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There is one thing that is virtually guaranteed….if you go to a mental health center, you will probably see a psychiatrist for medication. In my private practice probably 10-15% of my patients take medication. When I worked at a mental health center, it was closer to 90-95%. What accounts for this vast difference?
1. In a mental health center, the assumption is that patients will be referred for medication. It is the basic assumption. There is also a financial insentive. Mental health centers get paid more for the services of psychiatrists than therapists or psychologists. Funding is ALWAYS a very important issue in mental health centers.
2. In private practice, most of the responsibility falls on me (instead of a system). I explain the options to my patients, that they may be interested to try medication, but as long as the problems do not represent a serious risk (loss of job, harm to self, ect…), medications may not be warranted. Although it is a very individual decision. So far, every patient I have seen that comes to me first without being on medication, does not start on medication. The majority of those who are intially on medication are able to get off of the medication eventually.
3. Expectations… All shrinks are human beings. They have different expectations of their patients. They have different expectations about what is possible with psychotherapy. They have different levels of knowledge. They have different levels of comfort. They have different views of human nature. These factors are critically important in how psychotherapy unfolds with a patient.
4. What seems to be much more important than diagnosis is a willingness on the part of the patient to keep coming in to treatment, to think about what is discussed in session between sessions, and to have a genuine motivation to make changes. Now, certain diagnoses sometimes make these things less likely (severe schizophrenia, severe bipolar disorder, or severe personality disorders for example). However, if these things are present (the positive factors), the diagnosis is much less significant.
5. Psychiatrists often “diagnose for the medication.” The FDA approves drugs for specific diagnoses. Nobody likes to be sued. So, psychiatrists often bend or distort the diagnosis in order to justify the medication they want to try. See my previous post, Diagnosing for the Medication.
So, while the desired medication is more important than symptoms at times for psychiatrists, for some therapists and psychologists, what is more important is a willingness to seriously consider what is talked about in-session, a willingness to follow through with recommendations, and a willingness to believe that psychotherapy may be helpful. To a great extent, the actual symptoms a person has are less important than these factors.
Now, I’ve seen some folks with the most rigid belief systems (such as blantant paranoia and fantasies of revenge), that are only addressable on a spritual basis. Absolutely nothing else works at all–believe me, I’ve tried. But, when they consider their thoughts in the context of their belief in God, they are willing to acknowledge the distortion and errors in their thinking. There are times when a person’s difficulties can be addressed in nothing other than a spiritual realm.
And when he was gone forth into the way, there came one running, and kneeled to him, and asked him, Good Master, what shall I do that I may inherit eternal life? And Jesus said unto him, Why callest thou me good? There is none good but one, that is, God.
Mark 10:17
Ah yes, but we are separated right? Good people and bad people. In this case, the bad people are the mentally ill. I would not be incorrect in saying that there are only bad people. Only God is good. But is there a need to protect ourselves from people who would do us harm? Certainly. But look at the statistics. Are you more likely to die from a spree killer or a car accident. What about a heart attack? I suppose it wouldn’t make a good headline to say, “1000 people died yesterday from a heart attack.” Or…”150 people were killed yesterday on the nations roadways.” It’s only the things that are novel or unusual that make headlines. It’s only things that are unlikely to actually occur.
Sensationalist media reporting increases both suicidal and homicidal behavior (see The Copycat Effect). But it seems that law makers and the media want to talk about how we can stop these “mentally ill” people from acquiring guns. Having a mental illness does not necessarily make a person any more likely to commit violence than the general population. In fact the research shows that individuals discharged from psychiatric institutions are of roughly the same risk of being violent as others in their community. They are more likely to engage in violence than others in their communities if they are abusing substances. The same is true for others who abuse substances (they are more likely to be violent). If the media are truly concerned about these spree killers, they’ll change their reporting practices.
In rural America, a lot of people take their rights seriously. It scares them to seek help if they know they could lose their right to bear arms. The state of Illinois wants to extend state reporting on mental illness to include outpatient settings. So, if a patient has exhibited violent or suicidal behavior they must be reported. Furthermore, there are proposed links to the federal database so that people reported to the state, would automatically be entered into the federal database. It’s difficult to imagine how I, in good conscience, could comply with this requirement. I can see it now, I tell a patient if they have recently engaged in suicidal or violent behavior that I must report them. They won’t tell me, and the problem won’t be addressed. Result….dead bodies.
Also, I wonder how far this extends. Does it extend to thoughts??? “I’d like to stangle Bob. He really gets on my nerves!” Does this fall under the mandatory reporting rule? Who hasn’t had a thought like that. Wait….I never have!! Please don’t report me. No, the difference between violent and non-violent people is a history of violence. There’s already a reporting system in place for that…it’s called a criminal record. Would that have caught Kazmierczak before he was able to purchase guns and kill 5 students?? No, but neither would any of the reporting laws. We don’t know what caused this guy to unravel, but don’t blame the mental health system and don’t think we need more restrictive laws. People have free will, and there is no way to legislate against that. I do think the recent reportings of multiple spree killings could have played a role. I’m sure there are other newsworthy events out there in the world, like the spree killings of tornados in recent months. Maybe we should pass a law against high winds and thunderstorms….but that would be ridiculous right??? Just saying…
Since substance abuse seems to be an actually important variable, maybe there should be mandatory reporting for people undergoing treatment for substance abuse problems. I don’t actually think that, but at least it is risk factor that makes more sense. I’m saying that just to emphasize the point that these laws are not based on protecting people from violence, but that there is an incremental political agenda based stereotypes of the mentally ill with the ultimate goal of limiting the rights of all people.
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