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The Sacrifice Within: The Struggling Economy Takes a Toll on More than our Pocketbooks

November 10, 2008

In the days since the stock market plummeted, the economy has led the pack of stress factors, according to a recent CNN poll, causing three quarters of all Americans to worry. Even those of us who havenít suffered the trauma of lower wages, lost jobs, overdue bills or foreclosed homes have begun to feel anxious, wondering what might happen to our retirement accounts or other resources that we had previously taken for granted. Stress in turn has manifested in anger, fear or irritability, and in many has extended to physical symptoms such as insomnia, fatigue, headaches, muscle tension, upset stomachs and even suicidal tendencies. Is it possible that what is going on in our minds these days is just as serious as our financial hardships?

In its most primal form, stress leads to the "fight or flight" response in which our bodies produce increased levels of adrenalin, our heartbeats and breathing speed up, blood flows more rapidly to our muscles and limbs, our pupils dilate, impulses quicken and our thoughts take the form of short, fearful bullets. This stress response has played an important role in human history because it improves the chances of survival in life-or-death situations: that is, our ability either to fight a savage foe or to run away. In modern society, however, the classic stress reaction has run out of room. The "economy" is not something we can punch with our fists, and our debts follow us wherever we try to run. We are trapped in a national or possibly global predicament we cannot stop or control. As stress hormones accumulate in our bodies, we are increasingly likely to find that we cannot concentrate, we are depressed, we have paranoid thoughts, or that we have high blood pressure, irritable bowel syndrome, allergies or any number of other unpleasant problems. When we are under such duress, we may tend to look out only for ourselves. We may argue more with others. As our stress filters down to our children, we may see them exhibiting undesirable behaviors they also can neither explain nor stop. We may find that the ties that bind us to others in our families and communities begin to erode. By sacrificing our mental health due to stress over the economy, we are stripping away our ability to function in the world. Like some of the characters in my novel Requiem for Locusts, our psychological deterioration may even cause us to lose sight of the boundary between reality and insanity.

The most pressing question for many of us as individuals is: what can we do to reduce stress in the face of an economic disaster? The first step is to recognize that stress is present, and that it may not go away anytime soon. Recognition of a problem sounds obvious, but it is surprisingly difficult to come to terms with oneís own mental health. Mental health problems, including stress-related symptoms, have been among the most ignored issues in society. This is undoubtedly because of the stigma associated with mental illness. No one likes to admit he or she has a problem that cannot be seen and that is likely to lead to being classified as "abnormal," "insane," or "crazy." Our minds define who we are, after all, and if something goes wrong with them we are at risk of losing not just ourselves, but our friends, our jobs and everything we hold dear. Also, many mental health issues are not covered by insurance, although the recent passage of the mental-health parity bill should begin to reduce discrimination by insurance companies against mental illness.

Once stress and its sources have been identified, the next question to ask is: how can we eliminate or reduce the main source of stress? Although the current prognosis for the economy is gloomy, we can act in small ways to improve our personal circumstances and to regain a measure of control. We may need to look for solutions to our mistakes rather than focus on what we did wrong. For example, we can meet with a finance expert, we can make regular visits to the unemployment agency, we can cut back on how often we use the car, how high we set the thermostat, and how many things we purchase but donít really need. Or we can simply make a list of things to do, with the goal of doing at least one item on the list each day. These actions will help not only by reducing the source of stress (our debt, for example), but by allowing us to take charge of our lives again and to focus on what we are doing right. We are not battling a savage beast to the death; instead, we live in a civilized country where hope, reason and intelligence can prevail.

The final step is to figure out how to manage stress-related symptoms. After years of playing my cello in front of large audiences and for juried competitions, I am no stranger to the fight-or-flight response. Although I no longer perform on the cello because of an injury, I can call up the familiar sensations of stress simply by remembering what it felt like to walk on stage in front of an expectant audience. My hands grew sweaty, my heart raced, my breathing became shallow. My mind raced without settling on anything for more than a second, and my stomach felt as though it had a fist in it. I usually experienced a last-minute thought of pure panic as I sat down to play, and afterwards I remembered only the mistakes I had made and often felt depressed. I knew that stress was getting the better of me, and no matter what I did, I could not stop it. It wasnít until I received a small piece of advice from one of my teachers at the Juilliard School of Music that I began to understand how to manage stress. "When you walk onstage," my teacher said, "smile. Look out in that audience and give everyone your biggest smile as though there isnít anything youíd rather be doing." I was dubious, but I tried it. I smiled when I walked onstage, I smiled during my performance, and I smiled when I walked offstage, no matter what I had done wrong. It wasnít an instant cure — I still feel nervous before performances of any sort to this day — but it helped. And the more I did it, the more it helped. Years later, after reading yet another self-improvement book on how to achieve oneís peak performance, I finally realized why it helped me more than anything else. Stress is a problem of the mind. Stress results in numerous disagreeable physiological symptoms, such as the fight-or-flight response, but ultimately it begins with our mindís perception of something as a threat. Thus, it is to our mind that we must turn for a solution.

A simple behavior such as a smile can go a long way towards convincing oneself that there is no threat. No only does a smile relax the facial muscles, which can have a cumulative dampening effect on other physiological stress responses such as respiratory rate, but a smile helps us pretend that everything is fine. Studies have found that our conscious minds can only think of one thing at a time. If we focus on a positive behavior such as smiling, and if we associate this smile with a positive thought, such as "I am calm and in control," we will dispell the negative thoughts from our minds and, consequently, the negative biofeedback from our bodies. Eventually, to our surprise, we will find that we actually are calm and in control. Even better, studies have found that our minds often cannot discern between vivid imagery and actual events. Thus, we can lie in bed at night and rehearse our calm response to a potentially stressful scenario, and we will automtically improve our chances of feeling this way during the real event.

The stress experienced by a teenage cellist may seem miniscule compared to the stress caused by the economic demise of a nation, yet the dangers to mental health are the same. We all risk large disruptions to our personal well-being and our relationships with others in our community unless we acknowledge and manage our stress. Ultimately, we may be able to reduce the sources of economic stress by finding ways to turn our problems into solutions, perhaps by eliminating the attitude that we are victims of our environment and by realizing that we can find ways to take control. This may start on a small scale, as it does for the lonely residents of Locust Street in my novel Requiem for Locusts. These people, who could live anywhere in America, struggle to cope with the stresses of missed career opportunities, aging, the death of others close to them, and the arrival of a young neighbor with a serious mental illness. Despite their disparate lifestyles, the neighbors begin to converge and communicate, demonstrating that small changes in individual actions can result in broad consequences for the entire neighborhood. And if individuals can change a neighborhood, what is to stop individuals from changing the nation or the world? Our solutions to stress may require a new kind of inner sacrifice from all of us as we tighten our belts during difficult times, but it is my hope that if we realize that we all need to take some responsibility for this countryís problems, the problems themselves will eventually diminish.

Does the Federal Bailout signify a New Era for the Mentally Ill?

October 20, 2008

When the federal bailout bill was signed into law this month, it included a provision meant to end health insurance discrimination against mental illness. Formerly, people werenít able to use their insurance to cover as much of their mental health care as they could for the care of their physical ailments. Now, for the first time since Senator Pete Domenici and the late Senator Paul Wellstone began the fight more than a decade ago, business health insurance plans that offer mental health coverage will be required to offer them on an equal footing with all other benefits.

This billís passing has given me, and perhaps others, hope that discrimination against the mentally ill may be on the wane on a scale even broader than health insurance. The tide may be strong enough to change how we interact with mentally ill people in schools, libraries and concert halls where their unbecoming behavior can be disruptive, in the line at the Department of Motor Vehicles where weíre forced to wait with others not like ourselves, on crowded airplanes and buses where we may find ourselves seated near someone in distress, in the parks and alleys where misshapen lumps under blankets try to find some measure of peace, and perhaps most importantly of all, in our own neighborhoods. I hope to see change in how we view and treat the mentally ill within our own homes and families.

Admittedly, I am biased. I do not work for an insurance company, nor do I own of one of the businesses that must conform to the new law. I have a sister who has endured a serious psychosis for the last twenty years. I have witnessed her transformation from a chatty teenager who loved music, drama and children and managed to attend a community college despite various learning and physical disabilities to a frightened and often wildly paranoid woman who can no longer take care of herself and whose conversations often deteriorate into disjointed ramblings associated with the hallucinations she is currently seeing, hearing and smelling. I see my sister as two people: the sweet, friendly, vivacious person she once was and the dysfunctional, socially tactless, mentally ill person she now is. I wish that the people who know her now could have known her then because it might have spared her the uncharitable reactions they sometimes may have. I wish that strangers in the grocery store didnít look the other way when she asks them their names in a loud voice, or swallow uncomfortably when she tries to introduce them to some member of her family. Not a day goes by when I donít see her as a victim of a sort of opaque discrimination, the politely-contained revulsion, the "wish I were elsewhere" line of thought that is the lens through which society views its mentally-ill members.

Most of all, my view of discrimination has been shaped by how I have seen my sister treated in the context of her own community. She has been virtually forgotten by her childhood friends. It is true that other lifelong disabilities (mild cerebral palsy, for example) kept her from having many friends, but even the ones she did manage to make disappeared after the psychosis took over her life. A few still know what is going on, but it is through me that they ask questions of her; they have little interest in spending any time with her themselves. Nor do they realize how much a letter or a phone call to her group home would mean to her: she is very aware of social relationships and often feels lonely and sad that she has no friends.

It is to my motherís credit that my sister is still visited by some older friends of the family or the occasional relative, although even their visits are infrequent. I wonder how many visitors come to see other people with severe mental illness, those with parents who are less involved than ours. During my infrequent visits to my sisterís group home, I see the residents sitting silently in chairs, smoking and staring into space with no one to talk to them, even on holidays. But even in my own family, in which my parents try so hard to maintain my sisterís sense of belonging, shuttling her to and from her group home for holidays and family gatherings—even in this family, the hint of discrimination resides. I, for one, am not above blame. I live far away and am often so immersed in my own life that I forget how easy it would be to scrawl a few sentences on a card or make a simple phone call, either of which could turn my sisterís day around. When I return to my familyís home, I am so busy visiting other friends and relatives that it often feels like a chore to save a little time for a small visit with my sister.

The truth of my own feelings sits in my stomach like a stone. Perhaps my hope for change is wishful thinking, entirely unrealistic. I remember, too, my paternal grandparents. They were both wonderful, hard-working people, world-travelers, intelligent and highly educated. But my grandfather, an internationally-renowned doctor, would watch my sister wolf down her food with a look of disapproval. He refused to understand her enormous appetite from a mental health perspective, although it was entirely due to the drugs used to combat the problems in her brain. And my grandmother, who said that they moved close to my parents to "help take care of" my sister, only once invited my sister to come have lunch at their house. Even though my sister ended the visit happily, saying "letís do that again," it never happened. Christmas presents, too, were purchased for all the grandchildren but my sister, as if she no longer existed. And the saddest thing of all is that now they are gone, without ever truly understanding the change in their eldest grandchild or how to relate to her as a mentally-ill individual.

Remembering these things, I might conclude that I am indeed engaged in wishful thinking when I hope that societal discrimination against the mentally ill would simply vanish. But then I am reminded of the words of Senator Wellstoneís son David, who lobbied extensively for the mental health parity bill after his fatherís death. He said, "Everybody's affected by either some mental health issue or addiction. Everybody has it in their family." He is right, and this truth becomes even stronger when we consider mental illness in the context of our community.We all know someone. We all have experience with the mentally ill. Understanding, I believe, is the first step towards tolerance, towards the building of families and communities that can include their mentally-disabled members to the fullest extent. If we try to understand people who suffer from mental illness, we can help to usher in a new era of compassion that the mental health parity bill has, hopefully, only just begun.