On excuses, reasons, and choice

I met someone some time ago who had some personality features I didn’t quite like. We were close for a time and so I told her that some of the things she did bothered and sometimes even hurt me. She told me that it was all because that’s just how she was, that that’s how she had turned out after been raped as a teenager by her father. Of course, that is a terrible thing to happen to anyone and I know it takes a lot of courage to tell your own story. And, of course, I also realise that childhood sexual abuse really does mess you up in so many ways! The strangeness of this particular situation was that this friend said to me fairly often “that’s just how I am” and reminded me about her father. I knew; I wasn’t going to forget what she had told me – it was something deeply serious! However, after so many times that she told me that that’s how she is and it’s due to the childhood sexual abuse she had suffered, I remembered that she wasn’t the only person this had happened to. Don’t get me wrong, it’s a very sad and disturbing thing and every single person this happens to will experience it differently and will be affected differently by it in the long-term. However, I felt that with me she was using it as an excuse for her behaviour so as to avoid apology, or – God forbid – change.

I have known a very many people who have been sexually abused as children and not everyone was as mean as this ‘friend’ was to me; they weren’t obligated to be mean by reason of their terrible experiences. When I remembered this, and at the last straw with this friend, I walked away from it all. Yes, I know that people with histories of abuse in childhood are more likely to have a personality disorder in adulthood than those who never had those experiences. And yet I also believe in the human potential for change. I know that you can take away every choice from a child when he is abused. I also know that at some point a child becomes and adult and all adults have the choice to continue to be victims to the past or to progress from there. It’s a choice. My friend wasn’t without awareness of how her personality and the things she said and did hurt others (myself included), and she was a very smart woman academically and creatively. When I told her that something she did or said hurt me, she didn’t say “I’m sorry. I will try not to do it again”. No, she would say, “that’s just how I am. You know with what my dad did to me”. Yes, I knew that. I also knew he wasn’t currently doing that her; she was no longer a victim, she was just choosing to continue to wear the victim cloak as an excuse not to alter her adult behaviour. Finally, it hurt me too much to continue to be her friend when she found it easier to say “this is how I am” than to alter her behaviour to prevent hurting those that were simply trying to be a good friend to her.

On making "the unhappy" happy - Part 2/2

Of the war veterans I meet with post-traumatic stress disorder (PTSD) and depression, do you know what they value most in their lives? Not finding a “cure” for PTSD and depression, but just appreciating and being able to be with the people in their lives. They accept very courageously – not cowardly – the goals of treatment of these disorders: minimizing symptoms, moving forward from the last exacerbation, and decreasing the number of further exacerbations. They don’t seek a cure, though of course if it were feasible, they’d pay any price to have it. But why fight futile battles? So, I say again that they very courageously choose to expend their energies on the things that matter instead: love, productivity, enjoyment. But before you assume that I am making a claim such as “there is no cure for depression”, let me clarify that that is not the broad statement that I am making.

I used to think, naively, that once I fell in love, once someone loved me and I had someone to share my life with, I’d be happy. I wondered why the people I met who had the things that I thought would bring me happiness weren’t happy. How could they be depressed when they had a partner, children, a job they didn’t hate, generally good physical health, etc.? Why hadn’t the love they had in their loves not cured their depression? Because lack of love didn’t bring about the depression, nothing that was correctable did. Yes, they had love; but completely unrelatedly they also had a mental disorder. Finally I realized why people give flowers to sick relatives in hospital: the flower isn’t meant to “cure” the illness, just make it more tolerable by giving you that warm feeling inside that you’re not alone and reminding you that people care about you.

In persons who have become depressed or suffering PTSD as a result of some psychological social trauma, there is nothing in this world that can erase the memories and/or the cognitive processes that get programmed into your brain. Remarkably, though, a human being can go about their lives being perfectly functional and socially involved despite these demons we carry around in our head. When you have a chronic depression or PTSD of this kind, the best you can wish for is not being “cured”, but having people around you who understand you and stick with you on the journey. Not even “love” can erase the inner hell we experience with these mental disorders, but love can motivate the people around us to give us the all vital support and understanding. Conversely, if you find yourself in a relationship with a person who has depression or PTSD or a similar complaint, you will only hurt yourself by believing that your role is to bring about “cure”; it’s not. Your role is no different to that of anyone else who ever loved: to love, to give (including understanding), to receive, and to share life together.

On making "the unhappy" happy - Part 1/2

One thing that took me a while to understand when I was younger is that “love”, or having a romantic relationship, doesn’t cure everything. In fairy tales, people fall in love and love rids you of physical “ugliness”, of having an evil heart, of disease and death, of financial poverty, of social oppression, of emotional and physical abuse, of low self-esteem, of disability, and of every negative thing that can happen to a human being. And don’t get me wrong, I like those stories as much as anyone else, and I'm also aware they are often metaphors for what love can actually achieve. Essentially love, being in love, being loved, loving, discovering love, etc. has the effect of giving human beings courage to believe in their own strength and to take risks. The greatest motivator for positive change and the strength to bring about that change is love. Love can conquer all…

The second most difficult thing for a human being to do is to bring about change in this world. The single most difficult thing in this life for us to do is to bring about change in ourselves. Love is supposed to make all things possible, right? That’s what the fairy tales tell us. That is what we have learnt personally from life. I still believe this is true. But there is one scenario unique to human beings I find particularly interesting when considering all that love can do.

Depression and post-traumatic stress disorder (PTSD) result in unique states of mind where the “enemy” and the “villain” that we fight everyday lives exclusively within our hearts and minds. He may have been created by exposure to psychologically trauma or neurobiochemical imbalances or social oppression and abuse, or any of a myriad of negative human experiences. Yet the outcome of these situations are so common that someone has been able to make lists of the cognitive effects that result. They are described commonly in books and medical and scientific literature and classified into categories that receive the names of “mood disorders”. Depression, anxiety, and PTSD are very common diagnoses given to the people who suffer the effects of having these internal enemies to fight; the low mood, the lack of self-esteem, the sense of worthlessness, the compulsion to self-harm, the feelings of inability to better one’s own situation, and the inability to envision a future different to the inner world they seem trapped in.

I have seen many patients with PTSD, mainly war veterans, but all survivors of some sort of abuse or extremes of human experience. These people have lived through horrible things – and survived! If anybody can be called strong and honorable, it is them. Yet, they often are the first to believe they don’t deserve to be alive or to have good things in life. Bullets kill many soldiers in combat; depression and PTSD kills way too many survivors. People don’t choose to suffer depression, anxiety, or PTSD, the same way none of us choose to voluntarily suffer. And the worst part is that with these psychiatric complaints, you also can’t choose to “just snap out of it”. The goals of treatment in these disorders are not aimed at cure, but at managing symptoms, learning new ways to process information to help stop triggering these inner beasts, and minimizing the number of exacerbations. Of course, there are many ways we go about doing this (medication, psychotherapy, self-directed education, meditation, etc.), but generally there’s no way to completely cure these problems.

But wait, what about love? Doesn’t love “conquer ALL? Doesn’t love give you strength, courage, motivation, hope, etc. to achieve anything in life – even to change the world? The thing with depression, PTSD, and other psychiatric complaints is that the thing to conquer lies within. But love should be able to help you achieve even that, right? Isn’t love also able to change a human being? I used to believe just that.

On logical suicide

I was at an internal medicine grand rounds talk one day when a colleague started speaking about “logical suicide”; as in suicide that does not seem like the irrational choice we all have come to believe it is. Experience, philosophy, or science, have taught us that a human being’s overriding desire in life is to live. If we deviate from this, if a person wants not to live, then that human being must be ill or evil. But are there ever situations when suicide can actually be thought of as logical? It takes a little bit of tearing down of our usual norms to even contemplate this, but I was curious to explore this further.

A life worth living

In medical ethics circles you’ll often hear the terms “a life worth living” and “quality of life” banded around. What is a life worth living? Most of our lives. We have our basic physiological needs met; we have freedom to think, decide, and act accordingly; and we have (most of us, I mean) the physical capabilities to transform our desires into acts. But, then, just what is a life not worth living? You could say that it is a life that lacks those things we spoke about before, but that’s not true. You may lack any, a few, a lot, most, or all of your physical abilities and yet still consider your life worth living. The important thing is that decision on the ‘worthiness’ of your life is made by you, the owner of that life and body.

A life not worth living

The medical profession and some societal groups, though, have decided on certain broad aspects of a human being’s existence which, if lacking, deem that person’s life a “life not worth living”.  Things like if a person’s brain lacks measurable electrophysiological activity, or if the person requires constant support in their nutrition, hydration, breathing, etc. Of course, the problem with a third party deciding which life is worthy and which not worthy of living is a very fearful one. The Nazis, for example, conceived a concept of “a lifeunworthy of life”. Initially, they considered it a socially useful tact to destroy peoples who were brain dead, brain impaired, mentally retarded, or psychiatrically ill to the extent that they could not survive without the assistance of others. It was considered that these people weren’t worthy of life and in fact were unaware of what life meant, therefore, eliminating them from society (by purposely killing them) was totally acceptable. We are now all very aware that the Nazis’ category of “life unworthy of life” eventually extended to some very broad groups of people and resulted in mass killings without a logical rationale. I, am, however, now digressing…

Suicide

Why do people suicide? That is a question psychologists, scientists, doctors, religious people, and a lot of us ask every day! What do people who suicide tell us (in their last writings or after a “near miss”)? That they did it to end to the pain, that they could see no other options in their life, that they no longer wanted the mundanity of life, that they had failed beyond what they considered remediable, that they had succeeded enough that anything further would be a downhill decline which they didn’t want to face, that they had nothing left to live for, that they had more to gain in death and the afterlife, that they didn’t want to be a burden on others around them that supported them in their existence, etc., etc. People’s reasons for dying are as complex as those we live for. And yet, for most of us, living just seems like the right thing to do. Most of us don’t even question it. And when we become ill or our life is threatened in any other way, our instinct is to try to preserve it. Then what is wrong with people who want to die? People will often quote you that up to 95% of people who commit suicide have a mental illness, for example, depression. But I’ve always wondered about the other 5%. OK, OK, 4% didn’t have a diagnosed mental illness but were intoxicated with drugs or alcohol, acted impulsively after a sudden change in life circumstance, or suicided “accidentally”. But what about the remaining 1%?

Logical Suicide

I’ll start by acknowledging that I’m playing devil’s advocate here just to explore this question further. My colleague who spoke of logical suicide was in fact speaking of one of our patients. It’s not that he disliked this patient and wanted him to die, he was just saying that if this patient decided to suicide, it wouldn’t be considered a totally irrational thing to do. Of course, there were a gasps of disbelief in the room and a few chuckles thinking he was purposely trying to bring up a taboo for a few laughs. How could he speak such preposterous ideas? Because he knew the patient was very aware of his own conditions. The patient did not suffer an intellectual impairment and he knew what he had been through with his condition and that it was only going to get much worse for him. He was in constant pain and discomfort. He was still physically able to act so as to procure his own death and he was not depressed or suffering any other mental illness. Would he want to face further suffering and physical deterioration? If he didn’t, would his opinion be irrational? If he suicided, could you consider his decision illogical? What happened in that room with our colleague having raised this, is that the conversation quickly changed topic. It is still taboo to speak of these things, apparently.

Now, consider a person who, like most of us, has set an agenda for his life, something he would like to achieve and this is what motivates him day to day to keep living. For some of us this is doing a particular job, helping others, marrying the person you love, competing in a sporting race, raising your children, making music, self-expression, visiting a particular place on earth, caring for your parents, etc. These are things worth living for, for you, at least. Now, let’s consider, for example, a person whose sole motivating thing in life is to get married and have children. He wants that more than anything else in life, and that would make his life happy and complete. He is not unhappy without it, however, but he is just existing with the purpose of achieving his dream. What if he was born with a physical impairment that meant he was completely dependent on someone else to care for him and as a result wasn’t able to meet any women to have potentially fall in love with him, marry him, or have his children? He reaches 20 and hasn’t met anyone yet, online or in person. He reaches 30 and he is still in the same predicament. He reaches 40 and his parents, who are his only source of real meaningful love (but not of romantic love, which he desires), are becoming elderly and still his predicament hasn’t changed or improved. He isn’t any more likely now to a) become free of his illness, b) prevent his own physical deterioration, c) find a new overwhelming desire/purpose for his life, or d) fulfil his own self-designated mission in life. What is he living for? How does he answer that question to himself if he isn’t a religious man? Is he living to wait for his death one day?... Well, if this man suicides thinking he has nothing of value to him to live for, could you honestly say his suicide was not logical?

Living

When someone speaks of suicide, of contemplating it, we often see ourselves come up in defence of “life”. We tell the person that they should seek treatment for a mental illness, or we “remind” them how wonderful life is, or we tell them how missed they will be and how many people love and care for them, or we say that perhaps soon medical science will come up with a solution to what discourages them from life, or we tell them to think of how much they will hurt others if they go through with what they’re contemplating… We’re actually pretty good advocates for life! However, perhaps what we should be doing instead of telling others how to feel or what to think, is ask some questions of how they’ve reached their conclusions. The person most likely to convince you of something, even living, is yourself. And hearing back your own arguments for life vs. death is perhaps the only way to have a person change their minds on suicide.

Until recently we still spoke a lot on suicide prevention, but that lead to a lot of people (family, friends, religious ministers, health professionals, etc.) feeling guilty. They were feeling guilty because suicide was being discussed as purely “preventable”, which mainly implied that it could and should be prevented, and if a person succeeded in suiciding then it meant that someone (or everyone) had failed this person. The emphasis is now shifting to raising ‘suicide awareness’, to be able to recognise those at risk of suicide. Most of these people can be helped. The others we may not be able to prevent from suiciding, but we can equally help while they’re living. You don’t need to be anyone special or especially-trained to do this, all you have to do is be a human being and engage the attention of another human being. Who knows, they may just help you too.

On telling

I remember as a medical student being told by a psychiatrist who was teaching us about clinical communication skills to always ask yourself “is this for the patient or for me?” A little bit of self-disclosure in clinical scenarios is helpful; it helps establish rapport, trust, and confidence that the person we have entrusted with our psychological care knows exactly what it’s like to be human. That’s the purpose of self-disclosure in medicine, that’s how we can justify telling patients our sins, our glories, and just our everyday occurrences. Besides that, all we are being paid to do is provide a clinical service of diagnosis and treatment. Needless to say, it’s not appropriate to start telling our patients intimate details about our personal lives and thus introduce potentially biasing information that will impact on the patient themselves or their views on us as their clinician or the clinical advise/treatment we provide. But this rule about what we tell and don’t tell got me to thinking to how it applies to life in general, not just as it applies to health professionals.

Two key features of a successful and happy relationship are honesty and trust. You want to be able to trust that your spouse/partner/friend/business associate/etc. is an honest person that does not lie or betray you, right? But at the same time you need to be able to trust that they won’t, otherwise the relationship will be ruined by the constant questioning of their (or your) honesty. Consider, for example, an ideal romantic partnership where the two people involved love and care for each other and have romantic interactions exclusively with each other (including sex, but also other forms of physical or psychological intimacy). That would be a good relationship, right? But what if a similar scenario arose where the two people involved in a romantic partnership love and care for each other and have romantic interactions exclusively with each other BUT the partners were repeatedly asking of the other: “have you slept with anyone else today?”, “have you told any lies to me today?”, “do you love me still today?”, etc. etc. Now, the other partner could repeatedly be honest and say “No”, but isn’t it likely that this good and honest relationship will be destroyed by the lack of trust?

Now consider a scenario where you have the trust but not so much the honesty. You could, for example, have two people who love and care for each other but their romantic interactions are not exclusive to each other. They may every once in a while have sex with other people. They don’t, however, ask of each questions of fidelity, it is only assumed – they assume the other person is honest or sexually monogamous or that they have romantic feelings only for them. You could say that these are either happy human beings or you could say that this is not a good relationship, even if the two parties seem outwardly happy with themselves and each other. You may say that even if everyone it is happy then that happiness is invalid because it is predicated on dishonesty – or better said: lack of honesty.

This ‘happy couple’ to me poses a very interesting human dynamic, because as happy as the members of this couple are and as happy as the whole scenario is, it often fails. And it doesn’t fail because of dishonesty or mistrust. No, it fails, because of misplaced and selfish honesty. Again, let me repeat the scenario. There are two people who love and care for each other and are not unhappy in their relationship, but one (or both) of them engages in an act of intimacy (however you wish to define it) with another person (or persons). They’re not unhappy with each other, their relationship works and is otherwise normal. The relationship can function this way for months, years, decades, or until death parts them. What’s wrong with that? What’s wrong with having a happy life and a happy relationship, right? Well, probably nothing, except that it rarely happens. And I’ll tell you why.

After one of the members of a partnership has committed an indiscretion to whatever gravity, something happens but not to the partner who may be blissfully unaware or to the relationship which still has as much potential as it did before, but something happens to the offending partner. You know what it is? Guilt. Guilt creeps in, escalates by the minute, and this thing we call a conscience tell us that we should tell our partner what we did. It goes over and over in your mind, you convince yourself you are a bad person, you are convinced what you did was wrong, but overwhelming the feeling is guilt. Tony Robbins once said that guilt is really a trigger to correct your behavior, it means you have a standard which you haven’t met and as a result of this failure you feel guilt. That’s the point of it, to correct behavior back to what your standard is.

The truth is most of us do sign up to relationships to be an exclusive intimate partnership between only two people; that’s our standard. That’s what we expect to receive and that is what we expect to give in the partnership. So when we fail, when we don’t reach our own standard, we feel guilty. But what a lot of people do is mistake the trigger to change our behavior for one of simply anxiety or an unpleasant sensation. Therefore instead of thinking that what we need to do is change the behavior, we become convinced all we need to is just to relieve the guilt. So maybe we’ve stopped doing what we once did that caused us to feel guilty initially but we continue to experience the guilt because we can’t forgive ourselves. And we’ll keep feeling guilty until the day we decide to do two things: 1) meet our own standards, and 2) forgive ourselves. The second part is actually a lot more difficult than the first one is, so we often – mistakenly – substitute it. You know what we do when we can’t forgive ourselves? We ask others to forgive us.

When you can’t forgive yourself for cheating in a relationship, even if it was a once-off, we often make the mistake of asking our partners to forgive us. And we ask not because we care about them or because we love them and think they deserve to know the truth. No, I don’t believe that at all (although that is what we tell ourselves and our partner)! We tell of our indiscretions purely as a selfish way to ease our anxiety and guilt. This is what I mean by selfish honesty. There is nothing honorable about wiping your filthy hands on someone else just because you want to have clean hands again. That is selfish, self-indulgent, and spiteful. Don’t get me wrong, though, there are cases when we must confess to our indiscretions, such as, if we have placed another person’s health at risk or there are legal ramifications to our acts, etc. And here is where we need to ask ourselves: “is this for the other person or for me?” What exactly do you expect to gain?

If we tell our stories purely to ease your guilt, then don’t expect a reward for your honesty. I think that is so banal. Yet that is often what a lot of people do, confess their “sins” to their partner, tell them that they are confessing because they didn’t want to lie to them anymore (even though they had caused the other person no harm at all), and then expect to be forgiven because that is exactly what they need to ease their guilt. That is an even greater violation to the relationship. We shouldn’t use our partners to wipe our conscience. If the anxiety of holding a secret is really tearing us apart, if the guilt of what we’ve done is eating us away, there are more responsible ways to deal with it. As I said, what you really need to do is change your behavior. And if you must tell, tell a friend or pastor or psychotherapist, etc. The only reason we should tell our partners - hurt our partners, their self-esteem, their self-worth, their trust, their sense of identity, their faith in you – is to benefit them, not selfishly ease our conscience. And then we must expect not forgiveness but consequence. 

On the military and PTSD

There’s something I have wanted to discuss for a little while now but didn’t feel quite ‘qualified’ to. In fact the other reason I hesitated was because I was unsure of my future career direction/choices. It is a comment about the military, or more specifically I should say it is about post-traumatic stress disorder in ex-military persons.

What do I know about the military? Actually, having always been a civilian and having no family members with military or political pursuits, you could say I know nothing about it. Even growing up during the course of a civil war of the kind South and Central America was famous for in the 1980s, my own family was always politically neutral and non-participant. But I admit I do have a very privileged position in my job where people often share with me their stories – and don’t we all have our own war stories to tell!

Now, I won’t violate the trust gifted to me by the men / patients who have told me their stories, but I don’t even need to because the themes of their stories are all so similar. At some point in their journey they have come across me for very simple reasons, for something so banal as to re-prescribe them a certain medication. Usually they will tell me that they have been on some medication for years and just need to continue it, they are content with it, and they need it. And the types of medications they are on are pills for insomnia, for anxiety, to help deal with substance dependency, for depression, for psychosis – essentially medications to help them deal with negative thoughts and noxious mental states. I have previously discussed how men in particular are rarely keen to take psychotropic medications because of some concept of misplaced pride, and yet here I encounter men who are almost desperate to continue on these medications. Do you know what the difference often is? These are men who have seen hell, it lives in their thoughts and memories – they are the men who have been in military combat. These are not weak or desperate men, on the contrary; these are the men every country calls their “heroes”!

Post-Traumatic Stress Disorder (PTSD) is not a new concept nor is it specifically related to military service. Basically it describes a negative mental state that occurs after a person has suffered any traumatic experience. They will often re-experience the negative emotions experienced at the time of the event; often accompanied with vivid recollections of the event itself also. They will feel fear, panic, pain, hypervigilance, etc., exactly as they once did, and often this will be unaffected by the time that has elapsed since the initial event. The initial event can be any traumatic experience, and it is different for each individual with PTSD. Having said that, there are few things in life quite akin to active military service life. And you know what kind of people go into the military? All kinds.

The men I’ve met who tell me their stories almost invariably say ‘I wish I had known’. They wish that someone had told them about the nightmares every night, the hypervigilance and anxiety that denies them enjoying even simple things like just walking down the street without feeling on edge as they once did fearing they would be shot, etc. They wish that someone had told them that joining the military wouldn’t just be a way to secure employment training, to learn self-discipline, to defend and serve one’s country, to procure excitement, or the other variety of reasons a person may join military service. The disenchantment comes when the brave men taking life-and-death risks consider that they were deceived by a sin of omission. And more than disenchantment is the reality that few tasks in this life are as psychologically-endangering as the tasks encountered in warfare.

Of course, the military is possibly the best institution at training personnel in a variety of tasks, and their personnel learn how to “do their jobs” effortlessly. However, how many other jobs are there where you are personally in charge in deciding whether the person standing in front of your weapon will live or die, or that the chances of you killing someone are about the same as those of getting yourself killed, or seeing other human beings (adults, children, civilian, enemies, comrades) been purposely injured with weapons / things that were specifically designed with the intent to harm others? My job is not that stressful; I’d dare say very few other people’s are too. There's no way of estimating which types of events will be psychologically-traumatic to a person - but you can almost be sure that the kind of tasks encountered in military service are quite unique and should at least come with a forewarning.

And that is what these men wish they had been told; that’s why a lot of them become disenfranchised with the whole institution. A lot of these men feel that they have been treated not as men, not as humans, but as “things”, as these commodities that shoot the guns, as if they were merely an extension of the firearms themselves and not human beings with thoughts and emotions and brains that capture moments and memories for years to come. They wish they had known that. It’s a shame we do this to our “heroes”. It’s a shame we feel the need to go to war at all or that those few in charge of making national decisions send others to “represent” them; but if we must fight, I dare to propose that we are at least kind enough to those on our side.

On pride and prejudice... (not the book)

I have previously discussed aspects of the discrimination against people with mental illness. Specifically, I have spoken about it in the context of romantic relationships, how remaining together “in sickness and in health” means in health and in most other illnesses expect psychiatric ones. And of course, intimate relationships are not the only context this occurs in. Even in the health industry there is a deep-seated contempt of those coming into hospital medical departments with wounds that are related to a psychiatric disturbance. But what I find even more bizarre is how people can discriminate against themselves, often denying themselves a better existence, because of a connotation to mental illness!

In my job I meet a lot of people, people who we as medical professional often create. Almost every health professional can tell you a story about “some junkie”, a person with a substance addiction that they met along the way. But there’s a particular sort of person that we at times encounter and we don’t immediately think of as “a junkie” but we know that they’re addicted to prescription medication. In my experience, it’s usually the benzodiazepines class of drugs, the Valium-type medications. There’s a few main reasons why benzos are particularly good to get yourself hooked on: 1) they work, 2) gives you immediate ‘results’, and 3) doctors have fewer qualms about prescribing it than other dependence-forming drugs.

A scenario I see very often, and which I admit frustrates me to my core every time, is the young man coming in to see me for his repeat valium (diazepam) prescription. I ask why he’s on it. He says anxiety. I ask how long he’s been on it. He says years. I ask why. He says for anxiety; it’s really “good” at “treating” it. I ask how much he takes. He takes it “only” 2-3 times a day. I do the sums – he is taking huge amounts of it! I ask why he never had his “anxiety” treated, why he didn’t get proper treatment, why he never had counselling, why he isn’t on more appropriate medication. He says it’s because he doesn’t get “anxiety” that often or that it is not very severe; he only uses the tablets every 5 or 6 of the 7 days in a week, 2-3 times a day.

Usually at this stage my heart sinks because the next part of the conversation is also very predictable. I ask does he know it is very addictive. Yes, he knows, but he only takes it when he needs it, those 2-3 times a day on those 5-6 days a week. Again I ask why he takes it (yes, I always pray the patient will have an epiphany – and no, they never do). He takes it for anxiety, of course. I tell him that it must be pretty devastating to be feeling anxious to the point of needing external relief 2-3 times a day almost everyday; surely that would be very uncomfortable. Yes, he tells me, it is pretty unfortunate – but luckily the drugs are so good at “treating” it that as soon as he takes one, within minutes he feels better. I offer a friendly suggestion: wouldn’t it be better to be able to function without having to feel so anxious almost all the time, wouldn’t it be great to be free of the anxiety? Yes, he concedes. Good, I am relieved he agrees! I say ‘ok, let’s get rid of the anxiety then’ (usually I’ll have figured out by this stage that this guy has no time or patience for psychotherapy, he prefers a pill, even a bandaid if that would do it). I suggest this tablet, you take it only once a day, it’s safe, not addictive, and it has a longer time of action so you need only take it once and you won’t have those flare ups of anxiety at random times during the day or week. He doesn’t believe that’s possible. I assure him, it is; in fact if he takes it everyday he won’t even need the valium for those random daily attacks of anxiety because he just won’t be having them anymore!

He has a question for me now: is the medication I am talking about also called an antidepressant? I say, well, it is an SSRI medication which are classed as such, but has a mode of action that will relieve him of his symptoms. At this point he says No!.. But, but, why? He tells me the story again about his anxiety not being that bad, he doesn’t get the symptoms that often (only 3 times a day, 6 days a week), he’s not depressed, he doesn’t need an antidepressant tablet, he’s not crazy, why change what is working, etc., etc. I explain in vain that what he is taking currently, the valium, isn’t working because if it was he wouldn’t need it everyday, multiple times a day. He assures me it does work, because he takes it and he feels better… and eventually I realize that no-one has ever made a person addicted to a substance rationalise about their dependency. It’s the very nature of addiction, there are no great epiphanies – at least not about why ‘feeling good’ is bad. And it breaks my heart that this person would rather take a tablet with much less stigma amongst prescription pills, almost with the status that alcohol has compared to illegal substances, than take the one he really needs. And he makes his choice because of the association this other medication has to “bad things”: a mental illness such as depression. Apparently it’s a matter of shame to have ANY association to mental illness.

Let me now tell you of another class of patient. He also doesn’t want to be thought of as mentally ill. Luckily for him, he isn’t! He has this condition, a complex pain syndrome, a condition that is very difficult to treat. I met a man once who had been diagnosed as having fibromyalgia. The poor guy, was such a shame to see him; he was in discomfort and pain all the time. He had seen a lot of GPs, a few specialists, spent hundreds on natural remedies and iridologists, spoke to anyone that might be interested and asked for help. Eventually one medical specialist got him started on a medication he hadn’t tried before. He didn’t get his hopes up because he had tried many many medications with no relief. But, amazingly, this one worked! He was free from pain; it’d been months, maybe years since he felt so ‘normal’. And then one day he picked up his tablets from the pharmacy and started to read the consumer information page in the pack. And then he read in there that this drug was a TCA – and that the A in that means antidepressant! He was furious, disgusted, so angry at the doctor that told him to take it. It didn’t matter that the tablet alleviated his symptoms; what was intolerable about it was its name, its association. He stopped taking it immediately and attended his doctor to express his disgust.

I spoke to him a few months afterwards, his face was all cringed and he seemed in a lot of pain. He told me the story of what had happened and about how disgusted he was that the doctor had offended him by giving him an antidepressant for his fibromyalgia. He imagined that the doctor thought he was “crazy”, that he was only pretending to be in pain, etc. I let him speak and then I asked it the medication had worked, though. Yes, he said it had – but that was not the point. My heart again sank a little and I explained to him (gently, not trying to tell him what to do), that the TCA type of drugs are commonly used for some types of pain, and that they are very effective. I said they are called tricyclic antidepressants because their original purpose was to be used as an antidepressant but this new use for them had been found and it was great for pain of that particular sort. Yep, good story, Vanessa; he believed me because he knew I have a medical degree, but pride isn’t always about having rational or accurate information. Poor guy, I still see him in so much pain.

Now I’m going to deflect a little to tell you about something I initially thought about when I was at university. There was a ‘gay rights’ rally and in response to someone’s judgement that homosexuality is a disease and a social evil etc., someone had made a banner saying “homophobia is a disease”. It was like the perfect comeback. Only I’m a nerd who probably overthinks things and I was at the time studying medical microbiology and infectious diseases, so I immediately thought: cancer is a disease too. The point is no-one chooses to suddenly grow a cancer because they want to endanger their life or a limb or organ, or because they like to suffer. Most of us can at least empathize on seeing a person sick with cancer, ravaged either by disease or chemotherapy. I have never met anyone who would discriminate negatively against someone with cancer, someone with a disease they did not ask for, a disease that is beyond their control. Mental illnesses are a disease also, something no-one asks for or can internally control. Why should we accept that it is OK to discriminate against those suffering an illness? It’s sad that almost any reference to mental illness, whether people, disease processes, and even the medications used to treat it, still attract such great discrimination. Maybe the time for a new human rights movement is arriving.

On mental illness / addiction

Recently I went to a show by comedian Wil Anderson and he spoke of what we commonly call addiction and mental illness. Now, I don’t mean to spoil the show for anyone, but I thought some points he made were very valid (and hilarious).

Last week I wrote about the strain mental illness places on relationships and about having more tolerance for the mentally ill. The point arose about certain people then using their illness as an excuse to any and all misbehaviour. I suggested that the person whose behaviour is really a result of their mental illness and not just personality traits will often lack insight into what it is they are doing or saying, but upon being confronted will often be apologetic of their behaviour and try to change. The person who is simply someone acting wrongly and then not apologizing for their behaviour but rather suggesting it is all part of their illness and you are in fact wrong for judging them negatively – that person is most probably just a person will a bad attitude who happens to also have a mental illness. Of course, it’s not always that simple and the lines are often very blurry between what is intentional misbehaviour and what is sequelae to the condition. Now, let me raise another scenario (which Wil Anderson raised in the show): what about those people that don’t have a mental illness diagnosis misbehaving?

What I mean is people who are not known to be suffering any mental illness suddenly noted to be doing something wrong and then identifying themselves as mentally ill and thus not responsible for their misbehaviour. As an example suggested by Wil is someone like Tiger Woods who as far as everyone (even his partner) knew was just a normal guy doing extraordinary things on the golf course. Then it became widely known that he was engaging in sex with a lot of women outside of his marriage, and without the knowledge of his spouse. He didn’t deny what was reported, but he did then claim to have a sexual addiction which no-one not even close family and friends had ever known he had. Not having ever met Mr. Woods, I can’t comment on his specific case but the questions that arises are: Isn’t that suspect timing for a diagnosis? And is there such a thing as sexual addiction?

Diagnostically a mental disorder implies that there is interference in a person’s social and or psychological functioning due to the behaviour, for example loss of jobs or relationships, etc. Substance abuse / addiction implies that a ‘substance’, which can be anywhere from alcohol, heroin, or a behaviour such as gambling, continues to be used/repeated despite negative sequelae from it. For example, a person who uses intravenous heroin on the weekends for recreation and the rest of the week holds down a job and has a good relationship with friends and relatives and is not in financial strife isn’t a “heroin addict”, simply a heroin user. If as a result of his heroin use he came to lose his job, money, relationships, housing, etc. and still continued to use heroin despite this, then that person could be said to have an addiction. The interesting thing about celebrities claiming sexual addictions (or other mental illnesses for that matter) to account for their misbehaviour is that they do often lose out financially and psychosocially after their misbehaviour is uncovered. The usual course of the story is that they then enter an addiction rehab centre and they’re “cured”. Suspect? Maybe. Real? You could anecdotally note that celebrities seem to have a much lower relapse rate after rehab than your traditional addict entering a rehab program… or maybe they have better support systems as a result of money and/or fame or family and friends… or some would say maybe they were never sick in the first place. It’s easier to cure a paraplegic who can walk than one with a severed spinal cord.

What about sexual addiction? If it meets the criteria of interfering negatively on a person’s psychosocial functioning and the person continues to engage in it despite these negative effects, then a person can be addicted to almost any substance or behaviour. A person with a sexual addiction, for example, may continue to engage in repeated sexual activity until the extent that it impacts on their ability to hold down a job because they ‘need’/want sexual stimulation at regular times, they may struggle to keep stable romantic or even family/friend types of relationships because of promiscuity and perhaps even indiscrimination as to sexual partners or context; it may cause legal problems, and it may cause physical health complaints such as sexually-transmitted infections. The short answer is yes, there is such a thing as sexual addiction. Is everyone who cheats on their partner a ‘sex addict’, though? No, of course not. If he/she manages the rest of their life well and just happens to be very adept at concealing sexual encounters with other people from their partner, then they’re probably not ill, just claiming to be so as to deny responsibility for their behaviour. Which raises another concept Wil Anderson spoke about, you can’t be “a little” addicted, or “a little” mentally ill. Psychiatry makes it really easy, actually: you either meet the criteria for a mental disorder or you don’t.

And one last topical mention: Charlie Sheen. When he started shooting off his mouth, behaving differently to the ‘good boy’ Charlie Sheen we all for some reason thought we knew, people started branding him as “bipolar”. Now, Mr. Sheen himself denied ever being diagnosed with bipolar disorder and reported drug and alcohol use which he was not ashamed of. Was he lacking insight into the manic phase of a bipolar disorder? Could be. Or maybe he just wasn’t sick at all and is one of a few celebrities who is honest enough not to use a mental disorder as an excuse for general human misbehaviour.

On love... in the time of mental illness

You know how wedding vows often have that clause in them ‘for better or for worse, in sickness and in health...’? Well, then you meet these couples and they’ve been together 20, 30, 40, 50+ years and they are beyond being husband-wife teams; they are friends, lovers, and often also carers to each other. You see them push through illness, which unfortunately becomes more frequent with increasing age. They remain together despite mobility impairments, despite serious acute illnesses, despite chronic degenerative disease, despite even complete machine-dependent living. They remain together because they love each other, because they’ve become interdependent, and because what or who is essentially the person whose life they’ve chosen to share with remains intact despite the machines, the physical illness, and the sensory or expressive deficits. This is true of most illness - expect mental illness.

Centuries ago someone became intent on separating the “mind” construct from that of human anatomical structure. Humans were believed to have this thing associated to them called the spirit which did not occupy a physical place in the human body, but rather was related to it metaphysically. Eventually, through serendipity (or accidents and disease) it was noted that if the brain were to sustain structural damage, often so did the person’s spirit or mind; what we now call ‘personality’ as well as sensory and motor function changes/deficits could occur. So then it was determined that the essence of what we speak of when we use the word “I” inhabits the brain. Soon, others (again, often through accident or disease) became able to map particular human responses, emotions, and sensations to certain areas of the brain. The current understanding is that there is a predilection of certain brain structures to be associated with the central processing of a particular human function, but that this function can be diffusely localized throughout the brain.

Psychiatric illness used to be subdivided into organic brain disease and other mental disorders. Not all problems related to human cognition were thought to be able to be localized to a defect in a particular brain structure or group of structures. For example, a disease like Alzheimer’s dementia was considered an organic brain disease because it causes biological changes in the brain that can be observed macro- and microscopically at autopsy. On the other hand, disorders like depression were by conventional techniques not able to be pinpointed to any particular place or sets of places in the brain; these were the “other”, i.e. non-organic, mental illnesses. With continuously evolving brain imaging techniques, there have been increasingly new biochemical or anatomical related structures or pathways identified that have been found to be associated specifically with the majority of mental disorders. Now the different diseases affecting human cognition are subdivided preferably into classes of acquired or intrinsic aetiology, affecting motor function, affecting sensory function, and related to intellect or cognition, etc. In essence, there is no longer a question of whether any mental illness is related to physical brain substance or not; a physically-related change is implied.

Okay, again back to the “for better or for worse...”. So a person falls in love and he/she makes a commitment to someone else to be a partner to their person. Simple. Right, but what is a person, who is the “person” you marry? If your partner is well and healthy then that person is their physical body and their intellect and everything they express and sense. If that person, say, had a leg amputation, he’s still your partner. If he had a bilateral leg amputation, he’d still be your partner. He could lose gall bladder, arms, a segment of bowel or liver, thyroid, spleen, kidney, bladder, or lung and he’d still be the person you married. You would know this as soon as he communicated with you and you recognised their expressed thoughts as their own.

Now, consider a person who enters a comatose consciousness state suddenly due to either accident or disease. Their partner will have a memory of what this person was like physically, without any medical attachments, and, more importantly, of their “personality”. You can’t suddenly stop loving a person, or even just stop recalling suddenly what they were like. Often the partner will visit the comatose version of their partner for some time until he either succumbs to illness or regains consciousness. Why do they do this? Is it because they love them? Probably to a degree (like I said, you don’t suddenly stop loving a person), but I would argue it has more to do with the fact that you also have a recent memory of their functional personality. You loved the person physically and cognitively, yes, but you still recognise the living body under the hospital clothes, dressings, tubes, wires, etc. as your spouse because you fall in love really with the intellect, the ‘personhood’, the mind of someone. And you are aware, or at least believe, that under all these physically palpable things lies the “person” you knew.

You could call the above scenario an example of an acquired injury affecting brain function. What of “intrinsic” mental illness, then? Let’s consider as an example depression. Okay, so you meet your partner and you fall in love with their personality, what they say and think, and (at least accept) what they look like. Gradually (these things are often gradual) your partner starts to change. Physically he may remain the same or he may change also, but more markedly his mood and thoughts change. The mental illness affects his ability to concentrate, to attend to things, to enjoy things he previously found pleasurable, etc. You notice these things every time you interact with him. He may become irritable or unable to be roused into anything that requires enthusiasm. His expressive behaviour changes as do his cognitions. Maybe you know something about depression, maybe you don’t but you still love him. You recognize this person is going through a low mood stage in their life because everyone has had these at least transiently. You empathize, maybe even sympathize. You notice he’s changed in the way he interacts with you and it is much less desirable or pleasant to what he used to be. You put up with it for a week, two, a month, a year maybe, and then what? Assuming the person makes no dramatic improvement in their mental illness, such as what some medications can bring about, you with time forget that memory you had of the person you fell in love with. Maybe you can remember what they were like a week ago, maybe a few years ago, but with more and more experience with their “depressed self” you start to evaluate the person as they are and have been. Then guess what happens? You just can’t do it anymore. The love, the relationship, and the person has changed so much you can no longer relate to this person and love them like you once did. You fall out of love and either emotionally or physically move on.

What happened to “in sickness and in health...”? Acquired brain injury is a disease but endogenous depression isn’t? It is hard to love in the context of any ailment because it literally changes EVERYTHING! We used to think disease affected one person, but we’ve gradually come to realize that one person bears the sick body, but the disease affects a whole family unit. Having a romantic relationship (and even kinship) in the context of mental illness presents a particularly challenging scenario. No one can tell you who to love and for how long and in what circumstances, but I hoped with this discussion to raise only one point: mental illness is a disease state also. Judge the mentally ill as you would an amputee or a cancer patient.