Perspective Magazine
Number 1, 2004
Inside this issue:
Excessive behavior may target spirituality
by Constantina Boudouvas, LCSW, former Menninger director of Social Work and Social Work Training.
The doubt reflected in the following composite is characteristic of someone who has scrupulosity. "Scrupulosity" is the term professionals use to identify people who suffer obsessive-compulsive disorders (OCD) with a specific preoccupation with moral and religious obsessions.
The word scruple comes from the Latin scrupulus, which means a "small stone." Webster's defines a scruple as being "a dictate of conscience or ethical principle that inhibits action."
"I can't remember if what I am about to write down in the next minute or so is truth. I think I might leave something out, it could be a lie... so why should I write it if doubt is the only certainty I have? I can't recall with exact precision what my last thought was and so I can't be sure I did not miss something and accidentally do something that might offend God. St. Paul said 'we must all pray unceasingly' but I have trouble with remembering from one moment to the next if I've said the right prayer in the right position with the exact accuracy that would warrant the forgiveness that I've requested of my Lord for the 100th time since I woke up this morning. Oh God, another absurd thought; now I need to clarify the intention of the thought I had. I know this is crazy and senseless, but I can't stop it...I pull my hands to my ears and I am frustrated and feel the rising of panic that swells into tears as I sweat out of my eyes and let it drip down my face, and now I need to pray for being a coward and not having enough faith...."
A bit of scrupulosity in the worst of us would make this world a better place. However, people with OCD are thrown into a cycle of doubt and fear of having offended or transgressed, then of praying for forgiveness on the overestimated chance that they may have committed a sin, violated a moral tenet or not lived up to God's way.
What is OCD?
Obsessive-Compulsive Disorder is a neurobiological disorder characterized by intrusive persistent thoughts, images or impulses, which an individual views as intrusive and senseless, according to the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV), the accepted guide to diagnosing psychiatric difficulties. These obsessions are usually coupled with rituals or repetitive acts a person feels compelled to carry out to neutralize anxiety associated with the obsessive thought.
The required rituals worsen and may significantly impair a person's life and health. OCD can "hijack" any aspect of a person's life: relationships, food, religion. Media coverage of characters with OCD usually depict persons who suffer with contamination obsessions and checking rituals such as the television sitcom Monk and the movies Matchstick Men and As Good as It Gets.
Full of doubts
OCD is also commonly referred to as the "doubting disease," which is due in part to the OCD sufferer's engagement in a cycle of rituals for the purpose of securing some closer certainty that nothing bad will happen. This sense of inflated responsibility leads them to engage in compulsions to neutralize the anxiety created by this overresponsibility In the case of the young patient of this article's earlier monologue, the boy's greatest fear was that he might accidentally, even by omission, think a sinful or amoral thought and offend God.
In another example, a man might utter a word that starts with the letter "H" along with his daughter's name in the same sentence. He would then obsess that he has sent his daughter to hell because hell starts with "H." He would feel compelled to engage in a litany of prayers (compulsions) as a way to neutralize the thoughts of responsibility.
Degrees of scrupulosity
Being scrupulous and having OCD are two separate things. A scrupulous person may strive to be principled in all her actions for the purpose of developing and enriching her spiritual and personal life. For the OCD sufferer, anxiety relief supercedes spirituality.
Beliefs of persons with scrupulosity often exceed or disregard religious doctrine or law. For example, the OCD sufferer may lose the spirit of the prayer because of the focus of how it needs to be recited. Another example is the person who will go for multiple confessions or seek out different ministers to eradicate her own doubt about whether or not she has been forgiven for a sin.
For persons with scrupulosity, the very act of entering treatment and working on their religious obsessions is so frightening because it raises a question in their minds whether or not they will become a "depraved" human being. I've had multiple patients ask me whether or not treatment will cause them to become antisocial and immoral, which it doesn't.
Scrupulous thoughts vary
Following are some examples of thoughts that regularly plague persons with scrupulosity:
A five-year-old girl is afraid to say "yes" or "no" to any question her mother asks her because she may accidentally omit an answer. Her responses are inclusive of some uncertainty so that she may be "certain" of not inadvertently lying. She will say things such as "maybe yes, maybe no;""I don't know;" "sometimes," but never anything with certainty. She will end every phrase or story she tells about her school day with "maybe" and ask her mother 50 times in a half-hour ride to school: "Mom, if I lied, would you still love me?"
A man goes into a store to buy something and engages in checking rituals to ensure that the clerk did not give him too much change. He may ask the clerk or his wife to check the receipt in order to make sure he doesn't leave the store in the event of a mistake.
A man changes his child's diaper and has an intrusive thought that he may touch his child's genitals. He gets so anxious that he avoids changing diapers or holding the child for fear of acting on this obsession.
A man sees a billboard bearing the picture of an attractive woman. He feels as if this sexual thought equals cheating on his wife. He goes to multiple confessions and engages in prayer rituals as a way to cleanse himself. He also changes his route to work.
Exposure Response-prevention
Treatment for Obsessive-Compulsive Disorder is counterintuitive in some ways. As opposed to helping ease a patient's concerns/worries/fears, as a cognitive behavior therapist with Menninger's OCD Treatment Program, I actually want to create situations, called "exposures," that will trigger anxiety. We invite into the mind of the OCD sufferer the obsessive thoughts he or she try so steadfastly to resist and then prevent him or her from acting on rituals. This is called exposure-response prevention and has been empirically proven to help persons suffering OCD live with the symptoms of this disorder with considerably fewer disturbances in functioning.
Training the body
It is a biological fact that the human body can "get used to" and put into the "background" the noises or sensory experiences to which the body physiologically responds. This process of "getting used to" or being "bored" with a stimulus is called habituation. Some examples of habituation include the boredom that comes with riding the same roller coaster time after time or driving to and from home to work enough times that the trip is no longer remarkable.
The key element in treatment is for the person to truly make an effort to be ritual free after exposure. Engaging in compulsions is a powerful learning process that reinforces for the OCD sufferer that doing these rituals reduces their anxiety momentarily. However, when plagued with another intrusive thought, their only method of reducing the anxiety is once again engaging in time-consuming rituals. Through exposure and response prevention, the therapist teaches the patient to resist the urge to ritualize so that they may have the opportunity to habituate and see their anxiety decrease over time.
For example, recall the man who changed his driving route to avoid looking at a billboard of an attractive woman. He was attempting to avoid anxiety.
Here's what treatment with him would look like:
He and his therapist would skim through magazines in the office and the patient would make a commitment to resist the urge to pray (a mental compulsion) when he had an intrusive thought about sin. Homework assignments would include having him drive by the billboard and looking at it without then engaging in his rituals.
Is it true? Is it true?
Most OCD sufferers have the distorted belief called thought-action fusion. This belief translates into "if I think it, it must be true." Imagine taking seriously all the thoughts that come to mind during the course of a day? We all have intrusive thoughts. What differentiates a non OCD sufferer from an OCD sufferer is that most people don't get stuck on intrusive thoughts. Over time, engaging in exposure response prevention provides evidence for the OCD sufferer that "thought does not equal action."
A quote by Sam Keen from his book Learning to Fly captures what I so often witness in my office in working with persons with this disorder:
"Albert Camus once said that it is only after we accept the absurdity of the world that we can begin to write a manual of happiness. Paradoxically when we invite our fears into the hearth of our awareness they cease to be an undifferentiated mass of terrifying demons and become tolerable guests. Each day befriend a single fear and the miscellaneous terrors of being human will never join together to form a morass of vague anxiety that rules your life. We learn to fly not by becoming fearless, but by the daily practice of courage."
Constantina Boudouvas, LCSW, is Director of Social Work at Menninger. She is also a behavior therapist in the OCD Treatment Program.
Stalled treatments get a helping hand
Patients with severe mental illness may become mired in their progress despite numerous hospitalizations.
Menninger treaters operate from the premise that despite the severity of any illness or combination of illnesses, there is always hope that the human condition contains a certain resilience that, once tapped and directed, can recharge and energize an individual's life.
Those treaters involved in mental health and the people who support such work abide by the maxim spoken by co-founder Karl Menninger, MD, who said, "There is no such thing as idle hope." And when confronted with a seemingly impossible case, treaters have found solace in the words of Dr. Karl's father, C.F. Menninger, MD, who once proclaimed: "Hope never dies in a real gardener's heart."
Henry's story
Hope served as an essential ingredient for Menninger treaters when Henry, a 40-year-old, severely mentally ill man was admitted to The Menninger Clinic's Hope Program for Adults. His admission came about following a suicide attempt shortly after a family argument. Henry had a thick history of treatments for an assortment of ills, both physical and mental, especially depression, which were often complicated by drug use. The last incident was a long binge on methamphetamines, which resulted in taking medical leave from his job. Drug use was nothing new to Henry who began drinking and dabbling in psychedelic drugs beginning at age 17. Meth eventually became his drug of choice. (Methamphetamines, highly addictive, create euphoric feelings in the user and damage the central nervous system. Use is also characterized by restlessness and anxiety.)
In and out of sobriety, Henry was at the end of his rope. Prior to his suicide attempt, he had had a sporadic work history and was in a stable relationship for some years until his conduct drove his partner away. Though he was able to maintain a minimum level of functioning, he felt little improvement in his life after 20 years of intermittent stays in various treatment settings.
After an initial assessment by his treaters at Menninger, Hope Psychiatrist Stuart Twemlow, MD, a member of Henry's treatment team, said: "His illness had lasted most of his adult life, with only a partial response to treatment. He had a sense within himself that he was going nowhere." A key goal of his eight-week stay at Menninger was to get Henry "unstuck" in his treatment regimen and back on a path to an improved quality of life.
In understanding the Hope program's approach, consider the physical rehabilitation of an individual who is paralyzed in both arms. Although modern medicine cannot undo the paraplegia, it can leave the willing patient with the skills to cope with his condition and to enjoy a quality of life. Psychiatric rehabilitation is infused with the same goals. Despite the severity of mental llness, a patient can understand his condition and realize a degree of functioning. The patient also can become aware of his or her potential for continuing recovery without everpresent clinical support. The object of treatment is to provide what is needed to live in the real world, to have goals and to pursue them with independence.
Observing Henry
Observing a patient as he spends his day on a treatment unit provides the team with enlightenment about how he might conduct his life outside the hospital. A patient's interactions with fellow patients and with nurses, social workers, psychologists and others can offer insights into how his illness manifests itself. Consequently, team members keep patients under a watchful eye and none of these observations go unrecorded. They are used as ballast to support a hypothesis that will be used in formulating a treatment approach. Understanding Henry's thoughts and feelings might reveal the motivations behind his actions. Additionally, though an individual has been in treatment in the past, Menninger team members do not assume a patient has received a comprehensive or correct diagnosis or that the patient was ready for treatment when it was presented in the past.
Upon introduction to Henry, treatment team members met an anxious man. He nervously stretched his neck and restlessly moved his feet. He exhibited breathing irregularities. He had a history of anorexic behaviors, eating and starving to control his weight, as well as a series of surgical "tummy tucks." It was clear Henry used food to soothe his emotional turmoil.
Upon admission he was initially diagnosed with bipolar disorder and borderline personality disorder (BPD). Bipolar disorder causes emotional mood swings from depression to mania. BPD is characterized by significant instability in relationships, emotions and impulse control. It may have a biological component and a component related to developmental life experiences. It is difficult for people who suffer BPD to maintain stable relationships. They exhibit impulsive behavior, experience emptiness, fears of abandonment and an unstable self-image and are prone to angry outbursts. Otherwise, team members observed that Henry was pleasant, engaging and open about his problems.
Some conclusions
After deducing that the medication he was taking upon admission contributed to his anxiety, some psychotropic dosages were adjusted and other medications were exchanged to better control Henry's bipolar downswings.
In addition to medication management, Henry's eight-week stay involved a host of interventions that included individual and group therapy, coping and self-awareness skills training, anger/stress management, self-esteem building, treatments for overcoming perfectionism, depression and anxiety, information about trauma, a 12-step program for addiction, as well as an integrated series of groups that prepared him for preventing relapse after discharge from Menninger and steps for reintegrating himself back into his community.
Therapy groups are an integral part of the Hope Program. Rather than centering on a patient's diagnoses, efforts focus on recognizing and addressing impairing behaviors, thoughts and beliefs that cause daily difficulties in the patient's life.
As he attended these sessions and others, Henry's daily staff interactions were revealing. He was demanding of staff, felt he deserved special treatment, had an overwhelming sense of entitlement and was critical of his treatment team members as not being attentive enough or supportive enough. He attempted to manipulate staff, praising some while speaking critically of others. Angry confrontations with staff led him to withdraw to his room or to tears and to utter further threats of suicide. Henry was self-centered and elitist. He was often contemptuous of others.
Martha McCrory, MT-BC, director of activity and rehabilitation services for The Menninger Clinic, ran many of these group sessions. This was the same therapist Henry had once called "a flunkie" because she did not provide him with answers he demanded. "This is a pretty common attitude among Hope patients," Ms. McGrory said. "Patients with severe mental illness have difficulty with abstract thinking and then they blame treaters."
Two weeks into his Menninger stay, the team drew this conclusion:
Henry's mood fluctuations appeared to be related to his perceptions of how special he was treated according to his own determinations.
His "depression" was primarily a feeling of emptiness and vulnerability; to which he reacted defensively and manipulatively, especially when he assumed he was being criticized.
His sense of entitlement was expressed in his open contempt of and snobbishness toward others, which only resulted in his own rejection and triggered in him anxiety over his sense of abandonment.
It was clear that Henry paid keen attention to some social cues, while ignoring others; that he frequently misinterpreted intentions toward him as hostile; and that he often attempted to solve problems through aggression.
Henry's treatment
Armed with a clear picture of Henry's life on a hospital unit, these observations offered suggestions as to how Henry might interact with others in his life, including employers, friends and especially family. Treatment team members created a master treatment plan that included two organizing principles:
Henry needed to restore his ability to mentalize, which is the innate capacity to assess one's own and others' emotions accurately and to produce creative responses to those feelings. Mental illness represents some problem in the mentalizing capacity of the mind, resulting in misinterpreting itself and others, a consistent behavior that caused Henry great difficulty in his daily interactions. Treatment intends to promote or rehabilitate the capacity to read oneself and others. Research indicates that certain basic human functions appear to result from the exercise of mentalizing despite the debilitating effects of such negative factors as childhood adversity and genetic vulnerabilities. These patient "enhancements" that result from mentalizing include the capacity to find meaning, to engage in two-way relationships with others, to find support in other people, to be an agent of one's behavior, to experience a sense of hope and to have some flexibility.
Henry also needed to become aware of coercive power dynamics and to understand how his fluctuation between being a helpless victim to being a contemptuous victimizer were merely defenses against his sense of being a vulnerable person who feared abandonment.
While treatments were under way, Henry entered into family therapy sessions, a direction suggested by Dr. Twemlow despite the deep divide between Henry and his father, an openly angry man and a stern disciplinarian. The relationship was so split, there was a time when Henry could not speak with his father unless his mother was present as mediator.
The sessions were overseen by Susan Romanelli, LCSW, PhD, the Hope treatment program's former director. The initial sessions were rocky, but they would become a critical element in Henry's recovery and in restoring some emotional stability within his family, where bipolar disorder and addiction were not strangers. His younger sister died of drug related causes; his uncle is a recovering alcoholic.
Discoveries
Henry's demanding nature entered the first family session. An interaction among the participants reflected the combativeness of the relationship between father and son, revealed an overwhelmed and tearful mother and, by the end of the session, produced an exhausted group. In subsequent sessions, events improved.
His parents spoke of guilt over the death of their daughter, one of the reasons they were so concerned about the hospitalization of Henry, who acknowledged that he felt slighted by the amount of attention his parents had given to his younger sister.
Eventually, Henry and his father discussed their differences and why they could not speak to one another without Henry's mother present. Henry revealed his deep fears growing up around his father's anger and how he drew closer to his mother as a result. Finally, the parents' unhappy marriage and its impact on the family were openly discussed. They admitted that they stayed together simply out of obligation to the tradition of marriage. Henry was counseled that despite his views of his parents' marriage, it was their partnership and not his.
Breaking the communications logjam among family members was a true breakthrough. Henry's own growing ability to listen, to empathize, essentially to mentalize, and to use the other skills he was simultaneously learning and through his interactions with staff on the Hope unit, significantly prepared him for a beneficial outcome in family group therapy. As the sessions progressed against the backdrop of Henry's busy daily schedule of therapies, his self-centeredness diminished. His actions spoke volumes. He began helping other patients with their own difficulties; he brought treats to fellow patients and acted in ways deemed thoughtful and unselfish.
"Henry's treatment revolved around rehabilitating his functioning in all areas of his life," said Dr. Romanelli. "An improvement in one aspect of his life would lead to other successes. Thus, the idea was to introduce him to the skills that will help him build on one success at a time."
Following his discharge from Menninger, Henry is involved in weekly psychotherapy and 12-step meetings. He remains drug free and has completed more sessions of family therapy. He resides at home with his parents and they have discussed the possibility of Henry joining his father in business.
Though Henry has not reached his full potential, he is far removed from the individual who first came to Menninger.
He now has the tools with which to continue on the road to restored health. He has the necessary understanding to see how others see him and he has the capacity to regulate his behavior so his responses are more creative than aggressive. He has a renewed and growing relationship with his family and with himself. And for a man who once felt isolated, abandoned and going nowhere, he has a roadmap to wellness and a companion to accompany him. He is no longer alone. He now has hope.
Adolescent addiction complicates illness
Treating addictions means teaching patients to manage their thoughts and cravings.
There is a scene in Bobby's head that may never go away.
He is on his back porch. It is morning. He is armed with a can of beer in one hand and a cigarette in the other. He feels absolutely fearless, scared of nothing. He loves sitting here staring into the backyard. He cherishes this spot. A sip of beer, a drag. A sip of beer, a drag. This is heaven, a place where Bobby feels untouchable, invincible. Now it is night. A sip of beer, a drag. He is woozy, of course. But tomorrow he can do this all over again. Something to look forward to. He has no problems. Life is good. Nothing can touch him. He wants to stay here forever. Tomorrow the timeless porch, the chair, the beer, the cigarettes. Bobby couldn't be happier, an amazing accomplishment considering he is all of 16.
Bobby's story
Bobby did not suddenly wake up one morning depressed, disinterested and drunk. There was an emotional and behavioral descent. By the time he arrived at Menninger's Adolescent Treatment Program, he was a veteran of multiple treatment attempts aimed at helping him with his burgeoning emotional plunge and his growing misbehavior. As a youngster, he had already established himself as someone who lacked self-discipline and consistently acted out. A learning disorder only contributed to his hostility.
At wit's end, Bobby's parents sent their son-then in his early teens-to a wilderness school where the harsh lifestyle of order and discipline was supposed to establish a fresh personality structure and change his deteriorating behavior. This effort was followed by several years of boarding school, military school and private school.
These programs have been helpful to many children. However, through all these moves, Bobby's behavioral and emotional decline continued. The family had relocated several times, which is almost always difficult for a young person who is trying to find himself and establish some inner identity. Depression fueled Bobby's behavioral problems, which in turn deepened his emotional fall. By the time he was a high school sophomore, Bobby's family moved to a permanent residence and he began attending a new school at home. He made some friends and life seemed to be on an upswing. He began to smoke and then came alcohol.
"Everything went downhill from there," Bobby said. He became more depressed. He began to experience extreme anxiety as well. Anxieties cause a state of uneasiness and apprehension and negative expectations. He felt these emotions for several months; he was exhausted. But other feelings also were surfacing.
"I had many thoughts of suicide and many problems with lying and stealing," Bobby recalled. "I was seeing tunnel vision in a world that was dark and cold. I couldn't cope with a lot of those feelings inside. I never cried so much and hated everyone and everything."
His parents felt helpless. Their son's behavior ranged from violent to comatose.
Eventually he dropped out of school altogether and took up his post on his parents' back porch.
A growing addiction
When Bobby drank, his anxieties slipped away and disappeared. But the more he drank, the higher his tolerance to beer, leading to increased consumption. After awhile, even the beer could not drown his anxieties.
"I was having anxiety attacks even though I was drunk. It nearly drove me crazy. The edge stayed there all the time. I couldn't escape it. I couldn't stop drinking. I quit going to school; eventually, I quit everything.
"I never wanted to do anything but drink and smoke on the porch and be in the chair by myself. I enjoyed just sitting there and wasting away night and day."
The family engaged an educational consultant who discussed the future with Bobby. The possibility of attending Menninger was brought up, and Bobby agreed he needed help. Later he would admit that his decision to get help for his depression was a stroke of luck since he was under the influence of alcohol at the time, the conclusion of a six-month binge.
Trading stories
The combination of mental illness and an addiction in a single patient is not uncommon. Dual disorders are seen quite often in the Adolescent Treatment Program, one of several specialty treatment programs at Menninger for adolescents ages 12 to 17. Patients who enter the program ordinarily have received treatment in the past in other settings but continue to experience family, school and social difficulties due to moderate to severe behavior, psychiatric, chemical dependency and coexisting disorders.
Treatment includes groups, skill building, individual and family therapy, medication, symptom management, a focus on cultural and spiritual values, as well as 12-step chemical dependency treatment when needed. The on-site school program allows school-age patients to continue their education during their stay.
The expected stay for adolescents is about three months. In a working relationship that involves the patient, family, the therapist at home and treatment team members, core issues that may not have been addressed or previously identified are diagnosed.
The Menninger staff designs a course of treatment with a focus and length of stay unique to adolescents' needs. The plan allows young people to capitalize on strengths and to work on targeted areas of their life among peers and a caring, experienced staff.
One of the first lessons a patient learns is that he or she is not alone in enduring mental illness such as depression or anxiety, and that others have also indulged in abusing drugs or alcohol and may have been confronted with violence or found themselves committing crimes.
Among the many psychoeducational opportunities presented to them is hearing these personal stories from fellow adolescents, an exposure that has a powerful sway.
Patients hear stories from peers in group therapy or in Alcoholics or Narcotics Anonymous meetings that provide a fresh context with which to compare their own lives. The frequent result is a renewed motivation for them to change themselves. They don't want to go through the horrific experiences they hear from others. Their own bad experiences are sufficient.
"My eyes lit up and I said, `Wow, that's a lot to go through in your life,'" said one young patient after hearing a particularly horrible personal narrative about a peer's experiences. These stories often include activities such as drug-related rape or assault and physical injury that results from serious eating disorders or from engaging in risky behavior such as sexual promiscuity.
"It amazes me," the young patient continued, "that that might have happened to me, but it didn't. I appreciate that. That's one of the things that helped me."
Pleasures and pain
Young patients learn that addiction can take a number of different forms. From drugs to alcohol, promiscuity to stealing, gambling to food or to immersion in the Internet, the common power of addiction is that on some level the activity initially feels good.
Even addiction to obviously harmful behavior such as cutting oneself provides perceived satisfaction through the process of self-mutilation, a frequent symptom among female adolescents with eating disorders, said Addictions Counselor Michael Rios, CADC, one of Bobby's treaters.
"What happens when a person cuts?" Mr. Rios said. "The activity releases endorphins, and endorphins numb pain, so cutting is used to release individuals from problems. They let go of their problems because some people consider it a high. They don't feel anything at all. Studies have shown people can go into withdrawal when they stop cutting. Some people see the blood flowing out and experience a sense of relief. We treat cutting addictions as we would any addiction and that is we also treat the individual's trauma and all the other mental disorders that are going on."
Hiding distress
Addiction often underlies significant emotional distress that fuels the use and abuse of drugs or alcohol. Self-medicating for anxiety or mood disorders such as depression is common and may complicate reaching and treating a diagnosis. After all, mental illness and dependency have similar characteristics:
- both manifest loss of control in behavior, thought and emotion;
- both afflict an individual completely: physically, mentally and spiritually;
- both afflict the entire family and other relationships;
- the course of both illnesses can be progressive, chronic, incurable and potentially fatal if left untreated;
- the risk of relapse for chemical dependency or mental illness is high and a relapse in one area will invariably trigger a relapse in the other.
Because young people are deeply drawn by the pull of peer pressure, their withdrawal from addiction is not only complicated by the very real craving for a drug or a drink, recovery also requires a psychological withdrawal from a lifestyle.
The threat of relapse involves the multiple "triggers" faced by recovering younger patients. Triggers can involve anything from the emotional fallout from romantic relationships to hanging out with the same friends who are themselves involved in drug or alcohol use. Adolescents are less apt to withstand the pressure of their peer relationships, making them vulnerable to fall back into old habits. In part, treatment attempts to teach young patients that if they are not in recovery, they're in relapse. During treatment, patients also receive significant counseling concerning the science of addiction and a clearer understanding of cravings, compulsions, thoughts and obsessions.
Thoughts, cravings
In order to control addictions, treaters offer young patients information about what lights up the brain.
"There is a difference between a thought and a craving," Mr. Rios said. "A thought is something that's going through your head. A craving is a step above that. One of the biggest hurdles for addicts is that when they have a thought they have to get rid of it. People who relapse are people who aren't talking about their wanting to use. They're the ones who have the most trouble. The ones who don't have any craving are the ones I worry about because they're not talking about their feelings."
Patients must learn how to manage their cravings. Without cravings control, relapse is inevitable.
"When you are talking about an addict, a person who truly has issues with dependency, if you ask them what obsession looks like they will tell you. There is nothing in their mind except using, whatever the compulsion is. If they don't manage that, they are in trouble. I think it's something the mental health community missed for many, many years because we didn't have enough information about it." Mr. Rios said.
"The bottom line is anxiety management and teaching the brain how to do something different. One of the exercises we do on the adolescent unit is about ending the craving for drinking or the desire to get stoned. Once you get a person to escalate their anxiety to where they are starting to crave, you can teach them to do something different. That's when you can break the craving cycle."
Recovery is not just about abstinence. Just as drug or alcohol addiction requires an individual to make a variety of personal adjustments, recovery also requires a change in attitude, personality and lifestyle.
A young person who attends a party and becomes intoxicated for the first time may eventually feel sick. But that's not the memory that is retained. The adolescent remembers that everyone at the party appeared to have fun. People were excited. The teen's mind develops a sense of what fun is supposed to feel like and look like. Fun becomes equated with drinking or substance abuse in spite of the risks.
"I ask adolescents what do you feel when you get high?" Mr. Rios said. "They say: 'I feel normal. I feel calm, I feel like I belong.' That's a very dangerous place to be."
The father of an adolescent patient at Menninger recalled coming across a videotape of his son and some friends who had recorded themselves indulging in drugs in the family garage. On tape it was clear that the participants looked dull and dreadful, not having any fun at all despite the son's recollection. The visual evidence contradicted the boy's view, yet he clung to the notion that he was having a great time at his own party. That distortion over what appears "normal" is part of the problem.
"Addicted young people are always looking for the next party," Mr. Rios said. "They believe that everybody in the world gets high, but that's not true. The kids they have surrounded themselves with get high, which is true. The progression is that they might mix alcohol and drugs first during weekends and then during the week.
"We're not talking about an adolescent who wants a beer," Mr. Rios said. "We're talking about having a six pack instead of one beer; smoking two or three joints instead of one drag from a joint. Using large amounts of a substance to feel normal."
Last word
Bobby, the boy who spent so much time on his parents' back porch, is lucky. With sobriety, he says he feels a lot better. He still must maintain an awareness of how his anxieties contributed to his addiction. He must manage his cravings and his daily medication for depression. But he is now thinking about his future, a subject that did not get much attention when he spent his days drinking beer in his backyard.
"When I drank, I actually didn't think about or want to be a part of the future," Bobby said. "When I started sobering up, I realized I had some skills, some things that might help me in the future, so I'm slowly getting my confidence back, trying to figure out who I am and where I'm at right now and it's helped a lot to be sober. I decided to get into gear and work my recovery program and my treatment. I've learned a lot so far and it's given me aspirations, which alcohol would never have done. I'm going on to boarding school and hopefully make it in a technology school. I hope to raise a family, which is a major goal of mine."
Many kids are not as lucky as Bobby.
Because of their age and emotional maturity, adolescents are at great risk for addictive behaviors. But they are also at considerable risk of mental illness.
A 1999 study estimated that almost 21 percent of U.S. children ages 9 to 17 had a diagnosable mental or addictive disorder that caused at least some impairment according to the National Institute of Mental Health.
The report estimated that fewer than one in five of these youth receives needed treatment.
Substance abusers come in all shapes and sizes
by Norma Clarke, MD
The face of substance abuse has no single look; in other words, you can't tell a book by its cover.
Ten years ago on the acute unit of an inpatient hospital, I worked with a 15-year old-boy named Scott. He was a tall, skinny boy with slightly unkempt blonde curls, green eyes that sparkled with amber and the kind of golden sun-kissed skin typically seen on California surfers. I remember him raging at his misfortune for having the kind of parents who messed up their kid enough to make him need to be in a psychiatric hospital. To make matters even worse, he said, they stuck him in the hospital in the middle of his summer holidays. The girls on the unit were thrilled by his constant anger and rages and his "so cute" good looks. And they agreed with him. How could any parent be so stupid as to admit their child to a hospital for something as silly as smoking marijuana?
Scott saw his parents as outsiders who were interfering in his life.
"They're so full of it with all that crap about how I've changed. They just don't want me to grow up. They want me to stay home and do what they tell me for the rest of my life!"
What Scott's parents saw in their son was a boy who, for the past year, rarely went to school and on the days when he did, spent most of his time in the bathroom smoking pot. He had stopped doing homework, had a whole new set of friends whom neither parent knew and he seemed to think he should come and go as he pleased. When confronted by his bewildered parents, he cursed and swore so much that sometimes they were frightened by their own son. He was sullen, moody, isolative and unpredictable. He had never been this way before. The hospitalization followed very soon after an incident in which Scott had come close to physically assaulting his mother, the police had been called and Scott's parents, realizing nothing they had done so far had helped, put him in the hospital. At the time of his admission Scott's father said, "I know he doesn't see it now, but we're the best advocates he has. We can't let him go on using."
A transformation
Scott's treatment, which occurred before the onset of managed care-at a time when you could hospitalize an adolescent in an acute unit for six weeks- consisted of education and group therapy on substance abuse. He had no access to drugs for six weeks, and despite his being diagnosed with a mood disorder prior to his admission, he was not treated with antidepressants or any other psychotropic medications. About five weeks into his stay, I sat in a group with Scott and I can still remember the look of amazement on his face. It was as if he had suddenly stumbled on a profound Truth.
"I didn't realize how smoking pot had changed me. I had no idea. I can't believe I ever threatened to hit my mother. I'm back to myself now, but I still can't figure out how all this happened."
"Myself" meant his moods were stable and he was no longer irritable and raging. "Myself" meant he was interested in the world again. "Myself" meant he wanted to go back to school, was interested in learning, could focus and concentrate again. "Myself" also meant he was back to being shy, socially awkward and tongue-tied around girls. But more on that later.
The 'world' of drugs
I was a brand new child psychiatrist then, fresh out of training, and to tell the truth, I really didn't have that much experience with adolescents (I was still a little scared of them) and had even less experience with treating drug abusers. That's probably why I was as amazed as Scott at the difference in his personality on and off drugs, and that's probably why I still remember Scott. His recovery made as strong an impression on me as it did on him.
Actually, I did know something about drugs, but it was information learned when I worked in the emergency room of a big city hospital.
In that setting drug users were mostly urban dwellers, Black or Hispanic.
If whites came to the hospital, it was because they had come to get drugs in the city and had been caught in the urban violence surrounding urban drug use. I assumed drugs were not available in the suburbs. Drug addicts used marijuana, LSD, cocaine, heroin, PCP. They murdered each other for drug deals gone wrong. They described a world of crack houses and shooting galleries, dirty, rat-infested abandoned buildings where drug dealers and users were the only occupants.
A vivid education
Intravenous cocaine and heroin are damaging to the lining of veins. After periods of use, the veins sclerose-harden-and the user has trouble finding an open vein in which to inject the drug. In my time in the emergency room, I met addicts, teenagers and adults, who literally had sclerosed every vein on the surface of their bodies, necks, hands, scalps, feet, arms, legs. Shooting galleries have people who are experts at finding veins and, for a price, provide a service for desperate addicts. As a second-year surgical resident (I thought I wanted to be a surgeon back then), my fellow residents and I developed our own expertise at finding veins, or intravenous access as we called it. One of our on-call duties was putting intravenous lines into the subclavian veins of the ravaged and ill addicts who came in for medical or surgical treatment. The subclavian is a large vein which runs behind each clavicle (or collar bone).
If the procedure is not done carefully, there is a great risk of puncturing the lung, which is very close to the vein.
It was nothing for us to do five or six of these every night we were on call. Back then I thought I could identify drug users and addicts...the coarse skin, dilated pupils (look for people who wear sunglasses all the time), the track marks on the arms (look for people who wear long sleeves in summer), the fingers, arms and legs swollen from circulatory damage. Urban. Black. Hispanic. Violent. Deadly.
The face of drug abuse
Scott met none of these stereotypes. He was a middle-class white teenager from a semi-suburban, semi-rural part of the state. He'd bought his marijuana from dealers who were students at his high school.
"Everyone knows who they are," he told me. "They can get you anything you want...weed (another name for marijuana), heroin, cocaine, Xanax® (a prescription anti-anxiety medication), Vicodin® (a pain medication). Anything you want."
Scott's friends, all of them from surrounding counties, got their drugs from suppliers at their respective schools. I'd never have identified one of them had I seen them on the street. My experience with Scott went a long way toward teaching me the danger of stereotypes, which serve, I think, as a way to keep most of us thinking the problem is elsewhere.
Read the findings of the National Institute on Drug Abuse (NIDA) 2002 National Results on Adolescent Drug Abuse: Crack and heroin use are not concentrated in urban areas, as is commonly believed, meaning that no parents should assume that their children are immune to these threats simply because they do not live in a city. ...Differences in use by socio-economic class are very small.
Contrary to popular assumptions... African-American youngsters have substantially lower rates of use of most licit and illicit drugs than do whites. These include any illicit drug use, most of the specific illicit drugs, alcohol and cigarettes.... African Americans' use of cigarettes is dramatically lower than for whites.
Publicity helps
According to NIDA, 53 percent of all the 8th, 10th and 12th graders surveyed had tried an illicit drug by the time they had completed their grade. Alcohol and marijuana are the two most common drugs of abuse, but there is significant use of heroin, cocaine, amphetamines, the so-called club drugs like Ecstasy and GHB, steroids, inhalants and cigarettes. In 2002 there were moderate declines in the use of marijuana and Ecstasy, amphetamine and methamphetamine and marked decline in the use of volatile inhalants. Heroin, cocaine, Vicodin® and Oxycontin® (a pain reliever related to morphine) held steady, while there were increases in the use of barbiturates (a kind of sedative) and drugs like Valium® and Xanax®.
Teenagers will gradually decrease their use of drugs with a high perceived risk of harm. Michael Rios, the chemical dependency counselor on the Adolescent Treatment Program of The Menninger Clinic, often tells me how little adolescents really know about drugs compared to what they think they know. He tells me that teenagers are often shocked when they learn how much damage drugs really do. That's why Michael is such a big advocate of drug education. NIDA agrees with him.
The decline in Ecstasy and inhalant use is directly related to NIDA's intense publicity campaigns, which have focused on the dangers of Ecstasy and inhalant use and very recent data indicate inhalant use may be on the rise again. Ecstasy use exploded when the drug was first introduced into the market, but now that it has been around long enough for its risks to become apparent, its use is gradually declining from its original peak. Inhalant use has declined because of negative publicity and the perception that inhalants are drugs for kids who are too young to afford "real" drugs.
After the cocaine-induced death of basketball star Len Bias, cocaine use among adolescents underwent a sharp decline because of the sudden increase in perceived risk. Over time, perception of risk with using cocaine has lessened and use has increased to its present level. Marijuana is more damaging to the lungs than cigarette smoke. The marijuana available today is up to 10 times more potent than the marijuana sold during the 1960s, but despite the growing evidence, many people, including parents, continue to think of marijuana as an innocuous drug and perceived risk remains low.
Mythical beliefs
Perceived risk aside, adolescents are notorious for their grandiosity. Imagined invincibility is a large part of normal adolescent development. Bad things will happen to everyone else, but not to them. I once had a 16- year- old drug dealer lecture me, with what I still think of as remarkable adolescent arrogance and condescension, on why he would not become an addict while all those around him were succumbing at an alarming rate. His mind was stronger than drugs, he lectured me. Anyone with a strong mind could be around drugs, even use drugs, and still be unharmed.
He used his product (he was a cocaine dealer) occasionally, but, he said, unlike his parents, cousin and assorted friends, he could stop whenever he wanted to. Despite all he had seen, his mother addicted, his father in jail for drugs, both brothers addicted, a cousin dead of an overdose, he still believed his "strong mind" could keep him safe. I've known many an addict to start at that place of invincibility, but eventually arrive at a time when, according to one addict, "I wasn't using cocaine, the cocaine was using me." The addict was acknowledging that something had happened which had led to his loss of control over his cocaine use. That loss of control defines addiction, and researchers are still trying to understand why it happens to some people and not to others.
The power of addiction
I used to be rather judgmental about drug use, thinking, not unlike the condescending drug-dealing teenager, that addicts were just weak-willed losers. I am embarrassed to say that I thought this even when I finished my adult psychiatry raining. I think I used to feel that if a person made a choice to start then that person could make a choice to stop. It was, to my mind, just that simple.
How could you call addiction a disease when the afflicted had made a clear choice to start using in the first place? But if you look at how people like Scott change with drug use, you have to ask yourself questions. If it was that easy to stop, why would a person lose job, home and family and still keep drinking or using cocaine? Why would an adolescent who has been raped multiple times in a crack house not stop using, but instead keep going back to that same crack house to get drugs? Why would a teenager who had been shot at and mugged by gangs on his trips to find drugs not stop using, but go back again and again to the very place where his life might be on the line? Why didn't Scott stop using when he realized he was failing all his classes, arguing with his parents every day and stealing from them to support his use? Why do people keep using when it is obvious to them and to everyone else that they are playing a losing game?
From almost every addict I have spoken with the answer is clear: they don't stop because they can't. It should be an obvious thing for us to grasp, but most of us do not consciously link our personality, behavior and thoughts to our brain, a powerful but delicate organ. Alterations in the brain can change who we are and how we behave. Drugs and alcohol alter our brains and change who we are. No one is exempt.
Brain damage
It turns out that drugs of abuse act on what scientists call the reward pathway in the brain. The pathway is a normal component of all brains, and usually acts to reinforce certain behaviors. The sensation of pleasure from a good movie, a good meal, a sexual encounter, are possible because of the action of the neurotransmitter dopamine and its actions in the reward pathway. In most life situations, the amount of dopamine in the pathway at any time is carefully controlled by a system of elegant checks and balances. This is important because the amount of dopamine is directly related to the intensity of the sensation of pleasure.
With substance use, the controls over the amount of dopamine are lost. Dopamine pours into the pathway, overwhelming the system and stimulating feelings of intense pleasure. The crash that follows use is related to the sudden depletion of dopamine. People begin to feel better, more normal, as their brains manufacture more dopamine. But the crash may be so severe that some people can't wait for their brains to manufacture more. This is where drugs like cocaine, heroin or amphetamines come in, because they can mimic the actions of dopamine, fooling the brain into thinking it has enough dopamine...and so the cycle begins...use, crash, use more to feel better, crash, use more.. and so on and on it goes.
In addition to the effects on dopamine, drugs like Ecstasy and amphetamines can do permanent damage to the serotonin system. This may result in changes in mood and behaviors. Many adolescent users report problems with memory and concentration after drug use. It is not clear whether these changes are permanent. Recent research is indicating that the adolescent brain may not be as resilient as once thought. There is new evidence that the adolescent brain may be more susceptible to damage from alcohol abuse. The surprise here may be that most of the damage occurs during alcohol withdrawal. There is evidence of shrinkage and cell death in the hippocampus and in the frontal lobes, areas important for memory, and focus and concentration. It is not clear how much function is recovered with cessation of use. Surveys indicate that nearly seven million young people between the ages of 12 and 20 binge-drink at least once a month. Two out of every five college students still binge-drink regularly.
Substance abuse motives vary
There are many reasons why adolescents use. Some are undergoing what I think of as routine adolescent experimentation, but their brains are too susceptible, and once they start, stopping is not easy. Scott, the boy we met earlier, was painfully shy. Smoking weed was his way of easing himself into social contact. He felt using marijuana was safer than using cocaine or heroin. He felt more comfortable, less awkward and seemed able to think of smart and witty things to say. He said he could feel his anxiety leaving him. It was like taking off a too tight jacket. The problem was that in order to manage his shyness he had to keep using. He was learning no new skills to help him manage his shyness. The new behavior was totally dependent on his having marijuana. Once he stopped using, the constricting shyness returned. To make things worse, he began to need more and more marijuana just to feel normal. As he said, drugs don't solve the problem, they just make it worse.
Many adolescents (and adults too) tell a story similar to Scott's. Using drugs to fit in. Using drugs to ease social contact. Using drugs to feel numb. Or to manage intense anxiety, depression or more frightening illnesses, like schizophrenia. The ups and downs in mood and the behavioral changes induced by drugs can be mistaken for a variety of psychiatric illnesses. When Scott's mood and behavior started to change his parents took him to a psychiatrist who diagnosed depression and began treating Scott with anti-depressants. His parents, believing they were protected in their part rural, part suburban world, never thought their son could be abusing drugs.
Times to be wary
Research has shown certain risk periods for drug abuse. One is leaving the family to attend school, and the others are the transitions to middle school, high school and college. The additional social, educational and emotional challenges, when added to the greater availability of drugs, leads to increased risk for some susceptible adolescents. Risk factors for use have been identified: early aggressive behavior, lack of parental supervision, peer substance abuse, availability of drugs and poverty. The more risk factors a child is exposed to, the more likely use becomes. It's the combination of risk factors that matters.
Early use often begins with alcohol, tobacco, marijuana, inhalants and prescription drugs, like sleeping pills and anti-anxiety medications. Adolescents who continue to use will move on to cocaine or other drugs while continuing use of tobacco and alcohol.
There is an anti-drug
It turns out that one of the strongest preventive tools is good parenting. Scott's father was right-he really was his son's best advocate. Parents, it seems, really are an anti- drug. The National Center for Addiction and Substance Abuse (CASA), has identified what it calls "hands-on" and "hands-off" parents.
The children of hands-on parents have a much lower incidence of substance use while the children of hands-off parents have a higher incidence of use. Hands-on parents are parents first and friends last. They keep close tabs on their kids, know where their kids are after school, monitor the CDs their kids buy, let their kids know how very upset they would be if their kids began to use, eat dinner together as a family, are aware of their teen's academic performance and monitor TV and Internet use. It may seem like work, but research indicates that it pays off and that adolescents from hands-on families report closer relationships with parents than adolescents from hands-off households.
Recognition of substance use in adolescence requires an awareness that all adolescents are susceptible. Remember the results of the NIDA survey-parents should not assume their children are protected because they live in suburban or rural areas. Be aware of behavior and mood changes. Look for changes in friends. Maintain a relationship with your adolescent.
There are huge amounts of good information on drugs available from NIDA. Read these things, online or in the print versions, with your adolescents. Such parental interventions pay off and are worth the investment. Adolescents who have been using for some time may need professional treatment. A substance abuse counselor can help with the decision about how best to proceed and whether outpatient or inpatient approaches are needed. But parents are not powerless in the fight against drugs. Well-informed parents are the best anti-drug there is.
Norma Clarke, MD, a child psychiatrist, is medical director of The Menninger Clinic's Adolescent Treatment Program.
The case for a Menninger education
by Richard L. Munich, MD
The face of substance abuse has no single look; in other words, you can't tell a book by its cover.
"Empathy often implicates morality...to empathize is to assess someone else's circumstances and character, to interpret that person according to one's profession, one's society and one's own personal history; to infer, on that basis, what that person feels; and, inevitably, to make a judgment about the rightness or wrongness of what has happened. To be able to empathize, you must understand why a person has acted and whether or not he intended the outcome of the act. In that sense, empathy is one of our primary moral resources." - T.M. Luhrmann,
Of Two Minds
"Hope is the consciousness of the realizable wish...all science is built on hope, so much so that science is for many moderns a substitute for religion. Man can't help hoping, even if he is a scientist; he can only hope more accurately. "-Karl Menninger, MD, Love Against Hate
It seems remarkable that after nearly eight decades of providing nationally and internationally recognized education for the complete range of mental health professionals, one would be called on to justify the educational mission of The Menninger Clinic. In spite of a landscape littered with sister institutions that were unable to survive, dramatic changes in the theory and practice of psychiatry and catastrophic reductions in the provision and payment for behavioral health care over the past three decades, Menninger has maintained a national ranking in the topmost tier of psychiatric providers. However, because of exponential increases in healthcare costs and the consequent and relentless efforts to minimize expenses, every aspect of The Clinic's operation comes under scrutiny. Thus, we present this case for a Menninger education.
In conjunction with our recent affiliation with the Department of Psychiatry at the Baylor College of Medicine, Menninger resumed its educational and training endeavors. Currently we are providing slots for five adult psychiatry residents, two child psychiatry fellows, a psychology intern and a post-masters social work fellow. At Baylor, as is the case at medical schools not supported by state funds, support for these positions is provided by the host setting, and these nine positions cost us approximately $400,000 per year including benefits but excluding faculty time and administrative support-so really, we are talking about a half a million dollars. Even this represents a substantial reduction from our Topeka days when as late as 2000, we had nearly 50 trainees on the payroll, representing a four-year residency program, a two-year child psychiatry program, and psychology post-doctoral, social work and international fellowships at an annual cost of nearly $3 million. The Clinic and Foundation also supported the training of psychoanalysts, making the Topeka Institute for Psychoanalysis one of the few subsidized analytic training centers in the United States and adding almost another $1 million to the educational costs.
Menninger's challenge in supporting this mission is not unique. The difficulty of paying for internships and residencies, the cornerstones of post- graduate education and training, is shared by every medical school and hospital setting in the country. Revisions in the Medicare and Medicaid formulae did not allow for the full cost of education to be supported, and therefore, medical education has been elevated to a national crisis that has, within the last five years, reached the halls of Congress..
Modern psychiatry-a short version
For most of the first 60 years of Menninger, the theory and practice of psychoanalysis dominated American psychiatry. Chairs of leading departments of psychiatry, medical directors of major psychiatric hospitals and certainly directors of residency training were either fully trained psychoanalysts or p> sychodynamically informed psychiatrists. Thus, there was a tremendous premium on candidate positions in psychoanalytic institutes in which matriculation was a virtual prerequisite for junior faculty and leadership positions in academic psychiatry.
In addition to the guiding principle that symptoms and behavior were motivated by unconscious (and difficult to know) factors, the core of Menninger's treatment and education was that the personhood of the patient could not be separated from their illness.
Improved medication
The early inroads into this psycho-analytic hegemony began in the late 1960s and early 1970s with the discovery and increasing sophistication of psychotropic medications. As medications became safer and more effective, they provided a powerful tool to ameliorate some of the most debilitating symptoms of mental illness, and for the most part, practitioners comfortably incorporated these medications into their practice.
This growing and now reinforced biomedical model coexisted with the more traditional psychosocial approaches noted above. In fact, the beneficial impact of medications reduced the need for very long-term and custodial hospitalizations and made previously unreachable patients available for psychotherapy and other interpersonal interventions. Of course, the biomedical model viewed psychiatric symptoms and illness much like a medical disease, separate in a way from the personhood of the patient, much the way a tumor could be excised or high blood sugar regulated. By the late 1970s, George Engel, MD, proposed a new integrative framework, the biopsychosocial model, linking the two points of view under one conceptual umbrella. This model promised a reduction in the depersonalization implied in the biomedical model, while bringing to the understanding and treatment of psychiatric disorders the scientific breakthroughs of neurobiology, genetics and psychiatric medicine.
A transforming revolution
Anguished about in many places, this integrative effort was brought to an abrupt end with the emergence of managed care in the 1980s. Not only were all forms of hospitalization dramatically reduced, but the office practice of individual psychotherapy also was brought under the purview of those incentivized to manage and reduce costs.
Coupled with the paucity of controlled studies of psychotherapy that matched the double-blind clinical trials of the new medications and the introduction of more cognitively- based and time-limited therapies, cost control signaled the end of the preeminence of psychoanalysis as a treatment paradigm. The new era of psychiatry heralded changes in leadership of departments and hospitals. Many psychodynamically oriented hospitals went out of business, other multi-specialty hospitals closed their psychiatry units and psychoanalysis retreated into training institutes and the intellectual academy. Most hospital treatment was reduced to lengths of stays of three to six days, focused on rapid intervention with medication, highly structured symptom management and environmental manipulation. As brevity of treatment and a more restrictive, medical model dominated the field and was reimbursed, most residency-training programs slowly but surely followed suit. Only through enormous effort was a holistic, genuinely biopsychosocial perspective kept alive. At residency training and other programs training mental health professionals, it became increasingly difficult to recruit the physicians, psychologists, social workers and other professionals able to practice in the integrative, whole-person model that defined the Menninger way.
Incidentally, one of the important attractions of our affiliation with the Department of Psychiatry at Baylor College of Medicine was its ongoing support for training in psychodynamic therapies, the liveliness and vigor of the Houston-Galveston Psycho-analytic Institute and the acknowledged shortage of those who provide psychosocial treatment in the greater Houston area.
Uniqueness of a Menninger education
Given this somber introduction, why then would one advocate for training in a treatment model that the culture deems outmoded, for which there is maximum trainee conflict, decreasing financial support and for which we have to pay? I want to answer this question by first describing the unique features of a Menninger education.
The defining feature of a Menninger education, imparted in different ways to psychiatric residents and child psychiatry fellows, psychology interns and post-doctoral psychology fellows, social work fellows and nursing staff at all levels, integrates all elements of a patient's physical being, mental state and the way in which he interacts with others-what is called the bio-psycho-social model. The model utilizes the vehicle of multidisciplinary teams that include the patient as an actual rather than virtual member and an active collaborator in his/her own treatment.
For those patients with a psychiatric disorder who cannot be managed with outpatient care, the customary form of inpatient treatment takes place in an acute program. The focus in this service is to rapidly describe the patient's illness; to identify the principal symptoms the treatment will target (usually acute psychoses, suicidal depression, severe manic states) and within a very few hours to begin or restart the appropriate medication. These interventions are invariably under the purview of a psychiatrist, and following the biomedical model, a friendly, physicianly and modest level of involvement with the patient as a person ensues. Meanwhile, the social worker assigned to the case explores issues in the patient's immediate environment that might represent stressors and attempts to reduce them. The nursing staff dispenses the prescribed medications, monitors their effect and attempts to maintain a safe and cohesive unit environment or milieu. Therapeutic activities staff provides creative and recreational interventions, thus providing some feedback to the team about social and vocational skills, as well as the patient's capacity to perform requisite activities of daily living such as grooming, mobility and social interaction.
These interventions are designed to promote the patient's return to a community setting in three to six days. Managed care would have been involved in this at admission and most likely two to four days into the hospital stay. Every psychiatric resident has between six to 18 months of training on an acute unit where patients learn the basics of diagnosis, medication management, symptom reduction and a smattering of environmental manipulation. At the Baylor College of Medicine, residents are exposed to the very best of this kind of care at the Methodist, Ben Taub and Veteran's Administration hospitals in Houston. In addition, they are in a position to watch their mentors in these settings take advantage of the most advanced collateral diagnostic techniques in medicine, neuroradiology and neuro-psychiatry.
A deeper experience
For the most part, we assume that when a patient is admitted to The Menninger Clinic, he or she has had all of the benefits of the acute approach described earlier-at least once and usually multiple times. But often it has not helped, or it helped only briefly, or partially, and the patient and family want more. Or even more disturbing, the patient's treaters or families are worn out, desperate and at the end of their ropes. Therefore, in working with the patient who is difficult to treat, the skill set the resident has obtained thus far in his or her education is neither applicable nor effective with these patients. Because the length of stay at Menninger is substantially longer (three to nine weeks) than acute programs, the following new elements apply.
The pressure to immediately modify and mitigate symptoms is reduced.
Therefore, the opportunity to understand the psychological and environmental factors contributing, maintaining, reinforcing or exacerbating presenting symptoms is enhanced.
Characterologically based ways of coping that complicate the individual's capacity to use treatment by fostering non-compliance and recalcitrance can be examined.
Opportunities are increased to observe the interaction between biomedical, neuropsychiatric and psychosocial elements in and the process of a major psychiatric illness.
From a treatment point of view, training at Menninger provides:
- the requirement to participate in a fully integrated, multidisciplinary team where the patient is an active partner rather than a passive recipient of care,
- the potential for implementing a genuine bio-psycho-social approach to treatment,
- the challenge of coordinating various and at times conflicting interventions for patients who have combinations of illnesses that are maintained, reinforced and exacerbated by the individual's characteristic ways of coping and relating,
- the opportunity to deepen one's understanding of the role of the family in illness and recovery,
- the chance to learn first hand the struggle of patients with a wish to change and the terror of abandoning what is safe and familiar in the context of a well defined and organized milieu,
- and the privilege of learning to utilize one's own humanity and the relationships we form with the patients as a path to restore hope in the healing power of human connections.
The whole patient
Unlike the psychiatrist on the acute treatment service and without relinquishing the tools and the knowledge of contemporary psychiatry, trainees at Menninger become immersed in the personhood, humanity and life of the patient. We maintain that whatever career path is ultimately chosen by the trainee, this immersion will enhance the resident's skill set and his or her effectiveness as a clinician. In short, a rotation at Menninger will make a more rounded and effective psychiatrist/team leader, psychotherapist, psychopharmacologist or researcher. It is for these reasons that we continue to make the case for a Menninger education. But there is more.
Medical student to psychiatrist Talcott Parsons, the eminent sociologist who wrote in the 1950s and 1960s, characterized the first transformation that happens to all physicians in training. Medical school teaches the idealistic college graduate that the best-prepared physician is capable of putting aside his or her feelings.
Although modern medical educators are beginning to raise questions about and suggest antidotes for this compartmentalization, this isolation of affect, this suppression of feeling is crucial to helping one get through the awe and stench of anatomical dissection, the self consciousness of profoundly intimate contact with the body, the terror of presenting to the attending on rounds, the vicissitudes of disease and deterioration, the excitement and depersonalization of the surgical suite, and the horror and fascination of death and its systematic examination at the autopsy table. The rigors of internship mainly serve to consolidate this very adaptive defense of detachment, and even more significantly, promote the idea of patient as "other" and of disease as the enemy.
The conflict
Tanya Luhrmann eloquently describes the second transformation- from graduate physician and intern to psychiatrist-in her recent book examining American psychiatry, Of Two Minds. This transformation is shaped by the new graduate's confrontation with two conflicting paradigms: the psychiatric scientist and the psychoanalyst.
Ms. Luhrmann is graphic in her description of the conflict, personalizing many of the details mentioned earlier in the description of the current state of American psychiatry and convincing the reader that this dilemma persists irrespective of an intern's initial preconception.
Except in very few places, the prevailing value in the new millennium is in the direction of the psychiatric scientist: criteria-based diagnosis, remunerative premium on reduced length of stay, rapidity of the effect of medications and the pressure to provide so-called evidence-based treatments. Also, there is the current bias of the National Institute of Mental Health, that is, the growing and exciting technical and academic links between psychopharmacology and neuroscience and the marginalization of psychodynamic therapies.
Compared to other specialty services, virtually every academic inpatient and outpatient service loses money, running the risk of becoming the devalued training setting in many departments.
For the resident who intends to practice psychotherapy or become a psychoanalytic candidate, the choice is a difficult one, requiring a tortuous training process and always involving a financial sacrifice as compared to his or her more biomedically oriented colleague.
These conflicting pathways plague most residents and lead to the third transformation, the final choice of a career path and the consolidation of one's psychiatric identity.
More adaptation
Most of the residents who choose to spend time at Menninger during their fourth year have opted for the psychosocial tract. With residents nearing and sometimes already in their fourth decade of life, the goal now becomes helping these advanced residents rediscover the now well-buried spark that initially motivated them to chose psychiatry in the first place. Finding the way through nearly eight years of a hardening socialization process is not easy. For example, it has been my recent impression in supervising advanced residents and psychoanalytic candidates that they seem preoccupied with what I want from them, rather than what they want from me or how I can be helpful to them. They want only my unadulterated approval. I might as well be the surgical physician attending on morning rounds. This is so even after I give the following lecturette at the beginning of supervision:
I do not really believe in super-vision in the literal sense when it comes to psychotherapy. Because I am neither in the room with, nor in the head or heart of the patient or therapist, there is no way I can see more. My view of the role is more like extravision, another set of eyes and ears to help you figure out what the patient might be saying.
This unique mentoring also often includes trying to figure out with the trainee what might be getting in the way of that seeing and hearing.
Individual mentoring, the core of psychodynamic training, involves more. In the course of any supervisory interaction, things accumulate, and it is incumbent on the participants to intervene before the accumulation gets too large. This is different from what happens in psychotherapy, but it has many of its elements. There are learning goals, observing goals and intervening goals in a supervision. Learning includes how to elicit and then begin to make sense of a story and then to observe how that story plays out in a variety of settings (assessment, rounds, milieu), as well as in individual, group and family or couples therapies. Special attention is paid to the congruence and potential incongruence between what is presented and what is observed. Observing and commenting effectively on these matches both provides support as well as an open window into the patient's mental processes. Because we believe now that most of our patients are here because of dysfunctional mental processes (more than the contents of their minds), this opening is where a true connection can be made and treatment potentially begins.
When it comes to interventions, there is, of course, the whole theory and technique of interpretation, the tower of Babel of theoretical diversity and the vicissitudes of titrating psychosocial with biomedical interventions. And because one person can never fully grasp another, the views of others involved with the patient, especially members of the core multidisciplinary team, become vitally important to the trainee's understanding.
Because the medical model privileges the solo role of the physician, Menninger training inspires a reconsideration of that indoctrinated treatment approach.
Special trainees
There are two more elements that characterize work at Menninger: hope and empathy. Empathy is an inborn capacity to identify and share in the emotional life of another. Being inborn and influenced in important ways by early life experiences, empathy is not, of course, a capacity that is easy to shape and teach. Fortunately the great majority of trainees who gravitate to Menninger are empathic clinicians in spite of the rigors of their medical education. Our task is to help the trainee "harness" this capacity in the service of patients; to help understand when empathy might be lacking, thus leading to harsh judgments and withheld help; or conversely, when it is so present as to obfuscate judgment and overwhelm the patient with dysfunctional help. By its focus on the situation of the whole person, Menninger education teaches the trainee to adjust the levels of empathy to maximize its effectiveness.
In this delicate balancing, empathy has much in common with hope. Esteemed clinicians from Karl Menninger and Jerome Frank decades ago and George Vaillant and William Anthony in more contemporary times have argued that hope is an essential element in a patient's recovery from mental illness.
Hope may be defined as a wish or desire accompanied by the confident expectation of its fulfillment. Vaillant differentiates hope from optimism and wishful thinking, contrasting it with suffering. Thus the absence of hope on the part of a clinician can inhibit progress.
Too much hope, however, increases the distance between patient and those who treat and may have sadistic elements as in the creation of false expectations.
Unrealistic hope diminishes balanced empathy and can lead to despair in the patient and family and demoralization in the clinician and treatment team.
Realistic hope comes from an accurate description and understanding of the clinical situation and the available resources that can be brought to bear, the collective input of the multidisciplinary team and the clinical experience that accompanies an abiding familiarity with the course of severe mental illness.
We believe a clinical placement at the new Menninger Clinic provides all of these elements for the trainee.
A complete integration
Implicit in what has gone before and fundamental to our desire for an affiliation with a major medical center such as the Baylor College of Medicine is that the conditions for implementing a genuinely integrated, biopsychosocial approach to diagnosis and treatment are now more possible than ever before. New and highly refined input from the bio-medical sciences, including genetics, neuroscience and neuropsychiatry, makes the traditional separation of domains more artificial.
The multidisciplinary team approach at Menninger uniquely provides the vehicle to bring the domains together, providing state of the art diagnosis and treatment and enabling trainees to have an enhanced view of their patient and their role in the process.
Recipients of a Menninger education will not leave burdened with a single theory of human behavior, nor a unified theory of psychiatric treatment. They will leave with a unique approach to treatment, one that is tailored to the individual patient, and one that will serve these newly minted trainers in a variety of clinical circumstances.
In the same way that contemporary Menninger treatment is designed to start or restart treatments that have not worked, a Menninger education is not the end, but rather the beginning of an education for a professional life.
Richard Munich, MD, is vice-president and chief of staff for The Menninger Clinic and vice-chairman of the executive committee and on the faculty of the Menninger Department of Psychiatry at Baylor College of Medicine & Behavioral Sciences. In addition to his administrative duties, Dr. Munich sees a regular schedule of patients and is deeply involved in the education and training programs of The Menninger Clinic.
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