Sunday, November 24, 2013

Putting a Dent in the Universe, One Way or Another

The two men's personalities were more similar than different: both were temperamental, easily slighted. They had similar views of themselves, believing that they had a special purpose in life. Both clearly burned with a desire to shape history.

As young men, both embraced alternatives to mainstream culture: one became a hippie, the other a Marxist. One travelled to India looking for enlightenment, while the other went to the U.S.S.R. in search of a communal utopia. They both returned to the U.S. somewhat disillusioned. 

They could both be quite cruel and controlling: one was known for tearing down subordinates and once implied that the mother of his child was a slut, saying "28 per cent of the male population in the United States could be the father." The other one beat his Russian wife and refused to allow her to learn English.

They both ignored reality, but whereas one was famous for his "reality distortion field" in which he would convince not only himself but also everyone around him that the impossible could be achieved, the other only distorted reality for himself: upon returning from Russia, he was surprised that the press was not waiting for him at the airport to hear his story. His wife later told investigators about "his imagination, his fantasy, which was quite unfounded, as to the fact that he was an outstanding man."

One of these men founded a company by the time he was 21 and became a multi-millionaire at the age of 25. He then went on to reshape the personal computer, animated film, music, and telephone industries. The other also made his mark, on a tragic day in November, and would be dead at the age of 24 fifty years ago today.

So what made their life stories so different? Was it because one of them was more intelligent than the other? Was born with more innate charisma, a better aesthetic sense? Or was it parenting and the environment where each grew up? One was adopted shortly after birth and raised by middle-class parents in a stable home, while the other's father passed away 2 months before he was born. His overwhelmed mother put him and his siblings in an orphanage, then later moved with him across the country, worked long shifts, and left him to fend for himself. He went to juvenile hall for truancy, and his social worker there thought he conveyed "the feeling of a kid nobody gave a darn about."

Looking back on history, one can never be sure of causation. But I can tell you with certainty that childhood matters. Growing up in a safe environment with loving family matters. Having nurturing adults who support a child's interests matters. I wish that all of the attention given to Lee Harvey Oswald and the Kennedy assassination in recent weeks had focused less on the final act of the shooter and more on the formative years that shaped him. As Steve Jobs once said:
I'm 100% sure that if it hadn't been for Mrs. Hill in fourth grade and a few others, I would have absolutely have ended up in jail. I could see those tendencies in myself to have a certain energy to do something. It could have been directed at doing something interesting that other people thought was a good idea or doing something interesting that maybe other people didn't like so much. When you're young, a little bit of course correction goes a long way.

Sunday, November 17, 2013

The Wizard: Psychopharmacology Magic?

One of the most memorable psychiatrists that I worked with as a trainee is someone I think of as The Wizard. He specialized in treating some the most difficult behavioral manifestations of autism and other genetic conditions like Fragile X syndrome. He had a magical ability to calm even the most agitated children and adolescents and seemed to inspire reverence and awe in their parents, who kept voting him to the top of various "Best Doctor" lists.

What most amazed me about The Wizard was his Zen-like serenity. Regardless of how much noise the patient was making or how many toys went flying around the room, he would be like the calm eye of the storm, holding still while everything else moved around him. His gaze was remarkable, intense yet warm and soft, like a bright candle. He would focus intently on whoever he was talking to, making that person feel important and special. His voice was smooth and soothing, almost soporific; perfect for those in emotional distress.

He took no notes during the appointments. His dictated progress notes were usually just a couple of paragraphs long, without pesky details like what medications the patient was taking and what medication changes were made during the visit. However, he did not have to remember those things. During the visit, he would shine his bright gaze upon the parents and say, "So tell me, what did we decide to do with the medications last time?" And the parents always provided the details. Maybe they knew that they would be quizzed this way, so they prepared so as to not be embarrassed. More likely, I think the parents were pleased that this eminent psychiatrist trusted them enough to empower them in this way.

The Wizard was an expert psychopharmacologist, often prescribing medications that I've seen no other psychiatrist prescribe. Things that may have had success in case studies, but no positive clinical trials (and maybe even some negative ones). Yet for him, he was able to get results using those medications. Perhaps he was lucky, or with his experience he was able to intuit the right medication for a certain patient. However, I firmly believe that just being in his presence was one of the major therapeutic interventions that he provided for his patients and their parents.

I attempt to channel him during every patient encounter. But try as I may, I can't help but continue taking notes while talking to patients and then writing overly detailed progress notes.

Sunday, November 10, 2013

On Bullying and NFL Culture

I have always been enthralled by NFL football. Growing up, I was amazed by the super-human strength, speed, and dexterity exhibited by its players, and how they seemed to (almost) always get up from bone-crunching hits and keep playing. Over the past decade though, it has become increasingly clear just what a physical and mental toll the game takes on its players, with the NFL's earlier attempts to deny links between concussions and lasting brain damage in the form of chronic traumatic encephalopathy at the forefront of recent reports.

For some observers, the NFL has definitely lost some of its luster. However, the league's popularity does not seem to be waning. The week-to-week dramas on and off the field have me convinced that the NFL is America's #1 reality show. What I wonder is whether this scrutiny can result in anything positive? Or will the NFL just take advantage of the increased attention, whether good or bad, for gain and profit? I think how the league handles the latest scandal will be instructive.

For the past week, there have been numerous news stories about Jonathan Martin of the Miami Dolphins, who left the team and checked into a hospital for emotional distress following alleged bullying by teammates. Martin, who graduated from Stanford, has made public some disturbing voicemails and text messages from Richie Incognito, a player who was kicked off two different college football teams.

What I haven't heard discussed much on sports shows is what exactly is bullying? The officially accepted definition is that bullying is unwanted, aggressive behavior that involves a real or perceived power imbalance, which is repeated over time. From this definition, it's quite clear that bullying was in fact what was going on. Incognito, an NFL veteran and a member of the team's player leadership council, is clearly in a position of power over the much younger Martin, and the abuse certainly was not a one-time incident, starting with Martin's rookie year and continuing into this season.

Watching the Fox NFL pregame show this morning, I was dismayed but not surprised by some of what I heard. Jimmy Johnson talked about how Martin was not drafted until the second round, meaning some teams must have thought there were some issues with him. Michael Strahan said that people only do to you what you allow them to, implying that Martin is somehow weak for not standing up for himself. Terry Bradshaw talked about how our culture has become too quick to judge. And then there was Jay Glazer's exclusive interview of Incognito, who admitted to sending insensitive messages, but denied being a bully or racist (link to ESPN's summary of the interview):
"When words are put in a context, I understand why a lot of eyebrows get raised," Incognito told Fox Sports during the interview, which aired Sunday. "But people don't know how Jon and I communicate to one another. For instance, a week before this went down, Jonathan Martin texted me on my phone, 'I will murder your whole F'ing family.'

"Now, do I think Jonathan Martin was going to murder my family? Not one bit. He texted me that. I didn't think he was going to kill my family. I knew that was coming from a brother. I knew it was coming from a friend. I knew it was coming from a teammate."
"You can ask anybody in the Miami Dolphins' locker room who had Jon Martin's back the absolute most, and they will undoubtedly tell you [it was me]," Incognito said. "Jon never showed signs that football was getting to him [or] the locker room was getting to him."
"All this stuff coming out, it speaks to the culture of our locker room, our closeness, our brotherhood," Incognito said. "And the racism, the bad words, that's what I regret most. But that's a product of the environment."
Now imagine a high school girl accused of bullying saying the same thing: "But I was her best friend! She said mean things to me, too! In the high school environment, that's just how we talk!" Not much of a defense, is it? Incognito is certainly right that the culture of the team played a role; he just clearly does not think that there's anything wrong with the culture. What the ESPN story does not include though, is the most important fact to come out of that interview: The one question that Incognito would not answer is whether his coaches had directed him to toughen Martin up.

The wisest thing any player has said about the situation has come from Brandon Marshall, a wide receiver who has experienced plenty of his own troubles, but who seems to have turned his life around after being treated for borderline personality disorder and courageously discussing his diagnosis in public.
"Look at it from this standpoint," Marshall said. "Take a little boy and a little girl. A little boy falls down and the first thing we say as parents is 'Get up, shake it off. You’ll be OK. Don't cry.' A little girl falls down, what do we say? 'It’s going to be OK.' We validate their feelings. So right there from that moment, we're teaching our men to mask their feelings, to not show their emotions. And it’s that times 100 with football players. You can't show that you're hurt, can't show any pain. So for a guy to come into the locker room and he shows a little vulnerability, that's a problem.

"That’s what I mean by the culture of the NFL. And that's what we have to change. So what's going on in Miami goes on in every locker room. But it’s time for us to start talking. Maybe have some group sessions where guys sit down and maybe talk about what's going on off the field or what's going on in the building and not mask everything. Because the (longer) it goes untreated, the worse it gets."
A T-group for NFL players, what an inspired idea! Marshall also addresses the role the head coach plays in shaping a team's culture:
“We [the Chicago Bears] look at rookies different,” he said. “You have to earn your stripes, earn your place on the team, earn your place in the NFL. But as far as crossing that line? Disrespecting guys? Demeaning guys? That just doesn’t happen here. Actually, Coach (Marc) Trestman did a great job of really going out of his way to make everyone feel comfortable from Day One.”
Will the NFL take advantage of this opportunity to change how coaches manage locker room behavior? Or will there be another flimsy attempt at a cover-up?

Sunday, November 3, 2013

How to Combat Stigma, Part 2

This is part of of a series of posts on how to reduce stigma around mental health. Part 1 is here.

I'm working my way through Anthony Beevor's The Second World War, a one-volume history covering the major military events of World War II. To me, one of the most interesting aspects of the book is how much the author repeatedly describes the psychological effects of stress from war, which affected everyone involved from civilians to front-line soldiers to generals. One particularly striking passage described an infamous incident that occurred in Sicily in August 1943 when General George Patton was visiting hospitalized soldiers [page 498]:
Patton asked a soldier from the 1st Division, a young carpet-layer from Indiana suffering from battle-shock, what his problem was. 'I guess I can't take it,' the soldier replied helplessly. Patton flew into a blind rage, slapped him with his gloves and dragged him out of the tent. He booted him in the rear, shouting: 'You hear me, you gutless bastard. You're going back to the front!' A week later, Patton had another explosion when visiting the 93rd Evacuation Hospital. He even drew his pistol on the victim, threatening to shoot him for cowardice. A British reporter, who happened to be present, heard him say immediately afterwards: 'There's no such thing as shellshock. It's an invention of the Jews!'
I thought about this passage a lot as I was writing this post. In many ways, it does seem that the stigma of having a condition like post-traumatic stress disorder has greatly decreased. No general today would claim that PTSD does not exist or publicly berate a soldier suffering from it. However, the silence and shame surrounding mental conditions continues to be pervasive. There have been numerous articles and reports about the difficulties returning soldiers have in readjusting to civilian life or having access to appropriate treatment. Suicide rates, which used to be lower in the military than in civilian life, are now higher among members of the military.

I have not come across any good studies about evidence-based ways of decreasing stigma related to mental health, so what follows is my own intuition and opinion. I personally do not believe that talking about how common mental illnesses are would do anything to decrease stigma. Just look at the example of obesity, which despite skyrocketing rates, is still something that leads to kids being teased and bullied at school. Likewise, emphasizing that mental illnesses are biologically-based is unlikely to help. Everyone knows that those with intellectual disability have a brain-based condition. However, that did nothing to stop previous terms like "mentally retarded" and "idiot" from becoming pejorative. Below I'll discuss two broad areas that I think can help decrease stigma.

Normalizing the Expression of Emotion

In the U.S., when someone asks "How are you?", the answer is almost always some variation of "I'm okay," no matter what the truth may be. I believe that this cultural taboo against honestly discussing one's emotional states is one of the root causes of stigma. I have had countless patients apologize to me for crying as they describe the stress or trauma in their lives. The perception that it is somehow a weakness to be emotional or to talk about such difficulties leads to shame, which perpetuates stigma. When I ask about a family history of mental illness, one of the most common things I hear is: "I think my ___________ may have _____________, but my family never talked about it." Needless to say, those family members probably never got any sort of treatment for their suffering.

However, in some cultures, the more open expression of emotion seems to help people be more willing to seek treatment, as this CNN report on psychotherapy in Argentina shows. Even in the U.S., there are starting to be efforts to teach children emotional skills, which are increasingly recognized to be as important as intellectual or social skills. I believe that if children (and adults, but it's certainly easier with children) learn that it's acceptable to acknowledge and discuss their own feelings of sadness, anger, frustration, anxiety, etc., then they will have more compassion for others who are in emotional distress.

Of course, this does not address the stigma surrounding serious and chronic mental illnesses. Tellingly, the CNN article linked above contains the following:
One of the soon-to-be psychology graduates is Agustina, 31, who did not want her last name used because her future patients may Google her name.

Every member of Agustina's family goes to some kind of therapy, but, she's quick to add, "It's not that we are completely crazy or something. Nobody has big issues."
So what can be done for those with "big issues"?

Access to Care/Quality Treatments

I believe that as with other conditions like HIV/AIDS or Hansen's disease (a.k.a. leprosy), nothing stigmatizes more than having a group of suffers treated as outcasts and isolated from the rest of society. Having hundreds of thousands of chronically mentally ill people living homeless in the streets and millions more locked up in jails and prisons is terribly stigmatizing. Similarly, having managed care erect roadblocks to patients getting quality psychiatric care is stigmatizing, as it reinforces the idea that mental conditions are second-class citizens compared to purely physical ones. Despite passage of the Mental Health Parity and Addiction Equity Act in 2008, insurers are still unwilling to pay for many treatments.

Unfortunately, this is not going to get better until we as a society come to our senses and implement a better model for mental health treatment. As fellow blogger Dr. George Dawson has pointed out many times on his blog, managed care's focus on cost containment over quality has had a horrendous effect on the ability of clinicians to provide adequate care. Likewise, taxpayers are paying billions to keep mentally ill people locked up, when the same money could be used to much better effect to provide interventions such as stable housing, assertive community treatment, and vocational training.

It does not help that the NIMH continues to emphasize basic biological research above all else, or that the APA does little to challenge the managed care system, accepting it as fait accompli. But hopefully, with enough awareness and activism around these issues, meaningful change will eventually take place, and we as a society will make a bigger dent in the stigma related to mental health.