Sunday, December 13, 2009

When faith and treatment collide

I spend a lot of time reading, devoting, consuming the ideas of others, whether they come in the form of books and blogs, magazines and television programs, newspaper articles and music. My taste in blogs run from If You're Going Through Hell, Keep Going, a thoughtful personal blog on mental health by a professional writer, Jim Romenesko's blog, which keeps me up-to-date on the latest happenings of my friends in my former profession and Gawker, the entertaining New York gossip blog that would be dangerous to read without one cocked eyebrow of disbelief. Recently, a random e-mail landed in my box from a pastor who writes a blog that touches on a topic that is dear to my personal story: the all-too-often unnecessarily twisted, and sometimes treacherous, intersection of spirituality and mental health treatment.

It's nice to see someone with a mental illness in a leadership position within a large religious domination to come out and speak about their struggles. It has made me think about my wonders about illness in my life, both mental and physical, and why any good God would allow them to happen, about whether my faith (or lack thereof) plays a bigger role in my health than I estimate and about those I know who have forsaken medications, which often have devesating side effects and take years to be tuned right, on the often desperate and dangerous belief that God alone will heal them, as if their God did not have a hand in creating the plants that lead to the chemicals that became the medications, or the creation of the doctor's and discovery of the science that is right in front of them.


"Just wanted to email support of what you are doing," read the note from the pastor who writes Hiding Behind the Pulpit. "I feel that giving back to the bipolar community is the best way to cope, learn and live. I am a ... pastor who was diagnosed with bipolar disorder ... Unfortunately 'coming out' of the [bipolar] closest would sound the death knoll for my ministry."

In a recent column, the minister writes about how years in management, he went into the ministry as a pastor. After years of hiding his bipolar disorder from his congregation, the minster came out and is now facing a campaign that would lead to his removal from his position. Without knowing the full circumstances of the case, it is hard to tell much, but it did make me think about the difficulty that many of my most religious friends have had with getting their heads around mental illness, and how this reaction has played a role in many scientists dismissing the even limited role of spirituality in recovery.

One of the pastor's most recent posts deals with the difficult issues he is facing with some in his congregation, problems that he links to the disclosure of his mental illness. Another confronts the painful question of whether God considers suicide a sin, and concludes with the line, "The only reason people see suicide as a sin is they don’t understand the cause. God would no more convict a person from taking their own life than He would do the same from a person having the symptoms of cancer." The cause of suicide, the pastor implies, is mental illness, which like cancer, is no more easily controlled by an individual's willpower than it is by prayer and faithfulness.

At the end of the day, in this example, I'm not so sure it matters all that much to me whether suicide is a sin when it comes to the treatment of mental illness here on Earth. Although some might see the notion as a deterrent to suicide, it all too often leaves people I have met struggling with the belief that their faith is not strong enough if they are having thoughts of killing themselves, ideations that we know are no more a choice than paranoia and hallucinations. But what it has left me thinking about is what an absolute disaster the intersection of faith and mental health treatment can become, when, they have the potential to be excellent tools, dovetailing together in mental health recovery.

From a personal perspective, I've been thinking about the topic more since my recent lecture at Patrick Henry College, a conservative Protestant liberal arts school in Purceville, Virginia. There, I had a conversation about the all-to-frequent disastrous intersection of faith and mental health treatment, in my own case, was a central part of a one-on-one discussion I had with someone in the campus community.

I'm the first to admit that I do not have the answers when it comes to religion and mental health treatment. I do know that I have seen the power medicine and psychotherapy, and in my own life I embrace the notion that spirituality, if not religion or a religious organization, has played in my ongoing recovery. I also believe that as long as their are tornado knocking over trailers, tsaumis killing thousands, hunchbacks being born each day and the Book of Job is still a part of the Bible, I'm not going to entirely be able to reconcile this notion of a good God with the idea of health, healing and Earthly justice. I do know that my lack of understanding is not going to keep my from dismissing the role that spirituality played in my recovery, or the deeper conflicts faced by those who more wholly embrace religious organizations and are attempting to reconcile that with the successes and failures of their mental health (and other medical) treatments. I walk a contradictory tightwire on this subject. Luckily, I'm okay with contradictions.

When I returned to the Washington, D.C. area from New York in 2004, some of the first people to reach out to me in earnest were members of the church I had attended in high school and other friends of faith. A year earlier, when my scandalous acts were uncovered, it was these same people who reached out in a ferocious wave of compassion. It came in hot and heavy, as the SWAT guys would say, as everyone from the pastor I had never met at my parents church sending a note of an encouragement to the minister of the church I attended in middle school in Georgia sending a long e-mail. Upon my not-so-triumphant return to the D.C. area, some of my most frequent companions were an active member of my parents' church and an elder who was involved in counseling. There were many others, and, as I told a professor at Patrick Henry, and there blinding love - love the sinner, and hate the sin model - was integral to my recovery.

As uncomfortable as conversations about my mental health treatment were with some of my religious friends (save the one who was a licensed counselor and whose daughter had struggled with depression), it was even more disquieting to see their reaction when I proposed hosting a support group for people with bipolar at their churches. Some churches responded with open arms, but there were others, who rejected the idea or pocket vetoed the proposal by promising to get back, seemingly hoping that we would have found another location before they had to deliver an answer. At first, I assumed that there concern had to do with stigma and fear that surrounded the idea of a bunch of people with bipolar meeting alone in a room in their building once a week. After digging a little deeper, however, I found that it was driven more by perceived conflicts between mental health treatment and religion. The underlying premise of some of those who did not want the groups seemed to be along the lines of "Come on, you know that these medications don't work; God and prayer are the answer." Virtually these words were delivered to me by a man I respect whose wife was undergoing, at the time, successful cancer treatment. I don't doubt that he honestly felt that way, and saw her taking the pills as some sort of bet hedging, while his faith in her recovery was completely tied up in the much simpler notion of his and her faith and devotion to God (not such a simpler notion, but something that they felt they could have some control over, unlike science and medicine). It was God versus Science again, and God had to win.

For me, its never been that black-and-white.

In fact, one of my driving inspirations for starting mental health recovery groups in Northern Virginia is a man name Bob Mills, a vice president at Wake Forest University, who I met while giving a lecture several years back at Winston-Salem State University. Mills shared his own story of struggling with leukemia and then bipolar disorder, and the different reactions people had to reach, and talked about the support ministry he helped start at First Presbyterian Church in Winston-Salem. Mills wrote about the different reactions people, including those of faith, have to physical and mental illness in a guest column in 2003 in The Winston-Salem Journal, deftly headlined "A disease that gets no chicken pie."

In his piece, Mills describes some of the silted reactions those who were religious had to his bipolar diagnosis, and compared it to how they reacted to his diagnosis of cancer. Since then, Mills has been on a crusade to educate the faithful about mental illness, to break down the barriers of stigma and show how proper treatment and faith can work together.

"My particular calling is to engage churches and other faith communities in the fight against stigma," Mills writes. "We are seeing remarkable recoveries in families as others who have been broken by these illnesses - yet strengthened by their trials - come alongside them with encouragement and prayer."

He continues, "There are few churches I know of that would allow stigma to keep them from ministering to people who have cancer. Fifty years ago this was not the case. My dream is that in less than a decade, nearly all churches will minister to those with brain diseases and other mental illnesses."

A few years back, Mills e-mailed me looking for information on churches that offered similar mental health ministries in the Washington, D.C. There were some who had counseling programs and allowed support groups like ours to use their space, fewer still that had their own ministries - but, out of thousands of congregations of faith, it was striking how few dealt with mental health recovery in as a series part of their work.

One element of my earlier substance abuse recovery (I went to rehab for drug and alcohol addiction in 2002, and our best guess is that getting clean and sober greatly improved my life but also ushered in underlying symptoms of bipolar disorder that I had been self-medicating) that I had a hard time adopting, although eventually found to be true, was that recovery was a mental, emotional, physical and spiritual journey. Spirituality can have a variety of definitions, depending on whom you ask, but, for me, it is most broadly defined for the purposes of this conversation about recovery on acknowleding that which is not tangible. Where religion is a system of thought that usually includes a set of beliefs, narratives, practices and symbols that give meaning through the notion of a high power and truths, spirituality is less focused on communal faith but individual relationship with the intangible. I've seen spirituality play an important role in mental health recovery, whether the person's chosen higher power that the person is focusing on comes from Buddhism, Hindi tradition or Paganism, whether it involves New Age or Kabbalah, comes in the form of science, philosophy, religion or some combination of the three, whether it is Jesus Christ or Curious George and Care Bears. It's, at the very least, nice to have something bigger than yourself to hold onto. Much of psychiatry, psychology, life coaching and most certainty the 12-Steps and 12-Traditions of Alcoholics Anonymous and many other self-help programs incorporate spirituality into their programs of recovery.

Despite the interconnections between religion and spirituality, and recovery, I have encountered numerous people who have come to help me or have come to me for help who have struggled with religion and mental health recovery. The most common underlying struggle I've encountered has been over the fundamental notion that God, through prayer and devotion, can heal mental illnesses. Anyone who has been through a long struggle with mental illness, either as the person who has the illness or a loved one, knows that some of the most sick are some of the most faithful, and that their hours praying in the chapel or on their knees can have a positive impact on their lives, but will not make the hallucinations, delusions, depression or mania go away.

There is this underlying, not-so subtle notion that can be heard in the undercurrents of some of these conversations. It's the idea that religion and science are in some sort of competition, and that God has got to win out, sort of like when Galileo was convicted of heresy because of the belief that the world having to be flat and the Sun revolves around it because the Bible talks about its "four corners" and "How the Lord set the Earth on its foundations; it can never be moved." We have a terrible history when religion attempts to answer scientific questions, and when science attempts to answer religious ones. In my mind, those Bible verses no more disprove Galileo's theories than NASA pictures of the Earth rotating and revolving around the Sun disprove claims in the Bible (it might, however, disprove the interruptions of those verses). Mental illness clearly falls within the realm of science, and its time to remove religion from the list of possible answers to the cause of mental illness, and for us to put spirituality in its proper, but limited, context when it comes to treatment. Yes, the intangible probably plays a role in mental health treatment, but the best recommendations of science should take precedence and be the central focus of recovery.

There is a temptation, even for those who suffer, to believe, when the medications are not working and the doctors are struggling to find the right treatments, that if the person suffering were to reach out more to God then they would be healed like the healing of the blind and the paralytic, the cleansing of the leper and the other recorded miracles of Jesus. We are not dealing with Christian Scientists, who choose a religious healing system over drugs and medicine. We are dealing with generally middle of the road folks, who, in one case that literally happened in front of me, would question the wisdom of medicine of the mind at the same time they handed their wife her medications for her cancer treatment.

While there is no question that there is a need for sensitivity to religious beliefs in any form of medical treatment, the re-action of some mainstream Christians to psychiatric treatment, as opposed to current views on treatment for diabetes or paralysis, still has not let go of its roots in demonology, which held that many illnesses, and virtually all mental illnesses, were caused by lack of faith or demon possession. This explanation for the unknown still impacts our views of mental health treatment today, the notion problems of the pancreas are created by glucose and genetics, while maladies of the mind are driven by some darkness that can be healed by God's power.

The Oxford Textbook on Psychopathology, a mammoth book that includes an extensive history of the classification of psychiatric and psychological disorders, suggests that our present system for classifying mental disorders owes a debt to demonology, and those who attempted to determine which demons were causing which illnesses. While their primitive "therapies," such as blood letting and murder, were not effective treatments, and their beliefs about the causes of mental illnesses, such as demon possession and animistic spirits, much less plausible than modern science, their attempts to observe symptoms in order to identify the right type of possession and treatment provide evidence that many of the mental illnesses we see today have existed in some form since the beginning of recorded time.

"Primitive man and ancient civilizations alike viewed the unusual and strange within a magical and mythological frame of reference," writes Theodore Millon, the research psychologist most noted for his work on personality. "They thought that behavior that could not be understood was controlled by animistic spirits."

"Although both good and evil spirits were conjectured, the bizarre and often frightening behavior of the mentally disordered led to a prevailing belief that demon spirits must inhabit them," he continues. "People viewed possession of evil spirits as punishment for failing to obey the teachings of gods and priests. Fears that demons might spread to afflict others often led to cruel and barbaric tortures."

The days when madness was considered a divine plague or punishment have given way, through the the work done by Hippocrates and then by physicians in later centuries - to the modern system we have now where the belief is that genetics, science, nurturing, the physical world, life experiences and environment play the key roles in the development of mental illnesses. But the work of earlier researchers of the mind as not stopped this distorted view of mental illness from having a difficult time being washed out of our collective consciousness.

Just as fears of witchcraft had subsided after almost five centuries of active witch-hunts, the Salem Witch Trials showed us how this demonological misconceptions about cause-and-effect, between person and behaviors, that it is very hard us as people to let go of these much more simple explanations for afflictions. The idea that so recently the inattention, mischievousness and disobedience of two little girls with a strong family history of mental illness - 9-year-old Betty Parris and her cousin, 11-year-old Abigail Williams - could lead to hysteria where mental health and other medical problems could be labeled demonic possession is sometimes hard to fathom.

But, at least in Salem, they did not have better explanations. Research published in the 1981 edition of the American Journal of Psychiatry showed that psychiatrists in the Christian Psychiatry movement thought that psychotropic medication was the most effective treatment for acute schiozphrenic or manic episodes, but they rated the Bible and prayer for suicidal intent, grief reaction, sociopathy and alcoholism.

At its core here is an unfortunate conflict at the intersection of two ideas that could be working together in people's lives - the power of science and the power of spirituality. It is difficult for many modern practitioners, with all their knowledge of science and training, to give credit to spirituality in terms of recovery, to the notion that the tangible plays a tangible role in the health and well-being of those who suffer from illnesses. At the same time, it can be difficult for those who put much stock in faith to believe that there higher power, that their God has given us scientists and science as the ultimate tool to solving these questions.

Many of my clients are spiritual, and there is no world in which I would ask them to leave their faith at the door.

I ask them to trust that God has brought us together for a reason, that the same science that led nuclear weapons and chemotherapy contributed to psychotherapy and psychotropic medications, to not trust me if I start telling them what their priest should deliver at the next Sunday homily and to not trust their priest if he starts telling them what their therapies, medications and other treatments should be, and that we should all do our best to work to blend the emotional, mental, physical and spiritual into a healthy, holistic, individual recovery.

Wednesday, December 2, 2009

What I learned from my friend who couldn't eat


Sometimes I have to remind myself that there was time when I thought that there was no mental illness in my family. Sometimes I have to remind myself that there was a time when I thought that mental illness was not a part of me. Sometimes, I do, have to remind myself that I once saw mental illness as a sign of weakness. I have to remind myself that my views didn't change once I had my first encounter with mental illness or even a diagnosis. They evolved over time, where I began to see mental illness as a disease like diabetes, just as crippling, but with the upside of giving me perceptive and some talents I probably would not have otherwise had.

In recent lectures to college students on journalism, I have brought up the story of my friend from high school. The story is instructive about why I got into journalism - to help people, and I think that, as I say, while "it is hard for people to process the idea, to internalize the notion, that I once was so much like them" that it is "an important premise to looking at my career, because if you buy the idea that I could cross ethical lines that I did, you can buy the notion that you can."

"As F.B.I. profilers and forensic psychiatrists will tell you, recognizing that anyone is capable, under the right circumstances, of anything," I continue, "is the first step to guarding against the evil from within."

I talk about how I had been curious about writing and how as a high school student I saw the healing power of journalism in the form of a story in The Washington Post about a friend I had known who died. I saw the helping power of journalism in a series of stories in local newspapers and The Post about a classmate whose insurance company had denied medical treatment for anorexia nervosa that had her hospitalized and turned into a dying skeleton. "I saw the helping power of journalism when thousands of dollars were raised and the girl's insurance company reserved its decision because of bad publicity," I say.

What I don't tell them is another way that girl changed me. I learned from this friend that an eating disorder was not about pure vanity or purely about public perception. I learned that my friend did not not merely choose not to eat, a hallmark assumption of the pull-yourself-up-by-the-bootstraps version of mental health help, but that she couldn't eat. I learned that it took all her strength to live, to try to survive, to fight it. She was my hero.

Later in life, I would be able to take these lessons and apply the notion of will vs. treatment and support to substance abuse recovery, managing mania, dealing with depression and a host of other areas. I saw how important motivation for things to get better was, but I also saw that without the support systems, the treatment, insurance dollars and other elements, it was difficult to recovery from, and manage and cope with, these diseases.

It was not until later in life that I began to even see eating disorders as an intricate part of mental illness. They are not mental disorders simply because doctors cannot determine why people will not eat. Often, people develop eating disorders, such as binge-eating, to relive anxiety. I saw it first-hand in a good friend of mine and her 11-year-old daughter who was once found hiding within the cabinet sinks eating a can of cranberry toppings while she was supposed to be on a diet. It relieved her anxiety. I've seen how withholding, purging and other eating disorders often have to do with control - when a person feels they do not have much control over their lives, as teenagers often do, they turn to substances, cutting, not eating and other steps to exert control and relieve their anxiety.

Mental health professionals are busy working on a new taxonomy for eating disorders. There is something to be said for expanding the definitions of anxoerxia and bulima, and adding binge eating and other disorders. After all, as it stands now, research shows that 90 percent of people with eating disorders have subthreshold conditions, meaning they do not meet all the criteria of any particular disorder, and instead meet the criteria of a catch-all category called Eating Disorder, Not Otherwised Specified. Tightening the taxomony will help with research, diagnosis, education, awareness and possibility insurance reimbursement.

But the real next step is to see eating disorders, like cutting, often as a symptom of other psychological and psychiatric processes, such as obessive-compulsive disorder, anxiety disorders, postraumatic stress, personality disorders, mood disorders and others. Once people begin to look at eating disorders from that perspective we will be able to individually tailor treatment to each person, with harm-reduction, psychotherapy, medications, guided imagery, exposure therapy and other symptoms. No longer will eating disorders be seen as a confusing form of vanity.

Despite my early brush with this mental illness, even when I was diagnosed with bipolar disorder in 2003, I still saw mental illness as a sign of weakness, even though I also had been exposed to more and began to see some of the upsides. When I first walked into a psychiatric facility and they asked whether I had a family history of mental illness, I said no, not out of shame, but because no one told me that my grandfather was probably manic depressive, that I had an aunt who was probably schizophrenic, that I had another aunt who had bipolar disorder and I had substance abuse all over the other side of the family tree.

Well, the family I have now, both the biological one and the broader one is filled with mental illness. I recently reached out to my friend from high school who had the eating disorder to thank her for helping me learn, understand people better, grow and persue professions where Icould help people. She is doing well, but if she falls again, I'll be there for her, just as her example has long been with me.