Thursday, April 3, 2008

At Home in the Madhouse

I started my new job last week.

I now work in a group home for substance-abusing individuals with co-occurring mental disorders. The overwhelming majority of them have schizophrenia, along with depression and post-traumatic stress - I have yet to see any bipolars, but I know that they are out there.

I love it. I've learned an amazing amount in a short period of time, and I've been able to actually use all the skills I've accumulated and learned in the past to be able to help someone, and been fortunate enough - alhamdulillah - to be given the chance to see the results of my work, how well they have turned out.

The first thing I noticed working there, though, was simply how terrified I was, am, at chaos. Meaning: I'm not so much scared by mental illness itself, as when it manifests in a chaotic, disorganized, non-sensical manner. I can handle disorders of mood, I can understand paranoia. What I can make neither heads nor tail of is, well, gibberish.

I have one client who, more than the others, exhibits the classical schizophrenic symptoms of disorganized speech, and who suffers either from a degree of social anxiety, or else is suffering tremendously from the akithisia which is a side-effect of all the medications he is on, because he finds it enormously difficult to sit still.

In certain ways, he frightens me more than the others. It isn't that his illness is 'graver' than the others, because in all likelihood I doubt it is. I think there is also a great deal of intelligence just below the surface. It's more the surface itself, its chaos, disorganization, gibberish. I don't know how to act or react or interpret and understand what is going on. I have a hard time... well, reading his mind.

We all read each other's minds all the time. We may attention to a thousand small little cues in behavior and speech - both content and affect - which allows us to perform that singularly human and incredibly powerful act of placing ourselves in one another's shoes. With this client, I cannot do that. I cannot tell what is going on within him. And it terrifies me.

(I am led to understand, though I could be wrong, that this is rather what the autistic experience is like, which only heightens my appreciation for the bravery and perspicacity of autistic individuals)

Lacking knowledge of what else to do, I took this client out yesterday to get some coffee and play chess. As it turns out, we were pretty evenly matched at chess, though I beat him; that itself was a mistake, though, since I think he may be more averse to playing against me again in the future, therefore providing yet another obstacle for me to see how to connect with him. I am supposed to be working with him - with all my clients - on achieving rehabilitation/recovery goals, but I am unclear about how to proceed with this particular client. I am hoping that something, anything, will come along to point the way.

The more I work with all my clients, though, the deeper my appreciation for both their resiliency and bravery as well as the profundity of their illness. Most powerful of all, though, has been a growing understanding and recognition that really, they are not so different from myself, illness and all.

As I've begun looking into severe mental illness and psychosis, I've been pounded with two voices, one of which says that mental illness of this sort is organic and demands both organic - meaning chemical - solution as well as some degree of skills training. It says that the illness has no progressive order or makes any sort of underlying sense. Any view which postulates underlying order is merely imposing such a system from without.

The second set of voices says that there is an underlying order to mental illness of this sort, and that talk-therapy can both find this order and provide a framework for recovery without the need for a chemical solution, which is often a blunt-force-trauma instrument when it comes to attenuating the positive symptoms of psychosis, such as hallucinations and delusions. In fact, this view says, 'mental illness' is, in fact, sanity in a world gone mad.

I'm unconvinced by either voices entirely. My own battle with depression has been enormously aided by chemical solutions. In all likelihood I would not be here, functioning as I am, without the help of chemicals. I don't believe other solutions would, in fact, make a dent in my own problem. Nor am I willing to see my depression as 'sanity' in a world gone mad. Claiming that my suffering is some sort of political and social critique is really attempting to use my suffering to further one's own political and social agenda. Sorry, I am crazy.

Rather, as I learn from my clients as well as other case-study sort of materials, I'm discovering that what they experience is, perhaps, simply a more intense, actualized version of the inner dynamics of all minds; or at least my own. That's why there can be 'drug-induced psychosis' - the drugs do not cause the psychotic material per se, but rather heighten the latent material of the mind.

Which means, to me, the insane are no more, nor less, sane than the rest of us. The capacity for sanity is within them - and the capacity for insanity is within each of us. All it takes is the appropriate stimuli to activate these things.

The good news of this, to my mind, is that it means recovery is possible. These people, all of them, can live happy and healthy and meaningful lives. It requires effort, perhaps medication, and almost undoubtedly sacrifice, but it is possible.

The problem psychosis-prone individuals face, I think, is that we 'sane' people don't want to make the effort, and they do not want to make the sacrifice. Coping with my own mental illness(es) has required that I give up a lot of concepts that I once cherished - the prime example being that I should be able to live medication-free. I have had to accustom myself to the fact that, simply put, it is not my life when I choose to eschew medication, but a life which involves all the people around me. To go off-med is to cause suffering in far too many other people. Side-effects be damned - I have a responsibility to others.

Such sacrifices are rife in mental illness. Giving up paranoia means giving up the idea that one can ever be entirely 'safe'. Giving up delusions means giving up the idea that one is 'special' enough to be chosen by demons or angels. Accepting that one is crazy means accepting a degree of humility that is often hard to swallow.

Simultaneously, though, I think we 'sane' people are all too often eager to avoid working with the mentally-ill in a mutual effort towards greater sanity. Because, really, it is an enormous effort. It is not simply a matter of finding the right pill to cure the symptoms, or sending them off to 12-step meetings and expecting them to be able to cure themselves, but it takes something of us: courage to face the chaos, to overcome fear of being harmed, of treating these individuals as... well, human and sane.

At least, I know that's something with which I struggle.


Cat Chapin-Bishop said...

Hello, Ashiq,
I found interesting what you observed about your own response when you write of the one, very disorganized client, that he is particularly frightening:

"I don't know how to act or react or interpret and understand what is going on. I have a hard time... well, reading his mind."

I say this, having had some experience working with kids with autism or Asperger's. The inability to "read" those non-verbal cues is one of the typical problems these kids have, and it's worth thinking about the state of fear that kind of "head-blindness" can induce. After all, though the ability to read non-verbal cues may be impaired for some folks, that doesn't mean either that the social expectations around reading them, or the human desire to understand the other person, are any different than they are for you or for me.

I find it especially painful that so many people express doubt or skepticism around autism or Asperger's Syndrome--though I also suspect it's overdiagnosed, at least in some areas. But the doubts about whether or not mental illness is organic that you reflect on here are particularly likely to come up around people, like some Asperger's kids, especially, who seem to function so well, in certain settings. It becomes hard for people to believe they (or their parents) aren't just making excuses.

My own understanding of mental illness is that it involves both organic, brain-centered stuff, and human and social stuff, just as we do. After all, we are both individual and spiritual beings, and beings in bodies that can age, suffer injury or deformity, or become ill. We're both (and one of the reasons I stopped being a therapist was that I felt my profession required me to relate far more to one than to the other) and successful treatment will address both.

On the question of whether or not mental illness is really just "sanity in a world gone mad", and that organic approaches are not needed, I have always found it interesting that no one seems to find it necessary to take this argument to the extreme of denying the reality of senile dementia/Alzheimer's. I've always wondered why the purists can imagine brains malfunctioning in old age, but see no likelihood they might at earlier ages.

Thanks for a thought-provoking post.

Ashiq Chris said...

Thanks for the comment, Cat.

My understanding of mental illness has been shifting a heck of a lot due to this job, as well as the book 'Recovering Sanity' by Ed Podvoll. Some classmates of mine in college were involved with his Windhorse project for reintegrating those suffering from psychosis back into the community, and when I started this job my memory of what they had to say was, thankfully, jogged.

Mostly, I've latched onto the notion that if one looks for it, people suffering from psychosis do have moments of clarity; and as a counselor, it is possible to capitalize, utilize and build upon those moments.

A very specific 'set and setting' is necessary, though, I think. Working with such a population is difficult because very often they lack basic daily living skills, or interpersonal communication skills, and 99.999% of the time, stress-management skills. As a consequence, I've noticed that my co-workers - and probably myself too - have lapsed into a sort of 'parenting' attitude, which doesn't help because it removes self-efficacy from the clients, which further dilutes their ability to build upon those moments of clarity.

On a personal level, though? The more time I spend with psychosis, the more I'm coming to see the vast parallels between it and what I've considered 'spiritual states'. I've always, in the back of my mind, known that adage about spirituality and madness being a hair's breadth apart, but I'm just beginning to understand it, I think.

That's meant two things: firstly, everything I ever thought I knew about spiritual life is getting sucked down the drain. I'm questioning everything again, even whether there is a God. Which is great - I hate stagnant belief that's not subject to real doubt and criticism. I'm not an atheist quite yet, and doubt I will be, but I'm at least wondering if God really is just a figment of the imagination.

Secondly, and more importantly, I understand the lure of madness much much more. It is, in fact, a spiritual longing, the desire for God gone haywire.

Both of which have been solid reminders that spirituality is the gradual, annoying process of being steadily dis-illusioned without losing hope and love.

Or as one person put it, "... like getting kicked to death by rabbits."