Thursday, June 30, 2011

Mental Health, Therapy, and Psychopathology: Busting Some Myths

Elizabeth Zelvin

As an experienced psychotherapist, I frequently wince over errors on issues of mental health, mental illness, and related topics. The mystery community is well aware of some of these. For example, everybody seems to know that everything about the CSI TV shows is wrong. Crime scene and forensic scientists don’t interview witnesses or confront suspects. DNA results come back from the lab in months, not hours—except, of course, when the case has global high priority, as we saw following recent events in Pakistan. But some myths are extremely persistent. Giving life to them in fiction perpetuates them further.

Here are some of my pet peeves:

Myth: If you want therapy to deal with, say, relationship or family issues, you need a psychiatrist or psychologist. Reality: More “talk therapy” is done by clinical social workers (like me) than by psychiatrists and psychologists. Psychiatrists can prescribe psychotropic medications and get patients admitted to hospitals, so a competent therapist would refer a patient with severe symptoms of anxiety, depression, or a thought disorder to a psychiatrist for evaluation. But once they’re stable, the talk therapy could continue.
Psychologists are trained to evaluate a patient or client’s cognitive and emotional functioning, so they might be called in for psychological assessment testing.

Myth: “Multiple personalities” are rare but can pop up anywhere; a variant: they don’t exist or are somehow invented or induced by the therapist. Reality: The current correct term is “dissociative identity disorder.” It’s fairly common, and it develops as a response to severe sexual abuse in childhood. An ordinary therapist treating a client with DID would be well advised to read some of the very good books on the subject and seek supervision with a clinician experienced in such cases. The therapist needs to guard against being fascinated by the different “personalities,” while engaging as many of them as possible in the treatment. The goals are co-consciousness and, eventually, integration. The biggest challenge is when a client experiences an abreaction—a flashback, like those of military veterans with post-traumatic stress disorder, in this case to the experience of being sexually abused as a young child.

Myth: Accusations of sexual abuse, especially when memories have been repressed but recovered, are often lies or delusions. Reality: Wrong, wrong, wrong. As the Catholic Church recently admitted, the sexual abuse of children is an all too common phenomenon. Repression of memories is a psychological defense mechanism—a survival skill—as is the dissociation mentioned above. Most sexually abused children are not lying, just as most raped women are not lying. I believe that emphasizing the exceptions has a deeply damaging effect on societal beliefs and therefore on the ability of the abused and raped to achieve both emotional health and justice.

Myth: Psychopathic serial killers can have normal relationships and can be appealed to. Reality: A forensic psychologist who worked on the cases of some of the most infamous serial killers put it best: “Dexter doesn’t exist.” There are no magic words a victim can say to change the killer’s mind.

Myth: Alcoholics can go in and out of alcoholism and can eventually drink normally. That proves they don’t really have a problem. Reality: Alcoholism is a progressive illness, and somewhere between alcohol abuse and alcohol dependence is a point of no return. The compulsive drinking is just the tip of the iceberg; emotional, social, and behavioral issues are part of the picture, as are negativity, hopelessness, and despair.

Myth: Schizophrenia is the same as multiple personality and can be used as a synonym for ambivalence or mixed feelings. Reality: Schizophrenia is a thought disorder that is biochemical and to some extent genetic in origin. Symptoms include auditory hallucinations and thoughts and beliefs that depart from reality in various ways.

Myth: People who talk to themselves in the street must be schizophrenic. Reality: Sometimes schizophrenics talk back to their hallucinations, but some of the folks you hear cursing and making inappropriate remarks in public have Tourette’s Syndrome, an entirely different disorder. And even more of them are just talking on their cell phones.


Katreader said...

These myths that people believe annoy me too. I get especially frustrated with all the misperceptions about schizophrenia. I work in the forensic unit of a psychiatric center.

JJM said...

"The current correct term is 'dissociative identity disorder.' It's fairly common, and it develops as a response to severe sexual abuse in childhood."

That sounds as though the only cause is sexual abuse in childhood. To me, that's counter-intuitive. Couldn't other, non-sexual, forms of severe continuing / repeated trauma result in DID? And can DID only develop due to trauma in childhood, or can events later in life also result in DID?

I'm not challenging what you said, mind you. Just asking.

As for schizophrenia ... anyone who's ever dealt with someone suffering from that disorder would never mistake it for DID, but the etymology unfortunately makes it an easy error to make.

lil Gluckstern said...

Thank you, Liz, thank you. Does talking to myself in the produce aisle count? There are are always a few of us...

Elizabeth Zelvin said...

Dissociation occurs along a broad spectrum (with getting lost in a good book at the benign end and road trance somewhere in there), but my impression is that full-blown DID is most likely to develop when a young child has to split off parts of her/his personality to cope with sexual abuse (or torture, which is equally extreme).

Lil, my husband can be heard every morning making whole speeches in the shower. He says I do the same while I'm asleep. Each of us thinks the other is the weird one--hmmm. ;)

Warren Bull said...

One of the Law and Order version had one character who was referred to as a psychologist on some episodes and a psychiatrist on others. :)

Other providers of therapy include nurses, clergy and family therapists (who have different titles in different states. Levels of training and licensing requirement vary considerably.

JJM said...

Severe psychological stress, then, which is what I had always assumed. I confess I hadn't thought of its being at the extreme end of a spectrum with (as you say) getting lost in a good book as an example at the other end, so that's useful to know.

Thank you for your reply. It was a fascinating post.

Leslie Budewitz said...

Good post, Liz. Love hearing the pros correct the myths, esp to help writers get it right!

In some states, licensed professional counselors may also legally provide therapy -- as may clergy.

Leslie Budewitz said...

"Does talking to myself in the produce aisle count? There are are always a few of us..."

Lil, I think that's called "bananas." :)

jenny milchman said...

Great myth-busting! I appreciate your laying all of this out! The only one I would differ with is psychologists and talk therapy. I am ABD in clinical psych and worked as an outpatient therapist for 13 years; my mom actually finished the darn thing and has been in practice for more than 25 years. We both worked with psychologists, alongside social workers, and LPC's. I really loved having the different perspectives each degree brought to the table...

lil Gluckstern said...

@ Leslie


Elizabeth Zelvin said...

Jenny, I didn't mean to imply that there aren't clinical psychologists who practice psychotherapy. :) It's just that social workers are too often ignored or misunderstood. A lot of folks seem to think our sole job is taking people's babies away.

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