The False Self

A traveling exhibition by Active Minds, an advocacy group, consists of 1,100 backpacks representing the approximate number of undergraduates who commit suicide each year. CreditActiveminds.org

 

http://www.nytimes.com/2015/08/02/education/edlife/stress-social-media-and-suicide-on-campus.html?emc=eta1

 

Some transitional age youth,  budding adults who are trying to find their way in the world, pressured to succeed at Ivy League colleges, pressured to reflect well on their parents, are pushing back, not by failing out of school, or joining a cult, but by saying goodbye, by calling it quits. Each story is unique, and yet the common thread seems to be Winnicott’s concept of the “false self.” Living a life which does not feel genuine or authentic creates anxiety and distress, which when extreme, can feel that the only solution is to shut off the console, shut off the life force. This black and white thinking, so common in young adults who have not figured out the nuances of the world, puts them at high risk for drastic behavior. As the adage goes, “suicide is a long-term solution to a short-term problem.” The problem is that at this tender age, when these “kids” have worked so hard for a college admissions letter, their mental interiors can be shallow, with few resources to navigate internal pain and suffering.

Clay, twenty, female, comes to mind. She had an eating disorder in high school, but when she was admitted to a “respectable” college, her eating normalized. For years, she studied hard, worked on building her resume, and drilled down into the game of college admission. She never gave much thought to what her life would be like when she went to college; she only cared about getting in. When she finally went East for college, despite how proud her parents were, she felt no pleasure in the experience. She felt, by her description, that she was “around a lot of privileged kids who do not understand the world.” She said that not only did she feel empty, she felt that everyone around her did too. The world, by her account, was a meaningless game of giving her parents something to talk about at dinner parties. She resented her parents for making this step, her emergence into the adult world, so much about their narcissism, but she could not express that to them. As a result, she avoided talking to her parents, and if she did, she always said things were “fine.” Yet, things were not “fine”. She had multiple serious suicide attempts, which managed to fall below the radar because she regretted her behavior and then she only told me, months after the fact. When she confessed, she emphatically said that those thoughts are “gone now,” preventing me from being able to discuss her behavior with her parents. Clay, eventually, dropped out of college, reporting that she was now feeling more authentic. She was no longer suicidal, by her report, but she reports painful confusion over what college is supposed to be about. “If I could see how it was for me, I would have stayed, and maybe I should have stayed, but at the time, all I could think about was that I never wanted to go to college, I only wanted to get into college.” Clay’s parents feel she made a horrible mistake, causing Clay to be both resentful of them, and scared for herself. “Maybe I did,” she says, “I just don’t know,” she continues with pain which speaks to her dilemma as to whose life is she leading: hers or her parents? The question remains.

Treatment As Pause: The Question of Residential Treatment

When a person has lost his way, either to an eating disorder, substance abuse, and/or depression, should that person enter into a program which relieves them of daily responsibilities so that they can focus on their mental health, or should they continue in their home environment and integrate mental health treatment into their life? This question has no answer and it is surely not one size fits all. To take the question further, could it harm people to go to a residential setting in that this is a regressive experience, and as such, it could make the re-integration into adult responsibilities more challenging? On the other hand, to leave a person in their home setting, then the triggers remain and they may not be capable of re-booting their lives. In the days of “evidence-based medicine” there is no evidence for either approach. We swim in the dark, hoping that with support, patients can get better. Our level of ignorance about these decisions is deep and yet not easily discussed. Every program wants to believe that they have the “answers” to mental suffering, when, in fact, no one does. What we do know is that residential programs create a stressor at discharge which, for some, can send them right back to their original place of distress. For others, the discharge is a new beginning, where they feel grateful for a second chance at life. Likewise, keeping people at home, for some, allows them to reconfigure their lives slowly and carefully, avoiding the stress of discharge, whereas for others, the home environment is so toxic that staying there does not allow for reflection and growth. We, the mental health professionals, need to  honestly say that we do not know what will help an individual, but with our experience, we can make a  guess. The data are not in yet, so we rely on intuition, which is inherently flawed. That, my dear readers, is where we are at.  Humility is not only important for healing, it is important for healers too.

Do We Talk So We Don’t Have To Listen?

Talking and listening are different skill sets. Some people talk to stimulate conversation, whereas others talk so they do not have to listen. This art of conversation borders on the art of psychotherapy. When should I speak and when should I listen? This is the basic technique question of therapy. The rule of thumb is that listening kicks off a session, but when the talking seems to go to a defensive place, a place of boredom or cliché, then my job is to probe deeper into why the patient has lost his meaningful narrative. “I want to ask you something,” Ashley, sixty-nine, says. “I want your medical opinion about my friend’s cancer,” she continues. Why did she start off by saying that she wanted to ask me something, as opposed to  just asking me something. Is she anxious about her friend, or she avoiding other, more meaningful things on her mind. She wants my “medical” opinion, but she knows I am a psychiatrist and not an oncologist, so the internet, likely has more information than I do. What is with this formality? I wonder. I have known her for many years and I see her frequently, yet the formality persists through time. Am I rude to avoid her question and ask her about her question, or does she know that I am going to do this, since we have done this dance for years? With Ashley, the opening remarks speaks volumes about her mental state; she and I have come to understand. She treats me like a boss that she has to interrupt in order to get her attention. She wants to flatter me by asking me my opinion. She does not know how to mine her mind for the internal gears which churn out pain and despair, and so she avoids the deep work by engaging me in a discussion about cancer. She avoids her fear of loss and her own mortality; issues which are bound to come up when a friend is facing a potentially lethal diagnosis. Like a good book, the first sentence sets the stage, but in this case, for Ashley, at this moment, it is all unconscious.

Bipolar II

 

Pathologizing mood states is a justified criticism of modern psychiatry. Bipolar II is a good example. This is a diagnosis which implies that the person has pathological mood swings which vary from hypomania (which could be a desirable mood state) to mild or more severe depressive states. The treatment is a mood stabilizer, such as Lamictal, which often helps because Lamictal is an anti-seizure medication, and as such, it quiets brain activity. Once again we are in a place where the benefit of a medication does not, or should not, give rise to a diagnosis. In this case, the Lamictal helps with symptom relief, but that does not mean that the person is mentally ill. It would be the same as saying that if I take tylenol for my headache, and my headache subsides, then I have a “headache disorder”. Symptoms can be transitory, and hence, not speak to a prognosis or long-term course of the illness. Mood swings can be frequent or infrequent, like headaches, without casting a shadow of a mental illness on the patient. By contrast to Bipolar I, where the disease has serious implications for biological family members, and the course of illness is known, Bipolar II gives us no information about either genetics or the future course. We have returned to this line in the sand where there is a great controversy over when a patient has symptoms, but no diagnosis, as opposed to a diagnosis. The majority of my patients have symptoms, but do not meet criteria for a diagnosis. As such, I advocate for a deeper honesty about our tool box. We treat symptoms, and we do that well. Diagnoses, on the other hand, we need to improve.

 

“What makes her Bipolar II?” I ask my student as he presents a case. She gets irritable and she sleeps poorly. “Maybe she is going through a rough patch and she is unsettled,” I respond. “Maybe she has her panties in a knot:,” my new favorite expression. “Yes, yes,” my student agrees, as we both acknowledge that there is the language of training programs which forces diagnoses on people, and there is a language in the outpatient setting, which sees patients on a spectrum of coping skills. Students learn to be bilingual, in this way. Mostly, my students take this disagreement in stride. I, on the other hand, feel rage. I am deeply concerned about what these labels mean to patients. How do patients cope with getting a diagnosis, which might only apply to this particular period in their lives, and yet the diagnosis implies a long-term course? How do family members see their loved ones, when they carry a diagnosis of a “mental illness?” By labeling these patients Bipolar II, we strip them of the embracing the common human experience of stress, internal discomfort, and dis-ease. We teach them that the answer to their problems is embracing the sick role, rather than empowering them to learn to cope. Sure, coping skills are part of the treatment of Bipolar II, but it is different if there is a psychiatric label, as opposed to normalizing it as the stress of maturation, and coping in a world filled with uncertainties and pain. Once again, I conclude, Psychiatry has lost its way. Medications can help, but diagnoses for non-psychotic illnesses, at least most of them,  do not.

The Lonely Child

Is Psychotherapy Research The Answer?

http://www.nytimes.com/2015/07/19/opinion/psychiatrys-identity-crisis.html?_r=0

“The brain is notoriously hard to study and won’t give up its secrets easily.”

Eleanor, a blog reader, pointed me to this article, reminding me that I am not alone in my fight against the reductionistic approach to mental illness, either by promising a magic bullet, in the form of a pill, or a procedure, such as Transcranial Magnetic Stimulation, or by the form of a short-term, cookbook type of psychotherapy. In this New York Times, opinion piece, Dr. Richard A. Friedman argues that more federal dollars should be directed towards psychotherapy research. He reminds us that Dr. Markowitz published a study on PTSD where the helpful treatment was Interpersonal Psychotherapy, as opposed to exposure therapy. In other words, people with trauma need to re-build their relationships, and not just desensitize themselves to their triggers. My issue here is that psychotherapy research, although potentially promising, does not account for the individual differences between psychotherapists, along with the individual differences in the length of treatment required. We share this issue with physical therapists, who also do not have good evidence for how many sessions are needed for a back or knee injury. The numbers become arbitrary and so the payments are helpful to some, but not to all with physical complaints. Likewise, if insurance pays for 12 psychotherapy sessions, then this will help some people, but for many people this will not suffice. Is some psychotherapy better than none? I think so, but for training purposes, the therapists need to learn long-term psychotherapy in order to use those skills in a shorter-term setting. Dr. Friedman only highlights our identity crisis further, which by that I mean, that promoting psychotherapy research could also send us down the rabbit’s hole. How do we justify our work, if we assume that people have deeply unconscious reasons for symptom formation, and as such, the length of treatment is not knowable, and the measure of success is also not knowable. Patients often sit with ideas that we have generated in my office for months and years before the concepts penetrate, allowing them to release themselves from their self-imposed shackles. Healing is slow and not steady. Dr. Friedman and I agree on this, I am sure. Where we part ways is how the government, or insurance companies should support our treatment. Funding neuroscience is only partly the answer. On this, we concur. Funding psychotherapy research is questionable in my mind, and hence our ideas diverge. My suggestion: Introduce patients in psychological pain to psychotherapy, paid for by insurance, with a limit of 20 sessions per year, so that the patient and the therapist can try to find a way to fund the other 30 sessions, knowing up front, that those 20 sessions may help with symptom relief, or it may not, and as such, the journey begins, but the endpoint is not known and it is not knowable.

Growing Up Alone

Continuing on the topic of needing a “mother,” a person who is passionate and hopeful for your existence, I am thinking about those children out there, who for a variety of reasons lack that passionate advocate. It is my feeling that for some children, that passionate advocate is the key person who takes a hedonistic child and turns him into a productive and giving human being. Without that advocate, the child becoming an adult could be lost in a drifting world, where there is little future planning, and life is very self-centered, mostly as a means to survival. In other words, some children lack the imagination to see themselves as a powerful force who can bring change into the world, and with a passionate push, that child gets the confidence to grow, both personally and professionally. This is the tale as old as time. A supportive mother, friend, and/or wife, gives the child, friend, and/or husband the push to apply for a new job, move to a new city, or take on more responsibility, and in so doing confidence grows. Without the push, stagnation sets in.

Vince, fifty-four, comes to mind. He grew up with a mom who was always “busy” doing “charity things” and a father who was never home, and who years later confessed to having a girlfriend and another family. Vince was not good at school, but he managed to go through college, but dropped out when school got too hard for him. At thirty-five, Vince marries Cory, a thirty-year old female, who openly says  she is “desperate to have a family.” Cory encourages Vince to start a business in commercial real estate. Vince is scared, but Cory is a strong advocate that Vince can handle it, so with Cory’s encouragement, Vince starts and eventually grows a very successful business. What if Vince never met Cory? I would wonder if Vince would have remained a drifter. Vince is grateful to Cory, but he has a difficult time admitting it, because it makes him feel “small”. With time, though, Vince develops the courage to tell Cory how much he appreciates her push, and how now he is living a life he never dreamed he could. Vince opened himself to Cory’s ideas because he loved her, and he wanted to make her happy. Cory was able to push Vince because she saw potential in him that he did not see in himself. This is an example of how change happens, and sad lives become happy ones. Is it the “love cure”? Yes, the “love cure” with a “push”.

Trauma

 

Trauma, a word that is hard to define, in a mental health sense, and yet it appears to be at the root of many mental health issues. The problem with understanding trauma is that the environmental impact varies enormously based on the person’s biology. We return to the gene/environment interface. Genes load the gun, environment pulls the trigger, so to speak. Trauma, broadly speaking, is the upsetting experience, which the average person never has. Trauma, in other words, implies a major diversion from our basic assumptions. Losing a child is traumatic because in this day and age, we assume that parents will die before their children. A reversal of this order leads us to think that the heartbreak is enormous, and yet generations ago, losing a child was a predictable event in that many children did not survive to adulthood. So, trauma is contextual. The child who loses his mother when he is four, may experience a trauma, but at the same time, if that child is raised by a loving father, and perhaps a loving step-mother, then the child may not experience a traumatic loss, but rather a more “ordinary” sense of loss. On the other hand, if we let the patient define the trauma, then do we say that if the patient says that he had tonsillitis at age 6 and had his tonsils removed, then do we yield to him that this was the “traumatic” moment in his life, which now explains his job and marital difficulties. There are therapies which focus on “trauma” without a consistent definition of “trauma” making the therapy less rigorous, in one sense, and yet appealing, in another. The focus on trauma as an explanation for self-sabotaging behavior, lends itself to the reductionist notion that if the therapist and patient can “work through” the trauma, then the subsequent substance abuse and mood problems will resolve. Once again, I return to my thesis. If we can agree that trauma is a complex notion, shouldn’t we also agree that the treatment of trauma is also complex, and not amenable to limited duration cookbook kinds of treatment?

Clint, twenty-two, comes to mind. His mother committed suicide when he was five, on the fourth of July, “ruining my summer,” as he said with dark humor. His father re-married to a woman which Clint says “is OK”. After graduating high school, Clint has lived a life of homelessness and drug abuse. “Do you think that you would not have your current life if your mom did not kill herself?” I ask, wondering if he connects his current despairing life to the tragic death of his mom, sixteen years ago. “How would I ever know that, ” he says instantly, followed by, “probably, that is true.” He says, with tears in his eyes, and then mine too. “I never had anyone that was passionate about me and my development, and I think that really hurt,” Clint says with surprising candor. Suddenly, Clint has come to life for me. He is not the “homeless guy with a drug problem,” as he appears from the exterior, but rather, he is a little boy who really really misses his mom. Clint needs to feel valuable and important, a process which will take mentorship, and a deep therapeutic relationship. Losing his mom was traumatic, but the end result, put into the context of his life, was a deep feeling of worthlessness and hopelessness. Clint needs housing. He needs to live a sober life. Clint needs to feel loved. Short-term treatment is likely to reinforce his sense of hopelessness, as it will create another abandonment, the worst, most anti-therapeutic outcome. The theme, again, is constant. Complex problems require complex solutions. There is no way around that.

 

Oh My! Psychologists As Double Agents

 

http://www.nytimes.com/2015/07/11/us/psychologists-shielded-us-torture-program-report-finds.html?_r=0

 

The Hoffman report exposed that the heads of the American Psychological Association, on the one hand condemned torture, and on the other hand, taught people at the CIA and DOD about “enhanced interrogation”. There was money to be made, for sure. Businesses were started and consulting fees were obtained. Does this explain the breach? And, or, was it the power, the inside track to government officials? Is this about the thrill of living a lie? Is this the same dynamic as the religious figure who is caught messing around? Mental health professionals, as with all professionals, have the ability to help and hinder. Using the understanding of motivation to torture someone is akin to psychiatrists in the USSR who said people were insane because they had different political views? It is horrifying to think that leaders in my profession would use their skill sets to promote cruelty, and then cover it up. How can I be surprised though? I often write about how the human condition involves good and evil. We are all capable of both. There is no immunity based on the image we project of ourselves. I the “charmingly cynical” person, as one reader has characterized me, should take this new revelation in stride; one more example of how trusted officials can go to the dark side. Yet, I am taken aback. I know some of the players accused in this scandal. I have shared meals, hosted their speaking engagements, and generally felt like we were on the same side. That makes this story personal. I am shocked and not shocked at the same time. The American Psychological Association issued an apology. That was good. They took responsibility. That gives the scandal some closure. I am still disappointed. Given my understanding of the underbelly of human behavior, I continue to wish that people behave in the way they say do. That is my fantasy, I know.

New Academic Year

 

My old students have moved on and my new students have moved in, so to speak. “I saw a psychiatrist, but I did not talk to him,” a new patient says to me, and I  repeat to my students, emphasizing that we must turn this tide around. The twenty-minute appointment, even if you did that in practice, does not allow time for you to learn to speak to patients, I say, reminding them, that pre-Prozac, what we offered patients, that no other physician offered, was time. I teach in a program in which I fight for relevance. “There is no evidence,” the student reminds me, that psychodynamic psychotherapy makes an impact. “That is true, but how do I understand the look in a patient’s eye when I say something meaningful to him?” I respond. Yes, that is not scientific, but it is compelling that both the patient’s words and my words create meaningful change in the patient’s mental health. Together, the patient and I, can create new connections, new wiring, in which the patient learns confidence and impulse control. Confidence, meaning another word for self-love, I continue. Sometimes I wonder if I am teaching, or making a case for psychoanalytic training, or both, perhaps. I challenge my students to challenge their other professors, maybe not directly, but in their minds. “Head-meds only go so far,” I say, again pleading for a curiosity about motivation and self-sabotage. How did this happen? I wonder to myself. Who invented this 20 minute “head-med” appointment? Who thought to tell patients, if they try to extend beyond 20 minutes, that they should talk to their therapist? We, psychiatrists, are now telling patients we do NOT want to listen? This tide must turn!!!!