Lack Of Mental Health Services In Rural America

Approximately 70% of New York State is rural and I live in one of the poorest rural counties of the state.  I grew up in New York City where there is a plethora of services and resources for people who suffer from mental illnesses.  Unfortunately I left the big city and moved far out into the country to another world.  It was here in the country that I encountered the legacy of child abuse, addiction, domestic violence, homophobia and racism.  I don't mean to imply that these things don't exist in big cities, they certainly do, but in the country the sense of isolation and shame along with the extreme lack of resources create a much deeper and more resistant problem.  The key culprit is poverty and a lack of community organization.  Money provides incentives to overcome problems.  Without the money people have to rely on their own inner resources and in doing that they pull into themselves and away from the help they need.  On top of that the general poverty means lots of low income families, lack of employment opportunities, single parents, a lack of health insurance, a prevalence of alcohol and drug addiction among other things.

Life is hard, but it is harder in the country.  The ethic out here is rugged individualism and self-reliance, especially amongst farming communities.  Unfortunately, self-reliance is not all that is needed when it comes to mental health.  What is needed is community support and action.  In my county there is not one mental health support group for people with serious mental illness and there are only a small handful of psychiatrists and psychotherapists to cover several counties.  Most people don't have health insurance and rely on social services and the emergency room to help them get through crisis situations.    Even if one does have health insurance and the ability to pay for services, there are very few options.
I'm in the minority in that I have health insurance, though that insurance does not cover the cost of therapy.  My health insurance covers most of the cost of my visits to my psychiatrist every three months and the cost of my medications, but that's it, the bare minimum.  Because I am not eligible for social services I have no community support.

One in four adults in the US, over 57 million people, will have mental health problems in any given year.  One in seventeen will have major psychotic disorders.  A distinguishing feature of mental illness is a pervasive feeling of isolation from others.  This sense of isolation is multiplied in rural areas where there are fewer people living at greater distances from each other.  Without solid community support people get pulled again and again into cycles of mental illness, abuse and addiction.  The burden gets shifted onto the families themselves who are ill equipped to handle these problems alone.  There is some community support for addicts and their families mostly due to 12 step support groups, but only for those who are motivated to go to them.  The stigma of mental illness and addiction is greater in the country because small town life means people are into each others business.  The foundation of many support groups is anonymity, but in small towns there is no guarantee that you won't run into someone you know and this prevents many people from getting help.

The problem remains, mental illness is rampant in poor, rural communities.  Those who are court ordered to go to the minimal support groups and rehabs available, sometimes in place of going to prison, at least have some chance, but many people fall through the cracks in the system.  Social services are overburdened and community action virtually nonexistent.  What's needed are thriving community centers where various kinds of support groups can meet and take on some of the burden of caring for those who need help.  What's needed are community organizers.  Some mentally ill and/or addicted individuals have the strength to start support groups, but most do not.  Because of this there is a need for people who are not afflicted but are dedicated to helping those less fortunate to come forward and set up groups.  The few psychiatrists and therapists that are available are flooded with clients and have no time or energy to set up groups.  Those that remain who aren't suffering from mental illness are busy trying to make a living in an area where there is a lot of competition for even minimum wage jobs.

I think it's fair to say that there aren't many community organizers interested in moving to very poor, rural areas that have very few resources.  Truth is you probably can't make a living at it here, let alone raise a family of your own.  There's just not enough incentive.  Occasionally there is a charismatic, civic minded person willing to make a difference in the community, but even those people eventually burn out when others don't join in to take on some of the responsibility.  Maybe there could be people hired to act as a community organizers that temporarily come into a community and live there for a month or two while training volunteers to facilitate support groups.  I tend to harp of the importance of support groups because I don't have one, but I have seen from going to some 12 step groups that they are effective and low cost.  I do think that bringing small groups of people together can create not only an atmosphere of support, but some motivational magic to combat and lessen the grip of mental illnesses.

People with serious mental illness sometimes act out, but more often than not they pull into themselves, isolate themselves because they don't quite fit into society.  Support groups organized by confident, healthy individuals who have the training to pass on the rules and structure necessary to sustain a group could change the lives of many by teaching those with mental illness how to take better care of themselves and each other.  The people who commit to a support group find through their commitment that they can gradually take on more responsibility within the group.  Before that can happen there must be a catalyst to get the ball rolling.  When I was in early recovery I found one of the greatest obstacles to my happiness was a strong lack of motivation.  I needed someone else to appreciate me and encourage me to reach outside of myself.  I didn't find that in my community, except with my therapist. My main support all these years has been online on support forums and in this blog community.  That has helped a great deal, but it can't take the place of belonging to a local community, taking on more responsibility and directly helping those in need.

I've wanted to be that charismatic community organizer, but the pull to withdraw and avoid responsibility is part of my illness.  Like so many people in my community, I need the extra help to get things started.  But if we had that extra help in our rural communities, there's no telling how far we could go with it.

Memory Is Not Truth

"You never have a truly complete memory of an experience because it would take as long as the experience itself.  Most of our memories are like still photos or a series of photos highlighting something that was important or stood out about an experience.  They are whittled-down, highly edited versions of what happened.  Like an amateur movie they are jumbled and patched together, often without even a thread to the story line."   Nirmala   "Nothing Personal"  p. 3

There are some truthful things in our memories, but memory is not the truth.  At best it is a close approximation and at worst it is a fabrication.  Despite this we organize our lives based on short and long term memories.  Some of this is very necessary as in remembering where you put your keys and wallet or remembering to turn off the stove.  We need our memories in order to function, but how much faith do we put in memories?  After rereading the beginning of Nirmala's "Nothing Personal" I've been trying to look at my memories, but it is hard.  I find that many of my memories are slight impressions instead of being a clear and detailed image or scene.  Perhaps that why much of human culture attaches so strongly to photographs and videos -- they jog the memory and make it more vivid, more real.  But though they are artifacts that reflect a past reality in the present, they are not in themselves present reality and are not real.  They are fixed echoes.

We take our use of memory for granted and we assume that our memories are true.  In the course of a day, we make so many assumptions.  Memories and assumptions are like the glue that hold our fragile sense of self together.  Buddhists assert that this sense of self that we hold onto so tightly is an illusion.  And if the sense of self is an illusion, then much of memory is an illusion, too, which is why spiritual teachers regularly compare life to a dream.  I don't really want to believe that and yet for most of the day I am caught up in thoughts which necessarily include memories.  During those times I am not grounded and connected to the visceral present moment.  I exist in space and time and yet I'm not quite here now.  I'm very attached to my thoughts and feelings.  I even think that I'm doing some good for myself in thinking things through and sometimes I am, but I'm also living in ignorance and denial mainly because I'm not awake enough to be aware.

Nirmala writes about how thoughts are not real.  Because we over rely on our thoughts in the same way as we over rely on our sense of sight as opposed to the other senses, we miss out on training ourselves to be aware.  We follow our habitual patterns; we react to life instead of respond to it.  It's not fun for me to see how on automatic pilot I am.  And I'm confused.  I've convinced myself that I need my thoughts and that the key to happiness is inside of them.  If thoughts and memories are not real then the happiness I am weaving out of them is not real either.  And the self that I worry over is also insubstantial.  And yet this is not an existential conflict because the moments I have without thoughts are not barren and empty, but full and rich.  My awareness is much greater than my narrow thoughts.  When there is a gap, some silence in my mind, I am still flooded with sensory input and in this way still connected intimately to my surroundings.  Much of this input I ignore unless I'm being mindful.  Mindfulness is particularly effective when I am doing a simple physical task like washing the dishes or cooking dinner or practicing yoga stretches.  Mindfulness heightens the experience, makes the experience a felt experience instead of the disembodied experience of being lost in thought.

There are times when I really enjoy being lost in thought.  It's like reading an excellent book and stopping every page or so to reflect.  I think there is an illusory sense of safety in it.  I believe I learn important lessons from ruminating.  Getting into writing is similar.  I'm using the thoughts and feelings in my mind to deepen my understanding and to come to a conclusion of one sort or another.  For me, this is important work, but eventually I have to return to the simplicity of the present moment.  That simplicity is the foundation for my life, despite how I often ignore it to attach to thoughts.  What I'm waking up to is that in not taking time to just exist I have become unbalanced, a lopsided version of myself.  I read somewhere that the difference between a delusion and an illusion is that a delusion is one person's misapprehension, whereas an illusion is something that groups of people can come to believe in like watching a movie.  I know about delusions, but what I'm experiencing when I'm lost in thoughts and memories is a common illusion that we are what we think when we're not.

It's not that thoughts and memories are totally useless, no at points they are very necessary, but we over emphasize their importance and rely on them to make important decisions.  I guess it's like this, reading the instructions on how to put something together cannot take the place of actually putting something together.  The real importance and joy comes from the doing more than the thinking about doing.  My father, who is someone who lives inside his thoughts a lot, loves to study maps, but is at a loss at finding landmarks to make his way around an unfamiliar place.  As long as he has the map, he can manage, but without the map he is a babe in the woods.  Our thoughts are like that map, a virtual reality, but not the thing itself.  That goes for writing as well; it's something that points back to reality through the imagination, but it can't take the place of real time experience.  Fantasies give temporary respite to painful existence, but ultimately they are empty.  It's like eating a bunch of candy instead of having a good meal.

While I'm saying this with some conviction, I am resisting it as well.  I was taught as a very young child that language is a way of expressing thoughts and getting needs met.  I learned language through a great deal of repetition.  I labelled objects and people with words.  I let the word take the place of the thing.  I became enamored of the power of words.  The power lay in my ability to use my imagination and at times my imagination seemed able to move mountains.  I spent many hours lost in dreaming, especially when I couldn't relate to my family members.  Dreaming and playing are essential to learning a language and kids do it a lot of the time.  Of course some of that is healthy and necessary, but it also teaches children to get caught up in their fantasies to the point where they are not engaged in the world itself, are not mindful.  Children (and adults) hold onto memories especially of those wrongs done to them.  In that way memory gets transformed into fact, when it is still just an approximation of the lived experience.

I resist writing that memory is not truth because I use memory as a major building block to decide what is and isn't true.  If my memories are suspect, this illusory construction of my past leaves me open and vulnerable in my present moment.  And yet really all there ever is is the present moment.  That's where reality and truth reside, in the living, not in the imagining.  This is why there's so much emphasis on the importance of meditation because it breaks through over and over the trance of thinking we get hooked into and it places value and importance on the gaps between thoughts.  In those gaps is the heart of mindfulness which can be brought into daily activities once off the meditation cushion or chair.  Instead of imagining what might be true and what might not be true, we can experience truth directly in the gaps and in our daily life's activities.   

For Those Whose Voices Remain

It's a fact that some people have voices in their minds from an early age until they die.  I think I might be one of those people.  I take my medications because they reduce the intensity of the voices.  This gives me room to do some of my own thinking and feeling.  Without this cushion life would be much harder.  It also makes it easier to work with the voices instead of judging them or trying to block them out.  I've noticed that a lot of my peers, who take the medications but still hear voices, try various ways to keep the voices at bay such as, listening to music, watching television and movies, playing video games, doing craft work and art work.  Ultimately none of these things entirely remove the voices, but they do give much needed pleasure and in some cases allow for creative self-expression.  My worry is that too many people are overlooking the benefits of working with the voices and co-existing with them.

My impression of the people I've met online who suffer from schizophrenia and schizoaffective disorder is that they mostly view the voices as negative, something to run away from or block out.  That's a natural pattern, run away from pain and grasp on to pleasure, but it is a pattern that causes a lot of suffering.  Studying Buddhism, especially from the Tibetan perspective, has shown me that this pervasive pattern needs to be reversed; people need to move closer to pain in order to understand and accept it as a part of life experience and people need to let go of clinging to pleasant experiences and even offer them up to the benefit of others.  I know a lot about avoidance and running away from pain, but it doesn't work.  Eventually I return to my starting point, back to pain and the voices and to a lack of resolution.

I don't believe that my experience is unique.  I can't be the only one to have noticed that the voices are a mixture of positive and negative even during the most acute stage of the illness.  When things are painful, it is too easy to generalize one's experience and the voices as being entirely negative.  When we do that we place the blame on them and avoid self-responsibility; we breed resentment and we stay stuck and so we run away again and again.  Perhaps we convince ourselves that these voices are the result of having a biochemical glitch in our brains and that our only responsibility is to take the medications to try and correct that glitch.  I think biochemistry is definitely a factor, but it is not the whole picture.  Taking the medications is a good start for many who have chronic psychosis, but there remains much more to be done and experienced and reflected upon.

If you decide to try and work and co-exist with your voices, the first thing you've got to do is to acknowledge that they are real for you, that they exist in your life and that sometimes you have no choice but to interact with them or be influenced by them.  You grant them the dignity and responsibility of existing.  Telling yourself that they are not real and trying to block them out when you can leaves you in a cycle of avoidance and denial.  It doesn't solve the root problem.  After acknowledging that they are real, you can begin to move closer to them so that you can study them.  See and experience both their strengths and their weaknesses.  If you dwell upon their negativity, you distort the truth and lose your balance.  Conversely, if you train yourself to see the positive in them, you begin to move back towards balance.  It's just common sense.

Voices in order to be voices have to have some inherently good traits.  They have mastered language and are intelligent, they are creative because language demands that you be creative in order to express your intent.  There are also several voices coming from different places and perspectives.  This means that they are versatile and can take multiple points of view and so they are expressive.  They are capable of strong emotion, making them more like us than different from us.  And so, at the bare minimum they are intelligent, creative, versatile, expressive and have the ability to feel.  They can also use all these gifts to behave abusively.  They can lie, manipulate, intimidate and go so far as to punish and yet the basis for this bad behavior is still good.  They couldn't lie unless they could identify the truth; they couldn't manipulate unless they first knew how to be creative, versatile and expressive.  The good stuff comes first for them and for us.

I'm not denying, especially during acute psychosis, that the bad stuff is really bad.  There's no doubt about it, it's there and in your face sometimes 24/7, awake or asleep.  Of course I can see why people get into the habit of generalizing their experience with the voices as just bad, but that feeds back into   delusional thinking, because it is just not the whole truth, it's not reality.  What's worse is if you believe the Judeo-Christian idea that we are essentially sinful, you can easily get pulled deeper and deeper into delusional/paranoid thoughts.  I was very fortunate in that I believed in my essential goodness even during the worst parts of my life and when I began studying Buddhism and came across the concept of Buddha Nature in everyone and everything, I felt some of the weight of my unresolved illness lift off of me.  As I learned more about the essential need for compassion for myself and others, I knew I had to extend that compassion to the voices that had hurt me so badly.  I had a lot of resentment to wade through to get to that point, but I kept my spirit open to the possibility that Buddha Nature and the practice of compassion were not just Buddhist concepts, but the basis of what we experience as reality.

So I am presupposing two things, that the voices are real and that the voices are essentially good and not evil.  That makes it sound very clear cut, but it is not.  When you work with the voices, you are working with not only their faults, but your own.  I want to stress that when the voices are behaving abusively, do not follow them.  One of the overriding lessons I've learned from them is that when people (or voices) act out, you must return the focus to yourself and do what you need to do to take care of yourself.  People have a lot of trouble with this because you have to love and care about yourself in order to take care of yourself.  The more ambivalence you feel towards yourself, or worse dislike, the more the voices will step up their attack.  Self-denigration for many Westerners is our Achilles heel.  In our culture there's a lot of emphasis on the power of romantic love to heal everything, but what really heals individuals is the extent of their love for themselves first and foremost.  Once you can establish love and trust within yourself, then you can extend it outward to other people.

I know I was feeling a kind of detached self-hatred after I left my abusive boyfriend and from that platform the voices took over my life and I entered into the world of acute psychosis.  So I wasn't sure if I liked myself and the voices took that weakness of mine and forced me to look at it.  They showed me that I had used fantasy like an addictive drug in order to avoid facing reality.  They showed me this by taking the germ of one of my fantasies and blowing it up into an elaborate delusion, a delusion that I blindly followed for a time.  Delusions hinge on the individual having an ego imbalance.  That is, delusional people see themselves as either more important than they actually are, sometimes vastly more important (delusions of grandeur) or drastically less important or inherently bad.  The voices took my tendency to either over or undervalue myself and let that fuel the delusion keeping it alive and me trapped inside of it.

People who love themselves have a realistic view of themselves; they accept who they are and their place in life.  They are protected by this from getting pulled into serious mental illness.  But people with low self esteems are very vulnerable to praise and/or criticism.  If you base your worth on something or someone outside of yourself, you are then subject to all kinds of fluctuations which leads to a lack of personal integrity and emotional/mental instability.  For several years I had an on again off again fantasy about a rock star.  I invested him with a lot of status.  I thought he was very talented and hard working and attractive.  In my mind then he was someone who had become successful.  After I fell into the delusion that he was following me and was attracted to me, I began to look at myself critically.  I wanted to be with the rock star, but I didn't feel worthy enough.  I swung from overestimating my power of attraction to underestimating my essential worth as a human being.  The voices took that polarity in me and blew it up hugely.  They shaped me into a version of Jesus and once that took hold, they took that away and told me I was the Anti-Christ.  Then they made a compromise; I became a composite of myself following Jesus and the rock star as an Anti-Christ like serial killer.  The rock star was not really me, but he existed in my mental space and I couldn't get away from him.

Trying to be like Jesus, I had to love the serial killer I believed was a part of my mind.  In a sense, it was as if Jesus was helping Lucifer to embrace recovery from his self hating and other hating addictions.  In trying to love someone who I was also deeply afraid of, I had to face my fears over and over again.  Without the benefit of medication, this led to repeated breakdowns.  Perhaps I had to go through this as a kind of catharsis for my failed relationship with an abusive addict.  I didn't heal the serial killer, but I did prove to myself that I had a good and trusting heart.  I had come to believe in the value of loving this enemy who really wasn't an enemy, but a lost, sick soul, the part of myself that I had been rejecting.  When I finally asked the voices after my final breakdown if I could let go of the rock star, they said it was about time.  That's when I committed to taking the medications.  That's when I started loving myself the right way.

If I learned this major lesson, why do I still have voices?  Why do I dip into delusional thoughts and paranoia sometimes?  And why does the thought of this famous man being a secret serial killer still haunt me?  I think because I haven't learned the lesson that I can't be a savior to another person.  In the beginning I tried to be that for my boyfriend and then I tried to be that for my primary delusion.  The only person I can save is myself.  Yes, I can be supportive but I cannot take on the responsibility for living someone else's life.  I still have the dregs of romance addiction in me, which is what got me into trouble in the first place.  Addiction is not love.  And in order to have a loving relationship with someone else, you have to love yourself and respect your loved ones boundaries.  People have to be free to make their own discoveries and their own mistakes.

When you become willing to love yourself and take care of yourself, you enter into recovery.  Part of loving myself has been learning to love and appreciate the voices.  They challenge and guide me while I continue to learn old and new lessons.  If you can change you attitude of them from negative to positive, you can change your whole world.  For those of you who have voices I'm here to encourage you to try.

An Apology

I'd like to apologize to Karen especially and to those of you who have been reading my blog lately.  I acted impulsively when I wrote that my ex-boyfriend was a psychopath just because I read a list of psychopathic traits.  I did not do the research and feel as if I have painted a false or misleading picture.  That was not my intention.  I was so into my own perspective, doing a lot of remembering, but I don't know exactly what was wrong with Brendan.  And so I've changed the titles of my previous blogs from "The Ghost of a Psychopath" to "The Ghost of a Young Man" into order to not draw readers who may be pulled in by the word psychopath in the title.  I considered deleting the three entries, but decided against it.  Instead I put a cautionary note at the beginning of each entry saying that I may have misdiagnosed Brendan.  Hopefully this will suffice.

My voices drew me to the word psychopathic early on in the acute stage of my illness.  They encouraged me to buy books on evil, on psychopaths, on violence and prejudice, most of which I only partially read.  It was too much for me at the time to make a serious study and so I stopped.  Even now, years later it is still difficult to approach and I have been having psychotic symptoms surfacing in response to me writing about the idea of Brendan as a psychopath.  Some of my remembering and writing was helpful to me and some of it made me vulnerable to an old delusion.  The delusion centers around me being psychically connected to a famous man, a man who the voices have claimed is a psychopathic serial killer.  I was in the grips of that delusion for most of the acute stage of my illness and I have thought about it in the intervening years.  I have often wondered why I was directed to this particular delusion.  I have thought that maybe it was Brendan who was the serial killer and I didn't know it and so the delusion was a kind of punishment for me.

In the beginning of my illness the voices did a curious thing, they painted a picture of Brendan as a devilish angel, a teacher for me, someone with a good heart; they even called him Saint Brendan.  I could identify with some of that because I had seen the healthier parts of him and I knew he had it in him to be an upstanding person.  I imagined him becoming active in a 12 Step program and going on to be a speaker at meetings, warning especially young people not to do what he had done.  I thought Brendan could have led people who were like him -- addicted and mentally ill.  In my psychotic state I gave him one of my Al-Anon daily readers and encouraged him to go to meetings.  Unfortunately, that didn't happen and then he took his life, but the delusion of the psychopathic serial killer remained strong for a couple more years.

So I have a history of identifying the famous man in my delusion as a psychopath, but I never quite stuck the label on Brendan until recently.  All I can say is that it made sense to do that at the time.  I got intense about the apparent discovery and wrote a lot about it in a short time period.  My problem was that I was taking the position that I had the knowledge to make this claim, when I did not.  Thankfully Karen and another person tried to tell me that I was on the wrong path.  At first I resisted, but then I saw that I was being irresponsible in making a claim that I couldn't quite back up and that I might be misleading the people who read my blog entries.  I saw that I was at fault, which is why I am apologizing now.  There is no point in claiming to be an honest person if I can't admit to my own mistakes.