A Baffled Look

The straight dope on mental health

Belated Response

Robin Williams killed himself Monday morning. I learned about it from a message from the Washington Post on my phone as I was sitting on my couch watching the PBS Newshour Monday night. I sent two friends a brief email as soon as I learned. One wrote, “Yes he did not get the help he needed and where was his support??? It is very sad, but he is just one of the many who took their lives today. The others won’t make the news.” I think my friend was dismissive and may have viewed Williams’ unfortunate choice with harsh judgment because Robin Williams realized his dreams and had everything to live for, but with someone as famous and gifted as Williams it proves how devastating depression and addiction can be. I know a lot of people don’t understand why a person as accomplished and rich as Robin Williams would kill himself, but suicide isn’t logical. If it were, many of the clients of my local drop-in center would have died a long time ago.
That said, I think there’s merit to what my friend said. Even for famous, talented people serious mental illness wreaks havoc. It’s hell no matter who you are or what you have achieved. Even for artists and writers who don’t kill themselves serious mental illness can cripple. William Styron couldn’t do the thing he most loved for the last twenty-seven years of his life: writing novels. My hope is that Robin Williams’ suicide will teach the public about the signs of the risk for suicide before someone else’s tragic death occurs. My friend Jerry killed himself in anonymity, but for his friends and family it was devastating. It put me in the hospital. It’s not the same as a natural death or an accident. I hope Williams’ death doesn’t become some macabre spectacle instead of raising awareness. Genius and fame matter because of the opportunity to educate the public. Tragedy can be an opportunity.



I had an idea about a year ago that I’d like to have a silver ring workshop for women who have experienced physical or sexual trauma. I wanted the ring to symbolize their path to healing. I asked my jewelry instructor Jim if we could do it. I wanted Jim to teach most of the workshop because I wanted participants to have exposure to a man that all men should strive to be. Jim suggested I should see if I could get beads donated to my local drop-in center and teach beadwork. I got the bead donations from a company I’ve done business with for the past ten years, Fire Mountain Gems and Beads.
Soon after that Jim started volunteering at the drop-in center with me to help with my beading classes. One day Jim asked if we could teach the drop-in center’s clients how to make a silver ring. I told him that I wanted to do that for women who have experienced trauma instead. I told him I could recruit women from a support group for women who have suffered from interpersonal violence. Jim is a Vietnam veteran and occasionally we discuss Post Traumatic Stress Disorder before class. I simply told Jim I wanted to help women like me and said nothing about the organization where I go for support and participants. The organization told me that they could not be associated with the workshop because of confidentiality, but that after the support group I could recruit participants as long as I didn’t disclose where I’m recruiting from in order to protect the confidentiality of the women who wanted to participate.
The studio where Jim teaches is quite small so only four women at most could participate. Jim went to the Director of Education of the organization where Jim teaches metalsmithing classes for the general public. The director approved it. Four women were interested, but only two could attend because the other two women had to work. I made it clear that the workshop was free of charge.
The class was a great success. Jim was as excited to teach these women as I was and he was funny, kind and patient. He taught the two women how to make two stackable rings. I let Jim teach most of the class. He has over forty years of experience making jewelry and I wanted the women to see that kind, compassionate men exist. I attended mostly to make the women feel safe.
The steps of metalsmithing are simple; cut, weld and polish. After welding the rings, we discovered that the rings were a little too small. The way to make a ring bigger is to put it on a piece of graduated steal and pound on it with a rawhide mallet. The women told me that they loved hammering the rings to size because they could take out their aggression. After hammering their rings to the appropriate size, they polished their rings. They were very pleased with what they made. Jim told them that every second Friday of the month the organization Jim works for holds open studios from 6 pm to 9 pm. They both wanted to attend.
I’ve dreamed of holding a metalsmithing workshop for women who have suffered trauma for a long time and this is a dream come true for me. I hope Jim and I can offer this opportunity again. It was wonderful.

They’re not out to get you

The animation video is an actual rant by the conspiracy theorist Alex Jones. I laughed so hard the first time I saw it that I shed tears. Contrary to popular belief that people who believe conspiracy theories are mentally ill, most of them are not.
There are differing definitions of what a conspiracy theory is among researchers, but I found a lot of similarities in these definitions. I found a comprehensive definition that captures all the similarities in a special issue about conspiracy theories in “Psychology Postgraduate Affairs Group Quarterly” by Robert Brotherton in his paper, “Towards a Definition of “’Conspiracy Theory’.”

“I define conspiracy theory as an unverified claim of conspiracy which is not the most plausible account of an event or situation, and with sensational subject matter or implications. In addition, the claim will typically postulate unusually sinister and competent conspirators. Finally, the claim is based on weak kinds of evidence, and is epistemically self-insulating against disconfirmation.”

The only thing that links the academic articles is the notion that conspiracy theories are more comforting than viewing the world as random and that no one is in charge. That’s not to say that conspiracies don’t exist. They do. Consider Watergate. Usually real conspiracies are short lived and are more mundane and petty then big events like 9/11 or John F. Kennedy’s assassination. Humans are pattern seeking and sometimes see relationships where there are none. Cognitive dissonance – the discomfort you feel when you come across information that invalidates deeply held beliefs – is in play as well. Everyone experiences cognitive dissonance from time to time and we usually think of explanations that conform to our beliefs because cognitive dissonance is such an unpleasant experience.
People who believe in conspiracies usually are people who feel powerlessness, marginalized, cynical, have an external locus of control -a perception that outside events control behavior such as the notion of fate- and have little trust in others – even towards their friends and families. The biggest predictor for believing a conspiracy theory is believing in other conspiracy theories. In addition, people who believe in conspiracy theories often believe in theories that contradict each other. Basically, conspiracy theorists have an overarching view of the world that’s a bit paranoid – a consistent lack of belief in the “official story” and that people are out to get them, but not enough to make them mentally ill. They often cast themselves as skeptics, but are, in fact, gullible. They’d like to believe in an orderly world – no matter how sinister – than one ruled by chance.
Another factor that makes belief in conspiracies is a psychological phenomenon called confirmation bias. You form an opinion and look for facts that support it and dismiss those that don’t. Even scientists – people who make a career out of being skeptics – have trouble with confirmation bias. Human brains evolved to look for patterns even when there are none. The best way to not get sucked in is to ask questions before forming an opinion and be aware of confirmation bias.
That said, like many people I have a hard time understanding people who believe David Icke’s idea that we’re controlled by reptile aliens that reside among us that get orders from other aliens that reside on the moon.
Then there is a movement and slick YouTube video from the left wing futurist Zeitgeist movement that what seems at first like evidence of a conspiracy combined with gross misinformation that I almost got sucked into it because of my own confirmation bias. It had clips of my heroes George Carlin and Carl Sagan. I finally snapped out of it because they portray 9/11 as an inside job. I’m ashamed to admit this. There’s another YouTube video called “Loose Change” produced by Alex Jones that also claims 9/11 was an inside job. I was going to watch it, but I can’t stomach it right now. I’ve provided links to these films, but do you really want to squander two hours of your life on bullshit? Though they are great examples of the definition I provided above.
Learning about conspiracy theories entertains me, but some conspiracy theories are dangerous. The idea that vaccines cause autism has led to children getting sick from illnesses that were once thought to have been eradicated in the US.
I found a great video on YouTube that educates the public on how to think critically: “Baloney Detection Kit.”

That Which Once Was Mine

I just finished a chapter on Hans Prinzhorn in the book “The Discovery of the Art of the Insane.” Prinzhorn got a PhD in art history before he became a psychiatrist and head of the Heidelberg Psychiatric Clinic. He collected asylum art from all over Europe during the beginning of the twenty first century. He was not interested in making diagnostic inferences in asylum art as the asylum art psychiatrists had examined before him. He collected and published asylum art in his book “Bildnerei der Geisteskranken” which means “The Artistry of the Mentally Ill.” Prinzhorn was interested in the psychology of image making in all art. The work in his book was intended to reach Europe’s avant garde impressionist artists of the late 19th and early 20th centuries. His book succeeded. A movement called Art Brut emerged. Formally trained avant garde artists explored what is now termed “outsider art” that involved the works of persons not formally trained. Prinzhorn and artists of the beginning of the 20th century wanted to explore the roots of all creative expression.
At this time in history, the head of Switzerland’s Waldau Asylum, Dr. Walter Morgenthaler, collected the masterful art of Adolf Wolfli. Dr. Morgenthaler explored the aesthetics of Wolfli’s prolific works. Because of Morgenthaler’s book, “A Mental Patient as Artist,” Wolfli became famous.
The primary reason I’m posting about this topic is because of the similarities and talents of Wolfli and a schizophrenic former friend whom I’ll call X.
Like Wolfli, X worked in many mediums: drawing, music, writing and film. Wolfli produced much more than X, but both were incredibly prolific. I remember when I was in my twenties how much fun X and I had collaborating and hanging out. I made prints based on his drawings as well as animations. About 4 years ago he gave me some very short stories. They were full of language quirks such as what psychiatrists describe as clanging (where words characterized by association of words based upon sound rather than concepts) and onomatopoeias, but were also coherent and funny. The clanging actually added appeal to his stories. I photographed X often. One time he put shaving cream over his entire face and scowled in a mirror so the image has both X’s profile and the front of his lathered face. It was hilarious and I still have that picture. I took another picture of him wearing a mask that I gave him. X gave me a book of new drawings about five years ago and the quality of his drawings had diminished quite a bit. They lacked the humor and sensitivity to line that his earlier drawings had. I really wish I could share X’s work with the world, but we’re not friends anymore. He developed a delusion that we were together in a past life and was such a douche about it the last time I saw him that I felt threatened. Sure enough, I contacted his guardian of twenty years (he was considered too ill to be able to manage his trust fund without winding up homeless) and she had dropped him because he physically threatened her.
The parallels between Wolfli and X are eerie. Both were in foster care, both worked in similar mediums: visual art, music and writing. Wolfli’s art was much denser. X’s works were simple and humorous. X was a musical prodigy so he was trained to write and play music, but not trained in the visual arts, creative writing or film. X inherited schizophrenia from his mother. His home life was chaotic and he was neglected to the point that he was removed and put in foster care. Wolfli’s mother also couldn’t take care of him and Wolfli wound up in foster care also. It wasn’t called foster care during Wolfli’s youth but that’s essentially what it was. Both were abused while in foster care.
I treasure those early years. I guess this is mostly about X, but since I can’t show any of his wonderful drawings I’ll show this video of Wolfli’s work instead.

While I collaborated with X, I became interested in the art of other mentally ill people without any formal training. At about that time I encountered Wolfli’s work in an art magazine. I had hoped that by starting an art workshop at my local drop-in center that I would find someone as talented as X. No one comes close. It wasn’t a total loss. I report about what happens at the drop-in center in my other blog, Word Salad World and the amusing things the clients say. It’s good material, just not the kind of material I originally wanted.
My entire friendship with X was dysfunctional from the beginning. For years X kept reassuring me that he would go along with just being friends and then his ulterior motive of wanting to get in bed would surface and there would be some blow up and we wouldn’t speak for months or years at a time. We used to have so much fun collaborating many years ago. That’s why I continued to consider him a friend for so many years, but it was always the same pattern and always a meltdown on his part that would estrange us for long periods of time. Then he’d call and tell me he could cope with being just friends. But after a while he’d turn into a douche. The last time I saw him was the worst. He told me that my face aged into a frown. He said I’d be punished if I didn’t dump my husband and be with him. I’d come back as a cockroach or something like that. He said a lot more but it made no sense because he was incoherent. After that, I was done. I don’t know why I gave him so many chances because it was the same pattern over and over. I think it was because of his creativity. He was a muse. I’d like to write a piece of flash fiction about our last encounter – his ambushing me with his “spiritual advisor” and this man’s wife and their insipid, superstitious, new age bullshit. X was angry that I would only meet w him in public places. He kept leaving messages on my home phone about coming over to his apartment.
I got better and he got worse. He remembers absolutely everything anyone says and sees me as I was while I was drinking and smoking pot and I’m not that person anymore. I quit doing that over 20 years ago. It’s like he’s stuck. He reminds me of things I’d rather not remember.
I guess I have resentment, but I used X too. I wanted to incorporate his art in my work. My grief is about losing a muse and outrage over how he treated me the last time I saw him. I really wish I could show the world his talent like Prinzhorn and Morganthaler did for their artists. The video below is about Art Brut and shows some of the art from Prinzhorn’s collection. I hope you will be as fascinated with the work of these asylum artists as I am.

Don’t Judge a Book by Its Cover

The book by Charles Barber titled “Comfortably Numb: How Psychiatry is Medicating a Nation” isn’t antipsychiatry. Most of it isn’t about psychiatrists. It’s about the pharmaceutical companies targeting people through television ads to ask their general practitioners for antidepressants. The first half of the book explores how pharmaceutical companies target both the public through direct advertising and use data mining to market antidepressants to doctors. The second half of the book suggests how cognitive behavioral therapy can be more appropriate for the mildly depressed or people without mental illnesses that have trouble with a temporary situation in their lives. Barber, who worked for ten years with homeless people with severe mental illnesses, claims the people who need the most help are getting left behind because they are a much smaller market compared to people who have trouble adjusting to a temporary, but difficult life situation. Therapy can work as well or better for the “worried well” and mildly depressed. He states that psychotropic medication is absolutely necessary for serious mental illnesses such as major depression, bipolar disorder or schizophrenia. Barber discloses in this NPR interview that he has obsessive compulsive disorder and takes Prozac. It’s been a while since I’ve read this book, but this interview on altertnet.org sums it up nicely.
I really wish that Barber had named his book something else because it’s much more nuanced than the title suggests. I guess he wanted to grab readers’ attention. That’s unfortunate because an interview of him on YouTube gets lumped with antipsychiatry videos.

The Real Crazies

While I was watching some DVDs about the Holocaust I got an idea about how the Nazis euthanized people with mental illnesses. It made me wonder if physician assisted suicide could lead to people who can’t take care of themselves being euthanized as an official policy like it happened in Nazi Germany. In 2006, the Swiss Supreme Court ruled that mentally ill people can have access to physician assisted suicide. I found a lot on this online from many sides of the issue. The logic goes that since mental illnesses are accepted as biologically based mentally ill people should have the same options available as terminally ill people. If the mentally ill person is deemed in temporary remission from a chronic, debilitating mental disorder then they should be considered rational enough to be assisted in killing themselves. A lot of physicians, especially psychiatrists, see this as anathema. For psychiatrists, suicide is failure. What happened to “First, do no harm.”? Moreover, some people with terminal illnesses are depressed. Some articles were alarmed – including an editorial on MindFreedom International’s website. Many consider all physician assisted suicides a “slippery slope.” Will it lead to patients being encouraged to die so they are no longer a burden to society? In Nazi Germany, mentally and physically disabled people were exterminated for this reason. Many psychiatrists report that one consultation with a person who wants physician assisted suicide is not enough to determine if someone is rational enough to go through with a permanent solution for their suffering. Oregon has a law permitting physician assisted suicide for terminal illnesses, but now that intractable mental illnesses are viewed as biologically based, will the mentally ill have the same “rights” as the terminally ill? According to a Medscape article, “we are entering an era during which psychiatric patients do not need to be protected, but empowered. Our goal should be to maximize the options available to the mentally ill.” From a civil liberties perspective this seems logical, but mental illnesses distort reasoning. Should someone with impaired judgment be “empowered” or should they be helped to overcome their condition? Even MindFreedom International sees access to physician assisted suicide for mentally ill people as having potential to lead to coerced or forced euthanasia of those labeled mentally ill. MindFreedom usually supports civil liberties for persons with a mental illness.
If someone with a mental illness wants to kill himself, he will find a way without the help of a physician. There’s a libertarian type reasoning to some of these articles – a cold appraisal similar to the Nazi’s reasoning that those who can’t work and care for their survival shouldn’t be allowed to be a “burden to society.”
According to a 2002 article in the British Journal of Psychiatry, there are no clinical criteria to guide such an assessment for determining the rationality of the right to physician assisted suicide. It seems crazy that physician assisted suicide be available to the mentally ill – especially if there is no standard for a “rational” decision. Mental illnesses may be biologically based, but it affects your brain, where you need to think rationally enough to make an informed decision.

Poverty of Spirit

People who have a serious mental illness such as schizophrenia or bipolar disorder have a much higher prevalence of substance abuse. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), 25.7% of adults with serious mental illnesses have substance abuse problems. They are 70 percent more likely to abuse substances than the general population according to the National Institute of Health.
According to a video I watched of a presentation by Canadian psychology researcher Dr. Bruce Alexander, addiction is caused by dislocation – a loss in life’s meaning because of loss of cultural identity and support. People who are diagnosed with a serious mental illness often lose their sense of meaning. It’s a traumatic experience. People who experience dislocation try to fill the void with some kind of substitute that becomes a compulsive behavior. Alexander rejects the disease model because it supposedly doesn’t address psychosocial integration. The disease model posits that addiction has a genetic component and that consumption over time alters the brain. Addiction is incurable but can be managed. Treatment can work. This view comes from science. Although my experience with 12 step programs has enabled me to achieve psychosocial integration, I believe the avalanche of studies that support the theory that addiction is a disease. I don’t believe Alexander’s view provides a full picture because pleasurable activities release dopamine, a spike in the neurotransmitter causes a feeling of pleasure. I see how my mental illness dislocated me and how I finally became reintegrated socially through a twelve step fellowship and the treatment I received for my bipolar disorder. A multitude of studies show there’s a strong genetic component to addiction. Addiction is probably caused by both biochemical and psychosocial forces. It’s the same “nature vs. nurture” debate. The dislocation hypothesis of addiction does address part of the problem, but the other piece of the puzzle has a biological basis as well. It’s not either or, but both.
According to a paper by Alexander, the globalization of the free market economy has led to dislocation on a mass scale and has sparked an avalanche of addiction. I’m blogging about this because I think the dislocation theory has some merit, but the bulk Alexander’s claims that the definition of addiction is too narrow and vague and his assertion that that anything can be addictive is even more vague and imprecise. Where is the quantitative analysis of his hypothesis? With so many different kinds of addiction that he claims exist it’s not possible to provide a standard measure. Alexander claims addiction is a “poverty of spirit.” Twelve step programs address this issue. Most people who have recovered from addiction through a twelve step program also subscribe to the disease model of addiction. I think Dr. Alexander’s claim that anything can be addicting trivializes the suffering that occurs with addiction to alcohol and some drugs. I’m blogging about this because I think Alexander’s ideas might interest some people even though some of his assertions are beyond the scope of this blog. The video I mentioned above is worth watching because some of it addresses some of the reasons why some mentally ill people might abuse substances.

Family Matters

I’ve been thinking about what my brother went through after my bipolar disorder emerged when I was 14. He got ignored. He resented me. My behavior embarrassed him. My parents had to spend a lot of money for my treatment. My parents spent more money for my education too. I went to Interlochen Arts Academy, an expensive private institution for talented youth. My brother went to public school. He went to community college and I went to one of the most expensive private college in the country – Rollins College. My parents were blamed by my therapists and psychiatrists for my mental illness. They were made to feel guilty. I think that they tried to mitigate their guilty feelings by spending more on me. This increased my brother’s resentment. I read an article online about how much emotional damage can happen if the well sibling doesn’t have a close connection with at least one parent. My dad was frequently away as my brother and I grew up because he was a navigator in the Air Force. After my dad retired from his military service he went on business trips as a quality control consultant. That left my mother to meet both my brother’s and my needs. She had to spend most of her time managing me and my brother simply didn’t get the support he needed. It wasn’t anyone’s fault. It just happened. I often feel bad about what happened. When my brother was unemployed for 3 years my parents supported him financially. I was worried about him, but I felt gratified that my parents focused more of their resources on him. He was finally getting the support he needed. I found a resource online for the siblings of mentally ill people that features short videos of others’ experiences and that provides a network of support. My brother isn’t a reflective person. Even if I told him about these resources he probably wouldn’t take advantage of them. He’s pretty busy with his new job. There’s a book on this subject called “Mad House: Growing Up in the Shadow of Mentally Ill Siblings” by Clea Simon. I haven’t read it, but it may help someone understand the family dynamics involved with families that are facing serious mental illnesses such as bipolar disorder and schizophrenia.
Even though my brother and I aren’t close, he seems genuinely excited when we do get together. His resentment is gone. I wish I could see him more. I miss him.

Unknown Unknowns

I’ve been thinking about anosognosia, or lack of insight into one’s mental illness. I see a lot of coexisting mental illness and addiction occurring in some of the people I encounter at my local drop-in center. If mentally ill people don’t believe they have an illness then they’re not going to believe that they have an addiction either. Addiction is a mental illness, but many people that have only an addiction experience denial, not lack of insight into their condition. Denial is different. Many addicted people minimize their problems. People who are seriously mentally ill and experience anosognosia don’t minimize their condition. They experience the incapacity to even minimize their problem. They flat out don’t believe it.
There’s an article in the New York Times that addresses “everyday anosognosia” There will always be unknown unknowns for everyone. The article says the more aware we are of this predicament the smarter we are. Anosognosia in mentally ill people is not a matter of how intelligent they are. Researchers hypothesize that it comes about by right frontal lobe damage. It’s similar to stroke victims who have right frontal lobe damage. It has nothing to do with intelligence. Stroke victims with this condition retain much of their native intelligence in spite of their belief that the left side of their body isn’t paralyzed.
Even in the chapter “How It Works” in the Alcoholics Anonymous text it mentions people with “grave mental and emotional disorders” can recover if they have the capacity to be honest. The AA text also mentions that there are those who are incapable of being honest with themselves and that they are not at fault. They were born that way. Mentally ill people who have coexisting addiction who don’t believe that they are mentally ill are going to have the same lack of insight into their addiction. The ones who have both conditions at my local drop-in center are more likely to be homeless. I think many of the people at my AA group know this, but to me they seem callous towards the clients at the drop-in center where I volunteer. Maybe it’s because they know that the people with anosognosia have little chance of becoming sober. I’ve spoken to members of my AA group about this organization. They don’t seem to understand that there are also people at the drop-in center who don’t have substance abuse problems and others that have insight and are trying to address their addiction. My friends at my AA group write all of them off. My bipolar group understands. They donate items and food to the drop-in center. There are people at the drop-in center who will never recover because of their lack of insight, but they need compassion, not the judgment and dismissal I see at my AA home group. I guess this happens because the chapter in the AA text “Working with Others” says not to waste your time with someone who does not want help. The text says to move on to someone who does want to recover.
A psychologist named Dr. Xavier Amador has discovered a way to get some people with anosognosia to take medication. Dr. Amador emphasizes developing a non-judgmental approach in your relationship to a client or loved one. He developed a form of therapy that finds common ground on goals rather than trying to talk someone into believing that they are mentally ill. This article provides advice for family members on how to repair and change the relationship with a mentally ill loved one.
Dr. Amador’s approach is derived from a type of therapy called motivational interviewing. “It is an empathic, supportive counseling style that supports the conditions for change. Practitioners are careful to avoid arguments and confrontation, which tend to increase a person’s defensiveness and resistance.”
Some consider these therapies as coercive. Some of the side effects of psychotropic medications are horrific. That’s a choice and not the case with anosognosia. To people with anosognosia, it’s logical to not take medication. People who have mentally ill relatives seem to think medication will solve their loved ones problems. I know from my experience and from other mentally ill people that in spite of medications improving their condition they don’t make your condition symptom free. It’s always there no matter how much better your functioning improves with medication.
After being misdiagnosed myself I understand why someone would not want treatment. Not all noncompliance has to do with anosognosia. There are many reasons why people refuse to take psychotropic medication. Some can’t accept the stigma that comes with mental illness. They don’t like the side effects. They don’t like big PHaRMA, the pharmaceutical lobby of the drug companies.
Maybe Dr. Amador’s approach and motivational interviewing are coercive, but families of mentally ill people suffer a lot when their relative is ill. They are desperate. The medications, however, aren’t magic pills. Their relative may function at a much higher level, but the symptoms never completely go away. The medications are crude tools. There is so much we don’t know about the brain.

The Times

Here’s a December, 26, 2013 New York Times article about the cost of lack of specialized care for mentally ill people in crisis who get sent to emergency rooms. The rate of mentally ill who need help that get sent to emergency rooms is soaring as community mental health providers budgets are being cut more and more. There just aren’t enough beds available to accommodate them. There’s a pilot program in Raleigh, N.C. that has made more beds available and paramedics are trained to ask the right questions to know when to take mentally ill people to psychiatric facilities.