People With Mental Illness Think DifferentlyYou may have read the title of this post and said to yourself 'Gee, no kidding? What a genius!'
Now let's get going. When I say mentally ill people think differently than most of the rest of us, I'm talking about the mechanics of thinking, neurology, brain function, chemistry. For a variety of reasons, many people with serious mental illness such as schizophrenia, bipolar disorder, schizoaffective disorder, OCD, PTSD, major depression and some other disorders develop problems with cognition - the act of thinking. Much of the thinking you and I do goes on without us noticing. We become aware we're hungry, and sowe think about eating and the idea of eating an apple pops into our head and seems good. So we go out to the kitchen and get an apple. Now take that scenario apart. We become aware we're hungry. What if we couldn't tell when we were hungry? What if that message came to the brain and got ignored every single time for a week? We might die. Next, the idea of eating the apple comes into our head. It comes into our head because we either have an apple somewhere in the house or know where and how to get one. What if you didn't have access to an apple but you became obsessed with eating one? And finally, we go into the kitchen to get the apple. What if you're scared to go into the kitchen because every time you go there unseen voices suddenly start up and scare the crap out of you? What if you have some belief that says you can only go into the kitchen three times in one day and it's only ten a.m. and you've already been to the kitchen twice? You only have one trip left for the rest of the day. These are some of the dilemmas that people with mental illness face. Where you or I generally go from A to B to C to D when we are developing an idea or plan, people with mental illness may be going from A to W back to B back to A and onward to R. Or they may go back and forth between A and B for an unbelievably long time. Or they may not be able to hold the thought in their head long enough to act on it. All normal brains have something called executive function. In its simplest form, you might think of it as the brain's secretary or office manager. Executive function is an umbrella term that includes a bunch of cognitive processes, processes that allow us to do things like make lists (mental or on paper), estimate distance and time, look up phone numbers, commit things to memory, deal with money and figure out a bus route. If you say to me, 'I'll meet you at Louie's restaurant at five,' without a lot of effort my brain can figure out how long it takes to get to Louie's and then decide what time I should leave the house. I don't have to go get an atlas or get on a computer and look up Louie's, put the address into a GPS, determine the distance, etc. unless it's the first trip. If I've been to Louie's (or just driven by it). I can do all the necessary calculation quickly. But people with executive function deficits can't. They may have problems with incredibly simple arithmetic. They may not understand fully that to pay the rent on their apartment, they have to make sure they get a money order, go to the bank on a day when it's open (not closed), then take the rent check to the office that accepts rent payments for their building. They may get stuck on any one of those steps. They may go to the bank on Sunday and spend an unfathomable amount of time wondering why it's not open, when it will open and how they can get someone to come open it up. Another example of unusual thinking common among the mentally ill is something known as concrete thinking. This is thinking in the most literal way possible. I once had a patient who was regularly angry about the dosage of one of his medications. He reasoned that 100mg of any medication should always come in the same size tablet. For him, 100mg is 100mg, end of story. How can 100mg of Drug X be in a tablet that's half the size of Drug Z? Someone with concrete thinking, finds it hard or even impossible to think in abstract terms. I've encountered a number of patients who think the size of the pill reflects its potency. You put some pills in the palm of their hand and they see a tiny round yellow one, a much larger blue oval and a huge white capsule. They assume the blue one is more potent because it is larger and the yellow one is less potent because it's small. So they may tell you that you're not giving them a large enough dosage of the yellow pill. "Look how little it is! You got to give me more of this! This little pill ain't gonna do nothin'!" That's a quote, by the way. Concrete thinkers are often incredibly frustrated. And so are the people who try to straighten things out for them. Because they only understand one version of reality and it's an incorrect one. And the therapist or social worker or nurse is stonewalled trying to explain something to them. Everyone ends up frustrated. I've seen concrete thinkers totally lose their temper (at me and others) saying something like "Stop telling me the bank is closed on Sunday!!! I need a money order NOW!!!!" So when I say that the mentally ill think differently, I mean that they carry out the process of thinking in ways that are quite different. Children experience concrete thinking as a part of their development. If you say to a five year old, 'The door is ajar,' they might say, 'No it isn't silly! A jar has peanut butter in it! You don't put peanut butter in a door!' Cute when we're talking about children who grow out of it, frustrating and painful to watch in an adult with mental illness. I bring all this up to address an issue that comes up time and time again in working with patients who have chronic mental illness. Lawmakers and self-made conservative types always say things about the mentally ill like 'Why don't they work? They should have jobs and contribute to society! Why should my hard earned tax dollars blah blah blah blah.' I understand where that sentiment comes from, because it's my tax money too. But more times than not, I've seen people with serious mental illness fail at even a simple task because of problems with things like executive function or concrete thinking. People with these cognitive problems often can't follow simple instructions or remember what to do after they complete a task. If you tell someone with executive function deficits or other cognitive problems to go rake up the leaves in front of the house, they might well spend an hour trying to figure out that seemingly simple command. In front of which house? This one? The one next door? Rake them how? From side to side? Left to right or right to left? What happens if I rake them the wrong way? You wouldn't spend a millisecond analyzing the directive 'go rake leaves' but that's you. Lucky you. Once we control or even eliminate symptoms of mental illness like constant thoughts of suicide, hallucinations, paranoia, mania, impulsivity and so on, we tend to think that's the end of the job. Again, lawmakers and blockheads figure 'Well, the guy who was hearing voices telling him to hide from red cars because the CIA drives red cars is better now. Let's send him to trade school and get his life back on track.' Uh huh. Sure. I'll discuss it in more detail another time, but, getting people with chronic mental illness to live successfully in the community is not easy. There's a high rate of re-hospitalization, or, in layman's terms, failure. This, again, is why I often compare mental illness to diabetes. Diabetes never goes away. We don't cure it, we manage it, we control the symptoms. But you'll die with it. Same for many forms of mental illness. |
charles o'meara, r.n.I have worked as a registered nurse for more than two decades, ninety percent of that time as a psychiatric nurse. Archives
June 2017
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