therapy

05
AUG
2013

Well maybe it’s like physics. Kinda.

I was at a party once of non-medical people. A woman we’ll call Jill comes up to me. She’s a teacher, 28 years old, and talks to me about her teaching middle schoolers. I mention what I do, and I get a surprised look.

She’s intrigued, but then brings up all the complaints she’s heard. “My friend went to a psychiatrist, and they were horrible… And isn’t it true that the DSM is run by drug companies?” “So you’re pushing pills all day?” “Why can’t psychiatry figure it out better?”

Where do I start in addressing so many myths? Ultimately it’s hard to convey how difficult this field is.

In fact I hear critiques about my field (psychiatry) all the time. How it’s such a mystery. How it’s a soft science, and wondering why it can’t be more like cardiology. It would be nice for psychiatry and understanding the mind and brain to be finished. Nothing left to learn. But where’s the fun in that?

The truth is that the brain is the most complex “thing” on the planet, and with all we know (which is a lot), we still are only getting started. Mastering the information we do have is still a process, and it’s hard for those outside the field to comprehend how it’s not quite a linear process. It’s hard for them to understand that the brain can’t be understood linearly.

Understanding the mind/brain, as best I can find an analogy, is like learning physics.

At a grade school level, we learn a simple rule: nothing is smaller than an atom. We learn about how molecules are combined atoms, and the way they combine make up everything in the universe. That rule seems straightforward. And at that level it’s absolutely right.

Then as we grow older we learn that that rule wasn’t exactly true, and that really atoms are made of particles called neutrons, protons, and electrons. And the number of these in an atom determines what type of element it is, its weight, its charge, and so on. And we had to unlearn the first rule to accept the next. But in a way the first rule was a good foundation to move to the more complex. It’s easier to first learn about molecules when only thinking about atoms.

Then we continue, and we have to unlearn that electrons are particles. In fact they’re more like clouds, and don’t even exist in one place, but have “probabilities.” But being able to think about them like particles first was useful before unlearning the lesson, in order to understand them relative to protons and the net charge of an atom.

And with each step we learn a rule then unlearn it as we get more complex. Electrons aren’t even clouds, really. And then there’s quarks. And superstring theory. And so on. And it isn’t exactly that each rule was untrue, but just a simplified view was useful for that step of learning, to understand the larger picture, before moving into the more complex and detailed.

So it is with the mind/brain. But even less linear. At an early level is the DSM. It’s a guidebook, and its the best common language to describe illnesses so everyone can have some common language. But even the contributors know its far from the whole picture. It’s a fine starting point, so we can have a reference from which to deviate.

Then with each mental illness there is a body of research literature. Hundreds or thousands of published research papers on an individual topic. Every paper has data, some of it contradictory, that adds to the complexity of the picture. As each of us learns more, we learn to read between the lines in the research, to see some of the bias inherent in different papers. Often the data isn’t even applicable to the real world. Researchers each take different tacks on a specific question or dilemma. I’ll get into this more in future blogs, but suffice it to say that no one take is ever the whole picture. The more sophisticated we get, the better we can recognize which data is useful, and which isn’t.

And then there’s the brain models, from the ways the brain is wired in different conditions, to having larger areas of the brain in some conditions and not others, to more or less neurotransmitters in some conditions in some areas of the brain. And as interesting as it all is it doesn’t tell us enough. It tells us little aside from a hope it’ll pan out to something viable down the road.

Understanding the problem tells you very little as to how to change it. Reading the DSM tells us almost nothing about interventions (meds, therapy). So then comes training and incorporating various ways to actually deal with problems. The process of medication management of problems must incorporate what the pills are approved to do, what they do in addition, and everything else about them (research on them, side effects, how they affect other body systems). And then comes psychotherapy, from learning how to connect to a person, to the myriad of different therapy approaches (behaviorism, psychodynamic, CBT, DBT, IPT, and many many others).

In most ways understanding the mind/brain is not like physics. There’s not higher math. Physics is considered a “harder” science. But they both deal with the mundane, what’s right in front of us, and yet with the intangible. And the more complex aspects of physics and chemistry examine that which can’t be quantified with the senses alone.

So when people complain that the DSM seems incomplete, I agree. And when people tell me about bad psychiatrists, or therapists, I understand why. There’s a lot of information to “master,” and right now we do alright even with just simplistic uses of the information as a minimum.

We’re still looking for our grand unified theory to tie it all together.

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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