Visit to Psychiatric Clinic Gone Awry:
A Lesson Learned (Again)
Though this is a first-hand account of a recent event, it would not be worthy of sharing without the context for a broader issue: what part does psychiatry play in the mental health delivery system? Psychiatrists prescribe the drugs meant to compliment psychotherapy. That is my short answer. They also diagnose. And isn’t that a neat set up? First, they tell what they think your symptoms point to, in accordance with the accepted authority (American Psychological Association). This, of course, is meant to convey just how far outside the accepted limits your behavior falls. Then, after the label for one’s behavior has been chosen (for the mutual benefit of insurance company and any future psychiatrist reviewing patient records), they inform you of what pharmacological aid is available to address your symptoms. For that part of their process they use another nationally recognized authority – the DSM (Diagnostic and Statistical Manual) – currently in its’ fifth incarnation.
Anyone who has had anything whatsoever to do with the receiving end of psychiatry knows first-hand that those who practice it have varying degrees of respect for the complimentary field of psychology. And we, the clients, find that out in ways that vary on the scale of helpful all the way to harmful. We begin our understanding of these two titans’ longstanding war for supremacy when whichever one gets ahold of our needs first, begins to explain the need for the companion school of thought. If the first exposure comes through an inpatient stay, it will most certainly be psychiatry. They are the ‘medically trained doctors’ and they alone prescribe the drugs. But just as soon as the hospital stay ends, the need for ongoing care surfaces, and that is the job of a psychologist.
Notice I didn’t say, therapist. And that’s important because therapy is not a simple process to define. There are different types of therapy for varying situational needs. Having problems with your marriage? There are marriage counselors. Is your child refusing your attempts to be parented without turning your life upside down 24/7? There are folks trained to deal with the human condition as it relates to the developmental stages of human life. And so on.
Each of these help-mates (be they counselors, or therapists, or psychologists) have an accepted level of training that licenses them to practice. Forgive me if I find that word, practice, somewhat amusing. In point of fact, that is exactly what the process entails: practice. After schooling, after licensing, comes practicing. That is where my story of yet another lesson learned begins.
Here’s the tale:
I’ve had a diagnosis for some twenty-four years. Prior to that, I had ‘treatment’ sans diagnosis; thus, I’ve taken various medications at various points along the journey. And I’ve experienced several modalities of therapy. So, when I made an appointment at a psychiatric clinic located in a teaching hospital in my state, I deemed the salient question to be, “does your clinic’s philosophy accept the notion that benzodiazepines should be given over a prolonged period?” There answer was, “absolutely not.”
I didn’t think I needed to ask if the clinic believed in the diagnosis I hold (and that the Federal government endorsed when it afforded me Medicare insurance and disability compensation at the age of forty-four). My mistake.
The hospital clinic I chose encompasses the medical practice where my primary physician is located. As such, my physical and mental health records are combined in one database. The reason I see no need to name the hospital is that, in my experience, it is representative of many hospitals, and many psychiatric clinics, in many of these United States.
I had one purpose for scheduling the appointment: to receive help in stair-stepping off a medication I strongly suspect of causing more harm than good, Clonazepam; a drug that is part of a class of medications commonly referred to as benzodiazepines (more about benzo’s in a moment).
Arriving at the appointed time, I was given two self-report sheets to fill out. These were very blunt instruments designed to afford the attending doctor (or fourth-year resident/FYR in this case) some insight into a client’s current state of mind. As with all self-report instruments, a sliding scale was used. “Would you say that you are feeling sad: a. all the time, b. much of the time, c. sometimes, d. rarely, e. never” – is as good example as any. What I find almost comical about such options as A-E is this: relative to what? I could, for instance, “be sad, all the time” because I stopped at Starbucks before the visit and they didn’t have my favorite flavor of coffee to hand, or because I am currently living in an abusive relationship I don’t have the internal resources to get out of. Everything is relative; or so I’ve been told.
When I was finished filling out the self-reports (using N/A liberally), I took them to the check-in person sitting in front of her computer behind a glass partition equipped with a sliding pane. On my side of the counter was an electronic signature apparatus. I was at the point of wondering what this would be used for when the check-in person began a series of verbal admonitions (punitive measures) meant to inform me of what would happen if I came late to any appointment or failed to keep any future appointments without canceling 24 hours prior. Basically, additional charges would be incurred for one and refusal to allow further scheduling of appointments for the other. (I should interject here that Medicare is the usual primary insurance for patients at such clinics.)
I used the electronic signature devise I’d previously noted to provide my signature in acknowledgment that I’d heard and understood these conditions. Though I wasn’t expecting ‘Warm Fuzzies’ as welcome, this was a bit more surgical than I’d experienced heretofore – when my local county mental health center hadn’t yet been dismantled by a Federal mandate from a Supreme Court decision in 1999. Another appearance of that old scoundrel, ‘relativity’, I’d suppose.
After the usual intake detour to make sure I had blood pressure (admittedly elevated by this point), I was ushered into the room set aside for conference with the FYR. I brought my husband with me so he could hear first-hand whatever transpired – and so I wouldn’t have to repeat it later. We sat on a love seat couch, leaving the chair nearest the door (and the intercom) for the doctor. Within moments the FYR entered with her laptop in tow. Introductions were exchanged and we began the allotted time.
The rest is rather a blur; sequentially so. I recall verifying my address for the record. I certainly recall my abrupt departure some twenty-odd minutes later. In between those two are the impressions that began as vague and proceeded to alarm bells going off.
The view from where I sat:
Well for starters, I began switching almost immediately. It’s a common response for folks who have survived early childhood trauma using dissociation as a coping mechanism. The DSM-V terms the condition, Dissociative Identity Disorder/DID. Those of us who bear the label often refer to ourselves as multiples. While I was explaining why I was placed on Clonazapam and when, she interrupted with a question I took as a request for clarification. (It’s a well-known narrative for me, so perhaps I was going a bit too fast.) After I clarified the timeframe, another part-self must have chimed in to add their perspective because her facial expression was sending strong signals of confusion mixed with agitation (probably due to the time constraint).
Being in the 'executive position' is a dicey position for any multiple. The executive position is akin to the head of a table that has a revolving door attached, metaphorically. Those alters (or as I prefer, part-selves) who regularly conduct interactions with the external world sit immediately to the right and left of the executive chair; clustered close enough to hear what’s being said. And should the intensity of the exchange strike a chord with someone not seated, but near to hand, then a switch occurs. (It is also the case that those who do not normally interact with the external world can still ‘pass along their concerns’ to one who does; it varies per individual system design. Probably TMI, but we think it important.)
The point being, in the blink of an eye another part-self will take executive control and the external listener won’t have a clue that such a change has happened. They will have less than a clue if they have been trained to believe that multiples don’t exist.
When it began to be obvious to several of my parts that she fell into the category of disbelievers, things went to pot rather quickly. Allow me to explain how. We have a part categorized, for simplicity, as the Thinker of our system. He is not the gender of the body, and his ‘personality’ can be construed as aggressive by a female listener (or so he has been given to understand at various times). He prefers an Academic Approach to explaining things – much simpler and more direct than some emotional narrative that posits itself as victim, rather than recipient of the bad behavior of adults who abuse children.
That my Thinker is a male in his early twenties with an affinity to another part self who is a female teenager, and Feeler to his propensity to put feelings aside, only makes them an effective couple. When the FYR stated that she was beginning to feel “threatened”, we (many of us) were aghast. We were the ones with reason to be frightened. We were the ones with experiences to show that given the right circumstances, we could be placed on a 72-hour hold (locked up!) based solely on facility protocols. And a less prepossessing man than our life-mate is beyond imagining – especially since he is 73 years of age; so, it couldn’t have been his behavior the FYR was referring to. Neither he nor I had so much as leaned forward in our seats, yet after making her pronouncement, she rose and left the room (presumably to speak to the supervising psychiatrist on duty). It was at that point that ‘we’ and he made our escape.
Benzodiazepines and the Brain:
Benzodiazepines are a class of drugs that include Ativan, Valium and Xanax. They are used to treat anxiety but can cause long-term problems. Because of their short life (roughly 24 hours), they are meant for short-term relief. Speaking to the risk of dependence, I note that the Beers List of medications warns against their use for the elderly, specifically. 
Getting down to the nitty-gritty of the effect in the brain, it’s about chemical messengers, specifically GABA’s by name, that function by binding to neurons thereby reducing their activity. This reduction in the excitement of neurons has a calming effect that is experienced as a reduction in fear or anxiety. Benzodiazepines are designed to bind to these neuronal receptors and enhance the natural effect of GABA.  Think about that for a moment.
If a human being is in a situation where personal safety is at issue, and the fight/flight response is triggered, this is what is going on in the way of biochemistry:
“The fight-or-flight response is a physiological reaction that occurs in response to a perceived harmful event, attack, or threat to survival. It was first described by Walter Bradford Cannon. His theory states that animals react to threats with a general discharge of the sympathetic nervous system, preparing the animal for fighting or fleeing. More specifically, the adrenal medulla produces a hormonal cascade that results in the secretion of catecholamines, especially norepinephrine and epinephrine. The hormones estrogen, testosterone, and cortisol, as well as the neurotransmitters dopamine and serotonin, also affect how organisms react to stress. 
Basically, one isn’t acting, one is reacting. And speaking of reacting in this context, now would be a perfect time to present a phenomenon well-known to multiples: abreacting. A simplified way to think of human behavior has been stated by several observers over recent decades: human beings act, react, and abreact. I think of it by looking at the inducements for behavior. We act of our own volition. We react according to environmental circumstances. And, absent conscious intent, in the presence of strong association between the ‘here and now’ and the ‘there and then’, we abreact.
Abreacting involves the sudden reliving of a past trauma that has been triggered by association to an action in the present. What’s more, abreacting involves the same dumping of adrenaline into the blood stream as the triggered fight/flight response in those who do not dissociate.
It doesn’t require a professionally trained individual to imagine the toll taken by such occurrences – on the mind – on the body. As an intervention in the moment, taken only as needed, to counter the effect of excited neural activity (feeling the panic and fear over again), benzodiazepines’ calming effect is all well and good. But, to prescribe Clonazepam for daily use – for an extended period – is misguided and counter to the science that informs the drug’s interaction with brain chemistry.
Yet I have had it prescribed continually for the last quarter of a century. And when I had the temerity to ask the prescribing psychiatrist to comment on the literature I researched which warns against such action, I was told, “I would be comfortable with you taking [Clonazepam] for the rest of your life.” After sitting with that response for over a year, I decided to make an appointment with the psychiatric clinic at the hospital where I have been receiving medical care for what little physical ailments I possess (an underactive thyroid and hives).
(Well, my conclusion, at least.) What apparently never crosses some psychiatrists’ minds is the entire person – holistically speaking. How can it be sensible to mess with the chemical messengers of individuals who have survived childhood trauma by employing dissociation (separating emotion from the causal event) and living with the resultant compartmentalized sense of self?
And if a professional believes that such a person is having a panic attack instead of abreacting, does it really matter? Well, yes, it should. Many people who have panic attacks are not multiples. If symptomology is all that's being considered, a panic attack is a panic attack!
Drugs designed to reduce the excited neuronal activity will calm the individual. However, for the individual who employs dissociation to navigate daily life, controlling abreactive behavior is part and parcel of 'managing' their disorder. They don’t need their behaviors artificially controlled or modified to suit society. What they need is the kind of help that comes from such therapies as Dialectical Behavior Therapy/DBT, which is a type of cognitive-behavioral therapy designed in step-by-step fashion to increase mindfulness and aid the development of coping skills. After all, children who are busy trying to deal with chronic abuse don’t have spare time to figure out the niceties of accepted social behaviors like constructing safe boundaries for themselves, or learning how to conduct healthy relationships.
But if all you want to do is control their anxiety so they are more amenable to inpatient hospitalization conditions then prescribe away! And when they leave the hospital? Well guess what psychiatrists who can read the labels of what they are prescribing know? Weaning off such drugs requires strict attention to dosage and frequency. Who is going to do that? The psychiatrist? Nope. The next therapist who takes on such a client? Nope. Remember who can and cannot prescribe by law and license!
Children who turn to dissociation, do so from a place of need. And the chances are far greater that their need will not be recognized by any professional until they have survived into adulthood because chronic abuse of children is not the unnatural phenomena right thinking and acting adults want it to be.
Today is Sunday after the Thursday for this visit. It has taken me several days to accomplish a satisfactory postmortem, and several hours to decide what went wrong and what my part was. It has taken several more hours to write down my reaction. Was I wrong to ask for help? Did I fail to ask for it in the correct or acceptable way? When I realized that I was sitting before a Disbeliever, should I have been able to control my fears? Were my fears irrational? That’s is a reasonable question, I think. And it easily and honestly answered.
Some fifteen years ago, I had an abreaction in the same hospital as this visit – though I was there to visit a friend in the burn unit. A staff member witnessed the behavior and called for aid. In a matter of minutes, the abreaction was over; I had not disturbed anyone or done any damage to property. I explained this to the hospital staff. When they insisted that I be seen in the Emergency Room, I didn’t resist beyond saying it wasn’t necessary. When they explained that it was a matter of protocol (meaning they might incur liability if they allowed me to get in my car and drive home), I knew it would be seen as resistive if I couldn’t see their side of things. And when I was ensconced in the ER ‘holding room’ – with the door left open – and a guard posted outside? Well, again, things went to pot rather quickly. I waited for the guard to turn his head and made a break for it. I made it as far as the parking lot before I was surrounded by as many folks as they could turn out on short notice (a small army in my mind). I was then taken by ambulance to a state run psychiatric hospital and admitted.
What then? Well, in the morning when the attending psychiatrist came on duty to perform the ‘psychiatric evaluation’ and I explained in totally academic terms just what diagnosis I carried, she listened and then said, “I’m sorry you had to go through that. I will have a taxi take you back to your car (parked in the hospital parking garage at so much money per hour) and you are free to go.”
That is one of the better outcomes I’ve experienced. Because even though it was not pleasant to endure being involuntarily admitted, (nor was it convenient to be fired from my part-time job for not calling to say I wouldn’t be coming on shift that night), it was somewhat vindicating to have someone in a white coat admit that a multiple is not going to be aided by an involuntary admission, or have anything resembling needed care accomplished during such a stay.
As to my ongoing problem of being stair-stepped off Clonazepam, well I’m still studying on that!
1. The Brain From Top to Bottom (2014) http://thebrain.mcgill.ca/flash/d/d_04/d_04_m/d_04_m_peu/d_04_m_peu.html
2. Benzodiazepines Treat Anxiety, Cause long-term Problems (2014) http://www.bendbulletin.com/home/2119922-151/benzodiazepines-treat-anxiety-cause-long-term-problems
3. Fight or Flight Response (2017) https://en.wikipedia.org/wiki/Fight-or-flight_response