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Death Wish Recognized: A Case for Long-Term Treatment

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Posted on Feb 2, 2013

By Mark O'Connell

This piece first appeared on The Huffington Post.

Who creates a massacre? Can we identify those people? Can they be stopped? Congress hopes to answer these questions by the end of February. But where will these answers come from?

Enter the Bipartisan Task Force on Gun Violence Prevention and Children’s Safety, the Connecticut legislators who will draft a bill, informed in part by public hearings related to the tragic shooting at Sandy Hook. The “Mental Health Public Hearing”, which took place on Tuesday Jan. 29 in Hartford, garnered a variety of suggestions to improve state mental health services, most of which included the words: “psychiatrist”, “mental illness”, and “medication.” Do these words get us any closer to answering the interminable questions above, or do they simply attempt to soothe our desperate and restless desire to control the uncontrollable?

Massacres create chaos and despondency, both of which Americans abhor. We like to make sense of such things by compartmentalizing (blaming “mental illness”), putting someone in charge (a psychiatrist), and endowing them with a weapon to cut off murderous plots at the knees (medication). This is all implied when solutions such as involuntarily psychiatric treatment (which was recommended at the Hartford hearing) are put on the table.

For such solutions to be effective assumes the following: Potential killers all exhibit distinct and palpable neon-signs of a mental disorder (the words “schizophrenia”, “autism”, and “psychotic” were repeatedly used in Tuesday’s hearing). They will be compliant with mental health treatment, can afford treatment, and/or have insurance that covers treatment.  They will confess to a psychiatrist—on the first or second visit—that they have a clear and actionable plan to harm themselves or someone else; and if not, the psychiatrist (who after-all, tops the pecking order of mental health providers) can instantly identify the patient’s desire, intent, and potential to carry through with such a plan. After pinning the scarlet letter of a diagnosis on the patient, and prescribing corresponding medications, the psychiatrist will have successfully thwarted the patient’s plot to kill. And all of this somehow decreases the chances of future massacres.

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To me this sounds terribly Sisyphean, i.e., like a ton of wasted effort. It reminds me of the late psychoanalyst Stephen Mitchell, who compared the mental health practitioner’s hasty pursuit of solutions to what Taoists might say, “[It] is like pursuing a thief hiding in the forest by loudly banging a drum”.

Our mental health services currently have a lot of “drum banging”, and not a whole lot of listening, searching, or discovery. This short-term approach to treatment is largely imposed by insurance companies, which limit coverage for services—encouraging a “get’em in, get’em out”, revolving door culture at clinics, hospitals, and private practices—and also favoring medical treatment provided by a psychiatrist, as opposed to the more complex, relational work of a psychotherapist, social worker or counselor. It is also due to an ever increasing consumerist influence on mental health, whereby services are guaranteed to work fast, and are pitched in 140 characters or less—this has only been exacerbated by articles (several of which appeared in The New York Times last year) encouraging therapists to sell short-term treatment in order to remain relevant.

I agree with Dr. Harold Schwartz, the psychiatrist at the Hartford hearing who said, “The failure to recognize illness and the need for treatment… is a function of the disease’s impact on the brain”, but it is the word “recognize” I would emphasize, not the words “illness” or “disease.” We do not currently invest in the art of recognition in our mental health services, a process that requires time: Time to create a safe environment for anyone seeking help (not just those who blip on the radar as clearly"disordered”); time for the patient to establish trust with a practitioner (one who has cultivated the art of empathic relating, as opposed to quick labeling); time to allow nihilistic fantasies to enter the treatment; and time to help the patient separate these fantasies (which may be understandable, in context) from actions. None of this is possible using the quick-fire approaches to treatment we currently subscribe to, and continue to request.

The resistance to long-term treatment is partly due to the various misconceptions about it: that it is a “thing of the past”, that it exclusively implies Woody Allen characters sitting on a couch three times a week, jabbering on about bourgeoisie, “white-people-problems”, that it is a waste of time and money. These stereotypes are not only a problem for therapists who train and work tirelessly on the art of empathic, nuanced, relationship and analysis, but more importantly for the multitude of people who can greatly benefit from long-term treatment, but are never given the chance.

In my own work, I’ve been fortunate enough to “recognize” a long-term patient who had murderous fantasies. I met Harry while working at a community mental health clinic. He didn’t want therapy, and I didn’t want to give it to him. He was loud, anxious, and rambling. He wanted a psychiatric diagnosis for his application for Social Security disability insurance (which he should have received for an obviously distressing physical disability and lifelong learning disability, but had been denied several times because he seemed “mentally healthy”—an example of how unhelpfully categorical our systems can be). At our first session, I was disturbed by his relentless wish to “knock-off” a variety of people he believed were “conspiring” against him—though he wouldn’t specify the people or a plan, rendering these rantings unreportable. After two evaluations by our staff psychiatrist, it was determined that Harry did not exhibit symptoms requiring medication, and it was recommended that he engage in psychotherapy, with an emphasis on behavioral modification—fortunately he had good insurance.

Sitting through our early sessions was nearly intolerable for me, as I had to endure gruesomely detailed revenge fantasies, resembling one of the Saw films. I not only dreaded our sessions, but also what he might do afterward. I tried Cognitive Behavioral Therapy techniques, which are designed to alter patient thought processes, and corresponding behaviors, but he shut me down each time, convinced that no one could ever understand his feelings. It wasn’t until I learned to validate his fantasies, to encourage him to bring even more of them into the room (while also getting clinical supervision for myself), that he began to trust me. Why shouldn’t he feel that the Social Security office “had it in” for him, and why wouldn’t he, in kind, have violent fantasies toward it? (He had been denied benefits time and time again, though he was clearly ailing). Harry learned that someone could in fact recognize his pain, and that his understandable rage, and related revenge fantasies could have a life of their own, separate and distinct from taking action. Over the next couple of years Harry started group therapy as well, made friends, and gradually his mind became less troubled. With my help, he eventually got his disability benefits, but voluntarily continued treatment with me. The fantasies he reported shifted from the horror genre to films of the Rocky variety; he began to narrate his own story as a guy down on his luck who would become a champion with love and support.

Instead of forcing “mentally ill” people into short-term treatment and a “sentence” of medication,  we should be forcing insurance companies to cover long-term relational treatment—in tandem with medication management in some cases. Anyone with coverage should be encouraged to enter therapy, without fear of stigma or of limited time. There are no easy solutions to the horrific shooting epidemic we face, but airing on the side of caution means giving people the chance to be seen, and heard, as opposed to controlled, and numbed into oblivion. After all, why are these killers piggy-backing off each other’s news stories if not to be recognized?




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