psych

28
NOV
2014

Fear of Mental Illness

The fear behind mental illness reflects the nature of fear itself: We fear what we don’t know. We can never truly know what is happening inside the mind of another person. We as people follow fixed rules most of the time. Drive through an intersection when the light is green. Wear some amount of clothing outdoors. Don’t cross the double yellow line. So many rules.

When rules are broken, it is jarring to us as bystanders. Perhaps that rule breaker is innovative. Perhaps that rule breaker is a genius. Or perhaps that rule breaker is sick. The more bizarre the behavior, as in something so unorthodox that we cannot construct a rationale to make the behavior make sense, the scarier it is. That person no longer fits the parameters of normal, and thus cannot be understood. Except they can be understood. Once the parameters are broadened, and we understand what is happening inside the mind of a “crazy” person, then they become just as human as anyone.

The typical example is a psychotic man. They may do “strange” or bizarre things. People are afraid of them. They may mumble to themselves all day long, or talk to people that aren’t there. They might run around naked. They might hide in unusual places. These activities don’t seem “rational” by traditional standards. We can’t understand it, and the easiest label is “crazy.” By categorizing these people as crazy, we know they’re not us. And yet with that comes stigma, because there is still no understanding in that label.

The way to destigmatize these conditions is not just to educate the public that these are people with illnesses, but to take it a step further and understand the process that led to them doing this.

An individual with psychosis (schizophrenia, for example) is having a break from reality. That is a definition for psychosis. This might involve hearing things that aren’t there (auditory hallucinations), having paranoia or bizarre thoughts (such as that aliens will be imbuing them with special powers). There are commonly occurring forms of psychosis, and people with psychotic symptoms often fit into one of these categories.

How does this happen? The short answer is it’s a brain malfunction, and they are thinking things that are fundamentally disconnected from reality. Some paranoid beliefs or delusions might pop into their heads. This is like what happens in a dream, when you know something without having any idea why you know it.

If you could imagine hearing a voice that no one else hears which whispers in your ear, making you question everyone and everything you trust, then you might start to understand the difficulties of someone with psychosis. I myself can only imagine, having never lived with it myself.

So this brain malfunction leads to this false information, until they don’t know what’s true and what isn’t. Within this world of misinformation, though, they’re acting as best they can. If the voice is telling them they are in danger, they might strike out at anyone approaching them. This is not because they’re evil, but to protect themselves. I once had a patient who stripped off his clothes because his voice told him it would help him outrun the devil. He believed it. It’s often hard, even if they know it’s not true, to completely discount this false information they are getting. Even worse than our attempts to filter mass media messages about what we should buy or think, the false information in someone with psychosis is coming from their own brains. It’s hard to learn to NOT trust yourself. That’s why they need our help and understanding.  When we can understand what’s happening, then it’s easier to remember they are people.

Psychosis feels especially scary since there appears to be a level of unpredictability, and thus dangerousness. Research has never shown psychotic individuals to be more violent than the general population. But we’ll get to more on understanding the nature of violence in an upcoming post.

25
NOV
2014

Positive Psychology, Lindsay Doran, and Story

Many months ago I attended a lecture by Lindsay Doran on Psychology as an approach to understanding story. It was hosted by the Blacklist.  For anyone interested, her Ted Talk covers much of the same material.

Ms. Doran is a studio executive that has helped in the development of a number of films, including recently The Lego Movie. She also has a fondness for Positive Psychology. For those not familiar, the wiki page is actually pretty good on the subject. In short, it’s an approach to human psychology that focuses on the positive side of functioning, such as how to become optimistic, or what helps someone thrive rather than removing a problem or deficit.

I believe this is a valuable approach to understanding the human condition, and adds a necessary perspective to a world very preoccupied with pathology and problems. Dr. Martin Seligman is one of the most influential leaders in Positive Psychology, authoring such books as “Learned Optimism,” and “Flourish.” In a world so focused on tragedy all the time, turning our attention to developing the good things makes complete sense to me.

Doran went on to reference Seligman’s core components of well-being, namely PERMA:
Positive Emotion – Simply, about feeling good.
Engagement – Being absorbed in a process or activity.
Relationships – Feeling connected and involved with others
Meaning – Finding purposeful existence
Accomplishment – Achievement as a form of success

Seligman identifies these as the components of having a fulfilled life. Doran believes they are the key to what makes certain movies successful.

Doran even uses these ideas (PERMA) as a lens to identify what makes films inspiring or uplifting. She further draws conclusions about the movie industry going too dark, and that just as positive psychology redirected therapy towards the positive, lighthearted films without tragedy (like Airplane, Young Frankenstein) are fun for fun’s sake. She believes there should be more of these lighthearted fun comedies that help us to vicariously just have a joyful experience.

I agree with much of her message, though I believe she might be missing some points.

Regarding PERMA, Doran references an audience researcher who stated that he knew that people don’t really care about accomplishments. So even though we can be fixated on an achievement appearing to be the entire point of a story, we only care about it when it is tied to other things in the life of the character. So the A of PERMA seems less important.

Positive emotions obviously have their own point, and I would agree that lighthearted films serve a great purpose. Laughing feels good. Sometimes we just feel like a comedy for ninety minutes.

On the other hand, positive emotions on their own lack context. Sometimes what makes comedy so wonderful is that it is “comic relief,” as in relief from heavier topics. A comedic movie is really our comic relief from the heaviness of everyday life.

Movies serve a greater purpose than simply to entertain or distract. They serve a purpose in reflecting on the world, and in helping us gain perspective on how to live. Doran herself states that one of the purposes of movies is to answer the question of how we should live.

It is in that question that I believe Doran loses focus. She emphasizes the Positive Emotion of PERMA, while not sufficiently emphasizing the Meaning. I think she nails it with the importance of relationships, and has a direct point that women want to watch movies about relationships, and that men can only handle the relationships indirectly. Accomplishment in movies only feel good when it’s shared with someone.

This focus though on accomplishment and relationships, as well as on the positive, misses the reason that the industry has turned dark. We suffer. People feel a sense of suffering every day, and they are looking for some way to understand that. They are looking for meaning from it. And in the absence of meaning, they at least want to not feel alone in it. They want resonance, and portraying a dark theme that matches what they feel about the world resonates with them.

I posit the idea of suffering and sacrifice as being important values. In writing we set up stakes for protagonists, and often put them through hell to earn their accomplishment. That protagonist suffers and sacrifices, and what they do with that suffering and sacrifice gives meaning.

In that way it is the transformation of negative into positive that we want. We want ways to get through our own suffering, whether that be light movies (respite), or darker movies finding meaning (transforms suffering into something useful). Dark movies can masquerade as jaded, when really they may be vicarious relationship movies, where we can feel connected to someone who has suffered the way we’ve suffered. Which comes back to the idea of not wanting to feel alone. We connect to a character. We don’t want them to die because we want to stay connected to them.

Of course I agree with the point made by many (including Doran) that our fascination with pathology and problems, with what’s “wrong” can miss the larger picture. That process can even result in getting stuck in bad emotions, such as wallowing. Yet a focus on the Positive Emotions of positive psychology seems to neglect the real human suffering that occurs.

We become whole not through avoiding the negative but through owning it and transforming it.

Doran pulls many references from the AFI list of top 100 films to explore her hypothesis.

I’d like to look at a different movie, that of Cast Away.

At the surface it’s a story about survival. Chuck Noland (Tom Hanks) gets deserted on an island, away from the love of his life. He suffers. He learns to survive. He becomes so lonely he makes a relationship with a volleyball to have a friend. He builds himself a boat and gets away. We feel for him throughout. It’s primal. We see him cling to the last remnants of civilization in a beautiful butterfly on a box. He gets home, and he loses again. The love of his life has married someone else.

I love this movie. It was a massive success in the US and internationally. It doesn’t have many positive emotions at all. He loses his fiancee. He doesn’t accomplish anything but survival. His relationships are almost nil. He loses his entire identity. So it should be depressing. And yet there’s a transformative hope built into the film. We watch him suffer, and he finds a way out of it. There’s a lovely monologue of him talking about his loneliness and despair, and how he just remembers to keep breathing. A message for us all.

Finally he delivers this box that had kept him inspired. He meets a woman and we have a glimpse of hope. Maybe he was meant to meet her all along. Or maybe that’s my interpretation of it.

It’s a beautiful story of survival.

Viktor Frankl pioneered his own approach to therapy long before Seligman, which focused on meaning. I recommend everyone should read his book Man’s Search for Meaning. It’s a quick read. He was a psychiatrist who survived the concentration camps. At the time the wisdom was that when men have enough taken away from them, they’ll revert to animals. His experience was that people could be incredibly kind, and that those who survived had a reason to live. They found meaning and purpose in their suffering, even if it was just to survive to fulfill their purpose.

Now I don’t want to pretend that suffering, sacrifice, and transforming it into meaning is the key to what makes all movies powerful. Doran has clearly broke some great conceptual ground in thinking about films with a lens other than traditional formulas.  But the Meaning component seems underemphasized by Doran.  I heard many that night say that it was a transformational experience for them, yet in the vein that I hear so many emphasize “positive thinking” as a solution to the parts of themselves they dislike.

When we overvalue any one side, we miss the whole picture.

30
SEP
2013

How to Not Burn Out

“I just can’t do it anymore.”

People burnout everywhere, in every field. They burn out professionally. They burn out in taking care of others. I live in Los Angeles and I can understand how just driving a car can burn someone out in this level of traffic.

No one plans to burn out. Maybe they do have a little awareness that they’re going down that road, though.

We have a level of control over where we place our attention, as well as our effort. If you’re worried you’re burning out, consider preventing it.

There’s two parts, I believe, to preventing burnout.

For the first, I’d like to borrow from a simple model I first heard from Dr. Christine Moutier (a psychiatrist and former supervisor of mine at UCSD), modified a bit here. Imagine a gas tank. It’s feeding an engine. That engine is you. If the engine shuts down, you shut down.

dreamstime_m_30848081

This gas tank has a leak in it. It’s losing gas. Gas is pouring out. Eventually if we do nothing, the tank will be empty. When it’s empty, the engine stops. It doesn’t run anymore. The engine burns out.

We don’t want the engine to stop, so we need to fill the tank. It has to be filled faster than it’s losing gas. In life we each have our strategies to fill the tank. Sleep. Food. Socializing. Rest. Sex. Yoga. Watching TV. Meditation. Talking to people.  Exercise. Make a note of your ways to fill the tank, and note what others do, since one way might not be enough. One way might not be able to fill it fast enough.  It’s for your own well-being.

On the other side, look at the size of the hole that gas is leaking out of. This is the effort we put out into the world. We can try to narrow the hole, to hold back. That may be effective, to a degree. If done too much, it leads to apathy. The hole can’t ever be completely plugged up, in a normal life.

It’s not a particularly complex model, I’ll give you. Yet really smart people neglect themselves all the time. They think their tank will never run out, as if there’s a secret reservoir somewhere. Running on empty hurts the engine. So the first step is to keep the tank filled.

The second part of not burning out is to Not Overextend. We all have projects we’re asked to be involved in, whether that be something at work or even fixing up something in the house. Or maybe it’s arranging an event for family or friends. Presuming this is not a startup business that is your idea, ask yourself – how much am I putting into this? How much are the other people putting into it?

Here’s the key: If you’ve been asked to do this project by someone else, and you decide to invest a lot of time/energy in it, make sure the other person is as invested in it as you.  The plan, the approach, and if possible, the energy/time.  If you’re thinking up a lot of aspects of it, make sure the other person agrees along the way, or has as much skin in the game.

Let’s say I’m asked by my wife to plan a party for our friends. I put a lot of time into planning and arranging it, and then my wife tells me she doesn’t like what I did. I devoted hundreds of hours into the project, she devoted none. My response to any criticism she might have is anger and wanting to quit and disconnect. I would feel burned out. Such is the way when only one party in a group does most of the work, and the other critiques or doesn’t support it.

Now in many situations the division of labor is unavoidable. One side will do more work than the other. Chances have to be taken. When they are done with open eyes, though, the disappointment may be less.We can clarify the point, then, that the other party needs to buy into the plan at least. Don’t overdo it expecting the other party to be wowed by the amount of time you’ve put into it. What if they aren’t? You may end up apathetic and withdrawn. Check in with them frequently, to get their buy-in on the approach, so they won’t be surprised, and you won’t be surprised. And finally, try to discern endeavors that might not be worth the investment.

19
SEP
2013

Psychotic vs. Psychopathic

They aren’t the same. Going back to at least Hitchcock (one of my faves), who brought the muddy term “psycho” into the public psyche, conflated the definitions as if all are violent, and all “crazy” is crazy.

I’m sure there are briefer answers out there for those wondering what’s the difference between psychotic and psychopathic. And even though SRSLY made it into the OED because of its widespread use, lay inaccurate uses of the term psychotic will likely not.

Briefly in discussing how we got here, the words are interchanged because they sound alike, and are used commonly to describe someone “out of control,” often in an unpredictable or dangerous way.  In a way that is accurate for both.

Psychotic refers to someone who has detached from reality in a severe way that the common person would believe they are ill. Common examples of psychotic disorders include schizophrenia, schizoaffective (kind of schizophrenia and bipolar in one). People with psychosis can have hallucinations (hearing or seeing things that aren’t there), delusions (believing things that are known to be false or fantastical, like aliens are controlling their mind through a chip), paranoia (belief others might be following or trying to hurt them), magical thinking (believing they have special powers or could control things that they cannot), or ideas of reference (believing TV or commercials has special messages inlaid just for them personally). Now there are some mimics for any of these, so a single symptom shouldn’t be taken as proof of a condition, but instead the whole picture examined by a professional. Even then many professionals can get it wrong. We do the best with the information we have available.

People with psychotic disorders seem scary because their break from reality can make them unpredictable. Research evidence is quite mixed as to whether they are more dangerous than anyone else. Aside from some individuals who make headlines in terrible ways, on average they probably are not more dangerous than anyone else.

Psychopathic refers to someone without a conscience, who exists on a spectrum from your con man (self-involved, uses others for own benefit, not prone to violence) to the serial killer (predatory, gets aroused by hurting people physically or causing suffering). Psychopaths are scary because they seemingly have no limits to what they might do, including hurting others, just for their own benefit or enjoyment. If you want a bit more detailed discussion about psychopaths, see my posting here regarding Walter White and Breaking Bad.

Is it possible for someone to be BOTH psychotic and psychopathic? Unfortunately, it is. That raises all kinds of other topics, and I’ll leave that for my fictional writing.

Is being a psychopath a mental illness? That is an area of debate, both between mental health professionals, and between government/social services individuals and mental health professionals. Attributing it to an illness lessens the idea of culpability and choice, and directs thinking towards treatment and rehabilitation (of which there is little evidence that much works, though there are some small projects out there that might). Not attributing it to a mental illness or even acknowledging the lack of treatment options means the intervention of choice is containment (usually in prison), which raises all kinds of larger questions – should it be the crime that leads to containment? Can professionals feasibly identify psychopaths and identify those who can’t improve? A lot of controversy has arisen regarding the overuse of the PCL-R (a tool used to measure psychopathy), and that misidentified people might be incarcerated indefinitely. The UK has had an interesting experiment with all of this, with the government wanting psychiatrists to treat dangerous individuals with personality disorders. The psychiatrists didn’t want to do it, so the government forced the issue, creating their own name of DSPD (Dangerous and Severe Personality Disorder), and mandating that psychiatrists intervene. It’s an interesting social experiment, and continues to raise questions and controversy.

16
SEP
2013

Portraying Mental Illness in Story

Mental illness as a term gets thrown around a lot. It’s used by politicians as a scapegoat for problems or a target for funding. It’s sought by individuals to find meaning to their experience, or sometimes a justification for their difficulties. It’s a thing, talked about like any other disease. And yet the term is a lumping of many conditions under a single term, as if all mental illnesses are the same. They are not, but we talk about them that way and “let the experts sort it out.” I get that. At the same time it maintains the mystique and stigma behind mental illness. Because that is what the average person fears – the unknown. By keeping it labeled as one thing, whether that be to ostracize, excuse, or empathize, without educating the public more, we continue to leave it as a large unknown. So the stigma continues.

Media portrayals of mental illness usually fall into one of three categories:

1. Spectacle

2. Educational

3. As a relatable factor to human struggle and suffering

"Crazy" blonde girl.

The first reason clearly stands out as the most popular use of mental illness in the media. I can’t count the number of characters nowadays in movies and TV who are given mental illnesses primarily for the purpose of making them “different” or interesting. This misses the boat though, particularly when added to secondary characters or even worse, villains. The spectacle of the mentally ill involves the “crazy person,” usually meaning dangerous or unpredictable, which can be used for plot turns or as an explanation for the odd character. “He’s just nuts, man.” No one is “just nuts.” We miss the truth when we oversimplify.

Of course spectacle is the purpose of much of film and television. It’s entertainment. It serves its purpose in our lives. Using mental illness to have the “crazy guy” in a group of friends just becomes cliché, though. It isn’t that entertaining, anymore. And in the world of political correctness, it’s offensive.

Any good writer will not hold back from offending now and then, sometime more than that, all for the purpose of telling a good story. I don’t hold back, and others shouldn’t if it truly enhances the story. Adding in a mental illness just to add a character quirk can lessen the story, though. If the intention is to make the person more interesting, but is done only as a spectacle, where it doesn’t serve the larger story, then it hurts rather than helps.

I’m watching “The Bridge” right now, an FX TV show where one of the leads, Sonya Cross, appears to have Aspergers. In examining the story, it isn’t clear at first what the purpose is to the story of her having Aspergers. It isn’t a story about Aspergers. It does contrast well with the “normal guy” of her partner, detective Ruiz, who fits a different cliché of a cop. That may enhance the story as it makes her behavior and his more noticeable (by contrast), but there has not yet been revealed how her having these particular characteristics, with difficulty in social engagement, makes the serial killer stories more powerful. It may raise some obstacles against her pursuing the killer(s) as efficiently as possible, but that more extends the story rather than enhancing it.

Robert Mckee talks about this a bit in his book Story, when he describes the difference between characterization and character. Characterization are the demographics of an individual – their height, weight, job, clothing, background. That isn’t their character, and for the most part that isn’t what makes a story good. Whether it’s an accountant or a lawyer lying to the district attorney doesn’t matter as much as we might think. Character is revealed through the choices people make, with decisions under pressure revealing their deeper nature. Mental illness as a characterization doesn’t enhance a story. If it is left as that, as window dressing, then it’s a missed opportunity.

educational blocks

The second reason, that of educational, isn’t particularly useful in stories, either. I view it as the antithesis of spectacle. In fact, it’s usually boring. Royal Pains did some groundbreaking work from a health advocacy role by portraying a depressed person, and having that person receive ECT. It was shown realistically, with the usual anesthesia and care involved. Much of the episode centered around the stigma and one character fighting to keep the other from receiving ECT. When the ECT session was finally performed, all that was spoken was – “gee, you’re right, it really is a great thing.” It felt boring and didactic. While I appreciate the writers choosing not to further the cliché and inaccurate stereotype of ECT (e.g. Cuckoo’s Nest), it didn’t work as well as it could have as it wasn’t delivered in a way that enhanced the story. It became a story about stigma, which isn’t what the show is really about. Educational approaches require an investment from the viewer, and always risks losing them if it feels like just conveying information, similar to exposition in story. Exposition slows down a story. Education slows the story, and risks losing the audience. Even documentaries have a story structure to them to keep the audience invested.

Educational portrayals follow the rationale that “if we can increase awareness, that will solve the problem.” I disagree. Creating understanding and empathy is more important, and that comes not through the conveying of information, but through feeling a personal connection to another person, even if fictional. It is here that the true benefits of portraying mental health in media lies.

ideas

The third reason is as a relatable factor to human struggle and suffering. Mental illness is not a foreign entity. It is not like cancer, or something that “someone else” gets. Well, sometimes it is. In reality it’s usually a more extreme version of issues everyone struggles with. This is the avenue not only to make a character likable to the audience, but to make the path of that character relatable relevant to the path of the audience. Many people struggle with depression at some point in the life. Even more have lesser bouts of depression that they muddle through. Telling a story about someone with a worse depression could help the viewer, while also just being a compelling story. While psychotic disorders don’t seem relatable, more people than you’d imagine have an episode in their life where they feel like they’re “losing their mind.” These conditions are interesting because they are the extremes of human experience. The keyword is human. Understanding how to take what has been traditionally spectacle, and reveal the authentic human side of it that is relevant to everyone not only makes for good story, but indirectly helps with the stigma. Just as Orange is the New Black didn’t take the approach of a political campaign saying “women are marginalized in media.” Instead they told good stories about women, that made them empathetic and broke the mold on prior clichés.

So I encourage my fellow writers (as I remind myself) to think beyond cliché, spectacle, and even educating when it comes to portraying mental illness in story. Let mental illness be a window into humans, and let that enhance the story as a whole. Otherwise, the portrayal isn’t serving anyone.

03
SEP
2013

10 Life Lessons from a Psychiatrist

I run into the same issues everywhere, from patients, co-workers, and friends. People are stuck, and not sure how to “un-stuck” themselves.

I’ve noticed some basic rules on how to live a more fulfilled life, to make life easier, and make you more effective.

Consider them like guideposts if you feel off track. Some may be obvious. Others, maybe not so much.

It’s not about knowing them.  It’s about where you put your attention and effort.

1. Be Polite

I’m not suggesting to be fake or disingenuous. Instead find the way to being kind to others. And if kindness can’t be found, then at least be civil.

You may get what you want by being rude, angry, or demanding. The squeaky wheel does get the grease. In the process, though, you’ll burn the bridge with the person you’re getting it from. They won’t respect you, and given the choice they wouldn’t help you in an accident. I’ve worked with plenty of people that steamroll over others to get what they want. A lot of the time they still get what they want, but no one likes them.

If people like you, they’re more likely to want to help. Create allies, and start by being nice to people. Especially when you have no reason to be nice to them.

2. Be Flexible

I’m not talking about doing yoga backbends. This isn’t about physical health.

This is the holy grail in functioning in life, IMHO. The way to mental health is to develop flexibility, being able to function in a variety of situations, to find appreciation wherever you are, to be a leader when a leader is needed and a follower when that is needed. And to find enjoyment in every role. To be able to see multiple sides of every issue, and appreciate the opinions of everyone. Even if you disagree with it. Even if its hateful, to be able to understand what led to that person having that opinion.

See #10 for more on this.

3. Pick Your Battles

Stand up for yourself when you can, and when it will help. Assert yourself to make positive changes, but not just to exert your will on others. Don’t let yourself be trodden down by others, but be smart about it. If it’s important to finally stand up to your boss, do you have a backup plan?

People have variable lengths to their fuses. Some will let themselves be beaten down their whole life, never speaking up for what they want or believe. Others snap violently at the tiniest provocation. Neither approach works to get your needs met. Think ahead and plan the next three steps after you stand up for yourself, and plan how to weather the worst possible consequences.

4. Be Open to New Data

Medicine has few certainties. During medical school the lesson was: “Twenty years from now, 50% of what we know is fact will be wrong.” In a field of explosive egos and paternalistically telling others how to live their lives, it’s hard to be able to admit fault. It’s absolutely necessary though.

I could be wrong about everything here. I know I don’t know anything for certain. Anyone that says they do is wrong. This is more than being humble. New information could arrive at any point, and if we choose to selectively ignore that information because it’s a blow to our ego to change our minds, then we’re living in a delusional world. We’re ignoring reality.

I very rarely get all the information on someone’s background to be able to even make a definite diagnosis. I get pieces, and I put together the best picture from that information. If new information comes in, I have to revise that picture.

Think about your own philosophy on life. Any one thing you take for granted. Would you be willing to admit you’re wrong if some new information came in that didn’t fit? Most likely you’d want to discredit it, unless it came from someone you trusted.

The better stance is to be open to any credible information, and to recognize any belief or idea is only as good as the data it is based on. This is also the way of science, usually. At least when politics aren’t involved.

5. Paradox is the answer to many puzzles

I could give a thousand examples of this. You get more by giving. When in the black hole of desire and want, feel better through focusing on gratitude. Strength comes through vulnerability not hardening the walls. Fears are broken through experiencing the fear, rather than numbing it. Giving is the best way to get people interested. You have to stop chasing a dream to get it to stop running away.

We are creatures of habit. We do things because they worked in some way, at some point in the past. So we keep trying to do them, stuck in the hammer-nail paradigm all the time. We do what we do because our approach makes sense. It fits common sense.

Sometimes what we intuitively do is very effective. But sometimes it doesn’t work at all. Conventional wisdom tells us to “fight harder” and do more of it.

If you’re stuck on a problem, consider trying the thing that doesn’t make sense. Oppose your intuition. Trying to keep things from getting worse sometimes just makes the problem last longer. We do it because common sense dictates that things would be worse if we did anything else.

When desperate for love, we’re in a place of want. We desire. We feel empty, as though there’s nothing to give. We want someone else to fill us with love. Yet giving without expectation may be the very thing that results in getting what you want.

You just have to accept the worst outcome as a possibility. Some of those worst outcomes may not be acceptable, no matter what. I can’t speak to the specifics in your life. Just think of these as guideposts. There are whole schools of psychotherapy (lesser known) devoted to this approach.

6. Growth (or change) Requires a Degree of Risk, But Not Pain

There’s always risk in doing something new. Because it’s new and unfamiliar. The pain that’s expected comes from fighting change, from swimming upstream against the current, from holding onto the past. In order to change it means letting go of something, even if only as the sole way of doing something.

Weigh the risks and benefits, and make a choice to try something different.

7. Your Heart Will Keep Ticking

Even if it feels like the end of the world. Even if you feel like your soul is dying. You will probably survive. The pain will pass, like a wave. And you will survive. Don’t give up just because the wave is rising, or because it’s scary. Fear won’t kill you (unless you have a heart condition).

In that vein, I always appreciated this quote:
“I must not fear. Fear is the mind-killer. Fear is the little-death that brings total obliteration. I will face my fear. I will permit it to pass over me and through me. And when it has gone past I will turn the inner eye to see its path. Where the fear has gone there will be nothing. Only I will remain.”
― Frank Herbert, Dune

8. Balance is a Process, Not a State

No one is perfect. No one is at bliss twenty-four hours a day. Marketing (including by self-help marketers) sell you the idea of perfection. Or balance. Or happiness. Or Mindfulness. In truth that is not a maintainable state.

Stand on one foot. Even if you aren’t falling over, that’s because opposing muscles are working simultaneously. Balance isn’t about one thing only. It’s about finding the right amount of two things that might oppose each other, so you don’t fall over.

Find the balance between apathy and overinvestment. Being totally absorbed in anything is a recipe for burnout. In relationships or projects. Apathy isn’t living, but shielding yourself from any future risk, because it doesn’t seem worth it. Life is best lived in-between, in a state of mindfulness.

9. Everybody is Doing the Best They Can with the Tools They Have

Just sometimes their tools aren’t good enough. If that’s you, get more tools. Try new stuff. Shrugging your shoulders that you are the way you are doesn’t leave much of a path for your story.

If it’s someone else that is pushing your buttons, find some compassion. Whatever they’re doing, no matter how annoying, has served a purpose for them. They’re using what they believe is the best tools they have, even if it makes no sense to you.

10. Problems in Relationships Can Often Be Fixed by Trying Different Positions

Get your mind out of the gutter. I’m not talking about that.

Think about where you find yourself, in relationship to others. First, second, third positions.

First position (I) is looking at it through your own eyes. Some people literally cannot think for themselves, but are constantly caught in the needs of others.  They’re disconnected from their own needs and always put others first.

Second position (you), is about empathy and being able to imagine yourself as another person. Why they do what they do, and how they feel how they feel. Understanding that helps to understand how to deal with another person.

Third position (outside) is looking at the group from the outside, detached, and seeing the big picture. Seeing that when I push, he pushes back, which I might not be able to appreciate from the first or second positions. Each of these is like a muscle. Which of yours is underdeveloped?  Which is overdeveloped?

——

Now of course there’s lessons #11 – 20. But those will wait for another post.

Share this if you think it might benefit someone you know.

27
AUG
2013

Why I hate Xanax

A lot of people like Xanax. It’s given out like candy. People get it from their friends, from their primary care doctors, even from their psychiatrist. I hate it. I might go so far as to say it’s evil, though really it’s just bringing out the worst aspects of our nature. In my professional opinion, it’s bad for you.

But no one wants to hear that.

Yes, it feels good when you take it. People take it for anxiety. They feel less anxious (usually) after taking it. Must be working, logic would dictate. Unfortunately this is short-sighted, in the same way that we as a collective society (and medical establishment) view pain as something to annihilate.

Xanax makes you feel good. It brings on euphoria. Heroin feels pretty good too. Feeling good from it doesn’t mean it’s good for you. In fact it is this hedonistic approach of minimizing anything uncomfortable [painful] and maximizing pleasure that leads to more problems with both pain and anxiety. I’ll discuss pain in another post, particularly the overtreatment of pain as a phenomenon which is leading to a significant number of deaths from prescription pain pill abuse and misuse. Here Xanax needs to be addressed.

“My doctor prescribed it for me, so it must be safe.”

“The FDA approved it, so it must be safe.”

In truth nothing is absolutely safe. Water will kill you if you drink enough of it. Seriously. Every medication has its potential benefits and potential drawbacks. You are not guaranteed to get either the benefits or the drawbacks. It’s really a numbers game. Do the benefits outweigh the risks? In Xanax we both overestimate the benefits and underestimate the risks. And those that prescribe it like candy have a fundamental misunderstanding of how anxiety works, in my opinion.

Over and over again I hear –
“But you have to give me Xanax. It’s the only thing that works for my Anxiety.”

Really it doesn’t. It’s giving you the illusion that it’s helping, because it seems to give temporary relief. And it does. It works really fast. It gets into your system quickly, and feels really good really fast.

And then it’s gone.

The anxiety returns. Even worse, there may be withdrawal anxiety as the medication comes out of your system, bringing up all the feelings that your body and mind are out of control. So you turn to the same thing that seemed to help, even if temporarily: more Xanax. As you take it on a regular basis, possibly with increasing amounts, your body becomes tolerant to it. Tolerant means the same amount doesn’t have the effect it used to have. So again you need more of it. If you start to worry about the possibility of anxiety (anticipatory anxiety), you can then make yourself more anxious. Then you’d need a Xanax just to prevent the possibility of something bad happening.

I wish this was a fanciful diatribe with no grounding in reality. I’ve seen hundreds of these patients in my relatively brief career, caught in exactly this cycle.

The basics
Xanax is a benzodiazepine (aka benzo). It’s a tranquilizer. The same drug “family” includes clonazepam (klonopin), diazepam (valium), lorazepam (ativan), chlordiazepoxide (librium), and others. Xanax is notorious because it has such a short half-life, meaning it lasts in your system a brief amount of time. Surely the longer acting tranquilizers must be the better approach? Perhaps. Some people do function on benzo’s. That isn’t really in debate. The question is whether they function better with them than without them, in the long-term, and if there isn’t a safer alternative. In my opinion, they’re a third or fourth line approach, at best.

Anxiety is uncomfortable, and people in our culture don’t want to be uncomfortable. At all. Ever. So logic would dictate we should try to annihilate it. If something helps a little, use it a lot.

This is the rationale that actually leads to anxiety becoming an unremitting problem. Trying to keep it in check, to hide from it, or to hold it at bay, all feeds the problem. Fear is the problem. Psychotherapy figured out the truth: the way to lessen anxiety is to face it, not avoid it.

I had a patient once who had panic attacks. I think of panic attacks as the worst kind of anxiety, so severe it can feel like a heart attack or like you’re dying. He grew up on the streets (homeless for much of his life), coming from a tough childhood. He never had anyone he could trust. He got over his panic attacks without medication, and even without therapy. He had tried Xanax and other meds, and was on the slippery slope of trying to manage the anticipation of anxiety by using more and more benzo’s.  He would think about how bad anxiety could get, and would get anxious about that, and so would end up taking benzo’s just to prevent possible anxiety.  He was getting more and more addicted.

Then one day he got fed up. He was having a panic attack, and felt the fear of dying.

He shouted at himself, while beating his chest, “just fucking do it! Just fucking die already.”

He welcomed the worst possible consequence. And immediately the panic attack went away. The fear fed the panic. When he stopped fearing it, it deflated. It was still uncomfortable, but it didn’t build up the same way. He cured himself.  He doesn’t have panic attacks anymore.

If you want a medication for anxiety, look at the whole picture.

“I only want to take something as needed.” Your anxiety is all day, though. You have brief periods of it getting worse, but the rest of the time there’s some anxiety. So really you need something that works all day. You’re falling into the fear of chemicals while still wanting some chemicals. The issue is that the ones you’re asking for perpetuate or worsen the problem, rather than improve it. It’s a lot harder to treat anxiety in someone already addicted to benzodiazepines than someone not. Thus the slippery slope of good intentions and short-term outcomes.  And I believe medical providers with our good intentions cause more iatrogenic problems with this than we do help people.

The other risks
Unlike other medications for anxiety, the risks with benzodiazepines are much higher. Primarily the risks are seizures and death. If you take too much, you could get oversedated and die. If you mix it with anything that makes you sleepy (or pain medications), you could get oversedated and die. Withdrawing off of benzodiazepines can bring about increased anxiety, but more importantly the risk of seizures. Alternative medications like SSRI’s while not perfect, have far fewer risks to them, and are thus a much safer choice.

 

–postscript.  Yes, I float between the 1st/2nd/3rd person.

20
AUG
2013

Anti-Heroes Embodied: The Act of Killing

We love the bad guys. Scarface. Tony Soprano. Vic Mackey. Walter White. The Anti-hero is king in the world of TV and Film, especially of late. It’s probably a fantasy fulfillment, at least to some extent. We love to watch that unacceptable part of us get unleashed, just temporarily. We can barely imagine what would happen if the bad guy was unleashed permanently. What if his killing was legalized, even state-sponsored?

Without stating it, that is the subject of the documentary The Act of Killing by filmmaker Joshua Oppenheimer, produced by Werner Herzog and Errol Morris. A long time ago in a land far away from our Western “sensibility,” in the country of Indonesia, there were death squads. In the 1960’s, they killed Communists. They killed those accused of being Communists. They did it mercilessly. They did it with the backing of many groups including the US. Imagine if Joe McCarthy in the 1950’s started squads to exterminate everyone accused, rather than have the House Un-American Activities Committee to try them?

In Indonesia in the 1960’s there were no trials, and over a million people were murdered. The perpetrators were never tried. They now run the government. They’re proud of what they did. And they proudly call themselves “gangsters.”

Oppenheimer approached the heads of the former death squads, many of whom are now political leaders in the country, with the offer to have them re-enact the death squads in any way they choose. We follow them, as viewers, as if they’re the protagonists.  Now I have hypothesized about fictional anti-heroes and how we can empathize with them.  The Act of Killing layers a fascinating portrayal of a group of gangsters re-enacting their horrific acts proudly, with little sense of the basic moral code of the rest of the world. In their minds they are the heroes. What unfolds is a revealing portrait of mass murderers, and the rationale that goes into their creation and maintenance.

Now in their 60’s and 70’s, these men show no remorse for their acts.  The exception is the focus of the documentary: Anwar Congo.  He is celebrated by his cohort of gangsters, but hints at regret.  He has nightmares of those he killed, but he doesn’t understand why.  Nor do his colleagues.  We watch Mr. Congo with the vague inkling that he might be more moral than the rest.  He teaches his grandchildren to be nice to a duck, and apologize to it after they’ve hurt it.  For almost 50 years he has held the title of hero in this world, and never allowed regret to fully rise up.  In a world celebrating gangsters, regret might be viewed as weakness.

These leaders have shaped a narrative where they equate “gangster” with “free man,” (they state this definition publicly), and have sold the public in Indonesia on this twisted definition. As if being free means being able to kill without consequence. We (Americans) helped to form this narrative.  In this part of the world they still believe themselves as heroes, the champions of their land, free to take and do what they want.  Even their portrayal of the afterlife for their victims is glorified, as if the killing is justified.

TAOK_Waterfall

When they retold the history leading up to the murders, Anwar Congo  describes how he watched American movies of the 50’s and 60’s, including the celebration of gangsters. This doesn’t serve our usual rationalization in the US that TV violence doesn’t cause real violence. In this case, it at least inspired it, though may not have caused it.

There is a discussion between the main focus of the doc (Anwar Congo) and his friend/associate. They are both former heads of the death squads. In many respects they both appear without remorse, without perspective on the atrocities they’ve committed. Anwar Congo, while holding the party line that this is an act of pride, confides in his friend that he continues to have nightmares to this day. His friend recommends he go see a psychiatrist. But that would mean he’s crazy. So of course he wouldn’t go to see a psychiatrist.

In a world without the presence of morality, the one individual who has regret leaking through in his dreams must be crazy. It would be useful for him to see someone to talk about it, particularly someone who might recognize the cultural insanity that allows a group to murder their own people and justify it based on politics. History has never validated such acts, despite what the perpetrators rationalize for themselves in the moment that they’re doing good.

And yet in this society of Indonesia, few have awoken from the delusion. They keep their conscience in check by fear alone. Perpetuating a message of “freedom” through violence, as if being free means being able to act with impunity, these war mongerers have created an environment that reinforces this false belief system.

Sitting in the theater, the silence among the audience is astounding. The villains got away with it. There’s little karma apparent in a world where millions can be murdered and governments do nothing. So we all watch with an impotent sorrow. Horrible acts with no resolution. The dead stay dead. The criminals stay free.

Eventually we see a small change in Mr. Congo.  After decades of holding back the reality of his actions, he finally experiences it when he chooses to portray a victim in the re-enactment.  He can’t stand it, from the choking to the threatening.  The final transformation occurs when he watches the film of himself as the victim, and a transformation seems to take place.  For the first time in his life he considers the possibility that he really made people suffer.  Somehow he kept that locked away.

Following his realization, we watch an extended scene of him retching, dry heaving. He has swallowed propaganda his whole life, and only now, in his 70’s, is he able to try to vomit it out.  But nothing comes. Our Anti-hero cannot get it out him.

As a doctor and psychiatrist, the film reveals the humans behind the terrible acts.  They are people that did terrible acts.  Many just seem unfortunate, misguided by the false idealization of violence and power as empowering.  We could construct a context to their origins and explain these horrible acts, perhaps informed by the work of Philip Zimbardo, where we understand that these men were young at the time, in a period of social upheaval.  They came from poverty, and saw a chance to seize power.  Their society may have stripped away the identity of the victims as people.  That may lessen the reality of the individual though.

As a storyteller this reveals to me that the Anti-hero needs some bit of grounding to be sympathetic. Some lines can’t be crossed, some acts aren’t forgivable.  His colleagues seem unforgivable, as they have no regret.  Even Mr. Congo strains a connection to the audience.

In the end the  film holds a mirror up to the celebration of violence, reminding us of the division of fiction and reality, and challenging our usual internal emotional disconnect when we watch violence.  It’s a haunting view of our shadow selves.

See more of this film at: http://theactofkilling.com

24
JUL
2013

But I’m not crazy, right?

“But I’m not crazy, right?”

I get asked this question at least weekly. There’s a person, let’s say twenty years old. Or forty. Or eighty. Or fifteen. Doesn’t really matter the age.  And they’ve reached some point where they’re actually starting to question their own sanity, wondering if they’re about to “lose it.” So they come to someone for help. Are they really at risk? Maybe. If so, it’s probably being driven by the fear itself.

Of course there’s that old colloquialism that if you think you’re crazy, you’re not crazy. That has a grain of truth. One of the biggest issues in actually helping someone change their life or address a problem is getting them to admit that they have a problem. They need insight. Once they have it, the first step has been taken. There’s so many other important steps, though. And that’s really about crossing the threshold to try something different. We each have our normal ways to stay functional. It takes a lot to push us to realize that these normal strategies aren’t working.

The word “crazy” in the question raises a deeper issue of stigma. It’s the fear of “losing it” that may keep someone for far too long from actually seeking any help. And in help I’m not necessarily talking about professional help. That’ll be a distinction I make throughout this blog. People learn through many different paths (hence the blog title), and professional help (with a psychiatrist or other therapist) is one established path. It is not the only one, though. Let me illustrate on a brief tangent.

Borderline Personality Disorder (which will certainly be a topic for many future postings) is a kind of dysfunctional personality that causes a lot of impairment in the individual, but usually prompts treatment because it’s distressing to others. In fact people with borderline PD often get treated because they provoke reactions in others. This might take the form, for example, of a person cutting superficially on their arms, which can be distressing to others to observe. The person watching this happen feels like they can’t watch it any longer, and decided to get them help. Now we have many Evidence Based Treatments for this problem, which are proven to reduce certain symptoms, like cutting (“self-mutilating behavior,” AKA “Non-suicidal Self Injury”). Dialectical Behavioral Therapy, for example, is one of the most popular these days. But this is not the only path to improvement. In older teachings, personality disorders weren’t very treatable. Meds didn’t work. Maybe psychotherapy worked, kinda. Research now shows that when you check in with borderline PD patients later, they got better, maybe even without professional help. More specifically, they had symptom remission, even without having to have aggressive treatment the whole time. Now of course many were in regular outpatient treatment, but it raises a possibility (supported by other research) that even those with severe personality disorders can improve eventually, without aggressive treatment. So maybe these individuals are learning in other ways, from people around them, and it just takes longer for those changes to occur.

So maybe it’s all just a waiting game. For someone feeling out of control, though, part of the fear is it’ll go on forever, or pass the point of no return. Waiting means letting things get worse, or who knows? That’s scary. It’s unknown. There’s a message behind the fear of going crazy, which is really a worry of losing control, in a way that is irreversible. As if once you’re “crazy,” there’s no turning back. It’s a fear of losing a sense of self.

I had a patient a number of years ago, we’ll call him AJ, a young man without anything really unique about his life, who got brought into a psychiatric hospital out of “fear he might do something.” AJ was afraid that he would lose control of himself and do some horrible act that could never be taken back. It’s actually a common fear.

“I think I might lose it and hurt someone in my family.”

He was as normal appearing as anyone, dressed in a button-down and khakis, educated with a college degree, and had been working a regular job as a bank teller. He didn’t have any risk factors that we consider red flags, like a history of violence, drug use, etc.  But job stresses being what they were, he started worrying about his job, and if he might get fired. And he had a scary thought about “what if I did something bad.”  And that thought led to the concern “what kind of person am I that could have such a momentary terrible thought to hurt my family.”  And that led to this snowball effect. The fear of going crazy made him anxious, and being anxious made him feel all the more out of control. Until this all built up to the point that he went to an emergency room. It had taken a long time before he actually sought out any help, avoiding talking to someone out of fear he might be “crazy.” And his avoidance fed the anxiety, until he ended up in an ER. And by that point he had fought it so long he actually was having problems at work. How much easier it would have been to admit that what he was doing wasn’t working. That’s the second hardest step.

Now I’ve seen patients like this quite often, and half the time they’ll get hospitalized by someone to give a level of containment. No one wants to be the psychiatrist that says “OK, this is anxiety, just go home.” Because IF that person (heaven forbid) does something bad (like out of desperation lashes out and hurts someone), we don’t want to be responsible for sending them out of the ER. Sometimes the anxiety is so out of control they might even get misdiagnosed with a psychotic disorder, and end up carrying that diagnosis for a long time. If there was less stigma around mental health, people might seek help sooner.  The unknown and idea of losing self to an illness like schizophrenia is scary.  I’ll touch on that in future posts.  Uncommonly is this anxiety-ridden fear of loss of control driven by legitimate psychosis.  Again, the colloquialism has some truth to it, as most who are legitimately psychotic don’t realize it, at least not in the beginning.

The fear of loss of control fed the anxiety, and the stigma fed that fear. I don’t really like the word crazy. Or “nuts,” or “whackjob.” Or any of that crappy colloquial jargon that perpetuates stigma. I’m not even particularly a fan of “mentally ill.” For some people labels give them a sense of meaning behind their experience, which I think is fine, but it can come at the expense of labeling without explanation, or even externalizing all blame.  “I do this X because I have Y.”

After I’d spent some time with him, determined this was severe anxiety (with panic attacks), and explained it to him, AJ was able to calm down substantially. I started him on medication, taught him some relaxation exercises, and connected him with some therapy options. He had someone outside of himself to normalize things, and give him a way to feel better, quickly. It had a happy outcome.  And yet after he had heard the explanation and the options for treatment and normalizing and all that, he still asked the question – “But I’m not crazy, right?”

Most people will tell you we should decrease the stigma behind mental illness. Aside from awareness and increasing services (I.e. giving more services), few ideas float around. I am equally as concerned though about the increasing prevalence of mental illness (more people being diagnosed as having them). Maybe that’s an artifact of increased awareness, and decreasing stigma, leading to more seeking help. Simultaneously, though, is the very real concern that just more and more is being considered pathological or ill. Indiscriminate diagnosing and ignoring the context of a life may help some people, but in the larger picture causes a whole set of new problems, which now have a life of their own. #Psychiatricmemes that cause new problems, in an attempt to solve others.

No, you’re not crazy. You’re struggling and feeling out of control. Good thing we can help with that.”

[I’m aware I have many soapboxes, and will make attempts to limit the number of tangents per post.]

Coming up next week:
Well am I Bipolar, or not?

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