Reuniting With Self Identity and Overcoming Mental Inertia Begins by Stepping Forward

Reuniting With Self Identity and Overcoming Mental Inertia Begins by Stepping Forward

The “normal” child has usually established a sense of self identity by about age five. They are “trusting” and have a unique set of personality traits. They will often follow guidance without debating it, operationalizing, and intellectualizing the situation. This is in a way helpful in that they learn resilience and coping skills as there are some things that are more “hard wired” like their gene pool and other situations into which they are born that they cannot change. The sense of self matures over time and is a guiding life compass. However, there are life issues that can challenge this process.

This Blog has several layers of important implications: What could happen if you are basing your decisions on cognitive distortions? If a common theme underlies many if not all psychiatric disorders what could the considerations be for treatment?

Self-Identity Unifies the Gestalt

Self-identity and mental health are intimately related. There is a bidirectional relationship that ebbs and flows between the balanced state of a healthy sense of self and one wherein the psychiatric state is balanced.

What is evident in global research concerning mental health and substance use is that the loss or degradation of identity, that usually occurs early in life, is highly predictive of substance use/mental health issues that may occur later in life.

If fragile self-concept persists after formal treatment, this is correlated with future relapses. This may make sense, however. The type of therapeutic work that may be required in complex cases regarding repressed issues that have been dormant “buried” under years of multiple defense mechanisms and family issues for example may not be as easily “fixed” by CBT/DBT alone. I have seen many articles on techniques specific to different psychiatric disorders and varying philosophical therapeutic approaches to treatment. In fact, you can look up almost any psychiatric diagnosis and see not only a summary literature search of many individual studies that have been done on the different therapies and approaches to the individual clients’ but also data or measures of success rates, and comments on which types of clients may likely “benefit more’ from that sort of approach. This is not the point entirely. The point is that it is important in terms of how loss of self-identity affects clients and their feelings of self-worth and how this can go on to create the emergence of a new psychiatric diagnosis or the other way around. It may in fact be a “tipping point” for clients to really to consent to therapy if we also approach them in an empathic caring way.

Self-esteem and identity are concepts that should be addressed and followed throughout treatment progression as an indicator of treatment success perhaps even more so than some other more concrete measures because it would tend to indicate a more internalized level of recovery. For example, asking someone how many drinks they have had is the endpoint behavioral result vs. discussing a somewhat abstract mental construct of self-esteem. It requires more insight to discuss “self-esteem. Self-esteem has predictive value in early childhood of mental health and substance issues later in life. It also has predictive value for clients that may be at higher risk of relapses in the future.

Often clients can be “lost” in between their programs such as PHP, IOP, OP and suffer relapses. One way to extend care between programs may be to create protocols or something like sophisticated “chat boxes “that could be individualized. These protocols could utilize AI to collect and “sort” existing literature regarding self-esteem/self -identity and how it is connected to each individual DSM disorder / or syndromes or multiple disorders. Next maybe it could utilize the clients individual’ clinical testing information including screenings regarding now existing research tested and verified and inventories as well as other measures. The action steps would require or could include experts in the field such as psychologists /psychiatrist, as well as other pertinent fields. Something like this may help extend treatment especially in between programs when many relapses seem to occur as in those like PHP to IOP to OP. These sorts of protocols could also be used in our parental facilities to start working on self-esteem early on and to also put more focus on these whole areas on progress in treatment. Dual treatment programs could easily combine groups addressing the concept of self-esteem and self-awareness.

I know that substance use programs have included this sort of emphasis on self- esteem in programming, but I have often thought that not enough emphasis has been put on those individuals that have entered the recently sustained remission period and may be almost ready for discharge when they feel “different” and not sure who they should feel like as they are not identifying with their previous “old “self” and not with their substance using self. In these periods relapse risk is high. This is also a period when a Tool kit that could increase self-concept or help reintegrate it would be immensely helpful. The idea is to extend care and help prevent relapses and spare the use of more individual therapists.

Erosion Of Identity and Future Implications

What is the process that the ego or self-identity? Well, there are countless ways. There are acute stressors that directly affect the identity and can, if not addressed, proceed to mood disorders or other DSM diagnoses. Here are some other acute stressors: Divorce, PTSD, Domestic Violence, Abandonment/Deprivation. These sorts of traumas create long term assaults on self-worth and can set up a cycle of recurring trauma. This can occur in domestic violence and ongoing child abuse. Then Psychiatric Disorders including most Personality Disorders (although some of the Cluster B disorders have “inflated facades” of self-worth “) affect self-esteem and Identity and at times co-exist with other DSM diagnoses…

There are studies that rank Psychiatric Disorders in order from the most severe to less regarding effect on identity. The depressive and eating disorders are at the top and surprisingly anxiety is towards the bottom. In regard bipolar disorder, in this case a person’s identity is linked to the prevailing mood state. Medications would be helpful in stabilization but in early recovery there is still the issue of adjusting to a different mood stabilized version of self and that is why ongoing therapy is so important. In schizophrenia, which also has some creative components, sometimes patients describe some changes in identity. Recall that this syndrome involves decreased ability to “filter stimuli” as well as cognitive processing issues… I have had a respectable number of patients people with schizophrenia that did not wish to have all their auditory symptoms eradicated due to it seeming to feel “it was isolating” and they were used to the “company”.

The interrelationship between psychiatric/substance use disorders is bidirectional and can occur gradually so that the individual experiencing it is not always aware of the change that they have gone through while an objective viewer would most likely notice that the person is quite different. The person suffering from the psychiatric disorder may become so isolative and inner focused that they have had extraordinarily little if any objective external stimuli for some time. If there is a time of realization that the person realizes that they have “no purpose, are alone, don’t know who they are anymore” it may be fleeting compared to what it may have been earlier in the course of the illness. An exception to this is OCD in which the distress level may be high enough that the person may seek help earlier… To illustrate: The mind can become like an “Echo chamber.” This occurs over time.

People struggling with psychiatric conditions and or substance use disorders get caught in cycles of repetitive self-reinforcing thoughts and behaviors which worsen their condition(s) making recovery increasingly difficult. As the disorder proceeds, they see the situation as a “new normal” and not the reality, for the cognitive distortion it really is. Therefore, they are making decisions based on distortions and poor insight rather than asking for aid and help. This becomes harder for many individuals to do as negative thoughts tell them that “I’m not worth it,” while in the beginning when they could have asked for help more easily, they may have said “I can fix it.” For some people this can continue until there is a major life event such as job loss, DUI/vehicular homicide, health crisis, overdose, or worse. However, there is never a wrong time to ask for help as long as it’s NOW.

Perceived Barriers to Care

In the United States about 54 % of people seek mental health treatment overall. There are people that really have issues with affordability, lack of services in their area, high client to provider ratios that require long wait times, financially out of reach, (often utilize ER repeatedly if even that is available), unable to get transportation ( as in the elderly) . There are also the clients that have experiences that have gone poorly due to issues with : racism, cultural issues as in language barriers, misinformation, mistrust the provider(s), have encountered and now internalized stigma, fear losing their jobs, have a sense of mistrust, do not believe in medications due to issues such as their religion, feel that they can heal themselves, are fearful of having to report psych or substance issues or get under fire at their positions which are critical or “strict about all of this. Some of these issues are rational and make sense given the situation they may have been in before.

Therefore we (as providers) need to try to provide a dissimilar experience this next time for them as a provider. This means providing a safe , atmosphere (and sometimes tele-health if the client cannot come in due to issues with transportation, etc.) that is respectful well as being very transparent about the meeting and answering all questions, providing education that corrects misinformation, and giving excellent care along with reviewing the HIPAA paperwork so that they feel protected from and invasions into their privacy. In clients that may be somewhat impaired due to substance use or in an unstable psychiatric state that may cause them to not recall what is being said: It may be helpful to have another person from their family present in order for that person to listen in on the instructions if that client does require a higher level of care.

Health Care Risk Factors -Physicians

It is likely that physicians work long hours at their job and often more after leaving work. Also, they must work on EHRs all day, and there are also MOC requirements, and CMEs to do which also cost money and take time away from the family for example. But there may also other concerns such as perceived loss of “autonomy” the inability to make their own decisions and often having to “go along with “the policies of the workplace which they may feel are ethically incongruent to their own ethical principle. These potential issues, along with increased work demands, plus responding to patient and hospital satisfaction inventories as well as anxiety about the governing bodies that can present concerns of actions upon their medical licenses. Therefore, it is not a surprise that they tend to be driven, perfectionistic, often with inadequate work life balance.

Imposter Syndrome (not a psychiatric disorder) is present in 25% of physicians in which despite behavior showing that they are successful, their thoughts are perseverative in that they are “failing” and will be” found out”. These people experience internal feelings of inadequacy, anxiety and foreboding. If they struggle with a psychiatric disorder /SS or substance use issues even worse, and they receive help for this, they are terrified that their work may find out about this and that there will some kind of repercussions. Although this is at the “extreme “physicians in general are high achievers and often take on multiple projects and deadlines leaving and leave little time for self-care. It is often the case that physicians may put off seeking care for medical issues and psychological ones hoping that things will “pass” but in some cases this does not happen as they had hoped they would. After all physicians are people too. Sometimes a process set in motion proceeds until a “sentinel event” occurs.

So, to the health care workers: you deserve treatment in the initial stages of whatever you notice is changing your quality of life. Whether its substance related, mood related, or relationship, financial, etc. Anything that is making you feel “different “or as if you are not yourself.” The worries about invasive personal questions in the future on paperwork can be wait for now. It can be worked out and if you need legal help to decipher some questions on applications or contracts that can happen too. Waiting for the next best time to get help or “Doctoring “yourself always is a bad choice. Holding on in anxiety and fear until that “big shoe drops “is not only a risky idea but means that you are sacrificing many days to anxiety, dysthymia, and certainty that are unnecessary. There are some statistics that are concerning in NIH data: That female doctors suicide rate is far, far above the general population and that likely has to do with the dissonance created by work duties and what you also trying to do as a mother / running the house. The statistic that I found very troubling: Of the completed suicides only 29% were in treatment for mental health.

Throughout my career I have found treating physicians and other health care professionals extremely rewarding and at times challenging. I have experienced the loss of many colleagues beginning in medical school in fourth year and several after that. We get wiser as the years go by through life experiences and missteps when we could have taken “a speed-reading course” and then enjoyed the ride. Knowledge is power and knowing your legal requirements ahead of time is empowering as is maintaining your inner self by surrounding it with resources and professionals you trust who can support you in the future.

     Dr Deerfield

KEY POINTS:

The biggest message here is to SEEK HELP early on at the onset of mental health /substance use concerns before mental inertia, cognitive distortions set in and judgment is impaired. This is especially true in co-occurring disorders that symptoms can become so severe that often it is CRISIS situations will result in you receiving the care that is needed. For providers: consider the role of identity and self-esteem in treating mental health and substance disorders. Target protocols that provide longer continuity of care as lower self-esteem which is present in childhood are linked to increased risk of substance relapses and often require more in-depth therapy engagement. Future options could include looking at the potential use of AI were explored in preparing individualized treatment protocols.

Here are a few of the many articles that I thought exemplified the material that is readily available regarding the topics I discussed:

• The Role of Identity in Addiction and Recovery Nada Grigorova, The Journal of Applied Philosophy, March 2025
• Dr Valeria Young: published multiple articles on Imposter Syndrome
• Pub Med: Systemic Review: Narrative Synthesis of the literature regarding Psychosis and Identity Changes Pub Med 29;47 (2) 309-322 Sept 2020