Monday, February 27, 2012
I have recently become more aware of the dialectic between accountability and its lack. It's difficult to find a word for the lack of accountability that situates itself in easy and direct opposition to accountability. Perhaps synonyms would help. What I am calling accountability also resembles self-agency or the sense that we can do something to improve our situation, whatever it is. In the community mental health clinic where I have been working, the majority of the patients lack accountability or self-agency. Biomedical psychiatry has certainly facilitated that attitude and I expect we have had the most negative impact upon the poor for our attitudes reinforce their powerlessness. The wealthier classes come with a sense that we can do something to change our circumstances if only to throw money at it. Most of my patients believe that they are the victims of an illness that has caught them in its grip, much like a person might contract tuberculosis, lupus, HIV, or arthritis. They are not responsible for regulating their moods, for controlling their impulses, for their anger, for their sadness, for their actions. Their behavior is the result of their illness. Nothing can be attributed to them except in the sense of acknowledging the existence of illness. Of course, many have grown up in homes (or in several homes or in no home) in which emotional regulation was rarely achieved. Extremes of emotion were usual and common with family members continually reacting one to the other. No models existed for self-soothing or self-regulation. My patients expect me to provide them with a drug to regulate their moods and emotions, to make them feel "normal", though few can say what "normal" would feel like. The drugs rarely do this so they spend years searching for the "right" combination. Every new patient is sent for a medication because that's what we do, we prescribe drugs. Occasionally the drugs work (or seem to work, for the effects of placebo are also very powerful). Mostly, they don't accomplish what people want them to do. The rage this week has been bipolar. People have come to believe that if one is happy and sad in the same day, one is bipolar. Psychiatry has come to agree with this. Previously we called happy and sad in the same day "emotional lability", meaning one's emotions went up and down, sometimes unpredictably. It was a non-specific finding; not a criteria for bipolar disorder. That was before we invented the bipolar spectrum, in which every anyone can be a bit bipolar. We call it Mood Disorder, Not Otherwise Specified, or Bipolar Spectrum Disorder. Once upon a time, bipolar disorder was reserved for people who stayed up all night for days on end with indefatigable energy and disorganized creativity and then crashed with many variations on this theme, including or not including being psychotic. The label of "bipolar" used to be more difficult to earn. Here's one of my patients. She feels miserable. She spends her time at home, watching television. Her husband works. She doesn't go out. She has no friends. She feels anxious. Going outdoors makes her more anxious. Going into public places makes her very upset. In our first session, I explored her options, for there were many in the city. The Mental Health Association offered many free classes -- yoga, t'ai chi, chi gong, writing, painting, drawing, dance, and so on. Various churches in the area had healing circles, prayer circles, discussion groups, and so on. Exercise can be free, though joining a gym has its advantages. Meditation can be learned for free in a variety of settings. What was she willing to try? Nothing was the answer. She didn't like groups, she didn't like people, she didn't like to sweat, she couldn't meditate when she was feeling anxious, and she hadn't done the behavioral experiment I had recommended. An added calculation existed -- that she wanted to be approved for further disability. Where had my voice gone? Where was that voice that said that she could take action against this problem and by opposing, end it (to paraphrase Hamlet)? Here is the problem with once weekly psychotherapy visits, though most of my community mental health center patients are lucky to come once per month (they are usually scheduled for twice monthly and miss once). In weekly psychotherapy sessions it's hard to be heard amidst the cacophony of voices that is the person's life. In one hour once per week, it's hard to make a difference. Sometimes we do, and that's usually when the person does the behavioral experiments we suggest and external situations have changed to facilitate improvement. How is it that sometimes an idea will take hold when other times it won't? Recently also I saw an 18 year old who was threatening to kill herself to get the attention of her lover who had ditched her. It was a country music song gone all wrong. My client believed that the best way t show her lover how much she was hurt was to kill herself. "What if she doesn't notice?" I asked. That left her flabbergasted. "Of course, she'd notice. Maybe I'd even do it in front of her house." "But what if she thinks differently from you," I said. "What if she thinks people who commit suicide are stupid and you just confirm how smart she was to leave you?" "That's crazy" said my client. "No," I said. "A lot of people whom you haven't yet met, think this way" Through my questions and her responses, I was able to create uncertainty for her that she could accomplish her goal through suicide. Then she asked me what I would do, which I thought was progress. Immediately inspiration struck (or probably spirit guidance). I said, "I'd put up a facebook page dedicated to showing the world how miserable she's made you. That would be far more effective than killing yourself because you get to comment. You can still watch if you're dead, but it's much harder to keep posting and commenting and putting up more sorrow and suffering. You could be the most pitiable person on facebook! My client really liked this idea. She took to it immediately. She stopped thinking about killing herself. She had a new goal -- public display of pitifulness, at least until her girlfriend noticed! Through doing this, she learned that she could have an impact upon her emotions. She felt better as she worked away on her facebook page. She could change how she felt! That was dramatic news to her. I saw another patient in a family of bipolar (a new kind of bear, I suppose). For everyone in the family, all manner of bad behavior could be excused by attributing it to bipolar. Probably should be capitalized! My client's 14 year old sister was reliably calling the police to report domestic violence against her whenever she wanted to spend the weekend in the city. She would be taken to the group home downtown and then she could slip out and attend whatever concert or event she desired. My client was agonizing over the impact that all these arrests were having on her parents. In a puzzled way, I wondered why she didn't just bring her sister into town for weekends and save everyone a lot of hassle. For reasons I don't fully understand, she thought this was a brilliant idea. The calls to 911 stopped and the younger sister had her social life back (they lived on a farm some distance from the city). I don't know how it is that a question will sometimes change everything, but it does. And sometimes, no amount of questions or suggestions will make a budge. It's mysterious, how this happens. We are led back to stare uncertainty in the face. Everything is uncertain. What is certain, to me, is that we have some influence. Victor Frankl wrote eloquently about this in Man's Search for Meaning, telling how people had found some small sense of efficacy or agency in the German concentration camps (where he had been). The task is to find a way for people to realize they can do something to influence their world for the better. Furthermore, we must help people to be comfortable living saturated by uncertainty. A friend's niece epitomized this. Her niece invented certainty even though she knew that her plans would be forced to change. The creation of plans relieved her anxiety about uncertainty. We have to find ways to live with and embrace uncertainty. That is our next task.