How Did Medication Become the Norm?

Last week I had a personal situation that got me thinking.

My little guy has really been struggling with Kindergarten. Basically, a Kindergarten classroom is absolutely the worst environment for him that we have encountered. Although he still has occasional issues elsewhere, he does much better in other environments.

The school has been great - they have tried all sorts of ways of adapting things to make it better for him. However, he has had several unsuccessful experiences.

Due to feeling constantly overwhelmed, he was not experiencing any "just right challenges" inside or outside of school. After each school day, he was worn right out and had no tolerance left for challenges. I feel really strongly about "just right challenges" - if you have not read it already, you may want to check out my post on it: The Just Right Challenge.

He had so many negative experiences that it started affecting his self-esteem. It was heart-breaking to see my usually happy little guy feeling so bad. What really made me think that something needed to change was when I found him sitting by the garbage cans and he told me he wanted to be thrown out with the trash.

After careful consideration, researching the evidence on it, and talking to others who do it, we decided to homeschool him, so that we can provide him with a safe home base with "just right challenges" in the home and community.

When we informed the school, they invited us in for a meeting to discuss our decision. I explained our rationale, and quite a bit about homeschooling. I addressed their concerns about socialization, and explained the research on it. The meeting went quite well, and ended with them saying that although they would rather he stay in school, they respected our decision.

I just want to be clear that we have been really happy with our school - they have gone out of their way and worked really hard to make things go well for our son. I know they want the best for him. They also have been respectful about our decision.

Here is the thing I really want to talk about: If I had chosen to continue my life as usual and medicate my son, nobody would have questioned my decision. Nobody would have called me in for a meeting and told me they disagreed. I would not have had to explain the research on it. In fact, I would have been lucky if anyone had even taken the time to tell me the possible side-effects.

Yet when I look at the research on homeschooling, it is predominantly positive, with no side effects. Research on medication is often positive in certain situations, often lacking for children, and often shows that there are rather significant side effects.

I am not against medication - I think it can be a helpful tool, but that it is only one tool in a toolbox. Given the possible side effects, I believe that it should not often be the first tool we reach for. There is an illusion that if we just take the correct pill, we will be fine.

There are so many different options for what each person and each family can find helpful - counselling, therapies, homeschooling, sunshine, exercise, social connections etc. How did medication become the norm, while everything else is questioned?

Fake It Till You Feel It

Last week I could feel depression knocking at my door. I would not say that I was actually feeling depressed, but it was like it was lurking around me, hoping I would let it in.

This can be a really hard time of year. There still is not much daylight; the holidays are over; and around here, we are sick of winter but know that there is still so much of it left.

I find Groundhog day very depressing - it just rubs in the fact that in some regions, spring will be happening soon. Whether the groundhog sees his shadow or not, we know we will still have more than six more weeks of winter here.

Last week made me think about how insidious depression is. It makes you not want to do the very things that you need to do to feel better. Things like visiting with friends, exercising, and getting out in the sunshine. When it is serious and you need to see your doctor about it, you feel you cannot get out of bed or bother to make the appointment.

I have sometimes asked clients to "fake it till you feel it". You may not feel like you want to do these things, but you need to go through the motions of doing them in order to feel like doing them.

I have occasionally wondered about the client-centredness of asking a client to do something that he or she does not want to do. What I finally settled on is that it is still client-centred if it is directly related to client-identified goals.

We often will do things for others that we will not do for ourselves. All last week, I did not feel like getting out of bed. Yet I got up and made (and ate) breakfast and got dressed in order to get the kids ready for school. Sleeping in was not an option because I had my kids counting on me.

This is where the importance of the therapeutic relationship comes in. I talked about it before in a previous post called The Healing Power of the Genuine Relationship, and I think it is so important. If you have a close enough connection with your clients, they will do things for you (and therefore for themselves) that they would not do otherwise.

So many recovery stories have one or two people who really cared and made a difference. Patricia Deegan describes how her grandmother came every day for a couple months and asked her if she wanted to go grocery shopping with her. The one day that she said yes was a turning point for Patricia.

I attended a talk by Bill McPhee, who founded Schizophrenia Digest. He described how a friend convinced him to attend a weekly group with her. He was quite humourous when he talked about how he dreaded the event because it meant he had to shower, put on clean clothes, etc. Yet he did those things and attended because of his connection with her and the group. Eventually, he became involved with other projects and his commitments to other people increased so he was having to look after himself more frequently.

I think this is also a big reason why work can be so helpful for mental health - when people are relying on you, you need to take care of yourself. Work motivates you to get enough sleep, get out of bed, take care of your hygiene, get outside, etc. It pulls you out of your own thoughts to think about other people or activities.

I once worked with a co-worker who had serious mental health issues. She was great with the clients because she also lived it, so she knew exactly where they were coming from. She was also an example that recovery is possible. Unfortunately, she struggled with vacations. She was often not doing well when she came back from vacation.

Laughter yoga is another "fake it till you feel it" activity. I attended a session once, and it was a lot more fun than I expected. Basically, the facilitator leads you in laughter exercises. You fake laughing until you actually find it all so funny that you start laughing for real. The more you fake laughing, the easier it is to laugh for real.

I was so impressed with how happy this woman appeared and how easily she laughed, that I continued practicing laughing on my own. The drivers in the other cars probably thought I was a little silly. It felt a little weird, but after practicing for awhile, I found I was able to laugh much more easily.

Last week, I forced myself to get out for walks in the sunshine. Even though I was not feeling sociable, we had friends over on the weekend and I really enjoyed it. This week, I started an exercise class with a friend. I no longer feel that depression is knocking at my door. I faked it and now I feel it.

Adding a New Activity to a Daily Routine

This is the time of year when people are struggling with their resolutions (or have given up!). Often, people want to add something new to what they are doing every day. It could be taking a new medication or vitamin, checking the calendar for activities regularly, brushing or flossing, taking out the garbage, exercising, practicing a new skill such as mindfulness or meditation, using a SAD light, or many other things.

One of the best ways to incorporate a new activity on a regular basis is to make it part of your already established routines. If you think about it, there are already many things you do every single day.

I encourage clients to link the activity they would like to do with a specific activity they already do every day. The morning cup of coffee is one of the best activities I have found to link things to. If a person drinks coffee, he or she is not likely to forget that first cup, and is likely to still be at home for it.

If the person you are working with does not drink coffee, or wants to do the activity at a different time of day, you might need to be a bit more creative. Some people have taken medication for so many years that it is an established routine you can link to. Hygiene activities can work, as well as meals e.g. every night after supper I will...

It is important to take into consideration what time of day might be best to do the activity as well. Some things (like checking the calendar) need to be done first thing in the morning, whereas others are more flexible.

Our energy levels can vary throughout the day, so if it is something that requires a lot of energy, it is important to plan it for a time of day when energy levels are high. For example, I often feel tired right after supper, so this would not be a good activity for me to link to exercising.

Visual cues can be placed where the person does the activity that you are linking to. For example a sticky note on the coffee-maker, bathroom mirror, or medication bubblepack can be a great reminder.

Here is the catch though: people stop seeing things that they see every day. It is a process called habituation. We could cover the home with sticky notes, but if the notes do not change, within a few days the person will not notice them anymore.

The way to prevent habituation is to change the visual cues regularly. You can change the colour, size, or placement. I have printed out varied signs on varied colours of paper and then placed them all in a plastic sleeve that shows one at a time. This makes it easy to quickly change which page is on top to keep it fresh. Additionally, sticky notes come in a variety of sizes, colours, and patterns.

It can be really difficult to incorporate new activities on a regular basis, but hopefully some of these tips will be helpful.

The Connection Between Hoarding and OCPD

Up until recently, I never paid much attention to Obsessive Compulsive Personality Disorder (OCPD). I think I mentioned in an earlier post that I have been reading Too Perfect: When Being in Control Gets Out of Control by A. Mallinger and J. DeWyze, and it has been a real eye-opener for me. Many people with OCPD have trouble with hoarding, and a couple of the criteria are reluctance to throw out things and miserly spending style.

I guess that when I first learned about it, I lumped it in with Obsessive Compulsive Disorder (OCD), but it actually is very different. However, some people with OCPD have OCD, and they sometimes run in the same families.

In case you are not familiar with it, OCPD is basically extreme perfectionism and rigidity. People who have it tend to have unrealistically high standards for themselves and others. This can interfere with the ability to get tasks done. It can also severely impair relationships as often people with OCPD cannot tolerate having things done any way other than their own. They can be obsessively bound by rules, order, schedules, etc. They become overwhelmed by anxiety if they feel they do not have control over every little thing around them, and as this anxiety increases, they go to more extreme measures to regain control.

Now that I know about it, I can recall several past situations where it would have been helpful to know I was dealing with someone with OCPD. The trouble is, OCPD is vastly underdiagnosed. I do not think I have ever worked with someone officially diagnosed with it. It is similar to Korsakoff's dementia in that the person who has it does not feel he or she has a problem. People around them may tell them they have a problem, but they are unable to see it, and therefore feel the problem must be with the people around them. If they do end up seeking treatment, it is often due to anxiety or depression associated with their OCPD.

People with OCPD can vary dramatically in their housekeeping:

Some people are obsessively clean or tidy. I have a friend whose husband cannot tolerate having anything left out. If she leaves a book on the coffee table, it gets thrown out. Yet he has a huge collection of his own that took up most of their apartment before they moved to a bigger place. It is helpful to understand that there may be a reason why he is so controlling.

I once received a referral for a woman where the issue listed was, "Husband feels she needs to work on her housekeeping." When I arrived at the apartment, it was spotless. I found out the woman did all the housekeeping and laundry, and her husband spent most of his time complaining about how she did it.

His complaints seemed completely unreasonable too. He stated that his pants were wearing out, and it must be because of how she was doing the laundry. When I asked a little further, I found out he only had two pairs of pants that he wore all the time. I suggested that the pants were wearing out because he wore them so frequently, but he could not see it.

I stifled my impulse to tell him to stuff it and do the laundry himself, and instead worked on empowering his wife by encouraging her to participate in activities outside of the home. However, I think it would have been helpful if I had understood that he had a personality disorder. It definitely would have explained that feeling in my gut when I saw him - the same feeling I get when dealing with people with other personality disorders.

Perhaps it would have helped me have more empathy for him to understand that he was not intentionally being so rude, but that he was desperately looking for control over his environment, and he needed that control in order to feel safe.

Some people with OCPD can be obsessive about labeling and organizing. Their house may be stuffed, but it will all be on shelves, in alphabetical order, with labels or charts. Making lists is a favourite occupation. I walked into one woman's house that had shelving from floor to ceiling on every wall, including down the hallway, making her bedroom inaccessible. The shelving was all full of labelled items. They often fear that they will forget what they have, so they want it all to be in view.

Her house was a hazard because they shelving was unstable, and exiting would have been difficult if there were a fire. Yet there was no convincing her to part with any of her possessions.

Many people with OCPD have a really hard time parting with things. They hear that voice that says, "What if I need it someday?" much louder than most other people. To them, if they were to part with the object and then find out they need it, that would be a massive failure. They also can have a high level of anxiety feeling that they must save enough money (and objects) for any imaginable future event. Trust me, they can imagine many more terrible future events than most people.

I worked with one woman for a long time, who lived in a small apartment. Nobody could convince her that she would not ever need six buckets.

Many people with OCPD feel they must part with items the right way. With the same woman, it was not good enough to just give her possessions to charity, she insisted on giving each item to the charity that could use it the most. This complicated the process of sorting because she could not just have the regular piles - keep, throw away, and give away. She had keep, throw away, and then about 10 other categories of give away. It also meant that giving it away meant 10 trips instead of 1.

The other thing, is that if there is a chance they could someday fix and item, they cannot part with it. They have a hard time acknowledging their limitations, and that they realistically will not get around to fixing it.

People with OCPD often have trouble completing tasks due to their perfectionism. Because it was so complicated, the woman had a lot of trouble actually getting to the give-away part.

She wanted to sort her cupboards, but it was not enough just to go through what was there and organize it. Instead, she insisted that she needed to make a written inventory of everything she had. In the time I was working with her, she never did get around to sorting her cupboards.

People with OCPD can have a hard time accepting help. Other people cannot do things to their standards, so they are reluctant to delegate any tasks. Having other people touch their things, and move things around can be extremely stressful because the other person will not organize things the right way. For someone with OCPD, there is only one right way.


When I think back to my clients who hoarded, many of them likely would have fit the criteria for OCPD, yet I am surprised that with all of the reading on hoarding that I did, I did not come across OCPD before now. The two seem to be so closely tied together, that it seems we could really benefit from integrating the information on dealing with hoarding with the information on dealing with OCPD. I still have a lot of thinking to do on what this means for intervention strategies.

One thing I was wondering, is what percentage of people who hoard also have OCPD? Have there been any studies done on this? Based on my experiences, it likely would be pretty high, but I am wondering what other people have observed.


Here's the link for the book I referred to:

How Can We Make Mental Health Sexy?

Mental health services seem to be underfunded wherever you go. A huge number of visits to the doctor and/or hospital are really mental-health related, yet the funding does not reflect this.

I worked in a mental health institution for awhile. In some areas, the "patients" (I hate this word, but that is what people were called there) were expected to sleep in large rooms, with only cubicle walls separating them. There were some wards that were so sensory-offensive that I breathed a sigh of relief when I left them. I felt terrible that I had to leave the "patients" behind.

When I worked in vocational rehabilitation, there was not the staffing or funding to provide services that would actually make a difference.

When I worked in the community, programs and staffing had to be cut because the funding did not keep up with inflation.

The sad truth of it is, who do these people have to advocate for them? There are some people with mental health issues who are doing a great job of advocating. However, a large number of people with mental health issues are not in a good place to be advocating for themselves because they are busy trying to make it through each day.

I look at some other programs that seem to be doing a good job of raising money. Children seem to be a popular cause. They are cute; they tug at your heartstrings; and they have parents to be strong advocates. I see the Children's Hospital receiving a lot of donations. As a parent, I am glad for this.

Helping people in Africa seems to be a popular cause. I think it is nice and comfortable to help people who live that far away. It makes it easy to believe that everything is good here, and that there are no people starving in your city. I understand there is a real need in Africa. I just think that sometimes it prevents people from acknowledging the need that is right in front of them.

It seems to be really trendy to support breast cancer these days, and I think the breast cancer charities have done an excellent job of promoting themselves. They have taken a topic that was not talked about, and made it mainstream. They have used what they had available to them - this is your mom, your sister, etc. They have also made breast cancer awareness somewhat "sexy". Check out the Your Man Reminder App.

I think that mental health advocates could learn a lot from the breast cancer folks. I know it may be a tough sell to think of the homeless man talking to himself in a sexy way. That does not mean he has any less need of funding for programs than anyone else. A few years ago, I also would not have thought of breast cancer as sexy or trendy either.

There is a lot of talk about reducing the "stigma" of mental illness. It almost seems that the more we talk about "stigma", the more stigmatizing it gets. You may want to check out my post on "Anti-Stigma" vs. "Social Inclusion".

Instead of looking at the negative, I think we should look at how to put a more positive spin on mental health. Any ideas?

Teaching Daily Living Skills: Not as Easy as it Looks!

When a person is unable to perform a daily living skill, the usual assumption is that the person needs to be taught it. This seems to make sense, and is actually an integral part of some current models of practice. So, a person is hired to teach the client the skill.

There's one problem with this way of thinking - if you are working with an adult, it is likely that at some point in his or her life, there was already an opportunity to learn that skill. It is very seldom that no other person has ever tried to teach your client the skill. For some reason, he or she did not learn the skill in the usual way.

Reasons for not learning a skill can be numerous. Many of my clients had significant cognitive deficits that made learning new skills difficult. Some people are not motivated to learn the skills. Sometimes there is a physical barrier. Perhaps the person has unrealistic thinking about how the skill is to be done.

This can present many challenges to the person doing the skills-teaching. It may be that the person needs a different teaching style (e.g. client responds better to visual cues than verbal cues), or that the person is unable to learn the skill as it is and the skill needs to be modified. It may mean that the environment needs to be modified in order to support the person performing the skill. It may mean the person needs help finding the motivation to perform the skill.

Here's my peeve: Often the people hired to do the skills-teaching have little to no training, very few resources to use, are hugely underpaid (with no consistency to their hours), and sometimes do not even have the skills themselves that they are supposed to be teaching. It may be different where you are, but that is the way it seems to be around here.

Don't get me wrong - I have great respect for the people doing this job. They can be some of the most caring individuals you will ever meet. Many are very resourceful. I just feel they are under-valued and under-supported.

They must first figure out what the barriers to performing the skill are. Then they must figure out how the person learns. Then they must actually teach the skill and/or modify it. They often have to find their own resources to do this, and often they are not paid for the time they spend finding resources.

This is partly why I wanted to write Daily Living Skills Worksheets. I had worked with various different agencies and programs who were looking for training and resources for their workers. Yet so little was available for working with adults.

To teach children at school, you need a degree; you are given a good salary and benefits; you are provided with library access and planning time; and you are paid to attend high quality inservices. There seems to be a large disparity between this and the supports given to people teaching daily living skills to adults.

Bad Things Happen to Good People

I think we like to believe we have control over our lives. I've been reading the book Too Perfect: When Being in Control Gets Out of Control by Allan Mallinger and Jeannette DeWyze It is about the negative effects of trying too hard to be perfect, and to remain in control, and what people can do to learn a little more flexibility and comfort with not being in control.

One concept the authors talk about is that people often (subconsciously) believe there is a "cosmic scorekeeper" which is based on the concept that life is fair. If you do enough good things, life will be good to you. If you do something bad, life will be bad to you. I doesn't actually work that way, but it is a way people often find security in an unpredictable world. Sometimes this way of thinking is encouraged by religion, but it is often there even without religious influence.

What I have been thinking about is the flipside of that - if you use those standards to judge other people, and not just yourself. If you follow the same logic, when you see good things happen to other people, they must deserve it. When you see bad things happen to other people, they must have done something to deserve it as well. This is a very comfortable way of thinking, because whatever bad thing happened to another person clearly could not happen to you.

I have seen several examples of this way of thinking over the years. As a teen and much of my adult life, I have struggled with acne. Especially as a teen (when it was at its worst), I received so many insensitive comments from others who thought they knew the answer, "If you just did not wear makeup..." "If you just washed your face with Ivory soap like I do..." "If you didn't touch your face..." Like I hadn't tried those things. These people needed to believe that their own clear skin was due to the good things they were doing. If I had acne, it must have been due to something I was or was not doing, and not due to chance.

I have also seen this way of thinking about my clients with mental illnesses. It pushes people's level of comfort to believe that mental illness can happen to anyone at anytime. It is much more comfortable for others (including family members) to believe that my clients must have done something to deserve a mental illness. "If you only..." When you pass a homeless person talking to himself, it is way too uncomfortable to think about how that could easily be you or someone you love. I think one of the most hurtful things clients have told me that family members have said is, "You just need to pull up your socks!" Like they hadn't tried that.

I also see this way of thinking when parenting a child who does not easily fit into the activities that other kids so effortlessly enjoy. When my child is melting down, it is so easy for others to believe that I must have done something to cause the meltdown. If he has anxiety, it must mean that he has learned that anxiety from me. It is too uncomfortable to believe that your child could have similar experiences.

Maybe the reasons some of these comments are so hurtful is that we all secretly, deep down, believe in the "cosmic scorekeeper". Maybe it is because we second-guess why bad things happen to us as well. Was is something I did?

It is helpful to me to realize that others are not meaning to be insensitive when they say some of the comments I have heard - they are merely trying to find a safe place in a world that is ultimately not safe.

Here is the link for the book: