Saturday, October 16, 2010

Getting Through - Surviving Mental Illness 3

Maurice Neligan, 1937-2010, Heart Surgeon
Treating the Mentally Ill with Compassion

There is perhaps nothing as healing as a pleasant smile.  How often do we hear of the importance of a doctor's bedside manner?  Good communication with the patient is half of the battle in fighting any illness, be if physical or mental.  Patients are under enough pressure and stress without the hindrance of an impersonal professional.  General practitioners are always sympathetic listeners.  Those who do not possess people skills normally drop out of the profession or end up in medical research.  In the area of mental illness the need for a compassionate ear on the part of the mentgal health professional is a sine qua non.  On my own road to recovery from a bout of clinical depression some twelve years ago I can honestly say that the smiling face of my consultant psychiatrist and his ability to listen with great compassion was half the battle.

Maurice Neligan's  (R.I.P) final column from last Tuesday's Healthplus, the supplement to that day's The Irish Times is dedicated to the subject of mental health. He states that in his time studying medicine in the sixties of the last century psychiatry was a Cinderella subject looked on with suspicion.  Students at the time looked on this specialty as decidedly not popular and of lesser importance than the more prestigious specialties like surgery or neurology.  Those students, Neligan tells us, used to quip that psychiatry was "the care of the id by the odd."  He then goes on to quote from the great surgeon John Hunter (1728 – 1793) who wrote: "Perhaps there is nothing in nature more pleasing than the study of the human mind."  On the history of psychiatry, Neligan continues:

It has been a long and arduous road to the incorporation of psychiatry fully into the body of mainstream medicine.  Such illnesses are like most others - a mixture of genetic, social, biological and psychological functions.  The genesis of many psychiatric conditions is as yet poorly understood, but we must ensure that the treatment of those with such conditions is not allowed to be dealt with once more on the "out of sight, out of mind principle."  Society has for too long turned its back on such patients. (Quoted Healthplus Supplement, Tuesday 12th, page 20)
One can hardly disagree with this compassionate approach to those suffering from mental illness.  It is surely the legacy of the great pioneer of early medicine Hippocrates (ca. 460 BC – ca. 370 BC) himself whom I have spoken of at length in another post in these pages.

Neligan next discusses the contribution of the early pioneer Pierre Janet .  This Pierre Marie Félix Janet (1859 - 1947) was a pioneering French psychologist, philosopher and psychotherapist in the field of dissociation and traumatic memory. He was one of the first people to draw a connection between events in the subject's past life and his or her present day trauma, and coined the words ‘dissociation’ and ‘subconscious’. He studied under Jean-Martin Charcot at the Psychological Laboratory in Pitié-Salpêtrière Hospital, in Paris. In several ways, he preceded Sigmund Freud. Many consider Janet, rather than Freud, the true 'founder' of psychoanalysis and psychotherapy.  However, Janet made an interesting comment of how mental health is viewed from one class to another.  He argued that if a person is poor and mentally ill he is committed to an asylum as "psychotic."  If he s/he belongs to the middle or business classes s/he is diagnosed as "neurasthenic."  Finally, if a patient is from the upper classes and can be treated at home the patient is diagnosed as "eccentric."  (See The Irish Times Healthplus, Tuesday 12/10/2010, p. 20).

Maurice Neligan finished the last article he would ever write by wondering whether we were finally able to walk the walk as well as talk the talk with respect to mental health in Ireland.  One wonders if we are.

Getting Through - Surviving Mental Illness 2


Marxists used to say that context conditions consciousness, and, to my mind, there is a profundity of insight in that contention.  My consciousness is indeed conditioned by my context - a 52 year old teacher of thirty years experience working as a Resource and Special Needs teacher in an inner city secondary school in Dublin, Ireland.  I spend half my time working with ASD students in small group and 1-1 contexts.  Then I teach foundation Maths and Irish to Sixth Year students - no more than six in any one group.  These students present with varying educational disabilities - dyslexia, dyspraxia, dyscalculia, or even with emotional difficulties (EBD) like ADD, ADHD or ODD.  One has a psychiatric illness, viz., OCD.  The students in our ASD unit are all diagnosed with Asperger's Syndrome and most of them have at least one other disability added to this.  Teaching these boys is both challenging and infinitely interesting because I have a life-long interest in psychology and in trying to understanding and help people.  I also love teaching and meeting people from all walks of life.

Hans Asperger1906 – 1980, the Austrian pediatrician
During this last week I worked with an EBD group of three where I am working on their basic emotional development coupled with an anger management programme which I learned to implement in the past three years in partrnership with the NEPS psychologist.  I also worked with a sixteen year old Asperger's boy who suffers from OCD and who presents with extreme anxiety which is controlled by medication.  All of this requires skills of communication and empathy which I have learned over the years through doing psychotherapy courses and from completing a Graduate Diploma in Special Educational Needs.  However, nothing can substitute for lived expereience and for years of professional interaction with students of all psychological make-ups.  I am also working with one boy who thinks the world is against him - in fact he seems quite paranoid.  Now, I am a teacher with a fairly good background in psychology and psychotherapy, although I am not a qualified therapist.  However, I know enough never to get in over my head and when it is important to refer a student to the school counsellor or other qualified professional.  Real knowledge of any area is knowing where one's own qualifications, knowledge and experience end and where more specialist knowledge begins.  There is nothing as dangerous as working with people who think they have all the answers to life's woes.

Compassion for the Broken and Disintegrated Self:

With these preliminary comments in mind, I now proceed to comment on yet anothyer wonderful article on mental health in The Irish Times Supplement on health, this time by Dr Tony Bates who is founding director of Headstrong The National Centre for Youth Mental Health in Ireland. Headstrong is an independent charity committed to championing the mental health needs of young people and to working with communities to design and implement comprehensive systems of care and support for all young people. Tony’s core professional training is as a clinical psychologist, with a special interest in working with mindfulness-based programmes in mental health settings. He is also a full-time writer and editor of Ireland’s current mental health policy – A Vision for Change.  His short article in this supplement is the essence of compassion, something I'm not surprised at, given that Dr Bates is a psychologist and psychotherapist of such experience and expertise. Here is a flavour of this author's column:

Life has a curious way of breaking our hearts. It is full of violent eruptions of things that seem to come at us from nowhere. An old wound is suddenly reopened; an illness throws everything out of whack; a colleague betrays us; we lose someone we love – moments when suddenly the path we have been on disappears from beneath our feet.
One of the great lessons of life is that, while one may have an ideal picture of how things should be, we have to accept sooner or later that, rather than things being the way they should be, they are usually the way they shouldn’t be. Unless we can accept this about our life, family, organisation and friends, we’re going to have a really hard time.  (Tony Bates: That Crazy Little Thing Called Life )

That's been the experience of most, if not all, of us as we journey through life.  Things break, people get sick, nature intervenes in storms, earthquakes and even tsunamis, pollution occurs, dreadful accidents happen, we age and we die and the cycle continues.  Unless we can accept the distinct possibility of all these things, we certainly will have a hard time. As one of my colleagues puts it: "shit happens!"  How true that statement is.  There is no way it can be gainsaid.

However, it is often at these moments when things go badly wrong that we are offered the opportunity to grow as human beings.  As I have said in the last post - what does not destroy us, strengthens us.  We learn through our mistakes, and by very definition mistakes are a form of evil e.g.,  doing a physical undertaking wrongly, making human error either in mathematical or clerical settings, or even in handling a human interaction badly.  As Dr Bates so succinctly puts it in this superb article:

But it is also true that the moments when things go wrong are also the precise psychological points where we can grow. Even if that hurts, even if it means some of our most cherished illusions about ourselves end up shattered on the floor. Whatever wisdom we mine from the raw material of living comes from facing the episodes of chaos, growing through and being stretched by them.  (Ibid., see the above link!)
Interestingly, he tells us that most of what we accept as normality is in fact a distraction or indeed a fantasy.  I can see clearly what Dr Bates means by this.  We are all prone to set up our own little take on life, our own little perspective on living and to assume that things should be this way or that.  In fact our own little "pictures" of life or living or reality, call it what you like, are just that, "little" - a perspective, often loaded indeed with our own rigid prejudices, biases and blind spots.  In this way, we avoid what Bates calls "the terror of existence."  I can see a lot of the existentialist approach in his writing here.  He reminds me very much of Dr. Irvin Yalom in what he says.

Then the pain of existence in the form of real existential and lived suffering enters our little world through pain, real, dreadful and frightening pain.  Our little vision of things is shattered.  However, many of us seek to protect our closely guarded and long-built-up personal worlds, ordered to our own blinkered vision.  We may protect ourselves by denial, by self-contempt, depression or simply turn against the world in anger.  Each of these options is an effort to keep alive the old stories of continuity, the old patterns of meaning, the old brittle and blinkered vision of things.

Compassion and Kindness Towards Self and Others

Having read much in Buddhism from the Dalai Lama to Thich Nhat Hanh to Wiliiam Johnston and Sogyal Rinpoche, I am not in the least surprised that Tony Bates goes on to mention compassion for the Self.  I have long been of the belief, and I have written it here before, that compassion must start with the Self before it is given to others.  Real compassion begins at home at the very hearth of the fire of the Self!  Let us repeat here Tony Bates's own words:

At first we may feel acutely anxious and unsure how to react. It can take time to make sense of it all and figure out the next step to take. But when we cannot change how we feel, we can choose to relate to it with some degree of kindness. Compassion is perhaps the best place to start when our world gets turned upside down. It is the first step of any growth or recovery process. It enables us to stand firmly in the place we find ourselves; a place that may be painful, but the only ground we can stand on if we want to feel real. (Ibid., see the above link again!)

And compassion is no weak emotion or weak love or soft self-indulgence.  It is, in fact, very objective and very real, essentially accepting of the way things are and is also empowering of the person and a prerequisite to real and deep healing.

To be continued.

Getting Through - Surviving Mental Illness 1


Mental health has for the last twelve years been not just one of my "hobby horses," but virtually an on-going obsession.  Hence, as any reader of these rather sui generis and peculiar posts will have noted, this abiding interest stems from my own personal encounter with mental illness in my own life at forty - that classic mid-life crisis-time when the familiar pattern of things goes awry on us or simply breaks down.  My last eight posts have dealt with a potted history of mental health by reference to the history of madness and of the growth of psychiatry as a response to that history.  This post is a more personal response to Tuesday's wonderful Health Plus section of The Irish Times.  This daily broadsheet is second to none in Ireland for the quality of its journalism and the ethics of its reporting to my mind.  Its supplements are of an equal standard.  However, such a paper needs little praise from me because quality always speaks louder for itself that all the plaudits could ever achieve. 

Personal Suffering

There is no substitute in life for personal experience no matter what we speak about.  A philosophical or theological look at suffering pales into insignificance beside personal experience and the moving human accounts of suffering.  As I sit writing this post The Late Late Show, Ireland's premier Light Entertainment show, hosted by Ryan Tubridy is on in the background, or, more correctly foreground.  He has just interviewed the sports journalist Liam Hayes who has revealed that he has Non-Hodgkin's Lymphoma, which, in his case, is a rather aggressive form of that cancer.  He spoke with great calmness, honesty and insight about dealing with this life-threatening disease.  We need such courageous media people to inspire the Irish nation with hope in these rather depressing times when we are bombarded with a very negative and depressing image of the fiscal and financial future of our wee country.  We also need couageous and strong human beings like Liam to give sufferers from cancer hope and courage to face the inevitability of all that is associated with that dreadful disease.

Personal Suffering and Suicide

Speaking of mental health, the rate of suicide, especially among young males, is alarming to say the least here in Ireland.  Our young men do not cope very well with their emotions or with the expression of them.  For this reason, I have long been involved in teaching a certain course on Life Skills in Transition Year in our school called Mental Health Matters.  This course covers what positive mental health is and how we can go about ensuring that we can promote it in our own lives.  It's an excellent programme and I get great satisfaction from teaching it because I believe it can and does make a difference.  Also it is significant, if not an unhappy occurrence of synchronicity, that Liam Hayes went on to reveal that his brother Gerard had taken his own life tragically way back in 1982.  I believe I saw a documentary made by RTE on that tragic event which featured his mother talking about how she coped with her son's suicide.  Liam revealed an interesting insight into the lack of dialogue typical among male family memebers on this tragic subject when he told us that in the twenty years and two months between Gerard's suicide and his father's death that they had never once managed to broach the subject with one another.

More than Angst

Tuesday's health supplement to The Irish Times I found very comprehensive indeed and a tribute to the meticulous research of its editor and contributors.  I have had for many years an abiding interest in philosophy and in the role of philosophy in dealing with life's troubles and problems, and with that I have been quite intrigued with existentialism and its approaches as outlined in the lives and writings of various philosophers whom I have discussed in these pages many times.  However, it is one's own personal suffering that puts even this existential angst into perspective, and, indeed, into the shade.  Having sat with the engine of my car running on Howth Pier some twelve years ago, wondering whether driving off that pier at speed to end the mental suffering I was then experiencing was the best way out has led me to depths deeper than I had ever thought I could have plumbed.  It also convinced me that I was so much stronger than I had ever previously believed when with the help of others - professionals and family - I managed to fight my way back to a balanced peace of mind from where a calm  positive love for life grew within me, and continues to grow, indeed..  What did not kill me strengthened me.

I did a lot of soul-searching, read a lot of literature on depression and other mental illnesses, went to therapy and counselling, did two years of a counselling and psychotherapy course, engaged in a lot of meditation and other complementary health programmes and courses, while at the same time never once jettisoning the advice and medical prescriptions of the professionals - doctors and psychiatrists.  I have found that it is both/and not either/or when it comes to talk therapy or psycotherapy on the one hand and psychopharmacology (medication) on the other.  The worst fault in my opinion is where people become very reductionist insofar as one or other of them may say: medication is the only way to go or still another that a sufferer should throw away all their tablets.  Both of these stances are extremes. What's needed is balance.

One of the most moving articles in the supplement is an interview with a nineteen year old girl who suffers from clinical depression.  I will quote some lines from this young woman's observations on this dreadful disease of the mind which in my opinion possesses the sheer lucidity of William  Styron's prose in his autobiographical reflections Darkness Visible which he published in 1990. This memoir, originally intended as a magazine article, chronicled the author's descent into depression and his near-fatal night of "despair beyond despair."  It also reminds me of the wonderful book on depression Malignant Sadness: The Anatomy of Depression (1999) by the scientist Lewis Wolpert which I read soon after coming out of hospital some twelve years ago. This was turned into three television programmes entitled 'A Living Hell' which Wolpert presented on BBC2.  In this present article, which is an interview with the journalist Marese McDonagh, a young nineteen year old girl called Ruth O'Doherty tells her interviewer of her lifelong battle with this most silent of diseases - depression:

I'm friendly, outgoing and chatty.  Inside I am a mess and terrified of rejection... I think unless you experience it you cannot know... I was bullied... I started cutting myself when I was 11 or 12.  My arms are covered with scars.  I have done it all over my body.  I get urges to cut myself in different places.  Something in your head tells you,  you have to do it... I took an overdose when I was 13... When we broke up, all I could do was cry - I couldn't eat or sleep.  I was put on antidepressants when I was 13 or 14 and I am still on them.  The side effects are horrendous - the nausea, the lethargy.  I have been on antipsychotics.  They made me balloon and that made me feel even worse... But when I am depressed I don't have the energy to do anything... I feel so guilty about what I have done to my family... Unfortunately, it all came crashing down again.  I think I became immune to antidepressants and started hearing voices, getting panic attacks and shaking all the time...

I have come to terms with the fact that I might always need tablets and therapy.  I have never had a proper school life, proper friends or any normality.  My entire teenage years have been clouded with my depression.  I have very few happy memories of my teenage years.  Is that normal?  I don't know what normal is...  (The Irish Times Health Plus, pp. 6-7, Tuesday, Oct 12, 2010)
These words speak for themselves.  No commentary is needed.  Mental illness brings severe suffering.

Tuesday, October 12, 2010

Madness and Sanity 8

The Rise of Psychopathology

Roy Porter, 1946  —  2002,  was a British historian noted for his prolific work on the history of medicine.
In medicine, pathology (This word pathology is from Greek πάθος, pathos, "feeling, suffering"; and -λογία, - logia) is the study and diagnosis of disease.  The term "pathology" refers in the sciences to the study of disease, not specifically in the domain of biology. For example, in psychology, the term "psychopathology" refers to classifying mental illnesses and diseases.  Pathology, then, is how we study, describe, define and diagnose disease.  Psychopathology, consequently, is how we study, describe, define and diagnose mental illness or disease.

As the Enlightenment took hold in Europe, religion and the non-rational enthusiasm for religion began to be seen in more scientific and rational circles as a pathology itself.  Here is what Porter, the historian of psychiatry says:

The pathologization of religious madness led Enlightenment free-thinkers to pathologize religiosity at large.  In effect, this was also, much later, Freud's position.  God was an illusion, faith "wish-fulfilment," and belief, though all too real, was a mental projection satisfying neurotic needs, to be explained in terms of the sublimation of suppressed sexuality or the death wish. (Porter, p. 32)

Voltaire 1694 - 1778 - aka Francois Marie Arouet

It is not surprising that such philosophes of the French Enlightenment as Voltaire and Diderot had said that Christian beliefs were "the morbid secretions of sick brains." (Ibid., p. 32).

The Greek Heritage: The Priority of Reason

Porter calls the third chapter of this little classic Madness: A Brief History (O.U.P., 2002) by the title  "Madness Rationalized.".  In this chapter he seeks to trace the history of rational thought about madness as opposed to non-rational feelings-orientated reactions to this same reality of mind.  He starts with the thoughts of the Greeks to whom we owe so much culturally - their land was the very cradle of Western culture from philosophy to literature to architecture to mathematics, and this list could go on. Within Greek thinking, the rational loomed large and the sense of the irrational in humankind was feared as a danger to the soul or mind. Socrates notoriously slighted the gods, and, later his pupil Plato analysed the structure of the psyche, viz., reason, spirit, the passions and the soul.  Still later this latter's pupil, Aristotle, defined humankind classically as a "rational animal" which is surely one of the most quoted descriptions of humankind, thereby assuring the domination of the rational in Western culture. The following is, to my mind, a superb summary of the Greek influence not alone on Western thought in general but also on its thought with respect to mental health and mental illness.  I will quote Porter fully here, if the reader will have patience with the writer:

Plato (c. 428 - c. 348 B.C.) in particular condemned appetite as the arch-enemy of human freedom and dignity; and the Platonic polarization of the rational and the irrational, enshrining as it did the superiority of mind over matter, became definitive of classical values in such later philosophies as Stoicism, expounded by Seneca, Cicero, and Marcus Aurelius ...
By exalting mind and valuing order and logic, Greek thinkers defined for future ages - even if they did not solve! - the problem of the irrational.  In making man the measure of all things, the plucked madness from the heavens and humanized it... (Ibid., pp. 35-36) 
To be continued.

Sunday, October 10, 2010

Madness and Sanity 7

Going beyond Demonic Possession

The Spanish Inquisition - Burning at the stake
Humankind has always been wont to be afraid of what it does not know.  When we study the history of human beliefs and thoughts we immediately see that the role of reason and commonsense must, of necessity, be a guiding one in all things, and especially in the question of mental health and mental illness.  Why?  Quite simply because the wilder imaginings of religious minds have led to the greatest of crimes.  The witch craze which gathered momentum across Europe from the late fifteenth century, and which peaked roughly around 1650 managed to notch up some 200,000 executions, and needless to say, this number was made up of mainly women.  This says a lot about men and power!  Here, then, is one stark lesson of the more "crazed" notions of religion.  Bryan Magee, to my mind, puts the dangers of religion into context in his wonderfully enlightened The Story Of Philosophy when he discusses the contribution of one of the greatest early philosophers, namely, St Augustine of Hippo:

The doctrine of St Augustine's that was never officially accepted by the church but had long-term and in many ways tragic consequences was his doctrine of predestination.  This rested on his view that we cannot be saved through the exercise of our own wills independently of God, but that God's intervention and grace are necessary for our salvation.  Souls who go to hell are souls for whom God does not intervene.  Thus the damned are damned by God's choice.  This doctrine was used over future centuries to justify the burning and torture of many heretics - treating them, in other words, as if they were damned souls in hell - and untold thousands died appalling deaths in its name.  This is one example - Marxism provides others, and there are more elsewhere - of theories produced by a philosopher being used to justify mass murder.  It demonstates, if demonstration were needed, the immense practical consequences that can flow from an abstract idea.  More than a thousand years later this same idea of Augustine's was still exerting a powerful influence on leading religious thinkers, not Catholics only but only key Protestant church reformers such as Luther, Calvin, and Jansen. (Magee, op.cit., p. 52)
Epilepsy, which we know as a physical illness of the brain today, and a host of other physical and mental illnesses, which in earlier times were seen to be evidences of demonic possession, continued in more rational/commonsense religious circles to be illnesses still in need of religious intervention in the form of exorcisms (especially in Roman Catholic circles), blessings from priests and of other religious interventions like masses, penances and pilgrimages.  Burnings at the stake were seen as far too extreme, especially after 1650.

As I have already stated the Anglicans showed a more balanced approach to mental illnesses than did either the Roman Catholic Church or the more fundamentalist and evangelical wings of ProtestantismThomas Willis (1621 – 1675), a staunch Anglican believer was an English doctor who played an important part in the history of anatomy, neurology and psychiatry. He was a founding member of the Royal Society. In fact, he was the coiner of the term "neurologie" - which thus excluded the Devil as so-called possession was now all a matter of defects of the nerves and brain.  Porter continues the tale thus:

Especially after 1650, elites thus washed their hands of witchcraft: it was not a satanic plot but individual sickness or collective hysteria; eighteenth-century magistrates similarly deemed converts who shrieked and swooned at Methodist meetings fit for Bedlam - John Wesley himself, by contrast, upheld belief both in witchcraft and in demonic possession. (Porter, op.cit., p. 29)
Porter goes on to delineate the gradual retreat - quite a slow one at that - of the attribution of demonic causes to mental illnesses.  In the 1630s a learned medical doctor still gave evidence backing the reality of witchcraft.  However, around 1700 most knowledgeable medical doctors were of the opinion that "spectres are fictitious representations, against the laws of nature." (Quoted ibid., p. 30) Our author mentions many eminent physicians by name who argued against the folly of demonic attribution for mental illnesses.  They had to argue their cases for many years against the persisting fundamentalist beliefs of many religionists.  For several hundred years more enlightened medical personnel and scientists had to argue against the persistence of the survival of popular belief in the workings of the Devil or Satan and his influence on mental equilibrium.

Erasmus Darwin, the grandfather of Charles
Porter concludes this enlightening chapter by quoting from the works of that great English Enlightenment Doctor and scientist, Erasmus Darwin, Charles Darwin's almost equally famous grandfather.  Erasmus Darwin (1731 – 1802) was an English physician, a natural philosopher, physiologist, abolitionist, inventor and poet.  In his Zoomania book and elsewhere Erasmus blamed the Wesleyans for preaching hellfire and damnation and maintained that their influence left some poor ignorant hearers with their madness uncured, if not so whipped up that they went on to commit suicide. (See ibid., p. 31)  For Darwin and other more enlightened scholars all belief in the existence of supernatural intervention in human affairs was then turned into psychopathology which we shall discuss in the next post.