Sunday, June 10, 2018

The Mental Health Profession is Failing

We do best not to seek out deeper meanings in two high profile suicides. We do not know what medication Kate Spade was taking and how it influenced her actions. And we know very little about Anthony Bourdain’s suicide. We do not even know whether it was intentional or accidental and whether he left a note. We probably will never know.

Throughout my own comments on the issue of suicide I have tried to draw attention to the fact that a wave of suicides, coupled with a wave of depression and anomie, tells us that our mental health system is broken. It also tells us that our culture is broken.

Today, Benedict Carey argues these points at length in an important New York Times column:

The escalating suicide rate is a profound indictment of the country’s mental health system. Most people who kill themselves have identifiable psychiatric symptoms, even if they never get an official diagnosis.

The rise in suicide rates has coincided over the past two decades with a vast increase in the number of Americans given a diagnosis of depression or anxiety, and treated with medication.

The number of people taking an open-ended prescription for an antidepressant is at a historic high. More than 15 million Americans have been on the drugs for more than five years, a rate that has more than tripled since 2000.

But if treatment is so helpful, why hasn’t its expansion halted or reversed suicide trends?

As noted before, today’s antidepressants do possess a notable suicidal ideation risk. And, we also know, SSRIs disinhibit…. Actions you might be too afraid to take might become easier to commit when your medication has suppressed your fears.

But, what role does psychotherapy play in all this. Surely, it is widely available. But, how effective is it? How many people who suffer depression consult with therapists? How many of them prefer to pick up a prescription from their local internist?

Carey introduces statistics from Denmark:

But one recent study, by Danish researchers, supported the benefits of therapeutic intervention.

Using detailed medical records, the investigators studied more than 5,500 people who had been treated for deliberate self-harm, including cutting and clear suicide attempts.

Over decades, the portion of those people who got psychotherapy at suicide clinics were about 30 percent less likely to die or commit further self-harm than those who did not.

“I personally think that it’s the quality of care that matters, not the quantity,” Dr. Insel said. “We need more access, better measures and better quality of care.”

But in this country, many of those who commit suicide have received little or no professional help. Indeed, they rarely tell anyone beforehand of their plan — when there is one. Often the act is impulsive.

Since we do not live in Denmark and do not know how that therapy is practiced there, comparisons are difficult to make. 

When it comes to America, we must notice, as I have often said, that far too much American therapy is of the touchy feely variety. Patients are induced to get in touch with their feelings and to feel their feelings. Beyond the fact that this approach doubles down on the social disconnection these patients feel, there is very little chance that the average middle-aged male, belonging to a high risk population, is going to consult with a therapist who is going to mother him or is going to tell him to get in touch with his feminine side.

One can question how effective this approach is for women. Most likely, not very. The more therapy becomes a woman’s profession, the more people seem disinclined to consult. Or disinclined to take it seriously. If therapy is just offering professional mothering, why would anyone undergo the process? If therapists can do nothing more than to send you scurrying into your soul to dredge up repressed feelings, why bother? If therapists’ go-to solution is to drown every problem in empathy… what’s the point?

For people who are suicidal, the prospect of receiving empathy from a female therapist is not going to be too appealing. It's going to feel offensive. Especially for men, but likely also for women.

To be clear, I am talking about the public perception of therapy, not necessarily what your neighborhood therapist is doing. Surely, cognitive therapists are far more effective in treating depressed suicidal patients… but how much of it is really available. And how many people know the difference between touchy feely and cognitive therapies?


Ares Olympus said...

Stuart: For people who are suicidal, the prospect of receiving empathy from a female therapist is not going to be too appealing. It's going to feel offensive. Especially for men, but likely also for women.

I really can't say I know whether this is true or false. Empathy can just means a willingness to listen to someone who is in pain, and who may have been told to "suck it up" for years, and that approach has stopped working. So there's a lack of agency, or believe anything can change for the better.

I avoid affective empathy myself, giving or receiving, which basically means preferring to keep things impersonal and abstract. But that means my skills are untested when someone really needs something more personal from me. I'd not recommend suicide, but I'm open to imagining it, and exploring what problems can be solved by it, and then considering if the same problems can be solved in another way. It might be worth trying all your options, like saying "no" usually is better than killing yourself.

Steve H said...

I wish "trying all your options" were an option than more often came to mind in these cases. My experience has been more along the lines of "How can I make this incredible pain and frustration stop".
I cannot speak for everyone experiencing depression, but my case is (I believe) somewhat typical. The few people I know who are aware of my condition (I hide it fairly well) have a difficult time understanding that it is not "being seriously bummed out," nor is it something I can overcome by discussing it with them. Knowing there are others in similar straits helps a great deal, even though I feel badly for them as they do for me. I also helps when I occasionally communicate with them - yes, talking with people experiencing depression actually helps!
It also helps to consider the damage my death would cause those whom I love.
A sentiment I often hear (and occasionally feel) goes something like this: I haven't killed myself today, and that is victory enough.

JustOneMinute said...

There is a second possible problem with the Denmark example. In addition to not knowing the therapeutic approaches we don't know (from the description excerpted here) whether the patients receiving therapy were self-selected or randomly assigned.
If self-selected, confounding problems are obvious. E.g., someone who truly believes their situation to be hopeless (or pointless) may be less likely to seek counseling and more likely to commit suicide.

Jeff H said...

Worked inpatient psychiatry for 11 years, outpatient 4 years (not as a psychiatrist, but as nursing assistant, other administrative positions). Psychiatry has become almost exclusively medication management. After a diagnosis is obtained, medication is prescribed, and follow up consists almost entirely of making adjustments--if determined to be required--in dosage. There is no psychotherapy going on.

Tom Billings said...

I have been involved with psychiatry most of my life, ..either trying to access it, or trying to deal with what it refuses to do, or trying to deal with what it persists in doing. Note that it persists in doing whatever it gets paid for, and is paid mostly by the State for doing things that keep people from bothering politicians. It should be no surprise, psychiatry has been politicized for as long as this has been happening.

An older brother of mine committed suicide, when he finally found there was no one in the State Hospital in Salem that he could dominate. He had spent the first 20 years of his life either trying to dominate me, or kill me, while the family insisted "That sort of thing doesn't happen in our family." As a result, psychiatric care simply was not available to me, or to him, until he tried to kill my younger brother as well, leaving a scar from hip to collar bone. Since the family was still in denial about his earlier attacks, he was committed voluntarily, the psychiatrists probed no further, and he was in and out of hospitals for the next 6 years, till he did kill someone, who ran his Portland, Oregon half-way house.

Even then, after they finally read what I had told them about his attacks on me from the age of 7, he was allowed a one-day pass from Salem State Hospital. I went with Mother to take him to the Coast, to climb the Astoria Column, and when Mother was on the other side, he tried to throw me off the top of said column. When he seemed calm on the way home, I let Mother drive him from Portland to Salem, and after begging her to take him anywhere else than back there, he jumped from the car at 70 mph. He survived, and never was given a day-pass again. 7 years later, having run out of people to dominate, he hung himself when he succeeded in slipping between the boards and found he was on his ward without supervision.

This behavior has more to do with how caregivers get paid than anything else. They don't get paid for making waves, (listening to "fables" from a younger brother to "tear a child away from his family"), but for calming them, and mostly they get paid by the State.

Once US Psychiatry acknowledged that Asperger Syndrome exists in 1994, I was diagnosed by 2002. People isolated by ASDs are obvious targets for sociopaths like my brother. Once this, and the above history, was acknowledged, my Medicaid program *insisted* I needed psychological counseling, if I was to receive Medicaid, which continued for another 14 years. They could not afford to admit they were doing me no good, because "policy" demanded that they do it.

This, and the underlying academic politics driving psychiatry's denial of the hereditary nature of ASDs, when it did not deny their existence altogether, is what has driven psychiatric care-giving to failure. It is demanded by their paymasters that they cure what they cannot, and ignore the diversions from industrial culture that they *can* do something about. To do otherwise in state-driven care leads to their own poverty.