Mood, disposition and disorder

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

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

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

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

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

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

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

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

On supervision and treatment teams

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

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

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

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

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

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

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

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

The rest is history.

 

Mental illness and stigma

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

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

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

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

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

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

The Slow Death of a Dream

Whatever his personal shortcomings, President John F. Kennedy was undeniably a visionary. He envisioned and enabled a robust NASA space program, he established the Peace Corps, and he laid the foundation for a nationwide community mental health care system. NASA has sent astronauts to the moon and the Peace Corps is still making friends for the U.S. all over the world, but the dream of a national program of affordable, local preventive mental health services has been dying a slow death. Now we have a bare bones system inadequate to meeting the needs of the neediest, let alone providing preventive services to individuals and families in crisis.

The Community Mental Health Care Act of 1963 authorized federal funding for the establishment of local mental health centers all over the country, with the long-term goal of de-institutionalization. The plan was to enable states to empty-out their expensive centralized state hospitals/asylums for the custodial and medical care of chronically mentally ill persons, and to shift to less-expensive local outpatient care.  Little did I know when I began my career as a mental health professional in 1976 that I was joining the fledgling system near its zenith, and that I’d witness a steady decline in public sector service provision throughout the rest of my career.

The dream of an adequate nationwide community mental health care system died of legislative neglect, all over the country. Seeing a windfall for state general funds, most state legislatures pulled a bait-and-switch operation. They accepted federal funds for as long as they were available, but didn’t follow-through on the intent of the law with state matching funds. They saved a lot of money by closing their centralized mental institutions, but didn’t allocate nearly enough of the savings to establish adequate local care alternatives. Good outpatient care prevents costly inpatient treatment.

Most of my first ten years of clinical practice were in rural Alabama and South Carolina, at satellite offices of regional mental health centers. At that time individuals and families could get counseling for a very reasonable sliding scale fee, based on income. With such services available, suicides are prevented, marriages are saved, dysfunctional families become more functional, and individuals learn skills that enable them to function at a higher level. I’ve seen all those things happen. It’s been a privilege to be there as a counselor for people who can’t afford services from private sector providers, and I mourn the loss of that level of service provision in communities.

These days most community mental health centers are understaffed, and clinicians spend much or most of their time providing basic case management services to overwhelming caseloads. That’s why jails and prisons have become major mental health service providers, why hospital emergency departments are frequently overwhelmed by patients needing emergency mental health care, why so many mentally ill people are homeless, and why dangerous people increasingly fall through the widening cracks in the system.

Because of the legislative gutting of the mental health system, patient care is down to the bare bones. Outpatient counseling and other preventive services are hard to find. We desperately need more community resources. Effective outpatient services not only prevent hospitalizations, they save lives. Every dollar cut from preventive services ends up being spent elsewhere – in hospital emergency departments, jails, prisons, and homeless shelters. Our lawmakers seem to have forgotten the wisdom that an once of prevention is worth a pound of cure.

Looking back, I have my criticisms of the system I used to be a part of, but many of them are due to the diminished funding over the years. Community mental health has done a lot of good for a lot of people, and I saw lives change because affordable counseling was available to individuals and families. But the community mental health system didn’t offer alternatives to the dominant medical model. As resources dwindled, patient care for persons with chronic mental illnesses mostly consisted of case management services, occasional and short “psychiatric medical assessments” (PMAs), and the prescription of psychiatric medications – many of which have serious side effects. Sedating people with drugs is cheaper – at least in the short term – than providing support services that might reduce reliance on chemicals that only treat symptoms.

I’m not hopeful that the mental health system will be repaired anytime soon. Although I’m retired from clinical practice, I remain an active advocate for the rights of mentally ill persons. We need to modify the mental health system by taking a more holistic approach and providing alternatives to PMAs as the sole basis of treatment for people with chronic mental illnesses. I think that psych meds can be an important component of treatment. But I think there’s an over-reliance on their use, because of the influence of Big Pharma on the system and because of the lack of holistic support services available to people who suffer from mental illnesses.

If you want to know more about what’s wrong with the mental health system, I recommend Pete Earley’s still-timely 2006 book, Crazy – A Father’s Search Through America’s Mental Health Madness. In alternating chapters he tells the story of his own heartbreaking difficulties trying to get help for his bipolar son in a broken system, and details what he learned as a journalist at the Miami-Dade County Jail about how we got to this sad state of affairs. If you want to join others in advocating for the rights of mentally ill folks, check out NAMI, the National Alliance for the Mentally Ill.