Joining forces to heal the invisible wounds of war

by John Oldham, MD, MS on January 17, 2012 · 1 comment

 

Returning military deserve the best mental healthcare available.

With the war in Iraq over, our troops are returning home to their families and communities and attempting to re-integrate themselves into civilian life. It is not an easy task, especially for the increasing number of military with posttraumatic stress disorder (PTSD), traumatic brain injury and combat-related depression.

Many appear to be fine physically, but inside, their brains suffer the marks of war. Returning military with PTSD or combat-related depression find themselves quick to anger and at the mercy of their unpredictable moods, or lacking the energy or will to go about daily life. Those with mild to moderate traumatic brain injury, which often goes undiagnosed, may be at a loss for what’s wrong with them. They can’t concentrate or do the tasks required at work or at home. They just know something isn’t right.

Joining Forces

In January, as president of the American Psychiatric Association, I joined leaders of several national healthcare organizations along with the Departments of Defense and Veterans Affairs at the White House launch of Joining Forces, an effort organized by First Lady Michelle Obama and Dr. Jill Biden to help returning military, particularly those with posttraumatic stress disorder, posttraumatic brain injury (TBI) and combat-related depression. Joining Forces has a three-part goal:

  1. educate the public about PTSD, TBI and combat-related depression;
  2. improve access to healthcare when needed; and
  3. help returning servicemen and servicewomen find meaningful employment when they leave the military.

The stigma of mental illness and the culture of the military dissuade many members of the military from seeking the psychiatric help they so desperately need. An estimated 50 percent of returning military don’t get it. Access to quality psychiatric care for former military in the civilian world is also a challenge. I am proud to join our nation’s leaders, military and medical establishment to change that.

Joining Forces comes along at a crucial time for our country and military. Over the next four years, more than one million servicemen and women will be leaving the military—at one of the toughest economic periods in our country’s history. Many of our military are returning home with brain injuries because, thanks to amazing advances in medical technology, our troops are surviving their injuries in greater numbers instead of dying from them. For example, it used to take hours for those wounded in combat to go from the field to the operating room table. Now it takes an average of only 22 minutes—dramatically increasing survival rates for our troops.

While we are doing a vastly better job treating the bodies of our military, we have a long way to go in treating their minds.

On the home front

We are making progress on this front here at Menninger, following a long tradition of taking care of the military patient. In particular, Pam Greene, PhD, RN, a former member of the military and our senior vice president and chief nursing officer, has been actively training mental health professionals on suicide prevention in military veteran populations. Suicide is a tremendous problem for the military; in fact, statistics released in December identified 260 potential suicides in 2011.

But there is hope. Treatment for PTSD, TBI and combat depression does work and can help returning members of our military manage their conditions and live full lives. It is our job as mental health professionals to continue efforts to reduce stigma and other factors that block access to care. For their service and sacrifice, our military men and women deserve nothing less than our full attention, respect and the best mental healthcare available.

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Mentalizing and machines: Imagining the future of psychotherapy

by Debbie Quackenbush, PhD on January 10, 2012 · 0 comments

Can the future of psychotherapy be found in an iPad?

As I read Dr. Allen’s recent blog post “What’s Next? Psychotherapy by iPad?,” I had a few thoughts. I was reminded of the seemingly natural gradiosity that we humans possess in believing that there are certain behaviors that only we can do, or that we do best. I recall reading When Elephants Weep: The Emotional Lives of Animals and having that same thought: Is it not grandiose to believe that, as a species, we have the corner on the market of complex emotional worlds? As an avowed middle-aged geek, I was also reminded of Data from Star Trek: The Next Generation and his quest to be human. In one episode, the wise Captain Picard mused that perhaps humans ought to aspire to be more like Data.

Attachment and machines

In all seriousness, I think one question that begs to be answered is whether or not computers can simulate mentalization. I have a pleasant memory of the old computer program ELIZA that was created in the 1960s and programmed to give Rogerian-type responses to “clients” who chatted with it. Many people found ELIZA to “feel” strikingly human and some reported feeling helped by “her.” A more modern version of ELIZA can be found in MindMentor, a computer-programmed “chat therapy” developed by a pair of Dutch psychologists. According to one survey, 47 percent of individuals who used the program reported that they had been helped by it. Did they feel heard? Did the program mentalize them? Is it possible to attach to a computer in the same way that persons attach to other non humans such as family pets?

Though I realize I am straying away from the topic of mentalization and attachment, as Dr. Allen alluded to in his post, there are other, non-human modes of treating people out there. There are CBT sites, for example, that purport to help people with depression and OCD. Also, as he mentioned, thousands (millions?) of self-help books exists that presumably have helped individuals in their recovery. Did the individuals reading these books feel “heard” or “understood” when they turned the pages? Did the books “speak” to them?

In the future

The most recent Monitor on Psychology, a publication of the American Psychological Association, just arrive in my inbox, and on the front page, it says “Beyond one-on-one psychotherapy.” In Dr Allen’s post, he rightfully mentioned recent thinking by psychologists that we need to try to reach more clients. We ought to be able to provide services in many modalities, and to people who are geographically, financially and mobility challenged. It seems to me that ongoing debate and study regarding alternative delivery methods is inevitable. It’s conceivable to me that, in the future, I might pull out my smartphone and utilize an “app” that helps me think about an interpersonal problem I might be having. Will I feel “attached” to my smartphone? Well, I already am. :) (Just a little textual cue so that you might better mentalize me and the playful spirit with which this post was submitted.)

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Top tips for coping with New Year’s

by Anne W. Lupton on December 31, 2011 · 0 comments

So here we are wrapping up 2011. If you believe the TV commercials, movies and all the rest, celebrating the New Year is the best party of the year, one that everyone wants to attend. But surely not everyone can always be in the frame of mind for a party on December 31. I wondered about those who have to cope with a mental illness and those who care for someone with a mental illness. Surely it can’t be easy for them.

So I posed some questions about this to some Menninger clinicians, and thought I’d share their answers with you. Here they are:

What advice would you give someone currently struggling with a mental illness to help them through New Year’s Eve celebrations?

Thomas E. Ellis, PsyD, ABPP: Keep in mind that most New Year’s resolutions are a waste of time and good intentions, because they are too darned hard and doomed to fail. But here’s one worth considering: To spend a little time each day cultivating kindness and compassion toward yourself. Remember the reverse golden rule: Treat yourself as you would hope to treat others. There are lots of ways of doing this, from meditation that focuses on self-nurturing thoughts to engaging in acts of kindness toward yourself. When was the last time you treated yourself to a funny movie?

Elizabeth C. Cantini, MSN, RN, Professionals in Crisis Program:

  1. Sometimes a smaller group with warm and close friends can be safer and more rewarding to bring in the New Year. 
  2. Try not to get caught up in the hype and mindset of partying with everyone looking so happy and fulfilled. Everyone has challenges and difficulties to face in life.
  3. Celebrating New Years can be fun and meaningful with sparkling grape juice and other beverages without ETOH (regardless of what commercials advertise).
  4. Fun can be within reach while maintaining good judgment and discretion.
  5. Remember to regulate emotions before, during and after New Year’s.
  6. Role play before being around friends if social anxiety is an issue.
  7. Keep in mind that everyone needs friendship and affirmation.
  8. It is a myth that everyone has to stay up until midnight!
  9. Call, contact or visit someone less fortunate.
  10. It’s fun to talk about everyone’s goals and New Year’s resolutions.

Dee Henderson, MSN, RN-BC, Comprehensive Psychiatric and Stabilization Program:

For those struggling with a mental illness, some coping strategies for the New Year’s holiday include:

  • Stay close to friends or family that understand.
  • Take medications as prescribed.
  • Get adequate sleep.
  • Relax by listening to favorite music or doing other activities that relax you.
  • Make realistic resolutions.
  • Allow yourself to grieve losses of this year.
  • Don’t dwell on the negative.
  • Be gentle with yourself.

 Chris B. Webb, CPRP, MT-BC, Rehabilitation Services:

  • Refer to your wellness and recovery plan if you have one. If you don’t have one, start one.
  • Spend New Year’s Eve with supportive friends and family.
  • Spend New Year’s Eve at a place of worship.
  • Attend small parties if you are triggered by crowds and loud music/noise.
  • Ask how they would like to spend New Year’s Eve that will allow them to enjoy themselves without feeling overwhelmed or triggered.

Frances Fisher, CPRP, MT-BC, Rehabilitation Services: Someone living with a mental illness may view not view the coming of the New Year as a new beginning but rather as just more of the same old struggle. Life is not filled with possibilities; only the hopeless feeling of impossibilities and limitations. These feelings may be exacerbated on a day that is exclusively devoted to the celebration of ringing in this New Year. To this person who is struggling, I would say: Step back from the hype of New Year’s Eve and consider that EVERY day is a new day whether it feels like it or not. Know that recovery from mental illness is real and a possibility for your life.

What advice would you give someone with a friend or family member who has a mental illness to help them through New Year’s Eve?

Chris B. Webb, CPRP, MT-BC:

  • Ask them how they would like to celebrate it.
  • Ask how they would like to be supported.
  • Host a healthy and supportive NYE party with soft drinks, play games, share highlights of the past year or best and worst of the last year and expectations of the New Year.

 Dee Henderson, MSN, RN-BC:

For families trying to support a loved one with a mental illness at New Year’s, some strategies include:

  • Reach out to those who are alone or vulnerable.
  • Encourage honesty in how they are feeling.
  • Let them know you truly care about them.
  • Support ways of celebrating that are low-key.
  • Don’t compare this holiday with previous ones.
  • Focus on the positives.
  • Allow them to process feelings with you.

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All I want for Christmas is the end of stigma

by Anne W. Lupton on December 22, 2011 · 0 comments

‘Tis the season for giving and getting.

For many in the military, this “season” has been 10 years in the making. Now that the war in Iraq is officially over, the wishes of many loved ones across the country are coming true with the return of thousands of our brave warriors.

While their return will no doubt be joyful, our veterans face an uncertain future. Perhaps, if they remain in the military, they’ll be redeloyed to Afghanistan. If they return to civilian life, they face the prospect of searching for a good job in a bad economy. Either way, many will find themselves facing the challenge of mental health issues like depression, substance abuse or posttraumatic stress disorder (PTSD).

If that’s not enough, there’s also the challenge of combating the stigma of mental illness. According to the Department of Veterans Affairs, research indicates 10-18 percent of veterans are likely to have PTSD following their return home. While many will receive care at VA medical centers for physical care, many won’t seek treatment for mental health problems. The VA offers plenty of reasons why, including the fear of being seen as weak or of being treated differently. Stigma is the new enemy.

That’s why I was so happy to see this video clip of John Oldham, MD, MS, the president of the American Psychiatric Association and the chief of staff at The Menninger Clinic, talking about some opportunities for giving that the APA has in this battle.

(From American Psychiatric on Vimeo)

There’s lots more we can give to help these veterans–Santa, hint hint–and I hope that the coming years will prove that the mental health community has served these men and women as well as they’ve served us.

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What’s next? Psychotherapy by iPad?

by Jon G. Allen, PhD on December 15, 2011 · 2 comments

Current trends in the delivery of mental healthcare bring this question to the fore. We have long known that psychotherapy is a limited resource, plainly inadequate to meet mental health needs. This limitation is true not only of individual psychotherapy but also of all forms of psychotherapy combined: individual, group, couples and family. Not only is the distribution of mental health services grossly uneven geographically, the pervasive limitations of resources have also become more glaring in the context of healthcare debates and global economic woes.

New service delivery mechanisms

Thus, not without justification, Alan Kazdin and Stacey Blase argue that we must develop and disseminate a far broader array of non-psychotherapeutic interventions, even if the magnitude of their effectiveness is more limited than psychotherapy. Small effects with wide reach are better than no effects, given the unmet needs for mental health services. Joining a venerable chorus, these authors also advocate greater emphasis on prevention as well as the benefits of early intervention.

Yet, as a committed practitioner of Plain Old Therapy, I’m jarred by their advocacy of impersonal interventions now made possible by burgeoning new technologies. Telephone therapy is not new, and enhancing it with video seems eminently sensible; this expansion of service delivery can greatly enhance the likelihood of developing therapeutic relationships. How much is lost (or gained?) in video versus face-to-face interactions is an empirical question. But, as Kazdin and Blase review, we now have an expanding array of web-based interventions and smart-phone applications, for example, to monitor mood and promote coping skills, which are derivatives of cognitive-behavioral therapies.

Key limitation of technology

I find persuasive Kazdin and Blase’s basic point that we need to expand the reach of mental health services and that any form of help we can provide—even if modest in its effectiveness—is all to the good. Moreover, as these authors state, new technologies can serve well as adjuncts to psychotherapy. Books have done so for decades.

What’s next? Psychotherapy by iPad?

Yet, wedded as I may be to my iPhone and iPad, I find chilling the prospect of iPad therapy. A half-century of research on attachment relationships and the value of good patient-therapist relationships should give us pause. Doubtlessly, social networking is changing the fabric of relationships and will continue to do so in ways we cannot foresee. These changes already are influencing the delivery of mental health services and will continue to do so. While we need innovation in mental healthcare, we must wonder how much we will lose in further diluting our social connections—even to the point of relying on computers as proxies for social interactions.

Although we don’t seem to be able to live without them, computers don’t mentalize—hold mind in mind. For that, we need parents, friends, romantic relationships and—especially when things have gone wrong to the point that these ordinary relationships cannot adequately provide needed help and support—psychotherapists.

Reference

Kazdin, A. E., & Blase, S. L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6, 21-37.

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Facing the joys and challenges of the holidays

by Dee Henderson, MSN, RN-BC on November 30, 2011 · 0 comments

 

'Tis the season

This time of year creates different reactions in people. Most of us are blessed to have family and friends with whom to share the holidays, and are able to celebrate all the things for which we are thankful. It is a joyful time: We travel to be with people we miss and share traditions of food, song, decorations, lights, games and warm interactions. To most of us, it is a festival for the senses and a time we look forward to every year.

Unfortunately, not all people will feel that way. Some are alone, depressed, fearful and in need. For them, the holidays bring thoughts of what their lives lack, which can make their emotional distress worse. Travel challenges can trigger panic disorders and destabilize bipolar disorders. Eating disorders can be triggered by holiday foods and the pressure to indulge in them. Alcohol is free-flowing in some settings, and those challenged with addiction have additional pressure with which to contend. People may feel forced to be with individuals they may avoid the rest of the year, and old issues can arise, increasing the stress. Expectations run high, and disillusionment fuels conflicts. Even under the best of circumstances, the holidays are stressful, and stress can precipitate underlying depression and anxiety.

Some surveys indicate that not only do many people suffer from depression during the holidays, some experience distress to the extent that they cannot partake in the season’s activities at all, increasing their sense of isolation and exacerbating existing mental illness. At worst, the depression is severe enough to generate feelings of hopelessness and thoughts of suicide.

The positive news is that support from loved ones and treatment by mental healthcare professionals can help individuals cope with depression, anxiety and other mental illnesses, both during the holidays and when the regular routine resumes.

As you count your blessings this holiday season, consider giving to non-profit organizations that support those with mental health issues in gratitude for the health your family enjoys or maybe the help these organizations provide for someone you care about. 

Have a safe, happy and blessed holiday season!

Editor’s note: Many wonderful non-profits treat individuals with mental illness, do research into the nature of mental illlness and help families cope with the effects of mental illness. These organizations work at the national, regional and local levels to alleviate suffering and offer hope. Many, including The Menninger Clinic and The Gathering Place, Menninger’s psychosocial clubhouse, send out year-end appeals. Others, including the National Alliance on Mental Illness and Mental Health America, urge their web visitors to support their work. To find other mental health non-profits in need of your support this holiday season, a quick Google search will lead you to them. 

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What the Occupy Wall Street movement can teach us

November 18, 2011

  It has been more than a month since the demonstrations in New York began, and protests have spread to cities across the country. Occupy Wall Street started as a movement about economic inequality in the country, with the demonstrators’ common refrain, “We are the 99 percent,” referring to the gap between the top one [...]

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Depression + anxiety = anxious misery

October 31, 2011

In my last post, “Why can’t we just be neurotic?” I complained about problems applying the Diagnostic and Statistical Manual of Mental Disorders1 (DSM) to patients who suffer with a combination of severe depression and intense anxiety. That is, sometimes we are forced to diagnose depression over anxiety when patients have both. Where do we [...]

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Why can’t we just be neurotic?

October 21, 2011

I miss neurosis. It’s long gone from the official manual for psychiatric diagnosis, the Diagnostic and Statistical Manual of Mental Disorders, now in its fourth iteration, DSM-IV.1 Unfortunately, taking neurosis out of the manual has not eradicated it from the human condition. I can attest to that fact from personal experience, and I’ve had many [...]

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National Coming Out Day highlights double stigma of LGBT community

October 10, 2011

October 11 is National Coming Out Day for people who identify as lesbian, gay, bisexual or transgender (LGBT). This day is set aside to acknowledge the triumph and bravery of those who have come out as LGBT to themselves and their loved ones. Coming out is a never-ending process, not limited to a singular event [...]

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