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Enabling and Shame

As a harm reduction psychologist, it’s always a pleasure to work with parents who have the instincts and skills to maintain good communication with their teenager as well as the courage (and energy!) to set appropriate and consistent boundaries and limits.

Sometimes, however, these skills can be a double-edged sword and work against us, especially when the emotional and behavioral instability of our child keeps pushing us out of our parental ‘driver’s seat’ and into the passenger seat—or even worse, the back seat.

Being in the family back seat contributes to the fear that develops when we start losing control of a child’s behavior. This fear often motivates us to become even firmer in our resolve to ensure our child’s safety while keeping ourselves sane along with the rest of our family.

Enabling as a badge of failure

Parents learn about the ‘evils’ of enabling when support groups and counselors, in the interest in creating healthier boundaries, encourage us to directly confront our kids and not back down to the often self-destructive manipulating that at-risk teens will engage in.

The Ongoing American Tragedy Update

Several weeks have passed since I first wrote about the Tucson atrocity (AN ONGOING AMERICAN TRAGEDY) expressing dismay at what I described as an ongoing American tragedy: How the American public’s ignorance about mental illness and the shame and stigma associated with mental illness and mental health treatment directly contributes to the lack of appropriate treatment that could reduce the vulnerability of the mentally ill and the likelihood for them to commit these crimes.

I’m encouraged that the predictable blame game has seemed to run its course and some of the national debate has shifted a bit towards turning to a more responsible discussion of the woefully inadequate mental health and addiction treatment system in the United States and what needs to be done with the architecture of this system to reduce the likelihood of another attack.

As information became available about the perpetrator’s drug abuse issues, the silence about the drug abuse use part of the problem has been deafening.

Let me fill you in on the field of addiction psychology’s version of the blame game. It occurs thousands of times every day when decisions about who will provide the care for a mentally ill person who also abuses alcohol and/or drugs. Or, alternately, when a substance abusing person with serious mental health issues needs treatment.

Substance abuse and addiction never exist in a vacuum. Although I’m simplifying here for illustration purposes, addictions are a result of the interaction among our biological and emotional makeup and social/environmental influences. Problems that addictions cause are associated with the negative choices we make, often as ways of helping us feel better in the short run.

As humans we tend to move towards rewarding activities and away from uncomfortable ones. People with mood problems (depression, bipolar disorder), anxiety (panic attacks, excessive worry, obsessive-compulsive rituals) and schizophrenia (unwanted systematic delusions and beliefs) sometimes turn to alcohol and drugs as available options to self-medicate their brain disorders that create constant and intense emotional pain for them.

Professionals refer to this common and intertwining nature of mental health and addiction problems as a co-occurring disorder. Unfortunately, our treatment system forces us to split the person’s problems up in order to find the appropriate treatment program. Treatment programs are usually more prepared to address either the mental health problem or the addiction. This makes finding adequate, comprehensive care extremely difficult.

Our field has come a long way since the mid 1980’s, when, as an on-call clinician looking for an emergency hospital admission for a person who likely would be out on the street without immediate treatment, I’d have to stand by on the phone while administrators [a.k.a. those paying for the care] would literally argue over who had responsibility for the care. And I’d often be on the other end having to deliver bad news to the client: the comprehensive care he/she really needed wasn’t available. I then had to make a makeshift plan for the person to ensure the person’s safety for that moment until we manufactured a Plan “B”. These administrative “turf” battles are rare now and the dichotomy between mental health care and addiction is better today, but not much.

It’s evidenced daily by the responses in hospital emergency rooms when a mentally ill intoxicated person shows up, or when police are called to homes when a mentally ill family member is acting scary and threatening. “He’s drunk, he needs to sober up”; “He’s high on drugs. What do expect us to do?” are the usual responses of first responders. Parents and family members of those with co-occurring disorders live with the fear, dread, shame, guilt, and helplessness associated with these scenarios that are regular occurrences for them.

When someone has diabetes, cancer, or heart disease, their condition usually can be treated comprehensively with the necessary multidisciplinary approaches available. Good luck to the person with an emotional problem and corresponding substance abuse problem looking for quality, comprehensive care. It rarely happens. Part of this is due to the above dichotomy in care, but the major problem is due to the unwillingness of insurance companies and shortsighted employers who purchase insurance plans for their employees to provide funds necessary for the adequate care of mental health and addiction problems.

The Mental Health Parity and Addiction Equity Act of 2008 provides insurance for employed people. People with severe co-occurring disorders can’t keep jobs, so not much help there. President Obama’s Patient Protection and Affordable Care Act of 2010 is a step in the right direction, but the reality is that insurance rarely provides enough coverage for the seriously mentally ill and/or the chronic disease of addiction.

DJ Jaffe, a national advocate for the seriously mentally ill, displays insight and irony in his Huffington Post depiction of “Mom [as] the new mental institution, given the responsibility to see their loved one stays well but not the ability to enforce medication compliance or get the mental health system to take action….Mrs. Loughner never wanted Jared to become a headline for hate. This is the mental health system we have in America. It caters to the well not the ill”

It takes an enormous amount of courage to ask for help for an addiction or mental health problem. It’s usually even more difficult for parents and family members (and yes,especially the Mom’s!) to reach out for help for their loved one. I’m hoping the national debate will allow more people in the mainstream of America to learn more about the true nature of mental health/addiction problems and treatment, reduce the shame and stigma associated with asking for and receiving help, and give our moms and all the members of our families a better chance to be productive members of our families and society.

What happened in Tucson is a horrendous tragedy. What’s happening on a daily basis to the millions of Americans with co-occurring disorders who are not able to receive proper care is a tragedy we can actually do something about.

Stigma Busting

by Barry Lessin

December 9th, 2010

The stigma associated with addiction and mental health problems in our country is very disheartening. It's pervasive, existing at all levels of our culture and society.

As a provider of counseling and treatment services for these problems, it feels to me like an invisible wall or barrier that my clients and I are often trying to climb over to get to the other side. Then there are the people who are not yet in treatment, who experience stigma as an Everest-sized mountain, too high to begin to even think about climbing.

Dr. Harold Koplewicz, one of the nation’s leading child and adolescent psychiatrists and strong advocate for child mental health, recently posted and article on Huffington Post about the divisiveness associated with children's mental health. His writings are a welcome voice of reason and information in the struggle to lower the stigma associated with mental illness and addiction in our culture.

Some of the same extreme reactions to mental health treatment are seen in other areas such as racial/religious/political differences. Differences between "us" and "other" trigger fear in us as human beings. This fear is a natural physiological survival response otherwise known as the "fight/flight" response that we humans share with other mammals.

Accurate information usually reduces fear: when we turn a light on in a dark room after hearing a noise and see that there's nothing in the room to hurt us, we quickly calm down.

We've made some progress in the addiction field in lowering the stigma barriers to make addiction treatment more accessible to those who need it. We have a long way to go with mental illness, and this dialogue can only help.

Read Dr Koplewicz's article here: Why are People so Divided When It Comes to Children's Mental Health?

A great resource about all things related to mental illness, including an extensive grassroots effort to "bust" stigma at its roots, is the National Alliance on Mental Illness (NAMI).

Mental Health and Primary Care Medicine

by Barry Lessin

November 20th, 2010

Since my practice is located within a family medical practice where I act as a behavioral health consultant, I read with interest, and posted a comment on the article's website, about the following article:

Health Highlights: Nov. 19, 2010 - US News and World Report

What's very encouraging is that primary care medicine has begun to recognize the value of integrating mental health consultants into their practices. On-site psychologists in primary care practices, serving as behavioral health consultants/resources, when added to traditional medical staff/team helps to ease patient access to oft-needed counseling or psychotherapy.

As a psychologist located within a family medical practice, I see first-hand how the stigma associated with seeking mental health is reduced by my presence in the practice, and how the coordination of care between mental and physical health increases the likelihood of improvement in physical health.

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