Happy New Year, Bang, Bang

It's a new year.  I hope you are all healthy and happy, and that you and all those you love are safe and warm.

I am old and cynical, so take this for what it's worth, but 2015 does not hold much promise for being much better than 2014, except maybe for the Patriots -- that's the football team, not a bunch of Whooped-Up Americans.

For most people 2014 was kind of OK.  If you were rich you got richer.  Everyone else paid a little more and got paid a little less, but for most folks it wasn't too drastic.  If you were poor and struggling last year it looks like you will be poor and struggling this year. If you had psychological and emotional issues last year more of you will be able to get some kind of help, from some kind of somewhat trained helper.  They may give you a supportive place to list your difficulties.  They may offer some advice, the kind of which you knew before you saw them.  They may even help you see that you have some paths to choose that you didn't realize were open to you.  That can be very helpful.

But they won't be able to open any doors that are closed to you, or spend enough time with you so that you can retrain your brain to not be so reactive, or to learn totally new behavioral responses to stressful situations, or to change the stressful situation, or to change the fact that you may have chronic pain or a degenerative disease.

In short, there is still no really effective treatment for all the things we call "mental illness."

The guy who shot the two policeman in NYC, the kid who shot his adoptive mother and a couple of other people in Idaho, the veteran who shot his psychologist in Texas, and of course, the jihadists who killed so many people in Paris were all suffering from some form of discontentment.  I believe that  at sometime in their lives they had either actively sought help, or were at least known in their communities to be people who were "at risk."

Do we know what to do to help people who are "at risk?"  I think that most of the time we could figure out an answer.  Find a way to form a relationship, to not only offer help but to offer some resources so that they are able to use the help -- a place to live, job training, stable support people, food, warmth, trust, encouragement, understanding, new and better options to choose from.

But that is very time consuming and very expensive.  It's much simpler, easier, and cheaper just to wait until they go off the rails, and then shoot them.

there is always a well-known solution to every human problem — neat, plausible, and wrong.
-- H.L. Mencken.

NYT -- old rules -- not to follow

It is a bit of an embarrassment to the professions of anyone who does psychotherapy that the NYT would publish this piece.  Perhaps, this happens only in New York, where people still follow Woody Allen into psychoanalysis.

http://opinionator.blogs.nytimes.com/2014/11/22/the-rules-of-psychotherapy/#more-155056

Dr. Weiss is struggling by adhering to techniques that are a hundred years old and largely discredited.  It is good to see that as a psychiatrist she still does psychotherapy, as almost all psychiatrists outside of major cities only prescribe medications.  But if she is going to do therapy she should learn that things have changed.  That the relationship between the patient and therapist is very important and that, although it needs to be structured, and it is not a friendship, there certainly needs to be warmth and acceptance.  Then, there are many other approaches that have proven to be more successful than long-term psychodynamic treatment.

What I also find interesting is the wide range of comments that have been posted.  The differences in understanding the causes of depression are certainly very striking. Depression is a very serious condition, and a very complex one.  It often, but not always has some genetic component.  It also involves family history, job history, a history of loss or trauma, brain damage, illness, pain, unemployment, poverty, racism, and addictions.  It is not a “disease” with one clear cause.

Therefore the treatments have to vary accordingly, and should hopefully involve many disciplines, including, psychologists, geneticists, neurologists, social workers, and other branches of medicine if they are relevant.  Such treatments are very rarely available in our world of specialists who just do their own job.  That is why Dr. Weiss’s patient is still in treatment, and still suffering, many years later.

         

Not That Good

It's pretty clear to me now that I am in the process of winding down my practice.  I've been in a "private" practice in this city since 1981.  The reasons for my starting to close down and move along have been discussed here in several ways, and will be again.  But not today.

But, I have been looking back as well as forward and I can see that having a practice like this as mostly what I wanted to do.  My first choice would have been to be part of a real community mental health program, such as the one I was sent to school for, and where I had my first job.  These were places where people could go for evaluations and treatment of social, emotional and learning problems, and also for neighborhood problems and community issues.  We were just learning how to do preventive work, educational work and consult with other agencies when President Reagan decided that this sounded like Socialism and his government wouldn't pay for those things.

So, we got licensed and went into private practices and then we got paid by insurance companies.  That model was good for treating the kind of problems people brought to us, but  treating them one by one, which was often kind of frustrating, since many of them really were caused by what was happening in the community, or society at the time -- still true.

Also, looking back I can see how successful I was at treating people with relationship difficulties, with anxiety and panic problems, with many forms of depression, with loss, loneliness, addictions, and many of the other things that disrupt and deplete people's lives. Often that was very gratifying.

But we, mental health professionals: Psychologists, Psychiatrists and all the others, still have very little  success treating the real destructive kind of "mental illness," the kind that rips families and communities apart.  That is we offer very little help to the person who is angry, obnoxious, aggressive, upsetting and destructive.  These are people who get about six diagnoses during their lifetime, including Borderline Personality, Major Depression, Bipolar Disorder, Antisocial personality, Oppositional Disorder, and other such names that don't identify an underlying cause as much as they are just descriptive.

We offer these people many medications, dialectical behavior therapy, cognitive behavior therapy, and many other kinds of treatment that don't work, mostly because the people don't attend, don't follow, get angry and frustrated easily and leave.

There are many people who are afflicted, if that is what it is.  They bring heart-break and havoc to their families, they take too many drugs, make bad decisions, and cause problems in the community. I feel, that because so many of the tasks required in today's society are complex, and demand much more interpersonal interactions, and at a quicker pace than previously, that more people break-down and reach their breaking point.  Then they get angry, stop functioning, don't pay their bills, get in arguments and fights, and end up either in legal trouble or in bed for weeks. When they get out of bed they are further behind, angrier, and cause more problems.

I have seen many for therapy, and then they don't return.  I hear about so many more because their families suffer come to me for help.  They don't know whether to try to help or cut ties, and neither strategy is successful.

It's very sad.  We have all kinds of labels, but no real treatment.  The cause is probably a combination of genetics, family, community, timing, diet, toxins and luck.  But then what?

That is the real problesm in mental illness, and we don't have a clue.

Who is brave?

Let's think about three appointments I had in a row last week. Let's call them 10, 11, and 12.

10 is a woman in her early thirties who has been seeing me for several months because she had a series of bad panic attacks. She doesn't have too many full-blown attacks any more but she is constantly afraid that she will. This makes her afraid that she has lost control of her mind and that she is about to go completely crazy. She won't, but she thinks about it much too much, and with too much intensity.

She had been telling her husband about her fears, but after a few months of trying to reassure her, he just tells her to get over it.

I want her to take some medication. I think it would really help. But she is afraid that once she swallows the pill she has no control of what it will do to her mind, and that the pill will push her over the edge. She is a brave, tough young woman and she fights her fears all the time. You would never know that she is constantly fighting off thought of a mind explosion.

11 is a man I have also been seeing for a while. He is finally beginning to make progress battling a terrible depression. He has spent months in his house, mostly lying in bed trying to find the energy, and in his mind, a reason to get up. He has a lovely wife and a beautiful daughter and he stares at them, knowing he should do more to take care of them. He has been taking many pills, and they have helped a little.

He lost his job months ago. He is behind on his bills. He feels like a failure and is just beginning to get passed hating himself for it. There are some very complicated and involved reasons why this all descended upon him, but no one can see those. People look at him and wonder why he can't just go back to being what he was two years ago.

He is making progress. The thoughts of suicide are less frequent. He is bravely fighting through the dark clouds that have filled up every room of his life.

12 drags herself in on crutches. One leg is worse than useless to her, as it also causes her almost constant pain. Her ankle is not only busted, it is deteriorating, as are several of the bones in her spine. This deterioration has put pressure on her spinal chord and caused seizures. The seizures have caused her to fall and re-injure her ankle, as well has her knee and her wrist.

The pills she takes, and the devices she has implanted in her serve to somewhat diminish her pain. She can take more pills, but then she will sleep all day and all night and not be able to finish a sentence. She does that some times.

There are things she can have done to her that could help. There is a list of three more surgeries. They could relieve most of the pain, or they could paralyze her, or even make her heart stop.

She has one hand and arm that works without pain. She uses it to bravely kill hordes of zombies that attack her through a video game.