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Targeting the clinical grey areas in mental health treatment

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People with mental health diagnoses falling into clinical grey areas need the most help. Grey areas exist where clinical research and skills don’t have teeth to intervene effectively for people in distress. I have used the words’ mental health’, ‘mental illness, and ‘disorder’ interchangeably. I will no longer be so casual with my speech. 

Now, I realize each term has a specific use and meaning. Clinicians need to communicate with their patients and provide effective psychoeducation. Patients will never truly understand their clinical picture without hearing their therapists use the most appropriate language. 

Significantly impaired people have disjointed beliefs about what they can and can’t do. On many levels, a person’s insight into their impairments or limitations is stuck in time before their brain suffered structural or neurological damage. Unfortunately, tissue damage is often not reversible, with many people living with severe and persistent mental illness. Research indicates tissue damage is likely caused by having multiple psychotic episodes without periods of remission.

The author of the book I am Not Sick, I Don’t Need help, Xavier Amadortalks about the impact of neurological damage on the brain. On an organic level, psychotic episodes can result in neurological and brain damage. As a therapist, I have observed the impact of brain damage in the lives of people with severe mental health disorders. 

The effect is far-reaching and devastating in terms of the profound, pervasive insight loss and judgment. In these cases, it is not life stressors or clinical symptoms that require the attention of a therapist or psychiatrist. Their mental health symptoms cause only a tiny part of their distress despite being a considerable part of their everyday experience. 

This disconnect throws off and confuses so many therapists when mapping out treatment plans. Clinicians often think therapy must target symptoms if a patient is to experience relief from their disorder. In rounds, the patients I describe are often the ‘problem patients and ‘frequent flyers’ in the ER. The real issue is clinicians’ failure to identify the best possible course of treatment. 

The clinical greyness I described earlier often makes choosing the proper treatment fit difficult. The result is the deferral of progress, favorable outcomes, and the stabilization of clients in distress. My point is this is happening because clinicians have their blinders up and only see a tiny part of the bigger clinical picture. Clinicians do not understand that clinical symptoms are only a tiny part of their patient’s distress. 

As a therapist, I listen to other practitioners talk about their patients. In doing so, therapists toss around ideas and consult with each other. Sometimes, my head spins when I listen to their views when discussing clinical grey areas and how this impacts the treatment of people with SMI conditions. The conversation usually takes a dip at this point and a more somber tone as very often therapists’ biggest weakness, in terms of their clinical skill set, falls into this under-researched area of human behavior.

It comes down to this; treatment providers need to appreciate the complex and broken aspects of people’s lives they serve. More importantly, to truly support healing, therapists must focus on strengthening the human self-driven capacity for their patients to direct the world around them. To move patients closer to their dreams and goals requires supporting patients strive to obtain or maintain the standard or quality of life they deem appropriate.

Practitioners love to put together treatment plans to address the interfering symptoms. The supposed symptoms get in the way of patients reaching their goals. My point is that logic is a farse and terrible clinical judgment. In treating SMI populations, treating symptoms is not the biggest clinical issue. Most SMI folks have severe tissue damage. Depending on the individual’s goals, more attention needs to center on quality of life to drive treatment ahead. Practitioners need to strengthen the weak points in a person’s functioning. These are the areas impacted by tissue damage from chronic psychosis. Metaphorically speaking, clinicians need to extinguish the house fire before rebuilding the home or cleaning it up enough to be livable. 

To this end, clinicians need to create pathways for a person to maintain their desired quality of living. Therapists focused on working on the interfering or unresolved symptoms reject the organic and human implications of SMI on the body. Some people never experience relief from their symptoms. Due to extreme chronicity or untreatable impairments, sometimes people don’t experience comfort. Not every sign is rooted in a diagnosis, either. 

Sometimes, flaws in our personalities govern the expression of our limitations. Clinicians need to refocus treatment to target and identify the weak points in a person’s functioning regardless of the symptom blocking and creating impairments. Clinicians and peers dwell on unresolved and chronic symptoms as if strengthening a person’s weaknesses in functioning wouldn’t help them move in their healing.  In the end, patients more in command of their lives are more likely to be clinically stable.

Clinicians must address their patients’ impairments requiring ongoing care. Like the emphysema patient on oxygen, sometimes daily maintenance is the only way to keep moving and is the extent of recovery for people with SMI. Being an honest therapist and communicating with your patient will go a lot further than waiting for the miracle cure or, even worse, ignoring the problem because it’s unmanageable. Good health means healing and viable self-management skills. It isn’t the diagnosis or prevailing symptoms that must always be the focus of therapy.

About the Author

J. Peters

Max Guttman is the owner of Recovery Now, a private mental health practice in New York City. Through his work as a Licensed Clinical Social Worker, therapist, and disability rights advocate, Max fights for those without a voice in various New York City care systems. He received a ‘2020 Bearcats of the Last Decade 10 Under 10’ award from the Binghamton University Alumni Association.

Guttman treats clients with anxiety and depression but specializes in issues related to psychosis or schizoaffective spectrum disorders. He frequently writes about his lived experiences with schizophrenia.

‘I knew my illness was so complex that I’d need a professional understanding of its treatment to gain any real momentum in recovery,’ Guttman says. ‘After undergraduate school and the onset of my illness, I evaluated different graduate programs that could serve as a career and mechanism to guide and direct my self-care. After experiencing the helping hand of my social worker and therapist right after my ‘break,’ I chose social work education because of its robust skill set and foundation of knowledge I needed to heal and help others.’

‘In a world of increasing tragedy, we should help people learn from our lived experiences. My experience brings humility, authenticity, and candidness to my practice. People genuinely appreciate candidness when it comes to their health and Recovery. Humility provides space for mistakes and appraisal of progress. I thank my lived experience for contributing a more egalitarian therapeutic experience for my clients.’

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J. Peters

J. Peters

Max Guttman is the owner of Recovery Now, a private mental health practice in New York City. Through his work as a Licensed Clinical Social Worker, therapist, and disability rights advocate, Max fights for those without a voice in various New York City care systems. He received a ‘2020 Bearcats of the Last Decade 10 Under 10’ award from the Binghamton University Alumni Association. Guttman treats clients with anxiety and depression but specializes in issues related to psychosis or schizoaffective spectrum disorders. He frequently writes about his lived experiences with schizophrenia. ‘I knew my illness was so complex that I’d need a professional understanding of its treatment to gain any real momentum in recovery,’ Guttman says. ‘After undergraduate school and the onset of my illness, I evaluated different graduate programs that could serve as a career and mechanism to guide and direct my self-care. After experiencing the helping hand of my social worker and therapist right after my ‘break,’ I chose social work education because of its robust skill set and foundation of knowledge I needed to heal and help others.’ ‘In a world of increasing tragedy, we should help people learn from our lived experiences. My experience brings humility, authenticity, and candidness to my practice. People genuinely appreciate candidness when it comes to their health and Recovery. Humility provides space for mistakes and appraisal of progress. I thank my lived experience for contributing a more egalitarian therapeutic experience for my clients.’

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