Road to Hell

It’s been a while since I’ve posted. Different job, different life situation. I’ve been thinking about this a lot lately.

The road to hell is paved with good intentions.

I started thinking about relationships with this in mind. I usually tell myself I try to be honest about what I think I’m thinking. I know that all those qualifiers are there and I leave them there on purpose. I tell myself stories about what I plan to do about what seems to be really important now and then I translate it into language and best of luck to you to understand what the hell I’m trying to communicate.

Shunryu Suzuki in Zen Mind, Beginner’s Mind talks about the “shadow of the whip”. There’s an inclination in me to try to guess what your reaction will be, couch my words in such a way as to make it safer so I won’t feel the riding crop whack me.

That’s my agenda. My belief. My doctrine. Trying for an end point and not really noticing the harm it causes right now. Right now is the only thing that exists.

So, Road to Hell. Paris. Refugees. Kill lots of people.

FaceBook is crammed with ideologic rants, memes about Daesh. I am thinking more and more that the end whether it’s good, bad, indifferent, insouciant, inept is really not helpful. Based on my end goals I can help people become dependent on or independent of the government, deny or grant basic freedoms, stop or help you shoot people. And all the while I’m pursuing this wonderful end goal, I might accidentally smush you or your ideas.

The ideologic arguments are ultimately stupid. Hitler did not see himself as evil. Go to a seminar on Ethics with managed care or pharma execs and ask them who thinks they’re unethical–anyone? anyone? I get through life doing the hateful things I do because I’ve figured out the answer.

So I ask myself–as if my Self is over in that corner and some other self is asking it. I don’t always understand the reflexive tense.
Self, “What do you want?”
Self, “I want people to not hurt so often”

I anticipate peals of laughter and waves of ridicule after this. If your philosophy hurts someone now because in some really cool future with flying cars it will be better, it sucks, it’s stupid, it is evil.

So back to relationships. I need to say right now, right here what I think, what I hope, my desires for your joy. Don’t hold back because “if you think that I think that we might or she would…”

The Road to Hell is paved with good intentions. How about we recognize there’s no Road?

Frozen

No, not this one.

I was speaking with my daughter recently as she undertakes this journey to becoming a therapist. It was such a thrill to hear her excitement about what she’s learning. As we talked, it caused me to reflect on all the modes of therapy we mess around with in our field.

I remember all too well the questions about theory I kept having, “Which one is right?”, “Is that true?” As the years have gone by, I’ve come to realize that they all are and none are at the same time. Someone once wrote that you go to therapy to start something, stop something or to do something differently. In most cases, by the time someone reaches my offices, they’ve had a surfeit of advice, pointers, self-help, religious help and every other thing in the world. When they come to see me, things are stuck. They’re frozen.

My experience has been that therapy is a process of finding a story about that person’s life which isn’t frozen any longer. That depends so much on our interactions during therapy. Some people can really get attached to a particular theory. It resonates with their views of the world in a way which can show them some path forward to making a desired change. It also depends on my fluency in using the images and tales from a given set of therapeutic theories in a way which supports that way forward.

In my meditation life, I’m constantly wrestling with the whole idea that none of it is true. My mind constantly creates narratives of passion, aggression and ignorance based on all kinds of preconceptions. The kernel of practice is recognizing the inherently empty nature of all those thoughts. They don’t really mean anything.

In conversations with my teacher, Sokuzan, it occurs to me that it might be a bit much to meet someone in a therapists office and start right in on groundlessness and “no reference points”. Not in every case, but in many settings, a person’s life is in such turmoil that they need an anchor at least for a little bit. My hope is that in my work, I don’t tie them to that anchor with so many chains that they can’t ever get loose. My hope is that at some point, they’ll see the stories as just that, stories that helped them move at a time where they couldn’t see a path.

Moral injury

http://www.integralcarepieceofmind.com/?p=92

When I visit the Travis County jail to provide psychiatric services, one of the first places I go is the “slick cells.” A slick cell is exactly what it sounds like. Nothing moveable in the room, a hard shelf to sleep on, a stainless steel sink-slash-toilet combination and a drain in the floor for whatever doesn’t make it down the sewer pipes create a uniquely dehumanizing experience. To top it off, when someone’s sent to a slick cell, they’re stripped of all their clothing, and given a rip-proof garment to wear so they can’t hang themselves. Oh, and it’s really cold in there. Jail staff sends people to the slick cells when they are concerned that an inmate’s psychiatric illness is so severe, they wouldn’t be safe in a regular cell.

A slick cell is where I first met “Robert.” One day, I went into the hallway where the slick cells are, and Robert was sitting on the sleeping shelf shivering uncontrollably. Robert is African-American and suffers from Major Depression. He wasn’t emphatic enough when the jail staff questioned him about whether he was suicidal or not. Jail staff took the most conservative route, and placed him in the slick cell.

Now I can begin to treat the Major Depression, and I can provide supportive counseling to help him understand the impact of his illness, but how do I work with him to help him understand some of the profound injustices visited upon him by the authorities in the name of public safety? His offense was very minor–failure to identify when questioned by police officers. As a successful white man in this society, I’ve never been stopped by police to prove I am who I say I am. As a successful white man in this society, it probably wouldn’t occur to me to even question the officer about why I was being stopped. Unfortunately for people of color, it’s not quite the same situation.

I’ve had trouble articulating the dilemma until I began reading about a condition known as “Moral Injury.” Psychiatrist Dr. Jonathan Shay coined the term (it’s not an illness or a disorder), and describes the response some veterans have to combat. Dr. Shay writes that moral injury occurs when there is a betrayal of what is considered morally correct by someone who holds legitimate authority in a high-stakes situation. Unlike Post Traumatic Stress Disorder, it doesn’t necessarily have to involve threat to life or limb. Some symptoms of Moral Injury include shame, guilt, demoralization and self-sabotaging behaviors.

As I read more about this condition, it resonates with me that many people of color struggle with some measure of Moral Injury thanks to the inherent structural racism in our society. I hope that as our understanding of the complete spectrum grows, we’ll be better at recognizing it in the people who come to us for services.

You can learn more about Moral Injury here.

Posted in Thoughts. Tagged jails, major depression, moral injury, prisons.

Social Calvinism persists

Calvinism is a well-developed Christian theologic school. I’m not so interested in “true” Calvinism’s merits as in the distorted manifestations of it I see in society. My cuñado, Nathan Stone SJ, has long pointed out the twisted way Calvinism manifests in our society. Essentially, the twisted version is that you’re doing well because God has blessed you. You are among the “elect”. The poor are so because of some lack of energy or virtue or perhaps they’ve missed God’s favor due to some unseen pecado. This idea is pervasive and perhaps most insidious in health care.

This New Yorker article reminded me of the Calvinist threads in our social fabric. In general, most people are supportive of the idea of giving the poor good care when they come to an emergency department. In general, no one objects to using the best medications to treat medical conditions in emergency settings. As we move away from emergency settings, the debate heats up a bit. Treating and curing Hepatitis C comes to mind. As costs increase and acute need decreases our social evaluations of the moral worthiness of recipients increases. As we decide a person is “less worthy” (usually this means poor), then perhaps expensive treatments aren’t really necessary.

We see this in housing and in the avidity with which some conservatives approach drug testing welfare recipients. We start wondering whether someone is “getting away” with something by receiving things like affordable and safe housing or a minimal, subsistence support payment from us as a collective social group. The idea of giving housing to people in order to get them off the streets (nose, meet face) is seen as radical.

This social calvinism is a strong current against which US social services and supports must always swim. If we start calling it out and pointing out the underlying belief, that somehow the poor and less healthy have brought this upon themselves, we might make more progress in serving the least of these amongst us.

Health Care Reform

I’ve been mulling over the many challenges in reforming our health care system over these past 20 or so years while working in community mental health. We’ve struggled through implementing electronic health records and learned about the promises of “Authority-Provider” splitting. I helped our community mental health center develop a managed behavioral healthcare company so we could compete with the big boys in the field. Now we’re all supposed to look toward Accountable Care Organizations as the final solution. Solution to what is probably a question we avoid as it calls into question a lot of our basic assumptions about health care in this country.

I didn’t have a way to frame it in my own mind until I came across the image above. Credit to the Incidental Economist website with this post on “Deliberately Bad Designs”. The source sites are here and here. While all of the images bring to mind “solutions” I’ve had to challenges in my own life, the electrified hammer just brought it all home to me.

Try as we might, health care is a cottage industry. It ultimately relies on a practitioner having some form of contact with a person. Video makes distance less of a challenge. Electronic health records expose my spelling inadequacies, but render my records legible and, someday, sharable with others. Too often, payment methods seem geared to boosting financial incentives for managed care companies, shareholders and executives. There is a consistent downward pressure on reimbursement to providers of these direct care services. I suspect that our for-profit models are the real source of the problem. Note that I didn’t say, “capitalist” as there are health care systems around the world which use regulated capitalist models within a non-profit structure quite successfully. Both Switzerland and the Netherlands have successfully developed this model.

This all brings me back to the image of the electrified hammer. All of us managed care executives, shareholders and profits are that long plug. At the end of the day, there’s some form of contact which is person to person and critical to the healing process. We can add lots of technical aids and supports to smooth things out, but for the foreseeable future, health care’s richest resources are the people who sit together and work out a plan for mutual recovery.

 

Don’t Miss Your Life!

“Don’t miss your life!”

–Sokuzan Bob Brown. Sokukoji Buddhist Temple Monastery. August 29, 2014.

 

Whenever I have “writer’s block” it’s usually because I’m avoiding writing about something. If I’m avoiding it, it’s because I think it’s too sensitive or self-revealing to share. In a perverse sort of way, that probably indicates I should write about it.

 

At a recent retreat (sesshin) in Michigan at Sokukoji, one of the points in Sokuzan’s dharma talk was about not missing your life. I don’t think he meant it in the way that we often think. Not in a carpe diem, live life to the fullest, time to go learn sky-diving sort of way. I think he meant it more from the point of view of giving up our reference points, noticing what is happening in our body-mind state and fully experiencing what is happening in our minds as well as what we think of as “out there”.

 

Recent, somewhat abrupt changes in my professional situation have really put this into stark relief. I suddenly find myself deprived of a couple titles and all the ego stroking roles that go along with them. I’m still extremely lucky that I’m a doc and a psychiatrist and there are lots of opportunities to serve so I’m not looking at homelessness by any means. My license is untouched and if the FaceBook and email responses are to be believed, my reputation seems unsullied. (Notice I felt compelled to write that part, too?)

 

An issue I touch on fairly frequently here is about labels and roles. While titles and degrees do communicate a level of expertise, it’s very easy to confuse my “M.D.” with who I am. When I hang on to that reference point, I start to miss my life. I try to fit things into that little box with a neat lid which has just the right place in my personal closet. Similarly with grand titles and positions, I tend to identify myself with those and try to derive some sense of who I am from all that stuff.

 

I’ve noticed over the years while working with people whether they come to see me for psychiatric help or we are collaborating on projects that I fall into that reference point to feel more secure. I can’t tell you how many times, while listening to someone’s story, out of my puzzlement I found my hand moving almost unconsciously toward my prescription pad. “I don’t have a clue what to do next, let me write for a medication.” It’s the old saying, “if the only tool you have is a hammer, everything is a nail.” I hope I catch myself in these situations, recognize that’s a sign of my confusion and just wait a second. Sometimes I don’t have to provide the answer, sometimes the answer is already there if I’ll just get out of the way.

 

Moving forward into new adventures, I need to keep in mind that the people I work with are, like me, all too frequently missing their lives. While I don’t have any pretensions to ending their confusion, I need to make sure that I’m not injecting my own into their lives. It’s hard to sit in a room with another person in the midst of psychiatric crisis and not take refuge in that doctor role, but avoiding that my actually inject some sanity into all of our lives.

Childhood Mental Health and Illness

I was very honored to serve as a panelist on the 17^th and last Community Conversation held in Austin for Speak Your Mind Texas last week. The campaign tells us that around half of all mental illnesses begin before the age of 14 and that suicide is the #2 leading cause of death for people between 10 and 24 years old. Texans are coming together in these conversations seeking solutions supporting younger people struggling with psychiatric illness. We seek ways to reduce the stigma of the illness and to make treatment and supports more available. I absolutely support this effort and have in our community for the last 20 years or so. Psychiatric illness is real and is treatable. We need to do better.

 

I also want to talk about mental health in a broader context of which psychiatric illness is a subset. If I can have a divine revelation that a person suffers from a psychiatric illness, treatment and support ideas get very clear and sometimes even simple. If only it were ever that way. Somehow I’ve missed the divine word telling me what’s happening inside someone’s head.

 

Derek’s powerful story shared with us at the Community Conversation is illustrative. He speaks movingly about his sense of isolation and loneliness leading to self-medication and eventually to a psychiatric illness beyond substance use. I have to ask myself what would have happened had we intervened sooner? Could we address a young person’s sense of isolation and not belonging or limit the extent of bullying which can lead to this isolation? Would Derek have avoided a psychiatric episode if we had?

 

All questions we can’t answer in his case, but it leads me to the conviction that by the time we talk about psychiatric diagnosis and illness, we’re already playing catch-up.

 

I’ve been fortunate to work in our methadone maintenance clinic and have visited multiple jails around Texas. Over and over again I hear about dropping out at 9^th and 10^th grade. All too frequently this is because the didn’t quite fit in or didn’t fit the mold. We know that children of color suffer disproportionate removals from classrooms for disruptive behavior. That removal often leads to a psychiatric diagnosis such as Oppositional Defiant Disorder or Attention Deficit Disorder or to an assignment of criminal identity or, worst yet, both.

 

I don’t say there are no criminals in schools (although pre-adolescent criminals seem a far stretch) or that there are no psychiatric illnesses like this. I do think that we frequently make diagnoses of those who are “different” or label them as “wrong” in order to get a handle on that person. It gives us a way to think about and categorize them and shifts responsibility away from me and onto a “system” which should now respond.

 

I think about the role of trauma in the home and how if affects behaviors of the child trying to sit quietly through “Goodnight Moon” when the images of her bedroom are far from peaceful. I wonder about the response of an African-American adolescent when confronted by security in the halls in light of what we Anglos know a little better after Ferguson, Missouri and Michael Brown’s death. I’ve written about moral injury in some previous posts (here and here). I think the mental health field will understand some of the racial disparities in our nation better as we come to grips with the damage we are inflicting on communities of color manifest as moral injury.

 

Mental illness is real. I see it as a subset of mental health. How we deal in a compassionate way with those who appear different and ostracized may begin to attenuate some of the damage and trauma of psychiatric illness among the young.

Criminalizing Being A Woman

This is probably not going to end well. A Tennessee statue allows law enforcement to charge pregnant women with assault if their behavior causes injury to a fetus. I can’t imagine how it wouldn’t discourage women from seeking treatment for their substance use challenges as well as becoming a barrier to prenatal care. If I think I’m doing alright during my pregnancy and I don’t feel badly, maybe I shouldn’t take the risk that my obstetrician will turn me in to the police. The other concern I have is that it doesn’t seem to say “how” pregnant a woman must be before she can be charged with assault. Do police need to check every woman’s pregnancy status at any stop involving a suspicion of drug use? What if the woman didn’t know she was pregnant at the time? Frankly, could an officer decide that pregnancy tests for women in restaurants with a glass of wine were in order so that society could protect a fetus?

Does driving recklessly involve “endangerment of a child” if you’re pregnant? Does every woman stopped for speeding need a urine pregnancy test to decide if she’s actually endangering a child?

Time and again some of our puritanical instincts rise up in health care. The debate over contraceptives is one example. This is another. I see it most often in the arena of treatment for substance use disorders. There’s almost always a current of moral approbation when people come forward for treatment. There’s a disapproval I don’t see when people develop adult onset diabetes mellitus or other “lifestyle” illnesses.

If we truly believe that substance use disorder is an illness, then we have to learn to rise above that inclination and welcome people into care and treatment. Countless times I’ve had people very sheepishly say, “I don’t want to lie to you doc, but…” The urge to withhold information in order to avoid my anticipated disapproval might mean I don’t hear about critical parts of the life of the person I’m working for.

We know that our drug laws have driven our incarceration rates to be among the highest in the world. It’s had a particularly devastating effect on communities of color and those who are economically disadvantaged. Let’s hope that in our urge to protect a fetus we don’t start adding women to that community as well.

Labels–a repost

[I put this up on another blog some months ago, but think it’s relevant still. Amidst all the noise generated when a celebrity tragically dies, it’s very easy to forget that there’s not any real difference between them and us. In fact, there’s no distance or separation between “other” and me at all. There’s only a perception, an illusion that we are separate. Labels make that separation worse.]

One of the formative memories from my years in medical school occurred during a rotation on the obstetrics service at Hermann Hospital in Houston.  As was the practice, our whole team, along with Dr. Peter Boylan, the faculty member in charge, invaded a young mother’s room. It was my turn to “present” so I began.

Me: This is a 22-year-old female, gravida 1 para…

Dr. Boylan: Does she have a name?

Me: um, um, um….

“A female what?” he astutely followed up.

And so I began learning. When we first get to medical school, they put you in a room with a human body to dissect. It’s a privilege afforded very few, and still quite a shock. One common coping mechanism is to joke about it, name the body and do most anything to create some distance between me and what I’ll one day become. Later, I moved to the hospital floors, and found that if I referred to people as “patients” I could get just enough space and distance between her and me so that her problems couldn’t ever be mine.

As I moved into community mental health, it quickly became retro–and even uncouth–to refer to people we saw and worked for as “patients.” There were endless discussions about using terms like “client” or “consumer” and other names and labels. These discussions among clinicians and administrators almost always involved people struggling with psychiatric illness.

On the other side of the house, professionals working in the field with individuals with intellectual and developmental challenges were leaders in “people first” language while struggling with a horrible label like “mental retardation.”

For a time, I tried to rotate “patient,” “client,” and “consumer” through my vocabulary–sometimes all in the same paragraph. That would indicate I was still a physician, but also attuned to the currents of our field. I think that’s all worn pretty thin for me now. I realize now that part of my growth as a human being is recognizing the fundamental similarity between those who come to see me and myself. My personal experience of these labels has been that it creates a distance between me and others. It prevents me from seeing that the lives of those who are sitting across from me in the office or the people I meet on the street dealing with addictions or psychosis aren’t any different than I am. It’s a little more frightening because I don’t even get a figurative white coat to hide in, but I think it makes me a better human and maybe a better clinician. So, from now on, it’s “people first” for me.

Thinking about Thinking

(Dr. Ross Taylor linked to one of these articles on his Face Book page yesterday, so I owe him thanks for the reminder that I’d written something about this in late July. One of the posts that got hung up in work controversy.)

When I started practicing mindfulness meditation some 20 years ago, I struggled with one of the basic concepts of “thinking”. In most mindfulness practice, thoughts and emotions are all treated as “thinking”, manifestations of mind. This contrasts with much of our psychologically oriented Western approaches which tend to view thinking and emoting as separate functions of the brain. The challenge was to think differently about what my mind does moment to moment.

That made this article very interesting to me. Dr. Tanya Luhrmann, a Stanford anthropologist, studied the ways people in different cultures diagnosed with schizophrenia experienced voice hallucinations. Some may question whether or not an illness such as schizophrenia is simply a Western cultural construct, but the World Health Organization’s publications, including this, strongly suggest that these conditions are present in almost every culture surveyed.

Dr. Luhrmann and her colleagues found that people hearing voices in India and Ghana often experienced the voices as positive while none of the United States subjects did so. The US citizens felt that the voices were evidence of a brain disease. People in the study from Africa and India didn’t associate voice hallucinations with illness. In fact, the researchers concluded that Indian and Ghanaian participants in the study were “more comfortable interpreting their voices as relationships and not as a sign of a violated mind.”

Another study (abstract only) looked at responses to voice hallucinations by US citizens with borderline personality disorder and schizophrenia. People with schizophrenia tended to engage with the voices on an emotional level. Those with borderline personality disorder were more emotionally resistant despite the fact that the symptoms were described quite similarly. The authors suggest that it might be helpful to work with people with the latter diagnosis on a cognitive level, i.e. to assess how they think about the voices they hear.

Finallly, this abstract reports that mentally healthy Christians in the US who heard voices experience them in a positive way while non-Christian and Christian participants with psychiatric diagnoses did not.

From the Stanford study, “Our hunch is that the way people think about thinking changes the way they pay attention to the unusual experiences associated with sleep and awareness, and that as a result, people will have different spiritual experiences, as well as different patterns of psychiatric experience.”

In Western psychiatric treatment and not infrequently in psychotherapy, we treat voice hallucinations as a symptom of an underlying illness and tend to simply confirm their existence. It may well be that as we work with people who experience voices with no apparent cause, gaining an understanding of what they think about the voices, helping them “think about thinking” may allow them to find tools to manage some aspects of their illnesses. It does call to mind the training in insight meditation. Seeing thoughts as occurrences of mind rather than real things begins to give a handle for understanding and insight. It may be that these tools can also help the people with whom we work.