Usable Insight – Mental Help Classified and Clarified

After thirty two years of being a psychiatrist and psychotherapist, I am embarrassed to say that I was confused about a number of things that made me less effective than I could have been. I didn’t do it intentionally, but to any patients and their families that I worked with without knowing the following, I apologize and want to tell you that there is still hope.

What I didn’t see clearly were the distinctions between Psychiatry, Psychotherapy, Counseling, Psychosocial Rehabilitation, Mentoring.

I hope the following helps and I invite any and all to weigh in on this in the comments.

  1. Psychiatry – the role of psychiatry as it is now practiced is to stabilize a patient’s neurobiology (Axis I) through psychopharmacology or ECT or TMS so they can then benefit from psychotherapy (Axis II).
  2. Psychotherapy – the role of psychotherapy is to stabilize a patient’s personality so they don’t take things so personally, don’t overreact, don’t jump to conclusions, don’t blame others, themselves, make excuses or feel self-pity.  In other words to realize that what is is, and what isn’t isn’t.  Until this becomes stabilized, counseling is of little assistance (imagine trying to serve a tennis ball while standing on mud).
  3. Counseling – the role of counseling is similar to being a consultant, but assessing problems in life, work and relationships and proposing actional solutions.
  4. Psychosocial Rehabilitation – this is the stepchild of the whole system, and yet this is where the rubber hits the road or the crap hits the fan and all the prior efforts fail, when the patient relapses.  What would be the result of cardiac or orthopedic surgery if there was not cardiac rehab or physical therapy.  The long term results would be dire without either, and yet just as the cardiac or orthopedic surgeon has the hubris to think that what they do is all important, psychiatrists and psychologists have the same hubris to think that their treatment without rehabilitation will be effective.  And if these mental health professionals think that a polite and respectful but dysfunctional or toxic family is going to follow through on what you prescribe or suggest, then it’s the mental health professional who is crazy. Mental, alcohol and drug rehabilitation has to take place where the patient lives and where through the loving, compassionate and skilled care of professionals going into the patent’s residence and literally holding them by the hand to take them to doctor’s and therapist’s appointment, engage them in recreational activities, teach them interpersonal and even budgeting skills, the patient internalizes these new habits and makes them their own.
  5. Mentoring – this is where you go from taking charge of your life to stepping enthusiastically, vigorously and confidently into your future and to who you could be. A mentor’s role is to see a talent or gift or something special in you and offer input, guidance, and sometimes making introductions for you to actualize your talent.  A mentor is also someone who is not going to put up with much of your self-defeating, counterproductive behaviors.  They won’t judge you when you complain, make excuses or blame others, they will merely defer mentoring to the time when you have enough of your act together to utilize what they have to offer to turn you talent and gift into something that will live in the world.

I wrote last week about such an organization called the Life Adjustment Team (LAT), which I believe is the model for rehabilitative efforts of the future.  Several insurance companies have been so impressed by the cost savings of avoiding re-hospitalization that they have created special CPT codes for services provided by LAT.

I have written more about them this week, because since last week I have become aware of many other people who have relapsed and want people to know that it can be prevented.

LAT is in the process of expanding their services as the demand for them is starting to explode and go beyond the current population they serve to returning soldiers and veterans.   This is not a moment too soon, as we’ve all learned that more active duty soldiers die from suicide than are being killed in the Afghanistan war.  And that makes me sick to the pit of my stomach.

BTW I will be providing a full day program in Washington, D.C. to Women United in Ministry on March 5, 2013  following the 40th year celebration of women chaplains in the military that will be held at Arlington National Cemetery.  I only hope I can be of service to this worthy group.

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6 Responses to “Usable Insight – Mental Help Classified and Clarified”

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  4. Jeff McCracken Says:

    Dear Mark,

    The distinctions for the different levels of care are beautifully spelled out. However, no apologies necessary. In working with you over the years, you encompassed each and every level through your proactive style and approach to each person. Your gift and talent is in personally connecting and listening with such amazing intuitive insight before laying the ground work for healing and repair. In reflecting on the saying, “You can lead a horse to water but you can’t make them drink” – well, you more than inspire the horse to quench their unknowing thirst.

    My brother and sister are both alcoholics and trapped in the dysfunction of playing victim after losing their marriages, family, and jobs to years of boozing and drugs. And even after interventions, lending money, not to mention all the emotional and fiscal support, they still refuse to take responsibility for their alcohol abuse. It’s sadly become their only coping mechanism in dealing with life’s challenges – creating a circle of perpetuating dysfunction. When trying to assist them with getting constructive help, they ultimately end up using the excuse that the cost or stigma of professional counseling is prohibitive. Sadly, they’re probably never going to get well because they’re so entrenched in a faulty belief system – that booze makes it all better. Unfortunately, I’m out of moves for them and relinquishing the notion they will ever seek professional help until such time they truly realize booze is and always has been merely an ineffective and destructive band-aid for their emotional and personal issues.

    I’m so impressed with LAT and its mission. We’re that my siblings were ready to take the steps to set them on a path to reclaim their lives.


  5. Pete Linnett Says:

    Dr Mark and Jeff,

    I can’t tell you how he times I’ve heard family members express exactly that frustration and hopelessness.
    Alcohol affects judgment so you can’t use logic to convince somebody of something they can’t see.
    there are people with a lot of expertise in getting through to people in trouble and that actually starts with the loved ones understanding of how to handle situations that result in treatment rather than repeated drama filled events. There are also tools to reduce stress and provide a strategy which offers some comfort and hope knowing that there is a well thought out plan in place that is not dependent on anyone having to guess what to do about rescuing a family member in crisis. Hope this is of some help.

    Pete Linnett

  6. Aaron Says:

    Hello Dr. Goulston. Great post, thanks for helping to clarify the difference between the different forms of mental health treatment. One quick question, though, on psychosocial rehabilitation: can a patient of a psychaitrist ask for assistance in starting a social therapy group of similar peers to help one another in the context of working though issues that life presents them without stigmatization? Just wondering what your thoughts are, and again, thanks for sharing.