Part IV: Transitioning Into My Professional World

By Marc Rios-Klein

So, I’ve shared my personal story and insight into the life path that I’ve taken. My family issues and experiences with mental illness began at an early age and definitively led me, initially, into various psychotherapists offices. Later, as my desire to gain some type of understanding of psychiatric illnesses and treatment was replaced by a deeper wish to help people with these conditions, I entered the Masters of Social Work program at San Diego State University. My emphasis was in Clinical Mental Health. I found lots of personal healing in gaining, at first, a beginning amount of information and increased empathy for the level of internal struggles that those with these illnesses endure. Later, my formal education grew and, equally as impactful, so did my experiences working with adults of both genders who were struggling with various psychiatric illnesses.

I’d like to segue at this point into various thoughts that I have experienced, observed, and / or taught others while employed at Napa State Hospital. Each year, through my work with a great team of professionals and numerous trainings brought into the facility, my skill level became more effective and I felt that I continued to make a greater impact on those I was treating and caring for. Being real and expressing genuine empathy and respect went a long way in building true clinical trusting relationships!! The ability to work with these adults provided me with a deeper, more meaningful awareness from minor personal nuances to explicit symptoms that have been experienced. This took a great deal of vulnerability as people bared their souls in hopes of gaining the capacity to manage their symptoms more effectively than they had previously.

I also had the privilege of working with the loved ones and significant others of my patients in ways that my family could only dream about when my brother was in psychiatric hospitals. This is true especially with regards to psycho-education and an increased awareness of how their loved one was progressing in treatment and overall, as long as valid signed releases of information were in place. I remember that it was always so painful for loved ones when the patient was unwilling or unable to consent for this open communication. One wishes to be able to provide information to all their loved ones feeling understandably anxious, but are legally bound not to do so. Thankfully, this was more rare than common as the trust level was high, and most of our adults wanted the staff to inform their loved ones of how well they were doing and to help them better understand their illnesses, the forensic psychiatric system, rules of the hospital, and other questions.

This leads me to what I believe is one of the biggest issues and quite the long-standing dilemma within the field of psychiatric treatment and care. How does a mental health professional convince another adult that they are having trouble managing a mental illness (diagnosis) that they don’t believe exists let alone realize is actually happening to them and distorting their understanding of reality? This is especially true, I believe, with two significant symptoms regardless of the diagnosis – delusional thinking and mania. In both situations, a person tends to embrace the intensity of the feelings they experience and the “bigger than life” identity that often emerges in the midst of an elevated and grandiose sense of oneself. These adults report a heightened state of energy, a looseness of cognitive associations, and a grandeur within their thought process. In fact, it seems to me, that it also serves as a coping skill and therefore a defense against negative feelings of low self-esteem, insecurities, and a state of diminished assertiveness socially. I firmly believe that each person who is learning that they have a mental illness reacts differently although, overall, generally not much different than being told one has cancer. There is going to be a period of shock and denial similar to learning about any other serious health condition. Some stay in this state of denial, unfortunately, for a very long time, which can cause further complications. A model of grief and loss, established by Elizabeth Kubler-Ross and accepted internationally, explains that each person goes through five stages of grief / loss leading to a state of acceptance. The first stage is Denial, and then Anger as one begins to move beyond the shock and is overwhelmed by strong emotions. Often, in the third stage, there is a period of Bargaining. (What if I…? Is my illness real? Should I trust what the doctor told me?) The fourth stage is Depression as the reality of what is going on begins to really settle internally. And, finally, one hopefully achieves Acceptance where they can then move forward again. The difficulty, as I see it, is that the majority of the time, a medical / healthcare professional informs one of an illness, they get past the shock and other two stages, and then become more knowledgable as to how they can best help in the management of their illness. With these illnesses, that typical question is not readily available. I believe that if a diagnosis that includes psychosis came along with physical pain like an abscess in one’s mouth, adults would be running to their psychiatrists as fast as they would run to their dentists!! I don’t wish this type of pain to trigger awareness, of course. However, I can’t help but distinguish the reason for so many not being willing, especially initially, to accept what their psychiatrist and / or general medical doctor is informing them. These are tricky illnesses and, yet, I fully believe that the more that we embrace a delivery of care that is rooted in dignity and respect, and promote the values of non-shaming and anti-stigmatizing experiences, the more adults will be more likely to reach their own personal acceptance sooner rather than later.

Lastly, and not to sound too harsh, however I cannot deny my own experiences. Many criminal acts, which sadly included victims, could truly have been avoided if the denial of that person regarding the severity of their mental illness was broken through sooner. I spent almost 20 years working with adults who overwhelmingly did not have criminal-mindedness nor criminal histories prior to committing a felony crime behind their psychosis and / or manic behaviors. My own brother chased my father around the house with a knife one day when he perceived our father in some type of a demonic manner and felt threatened by his presence. Instead of waiting to be harmed as he, and MANY folks that I worked with did, they take an offensive position although they believe they are defending in some fashion and in a righteous way. My brother was unable to catch my father on that almost fateful day. However, too many of the adults I spent years working with had not be as fortunate. They completed some felonious act and then needed to face that full reality once in a clearer state of mind on appropriate and helpful psychiatric medications and receiving treatment. Too often this included a loved one taking the life of another family member, friend, known acquaintance, or possibly even a stranger. Every patient in these situations wishes they had the clarity they now had prior to the tragic event. This scenario exists in our society each and every day. Very nice, beautifully-minded people under the strains of these illnesses can harm those they care the most about and not realize it during the moment. I want to see a major shift in how we communicate the need for early diagnosing and treatment, and to ensure that the services, regardless of financial ability, is readily available for all!!!

6 responses to “Part IV: Transitioning Into My Professional World”

  1. smileandrelax says:

    Hey Marc,

    You asked: “How does a mental health professional convince another adult that they are having trouble managing a mental illness (diagnosis) that they don’t believe exists let alone realize is actually happening to them and distorting their understanding of reality?”

    I don’t mean to make light of this extremely urgent and serious question, and will return to it again sometime. I think it’s important to directly address the problem of psychological denial that you imply exists *in the person who has the illness*, versus existing *in the immediate family (and perhaps extended family)* of the person displaying the symptoms of illness.

    In listening to hundreds of stories at the state psychiatric hospital, family members usually report that their loved one’s mental health crisis (whether severe depression, crippling anxiety, mania, psychosis, or self-harming behaviors) is the culmination of many events which signalled that something was not quite right and was growing worse. And very frequently, family members describe making choices (and continuing to make choices) that facilitate or enable the progression of the disease, rather than intervening in ways that might stop it. It seems fully half of those people attending the group to ask for advice on how to help their loved one find it exceedingly difficult to do what is suggested, so deeply attached are they to their own behaviors and ways of thinking about their loved one and themselves.

    In short, it is very apparent that denial exists in *families*, and that figuring out how to work with denial in any one individual necessarily entails gathering much information about that person’s background and formative relationships. A family member with an obvious pathology is often serving as a conduit through which an entire family may be expressing its distress at what is hidden beneath the surface and unaddressed. A parent’s alcoholism, chronic dissatisfaction within a marriage, the ungrieved loss of a parent, abandonment/lack of supervision, and sexual trauma, are some obvious examples of background issues that impact the emotional development of children and statistically predispose individuals to mental illness later on in life.

    I also think that what a patient grieves is not the illness per se. In both my experiences as a person recovering from illness (in counselling over many years) and in my reading of psychoanalytic theory, it is previously unexamined and unprocessed experiences that are grieved. For example, as a teenager I had tremendous insecurity, began drinking excessively, and had a brief but confusing, and maybe traumatizing, phase of sexual promiscuity. I lacked any of the coping skills to work through the confusion and shame of that time. The loss of self worth lingered on into adulthood until I was provided with a safe and therapeutic environment in which to talk about and make sense of those events. The grieving of the past was not in any way a grieving of my diagnosis or a process of accepting that diagnosis. It was a grieving of what I lacked in adolescence that others had (a supportive and structured environment), a realisation that I was expressing my insecurity and need for approval and acceptance through inappropriate sexual behavior at that time, and then perhaps forgiving my former self for her choices…and embracing a more responsible, wholesome and integrated self.

    In making these comments, I’m obviously displaying my allegiance to certain tenets of psychotherapy, and trying to illustrate with more nuance what you’re putting forth as your beliefs. I hope, though, that my personal example serves to highlight for you the inseparability of the illness from the self. If the self has shame it is the source of the shame that must be addressed and reframed so that the symptoms of illness may be resolved. I have not studied recovery from bipolar disorder, but my reading on recovery from schizophrenia, and again, personal experiences, suggest that in this disease, if the self has anger, it is the source of the anger that must be addressed and reframed for symptoms to be resolved.

    There is not much here to offer that is upbeat. Recovery is very hard work, it can take a very long time, and it involves much looking back and looking inward, and often at that which is unpleasant. When people have mania or paranoia, talk therapy – as far as I know – is most meaningful and effective in tandem with the judicious use of medicine. Medicine stabilises the worst symptoms and actually provides a cushion and support for the talk therapy to proceed.

    There is a book called “Weekends at Bellevue” which is a memoir by the ER Chief at Bellevue in NYC. She repeatedly explains her preference for writing prescriptions by saying that a lot of people need “childhood transplants”. And since she can’t give her patients a new childhood, she gives them a scrip.

    Perhaps human beings who have emotional scars are innately driven to heal and that drive – at least in part – accounts for our unwillingness to medicate away our symptoms. After all, these symptoms – as painful and dysfunctional as they may be – are the only language we have found to express whatever distress we have lived through. It comes as a fantastic relief to learn that we can revisit what happened to us in the past, reframe it, heal, and experience new satisfaction and growth. Medication alone doesn’t quite provide the same effect, although in terms of immediate impact, it is superior, and some diseases do seem to warrant daily medication for optimal well being.

    I really do want to address the question of how to make someone accept treatment. Maybe another blog on the topic in the future? I have become a mental health wonk, lol.

  2. Marc Rios-Klein says:

    Dear Smileandrelax,
    I appreciate all that you shared including and especially our personal connection to this question I raised. Psychological denial is real and as you pointed out can either be shared or even driven by the individuals closest “support system”;their family members. Clinically, it is understood that this occurs to help maintains state of homeostasis, or balance even if it means that someone gets psychiatrically hospitalized. So, I fully agree with your point on this matter.

    I’m sorry that you needed to go through some personal discomfort and confusion in those earlier years but very pleased to learn that you found a safe and therapeutic environment to begin to explore and gain a deeper understanding of these prior thoughts, feelings, & actions. I am a firm believer in productive and healthy psychotherapy and have engaged in treatment personally numerous times over the years individually, maritally, and family therapy. Having an objective third-party with strong clinical skills should allow most people to become more liberated and stronger internally through a non-shame based level of treatment and care.

    Emotional scars and life traumas are real and have effected and psychologically impacted the minds and hearts of anyone who perceives that they can identify with those intense experiences. Everyone can heal or at least begin this process, as you say, of catharting and reframing these traumas. Medications alone are generally not enough to resolve these complex emotions and thoughts, and should be used judiciously as you pointed out. Prescriptions should be for the least amount of medication necessary to maintain mental stability and clarity of thought as well as regulation of one’s mood at a level of awareness to control major highs and lows.

    Overall, the question I raised was certainly not rhetorical. There are concrete steps and efforts to be made however direct challenging has generally not been a successful technique. I believe regardless of methodology and intervention , a genuine expression of compassion must exist and an understanding of mental illness symptoms needs to be at the root of any and all efforts.

  3. Amy D says:

    Wow very informative

  4. smileandrelax says:

    Marc,
    Thank you for offering such a helpful response. It really broadens out my understanding to view denial in the way you described. And my interest is not rhetorical, either. Confronting family members whose behaviors reinforce my illness has been one of the more challenging aspects of my own recovery, and I suspect it is challenging for a great many others as well. I have felt, at various times, frustration at being *the sick one* in the family, anger at family members who are resistant to change, and also, the desire to accept family members at whatever place they are – to show compassion and to forgive.

    The suggestion you make regarding medication dosages reminds me of a recently published book by Peter Kramer (the author in 1993 of “Listening to Prozac”). In his newest book, “Ordinarily Well: The Case for Antidepressants” he writes “I rely heavily on psychotherapy, often postponing prescribing until I hit a roadblock. Even then, I tend, relative to the literature, to undermedicate patients, in every way — lower doses at shorter duration.” I am quite sure my recovery occurred within the same parameters; I was prescribed the minimum dosage necessary for emotional stability while undergoing psychotherapy for a more lasting, permanent resolution of my illness.

    I’m looking forward to a continuing dialogue about how to bring someone afflicted with illness voluntarily into treatment.

    • Marc Rios-Klein says:

      You are very welcome and I appreciate your openness to discuss this, which is the darn point of having a forum such as this in the first place, right?

      Regarding family dynamics, it is tricky, confusing, undeterminable, complex, ….and that’s without any major health issue and/or mental instability for a family member thrown into the midst. I don’t claim to have all the answers either as we are all works in progress but I do know that compassion tends to be the key whether its self-compassion or those feelings received from others, especially the ones whose opinions matter and whom you’ll be potentially having the most contact. It all takes time, and I believe that this nation is slowly but surely moving in the right progressive direction with regards to the acceptance and deeper understanding of mental illness and how best to help those who are trying to live a life despite its interferences.

      I, too, look forward to further conversation about how to best engage another human being into the process of recovery, and I’ll share anecdotal but real scenarios from my experiences without of course breaching anyone’s confidentiality. I know how to speak in generalities but help you see the points where “change” occurred and where shifts toward acceptance began for others.

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