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March 30, 2011

Nanglyala Mental Health Center

By Lewis Mehl-Madrona

I write about the composite mental health center I have created in previous essays which comes from my and others' experiences working in mental health in New York State. I call it Nanglyala Mental Health Center, in honor of the Russian word for Valhalla, which one can't use, for it actually exists. I propose a thought experiment in changing the culture at NMHC, which I hope someone somewhere will be inspired to do.


For some time now, I have been writing about a composite mental health center in the State of New York, which is an amalgam of places I and others have worked.   I have received feedback from many that this imaginary site completely resembles where they are working.   I presume this is because the problems and pressures are the same everywhere and the responses that can be made are similar.   I want to state its imaginary nature again, because I want to begin a number of thought experiments in change and transformation of mental health, and wanted to be clear that I have been and am writing about a composite, a constructed place based upon my and others' experiences.   Therefore, as I start improving it, no one will be tempted to seek it, for it exists only in the realm of possibilities.   For that reason I am calling it Nanglyala Mental Health Center, or NMHC.   Nanglyala is a literalization of the Russian word for Valhalla.   I can't exactly call it Valhalla, for there is a city in New York by that name.   New York appears to specialize in exotic cities like Amsterdam, Rotterdam, Rome, Greece, Valhalla, Chili, Macedon, and more.   One can travel the world and never leave New York State.   The study I conducted on long-term outcomes of treatment in mental health centers, which I have briefly discussed, however, did not take place in New York.   However, as I will repeat at the end of the essay, I'd like to find places to try these experiments, and I invent anyone to contact me who wants help in doing so.

In my own small practice elsewhere, I have enjoyed the power of groups.   Therefore I am going to propose my first experiment for NMHC, and hope that someone tries it.   The culture of mental health is currently anti-groups.   I suspect this is because groups, in general, have been made boring and people dread them.   Whenever I have mentioned my group to my patients, many roll their eyes and say, "I go to groups.   Or, I've been to groups."   Whatever happened in those groups led them to never want to come again.   I've attempted to explore this in a number of Centers and have come to the conclusion that most groups are deadly boring.   They are used for "psychoeducation", which covers a variety of sins but are mostly aimed at instilling facts into patients.   As has been covered extensively in the narrative literature, recitations of facts do not produce change; shared stories produce change.   Novelty and interest produces change.   "Same old, same old" does not produce change.   People do not change unless they encounter something novel that awakens the parts of the brain which monitor the world for conditions that stand out as somehow being different than expected.   So groups must be different than what people have come to expect.

In the groups I and others of my persuasions have led, we tend to interest people with novel experiences such as mindfulness meditation, chi gong exercises, yoga exercises, singing, jumping up and down, art, drawing faces, making cartoons, using puppets and stuffed animals, drama therapy, and other embodied modalities to produce experiences that are different.   Yet, people come and go.

A big problem at NMHC is "no shows".    People don't come for their appointments.   Because we are almost entirely a biomedical model, then people are in crisis because they will run out of medicine before their next appointment.   The solution has been drop-in medication clinics, in which patients come on a particular half-day and just get prescription refills.   These clinics are largely run by nurses with a doctor present to sign prescriptions and to evaluate the occasionally difficult patients.   The assumption, which is not always a good one, is that people who are having difficulties will be motivated to make their appointments, and that the people who just need refills, are more likely to come to medication clinic.   In my and others experience, when we have tried to direct these people to come to group, we have largely failed, because of the existence of these other options.   So, my first proposal for NMHC is to make coming to group the only option for people who missed their appointment and need more medications.   I say this because it would force many people to come to at least one group.   In my groups, we always do medications first, though we could do them later, just to give people the chance to experience something novel.

Why would we want to do this?   To change the culture of psychiatry to one of story!   I argue that what Melvin Sabshin has called "biomedical biomedical biomedical psychiatry", as his preferred story over Engel's psychobiosocial psychiatry, actually doesn't work very well.   We hide behind studies that last 6 to 8 weeks and aim to prove efficacy of drugs to the FDA.   When we do long-term studies, like the CATIE studies and the World Health Organization studies of schizophrenia, we fail to show substantial efficacy.   My goal is to find ways for psychiatrists to listen to people again.   Group is ideal for the math works.   If enough people come, which, at Centers where I and others have worked, seems to be 4 people per hour, the economists are happy.   What I and others have found is that one can conduct medication business quickly and get onto the listening of stories or the teaching of techniques.   Of course, this assumes that we find psychiatrists who care enough about people to sit with 8 or more of them for two hours, but let's assume we can.   Or, let's assume we can make psychiatrists in training do this in order to teach them narrative competence.   Let's assume that there are enough people like me (and I think there are) who still care about stories, who can supervise residents to learn how to listen to stories.

So, here is my proposal for NMHC, and I hope that someone will adopt it and study it.   I propose that all "out of appointment" medication refills be directed to a group that lasts for two hours.   The group should consist of a doctor who wants to listen to stories and a nurse (hopefully one who also enjoys hearing people's stories).   The nurse quickly established the medication and refill needs for the group (as people enter).   The group begins with a discussion of joint and shared questions (and I have found that almost all questions are joint and shared) so that everyone can benefit, while mundane refills are written quietly, to the side.   When all the questions are answered, then the group pivots toward the personal stories and to learning techniques to change the mind.

The aim is to change a culture of mental health centers in which people don't matter, only medications matter (and I mean to change this for both doctors and patients).   Last night, at one of the facilities where I work, I led a group.   Of course, only three people came, because of the biases against group and other reasons I can only suspect, but still I am grateful that my economists have continued to allow me to do this.   One woman was there to get her medication, only, but stayed for the entire time, I suppose because she thought she would prevail in the end.   She wanted benzodiazepines which another doctor had refused, and the chart room was locked, and I didn't know why she had been refused.   Our small group focused on how she could start to control her mind and attention instead of relying on drugs to do so.   Though she claimed that she wanted to be different, it wasn't apparent from her refusal to try all the ideas presented.   In the end, she left angry that she would have to come back the next day so that I could see what was in her chart (of course, she could have been glad that I was working her into a non-appointment, since my first available actual appointment was 8 weeks later, but she was only inconvenienced by having to make two trips in one week.).   Nevertheless, I believe she might have gained something form sitting in the group -- not from me, for all doctors talk alike and are easily dismissed, but from the stories told to her by the other patients in the group.

So, at NMHC, where I rule the world, we are implementing this idea and will conduct a study on how it changes people and cultures and how it changes outcomes.   If anyone reading this wants to actually do this study, I will help them.   Please contact me.   Otherwise, I will continue to dream about innovations at NMHC in the hopes that someone will be inspired somewhere to do the small steps to move us toward a culture of stories instead of substances.

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Authors Bio:
Lewis Mehl-Madrona graduated from Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of Vermont. He is the author of Coyote Medicine, Coyote Healing, Coyote Wisdom, and Narrative Medicine.