Recovery - From What?

Recovery is the individual lived experience of moving through and then beyond the limitations imposed by the disorder, by the world around us, and even by the treatment itself.

Huh?

Okay, the deal is, unless you know where you are going, it's tough to get there.

Recovery Defined as Escape from the Symptom Silo

The docs know where they want to go.  They want to get rid of your symptoms.  Your illness is defined by a list of symptoms, found in the DSM and measured by survey instruments, and when you score in the normal range, then you have recovered.

Which is sort of like saying that if you don't have chest pain or shortness of breath, then you have recovered from heart disease.  Cardiologists don't think that way.  They want to know the condition of your heart, not just your symptoms.

Recovery - The Medical Model Continued

Last week I began scavenging my upcoming Mental Illness Awareness Week presentation Recovery: Rewiring the Brain for a series of blog posts.  I left you in the middle of the Medical Model.  The graphic is on the left.  The narrative left off as the person with the broken brain was reading the patient information sheet, gulped at that list of side effects, remembered the doctor said she should weigh her costs and benefits, and then discovered that, according to the patient information sheet, the doctor had already done the weighing for her, and all she had to so was swallow the damn pill.

The Chemistry Experiment

The way it actually happened was this.  The sixth antidepressant my doctor wanted to try, she said, I get really good results with this medication.

So I wanted to know, remembering the results I got from her last brilliant idea, or rather, from the samples she had just received from the last sales rep, What kind of results will I get?

Recovery - The Medical Model

My Latest Obsession Begins

It was a talk intended for a general audience.  Well, what was assumed to be a general audience.  Not many doctors attend the monthly meeting of NAMI Johnson County.  But some people in the room know a lot more about the brain, what goes wrong, why, what can be done and what really works than the average viewer of those Zoloft ads on TV.  We have to.  We have come to understand that our lives depend on it.

So when the new director of the psychiatry department explained it all, some of us caught the nuances, and squirmed in our seats.

What Is Recovery?

Apology?

So Robert Spitzer's Apology struck a nerve: apologies made or received, or not.  More like, Robert Spitzer's apology stuck a fork into a 220 volt socket, the nerve labeled Apology in the Clinical Setting, Or Not.

I have long been curious about this issue.  Fork in the 220 volt socket kind of curious.  I watched with wonderment as a therapist handled my complaint, which was, to me, about a life-threatening experience, steering the conversation away, time and again, from what I thought was the simplest, most natural direction, I'm sorry.

Now, I trusted this person.  Her avoidance of those words, her downright circumlocutions confused me.  My brain has long practice in making sense of the nonsensical behavior of people I trust.  So I decided there must be a rule, a therapy rule, that says a therapist shouldn't apologize, because it diverts attention from the real issue, which is about the client's mother, and not about the therapist at all.  Or something like that.

Grief/Depression IV - Not the Same/Maybe Both

So a woman goes into the doctor's office, three weeks after her husband died. I got through the funeral just fine. But now I feel awful. There is this ten ton weight on my chest. I'm exhausted; I don't have the energy to wash the dishes. I'm trying to pack up my husband's things, and I am too weak to pick up his shoes. I can't eat. Sometimes I get hit so hard with this wave of anxiety, I think I'm going to throw up.

What are the chances the doctor will say, Of course you feel awful. These are all very natural symptoms of grief. You just need time. But if you still feel like this a month from now, call my nurse and set up an appointment. What are the chances the doctor will not pull out the stethoscope and listen to her chest?

Answer: It depends on whether the doctor is stupid.

Or a psychiatrist.

These are classic symptoms of heart disease. There is significant overlap between the symptoms of heart disease and the experience of grief. But there is no Bereavement Exclusion for a diagnosis of heart disease. Instead, family physicians and cardiologists take the time to examine whether the person presenting these symptoms may have both.

Grief/Depression III - Telling the Difference

Once, when I was seriously under and still headed down, a friend said to me, There have been times in my life when I was sad, so sad I couldn't imagine being any sadder. But it seems that what you and others with depression are describing is a whole different level that I know nothing about.

See, that's what would be helpful, instead of, I know just how you feel. I remember when [fill in the significant loss]... I knew that he knew times of deep sadness, because I knew some of those times, and because he is a person is thinks and feels deeply. And listens deeply. Everyone should have such a friend.

It was Social Hour. We were in a corner to protect me from all those people being social. I leaned against a wall, because I was very tired. I guess the wall gave me the idea. I said, Yes, there are times I have been so sad I couldn't imagine being sadder. It's like the sadness became a wall I could lean against, because I was so tired. But Depression IS different. Imagine if the wall gives way. Imagine there isn't a limit. You lean and the wall gives way.

Grief? Depression? Both?

The New York Times reports this week on a proposed change to the definition of depression for the Diagnostic and Statistical Manual (DSM) V. Asking, When does a broken heart become a diagnosis? it raises the specter that normal grief at the death of a loved one could be classified as a psychiatric disorder.

An estimated 8 to 10 million people lose a loved one every year, and something like a third to a half of them suffer depressive symptoms for up to month afterward, said Dr. Jerome Wakefield, author of The Loss of Sadness. This would pathologize them for behavior previously thought to be normal.

Okay, before we get our knickers in a twist -- oops, too late. Knickers in a twist is the current US national pastime. Nevertheless, there is a larger context here. Several, in fact.

DSM Context I - Follow The Money

The Stages of Change and Weight Loss

Continuing the thread from last week, the average person in the US dies sooner than the average person in forty-nine other nations of the world.  Our higher death rates are linked to our astounding rates of overweight and obesity.  People with severe mental illness die even earlier, 15-25 years earlier.  We have the same life span as the people of Sudan.  The same things kill us as kill everybody else, heart disease, stroke, diabetes, cancer.  They just kill us sooner, because even more of us are overweight and obese.

Side bar: I have growing difficulty using the term mental illness, because I think the term leads to an artificial bifurcation of mental and physical illness.  The weight issue is a case in point.  Most psychiatrists accept the biological model of mental illness, that our diseases are brain diseases.  Nevertheless, most consider the physical aspects as outside their purview.  As a consequence, the part of our disease that is going to kill us does not get treatment.

Weight issues are a case in point.  Psychiatrists hand us prescriptions for medications that cause ballooning weight gain and off the chart cholesterol levels along with the pro forma reminder that we won't gain weight if we don't eat more than we expend in energy.  So all we have to do is eat less and exercise more.

This kind of help doesn't help anybody, regardless of mental status.  Here, as in any other aspect of our recovery, we are on our own.

Weight Loss Programs - Hah!

The temptation is to buy the promises of the commercials that flood the airwaves each New Year.  Here is the deal.  These promises are less verifiable than the ethically-compromised promises of your medications.  But what studies that have been done indicate a relapse rate of at least 50% weight regained within a year or two.

Bottom line, diets don't work.  You have to change your life.  And to change your life, you have to change your brain.

Luckily, you can change your brain.  You just have to understand how.  You have to take the time that it takes.  But you can change your brain.

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From Thursday, June 30, 2011 and edited a bit: 

Habit and the Stages of Change

I have been writing for several weeks now [June, 2010] about this mass of electrical activity inside our brains, dendrites and nerve endings, meeting at synapses, passing their spark from one neuron to the next, creating -- what?  A wink, a whisper, a sensation, the next big brainstorm.

Most of these connections could be called, in the widest sense, habits.  By habits, I mean that pathways get used over and over, form patterns, become familiar, channel us to certain outcomes.  Most bypass the frontal cortex, requiring no thought.  Like breathing, smelling, salivating at the cinnamon.
 

Most of the remainder are still automatic.  But with effort, they can be brought to consciousness where the frontal cortex could interfere, and a decision made.  Like blinking.  Or picking up the cookie somebody brought to the meeting.

What if you don't want to pick up the cookie?  Okay, you really do want to pick up the cookie.  What if you want to not pick up the cookie anyway? 

How Do You Change A Habit?

You're gonna take more than one step.

Last week, I put some numbers out there, the Wahls diet.  Nine cups a day of vegetables and fruits.  I broke it down for you: 3 cups leafy greens, 3 cups cruciferous veggies, 3 cups intensely colored.

This food plan helped Dr. Terry Wahls reverse her secondary progressive MS and get up out of her wheelchair.  It could help you reduce your symptoms of heart disease, lung disease, asthma, hypertension, depression, obesity, bipolar disorder, diabetes, Alzheimer's or Parkinson's.

If you have, or are tending toward any of these chronic diseases, you have already heard your doctor/mother/spouse tell you that you need to improve your diet.  Dr. Wahl's book, Minding My Mitochondria tells you just how much and why. 

Nine cups a day of vegetables and fruits:

3 cups leafy greens
3 cups cruciferous veggies
3 cups intensely colored

Stages Of Change 

So there is your canyon.  Here are the steps, more than one.  Several, in fact.  The steps are known as the Stages of Change.

The Stages of Change model appears all over the place lately.  This article from the journal American Family Physician uses the Stages to help physicians help their patients, something more effective than Just do it.  A Youtube search yields results for addiction recovery counselors, life coach trainers, weight loss clinics.

Different sites number the stages differently.  Some say Precontemplation is Stage 0.  Some give Relapse its own number.  Some add Transcendence, whatever that is -- said the priest who gets cynical when quasi-religious language gets used for the purposes of self-improvement.  Whatever we are supposed to transcend, evidently it is not our desire to improve ourselves. -- But I digress.

I like this site, which is the source of the graphic above, even if the author does use that word Transcendence that made me twitchy there for a minute before I got back on track.  It works through the stages from the perspective of the person who is making the change, not the person who wants somebody else to change. 

Crossing Canyons/Building Bridges In My Brain 

Dr. Wahls calls it a diet.  I don't diet.  Who wants to DIE-t?   Each chocolate chip cookie left on the plate represents a little death.  A diet is a temporary interruption.  When it ends, you go back to your life.  But there is nothing temporary about the nutritional needs of my mitochondria, without whom there would be no life.

I'm into changing my brain.  In that mass of electrical wiring, some potentially healthy pathways are blocked by the detritus of dead dendrites.  Other destructive pathways are carved into canyons of well-worn automatic responses. 

Changing my brain will take time.  It is taking decades.  It will take at least another blogpost. 

And The Word Became Flesh 

Question: What do the Stages of Change have to do with Prozac Monologues? 

Answer: Words.  The Stages of Change use language to shape the brain.

Language is one kind of pathway from neuron to neuron.  It connects electrical impulses from the autonomic systems, the olfactory nerve, the amygdala, through the hippocampus (memory and emotion) and the anterior cingulate cortex (pattern seeking) and into the frontal cortex (conscious thought).

Language is how all this electrical activity gets turned into meaning.  It is where the brain and the mind become one. 

The Stages of Change include a process of changing our patterned thinking about food.  And thinking is how we move from one stage to the next. 

Dr. Wahls writes about synergy, how exercise and diet work together to heal her myelin and reduce the symptoms of her MS.  I'm thinking the same process works for changing habits, particularly food habits.  Each new behavior reinforces the preceding thought that moved you to the new stage.  That repeated behavior patterns the thought that will move you to the next stage. 

Meanwhile, what you are eating while you are trying to make any change matters.  Your mitochondria need the right materials to build the dendrites that form the new pathways.  Like lunch for the road crew.

So don't try to skip stages.  And don't skip broccoli.

One of these days I will write my own food autobiography, my trip through these stages.

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Back to New Year's, 2012 

Pre-Contemplation 

The good news is, you have already moved past Stage One, Pre-Contemplation.  I presume you have moved past Stage One.  Pre-Contemplation is when you don't really think you have a problem. And why would you still be reading this post if it wasn't your problem?  So you have already made progress! 

Contemplation 

But don't try to jump that canyon.  Don't go from I have a problem to New Year's Resolution: no more cookies.  It is January 3rd, and that resolution is probably already in the toilet.  We are not talking about the New Year here.  We are talking about your life.

One step at a time.  Make a list.  Make it as long as you can.  Why do you want to change?  What difference would this change make in your life?  Go deep here.  Screw those little graphics with the magically shrinking ladies that show up in your Facebook sidebar.  What is at stake for you?  This is no longer a game.

Read that list every day.  That will help the re-patterning process.

That is enough for this week.  You have homework to do.  I have my life to get back to.

Happy New Year!  Happy Long Life!

No New Year's Resolutions - Change Your Life December 29, 2011 -- Overweight is a major health issue, the largest contributing factor to early death for people who have mental illness.

My Food Autobiography and the Stages of Change March 8, 2012 -- Pre-contemplation and contemplation.

Changing Food Habits -- Contemplation and Preparation March 15, 2012 -- Reviews The End of Overeating by David Kessler and introduces the brain science of the sugar/salt/fat trifecta.

Dopamine -- Can't Live Without It March 23, 2012 -- The brain science behind habit formation and an experiment to try.

Preparation/Action -- Reprogramming Your Brain for Healthy Eating April 26, 2012 -- How to change a habit.

Relapse/Maintenance -- Stages of Change May 24, 2012 -- Review and finishing up the series.

photo of salmon in Ketchikan Creek by Wknight94 and used under the terms of the GNU Free Documentation License 
photo of Women Working at a Bell Telephone Switchboard from the National Archives and Records Administration and in the public domain

photos of Hatherton Canal in Staffordshire by Roger Kidd, Coal Creek Falls by Walter Siegmund, Glen Canyon by Sascha BrückJeff Kubina used under the Creative Commons Attribution-Share Alike 3.0 Unported license.

Stages of Change graphic was created by Todd Atkins, who placed it in the public domain

Changing Attitudes - Building the Therapeutic Relationship

What if your chart had your picture on it?  What if, as your doctor picked up your file from the top of the pile, just before you walk in the room, there on the cover is a picture of you from when you were well?

Maybe several pictures, images of the life your illness or your meds took from you?  Images of the life you manage to live anyway?  What if your doctor could see, not only your diagnosis, but also -- you?

What if your doctor knew what you still can do?

Okay, the chart is digital where I go for care.  My photos could come up as a slide show!

I want my chart to include my degree from Reed College.  It would come up as soon as the doc hit escape from the slide show.  If your doctor still uses paper file folders, your degree or certificate or major award could be stapled to the inside left cover, right across from the case notes of last month's visit.

Maybe my degree from Yale would be more impressive.  It's a Master's, and it's in Latin.  But I want my doctor to know I went to school with Steve Jobs.  Just as he studied Shakespeare, because scientists study Shakespeare where I went to college, I studied science.  At Reed College even poets are required to learn how to evaluate a research design.  First you read the method.  If the method is flawed, the conclusion is still just somebody's fancy.  You needn't bother reading the rest.

So I know how to detect bullshit when the doctor is parroting back at me the bullshit he/she heard from the sales rep.  I want my doctor to remember that.  It will save us both a lot of time. 

You Want That Placebo Effect

Here is what is at stake in my photo fantasy:

One out of every nine people in the US took antidepressants in 2005-2008, one of every four women aged 40-59.  So how are they working for you?  80% of their success, if they are indeed successful, comes from the placebo effect, the healing power released in your body by your own belief that they will work.

Now you are more likely to believe if you have confidence in the doctor that prescribed them.  Given that you are taking antidepressants in hopes of alleviating some sort of suffering, and given that they cause their own sort of suffering, it is clearly in your interest to maximize the placebo effect, so that the benefits indeed outweigh the costs.

Recently I reported a study that discovered a particular wrinkle in this issue.  You get better results from the same med depending on who your doctor is.  In fact, some doctors get better results from placebos than other doctors get from the medication.  How about that!

It's all about the therapeutic alliance, the relationship between the doctor and the patient.  The relationship carries the weight of the healing. 

All I'm Asking is For A Little Respect

So my recent post, The Therapeutic Alliance - Or Not identifies one factor that I believe is critical to the therapeutic alliance, whether the doctor respects the patient.  We have greater trust in doctors who respect us, who think that we, our lives and our bodies are important, and who demonstrate that respect in specific ways.

I generally do not find that respect reflected in the writings of psychopharmacologists, doctors who treat psychological disease with pharmacology.  I hardly ever find it in anyone who writes about compliance, getting us to take our meds.  I do not find it in most writing about suicide.

Fortunately, my current psychiatrist does give me good examples of how to build trust by demonstrating respect.  So I don't have to invent this post all myself.

My doctor apologizes when common social convention calls for an apology.  My doctor listens to me and pays attention to how my illness and how my meds are affecting the life I want to live.  My doctor prescribes and changes her prescriptions based on the information I give her.  My doctor educates me about my condition, what different medications can do, and how well-founded the claims made for these medications actually are.  My doctor writes things down for me when I am having trouble remembering.  My doctor knows that I will make my own decision.  She asks, What do you want to do? 

Common Ground  Between Doctor And Patient

I suspect this next example is controversial.  My doctor establishes common ground.  We don't spend time talking about her personal life.  But she has photos of her children in her office and pictures they have drawn.

In the early history of analytical psychiatry, doctors were god-like figures who cured by force of their personalities.  Whether that ever was a good idea, the conditions under which this god-like distance was supposed to work no longer prevail, i.e., years of couch time to develop and explore the transferences and counter-transferences.

Nowadays, you could make, I have been making a case that The-Doctor-Knows-Best approach sets up the compliance power struggle that doctors are going to lose, they are going to lose, they might as well give it up, because they are going to lose.

But if my doctor and I have something in common, in this case motherhood, then the distance between us is reduced.  I can imagine that we share some values, an understanding.

Once my wife was in a restaurant that you could call acoustically alive, when she heard a toddler having a full metal jacket meltdown.  She turned, and every person in the room turned to look.  She recognized the toddler who was having the full metal jacket meltdown.  She had seen his photo in my doctor's office.  Sure enough, her eyes met my doctor's, who looked for all the world like the mother of a toddler who was having a full metal jacket meltdown in a restaurant that is particularly acoustically alive.

When I get a little crazy in the head, when my hippocampus takes me on one of those time travel trips and I confuse my current doctor with the one who doesn't do relationships, when I am scared and angry because the latest chemistry experiment is making me sick and I don't believe she will hear me, then the story about that toddler brings me back to reality.  When I see the picture of that child in her office, I remember she is not god-like.  We have some experiences in common.  We are on the same side.

The story even has the power to recall me to my own competence.  When my son used to have a full metal jacket meltdown in some public place (not often, but it happened), I discovered that if I turned him upside down and held him by his ankles, he would gain a different perspective on his world and whatever it was that had disturbed him so.  This different perspective seemed to make him thoughtful.  At least it made him quiet.

This is Car Salesmanship 101, by the way.  When you walk onto a successful car lot, within three minutes a salesperson will have established some sort of connection with you, a place where your lives or interests intersect.  Doctors are not salespersons, you say?  Then why are patients called consumers?

Caveat: Behaviors Are Not Enough

But behavior isn't enough.  Malcolm Gladwell's Blink: The Power of Thinking Without Thinking reveals how our adaptive unconscious helps us make judgments in an instant.  Sometimes this capacity is essential for survival.  Sometimes it makes mistakes.  Sometimes it can be brought into consciousness and trained.

Gladwell defines an instant as a unit of time measuring two seconds.  Those of us with extensive trauma histories, who are the most treatment-resistent, don't need two seconds.  We learned to jump, to duck, to cover on the briefest freeze of a smile or glaze in an eye, a nanosecond of body language.

That's called hypervigilance, and our care providers want to treat us out of it.  Hypervigilance does take a lot of energy, and can interfere with recovery.  But treatment can be dangerous, too.  And while it may be helpful to train our adaptive unconscious, it may not be in our best interest to lose this skill, even if it makes it easier for our caregivers to pull one over on us, such as, make us think that they respect us, nut cases that we are.

No, learning the behaviors of respect is a start, and the bottom line for competent care.  But the truth behind the behaviors lies naked before our hypervigilant eyes.  Better than learned respectful behavior is genuinely held respectful attitude.  Don't just behave as though you respect me.  Respect me!

Now really, patients have to cut our care givers some slack.  Remember, they see us at our worst.  They are not in the room when we are managing a meeting, delivering a speech, making a gingerbread house, organizing a party, taking care of the kids.  No, they see us sick, focused on our symptoms, angry about the last med and the doc who prescribed it, anxious about the next, ranting, delusional, scared...

These are not encounters that build respect.  We don't think much of ourselves when we display these behaviors.  Why would they?  Based on their extensive, though exceedingly narrow experience of people with mental illness, their adaptive unconscious is pretty hypervigilant around us, too.  Not always so unconscious.  Mental health workers experience five times the national average rate of violence on the job.  They write articles, develop protocols, and design buildings to protect themselves.  From us.

Hold on, Goodfellow -- save something for another post!

Changing Attitudes - Building Alliances

Experience forms attitudes; experience can change attitudes.

Another psychiatrist I know who demonstrates respect is on the board of the local NAMI chapter.  He partners with board members, including people who have mental illness, for common goals.  He spends normal time with people with mental illness.  Well, at least he occasionally has coffee with me.  We talked once about my symptoms in his office.  But we left the office and had coffee where normal people have coffee.  When I saw him once interacting with someone who was displaying delusions, I was struck by the respect he demonstrated.  I learned from him how to behave respectfully toward people who have delusions.

I began this post with an idea about putting in front of psychiatrists images of their patients that are positive, that reflect the larger reality of our lives, images of recovery and wholeness and worth.  It's all about how to help them learn to respect us.

Doctors and patients really do need to get on the same side.  The best doctors understand that to get there, they, too, need to move.  And first, from the inside.

photo of baptism by Malaura Jarvis

Team Prozac Monologues NAMI Walk photo by Judy

photo of gingerbread house by Margaret Doke

flair by facebook.com

book jacket by amazon.com

logo for Occupational Safety and Health Administration in public domain

college graduation photo by Jenny Krch

The Therapeutic Alliance - Or Not

My therapist asked, Does writing your blog help you overcome your trust issues with psychiatry?

Hah!  So she doesn't read my blog.

Not that I think she should.  Of all the many things about which I have strong opinions, whether care providers should google their patients is not one of them.  They can have that discussion among themselves.

Trust My Psychiatrist?

But her question started me thinking.  I trust my own psychiatrist.  How did that happen?  I tucked that question away for a future blog.

Then last September David Mintz wrote about Psychodynamic Psychopharmacology.  Psychodynamic psychopharmacology explicitly acknowledges and addresses the central role of meaning and interpersonal factors in pharmacological treatment.

One particular paragraph brought my therapist's question and my tucked away post back to mind:

The Prescriber and the Placebo Effect

An analysis of the data from a large, NIMH-funded, multicenter, placebo-controlled trial of the treatment of depression found a provocative treater x medication effect. While the most effective prescribers who provided active drug (antidepressant) had the best results, it was also true that the most effective one-third of prescribers had better outcomes with placebos than the least effective one-third of prescribers had with active drug. This suggests that how the doctor prescribes is actually more important than what the doctor prescribes!

Turned to the patient's perspective, if your meds don't work, maybe you don't need different meds.  Maybe you need a different doctor. 

That is not where David Mintz, MD went with this finding.  He cites research indicating that a strong therapeutic alliance is one of the most potent ingredients of treatment.  Well, an alliance has two partners.  But his article focused on just one side of the alliance, on patients, how our personal psychodynamics might interfere with treatment, (with a passing reference to countertransference in relation to overprescribing).  He pretty much ignored, as in, totally ignored the nature of the alliance.

Today I ask the question the way the patient would ask the question:

What helps me trust my doctor?

I didn't trust my first two psychiatrists.  I had very specific reasons.  When I told one of them that a particular behavior on her part had decreased my trust in her and damaged our relationship, she said, I don't do relationships.  I use pharmacology to treat psychological disease.

Well, I knew where I stood.

But I do trust my current psychiatrist.

I walked into her office predisposed not to trust.  Yes, I did.  I had so little expectation of being heard that I had laryngitis, literally.  Some of that distrust came from my own long-term issues, the psychodynamics of a trauma history.  I will own that.

Part of it came from my work on this blog, reading research articles, discovering the shoddy nature of some research design and unethical practices in publication, coming across the language that generated my OMGThat'sWhatTheySaid feature, disrespectful language, and reading case after case after case of unethical sales practices in the pharmaceutical industry, resulting in lawsuits and fines (not to mention neglectful prescribing practices and consequent harm to patients).

Part of it came from my experiences with those other two psychiatrists.

Mintz would put all this under the category negative transference.  Me, I would put some of it under the category of psychiatrists' behavior.

I can identify specific behaviors on the part of my current psychiatrist that helped me overcome this distrust.

Doctors Apologize?

The very first thing -- she apologized.  It was an institutional screw-up, not hers, that had me sitting in the waiting room for thirty minutes before our first appointment, not filling out paper work, not answering questions, just sitting, no explanation, silence.  But on behalf of the institution, she apologized.

Wow.  Like it mattered, the anxieties I went through during that half hour.  Like I had the right to be treated better.  Like I could expect that in this relationship, and there would be a relationship this time, I would be respected.

Ellen Frank wrote in Treating Bipolar Disorder, ...perhaps because many patients with bipolar disorder have had the great personal or familial success that often accompanies the energy and enthusiasms of bipolar disorder, a subset of patients with bipolar I disorder present with an entitled stance that is rarely seen in other outpatient populations [such as self-effacing unipolar] ... your IPSRT patients will sometimes expect that... you are never late for an appointment, that you never change or cancel...  sometimes there is nothing that can be done other than to apologize for this "affront."

That "affront," in quotes, confused me.  The notion that expectations about being on time come from a sense of entitlement confused me.  Oops -- that the doctor would be on time.  Me, when I am late or I cancel, I apologize, because I respect the doctor.  My new psychiatrist canceled once, is late occasionally.  Each time she apologizes.  I don't think she thinks I have a sense of entitlement.  I think she respects me.

Maybe Frank ought rather to be concerned about her self-effacing unipolar patients.  Maybe part of their depression is the habit of internalizing the disrespect of authority figures.

Respect As The Ground For A Therapeutic Relationship

Last October, John McManamy published a Mental Health Patients' Bill of Rights.  They included:

• The Right to a psychiatrist who listens
• The Right to a psychiatrist who values us as human beings
• The Right to a psychiatrist who values our uniqueness as human beings
• The Right to a psychiatrist who is committed to getting us well, not just stable.

I think "The Right to a psychiatrist who respects us" is the overarching category.  John's list includes actions and attitudes that proceed from respect.

If my doctor respects me, I can expect certain things to follow.  I can expect that the doctor has my interests at heart when handing me a prescription.  I can expect that the doctor will listen to, care about and remember my concerns, my values, my life outside the office, and the effect of treatment on that life.  I can expect that the doctor pays attention to the results of a particular treatment on me, specifically me.

These issues are important, because the treatments are powerful.  Whether or not they help, they sure can harm.  If my doctor respects me, I can believe that she will pay attention to the harm.

Then I can feel safe(r).  Then we can have a therapeutic alliance.

Next week -- more specific behaviors that demonstrate respect and build a therapeutic alliance.

flair from Facebook

Does Your Psychiatrist Respect You?

My biggest surprise since becoming a mental health blogger -- how little self-reflection psychiatrists do.

Healer, Know Thyself

Clinical education for clergy usually happens in a hospital.  For every patient contact hour, we would spend another hour writing verbatims (one third what the patient and the chaplain said, one third what the chaplain was thinking, one third what the chaplain was feeling), and then another hour discussing what we were thinking and feeling in group or individual supervision.

Continuing education for clergy includes more large doses of self-reflection.  I don't know how many times I have created my genogram, a family tree that includes the dynamics of relationships: alliances, roles, conflicts, secrets, patterns... for my first family counseling course, for a seminar on family systems in congregations, for doctoral work in congregational development, while training congregational leaders to show them how to do their own.  I once even made a genogram of a congregation and key diocesan figures when I took a situation to a consultant.

In this example, Sarah is extremely focused on her son, while Abraham and Isaac are distant; the brothers are in conflict.  The pattern repeats in the next generation.

Clergy groups do critical incident reports in support groups.  Similar reflection.  What is my part in this mess?  How do my needs and fears interact with somebody else's needs and fears?  How do I get out of the blame game?  How can I tap into my sources of strength (faith, friends, scripture, sacraments, grace, knowledge...) to get myself unstuck?

The point is to figure out how my issues interact with anybody else's.  If I can sort out my own stuff, I can be a healthier presence in my relationships with others, less bound by unhealthy patterns, more able to find creative solutions.

The two most helpful discoveries I have made from these exercises: sometimes my troubles at work have come from my repeating a script from my childhood, a conflict or alliance with a person who is no longer in the room; sometimes my troubles at work have come from inadvertently stumbling into a power struggle, when my first-born status runs into somebody else's position of power.

When I discover what is going on in me, and hence what is going on in the relationship, I can change my own behavior to defy the script.  I can do something unexpected that helps me and maybe even the other person break out of his/her script.  It works best if this unexpected behavior is funny.

Psychopharmacologists Don't Do Self-Reflection

It used to be that people training to be psychiatrists did psychoanalysis.  Then the mind was replaced by the medical model of mental illness, and this requirement went by the board.  Now it's all about the meds.

But we don't take the meds.  We don't.  The numbers differ for a variety of meds.  In one study, three months out from the original prescription for antidepressants, 72% of us have quit.

Psychiatrists call this noncompliance.   They write myriads of articles to explain the numbers, saying about us, they miss their highs or they lack insight.  These articles make no reference to what patients say about why we quit our meds, the meds make us sick and the meds don't work.  [That last link is to a rare exception.]

Systems theory would call these articles evidence of a power struggle.  Psychotherapy might recognize counter-transference, the feelings, in this case very negative feelings psychiatrists have toward patients who do not do what we are told or, even if we do comply, refuse to get better anyway.

Caveat

My therapist was surprised when I commented on how little self-reflection psychiatrists do.  Her field, psychotherapy is all over the counter-transference-type issues.  And there still are a few psychiatrists who follow the old model.  At the Gabbard Center, two of the three who interviewed me even had couches, not living room-type, but New Yorker-cartoon-psychiatrist-type couches.  I had never seen one before!

So I have to qualify my comment.  My reading has primarily been in the field of psychopharmacology, as in, the psychiatrist who told me, I don't do relationships.  I treat psychological illness with pharmacology.

It occurs to me that patients might be better off if this kind of psychiatrist skipped medical school and went to pharmacy school instead, with a specialty in psychopharmacology.  There they might learn about adverse effects and the consequences of adding one med on top of the other, to make it work better or to counteract its adverse effects, resulting in iatrogenic disease, the disease that is caused by the treatment itself.

You know, that overweight zombie you became, stuck on the sofa, unable to complete a sentence, until you die 10-25 years before your time on account of complications from liver disease, diabetes, and cardiovascular disease, on account of you actually took the meds that were prescribed..  Death by medical treatment.


The Power Struggle

The thing is, in this particular power struggle over medication, while psychiatrists think they have more education, more knowledge, more insight, more prestige, more standing, while they think they are the parent in this relationship and the patient is the child (yes, they do think this, they really do, they betray it in every printed word), all these things that make psychiatrists think they know best and should have more say matters not when it comes to whether that pill will go into the patient's mouth and down the patient's throat.  Short of physical restraints and a hypodermic needle (which every parent of a toddler in a grocery store has had occasion to covet), the patient is going to win this power struggle.

So why not recognize the power struggle for what it is, and give it up?  As long as you are bound to lose it, why not do something else instead?

I Trust My Psychiatrist

If, after all that, you still remember how I got onto this topic last week, and where I said I was going, then your cognitive functioning is not as bad as you thought.

I said when I feel respected by my psychiatrist, I am more willing to trust her with my body.  I promised I would name some behaviors that she exhibits that build the therapeutic alliance, notwithstanding the lack of respect that I find in vast numbers of articles by psychiatrists who write about why patients don't take our meds.

Collaboration

She asks me, What do you want to do?

When we have a med check, we exchange information.  She listens to my report about what I am doing with my meds, how they are helping and hurting my life, and what kind of life I hope to live.  Then I listen while she gives me information about how the things work, why I might be having certain problems, what might be possible.  I tell her my concerns, she tells me hers.

I know that she won't prescribe things that she thinks will be harmful, because she remembers how sensitive my body seems to be to these things, and prescribes accordingly.  She knows that I won't take things that I think will be harmful, because, well, nobody does, not for long.  She expects that I will do my own research and make my own decision, because she remembers that I know my stuff.

When I am not in good shape, she does not confuse a current cognitive deficit with lack of intelligence.  So she makes lists, writes down the major points.  I am still in charge.  She asks, What do you want to do?  I sometimes say, I don't know.  What do you recommend?  But she always asks, What do you want to do?

As it happens, I don't take antidepressants, antipsychotics or mood stabilizers anymore, because I never found one that worked and was tolerable.  But we worked together to reach that decision and to develop an alternative plan.

With my previous psychiatrists, I just stopped.  I made the follow-up appointment, then called the machine after hours to cancel, and stopped.  In a sense, that was childish, not to confront the doctor directly.  But honestly, when I did confront the doctor directly, I got treated like a child.

My current psychiatrist continues to participate in my decisions, and I continue to rely on her for help managing symptoms with rescue meds, because we are partners.

What About Lack Of Insight, Denial, and Stupidity?

So, I am on top of this.  I am motivated and informed.  I have lots of resources that support my recovery and carry me when I flag.  I have good insurance and get more than ten minutes for a med check.  I am not the typical patient in the typical setting.  I can imagine a psychiatrist reading this and saying, Collaboration just won't work in my setting.

So, does what you are doing work?

Follow up question: does blaming your patient work?

What About Frustration, Worry, Disappointment?

What if psychopharmacologists spent more time acknowledging that their work conditions are lousy, they are anxious for their patients, and they know they can't deliver on the promises of these miracle meds?  What if they wrote articles that addressed these issues, and how their frustration, worry and disappointment get taken out on their patients?

Maybe they could discover their patients share these frustrations, worries, and disappointments. with them.  Maybe they could figure out something new to do.

Respect

Examining ones own stuff takes work, and is not pretty.  Coming up with new behaviors that display respect and build a therapeutic alliance, experimenting, trying to change habits -- all of it is hard work.  And it might not make a difference anyway, if it's just behavior.  Even if it's respectful behavior.  If we can tell that the psychiatrist is faking it, is parroting a line.

Coming soon -- I will up the ante and write about:

Attitudes!

genogram of my own creation, please give attribution

flair from facebook.com

photo of mirror by Jurii and used under the Creative Commons Attribution 3.0 Unported license

clip art of tug of war by Microsoft Office

illustration of A Zombie, at twilight, in a field of cane sugar of Haïti by Jean-Noël Lafargue used under the Free Art License

sketch of hands shaking by Danieldnm and in the public domain

PTSD and the DSM: Science and Politics -- Again

Several weeks of what I call "swiss cheese brain" interrupted my series on PTSD.  Now with a couple posts in reserve and a two week cushion, I am trying again.  To get us back on the same page, here is a (tweaked) reprint of March 28, a history of the issue in the Diagnostic Statistical Manual and current context, to be followed by PTSD: The State of Treatment, and then PTSD: Hope for Prevention.

With the ongoing war in Iraq, Post Traumatic Stress Disorder -- PTSD is much in the news nowadays.  We can expect that to continue.

Nancy Andreasen, author of The Broken Brain, traces the social history of this mental illness in a 2004 American Journal of Psychiatry article.  The features of what we call PTSD have long been noted in the annuls of warfare.  More recently, in World War I it was called shell shock, and those who had it were shot for cowardice in the face of the enemy.  In World War II it was recognized as a mental illness and called battle fatigue.  Afflicted soldiers were removed from the front and given counseling designed to return them to battle within the week -- though there is one infamous story about General Troglodyte Patton who, while touring a hospital, cursed and slapped one such soldier for his "cowardice."

The DSM I, from the post-WWII era, recognized battle fatigue as Gross Stress Disorder.  It was removed from the DSM II in the early 1960s , when U.S. society was not regularly confronted with this cost of war.