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26 Jan 2022

Tag: Science

An Effort To Explain “Psychosis”

When confronted with a disturbed loved one, especially one who has been in the hospital with a psychiatric diagnosis, many people hear the word “psychotic” used to describe their behavior or thought patterns. What exactly does this term mean?

 

First of all, it is imperative to understand that those suffering from “psychosis” are often lost in their reality and thus are unaware they are “out of touch with reality” no matter how bizarre their behavior or ideas appear to other observers. 

 

“Psychotic” is a clinical judgment.

 

It is not a diagnosis but rather a symptom describing the status of a disturbance of a person’s mind. The difficulty with the word ‘psychotic’ is that there is no absolute state, or judge, of what constitutes “reality.” 

 

The word all too often is used to assess the condition of an apparently “sick” individual. Here is the issue– since all people live and operate in their perception– how can a court or clinician discern what a healthy reality is or is not unless their safety is a factor? 

 

A person with delusions of being God might well be perceived as psychotic (as was my case) and firmly believe their ideas. On the other hand, the constituents of a radical politician may applaud them for their “honesty” despite the negative emotions they might induce. After all, if people are not ‘harmed,’ what do feelings matter regarding health and perception.

 

Reality is always relative and never absolute, so that every diagnostic judgment is ultimately subjective to the clinician using it.

 

In society, “reality” is a cultural construct defined by the majority of that culture. In my case, I accept that it took me six years to return from my delusion enough to be able to have the mental and social focus to return to college after a schizophrenic “break” at my first university. It took a growing awareness and insight in a private “program” and nine hospitalizations before I was ready to re-integrate into an educational setting without regression to a state of illness.

 

But it was the transformation of my self-perceptions that finally freed me from the internal mental structures upon which my religious beliefs. All this work on myself and the steps to these changes has convinced me that my path forward hinges on bringing this awareness to the families of those diagnosed with schizophrenia. I want to help them navigate the challenges not only presented by their loved ones but more especially to themselves so they can believe “Recovery is Always an Option.”

De-bunking ACCCEPTANCE and COMMITMENT THERAPY (ACT)

Therapists are all talking about ACT (Acceptance and Commitment Therapy).

ACT is a ‘third wave’ behaviour therapy approach with a supposedly ‘expanded perspective on how to guide clients to skilfully self-regulate emotional distress and conflicting states of mind’, or at least, that is what all the literature suggests this new so-called approach to same age-old problematic experiences therapists encounter when treating their patients.

These are patients, according to the literature on ACT, who experience affective dysregulation from a new or existing anxiety, PTSD, depression diagnosis and/or deep interpersonal conflict.

The theory behind ACT is a framework which posits through the application of traditional mindfulness exercises and intensive psychotherapy targeting specific cognitive processes, the patient will experience relief through acceptance of private experiences; active cognitive defusion; being present; and self as context.

When all of these targeted modalities are mobilised in the course of psychotherapy, patients supposedly become more flexible in their interpersonal kinship networks and other interactions in their professional work and personal lives.

Building upon the assumption that firstly, a positive increase in prosocial interactions will result in the cultivation of value-based behaviours.

ACT theoretical underpinnings go a layer deeper. The literature suggests this algorithm for conducting therapy will yield further patient insight into their own personal set of values, developing a stronger commitment to positive action and behaviour. This chain reaction yields, what ACT terms, the behavioural and cognitive activation which contributes to the success of patients experiencing therapeutic gains in the course of their treatment.

The framework of ACT builds upon basic mindfulness. While I doubt many therapists would minimise the importance of patients understanding basic mindfulness or even a nuanced deep and complex awareness of self-awareness tools, the use and validity of research confirming this existing modality is already widely accepted and utilised across the board by therapists in mental health.

So, what’s really new then? Self-acceptance? I haven’t met a social worker, psychologist or psychiatrist that hasn’t, in the course of treating anxiety, depression, and PTSD, forgotten to teach self-acceptance strategies when the opportunity presented itself in the course of their patients’ treatment.

The next wheel I like to suggest isn’t so inventive is active cognitive defusion. Even more problematic, cognitive defusion, which has patients confront or raise problematic areas of their dysfunction or conflict without affective state escalation or agitation isn’t even accepted as completely effective in treating the symptoms of these disorders.

I have seen first-hand, both experienced and inexperienced therapists clumsily use this technique, and sessions collapse shortly after as their patients unravel, become irritated, and begin to flood with emotion and negative sense memory.

So, if this technique is so delicate and difficult to apply in practice, why incorporate it into this already complex and overly technical so-called ACT paradigm. I am assuming, much of this has to do with the assumption that ACT-trained therapists will go through rigorous training, and attend every webinar possible throughout their careers and tenure or practising ACT.

The final two underpinnings are in my opinion, the basic skills taught in social work 101. Maybe I am missing something here? Or, just maybe, contextualising the self in more meaningful and meaning-laden terms is what we are already doing as therapists. So many of these so-called new and exciting modalities we chit-chat about at the water cooler and gloat about to our colleagues should already be in our tool kit for practising psychotherapy.

Maybe I am a brilliant clinician, or just maybe, I’ve taken the time to truly be person-centred, read a diagnosis for what it is, and apply my existing and ever broadening skill set to my patients and experience good outcomes without calling upon the buzz of a new acronym or miracle modality.

I get it, we all do it and want to talk about our skills in broad colourful strokes of positive regard, but we therapists should also be a little more humble, and learn our craft from the moment we commit to the helping process. Instead, we blame our shortcomings and inability to successfully treat our patients on our incomplete education of new terminology and the next, ‘in’ therapy.

Binary Opposition & Dual Relationships

Depending on the profession, medicine, psychiatry, social work, peer work, there is a dual relationship. The worker and the person being ‘worked on.’ The binary opposition is bound up in language, power, and illusion, to name a few. The critical piece of the relationship is the directionality of the power, the use of language, and the mystique manifested through illusion. I will pass through each of these aspects of the binary to unravel its form and reveal it to the public for further examination.

Directionality means that there is a course heading. For power, in terms of the worker and worked on binary, management has a direction. There is a movement, and that energy is flowing back and forth between the work and the worked on. Depending on what is happening and the work being done, this energy moves in various directions to achieve specific aims. The worker and the worked on – each has some influence over this energy. Instead, they control, to an extent, the flow of power. The worker, of course, is privileged here. In most cases, the worker and situations in the human services and helping professions have more pull and influence over the energy’s ebb and flow.

Now, let’s contextualise energy in terms of this dual relationship. What do I mean by power? Energy use in human services can be as concrete as a clinical intervention, a type of therapy, and a medical treatment. In cases like these, the medical professional, the worker, certainly has more say over the course and direction the energy moves in during treatment, right? You don’t tell the doctor how to diagnose; they do it by their right and on their terms. Power can be a conversation held in a mental health seminar, and the energy will move in directions from the students learning and asking questions to the professor lecturing. As I said, power in this context is both abstract and concrete. It has a course heading and direction to its ebb and flow.

The worker and worked on invariably use language to communicate with each other. The worker typically has privilege here too. Doctors, social workers, therapists all celebrate the use of a specialised technical language. This language, and instruments that are bound up in this technical-speak, are used during mental health treatment. The worker knows how to access this language. They also know how to mobilise it to achieve various aims depending on the clinical picture and intervention needed.

The worked on merely is the object of the language.

The worked on, he or she listens, processes, but usually doesn’t push back and revise the language used or question its meaning. Some folks will do just that, question, protest, and go back on psychiatrists’ orders and the writing in the DSM. But, these technical instruments are legitimised through power. That power has an ebb and flows to its energy as well. It subsumes the patient and encircles him or her in its grasp and doesn’t relent until it swallows all doubt of its legitimacy.

The illusion is the sum of all these aspects of the binary. The unjustified privileges bound up within it manifest an illusion. The illusion is that all of this, what I’ve just laid out, needs to happen for the dual relationship to remain intact and viable. For the helping profession to do its work without crossing boundaries and holding a professional standard, working relationships must enter into this binary.

The worked on occupies one side of the binary with an unjustified privilege that cannot be mistaken.

The worked on needs to take it as common knowledge, and it is what it is the consumption of its truth. That is the mystique. I call it an illusion because it is a false image and a representation that doesn’t fit. It is an interpersonal stop-gap measure that creates the same distance between the worker and worked on that many protest against as unnatural and artificial.

By mystique, I mean a texture to the binary that exists to enable, keep the relationship psychreg intact, and diffuse any possibility of thinking otherwise. Dual relationships exist outside the helping profession as well. We all have multiple layers to us and our interpersonal life. However, I am convinced that no other discourse is so disjointed than the helping profession when making the binary visible and breaking it down into parts that can be digested by the public to determine its value to society moving forward. So, do just that, consider what was said here, and determine how you feel about helping and the disconnections that follow suit.

The Early Warning System

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I’ve always said, when it comes to mental health preparedness, there is no way to be clairvoyant about what the future has in store for your clinical picture. Alas, there is nevertheless a degree of planning that must be invested in your health and wellness moving forward, right? The question then becomes how and where to invest energy into preparing for the future and our mental health.

I want to introduce a concept called The Early Warning System. My idea isn’t new in theory, but I would say it is entirely novel in the application.

Nations have them to defend their borders. With the rise of regionalism and geopolitical warfare, countries need early warning systems to pick up and identify long-range and subversive covert/stealth weaponry on an attack course into their homeland. There are methods constructed through technology and information gathering to detect the enemy coming before it is too late from nations down to cities, townships, and other smaller municipalities.

Now, this is where the comparison comes into play. As the saying goes, I am just one man. Like the United States’ defense needs or another nation protecting its borders, we all need safety in our lives.

I need a way to defend myself against the flair up and activation of unwanted and disabling mental health symptoms before becoming too serious. I need a way to detecting, very quickly, when threats to my stability and mental status are likely to occur. Putting this theory into practice is a whole lot easier than it sounds.

Listen, no one will ever be able to predict every symptom worsening before they become too exacerbated. However, self-aware people and people that know themselves well will be a step ahead. Through ongoing therapy or life review, people can pick up specific patterns within their affective (emotional) range. In terms of affective lability (emotional dysregulation), our feelings follow cues from our thoughts. The fundamental basis for CBT (Cognitive Behavioral Therapy) is that our emotions lead to ideas, which spark our behaviors and are built.

I am not suggesting performing your own CBT or self-CBT to reregulate your emotional state when it gets off course unless you are ready and have the skills to do so. That is also not entirely necessary yet, so do not panic!

Until your behaviors run awry because your feelings are compromised from emotional lability, you have time to monitor your mental status. When you begin to be mindful of your personal, behavioral state, the pace and relative speed of negative affective changes will slow down, avoiding the need to worry about self-CBT and other advanced skills. Mindfulness, deep breathing, and checking in with yourself are all tools to halt a dysregulated emotional state’s advancement.

To do so, ask yourself questions that arent triggering to self-evaluate further where you are at in terms of your thinking and feelings. Even self-verbal reassurance goes a long way to slow down negative thoughts and titrate down the intensity of hurting feelings. These methods are internal early warning systems.

External systems are even more straightforward to operate. Some prime examples/suggestions for external systems are friends or other collaterals in your life. They don’t have to be great friends or even know that they serve as your early warning system. Then how can I mobilize them if they don’t realize they are helping me? The answer is simple. All you need from your collateral for them to serve as an early warning system is data or information. This data is specific to you and your symptoms.

Let’s examine the diagnosis of depression. During your conversation, if your friend makes remarks about your behaviors such as “isolating, sad-looking, morose, irritable,” then you’ve got all the information you need already. We don’t always realize when we are getting depressed. Sometimes, it takes a friend, like in this example, to point out and identify our behaviors to us to think about them, reflect, and determine how true it is for us and what and if we should do with this information.

Sometimes friends are off base; Sometimes, they are spot-on correct. The way to get a better handle on the validity of collateral input and advice is by gathering as much information as possible. Have a band of friends around you or just people in your life to can check in with and remark in general terms on your behavior if you solicit the information. While unsolicited details are even more compelling because you didn’t ask, they volunteered to speak and exercise concern.

In the end, unsolicited or solicited, gather as much information possible before jumping to conclusions about your emotional health. Be careful not to let information manifest into a new reality for you and create the very trouble you were hoping to avoid with this reflective exercise.

The more stable collaterals in your life, the odds of getting a better read on your clinical picture is more likely. People that know us well over the long haul are hands down better at evaluating small shifts in our behavioral and emotional health. In the end, this is an exercise about preventative mental health self-management. So, when using the skills discussed here. Listen, reflect, do not be reactive or defensive. After all, who are you hiding? Just a better understanding of your mental health clinical picture and well being.

THOSE LIKE US AND FIGHT FOR US

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Most of us with mental illness are far too aware of one major fact: the only time mental health issues makes the news is when something tragic involves someone with mental illness. A name makes the front pages, there’s call for health reform, then – forgotten. No analysis of the various types of mental illnesses, no calls of examination of the mental health system, no discussion on care, its cost, monetary and lives incomplete. Will it change? The stigma around mental illness can be crippling. Minorities face some of the greatest hardships and burdens dealing with mental health, care and the stigma.

Below are just a few we all should know, follow and support.

Writers and Links:

 

John Green, anxiety, OCD “The Fault in Our Stars”, “Turtles All the Way Down”, a wrenching and revelatory novel providing a window into living in constant fear of your own mind.

Monica A. Coleman, author, “In Not Alone: Reflections on Faith and Depression”, she speaks as minister, woman, friend, professional living with depression. A forty-day devotional displaying experiences of strength, hope, love, and spirit. Another book, Bipolar Faith, discloses her trauma, depression, and the threat of death.

Liz Funk, OCD, freelance writer, author, covers entrepreneurship, productivity, careers. Her website is http://www.lizfunk.com/speaking

 

Mental Health Professionals with Mental Illness who Spoke Out:

 

Rufus May. Clinical Psychologist, England. Diagnosed with schizophrenia in 1986 at age 18, compulsorily detained on three occasions. Involved in consumer recovery groups and campaign group, Evolving Minds.

Marsha M. Linehan, creator dialectical behavior therapy (DBT), psychotherapy combining behavioral science with concepts including acceptance and mindfulness. Professor of Psychology. Adjunct Professor of Psychiatry and Behavioral Sciences, University of Washington in Seattle. Director of the Behavioral Research and Therapy Clinics.

Kay Redfield Jamison, PhD, Clinical psychologist, author, An Unquiet Mind: A Memoir of Mood and Madness, her life with bipolar disorder. Holds post of Dalio Professor in Mood Disorders and Psychiatry at Johns Hopkins University School of Medicine.

 

Business Leaders, Entrepreneurs:

 

Researchers found that 49% of entrepreneurs surveyed deal with at least one mental illness and about one third struggle with 2 or more issues. Only about 32% of adults in the U.S. report diagnosis with one or more illness.

Dennis C. Miller, bipolar disorder, former CEO of Somerset Medical Center and Healthcare Foundation. Without this disorder, believes he would not have been successful. Author, Moppin’ Floors to CEO: From Hopelessness and Failure to Happiness and Success. A leadership coach for many CEOs,

Dr. Indigo Triplett, Military veteran, diagnosed with bipolar disorder, 2013. CEO of Careers in Transition Inc., founder of Indigo Insights, a nonprofit providing mental healing by nourishing the spirit and mind of those challenged by life’s journey. She is also the author of a 2014 book about her experiences, with bipolar disorder,  Dueling Dragons: A Bipolar Journey from Darkness into the Light.

Ted Turner, bipolar disorder, causing periods of depression and suicidal thoughts; his father struggled with the same disorder and committed suicide. Created CNN, TNT and the Cartoon Network.

Joe De Sena, founder and CEO of Spartan, the world’s largest obstacle race and endurance brand. A NYTimes best-selling author of “Spartan Up”, “Spartan Fit,”, “The Spartan Way.”

Estee Lauder, a makeup mogul, was always preoccupied with women’s facial features. “…. couldn’t stop touching other women’s faces.”

Paul Orfalea, founder, Kinko’s. Book Copy This!: Lessons from a Hyperactive Dyslexic who Turned a Bright Idea Into One of America’s Best Companies, discusses the many struggles he faced in school, college and running his business. Never received high grades. Never top his class. Began selling pencils, paper out of college dorm.

Thom Hartmann, author of “The Edison Gene: ADHD and the Gift of the Hunter Child.” “My supposed “disorder” led me to create Spartan, the Spartan Up Podcast, and the SpartanX Leadership Forum.”

Jenny Dearborn, Dyslexia, ADHD, mild OCD. CEO Actionable Analytics Group. In special-ed classes until 18. Received a bachelor’s at UC Berkeley and a master’s at Stanford.

Damien Hooper-Campbell, 40, undiagnosed with ADHD until mid-20s. Chief diversity officer, eBay.  Pointedly discusses about reducing the stigma for others. “It’s ok to be open. That level of vulnerability helps others to be open. And those with learning disabilities have often suffered in silence and tried to cover for it. Now I intentionally talk about it.”

Elon Musk, CEO, Tesla, SpaceX.  Bi-polar

Some Sports Figures

 

Brandon Marshall Borderline personality disorder, former NFL wide receiver, vocal about his BPD diagnosis. Set up a charity, PROJECT 375, led by individuals dedicated to education, support, treatment of mental health.

Ricky Williams. Former NFL running back. Williams and open about struggles with social anxiety disorder, BPD, avoidance disorder (social anxiety).

 

Some Celebrities Revealing Their Mental Illness. Helping Others Find Courage

 

Maurice Benard, Plays a family man and crime family boss, making people disappear, born in Martinez, California, is of Salvadorian and Nicaraguan ethnicity, was diagnosed with bipolar disorder at age 22. As General Hospital’s Michael “Sonny” Corinthos, Jr., he had the writer’s incorporate his mental illness into the character and has become a spokesperson for treatment of the disorder with the Mental Health America.  He is active on Facebook discussing his personal anxiety issues via YouTube. His newly released auto biography, entitled, Nothing General About It, also has an audio version.

Glenn Close Founded, Bring Change to Mind (https://bringchange2mind.org/). Goal: to end stigma and discrimination. Her nephew has schizophrenia; her sister, bipolar disorder. “The biggest majority of people living with mental illness are more preyed upon than preying upon. But it does seem to be that somebody who does one of these terrible acts is suffering from some sort of mental disorder.”

And many others…

 

Obsessive Compulsive Disorder (OCD): Leonardo DiCaprio, David Beckham, Megan Fox, Lena Dunham,

Postpartum Depression: Hayden Panettiere, Gwyneth Paltrow

Attention Deficit Hyperactivity Disorder (ADHD): Adam Levine,

Bipolar Disorder: Demi Lovato, Catherine Zeta-Jones,

Depression: Jim Carrey, Jon Hamm, Angelina Jolie, Lady Gaga, Beyonce, Brad Pitt, Jared Padalecki, Rachel Maddow, Miley Cyrus

Bulimia: Elton John

Depression, Body Dysmorphia And Eating Disorders: Brittany Snow,

Anxiety And Trichotillomania: Olivia Munn,

The Mental Health Advocacy Spectruum

I have many colleagues in the mental health system. These colleagues are professionals, friends, prosumers, allies, and every shade of grey in between. With this said, I associate with people in every ‘camp’—Antipsychaitry, clinicians, prosumers, and people that straddle multiple silos within the mental health community. My stance is that each ‘camp’ has a little bit to offer everyone interested in learning about mental health, healing, and spreading awareness to folks that misunderstand it altogether. 

In my opinion, we all can benefit from more education/psychoeducation. Regarding stigma, misinformation, and total lack of mental health awareness, I believe the impetus becomes more significant and needs more urgent to define some terms that remain loosely articulated indeed. This loose articulation, this slippery and poorly defined language surrounding mental health and mental illness, is where the mental health community’s issues become to creep into the picture. 

As I said, I have many colleagues in the mental health system. Some of them I’ve never met face to face. These are advocates in other states, some of them, other countries. Most of the advocates I communicate with are like-minded. These are folks who understand mental health to be a deep, layered, and complex discourse. 

Most of the advocates I communicate with share my beliefs and stance on the more hot bottom topics:

  • AOT (Assisted Out Patient Treatment aka Forced Treatment)
  • medication over objection
  • the need to expand areas of inpatient psychiatric settings while limiting state-level ‘extended’ care units which seem to defer re-integration into the community

I believe in community mental health, above all. While community mental health is a broad and generic term, it generally is defined by both deinstitutionalization and providing access to treatment and support to people with a mental health diagnosis in their neighborhoods. With this said, we need to continue to (de)institutionalize our large treatment centers–the psychiatric state-level hospital/warehouses–and slowly fund additional beds at the local level. Without further delay, closing down ‘extended care’ units in state-level hospitals supplant them with community hospital beds and services.

I also welcome Open Dialogue approaches to treatment. I am a peer specialist and understand the importance of having peers in treatment teams and clinical conversations. I do not believe that peers or people in antipsychiatry camps are dangerous like some folks do. We all have something important to offer the exchange. I think voice hearers are also embarking on their inner-voyage to better health. If well managed and under the right supervision by their treatment teams, peers, and networks like the Hearing Voices communities, which provide support to folks who wish to live their lives on less medication and welcome a broader ecosystem of voices into their life. To say hearing voices isn’t ‘normal’ to folks who typically hear voices if left to their biological makeup without medication takes a big piece of the humanity for these folks who are just that: human. 

I am an overweight Jewish man from New York State with an active schizophrenia diagnosis in terms of my humanity. I have been committed to involuntary treatment numerous times for different stays at local and state psychiatric hospitals. Simultaneously, I believe that forced treatment for Violent and SPMI (Violent and Severe and Persistently Mentally Ill) people is both necessary and justifiable in particular individual situations. I do not think this treatment is the gold standard for this population (whether violent or just SPMI). Instead, we need always to revise our practices, moving studies, and research forward to move into an era where forced treatment is obsolete.

As for Kendra and the day when the very ground floor of modern mental health treatment in New York trembled and collapsed on itself, we patients will never forget it. Kendra’s death marked a new beginning for many violent and severe and peristently mentally ill patients facing possible incarceration, legal issues, and jail sentencing. That moment I am speaking was when Andrew Goldstein pushed Kendra in front of a train in 1999. Well, Andrew’s violent act is now history. But, we patients must never ignore the implications of his violence, which changed the face of mental health treatment forever in New York and stated adopting forced treatment laws.

Kendra’s death will not be in vain. The fate of so many violently mentally ill people is now changed. Now, there is hope and available treatment for this population. There is treatment instead of incarceration and re-entry into the criminal justice system. Her death signaled to the world that we need to radically shift our methods and approach to treating people who are violently and persistently mentally ill if we are to truly help people have a real chance at survival from their condition. This signal was the sonic boom that called upon legislative bodies, advocates, and allies of people with a diagnosis to realize our paradigm for the treatment of Violent and SPMI wasn’t working.

I am not suggesting that forced treatment works perfectly. I have seen it first hand as an ACT (Assertive Community Treatment) practitioner moved treatment under an AOT order fail for potentially violent and severe and persistently mentally ill patients. I’ve seen forced treatment create hatred, anger, and self-shaming cognitive distortions above and beyond the original altered perception of clients without being enrolled in compulsory care and treatment. Indeed, the stigma that evolves from an AOT (Assisted Out Patient Treatment) label under the county department of community mental health radar is demoralizing. The branding is humiliating, infantilizing, and demeaning for many connected to an AOT service.

Today, until the day we devise another approach to treating this population of the mentally ill community, we need to push hard truly. We persist in our creativity, clinical prowess, and research to build a new paradigm to supplant this existing AOT structure to treating the Violent or SPMI folks mandated to mental health treatment. However, I’m afraid I disagree with how this treatment paradigm is sold, packaged for consumption by organizations like SARDAA and The Treatment Advocacy Center. These organizations sell these treatment modalities to advocates and legislative bodies as client-centered. SARDAA packages these laws as in the ultimate interest of the patient with a diagnosis. However, packaging couldn’t be more misrepresentative of what is happening in practice and what is happening in the lives of those mandated to AOT laws.

People mandated to treatment lose a part of their independence, autonomy, and relative status as citizens equal in the law’s name. The law confines restrictions and places limitations on people’s movement and personal freedoms under the AOT regulations. Travel, medication administration, choice in treatment staff, and frequency of contact with mental health staff and treatment teams. These mental health treatment domains are prescribed, mapped out, and monitored closely by the county government. Thus, at any given time, when the patient violates the terms of the treatment team, he or she should be prepared to be taken to the hospital for forced treatment.

The real and more immediate problem exists in client-centered care for Violent and SPMI people. Practitioners working with mandated clients believe in many documented cases that they can aggressively engage in client contact without any client input and regard for their patients’ personal beliefs and values. It is an unspoken trend with all too many workers charged with providing care of people with an AOT status. These psychiatrists, nurses, therapists, and mental health clinicians will go about treatment without regard for client-centered care and harbor an attitude that this is a punitive measure. 

Despite the reality of this punitive approach, clinicians, take with AOT patients, TAC and SARDAA continue to whitewash the clinical picture for these patients and maintain AOT is not punishment. These organizations maintain these measures are to avoid further ineffective and inappropriate legal actions and sometimes criminal charges or jail time. Mental health treatment will never be the right fit for Violent or SPMI folks if the system understands this approach as a punishment for people with a diagnosis.

Kendra’s death will never be forgotten by mental health patients. For everyone with a severe mental health diagnosis who has flirted with the need for AOT treatment. We all feel the threat and loss of freedom or potential for losing our right to choose our care and treatment for our diagnosis. The loss of Kendra was subsumed by people carrying a mental health diagnosis, and we will never lose that scarlet letter that labels us and marks us as eligible under the law to lose our right if our conditions worsen. After Kendra’s death, our fate to make decisions for ourselves and care will ultimately be under the law’s provision and maintenance until a new paradigm arrives. 

Thus, the real problem then becomes how these laws are, in turn, mobilized by hardliners pushing (forced) treatment for everyone deemed ‘untreatable’ in a traditional mental health setting. 

While some forced treatment orders (AOT here in NY) may seemingly benefit patients in specific settings with limited options for mental health care and keep them out of the hospital for more extended periods. The greenlight for AOT or Forced treatment advocates say, “here is the proof we have that forced treatment works!” is a misnomer. The wrong approach to reforming the mental health system. Suppose there are limited treatment settings/options available in the community. In that case, the push should be to expand mental health treatment options and make them more accessible to people in need of treatment. We need to ask: why is this patient benefiting from the AOT mandate? We can offer community mental health treatment to supply this fundamental gap and need that goes unsupplied without an AOT order. 

In rural communities and extremely resource-deprived urban ghettos, advocates for forced treatment are pushing to tighten the nuse around people’s necks with severe mental health issues and limit, restrict, and make people with SPMI into forced treatment when they ‘fail’ out of treatment. As I stated before, the real problem is limited access to out-patient programs and mobile treatment/crisis/respite, to name a few. These treatment areas should be prioritized to expand the choices of people who want treatment and can not access it. We need to ask: why are people falling out of therapy?  Instead, these hardliners are taking steps to ensure they are forced into a treatment setting that doesn’t work for them. 

Sure, access is not always the issue. Sometimes, people with severe mental health issues do not know they are ‘sick.’ I was one of them. I had no idea I was on the brink of collapsing when the first episode of psychosis emerged on my mental health landscape. Due to anosognosia, a trademark symptom of schizophrenia, lots of folks share a problem I had years ago when I was first diagnosed. People pushing for forced treatment use this symptom as their rallying cry for expanding AOT and reforming the guidelines around forced treatment–making it easier for folks to get handed a court order to take medication, be hospitalized, or be picked up and taken to the hospital when non-compliant with medication and therapy.

However, here is the issue with using this symptom as a license to expand and re-regulate Forced Treatment. I had worked with many people with severe mental health issues as their clinician when I served under an ACT Team (Assertive Community Treatment) here in New York. Some of these folks had an active schizophrenia diagnosis. Some of our patient censuses were also mandated to treatment under an AOT. However, for the folks who did not know they were sick and under our care, was our ACT team anymore successful with treatment controlling patients’ psychosis with an AOT order? 

Some folks experienced relief from their severe symptoms and slowly returned to a more ‘normal’ life, gradually stepping down from AOT to a less restrictive treatment milieu. Still, we had several patients who were medication resistant and experienced zero relief from their most severe symptoms, even with medication. Even with an Intramuscular Injection (IM) and other drugs, most of these folks continued to have firmly fixed delusions and were actively psychotic.

With these severe cases, the most significant benefit of the AOT order was access to our patients. We were always able to meet and monitor our AOT patients. Expansion of AOT is not the answer to the mental health crisis–it is a bandaid and signal that we need to find the treatment that works for diverse subsections of the population requiring new treatment modalities and more research. For the most severe, chronic, and ‘hopeless’ cases, the people for whom AOT was designed to monitor and watch over. Our team was just another way for the government to mark these patients and keep them visible to the county mental health dept. That is, the whereabouts and activity of people felt were dangerous (posing a risk of serious harm to themselves or others). 

The other non-issue is with folks who need treatment and do not believe they are sick or need help. Like the situation I was in years ago, patients are not in treatment yet and do not think they even need treatment because they ‘not sick.’ These are not the supposed most significant risk to the community in terms of safety, either. These folks are more of a threat to themselves and at risk of being a victim of violence. So, why then push to expand AOT? Why are these folks used repeatedly to justify expanding AOT more than anyone else? These are the stories from the Treatment Advocacy Center (TAC) about how AOT ‘saved’ Joe Mental Patient from hurting someone and finally getting the help he or she needed. 

Why are these the poster patients of AOT? Because the most severely ‘disordered’ folks do not benefit from AOT. They may not benefit from any mental health treatment available. These are not the people seen on the TAC website or in the TAC stories. However, these are the folks most at risk of hurting themselves or others. The bottom line is that we need to expand further the mental health system, not just one area or silo. We need to develop access, improve medications, and all avenues and intersections of treatment. Until then, be wary of any ‘camp’ saying they have the answer to the mental health crisis.

Sleeping Amid the Ruins

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Insomnia. Somnolence. Soporifics. Somnambulation.

I have insomnia, and only sometimes feel somnolent. I use a host of soporifics, but never
somnambulate.

A big part of the bipolar disorder is spiraling mania. I maintain that mania is caused by insomnia. The patient stops sleeping and psychosis results. It would stand to reason that a soporific is the best defense against mania. The problem is that some soporifics aren’t strong enough.

I have a cachet of soporifics—clonazepam, melatonin, carbohydrates and alcohol.

When things are really bad there is the occasional opioid. I often sit at the kitchen table surrounded by vials of pills, bottles of alcohol, hot milk and honey, and bread or cereal. What kept me out of the hospital since 2009 is a steady ingestion of a daily dose of clonazepam at bedtime.

The importance of sleep cannot be overrated. Bipolar people might go months without sleeping. Sylvia Plath, in her book The Bell Jar, wrote of watching the clock tick out the hours for about thirty days before she was committed to the psych ward, where she played with drops of mercury, mad as a hatter.

Psychosis, disorganized thinking, and hallucinations are all part of the trip. I would suggest to medicating professionals to avoid prescribing antidepressants to their bipolar patients. Welbutrin, Prozac, etc. elevate mood and can unleash the demons of manic insanity. Depression can be bad, but swooning, spiraling mania can be positively chaotic and life-shattering, not to mention downright horrifying.

So I, the counselor-client, make sure I sleep. Sleep is the stuff that dreams are made of, and we all need to dream. These mental movies which keep us entertained in the depths of REM are necessary to stave off incoherent thought patterns, and help us problem solve in waking hours.

So I will risk being inappropriate and irresponsible and venture to give some advice to the sleepless among us.

Have a drink. Take a pill. Smoke that doobie if that’s your thing. Drift off into unconsciousness amid the pillows and comforters. Sleep the sleep of the dead, take a magic carpet ride.

Your families, doctors and society in general will thank you for it. And you, peacefully snoozing on a pink cloud amid the evening stars and moon, will be better for it. You may avoid the handcuffs, police presence and ambulance sirens so common among those who mentally disintegrate in the face of too much reality and wakefulness.

I’m a Social Worker: My Mental Health and Well-being Have Been Put to the Test by COVID-19

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These are hands down stressful times for everyone. After all, we are essential workers. As essential workers, we social workers can really relate to this stress. During the past few months, the way we practise as social workers has changed drastically.

From in the trenches face-to-face meetings, providing live critical treatment to children and families, the way we do our work has taken a huge tectonic shift. Today, during the pandemic, my care largely comprised of teaching basic internet, teletherapy, and telepsychiatry to my clients, as well as educating them on how to stay connected to treatment at all costs.

Many of my families do not have assets. In many cases, these are families which  are resource deprived. Thankfully, the Department of Education (DOE) has helped many of our families by providing iPads for the children to continue with therapy and their remote education. Despite all this, still, many families still struggle to connect with providers. My new role in connecting with families virtually and ensuring that all their services are still connected has been an ongoing challenge.

In this field we have emergency protocols in the event there is an acute risk of harm. Nothing has truly begun to prepare us for a worldwide pandemic. This sudden change shocked many of our families.

In addition to ensuring all my families’ are safe I also treat, under my care, another thirteen families with several unknown variables.

As a social worker I know my goal has been the same and which continues to be advocating for these families and support them in any way possible. My agency has been very supportive of my role during these hard times. In this sense, I have been able to assess families and provide them with resources such as gift cards for them to buy food.

Most of my work is done in the micro level, out in the field, and doing home visits or ‘face-to-face’ meetings with the families, visiting schools or therapist to ensure that the families are meeting their goals. That part has drastically changed due to the pandemic, now I have to continue to ensure that my families are still receiving such services but through a video conference or call. At the beginning the adjustments were very difficult for families and more so because we didn’t have that face to face contact where I could personally guide them through this process.

Since most of our work is done at the micro level (e.g., face to face interventions) out in the field, working remotely is something totally  having to balance everything out has been as been difficult and stressful.

Self-care is even more essential now than than ever before. As a social worker, all too often, we put our client’s well-being ahead of our own. During unpredictable times, my stress level has been even higher.

I am an MSW student, intern and hard worker. There is no question I had to adjust to the new changes emerging in my field. From re arranging my schedule so I could fulfil all of my roles, to just taking a walk in the afternoon around my neighbourhood. The way I do things has shifted and been altered right down to the way I take 10 minutes to meditate. Yet, taking the time to do just that and breathe has been a tremendous help and a way I’ve been able to adjust my process to this new situation.

The changes from this pandemic were totally unexpected to the human services and allied fields. Ultimately, we are resilient. Working together, I am fully convinced this crisis will only embolden our mission and strengthen our skills further in the social work profession.

 

This post was first published on psychreg.org

ANXIETY: SIMILAR FOR HAMLET AND FOR US

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To have anxiety, or not to have anxiety, that is the question? Whether ’tis nobler in the mind to suffer. The slings and arrows of my outrageous fortune. So begins a soliloquy by Hamlet in a play by William Shakespeare. Well, sort of. Throughout Hamlet’s acts, his feelings were never validated, so he was basically pushed to his mental breaking point. Was he thinking of suicide or being killed by those slings and arrows? We don’t want to have these thoughts, either.

There was no “my” in the Soliloquy. Still, I added this for the personal effect of showing extreme wealth while contemplating existence. Eventually, Hamlet’s life ended over his inability to cope with the emotionally stimulating events that led to his anxieties. Overall the actions, (or lack of same) from Hamlet and other characters around him show us what transpires when fear is not acknowledged, validated, or helped but passed as a regular event. 

Continuing, Hamlet feels responsible for all the immoral behaviors and actions in his homeland and now wants to make everything right. How does Hamlet relate to today’s stress and anxiety? Very, very much so, at least I think it does. For us today, due to the constant bombardment of social media, we feel the ever-mounting stress to solve issues like racism and sexism. Many of these problems have been around since America’s inception; however, today, more platforms are accessible. They allow us to be both seen and heard quickly and accurately. Although this is sometimes helpful, it also creates more anxiety and stress than the pressure to make societal change builds. 

As one looks further into Hamlet, it describes his peculiarities when disastrous events occur within his life. This is eerily similar to adults and can reveal to us a picture of might be transpiring in our minds today. 9-11 and COVID19 are but two examples of catastrophic matters. Generally, when they occur, our fear rises, and there is a heightened anxiety level across the land.

Hamlet, like people in current times, has and had symptoms of continual fear, sorrow, loss, worry, suspicion, and most significantly, they turn an assortment of many forms of anxieties. Diagnosing anxiety is not much different from Hamlet’s time, but it is much more prevalent today. It is also increasing at an alarming rate every year. There are several reasons individuals have developed a form of anxiety, including increased worrying or stress and exhibiting one of the symptoms of depression. 

Many people now live in horrible conditions that often burst into anxiety or a panic reaction where these feelings are basically swept under the rug for future use. In Hamlet, many characters may have had various anxiety feelings and issues that were not talked about for fear of losing status or their rank in his army. Also, they were afraid of their own deaths… Unfortunately, like in present times, these feelings are rarely discussed out loud and or mainly treated as isolated incidents. For many, the sentiments continue over and over anytime, a similar situation occurs. Shall we say, Obsessive-Compulsive Disorder?

When someone validates our feelings, it can help us get some satisfaction of being heard and not alone in the universe with our emotions. Yes, Hamlet, too. We are citizens here, and we deal with our feelings, our stress, and our anxieties the best we can, but we need to be seen and heard, too. Our messages must be plastered all over the media and on billboards. Even more important is that we are treated both fairly and equally. Everyone out there,

WE ARE HUMANS, TOO!!!

Today, anxiety occurs way too often in people. One in four of us have Mental Health Issues. Give mental wellness a chance. Individuals like myself who deal with anxiety are not much different from anyone else, yes, even Hamlet, and deserve to live our lives without fear of repercussions. Remember that our perspectives are critical, too. Equality does not have to be a privilege, but it needs to be commonplace everywhere we might be. People with Mental Health Issues can and do recover. Now, recovery is not only possible, but it is also probable. Keep in mind everyone, anxieties, and Mental Health Issues are not death sentences. 

See and hear everyone in the NewsBlogs.

Editors note: This is a series article. Next month, another Mental Health and other Shakespeare post will be published on Mental Health Affairs. 

Explosive Behaviors and IED

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Seemingly uncontrollable and unpredictable anger is a problem for some people with mental health condition. As a therapist, I diagnose people with intermittent explosive disorder which is a DSM 5 diagnosable condition.

Intermittent explosive disorder (IED) is an ‘impulse-control disorder characterised by sudden episodes of unwarranted anger’. The disorder is typified by hostility, impulsivity, and recurrent aggressive outbursts.

People with IED essentially “explode” into a rage despite a lack of apparent provocation or reason.  In my work, I have provided treatment for people carrying such a diagnosis and offered psychoeducation for the person diagnosed person and for their families.

In most of the cases I have encountered, adolescents and young adults, seem to have the most difficult controlling their symptoms in the wake of a new or mismanaged diagnosis. This prevalence of this disorder among teens and young adults is often rooted in access issues to treatment, developmental, environmental, parental, and cultural considerations which sometimes, due to stigma, families and other collaterals minimise the reality of this condition or don’t consign to the benefits of seeking mental health treatment.When I completed home visits for the most severe cases in NYC and the outlying boroughs, it became hard to ignore the very real cultural and ethnic considerations blocking many teens under my care from treatment.

This blockage and access to mental health treatment manifested in different ways. Sometimes families wouldn’t open the door for me, or would tell their son or daughter not to trust me, because of fear of I would report their parents to the government for either maltreatment, or neglect.

In many cases, as mandated reporters, therapists do open the door to such government investigations, and trigger home removal of children who have mental health disorders, and who are also mistreated, neglected, or abused.

In these situations, especially in cases with real abuse, and maltreatment, patients are particularly vulnerable to impulse control problems, and have underdeveloped mental filters, or present reactive, and disobedient, when in fact, it is a direct response to abuse.

Often, these are the teens and young adults that truly need the help and treatment of an in-home therapist, which according to the research, is the most impactful treatment milieu in targeting the root of this disorder, and most, if not all the underlying contributing external factors which exacerbate symptoms for people carrying this diagnosis.

Think about it, outpatient therapy in the office can only do some much in capturing the environmental problems in persons home, the family dynamics, and other external contributing factors which trigger teenage anger and misbehaviour.

Mobile therapists can observe their patients in the classroom too, and provide the sort of collateral treatment necessary to reshape and re-pattern the interpersonal landscape of people suffering from this condition. Thus, the expression of a patients personality, which can, in turn, contribute to a person’s volatility or lability can be monitored in vivid, live in a patients own environment, when they explode on their friends, family and neighbours during the course of session.

After working with so many angry people, I find that it is the most soft spoken, seemingly calm, and level-headed individuals, are diagnosed with IED or are outrageously quick to anger. Why is this? I have a few suspicions. People already ‘high-strung’, ‘Type-A’, or just plain loud are usually not the primary culprits for creating large displays and scenes in stores and public venues.

These are the people you are already expecting to have a voice and use it whenever they are in a situation in which they feel silenced or mistreated. Conversely, it is the soft-spoken and extremely calm people that even have the potential for such polarities in their demeanour. These are the people that go from zero to one hundred in less than a minute, sometimes less than a few seconds.

Very few people struggling with psychosis have the energy or the concerted mental coordination to carry out acts of extreme violence. As a person who experienced a psychotic episode, I spent most of the time disordered living in fear, extreme paranoia and disorganisation.

Globally, all people, with or without a diagnosis, in the wake of external negative consequences to the extreme or untoward behaviour, will go on exploding on friends, neighbours and family for just about anything. If you are interested in living in a slightly more predictable world with less volatility and exposure to anger, I suggest we all start pushing back when we see people living their lives without consequences or negative reinforcement.

Mental Health Affairs 2022

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