Wednesday, August 18, 2010

If Mama Ain't Happy...

What's the ugliest
Part of your body?
What's the ugliest
Part of your body?
Some say your nose
Some say your toes
But I think
It's your mind

Frank Zappa and the Mothers of Invention

"Since You Asked," Salon's advice column, features a strikingly detailed case of adult children trying to manage a parent's mental illness, in this instance severe anxiety and somatoform disorders superimposed upon baseline character pathology.

What is frustrating of course is the apparent lack of information and insight provided by psychiatry. The woman in question has no insurance, which in our benighted "health care system" renders her up a creek to begin with. To be sure, late-life anxiety and personality disorder are tough to treat--benzodiazepines can be risky, and rigid resistance to therapy is common. But one would have thought the family at least could have obtained a prognosis and suggestions for containment and harm-reduction, which psychiatry must be able to provide if nothing else.

Cary Tennis's "advice," such as it was, was unusually muted in this case: basically, deal with it (you will find the strength somehow) or don't deal with it (cut her off). Maybe he should have suggested that they plant themselves in a shrink's office and refuse to leave until they get an answer. As I've increasingly come to think recently, realistic prognostication is a lost art in psychiatry.

Much has been written about medicine's futile attempts to stave off inevitable death. Psychiatry is not directly involved in that fight, but it has its own counterpart, a perpetual stalling action in which medications and therapists are thrown at refractory symptoms willy-nilly in the notion that some day, somehow, either placebo effect or spontaneous remission will kick in. And perhaps they will, but patients and families should be told up front about the likelihood of that actually happening. Oops, honesty of that sort might disrupt the very placebo effect that one holds out hope for. So one can only steer between pessimism and disingenuousness.

1 comment:

Retriever said...

Those poor kids. The first thing I would tell them to do is go to NAMI, even if they have been before, and sign up for the Families 12 week course. Doesn't matter if they know it all, it's dinner and support and other harried families and some education and help with the advocacy.

The second thing would be to tell them to tell their mother that she cannot live with them unless she gets connected to Pathways or some equivalent community agency and/or a local Social Services department while she is there. Pathways is best because it is free.

The third is that even tho the mom has no interest in therapy it is possible she might benefit from DBT. If there is a group near her. She should do it in a group led by a psychologist or clinical social worker that insists that the members also have individual meetings (not one of the pseudo DBTs that just have group), and she should have homework, etc. She should also do one with at least a six month commitment, preferably a year. THese days, as DBT has become common, there are watered down 4 session versions that are pretty useless. Ideally, she should do one in a hospital setting where there is the ever-present sobering of more limiting options should her condition deteriorate.

I have a sibling with very histrionic tendencies, tho mostly the issues are bipolar. Periodically it near destroys the family. It is so hard on her kids. They cope by living in the Fair Palace of Denial 90 per cent of the time, then are heroic some of the time in a crisis and drop the ball in others.

Finally, the truth is that the children can love her, can bring her to treatment, but they cannot destroy their own lives. If anything, they should be careful to get therapy for themselves, find a church or temple or some congenial community for themselves to keep themselves from going bonkers and to re-inspire themselves. All they can do is love her, reach out, and pray a lot. Then get on with their life. We don't live in a society with a safety net.

And I don't believe it is children's duty to let a parent destroy their lives. I think one could let a severely mentally ill parent like this live with one under certain conditions such as:

--they go to therapy
--they be under a physician's care and take any meds recommended
--they help with household chores
--no physical violene
--so substance abuse
--no mental cruelty
--no criminal behavior

But easy for me to say right now when my own crazy making relatives are dead or two thousand miles away....