Illnesses, Images and Insights

People who suffer with mental illness have been attracting especially negative press recently.

Let’s look at the case of Mr. Alexis, the military contractor who killed 12 people at the Washington Navy Yard last month. According to The New York Times (October 5), his mother told his bosses one month before the shootings that her son had a history of paranoid episodes and most likely needed therapy. But Mr. Alexis’ managers at the Experts Inc., an information technology firm, decided to keep him on the job. An internal company investigation has found that they did not require him to seek treatment and concluded that the “Experts” mishandled Alexis and knew more about his mental problems than it disclosed.

(Alexis had been arrested three times in three states, including once after shooting out the tires of a car in what he told the police was an anger-induced “blackout.”)

In this case (and in others) signs and symptoms exist and are ignored; what appears  “out of the blue” and unpredictable is often not so.

Another kind of mismanagement (The New York Times, September 29) is the case of Melissa Morelli, whose treating physicians said “it was not safe for Melissa to go home” from the psychiatric hospital but whose family’s health insurance carrier would not continue to pay for her to stay. ”Over the course of five months, Melissa’s mother took her to the hospital roughly a dozen times, and each time the insurance company Anthem-Blue Cross, refused to pay for hospital care.”

Melissa’s mother sought the assistance of Connecticut state officials and an outside reviewer. She eventually won all her appeals, and Anthem was forced to pay for the care it initially denied. (“Anthem, which would not comment on Melissa’s case, says its coverage decisions are based on medical evidence.”)

Few people have the tenacity demonstrated by Melissa’s mother.  By implication, many people fall through the cracks. They may not receive the necessary treatment (in spite of paying the premiums) prescribed by the practitioners!

“Patients often find themselves at odds with health insurers, but the battles are perhaps nowhere so heated as with the treatment of serious mental illness,” according to another article in The New York Times (September 29).

A federal law, the Mental Health Parity and Addiction Equity Act of 2008, was aimed at avoiding fights like this by requiring insurers to cover mental illnesses just as they cover treatment for diseases like cancer or multiple sclerosis. The federal government has not yet written the mental health act’s final regulations for insurance companies, and a crucial gap remains between the act’s intention and application.

Many agree that, five years after President Obama signed it, the law has fallen short of its goal to create parity for mental health.

Mr. K. is a former patient from my practice. He was about forty years old when he reported to the Blanton-Peale clinic for counseling. He worked for a large corporation and reported abuses that he’d observed at work. He told me, “I am so angry that if I go back to work, I will shoot up the place.”

Mr. K. gave me permission to send the evaluation to his company. Within a year, I was called to court to deliver my findings. Of course I took his threats seriously and testified that he could not return to work.  Mr. K. was placed on full disability (worker’s compensation) which paid for weekly treatment and medication. Over many years, Mr. K. continued to rage about the company and express enormous gratitude to me, although I had done nothing more than acted in the line of duty. After more than ten years, he moved to another state where he presumably continued treatment.

When I read about the above cases in which appropriate treatment was denied, I realize the impact of Mr. K’s  treatment and his gratitude: It saved his life and perhaps those of several others.

I don’t like to think we have gone backward in our psychiatric care; but the confusion of our governmental policies and the failure to reel in the abuses of the health insurance companies have led (and, sadly, may lead to more) cases of violence.

Both Mr. Alexis and Melissa are like canaries in the coal mine. Their cases point to the noxious fumes (of system failure) penetrating and polluting our environment.

Conclusion: A dire situation exists in our health care system; mental health care does not have parity with physical illness for receiving care and reimbursement. Mental health practitioners, trained to determine the appropriate treatment, have lost power (to big business including insurance companies) to deliver the appropriate care.

Dear Reader, I welcome your response to this dire situation. jsimon145@gmail.com.

Acceptance and Authenticity, a tenuous balance

The struggle to become our true/real selves is, for the most part, an unconscious effort. Early in life, we learn to curb our aggressive tendencies and refrain from hitting our classmates in school in order to gain acceptance. However, balancing acceptance with our authentic being is often a subtle and life-long journey.

To a greater or lesser degree, we conform to expectations in order to be loved and accepted by our family and our world.

If we don’t receive “good enough” acceptance in our developmental years, we’re more likely to abandon the core of our “real” being, in order to receive acceptance and/or love.

The factors that determine our courage and honesty are complex and most likely involve environmental as well as genetic factors. However the following two examples illustrate the power of the environment.

Ms. L. a married woman, felt trapped in her relationship. In order to be true to herself, she divorced. She had the courage to trust herself enough to leave her husband in spite of her family’s disapproval. Her self-confidence, in this regard, may have been related to the acceptance she knew (from her family) early in her life.

A more extreme lack of acceptance from parents and his environment left Mr. M. confused about a real sense of himself, his sexuality and his talents, in spite of the positive feedback that he received from friends and colleagues later in life.

Fortunately, our society has become more open-minded regarding sexual preference. In an earlier post  (July 29, “Life Scripts”), I discussed the writer, James Morris, who after years of marriage, realized that becoming his authentic self involved a sex change operation. (He was fortunate to be accepted as a woman by his wife with whom he continues to live.)

Beyond everyday life, the theme of many plays and movies focuses on the dilemma of authenticity vs. acceptance. 

In Tennessee Williams’s play The Glass Menagerie (please refer to the post of September 30, “Consider the Chaos”), the disapproving mother, Mrs. Wingfield,  criticizes her children incessantly and drives them to escape into worlds of fantasy. Tragically, they do not experience the (relative) contentment that results from living an authentic existence in the “real” world.

Conclusion: The psychotherapeutic relationship and the arts examine the rich and fluid space/land between authenticity and acceptance.

Dear Reader: I welcome your comments regarding this human conundrum. Jsimon145@gmail.com

Consider the Chaos (in Ourselves and our World)

David Foster Wallace, the brilliant writer who died in 2008, wrote an essay titled  “Consider the Lobster.” I say let us consider the Chaos. which is actually related to D.F. Wallace.  (His suicide resulted from his internal mental state of Chaos-depression and self-hate.)

Inadvertently, our actions lead to Chaos in many small ways everyday- accidentally taking an extra playbill at the theatre, allowing the faucet to run too long. For the most part, these instances are unavoidable and need not overwhelm us.

But I’d like to pose the question, Would our world be different if we purposefully aim to diminish the Chaos and, in its place, substitute  order?

Let us start with our intra-psychic self (of which D.F. Wallace was a victim).

Our relationship with our own psyche has the potential to add order or the opposite, Chaos, to our lives. If we accept our efforts, we add order and energy as we plug away at our daily tasks. If we declare our efforts insufficient or “never enough,” we actually may work against ourselves and become our own worst enemy.

For example, Ms. C., an artist, suffers from self hate and depression. She doesn’t feel she deserves to be successful or loved.  Factors in her early environment failed (in some way) to support her talent and healthy psychological development. She doesn’t see a purpose in her life in spite of  her gift to create art and can’t “take in” the positive feedback she receives from the outside world.

Self-hate is like an eraser at the end of a pencil that wipes out a person’s accomplishments, rendering them imperceptible to the achiever. Like the reverse of the Hans C. Andersen story of the emperor and his new clothes, we outsiders perceive accomplishments that remain invisible or imperceptible to the achiever.

For a person who hasn’t grappled with self hate or depression the “erasing phenomenon” may seem incomprehensible.

Our intimate relationships can have the effect of adding Chaos and/or order to our lives. In fact, they probably cause the pendulum between the two states to swing back and forth, from moment to moment. In the final analysis though, a “good-enough” relationship adds a sense of increased order to our internal and external worlds.

In Tennessee Williams’s great play,  TheGlass Menagerie, currently running on Broadway, the mother, Ms. Wingfield embodies the tragic example of  a mother whose words create Chaos in her offspring. She achieves the opposite of an agenda she espouses, namely to want the best for her children. In bragging about her past accomplishments, and nagging them about their inadequacies, she undermines their self-esteem, driving them into their own private world of fantasy, detached from the “real world.”

The character of Ms. Wingfield  reveals a gapping flaw:  she lacks  self-awareness. If Ms. Wingfield were aware of her unconscious motives-to diminish her children in order to gird herself (against unconscious self hate- she might choose to change her tactics. Awareness grants choice and in turn, offers order.

Chaos has been generally viewed as a negative and order as the goal, but a recent article about Chaos in the New York Times Magazine (Clean up Your Desk! by Gretchen Reynolds, September 22) complicates the dichotomy. The author summarizes a recent study at the University of Minnesota (published online in Psychological Science last month) documenting the effect of messy and neat office environments on college students. The study found that a less- than- neat environment led to an increase in creative thinking, while a neat environment enhanced productivity. In other words, an advantage can be found in both order and Chaos.

Perhaps a valid goal is to consider organized Chaos, a situation   in which we’re sufficiently ordered to be able to connect thoughts, actions, and events, yet open enough to allow novelty.

 Awareness is the master key that opens the doors to increased order.  By contrast, lack of awareness adds Chaos to the psyche, the interpersonal world.

(For me, writing a daily journal is a powerful tool that increases my self-awareness and diminishes the Chaos and disorder in my mind.) 

Conclusion: The common denominator of awareness adds order to the physical, mental and spiritual levels while the absence of awareness adds Chaos. The process, of course, is unending, as infinite (we hope) as the ebb and flow of our oceans.

Dear Reader, I welcome your thoughts on this complex cycle.

Jsimon145@gmail.com.

Our Neurons and Ourselves

We are on the frontiers of an exciting time in neuroscience. Dr. Eric Kandel, the recipient of the 2000 Nobel Prize in Physiology or Medicine, explains that the area of the brain responsible for depression has been documented (in some cases) and the type of therapy to which the patient responds can be predicted (The New York Times, September 8). He cites a recent study in which Emory University’s Professor Helen Mayberg has demonstrated that people with below-average baseline activity in the right anterior insula responded well to cognitive behavioral therapy. These contrasted to those with above-average activity who responded to medication. In other words, observing the baseline activity in this area of the brain, the right anterior insula, can predict a depressed person’s response to specific treatments.

The case of Mr. M. exemplifies how this kind of predication could be helpful. He consulted me for long-standing depression, unresolved after ten years of psychoanalysis with Dr. L.  Mr. M. functioned like a car, running on three of a possible six cylinders; he declared he’d received no benefit from treatment. Within a few months on antidepressant medication, he felt like a car in which all six cylinders fired on time. He was able to access the knowledge he had gained and change his life.

Some people suffer for years unwilling to consider a pharmacological approach. Another segment of the population thinks pharmacotherapy is the only solution. The new research opens up a vast territory of possibility that would help to determine who will respond to which approach.

Dr. Kandel concludes the following:

1.              Neural circuits disturbed by psychiatric disorders are very complex.

2.              In certain cases, markers of a mental disorder can be identified and can predict the outcome of psychotherapy and medication.

3.              Psychotherapy as well as pharmacotherapy is a biological treatment that produces physical changes in the brain.

4.              The effects of psychotherapy can be studied scientifically.

Conclusion: Some amazing recent discoveries of the brain and mind include the budding potential to predict who will respond to a variety of biological treatments that include psychotherapy and pharmacotherapy.

Dear Reader, I welcome your thoughts on the advent of this exciting frontier of neuroscience. Jsimon145@gmail.com.

The Myth of the "Free lunch"

Opportunities arise almost daily to accept a free lunch. Some of us shun the idea of getting something for nothing, while others seem to crave it. In either case it is wise to think about the expectation involved.

There’s always a catch, obvious or not, whether it’s  free lunch for school children, a sample copy of a magazine, or a meal at an expensive restaurant (formerly offered in abundance to physicians by pharmaceutical companies but recently curtailed since the government applied restrictions).

The free lunch offered to schoolchildren implies that the kids attend and follow the rules.

We have to read the free issue of the magazine to decide if we want it or if not, then return the bill marked “cancelled.”  The physicians must listen to a promotional presentation at the dinner.

Probably most of us don’t object to receiving something for free. In the first few months of life in our infancy, no one demanded anything of us. We were fed, clothed, washed and cuddled, and given positive, unconditional regard. Perhaps the hunger for the free lunch is a throw back to the bliss we knew (buried in the unconscious) before we became individualized and saddled with the effort to meet our own needs.

The appetite for a free lunch is common, and detrimental only when compulsive. There is a big distinction between receiving a free lunch and maneuvering to get it, like a manipulator or, worse, a thief who helps himself.

Conclusion: The term free lunch implies an unspoken contract. Although it tempts, the “gift” doesn’t deliver carte blanche. The reciprocity of give and take anchors us to the human chain of relationships.

Dear Reader, I welcome your thoughts on this tricky topic. jsimon145@gmail.com

A Gift Free to Give (with Effort)

An aspect of human nature is to want to help others; a beneficent act can be as simple as assisting a blind person across the street, or as self-sacrificing as donating an organ.

In between these extremes, lies the vast and treacherous land of interpersonal relationships, a multi-layered terrain rippled by an awareness of self and others. Each of us harbors blind spots. We simply are not always conscious of how our words and/or actions impact others. Ideally, we help each other by increasing awareness.

Feedback can be as simple as a comment like, “I think the green dress becomes you better than the yellow one.” On a deeper, delicate level, we can point to a behavior that may work against a person’s goals.

Steve Jobs, the founder and mastermind of Apple Computers, exemplifies someone who would have benefited if he’d been able to heed feedback from friends regarding his verbal abuse. Instead he alienated some who tried to help him.

Many years ago my brother Bob pointed out that I seemed oblivious to the discomfort I was causing my sister-in-law in pursuing a family matter.

“You don’t seem aware of her Achilles heel,” Bob said.

“Really!’ I answered. Fortunately I felt more surprised and curious than insulted or defensive. I recognized the value of his feedback. His goal wasn’t to wound but to heal, to make me a better, more aware person.

The task to guide another person isn’t easy. Whether an individual will respond with openness or defensiveness, is almost impossible to predict. To couch a message in words that express caring and concern (vs. cutting criticism) is essential. Hurting someone’s feelings could complicate or jeopardize a relationship.

Putting yourself in the other person’s position (to imagine how you’d feel) can be helpful. Posing a question is another tactic that can soften a blow. (For example, “Have you ever thought about psychotherapy for yourself?”)

Conclusion: We each possess an invaluable tool to guide one another on the playing field of life.

Dear Reader, I welcome your feedback. Jsimon145@gmail.com.

Denial and Deceit: Gateway to Change

 

In the field of psychology, the word denial refers to a defense mechanism, an “unconscious” tool to protect the psychological integrity of an individual and help him function in the world.

 

By contrast, the goal of deceit or dishonesty is a conscious attempt to manipulate another person and/or

the environment for some nefarious purpose(s), major or minor, and undermines the integrity of personal and social relationships. Like a building constructed with faulty cement, a relationship built on deceit may crumble at any moment.

(One of the reasons we adore and enjoy very young children and our pets, cats and dogs, is their guilelessness. Although they can manipulate us, they aren’t capable of deceiving us.)

In the situation of denial, reality is hidden from the denier himself. If denial is too extreme, he may fail to grapple with reality and suffer dire consequences, but he doesn’t intend to harm or manipulate other people.

We can deny as well as deceive ourselves. An example of self-deception occurs when I promise myself I’ll eat one-half but instead, I devour an entire chocolate bar. From past experience, I know I have an addiction to sweets. To indulge in a morsel tests my self-control and invites trouble.  (People with addictive problems often play this game with themselves, whether the addiction involves an appetite or an action (behavior).

In contrast with denial, lying is conscious. The person responsible knows he’s spinning a web.  Dishonesty is an interpersonal matter that undermines a relationship and induces angry feelings; the deceived person feels duped, foolish, gullible, and may doubt himself as well as the dishonest person.

What underlies dishonesty? Why can’t the person be straight with us?

We learn to lie early in our lives. Our parental figures set the stage. A child naturally tests the limits and learns about boundaries and fairness from his caretakers. If they let him get away with lying, he will continue the habit.

Deceit in the context of a psychotherapeutic relationship is a conundrum. A client invests time and money while sabotaging his efforts and squandering his resources. Before a genuine intra-psychic journey begins, the wall of deceit must be broached.

Most psychotherapists shy away from confronting a patient over the deceptions perpetrated in therapy; we have to reach beyond the common tools of acceptance and understanding. Like a dog trained to detect bedbugs, in spite of the distasteful task, a psychotherapist has to root out deceit.  We have to challenge the client, risking anger, rage, and abandonment. But if the client succeeds in manipulating, we fail to accomplish the major task and the pattern of dishonesty is reinforced.

An example is Ms. M. who lived on disability payments. After a few years, she confessed she had a part-time job. Dishonesty undermined our relationship; her fear that I would discover her secret exacerbated her paranoia. (When at last she told me, I complimented her on her courage to tell the truth, but she didn’t return for treatment.)

(As black is the absence of light, deceit is the absence of courage to be honest.)

Although he had a job and could afford treatment, Mr. Y. tried to get out of paying for his sessions. When I set firm limits, he acted hurt, insulted, wounded, as if I had committed a crime against him.  If I had failed to take a hard stand, I would have side-stepped the work and he would have continued to assume he could “get away with it” in other situations. In this way, and in many others, the therapy room is a mini-laboratory for the outside world.

Conclusion: Deceit and dishonesty undermine any and every relationship with oneself and others. Coping with this behavior requires courage on the part of the client and the psychotherapist and offers an avenue to major change.

Dear Reader, Your comments (on this tough subject) are welcome. jsimon145@gmail.com