Therapy: who decides?

Nobody knows why therapy helps.  We have theories but no solid understanding of the mechanisms involved and we probably won't for a long time. Therapy isn't alone in this. Nobody knows, for example, why SSRIs, a commonly prescribed class of anti-depressant works either.

André Picard of the G&M: "As it stands, mental-health care remains an orphan. We can take another big step toward correcting this by adopting a more rational approach to the use and funding of psychological care."

André Picard of the G&M: "As it stands, mental-health care remains an orphan. We can take another big step toward correcting this by adopting a more rational approach to the use and funding of psychological care."

We do know that for certain categories of psychological problems -- some couple and family distress, mild to moderate depression or anxiety, certain personality disorders, and some psychotic disorders -- psychotherapy helps a significant portion of people and has minimal down sides (there are possible negative consequences to therapy some of which I discussed here).

These two points -- that therapy works and that we don't know why it works -- are important to emphasize because government and private insurance are increasingly involved in the practice of psychotherapy.  An example; this week the Order of Psychologists of Quebec announced that it is proceeding against two people for practicing psychotherapy without a license.  Here, in Quebec, since 2012 you must have a license from the Order to offer psychotherapy, which is defined as follows...

A psychological treatment for a mental disorder, behavioural disturbance or other problem resulting in psychological suffering or distress, and has as its purpose to foster significant changes in the client’s cognitive, emotional or behavioural functioning, interpersonal relations, personality or health. Such treatment goes beyond help aimed at dealing with everyday difficulties and beyond a support or counselling role.

Clearly, the provincial government is taking psychotherapy more seriously.  Also it is clear that it is hard for lawyers to write a good definition of a process that we don't understand very well.  How far in can the government wade?  So far it has been restrictive legislation.  André Picard of the Globe and Mail, who writes as well as anybody in Canada about psychiatry, mental health and mental illness, has written a very good piece aimed at beginning (again) a discussion around the funding of psychotherapy through public health insurance.  Currently, no provincial government funds non-MD-provided psychotherapy in the same way that it funds medical procedures.  Here in Quebec, non-MDs -- psychologists, social workers, creative arts therapists sexologists etc. -- who work as psychotherapists in the public sector get paid a salary through their institution, they don't charge per procedure.  They are also increasingly rare.  The vast majority of out-patient psychotherapy is provided by private practitioners for whom clients pay out-of-pocket and either get reimbursed by their private insurance or not.  This means that people who might greatly benefit from psychotherapy but can't afford it are unable to access it.  The more seriously mentally ill a person is the more likely it is that he or she is poor, and the less likely it is that he or she has private insurance so this way of delivering non-emergency mental health care is seriously off. 

I like the idea of people being able to access psychotherapy regardless of income.  But I have some serious reservations about the idea of public health care funding for psychotherapy.

  1. Psychotherapy is one thing that can help with mental illness.  There are lots of other non-medical treatments that can help the mentally ill: stable, supportive housing is a big one; case management is another.  If we want to spend billions helping the mentally ill do better in the hopes that we will benefit as a society, we need to take these two as seriously as psychotherapy and medication. 
  2. It can be a bonanza for some and create rich, entrenched interests that distort psychotherapy.  Research into psychotherapy can make for very dispiriting reading. It often looks like this; I have developed Wexler's Wonder Therapy (TM).  I test WWT (TM) on people with depression by giving them 8 sessions.  I exclude from my study anybody who has a drinking problem, couples problems, a history of childhood trauma, depression that has been treatment resistant or anyone with a cat because these other factors would confuse the research.  I begin with 15 people who meet these criteria.  Six drop out.  Of the remaining nine, six experience greater relief than they would if they were on a waiting list.  Wexler's Wonder Therapy (TM) is 67% effective!  It works on non-drinking, non-childhood trauma, non-treatment resistant, non-cat owning depressed people in only 8 sessions so it is incredibly cost effective.  It becomes the treatment standard for psychotherapy for depression.  I will train clinicians in WWT (TM) for a mere 1200$.  With that money I prove that WWT (TM) is also effective for anxiety and couples difficulties.  And so on.  This is not to say that psychotherapy isn't effective.  It is.  But for many conditions there does not seem to be much daylight between different therapies.  And people are a lot more complex in clinical settings than in research trials, which means that claims to deliver highly-effective, short-term psychotherapies are often over-hyped.
  3. Psychotherapy isn't medicine. These difficulties come of trying to shoehorn psychotherapy, and psychological care generally, into a medical model.  Psychotherapy is connected to medicine because of its origins and because there is real overlap, but it isn't the same thing and trying to use our health-care system to pay for it means putting a square peg in a round hole.
  4. It seems very unlikely to happen.  Quebec is in the midst of cutting hundreds of millions of dollars from its health care system and psychiatric outpatient care is being hit hard.  Proposals to take on additional expenses seem likely to be DOA here and elsewhere. 

I want to ensure that people who need non-emergency psychological care can get it regardless of income and at the same time maintain a practice of psychotherapy that is flexible and not overly bureaucratized.  Here is a suggestion: borrow from the Americans, specifically Obamacare.  Rather than expand Medicare to include non-hospital psychological treatment, require private insurance companies (which are making billions of dollars a year) to offer all Canadians 25$/year mental health insurance plans.  No cherry-picking, no pre-existing condition exclusions.  All plans must cover the cost of non-hospital services like psychotherapy, case management and emergency supportive housing.  Require all Canadians to have a mental health insurance plan.  Plans that do a good job of keeping policy holders out of hospital for a year get a portion of the cost of saved hospital psychiatric care.  Incentivize non-hospital based psychological care and let groups of clinicians experiment with what gives the best results.  This is  probably more likely to happen than provincial governments finding a few 100-million$ a year in spare change at the back of the couch and might preserve some creativity and flexibility in psychotherapy as well as ensuring non-psychotherapeutic treatments are on the table when necessary.  

Am I crazy?

Roz Chast's  Big Egg Lady.  To see more of Chasts's eggs click on the image

Roz Chast's Big Egg Lady.  To see more of Chasts's eggs click on the image

"Do you think that you might be crazy?"  It is one of those impolite questions that I get to ask that makes being a therapist fun and rewarding.  When people come in to see me they are sometimes half-convinced that they are crazy.  Sometimes people confuse the intervention with the malady.  Smart people can have the unexamined belief that "If I take the pill, if I see the therapist that means that I am crazy."  Recently, I've started asking more.  A lot of people who come to see me are.  Worried, that is.  I guess whether they are crazy or not depends on what you mean. 

People who have a personal or family history of mental illness are often very worried about being crazy, sometimes terrified.  They may have a very particular idea of what mental illness looks like and be terrified that that's what's in store for them.  Other people come in with a fear that is augmented -- with lots of good intentions and some greed -- by attempts to broaden people's picture of who can experience mental illness.  On the one hand, attempts to destigmatize people with mental illness are laudable.  On the other hand, hyper-sensitizing people to mental illness, encouraging them to view themselves and everyone around them as psychological orchids who need specialized interventions simply to survive in the world, is IMHO, plainly nonsensical, inimical to good mental health and partly motivated by the desire to sell us stuff (medicines or other therapies) that we don't really need

I recently saw a woman who is a new immigrant to Canada.  She is having difficulty learning French and is a new mother.  She felt stressed, scared, overwhelmed, sad and very lonely.  She had been prescribed anti-depressants and an anti-psychotic for sleep (the practice of GPs prescribing anti-psychotics off label without the simplest discussion of sleep hygiene is troubling to me).  On top of everything that was going on in her life she was terrified that she was crazy.  The persistency and intensity of the feelings, a family history of mental illness, her sense that she should be able to get over them and probably the fact that she had been prescribed medication all fed into her sense that she was going crazy.  This is not to say that the anti-depressant was not appropriate.  But it had a powerful meaning for her.  When I asked if she was worried she was going crazy, she began to sob.  She is scared to pick up her French classes again or try to find a job because she views herself as too anxious to take on anything new.  She is becoming more isolated.  I asked her if seeing me was going to make her think she was crazy because I did not think she was and I did not want to do anything that would give her that idea.  If coming to see me would make her think she was crazy I would refuse to see her.  Why?  Because viewing herself as crazy was making her crazy(-er). 

People have all sorts of ideas about what being crazy might look like and what it would mean.  I saw a young woman the other day who wanted to know if she had Borderline Personality Disorder.  First, I told her that I am not a doctor and I can't make a diagnosis.  Then I asked her what it would mean if she did have it.  She felt like then doctors would have some direction about how to treat her so that all the stuff that wasn't working in her life would get better.  "And what if you are sad and lonely because important people in your life have been hurtful towards you for a long time?  What would that mean?"  "Then I'm just a screw up."  Crazy might be better than the alternative; the frightening responsibilities of sanity. 

It probably isn't very wise of me to admit this but I use the term crazy in my own head sometimes when I think about clients.  Usually what I think is, "What a crazy thing to do."  It means something like 'inexplicable and self-defeating'.  In other words "Human."  One thing I don't mean is "mentally ill."  Mental illness to me means something is going on in the person's mind that is far beyond the usual degree of human irrational, self-destructive behaviour.  I think what my clients worry about -- or sometimes even long for -- is being far beyond the human pale, unable to return, irreparably psychologically destroyed. 

Resilient is the opposite of crazy in that sense.  Child birth is messy, it is occasionally very dangerous.  But our survival as a species up until the 20th century is incontrovertible proof that it can usually be done outside of a hospital.  Similarly, the fact that humans are around at all is proof that we are well-equipped psychologically to deal with hard stuff, to suffer, to hurt,  and be hurt even to go crazy and to recover. 

I am glad to live in an age of medicine.  I believe in therapy.  Part of resiliency is having people around who can help you.  But therapists also need to remember to 'first, do no harm'.  And if the cure is worse than the malady then it's no cure.  

Resistance is where the work begins

Ginger Campbell host of the Brain Science podcast, after a great interview with Norman Doidge about neuro-plasticity, said that doctors often don't prescribe behavioral therapies because they have the experience of patients not following through (1:05:00). "Many patients would rather take pills than follow treatment regimens that require them to do most of the work themselves."  I will write about Doidge at some point soon, but I thought a lot about Ginger's statement about homework and follow through. 

Recently, I have been finding that the most interesting moments in therapy come when I ask a client to try something that he/she/they won't or don't do and we unpack that resistance.  I have said before that on a handful of occasions, I have given people really good advice in therapy.  But much more common are people who know more or less what they need to do to make changes in their lives but resist it for reasons they cannot fully understand

I recently told a client who was feeling ambivalent about his marriage -- he couldn't commit to it and couldn't leave --  that he should try being fully invested in his relationship for 3 months.  At the end he could still leave or stay or continue being undecided, but in order to see what the relationship might be, he should try actually working at making it good for a limited amount of time.  He physically writhed at the idea.  He almost began to twitch.  What makes committing to the relationship, even provisionally, so hard? 

I told a couple that they should spend ten minutes a day talking about something tough in the day and supporting one another.  When I asked them about the exercise he said, "It feels weird because we see each other all day, she knows everything about my day."  They began to see how her being available to him for almost all his emotional needs throughout the day was not so great for their relationship. 

I told a client to meditate so that he could be a little more present to his partner.  "Sitting still for ten minutes is my idea of hell," he said.  She began to cry because she wants him to be able to be still for her.  It turns out that he has missed some crucial hurt feelings of hers because sitting still with emotions is so painful for him. 

People have reasons for not changing.  Sometimes it is a cost benefit analysis: "This requires a lot of work and I don't have enough confidence that it will make a difference."  I think a lack of confidence that medical science actually knows what is good for us is an important and neglected part of that cost benefit analysis.  It is hard to take your doctor's prescription seriously if you don't think s/he understands what is going on with you and what you want.  That doesn't come in 15 minutes.  Sometimes the road to such confidence comes from taking the time to unpack what else makes change hard.  

It is ironic that most doctors probably know that just prescribing behavioral change is unlikely to get people on board, yet they still do it.  Another opportunity to ask the question, "What makes it hard to do this?" And perhaps the beginning of real change. 

Cheese factor five; the therapist's secret fear of being Elle magazine.

"How about a nice Wensleydale?"

"How about a nice Wensleydale?"

I broke down and did it.  Between appointments, I wrote index cards that said, "Your partner's favourite band," "What your partner was wearing when you first met," and "Your partner's secret ambition."  These come from a series of exercises developed by John Gottman called "Love Maps".  You hand the cards to the client and s/he says what s/he thinks is the right answer or asks his/her partner.  Gottman is one of the most prominent and serious researchers of couples ever.  There's a whole lot of theory and research behind "Love Maps" but the first time I handed these cards to my clients, I cringed a little (I hope I did a reasonable job of hiding it). 

My cringe went a little like this: "I went to graduate school for three years and then did post-graduate training for years afterwards.  Now I am doing an exercise that feels like it has been clipped from Elle magazine."

Love Maps has a high 'cheese factor.'  That kept me from using it for a long time even though it is an evidence-based practice for helping couples do better. 

What is it about cheese?  I rely on being able to offer people something they can't get from a popular magazine or an online quiz for my living and my sense of professional attainment.  Not only that, coming to someone who they believe knows a thing or two, helps people feel safe, which is a prerequisite of a lot of the work of therapy.  I worry that the pungent odor of cheese can destroy that confidence that my clients and I rely on. 

Its not just me.  My training has been aimed at instilling a sense that therapists have complex, scientific knowledge that allows us to serve as serious professionals with something to offer that goes beyond the self-help section of a book store.  I think that is true.  But I also remember what Sylvain and Elise told me (names are made up).  They came every week to therapy and used it really well.  But at one point they said to me, "You're nice and all and you're probably good at what you do but for us the metro ride over is the most therapeutic part of the whole thing. We never have a half an hour where we are just sitting and talking about what's going on with us." 

Family doctors are highly trained professionals who spend a big portion of their time telling people stuff that their moms could have told them; "Have some soup and rest."  "Stop picking at it."  Sometimes you need a professional to tell you (because you won't listen to your mom).  In plenty of cases the mechanics of having a loving relationship aren't rocket-science; be kinder to one another, develop affection, show caring, stop bad habits that drive one another away, pay attention to your own and your partner's feelings etc.  What is hard is making the commitment to do it; taking the weekly metro ride over to my office may be some or even most of the therapy. 

So now I don't cringe (much) when I take out the Love Map cards.  Some couples roll their eyes and laugh at how cheesy it is and I laugh with them, but usually they smile at each other they laugh at one another's foibles or shared memories.  When they do the Love Maps exercise, couples understand one another a little more.  They have a little more feeling of affection after they do it.  And despite doing something they could have done online or from a magazine, many of them find it worthwhile to come back. 

Not doing things because they feel cheesy is actually a pretty big issue for some clients as well as for their therapist.  Some people hate the idea that doing basic, pedestrian things is going to help them.  (I wrote little about this here).  As the therapist, I sometimes have to model that we can push past our impulse to eye-roll just like we can push past other things that keep us from doing what helps. 

I would love to know your experiences of cheese in therapy.  The person who sends in the best example will get ... hmmm. a lovely stilton? or perhaps a nice wensleydale? whaddya say Gromit?

Review: Saving Normal by Allen Frances

I recently heard the wonderful Ginger Campbell interview Allen Frances on the Brain Science podcast.  Almost before my headphones were off I had run out to buy Frances' book "Saving Normal, an insider's revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life."  Frances clearly and humanely outlines his case that "The cruelest paradox of psychiatric treatment is that those who need it often don't get it, while those who do get it often don't need it." 

I had some concern, even after the very thoughtful interview on BSP, that this would be a soft-headed screed against psychiatry.  I know a lot of people who have benefited from mental health treatment including psychiatric medication, and I think it is very wrong to frighten people away from psychiatry who really can use it.  I needn't have worried. Frances is a psychiatrist with a great love for the profession and confidence in the good it can do.  He is absolutely committed to the idea that psychiatry can be beneficial to seriously mentally ill people and at pains to illustrate that.

But he is also clear-sighted about the failings of psychiatry and medicine generally (he is very much talking about the US situation.  I will reflect a little on the Quebec context below).  The big failing Frances takes on is 'diagnostic inflation.'  He means the tendency to expand the criteria that are used to diagnose mental illness, either by loosening criteria for exiting illnesses or by 'discovering' new illnesses.  What prompted this call was the American Psychiatric Association's process to issue a fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM.  Frances thinks the authors are too quick to expand definitions which will inevitably lead drug companies to step in and push for meds for people who could do without them.  Frances is in a good position to comment because he was in charge of the DSM-4.  He is very up front about his own failings in having lead that installment and apologizes for his mistakes.  It is extraordinarily refreshing to hear someone with such a level of authority offer a public apology. 

One of the diagnostic overreaches that he addresses is 'psychosis risk syndrome'.  We are close to being able to identify people who are at high risk of developing psychotic disorders like schizophrenia.  We know many of the risk factors including certain genetic markers, we think that delaying onset of schizophrenia means being less sick and we know that being very sick with schizophrenia is very hard.  Why not target teens who are at elevated risk and are exhibiting "prodrome" symptoms; self-isolation, quirky or aggressive behaviour in the hopes of forestalling or even preventing the onset?  Frances gives a very good answer to that.  First of all, target them with what?  The answer will probably be anti-psychotic medication.  We have no indication that taking anti-psychotics before developing psychosis will help stave off or mitigate the effects of schizophrenia and the side effects can be very serious, including obesity and diabetes and everything that comes with that.  And, he points out, we can identify teens who are at risk, but that would probably involve identifying a lot of kids who will never develop the disease and potentially subjecting them to this very serious intervention.  It begins to look a lot like the aggressive screening and treatment of prostate cancer, too many people, too invasive for limited benefit.  Frances doesn't mention the possibility that teens who are identified might benefit from interventions that have less potential downside like counseling about delaying use of street drugs including marijuana and psycho-education about reality testing.  Given the way Quebec is headed, it seems unlikely that we will see a targeted public health campaign that relies on disease prevention using labour-intensive methods like psychoeducation.  

Frances also alludes to something I have mentioned elsewhere in this blog; namely that not all conditions of the human soul are diseases in any recognizable sense and yet increasingly the DSM includes them.  The idea that mild to moderate depression, or attention deficit disorder, or anxiety is a neurochemical imbalance fits very nicely with a drug company's bottom line.  The emphasis of the last twenty years on neuroscience has tilted us towards a chemical fix for ailments of the mind.  Yet not one significant advance in diagnosis or treatment of mental illness has come out of all the important research on neuroscience so far.  Diagnosis remains entirely symptom-based.  The mechanisms for the function of treatments is poorly understood, if at all. 

All of this may seem very much like “inside baseball” for people who don’t spend their days thinking about mental health but Frances makes a persuasive case that a lot of people are already getting a lot of powerful psychiatric medication that they don’t need...

All of this may seem very much like "inside baseball" for people who don't spend their days thinking about  mental health but Frances makes a persuasive case that a lot of people are already getting a lot of powerful psychiatric medication that they don't need, medicines with serious side-effects that may not have been adequately tested on the populations for whom they are being prescribed.  He reports that the sale of anti-psychotic drugs at $18 billion (US) now delivers more cash to the pharmaceutical industry than anti-depressants.  Anyone who has any experience with them knows anti-psychotics are powerful medications with very serious potential side-effects.  They are helpful to people with psychosis.  But now they are being marketed for use with children and the elderly.  20% of people treated by primary care physicians for anxiety now receive an anti-psychotic as well, according to Frances.  The trend towards GPs prescribing psycho-active medication is troubling for Frances as well.  That GPs give out anti-depressants and anti-anxiety medications routinely should surprise no one, but I was amazed to learn that 50% of anti-psychotics are prescribed by GPs.  (I am not sure if that accounts for GPs taking over the prescription of anti-psychotics after an initial prescription by a psychiatrist.)  Frances goes through the familiar litany of the dangers and over-promises regarding SSRIs for treating the 'worried-well' market.  These are problems we see here in Quebec, though certainly not to the degree they are experienced in the US. 

Whose fault is all of this?  For Frances the answer is pretty clear.  Big Pharma and the big money it is willing to throw around to advertise direct to consumers (only in the US and -- apparently -- New Zealand as well), to co-opt the better judgement of doctors and researchers as well as to fight legal battles and pay fines when they get caught behaving badly (as with the off-label marketing of anti-psychotics for kids).  He gives policy recommendations for taming the excesses of big pharma.  Naturally, dear to my heart are all the plugs that he makes for psychotherapy as an alternative or adjunct to pharmacology. 

There is no organized psychotherapy industry to mount a concerted competitive push-back against the excessive use of drugs.
— Saving Normal

Here in Quebec, we are retrenching from any kind of public outpatient psychotherapy, at great cost to our well-being, I believe.  It is nearly impossible in Montreal to get psychotherapy at a CLSC (public health and social service clinic).  This despite the fact that we know that psychotherapy can sometimes head off   episodes of serious mental illness later for certain people and keep them from needing much more expensive hospital care.  Follow-up care after a psychiatric hospitalization is spotty and seems unlikely to get better with more cuts coming. 

The lack of a credible alternative is part of what is fueling the appetite for drugs. If we want to see the biomedical model of mental illness restored to a more modest role and with it the role of psychotropic medication, we need to take seriously the challenge of collectively creating a psychotherapy that is credible to the people it can help.

While I am a believer in psychotherapy, if I have a quibble with Frances, it is over this.  My experience is that many psychiatrists and other psychotherapists have been and continue to be high-handed, overly jargonistic, faddish, opaque and sometimes deeply anti-scientific.  Frances himself mentions the terribly misguided satanic ritual abuse accusations of the 1990s and the role played by therapists who "developed and instant expertise on day care sex."  Many people mistrust us because they view psychotherapy as elitist mumbo-jumbo that changes tack every ten years.  All those primary care doctors who are prescribing medications rather than sending their patients to therapists don't trust talk therapy.  Why should patients?  Hell, I have met quite a few psychiatrists who don't have faith in psychotherapy.  The lack of a credible alternative is part of what is fueling the appetite for drugs.  If we want to see the biomedical model of mental illness restored to a more modest role and with it the role of psychotropic medication, we need to take seriously the challenge of collectively creating a psychotherapy that is credible to the people it can help. 

Mystics in Therapy

I read a wonderful reflection on mysticism the other day and started to think about what makes it hard to put some things into words. 

Mysticism is a seemingly positive term that denotes a negative, as the word darkness, which seems a positive term, denotes only an absence — the absence of light... A nonmystic is someone who believes that when truth is explained to him in words, he should understand that truth. The mystic is some one who knows that real truth, meaningful truth, can never be fully expressed in words.
— Joseph Dan, The Heart and the Fountain, p 2-3

Sometimes I see clients in therapy who are mystics in the sense that Dan describes.  They may not identify as spiritually inclined but they mistrust language to adequately convey truth.  Dan goes on to says that for the mystic, "Only the trivial, or the false can be communicated and understood."  It is hard to administer a talking cure when a person views language as untruthful. 

Sometimes mysticism looks like a defense.  I will say something like: "Did that make you sad?"  The mystic replies "Not exactly sad."  I say, "So how would you describe the feeling?"  The mystic: "I can't describe it."  Talking about feelings is like dancing about architecture.  But in this scenario the mystic also can't dance about dance.  The mystic ineffability of inner experience can be a way not to experience feelings.  For many people, saying "I am sad" with intention is akin to God saying "Let there be light."  It is the baldest, most powerful truth of all, in that it creates the reality to which it refers.  (An odd variant on this theme: saying to another person, "I feel lonely" with intention can be a powerfully connecting thing).

Because being a mystic means having access to a truth which cannot be adequately conveyed, it holds a special status, for good or ill.  "I am sad," is a profoundly human statement, and it makes me like 99% of my fellow humans who have experienced sadness.  Saying "The word 'sad' is inadequate to describe what I am experiencing," means I stand alone.  Being an unremarkable human with unremarkable human feelings can feel good a.k.a. 'normalized,' or bad (as in 'unimportant').  To connect with another risks making my experience banal. 

Mysticism and depression are two degrees of separation apart.  Nihilism is the missing link.  The mystic denies the possibility of being able to bridge the gap between one's self and the universe beyond through language.  The nihilist denies the possibility of bridging the gap between self and other entirely.  Depression is the affective prison in which a person is convinced of the impossibility of connection with others, the world of sensation, God, even elements of the self. 

Some therapies have taken the mystical contention about language to heart.  Sue Johnson, the founder of Emotionally Focused Therapy views purely cognitive therapies as flawed because they don't address affective truth, a felt, experienced truth that is prior to and largely inaccessible through language or at least through cognitive language alone.  (I find it ironic that Sue Johnson has spent tremendous effort to empirically demonstrate EFT's claims that reasoning is insufficient for addressing matters of the heart.)

Rabbi Shais Taub talks about addiction as an expression of the urge to transcendence that is part of mysticism.  "Crippling self-consciousness is the root of addiction.  When they (the addict) take this poison it simulates the effect of spirituality in that there's this release from ego, rather than being self-transcendent release from ego... it is a self destructive release from ego.  ...(T)elling the addict... 'Don't you see you're destroying yourself?' is the most ridiculous thing you can say because if they could articulate what their soul they would say  'Yes, I am trying to destroy Self.'"  (You can listen to the whole episode of Tapestry here.  The interview with Rabbi Taub is at about 19 minutes).

I feel both the mystic's tendency to view some of the most important things as ineffable, the desire to connect outside of language and to transcend the crippling 'self'.  But I also feel a hard-headed commitment to the 'communicability' of many of our most complex and difficult truths. 

"It is not in heaven so that one could say, 'Who will go up to heaven for us, to get it for us and make us listen to it, to do it?' "Nor is it beyond the sea so that one could say, 'Who will cross the sea for us, to get it for us and make us listen to it, to do it?'"   For the thing is very close to you, in your mouth, and in your heart, to do it."






Is 'crazy' an illness?

I have been working in an inpatient psychiatric ward in a hospital for almost a year.  It has been sad and joyful and sometimes boring or infuriating and full of discovery and very occasionally frightening.  Before February, the last time I had been in an inpatient psychiatric facility was twenty years ago when I was a social work student at Columbia and I went on a visit to Ward's Island in New York.  In between, I viewed inpatient psychiatry as the place where people who were 'truly mentally ill' were treated.  By contrast, the people I worked with, people who were not in hospital beds, didn't seem ill in the same way that someone who is diabetic or has cancer is ill.  Of course, I would speak of mental illness when I talked about moderate depression or anxiety or Asperger's syndrome.  There are good reasons for this.  I have always believed that a person's biology is intertwined with how his or her mind works.  The things for which people seek the help of a therapist or a social worker are impacted by their brain chemistry, their genes, in short the organism in which the mind arises.  And almost everyone finds having a mental illness -- a biological condition -- less shameful and frightening than being labeled crazy. 

But I was never fully convinced that these conditions were illnesses like physical illnesses, either.  I am not a doctor and perhaps my layperson's lingering idea of illness -- a microbe from without setting to work to destroy tissues -- is part of the reason I have resisted the description of these conditions as mental illness (most types of cancers and diabetes do not meet this definition of illness).  Still, I imagined that behind the doors of a psychiatric ward there were examples of mental illness that clearly demonstrated a causal connection, while yet poorly understood, between disorders of the mind and the physical organism. 

I feel like my ideas about mental illness have been made more confused not more clear by working with people whose minds are so disordered they need to be in hospital.  I sat in the hospital hallway with a man who positively knew that someone was breaking into his brother's home hundreds of miles away.  When I asked him how he knew, he could not give any answer except that he knew.  The fact that his idea made no sense to others or to himself did not diminish its intensity.  But it saddened him deeply; he understood -- at least in part -- that this thought was nonsensical, yet it was absolutely real for him.  It seemed to me, at that moment, that something biological was clearly going on, as if this man had suffered a brain injury and it was only a matter of time before medical science could discover where exactly it was located and how he might be helped.  I imagine that almost everyone who has worked with people with schizophrenia must have had this experience and yet the causes of schizophrenia remain unknown after a century of research, and treatment is focused on symptom management.  This man has lived much of his adult life absolutely bubbling with paranoid ideas and the accompanying sadness and frustration of not understanding where these ideas come from. 

There are people who come into hospital deformed by love.  There are the suicide attempts and the severe depressive episodes brought about by failed or elusive love.  Occasionally people with no previous history of mental illness come to emergency manic and delusional because love has gone wrong.  On the one hand this is the most easy form of disturbance to extrapolate from for most people; everyone has experienced heartbreak or rejection and can imagine him or herself driven to extremes by love.  But it is precisely this universality that makes those who end up in psychiatry unusual.  After all, what makes one person see his love everywhere, believe she is sending him messages through strangers, chase her barefoot all over the city and fight with police and security guards, when nine hundred and ninety-nine other rejected suitors cry, listen to sad music and then move on?  Is that the difference between health and illness?  Or is it something else? 

In the hospital psychiatry ward you can find people who just about everyone would agree are ill.  Even though no one can explain exactly the mechanism, it seems that their biology is making their minds work very differently from the minds of most people and often in ways that feel awful to them and put them in danger.  But mental illness of this unmistakable type is a I-know-it-when-I-see-it kind of phenomenon because for every clear-cut case there are people who are odd or sad or exuberant who fall in a grey zone. 

None of the disorders treated by psychiatry today have a blood test or pathology lab test for diagnosis.  They are all diagnosed by symptoms and reading symptoms remains quite subjective. 

How we think about disorders of the mind has a real impact.  One of the most powerful impacts is the use of drugs to treat mental disorders to the exclusion of talk therapy.  Thankfully we have left behind the era of  psychoanalysis to treat schizophrenics (as well as  cruel theories about how schizophrenia was caused by bad mothering).  But now we have moved to a situation where -- in Quebec, anyway -- talk therapy is almost never viewed as a way to treat mental illness despite its proven effectiveness for many -- though not all -- disorders.  People discharged from hospital for surgery can get physio and occupational therapy to help with recovery as part of the services covered under their provincial health insurance.  Psychotherapy is almost impossible to get in the public system either in hospital or out.  I think that this is partly a function of not viewing talk therapy as a way to address a medical illness.  How can an illness be treated by talking?  As much as disorders of the mind may not look like illnesses, talk therapy doesn't look like medicine.  Not to patients and not to doctors and certainly not to ministers of health.

Here is a story that illustrates the constraints of operating solely with a illness/health model of the mind.  A man in his late forties was brought into hospital for running around in traffic.  He was a chronic schizophrenic.  How did we know?  Because that was his diagnosis for many years.  It was also possible that he had a mild intellectual handicap.  Doctors over the years had examined him and observed symptoms that pointed to these conclusions.  The psychiatrist I was working with spent a long time talking to him and his family.  What we learned was that the man had experienced a terrible set of traumas when he was young and had used a lot of street drugs.  He was very reticent but eventually he talked about the toll that the pain he had experienced had taken and his guilt over what he had done to others.  For years he had been a patient of various psychiatrists who saw a painfully inarticulate, inwardly focused man who had gone spectacularly off the rails at eighteen and came to the conclusion that he was schizophrenic.  But with time it became clear that he was a confused, deeply hurt person (absolutely no intellectual handicap) with very little if any of the psychotic features that are integral to schizophrenia.  The voices that he had reported hearing telling him he was bad were much closer to the 'voice' I hear in my head telling me that I better get my work done than the voice a psychotic person hears which causes him or her to look for someone speaking.  He had never,  in the course of twenty plus years of psychiatric treatment, been given enough space to talk.  When we asked him why he was running around in traffic pulling on car doors, he said "I guess I wanted to get away." 

This is not just a story about misdiagnosis, "House goes to the psychiatric floor."  It is a story about using the tools of medicine to examine something adjacent to -- but not the same as -- medicine.  Not every affliction of the human heart calls for a cardiologist. 

The physician, who through his studies has learned so much that is hidden from the laity, can realize in his thought the causes and alterations of the brain disorders in patients suffering from apoplexy or dementia, a representation which must be right up to a certain point, for by it he is enabled to understand the nature of each symptom. But before the details of hysterical symptoms, all his knowledge, his anatomical-physiological and pathological education, desert him. He cannot understand hysteria. He is in the same position before it as the layman. And that is not agreeable to anyone who is in the habit of setting such a high valuation upon his knowledge. Hystericals, accordingly, tend to lose his sympathy; he considers them persons who overstep the laws of his science, as the orthodox regard heretics; he ascribes to them all possible evils, blames them for exaggeration and intentional deceit, “simulation,” and he punishes them by withdrawing his interest.
— Freud, five lectures on psychoanalysis

Anger, Aggression & Diplomacy real and imagined

At the beginning of this week's This American Life there's a piece in which the writer David Hill,  who has dabbled in playing the strategy game Diplomacy, takes Dennis Ross, Bill Clinton's old Middle East envoy, to the world championship of the game. 

It is based on Hill's article in Grantland.  A couple of things were percolating in my head when I heard this.  The most prominent was that Dennis Ross seems like a jerk.  As much of a jerk as the people who get angry and overturn the board and yell at the Diplomacy tournaments.  Maybe more.  Not because he is evilly-intentioned or malicious.  Quite the opposite. 

Dennis Ross is sometimes referred to as the architect of the Oslo Peace accord.  For those who don't remember, the Oslo accord in 1993 brought together then Israeli prime-minister Yitshak Rabin and PLO chairman Yasser Arafat to agree on movement towards a two-state solution to the long-standing fight between Israeli Jews and Palestinian Arabs.  There are people who spend a lifetime studying the ins and outs of these things and they can't agree what went wrong, but one thing is clear in the summer of 2014 as a war rages in Gaza and the south of Israel; the Oslo peace process did not lead to anything that anyone could call a solution.  Meanwhile Dennis Ross is a prof at Georgetown in the school of foreign service and a Distinguished Fellow at a fancy institute and Diplomacy coach for hire. 

I am not going to go on about Gaza and Israel.  My interest here is in the dangers of bringing in expert-consultants and why some people chronically behave badly in interpersonal situations and what they have to do with each other.

Dennis Ross could have told David Hill, "If you want to win, don't take me to the game.  You will be painting a huge bulls-eye on your back.  And since I am busy at Georgetown I won't be able to stay and clean up the mess you will make for yourself."  Instead Ross comes in, gives advice based on his gut and his experience, then leaves Hill in an awful situation, possibly a worse situation than if he had just said "No."  Experts generally give bad advice. There are a lot of reasons for this.

1. Experience itself is at best an indifferent teacher.  People need clear, unambiguous, immediate feedback in order to learn.  In complex areas like adult human interactions its very hard to build in such feedback.  When Ross claimed there was a resemblance in the body-language between a Diplomacy player and a Soviet diplomat he dealt with I groaned.  I imagined hearing a cop say "Evidence?! I don't need evidence.  I've seen lots of guilty people and I can tell when someone is guilty."  Which leads to number 2...

2. People who believe they are great at reading people are usually no better than average and sometimes worse.   

3. Experts don't have to live with the consequences of their advice.  But their clients do.  In therapy, I very  rarely give advice.  I look at what I see and hear and offer it back to my clients.  I ask what it means for them.  I try to give them different perspectives on their situation, but I m extremely reluctantly to give advice or make predictions, first because I will likely as not get it wrong and, second because they have to live with the consequences, not me. 

I once worked at a social service agency.  The bosses brought in a consultant who started the session by saying something like, "I usually consult for business.  I don't know anything about mental health and social services but I am sure the principles of managing an organization I will teach you are the same."  I felt like I'd been slapped.  To me, it is rude to come into a room full of people who have over a hundred years of collective experience in their work and say, "Please do not confuse me with information about what you do."  If a consultant or expert is talking more than s/he is listening s/he isn't worth paying attention to. 

The second thing that caught my attention in this piece had to do with angry aggression.  There is a lot of discussion in the piece about whether a person's anger is real or strategic.  Angry aggression like swearing, yelling, threatening and ultimately violence is profoundly paradoxical in that it is a way of gaining control by 'losing control'  Virginia Goldner has written wonderfully (here for example) from a feminist, psycho-therapeutic perspective about how abusive men's anger is both a willed act of control and an out of control act.  Someone else's aggression often provokes such strong reactions in us, even when we know that there is no threat of violence, because it can makes us feel dominated, like control is being wrested from us. 

Because it is so frightening, people who aren't comfortable with strong, aggressive expressions of anger, often treat badly-behaved, angry people like they are weather systems, irrational forces of nature, vaguely predictable, but absolutely uncontrollable.  This can be a great way for the angry person to get others to defer or comply.  Most angry people have absorbed this; the out-of-control expression of real anger gets them what they want.  Angry aggression can be highly adaptive, at least until it becomes a disaster. 

Which brings us back to Diplomacy and one of the questions posed in the piece: How can less aggressive people deal with aggression?  One of the things that the piece explores is the context of angry aggression.  In the game what is strategic, would be unacceptable in real-life.  Except those boundaries are kept deliberately vague.  People are unsure whether aggression is notional or real.   The possibility that anger is real and may become out-of-control is what gives it its power.  If there were a card in Diplomacy that you could present to another player that said "I storm off, angrily," it would have no impact.  For anger to get people to change their behaviour, it has to be real enough

One of the most pernicious things Ross does is not to account for what the real-enough aggression of other players will do to Hill.  Most people can learn to become more detached from another person's angry aggression, to feel less out-of-control in the face of it.  Angry aggressive people can learn they won't regain dominance through an intimidating 'loss of control.'   But that takes time and establishing safety, things Ross (and IMHO many other fly-in consultants) view as outside their job description.