A counseling client recently began working with me and described how he’s felt like a broken toy his entire life. He had effectively learned how to deal with a rather severe case of Attention Deficit Hyperactivity Disorder (ADHD), including graduating from college, yet feelings of being broken have persisted for decades! He’s made significant progress, and urged me to address this publicly for other’s sake… From our discussions came the idea for this article.
For the last few decades our American health care systems have advocated patients being included as a member of a ‘team approach’ towards their care. I recall reading extensive articles on what might be included, all the way up to some hospitals allowing/encouraging patients to have special codes to call everyone together quickly. Unfortunately, there has often been a rather wide gap between what is advocated and what has come to be practiced. I hear increasing numbers of clients talking about not even being able to find a patient advocate or case coordinator (and being outright told such services no longer exist – period!). In many cases patients have had to learn the complicated and layered labyrinths of getting various issues/complications of their medical conditions addressed! They’ve had to coordinate doctor’s consultations, and try to resolve hearing conflicting/contradictory judgement calls, and pick up the pieces when various ‘systems’ simply don’t work (as appears ever increasing across various services in widely varied disciplines and all types of businesses). For some time I’ve tried to joke about when I try to do anything these days that involves a ‘service representative’, I’m expecting they will need to do their part some 2 – 4 times before it is successful (what I could have done myself IF I were able to) the very first time – an attempt at humor to diffuse growing frustrations.
A few decades ago, when ‘managed health care’ was first being introduced to professionals, I attended a number of conference presentations where the message was consistently that health insurance did not cover ‘curing’ a client’s mental health condition, but was there to simply ‘manage the symptoms’ so the client could ‘resume working at the level one day prior to their needing attention’!?! These were takls by various professionals at professional health care conferences, and were alarming to me and others to witness. As was often the focus at the conferences I attended (being an ‘addictions counselor’) alcohol and other drug addictions were determined to be a ‘disease’ which was to simply be managed so as to allow the patient/client to resume and continue working. It was explained that ‘relapse’ was to be expected and was found to be an ‘acceptable economic cost’, being determined in studies to be less costly than trying to determine and treat the underlying cause(s) of the addictive behavior in the first place. This was a profound change in focus of treatment and attitude as I had been taught, and again was very upsetting to hear from ‘professional colleagues’ now representing the insurance industry (and therefore medicine in general). Counselors, of course, were directed to quickly engage their counseling clients to regularly participate in a ‘Twelve Step’ prevention program, again without any further discussion of options or other possible protocols. A unified message was to be given to all… ‘the doctor knows best’!
While known and appreciated for the millions of lives various Twelve Step Programs have saved over the decades, everyone also half-heartedly joked that the motivation by the insurance companies (and the company’s management paying for the insurance of its employees) was more about that it was run for ‘free’… I recall seeing inpatient treatment programs go from 28+ days in length to a low of three days (basically detoxing the individual, and moving them on to a Twelve Step Meeting in their local area). Fortunately, programs have ‘progressed’ back to a level where there is the possibility of actually doing some productive cognitive learning work (beyond mere physical survival of detoxing) with varying degrees of satisfaction being reported. For programs that clients may gain insight from, I find they are now often having to look to ‘for-profit’ inpatient programs, many costing $60,000+ (which their insurance may or may no longer cover such ‘extensive programming’). Once, again, I find this alarming!
Perhaps, these ‘tiers’ of programming and treatments might even be viewed as discriminatory in the way(s) in which they are made available to people in need?
Unfortunately more recently (in my opinion), too, many mental health programs have been affected by our new national health care’s ‘parity laws’ (which says that if a person’s physical health care includes up to a certain level, say $1 Million in total coverage, then their mental health care must be equal). While this looks like progress (and was certainly cheered at the time), many insurance companies followed by significantly increasing their consumer’s insurance copays and deductibles (often by very large amounts, so that clients might not even be able to use their insurance benefits within an entire calendar year!?!). I had a number of clients that discussed how they didn’t feel they could afford their therapy any longer (or would ‘stretch it out’ over weeks without meeting). This was done without any warning (other than discussions I attempted with the clients I was aware who might be affected). For example, I had clients that had been paying $300 annual deductibles being told their new deductibles were $3,000 and more. Talk about a counseling/therapy ‘working relationship’ being strained and disrupted by outside factors… and I was the ‘bad guy’ news bearer (or otherwise they might hear it at annual insurance reviews in company meetings!?!) – ouch!
Returning to the basic counseling/therapy model of a client having a diagnosable ‘disease’, and we having to teach techniques to simply manage its symptoms as rapidly as possible, this raises a basic treatment model question. Insurance companies need a diagnosis of a disease to treat in order to be properly billed. While this makes sense, especially for physical medical issues, it requires that a client has to have a ‘problem’ that can be ‘treated’ and an anticipated outcome be designated for treatment of mental health issues, too… This, in my simple terms, lead to the current state of ‘behavioral therapy’!?! Everything had be to termed in sets of behaviors, which could be ‘adjusted’ back into a defined healthy state of affairs or often required a mental illness disease designation. Sounds simple enough, and even may make sense, EXCEPT when it comes to examples like the ‘disease of addiction’. This is where the concept of ‘behavior management’ comes into question, and IF a client follows the prescribed modes of treatment (e.g. Sixty 12-Step Meetings in Sixty Days) then they are labeled ‘compliant’, otherwise any other activity by an individual is labeled as they’re being ‘non-compliant’, and it is always the client’s ‘fault’ for not following their prescribed program to manage their symptoms. I don’t find this empowers or enhances the client’s sense of healthiness… It certainly doesn’t promote a team model!?!
Consider for a moment the ‘new’ idea that a client may never have known what is considered ‘normal’ healthy social behavior. IF they’ve had a lifetime of being raised and always around others that practice similar behaviors, then they may believe their behaviors are ‘normal’ and they are simply doing what ‘everyone’ else does. Consider the person who is referred for ‘alcohol dependence’, or having an addiction, or a behavioral problem. In their daily lives they were doing what they’ve always done (going to their local bar(s) with friends, coworkers and maybe even family, and have seen everyone around them doing so in a similar manner, so they never perceived they might have a problem, let alone a ‘disease’?!?). Recall how popular the TV show “Cheers” was for so many years. These became role models for may youth entering adulthood (or whatever they perceived it to be – humor). I would suggest young adults attempting to socialize in a bar situation might be an excellent example of the place not being healthy, but the person is not necessarily ‘diseased’. As long as things are playing out as they’ve seen and been told to expect, then they don’t see they have a ‘problem’. IF something comes along that doesn’t quite go as expected (including possibly an auto accident or being stopped for ‘intoxication’, chronic depression from not finding this American ‘ritual’ satisfying, too many physical fights, etc.) THEN they are told they have the ‘disease of alcoholism’ – period! It may be rated on a scale as to its severity, but it is the person that is identified as the ‘problem’. Society or their social peers are not considered as possibly part of a larger lifestyle problem (and what alternative lifestyles are potentially possible or even more desirable for them?!?). Are we having any discussions of healthy and enjoyable ‘alternative lifestyles’ (other than exercise)? They are told to isolate themselves from their former friends and their socializing, and must attend an alternative social system forever – Twelve Step Programs. They have this suddenly diagnosed ‘disease’ which they also learn they’ve had from birth (but managed health care cannot determine who will develop this until it manifests itself). IF family history is looked at, it is all in the name of supporting the ‘disease model’… (as I’ve written before, “Men!?! Still A ‘Treatable Condition’ – Wink, Wink”. Please let me say here, that in some cases, perhaps, many cases, this 12-Step Model may be and has been a lifesaver. But is it the only and more life enhancing approach or model??? I’ve seen clients reach other conclusions with support and education about dysfunctional families and society. Sometimes they’ve even adopted a ‘family of choice’ as an alternative…
A client once described his experience with long-term medication management as like breaking your leg and they put a cast on it. Some people have described medication as a ‘chemical constraint or restraint’, just as they used to do when they would restrain an individual to a bed. Only with medications for various mental illnesses, they are continued to be prescribed indefinitely, due to the diagnosis of the mental health ‘disease’ or a possible ‘chemical imbalance’ within the brain. The person said it was like keeping the leg cast on indefinitely, in that it will prevent the person from ever breaking their leg, again, BUT they have to live with the ‘side effects’ of having their leg in a cast now, too. I’ve had many clients come to work with me, describing how they had been placed on various medications, only to find the ‘side effects’ too difficult or frustrating and eventually simply dropped using the medications (often without any medical advise if that was wise or safe, since some medications need a required ‘step down’ process for stopping). I suggest this is also part of our ‘one size fits all’ mental health treatment programs… Do we need to have a one-party answer to all mental health issues (which tends to treat everyone from a mental illness or disease model, so where’s the health)???
Under our current model of simply ‘managing the presenting problem’s symptoms’ often this situation is occurring, without any discussion of the possible side effects of the treatment by medication, OR other medications may be added to the newly prescribed ones to address the first set of side effects (which may have their own side effects, which become additional burdens for the clients). While this may be necessary, and sometimes adequate for the client’s comfort and satisfaction, again I hear many people stating otherwise, and their doctor’s don’t seem to care or take the time to discuss this thoroughly enough for the client’s satisfaction or comfort, let alone ‘informed consent’. ‘Options’ are not usually part of any discussion these days. Perhaps, here is an additional ‘reason’ to consider the more time consuming practice of looking at the ‘presenting problem’ and symptoms as being reactions to larger, longer standing issues… including ‘poor quality coping skills’ learned in early years within a dysfunctional family or community or even the country of origin of the individual???
As I’ve written about for years, perhaps many of the issues clients present during their intake for mental health services could be traced to ‘family of origin’ issues, IF anyone took the time beyond finding a ‘diagnosis’ of what’s ‘wrong’ or the disease of the individual their insurance company is willing to provide payment for??? Our whole medical model is geared towards ‘fixing the presenting problem’ of the person, so there must be an identified problem with the individual that can be ‘managed’. Again, the client is usually left out of the team approach…
With our American culture having approximately one in three relationships with some level of domestic violence, perhaps here’s a useful example to show it is the place that is creating the problem for the client, and not always something ‘wrong’ with the client being within such an unhealthy social environment (especially IF that’s all a person has ever known). Often the person will be labeled as ‘co-dependent’ and helped to get out of their role, but it still starts with the client having the ‘disease’ of co-dependency… The person is re-enforced that they are part of the problem, rather than a victim (fortunately domestic violence programs do identify the client as the victim…). Again, we need to look at the consequences of our labels we put on to individuals, including that there is possibly something ‘wrong’ with them, rather than support them as they come to discover how they’ve survived such a hostile past (including any resulting emotional trauma, and the way(s) it might be presenting itself – PDST).
Then there is the relatively still unexplored area of men’s need/wish for affirmation from their fathers (and possibly other male leaders of their community). I’ve written about this for 30+ years now (see my online book, “Stopping The Madness” on Amazon.com). SO many men come to therapy feeling ‘wounded’ that they didn’t get ‘approval’ from their fathers, having spent HUGE amounts of time, energy and possibly money trying to establish this sense of OK-ness. Briefly, I would suggest our society would do well to question where this initial sense of not being OK originates, and it might hopefully lead to extensive talks.
We’ve had some success in addressing this through men’s group and conference work, but it has been woefully small when compared to what women have been doing on their issues and concerns for several decades now. Again, most often the male cultural system looks for a ‘disease’ (like alcohol dependency to ‘numb out’ their hurt feelings, or to fit into an unhealthy culture through single-solution places like repeatedly attending bars) without looking at the ‘underlying cause’ of a lack of nurturing and support as a child or youth (or adult)… leading to healthy expressions of ‘passion’. It can be that simple, and a profound new idea for male clients and men in general!??! It’s not the ‘person’ who has a mental health disease, but the ‘place’ that never educated and emotionally supported the individual in healthy ways – a ‘process’?!? This is an example of emotional neglect, which many female individuals clearly understand (through their own social institution’s educational efforts). Tragically, I would suggest, men are simply often ‘clueless’ and then are being told they have a variety of mental health issues or diseases that need to be managed by medication to prevent the expected outcomes of such neglect (e.g. too often chronic depression, self-defeating behaviors, lack of productivity, and possibly aggressive, ‘anger management’ issues and even ‘rage’). They’ve also learned to ‘self-medicate’ through alcohol, drugs and mis-used medications. We need to learn to appreciate the intended help in the constructive expression of ALL feelings…
I would briefly suggest this goes back to early experiences of events that challenged their sense of being a male in today’s society, and tragically there were no people there to reassure them that they were and are indeed OK (including their emotions and reactions) – thereby encouraging them to stay on their side. Bullying is the current classic example, and we still can’t agree to a clear statement that this is unacceptable – period!!! So, whether by intent (bully or perpetrator) or be accident (a misunderstood unintentional comment or non-verbal behavior), young men often take this to heart and then spend all these ‘macho displays’ and years to try and convince others they are OK as men, when they stopped believing or doubt it themselves.
A final example of how people are taught, encouraged, or seduced into believing they are the problem (having a ‘mental illness’ or ‘disease’) rather than being under various influences or poor quality coping skills/habits, came about while I was doing my graduate work towards my social work degree (some 40 years ago now – wow!). At that time there was a subtle but important shift in public education’s thinking. Rather than students being labeled disabled (and needing sheltered programs to protect them throughout their entire school day in isolated ‘special ed’ classrooms), there began the idea of ‘mainstreaming’ people with disabilities or what we’ve come to now call ‘special needs’. This meant they spent only the time in ‘special ed’ classes as they related to their special needs, otherwise they were encouraged to join in the main school society and activities. This encouraged their productivity and enhancement of all aspects of their lives (including socializing with other general population students) and so they felt more ‘normal’ than always needing protection. What IF this idea were adopted for the issues of people’s ‘mental health’, too? Rather than focusing on simply managing the symptoms of their ‘mental illness’ or disease (whether it be real, or a consequence of growing up in an unhealthy background), we helped them integrate into their desired (and healthy) mainstream group and lifestyle??? In my last article on ‘passion’ I referred to Michael Phelps, the Olympic gold medal swimmer who learned to address his ADHD through swimming (and going on to be the world’s best Olympic swimmer, ever!) I am not promoting any particular approach here, only examples of how ‘options’ beyond the disease model do exist.
Our U.S. Constitution spells out quite clearly that all people are created equal, and deserve the right to ‘life, liberty and the pursuit of happiness’… What’s causing us not to believe in our own standards and our practices in helping people feel in harmony to these basic rights, as they define them (and not as society labels them, as limited within or even worse, having a ‘mental illness’ or ‘disease’ and any possible guilt or shame or embarrassment?!?).
Our state legislatures are STILL trying to figure out how to pass ‘politically correct’ laws to prevent bullying in public schools (with strong forces saying it is a person’s right to aggressively challenge others – ‘boys will be boys’ and ‘men need to learn to be tough’, etc.). Society has already moved on to its next powerful discriminatory phrase of ‘body shaming’, ‘shape shaming’… anything about a person that can once again be picked out as different and thereby used to create a ‘we versus they culture’ now using the word, ‘shame’, “What IF There Were No ‘They’ “
For those old enough to remember, it can feel a lot like being picked last for a ‘game of dodge ball’ all over, again.. Where are the teachers, monitors or healthy parents that reassure the young impressionable mind to ‘not take it personally’? A group can effectively and quite easily change the intent of the laws, while skirting the letter of the law… Once, again, a dysfunctional family/community system is re-born or further validated as acceptable!!?! IF only all that creative energy were put towards positively regarding others (and ourselves)?!? Perhaps, at least we’d know and feel we’re OK (and some of society has our back as we tentatively venture out to become assertive, successful and satisfied members of our society…). Again, look at what the Olympic swimmer Michael Phelps has accomplished, and all while attempting to deal with his ADHD ‘special needs’ – smile!