Cognitive reappraisal is a top-down emotional regulation skill associated with resilience – the capacity to adaptively overcome adversity.
A person with this ability, also known as cognitive flexibility or reframing, monitors negative thoughts or situations and intentionally changes the way he or she views them. This reframing can involve retaining a positive outlook, trying to create meaning from a difficult situation, or finding ways to exert control over specific circumstances (Front Behav Neurosci. 2013 Feb 15;7:10). Some individuals cope with their mental illness by creating their own models of their illness (Achieving Cultural Competency: A Case-Based Approach to Training Health Professionals, Hoboken, N.J.: Wiley-Blackwell Publishing, 2009).
Creating a model of illness is a type of reframing to help explain what’s happening to an individual by placing the locus of control either inside our ourselves, adjacent, or far away and uncontrollable. Depending on the model, there might be choice that results in action taken to face the mental illness. Sometimes, there is surrender, either to the illness or the treatment.
Dr. Jacqueline Posada
In one of my weekly phone conversations with my mother in Texas, she told me that Ricardo, the husband of close family friend, had sunk into a deep depression to the point where he could no longer leave the house for work. Ricardo is an unauthorized immigrant, having crossed the border from Mexico into Texas 17 years ago with his wife and 2-year-old son. He lives a story common to many families in Texas: two undocumented parents working in local businesses, one child with a DACA (Deferred Action for Childhood Arrivals) permit and their second child born in the United States, all assimilated into American culture. With Ricardo’s descent into personal darkness, their American dream was fraying. Family and neighbors were gossiping about what could have happened – had Ricardo gotten into trouble with drugs and alcohol? Perhaps his wife had bewitched him; perhaps this was a godly test that only prayer could overcome.
I called his wife to see if I could offer her help navigating the local mental health system. She recounted a story of severe depression, and, most worryingly, a recent self-aborted hanging. Because of cultural beliefs, stigma of mental illness, and his immigration status, Ricardo would not call the local mental health authority for assessment and treatment.
So I made a trip to Texas to see Ricardo as a friend and psychiatrist, despite not quite knowing how to navigate the moral and legal ambiguity of this situation. I could at least offer a comprehensive psychiatric assessment and provide him with some understanding of his illness to help guide his decisions. My conversation with Ricardo found a man helpless and confused as to how and why he lost all drive, energy, and desire to live. We spoke about his and my understanding of depression. I tried to help Ricardo by shifting his perception of his illness from fear of an unknown specter to the idea that his current state of mind could be attributed to a treatable brain disease.
The trip to Texas was also an opportunity to see my older brother’s newly purchased home. This was a serious achievement, following 2 years where he had lived with our parents to save money for a down payment. He had initially been forced to live at home because of legal consequences related to his struggles with addiction and depression, both backdrops to his life as a devoted math teacher. In the car ride to his new house, he told me about his twice weekly, state-mandated addiction counseling group sessions. He has benefited from the instruction to fill his sober time with positive forces, telling me that he could not have bought his house and started working a second, part-time job without his sobriety.
Yet, he disagrees when the counselor tells his class that addiction is a disease that compromises his free will, and compared to his peers, he has less control over his mind when exposed to alcohol. He says it’s a mixed message – be proactive and take control over a new sober life, but be careful, your brain is too weak and diseased to ever have a healthy relationship with alcohol.
I was affected when he told me that he was afraid to ever drink again; that he cannot trust himself. He is afraid to fail and lose the life he is building for himself. Now he lives in conflict between two models of his illness: the determinism of addiction versus free will to overcome his abusive relationship with alcohol. To overcome this conflict, he has surrendered himself to a self-designed treatment program, working two jobs to fill his days and nights, and guarantee fatigue and sleep by the end of the day. No time to think or drink; just time to work and sleep.
The night before I flew to Texas, I had an overnight call in the emergency department. I encountered a young woman whom I’ll call Laura. She was in her mid 30s with HIV/AIDS with a CD4 count of less than 30, and had not taken medication for her HIV in years. Mostly, she lived in and out of hospitals, both psychiatric and medical wards. I was called to assess her suicidal ideation with a stated plan to slip and fall in her shower in order to hit her head and die. She was cachectic, tired, withdrawn, disheveled, buried under a heap of blankets.
Our interview was an awkward dance around why she could not and would not take medications for either her HIV/AIDS or posttraumatic stress disorder and depression. No money, no transport, intermittently homeless, no desire to live nor a future to live for.
In our conversation, I searched for reasons for Laura to live, and she countered with reasons why it was easier to die. It was a level of apathy I have encountered with other severely ill AIDS patients – the brain is so immunocompromised and muddled, the body so tired, the spirit so damaged. Her three children living with a sister had lost their potency as motivation to desire recovery of her physical and mental health. I doubted the active nature of her suicidality, and her apathy and physical deterioration made me question her ability to act on a plan. Nonetheless, I admitted Laura to the psychiatric unit for safety. Two weeks later, I learned she had died in hospital of AIDS-related sepsis. She had 10 days of treatment on the psychiatric unit with no movement in her depressive symptoms and apathy. Eventually, she physically crashed and was sent to the ICU, where she died.
As psychiatrists, we create our own models of what mental illness and treatments are, and we apply some version of the model to each patient. With the concepts of cultural psychiatry and therapeutic alliance, we learn to work within our patients’ models of disease to enhance their response to treatment. My initial reaction to Laura’s death was surprise, fear, and guilt that maybe I had missed a pressing medical issue that contributed to her death. Then I just felt resigned to her death, probably as she did. She told me in the emergency department she was set on dying, and her actions, well before this last admission, had indirectly ensured an early death. We psychiatrists feel failure when we are unable to prevent a suicide. What was Laura’s death: Was it a suicide by apathy that a psychiatrist could have prevented? Or just an expected complication of an untreated chronic illness? Many residents had done their job by admitting her again and again for either psychiatric or medical illness. Yet none of us could understand why she refused to treat her HIV/AIDS, and none of us was able to address the model she had created of her illness. Her model, that her HIV was a death sentence, was anathema to our training.
Because of that dissonance, it was difficult to understand her narrative, let alone find a way to help her reframe it. Her model of illness was misunderstood by a wide swathe of medical professionals, and together we were unable to tailor a treatment to her needs. Since, I’ve worked to reframe her death in my own mind as a way to better understand models of illness, learning from her as well as from my brother and my friend Ricardo. Both the patient’s and physician’s conceptualization of illness affects prognosis of whether to surrender to a treatment or the illness. As psychiatrists, we must strive to understand all models of illness, so we can plan and implement our treatment intervention accordingly.