Paradoxical Nation

I’ve just returned from San Francisco after attending the meetings of the American Academy of Psychoanalysis and Dynamic Psychiatry and the American Psychiatric Association. More than 13,000 psychiatrists and mental health workers gathered from over 50 countries, and occupied more than 31 hotels. The smorgasbord of presentations was overwhelming. The diversity of interests, approaches and opinions seems as vast as the Titanic.

Several seminars and symposia touched on the failure of our present-day U.S. system to take care of the vulnerable, seriously mentally ill people.

Perhaps the metaphor of the Titanic has greater relevance than we’d like to think. The ship, thought to be unsinkable, too closely resembles the sinking of our humanitarian principles.

Since the 1970’s, state institutions have closed down. The fact that more funds are spent on mental health now, does not equate to better quality treatment for the seriously mentally ill.  From one public psychiatric bed for every 300 Americans in 1955, the ratio fell to one for every 5000 in 2012.  

Three times as many mentally ill are incarcerated rather than hospitalized as a result of new spending priorities, according the founder of the Mental Illness Policy Org., to D.J. Jaffe.

Mentally ill offenders in prison suffer from serious  afflictions such as schizophrenia, bipolar disorder, trauma, sexual and physical abuse. In spite of the Right to Treatment Act, they do not receive treatment but, conversely, mistreatment, misunderstanding, and neglect.  People with psychiatric disabilities are more likely to be victims of homicide and suicide than the general population.

At least part of the solution lies in establishing residential facilities staffed by mental health professionals, according to Dr. Herbert Pardes, New York-Presbyterian Hospital’s executive vice chairman of the board, who delivered the presidential address at the American Academy of Psychoanalysis and Dynamic Psychiatry.

Beyond the amount of dollars and cents, the answer is how and where they are directed. Recommendations include:

1. Mental health consultations and formal training of police officers.

2. Careful screening of incoming jail detainees

3. Diversion to the mental health system of mentally ill persons who have committed minor offenses

4. Assertive case management and interventions to assure outpatient treatment.

5. The ability of the courts to order treatment when necessary.

6. The availability of 24-hour structured care.

7. Guidance to provide support for families.

8. Funds directed more appropriately to provide adequate mental health treatment for all.

Conclusion: The general consensus of opinion of many diverse professionals is that current policies in our country have led to a regression in treating the seriously mentally ill, reminiscent of  our failings in the 19^th century.

In spite of our status as one of the wealthiest countries in the world, our paradoxical nation falls short; in 2013, without proper direction of funds, the ship of humanitarianism seems to be sinking.

Dear Readers, I welcome your opinions.

Thoughts on the Diagnostic Statistical Manual (of Psychiatric Disorders)

In May 1817,  the first mental health hospital in the U.S. was founded in Philadelphia by a group of Quakers. Known as The Asylum for the Relief of Persons Deprived of the Use of Their Reason,  today it still stands as the Friends Hospital.

When it was founded, mental illness was widely misunderstood and treated as criminal behavior. Mentally ill people were tied up, put in chains, isolated, and/or beaten.

I’m posting this week’s blog from San Francisco at the annual meeting of the American Psychiatric Association, where

almost two hundred years to the day of the founding of the first mental hospital in the U.S., the fifth edition of the DSM-5 of the American Psychiatric Association makes its debut.

The initial impetus for developing a classification of mental disorders in the US was the need to collect statistical information. In this regard, it has been a colossal failure. To my knowledge, none of my colleagues regard this manual as a tool of statistics. Rather, we use it in obligatory ways to interface with various systems like health insurance companies,

Like me, many of my colleagues regard the protection of the patient as more important than statistical correctness. We don’t choose a diagnosis that may interfere with employment opportunities, unless, of course, the individual is unable to work.  We serve as allies, not adversaries, of our clients.  Furthermore, accuracy in diagnosing a psychiatric “disorder” on the basis of phenomenology, or observation of symptoms, is subjective and changeable.

The good news is that we no longer categorize mental disturbances as “criminal behavior.” We continue to elucidate the complex mechanisms of the intricate brain in order to decipher the nature of mental suffering.

Although the DSM has attracted praise for standardizing psychiatric diagnostic categories, it has also unleashed torrents of controversy and criticism for an unscientific system that has been said to enshrine the opinions of a few powerful psychiatrists.

Other criticisms include: ongoing issues about validity and reliability of the diagnostic categories; the reliance on superficial symptoms, and the use of artificial lines dividing  diagnoses from “normality.”

In general, psychiatrists are not enamored of any editions of this manual; I think I speak for many of my colleagues when I say we regard its existence as a necessary evil at this point in our evolution. In another hundred years, it may be categorized as a relic along with the chains, ice picks and bloodlettings of previous centuries.  

By design the DSM is primarily concerned with the signs and symptoms of mental disorders, rather than the underlying causes. It claims to collect and organize them based on statistical or clinical patterns. As such, it has been compared to a naturalist’s field guide to birds, with similar advantages and disadvantages. The lack of a causative or explanatory basis, however,  is not specific to the DSM, but rather reflects a general lack of patho-physiological understanding of psychiatric disorders.

Each of us humans is unique and less predictable than any animal on earth and therefore won’t fit neatly into a diagnostic label.

On April 29, the director of the National Institute of Mental Health (NIMH), Thomas Insel, announced that the lack of validity of the D.S.M. was limiting progress in mental health research. Less than two weeks “after throwing DSM under the bus,” he issued a joint statement with APA President-elect, Jeffrey Lieberman. DSM, they wrote, “represents the best information currently available for clinical diagnosis of mental disorders.”

Gratefully President Obama is allotting funds for research on the brain. An elucidation of the neurosciences will benefit us all.

Conclusion: Good-enough psychiatrists relate to the individual, to build a working alliance, regardless of diagnostic category, and to elucidate and minimize obstacles that interfere with a constructive and satisfying life.

We have come a long way since 1817; we’re on the path of the neurosciences to discover the underlying mechanisms of  “phenomenology.” In the meantime, patience and an open mind to change will ease our journey.

Dear Reader: I welcome your opinions. Jsimon145@gmail.com

Terrorists and Our Personal Power

In last week’s blog, I wrote about the gradual downhill spiral in which an individual becomes disillusioned, hopeless to achieve his ambition and connect to other people, and finally resorts to acts of violence, like terrorism.

But what can we as individuals do to ameliorate the situation? I think we have some options.

1.     We can become indifferent, sport the attitude that this just happens; it’s a part of life in 2013.

2.     We can foster the attitude of denial; this simply won’t happen here (to me).
3. We can become overwhelmed- that problem is too big for one little person like me to tackle.
4. We can recognize our real, individual power and take action.

 Each of us plays a role in becoming vigilant.

1.     The owner of the New Hampshire fireworks store where the Tsarnaev brothers bought explosive powder determined to train his salespeople to recognize signs of potentially dangerous individuals. Ideally other storekeepers and distributors of fire arms can rise above the profit motive, to recognize their power to prevent the perpetration of violence.

2.     We can reach out to engage people who seem to be in trouble, who seem disillusioned and isolated, whose activities and mannerisms have changed.

3. We can try to identify individuals who speak and/or write about aspiring to violent acts.

4. With the help of modern technology (cell phones, video cameras) we can record and help identify perpetrators.

Paradoxically, the same tool of communication-the Internet- that allowed homegrown terrorists to manufacture weapons can be used to prevent crimes of destruction.

Conclusion: Our human nature encompasses constructive and destructive forces and in this regard is unlikely to change. However, its manifestations continuously metamorphose. The good news is that each of us can make the world a better place with awareness and a willingness to do so.

Dear Reader, I welcome your comments: jsimon145@gmail.com

Transformation of a Terrorist (with thoughts for the future)

Tamerlan Tsarnaev did not begin life as a terrorist, nor did he appear to entertain the goal of violence until certain events occurred, cutting his dreams short.  The tragic trajectory led him to bomb the Boston Marathon with his younger brother, Dzhokhar, on April 15, killing three and wounding 260 people.

As I attempt to understand the motives behind the terrorist acts of Mr. Tsarnaev, the theme of hopelessness resonates like  an offending gong. He attempted to achieve the American dream. The reason he failed was not as much the system itself as his interpretation of events. He did not know how to follow the rules.

He is described as an “underachiever” because he did not dedicate himself to the proper training regimen. During a preliminary round of the New England Golden Gloves in 2010, he breached boxing etiquette by entering the locker room,  taunting his opponent as well as the other fighter’s trainer. “You’re nothing,” he said disdainfully. “I’m taking you down.” (Speaking in psychodynamic terms, he was most likely externalizing his deepest unconscious fear-his lack of self esteem.)

The trainer was furious and lodged a complaint, arguing that Mr. Tsarnaev should not be allowed to participate. Soon after, non-citizens were barred from the competition. A year away from citizenship, Mr. Tsarnaev was devastated.  Perhaps he feared that his arrest for a report of domestic violence would be an obstacle to citizenship, but this charge was dismissed.

Soon after he gave up boxing, he married the American woman, Katherine Russell, in a brief Islamic ceremony. He took care of his three-year-old daughter while his wife supported the family as a home health aide, supplemented by public assistance.

After he was married with a child, he withdrew from his friends, and felt guilty for having fun at the parties he had previously enjoyed. He dropped out of community college and lost interest in boxing and in music. He worked sporadically and seemed isolated. His mother returned to Dagestan soon after a felony arrest on shoplifting charges. His brother had left for college at Dartmouth. He further isolated himself, becoming an outsider with other Muslims; attending a mosque, he interrupted the prayers on two occasions to denounce the idea that Muslims should observe American secular holidays.

In early 2012, he left his wife and child for a six-month visit to Russia and failed to claim his renewed Russian passport and no longer had a valid passport in any country.

Conclusion: Some of the billions of dollars we spend defending ourselves from “terrorists” should be directed, not to stigmatization, but  to engagement, to help “outsiders” address their hopelessness and to find a way back to the mainstream, to connect to constructive bonds of caring and concern.

Sadly our “free” and “open” society at this point in history often gives us more freedom to kill than to heal. But there are psychological tools we can employ to accomplish this task without impinging on anyone’s civil liberties.

Dear Reader, I look forward to hearing your opinions. Jsimon145@gmail.com

Terrorism as Cowardice:Thoughts after the Boston Marathon Bombing

Tamerlan Tsarnaev, aged 26 and his brother Dzhokhar, 19, are accused of going on a violent spree. On April 15, they killed three people and wounded 260 with the pressure-cooker bombs they dropped near the finish line of the Boston Marathon. The debacle ended in Tamerlan’s death and Dzhokhar’s capture in a boat parked in a driveway in Watertown, Mass.

Like many others, I am devastated by these random acts of violence perpetrated by young men, whom many could not imagine capable of committing these gruesome acts.

In brief, their lives reveal trauma, turmoil combined with extraordinary advantages to live and love in a country without war. They had the possibility to acknowledge their confusion, disappointments, hopelessness, and to learn to love themselves and others. Instead of healing their divided minds, they chose radical thinking to unify their confusion and externalize their hate and rage.

Conclusion: Sadly our culture, as expressed in the media, often glorifies violence. Violence sells.  We associate violence with power.  Too rarely do we hear the opposing message: Real power lies in the courage to acknowledge rage and transform it to constructive action-to change the world for the better.

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

Manipulation: Pros and Cons

We often associate the word “manipulation” with a negative situation in which we’re not in control, perhaps beyond our awareness. Since we like to think we’re in control,  becoming aware that we’re not creates anxiety.

However, in medical practice, the term “manipulation” is a beneficial act, used to restore a dislocated joint to its socket.

Recently I had an experience with a patient who tried to cancel his session two hours before the appointment. I urged him to come. When he showed up, he said,

 “Please insist I come even if I try to cancel again.” He was asking me to ‘manipulate’ him for his own good.

In spite of the negative implications of mind control, we try to focus our mental processes in positive ways: choosing a healthy diet, participating in an exercise program. We respect people who have “self-control.”

In a sense many successful people manipulate social situations to their advantage. They know how to act appropriately. People who don’t assess a social situation accurately may fail to be promoted or may be fired.

Some of us attempt to manipulate our minds while asleep to have good or problem-solving dreams. But we aren’t always able to rule our unconscious. I’m aware of the effect of some of my dreams on my morning mood.  After the Boston bombing on April 15, I had a nightmare and awakened in a downtrodden state of mind.

Parents manipulate their children by rewarding constructive behavior and correcting negative and destructive behavior. They are responsible for teaching children how to care for their own needs and respect the needs and rights of others. (Please refer to my post, “Some Notions of Needs,” April 15, 2013)

In other situations the lack of positive manipulation can prove disastrous. For example, a sixteen year old blames his mother for everything that goes wrong in his life. He has no interests or friends, spends hours in his room, emerging only for meals.  He refuses to go to school or attend psychotherapy sessions. If he is allowed to remain an outsider in his family and society, he may become a sociopath, manipulating others for his own purposes. This young man must, instead, be manipulated to participate in life and connect to other people.

The person with an antisocial personality disorder becomes a master of negative manipulation because he has not been appropriately manipulated as a child.

CONCLUSION: Recognizing the negative and positive avenues of manipulation increases our awareness and offers choices: to manipulate ourselves, to be manipulated, or not.

Dear Reader, I welcome your experiences on this huge and fascinating topic. Jsimon145@gmail.com

Some Notions of Needs

Volumes have been written on the subject of the needs, the specific requirements for survival of each living creature. The psychologist Abraham Maslow wrote about the Hierarchy of Needs in his seminal 1943 paper, “A Theory of Human Motivation.”

When needs are met, they are as natural and automatic as the heartbeat, respirations, and the metabolic workings of every cell in the body.

Human needs are complex in at least two major ways:

First, we may tune in and be affected by the spirit with which our needs are met in early life. Second, humans have imaginary needs beyond the real ones.  These may or may not serve us well.

In the psychotherapeutic process, the team of client and therapist approach the perceptions of our psychological needs in our relationships with our self and others.

Donald Winnicott’s concept of “good enough” is useful. If our needs for love and safety were met in a “good enough” manner, they don’t impinge on our lives in negative ways.

At first parents must meet all their baby’s needs. The parent or care-taker must balance the infant’s needs with their own. Gradually the parent teaches the child about the needs of others.

 Examining our destructive behavior later in life, we’ll often find it is based on a distortion of our needs. We turn to food, money, or stuff to substitute for what we experienced as lacking.

The hoarder, for instance, accumulates and holds on to “stuff” to substitute for feelings of love and safety he did not experience early in his life. (Please refer to my post, The Paradox of Hoarding, March 25, 2013)

The sociopath (or person with antisocial personality disorder) has not learned to care about others’ needs. (Please look back to the post “Christopher Dorner and Bonnie and Clyde,” February 25, 2013).

The person with psychosomatic problems may not have had the opportunity to recognize and express her needs. (Please refer to the case of Ms Y in the post, “Age and Change,” July 16, 2012).

Conclusion: A major goal in life is to learn to meet our real needs (and distinguish them from imaginary ones) in constructive and creative ways and to recognize the needs of others.

Dear Reader, I welcome your contribution on this complex subject. Jsimon145@gmail.com