Who delivers mental health care?

Dr. Suzanne Koven has just written a great blog post that is required reading for anyone who cares about mental health care in North America, called "Should Mental Health Care be a Primary-Care Doctor's Job?"  She points out the degree to which medical mental health care has been downloaded to primary care docs who may or may not feel up to the task. 

“I’m comfortable helping people get through life’s more common emotional challenges, like divorce, retirement, disappointing children. If you’re hearing voices, or if you walk into my office and announce that you’ve decided to kill yourself, as someone did not long ago, I know exactly what to do: escort you to a psychiatrist. But what about the lawyer who’s having trouble meeting deadlines and wants medication for attention-deficit disorder? Or the businesswoman whose therapist told her to see me about starting an antidepressant? Or the civil servant trying to shake his Oxycontin addiction? They’ve all asked me to treat them because they don’t want or can’t easily access psychiatric care. ”

Here in Quebec, the recent Bill 21, which regulates the act of psychotherapy, gives physicians automatic access to the title of psychotherapist though their training in mental illness and mental health may be limited depending on what their experience in medical school and residency was.  While there are many doctors who are great psychotherapists and who have taken the time to get trained, becoming a doctor involves training in diagnosis of mental illness and some psycho-pharmacology and only a cursory understanding of different forms of psychotherapy.  (The purpose of Bill 21 is to protect the public by ensuring a minimum of training for psychotherapists.  It has serious ramifications for people who use mental health services but remains largely unexamined in French or in English media). 

Dr. Koven points out that fewer medical students are going into psychiatry in the US (sorry, I can't give Canadian stats) so both the public and general physicians have less access to doctors who specialize in mental health.  I also have seen that there is a feeling among patients that psychiatrists are pill-pushers while a GP may be more accessible and take the time to know a patient better ad this may make people even more likely to rely on generalists.  (My experience of psychiatrists has actually been that they are more likely to prescribe talk therapy with or without medication than GPs, but that is very impressionistic.) 

Recent changes to the way health care is delivered in Quebec make it harder to access a psychiatrist directly through the public system.  In order to see a psychiatrist you must first go to a public health clinic, a CLSC, rather than go to a psychiatrist in the public system directly (except for emergencies).  This can be good because people can be seen by a social worker or psychologist at a CLSC which may be what they need, but it re-enforces the model of psychiatry being practiced only with the very seriously mentally ill or the very wealthy.  Finding a psychiatrist to really follow someone with obsessive compulsive disorder, for example, to ensure that medication is appropriate and effective and to consult with the therapist, whether s/he is a GP or a social worker, is very hard.  It may account for why fewer people want to go into the field, too.  After all, who wants to go into a medical specialty where you are supposed to fathom the mysteries of the human heart and human relationships but are unable to form relationships with patients because you see them on an assembly line, and on top of that, you will mostly see people whose illnesses can at best be managed but are without cure? 

The label of "sex addict" and sex negativity.

Dr. Marty Klein makes a really fascinating argument about the term "sex addiction" in an article in "The Humanist"; that that label  is a way for people not to have to reckon with the conflict between their desire for what certain kinds of sex gives them and the consequences of acting out their desires.    

“New patients tell me all the time how they can’t keep from doing self-destructive sexual things; still, I see no sex addiction. Instead, I see people regretting the sexual choices they make, often denying that these are decisions. I see people wanting to change, but not wanting to give up what makes them feel alive or young or loved or adequate; wanting the advantages of changing, but not wanting to give up what makes them feel they’re better or sexier or naughtier than other people. Most importantly, I see people wanting to stop doing what makes them feel powerful, attractive, or loved, but since they don’t want to stop feeling powerful, attractive or loved, they can’t seem to stop the repetitive sex clumsily designed to create those feelings.”

— http://thehumanist.org/july-august-2012/you%E2%80%99re-addicted-to-what/

He goes on to argue that this condition of wanting certain things sexually and not wanting to take responsibility for the consequences is made more troublesome by a sex-negative culture which punishes people for wanting any kind of sex or relationship that isn't socially sanctioned. 

“...the diagnosis of sex addiction is in many ways a diagnosis of discomfort with one’s own sexuality, or of being at odds with cultural definitions of normal sex, and struggling with that contrast...”

The culture today communicates two out-of-sync messages about sex pretty strongly; one, that we should be ecstatically sexually fulfilled all the time and two, that non-socially-sanctioned sex is highly dangerous and scary (gay, non-monogamous, kinky).  And there is the meta-message which says that commenting on the discrepancy between these two messages -- "Everybody may not be sexually and romantically fulfilled with one, opposite-sex partner for the rest of their lives" -- is not allowed.  A million romcoms have taught us that everyone will end up in a monogamous, same-sex couple and will never feel the desire to masturbate or fantasize about other people or look at pornography because they are so fulfilled.  According to Marty Klein, the label "sex addiction" leaves us stuck in that double bind rather than helping us step out of it. 

"You worked hard" not "You're so smart"

Po Bronson, (co-author with Ashley Merryman of the great book "Nurtureshock") wrote an article a few years ago called "How not to talk to your kids" about the pitfalls for kids of receiving certain kinds of praise.  It was based largely on the work of researcher Carol Dweck.   

““When we praise children for their intelligence,” Dweck wrote in her study summary, “we tell them that this is the name of the game: Look smart, don’t risk making mistakes.” And that’s what the fifth-graders had done: They’d chosen to look smart and avoid the risk of being embarrassed.”

The article is a great read and the research is an example of interesting social science (that doesn't rely on over-interpreted fMRI images).  The upshot is that kids, probably all of us, need to be encouraged to view intelligence as maleable and process-related rather than static and inherent.  It is a good way to avoid trapping kids in what Alice Miller called the "drama of the gifted child," the need to protect a false, perfect image of one's self from failure.  "You worked hard" encourages us to try new things and, as the incomparable Ms. Frizzle says, "Get messy.  Make Mistakes."

When do kids 'get' irony?

The ability to understand that other people have different ideas and information about the world from one's self emerges in most kids by around four years old.  This ability that most of us share is really nicely illustrated by this video.  According to psychologist (and brother-of-Borat) Simon Baron-Cohen, kids with Autism Spectrum disorder have a much harder time with tasks such as these.  A recent study in Frontiers in Psychology found that empathy and the ability to understand irony are correlated in kids. 

“Empathy was strongly associated with several aspects of irony comprehension and processing, suggesting that emotional reasoning abilities are important to development of irony comprehension. ”

— http://www.frontiersin.org/Journal/10.3389/fpsyg.2013.00691/full#h5

Makes sense.  Irony is a disconnect between what a person says and his or her inner state.  By around eight years of age most kids can 'get' that disconnect.  The authors point out that these are both areas that are difficult for people with ASDs.  Empathy and reading irony both require projecting one's self into another person's inner experience; Theory of Mind.  In the case of irony, one has to do that while swimming upstream, as it were, against the current of the literal message.  I have noticed in my practice how hard and frustrating it is for kids with ASDs to read and irony. 

3 great insights into couples' trust and betrayal in 4 1/2 minutes

John Gottman, the most important researcher into how couples function and fail working today, offers three great, research-based insights into what helps or hurts relationships. 

We have a choice to turn away or connect with our partner dozens of times a day and that is more important for the health of a relationship than betrayal itself.  What turning towards a partner looks like: ATTUNE, an acronym for Awareness of feelings, Turning towards the feeling, Tolerance of two different viewpoints, seeking Understanding of one's partner, responding Non-defensively, Empathy.  How CLalt (Comparison Level Alternative or "I can do better") when you are frustrated with a partner can lead to relationship destroying cascades.  Great!

What's in a marshmallow?

I mean aside from gelatin and sugar... 

This great video shows a recreation of the Stanford Marshmallow Experiment.  It's funny but behind it is a really interesting and somewhat daunting piece of social science.  The Stanford psychologist, Walter Mischel, who performed this experiment in the late 60s and early 70s wasn't looking for cute video of kids contorting themselves to exercise some restraint.  He wanted to know when children develop the ability to defer gratification, when do they become able to say, "I'll suffer a little now for a payoff later".  He wanted to know what variables allow children to hold out and what internal mechanisms they used to defer getting the goodies.  It was no surprise to Mischel that older children generally held out more effectively for the doubled treat.  What was most surprising was that happened when Mischel followed up with the original test subjects years later.  Mischel and others have found that when adjusted for age at the time of the original testing, children who put off eating the marshmallow do better on SATs are more socially competent and self-assured, feel a higher sense of self-worth and are perceived by their parents as more mature.  They cope better with stress, are more likely to plan ahead, and more likely to use reason.  It turns out that learning how to defer gratification is incredibly important in our society.  No doubt some of us are genetically predisposed to be a little bit better at deferring gratification than others, but there definitely learned skills that make up a huge piece of it.  Learning to distract one's self and focus on the promised reward are important pieces that can be learned.  Another important piece which isn't often mentioned in discussion of the marshmallow experiment is trust.  In his original experiments, MIschel had some kids get betrayed by the tester in a small way before being offered the marshmallow.  Quite sensibly, they were much more likely to gobble what was in front of them rather than wait for a reward offered by someone untrustworthy.  Kids who learn that others generally follow through on their commitments will be more likely to defer gratification and reap the benefits.  Kids whose experience shows them that people don't follow through will be prepared for a world of subsistence, grabbing what they can in the moment. 

So what's the takeaway.  Give your kids practice with deferred gratification. View deferring gratification as a set of skills that can be improved.  Those old parental standbys, distraction, focusing on the future benefits need to be repeated and repeated and repeated.  And make sure to follow-through with what you said.  Deferred gratification on;y makes sense when you think you have a chance of getting the second marshmallow in the end. 

A lovely piece on the delights of Daydreaming

Brain Pickings' Maria Popova has a beautiful piece about the largely forgotten work of psychologist Jerome Singer on daydreaming, its under-heralded benefits and some pitfalls for our mental health, and how it has recently been dusted off by cognitive psychologists.  I am sure this will bring delight to my fellow wool-gatherers and middle-distance-gazers.

Is it discipline or punishment?

Distilled parenting wisdom has it that discipline helps kids and teenagers understand limits, have a sense that caring adults are watching out for them, and that the world has some order.  Punishment makes them feel bad about themselves and more out-of-control.  Tim Elmore makes the point again in Huffpost and has research findings from the University of Pittsburgh which he says back it up.  But discipline and punishment can look very similar.  Just calling something a consequence doesn't make it nurturing limit-setting.  When you are a parent or teacher, frustrated with a young person who has failed to follow the rules, it can be really hard to know if what you are doing is discipline or punishment (this assumes that the rules are reasonable). 

Elmore points out a really good way to distinguish between punishment and discipline if you aren't sure: future-oriented versus past-oriented.  If you want to discipline a kid, ask yourself,  "Is what I am thinking about doing (grounding, taking away a privilege, ignoring the behaviour, giving a warning) going to help this kid do better in the future?"  Punishment tends to be more backward-looking, while discipline is about doing it differently next time.  This takes some self-knowledge ("Am I acting out my anger or frustration or fear about what happened?") and some knowledge of the kid ("Is this consequence likely to help her -- in all her wonderful, infuriating uniqueness -- make a change?").  Sometimes just calling the question can help.  "I want to figure out what we need to do that is going to help you do it right the next time." 

One final note: as with all "parenting" expertise, if, after a fair try,  this tool leaves you feeling tied up in knots it should probably be jettisoned.  Being confident with your child or students is important and the parento-advice industrial complex can sometimes rob parents and educators of that.  Go forth and conquer, gently!