REFLECTIONS ON OUR MENTAL HEALTH SYSTEM
By John Bell
“I’ll throw your baby out the window!” This is what Alida said about our new born when I invited her to come stay with us in the midst of her first of many psychotic breaks. Fortunately, my wife Dorothy was more level-headed and said “Absolutely not! She is not coming to stay with us!” Instead, the police finally came and took her to Bellevue Hospital where they shot her up with Thorazine and there she stayed for weeks until released.
When I met Alida in the 1970s, she was a distinguished child psychologist and head of child psychological services at a major New York City hospital. She began hosting spiritual exploration sessions in her home on the Upper West Side of Manhattan. Every Friday night, a group of us would gather to meditate, chant, talk, and sometimes smoke marijuana. Besides Alida, regulars included a philosophy student, a modern dancer, a teacher, a couple of therapists, a minister, and some political activists. The evenings were rich in thought, laughter, and heady new age speculation.
Alida began using hallucinogenic substances frequently. Eventually she left her position and career, moved down to a large funky loft near Union Square. It had an old freight elevator that came up from the street and opened directly into her third floor loft. The Friday nights turned into long drumming and chanting sessions. She devoted herself increasingly to spiritual practice but also to drugs and alcohol. Things began to spiral downward.
One night I got a call at 2 am. “John, this is God calling!” The phone clicked off. It was Alida. It knew something was not right. I dressed, left Dorothy with our newborn daughter, and made my way down to her loft from my house in Harlem. When I got upstairs, the place was a mess and she was pacing around with a wine bottle in her hand. When she saw me she lunged at me swinging the bottle at my head. I moved in and pulled her close, holding down the hand with the bottle, and whispered into her ear, “Alida, I’m here. It’s me, John. I know you are in there. You are safe. It’s okay. You can relax.” Her body relaxed and she slumped into my arms for a moment. Then she stiffened again and began cursing me. I kept holding her close and telling her that I knew she was okay inside there, that she was safe with me.
I had been trained in a peer counseling method that I’d been practicing and teaching for previous five years. The theory says that by nature, human beings are inherently valuable, deeply caring, immensely intelligent, enormously powerful, naturally cooperative, infinitely creative, and innately joyful, except to the extent that we get hurt. The hurt obscures our natural state and we act in rigid and patterned ways. Healing happens when a person is listened to well enough that she or he can release the distress feelings through crying, laughing, shaking with fear, getting angry, and other expressions of emotions. Deep distress, even some types of psychosis, is seen essentially as a state of mental terror which requires enormous amount of safety, acceptance, and patience provided by a caring and skillful person in order for the release of fear to occur.
In addition to this training which prepared me to keep Alida’s humanity in view even as she was swinging at me and acting “crazy,” there was another deep life stream that helped me do this. I had grown up with a father who was alcoholic. When sober, he was kind, humorous and loving. But when he was in the grips of alcohol, his mental states and behavior could show up as angry, or maudlin, or morose, or dangerous, or bizarre. I saw a lot of “crazy-like” behavior up close. I repeatedly watched as alcohol lit up his inner suffering and changed him from kind to crazed, for some long horrible hours, and then it would pass. So, when Alida had these episodes, I felt like I’d seen this before.
In the course of that first night, she alternated between crazed rantings and lucid talk. I knew I couldn’t leave her alone. That’s when I thought of bringing her home with me where I thought she would be safe. This was a well-intentioned but naïve impulse. In truth, I was not prepared to handle this situation. First, Alida’s state made her dangerous to herself and to others. She might have even acted on her threat to “throw your baby out the window”. Secondly, I had never worked with someone in a psychotic state, so I was over my head, wanting to believe that I could help her myself. Even if I had had the skill, it would have been a full time job for who knows how long to try to bring her out of her psychosis. Dorothy, my partner, sobered me quickly. So, instead, I called 911 for an ambulance, and rode with her to Bellevue Hospital.
Over the next three years, I would periodically get one of those middle-of-the-night calls from “God”, and I would go down to her loft. One time it was about 6 am on a warm summer morning. The place was in shambles and she looked like a wreck. As before, I immediately moved in close, holding her. She started to cry. For the next few hours we sat on her couch near the open loft window. She would have long fits of gibberish, crazed talk, but with recognizable themes of fear. This would give way to talking clearly about what she was scared of: her father had died of cancer; her lover had died of cancer; and now she had just been diagnosed with cancer. She was terrified. She’d shake and cry about not wanting to die, and about the stored-up grief over her father and her lover. In these times, she was as normal and lucid as she could be. But then she would again be overtaken by terror and bizarre imaginings. I would continue to hold her during these bouts, both to re-assure her that I was staying close to her, and to protect myself.
At one point in one of her crazed moments she began yelling repeatedly out the open window, “Help! Help! I’m being raped!” I couldn’t stop her. A few minutes later, I heard the freight elevator ascending. Out stepped a policeman, and saw me holding Alida. In a flash I realized that I could be in real trouble here. He quickly looked around at the torn up place and at the disheveled Alida. I said in my calmest, professional voice, “Officer, this is my friend. She is going through a hard time. She’s is mentally ill. I’m trying to help calm her.” All the while, Alida is yelling, “He’s trying to rape me!” Fortunately, the officer believed me and not her. He gave me his number in case I needed help, and went back down the elevator. Was I relieved! But, alas, eventually I had to call the medics to come take her to the hospital for another Thorazine stay.
Another time after I got the call from “God”, I arrived in her loft to find her whole family there. She was snapping a bullwhip and ordering them to do her bidding. And they were complying! What a perfect scene of a fantasy played out—the daughter finally whipping her parents and siblings into shape! Upon sizing up the situation, dodging the bullwhip, I moved in close and held her, as before, whispering that I knew she was in there, that she was safe, that she could relax. Her bizarre behavior subsided. But by then the family had called 911 and the ambulance arrived to take her away again.
I would visit her in the hospital each time. When the medication, rest, and therapy had calmed her system, and she was once again the Alida I knew and loved, although subdued and exhausted, she would tell me that through all these episodes, I was one of few people who treated her like a real person and not just a lunatic. Even in her psychotic fog, she could recognize the difference.
I wish I could say that this story has a happy ending, but it doesn’t. In 1979, Alida moved back to her childhood town of Winnetka, IL for few years, and then to Plymouth, Wisconsin where she ran a trout-raising farm. I would hear from her or about her from time to time. She struggled with alcohol and depression. Eventually, she took her life. Here is the notice in the Chicago Tribune, August 7, 1986. This was one of two references I found for her on the internet as I was writing this. A rich life of accomplishment and suffering summed up in a thin, pallid paragraph:
Services for Alida W. Sherman 56, a onetime North Shore resident who gave up a career as a child psychologist in New York to operate a trout-raising farm in Wisconsin, will be held at 7 p.m. Thursday in the chapel at 123 S. South St. Plymouth, Wis. Miss Sherman died Monday in her Plymouth home. She had operated the Silver Spring trout farm near Plymouth since 1981. From the late 1950s until 1979 Miss Sherman, who was born in Evanston and grew up in Winnetka, had been a child psychologist in New York. She lived in Winnetka from 1979 until she moved to Wisconsin in 1981. She is survived by a brother and a sister.
I am writing this decades after I last saw her. The times I spent with her during her psychotic periods are still vivid in my memory. The lessons I learned then and amplified since are also vivid, and have proved useful in many situations. Here are four of them. I offer these reflections knowing that mental illness and its treatment is a complex issue, with no easy answers. I have taught and practiced peer counseling for over 40 years, and have deep experience working with people in severe distress. But I am not a psychiatrist nor deeply knowledgeable in the area of psychopharmacology. Thus, I offer these reflections with respect for all those caring folks who spend their lives in the field of mental health.
1.Always respect a person, no matter what mind state or life condition you find them in. Even in the grip of psychosis, Alida knew that I would do her no harm, that I loved her and never lost site of her humanness. But even if she hadn’t been aware of this, she still deserved respect and dignity, even as she was in the throes of a crazed mind or dangerous behavior. A person’s story is complicated, well beyond anyone’s knowing. The causes that give rise to abnormal behavior and thinking are infinite. A person might need to be stopped from hurting themselves or others, but they do not need to be punished or shunned. This is true for people who are acting “crazy” or “cruel” or “criminal” or “lecherous” or “depressed” or whatever. Each person, if all the forces and factors impinging on his life could be known, would be seen as doing the best he can, given everything. If she could do better, she would. Thus, each human being deserves nothing less than complete respect, plus a good dollop of compassion. The poet Henry Wadsworth Longfellow expressed it this way: “If we could read the secret history of our enemies, we should find in each man’s [sic] life sorrow and suffering enough to disarm all hostility.”
2.Labeling people does not help them, or us. Alida was not a “psychotic” or “a crazy person”. At times her mind was as clear and capable as ever; she was rational and a delight to be with. At other times, fear, biochemistry, or whatever would overwhelm the rational functions of her brain and produce delusional rantings and bizarre behavior. But her state of mind was always changing, as is everyone’s. I find it useful to think of what I call a “spectrum of attention”. At one “end” of the spectrum are people whose attention is locked up in deep distress, who cannot distinguish their imaginings from reality. At this end are people we call schizophrenic or psychotic. At the other “end” are people whose attention is completely absorbed in the awesome and interrelated nature of creation. These are people we call mystics, great spiritual teachers, or realized beings. At any moment, each of us is somewhere along this continuum, sometimes tilted towards our pain and contraction, sometimes toward a feeling of oneness and freedom. And it changes from moment to moment, hour to hour, day to day, stage of life to stage of life.
There is a difference between saying “I am an angry person (or depressed or shy or aggressive or…)” and “I sometimes feel angry”, or “Anger sometimes goes through me”. Putting someone in a permanent box belies the changing nature of reality. Such labeling might seem convenient. It might let the labeler feel more secure, as if we understood it. It might describe a moment in a person’s journey, but it is not the whole truth. Like any stereotype, a label narrows our view of a person, causing misunderstanding and hurt.
3.Our mental health system lacks adequate models of human mental health or adequate resources to help people recover from episodes or patterns of deep distress. Alida was given Thorazine and other heavy anti-psychotic drugs with the expressed aim of reducing the delusional thinking and wild behavior and stabilizing her mind. In effect, it acted as a depressant, numbing many of her mental faculties, adding toxins and other kinds of damage to her system without releasing the hurt and healing the underlying distress that caused the temporary “insanity”. What therapy she did receive was short term and ineffective, palliative rather than curative. What she needed, in my estimation, was a skilled healer-therapist-guide who could stay with her over many, many sessions as she cried and shook and raged and laughed and shivered and talked in fresh ways and unpacked the grief, fear, insecurity, and self-loathing that she carried from her early life, and family history. (On this later point, one of the themes she raised in her sessions with me, sometimes in an angry political rant and sometimes while crying with shame, was her guilt at being related to General Sherman, of Civil War fame, who marched mercilessly through Georgia to the sea killing, looting, and burning everything in his path. This family legacy haunted Alida.)
This level of healing is rarely done in our society. This is what I foolishly thought I could do with Alida in that first episode, but I was ill-equipped. I couldn’t quit my job to be with her full time for months, which is probably what a deep process of thorough catharsis and re-integration would take. My family was not willing or able to have me go into rescue mode. I was not experienced or skilled enough in staying present with someone as she goes through such a deep healing journey. I couldn’t be a sufficient guide. I had no backup help myself. I couldn’t protect her or my family from possible dangers of her psychotic episodes. Nonetheless, I believed then and still believe now that this deep healing process is possible and desirable under the right conditions.
In the years since my encounters with Alida, I have come to believe that doing this level of healing work would require the following: a positive and uplifting view of human nature; a clear perspective about root causes of deep distress and dysfunction; an appropriately human and safe physical environment; a team of healer-therapist-guides who skillfully provide safe conditions, patiently welcome out any and all feelings from the individual, believe in the individual’s ability to heal on the way to regaining his or her own power and intelligence, and stick with the person through thick and thin, as long as it takes to largely recover from the depths of deep mental distress. In truth, I would add a healthy measure of good fortune and grace.
Obviously, this is a far cry from the current practice. There are a few places that do this level of healing work, where experience shows that even in the best of circumstances this work is difficult, challenging, and not often successful. However the dominant model consists of labeling the illness and prescribing medication. The long term care facilities are little more than warehouses for people with deep distress. To be fair, illnesses of some individuals are rooted in organic, and sometimes genetic, causes and are incurable. These folks need safe and humane care in an atmosphere of respect, dignity, and as much self-determination as possible. Also, the judicious use of medications can help manage the symptoms and stabilize a person who can then benefit from therapy. I do believe that the vast majority of mental illnesses could be cured if the conditions listed above were in place. However, our society has not yet embraced this approach. The belief in cure and exceptional mental health as the norm is not there. The majority of mental health professionals are either not trained or not comfortable enough to facilitate the deep emotional work called for. It would require more resource than can presently be covered under most health insurance plans. Thus medication has become the primary treatment.
4.Increased diagnoses are rooted in profit. Unfortunately, a key driver for treatment through medication has become the influence of the pharmaceutical companies. In recent decades there has been a huge increase in the number of mental illnesses that can be identified. The American Psychiatric Association published the first Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952. In the years since then the number of mental illnesses and conditions have multiplied from 182 mental disorders to over 400, with many more added to the most recent edition, released in the spring of 2013. What is going on here? Are there actually more mental abnormalities than at any other time in history?
In part, the multiplication of disorders comes from the effort to make finer and finer distinctions in hopes of directing a more and more precise treatment. This is understandable. But there is another driver. Enter the pharmaceutical companies. These companies make huge profits by selling drugs. They are continuously opening up “new markets” by helping to create new diagnoses and discovering mental disorders in younger and younger people. For example, pharmaceutical companies hired a well-known Columbia University psychiatrist to devise a screening test for middle-school age children. Many school systems now routinely administer this test to students. So what used to be ordinary social growing pains, like shyness or sprouting your wings now get “diagnosed” as a “social phobia” or “ODD—Oppositional Defiant Disorder”. ODD was added to the DSM in 1980. The official symptoms of ODD include “often actively defies or refuses to comply with adult requests or rules,” “often argues with adults,” and “often deliberately does things to annoy other people.” Sounds like many teenagers I have known. Parents are called in and told about their child’s “condition” and informed that there are medications that can treat it. Parents are naturally concerned and want to help their children, and may be conditioned to accept the word of school or health authorities. They may be persuaded to put their child on medication. There is now a multi-billion dollar market for drugs among middle-school age children.
Or consider that ten percent of elementary school boys are on Ritalin or Adderall to treat ADD or ADHA. Ten percent! Normal energetic boy energy, physically active testosterone-laden boys, meant to be out climbing, running, playing ball, riding bikes, building things are, by law, forced into seats in classrooms, mostly to listen to an adult talk, and asked to do small motor tasks using a pencil. Most boys (and most girls too) understandably get restless, maybe even agitated, at this unnatural containment of their energy. So then it becomes a behavior management job for the teacher, using a range of approaches that might include, depending on the inclinations and talents of the teacher, discipline and punishment, busywork to keep young people occupied, carefully constructed and exciting projects that engage student’s minds, or love and rewards. If none of these work, then the child must be ADD or ADHA, and the drugs offer another behavior management tool that helps the teacher. To be fair, a certain percentage of young people, and adults, do in fact have ADD or ADHD, and medications have shown to greatly improve their lives. But the overuse of the diagnosis and the drugs tends to make a pathology of much that is normal active behavior, and adds another label to a young person’s identity.A psychiatrist friend of mine recently talked with me about his growing discomfort with the medical establishment’s tendency to treat with medications rather than psychotherapy, even though he believed psychotherapy brought about deeper, longer range health. He says even the patients want the short term fix of a pill.
The point here is that what may have begun as idealistic efforts to develop medications to relieve suffering have been taken over by the profit motive which now drives the need to develop of ever more illnesses which can be diagnosed in ever more populations which results in ever more people becoming conditioned to accept drugs as the cure, but which drugs mostly manage or mask the root causes rather than cure them, and often add their own level of toxins and damage to the system. A mental health approach that is driven by profit, not health, is a disaster.
Final comment. My friend, Alida, is only one of millions of people hurt rather than healed by labeling, disrespect, a poor model of model of mental health, and the ready use of drugs in a mental health system that, despite being populated by well-intentioned and caring professionals, is part of the problem. Most every family in this country has someone who has struggled with mental illness. Alida and our family members deserve better. I am convinced that better is possible.
John Bell is a Buddhist Dharma Teacher who lives near Boston, MA, USA. He is also a founding staff and former vice president of YouthBuild USA, an international non-profit that provides learning, earning, and leadership opportunities to young people from low-income backgrounds. He is a certified peer counselor, an author, lifelong social justice activist, international trainer facilitator, father and grandfather. His blog is www.beginwithin.info and email is email@example.com. (12)J