Looking for Justice

Today, we observe the birthday of Martin Luther King, Jr. as a reminder to continue working toward the ideal of "liberty and justice for all." In his famous "I Have a Dream" speech, King wrote:

... we refuse to believe that the bank of justice is bankrupt. We refuse to believe that there are insufficient funds in the great vaults of opportunity of this nation. So we have come to cash this check — a check that will give us upon demand the riches of freedom and the security of justice. We have also come to this hallowed spot to remind America of the fierce urgency of now. This is no time to engage in the luxury of cooling off or to take the tranquilizing drug of gradualism. Now is the time to make real the promises of democracy.

So, how are we doing, almost 50 years later, on that justice thing? It depends, of course, whom you ask. It also depends on whether you see the metaphorical glass as half-empty or half-full. I tend to see it more as a dialectic: it is true both that we're working toward justice, and that we've got a long way to go.

On the positive side, we've seen an upsurge in community organizing and activism worldwide, from the "Arab Spring" revolutions, to the Occupy movement. The former has not fully realized the goal of justice, but has moved in that direction, with the fall of dictators and the rise of democratic elections. The latter has resulted in consciousness-raising, but few concrete steps toward justice...at least as of yet.

That points to the negative side - it is still true that the majority of power and resources are in the hands of a small group of people...a group that is largely wealthy, White, and male. The Republican primaries are an excellent illustration of that (with the big concession to diversity being Romney's Mormon faith). While there is slightly more racial and gender diversity in the Senate and House of Representatives, our politicians tend to be uniformly wealthy. The degree to which they are out of touch with the rest of the population is clear in the stalemate they've created through petty refusals to compromise, and the resulting all-time low approval rating on 9%.

A part of the mission and responsibility of social work is to advocate for the needs and rights of our clients, many (if not most) of whom face unequal treatment as a result of race, class, or (dis)ability. Mental illness still carries a heavy stigma, and our health insurance structure is more geared toward denying care than providing it. We fight an up-hill battle to get our clients' needs met - needs for treatment, as well as more basic needs (e.g., food, shelter, safety, transportation) that may otherwise create barriers to treatment.

How do you approach this challenge in your work? How do you think about your role as an advocate for justice?

Would You Rather....?

You've probably played the "Would you rather...?" game - basically, you have to choose one of only two options. They might both be decent options...or both might royally suck!

For example:

Would you rather lose your keys, or your cell phone?

Would you rather be stuck for five hours on a broken elevator, or a broken ski lift? (obviously if you're afraid of heights you'd choose the first, and if you're claustrophobic, the second)

My clients get to play this game all the time...the stakes are just a little higher. For example:

Would you rather feel bad about yourself because you cycled back into  a depression...or because you're obese?  

Would you rather think people are trying to hurt you...or know they're laughing at you because you're missing most of your teeth?

Surely I exaggerate, right? Not really. In spite of the vast improvements in psychiatric medications over the last 10 years, serious side effects continue to plague patients, often leading stigma to multiply rather than decline with treatment.

For people who think medications are helping them, the top reasons for discontinuing medication are sexual dysfunction, and weight gain. Unfortunately, the vast majority of antidepressants (Prozac, Paxil, Celexa, etc) cause sexual dysfunction, while common mood stabilizers (Lithium, Depakote) and antipsychotics (Seroquel, Zyprexa, Risperdal) can all cause significant weight gain - with all the other health issues that go along with it.

What about the tooth loss? All of the above classes of medication cause dry mouth. While dry mouth is not usually uncomfortable enough to stop people from taking their medications, it significant increases the rate of tooth decay, and may contribute to inflammation or infection of the mouth's lining. When coupled with inconsistent dental care (due to hygiene issues, lack of insurance, or both), recipients of psychiatric treatment often experience tooth loss. Think about it: how many of your clients are missing teeth? Versus how many of your colleagues?

And all of this is completely ignoring the possibility of antipsychotics causing the development of Tardive Dyskinesia - motor tics, usually of the mouth and extremities, which is often permanent.

Sure, there are strategies for lessening some of these side effects. Diet and exercise may reduce the rate or amount of weight gain (but are hard for people even without any mental health issues). Drinking more liquids, and sucking on sugar-free hard candy can counteract dry mouth.

Nevertheless, we do our clients a disservice if we minimize the real dilemma of whether to take medication. Calling it "noncompliance" when clients skip or stop medication is both paternalistic, and an oversimplification of a complex and personal decision. Who am I to say someone "should" prefer obesity to hallucinations? I'm not sure I would be willing to make that sacrifice for "sanity!"