Straight Talk about Your Mental Health

The Guilford Press

Chapter One

What Mental Health Clinicians Do

In this chapter I outline how clinicians go about the business of taking care of their patients-how we gather information and how we use it to make a diagnosis and recommend treatment. Any mental health professional is likely to approach your problem using an approach similar to this one.

GATHERING INFORMATION

Like others who do detective work, clinicians don't intuit our findings, we deduce them from information obtained from many sources. The first step is simply to ask what is troubling you. This usually occurs during an interview that lasts an hour or more, during which you'll reveal the clues that will identify the nature of your illness. Such clues are called symptoms, which can include a huge variety of behaviors, emotions, ideas, and thoughts-just about anything that is unusual or abnormal for a particular person or in a given culture.

Some of the areas covered in the interview may surprise you, because they don't seem immediately pertinent to your problem. Suppose you're being evaluated for anxiety symptoms. You'll probably be asked about your sex life, drinking habits, and how you get on with your relatives-information that may seem off the pointbut that can have a bearing on nearly any mental disorder. To develop the fullest picture possible of you as a person, you'll be asked about many areas of your life. Even the most sincere patient in the world will have certain blind spots, such as areas of character development or past experience that appear quite different when viewed by others. That's why 21st-century clinicians also recognize the importance of obtaining any records of previous evaluations, hospitalizations, treatments-any possible clue to the cause and appropriate treatment of what is troubling you. Another potential source of information is your physical exam. Mental or emotional symptoms can be caused by endocrine disorders, head trauma, tumors, and other medical conditions. That is why you may be referred to an internist or family doctor for a complete medical workup.

Sometimes your doctor may want to consult with your relatives, friends, or other physicians and medical caregivers-anyone who can help complete the picture of you as a person. Although clinicians know that it is sometimes in a patient's best interest to share information with family and others, as well as to seek information about you from them, we are honor-bound to maintain confidentiality. Only with your express permission can we talk about your symptoms, treatment, or prognosis, even with your spouse or trusted friend. (If a patient is not competent to give such permission, we would have to obtain the consent of the person legally designated to act as guardian or conservator.) Only if a life is seriously, immediately threatened can we breach the duty of complete confidentiality. The bottom line is this: Barring exceptional circumstances, the only people who will learn about your mental health consultations are those you yourself tell.

MAKING A DIAGNOSIS

Once we have obtained all the relevant information, we look for familiar patterns of symptoms-in short, a diagnosis. The value of identifying a specific diagnosis has been questioned in the past: why not just treat the obvious complaint? If I had done that with Dorothy, a young homemaker I saw several years ago who complained of anxiety, I might have prescribed Valium. On further inquiry, I learned that she was also depressed. Should I have offered her Prozac instead? Perhaps, when I found out that she had been drinking, I should have prescribed Antabuse and recommended Alcoholics Anonymous. Finally, though, I discovered that throughout her adult life she had experienced many physical and mental symptoms. I diagnosed her as having somatization disorder, which doesn't respond to medication, but does-as did Dorothy-respond to regular office visits for psychotherapy.

From Dorothy's example, you can see how strongly context determines the meaning of symptoms. Coughs can be caused by a cold or by cancer; auditory hallucinations can be caused by dementia, substance abuse, schizophrenia, or a mood disorder. Words express thoughts only when put into a sentence; symptoms require the context of diagnosis (the sentence) to tell the full story of your mental or emotional problem. This is why it is important for your clinician to learn all about you before prescribing a specific treatment.

Some clinicians worry that diagnosis somehow harms patients by "pigeonholing" them in a category with a meaningless label that diminishes their value as individual human beings. Suppose you had a sudden pain in your abdomen and, in great agony, you went to your doctor. Would you want your doctor to say, "Gee, I wouldn't devalue your humanity by trying to classify you. Your pain is unique to you; it could be anything. We'll just have to wait and see"? Perhaps you'd prefer to hear, "Based on your symptoms, age, and physical exam, it's probably appendicitis. We'll do some tests to make sure, and we may need to operate." There's no contest. Of course you can have a diagnosis and retain your individuality; all you stand to lose is your appendix. The same reasoning is just as valid applied to your depression, hallucinations, or insomnia.

However, I would criticize the tendency of some to confuse people with their diagnoses. When we call someone "an alcoholic," we imply that alcoholism defines the person. If we say "Oh, you can't take Murray too seriously-he's manic-depressive," we imply that Murray's (episodic) disorder drives all of his actions, thoughts, and feelings, all of the time. We don't do this with medical illnesses, such as diabetes or heart disease, and it's not right to do it with mental illness. Careful clinicians try to avoid this sort of harmful labeling by using phrases such as "a patient with schizophrenia" instead of "schizophrenic."

Properly used, diagnosis helps us decide which treatment program is likely to help. We know what would be likely to happen if a doctor prescribed only aspirin to someone whose chronic headaches were caused by high blood pressure or a brain tumor. Now imagine the effect if your anxiety or depression was physically caused, but an antidepressant was the full extent of your treatment. We need the whole story, in context, to determine how best to proceed. Diagnosis also relieves individual patients of the need to be pioneers-today's patients can benefit from all that we have discovered about symptom patterns and effective treatments.

Diagnosis enables us to communicate about disease and extend the benefits of scientific advances to people around the world. Today, two diagnostic manuals are used worldwide to help clinicians identify and talk about disorders. In North America the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition, of the American Psychiatric Association) is the standard. Throughout most of the rest of the world the ICD-10 (International Classification of Diseases, 10th edition) is used. For most disorders, these manuals substantially agree as to the types and diagnostic features of mental illness. Making a specific diagnosis is not a matter of arbitrarily attaching a label to a person; it should mean determining, through a careful evaluation, that a person meets the well-defined, science-based criteria for that disorder in DSM-IV or ICD-10.

RECOMMENDING TREATMENT

Even today, treatment frightens many people, whose impressions of it seem based on reruns of early Hollywood versions of mental health care. Take, for example, the 1950 movie Harvey, in which a psychiatrist plans to use "Formula 977" to make a grumpy misanthrope of happy, lovable Jimmy Stewart, who has a harmless friendship with an invisible 6-foot-tall white rabbit. In the 1964 Shock Treatment, Lauren Bacall plays an evil psychiatrist who experiments on healthy people by administering electroshock. In reality, patients today have a broad range of treatment options (described in full in Part II). When you're considering seeking professional help, it's useful to think of these options in terms of three broad categories: psychological, biological, and social. Together, they make up a three-legged approach to treatment that all mental health professionals are familiar with.

Psychological

For more than a century, psychotherapy has been the mainstay of mental health treatment. Perhaps you are like many people who think that psychotherapy means psychoanalysis, in which the patient spends years talking to a doctor who takes notes and doesn't say much. This is one style of psychotherapy, but we now have available many newer, more quickly effective psychological treatments. Probably the most popular of these is cognitive-behavioral therapy; it certainly has the most research demonstrating its effectiveness in a variety of disorders behind it. I discuss effective forms of brief psychotherapy in Chapters 13 and 14.

Biological

Today, effective medications are the mainstay of treatment for many mental disorders. That wasn't the case when Harvey was filmed. In fact, most of the drugs we use today were introduced only within the past two decades. With medication we can now treat such major problems as depression, mania, psychosis, and anxiety, as well as disorders of appetite and sleep. We'll talk about all of these medications in upcoming chapters. Other biological therapies I discuss include bright light therapy, useful for some mood and sleep disorders, and electroconvulsive therapy (though not as used by "Dr. Bacall"!)

Social

A variety of social problems can result from mental or emotional discomfort; sometimes they even cause it. Your clinician may suggest measures to deal with them. For example, consider Arnold, an 85-year-old depressed widower who lives alone. He may benefit from homemaker services, Meals on Wheels, and transportation to a senior day-care center. Mary, arrested for stealing food from a bakery, is a homeless patient with schizophrenia who needs shelter and legal services. She may do best under case management, in which a field worker would visit regularly to make sure she is taking her medicine, keeping her medical appointments, and getting adequate nutrition. Other interventions that address social aspects of problems include vocational counseling and job retraining, social skills training, providing for child care, help obtaining disability payments, and counseling for domestic violence, neglect, or abuse. Although these approaches don't reduce symptoms directly, they can enhance a patient's ability to use other treatment options.

With so many possible treatments and so many issues to consider for each individual patient, how do we know which treatment will be appropriate for you? Modern-day clinicians use the results of studies that compare outcomes in groups of patients carefully selected on the basis of scientific criteria (see sidebar). Even though choosing the best treatment for each individual is still partly an art, several principles generally apply:

If a given treatment helped during a previous episode of your disorder, it probably will again.

A treatment that has helped a close blood relative is likely to help you, too.

Of course, both you and your clinician will prefer treatments that are safe and have few unwanted effects.

You should begin to see improvement shortly after beginning treatment. With medications, that can be as short a time as 2-3 weeks, and sometimes within the first couple of days. All physical treatments, such as drugs, bright light, or electroconvulsive therapy, are likely to work faster than most forms of psychotherapy.

Patients with personality traits such as suspiciousness, isolation, or dependency will respond more slowly.

In Part III of this book you'll read how clinicians use these principles to recommend the best treatment for a wide variety of mental disorders.

Regardless of the treatment employed, one of the most important considerations is your safety-and that of those around you. Suicide is a risk that every clinician must consider for every patient, every visit. In the general population, the chance of suicide is about 1 in 100; many mental disorders carry a much greater risk. A clinician would be especially wary if you were depressed, psychotic, or using alcohol, conditions that entail the greatest risk of suicide, or if you had made previous attempts. I would especially worry about an elderly man who is also medically ill, unemployed, owns a gun, and lives alone-each of these characteristics increases the risk of suicide.

I would move very quickly to protect such a person. Most of the time, patients agree that hospitalization is an appropriate step, and remain hospitalized voluntarily until sufficiently improved to return home. However, the occasional patient may have to be detained involuntarily. Although the laws vary slightly depending on the jurisdiction, involuntarily hospitalized patients have the right to argue before a judge (with the help of an attorney) why the commitment should be terminated. Then the judge must decide whether to order a release. If release is refused, the commitment will usually be extended briefly (perhaps 2 weeks) before another judicial review.

Although most psychiatric disorders respond readily to treatment, your road to health could still involve some wrong turns. In some of the following circumstances, your clinician might ask a consultant to help map other avenues to explore:

1. When your response to treatment is less than expected. An outcome that differs from predictions doesn't mean that either you or the clinician has failed. It does suggest that another pair of eyes and added brainpower may help devise an approach that works better.

2. If your doctor proposes new or controversial treatments. Research drugs or medications that haven't been approved for your condition are two examples.

3. Whenever electroconvulsive therapy seems warranted. Many states require consultation in such a case.

4. When you need reassurance. If you have serious reservations about diagnosis or treatment, some clinicians will suggest a second opinion. If your clinician doesn't suggest this step, you may have to act as your own advocate and ask.

HOW WE DETERMINE WHICH TREATMENTS WORK

Treatment is only therapy if it works-that is, it either hastens your recovery or increases the degree to which you improve. Although it is relatively simple to tell when someone has improved, it isn't so easy to know why. Until we know why, we don't know which treatments are effective and which are not. Let's say you have a cold that you "treat" by drinking orange juice. In a few days, your cold is gone.

Continues...

---

Excerpted from Straight Talk about Your Mental Health by James Morrison Copyright © 2002 by The Guilford Press. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

---