Prozac Monologues

For When Your Therapist Goes on Vacation

2012-02-08T10:42:00.000-06:00

I have two therapists and they were both on vacation the week I got home from my mother's funeral and all those issues and all the family and all those issues. And still on vacation the week after that! My brother-in-law subbed - thank you, Darryl - with the following email. I offer it as a resource for when your therapist picks a lousy time to go on vacation.

For extra entertainment value (my entertainment, anyway), I have identified which one I hear Michael telling me with >>, and which ones I hear Liz telling me with **. One of them regularly irritates me. I'll let you guess which one. I have to keep both, because the double-teaming seems to help.

Wisdom Learned From the Seat of a Tractor

Your fences need to be horse-high, pig tight, and bull-strong.

Keep skunks and bankers at a distance.

**Life is simpler when you plow around the stump.

A bumble bee is considerably faster than a John Deere tractor.

Words that soak into your ears are whispered, not yelled.

Meanness don't just happen overnight.

>>Forgive your enemies; it messes with their heads.

Do not corner something that you know is meaner than you.

**It don't take a very big person to carry a grudge.

You cannot unsay a cruel word.

**Every path has a few puddles.

>>When you wallow with pigs, expect to get dirty.

The best sermons are lived, not preached.

**Most of the stuff people worry about ain't never gonna happen anyway.

Don't judge folks by their relatives.

>>Remember that silence is sometimes the best answer.

Live a good and honorable life. Then when you get older and think back, you'll enjoy it a second time.

**Don't interfere with something that ain't bothering you none.

>>Timing has a lot to do with the outcome of a rain dance.

>>If you find yourself in a hole, the first thing to do is stop digging.

Sometimes you get, and sometimes you get got.

**>>The biggest troublemaker you'll probably ever have to deal with watches you from the mirror every morning.

>>Always drink upstream from the herd.

>>Good judgment comes from experience, and a lotta that comes from bad judgment.

Lettin' the cat outta the bag is a whole lot easier than putting it back in.

If you get to thinking you're a person of some influence, try ordering somebody else's dog around.

Live simply, love generously, care deeply, speak kindly, and leave the rest to God.

Don't pick a fight with an old man.

If he is too old to fight, he'll just kill you.

And finally...

That's me, waiting for next week's appointment...

photos ripped from an email. I have no idea where they came from

Grief? Depression? Both?

2012-01-28T11:22:00.000-06:00

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 new publication deadline for the DSM V is December, 2012. You can expect the volume of criticism to rise. The New York Times health reporting department will not have to come up with an original idea for the next 11 months.

First is the push/pull over including more diagnoses and loosening criteria so that more people receive diagnosis, followed by a storm of criticism that has led to tightening criteria to exclude people from diagnosis.

The thing is, if you don't get diagnosed, you don't get treated.

How do we deal with the explosion of PTSD cases? DSM V decides, let's limit the definition of trauma to rape and violence with the expectation of death (as determined by an outside observer, not by the expectation of the person who experienced or witnessed it). How about so many autism diagnoses? Again, change the definition so you don't qualify if you can dress yourself. (I may write more about that one later...)

I had an epiphany the other day. We could save billions in health care costs in the US. Right now if you have a blood pressure reading of 140-159/90-99, you have hypertension. You should lose weight (hah!) or talk to your doctor about medication. If it's 160/100 or above, you are in deep doodoo and your doctor is liable for lawsuit unless you start taking Lipitor immediately. Lipitor has the second highest sales in the US, bringing in over $5,000,000,000 for Pfizer every year.

So change the scale! If we decide hypertension begins at 150/100 and you don't have to be concerned about the stigma of a diagnosis, carrying with it difficulty getting a job with your high health care costs until you get to 170/110, we get a massive overnight reduction in the hypertension levels of the US, and billions of savings in the cost of drugs.

Enter the requirement that health insurance cover diseases of the brain the same way it covers diseases of the heart, and we have big pressure for the shrinks to shrink the DSM.

DSM Context II - Can't We Just Drown This Puppy?

Meanwhile, science has overtaken the DSM. The DSM answers questions that scientists don't ask. It gives names to lists of symptoms, manifestations of disease. The DSM debate is all about how many symptoms to put in a silo to which we give this particular reimbursement code?

Scientists don't ask, how many? They ask why? And the thing about depression is, we don't know. Or rather, when this particular person is sitting in the doctor's office with one symptom from depression's Column A, four from Column B, we don't know why he/she has these symptoms.

There are lots of ideas. Lots. The truth is, for you it's one thing, for your neighbor, probably something else. For your neighbor's brother, probably the same as your neighbor.

For the widow who isn't getting over it, maybe it's normal grief, and she will get over it in time. On the other hand, maybe she's got what you've got, and has had it for months already, but the anxiety about her husband's medical bills disguised the symptoms.

This is why, if your antidepressant works for you, you are just plain lucky. It happens to treat the problem in your particular brain. Most of the time, it treats somebody else's problem.

But it's all called depression.

We actually have the tools to figure out depression, the tools that scientists use to study the brain, not the amateur chemistry set that you and your doctor are playing with. We just don't have the money for the research. Nor the political will to raise the money.

But if ever we do, and for schizophrenia, as well, then you won't be able to give away your DSM, whether version IV, IV-TR, or V, for the price of shipping at Amazon. Because your doctor will treat the cause of your problem, not this sad sorry list of symptoms that could be all sorts of things.

Mind/Brain Debate Context III

The 1968 version of the DSM (II) distinguished between depressions caused by something gone haywire in the brain and those caused by an external event. Like, is it a chemical imbalance (endogenous, from the inside), or did your boyfriend just break up with you (exogenous, from the outside)?

Dr. Wakefield, featured in the Times article, thinks we need to make this distinction, which is the thesis of his book. Sadness is a natural human emotion in response to all sorts of things, and we shouldn't try to medicate it away.

Well, that boat sailed without him some time ago. It turns out that your boyfriend breaking up with you changes the chemistry of your brain. What happens in the mind manifests physically; what happens in the brain manifests mentally. Doctors can't tell whether the breakup triggered a disease that lay dormant, or it tipped the capacity of your resilience, such that this time you can't get over it, or it's simply a coincidence. For that matter, maybe you got dumped because you were already sick and your boyfriend thought you were becoming a downer.

So they decided to focus on the evidence in front of them, asking What is going on now? How many symptoms indicating depression does this person have; for how long; and how severe? Whatever made this person unhappy, if it has gone on this long already, does he/she need help to get over it?

The Bereavement Exclusion is the only remnant of exogenous depression in the DSM. Well, there is adjustment disorder, which is a whole other mess for some other day. I am talking about depression. You can get cancer and lose your house because you chose your chemo over your mortgage. You can work your whole life for a company whose suits ran off with your pension plan and you have to go back to work at age 72. Your daughter can become Newt Gingrich's next personal assistant. You can get treatment for the depressions that follows any of these events, if you have the requisite five symptoms and two weeks. Dr. Wakefield doesn't think you should, but like I said, that boat has sailed. He is trying to hang onto the one exception, that somebody died.

Remember Bereavement? - Context IV

There is more: poor diagnostic skills, limited range of imagination in the area of treatment, what the people who proposed eliminating the bereavement exclusion have to say, what those little old ladies who never got treatment are like twelve years down the line, maybe even some personal reflections on the difference between depression and bereavement from one who has a lot of experience of the former and current experience of the latter...

One symptom of depression common to bereavement is fatigue. So I will quit for now and hope to get back to you soon...

flair from Facebook

photo of Chinese menu by Hoicelatina, used under the Creative Commons license

photo of pair of dice by Roland Scheichder, in public domain

book jacket from Amazon.com

In Memoriam - Mary Kirigin

2012-01-19T10:37:00.001-06:00

This is one of my favorite photos of my mother, standing next to my sister Mary. That smiling mouth agape, as if to say, Can you believe what I got to do now!

I am writing on Monday, in the few minutes before I head over to the Pato Loco for the memorial service, to be followed later by a funeral in Utah. Not sure about my publication schedule for the next few weeks, and taking personal privilege with the topic. It's your blog, my doc once said. So it is.

Mama was a survivor, in the real world, not reality TV world sense of the word. She was also a public person, and I learned from her how to set a public face, mostly a kind face. Privately it was more often harried, the face I see in the mirror, more every day.

The thing therapists think you are supposed to say to survivors is Wow! You are so strong! Me, I don't care for that line. Yes, evidently I can bench press 300 pounds, because it has indeed been piled upon me, and so far I am indeed still here. But. In the first place, weight lifters get to put it down. And. In the second place, that extra feather somebody added to the load four years ago was finally one feather too many. Strong, but not that strong.

But Mama would have liked that line, not that she ever would have gone to therapy. She was proud of her strength and taught her children to be strong. I have a fever, too, and I am going to work. So you are going to school.

She was a radio broadcaster and among her high moments, interviewed Rosa Parks on talk radio. She later owned a station in Tooele, Utah, and used it to do community organizing. If the hospital closes, there will never be another job that comes to Tooele... She built schools. She got Democrats elected to public office in the state of Utah. She was a force to be reckoned with, and utterly charming to boot.

Her final vocation was to feed the world. At age 72 or so she came out of her second retirement to buy a hotel and restaurant in Costa Rica, the Pato Loco. Christ has no hands on earth but mine. The mis-quote tells a lot about who she was and how she would do it.

Ceaselessly. And graciously. And ceaselessly.

The early years were hard. As I said, she was a survivor. The later years she found love, success, fulfillment, and then adventure. She traveled to Italy, Ireland, Poland, Croatia. She introduced her granddaughters to this wider world. She went to cooking schools, met and visited her hero Paul Prudhomme. She moved to Costa Rica. The last years took a turn again, toward loss, disability, pain. Even in pain she set her public face to attend Happy Hour twice a week, so she could welcome her guests.

She was ready, way past ready to go. The end was not unexpected. But it was sudden, nonetheless. My phone rang just as I put my bag into the overhead bin. Costa Rican officials sped my sister Karla through immigration and customs, My mama just had last rites this morning, I have to get out of here... But once outside, Karla heard the news as her friends met her with the taxi.

Now we will gather, not just three sisters (a fraction of the blood family), but also a standing room only crowd of the new family she created with sacraments of hospitality and food, people who came to the Pato Loco because they heard it was a good place for breakfast, and never left. They just up and moved here. A nationally known flamenco guitarist will play. An African-American business woman will sing Gospel music. A Nicaraguan housekeeper will speak from her heart.

Mary Kirigin, Mama Mary, as she was known in Costa Rica, Grandma, your mother was so much more than I knew. Mine is a fragmentary account, one facet.

But I will add one last story.

She had a Bible, with a quilted cover, zipper, handles, the kind of Bible old ladies own, who read it a lot and stuff it with bookmarks, photos, mementos. The zipper holds the whole thing together. Our sister Mary handed it to me, and asked me to interpret what was clearly a message.

There were things that Mama left undone. The dying have different priorities than their survivors. This is always so. But one thing she did do. The souvenirs and old parish budgets were removed, stuck in the inside cover. Three bookmarks remained.

The verses were not marked, just the pages. No notes left. But the tea leaves were there to be read. Isaiah 25, Romans 12, John 14.

There is a funeral mass to be said state-side next week. She marked the three readings, Old Testament, New Testament, Gospel.

I know her favorite. She talked about it for years, ever since the funeral of the love of her life. So in the home she found for herself and she made for others, in the dining room at the Pato Loco, a place made sacred by other worship services but mostly by meals, by hospitality and welcome, these words will be read as the blessing at the end of the memorial service.

On this mountain the LORD of hosts will make for all peoples
a feast of rich food, a feast of well-aged wines,
of rich food filled with marrow, of well-aged wines strained clear.

And he will destroy on this mountain
the shroud that is cast over all peoples,
the sheet that is spread over all nations;
he will swallow up death forever.

Then the Lord GOD will wipe away the tears from all faces,
and the disgrace of his people he will take away from all the earth,
for the Lord has spoken.

It will be said on that day,
Lo, this is our God, we have waited for him, so that he might save us.
This is the LORD for whom we have waited;
let us be glad and rejoice in his salvation.

For the hand of the LORD will rest on this mountain.

And then the feasting will begin.

film shot by Merrill Nelson and used with gratitude and by permission

God, Tebow and the Problem of Suffering

2012-01-12T16:09:00.000-06:00

You know, they could be right. Maybe God is responsible for Tim Tebow's astounding success.

First, the one take away from this article: It's not magic-thinking. It is pattern-seeking, hard-wired into our brains, one of the things our brains are built to do.

I Am A Professional -- Do Not Try This At Home

A whole world of football fans are suddenly theologians, explaining the ways of God. And how silly for me to caution non-professionals from this endeavor. Everybody with a frontal cortex is a theologian. Our brains are built to ask Why? Everybody with an anterior cingulate cortex looks for patterns that make sense of the events of the world. That is what the anterior cingulate cortex does.

How is this for a pattern -- A new quarterback about whose talents many have doubts delivers a win. Somebody sticks a microphone in his face. He gives glory to God. Next week, he wins again. Again he gives glory to God. Again he wins. Again he gives glory to God...

And what is with that 316 yards thing?

If this were a baseball player on a streak, it would be the same socks he wears each game. It's the God-thing that makes people twitchy. More than that. If it were basketball, he'd be crossing himself at the free-throw line, and nobody would miss a beat. But it's the politics of the God-thing that have raised the stakes.

Suddenly people who should know better are doing bad theology. And people who do know better let their chains get jerked. I don't except myself here. Twice a day I write something snarky on Facebook, and have to delete before I post. (It's a thing I have about public discourse on Facebook. I try to save my snarkiness for my blog.)

At Prozac Monologues my readers can expect more than snarkiness. I have to bend the topic a bit. So here we go.

God Improves Athletic Performance

Really, I'm serious.

Well, in a particular way. Anybody else have a hometown team whose weekly police report is longer than its injury report? And the results -- Hawkeyes went where this year? The Earwax Bowl?

These days a little clean living gives an incredible advantage in the world of collegiate and professional sports.

Now this is not about Tim Tebow. I don't know anything about his private life. I do know a lot of athletes flame out on dissolute living, leaving behind only fumes of what had been promising careers.

I also know that some people find their way back.

The Twelve Steps

We admitted we were powerless over [our addiction] - that our lives had become unmanageable.

We came to believe that a Power greater than ourselves could restore us to sanity.

We made a decision to turn our will and our lives over to the care of God as we understood God.

There are more steps. These are a start, the part that matters to a mental health blog.

However and why ever they do it, and how seriously they need to work on it, a lot of athletes and a lot of the rest of us could improve our lives by acknowledging a Higher Power. It's a bottom line sanity issue. People who think they are the center of the universe have their own DSM code. It's 301.81. But they aren't in therapy. Those closest to them are.

No, you don't have to be a Christian, religious, not even spiritual but not religious to work the Steps. I heard somebody used gravity for his Higher Power. Like I said -- I am not the center of the universe is a bottom line sanity issue.

Tim Tebow's Higher Power

Again, I know nothing about the man's private life, and less than nothing about his heart. But to the extent that his publicly professed Christianity conforms to orthodox Christianity, and by that I mean not making it up as we go along, I do believe the claim that his athletic prowess comes from God, the Creator of Heaven and Earth who delights in creation and said of it, It is good. We have something in common here, Tim Tebow and me. We each believe that God delights in us. Well, I am willing to be a little less specific about the details.

If nothing else, think of this also as a comparative claim. If he thought it was all about him, he would be at greater risk to flame out, and thereby not be able to complete as many passes as he does manage to complete.

Of course, there has to be somebody to catch those passes. Writing now as a one-time Bronco fan, I wish I heard him say more about his receivers and his left guard. He might make a better spokesperson for the Lord if it didn't seem like his personal miracle.

Alert: Rocky Shoals Of God-Talk Ahead

So far, I have been in the realm of orthodox theology, not making it up as I go along.

Everybody is a theologian. The advantage of professional status is that you recognize the potential shipwreck before you get there.

Oops. Too late.

A status update from a Facebook friend Sunday night: This is what happens when God is in charge!

Pastor Wayne Hanson, Summit Church, Castle Rock Colorado said, It's not luck. Luck isn't winning 6 games in a row. It's favor, God's favor... God has blessed his hard work.

So... how about 19 games in a row? Was that luck? What happens if the Broncos make it through this weekend and next, and Tim Tebow comes up against Aaron Rodgers, who also happens to be a stand-up kinda guy? Not to mention one hell of a quarterback. Will that be about God's favor?

The Problem of Suffering

I think what really drives people nuts, including a lot of Christians of the orthodox/not making it up as we go along variety, is this:

While God was blessing Tim Tebow's hard work on Sunday afternoon, 720 children around the world died of hunger. 270 people committed suicide. Two of them, by the way, were veterans of the United States Armed Forces.

That was before overtime. Good thing overtime was short, huh?

So on Monday morning, nearly 1000 mothers were asking, If God could help Tim complete that pass, couldn't he have paid some attention to my child? Billions still listen for their answer.

This is not a question to be answered blithely. We have to put football, even America to the side.

See, we have been here before, trying to find the pattern. That is what our brains do, search for patterns, notice anomalies, then respond to new information.

There is one pattern we really, really want to find, that good is rewarded and evil is punished. For the LORD knows the way of the righteous, but the way of the wicked it doomed.

That's from Psalms. And to some extent, we do find evidence to confirm the claim. Usually people who treat their spouses right have happy marriages. Or at least happier than their marriages would be if they were out running around at night, coming home drunk and violent.

This pattern gives us a way to arrange our own behavior to get outcomes we desire, which is a good thing, and the evolutionary purpose of the development of this capacity.

This is from Psalms, too: I have been young and now I am old, but never have I seen the righteous forsaken, or their children begging for bread.

720 mothers whose children died of hunger while the Broncos pulled out that squeaker against the Steelers would beg to differ. All you have to do is turn the channel to CNN to find that pattern disrupted.

The Bible Knows Better

Well, if you actually read the whole Book, and read it several times, over different times in your life, so you have a wider experience that helps you catch things you missed the first time round, you discover that the Bible says some other things about the ways of the righteous and the ways of the wicked. Read Jeremiah. Read Job. Read the rest of the Book of Psalms. Go do relief work in Haiti or Sudan and read them again.

The Bible records how a whole community of faith over centuries has struggled with this issue. Sometimes the Psalm begins, O LORD, my God, my Savior, by day and night I cry to you. And at the end, it still says, Darkness is my only companion.

The Psalms of Lament speak the truth of people who do love the LORD, who are faithful. From Jeremiah thrown down a well to Paul shipwrecked on Malta to Mother Teresa struggling her whole life with severe depression a couple millennia later, faith does not turn out to be bankable. My God, my God, why have you forsaken me? Maybe the Psalms can give voice to your own experience.

Creativity and the Absurd

The ancient Israelites were sure of the pattern, that they held God's favor. They lived in the Promised Land, after all. Then something else happened, off pattern. A new super power came on the scene, destroyed their temple and threw them into exile. By the waters of Babylon we sat down and wept, when we remembered you, O Zion... How can we sing the Lord's song upon an alien soil?

When faced with the unpredicted, the absurd, the anterior cingulate cortex shifts into high gear. Its job is to modulate emotional response, to manage the panic. It does so by reasserting sense.

Sense can be found in two ways.

The first is to revert to the familiar. When the brain is overwhelmed by stress, it becomes more efficient. It shuts down brain-derived neurotrophic factor, stops learning and concentrates on what it already knows, or what it is habituated to trust. It was the forces of evil (gays, the First Amendment...) We are being tested, we have to believe harder... People confronted by the absurd sometimes cling to habit, reject the unfamiliar (immigrants, head scarves). After 9/11 there was a spike in sales of mashed potatoes and mac and cheese. That is the anterior cingulate cortex at work, modulating emotional response.

The second way is to ramp up the pattern seeking by noticing connections that had been overlooked.

The second way is the way of creativity. For the Israelites, the Babylonian Exile resulted in an explosion of creativity, poetry, philosophy, history, new forms of worship, the legal code, and the development of a religion that was larger than their prior notions of land=success=God's favor. They came up with a religion that could handle exile, handle loss. It could travel and face the future.

Their brains found new patterns. They recognized a kinship and developed compassion, even obligation toward others who were immigrants or poor or who had lost.

America At A Spiritual Crossroads

I was approached once to be a supply preacher at a Unitarian Universalist Church during an interim. I realized I had no idea how to do that, how to preach, if not the Gospel. So perhaps it is inevitable that I fail my nonChristian readers at this point.

But I will do my best.

The 20th century witnessed horrors when people responded to their suffering by pulling away, by blaming others and cutting off connections, dividing nations into smaller and smaller subgroups to despise. The brain that does that eventually goes senile.

A lot of us have lost a lot since the start of the 21st century. And the rules have been rewritten, so we can expect more of the same. This would be a good time to seek deeper than the theological optimism that cheered us when there was still a frontier and we could always walk away from our failures. This is not the time to place our hopes for spiritual vindication on the thin reed of an untried and immature quarterback and Christian. Give the kid a break. And, by the way, give the people who are rooting for him a break, as well. They are having a hard time, too.

The good news is that there are other patterns to be found.

The brain that remains open to new experiences, that searches for common ground, grows, creates, delights, has fun! Ditto the nation. Ditto the world.

Imagine that. We are hard-wired for compassion. And for fun.

Go Cheeseheads!

photo of Tin Tebow from tempecarnivore.blogspot.com/2011/12/hate-time-tebow-here-are-10-sports.html

Hawkeye and AA logos in public domain

Creation of Adam by Michelangelo, 1510 in public domain
The Shipwreck by Claude Joseph Vernet, 1772, in public domain
photo of Haiti earthquake victim by Lohan Abassi, used under the Creative Commons Attribution License
photo of UA 175 striking World Trade Center in public domain

The Stages of Change and Weight Loss

2012-01-03T13:40:00.000-06:00

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.

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.

+++++++++++++++++++++

Back to New Year's, 2011

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!

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 Brück Jeff 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

No New Year's Resolutions - Change Your Life

2011-12-29T18:18:00.001-06:00

Weight Loss For Sale

It's all done with computers. Automatically, 12:01 AM !2/25/2011, the Target ads disappear from television screens and Facebook sidebars, the Jennie Craig ads go up. Next morning, the Lifestyle section of the newspaper switches from appetizer and eggnog recipes to yogurt and exercise programs. After months of selling excess, now it is time to sell restraint.

How did it work for you last year? It worked really well for the media. How did it work for you?

You can't buy change. And sure as one set of ads replaces another at 12:01 AM, you cannot lose weight by buying a weight loss program. You yourself, not just your body but even your brain has to change.

Meanwhile, Excess Weight is Killing Us In The US

How many times have you heard that the US has the best health care in the world? I won't dwell on that nonsense. But clearly we do not have the best health. Out of 221 nations, the US ranks #50 in life span. That puts us at the 77%, a low C at St. John's Parochial School where I went, maybe a B in public school, grading on the curve. So to speak. Meanwhile, compare Jordan at #29, South Korea at #41 and Bosnia/Herzegovina at #45.

Those numbers come from the CIA's World Factbook, where they say Life expectancy at birth is also a measure of overall quality of life in a country and summarizes the mortality at all ages. It can also be thought of as indicating the potential return on investment in human capital. In other words, a low C, B if grading on the curve, is the quality of life you get healthwise if you were born in the US, the country with the best health care in the world. Who came up with that claim, anyway?

In a different but related index, the World Health Organization charts BMI, Body/Mass Index, a measure of weight in relation to height. The US ranks #54 out of the 60 nations for which it has data, for percentage of people with normal weight, neither too heavy nor too thin. That puts us at the 10th percentile, an F-, whether grading on the curve or no curve. Only 36% of US citizens have a healthy weight.

And the cost? Cardiovascular disorders (high cholesterol, high blood pressure, heart attacks, stroke), metabolic disorders (diabetes) cancer (breast, cervical, uterine, prostate, colon, kidney...), arthritis, sleep apnea... That is the short list of health complications and loss of life associated with excess weight. I will let you come up with your own list for what you have less of on account of what you have more of...

Excess Weight Is Slaughtering Those With Mental Illness

Meanwhile, back in Prozac Monologues Land, people with severe mental illness beat out the rest of the population in the race to break the scale. Clinical studies have reported rates of obesity in patients with schizophrenia or bipolar disorder of up to 60%. That compares to 34% in the US population, a number that already staggers the imagination as it is.

The reasons for the difference are many:

The most common medications for these disorders, lithium and antipsychotics, especially the new ones are notorious for weight gain. It is surmised that the weight gain comes from disrupting both metabolism and the neurotransmitters that regulate appetite.

But medication-naive patients also have a higher risk for overweight and obesity. The negative symptoms of schizophrenia and the depression-part of bipolar (lack of interest, inability to feel pleasure) lead to more sedentary lifestyles and more weight gain.

From the Damned-If-You-Do-And-Damned-If-You-Don't Department, the medications for schizophrenia and bipolar mostly reduce the positive symptoms (delusions in the case of schizophrenia, high energy in bipolar - the symptoms that scare your families and your care providers who write the prescriptions). They tend to increase the negative symptoms (thereby relieving the anxieties of your families and your care providers who write the prescriptions), providing that synergistic effect that nails you to the sofa.

There may be pre-existing genetic connections between what is considered two different conditions, overweight and mental illness. The DSM defines mental illnesses on the basis of certain symptoms. It does not describe what is actually going on inside the body to produce the symptoms. Metabolism, energy levels and regulation of appetite are all controlled by parts of the brain, often with genetic predispositions. While these are included in the symptom lists for mental illness, they are not the defining symptoms targeted by treatment.

Add it all up, what do you get?

People with severe mental illness die 15-25 years before the US national average. Rwanda beats us. We have the life span of people born in Sudan.

What do we die of? No, suicide is not a significant factor in this equation. We die of cardiovascular disorders, metabolic disorders and cancer. Just like everybody else who weighs what we weigh.

What Are Our Doctors Doing To Save Our Lives?

Our doctors are doing their best to prevent symptoms of our mental disorders, the scary symptoms, hallucinations, delusions, too much energy combined with poor judgment that get us into trouble with the law.

They are not doing anything about what is going to kill us.

Well, okay, they are psychiatrists; they treat psychiatric disorders. They are not general practitioners nor weight-loss specialists.

So here are two more reasons embedded in the US health care system that contribute to our lethal obesity.

Notwithstanding that excess weight is a symptom of our disease and also a side effect of treatment, our psychiatrists consider our weight issues to be none of their business. Never mind how significant this unaddressed health issue is when it comes to whether we are even willing to take the meds they prescribe.

People who have mental illness are less likely to have health insurance. We are less likely ever to see any doctor other than the one at the community mental health center who is treating our mental illness. Not to mention access to weight loss programs. Not to mention money for fresh foods or exercise programs.

The upshot: what are our doctors doing to save our lives? Precious little.

Okay, having said that, some doctors are doing more. My doctor listened when I told her my family medical history, that everybody in my family dies of heart disease, that my younger brothers had heart attacks at age 55 and age 29. When I said I would not take Seroquel unless I was psychotic, she paid attention. She tried to find meds that are weight neutral that I could tolerate.

But from the things I have written lately about my current psychiatrist, my readers who have real life experience with psychiatrists know that she represents a minority in the profession.

We Have To Lose Weight Anyway

What most patients get from most doctors is 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.

There. Their responsibility has been discharged.

Here, as in almost every area of our recovery, we are on our own. Recovery is up to us.

We have to lose weight anyway. We have to. It's our hearts, our blood vessels, our pancreases, our knees and hips, our brains, our lives, 15-25 years worth of our lives that are at stake.

We will be swimming upstream, up against the forces of whatever is going on in our genes, our dopamine channels, our pineal glands, our medications, our lack of health care, our poverty. So? Salmon swim upstream all the time.

Salmon are programmed to swim upstream. We have to program ourselves.

A New Year's resolution will not change the program. Did it last year?

So here comes a series on reprogramming our brains. It is a series, because we have to take it step at a time.

Word of encouragement: If you made it to the bottom of this post, you are probably already past the first step.

Who knows, maybe this series will carry us past the New Year's/Jennie Craig/NutraSystem et al season and up to the Super Bowl/Bud/Doritos season!

clipart and photo of school paper from Microsoft

photo "Angry Father" by Akapl616. Permission is granted to copy under the terms of the GNU Free Documentation License

photo of salmon in Ketchikan Creek by Wknight94 and used under the terms of the GNU Free Documentation License

Hey, Jesus - Happy Hanukkah!

2011-12-21T10:15:00.000-06:00

I must be one of ten people with mental illness in the United States of America who does NOT have holiday trauma issues. My personal desperate darkness starts each year in late July and breaks some time in late October, with mild depression fading out through November.

Thanksgiving to New Year's is pretty much my best time of year.

Nevertheless, this year I have been sad, not depressed really, just sad, as I read on Facebook the hostility that has come to be the litmus test of Christian fervor. Evidently inspired by Fox News, Merry Christmas is no longer an expression of joy and good cheer, but a battle cry against the First Amendment and the great American experiment of freedom and tolerance of difference.

Irony abounds here. One of my own ancestors came over on the Mayflower, as a matter of fact. The Puritans wanted freedom to practice their religion, not anybody else's, just their own, including a prohibition against Christmas, which they outlawed in 1659. They knew their religious history, that the holiday originated as a pagan festival, full of excess of every sort, with the thinnest wash of Christian appropriation added later to assure pagans they could still celebrate the Winter Solstice after they got baptized.

The Puritans had mellowed by 1712, when Cotton Mather, whose credentials are as Christian as you get, preached tolerance for other Christians who did want to celebrate the baby's birthday. I do not now dispute whether People do well to Observe such an Uninstituted Festival at all, or no, he said.

He went on to encourage a Romans 14 attitude: Good Men may love one another, and may treat one another with a most Candid Charity, while he that Regardeth a Day, Regardeth it unto the Lord, and he that Regardeth not the Day, also shows his Regard unto the Lord, in his not Regarding of it...

According to Cotton Mather, he believed in "political correctness", because he found it in the Bible, in Paul.

The Brain And Christmas, Or At Least Something, Anything

Christian, Jew, Zoroastrian, Wiccan, Druid, "spiritual but not religious," and plain old capitalists, as the days get shorter, our pineal glands go into overdrive, pumping out all that melatonin that makes us want to hibernate. Our brains cry out for relief. Push back the darkness! Light a candle! Light a bonfire! Wait a minute -- just a log. Nothing in the brain requires that anybody get burned at the stake.

Regular readers know that, while Prozac Monologues is not for the purposes of evangelism, I make no secret of my Christian faith, and even defend religion and the disciplines of church membership as resources for mental health.

But not any religion. Not what passes for Christianity but looks suspiciously like, well -- fascism. There, I have said the word. When the cross gets wrapped in the flag, no matter whose flag, you know that the frontal cortex is offline, the lizard brain is in charge, and somebody is about to get crucified.

Which is so not what Jesus would want for his birthday present.

I mean, the first guests invited by heaven to his party were the scruffiest low lifes of the neighborhood, who had probably been passing the bottle to keep warm that night, and some foreign fire-worshipers, for crying out loud!

Theology Alert

He came as a baby. He came vulnerable. He came helpless. In the core and mystery of what Christians call Incarnation, God-in-flesh, that very vulnerability is how God tells us how much God loves us, that the great Almighty would set almighty aside in order to pitch his tent among us.

That God desires to be with us, and will pay whatever price that requires, and would indeed require, is the core of the Gospel, all we need to know that we are beloved. We are worthy. Knowing that, then we can exercise the courage it takes to treat others as beloved and worthy.

We can even say, to show our rejoicing for the worth that God gives us and our rejoicing for the worth that God gives our neighbors, Happy Holidays!

These days are holy, they are graced by God's presence among us, whatever days you keep. That is what I believe. And I hope for you that these days are happy.

Research on Vulnerability

So here is where the deep truth about God-With-Us and mental health research come together: Brene Brown, research professor at the University of Houston Graduate College of Social Work on The Power of Vulnerability.

That baby who slept in the cold and all the babies who tonight sleep in the cold call us to look deep, deep into our hearts, the hearts of our neighbors, the heart of the world, the heart of God.

Happy holidays.

painting of Announcement to Shepherds by Gaddi Taddeo, c. 1327, in public domain

mezzotint portrait of Cotton Mather by Peter Pelham, 1700, in public domain

photo of Luminaria at Lake Washington from Seattle Municipal Archives, used under the Creative Commons license

painting of Madonna and Child with Cherries by Jan Gossaert, c. 1520, in public domain

Changing Attitudes - Building the Therapeutic Relationship

2011-12-17T14:55:00.000-06:00

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

2011-12-01T13:42:00.000-06:00

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?

2011-11-29T18:12:00.451-06:00

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

Holiday Shopping for True Happiness

2011-11-23T17:15:00.000-06:00

A friend of mine reports for work at Target on Thanksgiving, 11:30 PM. They are ready with extra security. Only thirty people can enter the store at a time. There are even line judges, to prevent jumping. Oh, the humanity!

Me, I will do my shopping right here in the very chair in which I am writing this post. Save your hippocampal glial cells damage from your overactive HPA axis! Save your toes! Internet!

Oh, and because this year's flu shot missed, this week's blog post is a rerun, dedicated to the topic of shopping for, of all things, meaning.

From Friday, December 17, 2010,

Holiday Shopping for Loonies and Normals Alike

Last year I got an earlier start with my efforts to help you purchase the perfect Chanukah/Kwanzaa/Christmas present. Here are the links, one for your favorite loonie, the other your favorite normal. The first is even diagnosis specific. The most popular pick turned out to be a bluetooth phone for the one who talks back to his/her voices, but is trying to pass.

This year, regular readers know that I have been living and breathing gingerbread. So this post, like my own shopping, comes late in the season -- Chanukah has passed us by.

Internet. God bless the internet.

And what with last week's post on happiness fresh in my mind, this year's holiday shopping picks combine the two issues -- where to get what makes for true happiness on the internet. No, really!

The Sources Of Happiness

Martin Seligman's Authentic Happiness identifies three major sources of happiness, pleasure, engagement and meaningfulness. So here are suggestions to enhance all three for your favorite loonie or normal.

Let's address one issue first. Life circumstances, beyond having the essentials, are not really that important an influence on the measure of ones happiness. But poverty does matter. If the one you love lives in poverty, go to Amazon.com's gift card section, where you can find gift cards for clothing stores, restaurants, general retail, entertainment and more. Give us bread, but give us roses are lyrics of a working women's song from the early 20th century. It's nice, when you are poor, to have the opportunity to choose which is the higher priority this week.

Pleasure

Well, yes. Feeling good makes you feel good.

On the other hand, have you seen that bumper sticker, The one who dies with the most toys wins? That bumper sticker is an example of irony. I hope it is an example of irony. I am sure the person who came up with it meant it ironically. It is possible that the person on whose Lexus SUV you saw the bumper sticker might have missed the point. That would be sad.

Irony means that the bumper sticker is not true. The one who dies with the most toys does not win. I just wanted to make that clear. Of the three top sources of happiness, pleasure, engagement and meaningfulness, pleasure ranks lowest on the list, happiness producing-wise. Our mindless pursuit of it notwithstanding.

Nevertheless, perhaps the heart's desire of the person for whom you are shopping is toys. There are all kinds of toys out there. Almost all of them, you can find, again, at Amazon.com. I thought they were a book store. No, from Automotive to Watches, with books, electronics, movies and even musical instruments between. If you know what that heart's desire is, you can probably find it there. If you don't know what that heart's desire is -- are you noticing a theme developing here? -- gift card.

Yes, I know. This reads like an infomercial for one particular corporate giant that is destroying local businesses across America. But give me a break. And give yourself a break. Your Chanukah presents are already late. Christmas and Kwanzaa are bearing down like a runaway train. I don't have time to look up a bunch of choices for you. I have my own shopping to do. Internet.

Who am I kidding? I can't go into stores anyway unless medicated. Maybe you can relate. At least I have the Rx!

Engagement

Engagement means being absorbed in the here and now, whether in family, romance, work or hobbies. That being absorbed is the key, because the wandering mind is an unhappy mind. Gifts that bring the family together, or send your recipient out on a date or relate to his/her interests can enhance that person's happiness. And you can find just the gift or gift card at... what has evidently become the Shameless Commerce Division of Prozac Monologues.

Meaningfulness

Okay, all the above is filler. Here is what I really want to sell this season. Making a difference. What makes for meaning is using one's personal strengths to serve some larger end (Seligman's definition.)

One kind of strength is passion. So let's start with a question. What is the passion of your gift recipient?

I knew an old lady once who absolutely would not deal with that word passion. It's a wonder she reproduced. Like Queen Victoria, she probably closed her eyes and thought about England. Or, being American (and Episcopalian), she probably thought about The Book Of Common Prayer.

So here is an alternative for Thelma, God rest her soul, and for you if you can't relate to the word passion. Determination. What is the determination of your gift recipient. What is he/she determined to support/challenge/change/make possible in the world?

Now let's go shopping for meaning.

Clean Water For Africa

Here is my passion/determination story. The Episcopal Diocese of Iowa has a companion relationship with the Diocese of Swaziland. Swaziland has had a drought for a decade or so. There are things that could be done. But the king has about a hundred wives, and he can't play favorites, can he? If one has a Mercedes Benz, then each have to have her own Mercedes Benz... So who can afford to dig wells?

But then this guy in Southeast Iowa developed this technology that turns table salt into chlorine. For $150, we could get this thing called a chlorinator that produces enough chlorine to give clean water to an entire village. [Here is an update from the original article about how the system works.]

Well, heck. I'll buy two!

We took a lot of them over. Now the Swazis are making them in country. One year a mission team came back from Swaziland with the story. An elder from one village had told them,

Since we got the chlorinator, not one child died last year.

Not one child died last year.

I have never spent any amount of money that has ever given me and will forever give me as much happiness as those six words.

Not one child died last year.

Give your mother or your father this story and clean water for a whole village in Africa right here. Now we are doing Haiti, too.

NEWS FLASH November 26, 2011 -- This just in from Earl Ratcliff, the inventor:

As you noted the cost of our CPU WAS $150. The Lord has been good to us. We've been able to reduce the cost to $50. Assembly time went from 1 1/2 hours to 10 minutes and from 20 pieces to 6. Plus overall quality has improved.

So that is how this year's holiday gift-giving guide is going to work, using one's personal strengths/passions/determinations to serve some larger end.

Shopping To Serve A Larger End

UNICEF

So look again, more deeply this time at those pleasures. Do you have a friend who loves camping? Insecticide treated mosquito nets are a bargain for $18.57, delivery included to places in Africa where one person dies of malaria every 30 seconds.

How about a friend who bakes? High energy biscuits will feed young children in disaster sites, 600 for a mere $24.98, again, delivery included.

You can find these and a whole assortment of Inspired Gifts for the health, water, nutrition, education and emergency needs of children around the world at unicef.org.

Heifer International

How about a gift that keeps on giving? Heifer International provides livestock and training to improve nutrition and generate income, lifting families out of poverty. Recipients share the offspring with others in the community, multiplying the impact of each gift.

So do you have a friend who wants a pet but is allergic? Three rabbits, $60. Aaahh, aren't they sweet?! We bought bunnies for China one year. Hunger has been wiped out in China. Heifer International has moved on to another country.

Do you know a cowboy wannabe? One heifer, $500.

How about a whole ark with two cows delivered to a Russian village, two sheep to Arizona, two camels to Tanzania, two oxen to Uganda, two water buffalo to Cambodia... There are fifteen pairs in all for $5000. For your friend who is delusional? (Noah/end of the world/delusional -- get it?)

We are just getting started. Knitters, a knitting basket (llama, alpaca, sheep, angora rabbit) -- $480. Gourmet, cheeses of the world (how cool is that! heifer, goat, sheep and water buffalo) -- $990. Homesick Iowan, pig -- $120. Let's not neglect our vegan friends, trees -- $60.

If you are shopping for me, I have long had my eye on that water buffalo, a mere $250.

All of these are available in shares, by the way, if that fits your budget better.

Seriously. Water buffalo.

Habitat For Humanity

Now let's return to where this series started and my life for that last two months, Habitat for Humanity, building affordable housing by using volunteers, including those who will own - and pay for - the houses. Whether your designated gift recipient is Martha Stewart or Frank Lloyd Wright, Habitat has its own gift catalog with everything from light switches to flooring. One year my sister-in-law gave me a kitchen sink.

One.org

If I haven't hit a bulls eye yet, one.org is the meaningfulness equivalent of amazon.com. This one may appeal to the rockers in the crowd. Cofounded by Bono, Bob Geldof, et al, one.org created a partnership of all sorts of groups working to eliminate world poverty by 2015 -- the Millenium Development Goals.

Here you will find more about one.org. Here you will find the partners (Bread for the World, Oxfam, Bill and Melinda Gates Foundation, various churches, etc.) Each one has its own focus, allowing you to find your perfect match.

And since this is my blog, after all, I will put a word in for Episcopal Relief and Development, ER-D. When earthquake or hurricane strikes, ER-D listens to local people to determine how best to help. Then they stay with it after the cameras move on. For example, ER-D is still working on economic redevelopment in New Orleans. And this is one church organization you can support that will NOT ask potential recipients where they go to church.

Joy That Lasts

So there you have it. Without leaving the comfort of home, without even having to change out of your jammies, you can find the perfect gift, one that will give joy beyond the end of the year.

Not one child died last year.

photo of Hindenburg in the public domain
clipart from Microsoft

cotton candy photo by Maggie D'Urbano,

used under the Creative Commons License (cropped)

child with unsafe water by Pierre Holtz - UNICEF, licensed under Creative Commons

child drinking well water by Scott Harrison licensed under Creative Commons
mosquito netting by Tjeerd wiersma, licensed under the Creative Commons Attribution 2.0 Generic license
photo of rabbits by Kessa Ligerro and made available under the GNU Free Documentation License
Entrada dos animais na arca de Noé by Giovanni Benedetto Castiglioni, public domain
photo of water buffalo by Da and made available under the GNU Free Documentation License
GNU -- somehow seems appropriate, doncha think?

Narrative and the DSM

2011-11-18T12:55:00.000-06:00

My therapist once picked up the DSM and said, This could be called The Book of Behaviors That Make Therapists Nervous.

An apt description. It is filled with descriptors: adjectives, behaviors, impulses, thoughts, feelings that are all human adjectives, behaviors, impulses, thoughts and feelings. Almost none of them are strange in and of themselves. Almost all of them are familiar to all of us.

It's just that at some point, when these descriptors add up, somebody starts to get nervous.

Diagnosis -- Recognizing Deviation From The Norm

Well, our brains are wired that way, to recognize patterns and deviations from what we expected, and to discern the potential consequences of the deviations. If the deviations are sufficiently nervous-making (and are not caused by organic disease), then we have what is called a mental illness.

That is diagnosis. That is how the Diagnostic and Statistical Manual, DSM works.

At that point, evidence-based medicine steps up to the plate. What are the medications and other interventions that have demonstrated the potential to reduce these descriptors to levels that are not so nervous making?

Inevitably, certain symptoms get more attention than others. Psychiatrists are not concerned when patients sleep too much, do an astounding amount of work in three days or die twenty-five years before our natural lifespan due to complications of obesity, as long as we don't have hallucinations or delusions or try to end our misery by self-harm.

It's all about the descriptors, and how nervous they make people.

DSM V - Passé Before Published

I think the real reason the DSM V is years behind its publication schedule is that it just doesn't make sense anymore. Two glaring flaws come to mind.

First, the people it purports to describe are dissatisfied with the treatments that it supports. Well, it's not that anybody actually consults us. They call us consumers. But the focus groups and satisfaction surveys are conspicuously absent. When we vote with our feet (become non-compliant), they simply diagnose that, as well.

Second, and more telling, Nature has not read the DSM. -- That is the epigram of the Wasn't-that-book-supposed-to-publish-last-year? season. In other words, there is not good correspondence between the sorting the DSM does by symptom and the sorting that researchers are more and more able to do by brain dysfunction. A disregulated HPA Axis can manifest the symptoms of Major Depression in one person and PTSD in another. The same gene configuration manifests as schizophrenia in one and OCD in another.

It's like, the DSM tells you what color the car is and how many cup holders it has. Big Pharma has made a lot of money tinkering with the placement of the cup holders. Meanwhile, what patients want to know and what scientists actually are working on nowadays is, what's under the hood? [John McManamy gets credit for the metaphor and his persistent question.]

What To Do With The DSM?

Meanwhile, there is another strand running through these journals and debates. Trauma-informed care is shifting the nature of the conversation.

The Substance Abuse and Mental Health Services Administration (SAMHSA), among others, sponsored a report on trauma informed behavioral health systems by Ann Jennings. The following summarizes the basic principles:

The new system will be characterized by safety from physical harm and re-traumatization; an understanding of clients and their symptoms in the context of their life experiences and history, cultures, and their society; open and genuine collaboration between provider and consumer at all phases of the service delivery; an emphasis on skill building and acquisition rather than symptom management; an understanding of symptoms as attempts to cope; a view of trauma as a defining and organizing experience that forms the core of an individual’s identity rather than a single discrete event; and by a focus on what has happened to the person rather than what is wrong with the person (Saakvitne, 2000; Harris & Fallot, 2001). Without such a shift in the culture of an organization or service system, even the most “evidence-based” treatment approaches may be compromised.

What Happened To This Person?

If any consensus about mental illness exists among scientists, it is that it results from interplay of genetics and experience. Genes provide the backdrop of strengths and vulnerabilities. The brain itself is plastic -- it wires itself in response to what happens to it. Sometimes the same gene provides both strengths and vulnerabilities -- See a recent post from John McManamy at Knowledge Is Necessity.

Meanwhile there is growing awareness that the vast majority of people with mental illness have experienced trauma of one sort or another (or many). Well, maybe the vast majority of all of us has. But those with mental illness have genetic predispositions to problems processing the trauma. Then the brain rewires itself in response to the trauma. And there you have the root of the problem.

The DSM does not address the root of the problem. It asks, What is wrong with this person? Yet even beneath its endless lists, there lurks another issue. You could call it the counter narrative. Or simply, the narrative. What happened to this person?

Narrative In DSM Categories

Let's imagine the DSM as a book of short stories, and ooh, ooh, give the stories some alternative titles.

Hotel Rwanda: The first, least fun and most obvious example-- a diagnosis of PTSD has behind it a traumatic event. The sufferer nearly died or watched somebody die or nearly die.

Ferris Bueller's Month Off: Moving on to mood disorders. You sold your house and went out to save the world -- the story behind Bipolar I. You stopped sleeping, ignored your grandmother you hadn't seen in seven years, never went to the beach, and instead wrote a book during your tropical vacation. But (very important for differential diagnosis) you didn't get arrested! -- Bipolar II.

Alexander and the Terrible, Horrible, No Good, Very Bad Day: So what about Major Depression? Here a story can even negate the diagnosis. Sure, you haven't eaten or slept in a couple weeks, you have lost all will to live, you can't make decisions and feel hopeless. On the other hand, your spouse was inside the house when the tornado blew it away. That's not MDD.

Here is my favorite. The aforementioned therapist said the chapter on personality disorders could be used for examination of conscience. (She can speak fluent Catholic and knows I can, too.) But I like the title Why Your Wife Divorced You, Your Boss Fired You, And Your Therapist Doesn't Much Like You Either. See, if your therapist says you believe you are "special" - quotes added by the therapist - require excessive admiration, have a sense of entitlement, lack empathy, and take advantage of people, then you know there is a story, probably several, behind that little list of "symptoms." Or in Catholic-speak, sins. (The stories about people with that particular list of symptoms usually are told in third person, by the ex-wife to her therapist.)

Any readers have other chapter titles to suggest?

Listen To The Story To Get The Diagnosis Right

Remember, I have two new diagnoses? When I originally complained of the symptoms of PTSD, my own psychiatrist asked me the cause. What do I know about cause? I told her the story that triggered the symptoms. And frankly, that story just didn't measure up to the diagnosis. So she called it Anxiety NOS (not otherwise specified.)

But the Gabbard Center asked me straight out about traumas in my life. I have a list. Boy, do I have a list. They heard the triggers in the context of the original events that wired the brain. So they say I have PTSD.

On the other hand, they were so determined to hear this trauma story nobody else had been hearing that they didn't have time for the rest of the story. They didn't hear the bit about the book, or the seasons I would spend building a dozen gingerbread houses in two weeks, each unique in materials and design, or the paint job I did on our rental house that I still say was not excessive, though my friends and family insist it was and were quite worried about my behavior... So the Gabbard Center says I have MDD, not Bipolar II after all.

Listen To The Story Because The Listening Itself Is Healing

Each time a long term memory is repeated, it moves temporarily into short term memory. From that position, new meaning gets added. It can be the meaning of being dismissed once again (retraumatized). Or it can be the meaning of an encounter with somebody who respects the teller, who recognizes the person, not the list of symptoms.

Psychotherapy works because the brain is plastic. When the long term memory moves into short term, has value (the experience of somebody listening to it) added, and returns to long term memory, its meaning is transformed. The wiring changes. Maybe a little, maybe a lot. It takes longer to work than a pill. But it lasts longer, too.

The Rest Of The Story

Prozac Monologues is all over the power of language. There is power in these labels given us by the DSM. The person who suffers is affirmed when the suffering is recognized. It's real; it's not just in my head. The family's anxiety is reduced once the pattern is recognized and named. They knew something was wrong. The therapist's anxiety is reduced, as well. S/he is empowered, knows what to do.

It's just not enough.

Peer to Peer devotes two of its ten weeks to the DSM. Often participants don't know why they were given the particular label they have. Often the opening of this magic book gives us power, too, to name ourselves.

And then we spend the other eight weeks deconstructing the labels. Because whatever our diagnoses, we discover that we travel similar paths. Not identical, but similar. The labels help us find each other. When we get to the specifics behind the labels, then we begin to help each other.

The DSM As Literature

What if we thought about diagnoses as genres in literature, rather than scientific categories? What if we used it to describe the arc of the story, to guide the way forward?

So the guy was walking down a street one night and fell into some dark hole you can find described on page xxx. He yelled for help. A psychiatrist walking by threw a scrip into the hole and said, Call me in three months to set up a med check. The guy yelled for help. The spiritual person said, Sending positive energy! :-) He yelled for help. The therapist said, Tell me about another time you found yourself in this hole. He yelled for help. And the next passerby jumped down into the hole with him. What did you do that for? Now we're both in the hole.

Yes, but I have been here before. I know the way out.

See, it's all about what happens next.

Photo of Bible be Walter J. Pilsak, permission to copy under the terms of the GNU Free Documentation License

Sketch of anterior cingulate cortex from NIMH and in the public domain

Photo "Angry Father" by Akapl616. Permission is granted to copy
under the terms of the GNU Free Documentation License

Queen from Disney's Snow White -- I think this is in the public domain

I Told Them I Was Sick - DSM Revisited

2011-11-10T16:00:00.000-06:00

Have you heard about the man whose tombstone read, "I told them I was sick"?

A New Diagnosis Or Two

So, the docs earned their big fee and the Pension Fund got its money's worth out of this three-day psychiatric evaluation. I have a couple new diagnoses.

That is really not so remarkable. If you attend a Peer to Peer course, NAMI's signature ten-week self-help program for loonies, you know this. One week, the participants go round the circle and tell their diagnoses, or rather, their history of diagnoses. Most trace a whole tour through the DSM, the Diagnostic and Statistical Manual.

Where Diagnoses Come From

The DSM originally was intended to give a common language, distinguishing one sort of loony from another, so that scientists could compare their research results and build up a common body of knowledge. Then came insurance codes...

We are sorted by symptoms and severity: delusions, irritability, instability in relationships, difficulty concentrating, intrusive and persistent thoughts... I am sampling here from different chapters. Each diagnosis has its own profile of a minimum number of symptoms from a particular list, with a certain level of life dysfunction resulting from the symptoms.

There is overlap in these lists. Irritability and insomnia, for example show up in a number of them. Some lists define their own diagnosis (like depression) and then become subsets of another (like bipolar). Then there are a few that include life events as criteria, like getting arrested or hit by a bus, as well as symptoms.

The system is a bit unwieldy. Researchers never rely on somebody else's diagnosis, and often write articles about how many people are diagnosed with depression who actually have bipolar, bipolar who actually have a personality disorder.

DSM Revision

So they keep trying to rework the DSM. The current rewrite is a couple years off its original publication date, as scientists debate the number of angels on the head of a pin, claiming they will get better results if they distinguish between people whose hypomanic symptoms last at least four days from those whose episodes last only three, while others plead the case of those who go untreated because they don't make the cut.

Doctors mostly just want to know which diagnosis the insurance company will pay for. They have to fudge sometimes when, whatever the label, the person in their office should not be let out on the street.

Therapists say it doesn't matter what the label is, as long as you get the right treatment.

Patients' Perspective On Diagnosis

Then there are patients, who do not have a voice in these debates. Well, we do have our blogs. We have discovered it does matter what the diagnosis is. The doc may say you have bipolar, because that is the only way s/he can get you a bed. But once tagged by the ER doc, the next doc prescribes those meds. And if they are the wrong meds... well, you end up in a Peer to Peer course years later, telling a tale of woe that everybody in the room already knows.

Then there is that pesky issue, even if the diagnosis is correct according to the strictest application of DSM criteria, the "right" treatment might be wrong anyway. Suddenly, once your mind has gone south, the doctors who originally prescribed the med, assuring you that they are scientists, unlike the commentators you read on message boards, turn around and remind you that medicine is an art.

Mental Illness Is Physical Illness

The whole thing is a peculiar way of going about it. Everybody has figured out that mental illnesses are physical illnesses, that there are biological differences inside the brains and in the processes of the brains of those who have a mental illness and those who do not. They have taken pictures, both brain structures (MRIs) and brain functioning (fMRIs). They have sampled neurotransmitter and hormone levels. They have found genetic variations.

None of this verifiable information has any place in the DSM. None of it is used in the exam, not even if the exam goes on for three days. They examine our heads, not our brains. They consider their prescriptions a success when symptoms (and only certain symptoms, at that) go away, not when the dysfunctions that caused them are repaired, and not when we actually get well.

What If Cardiology Worked Like Psychiatry?

Okay, so imagine you went to your doc complaining of tightness in your chest. Let's call this Tight Chest Syndrome. Big Pharma has spent years developing remedies for tight chest syndrome. Each company runs its research, comparing its remedy with the other companys' remedies and suppressing the publication of studies in which the other company came out looking better.

Great news! Your doctor has a whole cupboard of things to try for your tight chest. Ben Gay, antibiotics, beta-blockers, Valium -- just the beginning. If one doesn't work, keep trying!!!

GABA And Glutamate

So once upon a time I met the diagnostic criteria for Major Depressive Disorder, and was given Prozac, the starter drug from the doctor's cupboard. Prozac, like most of the antidepressants that 11 out of every 100 people in the United States are currently taking, is a stimulant. It perks up glutamate, the neurotransmitter that tells the brain cells to go.

The go message from Prozac and every other SSRI and SNRI I took said go to my anxiety and suicidal thoughts. Not a good idea. The fact that they made me so much worse was part of the evidence that maybe my glutamate didn't need perking up after all.

The results of that chemistry experiment is the most common path by which a diagnosis of MDD is changed to bipolar.

So then I started taking a med to increase my GABA, the neurotransmitter that tells the brain to slow. And that does help with the anxiety, though it has its own drawbacks, chief among them that it doesn't cut the depression and could become addictive, a new problem I don't need.

So which is it? Too much glutamate/not enough GABA, or the other way round?

Biological Markers

They spent a whole lot of money on research in heart disease, found biological markers, and use them to make a better diagnosis. Like, your doctor checks whether your cholesterol or blood pressure are out of whack, if things are firing as they are supposed to, if your arteries are blocked. They listen to your chest to find out if maybe your tight chest is from pneumonia. They ask if you just joined a gym and overdid the bench presses.

Then they prescribe meds on the basis of measurable results. As a consequence, the death rate from heart disease is dropping.

Over in psych, we are still guessing. These people in Houston question the bipolar diagnosis, went back to MDD. But at least they paid attention to what happens when I take the meds for MDD, so did not recommend I try the newest one out.

Wouldn't it be nice to take a test before taking a pill that could kill me?

HPA Axis, Other Neurotransmitters, Genetics

Well, there are lots of options here for the source of the problem. Many are interconnected. We have the research tools today to make the breakthroughs. We don't have the research dollars. We don't have the political will.

Patrick Kennedy is putting his name behind the Moonshot to the Mind, an effort to generate that will and to replicate the successes we have achieved in curing heart disease and cancer. We'll see.

The Power Of Story

Meanwhile, what do I do with my set of diagnoses, the work of one family practitioner, one psychologist and three psychiatrists, now superseded by another three psychiatrists?

I plan to tell a different story about mental illness, mine and yours. It is the power of story. This critique of the DSM continues next week through the lens of story.

Photo of Bible be Walter J. Pilsak, permission to copy under the terms of the GNU Free Documentation License

MRI of corpus callosum by Frank Gaillard and shared under the Creative Commons Attribution-Share Alike 3.0 Unported license
schemata of GABA/glutamate/dopamine transmission in public domain
flair by facebook.com

Support the Troops - Stop Shopping

2011-11-01T13:30:00.000-05:00

So I am back from getting my head examined, that three day intensive evaluation. I had my doubts about this enterprise. At my most anxious, my therapist reminded me I would get air miles. That would be something, at least. To my surprise, I also received some surprises. And the experience was worth a couple of blogposts. This one will be about PTSD, or make reference to it. Next week we will play with the DSM.

I start at the Hilton. Well, before that, my pension plan, which is how I ended up at the Hilton, not to mention how I ended up getting a three day psychiatric evaluation at the Gabbard Center, which does not usually happen for loonies in my tax bracket.

Decent Benefits For People With Mental Illness?

The Episcopal Church Pension Fund was established by one of the biggest robber barons of the 19th century, J.P. Morgan, doing penance for his sins. Like how Charles and David Koch aren't. Since then, clergy have put the equivalent of a whopping 15% of our salaries into the fund.

Unlike United Airlines or General Motors, this retirement fund is not run by people who have the option of stealing it by threatening to close up shop unless the pensioners just hand over their hard-earned savings to increase the compensation of the CEOs. The shop being the Episcopal Church. Plus for some reason, in defiance of the way managed mutual funds work in the real world, the Pension Fund beats its performance indexes year after year after decade after decade. Maybe this has something to do with karma. Maybe the angels. Choose your metaphysical system. Whichever, for me, this is good.

As a consequence, my disability pension comes from one of the last defined benefit plans in America. And it regularly has to come up with ways to spend its excess revenues, like by providing good benefits for its disabled beneficiaries, even those whose disability is of the loony variety.

And since the people who manage that much money are used to staying in places like the Houston Hilton, then that is where they put up their loony beneficiaries when we are getting our heads examined.

Which is how I came to spend four days there, two blocks north of the Galleria.

Galleria As A Tourist Attraction

Malls called Galleria don't have stores with names like Old Navy. They have stores with names like Giorgio Armani, Christian Dior, Chanel, Louis Vuitton, Saks, Baccarat, Tiffany's, Cartier, De Beers. A whole store called De Beers, for God's sake.

Galleria is where the restaurants are, where we went when we were tired of sitting next to tables at the Hilton where we had to overhear earnest mentors training earnest mentees for their presentations to their big clients. The oil companies were meeting at the Hilton. Down the street, Bechtel was meeting at the Westin. Bechtel is the construction company to the Saudi monarchy. So it may be the timing was not a coincidence.

We walked to the Galleria. The neighborhood isn't really designed for walking. Houston is more of an internal combustion engine kind of place. So as we picked our way through parking lots, we overheard a father and young son comparing their Beemer to the Beemer they parked next to. We dodged Maseratis and Mercedes while crossing streets. Well, you get the idea. There was a closer restaurant. But the doorman appeared to be wearing Kevlar under his vest. Well, you get the idea.

One of my docs, making small talk as we entered her office, asked if I was getting to look around Houston in the off hours when I wasn't getting my head examined. I said, No I am too tired. Except, we went to the Galleria. She responded, Well, THAT's something!

It was something alright.

Galleria As A Mental Health Hazard

One evening on our way toward sushi, a young man held out soap samples. I said, No thanks, I don't do scents. Then he grabbed my hand. Okay, he asked permission. I see your nails are clean. You don't paint your nails? No I don't. Let me show you something. So he explained about ridges and natural oils while he did his flirty little small talk and buffed one of my nails. Now don't scream when you see the results. Indeed, the nail was beautifully shined, and made the notion of painting nails seem cheap. I agreed it was beautiful and said I was not going to buy the buffer anyway. Why not?

Because I don't buy things.

That took some explaining, both to him and to myself, since I had never said those words before. He decided I had made a life style choice. Well, okay. That would be one way to look at it.

But it was more like a commitment than a choice, made then and there. I would no longer buy things.

Don't get me wrong. I am as fem as they come -- short of destroying my feet in those instruments of torture that women willingly put on their feet nowadays. Evidently, all that work we did in the 1970s to get women to love ourselves was a waste. In other cultures, women are forced to deform their feet. Having stopped in the 70s, now we do it again. In the US, we call that freedom.

Where was I? Oh yes -- I found those beaded dresses in the Gucci windows quite lovely. And I have some beaded things in the back of my closet from pre-loony days. Maybe not pre-loony, maybe just not-yet-identified hypomanic days, who knows.

But tripping past them, dodging the Lexus SUVs, all of that, I felt this growing sense of doom about the American way of life.

What The American Way Of Life Costs

I couldn't shake the images of three young men. One is a friend of my son's, who came home from Iraq with a TBI and PTSD. Another is a relative with a couple tours of duty in Afghanistan and a troubled marriage. The third is a young man I counseled, who signed up, hoping to come home a hero in a box.

Support the troops, people say. Support the ones who are protecting our freedom. Freedom to shop at Galleria.

There I was, surrounded by the way of life they were protecting at the cost of their brains and their families and their lives.

It is too high a cost.

It is too high a cost.

These thoughts, coming in the midst of getting my head examined, make me think we need to get America's head examined.

Money, Military and Mental Health

This isn't a political blog. I do advocacy about mental health issues. I am not here to plug political opinion.

This is not an opinion. This is a photograph.

This is another photograph.

And here is another.

And now we return to the shoes.

As I look at one picture, then another, as I listen to those young men, and then to the people in that restaurant next to me, I do have an opinion. Here it is.

These shoes cost too much.

They cost too much.

Actually, I don't think this is about mental health, after all. It is a sickness of the soul.

What Is The American Way Of Life?

I did meet some very nice people at the Houston Hilton. One man was from Ethiopia. He drove the shuttle, and we got to know each other in twenty-minute conversations each day on the way to the Gabbard Center. He came to this country because he wanted opportunity. And he found it. He drives a shuttle bus. His eldest is a policeman. His daughter is about to graduate from college, and his youngest about to enter. He doesn't need a Maserati to have the American way of life.

The other shuttle driver came to the US during the war in El Salvador. We talked about Archbishop Romero, and the strength we still get from his witness. If I remember right, somebody gave Archbishop Romero a pair of shoes for his consecration. People gave him lots of things, but his friend asked him what he wanted, and he said shoes. This former refugee, now shuttle driver, also found the American way of life. Emphasis on life. He doesn't need a Lexus.

Freedom And Addiction

People say our young men and women are sacrificing their minds and their bodies to protect our freedom.

We need to protect our freedom ourselves. We are not free. We are addicted. Addiction is a disease of the soul. And it is progressive. The more you feed it, the worse it gets.

Our freedom begins when we acknowledge our addiction for what it is.

Step One -- We admitted we were powerless over our addiction - that our lives had become unmanageable.

I don't want those shoes. But I do want that beaded dress. And having resisted it, having told that young man I don't buy things, the very next day I still almost bought an Eileen Fisher sweater at Nordstrom's across the street. Because it was on sale.

Just in time I remembered those three young men. That sweater cost too much.

My Bit For The War Effort

PTSD, Post-Traumatic-Stress-Disorder is bankrupting the defense budget. Researchers are trying to figure out how to prevent it. Does it take a neuro-scientist to figure out that you prevent Post Traumatic Stress Disorder by preventing the trauma?

I have decided to support the troops the way the troops do, by caring about what happens to their buddies and acting to prevent harm from coming to them. I will not wrap a flag around my shoulders nor post one on my facebook page for Veterans' Day. I will hold before me the faces of those three young men, and wrap myself in my love for them.

I will work the Steps, always remembering that I am just as addicted to things as any of you.

With God as my higher power, the next time I buy something, it will be a bicycle. So I can leave my Civic in the garage.

photo of J.P. Morgan by Edward N. Jackson and in the public domain

photo of Bacarrat Chrystal Sculpture used under the terms of the GNU Free Documentation License

photo of Maserati, Gran Turismo by Rudolf Stricker and usedunder the termsof the GNU Free Documentation License

photo of Louis Vuitton shoes used under the Creative Commons Attribution-ShareAlike 2.5 Generic license

photos of medical evacuation and coffins in public domain

Getting Shrunk

2011-10-16T21:23:00.000-05:00

I'm off this week to get my head examined, so am taking a break from using it. This would be your opportunity to examine the many features of Prozac Monologues. Here is a brief tour of the site and some tips for cyber-dinosaurs.

The basic breakdown: on the left are mental health and medication resources. To your right are helps to navigate around the site, plus some fun stuff.

Text that appears in tan is a link to somewhere else. The links on the left are to sites outside Prozac Monologues. Most on the right go somewhere on the blog itself. Notice in particular the feature called Labels. If you click on a word in that list, several past posts on the same subject will appear. The bigger the word, the more often I have written on it. The right side also includes videos that change occasionally and sometimes coordinate with the current post, and sometimes not. Ditto the Word of the Week.

The text in the middle is the new stuff I try to write once a week, weather and brain waves permitting. Again, the tan text links to something else. It could be a research article, an Amazon.com review, another blog, or an earlier Prozac Monologues post.

Below each post are some icons. Click on comments to read other peoples' comments or add one of your own. Click on the envelope to email the post to somebody else. Click on one of the letters to share the post with whatever social media you use. Click on the number to bring the post to the attention of the cyber world. I don't actually know how that feature works. Can somebody tell me? Then there are more labels, links to other posts that deal with similar matters. At least, I think they are similar matters.

That's enough to keep you busy while I spend the week filling out bubbles on instruments of torture devised by psychologists, and telling my tale of woe to psychiatrists who have heard worse, even if I can't imagine it, and who think they can come up with a new idea that my own doctor hasn't come up with, though I can't imagine that either.

Catch you later...

flair from facebook.com

Mental Health Day -- The Funner Version of Advocacy

2011-10-10T10:12:00.001-05:00

Last week it was Mental Illness Awareness Week, according to NAMI. So today it's World Mental Health Day, according to WHO. The World Health Organization, that's WHO.

That's a week for mental illness, a day for mental health. Whoever organizes these things must be reading my mood chart.

I cycle within cycles. In the larger circle, I have been able to maintain a stable state for a while now -- the state of jaded, that is. So I take up this week where I left off last week, continuing the repost of a series on the sorry state of mental health advocacy. This second post takes a glass-half-full approach.

Not exactly mental health, but at least the upside of mentally interesting. I mean, we got these diseases for life. We might as well learn to make them work for us.

Healthy, some of us struggle to pull that off for a whole day, even to support the WHO. But fabulous, we can do fabulous! -- As long as we match the weirdness with the job that is best done by that particular weirdness.

That is what you call vocation, matching ones weirdness with the job that is best done by it. My vocation used to be to help people find their weirdness, train it up right, bless it and set them loose to do it. And boy, did other people think what I did was weird.

Anyway, enough blather. From Saturday, March 19, 2011:

Mental Health Advocacy -- The Funner Version

Okay, last week was weird. That's what you get for reading a mental health blog written by an Episcopal priest. You never can tell when Jesus might interrupt with, No, what would I really do?

As it happens, that is where Gandhi got his program for freedom fighting, from Jesus.

First they ignore you.
Then they laugh at you.
Then they fight you.
Then you win.

There's a Lenten meditation for you. Overlay Gandhi's road map on the birth, ministry, death and resurrection of Jesus. Gandhi taught us to do what Jesus would do, what he really did do.

But not all of you are Christians. Not all of you follow The Way. Not all of you even follow my train of thought! What does death and resurrection have to do with mental health advocacy?

Well, never mind. The post stands on its own, as the tried and true program for addressing oppression, the institutional arrangements that support an unjust system.

This week's post turns to a different path, what we think of as stigma-busting. But I have come to suspect that the word stigma itself conveys the stigma it is trying to bust. It directs attention away from the stigmatizer and toward the stigmatizee.

No, what I am talking about is flat-out prejudice, the irrational thoughts and feelings of individuals. Focus on the person who has irrational thoughts and feelings. How can we help him/her get over these nonproductive and painful experiences?

This path parallels last week's -- we're all headed in the same direction. But this one you can travel while wearing designer shoes. In fact, designer shoes might just be the ticket!

Come Out, Come Out, Wherever You Are

First step, come out.

See, if all you know about African Americans are those cop shows, all you know about Islam is Osama Bin Laden, and all you know about people with mental illness is Jared Lee Loughner, then you are not going to want to live next door to a black person, let your daughter date a Muslim, or hire a person with a mental illness.

People want to stay away from people that they think are dangerous. This is because our brains are hard-wired to help us survive. This is a good thing.

The problem comes when people's estimation of danger is out of whack, when they think that a whole class of people is dangerous, and when those thoughts do not have a basis in reality.

People whose fears are out of proportion to real risk need our help. They need evidence if they are going to change what they know. You can cite statistics until you are blue in the face. But the most persuasive evidence is personal. They need a face.

What does Jared Lee Loughner have to do with your child's kindergarten teacher, the kindest, gentlest person you know? Or your Uncle Charlie, funny, generous, hard-working? Or your roommate from college, who really struggled freshman year, and still does on occasion, yet runs a successful business anyway? Jared is one lost soul who didn't receive the help his parents tried hard to find, and whose story could have been so different -- as demonstrated by the evidence of all these other people with mental illness whom you know.

NKM2.org

Remember these guys? They are Joey Pants Joey (Pants) Pantaliano's bid to make mental illness as cool and as sexy as erectile dysfunction.

That's right. Joey Pants (The Sopranos) has major depressive disorder. And he wants the rest of us loonies to come out of the closet, too. I described his No Kidding, Me Too campaign last October. He represents the funner version of mental health advocacy.

Joey has a bracelet with the birds on it, a cute little way to identify yourself. Go here to buy one. If these bracelets catch on, then when you see somebody wearing one, you say, No Kidding? Me, Too! When somebody else asks you what your bracelet means and you explain, their response, one chance out of five, will be No Kidding? Me, Too! Or, No Kidding? My Brother, My Boss, My Priest, My ... Too!

One brief exchange at a time, people learn that people with mental illness live and work and function and add quality to life all around them. We are no more dangerous than anybody else. That is not only a cold hard fact, it is also the experience of people who know people who have a mental illness. And a number of us are rather fabulous!

Got it? For those of you who are not ready to set a trash can on fire (last week's post on oppression), you can wear a bracelet. You can come out and be one of many people your neighbor knows who have a mental illness and sometimes exhibit symptoms and usually get the lawn mowed anyway.

NKM2 Needs Some Bipolar Help

It's a great idea, potentially cool and sexy. But somewhere the program got hijacked. Each of us has our abilities and our disabilities. And Joey needs an assist, assigning the right task to the right section of the DSM.

That is Prozac Monologues' task for the day, to get these birds back on track.

To start: Joey's medallions come in 144 combinations of colors and finishes and a twelve page catalog from which to choose even more medallions. My guess is he handed the bracelet job to somebody with Asperger's, who can see every potential option and wants to make each one available.

You always want to have somebody with Asperger's around to find the option outside your neurotypical box. That person might redesign your computer platform, or notice the pothole that will break your axle if you don't swerve now, or find the resource you never dreamed existed, or restate the problem so the solution is both easy and joyous. You always want to have an Aspie around.

My Aspie friend says, Give the Aspies the money. Tell us the rules, and we will make sure they are followed.

But this medallion thing falls into marketing. Go to the bipolar spectrum for marketing.

The Silver Ribbon Campaign

So maybe you have noticed there is a ribbon for every cause you can think of and many that you have never heard of. A cloud ribbon for Congenital diaphragmatic hernia?

Nobody is in charge of this ribbon thing. In our field we already have orange for ADHD and for self-injury, checked (they call it jigsaw) for autism, yellow for suicide, white for gay-teen suicide, green for mental health and for childhood depression, purple for dementia, silver for mental illness and for brain disorders. A marketing nightmare.

Marketing 101: Get yourself a message. Attach a brand to it. Stick to it.

So we need a ribbon. One ribbon. One color that umbrellas all the rest. Prozac Monologues here and now declares the color -- silver. Just because I said so, that's why.

No, not just because I said so. My eye is on the platform.

The Oscars. The Emmys. The Grammys.

We need a color that is Oscarlicious, that will stand out and look fabulous on tuxedos and those designer dresses. We need a color that designers will design around.

AIDS awareness soared when the red ribbon became the de rigour fashion accessory at the Oscars. The entertainment industry knew that AIDS was their issue, and they got on board.

Even more so, mental illness. If suddenly tomorrow, the entire planet went neuro-normal, comedy would die. Just die. Ditto any other writing, music and set design.

So, one color for the bracelets. One color that will take over the award shows and establish our brand.

Fire That Guy!

Next, the latest NKM2 PSA features solemn music against words on a screen about how few people with mental illness commit violent crime, alternating with video of police cars and ambulances at the sight of the shooting in a Tuscon shopping center. WTF?!?!! I don't know who is responsible for this marketing mess. But fire that guy! Or rather, channel his/her energies in a different direction.

In a nutshell: Confucius said A picture is worth a thousand words. Maybe it was Confucius. He usually gets the credit, sometimes Napoleon Bonaparte. Anyway, a moving picture with *flashing police lights* is worth a whole lot more words than a mere one thousand. It does not matter the teeniest, tiniest bit that the text says we are not violent. The picture shows something very different.

There is nothing cool and sexy about Jared Loughner. I don't want to live next door to him, either.

Recall NKM2 To Its Mission

Most of NKM2's videos feature depressed people ruminating about stigma. It's what depressed people do best, ruminate. Which is why they don't belong on camera unless they are acting. Let's get back to cool and sexy!

Mount Rushmore And Marilyn Monroe

So let's we put those loonie birds to work in a new PSA!

One bird says to the other, I have a mental illness. The other: No kidding -- me, too!!

Then Joey says to the camera, I have major depression. Abraham Lincoln answers from Mount Rushmore, No kidding -- me, too! (Monty Python can do that moving jaw bit.) Buzz Aldrin in his space suit chimes in, No kidding -- me, too! Next up, J.K. Rowling, Where do you think the dementors came from?

Back to Mount Rushmore. Teddy Roosevelt says, I have bipolar, to which a flying nun Patty Duke answers, No kidding -- me, too! Charlie Pride can sing it.

Green Bay Packer Lionel Aldridge steps up to the line and says, I have schizophrenia. Picture of John Nash and caption, receiving his Nobel Prize in Mathematics, with voice-over, No kidding -- me, too!

Jane Pauley, I have a mental illness. Then pile on the animations, illustrations, faces speaking to the camera, No kidding -- me, too! Harrison Ford, Beyoncé, Patrick Kennedy, Ann Hathaway, Amy Tan. Include an apple falling on Isaac Newton's head.

Joey's voice comes on again, on top of photo after photo of famous and not so famous people in daily life: In science, the arts, government, business, sports, people with mental illness make valuable contributions to your life every day. Your teachers, doctors, clergy, barristas, mechanics, neighbors, coworkers, one out of every five has a mental illness.

And the closer -- surely somewhere in Marilyn Monroe's body of work, sometime that breathless voice utters those now immortal words, No kidding -- me, too!

Are we getting closer to cool and sexy now?

Coming Out As Evidence-Based Stigma-Busting

But coming out is scary! Bad things will happen to me if people know I have a mental illness!

I can't argue with that. I don't know what will happen to you. There are ways to protect yourself. I expect that Prozac Monologues will address this topic in the future. This post is on how to help prejudiced people become less prejudiced. And the research supports me here. The more experience the general public has with people who have mental illness, the less prejudice.

Notice, I said experience. Not knowledge. Knowledge hasn't helped. Experience does.

Personal Experience Mitigates Prejudice

Here is a study that shows familiarity breeds respect. 208 community college students, of diverse backgrounds and ages, were asked about how familiar they were with people who have a mental illness, whether that exposure was from movies, documentaries, work with, work for, friend, family member, own life. They answered questionnaires on their estimation of how dangerous people with mental illness are, their fears of people with mental illness and their desire for social distance (whether willing or not to work with, live near, or associate with people with mental illness).

Sure enough, the closer the contact, the less expectation of danger, less fear, less desire for social distance. And note: when you are asked whether you work with or live next door to somebody with a mental illness, the real questions is whether you know that you work with or live next door to somebody with a mental illness.

Strategies For Reducing Prejudice

These findings are consistent with a large body of research over a long time about how people who are familiar with members of a stigmatized group have less prejudice toward that group. The following paragraphs are quoted from the report. You can find references for each point in the original.

Social psychologists have examined several variables that are relevant to ethnic prejudice and that could be adapted for research on contact with and stigma surrounding persons who have mental illness. One important variable that affects contact is opportunity: members of the majority must have opportunities to interact with members of minority groups if stigma is to be reduced. Thus persons who have serious mental illnesses must have formal opportunities to contact and interact with the general public.

Other factors that augment the effects of interpersonal contact include treatment and perception of the participants as equals by members of the public, cooperative interaction, institutional support for contact, frequent contact with individuals who mildly disconfirm the stereotypes of mental illness, a high level of intimacy, and real opportunities to interact with members of minority groups. Each of these factors suggests specific hypotheses on how contact between members of the general public and persons who have serious mental illness can be facilitated.

These citations are for ethnic prejudice. One's ethnicity is usually more observable than one's medical status. Gay and lesbian people have gotten the same results with the same strategies -- by bringing their membership in a stigmatized group to the awareness of their friends, family, coworkers, neighbors, fellow church members, golf buddies...

So Come Out, Come Out, Wherever You Are

All you have to do to reduce prejudice against people with mental illness is be one. Out loud. We need every one of you who possibly can to come out. We need family members and coworkers and neighbors and friends to talk about you, too. We need to start laughing at the stereotypes and at the people who hold them. We need to be out loud proud of our recovery.

Because there is a lot at stake here.

Silence = Death

flair from facebook.com
icon of Christ Pantokrator in public domain

photo of Mahatma Gandhi in public domain

photo of Dorothy's ruby red slippers by Alkivar, used under the GNU Free Documentation License.
photo of kindergarten teacher in public domain
photo of Oscar Su Sfondo Rosso by Idea go
photo of Harrison Ford as Indiana Jones by John Griffiths and used under the Creative Commons Attribution/Share-Alike License
photo of Mount Rushmore by Kimon Berlin and used under the Creative Commons Attribution/Share-Alike License
photo of Charlie Pride in public domain
portrait of Amy Tan by David Sifry and used under the Creative Commons Attribution/Share-Alike License
screen shot of Marilyn Monroe in public domain

Mental Illness Awareness Week - Because We Are Really Good at Delusional

2011-10-06T13:55:00.000-05:00

Imagine this -- Somebody from NAMI attends one of those campaign events and gets to the microphone. Intending to ask about the candidate's views on funding for community mental health, this poor parent begins with a statement:

People with severe mental illness die on average twenty-five years before everybody else. They have the expected lifespan of Somalia.

Nowadays the crowd will cheer. But that particular youtube wouldn't go viral.

I am jaded about this Mental Illness Awareness thing. It will not be subjected to any Best Practices evaluation. NAMI and the pharmaceutical industry have been making us more aware of mental illness for decades now. The numbers on prejudice have not budged. They have not budged.

That negativity -- does it mean I am currently displaying symptoms or that I have done my research? Both, actually.

I'll cop to the irony here. I myself was a speaker at one of those Mental Illness Awareness Week events once, held on a Sunday night in a not-much-traveled portion of a university campus.

It was very moving, the candles and all that. And it did raise awareness, in the sense that it made those of us who were there, people with mental illness and those who love us aware that we are not alone. But did it increase funding for research and treatment? Did it reduce prejudice? I don't think so.

Let me answer that another way. Did it increase funding for research and treatment? Did it reduce prejudice?

Nope.

So symptoms, research, irony and all, my contribution to Mental Illness Awareness Week is a repost of what I think we ought to be doing this week. And next. And next.

From Friday, March 11, 2011:

Ignore/Laugh/Fight/ -- Mental Health Advocacy That Wins

If they don't want to employ you, if they are afraid of you, if there are four times as many of you in jail as in the hospital, then it's not just stigma. It is prejudice and it is oppression.

The twentieth century offered a whole degree program in prejudice and oppression. Others have made progress against what beat them down. Though we are now stalled and falling behind, we can move forward when we adopt their methods.

The Map to Liberation

Mahatma Gandhi was not the first freedom fighter. But he is the great theoretician. He gave us the map.

First they ignore you.
Then they laugh at you.
Then they fight you.
Then you win.

Four simple steps. The good news -- we have already taken the first. Got that one down pat.

Liberation 101:

We are in charge of the map. The oppressor doesn't decide that oppression will end. It endures until the oppressed decide that it will end.

What we have to do is provoke the next step.

Then they laugh at you.

Well, that's where we are stuck, because we are unwilling to be laughed at. Last month's NAMI meeting was about Iowa's upcoming budget cuts. Somebody said, When we complain, they say we are crazy. I think she is a therapist. She has that therapist look, if you know what I mean.

Therapists say the funniest things. When we complain about how we are treated, they say we are crazy.

But we are crazy! We start off ahead of all the other liberation movements that had to get crazy to take it to Gandhi's next step.

Think Martin Luther King. Think Nelson Mandela. Freedom? People called them communists. Either that or just plain nuts.

Like these other movements, we have to find a spiritual taproot deep enough that we can endure being laughed at. Just like the tree, standing by the water...

The spiritual work will be impossible if we expect our care providers to lead. They get twitchy if we talk spirituality. I will address that work another time. Right now I will sketch out how we break beyond First they ignore you, and move to Then they laugh at you.

What that means more precisely is, we have to do things to make people think we are nuts. Like, DEMAND that we receive funding for research and treatment, DEMAND that we have the same access to health care as anybody else, DEMAND that we receive our health care in health care facilities, not in jails.

It's all about budget cuts right now. Corporate tax cuts -- that's a given. Corporations spent good money for our current crop of legislators, and they expect a return on investment.

So who will pay for these tax cuts, the people with mental retardation or the people with mental illness? The Iowa State legislature has a committee that has asked us to decide. Well, isn't that special.

We have to DEMAND that they change the rules of this game. We have to REFUSE to play Survivor. We have to refuse LOUDLY.

How? African Americans sat down. That is when they moved off Step One, when they REFUSED to be ignored any more.

So how about we lie down?

Lie In/Die In

Picture this. The next Loonie Lobby Day at the state legislature, we don't get all showered and neatly normaled up and go have sincere conversations with our legislators who are really sympathetic (their brother has depression, so they know what we are up against, but their hands are tied by that pesky deficit...)

Instead, we stand in the rotunda and read off the names of their constituents who have committed suicide. Each time a name is read, somebody falls down. They have to step over our bodies to get out of the building.

Mental Health "Parity"

The Mental Health Parity and Addiction Equity Act would be better called the Swiss Cheese Mental Health Act.

1) Only large employers are affected.

2) If they can demonstrate it causes them financial hardship, they can get an exemption.

3) Parity is a laugh anyhow, if reimbursement rates are so low you can't find a provider who accepts your insurance.

4) The provisions of even this piss poor legislation that address reimbursement rates are now the top of the list on Congress's chopping block.

So off we head to Washington. There are 13,000,000 million of us with serious mental illnesses in the US, including 5.7 million with bipolar, 2.4 million with schizophrenia and 7.7 million with PTSD. The numbers add up to more than 13,000,000, because some of us get to double dip. Piece of cake to pull together 34,000 to do a die-in around the steps of Congress, representing one year's worth of the deaths by suicide in the US. We will drape American flags over the bodies of the vets.

Yes, we are dying out here. Let them step over us.

How nuts are we to think we can turn around this systemic discrimination? In this political climate?

Progress Report

Remember, When we complain about how we are treated, they say we are crazy? By now some of my readers seriously want me to reconsider Seroquel. Others -- if you are still reading, your doc wants you to up your dose. This means we are making progress.

At some point, laughter becomes a cover for scared. Then it's time for the next step.

Then they fight you.

Remember, this is our map. We are the ones who push it forward. Nobody else will. And if I am scaring you, look at it this way. If we aren't scared already, we'd have to be crazy.

Until we change our advocacy, we will continue to lose psychiatrists. We currently have less than half the psychiatrists we need to provide a even a shoddy level of token med checks. In Iowa, we have one fourth. While demand is going up (think Iraq, think Afghanistan), supply is going down, as retiring psychiatrists are not replaced by new doctors. Why go that far in debt to get through med school and then choose a specialty with the lowest pay scale on the block?

Until we change our advocacy, we will continue to lose community mental health centers. Remember community mental health centers? The places we were supposed to go when they kicked us out of the hospital? They are disappearing already. Here are the Kansas numbers. You can find the same story for any state you google.

Until we change our advocacy, we will lose what parity was promised. Again, all employers have to do to avoid it is demonstrate that it costs them money to provide it.

Until we change our advocacy, we will lose even the programs that jails now provide. Why should criminals be coddled?

Desperate Times Call For Futile Gestures

What were we thinking? That public demonstrations would make a difference to cold hard facts? Were we nuts? (By the way, what have we been thinking, that talking would make a difference?)

After the strategies designed for Then they laugh at you prove futile, we up the ante. In place of our bodies, we substitute urns full of ashes and dump them on the floor of the assembly halls.

In 1987 AIDS activists entered the New York Stock Exchange. Seven people unobtrusively chained themselves and a banner to the rail overlooking the trading floor. At the opening bell they unfurled their banner and blew fog horns. They drowned out the opening bell, and prevented traders from trading, while they brought national attention to their demand that pharmaceutical companies stop profiteering at the cost of their lives.

Wall Street is our audience, too -- all the businesses that insure some of their employees but not us, all the health care companies that pay reasonable reimbursement to some doctors but not ours. How about we bring ambulance sirens?

A Day Without Mental Health Care

Next we head to Main Street.

The 2004 film A Day Without A Mexica n imagined what would happen if one day everybody in the US from Mexico, Guatemala, Honduras, Nicaragua, et al disappeared. Economic havoc, that's what. A few years later, the movie inspired a political demonstration. Workers stayed home for a day. In some places, restaurants simply closed for the day, unable to serve their customers.

So last week the Wall Street Journal reported a survey by Workplace Options. The survey discovered that 41% of workers polled had taken 4-9 days off work in the previous year to care for their own, their friends', their coworkers' or family members' mental health issue. Half work in offices with no benefits, support or services to deal with mental health issues.

They think they can't afford to provide services? They haven't a clue how much it already costs them not to.

There you have it, a National Day Without Mental Health Care. Everybody who has a mental illness or loves somebody who does -- stay home. I'm thinking Monday -- to make that moon connection, and maybe even disrupt Monday Night Football?

Going To Jail

At this point, we are littering, destroying property and generally disturbing the peace. We are going to jail.

Everybody on a three-month wait list for an intake interview,

Everybody on a two-year wait list for the judicial review of an SSDI application,

Everybody on a four-year wait list for sheltered housing,

Everybody who had been doing okay, but stopped taking meds when the day program closed,

Everybody who can't afford the copay for that third tier prescription anyway,

Everybody who doesn't have health insurance at all,

Everybody who is homeless,

Go downtown and set a trash can on fire.

We Need Some Coordination Here

No, not everybody. Jail is not a good place for people with OCD, PTSD, nor Borderline. You all, your part is to run right down to the courthouse, legal brief in hand, to make sure the police department fulfills its obligation to get the rest of us our meds.

Prejudice And Oppression -- Some Observations

This post has been about fighting oppression, the institutional arrangements that support an unjust system. Oppression is weighty. It is fierce. It does not respond to reason. Power yields only to power. The strategies and actions I have described are the power of anger that has been organized.

Our families and our care providers are just as scared as everybody else of our anger. So they will not help us here. They want to address prejudice, not oppression.

Prejudice is the irrational thoughts and feelings of individuals. Well, prejudice also needs to be addressed. There is work enough for everybody. Think of differential diagnoses as differential skill sets for the differential tasks of freedom-fighting.

That's coming next week...

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Manifesto: The Mad Farmer, Consumer, Blogger, Whatever

2011-09-29T15:38:00.000-05:00

As in the days of Amos, John of Patmos, John of the Cross, it's the poets who will save us, those of us who have ears to hear. For the rest, it's the poets who will preserve the evidence, in hope that there will yet be ears to hear.

So today, Wendell Berry's Manifesto: The Mad Farmer Liberation Front.

First, one liner note: Your mind will be punched in a card and shut away in a drawer. In the early days of computers, data was recorded by punching holes into cards, literally, card stock, roughly 3"x7". This was before web crawlers could find the word bread in a Facebook comment and then put up ads for kitchenware on your page. The line in the poem, first published in 1970, is truer than ever. The technology has simply got more efficient.

Manifesto: The Mad Farmer Liberation Front

Love the quick profit, the annual raise,
vacation with pay. Want more
of everything ready-made. Be afraid
to know your neighbors and to die.
And you will have a window in your head.
Not even your future will be a mystery
any more. Your mind will be punched in a card
and shut away in a little drawer.
When they want you to buy something
they will call you. When they want you
to die for profit they will let you know.

So, friends, every day do something
that won't compute. Love the Lord.
Love the world. Work for nothing.
Take all that you have and be poor.
Love somebody who does not deserve it.
Denounce the government and embrace
the flag. Hope to live in that free
republic for which it stands.
Give your approval to all you cannot
understand. Praise ignorance, for what man
has not encountered he has not destroyed.

Ask the questions that have no answers.
Invest in the millennium. Plant sequoias.
Say that your main crop is the forest
that you did not plant,
that you will not live to harvest.
Say that the leaves are harvested
when they have rotted into the mold.
Call that profit. Prophesy such returns.

Put your faith in the two inches of humus
that will build under the trees every thousand years.
Listen to carrion - put your ear
close, and hear the faint chattering
of the songs that are to come.
Expect the end of the world. Laugh.
Laughter is immeasurable. Be joyful
though you have considered all the facts.
So long as women do not go cheap
for power, please women more than men.
Ask yourself: Will this satisfy
a woman satisfied to bear a child?
Will this disturb the sleep of a woman near to giving birth?

Go with your love to the fields.
Lie down in the shade. Rest your head
in her lap. Swear allegiance
to what is nighest your thoughts.
As soon as the generals and the politicos
can predict the motions of your mind,
lose it. Leave it as a sign
to mark the false trail, the way
you didn't go. Be like the fox
who makes more tracks than necessary,
some in the wrong direction.
Practice resurrection.

from The Selected Poems of Wendell Berry

And your homework for this week, gentle reader --

What does it mean to Practice resurrection? What tuition will you pay?

Johannes der Evangelist in Patmos from a triptych by Hans Memling, 1479

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Differently Abled - More, Please

2011-09-23T16:28:00.000-05:00

It's like he is in a world of his own. The first grade teacher, old school, same worksheets for the last thirty years, did not mean it as a complement.

The mom was confused. She asked her son's Montessori preschool teachers for their take on it. They, too were confused. Then the light dawned. The way they put it was, He has immense powers of concentration. They thought he was marvelous.

The problem was, he was still absorbed by the story he was writing, when the first grade teacher had moved on from writing to math. The world he was in was not her world.

His second grade teacher recommended him for the Talented and Gifted program.

His fifth grade teacher thought he had ADHD.

People who are different get diagnosed. The Diagnostic and Statistical Manual (DSM) is all about describing the various ways we don't fit. But if you can pass for normal, you don't have a disability. If they can pick you out in that One of These Things is Not Like the Others game, then you do.

To bottom line it, normal means that a person can function successfully in the normal world.

So the young man I have described does not have autism, though the first grade teacher's comments were spun in the direction of cognitive difficulties. Nor does he have ADHD. Today he is writing his PhD dissertation on the ethics of Nietzsche at a university with a highly ranked philosophy department. He gets paid to do what he loves, teaching young people to think. And he has health insurance.

So there.

But I was reminded of him when I read Top Ten Terrific Traits of Autistic People by Lisa Jo Rudy. Rudy writes,

If you're sick of hearing about all the "deficits" challenging people on the autism spectrum, join the club. But for every down side to autism, there seems to be a positive -- an unusual trait that rarely appears among the "typical" community, but shines out among autistic folk. These pluses are well worth celebrating.

Here is a summary of her ten points. You can read her expansion at the link.

Autistic People Rarely Lie
People on the Autism Spectrum Live in the Moment
People with Autism Rarely Judge Others
Autistic People are Passionate
People with Autism Are Not Tied to Social Expectations
People with Autism Have Terrific Memories
Autistic People Are Less Materialistic
Autistic People Play Fewer Head Games
Autistic People Have Fewer Hidden Agendas
People with Autism Open New Doors for Neurotypicals

I have a friend with Asperger's, on the autism spectrum. And this is indeed a list of things that she has brought into my life.

Of course, some of these traits are immense disabilities. I watched her get ground up in an organziational meat grinder, because she couldn't manage the head games.

The thing is, an organization that runs on head games eventually becomes a Ponzi scheme, a house of cards built by selling a product, service or idea which has no solid foundation in objective fact or even metaphysical reality to people who sell to more people who sell to more people, until the people at the top bail out on their golden parachutes when the house collapses, and every other poor sucker with it.

Whether we are talking about financial institutions, government, churches, psychiatry, just about any institution you can name, the United States of America has a serious case of Ponzi scheme.

I won't bother to document that last statement. If you think any of the above are innocent of the charge, then howl away. But here are a couple links on psychiatry, more directly the topic of this blog. John McManamy's latest post at his blog, Knowledge is Necessity refers to John Gartner's, Has Psychiatry Been Corrupted Beyond Repair? It really does seem that psychiatrists actually believe what Big Pharma paid them to believe.

Ironically, Gartner writes for Psychology Today. Just last week I was ragging about another Psychology Today article on anti-psychotics. (You didn't miss the rag. It was a Facebook comment.) The article was accurate, but missing the basic and very simple information that would have made it a useful contribution to people attempting to weigh their risks and benefits, instead of what it was, a sensationalist headline grab that would discredit any patient who brought it into a doctor's office -- thereby contributing to the mass of flotsam and jetsam that passes for information in the information age, overwhelms our poor pitiful processing units, and making us vulnerable to the loudest, sexiest, next Ponzi scheme come down the pike.

What to do? Take a deep breath. Find a friend with Asperger's. Learn to accommodate the challenges of communicating with a person whose brain is wired differently from yours, so you can benefit from what that person can figure out which is beyond your poor pitiful processing unit.

Then get that passionate, bullshit-detecting, truth-telling (read: diagnosable) person into the leadership circle of any organization you care about that could use some authenticity at its core. Because without leaders who are passionate, bullshit-detecting and truth-telling, we are going under. We are going under.

Having done that, it would only be fair to stand with that person when the shit hits the fan, i.e., when your friend is rejected because you encouraged him/her to share the brilliance of his/her difference, thus outing him/herself as diagnosable.

Oh, well. Maybe next I'll get around to writing the column in which I serve up us bipolars as the season's sacrificial lambs. Or maybe not. People with bipolar are good enough at throwing ourselves into the flames as it is.

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Survival - Three Things Learned From Danny MacAskill

2011-09-16T16:44:00.000-05:00

1. To keep your audience, edit out most of the falls.

2. To help your audience, keep some of the falls.

3. Find the Iron Rule and do not break it. In MacAskill's case -- the front wheel is for steering; you want to land on the back wheel. In my case -- the frontal cortex is for steering; I will inevitably land on the amygdala.

A repeat from:

Thursday August 26, 2010

Tribute To Survival

This is dedicated to those who are surviving the Chemistry Experiment, and to those who hang in there with us.

Bring your courage and your hope, whatever you can manage.

And your helmet.

Thanks to Danny MacAskill and Band of Horses.

Suicide Is Not a Mystery

2011-09-08T08:19:00.000-05:00

This is Suicide Prevention Week

When I started Prozac Monologues, I didn't know there was a Suicide Prevention Week. I spent a month writing about suicide in June, 2009. I chose June because it is the month when the highest number of suicides take place. So I wonder why the officially designated week is in September. Maybe because when everybody else is so happy about the sunshine in June, they wouldn't give any thought to the darkness?

If you want to know my take on suicide prevention, here is the link for those original posts. Among the Labels in the right-side column, you will find links to other posts tagged suicide, suicide prevention, and the like.

Looking back at these posts, I wish I had less to say about suicide. But having this much to say, and frankly, a lot more, I think it's best I go ahead and say it. I urge you to take the same approach. If you have something to say about suicide, say it.

You know, all those years we never talked out loud about cancer, our silence never saved a single life.

Two years ago, John McManamy, Knowledge is Necessity, gave the day over to an exerpt from Nancy Rappaport's book, In Her Wake: A Child Psychologist Explores the Mystery of Her Mother's Suicide. Rappaport wrote about how even psychiatrists sit around and wonder how a person comes to the conclusion that he or she wants to die. Most of us want to live. Even those of us who want to die, for the greater part of our lives, we want to live. Her mother's diaries are full of her struggles to survive. What happens in somebody's mind to make that change? Rappaport says it is a mystery.

In Her Wake is a powerful memoir of the aftermath of suicide. People who struggle with suicide need to read such accounts to fortify them in their struggle. But I think she has misidentified the mystery.

I think every person is a mystery.

We have our joys, sorrows, strengths, dreams, fears, failures. We have capacities and weakness that sometimes we tell to others, and sometimes they divine. But the core of the person remains a mystery.

I am a Christian, so I believe there is One to whom we are not a mystery, One who knows our true name and calls us by it. And we ourselves don't even know that name until we hear that One call it. And when we do, then we know ourselves for the very first time.

But I don't think suicide is a mystery.

Suicide is simple. Each of us wants to live. That is how our brains and bodies and souls are constructed, for life. And each of us dies anyway, when our brains and bodies and souls give out. Suicide is one way that we give out. We don't give up. We give out. We reach the limit of what we can survive, whether it be a tumor, lack of oxygen, or a knife that turns in our chest, whether figuratively or literally.

I learned this perspective from David L. Conroy, who learned it from his practice and from his own experience. And I confirm it in my experience. He says, and I repeat it from time to time in this blog,

Suicide is not a choice; it happens when pain exceeds resources for coping with pain.

After a suicide, the survivors are indeed immersed in mystery. It is the mystery of the heart of the person who died. It is the pain of questions we cannot answer. We never know the sum total of the pain another had to bear, or was able to bear, or not, nor who or what was available to help, or not. I don't know that psychological autopsies ever satisfy. What we really want to understand is the core of a person. That is the mystery.

But we can understand suicide. We can recognize its broad strokes. And we can prevent it, not every time, but most of the time, the way that suicide crisis lines do it, by relieving pain and by providing resources for coping with pain. If we can help shift that balance, between the pain and the resources, then the person at risk will be able to do what he or she really wants, to live a life worth living.

45,000,000 Suicides Prevented

Fifty million people who are alive today in the United States have or will at some point struggle against suicidal pain. I am one of them. I have a disease with a 15-20% mortality rate. Someday I will die of something. It is my fervent prayer to be one of the forty-five million who survive suicidal pain and die of...

something else.

It doesn't improve my odds for me or you or psychiatrists or anybody else to ponder the mystery of suicide. You can't prevent mystery. You can provide resources to prevent suicide. Here is a list to get you started.

If it is your own suicide that needs preventing, tell somebody. Tell somebody who cares about you (and is not an idiot). Or call 1-800-273-TALK (8255) in the US. The Trevor Project at 866-488-7386 is particularly for young people, lesbian, gay, bisexual, transgender or questioning, and the people trying to help them. There is a link at the top of this blog to find numbers outside of the United States.

I want you to die of something else, too.

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Prozac Monologues - How It Began

2011-09-01T09:45:00.000-05:00

First conceived as a stand up comedy routine, birthed as a book, morphed into a blog, on August 29, 2011 Prozac Monologues came full circle at Happy Hour at the Pato Loco, Playas del Coco, Costa Rica. This was the very spot where in January 2005, the book was originally written over the course of eight heavenly (my wife wouldn't use that word), hypomanic days. Micah pulled out his laptop. Patricia set it up on top of a bar stool. And I held forth.

You can hear a bit of our little beach town's rush hour in the background. So here is the text:

Prozac Monologues - How It Began

2004 was not a good year for me. My doctor tried to make it better by prescribing Prozac for major depression. Only Prozac didn't make it better. So she prescribed more Prozac. And that made it so much more not better that I concluded the only way I could describe how much more not better would be a stand-up comedy routine. And thus was planted the seed for what has become Prozac Monologues.

So I went off Prozac, and on January 25, 2005, I boarded an airplane for Costa Rica, armed with a yellow legal pad and a ball point pen.

Hypomania In Action

For eight days in beautiful, tropical Costa Rica, my wife went to the beach, explored neighborhoods, visited with family, tried new foods, while I wrote. And wrote. And wrote. When I filled up one side of the yellow legal pad, I wrote on the back. When I filled up the back, I wrote in the margins. When I filled up the margins, I wrote between the lines.

I came home with seven chapters. Two weeks later, the book was done.

I told my doctor about my book and maniacally writing it. That word maniacally raised a red flag. So she screened for bipolar. She said, Are you manic?

I said what anybody who thought she was Jesus Christ come back as Jessica Christ might have said, I'm not manic. I'm excited!

Oh. Okay. So she prescribed the second antidepressant, and began what will have to become a new book, but I haven't recovered enough to write it yet.

Was I manic? No, I was hypomanic. But I didn't know that word. And maybe you don't know it either. So I submit for definition and for evidence the first four pages of

Prozac Monologues

Willa Goodfellow

Chapter One

Bizarre: In which I decide to write a book

Okay, let's start with the basic Prozac dilemma. Just who is the crazy one around here? If, after you read the morning paper, you are happy, content, secure, at peace, able to get up, go out and carry on your activities of daily living, full of confidence and a sense of purpose, then tell me -- are you pathologically delusional?

Or are you on Prozac?

Citizens of the United States of America (called Americans and thereby hijacking the identities of thirty-eight other nations in the Western Hemisphere -- Remember Canada? Every heard of Paraguay?) make up 5% of the population of the planet and consume 24% of its energy resources. We spend more on trash bags than the gross national product of 90 of the world's 130 nations.

What was that?

We spend more on trash bags than the whole gross national product of 90 nations.

So who is the crazy one around here?

The Crazy Delusion

Weget such a sliver of time to enjoy this wildly extravagant planet, and we spendprecious moments of it, watching couples on TV compete for cash prizes on thebasis of how many maggots they can eat.

Untilthe maggot-eating is interrupted by somebody who wants to sell you an airfreshener that uses an electronically operated fan to circulate chemical compounds around yourliving room to make you think you are out of doors.

Thefan is the latest advance in civilization which will enable you to stop feedingyour Shiatsu little treats, which you previously had to do to get it to wag itstail to disperse the chemical compounds around your living room.

Sonow you have to take Prozac, so you can get yourself up off the sofa where youhave been sitting in a semi-catatonic state, watching the maggot-eating anddog-treating, out of your pajamas and into your four-wheel drive SUV, which youwere compelled to purchase after viewing those commercials of SUV’s climbingover mountainous terrain beside raging rivers,

Butwhich you happen to use to commute an hour and forty-five minutes on somefreeway to work in a cubicle with a picture of mountainous terrain and ragingrivers and some motivational caption underneath, so you can buy the airfreshener with its self-contained and electrically-operated fan that dispersesthe chemicals that make you think you are out of doors, because you wouldn’twant actually to go out of doors – the air is so nasty from the fumes of yourSUV. Who is the crazy one around here?

Anddon’t even get me started on the taxes you will pay from your job in yourcubicle to fund somebody’s research into that missile that can shoot anothermissile out of the sky, to protect us from the bad guys who can bring down two100-story buildings armed with the equivalent of a Swiss Army knife. If it’s your job to figure out how to shootthat missile out of the sky, stop taking Prozac and go do something else to dowith your life. Or just go back to your sofa. Please.

Okay,now I sound like Michael Moore. Let’sjust call this the Crazy Delusion, a concept not original to me, and of whichyou can think of your own examples, so I don’t need to continue this rant whichis not really the point of this book, but only the context of our considerationof the title of its first chapter.

Inshort –

It’s hard to know whether depression is a problem of distorted thinking or theresult of clarity.

In either case,sitting on the sofa in your pajamas does not turn the economic engine of thisgreat nation, no matter what you’re watching.

Exceptfor the pharmaceutical industry’s economic engine. They keep making money, as long as they areable to sell you images of people who are happy and confident, popping theirProzac, (nowadays it’s Abilify), which you really start to believe when you’restill sitting on that sofa, watching those images over and over and overagain.

Ads For Antidepressants

Haveyou noticed how all the ads for antidepressants run during the afternoonsoaps? (If you are not depressed, youhaven’t noticed, because you’re off at work, turning that economic engine.) No, those pharmaceutical guys know where tofind their audience, and when, on the sofa, in our pajamas, in the middle ofthe afternoon.

NowI’m talking to you, the one in the pajamas. You thought you might get up and go for a walk, like you promised yoursweetie (who has gone to work) that you would. But here it is, two o’clock in the afternoon. The recap of yesterday’s episode comes on,and before you can find the remote to turn it off after the last soap, thattheme song begins. It soundsinspirational, but for some reason, you start to cry.

Afterthe theme song, and before the start of today’s episode, it’s time for thatgentle, compassionate voice, who lists all your symptoms, including another oneyou have, now that the voice mentions it, but up until now you didn’t realizethat it also is on the list, so you must be even sicker than you thought. Who is that voice that understands you sowell, better than your doctor, it seems, and so must know exactly what you needto ask your doctor to prescribe.

Symptoms Of Depression

Hereis that list, by the way: sadness (no duh!), sleep disturbance (too much, toolittle ) weight gain (or loss), lack of energy, loss of interest in the thingsyou used to like to do, loss of motivation (hence, all that time on the sofa),slowed pace, poor memory, poor concentration (they don’t want you at workanyway – you might break something), loss of self-confidence (like, they reallydon’t want you at work – you might break something), guilt, feelings ofworthlessness, suicidal thoughts or attempts.

Ifyou have been sad or lost interest in things for at least two weeks, plus fourof the others, I’m talking about you. You and 12% of the population who willexperience an episode of depression sometime in their life (that’s majordepression), plus another 6% who just feel lousy all the time (that’s dysthemia),and another 6.4 who sometimes are way up and sometimes way down (that’s bipolar),or …

Onein twenty people in any given month.

Whenyou have so much company, how is it you feel so alone?

Youare not alone.

ProzacMonologues

photo of Playas del Coco by Helen Keefe, used by permission

photo of trash bags by Yuyudevil, in public domain

photo of Cubicle Land by Larsinio, in public domain

photo of prozac by Tom Varco, used by permission

photo "Loneliness" by graur razvan ionut

Bar Tales of Costa Rica

2011-08-25T15:05:00.000-05:00

I need a break from upset. Maybe my readers do, too.

Once when I was in Costa Rica, working on another unpublished book, Deep Calling -- that's my depressing book about being depressed, as opposed to Prozac Monologues, my funny book about depressed -- I needed a break from being depressed. I took my breaks at the bar at the Pato Loco in Playas del Coco, Costa Rica.

My sister, the Voodoo Princess and proprietor of the Pato Loco also needed a break from my being depressed. So she was delighted to learn that the Pato Loco inspired and regularly supplied material for my third book that is not published, Bar Tales of Costa Rica. Bar Tales is not about depression.

This week we all take a break together, with the first of the Bar Tales of Costa Rica.

Shut Up, Lenny!

How are youtoday, Rosie?

Oh, I could usesome de-stressing. You can’t tell bylooking at this big black beautiful woman in shorts, sleeveless and flip flops,but she’s running a several employee travel agency back in the States while shesits in front of her laptop in the dining room of the Pato Loco.

Rosie set up the wireless for the hotel, whenshe was living here while her condo in Hermosa was under construction. That took so long, she became a member of thefamily, another sister. Mama had acolorful past, we say when somebody raises an eyebrow at the introduction. As a matter of fact, she did.

De-stressing youneed? Let me see what I can do. Here’s a story for you. You know our neighbor, Lenny, the Hot Dogman?”

Yeah, I’ve beentrying to buy one of those hot dogs. Every time I go downtown, he’s never open.

No, he‘s out ofbusiness for the time being. I guess thePizza Hut truck had a prior lease on that lot where he had his hot dogstand. They moved back in, what withhigh season coming. So he doesn’t have aplace to put his cart.

It was a greatspot, right there across from Zouk Santana and the Lizard Lounge. Lenny said he was selling 70 hot dogs an hourbetween 2 and 3 AM, when the bars closed. He said one night, he ran out of chili. They kept buying the dogs. He wasselling them faster than he could cook them. They bought them raw. Four bucksa pop, chili or no, 300% profit.

It is a triumph,that hot dog stand.

Costa Rican Developers

I don’t really care aboutLenny’s success. He’s a newbie fromTexas. And he isn’t a hot dog salesmananyway, at least, not in his head. He sayshe’s a developer. Everybody claims to bea developer. Except me. I claim to be awriter. I guess it comes down to thesame thing, a lot of dreams, not so much cash. Except I really do write. I don’tpublish, but I write. Developers seem totalk mostly, over beers at the Pato Loco, since the Bohio has been torn downfor being too close to the beach, now that the tides have shifted.

The tide comes in, the tide goes out. The beach is never the same. They’re putting in a marina where the Bohioand a lot of other nicer bars and restaurants used to be. I don’t cheer for developers.

What Lenny reallydoes, or talks about doing, while the luxury condo deal is still in development,is sell vacation packages. Ninety-fivebucks buys you four vacation packages in Maui, Orlando, Las Vegas or PuertoSomething. Ninety-five bucks and acouple hours of your time while people try to sell you a time-share in Maui,Orlando, Las Vegas or Puerto Something.

The hot dog stand is the hook. You’re cooking the dog to order, piling on the chili, the onions,peppers, cheese, and all the time talking about vacation packages, four peryear, ninety-five bucks. Except when the bars let out and you’re selling thedogs seventy per hour at 2 AM. Not somuch time to talk then. Just, You want ketchup? Mustard? Mayo?

We didn’t meetover hot dogs, but on my front porch, Lenny and me, when I returned to CostaRica this winter and said hello to my new neighbor. He was telling me about the hot dogs when,out of the blue, You want to make a couple thousand a week?

Couple thousandwhat, colones? (That’s four bucks.)

I’ll pay youtwenty bucks for every vacation package you sell.

No, thank you,Lenny. I do not want to sell vacationpackages. I do not want to make a couplethousand dollars a week. I don’t makethat much money in the States, and I didn’t move to Costa Rica to make that much money here. I moved so I could live on what I make in the States, so I could write. I am not asalesman. I am a writer.

As far as I cantell, it’s a pyramid scheme. Lenny sellsthis job to apparently (and in this case mistakenly so) aimless people who wantto stay in Costa Rica on dreams of a couple thousand a week. The job is to sell brochures that will luredrunks, who actually intended to buy a hot dog after they were evicted from thebars, to go to some other vacation spot, where somebody else will try to sellthem time-shares, so they can come back to where some other hot dog vender, ormaybe Lenny himself next year in a different location, will try to sell themsome condo that he has developed, thereby justifying his self-identity as a developer.

But to pull this off, he needs the person willing to serve the hot dogs in the hopes of selling the brochures. Since I do not want to make a couple thousanddollars a week, I do not qualify for this job. Ironically, with a different pitch, I might be willing to help him outwith his dogs.

That’s what Ithink Lenny really does, sell hot dogs.

Costa Rican Hot Dog Stand

And it is atriumph, not for Lenny the developer, but for our other next door neighbor,David, who bought the hot dog stand online from Canada, had it delivered to hishome in Atlanta, and then shipped it through Miami to Costa Rica.

David isn’t a hot dog salesman. He’s a pool man. He’s also a very nice guy who made somesudden and poor financial decisions last fall. It was a bad time in his life. Hedecided that Dennis, the maintenance man at our condo, could use some extrabucks. So David decided to set Dennis upin business as a hot dog salesman.

Except Dennisisn’t a hot dog salesman, either. He’s aconstruction guy, who can do a million different things with his hands, all of them very well, but isnot into handling hot dogs. Dennis isCosta Rican and proud, and Costa Ricans are not into hot dogs, neither buying norselling, which is why it’s hard to find a good hot dog in this country.

But both of them, David and Dennis are very niceguys, and their friendship survived this awkward spell, when the hot dog standwas taking up space outside the bodega (storage shed)next to the pool for several months, until Lenny moved to town and discoveredit there while he wasn’t developing anything but his story.

I will say thisfor Lenny, he makes a very good chili. And he did manage to find a vender, a German who lives in San Jose, who sellshim a decent quality dog. Not Chicagoquality. There’s no snap, none at all. But it’s got a bit of smoke, and for CostaRica, it’s pretty darn good. And lots ofthe ex-pats (the North American ex-pats) get frustrated, looking for the hot dogstand, which often is not in operation for one reason or another.

I will also say this for Lenny – he operateson Costa Rican time. Which is to say, hegets it open when he gets it open. If hesays 5 o’clock, don’t bother showing up until 7. The frustrated ex-pats don’t get his businessplan. He is not into food service. He is into money. And he can make a whole lot of it, more thanenough to live in Playas del Coco, between 2 and 3 in the morning, seventy dogsan hour, $3 profit on each one, even when he is selling them so fast hedoesn’t have time to cook them. He doesnot have to open when he promises or sell hot dogs during the lunch hour.

But right nowhe’s not selling hot dogs at all, since the Pizza Hut truck came back to townwith the same business plan as far as volume and drunks go and, moreimportantly, the lease on his location.

We think maybe hewent on a bender. We didn’t see him forthree days, but his car’s been there. And with his muffler, we know when he moves it. He starts it up, backs the car the hundredfeet to the gate, turns off the engine, gets out and opens the gate. I guess he only has one key chain. Then he starts the car, pulls through thegate, turns the car off again, gets out, closes the gate, gets back into thecar, starts it the third time, and leaves. Our house is right by the gate. So we know when he goes anywhere, since he doesn’t even walk the hundredfeet to the gate. Lenny doesn’t walk.

The VoodooPrincess, owner of the Pato Loco, interrupted, You could buy him another keychain. She likes Lenny, and he eats atthe Pato Loco a lot, since you can eat only so many hot dogs, if you want tokeep selling them.

I’m telling astory here, little sister. Work with me. The Voodoo Princess is my little sister. We have a diverse family. Mama had a colorful past.

Costa Rican Neighbors

Anyway, thismorning we heard from him again. It wasabout 9 o’clock when he shouted, Shut up! A couple minutes later, we heard it again, Shut up! It took about three or four times, Shut up!before I figured this out. Luis, theneighbor on the other side of the wall, has a mynah bird that says, “Buenas!” The bird says it all day long, “Buenas.”

It used tobother me, David interjects from the bar where he is nursing a club soda, ButI have become one with the mynah.

Yeah, now it’sjust part of the sound track of Costa Rica. But this morning it was:

Buenas – Shutup!

Buenas – Shutup!

Rosie is laughingnow. It’s good to hear Rosie laugh. He knew he was talking to a bird?

Well, I don’tknow. Because then it became –

Buenas – Shutthe f*** up!

Buenas – Shutthe f*** up!

Rosie is doublingover, He said, f***?

No, actually, hefilled in the vowel and the final consonants. Things were definitely escalating. I wondered if he was going to go next door and throttle a mynahbird. And then I hear it. Our whole condo association hears it –

David knew whatwas coming. He verified it, Yes, wedid.

Buenas – Shutthe f*** up! Comprende? Shut up!

She’s screamingnow. Comprende?

Comprende. One more time, I was just about to go overthere, if he said it one more time. –Lenny, it’s a bird! I know it’sirritating, ‘Buenas.’ [I flattened thosevowels as flat as a tortilla.] But me, I’mlistening to ‘Buenas’ – ‘Shut the f*** up!’ I don’t think I’ll have much success with the bird. So I’m going to try with the drunk. Lenny, shut the f*** up!

So, how did thatwork out?

Well, I nevergot the chance. Maybe the bird didcomprende. Because they both got quiet. So, how are you feeling now, Rosie?

Thanks, I neededthat. I’m feeling a lot better.

Pato Loco logo used by permission

photo of family table at Pato Loco by Mary Cox and used by permission

photo of chili dog by LG2, in public domain

drawing of condo by tomwild, in public domain
photo of bird of paradise and front porch by author

photo of mynah bird by Dhabyany, used under the Creative Commons Attribution-Share Alike 3.0 Unported license

Uptown Bill's - One Candle

2011-08-18T19:06:00.000-05:00

Okay, let me be very clear. And let you not perversely misunderstand. Justice beats charity any day. The current tax structure of the United States is unjust. At least, that is what Jesus and the Prophets would say. Charitable people can't make up for the size of this injustice, and shouldn't have to try. The fixed notion that we can is diagnosable.

Fair Taxes

Warren Buffett was curious and did some research. Last year Buffett's taxable income was roughly $40,800,000. That's after deductions. His taxes were 17.4% of that amount. Every other person in his office paid somewhere between 33% and 41% of their taxable income, an average of 36%. He doesn't think that's fair.

Nobody thinks that is fair. In fact, a lot of rich people and the Republican Congress think he paid too much. Nevertheless, there are indeed other rich people who agree with Buffett, that they get more than most out of government services, the type of services that help them accumulate even more, and they should pay more.

I have enough to rant about without taking on tax policy. So let me focus on the implications of our current tax policy for mental health policy.

What Jesus And Amos And Muhammed Said

Last week I told you it is time to step up, join with others, and do what the government and the people who own the government do not have the political will to do. Feed the hungry. Welcome the stranger. Visit the sick and in prison. Those phrases come from the Christian Scriptures, Matthew 25, but were spoken by a Jew who got his religion from a long line of Jewish prophets. We can round out the authorities of monotheism with the Muslim requirement to give alms. For you non-theists, you have to be your own authority.

I'm just saying -- Do it. Charity is an insufficient substitute for justice. Do it anyway. While Facebook and the blogosphere are filling up with calls for justice, people are dying out here.

That is where I left off last week. This week, the example I promised, one light lit against the darkness, Uptown Bill's.

Bill Sackter

Bill Sackter spent most of his life in a Minnesota state institution, placed there when he was seven, because he was mentally retarded. He got out when he was 53, when institutions downsized and transferred care to the community. Only there wasn't a community. There was one social worker with a case load too large to give Bill adequate help to adjust.

Bill was on the verge of going back to that hellhole, as he called it, when Barry Morrow, a young filmmaker in search of a project met him, befriended him, became his guardian and brought him to Iowa City, Iowa.

Barry worked for Tom Walz, the head of the University of Iowa's sociology department and the kind of idealist that thrived in Iowa city in the 70s and 80s. Except Tom is a practical man. And he listens. And he got Bill the kind of job that Bill could do. He could make coffee. He couldn't make change, but he could make coffee. That was fine, because the social work students who patronized Wild Bill's Coffee Shop could make change for themselves.

Barry made two movies about Bill's life, starring Mickey Rooney, and Bill became a symbol of how people with disabilities can contribute to our common enterprise.

Uptown Bill's

That would have been the end of it, but, like I said, Tom Walz is a practical man. A practical man with a vision. When Bill died and Tom retired, Tom helped to create Uptown Bill's, a small mall of businesses owned and operated by people with a variety of disabilities, a book store, a graphics design business, vintage store, furniture repair and refinishing, and yes, Wild Bill's Coffee Shop.

Today Uptown Bill's includes all of the above, plus a music shop, home repair and maintenance business, classes on how to start e-businesses, and programming in the arts.

This is community care that works. Emphasis on the the works. I think it works for two reasons:

1) People with disabilities have abilities. My dog Mazie taught me that we all come with surplus. To lose one, or even several, leaves us with loads. Well, we all have things we can and cannot do. Whether we fit into the economy, whether the community is structured so we can contribute and receive, says more about the community than about us. For that matter, our labels say more about the way the community is structured and less about us.

That is both obvious and invisible in the public arena. But some people have eyes to see. So a place like Uptown Bill's is possible. People with disabilities can run our own businesses.

2) If you own the business, you don't get laid off when the funding gets cut.

Now after the manner of Hebrew poetry, I said there were two reasons why Uptown Bill's works, and I add a third.

3) There are people who do not carry the label disabled who decide to work in partnership with others who do carry the label. They don't run the show, but they add their own abilities to the mix. These people don't have to believe in one sort of tax structure for the United States or another, have one faith perspective or another or none at all. They just have to want to live in a community that can receive the contributions of every member of it, without regard to labels.

Off The Grid

I write this from Costa Rica. I live in a little fishing/tourist/beach town with enormous disparities of wealth. Michael Jordan and Madonna own property in this part of Costa Rica, though I don't think they can see the doorway where that man sleeps from their infinity pools. I live behind razor wire, in a middle class/working class mixed neighborhood. Some of my neighbors make do with barbed wire. And I watch the United States on a trajectory toward the same. Except there won't be papaya trees growing wild up north.

When I go downtown, I see a mentally ill and homeless person who makes a living by buying a pack of cigarettes and selling them one and two at a time for a profit. I see people who buy their cigarettes one and two at a time from him. Because they are a pueblo.

Sure, keep trying to turn the Titanic around. But do something else, as well. Our government doesn't work for us. I think it is time to figure out how to piece together a pueblo, instead, to join with others and do what we can with each other. One candle, one cigarette at a time.

flair by facebook.com

scales by Johannes Regiomontanus, 1512, in public domain.

image of the prophet Amos by Gustave Doré, 1866, in public domain

book cover by amazon.com

dvd image by amazon.co

photo of razor wire by Helen Keefe and used by permission

photo of cigarette in public domain

1000 Points of Light Revisited

2011-08-14T11:00:00.001-05:00

OR

Gosh, We Could Use A Candle Down Here

I wonder if the US has passed the tipping point. For decades, a thriving middle class fueled the economy and supported our democracy. In the Bush years we decided to pay for those two wars, um... later, so the super rich could get richer. During the Obama administration we decided the tax cuts will stay; so the poor, the sick and the elderly will pay for those wars and the tax cuts. Meanwhile, the middle has shifted.

From Vernellia R. Randall, Professor of Law, The University of Dayton: [In the last two decades] the gap between the rich and poor in the United States grew at the same pace as the economic growth. Statistics show that the richest 1 percent of the US citizens own 40 percent of the total property of the country, while 80 percent of US citizens own just 16 percent.

Since the 1990s, 40 percent of the increased wealth went into the pockets of the rich minority, while only 1 percent went to the poor majority.

From 1977 to 1999, the after-tax income of the richest 20 percent of American families increased by 43 percent, while that of the poorest 20 percent decreased 9 percent, allowing for inflation. The actual income of those living on the lowest salaries was even less than 30 years ago.

Businessinsider.com tells the story in graphs for you visual learners.

And here is the way Warren Buffet tells it.

The upshot from the mental health perspective -- states are slashing mental health budgets.

After the Jared Loughner shootings, Arizona talked a lot about the need for better services. Then it cut $36 million from its mental health budget, or 37%. Across the nation, the average cut is 8%. Emergency rooms, jails and homeless shelters take up the slack.

There is a lot of slack.

Home ownership, those 401K's we were supposed to use to replace pensions... I won't linger here. I just wonder if this income shift can be turned around. Mostly I wonder what we will do in this new America, which will look more and more like other countries that have wealth gaps this large and the security budgets to protect the spread. Mexico comes to mind.

What We Will Do

We were a decade into the beginning of the shift when in 1989, at his inauguration George H. W. Bush called for 1000 points of light, voluntary organizations across the country to address human need, the homeless, children, persons addicted to whatever substance (including welfare, he said), unwed mothers.

This was the Read my lips: No new taxes guy. So there was a certain cynicism mixed with his compassion, a rich man calling on the virtues of those with less to take care of those with even less.

It sounds different when the poor themselves say it. And, of course, Bush was referencing the poor man who said, You are the light of the world... let your light shine before others, so that they may see your good works and give glory to your Father in heaven. (NRSV) The guy who said that said it to other poor people who were taxed into poverty to pay the salaries of the police state that was just looking for a reason... In his case, they found one.

The philosophical debate, to what extent should the United States of America accept a common responsibility for the common welfare, is just that, a philosophical debate. As a political debate, it is pretty much over. We won't. Them that's got shall get; them that's not shall lose. And them that's got have got the government, the means to keep the government, and no intention whatsoever of paying for the benefits they receive from the government (infrastructure, security, subsidies, an educated - more or less - work force, international trade agreements, subsidies.)

So we are back to those 1000 points of light, or rather, to You are the light of the world. For what it's worth, the only light there is going to be.

Those voluntary organizations that Bush Sr. was counting on to pick up the tab never had the resources to do it. And they have less now. Voluntary organizations have been contracting since 1964.

This is candle in the wind time, folks. But it's time to sign up. Why? Because it's getting dark down here, and you are the last flame.

It is time for secular humanists to get over their sense of intellectual superiority. It is time for the spiritual but not religious to get over their allergy to accountability. It is time for religious people of whatever stripe to get over their delusional straining for influence. The only shot we have is to do it together.

Somebody has to do something, and it's just incredibly pathetic that it has to be us. -- Jerry Garcia.

But there it is. Those of us who have lost our jobs, our pensions, our insurance, our health, or are bracing for the blow have to get it together and do it ourselves, have to organize, to feed the hungry, welcome the stranger, visit the sick and in prison -- whatever kind, compassionate, fair, sensible thing it is.

Next week, an example.

book jacket for The World is Flat by Thomas Friedman from amazon.com
photo of emergency room by Thierry Geoffroy and used under the Creative Commons Attribution-Share Alike 3.0 Unported license
print of Lazarus and the Rich Man be Print by Gustave Doré, 1891, in public domain
photo of candles by Nevit Dilmen, Permission granted to copy under the terms of the GNU Free Documentation License

NAMI Convention and the Persistence of DNA

2011-08-04T15:50:00.000-05:00

The second of my NAMI Convention posts is about opening my heart to the other side.

History Of NAMI

Even if its origins were to be forgotten, a system does not escape the DNA of its founding.

But it is not forgotten. NAMI began in 1979 when a mother in Wisconsin published a notice of a meeting at her house for the parents of children with difficulties. She discovered she was not alone. Her living room filled to overflowing by parents, desperately concerned for their children with schizophrenia. Together they pushed back against the medical establishment that said it was their fault. Together, they pressured for the research that revolutionized basic scientific paradigms of mental illness. No, schizophrenia is not caused by schizophregenic families. It is a disease of the brain.

Then real treatment began. Better understanding about the disease led to better medications. People were able to leave those lost locked wards. Yes, some live in the streets today. But some live in sheltered homes. And some live on their own. I know people with schizophrenia who work, who are married, who have good lives.

Okay, some have moved from locked wards in psychiatric hospitals to locked wards in jails and prisons. More than half the residents of our jails and prisons have a serious mental illness. But back to NAMI...

NAMI was created by and for families. Its signature program is Family to Family, and this year's convention celebrated its 20th anniversary. The testimonials go on for days about the difference, the support, the education and hope this program has offered a quarter of a million people so far.

Family to Family is part of the DNA and enduring legacy of NAMI.

The Miracle Of Medicine

NAMI was built on the medical model. The medical model created the medications. The medicines made miracles. And that, too, is the DNA of NAMI.

Nineteen companies and organizations supported the Convention at the Logo-on-the-program level. Nine of them were pharmaceutical companies.

A regular feature of NAMI Conventions is the Ask-A-Doctor sessions, where people line up at the microphones and get little five minute consultations on how to tweak their current medications and what else to try. There is always something else to try.

NAMI's Mission Grows

Meanwhile, people who themselves have mental illness joined NAMI. And this part of the history I can't tell you, because we aren't celebrating it yet.

Our part of the story is different.

Families talk about the miracles of medicine. What they want to know is how to get their loved ones to take them. People who have these brain diseases talk about how how the medicines aren't good enough. And we want to know about Recovery.

Recovery?

There are no biomarkers. There are no cures. There are no vaccines. There is no War on Brain Disease, no national motivation, and less money for research and treatment every day.

Half of us have developed our brain disease by age 14 and 75% of us by age 25. So we have to live with it a long time. Granted, not as long as we might otherwise. We die, on average, 25 years sooner than everybody else. We have the same life span of the people of Bangladesh. These numbers come from Dr. Thomas Insel, Director of the National Institute of Mental Health, who spoke at a special session the second night of the Convention.

We are not impressed by the Miracle of Medicine by trial and error.

So while some of us are still stuck in those Ask-A-Doctor lines, looking for a better miracle, the rest of us have gone to work on a concept called Recovery.

Recovery is the core concept of the NAMI program that didn't get mentioned at this year's convention -- Peer to Peer. P2P is a ten week course on what to do after you have been discharged with a prescription and a follow-up appointment, what nobody told you about when they showed you the door, because frankly, they don't know about it. Dr. Ken Duckworth, medical director of NAMI was asked about nutrition at the PTSD Ask-A-Doctor. His response, Doctors don't learn anything about nutrition. It's just too bad there was no Ask-A-Nutritionist session. Because even if you have found the very best hammer in the world for your job, if you want to build a house, you will also need a screwdriver.

Recovery is about building the whole house, about living the best life possible under the circumstances. It is about every paradigm, every treatment, every health practice and habit we can find that will improve our lot and add value to our lives, short as they may be. It is about putting it all together and getting on with our lives.

Recovery?

I didn't hear about Recovery at the NAMI Convention. Well, I wasn't everywhere. I have the dvd with powerpoints and audio, and will be exploring and reporting on what I missed. Rumor has it that the sessions on borderline discussed therapy. Therapy would be one of the tools in the Recovery toolbox.

There were recovery tools in evidence at the convention. I attended a drumming circle during lunch one day, drama during lunch another day. There was an exercise class during lunch. Yoga was offered during dinner, a poetry slam during the party.

I expressed my regret on the evaluation form that there was so little coverage of recovery concepts, and that little bit was pushed to the corners of the schedule. Two pages later on the evaluation form, I found a question asking me to evaluate the entertainment portions of the program, the drumming, the drama, the yoga... Entertainment?

So, yes, people living with mental illnesses are part of NAMI and were present at the convention. But we are still at the kiddie table.

Parents With Adult Children With Schizophrenia

So there I was, at the end of the Stars of Light Theatre Troupe's amazing performance, when the players were introducing themselves. It was Saturday, the last day, and I was feeling irritated by the organization of the conference and its emphasis on pharmaceuticals, even while speakers recognized they don't work that well. (I haven't even mentioned the previous night's major speaker slot given to the guy who has a book and a treatment plan for how to get people to take their meds. That was offered and addressed to family members entirely, while the rest of us were invited to a movie... Now in an of itself, it raised some excellent issues -- but I am talking about a pattern here, a deeply encoded pattern.)

Evidently, this irritation of mine is because I have bipolar, and when people with bipolar experience something that doesn't seem right, we get irritated and complain because we have a sense of entitlement. Duly noted.

Somebody asked if being in the troupe helped the players deal with their symptoms. That would be a recovery-type question, and why I would not have thought to call this presentation part of the convention's entertainment. And one woman answered, Not only do I have bipolar and borderline and some other things, my son also has bipolar with psychotic features. I don't know where he is right now. Without this group, I don't know how I could manage.

So I was flipping madly through my program looking for an empty space where I could write down her words, because I knew I needed to remember them. I saw, and with this woman's words in my head the eyes of my heart were opened so that I saw, that half of Thursday morning's sessions had been given over to estate planning.

Estate planning. At a mental health conference.

My wife and I are doing retirement planning right now, a little concerned about how we will manage to make that money last as long as we do. We are not doing estate planning. Because we don't need to. Our son does not have schizophrenia.

Then a woman stood up in the audience and expressed her support of the first. She said, I am not worried about my son this weekend. Because I do know where he is. He is in the hospital.

I thought about my son. I know where he is. He is living with his most excellent wife, getting a PhD at a major university and doing the thing he loves best, teaching. That's a Phi Beta Kappa cord around his neck in this picture, taken the day he graduated from college.

Broken Hearts

And these words, which I command thee this day, shall be upon thy heart. -- Deuteronomy 6:6. The student asked the rabbi, Why on? Why not in? His answer, That way, when your heart breaks, it will fall in.

NAMI is about broken hearts. The DNA of NAMI is mother love. Does a mother forget her baby, or a woman the child within her womb? Being a mother, I know there will be no forgetting, no changing what NAMI is about.

It will take time and tears, no small irritation, some shouting, experiments, mistakes and careful negotiation for people with mental illness to take our place at the grown-up table. Somehow in that process, we will have to take care of our mothers. Because they do not forget us.

It's just that, some of us do not have such parents. And even the others grow up.

graphic of clozapine's chemical formula by Harbin and in the public domain

photo of Thomas Insel, Director of NIMH, in public domain

photo of toolbox by Per Erik Strandberg and used under the Creative Commons Attribution-Share Alike 2.5 Generic license

ceramic of children playing by Hannie Mein and used under the Creative Commons Attribution-Share Alike 3.0 Unported license
photo of graduation day by Jenny O'Day

Jared Loughner -- It Doesn't Have To Work This Way

2011-07-28T12:31:00.000-05:00

The man who wants to put Jared Loughner to death is concerned for his health.

The United States attorney for Arizona, Dennis K. Burke, wrote to the Ninth Circuit Court of Appeals that despite being under suicide watch, Loughner’s unmedicated behavior is endangering him.

It has been determined that Jared suffers from schizophrenia, and is unable to participate in his defense against the 49 charges stemming from the Arizona shootings that left six people dead and thirteen wounded. Now somebody wants to get this desperately sick young man some help. Because if he can't stand trial, then he can't be prosecuted, convicted and executed.

Jared's attorneys think it is not in his interest, under the circumstances, to take Risperidone, a standard antipsychotic medication given to people who think that somebody is trying to kill them. It might have been in his interest earlier on. But the community college that noticed his bizarre behavior, including the speech salad that is the dead giveaway of schizophrenia, simply expelled him.

The Ninth Circuit Court of Appeals agreed with the prosecution, and Jared is now being forcibly medicated.

I intended to return to my NAMI Convention reporting this week. But wow. This story lands on my laptop, the very essence of the Prozac Monologues spirit.

There are so many layers of meaning here. I don't think I am up to the task of analysis. Instead I will tell another story, the original sequel to last week's rerun.

This is how a Christian community responded to the violent act of a mentally ill man. -- as they understand what it means to be Christian. From January 21, 2010 --

The Miracle of Gheel

It was seventh century Ireland. The Queen died. King Damon's grief was so deep that it moved into depression and then psychosis. He thought his daughter Dymphna was his queen. Rather than submit to his advances, Dymphna fled to Belgium, to the town of Gheel. But her father followed. When she again rebuffed him, he killed her, cut off her head. Dymphna was buried in the local church.

Six centuries later, her coffin was found during renovations. Signs on the coffin demonstrated her holiness. She began to be venerated. Cures of the sick were attributed to her. She was canonized in 1247 as the patron saint of the mentally ill.

Okay, here the one last bit of unrecovered Catholic in me demands to be heard, to note Rome's fascination with girls who prefer death to rape. Even as a nine year old, that troubled me.

Abandoning The Mentally Ill -- Or Not

Moving on. People came to Gheel for healing. Many brought family members who were mentally ill. Sometimes they left them there. The priest housed these abandoned ones next to the church. When the job of caring for them became too much for him, townspeople started bringing in food. They built a hospital in the 14th century. When it was full, the real miracle of St. Dymphna occurred, or rather, began. Townspeople took some of the patients into their own homes, reserving the hospital only for those most ill.

All across Europe, people with mental illness were thought to be possessed. They were exorcised, tortured and burned at the stake. But not in Gheel.

Imagine it! A psychotic foreigner commits a terrible deed. But the townspeople do not close the borders. No, they open their homes.

And they still do. Through plagues, wars, revolutions, recessions, depressions, during the Napoleonic "Reform," when all the mentally ill people in the country were ordered into one big hospital, during the Nazi occupation, with their "final solution" for mental illness, during the latest reform when the U.S. of A. was/is dumping all our mentally ill people out of the hospitals, onto our streets and into our jails, the people of Gheel developed and continue genuine community-based mental health care.

What Community Care Looks Like

Today, there are 700 foster homes for 1000 people with mental illness. A person will enter the hospital for evaluation and stabilization. S/he meets the psychiatrist, psychologist, nurse, social worker and family practitioner who staff one of the five neighborhood community mental health centers. Each of these staff people spends half a day each week in the hospital, so everybody gets to know everybody. The potential foster family and patient meet at the hospital, then over tea at home, then over a meal, then over a weekend before placement. Outpatient care, medication monitoring and therapy continue at the neighborhood center. If possible, the biological family participates in the treatment plan.

Once part of the family, the person shares in family activities, chores and church. The church doesn't have special bible studies, services or programs for the mentally ill. They are fully integrated, regular readers, members of the choir, ushers, etc.

But What About Relapse?

What if the person's symptoms flair? We say s/he is having a bad day. Because the person lives in a family, not on the streets or alone in an apartment, problems are caught and addressed early, not after getting fired or evicted or arrested or in a bloody mess. If needed, s/he can go back to the hospital for a while. In fact, the hospital is not the place of last resort. When the foster family has to go out of town, say, for a funeral, the person can stay at the hospital. There is continuity of care. There is care.

Three years ago I wrote a chapter for Deep Calling called, If This Were Cancer. I detailed all the ways that hospice patients receive the support of others, and that people who have suicidal depression do not. If this were cancer, there would be casseroles... I imagined the total collapse of care for the mentally ill, under the weight of our crazy health care system. In fact, it's happening as I write.

I imagined that the Church would step in to meet a desperate need, to create hospice for the mentally ill, as the Church originally created hospice and hospitals. I claimed that the Church has the resources to organize for such care on a local basis. It has the faith to imagine such a thing, the love to cast out fear, and the values to demand it. I will have to rewrite that chapter. I didn't know it had already been/is already being done.

I am ever so grateful to Janet, whose last name I don't remember, who gave me Souls in the Hands of a Tender God: Stories of the Search for Healing and Home on the Streets by Craig Rennebohm, the source of this story.

Lord God, Who has graciously chosen Saint Dymphna to be the patroness of those afflicted with mental and nervous disorders, and has caused her to be an inspiration and a symbol of charity to the thousands who invoke her intercession, grant through the prayers of this pure, youthful martyr, relief and consolation to all who suffer from these disturbances, and especially to those for whom we now pray. (Here mention those for whom you wish to pray.)

We beg You to accept and grant the prayers of Saint Dymphna on our behalf. Grant to those we have particularly recommended patience in their sufferings and resignation to Your Divine Will. Fill them with hope and, if it is according to Your Divine Plan, bestow upon them the cure they so earnestly desire. Grant this through Christ Our Lord. Amen.

... I think maybe Jared could use our prayers, too.

photo of Risperidone by V1ND3M14TR1X and used under the terms of the GNU Free Documentation License

image of Dymphna in the public domain

A Kitchen Interior by Joachim Beuckelaer, 16th c., in the public domain

book cover from amazon.com