As a research/diagnostic interviewer, it’s my job to determine if a patient’s symptoms are severe enough to be labeled “clinically significant” and thus to warrant a psychiatric diagnosis. This is much easier said than done. 

Diagnosing clinical syndromes, such as depression or anxiety, is much more straightforward than diagnosing personality disorders. To meet criteria for a personality disorder diagnosis, the patient must have several traits characteristic of that particular disorder – a whole pattern of traits. Thus, diagnosing personality disorders is a two-step process. The first step is to determine if the patient meets the threshold for various individual traits. The second step is to determine if the patient has a sufficient number of traits within each category to qualify for the diagnosis.

Common personality disorder traits    

Recently, I have been entering information about personality disorder traits that patients have met into a database, and I have noticed several personality disorder traits that are the most common among patients at The Menninger Clinic. One is “rigidity or stubbornness,” which is one of the traits considered in the diagnosis of obsessive-compulsive personality disorder. According to the current data, more than a third of patients meet the criteria for the “stubbornness” trait. The Diagnostic and Statistical Manual for Mental Disorders-IV (DSM-IV) gives no guidelines regarding the prevalence of this trait. Based on our findings, a substantial minority of patients either believe they are stubborn or have been told by others that they are stubborn. This begs the question: Exactly how stubborn does someone have to be to meet the criteria for the stubbornness trait? 

The Merriam-Webster Dictionary defines stubborn as “unreasonably and perversely unyielding.” The DSM-IV description is a tad more in-depth. Persons who are stubborn are so concerned about having things done the one “correct” way that they have trouble going along with anyone else’s ideas. These individuals meticulously plan ahead and are unwilling to consider changes in plans. Such persons are wrapped up in their own perspective and have difficulty acknowledging the viewpoints of others. Their rigidity frustrates friends and colleagues. Furthermore, persons with this trait might recognize that it is in their best interest to compromise, but they stubbornly (for lack of a better term) refuse, arguing that it is “the principle of the thing.” The diagnostic trait of stubbornness or rigidity means more than simply being “unreasonably and perversely unyielding.”

Borderline personality disorder

Another common trait I observe is “chronic feelings of emptiness,” one of the traits of borderline personality disorder. In fact, one third of patients have this trait. Merriam-Webster defines empty as “having no purpose or result” or “marked by the absence of human life, activity or comfort.” The DSM-IV adds little to this definition beyond the point that people who suffer from chronic feelings of emptiness get easily bored and are continually seeking something to do. “Emptiness” is left to the eye of the beholder.

The DSM-IV offers some explication of stubbornness and emptiness, but the decision is left to the interviewer as to whether a patient indeed has the trait at a clinically significant level. There is no clear line distinguishing normal from clinically significant levels of a trait. This is a judgment call for the interviewer, taking into account the degree of functional impairment that the trait causes. For example, a person’s stubbornness may be so extreme that it inhibits him or her from maintaining mutually satisfying relationships. Similarly, persons may feel so empty inside that nothing provides them with joy. For a trait to be functionally impairing, there must be an enduring and pervasive influence on the person’s behavior or attitude. It is important to note that traits are only a part of the constellation of the associated personality disorder.

Traits vs. clusters

Moreover, the distress or impairment is not based on any simple trait but rather several traits that make up the disorder. For example, other traits of obsessive-compulsive personality disorder include preoccupation with details, perfectionism, excessive devotion to work, unwillingness to delegate tasks and so forth. We must also keep in mind that individual traits (stubbornness) and clusters (obsessive-compulsive personality disorder) can be beneficial in moderation. Having too little stubbornness might lead to being too easily swayed or influenced.

Other obsessive-compulsive characteristics such as a need for order, structure and organization can certainly be helpful. Think of Steve Jobs: He was notorious for his need to have things exactly right, and he was tremendously successful because of it. Once again, it all comes down to the level of clinical functional impairment that a trait or cluster causes. In personality disorders, this occurs mainly in the context of relationships. As I have illustrated, the diagnostic manual goes beyond the textbook definition found in the dictionary.

More generally, there is an inherent difficulty in drawing a bright line when all traits come in degrees. It is important to avoid overdiagnosing. When we overdiagnose we risk stigmatizing the patient. When given the diagnosis of a personality disorder, patients are liable to misinterpret it, thinking they are being told they have a “bad personality.” Not true: The diagnosis refers to a specific problematic aspect of personality functioning, not the entire personality. A person might have a personality disorder coupled with many positive personality traits. In my work as a diagnostic interviewer, I aspire to pinpoint problems to help guide treatment. Yet treatment must be based on a full understanding of the whole person.

In my work conducting the structured clinical interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID) at The Menninger Clinic, I have the distinct privilege of discussing with patients, among others things, personality traits. This aspect of my job is particularly enthralling not only because I enjoy listening to and learning about our patients, but also because patients, for the most part, equally enjoy discussing their life experiences.

Patients help guide the interview by completing a brief personality questionnaire, which is concluded prior to the interview. They are then invited to expand on their answers, provide examples and generally talk about the kind of person they believe themselves to be. The SCID has been instrumental in uncovering problematic personality traits that can significantly impact a patient’s clinical treatment.

Personality traits

Problematic personality traits may seem readily recognizable; yet interestingly, personality disorders are some of the most under-diagnosed disorders in mental health treatment. Patients typically seek treatment for more acute problems, such as mood disturbance, anxiety and substance abuse, and often they experience relatively rapid relief of acute symptoms with the aid of medication and therapy.

By contrast, personality disorders require long-term treatment, typically including extensive psychotherapy, which, while effective, is by no means quick. Treatment for personality disorders, however, is especially critical as problematic personality traits can lead to conflict and stress in interpersonal relationships, which in turn play a role in mood disturbance, anxiety and substance abuse.

Failure to diagnosis

So why the failure to diagnose personality disorders? First, psychiatric treatment, as mentioned above, is often focused on the most acute concerns (typically mood, anxiety and substance-related). Second, labeling someone with a personality disorder diagnosis can be stigmatizing. Indeed, patients are likely to be opposed to a personality disorder diagnosis, feeling it might brand them as “a bad person” or, worse yet, beyond help. While avoiding stigma, we also must be judicious in diagnosing these disorders and acknowledge that it is hard to draw a firm line between adaptive and maladaptive traits.

Proud to be a narcissist

One of the most recognizable, if not inadvertently glorified, personality disorders is narcissistic personality disorder. Patients who endorse narcissistic traits are, perhaps not surprisingly, quite proud of them. They report:

“I would not be the person I am today if had not taken a hardnosed approach to business. You do whatever it takes, even if that’s at the cost of friendship.”

“If there is a problem I am going straight to the top; they need to know who they are dealing with.”

“The ends justify the means. I couldn’t let anything stand in the way of my success, and it paid off.”

Narcissistic individuals might acknowledge their inflated views of themselves, or they might skirt around how they truly feel, not wanting to reveal any type of perceived weakness. Those who acknowledge these aspects of their personality outright tend to have a well-defended reason for such traits: It helped them be successful. What might not be obvious to them, however, is the personal cost associated with such achievements.

Paying the price

 Extreme personality traits also can contribute to vulnerability to clinical syndromes, including depression, anxiety or substance abuse, in part by creating stress in significant relationships, such as with a spouse or partner, co-workers or bosses. Persons who exhibit extreme personality traits may find themselves at odds with others who do not “buy into” their views, expectations or standards. Extreme personality traits contribute to rigidity and insensitivity to others’ viewpoints. In addition, they can lead to social isolation, reduced opportunities for relationships, limited support networks and less satisfaction in life.

Yet, as obvious as these problematic behaviors may to be others, the person exhibiting such traits may be oblivious to them or their social cost. The individual may be the last to see that the root of their troubles is potentially within their control.

Adaptive vs. maladaptive

 So where is the line between adaptive and maladaptive? Sometimes exploration and reflection can help make patients aware of their maladaptive behavior patterns. Questions I ask in the SCID interview include: “How has this (trait) affected your relationships with coworkers, family members and friends?” “How do you think others would describe you as a person?” “Has this (trait) caused any problems at work or home?” A chance to be introspective and “mentalize” about another’s viewpoint can help an individual learn how their behaviors may be contributing to strained relationships and additional stress in their lives.

Personality traits define us; they make us who we are. They are the instigating factors behind relationships, career choices and life experiences. In moderation, such traits are valuable; in the extreme, they become detrimental to our relationships and wellbeing. So, the next time you happen across an individual justifying their narcissism through their copious achievements—remember the high price they might be paying in their relationships.

For the past week, the vast majority of sports media has focused on the end of the labor lockout in the National Football League. With a spate of free agency announcements, trades, signings and wage negotiations, the lockout has provided sports fans considerable drama in a short amount of time. Amid the fervor surrounding millions of dollars exchanging hands, however, one announcement stood starkly apart from the rest.

Brandon Marshall takes on borderline personality disorder

On Sunday, Miami Dolphins’ wide receiver Brandon Marshall announced in a press conference that he had been diagnosed with borderline personality disorder (BPD) earlier in the year, and he had subsequently sought treatment at McLean Hospital in Massachusetts.

The Beast and his behaviors

Marshall, 27, spoke all of 30 minutes during the press conference, describing a series of events from child abuse to a rash of arrests for various offenses that led him down a dangerous path. From driving under the influence and disorderly conduct arrests to misdemeanor battery charges, there was enough weight in the court of public opinion for most to consider Marshall aptly deserving of his nickname “The Beast.”

Things came to a head this April when Marshall was hospitalized after his wife, Michi Nogami-Marshall, reportedly stabbed him in the stomach (Marshall filed charges and then dropped them). And while Marshall had already been conducting phone talks with clinicians at McLean before the altercation, he cites this incident (where he admittedly tried to trap his wife in a closet to keep her from leaving) as one of the chief precipitating factors in pushing him into treatment.

Battling stigma

After three months of treatment and therapy, Marshall knows he is not fully “healed or fixed,” but understands he now has the necessary tools for his recovery. What’s more, rather than merely publicly admitting to a BPD diagnosis, Marshall has taken on the mantle of dispelling the stigma associated with borderline personality disorder. As he said to the Miami Sun-Sentinel,

“I’ll be the face of BPD. I’ll make myself vulnerable if it saves someone’s life because I know what I went through this summer helped save mine.”

In an upcoming documentary (whose trailer is featured below), video cameras follow Marshall on his journey through treatment. His brave efforts to raise awareness of BPD, combined with a candid look inside his treatment experience, could introduce a large portion of the public to an updated perception of treatment, one that isn’t filled with stereotypes in white lab coats, caricatures in straight jackets and an endless hallway of seclusion rooms.

Actress Catherine Zeta-Jones has acknowledged having bipolar disorder.

Some people will speculate about why actress Catherine Zeta-Jones released information yesterday about her decision to check into a mental health facility for a brief stay to treat her bipolar II disorder. Many of us don’t care about the reason; we just applaud the support and encouragement she is receiving from the media.

On ABC’s Good Morning America today both physicians discussing her announcement and the implications of her illness presented balanced commentary and, in doing so, advanced eliminating stigma. It was a healthy discussion about the facts and did not include any shame, disgrace or negativity, which are often included in conversations about mental illness. Absent from the discussion were “long term negative effects,” “out-of-control” and “crazy.” Instead, we heard “hope,” “treatable” and “successful road to treatment.”

When discussing the disorder, Dr. Igor Galynker, director of the Family Center for Bipolar Disorder at Beth Israel Medical Center in New York City, said, “It can start at any time in a person’s life, and it’s a lifelong illness.”

But according to Galynker, there’s hope for most who have been diagnosed with bipolar disorder:

“It is not curable, but it is treatable with medications and psychotherapy. People with bipolar illness can have productive lives like anybody else, once they’re in treatment and compliant with treatment.”

The first step, according to Dr. Richard Besser, ABC News chief health and medical editor, is to recognize that you have the disorder. Self-recognition will help pave a more successful road to treatment, said Besser.

“When it comes to mental illness, you talk about it more as controlled and managed, and it’s something she will probably be dealing with for her entire life,” said Besser.

Thanks much to Dr. Igor Galynker and Dr. Richard Bessler for saying “no” to the stigma associated with mental illness. We applaud your courage and honesty, and even more, that of Ms. Zeta-Jones.

Editor’s note: Shawna last blogged about the shooting of Congresswoman Gabrielle Giffords.

Now this is the kind of science I can get behind: French psychiatrists and psychologists, who are clearly using their time well and are probably not at all putting off more pressing work, have written a letter to the editor of the journal Psychiatry Research titled “Is Anakin Skywalker suffering from borderline personality disorder?” This, my friends, might be the best letter to the editor of a scholarly psychiatric journal ever. I kind of want to take back all the mean things I’ve said about the French.

While I’m sure you’ll agree this is a wonderful use of science that should be encouraged, that doesn’t mean the subject matter is a joke. Borderline personality disorder (BPD) is a serious mental illness. Individuals who have it generally exhibit unstable relationships, a negative sense of self, inconsistent moods, a high degree of impulsiveness and a sometimes crippling fear of abandonment.

Eric Bui, a psychiatrist from Toulouse University Hospital in France, watched Episodes II and III of the prequel trilogy and realized that Anakin was a good candidate for the diagnosis. According to LiveScience,

Skywalker hit six out of the nine borderline personality disorder criteria as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition. He only needed to meet five criteria to qualify as suffering from the disorder.

For instance, the future Darth Vader showed both impulsivity and anger management issues as an overexcited, lovelorn Jedi. He went back and forth between idealizing and devaluing Jedi mentors, such as a humorless young Obi-Wan Kenobi.

Abandonment issues also surfaced. Skywalker had a permanent fear of losing his wife, Padme Amidala, and he went so far as to betray his Jedi mentors and companions to try to prevent her death.

“From what we know of the future DSM-V, Anakin is a ‘good’ to ‘very good’ match to the future BPD,” Bui said.

Darth Vader meets Hello Kitty

Bui analyzes more of the films if you follow the above link, and it’s a pretty light read if you don’t want to get all science-y. I like to think that Anakin’s wild mood swings are probably responsible for this version of the Darth Vader costume.

I find myself torn on this subject. On the one hand, it’s comforting to note that Bui thinks psychotherapy would’ve really helped in this case, and probably would have stopped Anakin from turning to the Dark Side. Of course, that would mean that the original trilogy wouldn’t exist, and I don’t want to live in a world where that’s possible.

I’m looking forward to Bui and company’s next article on the effects of the prequel trilogy on the psyches of Star Wars fans. I can think of plenty of people who exhibited “both impulsivity and anger management issues” after watching the train wreck that was The Phantom Menace.

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 there ever was one) and, since this is a hobby I quite enjoy and therefore take seriously, I keep up with several comics related websites.

Thanks to this obsession healthy interest, I came across a post, Batman vs. Psychiatry, which discusses various Batman foes who also happen to be psychiatrists (and psychologists, but I’ll use the former as a catch-all for this post). It’s an interesting topic that I wish I had thought of first. Instead, the author is responding to a question posed by an 8-year-old girl. (If this is the kind of thinking they’re teaching in grade schools, I am no longer worried about future generations.)

Batman as society

If you’re wondering why this topic is worthy of a blog post, it’s probably because you:

1. don’t read comics,
2. think they’re for kids and
3. don’t care who Batman fights on a monthly basis.

To this I would reply:

1. you’re missing some great stories
2. they’re actually aimed at adults these days and
3. how could you not care?

Batman is the most popular superhero in the United States in a time when superheroes are in the mainstream.  The Dark Knight made over $1 billion worldwide, and you and I both know you saw it and enjoyed it. No one would much care if this was Aquaman’s rogues gallery, but this is Batman we’re talking about. Batman looks at all those Chuck Norris facts and thinks, “That sounds like a lazy Sunday afternoon.”

The super villains we read about in comics and see in movies are often portrayed as “crazy,” right? Lex Luthor is a narcissist and a xenophobe. The Green Goblin had a psychotic break and (in the movie) developed a second personality after being exposed to super-steroids (or something like that). The same goes for Harvey Dent/Two Face after his fiancee was killed and half his face burned off. The Abomination (the monster the Hulk fought in his most recent (and underrated) movie) is the id unleashed. The Joker…I honestly have no idea what he has.

It had never occurred to me that so many comic book villains came from the world of mental health. Of course, fiction likes to pick on scientists in general; we wouldn’t have the Hulk, the Fantastic Four, Spider-man or Captain America if it weren’t for a scientist making a mistake. Until I read Batman vs. Psychiatry, I hadn’t given the psychiatrist angle much thought.

Batman’s shrinks?

Scarecrow

Scarecrow: His look in the comics changes constantly, but you’ll recognize him from this picture (unless you’re one of the 26 people who hasn’t seen Batman Begins or The Dark Knight). Dr. Jonathan Crane was so obsessed with the psychology of fear that he created a chemical gas that makes his victims experience their worst nightmares. He uses it to get whatever he wants, and then usually gets punched out by Batman because, after all, he’s just a skinny, nerdy dude in a homemade scarecrow costume.

Harley Quinn

Harley Quinn: Dr. Harleen Quinzel was a criminal psychiatrist working at Arkham Asylum when she was tasked with treating the Joker. She fell in love with him and became his psychotic sidekick. (Clearly, the employee screening process at Arkham is less than rigorous.) Unlike Scarecrow, she doesn’t really use her psychiatric training to commit crimes. Instead, she prefers to use old-fashioned violence.

Hugo Strange

Hugo Strange: While he’s not a character a lot of people know about, Dr. Hugo Strange is an important figure in Batman’s story. Strange predates the Joker and Catwoman, and was one of the first bad guys to deduce that Batman and Bruce Wayne were one and the same. Obviously, the only thing the good doctor could do with that info was to try and kill Batman so Strange could take his place. That makes sense, right? I believe Strange is dead in the comic world, so this plan worked about as well as you’d expect.

Arkham hallway

Arkham Asylum itself is more than a little problematic. It can’t seem to keep the criminally insane behind bars and sees more breakouts than a dermatologist. Second, the Arkham family was probably not the best clan to start a psychiatric hospital. Founder Amadeus Arkham murdered a man and was subsequently committed to his own hospital. Dr. Jeremiah Arkham, the most recent administrator, recently adopted a supervillain persona himself (and was of course then punched out by Batman).

On top of the dubious family tree, the institution itself is always drawn to look like a straight-up prison. Metal bars on the windows, steel cages around the nurses station and every other prison stereotype you can think of has been drawn into Arkham Asylum. Take a look at a couple of screenshots of the recent video game Batman: Arkham Asylum to see what I mean. A place like this couldn’t rehabilitate a jaywalker.

Batman: Arkham Asylum won several Game of the Year awards and has been hailed as the best superhero video game ever. A toy company is releasing action figures based on the game, and a sequel is already in the works. Hundreds of thousands of game players now think this is what a mental hospital looks like. 

The points made in the article linked to earlier are good ones (Batman’s whole deal is to intimidate bad guys using psychology, his world is a good place to tell stories with a psychological bent, etc.) so I encourage you to give it a quick read. I could go on and point out more evil psychiatrists, but that’d be even more self-indulgent.

But what does this mean?

I bring all this up because I can’t help but think there’s something deeper at play here. There’s a reason why there are so few good examples of psychiatrists in popular escapist fiction, and so many bad examples to point to.

I think we’re scared of psychiatrists in a way that’s different from the way we’re scared of dentists.

We know the physical pain caused by someone rooting around in our mouths will eventually fade. We’ll leave feeling bad about not flossing or relieved because we don’t have to sit through another exam for six months or so but, unless we have seven cavities or something, there aren’t a lot of lasting effects.

We can’t say the same if we give someone else access to our minds. We’re vulnerable when we see a psychiatrist in a much different, much scarier way than at any other time.

At the dentist, we open our mouths.  At the psychiatrist, we open ourselves.

And that’s terrifying.

It doesn’t matter that we learn skills to help us function better. It doesn’t matter that psychiatrists help us understand ourselves and why we behave or think the way we do.  It doesn’t matter that we know how much psychiatrists can help us. In the end, we’re simply projecting our self-doubt, our fear that we’re not good people on the inside, onto the very people who can help us.

So Batman stands in for his readers, punching out doubt and fear in the guises of a scarecrow or a dude with a creepy smile and a sweet beard. Unfortunately, these “victories” over psychiatrists aren’t always satisfying because, while the external foe is vanquished, the internal villain persists.

Because there’s only person who can really beat Batman, and that’s Batman himself.

The field of psychotherapy suffers from acronymania: a proliferating plague of acronyms. Your psychotherapy brand will not be taken seriously if you don’t have a good acronym for it, preferably three letters, although you can get by with four or two. A short list: CBT, DBT, TFP, DIT, CPP, TPP, SIT, ERP, IPT, PCT, CFP, EFT, MBT, RLX, EMDR, ADEP and PE. Ideally, your therapy will qualify as an EBT or EST (evidence-based or empirically-supported treatment), that is, a treatment of experimentally-proven effectiveness that comes with a manual instructing the therapist on how it’s to be conducted.

More acronyms, please

Of course, we also have acronyms for psychiatric conditions: MDD, OCD, PTSD, BPD and so on. The crowning glory is having an EST for a particular condition: CBT for MDD, ERP for OCD, PE for PTSD and MBT for BPD (translation: cognitive-behavior therapy for major depressive disorder, exposure and response prevention for obsessive-compulsive disorder, prolonged exposure for posttraumatic stress disorder and mentalization-based treatment for borderline personality disorder, respectively).

We are truly blessed that clinician-researchers have developed all these ESTs for various psychiatric disorders. We need these specialized treatments for specific disorders and symptoms. Yet there are two problems with this state of affairs. First, to be fully competent in treating a range of psychiatric disorders, the therapist would need to learn 150+ treatment manuals—a daunting task. Second, many patients who seek treatment have a number of different disorders and problems at the same time (e.g., depression, anxiety, alcohol abuse, an eating disorder and personality disturbance).

Do we send such patients to several psychotherapists, as we might send patients to several medical specialists? Does the same psychotherapist administer several treatments sequentially, one after the other, or even concurrently?

Common factors

The problem I am addressing is not unique to psychiatry or even general medicine. We live in a world of increasing specialization such that individuals can hardly even keep up with the knowledge in their own field of endeavor. In the field of psychotherapy, there has been, in response to ever-increasing specialization, a countervailing movement for decades: the emphasis on “common factors” that account for the effectiveness of the therapy, regardless of the therapist’s specific technique or the brand name of the therapy. There is solid research support for this focus on common factors: it is extremely difficult to demonstrate that any good type of therapy is more effective than any other.

For example, we know that a positive therapeutic alliance—a trusting relationship in which the patient and therapist are working together toward common goals—is a major contributor to the effectiveness of therapy. Another important common factor is the therapist’s empathy. Recently, we have been advocating another common factor based on attachment theory and research: mentalizing, that is, an open-minded or mindful attentiveness to mental states such as thoughts, feelings and needs in oneself and others. It is a truism that psychotherapy requires interest in what is going on in the mind—and a meeting of minds. We use our colleague, Peter Fonagy’s, phrase for this process: holding mind in mind. We describe the ubiquitous role of mentalizing in relationships—including psychotherapy relationships—in our book, Mentalizing in Clinical Practice.

New psychotherapy brand

I am more concerned with common factors than specific techniques; I aspire to mentalize and help my patients to do so with me; and, not denying my competitive response to social pressure, I feel a need for a catchy acronym.

Hence, after more than four decades of practicing psychotherapy, I have decided on my own brand of psychotherapy: POT, Plain Old Therapy.

A patient once asked me at the beginning of our first session, “What kind of therapy do you practice? Talk Therapy?” I replied, “Yes, Talk Therapy, that’s what I do.” But I like POT better than TT.

To the extent that psychotherapists are returning to a common core of effective elements, the psychotherapy field might be going to POT. For many patients whose symptoms are multifaceted and rooted in problems with self and others, POT is in order. I acknowledge that POT is not optimal for treating patients with specific disorders for which effective specialized treatments are available. But even these specialized treatments, well delivered, must be laced with POT.

In his popular book, A Secure Base, John Bowlby, the psychiatrist and psychoanalyst who pioneered attachment theory, stated that the psychotherapist’s role is

“to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance.”

In a trauma education group, I once remarked, “the mind can be a scary place.” A young woman in the group spontaneously replied, “Yes—and you wouldn’t want to go in there alone!” She thus epitomized Bowlby, and I have never heard such a trenchant characterization of psychotherapy since. This is POT, as I endeavor to practice it.

A colleague sent me a recent David Brooks’ op-ed from the New York Times about Alcoholics Anonymous (AA) and its founder, Bill Wilson. And like a good op-ed does, it got me thinking; specifically, it got me thinking about two things:  1) how challenging it can be to overcome an addiction, bipolar disorder, borderline personality disorder or any other mental illness, and 2) how grateful I am that Brooks used his column to highlight AA’s profound impact while acknowledging the complexities of treating addiction, despite considerable advances in brain research and the mental health field.

In the piece, Brooks says “in a culture that generally celebrates empowerment and self-esteem, A.A. begins with disempowerment.”  True enough. And it’s my guess that is partly because mental illness, including addiction, is disempowering. It robs individuals of sound judgment, energy (unless, of course, you’re someone who experiences mania), direction, focus, hope, etc.

I’d even go so far as to say that this disempowerment is the definition of “rock bottom,” a common-enough phrase these days, which in my mind can only be a place of abysmal, unadulterated loneliness. It’s no place for a loved one, or even, dare I say it, an enemy.

Rock bottom

Once in, there’s only one way out and that’s up. And the only way up is through the good strong grip–maybe physically, definitely symbolically–of another person’s hand. In all likelihood, that hand will belong to a stranger, perhaps even to one of the 1.2 million members of AA, each of whom could probably teach the rest of us a thing or two about “rock bottom.”

Which leads me to another powerful statement of Brooks:  “Individual repair is a social effort.” When AA proves successful for one of its members, that success is predicated on the idea of social effort.

This makes sense to me, just as its opposite does:  individual disrepair is a social effort, too.

Between nurture and nature we’re each shaped by things beyond our control–not always entirely, of course, but often enough. These things (childhood abuse, death of a loved one, extreme poverty, family genetics, etc.) have a great affect on us as we mature and become independent adults (or at least try to).

Sometimes the convergence of these things makes us vulnerable as adults to addiction and mental illness. No one ends up dealing with alcoholism or mental illness because they’ve been living in a vacuum; so we shouldn’t expect people to overcome these problems on their own either. And when you get right down to it, the mental health profession has always been a social endeavor between patient and clinician. I mean, Freud wasn’t analyzing imaginary patients on his couch all those years ago….

Milieu therapy

At Menninger, you hear a lot of talk about milieu therapy, which is, according to the Oxford Pocket Dictionary of Current English 2009, psychotherapy in which the patient’s social environment is controlled or manipulated with a view to preventing self-destructive behavior. It may sound like a fancy term for group therapy, but it’s far more than that.

Patients here live for weeks with one another and often see each other at their worst. Because they spend so much time together, they reap the benefit of becoming, as Brooks describes AA members, “deeply intertwined with one another–learning, sharing, suffering and mentoring one another.” They see–and feel–the importance every single member of the group has on the rest of the group. It’s pretty potent, healing stuff, and it’s the social effort of the group members that makes it possible.

I’m really glad that someone as prominent as Brooks shared some of the history of AA. He’s got a big following, and it’s not everyday that addiction finds its way into such valuable real estate as this prestigious op-ed column. It’s clear that the stigma surrounding people with addiction, particularly alcohol addiction, has decreased dramatically since AA was founded, and I think Brooks has, whether he intended to or not, whether he knows it or not, has further destigmatized addiction by devoting a column to the topic.

Now if borderline personality disorder, bipolar disorder, PTSD, schizophrenia and all the rest of diagnoses in the world of mental illness can find their versions of Bill Wilson soon, there’ll be more and more of us who will find ourselves just saying “no” to stigma. Plus, Brooks will have more great stories to tell in future columns, and I, for one, am looking forward to reading them.

In case you missed it, CBS recently ran a public service announcement (PSA) about bipolar disorder as part of the network’s “CBS Cares” series. In it, Mark Harmon, the star of NCIS, gives the audience a short, sweet and incredibly compelling definition of the disease. He goes on to say that most people suffer from bipolar disorder for years without diagnosis because the symptoms can be confused with other illnesses, like depression, and encourages his audience to learn more.

PSA

Below you’ll find the video. I’d prefer to give you the clip straight from the source to give CBS their props, but the network’s website doesn’t allow embedding.

Mark Harmon’s PSA about bipolar disorder

You might be thinking, “Big deal, it’s just a PSA that very few people see because everyone has a DVR nowadays and fast forwards through commercials.” You’d be wrong.

Well, you’d be mostly wrong. Yes, a lot of people might miss this PSA because commercials are annoying and we all hate them.

But the PSA I saw was the full 30-second version. That’s 30 seconds of Mark Harmon talking straight to the audience with no cutaways. Even if you’re skipping over commercials, you’ll notice that the normal screen full of flashing images has stopped and been replaced by a static talking head.

And this is Mark Harmon, not the 4^th male lead of the 3^rd CSI spinoff. NCIS was once the #1 show in all the land despite the fact that no one you know will admit to watching it. (Full disclosure:  I watched it up until this year when my two-year-old daughter decided it was her mission in life to wear her parents out so they are in bed by 10 pm every night.) It’s now comfortably in the top 20 and gets close to 4.5 million viewers a week in the key 18-49 demographic.

In other words, Mark Harmon may not be a huge or “hot” name, relatively speaking, but he is a big deal.

Besides being mostly wrong, you’d also miss the point. Harmon directs you to CBSCares.tv, a site dedicated to raising awareness for several causes. Among the usual cancer- and civil rights-related topics you’ll find two that we deal with at The Menninger Clinic:  bipolar disorder and depression. And it doesn’t appear to be lip service. Take a look around and see what you think.

Here we have “America’s Most Watched Network” devoting a full 30 seconds of important advertising space during prime time to discussing a mental illness that a lot of people either don’t know about or like to downplay as a punch line.

Changing minds

You might think “CBS Cares” is trite or insincere or only exists out of the network’s obligation to the FCC, and at one point I might have agreed with you. But then I saw a huge force in the entertainment industry devote quality time to an issue that doesn’t seem to garner as much attention in the media, let alone around the proverbial water cooler, as it should. So I changed my mind.

Thank you, CBS. You’ve helped me feel better about liking The Big Bang Theory so much.

(As if I needed another reason. Come on, that show’s hilarious.)