Author:Paul Gilmartin

Mental Health after Disaster: A Missed Opportunity in Bangladesh – A Guest Blog by M. Sophia Newman

It was the end of April. Police had stopped transportation on the busy road leading to Savar; a stream of people walked along the hot, dusty road. We were all going to the same place: the site of the former Rana Plaza factory. Days before, on April 24, 2013, it had collapsed with over 3500 workers inside. Now, six days later, the rescue operation had dwindled to the recovery of the 1,116 bodies in the wreckage. Nonetheless, onlookers streamed to the site. Some protested or brought donations. Others just came to witness the worst industrial disaster in the history of Bangladesh.

Outside the factory, women holding pictures of missing loved ones wailed. As a rare foreigner, they targeted me for attention, begging me to do something. I hugged two, one under each arm – and when a camera crew noticed, I was suddenly on live TV. A journalist asked in English what I thought should be done. “These people need access to mental health care now,” I said.

I knew my words were in vain. I had come to Bangladesh months before as a Fulbright research fellow to study the mental health system – or, to phrase it more accurately, the lack thereof. Bangladesh is a nation of 163 million, of whom about one in seven have a diagnosable mental health condition at any given time. (This figure is on par with most nations.) Yet the country has just 123 psychiatrists and 40 clinical psychologists.

In some ways, the lack of mental healthcare is typical. Internationally, most mental healthcare is concentrated in wealthier countries. But Bangladesh is a particularly bad case. Its 123 psychiatrists are enough to serve just 1% of the 26 million Bangladeshis with mental health disorders – and not nearly enough to answer the need for popular education and the removal of public stigma. Per capita, it has less mental healthcare providers than Afghanistan.

Curiously, though, the interest in scaling up mental health systems in developing countries comes mostly after armed conflicts or disasters, like the collapse of Rana Plaza. (Perhaps it is because the cases of post-traumatic stress disorder some people will suffer after catastrophe are seen as an injustice requiring redress.) Across time and geography, the pattern is so clear the World Health Organization now suggests waiting for an atrocity to generate public interest in mental health system development.

Standing in front of Rana Plaza, I noticed many people acknowledged ongoing grief and trauma. Without knowing exactly what mental health care would offer, people expressed worry about the lonely women who stood near the ruin weeping. Institutional shortcomings aside, Bangladesh’s apathy towards mental health may have been cleared away with the rubble of the building.

It was a necessary awareness. The country’s main psychological research department predicted 1,000 cases of post-traumatic stress disorder (PTSD) among workers, rescuers, and families of the dead. Government officials wrote an action plan assuming only 200 PTSD cases will occur. With outreach remaining poor, it’s never been clear which was accurate.

Now, as the first anniversary of the atrocity approaches, many are well again. A Bangladeshi friend traced a typical pattern. He volunteered at the site for over a week in April. In August, he often told me about his irrational guilt, sleeplessness, and fixation on his own death. I worried over him. But by January, he was alright. For a significant portion of otherwise-healthy individuals with a reasonable level of support, PTSD sometimes remits within a year.

For those who have not sprung back, clinical care remains important. As the international corporations that sourced garments at Rana Plaza finally begin pay-outs to workers and their families, paying for mental healthcare has been overlooked. Remembering the sound of women crying in my arms last April, I know it shouldn’t be.

Bio:

M. Sophia Newman, MPH, was a 2012-2013 Fulbright fellow to Bangladesh. See more of her writing at msophianewman.com.

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What’s the Difference Between “Therapist”, “Psychologist” and “Social Worker” – Guest Blog by Matthew

Hi Paul,

As a social worker who works full time as a psychotherapist in New York City, I had a thought about something that could really use some clarification in the world of mental health care.

“Social worker” can mean a person with a bachelor’s degree in social work (BSW), a master’s degree (MSW), or a doctorate (DSW or PhD). Each of these degree levels qualifies you for a different kind of work:

—  A BSW can practice as a “generalist”, such as doing crisis intervention, or interviewing, or case work (like your guest, Ray). A BSW cannot, in any state, practice psychotherapy.

—  With an MSW, you can choose to specialise in clinical practice — like a psychologist specializing in clinical psychology — which entails additional supervised training in diagnosis and treatment of mental disorders. Social workers must be at this level of education and training to become licensed therapists.

— A doctoral degree (sometimes called DSW, sometimes called PhD in Social Work) does not give you more clinical authority, but does give you additional qualifications for research and teaching in the field of social work.

 

This is from the web site of the National Association of Social Workers:

“Did you know that social workers provide most of the country’s mental health services? According to government sources, 60% of mental health professionals are clinically trained social workers, compared to 10% of psychiatrists, 23% of psychologists and 5% of psychiatric nurses.”

There’s lots of confusion in the public, including people seeking mental health care and even among those of us in the field, about names and functions of the various professions involved in providing psychotherapy  and medication to treat mental illness. (This is totally understandable to me, as I had no idea what the differences were before becoming a social worker myself. It’s confusing!)

The basic issue: people often use the words “psychologist” and “psychotherapist” or “therapist” interchangeably, even though each means something different. So you’ll often hear someone say they went to a “psychologist” when they mean they went for therapy — and it’s quite possible they were actually treated by a licensed clinical social workerIn every state in the US, clinical social workers, like clinical psychologists, are authorized to diagnose and treat mental disorders by providing psychotherapy and other services reimbursable by health insurance. In New York State, psychotherapy can also be provided by licensed practitioners of marriage and family therapycreative arts therapymental health counselling; or psychoanalysis. The only practitioners who can also prescribe medication are physicians (usually psychiatrists or GPs) and nurse practitioners, which I think is also true in other states.

There’s a huge upside, of course, to having so many professions involved in mental health care. As a clinician I’ve benefited greatly from the opportunity to work with terrific psychologists, art therapists, counselors and psychiatrists. I’ve learned so much from them precisely because each discipline brings its own focus and its own toolbox to the field. Talking to a talented colleague who is trained to look at things from a totally different (but complementary) perspective can really open your eyes.

The problem for social workers, though, is that despite our prevalence and the scope of our practice, most people have absolutely no idea that we constitute the majority of US therapists, working in every kind of venue in mental health care — from private practice to clinics and hospitals to federal agencies and the military.

I think some of this has to do with our name. “Social worker” is often used interchangeably, and incorrectly, with “case worker.” (To understand the differences in education and training between social workers and case workers, think of the difference between lawyers and  paralegals or law clerks.) Because of this, and because of the stigma around caseworkers in many communities (e.g. “they’re the ones who take your kids away”), many clinical social workers downplay the title and simply call themselves “therapists” instead.

Another factor in our popular invisibility, it seems to me, is that we definitely lack the professional swagger and collective ambition of our clinical psychologist colleagues. Although I know many social workers who have PhDs, run agencies or departments, or have successful private practices, they are generally the kind of people who introduce themselves with their first names. For whatever reason, it’s easier for us to see that making everyone call you “DOCTOR So-and-So” will never win you the magical status or obscene salaries accorded to physicians in our culture, no matter how many times you say it. Unlike at colleges and other settings, in the health care world everyone knows that the real “doctors” are the ones who write the scrips, call the shots, and make the bucks. Social workers know that for better or worse, we’re never getting an invite to join that club, any more than psychologists are. The difference is that we know it – and that many of us, including me, don’t want to be “doctors,” however much we’re subject to the same kinds of envy and resentment as anyone else.

I have realized that for me, however, when it comes to the titles we use, there’s something much more important at stake than disciplinary rivalries and vanities. When I ask patients to call me Matthew, I am trying to implicitly convey to them a core value of social work: though our roles here are different, we are equals. I’m saying, in a way, “Here’s the bad news and the good news all in one: getting better isn’t about you believing in me — it’s about us believing in you.” That’s why, no matter how many degrees we might end up with, if we became “doctors” we would no longer be social workers.

In terms of our particular skill set, what makes social workers different — and too often we don’t do a good job speaking up proudly about this — is that we are uniquely trained and equipped to treat mental illness as a biological, developmental, psychological, spiritual, sexual, economic, cultural, relational and communal phenomenon, in which none of these factors can be separated from the rest. Though we work with people from all backgrounds, our discipline was born, and is sustained, at the grassroots, and particularly among the poor and marginalized. This means we cannot conceptualize ‘mental health’ without taking into account the crucial psychosocial factors (like poverty, racism, sexism, homophobia, colonialism, exclusion, etc.) that create and perpetuate so much human suffering. When we are true to our mission, we are committed to equality and social justice, both for their own sake, and because as mental health care practitioners we know that human wellness is incompatible with leaving injustice, inequality and violence unchallenged.

When it comes to the clients we serve, our motto is “meet ’em where they are”, not “let ’em come to me.” We don’t toot our own horns very much, we’re often overlooked and most of us are seriously underpaid (no coincidence, of course, that 80% of social workers are women!). But make no mistake — when it comes to client/patient outcomes in recovery from mental illness, the results we get are second to none.

Anyway, Paul, that’s my spiel as one social worker doing my best here in the therapy trenches of Gotham. With apologies for the long email, hoping you can do your part to get the word out about who we are and what we do– and, as always, with much love and gratitude for who you are and what you do,

Matthew

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Nandi La Sophia

At four years-old he told his mom he wanted to be a lady when he grows up.  He shares about the violence inflicted by his complex father and classmates.  He talks about managing his PTSD, insomnia, Bipolar II, night terrors and being a rape survivor.

DailyBurn sponsors this show.  For a free 30 day trial membership  go to DailyBurn.com/happyhour.

SquareSpace sponsors this show.  For a free trial and 10% off   go to Squarespace.com and use offer code “doctor”.

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Are You In An Unhealthy Relationship? Guest blog by Maddy (The Great White Oprah)

1. Is my relationship abusive or unhealthy?
-Firstly, if you’re asking this question, that’s a clue. If someone asks you if you feel safe in your relationship and you can’t immediately, uninhibitedly say yes, that’s a problem.
-An abusive partner will separate you, if not isolate you completely from your family or friends. There could possibly be an ultimatum, verbalized or otherwise, a threat about what might happen if you decide to hang out with anyone else. The more time you spend with friends and family, the less power your abuser has, so they don’t want that.
-An abusive partner will invalidate your feelings or reactions in order to maintain control. Phrases to look out for include but are not limited to “are you STILL upset about that?” “Why can’t you just let it go?” And “we were having such a good time, don’t ruin the good times we have.”
-It should also be stated that the best abusers will not be all bad, otherwise they’d have to get new victims more quickly. My abuser cooked for me, took care of me when I was sick, drove me to surgeries, held my hand at the dentist. These positive experiences make question 2 harder to handle.
2. If I’ve concluded that my relationship is unhealthy, what do I do now?
-DTMFA. (Dump The Mother Fucker Already) It sounds difficult, but you’re never going to want to do it, they’re never going to make it easy, and this relationship will never get any better. It’s a piece of duct tape covering a patch of skin: rip it off now or later, but it’ll hurt just the same and the longer you wait the longer you deprive your skin of oxygen. (Did that make sense?)
-They WILL try to make it harder for you to dump them, using any tactic they can to make you stay. Mostly, they will try to make you feel bad for leaving. Shake it off, stand your ground. Don’t let the jedi mind tricks work on you. You will only feel worse if you try to break up and they win.
3. How do I recover after an emotionally abusive relationship and a nasty breakup?
-Get all the bad out, and fast. Rebound with stupid people, eat/drink things you’re not supposed to, annoy your friends with the horror stories of your crazy ex. Wear condoms, nurse your hangovers, and bingewatch a new favorite TV show, something you and your ex didn’t watch together. Doing this quickly is important to prevent from becoming a pathologically obnoxious alcoholic, so get on with it.
-Forgive yourself. Beating yourself up for putting up with that shit, waiting that long to leave, et cetera won’t help, so say you’re sorry. Say you’re sorry to yourself, for letting that go on, for letting yourself get that badly hurt.
-Take care of yourself. Carry a water bottle, three square meals and a snack, wash your face before you go to bed, things like that. It matters a lot more than you think.

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Sophie B

The 27 year-old listener discusses hearing voices, dealing with Borderline Personality disorder and/or Bipolar II, hypomania as well as the abusive “relationship” she had with a 22 year-old when she was 12 and how she began self-harming then.  The surveys are pretty dark.

DailyBurn sponsors this show.  For a free 30 day trial membership  go to DailyBurn.com/happyhour.

Naturebox sponsors this show.   For 50% off your first box go to Naturebox.com/happyhour

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Andrew Donnelly

The 46 year-old comedian talks about the frustration and shame of battling ADD and depression while trying to be a good husband and father.  He and Paul talk about how to deal with anger when feeling overwhelmed and the bright side of living with mental illness.  This episode is sponsored by DailyBurn.   To get a free 30 day trial membership go to www.dailyburn.com/happyhour

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Dr. Jessica DuBron

The PhD (clinical psychology) shares about working with at-risk youth particularly in the LGBT population and in a Psychiatric Evaluation team, responding to mental health emergencies.  She also talks about the addictive rush of working in crisis.  Sponsors of this episode are DailyBurn and SquareSpace.   For a free 30 day trial membership to DailyBurn go to DailyBurn.com/happyhour  and for free trial and 10% off  for SquareSpace go to Squarespace.com and use offer code “doctor”.

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Jim O’Brien

The handyman/comedian opens up about growing up with a seriously ill single mother (Addison’s disease) and alcoholic father.  He recounts the breakup with a girl, the depression that wound up getting him committed to a mental facility against his will and what he took from the experience.  Sponsors of this episode are DailyBurn and SquareSpace.   For a free 30 day trial membership to DailyBurn go to DailyBurn.com/happyhour  and for free trial and 10% off  for SquareSpace go to Squarespace.com and use offer code “doctor”.

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Lindsay

The list of major health issues (Arnold Chiari Malformation, Scoliosis) she dealt with in childhood including brain and spine surgeries pale in comparison to the complicated relationship with her father; an alcoholic with no boundaries.  Paul and Lindsay discuss the parent who is oblivious to the way they leer at, talk to and touch their children.  They also discuss her Bipolar II, OCD, co-dependency and perfectionism.  This weeks sponsors are Naturebox and DailyBurn.   To get 50% off your first box, go to Naturebox.com and use offer code “happyhour”.    To get your first 30 days free go to DailyBurn.com/happyhour.

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