Models of Madness

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

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

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

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

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

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

Changing habitual behaviors

Everyone has habits – some good, some bad, some inconsequential. One study suggests  that something like 43% of our behavior is habitual. This includes sequences of behavior that we’ve “chunked” together, and often perform automatically, so we don’t have to make myriad decisions every day. When you get in your car to drive to your friend’s house, you’re probably thinking about your destination or what you want to say to your friend. You don’t have to decide on each action as you automatically depress the clutch, turn on the ignition, fasten your seat belt, release the parking brake, shift into first gear or reverse, and  step on the gas pedal while easing off on the clutch. You don’t always have to be mindful about driving until you’re in traffic. We spend part of each day on “automatic pilot,” not having to make individual decisions about routine behavior sequences – which can include such things as drug abuse or “screen addiction.”

Throughout most of history, an individual’s habits arose from the culture and that individual’s circumstances and proclivities. These days, many of our habitual behaviors have been conditioned by corporate social engineers, applying principles of social science in the fields of advertising, marketing, public relations, and political consultancy. Using classical (Pavlovian) conditioning and other psychotechnologies of influence, they “invisibly” shape habitual behavior on a mass scale. I’m convinced that America’s obesity epidemic is largely due to the constant barrage of advertisements for tasty, if not necessarily healthy, foods. I’ve written about this corporate social engineering in my book, Ad Nauseam: How Advertising and Public Relations Changed Everything.

Everybody knows how hard it can be to change a bad habit. During my career, I had many clients who entered therapy because they needed professional help in order to change a bad habit. Willpower by itself is seldom sufficient to establish a desired change, because you have to maintain mindful awareness of your triggers and urges/cravings every waking hour, and to persistently resist temptation. The rewards of (for instance) dieting are long-term; the reward of giving in to a food craving is immediate. The good news is that once you’ve successfully changed a habit, it gets easier and easier to  maintain the change as time goes on. Quitting smoking, my nicotine cravings used to last all day. Eventually they only lasted for seconds, and now I haven’t had one for years.

Whether smart phone use can be addictive depends on your definition of addiction. I’m “old school” on the subject and believe that tolerance (needing more over time to meet your need) and physiological withdrawal are hallmarks of true addiction. Sex and gambling and screen time don’t qualify as addictions by the classic definition, but the physiological responses of gambling/sex/smartphone/gaming “addicts” are very similar to the responses of drug addicts. There may be withdrawal, in the form of cravings, but they’re psychological in origin.

Changing a habit often requires  a strategic approach to the problem. What mental, emotional, and social factors tend to keep the undesirable behavior in place? Once you’ve analyzed the factors that support your bad habit, make a plan. Visualize how your life will be better when you’ve succeeded.

Here are four things you can do to replace a bad habit with a good one. (1) Your plan should take into account the things related to the bad habit, such as time, place, emotional states, and social factors ( i.e. It’s not a good idea to hang around with your drinking buddies early in sobriety). (2) Declare your intention and your criteria for success to friends and family. This gives you an added social incentive to succeed. (3) Build-in  consequences, positive or negative. They can be natural consequences, or constructed. A natural, positive consequence if you’re quitting smoking is to add up the money you’re saving, and when you accumulate enough, treat yourself to a trip to Disneyland, or Vegas, or wherever. A negative, constructed consequence might be writing a $100 check to some organization that you despise, and giving it to a friend, to be mailed if you fail to change the targeted habit. (4) Don’t rely on good intentions and willpower, but structure your environment to make the bad habit more inconvenient. You can’t binge on cookies and ice cream while watching TV if you don’t buy them and bring them home in the first place. Other environmental factors are social – enlisting the support of those around you to help you meet your goal, and avoiding those who might undermine your resolve.

I’d never say “Good luck” to someone who announced his or her intent to kick a bad habit. Luck has nothing to do with it, and willpower is only one of the things you’ll need to succeed.

Existentialism and psychotherapy

Although I studied a variety of therapies in my preparation for a career as a psychotherapist, I never identified exclusively with one approach – gestalt, client-centered, behavioral, psychodynamic – as a descriptor of my style of therapy. I was an eclectic practitioner, but have always considered my therapeutic orientation to be existential.

I respect that there are therapists whose work has a religious foundation, but mine was a secular practice. I validated faith in God and prayer as best I could, with clients who found meaning in their religious beliefs; but if clients asked me to pray with them, I declined. Although I was raised as a Christian, and most of my values are rooted in the Judeo-Christian ethic, I’m an agnostic of the kind that’s very comfortable with saying “I don’t know” when asked about specific religious beliefs. I think that it’s just as arrogant for an atheist to assert sure knowledge that there is no God as it is for a religious person to assert that I’m in error for not believing what they believe. Define God, then we can talk.

I don’t believe that I have the authority to definitively answer questions about religion and am tolerant of  those who claim to “know” that their beliefs are true, as long as they do no harm as a result of religious beliefs. Of course, there’s considerable room for debate about what constitutes harm. (I personally consider any form of indoctrination to be harmful.)  I consider myself an existentialist because existentialism directly addresses morality and personal responsibility, without the excess baggage of sin and redemption and pleasing God. I’ll briefly summarize some of the basic principles of existentialism, as I understand them.

First, existentialism asserts that there’s no universal Meaning “out there” that all right-thinking people can apprehend – as opposed to religions, which assert that there is, i.e. “God’s plan.” To existentialists, concepts like Sin and Redemption and Divine Intercession are constructs based on religious doctrine. They don’t exist in any objective sense. Meaning only exists in the eye of the beholder. Life is absurd, as illustrated by Albert Camus in “The Myth of Sisyphus.”  Sisyphus continues to push the boulder up the hill, despite knowing that it will just roll back down. He persists, despite the absurdity of his efforts, because the act has meaning for him.

Because there are no absolute rules, or Divine rewards or punishments in an afterlife, we are each free to do whatever we want. But the other side of the coin of freedom is responsibility. We’re absolutely responsible for whatever we choose to do, and can choose to behave morally even if we don’t believe in Heaven and Hell. We can choose to live in good faith with others, because of our moral responsibility for all of our actions. Although we can find joy and meaning in authentic relationships, we’re all essentially alone in our lives. (A song sung by Country singer Bill Monroe expresses this as well as anything I’ve read on the subject; “You’ve got to walk that lonesome valley,/ You’ve got to walk it by yourself,/ ‘Cause nobody else can walk it for you./ You’ve got to walk it by yourself.”) We each have to deal with Angst (anxiety) and dread that comes from the knowledge that we will someday cease to exist. Existentialists don’t rely on the comfort of religious promises of eternal life for the faithful, to come to terms with our mortality.

To say that there’s no objective Meaning to existence “out there” isn’t to say that meaning is unimportant. As an existentialist I’m free (like Sisyphus) to find, or create, my own meaning. One of the best-known existential therapists, Viktor Frankl, named his school of psychotherapy logotherapy – from the Greek “logos”: meaning, or reason. (I’ve written about Frankl in previous posts. I’ve recommended his book, Man’s Search for Meaning, to more clients over the years than any other book.) Although I didn’t practice logotherapy, per se, I’ve worked with many therapy clients to help them find or create meaning in their lives. It can be a life-or-death matter with people who are suicidal.

I initially saw existentialism as grim and forbidding: if there’s no extrinsic Meaning to existence, then all we can do is to sweat along with Sisyphus, acting as if there was meaning to our lives. But now I see the richness of choice, where I once saw austerity. Existentialism gave me a philosophical context for the I-Thou encounters of psychotherapy. We all have a need for our lives to mean something; but we needn’t rely on “God’s plan,” as taught by this or that religion, or on promises of eternal life, to find meaning in our lives.

If you want to learn more about existentialism and the colorful characters (Jean-Paul Sartre, Simone de Beauvoir, as well as Camus, Heidegger and Merleau-Ponty) who formulated its principles, I recommend Sarah Bakewell’s highly-readable At the Existentialist Café: Freedom, Being and Apricot Cocktails. I’d never have guessed that phenomenologist Maurice Merleau-Ponty was good at dancing the Jitterbug.

My love story

I fell in love with my first wife, Doris, as an Army lieutenant serving in Germany. She’s a German who spoke fluent English when I met her. I still spoke some German, having lived in Vienna  for four years, when I was in middle school. Doris was my first lover, still living with her parents; but we soon found an apartment and moved in together. Believing that we were destined to grow old together, we got married – much to the relief of her parents. I had a Top Secret security clearance and had to get permission from the Army to marry a foreign national.

We had an unconventional marriage. Although we were in love, we discovered that neither of us was reflexively jealous, or a conventional thinker. We read the popular book Open Marriage, by Nena and George O’Neill to one another, and discussed the option of having other lovers. Some open marriages are monogamous. Only one chapter of the book is about the option of having other lovers, and the O’Neills  expressed their dismay at the wide perception that open marriage automatically meant polyamory. Open marriage is a concept much larger. It’s a concept – radical for its day – of the marriage bond as an ongoing choice to be together in a loving, committed relationship, as equals. We wrote our own wedding vows, pledging to be together “as long as we both shall love.”

During the six years of our marriage, Doris and I each had other lovers, and jealousy wasn’t a problem for either of us. We usually got to know and like one another’s lovers, and there was never any secrecy or deception. We never considered ourselves “swingers,” and we didn’t seek out strangers to have sex with. It’s just that we had the option to become lovers with some of our opposite-sex friends. When we divorced, amicably, it wasn’t due to our polyamory. We remained friends and, for several years, lovers. Even after the divorce, my parents still treated Doris as a family member. She lives in Germany now, and we remain close friends to this day.  My wife Maria and I visited her two years ago.

Doris came to visit me in Beaufort, SC after our divorce and, to my delight, she and Maria hit it off right away. Maria and I were lovers, but at that point we were seeing other people, too. Years later, Doris told me that she’d regretted our divorce, and had hoped to “win me back.” But when she saw how Maria and I were together, she knew that we were meant for each other. Despite this discovery, she was never jealous of Maria, and over the years they’ve come to be like sisters. They have three things in common: each is a lovely woman, they are among the most honest people I’ve ever known, and neither of them has a mean bone in her body.

I knew from early-on in our relationship that I wanted to marry Maria. She had just divorced her husband of seventeen years, and I knew that she needed to “play the field” before she might decide that she wanted to spend her life with me. (I feared that I might turn out to be her “transitional man.”) She knew that Doris and I had had a polyamorous open marriage but she knew, once she decided to marry me, that she wanted our marriage to be monogamous. We’ve both been faithful to one another since the day we agreed to marry, and I’ve never regretted giving up a polyamorous lifestyle. I consider our marriage to be an open marriage because we’re autonomous equals, neither of us tries to control or dominate the other, and we’ve been together in a committed relationship for thirty years out of loving choice, not momentum or a sense of obligation.

For a polyamorous open marriage to work, both partners have to want it, to trust one another and be trustworthy, and to always remember that theirs is the primary relationship in both lives. I have friends who have had a polyamorous open marriage for over forty years. It’s my belief that polyamory can be a valid choice in a loving marriage. While most marriages probably need to be grounded on a pledge of marital fidelity, I don’t consider monogamy to be morally superior to polyamory. It’s just a choice that some loving couples can make.

I don’t miss having other lovers because I’m happily married to the love of my life, who isn’t polyamorously inclined. But I can still tell Doris that I love her, over the phone or in person, and Maria isn’t jealous. Doris and I get along better as brother and sister than we did as a married couple. I have the good fortune of still being a close friend to my first lover, and one of the great joys of my life is to see and hear Doris and Maria talking and laughing together. Even if they’re laughing about me.

Suicide prevention

While the act of suicide is sometimes a long-considered, planned option which nobody can prevent, most suicide attempts are impulsive. According to one study, approximately one quarter of the people who try to kill themselves do so within five minutes of their decision to attempt suicide. Only a small fraction of people who survive a suicide attempt go on to die by their own hand. Throughout my career as a psychologist, I assessed many people shortly after a suicide attempt. A question I always asked of them was, “Are you glad that you’re still alive?” Almost all of them were glad that their suicide attempts had failed. I concluded that most suicide attempts are mood-specific behaviors, often involving intoxication on alcohol or other drugs. Once their mood changes, or they sober up, they no longer want to end their lives.

While in grad school, I volunteered as a telephone crisis hotline worker. I was trained to talk to people who were in crisis, to keep them from engaging in attempts to harm themselves or others. From early in my clinical practice I was called on to evaluate the suicide potential of clients. I learned that many people who attempt suicide are ambivalent about living. “To be, or not to be; that is the question.” At the core of this ambivalence is the issue of existential meaning.

One of the major existential therapists of the twentieth century was Viktor Frankl, an Austrian psychiatrist that I’ve written about in previous posts. His book Man’s Search for Meaning was based on his experiences as a survivor of a Nazi death camp. He observed that in such a hellish environment, those who fought to live were people who had a sense of meaning in their lives. He called his method of psychotherapy logotherapy (logos means “reason” or “plan” in Greek), and his therapeutic approach was to help patients find, or create, meaning in their lives.

Lives bereft of meaning are empty lives, but sometimes the vacuum can be filled. Although I was able to help some suicidal clients to find something to live for, one of my severely depressed therapy clients died by his own hand. It was the worst thing that happened in my career. I really liked “Allen,” saw strengths and personal qualities that he couldn’t see, and worked in therapy to help him find reasons to go on living. I saw him on Wednesday afternoons, and he always kept his appointments. When he didn’t come in one Wednesday, I immediately called his apartment. When he didn’t answer after several tries, I looked up his address and drove to his apartment. When he didn’t come to the door when I knocked and rang the bell, I intuited that he was dead, inside. Sadly, this proved to be the case. It turned out that he’d bought a gun that morning, gone home, and used it. On a Wednesday, instead of keeping his therapy appointment.

I went through predictable self-recriminations and judgments. Could I have done anything differently that would have prevented his suicide? But I recognized this as a question that could never be answered. My colleagues knew that I was grieving as if I’d lost a family member, and supported me in my grief process. A peer review of my clinical records found that I’d done and documented everything properly, in terms of recognizing and dealing with Allen’s suicide risk.

A few years ago a close friend committed suicide. She suffered from bipolar disorder, and had confided in Maria and me that she would take a drug overdose in certain future hypothetical situations. She said it matter-of-factly, and wasn’t depressed when she said it. We knew that there was nothing we could say that would change her mind. We hoped that she’d never find herself in one of those imagined situations.

Philosophically, I’m torn on the issue of the “right to die,” because if suicide were to be legalized, it’s inevitable that some depressed people would convince themselves – or be convinced by others – that it was their duty to die, perhaps because they felt useless, or they wanted to leave an inheritance, rather than spend their money on their own medical care in old age. I’m no longer a therapist, but if I knew that someone was acutely suicidal, I’d do whatever I could to try to prevent an impulsive suicide attempt. (Many times, as a Designated Examiner in the Probate Court, I recommended involuntary hospitalization for suicidal people.) But once a person has suicided, I don’t make judgments about their decision to end their life. I don’t have the authority to judge.

Most people who end their own lives do it to escape intolerable pain – whether physical or emotional. Allen killed himself because he could no longer endure living with severe depression. His life had no meaning worth living for. I tried unsuccessfully to help him find reasons to live. Albert Camus considered suicide to be “the fundamental question of philosophy.” He wrote, “I see many people die because they judge that life is not worth living. . . . I therefore consider that the meaning of life is the most urgent of questions.”

Which takes us back to Viktor Frankl, who found meaning in the Hell of a Nazi death camp, survived, and went on to be a founder of the humanistic psychology movement.

Psychotherapy in movies

In this post I’ll write about realistic depictions of psychotherapy in movies. Not many get it right. Barbra Streisand’s portrayal of a psychiatrist  in The Prince of Tides comes to mind. Her approach to therapy relies on the inaccurate cliché that when the client recovers the repressed memory of his trauma, he will be cured. More often than not movies about psychotherapy (i.e. Analyze This and Anger Management) treat it as a joke  – probably because the idea of being in therapy makes a lot of people nervous. Therapists routinely hear nervous jokes about their profession when they’re introduced to people as a psychotherapist. I can’t tell you how many times I’ve heard comments along the lines of, “I’d better watch what I say around you.” or “My wife really needs to talk to you.”

One of the most realistic depictions of psychotherapy I’ve ever seen in a movie was Ordinary People (1980), the first movie directed by Robert Redford. It depicts the dissolution of a family after the elder son of a loving couple dies in a boating accident. Timothy Hutton won an Oscar for his portrayal of the younger son, who feels guilty for surviving, when his brother died. Mary Tyler Moore distinguished herself as a dramatic actor in her role as the devastated mother, Donald Sutherland was totally convincing as the grieving father, and Judd Hirsch was perfect as a skilled and caring therapist who has to win the trust of his grieving, suicidal client. It’s a sad, beautiful movie, for which Robert Redford won an Oscar.

Good Will Hunting (1997) is another movie that portrays psychotherapy realistically. Matt Damon plays Will, an alienated, self-taught mathematical genius, orphaned and raised in foster homes. He’s grown a hard shell, to keep people out, and trusts nobody other than – to some degree – his best friend, played by Ben Affleck. Robin Williams portrays the therapist, who is willing to try to connect with this tormented genius. Will has to go to therapy in order to stay out of jail, but that’s his only motivation. He does everything he can to provoke and alienate his therapist, and to sabotage therapy. Robin Williams convincingly portrays a therapist who immediately sets boundaries when Will disparages his deceased wife. He’s briefly unprofessional, physically accosting and threatening Will; but this scene reveals that psychotherapists are also flawed human beings.

He clearly sees the sarcasm and hostility that he encounters as weapons that Will uses to push people away. He knows not to take the attacks personally, and works with patience and good humor to win Will’s trust, and to “disarm” him. I’ve dealt with well-defended clients like Will, working to get to the place where they were ready to hear something like this: “Look, we both know that your armor works. It makes you feel safe. The thing is, the only way you can learn that it’s safe – at least sometimes – to go out into the world without your armor is to take it off and venture out into the world.” The final therapy session in Good Will Hunting is riveting, and rings true to me as a therapeutic breakthrough.

Although it takes place in a “mental institution,” there’s not much psychotherapy in Girl, Interrupted (1999). Winona Ryder plays a young woman diagnosed with Borderline Personality Disorder and Angelina Jolie plays an antisocial manipulator. Parts of the movie are melodramatic and implausible, but the acting is good. One thing that the primary therapist in the movie – played by Vanessa Redgrave – says has stayed in my memory, because it’s point I’ve made in therapy about the meaning of the word ambivalence. Ambivalence doesn’t just mean, “Oh, I really don’t know if I want to do this or do that.” or “I don’t care if it goes this way or that way,” serving to deflect or minimize an issue. It can also mean being deeply conflicted regarding two opposing courses of action. An addict can both really want to quit using, but also really want to get high. Suicidal people can be ambivalent about living. Part of them wants to live, but another part wants to die.

The most realistic portrayal I’ve seen of therapy on TV was HBO’s series, In Treatment, with Gabriel Byrne as a therapist with, let us say, an extremely challenging caseload. He’s an excellent therapist, but his own life is something of a mess. One thing I liked about the series was that it not only depicted therapy sessions with a variety of clients and issues realistically, but it also showed us the therapist’s weekly sessions with his own therapist and clinical supervisor, played by Diane Wiest. Healers often need healing, themselves.

 

Paddy Chayefsky

I’ve been a cinema buff all of my life, and one of my favorite screenwriters is Paddy Chayefsky. He wrote the screenplays for some of my favorite movies – most of them dark comedies. In this post I’ll write about my three favorite movies scripted by Chayefsky. Those of you who’ve read my previous philosophical and metaphysical posts will appreciate why the one Chayefsky  movie I’ll cover, that is not one of his dark satires, takes us deep into the realms of ontology and quantum physics.

The first Chayefsky movie that captivated me was The Americanization of Emily (1964), a WWII satire starring James Garner, as a US Naval officer, and Julie Andrews, as an English Army driver. I regard it as one of the best anti-war movies ever made. The Allied forces in England are awaiting D-Day, and Garner works for an Admiral. He’s an admitted coward who thinks his job as a “dog robber” (procurer of whatever the Admiral wants) will keep him out of combat. He meets Emily, who hates war, having bedded one too many soldiers who have since died in combat. She falls for the charming American officer and is glad that he’s a coward, and unlikely to participate in the coming invasion. Powerful people going mad is a recurring theme in Chayefsky satires. In this case it’s the Admiral, who goes off the deep end and decides that he wants Garner’s character to be the first man to land on Omaha Beach, so he can film the Allied landing! I remember the essence of a powerful anti-war speech in the movie, about how honoring the fallen with medals and flags and parades ultimately serves to glorify and perpetuate warfare.

Chayefsky’s best-known film was Network (1976), starring Peter Finch as a network news anchor, and Faye Dunaway as his flint-hearted producer. Finch won an Oscar (posthumously) for his portrayal of Howard Beale, whose increasingly unhinged behavior from behind the news desk leads to higher ratings. The network exploits his growing madness to get more market share, and hires fortune tellers and performers to make the news broadcast more entertaining. The best-known scene in Network  is when Beale, rain-soaked and disheveled, exhorts his audience to stop watching, open a window, and scream, “I’m mad as hell and I’m not going to take it anymore!” He goes on to tell his audience to tune in and watch him blow his brains out on live TV. It’s savage social satire, with brilliant dialogue. I’d hoped when I first saw it that it would prove to be an inoculation, to prevent the continuation of the trend of chatty news and “infotainment” on network news broadcasts. But, alas, it proved to be predictive, not preventive. There was a time when network news organizations didn’t compete for ratings, and pretty much stuck to news reporting. Today, the Evening News  greatly resembles the circus depicted in Network.

The third Chayefsky film I’ll cover is Altered States (1980), which starts out as science fiction, but turns out to be a love story. Chayefsky became fascinated with the work of consciousness researcher John Lilly, and did a lot of reading about psychedelic substances before writing his only novel, Altered States. The book was adapted for the screen by it’s author, and the movie was directed by British bad boy director Ken Russell. It stars William Hurt as Eddie Jessup, a brilliant neuroscientist obsessed with consciousness research and plagued by existential angst. Blair Brown co-stars as his wife, a brilliant biologist who has to live with her husband’s emotional distance. Dr. Jessup is willing to be his own guinea pig and ingest strange psychoactive substances in the course of his research. One day, while he’s alone in the lab for an unauthorized “trip” in a flotation tank, his body reshapes itself, in an evolutionary regression. He temporarily becomes a primate, an early ancestor of man.

Accounting for this transformation requires a paradigm shift in the relationship between corporeality and consciousness. One school of thought (material realism) holds that consciousness is an epiphenomenon of being a complex biological organism: it serves to enable the organism to survive. The other major school of thought (monistic idealism) posits that physical reality arises out of consciousness. Dr. Jessup has personally experienced a physical transformation that his mind enabled, and his new understanding of the nature of reality has terrifying metaphysical implications. He loses all control of the now-constant shapeshifting and becomes something monstrous, damned. He is rescued from the Abyss by the power of love.

I recommend the novel as well as the movie. Chayefsky’s name doesn’t appear in the film credits, because of disputes with Ken Russell. Russell’s contract specified that he couldn’t edit out any of the dialogue in Chayefsky’s script. He kept to the letter of the contract, but had some scenes with multiple overlapping conversations going on at once. Chayefsky didn’t like that, and didn’t want his name associated with the film. What dialogue you can make out is brilliant and thought-provoking, but you’d have to read the book to fully grasp the depth of Chayefsky’s speculations about the nature of consciousness and its relationship to physical reality. Apparently the book wasn’t widely read, but it remains one of my favorite modern novels.

Hatred is not a mental illness

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

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

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

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

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

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

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

 

 

My Red Cross service at Ground Zero

In my last post I wrote about my first tour (with my wife, Maria) as a Red Cross Disaster Mental Health Volunteer  in Manhattan, weeks after the 9-11 attacks. In 2001 Maria was employed, and I was between jobs. She’d been given two weeks leave to serve in New York, but couldn’t get an additional two weeks for a second tour. So, after my first tour ended, I was in a position to apply for a second tour and was again assigned to Manhattan. By this time luxury hotels were filling their rooms again, and I was given a shoebox of a room at the Pennsylvania Hotel – which happens to be my preferred lodging when I visit The City. And this time, when I in-processed  at the Red Cross headquarters in Brooklyn, I was given a prized assignment. I would be working at a Red Cross Respite Center at Ground Zero.

Ground Zero was fenced-in, and access was restricted to those who worked there. The sacred ground where the World Trade Center towers had stood was now known as the Pile by those who worked on it. Two weeks earlier, superstructure was still being torn down by giant machines resembling metal dinosaurs, and the wreckage could still be seen from outside the fence. Now operations were mostly subterranean, and Ground Zero was a vast pit, crawling with activity. The Respite Center I was assigned to at Ground Zero was there to serve anyone who worked on the Pile. The cafeteria operated 24/7 and free services were available for off-duty workers. Our clients included police and firefighters, demolition workers, engineers, telecommunications workers, machine operators, and National Guard troops.

Outside at Ground Zero, everyone had to wear a hard hat. The Respite Center was housed in a college student union building with a large atrium, a cafeteria and big rooms on the ground floor, and two more stories of smaller rooms, behind wide balconies  overlooking the atrium. Serving at the Respite Center was a very different experience than serving at a Family Service Center. It was where people working on the Pile went for meals, and when they were off-duty. Everything was free, from the cafeteria to a supply store with batteries, towels, work clothes, boots, gloves, etc. Workers who had long commutes could stay to sleep in dormitory rooms, without going home after each shift. There were also showers and darkened nap rooms with recliner chairs. There was a big media center where off-duty workers could play cards, or watch TV, or use a computer to play games, send e-mails, or surf the Web.  They could sign up for free massages or attend twelve-step meetings.

All Red Cross volunteers were there to pamper our clients and to help them deal with  the stresses of working on the Pile. We disaster mental health volunteers were there to listen to those who wanted or needed to talk, to be available and accessible. We knew not to ask intrusive questions or to initiate conversations about working on the Pile. We ate with the clients in the cafeteria and we schmoozed. We took snacks and coffee out to the cops and the National Guard troops providing security around the perimeter of the Pile. We filled in for other volunteers, washing dishes or making sandwiches, so they could take a break.

As with my first assignment in Manhattan, I was there to serve as a facilitator and troubleshooter – but in a different context. Our primary job was to provide respite to people doing stressful work. Bodies and body parts were still being found in the rubble. At one point I heard a local Salvation Army volunteer at a cafeteria table with firefighters ask a question about finding body parts. I took her aside and told her why her question was inappropriate at a Respite Center, where workers went to get away from their work on the Pile. She caught on.

There’s no telling how many New Yorkers developed Post Traumatic Stress Disorder (PTSD) due to the events of 9-11, but in my two Red Cross tours in Manhattan I encountered quite a few. Some had seen bodies falling from the burning towers; others had run for their lives when the towers fell. I was asked time after time if what the person was going through was “normal.” The people asking that question might be experiencing depression, anxiety attacks, fear reactions, anger, and other PTSD symptoms. I don’t know how many times I said something like this to trauma victims: “What you’re experiencing used to be called ‘shellshock’ or ‘combat fatigue’. It’s not just soldiers in combat who have the kind of symptoms you’re having. You’re a civilian who suddenly found yourself in a war zone. What you’ve described to me is a normal reaction to an extremely abnormal experience. You’re not going crazy.”

Another question I got a lot from people experiencing symptoms of PTSD was, “Will it always be like this?” While I had to tell them that I couldn’t answer their question, my replies included positive suggestions about recovery: “Everybody’s different. Some people keep re-opening the wounds, or convince themselves that they’ll never get better, and don’t. Some people just get better over time. If your symptoms don’t begin to diminish, and disable you in some way, you should consider counseling..  But the important thing is to keep an open mind about your recovery. Trust in your ability to heal, and get help if you need it. Nobody has the right to tell you that you should have already gotten over it by now.”

Police (“New York’s Finest”) and firefighters (“New York’s Bravest”) were especially hard-hit by the 9-11 attacks, as they were mourning the loss of so many colleagues. All human remains found in the Pile were turned over to a special squad of policemen and firefighters, to be removed with ceremony and respect; so people were still being traumatized, weeks after the attacks. I felt privileged to be in the company of the men and women of the police and fire departments, and to play a small part in New York’s healing. I’d visited Manhattan before, but this time I felt a part of it. I fell in love with it.

 

Red Cross Disaster Mental Health Service

I’ve served three two-week stints as a Red Cross Disaster Mental Health Volunteer, twice in Manhattan in the weeks following the 9-11 attacks, and once after a hurricane in Louisiana. To qualify as a disaster mental health volunteer for the Red Cross you have to be a licensed mental health professional, and you have to go through Red Cross training. Because of the unique challenges of being a disaster mental health worker, the tour of duty was for two weeks, while most other Red Cross volunteers served for three. The Red Cross is paramilitary in its organization and operations, with a strict chain of command and very specific job descriptions: driver, food service worker, family services worker, logistics and supply worker, etc. To serve in a Red Cross disaster operation is to become part of a well-oiled machine.

Not only can the workdays be long and stressful, but if there are no local hotel or motel rooms available, workers might have to sleep on cots in a big tent or at a shelter. You get one day off a week. While most volunteers have a specific duty station, disaster mental health volunteers are flexible and have the run of the entire operation, doing whatever they can do to be helpful and to keep things running smoothly. We were taught in training that we were not going to be doing counseling, but rather using our clinical judgment and skills as troubleshooters and facilitators: doing interventions when tempers flare, soothing people who’ve been yelled at by an angry client, listening to people who just need to unload, and talking to people about stress management. We would be working with both Red Cross staff and volunteers, and clients (disaster victims), some of whom would be suffering from symptoms of PTSD.

Like most Americans, the events of 9-11 had left me grief-stricken. I was as depressed as I have ever been, feeling like I’d lost family. My wife Maria had already taken the Red Cross courses required for certification as a disaster mental health volunteer. I immediately signed up for the training and within two weeks was certified. We put in our applications for service and were assigned to Manhattan. Airline flights had just resumed, and we were issued some of the first available tickets to JFK. We wouldn’t know where we would be assigned until we in-processed at the Red Cross headquarters for New York City. I’d volunteered so that I wouldn’t have to go on feeling helpless; I would be helping the healing process. It was my therapy, the best way for me to deal with my grief.

One term our trainers used in describing our function within the site operation was “schmoozing.” This meant just walking around the site and getting to know folks, greeting people and chatting with them, asking open-ended questions, letting people know that you’d be there if needed. We wore the same vest that all Red Cross volunteers wear on duty, with nothing to identify us as mental health volunteers; but within a few days at least someone at every duty station knew who the “mental health folks” were, and understood our function.

It was our job to be available where we were needed, and accessible. Sometimes we filled in – making sandwiches or toting trash bags to the curb – to enable volunteers to take a break. We tried to de-fuse tense situations when we could. We asked people, “How’s your day going?” and told duty station managers, “Let me know if I can be of help.” We assessed the morale and did what we could to keep it high. Sometimes volunteers came to us with things like, “You might want to ask Fred how he’s doing today. He just found out his mother’s in the hospital.” Other times a staff member or volunteer might approach one of us, ask “Got a minute?”, and talk for twenty minutes.

Maria and I were assigned to a Red Cross Family Service Center housed in a huge gymnasium/sports center in Greenwich Village – a ten-minute walk from Ground Zero. You could still see and smell the toxic haze from the fallen towers. Manhattan was on edge: recovering from the shock of the 9-11 attacks, and fearful of another attack. The swank hotels were near-empty, so we were assigned a room in a luxury hotel, a block from Carnegie Hall; but we worked fourteen-hour days, and were too exhausted to appreciate the luxuries. Contrary to the stereotype of rude New Yorkers, we found the local folks we encountered to be friendly and helpful. People on the street, seeing our Red Cross i.d. badges (which enabled us to ride the subway for free) made us feel welcome, and many thanked us for “coming to help us out.”

A family service center is where people who’ve lost their residence or their livelihood due to a disaster go, to apply for and receive (if they qualify) vouchers for food, housing, and other necessities. A kitchen on the premises dispensed free hot meals, and there was a free snack bar next to the huge waiting area. Clients were given a number and often had to wait for hours to see a family service worker, who would screen them for eligibility and fill out the requisite forms. Supervised child care was available. The primary task for mental health volunteers was to keep an eye out for potential problems and to schmooze the waiting area, available and accessible to the waiting clients. If things got volatile in the desk-filled basketball court, where family service workers sometimes had to turn down clients who couldn’t establish eligibility, mental health volunteers might be summoned to facilitate the situation.

Clients who clearly needed to talk to someone, or were in evident distress, were told that while we couldn’t “do counseling,” we were mental health professionals and good listeners. Sometimes we were able to answer questions, do brief interventions, or refer people to local agencies and resources, if they needed clinical services. I remember one ad hoc psychoeducational group that Maria and I led for parents, in a room off the waiting area. We heard such things as, “I can’t tell my kids not to be scared. I’m scared!” and “Is it normal for my teenage daughter to still cry every time I leave the apartment?”

More about my experiences as a Red Cross mental health volunteer – including my assignment to a Respite Center at Ground Zero – in my next post.