‘Complexity’ by Jonathan Keyes

PdxJonThis powerful blog is one of the best I have read in some time. Jonathan recognises the challenges we face in trying to improve the mental health system. Essential reading!

‘The movement to radically reform the modern mental health system is rooted in a desire to offer people going through emotional distress a wider variety of options for care.  As a society we have largely shifted to a model of care that is limited to a select few options that primarily advocates the use of strong psychotropic drugs and simplistic diagnostic labels for complex and widely varying narratives. 

Recently I read that from 1998 to 2011 there has been a 400 percent rise in the prescription of antidepressants.  Likewise in Canada, at least 60 percent of female prison inmates are prescribed psychiatric drugs.   

Most people receive psychiatric medication from their general practitioner.  The stigma of going on an antidepressant has been lessened to such a degree that one out of nine people in the US now takes this class of drug.

In this context of the astronomical growth in drug based therapy, reformers are rightly calling for a dramatic reappraisal of how we are treating emotional distress.  Though many of us are working hard on creating alternatives, we often have to live within the parameters of the system that exists. 

Someone who is on a multi-med cocktail cannot simply throw their drugs out the window and avoid all interaction with this system.  Slow and steady tapers off of psych drugs require interaction with doctors who provide those meds. Those who are experiencing mania, severe agitation, violent impulses and extreme states often end up going to a hospital setting even if they hate that system because there are no other alternatives.

We are left with the complexity of interacting with the mental health system while deeply resenting aspects of it that are damaging and destructive.   People with family members who have been civilly committed are forced to watch as that person’s rights are taken away.  Doctors can choose what medications to take and force that decision on that person while family members have to sit by and watch. 

Family members may understand the short and long term health implications of those drugs but have no choice in the matter.  If they become angry, they may be turned away by the hospital.  If they plead their case to be cautious in drug dosages and cocktails, they may be branded as “enmeshed” and ”overly protective.”  So they are forced into a place of resentful cooperation.

Still others may find that though they have serious reservations about the system of mental health care in this country, they may still want to take psychiatric drugs.  Perhaps they feel that the drugs are damaging but they work for them to quell extreme and deeply uncomfortable states. 

Some may want to use these drugs intermittently for crisis states.  Some may have family members who choose to take psychiatric drugs.  Others may feel it is too challenging and risky to come off the drugs they have been placed on.  All of these folks are confronting the complexity of desiring fundamental reform while still interacting with the system at large.

In this complicated process of working with the system while fighting for change, it is important to honor the gray area that many of us walk.  How do we manage these conflicting patterns while still staying true to the desire for reform and complete and separate alternatives?   Is purity required while fighting for change?

I work part time in an acute hospital setting and am confronted by the complexity of my role regularly.  I choose to work part time in a setting where people are coerced into taking strong and often damaging psychotropics. 

But I also acknowledge that people, and generally the poorest and most disadvantaged, come there in a state of crisis, and I can offer deep and authentic support by listening and honoring their process.   I also try and create a setting where people can experience extreme states without forceful staff intervention, though I acknowledge that is not always possible, especially in cases of violence.  

Through thousands of interactions with people in extreme states, the process of listening, offering food, drink and empathetic care almost always has helped diffuse potentially volatile situations.  There is a need for that type of care even in a larger system that is destructive.

I have been asked how I can let patients know that I don’t think what is happening to them is the best course of action.  This is tricky.  Sometimes when someone has gone cold turkey off their psychiatric drugs, a good course of action is to go back on them.  But I talk about the importance of tapering slowly off medications and gaining additional supports in the community. 

The largest issue I see are people who are homeless and in severe poverty coming to the hospital and looking for help.  A hospital rarely provides that outside of some shelter vouchers.   Medications can seem like a cruel joke.  “Take this prozac and you’ll feel better.”  

My worst conflict is seeing young people who are going through a first episode of psychosis come in to the hospital.  I think . . . man, I wish this guy could receive true support such as through an Open Dialogue program. 

But instead they are started on psychotropics with little additional supports.  I watch as other nurses talk about a disease process, about the necessity of staying on meds and I wince. 

We could do so much better and I feel like another one is being lost to the system.  I talk to the parents about EASA, about ways of working through psychosis outside of the traditional plan such as the Hearing Voices Network.  But I know my small efforts are overshadowed by the dominant paradigm.

Hopefully, in time, the messages of authors on MIA and voices like Robert Whitaker will come through, start to change how hospitals are run, lead to alternatives to hospitals. But for now, many of us walk in the gray world, knowing that large changes are needed, but forced to reckon with the system as it is.  

There are multiple challenges to walking in these gray worlds.  Reformers  can blame themselves or judge others for being on psychiatric meds.  Some family members feel guilty, or like they are giving in if they don’t fight hospitals tooth and nail over the care of their kin. 

People who work within the system can feel like they are being co-opted even if they do good work.  Purity is often an impossibility and yet the desire for real and radical change is essential.  My hope is to let go of some of that blame and guilt as we embrace deep and lasting change.’