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.”

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.

Identity and diagnosis

I’ve  written two prior posts on the paradox of identity, and now I want to return to the topic. I’ve run into different versions of the  following affirmation/mantra and I don’t know who to attribute it to, but it’s a good starting point for this brief examination of what identity is and isn’t: “I have a body. I am not my body. I am more than my body. I have emotions. I am not my emotions. I am more than my emotions. I have thoughts. I am not my thoughts. I am more than my thoughts. ” For people with identified mental illnesses I’d add: “I have a diagnosis. I am not my diagnosis. I am more than my diagnosis.”

Folks grappling with mental illnesses often find themselves stigmatized, treated as the modern equivalent of lepers, although they’re not contagious. Even within the mental health community individual patients are sometimes referred to by clinicians as “a schizophrenic” or “a borderline.” Mentally ill people often sense that others stereotype and define them by their mental illness. One of my great revelations early in my career (I already knew it intellectually, but not experientially) was that people with mental illnesses are, first, unique individuals – like the rest of us. Their mental illness is a feature of who they are, not a defining characteristic.

When I worked in a Dialectical Behavior Therapy (DBT) program, designed to help “borderlines,”  one of my individual therapy clients was a highly intelligent and assertive  woman. She let me know up front in our first therapy session that she wouldn’t abide being referred to as ” a borderline” by me or my colleagues. “I’m a person who meets the diagnostic criteria  for  Borderline Personality Disorder.” And that describes her better than any diagnostic label. (Years later she saw me at a mental health event and gave me one of the finest and most honest compliments I’ve ever gotten from a former client. She said that I was the second-best therapist she’d ever had.) She refused to let others define her by her diagnosis, and was her unique self. I’ve worked with a number of people diagnosed with Borderline Personality Disorder, and no two of them were alike. I’ve worked with many more who carried the diagnosis of schizophrenia, and no two were alike.

It’s easy to stereotype people we don’t understand, and whose behavior might confuse or threaten us. As with homophobia, fear of crazy people – the most common stereotype –  is rooted in the unconscious or conscious fear, “what if I were that way.” The idea of “losing your mind” is frightening to anyone who thinks about it. Les aliens is a French term for the insane. Many people with chronic mental illnesses feel internally alienated because of their symptoms, whether depression or hallucinations. But on top of that, mentally ill people are frequently treated as aliens by people who don’t understand, and therefore fear, them.

People struggling to cope with the symptoms of mental illness often find themselves judged or blamed for their symptoms. A person in a manic state may be told, “Just pull yourself together and stop acting crazy!” A person suffering from clinical depression or PTSD might hear, “What’s wrong with you, anyway? You should have gotten over that by now.”, as if they had a choice.

Psychodiagnosis is a necessary part of the medical model but, as discussed in a previous post, it’s based on decisions made by committees and applied to unique individuals. It’s not rocket science. Psychiatry puts the people it treats in the patient role, or sick role. There are both advantages and disadvantages to being conferred the sick role. It absolves you of responsibility for certain things you’d normally be held responsible for; but it prescribes what you must do as a patient, and often keeps you dependent on ongoing treatment. This makes sense for a kidney dialysis patient, but not necessarily for everyone with a psychiatric diagnosis.

In some circumstances, for mentally ill persons there’s no substitute for good psychiatric treatment. But all too often patients are told that medication is the only option, and that they’ll have to depend on medications with awful side effects for the rest of their lives. The recovery model is person-centered, not patient-centered. Centers run on the recovery model work with their clients to come up with a unique recovery plan that serves to empower them, encouraging autonomy and hope. The plan may include referrals for psychiatric treatment when it’s needed, but other options are explored. More about the recovery model soon.