Thursday, December 29, 2011

No New Year's Resolutions - Change Your Life

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!

Note added, 01/02/13 -- The following are links to the rest of this series:

The Stages of Change and Weight Loss January 3, 2012 -- How do you change a habit?
My Food Autobiography and the Stages of Change March 8, 2012 -- Pre-contemplation and contemplation.
Changing Food Habits -- Contemplation and Preparation March 15, 2012 -- Reviews The End of Overeating by David Kessler and introduces the brain science of the sugar/salt/fat trifecta.
Dopamine -- Can't Live Without It March 23, 2012 -- The brain science behind habit formation and an experiment to try.
Relapse/Maintenance -- Stages of Change May 24, 2012 -- Review and finishing up the series.

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

Wednesday, December 21, 2011

Hey, Jesus - Happy Hanukkah!

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

Saturday, December 17, 2011

Changing Attitudes - Building the Therapeutic Relationship


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



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

What if your doctor knew what you still can do?


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

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


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

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

You Want That Placebo Effect

Here is what is at stake in my photo fantasy:

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

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

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

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

All I'm Asking is For A Little Respect

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

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

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

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

Common Ground  Between Doctor And Patient

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

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

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

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

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

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

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

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

Caveat: Behaviors Are Not Enough

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

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

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

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

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

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

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

Changing Attitudes - Building Alliances

Experience forms attitudes; experience can change attitudes.

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

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

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

photo of baptism by Malaura Jarvis
Team Prozac Monologues NAMI Walk photo by Judy
photo of gingerbread house by Margaret Doke
flair by facebook.com
book jacket by amazon.com
logo for Occupational Safety and Health Administration in public domain
college graduation photo by Jenny Krch

Thursday, December 1, 2011

The Therapeutic Alliance - Or Not

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

Hah!  So she doesn't read my blog.

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

Trust My Psychiatrist?

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

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

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

The Prescriber and the Placebo Effect

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

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

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

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

What helps me trust my doctor?

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

Well, I knew where I stood.

But I do trust my current psychiatrist.

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

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

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

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

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

Doctors Apologize?

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

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

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

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

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

Respect As The Ground For A Therapeutic Relationship

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

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

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

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

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

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

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

flair from Facebook

Tuesday, November 29, 2011

Does Your Psychiatrist Respect You?

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

Healer, Know Thyself

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

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


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

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

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

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

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

Psychopharmacologists Don't Do Self-Reflection

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

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

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


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

Caveat

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

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

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

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


The Power Struggle

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

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

I Trust My Psychiatrist

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

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

Collaboration

She asks me, What do you want to do?

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

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

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

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

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

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

What About Lack Of Insight, Denial, and Stupidity?

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

So, does what you are doing work?

Follow up question: does blaming your patient work?

What About Frustration, Worry, Disappointment?

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

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

Respect

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

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

Attitudes!

genogram of my own creation, please give attribution
flair from facebook.com
photo of mirror by Jurii and used under the Creative Commons Attribution 3.0 Unported license
clip art of tug of war by Microsoft Office
illustration of A Zombie, at twilight, in a field of cane sugar of Haïti by Jean-Noël Lafargue used under the Free Art License
sketch of hands shaking by Danieldnm and in the public domain

Wednesday, November 23, 2011

Holiday Shopping for True Happiness

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?  

Friday, November 18, 2011

Narrative and the DSM

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