May is Mental Health Awareness Month.

The Menninger Clinic family of staff and patients recently experienced one of life’s stressful events: moving.

Even though we all love our wonderful new facility, the process of preparing for the move, making the move and settling in have created stress that is challenging for us all. During Mental Health Awareness Month, one of the areas of focus for the month is stress and how it affects health.

When under pressure, we all experience similar feelings, such as fatigue, irritability and a decreased ability to cope. We may experience headaches, stomachaches or other physical manifestations of tension. However, there is a difference between common stress and abnormal stress. With common stress, the symptoms are temporary, and emotional and physical equilibrium are re-established once the stressful stimulus is over or has significantly lessened. When the symptoms of reaction to stress persist and compromise functioning, it can indicate mental illness.

Sometimes a simple change such as deep breathing, taking a walk, talking with a friend or having a cup of tea can help relieve some of the feelings generated as a reaction to stress. As clinicians, we need to appreciate that we may experience the effects of the strains of everyday life and that simple techniques may be adequate to help us get through periods of difficulty.

Yet our patients come to us with emotional challenges that make them more susceptible to the negative symptoms of the pressures they face, and their response to stressors may evoke maladaptive behaviors. It is our task to do more than provide support and care to help them get through short-term stresses like moving. We must teach coping skills that will help them not only survive stress but prevail over its often deleterious and pervasive effects on their lives and their health.

NFL great Junior Seau commits suicide at 43.

When the news of Junior Seau’s death broke on May 2, my mind immediately flashed back to Dave Duerson. I wondered if Seau was the victim of some heartless act or if he had done this to himself. However, as more details began to emerge — he was found in his home alone, dead from a gunshot wound, a gun near his hand — it became clear Seau had taken his own life. The circumstances of his death instantly drew parallels to Duerson’s own suicide, and naturally, speculation arose about the role chronic traumatic encephalopathy (CTE) may have played in Seau’s death.                                                                        

It may be weeks before an autopsy determines what (if any) role CTE played in Junior Seau’s death, but the paramount concern in this tragedy shouldn’t be what drove him to this end; rather, it should be what could have been done to prevent it. In the wake of Seau’s suicide, scores of opinion pieces and memorials have come out, often offering commentary on the issue of concussions and player safety in professional sports. Brandon Marshall, for example, recently wrote an op-ed for the Chicago Sun-Times, but rather than look for somewhere to lay blame, Marshall looks for a means to preventing further tragedy. 

A professional football player, Brandon Marshall recently announced he had been diagnosed with borderline personality disorder and had been seeking treatment for it. In doing so, Marshall became a passionate advocate for not just mental illness issues, but for treatments available to help individuals with mental illness. In his op-ed piece, Marshall briefly broaches the topic of CTE, but mainly focuses on the stigmas associated with mental illness, gender roles regarding emotion, the idea of the machismo persona in sports and the interplay between the three.

He also talks about the attitudes toward emotional expression that are espoused early on in life (it’s okay for girls to cry, but not boys), and how those attitudes set up misguided perceptions of what defines strength. Marshall argues that this stigma is only exacerbated in professional sports, where an athlete’s ego is the measure of toughness and ultimately, success:

In sports, those who show they are hurt or have mental weakness or pain are told: ‘You’re not tough. You’re not a man. That’s not how the players before you did it.’

“It’s a cycle,” Marshall writes. While in treatment, Marshall had to learn “how to think, not what to think.” Indeed, overcoming decades of a stringent way of thinking takes effort, competent guidance and a good deal of faith. While it was too late for Dave Duerson and Junior Seau, Brandon Marshall saw that he was fortunate enough to break the cycle and understands that it’s not too late for the living. He ardently endorses the various forms of therapy he utilized in treatment — namely DBT, and mentalization therapy — and calls for fellow athletes to utilize the resources at their disposal to get the proper help they need. 

Marshall speaks to the greater need to eradicate stigmas associated with mental illness, thus lifting any potential barriers to successful treatment. The unfortunate fact is that with mental illness, a definitive diagnosis is much more elusive than a broken rib or a sprained ankle. It is not a body part that can be wrapped, iced, stretched and rested back to health. It’s an entire state of being that has to be dealt with in a coherent and comprehensive manner.

What brought Marshall back from the brink could prove to make a difference in so many lives. As vital as it is to discern the causes of mental illness (physical trauma, emotional trauma, genetics, etc.), an equal emphasis must be placed on effectively treating these issues as they come to light. Brandon Marshall’s position as an advocate is important in light of this tragedy, but all could be for naught if others don’t step up and reclaim their mental health.

March is Professional Social Work Month. It’s designed to acknowledge that our nation would be less successful without the contributions of America’s 640,000+ social workers. The primary mission of social work is to enhance human well-being and help meet the basic needs of all people, especially the most vulnerable. Given this mission, it is fitting that this year’s theme for Professional Social Work Month is “every person matters.” Social workers help people, who are often navigating major life challenges, find hope and new options for achieving their maximum potential. They function as specialists, consultants, private practitioners, educators, community leaders, policymakers and researchers to achieve this mission.

Below, several social workers at The Menninger Clinic share their reflections on “every person matters” and how it has impacted their personal and professional identity. Join us as we celebrate the social workers at The Menninger Clinic and the social work profession.

Adapted from www.socialworkers.org.

Lauren Walther, LMSW
Professionals in Crisis Program

My interest within the social work profession originally stemmed from a ‘micro’ perspective: working with the individual. For me this began as a child listening to friends in need and enjoying being in a helping role. Over time I began to find myself in positions of helping others personally and professionally until I realized to be truly effective I’d need more education.

After graduate school I worked with teenagers who struggled with poverty, had little to no support at home and found mentors in gang members and through crime. From there I began to work with the family system, realizing that working only with the individual would provide limited impact. By working in that system, I soon realized that it’s made up of individuals, all of whom have their own difficult history, which impacts the adolescent. Recognizing rather than blaming authority figures in those troubled systems, and treating them as people who matter, helped me to better understand each member, and begin to intervene in ways that would be most effective for them as a family and as individuals.

Hans Meyer, LCSW
Pathfinder, a community integration program

Everything we do in our life and work can be boiled down to relationships. In my high school and college years, I was treated like I mattered by a variety of teachers, professors, supervisors and mentors.  I was not just a job to them. Looking back, I feel like they each took on the mission to model for me, implicitly or explicitly, what it meant to be in a relationship. The message I consistently received from them was that “I mattered.”  They made me feel important and a part of their life on an ongoing basis regardless of my daily performance.

Social work is about instilling this feeling in as many of our patients as we can, regardless of our theoretical orientation or job description. I have embraced the activity of mentalizing with my adolescents and families, co-workers and in my own personal life since being here at The Menninger Clinic because it is the best tool I have learned that encourages this feeling. The social work value of “dignity and worth of a person” really gets to the heart of “every person matters.” I believe that when a person feels like they are important to others, they are better equipped to treat themselves and others in a similar way.  

Chris Grimes, LCSW
Adolescent Treatment Program

I’m proud and honored to participate again this year in recognizing the 28 social workers who work tirelessly with patients at The Menninger Clinic, including a social work colleague who heads up The Clinic’s outreach program with the chronically mentally ill. Altogether, we have nineteen full-time social work staff, along with four contract social workers, four postgraduate fellows and two advanced social work graduate student interns. This is a large group of clinicians with diverse backgrounds and interests. However, it is a comfort to know that drawing us together is the important notion that in our lives and in our work “every person matters,” the very apt theme of National Social Work Month this year.

It has been my experience that the person drawn to social work has a strong belief in the “dignity and worth of every individual” as stated in the Social Work Code of Ethics. Moreover, we are involved in a profession whose mission is “… to enhance human well­being and help meet the basic human needs of all people….” These concepts inspire and help us move forward and challenge stigma, bias and prejudice that impact our patients, colleagues, family, friends or even ourselves. 

Here at The Clinic we remember that Karl Menninger, MD, turned to psychiatric social workers as those who could “glean from a study of broken personalities…the sociological and environmental data necessary to evaluate the case.” (1930)

It is not difficult for me to see that the principle of “every person matters” is clearly reflected in our current social workers – talented clinicians who not only dedicate themselves to best practices in patient care, but also extend these virtues, often passionately, to everyone in their sphere. It is a great honor and privilege to be a part of this group of stellar, supportive and caring professional social workers. 

Janice Poplack, LCSW
Director of Social Work

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.

We have all known someone who is struggling with or has suffered from an eating disorder.

 Some are dealing primarily with anorexia, restricting their intake of food and fluids to the point that basic body functions are threatened, even life itself. Others find themselves driven to bulimia, bingeing on foods to excess only to purge them from their bodies by vomiting, taking laxatives, over-exercising or a combination of these. This puts their bodies at risk for dangerous fluid and electrolyte imbalances that can trigger conditions including heart attack, liver damage, kidney failure and death. Other people overeat without purging and gain unhealthy amounts of weight, increasing their risk for hyperlipidemia, cardiovascular disease, hypertension, liver disease and diabetes.

The National Eating Disorders Awareness (NEDAwareness) Week is an effort by healthcare providers and others committed to raising awareness of the dangers surrounding eating disorders and the need for early intervention and treatment. This year’s theme is “Everybody Knows Somebody” because awareness of eating disorders is crucial to recognizing the illness so that it can be treated as early as possible and treated properly.

Eating disorders contribute to altered mental states, which puts patients at increased risk for suicidality, depression, psychotic episodes, OCD and other kinds of self-harm such as cutting or burning themselves and substance abuse. The social stigma about body image compounds the stigma around mental illness.

There are so many misconceptions about eating disorders. Some people attribute these eating-disordered behaviors to vanity or social acceptance. Others think it is a personality problem in which the patient is trying to exhibit “control” over their lives or others through their illness. The real etiology usually lies in deeply felt damage from trauma at an early developmental stage, undermining the most basic of Maslow’s needs for sustenance and survival.

The good news is that increased awareness can help get those suffering from eating disorders into appropriate treatment, which to be successful requires a team approach of psychiatric, medical and nutritional care. Eating disorders are serious, life-threatening illnesses, and it is important to recognize the pressures, attitudes and behaviors that shape them.

The legendary Whitney Houston

My treasured colleague, Tom Ellis, wrote an impassioned post protesting simple-minded thinking about Whitney Houston’s death. I, too, am irked by glib media interpretations of the behavior of stars. I find it challenging to fathom the complexity of individual patients who courageously confide their inner life in psychotherapy; I am loath to pretend to understand anyone I observe only from afar. And diving into the murky territory of death wishes in my part is a prime example of fools rushing in where angels fear to tread. Far more foolish than angelic, I proceed.

Muddling through

I agree with my colleague in some respects. We can kill ourselves in the quest for pleasure — witness heart-stopping doses of cocaine. I am partial to the idea that addictive drugs “hijack” the normal brain reward systems. And there is no reward greater than escape from unbearable pain. Karl Menninger viewed nonsuicidal self-injury as “anti-suicidal” behavior. Cutting, banging or burning oneself can reduce emotional distress dramatically. Such behavior appears “self-destructive” only to the outside observer; to the person engaging in the behavior, it is self-preservative, a way of muddling through to live another day. The same might be said of addiction.

Penchant for self-destruction

I am less sanguine than my colleague about a thoroughgoing constructive orientation in human nature. He writes, “…All of us have the same basic agenda to find happiness and manage physical and psychic pain the best we can.” I find myself more sympathetic than he with Freud’s view of divided forces in our nature, constructive and destructive. Freud gave us a naturalized version of the age-old battle between good and evil, an enduring contest. I find ample evidence that destructiveness can be self-directed.

Granted, we are the products of evolution, and survival is the engine of evolution. But we should be humbled by the fact that well over 99 percent of species that ever lived are now extinct. Evolution does not necessarily lead to progress, much less to perfection. Perhaps we humans are not unflawed in our orientation toward life. We are hardly single minded, as Freud well understood.

Our capacity for gaining knowledge through science is stunning, but we also are developing increasingly sophisticated, life-threatening technology. Prescient about the human species’ capacity for self-annihilation and the anxiety that goes with it, Freud wrote before the advent of nuclear weapons. I wish our sociological knowledge were keeping pace with our dangerous technological advances. We humans might be unique among species in our seeming penchant for self-destruction. Above all, we need to learn how to cooperate before we join the other 99 percent (not the non-super-rich, the extinct).

Death instinct

I have no idea what was on Whitney Houston’s mind in the hours, days, weeks, months and years before her death. And I have no idea if Freud’s idea about the death instinct is best regarded as crazy or as something we should take very seriously as we witness horrific destructiveness across the globe. Our consciousness is misleading; we are aware of a tiny fragment of our mental activity, and we have little idea what our brains are up to. I think we should be more modest in our conjectures about others and, as Freud showed us, even about our own motivations. And we must be careful about generalizing about addicted persons or any other group in light of enormous individual differences — another engine of evolution.

I am not ready to throw up my hands in the face of destructiveness and self-destructiveness. I cannot fathom solutions to global problems. I cling to one uncommonly wise young woman’s reply when I asked patients in an educational group, “What gives you hope?” She replied, “I can be surprised!” But I take heart in small-scale victories. Day in and day out in this clinic, we help patients grapple more successfully with their self-destructiveness.

Whitney Houston dies at 48.

Fox TV personality Bill O’Reilly has encountered a firestorm of protest in defense of Whitney Houston following his provocative remarks about her death. However, he may have done all of us a favor by opening a door to discussing something on all of our minds.

Here’s what he said (as part of a general statement opposing efforts to reform drug laws):

Nobody takes drugs for that long if they want to stay on the planet. She follows in the footsteps of Elvis, Janis Joplin, Michael Jackson, and scores of other entertainment figures. The hard truth is that some people will always want to destroy themselves, and there’s nothing society can do about it.

If we filter out some of the harshness (and perhaps add names like Judy Garland and Joseph McCarthy), we might express this as a question:

Just as a healthy lifestyle reflects desire to live, doesn’t it make sense to assume that people with unhealthy or reckless lifestyles have a death wish?

While this brings us uncomfortably close to “blaming the victim,” one can’t help but notice something appealing about this perspective. It certainly gives us something to do with the anger we inevitably feel about poor decision-making by someone we cared about. And, conveniently, we note that the issue gets buried with the individual. After all, the problem was in the mind (soul?) of the deceased. Case closed. Better yet, as seen in O’Reilly’s remark that such will always be the case and “there’s nothing society can do about it,” we are forever excused from worrying ourselves, looking for ways to address other influences, whether social, psychological, biological or otherwise. Nope, not much you can do about human stupidity.

Must feel pretty crummy to Whitney’s family…

Here’s the fly in the ointment: Applying this mindset, we suddenly all have a wish to die. Certainly this includes all smokers and couch potatoes, who we know have shorter life expectancies. But even among us non-smoking, exercising, healthy-eating, seatbelt-wearing respectable citizens with good judgment, which of us adheres perfectly to our medication prescriptions? (Studies say less than half.) Who among us never exceeds the speed limit or occasionally takes a peek at our cell phones while driving? Doesn’t this point toward at least a hint of a death wish?

A death instinct?

Probably not. Sigmund Freud thought this was an intriguing idea and wrote at length about a “death instinct,” but eventually abandoned it as unsupportable. Suicidologists still occasionally talk about “indirect suicide” in the form of everything from unsafe sex practices to sky diving; but as we do so, we soon find that the construct of suicide itself evaporates, because it ultimately becomes identical to living itself.

A human agenda

A more reasonable idea is that we — all of us — have the same basic agenda to find happiness and manage physical and psychic pain the best we can. The fact that some get lost on this quest and end up destroying themselves in the process does not change the fact that the wish in most cases is not to die, but to find a path, at least, to a more tolerable existence.

By the way, here’s another problem with observations like O’Reilly’s: A circular explanation is one that loses meaning because it turns back onto itself. To wit: Why did Whitney do those unwise things, resulting in her own death? Because she wanted to die. How do we know she wanted to die? All together now … because she did all those unwise things!

Really, O’Reilly. We can do better than this. Scientific research over the past few decades has revealed a great deal about motivations behind unhealthy and self-destructive behaviors, and effective treatments have resulted. We still have a lot to learn, and we still lose battles more often than we would like. But stigmatizing and blaming the sufferers only impedes our efforts to win the war.

I guess the answer to that question depends on whether you are asking about understanding mental disease or mental illness. Just to clarify: Disease is a diagnostic term used to classify a pathological condition. Illness is more contextual. An illness is the subjective experience that arises from living with a disease. There are many published accounts of illness narratives written by people who live with a disease, but I don’t believe I have ever heard of a disease narrative. So back to the question: How well do we understand mental illness?

Through the written word 

Tom Ellis, PsyD, ABPP, recognized how noted psychologist Marsha Linehan courageously publicly disclosed her experiences with living with mental illness and suicidality. He called our attention to others in the field who have written eloquently about their own experiences with mental illness, such as Kay Redfield Jamison (An Unquiet Mind) and Norman Endler (Holiday of Darkness).

Many others also have shared their mental illness experiences,including Pulitzer Prize-winning author William Styron (Darkness Visible: A Memoir of Madness), poet Sylvia Plath (The Bell Jar), actress Brooke Shields (Down Came the Rain), attorney Terry Wise (Waking Up: Choosing to Die, Deciding to Live) and writers Joanne Greenberg (pen name, Hannah Green) (I Never Promised You a Rose Garden) and Julie Hersh (Struck by Living), to name a few.

David Lovelace (Scattershot: My Bipolar Family), Michael Greenberg (Hurry Down Sunshine), Patrick Tracey (Stalking Irish Madness: Searching for the Roots of My Family’s Schizophrenia) and Christopher Lucas (Blue Genes: A Memoir of Loss and Survival) have given us views into families’ experiences with mental illness.

Through the arts

Self-portrait with Bandaged Ear, 1889, by Vincent van Gogh

This is merely a partial listing of mental illness narratives. There are also many other genres that are readily available to help us understand the experience of living with mental illness. Who has not gazed upon a Van Gough self-portrait and not recognized distress and known it in a slightly new way? The photographer Michael Nye (Fine Line: Mental Health: Mental Illness) has given us a photo voice exhibit that profoundly captures the lives of some of the most vulnerable, poor, desolate people with mental illness.

Learning from the arts

The question is: How do we use these media to really understand mental illness? After all, it is in understanding something that it becomes less taboo, that the stigma is reduced.

I have a couple of ideas about this. First of all, what would happen if medical, nursing, psychology and social work educational programs made understanding the illness experience a core part of the curriculum? Programs that include courses in narrative medicine are aimed at training interdisciplinary clinicians in the art of using patient and family illness narratives to provoke reflection, empathy and compassion in the service of patient-centered care.

Second, what would happen if researchers applied narrative analytic methods to the published illness narratives? Lt. Cmdr. John Fleming, a psychiatric nurse practitioner in the U.S. Navy, and his colleagues conducted such a study of Michael Nye’s exhibit. Reports from such studies have the potential to stimulate future research in understanding how to incorporate the patient and family experience into clinical practice.

Next, what would happen if narrative medicine were included as a core component of continuing education programs? Such a development could help enhance the development of the therapeutic alliance by providing an additional lens through which to interpret the patient’s perspective. 

Regardless of the approach, the call to patient-centered care is a call to understand the illness experience. I believe in doing so we will be better informed about mental illness.

Have you ever made a wish that came true? Or considered Fate or Providence to be at play when someone or something entered your life at an opportune time? What about dreaming about an event that intriguingly played out in real life? Have you ever mourned the passing of a loved one, only to inexplicably feel their presence?

Most people probably identify with such experiences, and many would assign value or meaning to them—perhaps identifying them as divine intervention, believing in the gift of clairvoyance or feeling a special connection with the spiritual realm. Such experiences can impact an individual’s life by providing reassurance, guidance or a stronger sense of spirituality.

Is it possible that people’s stories about miracles or spiritual encounters are merely symptomatic expressions of something more ominous—a psychiatric illness perhaps? From a diagnostic viewpoint, such experiences may be labeled “magical thinking,” “delusional” or “psychotic.” Could they be chalked up to a diagnostic label? And how do clinicians have the authority to make this determination—especially as they interpret such experiences through their own spiritual (or agnostic) lens?

A matter of perspective

The issue of spirituality versus psychopathology seems to be a matter of perspective. Overvalued ideas about one’s spiritual belief system can be interpreted by others as symptoms of a personality disorder or psychosis. How do we differentiate between healthy spirituality and psychopathology? The Diagnostic and Statistical Manual of Mental Disorders (DSM) offers some guidance, defining delusional beliefs as beliefs “not ordinarily accepted by other members of the person’s culture or subculture.” However, with ever-increasing spiritual sects, it can be difficult for the clinician to know what beliefs might be shared. Additionally, the DSM references the level of impairment, context of behavior or belief and symptoms that may be substance-induced. Thus, isolated experiences that are not part of a broad pattern of disturbance should not be diagnosed.

At times a patient’s spiritual beliefs can interfere (from the clinician’s perspective) with their ability to function in a social, occupational or academic setting. These cases can be challenging to filter through the diagnostic decision tree, especially when it seems as though no one can know for sure the extent of truth to any unusual experience.

For example, I met with a patient who had a strong sense that he was “different” from others; he believed he had lived many past lives and had a special connection with the world that most people he encountered could never understand. He described countless “messages from the universe” directing him in his everyday activities. 

From a diagnostic perspective his descriptions bordered on quirky if not impairing. He became quite concerned with physical symptoms, such as feeling like his body was being taken over by an unexplained force, which doctors could not explain. He continually found hidden meanings in TV commercials or friends’ comments that most would consider ordinary experiences. Although he was able to function for the most part independently, he maintained an outlook on the world that made it difficult for him to relate to others and ultimately caused rifts in his relationships.    

SCID platform

The topic of unusual events, or what some define as paranormal or supernatural phenomena, is not typically at the forefront of most clinical discussions between patients and clinicians, in part because they are not of primary concern for patients seeking treatment. However, in my role conducting the Structured Clinical Interview for the DSM Disorders (SCID), I have a platform for discussing them.

In the psychotic symptoms module is a question about unusual religious experiences. Inevitably, patients pause before asking, “What do you mean by unusual?” At this point a dialogue ensues regarding a patient’s personal experience with the supernatural (however they choose to define it) and their interpretation of this experience. The question “Have you ever had visions or seen things others couldn’t see?” sometimes elicits responses about encounters with apparitions of deceased loved ones or patients hearing their name being called or seeing menacing, dark entities. 

In the schizotypal personality disorder module are questions about experiences with the supernatural, unseen forces and unusual perceptional experiences. Interestingly, many patients will disclose personal experiences, such as encountering an animal they believe is the spirit of a deceased relative or describing an ability to predict events that others cannot. Some patients report being guided by entities not of this world—or being protected from near fatal situations by inexplicable forces. Such experiences, while unexplainable, may have a profound impact on their outlook for the future or their belief in forces that transcend our worldly knowledge. 

I am always struck by patients’ initial hesitancy in sharing these extraordinary events; however, I understand discussing them during a diagnostic interview can seem more stigmatizing than normalizing. I find interesting patients’ insistence on presenting their story with the disclaimer,

“This probably means I’m crazy, but….”

It seems as though there is a tendency in the mental health field to dismiss such occurrences as not only strange but indicative of psychiatric illness, implied, in part, by the fact that such questions even exist in the SCID. At times patients decline further elaboration because their experience is deeply personal and meaningful and fear a diagnostic label or quizzical reaction would be demeaning. 

James vs. Freud

The topic of supernatural experiences is nothing new in psychology. In fact, psychologist and philosopher William James wrote about an enormous range of spiritual experiences in The Varieties of Religious Experience: A Study in Human Nature. James believed in an unseen reality and that mystical experiences contributed to a more fulfilling life. Rather than categorizing them as pathological, James sought to include spirituality as a healthy component of psychological functioning. James recounts examples of patients’ mystical encounters in which they felt connected to a higher power through events that ranged from auditory experiences of God talking to them to inexplicable physical energies. 

In contrast to James, Sigmund Freud tended to pathologize religion and religious experiences. In The Future of an Illusion, he depicted religion as a manmade illusion created in an attempt to control human instincts (cannibalism, incest and desire to hurt or kill one another). Freud, an outspoken atheist, likened religious practices to neurosis, claiming that humankind had an obsessive need for protection which could only be achieved through a relationship with a father figure (God). Unlike James, Freud viewed spiritual beliefs and experiences as illusions, in part because they lacked scientific explanation. The opposing viewpoints of James and Freud reflect the significant divergence in clinical perception regarding spiritual experiences that persists to this day. 

So is it psychotic or on the fringe of psychosis to believe in a spiritual connection with a deceased loved one? Should you be diagnosed with schizotypal personality disorder if you believe that ordinary things in your life are meant to give you a special message? The answer is a resounding…it depends. Schizotypal personality disorder is diagnosed not on the basis of isolated experiences or quirky beliefs, but rather on a cluster of problematic traits. Psychotic disorders are diagnosed on the basis of a major break with reality and significant impairment in functioning. It is unlikely that science will ever be able to make an absolute distinction between what is symptomatic of psychopathology and what is merely an aspect of diverse human experience. This illustrates the significant influence of cultural considerations on diagnoses and demonstrates that diagnoses cannot be reduced to a science. Ultimately, we must rely on human judgment, which makes my work all the more intriguing.