Life's Instruction Manual

Congratulations. You are now eighteen years old and possess this text, Life's Instruction Manual. Some of this information will be review, but some you have never heard before. The table of contents is below. You have until 12:00 AM to have the book memorized. 

Table of Contents

(In No Order of Importance, Since You are Required to Remember Everything by Tomorrow Anyway)

Chapter 1: Paying the Bills

1. Viable Employment Options: Money Laundering, Drug Trafficking, Stripping, and Porn are Not Included. 
2. Job Searching.
1. How to Not Act Like a Jerk at a Job Interview.
2. Fast Food: You Often Get an Employee Meal.
3. The Temp Agency: Friend or Foe?
4. Putting Out a Shingle: Sorry, Business Skills Are Not Included In This Guide.
3. Where to Store the Cash.
1. The Advantages and Disadvantages of The Bank of Your Mattress.
2. A Real Bank vs. a Credit Union.
3. Cash, Check, Charge, or Debit.
1. Don't Overdraw. Just Don't. 
4. Pay Your Bills On Time. 
5. Taxes.
1. Saving Money on Filing. 
6. Cars: Drains Bank Accounts, Usually Necessary in America.

Chapter 2: Minimizing Disease

1. Exercise: You Can Do It In Your Apartment. 
1. Yoga, Weight Lifting, and Ironmans: Only Good if You Know What You're Doing.
2. Diet: Ramen Noodles Will Not Sustain You for Long Periods of Time.
3. The Doctor:
1. Free Clinics, University Laboratories, Your First Aid Kit, and the ER: The Providers for Medicaid Recipients and the Uninsured.
2. Ice Packs and Heating Pads: Literally the Most Useful Tools in Pain Management.
3. Making the Most of Your Five Minute Physical.
4. Mental Health: Yes, Brains Hurt, Too.
5. Alternative/Complimentary Medicine: Eh, Whatever Works.

I could keep going with a table of contents for a how-to on basic living, but that would take too long and would probably bore everyone who will view this blog entry. But you see where I'm going.

I still remember the first few days after my daughter's birth. Newborns don't know much of anything, but the most striking thing was that she didn't even know how to eat. Of course she had the instinct of, "Hey, this smells like something I should put in my mouth", but she didn't know the most effective way of eating or how her crying resulted in food. Someone who is a few minutes old doesn't know that crying is supposed to get a response - the cry is out of confusion or pain. Babies learn to use crying to communicate as time goes on.

People don't come out knowing anything, but they learn over the years by instruction from adults and imitation of what they see. There is a set of rules that kids are taught, often through mowing lawns or babysitting in return of money, setting aside time for homework, and being prompted to say please and thank you. Discipline, work ethic, and etiquette are the result. The basics.

Here's the problem: some babies aren't fed when they cry. There might not be money to give to a kid for an allowance or in return for chores. A school system might ostracize a kid because they aren't the right race or don't learn the right way or simply the teachers are underpaid and burned out and they don't have the means to be the educators they hoped to be. Not all kids learns "the basics." No one is handed a book called Life's Instruction Manual. We get what we get growing up, and then it's trial and error in adulthood.

We all have the responsibility to take care of ourselves physically and emotionally. But what happens when all of our knowledge of the world is rooted in abuse, poverty, and prejudice? We would need a modified frame of reference. Unfortunately, society isn't exactly set up to help with that.

What Makes That Orange Different Than The Others?

My husband and I have finally gotten around to watching Orange is the New Black. If you haven't heard of it, it's loosely based on the memoir of a woman who went to prison for around a year due to being involved in a drug cartel shortly after college. She stopped being involved, ten years goes by, and then she is named as an accomplice. The statute of limitations was not over, and she was advised to plead guilty and serve time.

In the series, the main character Piper (based on the author) appears to be treated with more respect than the other inmates by Sam, an officer and counselor. Sam seems to have clout in managing the prison. We haven't finished the series, so I don't know how their relationship plays out. After watching the fourth episode, my husband asks, "Why does Sam favor Piper? She's an inmate, too."

The show is sensationalist, but the general social dynamic reminded me of what someone might find in some mental health settings. This is how I explained the Sam/Piper phenomenon:

"Imagine you work in a mental health setting. All day long, you interact with people who yell at you, use drugs, ignore your recommendations, and come from an environment that is socioeconomically disadvantaged. And then, every so often, there is that one person who comes to your office that seems a little like you. They have some sort of education, do what you ask, make polite conversation, are of a socioeconomic class similar to yours, and may even be the same race as you. You click with them. It makes you feel like you're actually making a difference because they seem to be doing well in the grand scheme of things."

Made sense to him.

Behavior occurs as the result of circumstance. In most situations, people have legitimate objections to what goes on in their environments and the recommendations they are given by mental health professionals. Do people always use strategies that are effective and not harmful? No. If people were always skillful and rational, I would not have a career. Some folks go to extreme ends to meet their needs, but at the end of the day meeting needs is what we all do.

I have witnessed the scenario I described above on more than one occasion in multiple health professions. I don't think providers do it on purpose in general, rather they do it unconsciously. Everyone gets along with some people more than others, usually people who have things in common. It's normal. I think the key for professionals is to be mindful of how we act towards the people we work for (The people we serve), and find ways to assist in differing needs as opposed to assuming what works for one person works for everyone.

My generalizations and opinion.

Gosh Darn Those Doctors, or, A Problem with the DSM-5 Committee That No One Seems to Talk About

The DSM-5 has been out for a few months now, and some articles on the Internet may lead you to believe it's a load of garbage out to ruin what has been known for thousands of years as normalcy. Or at best, a book of codes that allows us mental health people to actually get some money so we can afford light bulbs for our offices and toner for the copy machines we use to duplicate worksheets.

For the those who don't know what I'm talking about - and I wonder if you've only recently gained access to the Internet if that is the true - the DSM-5 is the abbreviation for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. It's a gigantic book with criteria for psychiatric diagnoses, formed by a committee of psychiatrists in the American Psychiatric Association who have extensive research experience (and maybe one or two psychologists to get some non-physician representation). It's usually called "The DSM." I've also heard it referred to as "The Bible of Psychiatry," despite a lack of detailed portrayals of human nature, potential solutions to human suffering, and divine inspiration. While it was originally written by psychiatrists for psychiatry research (Hence the "Statistical" part of the title), it has now turned into a framework for use by mental health professionals in clinical practice. And insurance companies. And court systems. And school systems. And the Social Security Administration. And..

I haven't read the thing yet. I've read the DSM-IV-TR (previous edition) twice for two different classes - and by twice I mean the whole thing twice. The DSM-5 criticisms in the media sound like criticisms one could make of the DSM-IV-TR: research ranging from solid to questionable, vague criteria with little description of what characteristics look like "in the real world," norms based on people of Western European descent, and a dash of sexism (I'm looking at you, "personality disorder" criteria). I don't plan on reading the thing until I can get a dirt cheap international edition on eBay, and I don't intend to go into great criticism of the latest work until I actually read it.

What I'm going to talk about today is the large number of committee members receiving grants and honoraria from pharmaceutical companies. You know what?

I actually sympathize with the psychiatrists.

Now, pharmaceutical company funding is a problem. Medication has been an effective tool in mental health recovery for many people when used ethically. It was a major contribution to deinstitutionalization and reducing horrendous psychiatric hospital conditions. I don't have a problem with simply the existence of pharmaceuticals or companies that produce medication for a profit. But those little grants influence prescribing Really Expensive Medication, which isn't necessarily anymore effective or tolerable than cheaper medication prescribed at therapeutic (read: not for chemical restraint) doses. Really Expensive Medication tends to contribute to high insurance copays and strapped public mental health entities, and should be reserved for situations in which it is the best choice: someone has had no success with cheaper medications, evidence suggests the Really Expensive Medication is ideal given the person's current challenges, age, sex, etc.

So why do I sympathize with these guys if they are potentially prescribing and diagnosing based on some randomness a drug rep with a medieval studies degree said over sandwiches a few years back as well as a bunch of Pharma grant applications they probably didn't even write?

Well, funding for mental health research, education, and social services isn't stellar. It's hard to do research when you have no money. It's hard to provide education to the public when you have no money. It's hard to implement community programming and medical services when you have no money.

How do we raise money? I don't see any pastel ribbons in our future. Mental health challenges still suffer from stigma, are hard to quantify, and people tend to wonder if they exist at all. Grant funding from nonprofit (and presumably less biased) organizations is limited (I say this as someone who did a stint in fundraising). Why throw money at a nebulous concept, the public cries? And thus Pharma to the rescue.

The idealistic side of me says some of these physicians accept funding from these companies with questionable ethics because they think it is the best means to further our understanding of mental health. They're not going to get enough money elsewhere. Mental health tends to be first cut, last funded when it comes to government priorities. It costs money to do interviews, brain imaging, writing, education, and everything else academic psychiatrists do. Academia doesn't always pay that great, either, and it can take years before one is out of adjunct land after the years of schooling. I think people do the best they can in order survive, and funding is survival for this branch of psychiatry.

That said, why do they put up with the abysmal state of mental health funding? Pharmaceutical grants have produced good at times, but they perpetuate inadequate funding by "picking up the slack" for government entities. Rather than tolerate the current system, could it be better to take periodic breaks from research to focus on advocating for government funding that is on par with funding for other health needs? Psychiatrists are honestly at the top of mental health food chain whether we like it or not, and more of those who are able to advocate need to utilize their acceptance by the government as the authorities on mental health identification and biological treatment in order to put pressure on said government to step up and provide the means to facilitate productive research outcomes.Which should include some more of what those wild psychoneursomethingorother people are doing, light therapy, personality, multiculturalism, and whatever else that could use some of the attention currently occupied by our friends at Pharma.


Rather than cut funding altogether as is current practice, perhaps we should work towards not actually needing current amounts of funding via prevention, education, and providing better treatment based on sound research. Which would initially take more funding, but you have to spend money to make money, right?

I suspect physicians on the DSM committee didn't go into medicine with the intent to become drug company pawns. Again, idealist in me. Maybe it starts with one those dry CME things with GlaxoSmithKline backing resulting in some supernatural entity a la The Ghost of Christmas Future talking about the sky falling if generic lamotrigine is prescribed over Lamictal XR because a 38 hour half-life is just too short, I don't know.

On a final note, other disciplines share responsibility in improving services - not just our friends on the DSM committee. In the spirit of interdisciplinary practice and social justice, all mental health professions should join those already involved in advocacy regardless of their professional identity in order to demand resources to better serve everyone. The more the merrier, right?