Dispatches from a Reluctant Guide
on the Path to Disability

I am very grateful for all of the comments on the last post. At the time of this writing I am still employed at the hospital.

I graduated in 1987 with a Bachelor of Science in Psychology from Slippery Rock University of Pennsylvania. We were all very proud that Playboy Magazine had just listed Slippery Rock as one of the “Top 10 Party Schools in America.” However; it was an excellent education. I have worked in the field my entire adult life and have never needed another degree.

1987 was also the year Prozac was introduced and Milton Erickson died.

The attitude of my professors in the Psych Department was that the science of Psychology was coming to an end. The mysteries of the mind had been unraveled through the new neuroscience, and all that was left was some mopping up. It all seemed very convincing, and I believed it myself for many years. The theories of Freud and Jung were interesting relics for academic discourse, but contemporary clinicians were reluctant to embrace their ideas, or apologetic for ever having believed in them.

We were discouraged from expectations of making a career in psychology. Even with an advanced degree, “All of the money will be in neurology.”

We had no neuroscientists in the department, so the curriculum remained what had been taught to previous generations when psychology was still vibrant.

My favorite class was A History of Psychology in which we analyzed TS Kuhn’s Structure of Scientific Revolution and applied it to the current biological paradigm shift we would soon be confronting as graduates. Because of Kuhn I entered the field a bit more skeptical than most about the coming new zeitgeist. It preserved my capacity for critical thinking.

My professors were completely correct in assuming that psychoanalytic ideas would not be popular in the new paradigm. They were also right about the money.

I spent the next 15 years working in residential treatment facilities, mostly with teenage boys, and I’m still paying off the last of my student loans.

Almost every kid in treatment was on meds. It was rare for a kid not to be on meds. These programs were not “medical models” (we had no nurses or doctors on staff). The students lived on an unlocked campus, usually for about one school year. They were typically in very serious trouble with the legal system or had not been able to adapt to living in an unrestricted setting at home or in foster care.

We didn’t automatically focus on meds or diagnosis. I think our assumption was that the kids would be worse if they weren’t on the meds (i.e., the meds were doing something, or they wouldn’t have been prescribed.)

Sometimes staff would comment “I’d hate to imagine that kid off his meds,” inferring that the kid would be more aggressive if not for the medications.

Occasionally someone would comment on the dose a kid was taking, saying “that would drop a horse.” The inference was that the kid’s natural, unmedicated state might be completely out of control if not curbed by very powerful sedatives. We never considered tolerance or dependence as factors.

We also assumed that someone, somewhere, had given careful thought to and practiced restraint in assessing, diagnosing and prescribing powerful daily medications to a young person, particularly one who was at the mercy of the system. We assumed a Doctor, because of their oath, would attend more carefully to a kid whose parents weren’t available to advocate for him.

I chose a “leadership” career path (rather than “clinical”) in order to avoid having to go back to school for a Master’s Degree. However, I always remained a clinician at heart and in practice. As a leader I simply continued to run groups and participate in clinical discussions regardless of my job title. I read the same books as everyone else, and co-facilitated groups whenever possible (a practice I still recommend). I contributed to countless thesis papers and dissertations of other people over the years.

My cognitive-behavioristic orientation was tempered by teammates who were humanists, psychodynamicists, gestaltists, addictions counselors, chaplains, and true eclectic free thinkers. I made a point of encouraging dialectical points of view as a way to teach and maintain a healthy, dynamic team. I have run almost every kind of group you have heard of at one time or another.

We relied on the environment itself to shape different patterns of behavior, using a positive peer culture and a very strong commitment to consistency. For example, when gangs became a common theme among the kids being referred to us, rather than label the narrative as “gangs are bad”, and attempt to stamp out gang-related memorabilia, we identified the aspects of gang culture that were attractive to the kids. (Gang culture often embraces a set of values much like the military culture.) These are virtues, if used in a different context — Honor, loyalty, valor, justice, fellowship, family, tribe, self-sacrifice. etc. — and result in different consequences. New habits could form around the same behavioral expression.

It seems obvious why gang culture would appeal to boys. The gang provides a chance for a young male to test himself, his courage and ferocity in defense of his tribe. We simply developed an environment in which these virtues could be expressed more productively, and reinforced it consistently with increased personal authority (rank) and actual power in the community. (i.e. the ability to make changes to structure, rules, etc.).

We had similar counterintuitive approaches when various contagious behaviors swept through programs, such as self-mutilation and eating disorders.

Residential work is a lifestyle. It is a science and an art form. If you work with kids (and are not a teacher, or working within education) you probably work evenings, weekends, and holidays. That is when you are needed at work the most. The hours are genuinely 7-11 and someone has to stay up/be on duty all night.

Surprisingly, medication compliance was not a common problem. The kids rarely refused to take the meds or complained about side effects. We were always more conscious of avoiding power struggles, since none of us were prepared to force feed pills to anyone, and the pills never seemed to make an immediate or notable difference in their behaviors one way or the other. We saw the meds as being an agreement between the kids and the Dr. prescribing them. If a kid chose to not take his meds, he was just as accountable and responsible for himself as if he did take his meds, or never had meds at all. This way the meds didn’t become an excuse for acting out either.

I really never saw a big difference when a med change happened but, then again, I wasn’t looking for one. In all the years I worked residential treatment I can’t remember a fatal overdose or suicide. I’m sure there must have been “cheeking” going on, but I don’t remember any big incidents. By this time I had my own diagnosis and relationship with the meds, and I personally respected the kids who insisted on doing well without “help”.

It was also unusual to focus on a diagnosis. Most of the kids came in with a history of ADHD, Oppositional Defiant Disorder, and Conduct Disorder. Most were angry. Many were depressed. But we didn’t think of these as medical problems. Bipolar disorder didn’t become a common diagnosis in the kids until the late 90’s.

It was easy to see the progression of the ADHD-conduct disorder as a predictable trend, and perceive it, rather than a problem with the kid’s brain, as a defensive reaction from a kid who felt powerless or misunderstood. Put another way, what we saw in the actions and attitudes could be interpreted as healthy, perfectly adaptive reactions to a chaotic or extreme environmental condition. In the same way paranoia could be adaptive and functional to a person thrust into war.

Obviously my behaviorism is showing here: Although I am convinced we are all the product of both “nature” and “nurture”, I think “nurture” is most important. My world view is that people generally behave the way they have been “taught” to behave, they do what works or has worked in the past. People will subconsciously stick to these habits until they either no longer work or find a different way to meet the same need. I agree most with Milton Erickson’s writings on the subject.

I burned out of my residential lifestyle in 2003, a few years after managed care came to Pennsylvania. I took my current job in the hospital, in an outpatient program for adults, and refused any role in leadership in the nine years since. It was a great relief to be insulated from the administrative headaches and to focus entirely on the people I was assigned in groups.

There was some culture shock in adjusting to a hospital setting/ medical model. To begin I had to think of the people I worked with as “patients”.

Another difference was the money. I had worked entirely for private, nonprofit organizations and no longer needed to solicit donations for basic materials and office supplies. I was treated to expensive Pharma luncheons and dinners by attractive reps that smiled and agreed with anything I said. It was seductive.

And finally there is the medical hierarchy. Having never been in the military I haven’t completely adapted to the idea that a rank or title demands philosophical deference. People have tremendous faith in authority. To most people “Doctor” is a sacred narrative. The hospital was the first time (as an adult) in which I experience someone as unquestionably right simply because of their rank. Having facts, or accurately predicting outcomes, made no difference.

I can understand how having faith in the generals is functional if you are a soldier, but faith is an enemy of science. You simply cannot argue matters of faith with evidence. An interesting recent example of this narrative is in Dr. Lieberman’s editorial in Scientific American.

By my third year at the hospital I began to detect patterns in the people who returned to our program over and over. The vast majority of the people who return to my level of care report being compliant with medications and are usually are involved in therapy as well. They sometimes describe themselves as their illness, which does not suggest a great deal of “anosognosia”.

This trend challenges some general assumptions, (which persists despite daily evidence to the contrary): That people will tend to deny their illness because of the stigma, and/or they will stop taking their meds, and their symptoms come back.

I found the trend most predictable in people who were prescribed benzodiazepines. The people who returned to my level care on benzos consistently reported increased levels of anxiety across time despite gradually increasing dosages. Very often these people had apparently functioned normally most of their lives. I began to suspect that the benzos themselves had become the problem, and offered that hypothesis for discussion.

Naturally this shift created some conflict on my treatment team.

Challenging the assumptions about benzos resulted in my first disciplinary “counseling” session. In this meeting, which I naively assumed to be an opportunity for open discussion, I responded with counterpoints to every point I was offered. In the end I was told for the first time “you can’t think that and work here”.

It surprised me that the official position at the time was that benzos were not “addictive”. I resolved this somewhat by substituting the word “dependent” with “addiction”, which seemed to be tolerated better by the medical people. But my hypothesis is that the effects of tolerance, withdrawal, and eventual dependence, etc., would be conditioned by anything a person is continuously exposed to across time. The trend is possibly more obvious in benzos (as well as sleep aids and pain meds), but might also be true for all meds and even therapy — or trauma, for that matter. It’s basic Pavlov, for crying out loud!

In another counseling session, I was assured that these observations constituted “black and white” thinking on my part.

Whenever I mention Pavlov these days I notice everyone’s eyes glaze over, which is — ironically — also the result of conditioning.

A few years later, when it became clear that benzos were obviously addictive, the thinking shifted to the use of longer-acting benzos being less addictive and therefore “safe” for long term use.

Even today, when a person’s “dependence” on meds or therapy becomes too obvious to ignore the person is sometimes diagnosed with a personality disorder. It can never be considered that perhaps the person isn’t responding to treatment because their problems aren’t medical. I suspect that some of these people have no idea that they have become “dependent”.

I want to emphasize that my observations are entirely anecdotal. My hospital does not track (or at least publicize) patient outcomes in regards to disability or recovery. We have no record of who leaves treatment and gets better. I am not aware of any database of how many people deteriorate despite receiving services or how many become permanently disabled after getting into treatment.

Therefore it is possible that the majority of patients I meet in groups stay on the meds, accept their illness, and thrive. Most people do not return to my level of care repeatedly, and I have no idea what happens to the people who never return.

It is also possible I am working at the trailhead of the path to disability.