Lisa Loren: Catalysis

Imagine a world where psychiatric medication works 100% of the time, relieves 100% of symptoms, and causes no side effects. In this world, we all agree on the precise differences between mental illness and personality. It’s easy to tell the difference between someone who tires easily and someone who has the flu, right? Why should mental illness be any different? Imagine that drugs work perfectly, and they don’t alter who the “real” person is. In the world I’m describing, there are no rational reasons to refuse treatment - unlike in this one. Do people with mental illnesses still have a right to refuse pills, or inpatient commitment, or whatever we find works well?

In the real world, this world that we live in, there are no absolute cures for mental illness. Up until pretty recently, scientists considered brutal procedures like the lobotomy acceptable treatments for mental illness. Today the lobotomy has been replaced by drugs that can cause permanent facial ticks and neurological symptoms, drugs that cause massive weight gain, diabetes, and heart disease. Electroconvulsive therapy, which can cause permanent memory loss, is coming back into fashion. In addition to whatever personal objections they might muster to treatment, often patients only have the option of treatments that stand to cause them significant, lasting harm.

This confuses the issue of the right to refuse treatment. It makes perfect sense to refuse a treatment that could destroy your memory, right? It seems reasonable that people might rather hallucinate than have a heart attack. Unfortunately, this leads us to focus on medication only as a heath decision, weighting the health benefits versus the health costs. Given that side effects generally don’t show up in the medical community’s consciousness, this leads doctors to feel safe in trying to force newer medications on their patient. But, more than that, it ignores the fact that these kind of decisions ought not to be based on a simple balancing of the possible heath benefits and risks. The right to refuse treatment is a human right, the right to sovereignty over one’s own mind. We cannot deny people their rights simply because we think we know what would benefit them.

It doesn’t matter, then, how close to the ideal our world may be. We don’t abstain from medicating people against their wills because we think that they understand the risks and benefits better than their doctors. While occasionally, as compassionate human beings, it may be necessary to stop the sickest among us from destroying themselves, for the most part we cannot ethically interfere with the way people chose to live their lives and deal with their illnesses. The law allows people to make their own choices about what they do to their bodies and minds because we respect their autonomy as human beings.

Thinking of suicide?

Wait. Just for a minute. Take a deep breath. Make yourself a cup of tea, if you like.

Read this first.

I do not want to talk you out of your bad feelings. I am not a therapist or other mental health professional - only someone who knows what it is like to be in pain.

Try this. Or this. Or this. Maybe this.

I believe that people don’t attempt suicide until they’ve run out of other options. I’m putting this page together because I want to offer people way to stay alive for a little while longer. The desire to die does fade, in time, but death lasts forever. This is a list of ways to cope with thoughts of suicide.

Talk to Someone

A hundred years ago, Sigmund Freud discovered something that people have known since we learned to walk upright and draw pictures: talk helps people heal. Talking to another person can ease despair, reduce suffering, and help you cope with pain. Thousands of people out there want to help you so much that they man the phones at crisis centers and suicide hotlines for the chance to help people hurting just like you. These aren’t professionals, and they aren’t getting paid. The only reason they show up is to help people.

• 1-800-273-TALK (8255)
• 1-800-1-800-SUICIDE
• Find a helpline at http://www.befrienders.org/ (US and international)
• Email the Samaritans

Ask for Help

If you have friends of family that you trust to help you out, try talking to them. (Needless to say, if you think someone will be overemotional or angry, he or she is probably not a good candidate for this.) Most untrained people won’t know what to say when dealing with a suicidal friend, so you may have to be clear on what you need. Consider printing out one of these sheets from metanoia.org, this one from the American Association of Suicidology, or anything else that you find helpful. Ask someone to sit with you for a little while, or listen to you. You don’t even need to say that you’re suicidal, although if you’re seriously considering harming yourself, it might be best to let someone else know. Don’t be afraid of waking someone up or interrupting them. Suicidal people often feel guilty, or as if they’re not worthwhile, but you’re important to the people around you. Your friends would much rather lose a night’s sleep than lose a friend.

Learn Coping Techniques

Try Distress Tolerance. Originally developed to handle the suicidality and self-harming behaviors in Borderline Personality Disorder, these techniques can work well for anyone in crisis. Some of it might seem a little corny or oversimplified, but it’s kept people in a lot of pain alive and out of hospitals.

• Distract yourself (the link has examples of ways to do this)
• Invoke your senses (this grounds you and helps you take control of your emotions)
• List the pros and cons of hurting yourself

DBSA has these suggestions:

• Keep a journal to write down your thoughts. Each day, write about your hopes for the future and the people you value in your life. Read what you’ve written when you need to remind yourself why your own life is important.
• Go out with friends and family. When we are well, we enjoy spending time with friends and family. When we’re depressed, it becomes more difficult, but it is still very important. It may help you feel better to visit, or allow visits from, family and friends who are caring and can understand.
• Avoid drugs and alcohol. Most deaths by suicide result from sudden, uncontrolled impulses. Since drugs and alcohol contribute to such impulses, it’s essential to avoid them. Drugs and alcohol also interfere with the effectiveness of medications prescribed for depression.
• Learn to recognize your earliest warning signs of a suicidal episode. There are often subtle warning signs your body will give you when an episode is developing. As you learn to manage your illness, you’ll learn how to be sensitive to them. They are signals to treat yourself with the utmost care, instead of becoming ashamed or angry with yourself.

Educate yourself about suicide. Try Psych Central’s FAQ, the AAS fact sheets, or the chapter on suicide in Andrew Solomon’s Atlas of Depression.

Seek Professional Help

If your feeling about suicide last, or if they’re too strong for you to cope with, you should consider looking for professional help. If you have health insurance, most insurance companies will give you a list of professionals they’ve approved in your area. (They say they’ll only give you a few sessions, but usually will pay for more if it means keeping you out of the hospital. It’s worth a try, at least.) Your local crisis center will also probably be able to refer you to someone. Therapy can get expensive, but some therapists work on a sliding scale. Still, going to therapy is an investment of time and resources.

Call 911

Hospitals see people in crisis all the time. Police deal with people in crisis all the time. It’s extremely difficult to kill yourself in a hospital, so if you’re worried that you might do something impulsive, going to your local emergency room can give you a chance to get a grip on your emotions. I don’t honestly believe that checking yourself into a hospital helps most people get better, but it can buy you time. Furthermore, most hospitals will set you up with outpatient treatment when you leave. When you’re not feeling well, going through your insurance company’s big list of therapists can be exhausting. The people at your local hospital can help you with that.

Don’t try to do it alone.

Most people can’t do everything by themselves, no matter how much they want to. Maybe you’re an exception to the rule, and maybe you don’t need anyone else, but do you really need to take that chance? You’re important. Make yourself a priority. Get help.

From, Science Daily, an interesting little piece about the results of new fMRI studies done on borderline patients: Brain Abnormalities Underlying Key Element Of Borderline Personality Disorder Identified.

The research may help explain how specific biological or psychological therapies could ease symptoms of borderline personality disorder for some patients, by addressing the underlying biology of impulsivity in the context of overwhelming negative emotion. The more scientists understand the neurological aberrations that give rise to the disorder, the greater the hope for new, highly targeted drugs or other therapeutic interventions.

In the afterword to her book, The Center Cannot Hold, Elyn Saks mentions that a psychiatrist friend cautioned her to use a pen name, lest she be known publicly as “the schizophrenic with a job.” Her descriptions of psychosis are so lucid that it’s easy to see why friends would want her to hide it. Saks has been crazy in the worst sense possible, paranoid and raving and threatening violence. In this memoir, I feel like I’ve been given a window into what schizophrenia looks like from the outside and feels like from within. If this written had been written by someone who didn’t suffer from schizophrenia, I would call it “compassionate”, but the word doesn’t quite seem to fit in this case. Saks wastes no time in self-pity. This is a brave book, at the heart of it, filled with the hope that one day we all can get the help we need to live.

I admit, I came to the book already in awe of Ms. Saks. Only one out of ten schizophrenics manages to hold a job, let alone win awards or publish books. Forty years ago, Saks would have been confined to an institution for life, without the hope of treatment. Her CV is inspiring. This book is less a motivational speech than a window into another world, where beings from the sky control people’s thoughts and someone can die ten times a day and still be around to worry about it happening again. That she built herself a sane life, however fragile, is a testament to her doctors, her friends, and her own iron will.

Highly recommended.

The issue of individual civil rights for the seriously mentally ill is a major controversy today. Do you feel that schizophrenic patients should ever be institutionalized against their will? If you answer yes, under what conditions should the decision be made and who should have the authority to make this decision?

In our country, schizophrenics tend to be disruptive, scary. In a place where we can, for the most part, cordon ourselves off from the unpleasant realities of human poverty and sickness, schizophrenics stick out as reminders of the frailty and eventual decline of the human psyche. They make us uncomfortable; they make us afraid in a way that bears no relation to to harm they may bear us. I cannot talk about institutionalization, about the involuntary confinement of these people, without acknowledging the degree that it makes us more comfortable to have them locked up and put away where we do not need to see them. These people may benefit hugely from treatment, but any “treatment” that makes them docile and calm and non-disruptive also benefits us. When we consider involuntary confinement, it is important to make sure that we are helping the people in question, not merely removing our own discomfort and guilt.

This is what I believe about involuntary hospitalization: it’s wrong. Two hundred years ago lunatics were rounded up in asylum and showed off to crowds, the freaks, animals in cages. To imprison some against their will is to deprive them of their humanity, to reduce them to the status of pets and children. Imprisoning the innocent against theirs wills is barbaric.
This I also believe: when you have to tools to help a person, it is wrong to allow them to suffer and die. Schizophrenia undoubtedly causes anguish, and 15% of sufferers kill themselves. This is an illness that strips people of their reason and drives them to suicide. If they are incapable of comprehending, by reason of illness, that treatment may help them, don’t we have an obligation to force them into reason long enough for them to make their own choices?

Two wrongs, they say, don’t make a right. It is no less evil to imprison someone when they are incapable of comprehending what they’re doing, and it is no less moral to turn your back on someone because they can’t understand that you can help them. Treating schizophrenia, then, becomes a question of picking the lesser of two evils. I believe that it should always e a hard choice to make, to commit someone, and that anyone who doesn’t feel anguish at depriving another human being of their rights shouldn’t be in the position to make that judgment.

Anguish, however, can’t easily be proven in a court of law. The decision to imprison or free a person, them, needs to be made someone who at least has nothing to gain from hiding the patient away. I suggest a judge. Family members may care deeply about the person in question, but they often become the primary caretakers, and therefore have a vested interest in letting someone else take care of their schizophrenic relative. I sympathize with them, hugely, but decisions involving involuntary commitment need to be made purely based on the needs of the sick person, and family members simply aren’t capable of that. I believe psychiatrists ought to be involved in the process, but I believe that they shouldn’t have the final call. In clinical practice and in diagnosis, I think, it becomes too easy to address the symptoms rather than the person. Schizophrenia may be better treated in a confined and easily monitored setting, but Joe, the person, might do better with outpatient treatment. In addition, the psychiatrist who commits a patient often end up caring for him, and so it would be a poor business move to turn patients away.

Given that commitment is a form of imprisonment, it makes sense that only a judge ought to be able to do it, and the need to follow pretty stringent guidelines. First, someone must establish that the person is incapable of making rational decisions. That, I suppose, is where the psychiatrist comes in, as we can only rely on his judgment. Beyond that, I propose that one of two conditions must be met. First, if a person can be proved to be a danger to himself or people around him, he can be confined, and likely medicated in an attempt to restore reason. Seeing as schizophrenics are not actually much more violent than the rest of the population, I’d propose that people be considered nonviolent by default unless proven otherwise. If no one could provide evidence (including statements, therapy transcripts, et cetera) a person could only be involuntarily committed if they had, clearly, under no duress, and in writing, provided directions that they wished to be hospitalized during a schizophrenic episode or psychotic break. That way, those who need and might want help can get it, while those who want nothing to do with psychiatry aren’t forced into hospitals purely by virtue of their illness.

by Pete Earley

In reading about mental illness and treatment, you come across crazy people who think that all psychiatric drugs are poison, and crazy people who thing that all mentally ill people should be forcibly medicated. Pete Earley isn’t a another distinct type of personality; one of those family members who believes that everything would be okay, if only they had the power to hospitalize and drug their family members without their consent. It’s kind of touching and a little sad. If only hospitals were that much better than the prison wards, and everyone could get enough time in them. If only we could cure mental illnesses instead of trying to manage them, and picking up the pieces when out loved ones inevitably fall down.

I’ll be honest: this book scares me. Pete Earley takes the sickest of the sick, the most violent and disjointed of the mentally ill, and generalizes out from them. He doesn’t come out and say it, I don’t think, but it’s pretty clear that he thinks all mentally ill people should be forcibly medicated, and possibly hospitalized long-term. Thanks, Pete, but I’ve read about the days when family members could lock people away on word-of-craziness alone. Back when women who didn’t want husbands were considered insane and institutionalized? I don’t deny the existence of mental illness, oh no, but I’ve read my history, and I know that it’s subjective. There are no tests for schizophrenia or bipolar disorder, no way to tell for sure if someone ought to be given medication. Our mental health system is pretty horrific for criminals, but Pete Earley doesn’t have any good solutions for fixing it.

I know this man comes from a fundamentally compassionate place, but I feel like I need to read an anti-Prozac diatribe just to get the feel of it out of my head.

There is evidence that depression is associated with biological changes in the brain, for instance dysregulation of neurochemicals. Do you think that depressed individuals who have committed violent crimes against others (case in point: Andrea Yates, the mother who drowned all five of her children while suffering from depression) should be held morally accountable for their actions?

To blame neurochemicals for our actions is, at once, entirely reasonable and horribly misguided. Our minds, our brains, are all neurochemicals and electricity: saying that someone’s neurotransmitters make him want to kill people is essentially the same as saying that his mind makes him want to kill people. Mentally ill people are, in fact, sick, and studying the dysfunction of the brain can help find ways to treat their very real illnesses, but that doesn’t make them separate and uninvolved from their brains. The in mental illness, the brain doesn’t step in and take control; the brain is always the controller. Mental illness may affect the way that people are help responsible for their actions, but mere pathology of the brain does not.

This may sound cruel, but I believe that in a moral sense people are always responsible for for their actions. Always. Regardless of our insanity, or intoxication, or anger, we always have to live with our pasts, and what we’ve done. It’s not fair to blame our illnesses for our crimes, as if we could so cleanly and easily cut our diseased minds of from the rest of us. I’m not saying that people with mentally illnesses don’t deserve more slack and more forgiveness than sane people who kill others, but if a woman kills her children in a fit of psychosis, shouldn’t she be overcome with grief and remorse? Could we call her human if she isn’t?I believe that mentally ill people have an obligation to seek treatment. I believe that if any of us wake up in the morning with a flicker of my children would be better off if I drowned them, we have an obligation to go to an emergency room and check ourselves in for psych evaluation immediately, before letting things get worse. People don’t control or create their mental illnesses, but it is up to us to decide how we deal with our problems. There are always warning signs when psychosis strikes, and there’s usually some way or some place to put yourself where you can’t hurt yourself. If you are foolish to think that, in the face of mental illness, you can carry the lives of other people with your will alone, you deserve to feel responsible when you break. It’s a different kind of responsibility than rationally going out and shooting someone, but it exists nonetheless.

I feel a lot of compassion for people with mental illnesses. I feel that, by saying this, I’m condemning people who are essentially not in control of themselves to suffering. I want to be very clear that I don’t think mentally ill people ought to be shunned for things the do while not in their right minds, and they certainly shouldn’t be held legally responsible for these things. When I talk about moral responsibility, I mean something highly internal and personal. People prone to delusions ought to, even need to doubt themselves when they start thinking things that other people would find crazy. They need to take responsibility for those thoughts, take responsibility for dealing with them in a way that won’t end with anyone dying.

I guess I’m being a little idealistic here, because I’m assuming that anyone who tries will be able to get the help they need, or at least enough help to prevent them from hurting anyone else. I know that isn’t true. If a trip to the emergency room means thousands of dollars that you don’t have, I can see that it would be hard to check yourself in somewhere. If you can’t get someone to take you to the hospital, or if they give you antipsychotics and kick you out the door, that’s a different story than simply believing you could handle it. If that happens? I can’t blame a person who’s tried the best they could to get help, and been rejected by the world.

I believe, and the evidence supports, that people with addictions require treatment to overcome them. Many addictive substances can cause long-term lasting harm, and can have huge financial and relationship-related costs. Addictive substances can physically alter the brain. People may be more prone to addiction due to their genes as well as their personalities. Addiction can be hugely destructive.

That said, addiction is fundamentally a behavior pattern. I believe that behaviors can be maladaptive without being pathological, that is, I believe that people can repeatedly indulge in self-destructive behaviors without having a mental illness. People who regularly go 100mph on the highway don’t have “speed addiction disease”, even though they may be at higher risk of driving-related injuries than people who stay close to the speed limit. People who are physically addicted to coffee don’t consider themselves ill.

I don’t have a problem with people who struggle with alcoholism define it as a disease. If it encourages insurance companies to pay for treatment, in fact, I encourage it. Whatever helps people improve their lives is good, I think. It worries me, though, that in our culture maladaptive behavior patterns are increasingly being defined as diseases.

I don’t believe in personality disorders. I’m not saying that I don’t believe people with a certain character/symptom set appear, or that people can’t identify with these labels, but I don’t believe that they constitute a set of disorders discrete from other mental illnesses. I don’t believe that “personality disorders” are actually problems with a person’s personality. A couple reasons:

1) Many of them seem like mild versions of Axis I disorders.

If you want to define “personality disorder” as something like an Axis I disorder, but without the same severity, I’m not crazy about your choice of terminology, but I suppose that’s fair. However, I notice that Cyclothymia has a place in Axis one, instead of being “cyclothymic personality disorder”. How is that fair? If a person with moderate-but-significant mood swings has a clinical disorder, shouldn’t a person with moderate-but-significant paranoid delusions rate the same respect? Which brings me to my next point:

2) This is pretty much a list of people that are hard for psychiatrists to deal with, isn’t it?

Borderlines are emotionally manipulative. Paranoid people don’t trust in your clear and overwhelming expertise. Histrionics are overemotional women. Avoidant people skip therapy. OCPD people want to control it. Guys with antisocial personality disorder are scary. Depressive personality disorder will probably never make it into the DSM, because it isn’t all that hard to listen to a person talk about how they’ve failed in life. I’ve heard that a diagnosis of Borderline Personality Disorder can become a placeholder for “difficult to deal with” instead of actually implying that the person in question has a certain symptom set. It seems to me like diagnoses exist as much to point out potential problems as to facilitate treatment.

3) Personality isn’t stable over time.

I’d like to think that there’s some special thing inside me that remains constant no matter what happens to me. Something that makes me me. However, I can’t think of a person I knew as an early adolescent who’s retained such specific personality traits. We’ve changed a lot, grown up a little. Schizophrenia can last a lifetime. Mental illnesses persist. Personality tends to change.

There’s a school of motivational theory that basically says hey, kid, you’re never going to be spontaneously motivated to do the laundry. Nobody wakes up at three AM wanting to do laundry unless they’re manic or on cocaine. The trick to finding motivation is to just start doing whatever it is that needs to be done. Even if you aren’t motivated to start, you may be motivated to keep going. The mental process of wanting to start doing something is fundamentally different from the process of wanting to continue doing it.

New research suggests that these two elements of task completion activate biologically discrete systems within the brain. Difficulties in starting tasks may be about more than overcoming fear or inertia. The process is controlled by a system independent of the one involved in keeping a task going.

ScienceDaily: Brain’s Voluntary Chain-of-command Ruled By Not One But Two Captains

Distinct brain networks for adaptive and stable task control in humans (abstract)

I’m looking forward to seeing how this might play out with regards to bipolar disorder and depression.  Could some imbalance between these systems be behind the infamous manic half-finished projects, or the can’t-find-the-car-keys inability to self-start that depressives suffer from?