ShrinkTalk.net

Mentally Ill or Just a Scumbag?

I recently watched the film What Doesn't Kill You, starring Mark Ruffalo and Ethan Hawke [1]. Without giving spoilers, at one point in the film both men beat up a known Pedophile. As the two characters are punching and kicking and basically using the guy's face as a speed bag they are both yelling, "You sick fuck! You sick bastard!"

I immediately had questions: if the two characters thought that the perpetrator was actually sick, why were they wailing on him? Was their labeling of him just a figure of speech and they saw his actions as simply that of a reprehensible asshole, or did they really believe he was ill?

These questions are what make mental health such a tricky animal. Conditions that tend to pull at our sympathy strings often don't get questioned [2]. When a woman is crying all day long, loses 20 pounds from not eating and tells her friends that she is suicidal, we say that she's depressed. That's an illness and it's not often scrutinized. When a man gets fired from his job because he can't leave the house until he's counted every ceiling tile in his home and washes his hand 200 times per day, we say he has OCD. That's also an illness. And when voices that no one else can hear begin to pound in the head of a young woman, telling her that she's worthless and that aliens are probing her brain, we call her Schizophrenic. Again, an illness. Even though we can't see the actual disease the way we can when someone has the flu, most of us take the sickness at face value [3].

But what about those conditions that appear more nefarious? Narcissistic Personality Disorder is in the DSM-IV so does that make it an illness? What about Sociopathy? And of course sex offenders. These groups of people act in ways that, at a minimum, piss us off and, at worst, cause irreparable damage to people. When the schizophrenic woman runs out of the shrink's office because she thinks he can read her mind, we feel sorry for her because she's the only person suffering at that time. But when she drowns her children, she's suddenly the most evil person on earth, condemned to Hell. Is she not sick anymore [4]? Of course she is still ill, but now she's brought another person into the equation. As people, this is where when we cross that line from sympathy to anger. And this is why people like the characters in the film are praised by some. It's not as if they would have kicked the shit out of someone who had thoughts about children, it's because he took action on them, damaging a helpless child. It's the hurtful behavior that leads many to move from Illness Model to Scumbag Model. Even in prison, you can't beat up someone who is sick, but you can when he's an asshole. When he crossed that line, the characters in the film decided he wasn't sick, he was a scumbag. And while virtually all crimes have a victim, you don't often hear about a prisoner getting beaten up for murdering a 35 year-old man. That's because there isn't an overt power differential between perpetrator and victim that's seen in Pedophilia or perhaps abuse of the elderly. It's when we see such a disparity in control some of us will laud the violent behaviors of others because in a way they have leveled the playing field.

So as not to oversimplify, perceptions of illness vs. choice will vary from person to person and even by mental health pro to pro. Cultural norms, religious views, personal takes on the conscious and subconscious mind, as well as knowledge of brain structure and biochemistry, all influence how someone views psychological/psychiatric problems. You can find plenty of shrinks to say that Michael Jackson was deeply and profoundly suffering from a psychological disorder, but turn around and there are just as many who say that he made conscious behavioral choices and isn't deserving of any sort of "mentally ill" pass. Society allows us to think strange things but won't accept behaviors that damage others. So if Michael believes his mission in life is to start a Boy Scout troupe he's not going to be met with the same scrutiny as having young males sleep over his house. That's because the latter is much more suggestive of harm.

I've said this before but it bears repeating: until we have dipsticks that we can put into people's heads to give us a formal reading on how 'sick' someone is, there is going to be guesswork involved [5]. When I worked with sex offenders and heard about the horrific things they did it was hard for me not to think that only someone truly ill would engage in those acts. When I meet a certifiable Narcissist it's hard for me to not empathize with the fact that he truly, deeply sees himself as special, independent of any evidence to support his claim. It's as if the belief is so entrenched, almost like a delusion seen in people with psychosis. But the general population is going to cut him out of their lives. This isn't necessarily a bad thing because Narcissists are generally toxic people, but most will drop him based on labeling the guy a dick rather than being ill. This, unfortunately, creates a culture of hate and anger rather than one based on what is healthy and pro-social. In other words, there are competing interests for what is best: removing the Narcissist benefits the people but not necessarily the Narcissist. Unless he says, "Wow, being a douchebag is upsetting a lot of people. I should probably stop acting that way," he is not going to change his ways. And how likely is that? Instead our action of kicking him to the curb may in fact reinforce his behavior, because we "don't get" how great he is or are simply jealous of his greatness.

So I view people who say and think and do messed up things as ill. Does that make it fact? No, of course not. Having expertise in a field doesn't mean that what you say is gospel. But I will ask you to consider the notion that just because something doesn't make you say "wow, poor guy" doesn't mean it's not pathological. A mental condition may not always pull at our heart strings, but that's doesn't mean it isn't an illness.

[1] I'm not reviewing the film but feel free to click here for my mind-bogglingly awesome coverage of Star Wars.

[2] Unless you are one of those uber-conservative types who don't see anything in the brain as an illness but simply a conscious choice. You're probably not a person who would be reading this site anyway so it is kind of a moot point.

[3] Dr. Gail had the flu last week and she looked like the offspring of Golom and the Crypt Keeper. Scary stuff.

[4] Note that this is not an argument for or against imprisonment versus psychiatric treatment or a comment on the plea of Not Guilty by Reason of Insanity. These are topics that can't be covered in entire textbooks, let alone this website.

[5] That data is starting to accumulate. For example, some fMRI results show differences in brain blood flow in depressed vs. non-depressed people, while PET scans show a trend of low neural activity in the frontal cortex in Schizophrenia.

Next to Normal

There's a world, there's a world I know
A place we can go, where the pain will go away
There's a world where the sun shines each day

There's a world, there's a world out there
I'll show you just where, and in time I know you'll see
There's a world where we can be free

Come with me...
Come with me...

There's a world where we can be free
Come with me...

These are the lyrics from a song in the Broadway musical, Next to Normal, which are heard over a slow, haunting piano and violin. These are words you would likely hear in a horrifically cheesy love song, or perhaps in a concentration camp where characters are looking to overcome an oppressive regime to build a better life.

Does the song sound inspirational? Actually it is about suicide and it's an eerily accurate depiction of the mind set of many who have either seriously considered or attempted to kill themselves. I've discussed this before here but with an increase in depression, anxiety and overall stress from the economic collapse, certain points bear repeating.

People do not kill themselves because they want to be dead. They do it because they want their pain to end and cannot create any alternative solutions that are viable to achieve that goal. The song holds water because it gives an image of peace and happiness, a freedom from the daily agony that generates suicidal ideation. Is that what death is? I'm not going to pretend to know the answer but I am skeptical of the portrait painted by the lyrics [1].

Every suicidal person I have spoken with has agreed that if they could simply feel better they might want to remain alive. This admission by a client is often an opening to offer help and the possibility of thinking and feeling differently. And with time and intervention most people are able to stop thinking along these lines. And I stress the term most because it's no secret that mental health treatment has limits, a ceiling effect, and many remain ill for their entire lives.

But a chronic illness does not necessarily translate to giving up. Many clients need a cheerleader, to be pushed to continue to fight for a decent quality of life. Instead of opting out of their life contract I encourage them to rail against the struggle and seek out meaning, create a reason for getting up in the morning. Does it always work? No of course not. But more often than not those who are chronically suicidal can make a model of something worth striving for. They can defeat the seductive nature of ending it, of "having no more problems."

If you are one of those who are dancing with suicide as your partner, think more about what you are really trying to do. I suspect it's not a desire to cease your existence. If I am right about this remember that when people are actively suicidal, their problem-solving skills fall through the floor. Get help, exhaust every option, don't surrender to this sole choice. I have a strange suspicion the end result isn't what you're envisioning.

[1] In fairness to Next to Normal (an excellent show, by the way), the play wasn't promoting suicide; rather it was effectively demonstrating the seductive quality of the action for those who are entertaining it.

Dr. Rob's Simple Advice to Ladies so You Don't Get Dumped

Dear Dr. Rob,

After you wrote this post for men I thought for sure we'd see a follow-up for the female readers, something to help us in our relationships with our boyfriends. And yet, nothing! Do I have to go to Dr. Phil for good advice?

Lynn

Let the word go forth and make no mistake: if anyone here takes Dr. Phil's advice over mine, she will be banned from this website forever, never to return. Banished for life.

A few years ago a large portion of my clientele was women, aged 21-35 or so. Most of them had what seemed to be potentially great relationships with their boyfriends. However, all the women had a common feature: a need for excessive attention from their boyfriends and a constant reassurance of the relationship's stability.

None of these women were narcissists or suffering from Histrionic Personality Disorder (more commonly known as "Drama Queens"). They all hated the idea of being labeled "That Girl," the one who might have a few too many drinks and blow a gasket when their boyfriends didn't call or wanted to spend a night with the guys. And yet that is exactly what they were turning into. Successful women with great jobs, loving friends and goals that ranged from writing books to raising large, healthy families. So why were they needing to be the sole focus of their significant others' world? Why the constant and debilitating anxiety from any signal suggesting a lack of complete and total devotion? Simply put, they were all afraid of loss, and this fear was a huge problem.

The women would come to me seeking ways to lower their anxiety levels, feel less jealous about ex-girlfriends, develop ways to not freak out that their partner didn't say 'I love you' often enough. I will tell you exactly what I told each of them.

There are no magic words, no breathing or muscle relaxation techniques, no amount of drugs (recreational or medicinal) that can take away all of the angst and distress if you insist on making a small number of erroneous and perhaps not entirely conscious assumptions:

1) There is such a thing as a 'guarantee' in relationships or life in general. Read my post on why marriages fail for more on this. Life actually brings just the opposite: a constant series of risks, especially at the romantic level. Just think of the number of dates/hook-ups/boyfriends you and your friends have had over the course of your life. How many of those have ultimately ended? Almost all of them.

2) Men can essentially be put in a bubble, removed from their history and current interactions with the outside world, that they can have a healthy life generated solely by your relationship with them.

3) That you 'can't live without him.'

In other words, unless you embrace the fact that your man has a past and present that doesn't include you, that there's no way to ensure things will be Happily-Ever-After and, perhaps most importantly, that you are not made of glass and would survive if the relationship dissolved, then you've ironically already destroyed the good thing you have. If you can't be comfortable in your own skin - knowing that if you were betrayed or dumped or both, that you'd get up, dust yourself off and move on - then give up on that relationship now. As cliché as it may be, you simply can't ask someone else to tell you that things will be okay if you are unable to do it yourself. There's no way the relationship will work. There's no chance.

The good news is that once you've eliminated the aforementioned assumptions from your mind set, all the 'symptoms' will go away. No more worry, no jealousy, and finally some fucking inner peace. Why? Because you'll know that while it's painful to lose someone important to you, loss is a part of life and that you can be okay with that fact. You can and will move forward, as hard as it may be.

One further piece of good news: men who are interested in meaningful relationships will find this mind set attractive. You'll strangely get so much more out of your relationship if you're fully prepared to lose it.

Easy to say, right? Of course it is, and that's why therapy is actually quite simple. It's not a collection of mind-blowing words of wisdom that you've never heard before. Not at all. But unfortunately it is a process, not an event. You have to take information that you might actually already know and absorb it. It has to transform from an intellectual understanding to a more visceral one. And when that happens, people feel better.

Give these words some thought. Not just 'yeah yeah, I get it' thought. Sit with the three assumptions above and embrace how untrue and maladaptive they are. That will help. Trust me, I'm a doctor. Not a real one, but close enough for the purposes of this discussion.

Groundhog Day

During my post-doctoral training I was fortunate enough to be educated at a prestigious hospital in upstate New York. My office overlooked an executive golf course and lots of small, rolling hills and greenery. Albeit slightly pretentious, the whole campus smacked of top-shelf, brand name mental health riches.

On the grounds of the hospital were lots of groundhogs who seemed to patrol the campus, almost like sentinels. My fellow students and I called them Land Monsters [1]. We often tried to pet them - despite the potential diseases they carried - but they would never allow us to get too close before scurrying off to safer pastures. But when you saw them from your office chewing on leaves or grass, you felt at peace. Top notch training, a killer office, wild beasts running amok. This is what it's all about.

One day I received a call from a client who was an avid animal lover. Her cat had just been diagnosed with a terminal illness and had only a short time to live. She lived at least an hour away and since I only had a small number of open therapy slots that day it seemed prudent to have a telephone session right then and there.

As we talked about loss, grief and human attachment to pets, I glanced out the window. On the grass was one of the Land Monsters who was whittling about on a twig. In the distance, a bus approached, one that usually carried patients who were receiving partial hospitalization treatment [2]. As my patient was crying, practically wailing into the phone about how she would miss her cat, the Land Monster started to work his way toward the road that twirled its way through the hospital grounds. It crossed my mind at that point that tragedy might ensue but since the driver was too far away to hear me my focus needed to stay on the conversation.

As the client continued and my eyes fixed upon the scene developing outside, the Land Monster moved into the street just as the bus cross his path. Pow! While the driver had attempted to turn at the last second, the Land Monster was struck by however many tons of steel and could barely move away as the bus continued on. It shuddered on the pavement for a few moments, then suddenly lay still. Dead.

I couldn't believe what I had seen and stared out the window, mouth agape. Meanwhile, the client was moaning into the phone about her impending loss. As blood trickled away from the dead Land Monster into the grass - an image that is as fresh in my head today as it was seven years ago- I completely lost focus.

"I'm sorry, I...I can't concentrate right now."

My client and I had worked together for many months and she knew I wouldn't pull some psychological hamstring injury on her for no good reason. "What's wrong," she sniffled into the phone.

Knowing her passion for animals (what she called "critters") I paused. "I don't think I should tell you. Trust me, it's for the best."

"Well, alright," she said. "Can we talk later?"

"Yes yes, I promise. I will call you later this evening and we can talk more."

I'm a huge believer that shrinks need to check their problems at the door when they start working (with the exception of when I reinjure my back because there's just no hiding that pain). That's part of the contact with the client. She is paying me for my time and attention to focus on her problems, not mine. But how do you keep your focus on the client when you are both traumatized at the same time? In this case, you can't. Or at least I couldn't. Normally I would suppress whatever I was feeling for the eight hours or so that I am at the office and deal with things later. But in this case I got off the phone, sat in my chair and rocked back and forth, freaking out that I just watched a small animal get crushed by a bus. I actually considered sucking my thumb or falling to the floor so I could enter the fetal position, but there's only so much drama that's acceptable for one afternoon.

To this day, when I see a groundhog, I feel a sense of grief for his brethren, guilt at bailing out on my client, and anger toward the bus driver for not paying closer fucking attention. I never did tell my client what happened. I just simply apologized for needing to hang up so abruptly. Given her passion for animals and her current state of mind, I think she would have responded even more emotionally than I did.

[1] We actually stole this name from an obscure Simpsons episode in which Homer refers to a groundhog in his presence during his stint in the Garden of Eden.

[2] This is a very intense form of treatment where patients spend the majority of the day at the hospital, engaging in group and individual therapy, then return to their homes in the evening.

A Legitimate Beef or Simply Hating on the Shrink?

A few years ago I performed a weight loss surgery evaluation on a young man, 25 years of age [1]. For reasons that I cannot go into, he was clearly unprepared for the extensive lifestyle changes that were required of him to make the surgery successful. When he was informed that my recommendation would be that he would need to need to get both nutritional and psychological counseling he blew a gasket. He hemmed and hawed, threatened to call the licensing board, promised to have his check for the service canceled, and called me a "dripping gay wad." That seemed like such an infantile and unusual insult for a mid-20's man to throw out so I looked it up. I found nothing.

The next day I got a call from the man's mother. She was equally upset because the surgical team had, in fact, decided to delay surgery. I immediately explained to her the following:

- Because her son was an adult, I was unwilling to go into extensive detail about her son's case. He could explain that information to her himself should he choose to.

- Her son was not disqualified from having the procedure; rather, that he was required to have further counseling to make him a more viable surgical candidate.

- I was not a "dripping gay wad," whatever that meant.

Rather than listening to my points, however, she simply called me a charlatan and accused me of purposely denying her son the chance to have multiple medical problems corrected for my own personal gain [2].

This is where I lost it. What possible motive, by any stretch of the imagination, would I have to temporarily deny a morbidly obese man a surgical procedure that would clearly improve both his health and quality of life? Why, on Earth, would I do such a thing? Because I'm against the procedure in general? If I were anti-surgery I wouldn't be part of a surgical weight loss team. Because I wanted to mandate further sessions with me for financial gain? Hardly. Not only do denied patients rarely come back to see me specifically due to being pissed off, but there are plenty of other Psychologists in this city who are better, cheaper and move conveniently located. Because I get off on making people angry? The man's name wasn't Dr. Steve so wrong again.

So why then? Because I noted things that qualified him as high risk. He was set-up to fail due to psychological factors. If he went forward with the surgery right then and there, as he had planned, the likelihood of success was small. However, if he addressed a few minor points, including spending more time with the dietician, his likely prognosis would be significantly better. At 25 years of age his need for surgery was not imminent and I was told a few more months would not put him at any further medical risk.

I was so irate at her accusation that I got up on the highest horse I could find and told her that she should be thanking me for protecting her son from significant medical risk.

"A good mother would be grateful that I'm not putting him in harm's way," I yelled into the phone.

"Did you just insinuate that I'm a poor parent?" she asked, and I could practically hear her angry breath reaching through the phone to choke me to death.

"I...I'm sorry," I said, suddenly very ashamed.

"Whatever my son called you, he's right. You are a Dripping Way God."

The woman's take prior to the shouting match is an example of mindset that gets us into trouble so much. In the face of problems people far too often say not, what can I do?, but rather who can I blame? Rather than accept what is and work within the framework given, they decided to attribute the problem to me. Some may consider this a form of resolving cognitive dissonance, where a person needs to deal with the distress of holding two contradictory ideas at the same time. I want/need to have the surgery, yet it is not going to happen, at least right now. To get rid of this feeling, I'll blame the Psychologist. But it's really just a rationalization, because taking responsibility is, in all honesty, a pain in the ass. It's often easier to just lay the problem at someone else's feet than to say I'm at fault, perhaps even flawed or defective.

But here's the rub: there is no one to blame. No one is at fault or weak. It is what it is, and if the man did what was asked of him he would have had the surgery. Instead, though, he decided to find another hospital where they would perform the procedure without a psychological consult. That was his prerogative and people seek 2nd opinions all the time. But bypassing the psychologist via another hospital isn't accumulating new opinions, it's ignoring direct advice and assuming you know more. Maybe he got lucky and I was mistaken. We all know that psychology isn't an exact science. Perhaps the surgery was a success, that I'll never know. But had he and his mother simply followed the recommendations given he would have avoided a significant number of potential pitfalls. And he could have done everything asked of him without having to deal with the dripping gay wad again.

[1] Click on that link to read about the specific arguments both for and against weight loss surgery for morbid obesity.

[2] It is well documented that weight loss surgery can treat a number of medical issues simultaneously, such as high blood pressure, high cholesterol, diabetes, sleep apnea, etc.