Is It Me or the Medicine?

As I reflect on the last five years working in the partial hospitalization program at Tanner, I think of the hundreds of children I have treated and consider the many ways I measure progress. I have conjured up a measuring stick that looks at success very creatively at times; and at other times has very clear, quantitative measurements such as identifying 3-5 angry triggers and 5-7 positive coping skills, etc.  Though at times I have to ask myself: Is it the medicine or is it me?  Of course the answer is that it is both.  Some may say it is neither.  :) But some days I am convinced that we keep patients in the program simply to observe them on the medication, and that no great thing that I bring into my group room or bring into the playspace can hold a candle to what medication can do. 

The thing that concerns me the most, however, is seeing children from age 4+ on medication.  To hear a child say, "I'm behaving this way because I didn't take my medication today" is an incredibly powerless - non-person centered stance.  It takes all of the agency away from the child and gives them something even more crippling: an excuse.  And at the same time, when you have children who are actively psychotic or so ADHD that they can't focus long enough to tie their shoes, you beg the doctor for medication!  As the therapist, it is difficult to help a child understand that yes, the medication is helpful for the chemical processes in the brain, but that they, themselves control their mind - their choices - that they can manage their symptoms with behavior modification.  And that they can express their feelings without fear of becoming overwhelmed by their emotions.  That can be difficult for an adult, much less a child, to understand, or to trust.

It is equally as difficult to explain to an adolescent that no, you cannot self - medicate with marijuana because it is illegal, but you can take this other drug to help with your anxiety or depression or - fill in the blank -  simply because it is not.  But it is still a drug!  It is still a chemical compound you are ingesting into your body to alter you in some way as opposed to identifying your own inner resources to overcome whatever issues brought you into therapy in the first place.

I found myself recently trying to give an analogy to one of my patients about medication vs choices.  I used the example of me taking my blood pressure medicine.  I listed all of the ways that I help my medicine to work.  I take my medication everyday, but I also eat healthy and exercise and I don't smoke.  This very logical, 8 year old child looked at me like I was speaking a different language.  In his world, you have a headache, you take Tylenol, your headache goes away.  You are coughing, you take cough syrup and your cough goes away.  Medicine is King!  And I completely understand the logic.  I, myself, have tried on several occasions to manage my blood pressure without meds.  And so far I have not been successful.  And in the context of full disclosure, I know what it is like to feel like a slave to psychotropic medications.  I started taking Wellbutrin last year, and after about 6 months, I decided that I felt happy on a daily basis, and was therefore ready to  come off of it.  So I did - Cold turkey with no titration- and I crashed hard. After two weeks I was FEIGNING for more Wellbutrin - shaking as I refilled my prescription.   I was mortified when I realized that I was dysfunctional without it.  It was as if I could not imagine any happiness prior to taking it.  And I would think to myself, "surely I have been able to make my own self happy.  Clearly I know how to do this - I teach others to do this!" I did not want to be a slave to my medication.  So, I realized I needed to shore up my positive coping skills and gather 'round my support system and a month later I was able to come off of it.**  But I had to remind myself that it was possible to do this.  That I don't believe people need to be on medication (or for that matter in therapy) for the rest of their lives.  Ultimately the goal is self sufficiency, right? Wellness - or better yet, Healing? Or is the goal to keep people enslaved to the medication?  We live in America, right? 

Mental illness = drugs= a lifetime of cash flow.

 I have a job because people take medication.  Working for a hospital, we are at the mercy of insurance companies who will threaten to not cover a patient if they are not medication compliant.  Or if their symptoms persist, and there is not a medication adjustment - higher dosage or more drugs- then ta-ta!

I have to believe that people can be and should be HEALED - not just engage in capacity building to manage symptoms, but HEALED.  Maybe I am being too idealistic and unrealistic.  Some people may even argue that I am being unfair. These same people may argue that there are certain illnesses - mental or physical - that REQUIRE that people be on medication for the rest of their lives.   I know some of these people.  And I see them taking medication for the rest of their lives because they have bought into the myth that they can't be helped, they can only be managed.  It takes a tremendous amount of faith and will (because it takes more work to do it on your own) to responsibly live a life without having to take a pill everyday.  And as I say that I see the faces of some of my friends who I know have to take medication daily.  And wonder what they will think about me having said this about them.  I do not think for a moment that anybody who has to take a pill everyday is weak.  Hell, I still take a pill everyday.  My hope is that they will read in this my deep love for humanity and desire that we all live a long, healthy and happy life.   I watched my mother suffer and eventually die taking pills everyday instead of being healed so that she could live a long, healthy life.   I have to believe that people living their best life, their healthiest life is possible.  I have to believe that just because there are hundreds of commercials daily advertising the benefits of medication, does not mean that we have to buy into the myth of perpetual sickness.   I have to believe in the true benefits of therapy in order to continue to do the work that I do, as opposed to believing that therapy
is merely an adjunct to psychopharmocology.  I have to believe.  I have to believe.  I have to believe.

             

** It is not advisable that you stop taking medication without first consulting your physician.

Treating the immediate effects of trauma with drama therapy

Treating the effects of immediate trauma can be quite daunting.   Often the emotions have not quite coagulated because the experience is so new and the client may still be in considerable shock.   Research suggests, however, that the earlier the trauma is addressed and treated the more resilient the patient is likely to be and the less likely it will be that the patient will experience the lingering effects of the trauma.

I had one such experience recently with one of my patients who experienced a trauma while in treatment with me.    She was physically caught in the middle of a physical altercation between two older girls.  This new trauma was compounded by earlier traumas she experienced which in fact brought her into treatment.

After witnessing the trauma my patient was visibly distraught.  She was tearful, screamed and was to her own admission: "terrified".  She said to me that she expected to have nightmares that night (which in fact she did).  Her grandmother later reported to me that she had nightmares the whole weekend and catastrophized (my word) the experience - thinking that the victim of the altercation had in fact died.  My patient, who we will call "Gina" was tearful, hypersensitive and struggled with her interpersonal relationships all weekend. 

The next Monday when she returned to therapy I was prepared to work with her at her own pace.  I was certain that she would want to talk about it as a part of the group therapy experience, but I was not certain that she would want to share it publicly so soon.  She surprised me.  Not only was she interested in sharing the experience with her peers, but she was also interested in working dramatically with me. 

Using the dramatic process creates a good amount of distance between the patient and the trauma thereby allowing them the ability to access their emotions safely.  For Gina, she wanted to use the drama of the "Broadcaster".   It is not unusual for victims of trauma to want to "broadcast" the experience.  It gives them an opportunity to tell and re-tell the story.  It empowers them by giving them a voice where during the trauma they may have felt silenced. 

As the "Broadcaster" Gina asked me to scribe what she spoke , and I did so dutifully.    She then performed it for me.    The script read: "Nina punched Hope in the face.  That's all we have for now.  Stay tuned for more on Chanel 5 Fox 5 News".

The next day, Gina went through the routine again - each of us assuming our previous roles.  The script read the same, but this time, sensing that Gina might be willing to be pushed a little (and myself falling victim to the pitfalls of short term therapy and insurance companies), I interjected, "I think we have a clip of that".  And she silently agreed to watch it with me on our imaginary screen.  As soon as the violent perpetrator made physical contact with the victim, Gina pushed the imaginary "off" button and immediately switched it to a clip about kittens and puppies.  She would talk about how sweet and cute they were and at one point even asked if I had the clip of "Little House on the Prairie".  I was shocked that she knew anything about Little House on the Prairie seeing as how she is only 6.  But naturally  I obliged.  Gina commented on how beautiful Laura is and then inevitably something would happen to Laura or one of the kittens or the puppies.  They would get kidnapped or hurt or tangled or even sometimes killed.  I sensed by her act of sabotage that she was not quite ready to be pushed.  So, I regressed her back to the more safe words - releasing images for which she was not quite ready.

Later during the same session the group was engaged in round robin storytelling - fantasy story.  Gina's offering to each newly created story was always a sad offering.   If one patient revived a character who died in the story, Gina would kill it.  She even titled the story "The boy who kept dying".  Gina's title seems to suggest that she may feel victimized and re-victimized over and over again - compounded trauma.  After the story was complete she asked if she could tell the story of what happened the week before - her trauma.  I obliged though attempted to create some distance for her by employing the "Once Upon a Time" technique.  But Gina was not willing to let me hijack the time and setting of the story.  She wanted to tell a REAL story, not an imaginary one.  In drama therapyspeak we would say that Gina was underdistanced.  No sooner than I started the story with "Once Upon a Time in a land far, far away", did she cut me off abruptly and said, "No.  Friday at Willowbrooke".  I was immediately aware that she was too close to the trauma and not ready to move away from it, and that our work would become creating appropriate therapeutic distance between herself and the trauma.  At this time she had become too identified with the trauma to let it go.

Over the next few weeks, we were working less and less with the specific trauma and including it as a part of our overall work together.  Eventually Gina was able to tell the story of what happened - or reference what happened with an appropriate emotional response.  Her story referencing lessened over time and her trauma symptoms waned including - fewer to no nightmares - improved peer relations- fewer to no emotional outbursts - and no catastrophizing. And for me, the best sign of progress was listening to Gina tell a story - a fantasy story - where she did not feel the need to sabotage and where death was not a recurrent theme. 


 

Cracking my High C and forgetting my lines

I realize that I forgot my lines.  I forgot the words that asked to be written.  They simply slipped my mind.  They slipped my mind because there was no space there.  It had been filled up with jobs and relationships and life.  It was filled to overflowing with thoughts about my feelings and my body and my work.  This meta cognition was beginning to bore holes into my skull and I just could not escape the rapture of it all. 

Well, okay, this is how I REALLY forgot my lines:

Something happened to jolt me back onto the stage of life - and take me out of the rapturous bliss of simply living life.  An intern said that because of ME, she was unable to fulfill her responsibilities as a clinician in training.  That I was critical and made her feel like she was in grade school.  Logically I knew that it was nearly impossible for me to wield that much power.  But that was what she felt.  Psychologically I knew that she was projecting.  But that is what she sensed.  My relationship with her and the rest of the staff told me that her poor performance was felt by EVERY SINGLE STAFF person, but it was me she scapegoated.

So, I forgot my lines.  I could not think of anything to say and there were no cue cards.

This is not who I believed myself to be as a human being or a clinician.  I had to do some serious self care work around that so that I did not feel like I failed this woman.  I wanted her to take some responsibility for her life - for her work - for how much energy, time and thought she did NOT put into therapeutic interventions. But I could not do her work for her, so instead I focused on me.  I thought about past interns and how I really try to mentor them.  I really try and take time to listen to them, explain the impulse behind my interventions, give them helpful, honest feedback about their own work, help them write a perfect clinical note, describe the ins and outs of expressive therapy, etc.  And I had to ask myself, "Did I do all of that for her?"  I would like to think that I did, but maybe I did not do all that I could for her.  Maybe I had a bit of countertransferrence going on.

Ultimately, I read this as a lesson: Not every encounter I have, not every workshop I do or therapy group I lead is going to end on a High C note (as my opera singing sister would describe it).   Sometimes you are going to Crack your High C AND forget your lines.  But, of course, the show must go on.

Oddly enough, a week later, I got a message from one of my former interns asking me if she could write about me for a paper she was completing for a Master's level course about  a leader in the field of counseling who is also an advocate.  I felt honored... and relieved.

I hit my High C AND remembered my lines!