Say No To Stigma — a blog of The Menninger Clinic

Stories told and lessons learned: the power of patient reunions

by Anne W. Lupton on September 1, 2010 · 0 comments

In just a few weeks, Menninger will host its second annual Patient Alumni Weekend, which is kind of like a class reunion, only without the alcohol.

Promoting this event got me thinking about last year’s inaugural event. Although I’m not a reunion going kind of girl (I’ve never been to my high school or college or grad school reunions), I went to help out and ended up sitting in on a few of the presentations, one of which was given by my fellow blogger Jon Allen, PhD, who writes a lot about attachment, mentalizing and POT (no, not that kind—the Plain-Old-Therapy kind).

At first I felt a bit funny about going to the presentations: I’m not a former patient, although some probably wish I were, and I was worried I might feel like I was invading the privacy of these former patients.

Well, I went anyway, and the truth is, it was the single most powerful, moving experience I’ve had professionally in the nearly three years I’ve worked at Menninger.

Change is possible

For one thing, getting to hear some of these folks talk about their lives after treatment was amazing. Yes, some still had their struggles—no surprise given the recurrent nature of severe mental illness—but many were clearly relishing newfound balance and hope.

One young woman talked about how dramatically her life had shifted in the previous year or so—something she said she never would have thought was possible before treatment. She moved halfway across the country, enrolled in a new school and found a job. She even used the word “happy” to describe herself. If you could have been there to hear how her spirit seemed to sing as she recounted the changes, you’d probably think what I thought at the time: AMAZING.

Stigma comes in different measures

For another thing, it was fascinating, albeit painful, to listen to former patients talk about how the stigma that still surrounds mental illness—maybe even especially for those who’ve been hospitalized—affected them.

Before I heard this discussion, I guess I was naïve enough to think stigma was an equal opportunity issue and that all mental disorders engendered the same level of stigma. Clearly I was wrong: Many of the former patients had struggled with multiple disorders and/or an addiction, and I learned that some were more comfortable sharing with family, friends and colleagues information about one, but not another, of their disorders.

For instance, one alumna said she preferred to keep to herself that she was treated for alcoholism, but that she was comfortable sharing with her co-workers, neighbors, family members, etc. that she had been treated for a mood disorder. But for another alumnus, it was just the opposite: he said he willingly shared that he was an alcoholic, not that he was treated for depression.

Listening to these former patients talk about this made me glad about three things:

They had a safe place to talk about these things (and its corollary: Safe places, like safe houses, are not just necessary, they’re very valuable real estate).
I had the chance to learn about stigma from their perspectives.
I had my eyes opened to just how complex the issue of stigma is.

Which is to say that we must keep talking about stigma and mental illness. Because if it keeps folks like that young woman who’d sought treatment and turned her life around from sharing their stories of recovery and renewal, we’ll never be free of the spirit-crippling, mind-numbing shame that is stigma. And that would be a shame.

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Tagged as: addiction, alcohol, attachment, depression, hope, mental illness, mentalizing, patient, Patient Alumni Weekend, reunion, shame, stigma, The Menninger Clinic

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Psychotherapy: Bring on the POT, but don’t forget the BEER

by Tom Ellis, PsyD, ABPP on August 27, 2010 · 0 comments

First, a clarification: My post “Make my therapy plain, but with a twist” ended with the question (comment, really), “Who says there is nothing new in the world of psychotherapy?” One could easily get the impression that this referred to Dr. Allen, whose post I was discussing. It did not. In fact (as is clear in his latest post), Dr. Allen appreciates advancements in psychotherapy as much as anyone I know. I erred in not noticing the apparent implication of that closing sentence.

However, that’s not to say that sentence was thoughtless or random. In fact, it was born of frustration (call it a pet peeve) over the course of 30 years in the field, hearing statements from a range of people, including patients, students and professionals, that “all therapies are the same,” “There’s nothing new under the sun” and “It doesn’t much matter what a therapist does, patients will get better.”

New remedy on offer

I’m sure Dr. Allen is as bothered by such statements as I am. True, a variety of interventions are generally (though not always) beneficial. However, it does not follow from this that it doesn’t matter what you do. There is plentiful evidence that some interventions work better for some disorders than others (for a sampling of research supporting this statement, visit www.academyofct.org). It is also true that therapy also can cause harm (more on this, perhaps, another time).

Dr. Allen’s post reminds us that the argument about common factors versus prescriptive therapies is a bit like the old “tastes great-less filling” debate: It doesn’t really take us anywhere. Is cure more about empathy or cognitive restructuring? A caring relationship or skill acquisition? Active listening or exposure to feared stimuli? Answer: Yes!

I think what Dr Allen and I are both saying is that the field is moving in the direction of an old-yet-new psychological remedy that I propose we label POT/BEER: Plain Old Therapy, But Empirical Evidence Required!

What works, and why?

The human element that Dr. Allen so eloquently describes has brought comfort and healing to innumerable distressed souls through the years, not only by mental health professionals, but also by members of the clergy, school teachers, family members and other caring individuals who listen well and without judgment. This must continue to be appreciated and cultivated, even (and especially) as we introduce new, more prescriptive, interventions based on the latest research. At the same time, we must seek to better understand how, why and under what circumstances these “common factors” work.

This is not as obvious as it may sound. For example, when therapy relieves depression, patients and therapists alike may give an assortment of explanations: Because I felt accepted and understood. Because I helped her to better understand her past. Because of increased self-affirming thoughts. Etc. All of these processes may have, in fact, occurred, but what was the actual mechanism that lifted the depression?

This is something that we in the research arena seek to understand, because the short answer at this stage is we really aren’t sure. What’s more, we cannot assume that all common factors are helpful for all people.

For example, is empathy beneficial for all patients?

A lesson learned in therapy

The Devil Wears Prada

This may seem like a silly question: Isn’t empathy good for whatever ails you? I will never forget the lesson I learned early in my career from a patient who consulted me for interpersonal problems that she was having, both at work and in her personal life. The reason was clear—she was a bully! Think Meryl Streep in The Devil Wears Prada: a self-made woman who worshipped her creator! She was always right and God help anyone who disagreed with her. Her controlling style made ordinary conversation difficult and therapy well nigh impossible.

Or so I thought, until it occurred to me that my usual efforts to communicate warmth, understanding and acceptance were going nowhere. To the contrary, this woman viewed such “softness” as a sign of weakness, to be disrespected or even exploited. When I adjusted my stance to one of greater distance and started communicating some actual disapproval, her behavior changed dramatically; she actually started listening a bit, and we were able to do some meaningful work.

We can speculate about why this proved helpful; but, the fact is, I was improvising—flying by the seat of my pants, because there was (and is) little in the research literature about matching my relationship style with a specific individual’s problems. As a clinician, I recognize this as part of the artistry that Dr. Allen describes. As a scientist, however, I find it less than satisfying. And as a teacher, I know that “improvise” is an instruction that sends therapist trainees into a state of panic. I hope it is not unrealistic to hope for greater precision in our interventions as our science advances.

As Dr. Allen notes, research into curative factors is in its infancy. We need to know what each individual needs and why he or she gets better. On the other hand, I suspect that how we help that individual get better will always share much in common with Plain Old Therapy. Indeed, it is safe to say that simple humanity will always be a key ingredient in the elixir of healing.

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Tagged as: depression, empathy, humanity, intervention, mental health, psychotherapy, research, therapist, therapy

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Giving equal time to horrible therapists

by Cody Dolan on August 22, 2010 · 4 comments

Last month we shared with you what I’m sure we can all agree is the ideal psychiatric environment: Strobe lights, thumping bass, Lil’ Jon imploring you to “get outta your mind,” a cheering crowd and a frank and open discussion on accepting who you are through the medium of dance all added up to a fantastic two-minute clip that’s no longer available because Fox doesn’t want people to get excited about the incorrectly punctuated So You Think You Can Dance. You can, however, find a very low-resolution copy here.

Today, we present you the other side of that coin, the side that’s all scratched up and ugly like Two Face’s coin in The Dark Knight:

I’m pretty sure no one would see a therapist if the sessions went like this. In fact, I’m pretty sure a few therapists like this would kill the industry.

Aside from the obvious, there’s a lot wrong with this GEICO commercial. A quick rundown:

No one goes to the trouble of finding a therapist, scheduling a visit, clearing it with the insurance company, working up the courage to admit they need help and actually going to the appointment to talk about the color yellow.
I’ve been in a few psychiatrists’ offices, and I have yet to see a couch/recliner like that.
It’s a little dark in there, no?
What, exactly, is a “jackwagon,” and why is it a bad thing?

Of course, absolutely none of these issues stop the commercial from being hilarious. R. Lee Ermey is a national treasure. I laugh every time he tosses the tissues away in disgust.

But I’m curious what you think. Is this commercial harmless fun, or does it contribute to the stigmatization of mental illness?

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Tagged as: mental illness, psychiatric, psychiatrist, therapist

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Therapy: How do you know when you’ve had enough?

by Tom Ellis, PsyD, ABPP on August 19, 2010 · 3 comments

“All those years, all that money….”

So begins “My Life in Therapy,” an autobiographical saga that appeared recently in The New York Times Magazine. Here, Daphne Merkin writes in great detail about her 40-plus years (!) in therapy, mostly psychoanalysis. Early in the piece, she starkly declares,

“To this day, I’m not sure that I am in possession of substantially greater self-knowledge than someone who has never been inside a therapist’s office.”

Oof.

At this writing, more than 600 comments to her article have been posted online, ranging from “Thank you for this eloquent and insightful account” to “Grow up and get a life!” By eyeball reckoning, the latter outnumber the former by at least 2 to 1.

What’s interesting (ironically) is that Ms. Merkin never quite comes out and says how she feels about her therapy experience – whether she is satisfied, frustrated about the time and money, enraged about the lack of results or grateful for having had the opportunity. Perhaps some of each.

Reading the article brings to mind a fairly common question raised by therapy patients: How do I know when it’s time to stop therapy? To the casual observer, this is a silly question: Obviously, you stop when the problem is resolved – the panic attacks stop or the depression lifts.

But as you know if you’ve been there, sometimes it’s not so simple:

If my problem is low self-esteem, how do I know when I have “enough” of it? Ditto for reducing one’s stress level or increasing assertiveness. Not to mention more nebulous objectives such as figuring out who I am or finding intimacy in relationships.

Sadly, therapists are often of little help here. Patients asking this question may be met with platitudes such as “Things take time,” or simply more questions, such as “What do you think it means that you ask this question?”

Well, as Freud famously commented, sometimes a cigar is just a cigar, and sometimes a question deserves an answer!

Here’s the short answer: Therapy should end when your goals have been reached or when it becomes apparent that it’s not helping.

Two qualifications: “Supportive” therapy may go on for extended periods of time without apparent progress in the sense that a “cure” is never achieved, but the individual needs help to prevent relapse or severe deterioration. Such therapy, while life-sustaining for some, is quite different from what Ms. Merkin describes.

Second, therapy for the purpose of personal growth and self-knowledge may not fit the framework presented here. I think this may be why Ms. Merkin isn’t more upset: Her therapy may have been more about the journey than the destination.

Fair enough. But it’s my impression that relatively few people enter therapy with the equivalent of a EuroRail pass, without limits on time or money, just traveling for the sake of the scenery. Most are interested in results – a destination, if you will – and most, in my experience, would opt for the quicker, rather than the scenic, route.

If this is where you are “coming from,” then your best bet is to talk frankly with your therapist, preferably early in the therapy process. Now not all therapists speak this “language” (important information, in my opinion), but many, perhaps most, will be more than happy to “go there” with you.

So, what should you discuss? There are actually two related questions here:

What exactly are we trying to accomplish?
Are we there yet?

You’ll notice right away that it’s difficult to answer the second question without a clear answer to the first. The first, in turn, requires “operationalized” goals. This means defining your objectives in ways that are specific and observable.

For example, “being better adjusted” is hard to measure and means different things to different people. But if you were asked, “What would we see if you were better adjusted?” you might list things like worrying less, socializing more and sleeping better, all of which can be measured.

Even an apparently straightforward goal like “overcoming my depression” is too vague, because it may mean one thing to you and something quite different to your therapist. But exploring this together with your therapist might help identify goals like crying less often, resuming sexual activity, reducing indecision and thinking better of yourself, all of which reflect recovery from depression. Such goals are observable and less impressionistic than simply wondering if you are “getting better.”

Another goal to consider (a given with many therapists) is the internalization of the therapeutic process, what some refer to as “becoming your own therapist.” This is important when it comes to relying on yourself rather than needing to re-enter therapy whenever life presents you with new challenges.

So, here’s the bottom line: It’s time to end therapy when you determine that your goals have been met (unless, of course, you want to set some new goals). On the other hand, it may also be time to stop (or make a change) if, after reasonable time and effort, your goals haven’t been achieved. The definition of “reasonable” is a matter of opinion, of course, but let’s hope that it’s well this side of 40 years.

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Tagged as: assertiveness, depression, Freud, New York Times, panic disorder, psychoanalysis, psychotherapy, relationships, self-esteem, self-knowledge, therapist, therapy

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Pride and prejudice: the twin pillars of stigma?

by Jane Mahoney, PhD, RN, PMHCNS-BC on August 12, 2010 · 2 comments

You know how sometimes you have a couple of seemingly unrelated experiences and awhile later you make a connection between them? Serendipity! Well, recently, this happened to me.

Pride, prejudice and honor

Men of Honor, starring Robert DeNiro and Cuba Gooding Jr.

I was watching Men of Honor about a week ago. I have always enjoyed the hero’s story in this movie. In spite of all of the obstacles thrown before Carl, he triumphs! At the beginning of the movie Carl meets Jo, a librarian, and is really “taken” with her. Jo is an utter snob, who haughtily (pride) asks Carl about his education. He tells her he has not finished high school. She announces that she is too busy for him. She has high ambitions to go to medical school, and she can’t be bothered with someone who lacks education (prejudice). Undaunted, Carl surprises Jo with one bright flower. She smiles. Carl “melts” her pride with one simple flower, and a true-love life-long commitment is born. In that moment, her pride and prejudice dissolve—the rest is history.

Later, Carl meets up with his Master Chief who lets Carl know, in no uncertain terms, that he will never be a master diver in the U.S. Navy because no black man has ever accomplished this—and basically this isn’t going to happen on the Master Chief’s watch either (prejudice). Carl retorts, “I am making something of myself, Master Chief” (pride).

I realized as I was watching the movie that pride can come in two forms: the arrogant, disdainful, haughty form and the pride that comes from a healthy sense of self-respect. Prejudice is always the same – it just closes the door.

Pride, prejudice and a Pulitzer

A few days later I started reading To Kill a Mockingbird with my 14-year-old granddaughter. I thought this could be a great bonding moment for us, especially since this the 50^th anniversary of this Pulitzer Prize-winning novel, but I digress.

In one scene, Tom has been taken to jail accused of raping a white girl. Atticus, Tom’s lawyer, is sitting guard outside the jail anticipating there might be trouble for Tom. Sure enough, trouble comes knocking. A mob of townsfolk

Gregory Peck starred as Atticus in the film version of To Kill a Mockingbird

descend with a vengeance (prejudice). It is Atticus against the mob, and the odds are not in his favor. He tries to reason with the group, but has no luck. Scout, Atticus’ young daughter, stumbles onto the scene and suddenly realizes that she and Atticus are over their heads. Then she remembers her mother’s advice about how it helps to talk with people about what they are interested in. So, she starts cheerfully greeting one of the men, mentioning that his son is in her class at school. She continues talking about his son, how they get along, and how he’s doing in school. Basically, she talks to the man about something important to him. The man eventually loses enthusiasm for going after Tom and tells the mob, “Let’s go.”

I started thinking that this was another way to “melt” prejudice, even if only temporarily. Atticus puts his arm around Scout, and they walk home together. You can picture the pride Atticus feels about Scout in this very moment.

Pride, prejudice and the military

The next day I was driving to work listening to NPR. Army Vice Chief of Staff General Peter Chiarelli was being interviewed about a study the Army had conducted related to suicide in soldiers. The general talked about all of the stresses related to deployment, but he also talked about the stresses of being a young adult in today’s world. He mentioned the common factors of trying to make it in a world of economic uncertainty and inflation. He talked about drug use and family discord and many other real life problems that soldiers face each and every day. He also mentioned the stress many soldiers face from living in a military culture in which pride often overrides compassion for those with mental illness (prejudice). He assured the public that is changing.

The next news segment featured a report about the Tragedy Assistance Program for Survivors (TAPS). I was so taken aback when I heard a young widow interviewed about her husband, who died by suicide while the family was on vacation at Disney World. I tried to imagine the shock, trauma and grief that young family experienced. She talked about how she and her children were ostracized (prejudice). Then she found out about TAPS, which she and her children began to participate in. She spoke about being honored as a family whose deceased family member was appreciated for his service. They began to heal because someone honored their loved one. Nothing more, nothing less. I started thinking that honoring someone in this way is another method some people have used to help “melt away” the stigma surrounding suicide.

Connecting these three stories underscored for me the need for all of us to find novel ways to melt away hurtful pride and prejudice in so many areas of life. All three stories highlight some way a person changed a situation for the better through making a positive human connection. The case of the TAPS story is an example of how healing relationships can foster dignity and respect and dissolve stigma in real life, not just in books and movies.

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Tagged as: mental illness, posttraumatic stress disorder, prejudice, research, soldiers, stigma, substance abuse, suicide

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Psychotherapy: can we grow more potent POT?

by Jon G. Allen, PhD on August 9, 2010 · 2 comments

More invested in what is important than what is new, and protesting the proliferation of new therapies with their accompanying slew of acronyms (e.g., CBT, DBT, IPT, MBT, etc.), I have declared myself a practitioner of POT: Plain Old Therapy. In response to this declaration, my colleague, Tom Ellis, responded, “Who says there’s nothing new happening in the world of psychotherapy?”

Dr. Ellis has not persuaded me to give up POT. But his counterpoint to my blog post leads me to introduce a caveat: while respecting the essential ingredients, we must strive continually to improve the quality, effectiveness—indeed, potency—of POT. In advocating POT, I do not mean to imply that we learned long ago how to conduct psychotherapy in the most effective way and that there is no need to question, modify or improve our practice. We have much to learn from research on psychotherapy and, indeed, the quality of research on psychotherapy is improving. Dr. Ellis’s critique made me aware of the extent to which I am continually striving to learn more and improve the quality of my practice.

Perhaps being hooked on POT will allow me to speak out of both sides of my mouth without concern for self-contradiction. On the one hand, I believe that some essentials of psychotherapy are venerable and cannot be improved upon. These essentials boil down to the quality of the human relationship the therapist is able to establish with the patient.

In this sense, therapy is an art.

Therapists vary from one another in their capacity to form a therapeutic relationship, and their capacity to do so also will vary from patient to patient. I think this therapeutic capacity is fundamental to the therapist’s humanity. We all share a common core of humanity, but I believe that we differ from one another in being more or less skilled in being human. I find myself admiring some individuals who seem to me to be gifted at being human.

I also find psychological theory and research helpful in understanding what goes into this skill at being therapeutically human: the capacity to mentalize (i.e., to be emotionally attuned to mental states in self and others) and the thoroughly intertwined capacity to form secure attachment relationships. This core of our humanity develops—more or less completely—in the context of attachment relationships. What makes for a good parent or romantic partner makes for a good psychotherapist. Of course, as effective psychotherapy demonstrates, we can always improve our individual humanity, that is, become more skillful at being human. Perhaps it makes sense that psychotherapy is a common part of the training (or development) of psychotherapists—maybe the most essential part for many.

The conduct of psychotherapy is a rather messy amalgam of the therapist’s humanity and expert knowledge, art and science. Thus, on the other hand: in addition to developing increasingly refined evidence-based treatments for specific disorders, we can continue to refine our understanding of the “common factors” that cut across different brands of psychotherapy (i.e., cognitive-behavioral, interpersonal, psychodynamic).

Group psychotherapy

Whether we call it “talk therapy,” “generic psychotherapy” or “plain old therapy,” we can clarify what we are aspiring to do and do it more effectively. From this perspective, we have most to learn from research on “mechanisms of change,” that is, the psychological processes catalyzed by psychotherapy that facilitate amelioration of psychiatric disorders along with improved functioning and quality of life. Attachment security and mentalizing capacity are examples of potential mechanisms of change, but research on these factors in psychotherapy is in its infancy.

Dr. Ellis has made me aware of the hope that the POT of tomorrow will not be the POT of today. In writing this post, I was reminded of the 2008 address our esteemed colleague, Irv Rosen, gave to graduates of the Menninger training programs. Among many other distinctions, Dr. Rosen was the first graduate of the Menninger postdoctoral training program in clinical psychology. I conclude with a quotation from his inspiring address, which applies to psychotherapy as well as psychiatric treatment as a whole:

The techniques that characterize a clinic or hospital at any given time are ephemeral, provisional, to be inevitably replaced by newer and better methodologies. What forms the core of a place of healing are its values…. I am confident that those values of hope, transmitted through a caring relationship and sustained by a spirit of ever-present inquiry, will continue to inspire your work….

To the good fortune of a great many, Dr. Rosen, a master therapist, served for many years as the director of the psychotherapy service at The Menninger Clinic when it was located in Topeka, Kansas. As I hope this brief quotation illustrates, he is an exemplar of a person who is gifted at being human.

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Tagged as: attachment, cognitive-behavior therapy, humanity, mentalizing, psychotherapist, psychotherapy, The Menninger Clinic, therapy, treatment

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Self-help: listening to the noise of love

August 6, 2010

Recently I’ve been hearing instructive quips about my behavior, as in “get right with the world” and “negative thoughts draw negative thoughts.” At first I believed I was merely hearing voices. Then I realized my whispering wife was essentially proselytizing on behalf of some self-help gurus who have written something called The Vortex. The Vortex [...]

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Psychiatry: the ultimate arch nemesis?

July 30, 2010

As it says in my bio, I like to read; it’s one of the few hobbies having a 2-year-old allows me to keep up with. Aside from traditional works of fiction and non-fiction (and the nigh constant Sandra Boynton books), I read a lot of comics (a genre that deserves its own de-stigmatizing blog if [...]

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Chipotle doesn’t care about the stigma of OCD

July 27, 2010

Recently a coworker went to Chipotle Mexican Grill for lunch. She came back with some righteous fury to go along with her burrito. “How can a company that advertises they do everything the right way put out a bag like this?!” she wondered. So I took a picture of that bag with my phone. (Here’s [...]

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Make my psychotherapy plain, but with a twist

July 23, 2010

Jon Allen’s post “Is psychotherapy going to POT?” is spot on in terms of describing the quandary faced by psychotherapists and their patients with respect to the double-edged sword of “prescriptive therapies.” New weapons Indeed, recent decades have brought us many new “weapons” to use against some of the most troubling psychiatric conditions. For example, [...]

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← Previous Entries

a blog of The Menninger Clinic

Change is possible

Stigma comes in different measures

New remedy on offer

What works, and why?

A lesson learned in therapy

“To this day, I’m not sure that I am in possession of substantially greater self-knowledge than someone who has never been inside a therapist’s office.”

If my problem is low self-esteem, how do I know when I have “enough” of it? Ditto for reducing one’s stress level or increasing assertiveness. Not to mention more nebulous objectives such as figuring out who I am or finding intimacy in relationships.

What exactly are we trying to accomplish?

Are we there yet?

Pride, prejudice and honor

Pride, prejudice and a Pulitzer

Pride, prejudice and the military

In this sense, therapy is an art.

Affiliates of Menninger