Jung At Heart Archive August 2008

Paving the way

I suppose that mid-life could be seen as the opening of the issues of the last act of life. Certainly Jung seems to; remember this?

In the secret hour of life's midday the parabola is reversed, death is born. The second half of life does not signify ascent, unfolding, increase, exuberance, but death, since the end is its goal. The negation of life's fulfillment is synonymous with the refusal to accept its ending. Both mean not wanting to live, and not wanting to live is identical with not wanting to die. Waxing and Waning make one curve. 

Midlife can be a time of stress as emotion breaks through ego boundaries – reflecting that which feel injured or neglected.

“Emotions are not chosen; they choose us and have a logic of their own.” James Hollis

One person may experience the fear of losing control and the sense of self that once worked. Another may feel the fear of further losing areas of self-expression. Frequently, there is the existential fear of mortality and diminishing time, the realization that half of life is gone.

It is common  to experience anger or depression in response to lost time and opportunity for more authentic experience. Depression and underlying regret may reflect an emerging sense of emptiness and the superficial relationship to life of the “adapted self.”

These are calls to attend to life issues which have been neglected. As Jung said,

We cannot live the afternoon of life according to the programme of life's morning, for what was great in the morning will be little at evening, and what in the morning was true will at evening have become a lie.

In drama the first act is used to establish the dramatic situation and introduce the main characters. At the end of the first act, an inciting incident complicates the story and moves the screenplay into the second act. -- This is childhood through young adulthood, when we set the stage for our lives, choose our work and relationships.

The second act, commonly described as "rising action", typically depicts the protagonist attempting to solve the problems caused by the inciting incident. The Climax, which ends the second act, is the scene or sequence in which the main tension and dramatic questions of the story are brought to their most intense point. --  This is the time from 35 or so to 55 or 60, what has classically been known as midlife.

Finally, the third act features the resolution of the story and its subplots. It is the third act that I am becoming most interested in, the time in which life's loose ends, unresolved plotlines, the denouement of life. 


Aug 26, 2008 1:43 PM

Good news?

I have been mulling over this whole thing about pediatric bipolar disorder, medicating kids, contaminating influences thing this week. I am trying really hard to see meaning in the rush to diagnose and then medicate so many children and I confess I am baffled. I think about my son, getting ready now to start graduate school to become a therapist himself, and what he was like as a young child -- intense, rarely sleeping, challenging. He gave his father and me a run for our money but not for a minute did we think of him as a problem. He was challenging because it took us time to learn how best to deal with him, how to deal with his relentless drive to take things in, to see and learn and his apparent lack of interest in sleep. But learn we did and he did also. We used to joke that anyone could be a good parent to his sister but the challenge he presented us made us into really good parents. I shudder to think what might have happened to him or  us had we been less confident in our abilities to figure it all out or less knowledgeable about mental health (we are both psychologists) because he might have becomes one of those kids placed first on this drug and then on another. Instead he remained bright, alert, active, intense and delightful -- a challenge yes, and an engaging and loving child now grown into a mature and considerate man.

So as I read all of these reports of off-label uses of atypical anti-psychotics with kids, of the FDA chief deciding that pediatric bipolar  disorder exists despite conflicting expert opinion, the revelation of his, and many other so-called leaders in psychiatry, conflicts of interest, and I feel slightly ill. (If you have not been following all of this on Furious Seasons, you certainly should do so). Why on earth are these people so eager to stigmatize so many children with diagnoses of major mental illness -- and there is no way to get around the reality that such a diagnosis is stigmatizing -- and then place them on major psychotropic drugs whose long term effects in children are unknown? How on earth did we get here?

The story last week that so few psychiatrists are practicing therapy certainly points to one piece of this puzzle. Whether those of us who are psychologists and social workers like it or not, the lay public sees psychiatrists as THE experts in mental health. The subtle nuances of the various disciplines in mental health are unknown and meaningless to the average person. So if psychiatrists are more and more inclined to psychopharmacology and less involved in therapy, then to the average person that must mean that this is the best approach. Of course other influences come into play -- relentless advertising by the drug companies, insurance companies which prefer the control they have over prescription drugs to the harder to control treatment by psychotherapy, and of course, turf wars among mental health professionals.  I want to believe that many of these psychiatrists, untrained in and not practicing psychotherapy, have reached the place where because all they have is hammers (psych meds), everything they see is a nail. I want to believe this because that almost makes it understandable.

Today I ran across this excellent piece in the Dallas Morning News, reporting 

" A state mental health plan naming the preferred psychiatric drugs for children has been quietly put on hold over fears drug companies may have given researchers consulting contracts, speakers fees or other perks to help get their products on the list.

The Children's Medication Algorithm Project, or CMAP, was supposed to determine which psychiatric drugs were most effective for children and in what order they should be tried at state-funded mental health centers. In April, high-ranking state health officials gave researchers the go-ahead to roll out the guidelines."

Never mind how mind boggling it is that there is a need for such a list. The existence of the project tells us already that there is a heavy bias in favor of medicating children. The protocol will govern particularly those children in foster care and on Medicaid, because of course, such children are simply rife with mental illness -- or maybe they have less well-educated parents or have caretakers more interested in ease of management than they are in longer term interventions?

The report goes on:

"Drug protocols are designed to ensure all patients with a particular diagnosis receive the most effective, proven treatment available. They're created by bringing together academics, researchers and public health experts, who run trials, compare best practices and recommend a road map, or algorithm, for which drugs should be used.

While the protocols are generally created with the best intentions, they can be controversial, particularly when drug companies have a hand in designing them.

Some lawmakers and activists say it's time the state took a close look at the financial motivations of experts making drug decisions for hundreds of thousands of Texans. The adult protocol determines treatment decisions in state mental health facilities, despite the lawsuit and studies that have played down the benefits of some of the drugs chosen for it.

"In our country, there's been a switch from taking care of people to focusing on big corporate money," said Rep. Juan Escobar, D-Kingsville, who unsuccessfully offered legislation last year that would have banned researchers or government employees funded by the pharmaceutical industry from designing state psychiatric drug protocols. "There need to be restrictions on how these things are done, because the victims are our children."

But it was this that really grabbed me:

"At least four of CMAP's key developers – all affiliated with the University of Texas system, and all of them published child psychiatry experts – have received research funding from drug companies, or have been consultants and speakers for several different pharmaceutical firms, according to their own published papers and financial disclosure forms filed with the university. Drugs made by some of these manufacturers appear in the children's drug protocol.

The doctors say there's no room for improper influence when their reputations are at stake. If the drugs weren't effective, they wouldn't endorse them – and the research they conducted to craft CMAP wouldn't have been published in prestigious medical journals."

Reputations trump all?? Mightn't the well being of children, who have no say in treatments they receive, mightn't that be more important than the professional reputations of those seeking to prescribe for them?

So, I believe it is good news that the CMAP is on hold. I only wish it were because the whole premise for it were under question.

And the question remains, what does it mean that we have become so willing to medicate ourselves and our children? And what price will we be paying for it in the future?

Aug 18, 2008 8:04 AM

Conversations in the Third Act

That's what I plan to call what I am working on. First up is  a course/workshop I will offer at Senior College here in Belfast in the spring. I will to use a combination of writing and discussion to explore the psychological aspects of this last stage. If life is a drama in three acts, then all of us over 50 are in the third act and dealing with a whole new set of issues, questions, and challenges.

                        A poem I ran across today apropos the third act --

No, no, there is no going back.

Less and less you are

that possibility you were.

More and more you have become

those lives and deaths

that have belonged to you.

You have become a sort of grave

containing much that was

and is no more in time, beloved

then, now, and always.

And so you have become a sort of tree

standing over the grave.

Now more than ever you can be

generous toward each day

that comes, young, to disappear

forever, and yet remain

unaging in the mind.

Every day you have less reason

not to give yourself away.

 

~ Wendell Berry ~

Aug 7, 2008 12:07 PM

Collision Course

Two articles in the news this week point to a glaring contradiction in current mental health policy.

First, as referenced by Philip Dawdy and Reuters, noting a study in the Archives of General Psychiatry noting the dramatic decline in numbers of psychiatrists who practice psychotherapy --

The percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2004-2005 (P < .001). This decline coincided with changes in reimbursement, increases in managed care, and growth in the prescription of medications. At the practice level, the decrease in providing psychotherapy corresponded with a decline in the number of psychiatrists who provided psychotherapy to all of their patients from 19.1% in 1996-1997 to 10.8% in 2004-2005 (P = .001). Psychiatrists who provided psychotherapy to all of their patients relied more extensively on self-pay patients, had fewer managed-care visits, and prescribed medications in fewer of their visits compared with psychiatrists who provided psychotherapy less often.

Conclusions  There has been a recent significant decline in the provision of psychotherapy by psychiatrists in the United States. This trend is attributable to a decrease in the number of psychiatrists specializing in psychotherapy and a corresponding increase in those specializing in pharmacotherapy—changes that were likely motivated by financial incentives and growth in psychopharmacological treatments in recent years.

 As I have noted before, a psychiatrist can earn at least 57% more in a medication only practice than he or she can providing psychotherapy. So certainly money is a primary driving force here. But also implicated are the turf issues I have written about before, because prescribing is pretty much limited to psychiatrists though a few clinical psychologists do so as well. Limiting the turf to a single group also helps feed the coffers and even more so when it also serves the interests of the drug companies -- more sales -- and the insurance companies -- fewer visits.

Now I think it is not such a bad thing that fewer psychiatrists practice psychotherapy these days. Because decreasing numbers of them have received much if any training in therapy, most significantly less than that of clinical psychologists and clinical social workers. And actually, because fee schedules and  reimbursement rates tend to be based on degree category and not skill level, leaving therapy to or favoring its provision by psychiatrists drives the cost up and out of reach of many. The real problem here s that it reflects the extent to which the notion that all mental illness and emotional difficulties are medical illnesses, biologically based, has permeated the system, which now favors psychopharmacology above all else. The question that was not answered is what percentage of these prescribing only psychiatrists also urge if not expect patients they prescribe for to also be in therapy? I know of a few but not many, certainly not enough.

In an AP article discussing the same study we find the following:

"The study did not survey visits to psychologists or other mental health counselors who are not medical doctors, but who also practice talk therapy.

Psychotherapy uses verbal methods to get patients to explore their emotional life, thoughts or behavior. The goal is to ease symptoms, sometimes through getting the patient to change behavior or mental habits.

Its benefits can be seen in brain imaging studies, said Dr. Eric Plakun, who leads an American Psychiatric Association committee working to restore interest in psychotherapy by psychiatrists.

"The couch is far from dead," Plakun said. "The couch turns out to be an effective 21st century treatment."

Talk therapy can be done by psychiatrists less expensively than split treatment, where a patient sees a doctor for pills and a counselor for talk therapy, Plakun said, citing two prior studies.

It also works better than drugs for some patients, such as those with chronic major depression and a history of childhood trauma, he said.

Accreditation requirements for psychiatric residency programs are putting more emphasis on talk therapy, Plakun said. That may slow the decline of the couch.

The new study doesn't answer an important question: whether other professionals are picking up the slack, said psychologist David Mohr of Northwestern University's Feinberg School of Medicine. Psychologists and social workers provide counseling but most cannot prescribe drugs, so it's possible that for patients who require both talk and pills, some coordination in care may be lost, Mohr said."

Better but still with the assumption that therapy provided by psychiatrists is better than that by other mental health professionals because of the presumption that medication is almost always required. Says who? Does it not matter that these meds, mostly SSRIs are being shown to be far less effective than the ads would have us believe? This reminds me of my ex-husband's grandfather who used to tell him that he would pay his way through medical school so he could become a *real* doctor, this despite the fact that he was and is a successful clinical psychologists. It seems that there is a belief that *real* doctors are the best choice and the rest of us are just not quite up to the same level, even those of us who are also doctors but not M.D.s

Couple this with this opinion piece which appeared at the same time:

"What Americans are experiencing economically is clearly not "all in our heads," or, as former U.S. Sen. Phil Gramm, a John McCain adviser, recently put it, a "mental recession." But the increasing difficulty of the struggle to make ends meet and avoid homelessness is taking a correspondingly harsh toll on the mental health of our citizens...

...Increasingly, low-cost or free mental health services are being offered by nonprofit organizations like Atlanta-based Metropolitan Counseling Services. I became involved with MCS in part because I believe MCS and organizations like it can play a critical role in a community's efforts to recover from economic difficulties by addressing the mental health impact of such hardship. Indeed, counseling or psychotherapy can help one transcend despair and rebuild that healthy sense of perspective and self-esteem that is the foundation for effective planning and action in all spheres of life."

In my own community, the local paper recently suggested that it might be good to develop groups for citizens facing hardship this winter to give them a place to vent, to share and to get the relief that comes from talking with others in the same group. But community mental health centers have seen drastic cut-backs in their budgets and they have turned increasingly to revenue producing psychopharm treatment over therapy. In fact many clinics now offer case management and medication but no therapy. So, in the face of times that increase the demand and the need for therapy and counseling, what we see is money, insurance and turf making it ever ore difficult to get what is needed.




Aug 6, 2008 12:11 PM

© Cheryl Fuller, 2007. All  rights reserved.