Who defines “mental illness?”

 

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2018 can be looked at as a year the glass ceiling on stigmatizing “mental illness” was shattered. It will also be looked at as the year the term mental illness ran amok. Athletes from Kevin Love to actors like Ryan Reynolds have shed light on what roughly 40% of the population deals with, generalized anxiety. But, using the term mental illness suggests that anxiety is an illness, which for most people, it is not. And, since the term has been used to define heinous acts, like school shootings, it is time to formally provide a working definition that does not lump school shooters with the lay person.

This past week, two prominent celebrities, Kate Spade and Anthony Bourdain, both took their own lives. We were reminded, as the saying goes, that everyone fights his or her own demons. The talking heads on cable television were quick to label both individuals as struggling with “mental illness.” While they both might have had struggles, it is not fair to assume their deaths were the result of being mentally ill. Suicide is a complicated act, one that this society tiptoes around. As the CDC reported after the wake of both suicides,  the majority of those who killed themselves had relationship problems, not mental health conditions. This does not mean mental health issues are not major factors in suicide. But, to conclude that a psychiatric condition is the culprit for most self-inflicted deaths is irresponsible.  Suicide can often be the result of impulsivity, financial ruin, substance abuse and physical illness. In fact, it is a myth that truly depressive people commit suicide, as those who struggle usually do not have the energy to engage in such an action.

Too often, we are quick to throw such a loaded term (mental illness) on anyone and everyone who experiences difficulty. As we move closer to a fragmented society, with increased rates of loneliness, the dismantling of social norms and the ever-increasing demand of the illusion of happiness via social media, the world around us will continue to feel “off.” Routine feelings, such as sadness, hyperactivity, joy and subtle boredom have been and will be labeled as “mental illness.” Psychosocial factors, like friendships, family, employment and religious affiliation have been cast aside for psycho-stimulants (ADHD meds), misdiagnoses and gross entitlement (“You can be whatever you want to be!”) . This is not to dismiss or suggest that mental illness is not real, because it is. There are those who struggle with crippling psychotic conditions, devastating mood and personality disorders and anxieties that appear indefinite. What needs to be challenged is the course of treatment we currently provide: medication, behavioral modification and meditation.

If mental illness is as common as we believe it to be, why do we treat mental health conditions as second-rate disorders compared to other medical conditions? Why do we subject the “mentally ill” to jails, instead of invest in infrastructure to support real psychiatric and psychological treatment? Why has the the suicide rate increased 24% between 1999-2014, and as a nation, we have yet to address this as a major societal epidemic (suicide is now the 10th leading cause of death in the United States). Our answer cannot be more medication (antidepressants continue to have modest effects), more marijuana and brief behavioral psychotherapy.

A good start would be to be invest in families and children at an early age. Schools need full-time social workers/therapists and nurses. Schools need to increase socialization through group play, team-building and recess. Doctors need to stop (!!!) labeling children as having ADHD without assessing family dynamics, anxiety, culture and the like. Psychologists, psychiatrists and clinical social workers should not have their care dictated by insurance companies. Normal, everyday emotions should not be pathologized into mental illnesses.

We will not be able to prevent every suicide. We sometimes will never see the warning signs or the cries for help. Talking about suicide openly is a start, but let’s start understanding the person who is struggling, and not resort to relying on a misused term that has no real meaning.

 

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64,000 and counting

 

The numbers are in for 2016, and they are not good. According to the National Center for Health Statistics, Centers for Disease Control and Prevention, drug-related overdoses in the United States reached their highest level. What’s more, the rate of drug overdose deaths for people under the age of 50 is occurring at a faster rate than HIV at its peak. Given the rise of fentanyluse and easy access to heroin, the number of deaths from opioids is likely to climb for this year. The New York Times published a revised breakdown of data related to the opioid epidemic. Equally as troubling with the numbers is the news that prescription opioid-related deaths have leveled off, while cocaine and methamphetamine have reared their ugly heads as contributing factors in the surge of fatalities.

So far, the recommendations made by the newly formed Commission on Combating Drug  Addiction and the Opioid Crisis appear to be unoriginal and vague. The effort to have real mental health parity in the treatment of mental health and substance abuse disorders has been echoed for decades to no avail. While the commission encourages easier access to opioid replacements (“MAT”) such as subutex  , there is a greater need to understand and analyze the reason drug use is on the rise across various socio-economic, cultural and racial groups. The epidemic has not and is not affecting just white suburbanites, inner city minorities and Appalachia. In fact, the three states that saw the highest increase in opioid-related deaths were Delaware, Florida and Maryland.

State legislators have begun to implement prescription drug monitoring programs to detect the rate patients have been prescribed pain medication. However, this system regulates the patient, not the doctor. It is widely known that doctors (see pill mill crisis of 2011) routinely overprescribe, but 300 million prescriptions for pain medication were written in 2015. The commission does discuss the need for more screening tools to assess addiction and pain, but tools already exist.

One place to look for a new solution is the state of Ohio, where new rules for prescribing opioids caps doctors at dispensing a maximum of 7-day prescriptions for adults in chronic pain. Additionally, the state will require diagnostic codes on all prescriptions for pain medications beginning in December.

As I have written about in the past, practioners on all levels who work in medicine, psychology, addiction and the like, must look at the rise of addiction from a multi-disciplinarinary approach. The guidelines and suggestions handed out by the commission focus primarily on reactive measures. Those on the front line of treating the epidemic must return to analyzing family structure, mental health pathology, performance in school and other societal factors that are being sidelined as explanations for the explosion in opioid-related disorders and subsequent fatalities.

Dismissing Freud 2.0

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It happens every few years: historians, psychologists, journalists and investigators find “new” material to dismiss and discredit the work of Sigmund Freud. Since his passing in 1939, the man, who is often mythologized, has undergone numerous character assassinations. Many have said his work is both unscientific and offensive, while others have labeled him a racist and a sexist. Most recently, his work and its lack of empirical research, has been cause (somewhat fairly) for concern about the effectiveness of psychoanalysis. In his new book, the British author and critic Frederick Crews continues his take down of the late Freud. The book, “The Making of an Illusion,”  focuses on Freud’s shortcomings as a man and a professional, and rails against a form of treatment that created a “cult of personality” in the late 19th and early 20th centuries.

Freud’s most notable dissenters have spent years rejecting his theories on penis envy, the Oedipus Complex and the core concept of the sexual drive inherent in all humans. His experimentation with cocaine has poured into mainstream culture. But the main problem with dismissing Freud outright is the lack of understanding of the value of psychoanalysis. At its core, psychoanalysis is a talking cure (coined by Josef Breur in 1895). Patients are able to therapeutically process emotion, content, disturbances and conflicts. The contemporary relational psychoanalyst Susie Orbach said “Psychoanalysis is the study of human subjectivity. It is a clinical practice. It theorises the vicissitudes of human attachment, of the psychological development of mind and body that occur within a relational, cultural field.” She is correct. Furthermore, psychoanalysis proper is rarely practiced today because of the “need” for brief, concrete and managed mental health treatment.

Swept up in the Freudian revisionism is a more common problem, which is the dismissal of the magnitude his ideas have had on the field of psychology for 100 years. Freud’s groundbreaking understanding of transference and countertransference, along with his working model of the mind, are still understood and used today. Psychiatric assessments refer to “attitude toward writer,” which can be linked to a patient’s transferential projection onto the therapist. Because of Freud, we now understand the omnipotence of defense mechanisms and the unconscious motives of our drives.

Freud normalized sexuality for men and women. The ability to relate sexuality to early childhood experiences is a sensitive issue, but one that needs exploration in the therapeutic setting. Today, we have a greater appreciation for attachment theory, psychosocial development and the ego because of Sigmund Freud. The problem with the argument that Freud’s work was not empirical rests on the idea that therapy is strictly a science. Cognitive behavioral approaches, along with other standardized modalities are ubiquitous, but their long-term efficacy remains unknown. Behavioral interventions negate defense mechanisms, unconscious conflicts, inhibition, drive and attachment.

The mind is still a largely unknown construct. Psychoanalysis has allowed therapists, physicians and lay people to inch closer to understanding its processes. Replacing this with psychopharmacology and shallow methodologies of treatment that rely on labels and symptoms fails to grasp the rewards of the subjective therapeutic experience.

 

A disease of despair

 

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Addiction, specifically opioid addiction, has been in the news recently, as drug overdoses are now the leading cause of death for individuals under the age of 50.    While Big Pharma and its flooding of prescription pain pills to the market is a major factor in the epidemic, it is also important to look at the psychological and social factors that are influencing the rise of heroin-related deaths across the country. Heroin is less expensive than prescription pain pills, thus making it a cheaper high. Many individuals who use heroin began by using opioids such as Dilaudid and Oxycodone (often prescribed by a doctor). But to simply crack down on the Big Pharma pill dispensers will not and has not lead to a reduction in heroin and opioid addiction. The current treatment model for addiction is one rooted in a medical model, where individuals are told they have a medical condition (disease) that is treatable by opioid agonists and antagonists to reduce and stop cravings and urges. But, these bio-chemical treatments continue to underperform, as addicts stop taking the blockers or misuse them to achieve a high. Therefore, to understand addiction more accurately, and to begin to assess and explore the sharp rise in addiction, we must look to other explanations of addiction.

As my title states, addiction is not only a disease of dependence and physiological craving, but also one of despair. Addiction is a paradox, in that people invest in their drug use (scheduled times of use, financially and socially), but are also divested from the world, as addiction robs the user of his or her relationship to the outside world. In my working with substance abusers, the best modality for treatment has not been through a medical approach (I am not a doctor, but work with providers), but through a careful examination of complete loss of hope, loss of morals, loss of identity and loss of integrity. Addiction robs the individual of his dignity, yet also replaces prior values with deceptiveness, lies, theft and misery. To understand addiction, one must first understand the perils of drug use.

As a society, more and more communities are becoming fragmented, isolated and self-absorbed. The breakdown in face-to-face socialization, nightly family dinners and shared responsibility are influencing addiction. With the loss of work in towns across Ohio, Michigan, West Virginia and Kentucky, people are becoming increasingly isolated and depressed, seeing little hope for recovery. One can easily see the correlation between this mind set and the rise of addiction.

To effectively treat addiction, we must help restore the things that have been lost on those who identify as addicts- integrity, honesty, dignity and optimism. Hopelessness can be reversed if treatment can focus on individuals regaining their identity before addiction set in.

While medication plays a role in the treatment of addiction, it will not solve the problem. To “fix” the growing tide of addiction, there must be a societal response, as well as a push for greater access to treatment, a communal sense of providing support without enabling and greater understanding of the psychology of drug abuse.

 

Open letter to President-elect Trump: Mental Health and Addiction in the U.S.

Republican presidential candidate Donald Trump speaks to supporters as he takes the stage for a campaign event in Dallas, Monday, Sept. 14, 2015. (AP Photo/LM Otero)

 

President-elect Trump:

You have been elected as the outsider and someone who is expected to “drain the swamp.” You were elected because of your direct and unconventional ideas that alter the national discussion on many issues. You, along with the Senate and the House, have an opportunity to address and ultimately reform two major issues that have been swept under the rug and received little to no attention during the presidential election- mental health care in this country and the growing heroin and opioid epidemic that is ravaging our communities. As a mental health professional who works with drug addicts, I have seen the failures of the current system. Too many addicts are cut off from adequate, long term care that they need and deserve. Insurance companies are dictating treatment and not providing the necessary coverage for those in residential drug treatment programs. Low-income addicts with no or poor insurance coverage are left to fend for themselves because they cannot afford the existing treatment centers and because as a country, we do not provide sufficient care to the “have nots.” Families are mortgaging their homes, selling family heirlooms and dipping into savings just to pay for a child to go to rehab, usually on multiple occasions. While the insurance companies are deciding the length of care, our pharmaceutical companies are pumping pain pills out at an unimaginable rate, leading doctors to over-prescribe highly-addictive pills that are expensive and lead many individuals to find a cheaper source of pain relief,  heroin. While most of the heroin in this country is brought into the country from cartels south of the border, the real issue is the demand, not the supply. There will always be groups willing to step in and provide drugs.

Additionally, mental health care in this country is deplorable (to borrow a term from the election). Community mental health centers are poorly run, understaffed and driven by managed care. The services they provide are inadequate, as sessions are limited, professionals undertrained, managers underpaid and susceptible to quick burn out. The VA is a mess, as countless veterans wait for mental health care and benefits. Local hospitals are overrun with psychiatric emergencies and overdoses and are becoming overwhelmed in providing care.

As a clinician, the current state of care is sad and something needs to change. In this regard, I have outlined proposals that will address the issues listed above.

  • Reign in pharmaceutical companies ability to continue over-selling pain medications, particularly opioids, and lay out a 5-10 year plan where pain management doctors MUST find alternate measures to treat pain.
  • The department of Health and Human Services should track the amount of  pain pills doctors prescribe to a patient and ensure over-medicating patients is not happening.
  • Label fentanyl a Class A or B drug. This highly addictive pain pills is being used by heroin addicts and is 100 times stronger than heroin. If police catch someone with fentanyl, they cannot do anything. Empower police and local authorities to rid the drug from our communities.
  • Create a task force that will allow states to set up outpatient mental health and substance abuse programs at local hospitals to alleviate the emergency rooms. The outpatient care should be fully staffed with qualified mental health professionals and offer comprehensive care. These facilities will offer care to patients with Medicaid and private insurance. The care can be contracted out to private practitioners through a complete vetting process.
  • Cut the red tape at the VA and allow veterans to access private mental health clinics and providers.
  • Ensure that drug and alcohol rehabs are held to strict guidelines that ensure patients’ psychiatric and substance abuse care is treated properly. Along these lines, sober homes need very strict regulations
  • Empower school districts to hire full-time mental health professionals to provide on-site mental health care to students.

These are just some of the core suggestions that you, Mr. President-elect should consider. Your administration has a tremendous opportunity to tackle these issues. I hope you act boldly.

 

On the struggles with grief

 

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I wish I could have done more. More for my client who suffered. More for his family who suffered. More for the pain, the emptiness, the despair. But I couldn’t. I couldn’t keep him to prolong his treatment. Not long enough to make a dent in an otherwise broken, hurt and lonely soul. I thought about him when he left. I thought about him when I slept. And now, I think about him as I type. Today was the first, but likely not the last time I will hear that a client of mine has died. My reaction was not of surprise or shock, but of sorrow. Sorrow for the man who had decided his time was up.

As therapists, we are faced with mortality. As clinicians in the field of addiction, we are faced with the cruelty and the hostage taking drugs and alcohol become. And yet, we still hold out for hope. We still strive to make a difference and we still have hope that our clients can obtain the ultimate recovery- inner peace. But like so many of the suffering, that task was not fulfilled.

I was angry when I heard the news. I was angry at myself, angry at others, angry at him. I was angry at addiction. I was angry at depression. I was angry at work. But my anger will not succeed nor flourish. My anger will be invested into what I know how to do best- work with those in need of healing. The only way I can grieve is to continue with the work I do everyday. The grieving means advocating for my clients when they cannot advocate for themselves. My anger and shortcomings will be met with a continued passion for treating those who have been unable to treat themselves.

My client’s passing is a reminder of the tremendous difficulties we face as soon as we walk into work. We work with chronic and persistent drug abusers and mentally ill men and women. We work with altruists, sinners and criminals. We work with the sad and the angry. The confused and the hopeless. And on this day, I am mourning the loss of the sad. I am mourning the loss of the angry. I am mourning  the loss of the confused. I am mourning the loss of the hopeless. And I will continue to work alongside the individual who needs help.

When anger trumps compassion

compassionate-700x500   Can compassion  be learned or is it something inherent in certain people? Often times, patients will say they are understanding and empathetic to a particular individual in his or her life, but the actions demonstrated run counter to what is being said. I’ve begun to notice a trend in some of my patients, one that ties into my initial question of compassion: anger, resentment and hostility are usually the expressed before compassion.

One patient of mine, we’ll call him Eric*, came to see me and told me about a friend of his who needed a favor: money. Eric’s friend was in a hole and wanted to borrow some cash to buy Christmas gifts for her family members. As Eric continued to tell the story, he seemed to become enraged at the thought that his friend was asking him for money! As I let Eric continue on with his story and his remarks on the friend’s character and how he no longer saw this individual in a positive way, he mentioned how sorry he was for her. However, his tone, facial expressions and initial reaction said something completely different. When Eric was done presenting his case for why he was mad, I asked him why he appeared so angry and did not show much compassion for someone who was down on her luck. After all, Eric’s story is similar to his friend’s in terms of life experiences. I noticed Eric becoming a bit angry with me for questioning his compassion, or lack thereof. What was I to make of this? Did Eric think I did not believe he was genuinely compassionate? Did I fail to validate his anger? Possibly. After all, I can identify with Eric’s reaction as many of us probably can. People, sometimes even friends, ask us for favors we do not want to perform and we become angry with them. But why?

While it might be specific to Eric’s case, I’ll make the argument that what happened was a narcissistic injury and then a narcissistic rage (something that is common). Eric felt insulted and undermined, thinking that his friend wanted to take advantage of him, use him for her own gain. He unconsciously might have felt the same feelings as he did with an earlier experience in his life- one that produced anger, shame and hostility toward a needy individual. Perhaps Eric thought his individuality was being undermined. Maybe he wanted retaliation and was trying to gain the upper hand as a reaction to a prior feud.

All are possibilities, but for the work moving forward, it is important to see if compassion is ever the primary emotion. It will be important to explore the reasons for the conflict: verbalizing compassion, demonstrating anger.

Compassion is a hybrid of both nature and nurture. We are all products of our environments and often model what was mirrored for us as children. If compassion and sympathy were two emotions that were absent from childhood, it should not be expected that an individual will know how to have these feelings.

My work with Eric and other patients who present similar issues will require me to have compassion and and patience while I seek to  gain trust to explore the anger.

 

*name has been changed to protect the identity of the patient

To fix the gun problem, it takes a village

 

In the wake of yet another mass shooting, we continue to hear the same talking points from politicians, pundits and op-ed pages in the newspapers. Liberals hold tightly to the notion that if only we would have tighter background checks, gun violence would decrease. Yet, we know that a significant proportion of these shooters pass and could pass a background check. Conservatives defend the Second Amendment as if it were handed down from God and then turn to their new favorite reason for gun violence- mental health. We also know this is incorrect, as studies are virtually unanimous in their findings that most “mentally ill” people are the victims, not the perpetrators, of gun violence. In addition,  gun crimes involving those who have a mental illness parallels gun violence committed by those without a diagnosed mental condition. So there seems to be other reasons that might explain why we are the only country with lots of mass shootings, mostly at schools and universities.

One of the reactions we like to have in the wake of a senseless crime is to either blame or defend the NRA. After all, it is their lobbying, financial influence and public advertising that affect so much of the gun policy in this country. But if we take a step back, it is unfair to blame a lobbying group who is lobbying on behalf of a constituency that wants more guns! Which leads me to wander if the American public really wants to change the gun debate. Rather than point fingers at lobbyists, blame politicians and retreat to our usual corners, why don’t people stop supporting politicians who refuse to implement strict gun laws? Why not demand tougher laws for people found with an illegal gun? Why not change the background check system and make waiting periods longer? Until the American public is willing to collectively realize that guns…yes, guns are the problem, nothing will change.

What is rarely talked about is what a gun represents. Yes, other countries and cultures have guns. Other countries have hunters and arms collectors. But what other countries do not have is the mind set that the gun can solve all problems. The biggest problem that neither political party speaks about is the American gun culture. The American gun culture promotes gun use through music, television and movies. While research tends to argue that video games have no negative effect on gun violence, there does seem to be a strong correlation between being vengeful and retaliatory with a gun. Today, gun violence seems to mirror the notion that anybody can be a hero, a vigilante,a hero. But this is a delusion.  Too many people are armed and when you are armed with a gun, you want to use it. It is empowering for many.

To change this mindset about these horrific and routine killings, the country can no longer continue to make empty gestures that go nowhere. We must collectively agree that this is now an epidemic, and  our reasons for explaining mass shootings and gun violence fall short of a thorough examination of our culture, our enthrallment with seeings things only as right and wrong, good guy vs. bad guy. As long as people continue to have a carte blanch approach to guns,regardless of their rational, we will continue to witness atrocities. As long as we continue to be apathetic, nothing will change. Let’s begin with having a real conversation and examining what we value.

Where are we when it comes to dating?

How do you describe the current state of dating? I find myself struggling with this question more and more. I’m left with more questions than answers, which is puzzling. For this blog post, I want to to turn to you, the readers, and ask: In the age of online and mobile dating, can men and women form intimate relationships?

Before posting your comment, please consider the pros and cons of online dating; for some, online dating can be empowering. For others, it is a dreaded tool that has ushered in the decline of romance and chivalry.

Are men and women equally to blame for the frustration that seems to be swirling around millennials? How about our own expectations for what a relationship should consist of? Are the dating norms different than they were 10-15 years ago? Does work play a role? How about the fear of rejection and the ability or inability to take risk?

I hope to hear from as many people as possible.

I’d also like to strongly reccomend reading a recent Vanity Fair article about Tinder.

Enjoy.

Challenging transgender rules for college acceptance

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Should transgender individuals be allowed entry into women’s colleges? This question was posed in a weekend Wall Street Journal opinion piece. As it stands, some women’s colleges across the country are accepting transgender students- notably those who were born one gender and identify with another. Single-sex colleges, almost all being those for females, have long traditions of being beacons for liberal arts, free thought, common cause and were built as an alternative to the male-heavy East Coast schools. According to The Wall Street Journal article, 230 women’s colleges existed fifty years ago and today, there are only 46. As progressive policies finally took shape over the past fifty years, there was either no need for single-sex colleges or single-sex college became co-ed. Now that there are more women in college than men, near universal equality and few barriers to hiring women, the single-sex college model is no longer in great demand. The question is, can transgender students fit-in with the larger single-sex college communities and should transgender students be allowed entry into such schools?

While it is fitting for the times to blindly accept one’s identity, there are real questions and issues that exist. If a transgender student, one who was previously male and now is female, is accepted into a single-sex college, can a female student refuse to live with a recently transitioned individual? If you say yes, you would be incorrect, as federal anti-discrimination laws protect transgender students and their privacy regarding how they identify. Can schools, such as Smith and Barnard, who claim to be women’s colleges still be seen women’s colleges if someone identifies as genderqueer or androgynous? What about issues of religious freedom, notably orthodox Jews and observers of the Islamic faith? Are their religious rights protected that prohibit them from being with someone they see as male?

It seems that single-sex colleges are being reactionary and are quickly adhering to the sweeping movement of questioning little, sometimes alienating other students. In the Journal article, one Barnard student thinks the school compromised its identity as a women’s college. Initially, schools like Barnard are acting with the best intentions. However, hindsight appears to show a greater divide about how to proceed with transgender students.

Is it enough to accept someone simply because he or she identifies a certain way? I also bring this up in the context of Rachel Dolezal, the Washington state woman who says she is black (and was president of a local NAACP chapter), but does not look black and has lied about her parents’ identity. Is it fair or OK for her to say she is black and align herself with social, cultural and historical issues that are common in the African-American community? The answer is no, just as transgender students at single-sex colleges cannot identify with job discrimination based on perceived sex and the women’s suffrage movement. I am not saying transgender students cannot identify with discrimination, because they are frequent, if not the most frequent recipients of discrimination across the globe. But, I wonder if female students feel slighted during class when discussing issues that pertain to women.

It is important to be fair in the college acceptance process. But fair is not ubiquitous for  an open-door policy. In the long run, single-sex schools will lose students who feel uncomfortable around transgender students. These feelings should not be dismissed as prejudice. Rather they should highlight the real discomfort some students have with the gender issues.