reports, the perpetrator, Dylann Roof, expressed thoughts that black people were "taking over" and were responsible for raping white women. There is no evidence in reality for these beliefs. Rapists tend to pick victims from their own racial group, and the percentage of black people in the US is not growing. Of course, people can have erroneous beliefs based on misinformation or ignorance rather than paranoia. I suppose it's possible Roof subscribed to websites or other sources of misinformation that promoted these erroneous beliefs. It's also possible they were simply inventions of his own mind, in which case they could be classified as persecutory delusions.
Some may find this discussion irrelevant in light of the fact that Roof apparently committed murder and his emotional problems aren't the point. Others might fear that examination of the perpetrator's mental state could lead to a conclusion of lesser responsibility. I disagree with these points of view. Before any incident, there is a chain of events. To prevent crimes and disasters, it's important to analyze the factors that led up to the event. Moreover, having a mental illness does not preclude responsibility for a crime. To be found Not Guilty By Reason of Insanity (NGRI), a person has to be shown to be unaware of the difference between right and wrong at the time of the crime. A rationalization for the crime does not count as a lack of awareness of right and wrong.
What, if anything, could have prevented the murders in South Carolina? Sadly, psychotherapy does not have a good track record in treating delusional disorder. The delusional person doesn't necessarily think that anything is wrong with him or her. Sometimes feelings of paranoia respond to anti-psychotic medications, but this treatment is only possible if the patient agrees to take the medication. What we do know is that most mental conditions can be exacerbated by stress. Unemployment or financial problems, or lack of social support, could exacerbate paranoid and delusional beliefs. According to reports Roof was occasionally living in his car, prior to the incident.
Roof was also voicing violent thoughts to his friends and some were aware that he had a gun. Yet, no one took action to prevent what in hindsight seems like the inevitable. I believe that a gun license should require psychological testing, which almost certainly would have revealed pathological and dangerous thought content in the case of Roof. One of Roof's friends reportedly removed his gun, but then put it back after fearing he himself could get in trouble for owning a gun. It's easy to see that some creativity on the part of Roof's friends might have averted the incident, but we can't rely on lay people who may have their own problems to intervene in these circumstances. We need to screen out the paranoid and delusional from gun ownership.
Wednesday, May 27, 2015
Should "Research" Guide Psychotherapy?
A couple of months ago, a patient was telling me that a research study from some years ago that had concluded that there's no such thing as bisexuality was recently debunked. (She probably was intrigued by this because she's bisexual). I told the patient that I was surprised anyone had believed the original study, because bisexuality has been documented in historical, religious and literary texts going back thousands of years.
We live in a society that often seems to worship science, or what is alleged to be science, and denigrates common sense and the accumulated wisdom of the human species. The media play a strong role in this disinformation, advertising the results of each recent research study on a popular topic with headlines that blare "Scientists Say...." "Studies Report..." Any scientist knows that one research study is almost meaningless. Research results have to be replicated to have any credibility.
Social science research is trickier than research in the natural sciences, because research into human behavior is often based on the self-reporting of the subjects. I was amused by a recent story in The New York Times that declared "Severe Mental Illness Found to Drop in Young, Defying Perceptions" http://www.nytimes.com/2015/05/21/health/reduction-is-found-in-severe-mental-illness-among-the-young.html?ref=health
Not only was the headline and much of the article based on one research study, but the study was based on parental perceptions. Surely one does not have to be a scientist or a psychotherapist to know that parents' perceptions of their children are distorted by the parents' wishes and fears. Although the study compared two sets of parental perceptions, from the past and the present, the changes in perceptions might have nothing to do with changes in the children's symptoms. The study may in fact be more useful for how it is documenting that parents are increasingly underestimating their children's symptoms. That possibility would be in line with research (as well as anecdotal observations by therapists) that people are becoming more narcissistic and that parents are more psychologically invested in their children, than in the past.
I frequently get communications from health insurance companies exhorting clinicians to use "evidence-based" practices. I often wonder which evidence they have in mind. Over the course of my career and my life, I have seen different types of therapy first promoted and then debunked. When I decide what techniques to use with patients, I don't base my decisions on the latest research study. I base my decisions on what theories and techniques have stood the test of time, and what techniques I have found previously helpful in my own practice for particular types of patients. I use my professional experience, common sense, and the accumulated wisdom of previous generations of therapists.
We live in a society that often seems to worship science, or what is alleged to be science, and denigrates common sense and the accumulated wisdom of the human species. The media play a strong role in this disinformation, advertising the results of each recent research study on a popular topic with headlines that blare "Scientists Say...." "Studies Report..." Any scientist knows that one research study is almost meaningless. Research results have to be replicated to have any credibility.
Social science research is trickier than research in the natural sciences, because research into human behavior is often based on the self-reporting of the subjects. I was amused by a recent story in The New York Times that declared "Severe Mental Illness Found to Drop in Young, Defying Perceptions" http://www.nytimes.com/2015/05/21/health/reduction-is-found-in-severe-mental-illness-among-the-young.html?ref=health
Not only was the headline and much of the article based on one research study, but the study was based on parental perceptions. Surely one does not have to be a scientist or a psychotherapist to know that parents' perceptions of their children are distorted by the parents' wishes and fears. Although the study compared two sets of parental perceptions, from the past and the present, the changes in perceptions might have nothing to do with changes in the children's symptoms. The study may in fact be more useful for how it is documenting that parents are increasingly underestimating their children's symptoms. That possibility would be in line with research (as well as anecdotal observations by therapists) that people are becoming more narcissistic and that parents are more psychologically invested in their children, than in the past.
I frequently get communications from health insurance companies exhorting clinicians to use "evidence-based" practices. I often wonder which evidence they have in mind. Over the course of my career and my life, I have seen different types of therapy first promoted and then debunked. When I decide what techniques to use with patients, I don't base my decisions on the latest research study. I base my decisions on what theories and techniques have stood the test of time, and what techniques I have found previously helpful in my own practice for particular types of patients. I use my professional experience, common sense, and the accumulated wisdom of previous generations of therapists.
Tuesday, May 12, 2015
Bad Therapy
I often see people who've seen previous therapists. Some of them report positive experiences, and some report negative experiences. In either case, I often find that people don't give me a lot of details about their previous therapy. This is a problem, because it's important for me to know what worked and what didn't work in someone's previous therapy.
I have pondered if some persons think that if they talk at length about a previous therapist's failings, I will side with the previous therapist. This is not true, as I am well aware that many therapists are not good. In fact, I sometimes say to friends, "I wouldn't refer a cat to 80 percent of the people in my field." It's not a joke.
When I do hear complaints about previous therapists, the most common complaint is that the therapist talked about him/herself. Why does this happen? Probably for many reasons. One possibility is the decline in the popularity and influence of psychoanalysis and of psychoanalytic training. Although psychoanalysis has some limitations as a treatment, it does insist on the neutrality and relative anonymity of the therapist. Other schools of therapy don't necessarily encourage therapist self-disclosure, but they don't place as much of an emphasis on boundaries as psychoanalysis does. Unfortunately some less-than-competent therapists may assume that if their training didn't emphasize boundaries, it means boundaries aren't important.
I usually limit information on my personal life to answers to direct questions asked by patients, in cases where the information might be relevant--for example, if someone asks me "are you going away on vacation?" I will answer, as this could relate to the issue of whether I can be contacted in an emergency. Another example would be when a patient discusses a movie they've seen and wants to know if I have seen it. I've found that discussions about movies are often quite meaningful, as which characters patients identify with, or which ones remind them of their family members, can lead to interesting discussions.
Therapists should not talk about events in their personal lives or personal problems. I've heard two (!) stories about therapists who talked about their own upcoming weddings--I can't think of any way this could be appropriate and it could be damaging to the patient.
I've developed a hypothesis that some therapists talk about themselves because they are bored by their patients and don't feel a connection with them, and are hoping that if they talk about something they have "in common" with a patient it will help them feel more connected and less bored. This boredom usually represents a type of narcissism. Unfortunately, some people become therapists for the wrong reasons. Some people believe that as a therapist they will be super-important to their patients and will wield great influence over their patients' lives. Although this can happen, it's not a good reason for someone to become a therapist. People with narcissistic problems are often attracted to the field of therapy. These persons should not be therapists, but they are not screened out of graduate school programs.
Other personal problems of therapists that interfere with therapy include difficulties with the opposite gender or with cultural differences. I've heard stories about male clinicians who gave compliments to female patients on their clothing and make-up. It apparently didn't occur to these clinicians that this behavior might be seen as objectifying by their patients--the clinicians probably thought they were boosting the patient's self-esteem. I've also come across female therapists who can't work with male patients due to projections of anger or disgust that come from their own experiences with men. In conversations with therapists from other parts of the country, I've discovered that religious bigotry is not uncommon. It's hard for a bigoted therapist to practice in New York, but once in awhile I've come across a homophobic therapist here, or other types of issues.
The worst failings of other therapists that I have come across, however, are inaccurate assessments. Sometimes the end result of these errors is tragic. In the worst cases, there may be a preventable suicide. Fortunately I haven't heard very many of those stories.
Errors in assessment and diagnosis often stem from a belief that recognizing someone's severe pathology is tantamount to not liking them or not recognizing their strengths: Years ago, while working in a clinic, I worked with a paranoid schizophrenic whose previous therapist encouraged him to attend college. The vast majority of people with schizophrenia cannot complete college. The patient dropped out and was left with student loans he could not repay as well as a blow to his self-esteem. In another case, a therapist treating a family member of one of my patients didn't notice the woman's severe personality disorder and the extent of her pathological behaviors, which were affecting my patient. Many therapists have bought into society's stigma against mental illness, and this makes them believe that diagnosing a patient with a disabling condition is equivalent to condemning them or not liking them.
Being a therapist requires a sober view of humanity and its problems combined with a genuine interest in other people and their lives. Unfortunately, my field is filled with therapists who aren't really that interested in other people--especially those who are different from them--and others who confuse recognizing their patients' serious problems with not liking them. I keep a short list of other therapists to whom I can refer people when I can't treat them. I wish there were more people whose professional expertise and behavior I could trust.
I have pondered if some persons think that if they talk at length about a previous therapist's failings, I will side with the previous therapist. This is not true, as I am well aware that many therapists are not good. In fact, I sometimes say to friends, "I wouldn't refer a cat to 80 percent of the people in my field." It's not a joke.
When I do hear complaints about previous therapists, the most common complaint is that the therapist talked about him/herself. Why does this happen? Probably for many reasons. One possibility is the decline in the popularity and influence of psychoanalysis and of psychoanalytic training. Although psychoanalysis has some limitations as a treatment, it does insist on the neutrality and relative anonymity of the therapist. Other schools of therapy don't necessarily encourage therapist self-disclosure, but they don't place as much of an emphasis on boundaries as psychoanalysis does. Unfortunately some less-than-competent therapists may assume that if their training didn't emphasize boundaries, it means boundaries aren't important.
I usually limit information on my personal life to answers to direct questions asked by patients, in cases where the information might be relevant--for example, if someone asks me "are you going away on vacation?" I will answer, as this could relate to the issue of whether I can be contacted in an emergency. Another example would be when a patient discusses a movie they've seen and wants to know if I have seen it. I've found that discussions about movies are often quite meaningful, as which characters patients identify with, or which ones remind them of their family members, can lead to interesting discussions.
Therapists should not talk about events in their personal lives or personal problems. I've heard two (!) stories about therapists who talked about their own upcoming weddings--I can't think of any way this could be appropriate and it could be damaging to the patient.
I've developed a hypothesis that some therapists talk about themselves because they are bored by their patients and don't feel a connection with them, and are hoping that if they talk about something they have "in common" with a patient it will help them feel more connected and less bored. This boredom usually represents a type of narcissism. Unfortunately, some people become therapists for the wrong reasons. Some people believe that as a therapist they will be super-important to their patients and will wield great influence over their patients' lives. Although this can happen, it's not a good reason for someone to become a therapist. People with narcissistic problems are often attracted to the field of therapy. These persons should not be therapists, but they are not screened out of graduate school programs.
Other personal problems of therapists that interfere with therapy include difficulties with the opposite gender or with cultural differences. I've heard stories about male clinicians who gave compliments to female patients on their clothing and make-up. It apparently didn't occur to these clinicians that this behavior might be seen as objectifying by their patients--the clinicians probably thought they were boosting the patient's self-esteem. I've also come across female therapists who can't work with male patients due to projections of anger or disgust that come from their own experiences with men. In conversations with therapists from other parts of the country, I've discovered that religious bigotry is not uncommon. It's hard for a bigoted therapist to practice in New York, but once in awhile I've come across a homophobic therapist here, or other types of issues.
The worst failings of other therapists that I have come across, however, are inaccurate assessments. Sometimes the end result of these errors is tragic. In the worst cases, there may be a preventable suicide. Fortunately I haven't heard very many of those stories.
Errors in assessment and diagnosis often stem from a belief that recognizing someone's severe pathology is tantamount to not liking them or not recognizing their strengths: Years ago, while working in a clinic, I worked with a paranoid schizophrenic whose previous therapist encouraged him to attend college. The vast majority of people with schizophrenia cannot complete college. The patient dropped out and was left with student loans he could not repay as well as a blow to his self-esteem. In another case, a therapist treating a family member of one of my patients didn't notice the woman's severe personality disorder and the extent of her pathological behaviors, which were affecting my patient. Many therapists have bought into society's stigma against mental illness, and this makes them believe that diagnosing a patient with a disabling condition is equivalent to condemning them or not liking them.
Being a therapist requires a sober view of humanity and its problems combined with a genuine interest in other people and their lives. Unfortunately, my field is filled with therapists who aren't really that interested in other people--especially those who are different from them--and others who confuse recognizing their patients' serious problems with not liking them. I keep a short list of other therapists to whom I can refer people when I can't treat them. I wish there were more people whose professional expertise and behavior I could trust.
Tuesday, April 14, 2015
Addiction: Truth and Myth
I spent the first several years of my clinical career working in substance abuse treatment programs. On the front page of my website, I note this fact and state that I "frequently work with persons in recovery." If only this were actually true! What has happened over the years is that the people who've come to see me for my addictions treatment experience are mostly not in recovery. Most have been people who are still abusing drugs and/or alcohol. But psychotherapy is not the best treatment for addictions, which is why I tried, in the language on my website, to suggest that I want to work with people who've already stopped using drugs/alcohol and are looking for relapse prevention and treatment for other emotional problems.
"Recovery" means that you have stopped abusing substances--you are now abstinent from the problematic substance and any other substance with a similar effect, and are engaged in a different lifestyle. What I have found consistently in the course of my career is that 90 percent of addicts/alcoholics need a 12-step program to remain in recovery. Sadly, most of the substance abusers who have come to my office, although they may verbally express an interest in going to a 12-step program, don't stick with it and thus they don't stop using drugs/alcohol.
Most abusers of alcohol and drugs who come to my office claim that they "know" they have a "problem." This may represent a change from the attitudes found before the 1970s. Before the 70s, most alcoholics and addicts lied about their problem and were frequently in denial about its severity. Celebrities in the late 70s started to come out of the closet with their addiction problems. Now it's become socially acceptable to admit you have a problem with drugs or alcohol. But most people who "admit" this fact still don't really want to change. This may not make sense to most people, not only because using drugs/alcohol in the face of death or other severe consequences doesn't seem logical, but also because the media promote the myth that people use drugs because they don't have access to treatment. Nothing could be further from the truth, as the 12-step program is free and available all over the country. In addition, most inpatient rehabs are desperately seeking patients and some have closed.
Why would someone continue to engage in addictive behaviors despite access to treatment? There are many possible reasons, some that are psychological and some that perhaps could be better described as philosophical or spiritual, depending on one's beliefs.
Some recovering addicts have told me that before they found the 12-step program, they simply thought that they were destined to be drug addicts--it was their identity and fate. When they heard, in 12-step meetings, the stories of people like themselves who had completely changed their lives, they realized they were wrong. They realized they could choose their fate. They also realized that they needed help from others to remain free of drugs and alcohol. This may seem paradoxical, but all humans need both a sense of autonomy and self-direction and also social support.
People with intractable addictions--those who go to 12-step meetings but still don't arrest their addiction--may be people who are too narcissistic to accept their dependency on other people. This makes them unable to use the 12-step program. Others can be persons who just don't see a meaning in life. Ordinary activities that give others' lives meaning, such as the sense of pride in working for a living and doing a job well, mutual interpersonal relationships, and greater causes or beliefs, are meaningless to them. Without a sense of meaning in life, it's hard to see a reason to stop drinking or doing drugs. All experienced substance abuse counselors know there is a percentage of the population who cannot be helped and who will not recover from addiction.
Initially in private practice, I thought I would screen out all active addicts, and instead insist that they first attend 12-step or an inpatient rehab, or both. I changed that position when I realized some of the addicts and alcoholics coming to my office had severe depression or anxiety that needed to be treated. I didn't think it was right to deny treatment to someone for one disorder because the person refused treatment for another. I can say that I did help some of these individuals, whose depression and anxiety did improve, even though they did not completely arrest their addiction(s). (The fact that these individuals did not stop using drugs or alcohol despite recovering from their anxiety and depression shows that a popular theory, the "self-medication theory," is wrong. The self-medication theory, believed by many psychotherapists, holds that drug and alcohol abusers are simply self-medicating depression and anxiety and will stop their behavior if they take medication and go to psychotherapy. If this were really true, addiction would not be the vast social problem that it is). Recently, I've come to realize that active alcoholics and addicts present liability concerns for my practice. Therefore, I've decided to go back to my original position of requiring that addicts/alcoholics be in recovery before I will agree to see them.
"Recovery" means that you have stopped abusing substances--you are now abstinent from the problematic substance and any other substance with a similar effect, and are engaged in a different lifestyle. What I have found consistently in the course of my career is that 90 percent of addicts/alcoholics need a 12-step program to remain in recovery. Sadly, most of the substance abusers who have come to my office, although they may verbally express an interest in going to a 12-step program, don't stick with it and thus they don't stop using drugs/alcohol.
Most abusers of alcohol and drugs who come to my office claim that they "know" they have a "problem." This may represent a change from the attitudes found before the 1970s. Before the 70s, most alcoholics and addicts lied about their problem and were frequently in denial about its severity. Celebrities in the late 70s started to come out of the closet with their addiction problems. Now it's become socially acceptable to admit you have a problem with drugs or alcohol. But most people who "admit" this fact still don't really want to change. This may not make sense to most people, not only because using drugs/alcohol in the face of death or other severe consequences doesn't seem logical, but also because the media promote the myth that people use drugs because they don't have access to treatment. Nothing could be further from the truth, as the 12-step program is free and available all over the country. In addition, most inpatient rehabs are desperately seeking patients and some have closed.
Why would someone continue to engage in addictive behaviors despite access to treatment? There are many possible reasons, some that are psychological and some that perhaps could be better described as philosophical or spiritual, depending on one's beliefs.
Some recovering addicts have told me that before they found the 12-step program, they simply thought that they were destined to be drug addicts--it was their identity and fate. When they heard, in 12-step meetings, the stories of people like themselves who had completely changed their lives, they realized they were wrong. They realized they could choose their fate. They also realized that they needed help from others to remain free of drugs and alcohol. This may seem paradoxical, but all humans need both a sense of autonomy and self-direction and also social support.
People with intractable addictions--those who go to 12-step meetings but still don't arrest their addiction--may be people who are too narcissistic to accept their dependency on other people. This makes them unable to use the 12-step program. Others can be persons who just don't see a meaning in life. Ordinary activities that give others' lives meaning, such as the sense of pride in working for a living and doing a job well, mutual interpersonal relationships, and greater causes or beliefs, are meaningless to them. Without a sense of meaning in life, it's hard to see a reason to stop drinking or doing drugs. All experienced substance abuse counselors know there is a percentage of the population who cannot be helped and who will not recover from addiction.
Initially in private practice, I thought I would screen out all active addicts, and instead insist that they first attend 12-step or an inpatient rehab, or both. I changed that position when I realized some of the addicts and alcoholics coming to my office had severe depression or anxiety that needed to be treated. I didn't think it was right to deny treatment to someone for one disorder because the person refused treatment for another. I can say that I did help some of these individuals, whose depression and anxiety did improve, even though they did not completely arrest their addiction(s). (The fact that these individuals did not stop using drugs or alcohol despite recovering from their anxiety and depression shows that a popular theory, the "self-medication theory," is wrong. The self-medication theory, believed by many psychotherapists, holds that drug and alcohol abusers are simply self-medicating depression and anxiety and will stop their behavior if they take medication and go to psychotherapy. If this were really true, addiction would not be the vast social problem that it is). Recently, I've come to realize that active alcoholics and addicts present liability concerns for my practice. Therefore, I've decided to go back to my original position of requiring that addicts/alcoholics be in recovery before I will agree to see them.
Thursday, April 2, 2015
Evaluating Risks Part 2
I decided my last post needed a follow-up. In the last post, I discussed how employers can conduct psychological screening that could help them identify potentially suicidal and homicidal employees. For jobs that give people the power to endanger the public, I believe such screening is necessary. I noted that I discovered, through reading recent media reports, that airlines don't usually conduct such screening on pilots, which is incredible considering that pilots have the lives of hundreds of people under their power. However, it has occurred to me, after reading additional media reports, that some people may misinterpret employment-based psychological screening as something that keeps individuals from getting the mental health care that they need. The "argument" I've been reading is that people won't obtain mental health care if they think it will lead to loss of employment.
The Americans with Disabilities Act, passed in 1990, forbids discrimination based on disability, under most circumstances. Businesses have to show that employing a person with a disability would impose an unreasonable burden in order to be able to "discriminate" against such applicants or employees.This law means that you can't be fired for a mental health problem or even a substance abuse problem unless it makes you unable to do your job even with treatment and reasonable accommodation. Therefore, if you need to take a month off work to go to a treatment center, your job has to allow you to do so. If you need to leave early one day a week to see a therapist, your job has to allow you to do so.
If, on the other hand, despite your treatment you continue to do drugs and this impairs your work performance or causes disruption to other employees or clients, or creates a hazard, you can be fired. If you come to work late every day because you're too depressed to get out of bed, because you either refused treatment or treatment simply did not work, you can be fired. I believe the ADA is a fair law that has worked well. Someone who is too disabled to work qualifies for federal disability payments but most people with disabilities can work if they receive treatment.
Duty to Warn
Therapists in the US have to abide by something popularly known as "Duty to Warn." If we have a patient who threatens to harm someone else or whose illness puts the public at risk, we are required to break confidentiality to take action to prevent the loss of life or injury to another person. I had to do a "Duty to Warn" some years ago when a psychotic patient came to my office with a plan to kill a relative. In addition, he showed me a recipe for making bombs. I sent him to the emergency room and I also called the police in his relative's town. These are the requirements under "Duty to Warn." Even though I believed the patient was unlikely to act out his homicidal ideas, it didn't matter because it was possible that he would. The hospital re-evaluated him and, if I remember correctly, changed his medication. The patient didn't lose his job (he was a doorman) and no one was killed. (There was no evidence the patient had constructed a bomb or that he was actually planning on doing so). The hospital agreed to continue his treatment on an outpatient basis as it was too much for someone in private practice such as myself.
A colleague of mine years ago had a patient who was a motorman on the subway. The patient had severe panic attacks. My colleague did a Duty to Warn because panic attacks can occur without warning and can be disabling, and the patient was responsible for the lives of hundreds of people on the subway. I don't recall what the end result of this was, but I imagine it was something similar to what happened with my patient: The patient probably took a leave of absence, went on medication and then went back to work if his treatment was effective. In my opinion he should have been monitored by the MTA afterward to make sure he was complying with his treatment. I don't know whether this happened, however.
There are some people who are too sick to be able to safely work at jobs in which they hold the lives of others under their power. Most people who fall into this category are substance abusers, and only a small percentage are people with other clinical problems. Most people with mental health problems are effectively treated and can do most jobs. However, our societies do need ways to screen out people with intractable problems from jobs in which they can put the public at risk.
The Americans with Disabilities Act, passed in 1990, forbids discrimination based on disability, under most circumstances. Businesses have to show that employing a person with a disability would impose an unreasonable burden in order to be able to "discriminate" against such applicants or employees.This law means that you can't be fired for a mental health problem or even a substance abuse problem unless it makes you unable to do your job even with treatment and reasonable accommodation. Therefore, if you need to take a month off work to go to a treatment center, your job has to allow you to do so. If you need to leave early one day a week to see a therapist, your job has to allow you to do so.
If, on the other hand, despite your treatment you continue to do drugs and this impairs your work performance or causes disruption to other employees or clients, or creates a hazard, you can be fired. If you come to work late every day because you're too depressed to get out of bed, because you either refused treatment or treatment simply did not work, you can be fired. I believe the ADA is a fair law that has worked well. Someone who is too disabled to work qualifies for federal disability payments but most people with disabilities can work if they receive treatment.
Duty to Warn
Therapists in the US have to abide by something popularly known as "Duty to Warn." If we have a patient who threatens to harm someone else or whose illness puts the public at risk, we are required to break confidentiality to take action to prevent the loss of life or injury to another person. I had to do a "Duty to Warn" some years ago when a psychotic patient came to my office with a plan to kill a relative. In addition, he showed me a recipe for making bombs. I sent him to the emergency room and I also called the police in his relative's town. These are the requirements under "Duty to Warn." Even though I believed the patient was unlikely to act out his homicidal ideas, it didn't matter because it was possible that he would. The hospital re-evaluated him and, if I remember correctly, changed his medication. The patient didn't lose his job (he was a doorman) and no one was killed. (There was no evidence the patient had constructed a bomb or that he was actually planning on doing so). The hospital agreed to continue his treatment on an outpatient basis as it was too much for someone in private practice such as myself.
A colleague of mine years ago had a patient who was a motorman on the subway. The patient had severe panic attacks. My colleague did a Duty to Warn because panic attacks can occur without warning and can be disabling, and the patient was responsible for the lives of hundreds of people on the subway. I don't recall what the end result of this was, but I imagine it was something similar to what happened with my patient: The patient probably took a leave of absence, went on medication and then went back to work if his treatment was effective. In my opinion he should have been monitored by the MTA afterward to make sure he was complying with his treatment. I don't know whether this happened, however.
There are some people who are too sick to be able to safely work at jobs in which they hold the lives of others under their power. Most people who fall into this category are substance abusers, and only a small percentage are people with other clinical problems. Most people with mental health problems are effectively treated and can do most jobs. However, our societies do need ways to screen out people with intractable problems from jobs in which they can put the public at risk.
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