Thursday, July 30, 2009

Peer Professionals in Mental Health Crisis Situations

In advance, the moral of this story is not that there is nothing that some helping hands and a little Ativan can't cure. Although, its a good combination.

The experiences of a client with bipolar disorder responded me of the importance of having people in your life -- peer support -- who understand through firsthand experience what it has been like to walk in your shoes. This -- the notion that having help from someone who understands from their own experience can make a difference -- is a common mantra in the Depression and Bipolar Support Alliance of Northern Virginia groups and has become a tool in the vast arsenal at Ashburn Psychological Services.

Bipolar disorder usually presents itself in one of three forms: full-blown mania, hypomania and depression. In the depressed and manic states, some experience psychotic symptoms, such as delusions and hallucinations. Two less common presentations of bipolar are rapid cycling, where an individual shifts from mania to depression in very little time, and mixed states, where an individual is both manic and depressed at the same time (you would think that the two moods would be contradictory opposites, but, sadly, they are not).

One of the clients I share with a psychiatrist last weekend, clearly experiencing rapid cycling and mixed states. She had never been there before, but she was well-read and had no problem articulating to me the spot she was in. The only diagnostics her psychiatrist had to do was make sure that her and my observations were not off base. And they weren't. One common element of mania is having a decreased need for sleep and the client had not slept in four days. It would have been easy to write it off to mania and adjust her mood stabilizers accordingly. But in talking with the client about the history of this episode it is clear that she had been feeling anxious at first, and then the cycling, mixed states and lack of sleep followed. Anxiety is something that can often trigger mania, mixed states and rapid cycling, and so the question became: Were the rapid cycling and mixed states causing the lack of sleep, which was leading to anxiety? Or was the anxiety causing a lack of sleep, which was triggering the rapid cylcing and mixed states?

Between the three of us -- peer coach, psychiatrist and patient -- we concluded that it was the anxiety that was driving the train and that's what needed to be addressed. Part of what lead me to that conclusion was a five-day run without sleep that I had in 2007 that was not caused by mania (anxiety over some life changes) but certainty led to mixed states and psychosis. The three of us knew she was on the fast train to inpatient hospitalization if we didn't act. So, her psychiatrist added a good mood stabilizer, and I sent her to the hospital after not being able to get to sleep again that night to have the doctors administer a sedative that has hypnotic, muscle relaxing and anti-anxiety effects. Two rounds by IV and she was still awake. The emergency room doctors, somewhat amazed, added a dosage of a powerful drug to take the edge off the anxiety, and she feel asleep, and sleep for hours and hours and hours.

When I saw her the next day, well rested, she thanked me and pointed out that it was nice to have someone who doesn't doubt you and who has been through similar experiences when you begin to doubt yourself. Peer support has enhanced mental health in many ways, and, to me, this is just one of them. The other great elements in each situation like this I learn great lessons for myself and my own health, and things that I can pass along to other peers.

Career Coaching vs. Career Counseling

There has been a surge in recent calls to Ashburn Psychological Services from people looking to figure out what to door with their careers or to make a occupation change. One of the questions I often get during phone consultations is about the difference between career coaches and career counselors.

Though the lines between career counseling and career coaching have become blurred, there are some distinctions that can make a big difference in determining your future. Coaching is usually more individualized, results-oriented and guided by the client's agenda. Counseling and psychology often seek to fix what psychologists called pathology, whereas career counseling focuses on identifying career interests, aptitudes and creating a life skills plans that allows clients to accomplish those goals. A career coach can help you, like a career counselor, figure out where you want to be through talking and testing, but a coach usually also helps develop a plan, coach you on the interview process, helps you put together your resume and applications.

The follow through, the short-term, goal-oriented approach is probably one of the things that makes career coaching unique in comparsion to career counseling. Career coaches also have the ability to do somethings that career counselors rarely do -- and that's work with interviewing specialists, headhunters and others, instead of simply referring you to them for other services. Career coaches also get unique opportunities, with consent, to process boundary lines that counselors rarely do. For example, I have a very functional teenage client who has pervasive developmental disorder (or PDD-NOS) who has social anxiety and related problems communicating that make it difficult for him in work situations. I was able, with consent, to hook him up with another functional client, who has dealt with anxiety, who is working in a workplace that is very open to individuals with unique quirks. As my latter client headed off to college, he was able to walk my younger client's application into his managers and get him a job. Coaching allows you to cross other boundaries, like going to observe your clients at work and even providing them with some work with people you know to help them develop skills. In the end, there are advantages to both, but for a client looking to develop skills, trying to figure out what they want to do in life and who wants follow through, I'd recommend career coaching.

Then again, I'm a biased. :)

Monday, July 27, 2009

A Necessary Loss

In my own therapy, three years ago, my therapist handed me a passage from a book after I had been struck by a series of losses. I turned to the same passage today after a week that was filled with several punishing and piercing losses for someone close to me that shook the moors of my faith that I truly believe that which is so logical, a notion that I intellectually conceded decades ago, but that my mental and physical reaction this week told me that I truly have not let go of in my heart -- that I cannot protect, even those I love the most, from harm.

From Judith Viorst's Necessary Losses:

When we think of loss we think of the loss, through death, of people we love. But loss is a far more encompassing theme in our life. For we lose not only through death, but also by leaving and being left, by changing and letting go and moving on. And our losses include not only our separations and departures from those we love, but our conscious and unconscious losses of romantic dreams, impossible expectations, illusions of freedom and power, illusions of safely – and the loss of our own younger self, the self that thought it would always be unwrinkled, invulnerable and immortal.

Somewhat wrinkled, highly vulnerable and non-negotiably mortal, I have been examining these losses. These lifelong losses. These necessary losses. These losses we confront when we are confronted by the inescapable fact ..

That our mother is going to leave us, and we will leave her;

That our mother’s love can never be ours alone;

That what hurts us cannot always be kissed and made better;

That we are essentially out here on our own;

That we will have to accept-in other people and ourselves, the mingling of love with hate, of the good with the bad;

That our options are constricted by anatomy and guilt;

That there are flaws in every human connection;

That our status on this planet is implacably impermanent;

And that we are utterly powerless to offer ourselves or those we love protection – protection from danger and pain, from the inroads of time, from coming of age, from coming of death;

Protection from our necessary losses.

These are a part of life-universal, unavailable, inexorable. And these losses are necessary because we grow by losing and leaving and letting go.

For the road to human development is paved with renunciation. Throughout our life we grow by giving up. We give up some of our deepest attachments to others. We give up certain cherished parts of ourselves. We must conform, in the dreams we dream, as well as in our intimate relationships, all that we never will have and never will be. Passionate investment leaves us vulnerable to loss. And sometimes, no matter how clever we are, we must lose.

Tuesday, July 14, 2009

The Gift of Therapy

Just finished reading "The Gift of Therapy" by the noted psychiatrist and therapist, Irvin Yalom, MD. I had read Dr. Yalom's writings on group psychotherapy and his hilarious and poignant case studies in the book "Love's Executioner." "The Gift of Therapy" is a well-written look at case studies that form an open letter to today's therapists. As soon as I finished the book, I passed it on to a gifted client who is in graduate school, preparing to become a therapist. There is no more interesting writer in the field of psychotherapy than Dr. Yalom. He is a gifted storyteller with a wonderful mind that can easily analyze an individual client and the broader issues in the industry. What strikes me about Dr. Yalom is both how he truly belongs to no school of therapy -- cognitive behavioral or insight-oriented or psychodynamic, for example -- but instead has an amazing ability to pick and choose different elements of each school to create a unique therapy for each of his clients. What a neat philosophy - a welcome lack of orthodoxy, a recognition that each client has truly different needs that goes beyond that general concept -- which everyone can agree on -- and permeates his therapy. I find in my work life coaching and in my own personal therapy this line from the book sums up what works best: “the task of experience therapists [is to] establish a relationship with the patient characterized by genuineness, positive unconditional regard, and spontaneity.” One of the reasons I choose life coaching as opposed to tradition therapy is that it allows me to more freely bring to bear a wider variety of individualized treatments for my clients. The other striking thing about Dr. Yalom is his willingness to admit his mistakes, in the book and to his clients in session, and his ability to use those mistakes he makes as a touchstone for his clients learning and his own. It's insightful and a great read. I finished it in one evening.

Monday, July 13, 2009

Recovery month 2009

Dr. Susan Hamilton, a noted clinical psychologist, former director of substance abuse treatment programs and the former director of mental health at the American Red Cross, began working with me today to bring the federal Substance Abuse Mental Health Administration's Recovery Month 2009 to Ashburn Psychological Services and Loudoun County in September. Taking, Dr. Hamilton's lead we are looking at distributing tons of SAMSHA literature on substance abuse and mental health in the community, offering in-service training or a lecture that includes clinicians and our substance abuse treatment alums. Looking forward to more planning with Dr. Hamilton and making a difference when it comes to recovery.

Saturday, July 11, 2009

Summer bookshelf for ADD, with a nod to two modern classics on bipolar and postpartum depression

Several clients have benefited from two recent books I've tripped across for students with attention deficit disorder who are headed off to or back to college. The first book is "Making the Grade with A+DD: A Student's Guide to Succeeding in College with Attention Deficit Disorder" and "Survival Guide for College Students with ADHD and ADD." "Survival" confirms some good tips for selecting colleges, living arrangements and other issues for students with attention deficit disorder, while I would list "Making the Grade" as a must-read - I've already given away five copies in the last two months to client's who are college students, and recommended it to two others - akin to how Kay Redfield Jamison's "An Unquiet Mind: A Memoir of Moods and Madness" is a must read for anyone with or who knows someone with bipolar disorder and how Brooke Shield's "Down Came the Rain" is a must-read for anyone who has been touched by or with postpartum depression. Unlike "An Unquiet Mind" and "Down Came the Rain," "Making the Grade" is not a memoir, but it, like the others, offers great practical, intuitive and counterintutive advice for those with the illness and opens the eyes of loved ones who are trying to understand and help out.