Be Better

I found myself saying something to a family member I love very much.  I said "You need to take steps necessary to be better, to get well."  Right after that,  I saw the  picture above, which is a piece by photographer John William Keedy.  This started me thinking about how we perceive normal and abnormal behavior.

One of the interesting features of mental illness is the tendency of some sufferers to resist  treatment.  The resistance is caused by many things. One issue is the desire to avoid the stigma associated with the "mentally ill" label. The mind-altering/personality-altering effects of psychotropic drugs is another hurdle.  When a mentally ill person has full-blown anosognosia, they really believe that they are fine.  It is confusing and alarming to these folks when others tell them they are mentally ill.

Here is the other thing I am learning about mental illness - it is similar to physical diseases in some ways.  If you have diabetes or a heart condition or any other difficult malady and you don't get the appropriate treatment, your disease will progress and you will become  less healthy until you die.  This rule applies to serious mental illness, too.  Serious mental illnesses are progressive.  Untreated sufferers get worse, and often kill themselves when their misery and confusion becomes too much to bear.

Dr. Xavier Amador wrote a book in 2002 entitled "I Am Not Sick, I Don't Need Help."  As I struggled with my own confusion over relatives with mental illness, I ran into a wise person who recommended the book.  I read it, and learned how well-meaning actions can drive a wedge between a mentally healthy person and a mentally ill person. The book is well-written and understandable with a clear blueprint - L.E.A.P., which stands for Listen, Empathize, Agree, Partner.  While the blueprint is clear, executing the plan is hard.  "Sane" responses to the behavior of a mentally ill person get in the way of Dr. Amador's steps.  All the natural feelings that occur when dealing with mentally ill folks - frustration, anger, worry, fear - also impede progress.

After a discouraging series of events, I find myself clinging to hope.  These diseases can be controlled, people do recover.  Good things can happen to the people that I love who are suffering.  While the events "on the ground" may be challenging, this hope remains. 

This will sound trite and corny, but I will never give up that hope.

The story from a woman in recovery from bipolar disorder

This article, written by Linda Logan, will be in tomorrow morning's Sunday Magazine section of the New York Times.  This is one of the best first-person narratives I have read about the long road of recovering from bipolar disorder.  The good news is that those suffering from this disease can re-assemble their lives.  The bad news is that the life assembled via recovery is not the same life that was taken by the disorder.  The desire to "get back to where I was before I got sick" is a huge source of grief and frustration to folks with mental illness.

And here is a quote from another mentally ill person struggling with recovery:

"If the truth be known, I fear that I may be abandoned by my family.  I offer my family the same opportunity to accept and love me as I am, rather than seeing me as a blasted hope, whose life has suffered a sad and irreversible loss.  But it is hard to know if that will happen."

It is hard for a person with a mental disorder to accept and recover from their situation.  And even if they succeed, they may lose their family and friends anyway.

By the way, all of this effort to recover must be strong enough to overcome the continuing widespread social stigma and revulsion that "mentally healthy" people direct at people with mental disorders. And let's not forget that only the very rich and the very poor have full access to mental heath care.  Perhaps that will change someday, but that day seems quite a ways off.  And Medicaid cuts brought about by state budget issues will make care less available to poor people.

On any given day, 240,000 people with mental illness are homeless and another 283,000 are in jail receiving little or no treatment for their disorder. In the U.S., Canada and Western Europe, mental illness accounts for 25% of all disability.  By comparison, heart disease and cancer account for 5% and 3% respectively.

This is an epidemic that people don't talk about or think about.  And when many people recognize mental illness in a person they see on the street, they avert their eyes or cross the street and avoid that individual.

This is a bias that is still perfectly acceptable in our culture.

Mood Disorders

Like everyone else in America, I have been horrified and saddened by the mass murder of innocents at Sandy Hook Elementary School in Connecticut.  I am a parent.  It is an unbelievable nightmare.  And it is tied to mood disorder.

According to studies cited by the National Institute of Mental Health, about 26% of Americans aged 18 and over suffer from a diagnosable mental disorder in a given year.  When you are sitting on the bus with twenty other folks, five of them are probably mentally ill.  Heck, you might be one of the five!

According to the NIMH website, there are 14.8 million Americans with major depressive disorder, 5.7 million with bipolar disorder, 40 million with anxiety disorders, 7.7 million with post-traumatic stress disorder and 2.4 million with schizophrenia. Almost half of the people with mental illness suffer from more than one disorder. Some portion of mentally ill individuals, particularly those with severe mood disorders, slip into full-blown psychosis.

A reminder - psychosis is a general psychiatric term associated with a mental state often described as involving a "loss of contact with reality."  This can lead to everything from mildly aberrant behavior/beliefs ("the police are out to get me") to complex and/or catatonic expressions of very severe mental disorders (hallucinations, delusions, violent/murderous acts).

The vast majority of people with mood disorders pose no threat to others; in fact, mentally ill people are far times more likely than "normal" people to be a VICTIM of violence.  On occasion, however, psychotic people commit murders and other violent acts.  People in the grips of a psychotic episode are often terrified - their emotional recognition system is impaired and people, even people they know quite well, can seem alien and threatening to them.  People with mood disorders, especially people who are psychotic, often lack the insight to realize that they are ill so they don't seek treatment - often, they avoid it.  If you are terrified, in the grip of psychosis, you have to save yourself from that experience somehow.  All sorts of heinous behavior can occur, and seem perfectly justifiable to the psychotic person.

A very small subset of psychotic people fall into the category commonly labeled as "psychopaths."  These are the folks that appear to be sane; they aren't raving or noticeably crazy and they can actually be quite charming.  Psychopaths lack empathy and don't connect to emotions the way most of us do.  Professor Robert Hare has said, "A psychopath can use words like 'I love you' but it means no more to him than if he said 'I'll have a cup of coffee.'"  About 90% of serial killers are psychopaths.

Now here is the thing - in the United States, mentally ill people have the same rights as the rest of us, which is the way it should be, right?  This makes it very difficult to have a severely mentally ill adult committed to in-patient treatment against his or her will.  In addition, in-patient psychiatric care is in short supply.  Since insurance companies don't want to pay for any unnecessary hospitalization, the hospital in-take staff are biased against admitting anyone who shows up with a mental illness.  If an individual is sufficiently disrupted to be taken into the ER by the cops, they can sign that individual in for an involuntary 72 hour assessment.  If the individual refuses to stay after that hold period, there is little that the hospital or anyone else can do short of a court order forcing the person into the psych ward via involuntary commitment.  It is very difficult and time-consuming to obtain these court orders.

So we have this massive epidemic of mental illness, and the severely ill folks can avoid treatment if they wish.  The state of knowledge of psychiatric illnesses is quite inadequate; psychiatrists and therapists are usually making educated guesses about their patients (if that).  The old saying is "Psychiatry is to medicine as astrology is to astronomy."    I have spent a lot of time over the past few years interacting with mental health professionals as I tried to help loved ones with mental illness and I totally agree with that saying.

Now let's overlay the mental illness epidemic on top of the American gun culture.  Regardless of where one might stand regarding Second Amendment rights, it is easy to see that we have a problem.  The surprise isn't that psychotic people will commit murder on occasion.  The surprise is that we don't have a lot more murders committed by psychotics. It is as easy as pie for an undiagnosed psychotic individual to get a gun.  This demonstrates again that the overwhelming majority of folks with mental illnesses are not violent.

And while we do have a problem, it is also important to put the risk in perspective.  There were 14,748 murders in the U.S. in 2010 and a fraction of those killings were committed by mentally ill people; there were 32,788 people killed in automobile accidents. All parents need to remember that, statistically speaking, our children are much, much safer in school than they are in the backseat of a car. We fear automobile accidents, but we dread random murders committed by crazy people.   Dread is not subject to the rules of logic - we obsess over things that are very unlikely to happen, whether it is random murder or a jet crash. Dread is a lot worse than fear.

Having said all of this, I can't for the life of me figure out why any regular citizen of the United States needs to own an assault weapon; it seems to me that the threat to public safety outweighs the "right to bear arms." When the Founders wrote the Second Amendment, I don't think they anticipated that they would be protecting the right to own a weapon that can spray 400 rounds per minute.