Suicide

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Suicide remains an unmentionable in the US.  People who act upon suicidality are forcibly restrained, imprisoned (involuntarily confined), intensely and intrusively observed, and are subjected to treatment and conditions which make the already unbearable even moreso.

I aim to move upstream and address the conditions which lead toward unbearable distress, what Thomas Joiner has termed thwarted belongingness and perceived burdensomeness, and overwhelming despair.

I want to explore what people find helpful, how they are comforted and reassured, and what stops suicidality from developing to the point that the distress is incompatible with life – a phrase that is used in pathophysiology to describe a condition in which a living organism can no longer survive. I also want to go further and discover what prevents suicidality from occurring in the first place.

To that end, this blog is a safe venue in which to discuss the taboos, the precipitants, and all of the hidden and concealed facets around suicidality.  No one will track or monitor visitor identities.  There will not be online interventions responding to statements about intending to end one’s life. Your autonomy over your own life is respected.  To that end, comments that threaten harm as a manipulating device will not be published.

The overarching purpose is to address ways to relieve and to prevent feelings of intolerable distress.  People who would like to author around these topics are welcome and may drop me an email to discuss.

Rude Facts

Gawkers, voyeurs and righteously indignant moralists will find references at the reading list page. The CDC maintains a list of annual US suicide statistics. It remains unchanged despite all manner of suicide prevention programs and cruel false hope hotlines.

The work of Kipling Williams lately of Purdue University on ostracism may also be useful.

There are no suicide/crisis hotline numbers here because they are not only ineffective, but their use of deceit and dishonesty in the use of police and the forced loss of individuals’ civil rights in the absence of any evidence-based effective help for people suffering unbearable pain is unethical, ineffective (the biggest risk for suicide is a previous attempt) and cruel false hope snake oil substituted for effective evidence-based compassionate care.

Moreover, emergency department personnel have no specific interest, education or expertise in addressing suicidality.

The detective asked the man’s story, what brought him out here, and a dialogue began. The man, in his early 20s, explained that he had no job and no place to live, Detective Keszthelyi said.

“You might seem like you are alone, but you are not really alone,” he told him.

Lots of people lose jobs — and find others they like better, he said.

“You just have to find something in life that you enjoy doing, and when you find that special thing in life, you are going to be successful at it,” Detective Keszthelyi assured him.

The man wanted to know what would happen if he came down. The officers know to be truthful. “In my experience, you don’t want to lie to somebody like that,” Detective Keszthelyi said.

The detective told him that he would be escorted into an ambulance and taken to a hospital, where he would be evaluated and assigned a social worker and therapist.

As opposed to the NYT police interviewee who told a suicidal sufferer a standard whopper that he would be assigned a social worker and a therapist at a hospital, that’s an outright lie. Emergency department staff, like the NYT’s wet dream of its description of the ESU, are all about being adrenaline junkies. These folks live for trauma, clinical instability and quick resuscitation efforts along with races to the OR. They largely resent people who are suicidal and in distress, and they very often are sadistic and cruel toward them. In any ED, there are physicians and nurses who brag about the cruelty they reserve for suicidal patients – unlubed large bore nasogastric tubes, extra doses of activated charcoal, strip searches, ridicule, unnecessary urinary catheterizations, “misses” in IV starts, unnecessary use of restraints and seclusion as punishment and retaliation and on and on and on. Psychiatrists have the absurd notion that patients’ experiences must make them want to avoid remaining (malingering in their parlance) in the hospital – the psychiatrists delusionally viewing the prison like atmosphere as hotel-like.

Almost 100% of people seen in EDs for suicidality, suicide attempts and suicide ideation not only do not receive those resources, but they receive no followup care or contact at all.  They are left to their own devices to relieve their unbearable suffering after learning that “care” is based on dishonesty, deceit, coercion, humiliation and the loss of basic civil rights and dignity. That “therapeutic alliance” invoked by mental health providers is not based on a single ethical principle, and it’s aim is only at compliance. Trust is used to sucker in victims.

As a humane, painless death is not available to them, they are forced to turn to methods which entail self harm and violence. Companion animal end of life ethics are by far more advanced in the US than is terminal psychic suffering.

Degree of Writhing

She was impaled by a person. Along with the act, she was informed that she would remain there and that the means to remove her would be withheld. She was informed that should she appeal to others who would contact the impaler for collateral information, that she would be described as malign, foul and unwanted. A few others who knew what was in store for her promised their support and help.

She was impaled for all to see.

She writhed and contorted and struggled to reach something that could be used to wrench herself loose. Those who promised help disappeared and did not answer her calls for support. They did not help, and they did not call on others to help.

She found herself alone.

The pain, the agony and suffering were unbearable, just as the impaler intended.

But the place of impalement was strategically designed to cause the slowest dying possible, and was designed not to make death come earlier. It was executed to cause the maximum degree of suffering with full realization of the fate and future of the impaled writher.

One by one, and sometimes concurrently, the impaled person used up her means of escape. She learned that to struggle was futile. To writhe more actively only increased pain and fatigue. She couldn’t get to sleep, couldn’t stay asleep, and she awoke very early. Sleep soon became no escape and provided no rest.

Years passed, and on she writhed and agonized.

At this point, she realized that she was out of all resources, and she called out for help from learned helpers.

The highly credentialed, learned helpers poked and prodded and caused even more agonizing pain as they slowly and methodically assessed her symptoms. Although she repeatedly told them that she was impaled – Look! I need people who are qualified to remove what’s holding me fast to free me – they ignored her begging and pleas.

The learned helpers decided that her writhing and grimaces and pleas for help could all be treated as symptoms of depression. She was told that she was going to be treated for her pessimism and refusal to believe in hope. She was forcibly medicated and restrained so that the writhing was contained. She was told that treatment was to keep her safe.

As she adjusted to the medication, she saw her body react to the derangements done it by the sedating, restraining chemicals. She struggled to writhe and react to the agony of the raw and festering wound. But she learned to be silent and to deny that suffering to the learned helpers lest they inflict more restraint, punishment, containment and contribute to her agony.

Some helpers came only to stare. Some to ridicule. Others to condemn. A few saw opportunities for sadism, and they kicked her, made open fun of her and reported to the treating learned helpers falsities designed to induce the learned helpers to inflict more treatment and up the induced agony.

Some of her treatment involved being instructed on how her thoughts were negative and to employ strategies to replace negative thoughts with hopeful ones. Another treatment involved instruction on maintaining distress tolerance. Both of these considered writhing as something to be abolished. Neither strategy dealt with removing the wounding weapon and treating the gaping, festering, infected wound.

It was apparent that this situation was permanently incompatible with life. She decided that instead of struggling any longer to free herself, that she would instead, simply try to find a means to achieve a painless and peaceful death.

But the learned helpers decreed that this was evidence that she was psychotic. Therefore, she would be contained until she was deemed “safe”. But the definition of safe was solely that she would not try to end her life.

Safe did not apply to all of the others who were content to have her suffer or to contribute to her agony and suffering. Safe did not mean a secure home, safe did not equate with a means by which to support herself, safe did not mean acceptance and welcome by others she deemed potential neighbors, coworkers, friends, physicians.

She was told that there are many treatments for her symptoms. She learned that they conflated treatment with efficacious, benign, therapeutic and beneficial. She learned that treatments were risky, dangerous, caused temporary and permanent harm, and did not address the causes of the symptoms.

She was told that the learned helpers decided on treatments based on their professional judgment. She learned that treatments are determined largely on the whims and beliefs of the learned helpers, and often they are chosen to punish the person for their audacity to exhibit distress and to admit that their underlying problems are not being helped.

And so she remains impaled, actively looking for the means by which to give herself a painless and peaceful death while all around her, the means to remove her from being impaled are withheld.

She remains a freak, a pariah, and an untouchable. Indeed, when she was contained and forcibly medicated, no one touched her except to wield a needle and crowd her into a locked cell sans furniture – no window, a security camera, a cage. Just herself impaled.

No one spoke to her except to poke, prod and exacerbate her awareness of her suffering by ongoing clinical assessments, each designed only to elicit symptoms and to ignore root causes.

So as the means to achieve a quick and painless death are not within reach, she has decided to passively bring about her death by no longer eating.

She remains out of sight knowing that no one will look for her. No one wants to see because when they do catch a glimpse, it angers and disgusts them to see her writhing in their midst. It is not pretty, being associated with her could cause a risk of social or work harm (guilt by association), and she has been deemed worthless.

She can’t wait until it’s over, and she looks forward to being too weak to writhe, too weak to comprehend the agony and too weak to care. Those signposts mean that the total and permanent end of her hell at the end of the learned helpers’ road of good intentions is finally within reach.

The Lived Experience of Ostracism

h/t whatnot

I first discovered C. Fred Alford’s work about the experiences of whistle blowers. In it, he describes what constitutes “knowledge as disaster”, and my experiences jibes almost perfectly with this list:

“What must the whistle-blower forsake in order to hear his own story?

* That the individual matters.

* That law and justice can be relied upon.

* That the purpose of law is to remove the caprice of powerful individuals.

* That ours is a government of laws, not men.

* That the individual will not be sacrificed for the sake of the group.

* That loyalty is not equivalent to the heard (sic) instinct.

* That one’s friends will remain loyal even if one’s colleagues do not.

* That the organization is not fundamentally immoral.

* That it makes sense to stand up and do the right thing. (Take this literally: that it “makes sense” means that it is a comprehensible activity.)

* That someone, somewhere who is in charge knows, cares, and will do the right thing.

* That the truth matters, and someone will want to know it.

* That if one is right and persistent, things will turn out all right in the end.

* That even if they do not, other people will know and understand.

* That the family is a haven in a heartless world. Spouses and children will not abandon you in your hour of need.

* That the individual can know the truth about all this and not become merely cynical, cynical unto death.

Not only is it hard to come to come to terms with these truths, but when one finally does, it seems one is left with nothing.”

Now plug in this list to Smart’s diagram below.

Multimotive model of reactions to interpersonal rejection experiences.Smart Richman, L., & Leary, M. (2009). Reactions to discrimination, stigmatization, ostracism, and other forms of interpersonal rejection: A multimotive model. Psychological Review, 116 (2), 365-383 DOI: 10.1037/a0015250

That, in a nutshell, is my experience. Ostracism is a cruel death sentence where all of the means to sustain oneself are intentionally withheld. The victim is used as an object of ridicule, contempt and alienation. The dying is slow, and there is full self awareness of what’s happening. Think of open heart surgery being performed without end, night and day without anesthesia, where the surgical team continually ignores the cries for help and instead makes jokes about the patient and his plight.

That is ostracism. Alford describes whistle-blowers who are doomed, but somehow, he never connects their experiences to ostracism. He discusses living as though one is already dead. Yup, that’s ostracism, because in the eyes of those who know and those who commit it, the victim as person has been murdered and only a ghost remains. But because the ghost has a heartbeat and is still enfleshed, it’s an object used for entertainment. In this case it’s used to create a feeling of superiority and legitimacy by degrading the victim as an unworthy, repulsive “other”.

I have been an other for time out of time. There is no re-entering society. I have been a most compliant patient patient and have repeatedly tried and failed to find a job, volunteer, make a friend beyond the most superficial of acquaintance level, and find any meaning or purpose in continuing to exist this way and there is none. In writing about some of my experience, I attracted a cyber stalker nurse and her band of bullying nurses, ambulance drivers and a Texas ER doc who wrote that “if she’s still alive we can make fun of her”. I was diagnosed as having persecutory delusions because my story “reads like a novel.” The outpatient psychiatrist to whom my case was assigned – she sure as hell didn’t volunteer – is married to the CEO of a competing organization in which I had been an inadvertent whistle-blower. In that organization, the mid level manager and director paranoia ran on high octane, and ironically, I wasn’t paranoid enough to save myself.

The paranoid whistle-blower is absolutely fight (sic) that his organization is not just out to fire him, but to obliterate him or her. The whistle-blower’s paranoia is an accurate emotional reading of an emotional reality: the one who has become the scapegoat cannot just be dismissed, but must be destroyed, so that others will know.

It is this aspect of paranoia that is the most difficult of all for an outsider to come to terms with because it represents a truth that is hard to know: that if the organization feels sufficiently threatened by the individual, it will remove him or her. Not just beyond the margins of the organization, but all the way to the margins of society. The average whistle-blower of my experience is a 55-year-old nuclear engineer working behind the counter at Radio Shack.

I was so desperate for help that I eventually sought it from the mental health non-system system, knowing full well that I would be placing myself in the hands of providers who were as likely to treat me with contempt as those who ostracized me did. All of my concerns were validated. For my troubles, I was diagnosed with stigmatizing labels, received treatment which resulted in metabolic, immune and cardiac derangements, was repeatedly deceived, humiliated, degraded and dehumanized, and was coerced and threatened. Physical problems were not diagnosed and treated, but instead were recorded as being somatizations and dismissed, if they were acknowledged at all. I cannot expect to receive competent healthcare from any provider who accesses my medical record because I am permanently and prominently labeled as the “xx year old homeless patient with extensive psych history”. When I pointed out multiple examples in the medical record of that to the outpatient psychiatrist, she sent a note to some of the offenders very politely requesting them not to do that anymore, and she proudly relayed that to me. But still it continued, and having been on the provider side, I know damn well that once patients are labeled, that they are treated with contempt, do not receive even minimally acceptable care, and they suffer for it with higher morbidity and mortality rates.

I took myself off every prescribed medication as none had helped, some were prescribed to mitigate the adverse effects of others, and many had caused direct harm. I read my medical record, identified what lab and diagnostic values were abnormal, and then I did all of the self care activities that I could do with my resources to reverse the damage.

But ostracism can’t be treated with medications and meditation. It requires a real physical friend, a network of professional/work peers, and a place in the social order. None of those are available to me.

Stillman, et al, describe life without meaning and purpose:

Why should social exclusion reduce the sense of life as meaningful? The pervasive reliance on social connection as humankind’s biological strategy entails that people are deeply motivated to connect with other people as a fundamental aspect of nearly all human striving. Meaning itself is acquired socially. Hence to be cut off from others is potentially to raise the threat of losing access to all socially mediated meanings, purposes, and values.

The formation and maintenance of positive close relationships can aptly be characterized as one of the primary motivations for human beings (Buss, 1990; Maslow, 1968). This pervasive drive has been described as the need to belong (Baumeister & Leary, 1995). We define social exclusion as a perceived deficit in belongingness.

Oh, belongingness. Joiner has something to say about that:

The theory posits that serious suicidal behavior will not occur unless an individual has both the desire to commit suicide and the ability to do so. Two factors contribute to an individual’s desire for suicide, a thwarted sense of belongingness and a sense of perceived burdensomeness on others, while the ability to commit suicide can be acquired over time through habituation to the physical and mental pain involved in self-injury.

I have been cut off from a place in society. The mental image I have is the astronaut in 2001 whose oxygen line has been snipped by HAL, the malign robot. At least the astronaut suffocates quickly in the absolute freezing void of space. His awareness of his predicament is full, but brief.

Not so the ostracized, who have to find their way in a hostile wilderness which is incompatible with life. I am out of place everywhere. There is no place to escape to. There is no respite.

In my everyday world, I go places to kill time. To use up the eternal isolation. To go just for the sake of movement. There is no reason for a journey. There is no destination. I try to keep everything out of focus, like looking sideways out a car window, because any conscious realization of my plight is too excruciating to bear, even for a moment. Time has no meaning. There are no holidays, anniversaries, birthdays, wedding, births, deaths, or special events by which to measure life. There is no quality of life. Everything adds up to zero. It is exhausting purposeless, meaningless, hamster wheel work, which is unending.

The psychiatrist conflated psychological assessment with treatment (not just her – I have found this with all mental health providers across disciplines), and I find this in the literature, as well. Assessment of depression, chronic severe insomnia and suicidal ideation is intrusive and painful, and yet, that is the extent of what she did at each visit. I had nothing else to share. My story was invalidated by diagnosing it as delusional. I will not refer to it again. It is not able to be heard by anyone. And I don’t want to cause anyone distress, which this obviously does.

It reminds me of times when people who knew what was happening to me would turn away when they saw me, lest they be seen with me and thus perceived as being at risk for ostracism themselves. There’s nothing like having people literally run from you to bring home how your life is destroyed.

She asked me what I was reading, but I’d reported to her my increasingly and consistently poor ability to comprehend, let alone, remember what I’ve read. I no longer read anything longer than a headline. Culling the literature for this blog post is taking me an extraordinarily long time. It probably reads as disjointed and not terribly well-reasoned. My cognitive ability and memory stink, to use the technical term. Yet, I can’t distinguish whether my nonstop efforts to keep everything out of focus, and so to minimize the consciousness of my predicament is the cause of my ever worsening cognition or just an effect of ongoing isolation.

Except for the visits to the psychiatrist, I have not had a single substantive conversation with another person for many years. And I wouldn’t really call the content of the visits conversation. In reality, I was always on tenterhooks trying to not evince distress, lest she decide to forcibly treat me.

I’ve lost the ability to have a social conversation. I can’t relate to others because I have no social commonalities – no family experiences, no contacts with people considered friends, no work role, no social role – nothing on which to any longer identify with others. When I was still trying to regain involvement via volunteering, as soon as someone got a whiff of my isolation via lack of those connections, they would abruptly cut off the conversation. I never heard from any of them again. The psychiatrist had been told this repeatedly when she poked and prodded into why I no longer sought outside activities. That amounted to self punishment. It’s painful to be rebuffed and excluded over and over and over. I am a slow learner, but I finally got the lesson: in order to avoid inflicting pain on myself, do not try to go where you are not welcome. That would be everywhere.

But she did it herself. She’s in a position in which, if she were to go out of role, granted, she could have provided me networking referrals to jobs.

But of course, she didn’t. Boundaries, you know. I was an assigned case, a cluster of pathological symptoms. Not a person, not someone with advanced education and related professional experience, not even a plain old person. She made two specific suggestions about how she saw me being able to contribute: to serve as a personal care attendant (adult baby sitter and butt wiper) or as a pet sitter. As if that wasn’t confirmation of my deemed worthlessness. Early on I had given her a copy of my vitae, and to her credit, she read what I had offered to her via a sample of my writing and the Alford article referenced here. And I don’t believe that she conducted therapy as a rule. I’m pretty sure I was an exception and guess that she primarily practiced psychopharmacology along with her administrative duties.

In my medical record, it turns out that her sole treatment goal for me was to keep me “in the realm of suicidal ideation. Dx: existential despair, but no worse than usual.” And that was the most positive thing written in my entire medical record. How is that compatible with life?

Stupid me. If I had gotten my records earlier, I could have saved myself the repeated distress of being “clinically assessed” (read psychologically debrided without anesthesia with wounds left gaping) and left to try to forget until the next session of torture and tell.

In my world, no one returns phone calls and emails. I received a total of 6 pieces of US mail last year (not addressed to “or resident”) – all from organizations requiring paperwork and none from individuals or anyone who knows me personally. I used to keep NPR on to hear reasonable, non-violent human voices. But I finally stopped because I often couldn’t follow the patter and it became just more intrusive and irritating noise. Now I just keep a fan running to drown out gunshot season – any loud abrupt noise especially during open window weather. I exist in a noisy world but with more silence than a monastery.

I can’t get any enjoyment out of any experience. Food tastes like nothing. Everything is a tone of grey and shadow. Aromas that in the past evoked pleasant memories are undetectable, and most aromas smell foul. Music is just notes, too loud and evoking nothing. People are nothing but harbingers of pain and dread. No one has voluntarily touched me except to perform medical procedures using my body as just an object, such as blood drawing and injecting a joint, in many years. I know better than to reach out a hand or to offer a pat on the shoulder. It would most decidedly not be welcomed.

There is no reason to prolong this, but my attempts at providing my own euthanasia failed. The LD50’s weren’t enough, and I don’t have the means to provide myself with a peaceful and painless death. I’ve come to realize that a painful death is preferable to this unending dying.

Ostracism means that there is no burden to anyone. Society has already unburdened itself of me.

Ostracism is a death sentence, and every person who knows that it’s been imposed on someone and yet who does not intervene, is a member of that judge and jury.

I can’t stand the notion that the rest of my natural lifespan is going to be spent in this wholly silent, totally isolated and destitute way of existing. It’s enforced insanity. The conditions explain why most whistle blowers get sick and die early.

ResearchBlogging.org

Alford, C. Fred (2007). Whistle-blower narratives: the experience of choiceless choice Social Science, Volume 74 (1), 223-248

Smart Richman, L., & Leary, M. (2009). Reactions to discrimination, stigmatization, ostracism, and other forms of interpersonal rejection: A multimotive model. Psychological Review, 116 (2), 365-383 DOI: 10.1037/a0015250

Stillman, T., Baumeister, R., Lambert, N., Crescioni, A., DeWall, C., & Fincham, F. (2009). Alone and without purpose: Life loses meaning following social exclusion Journal of Experimental Social Psychology, 45 (4), 686-694 DOI: 10.1016/j.jesp.2009.03.007

Van Orden, K., Merrill, K., & Joiner Jr., T. (2005). Interpersonal-Psychological Precursors to Suicidal Behavior: A Theory of Attempted and Completed Suicide Current Psychiatry Reviews, 1 (2), 187-196 DOI: 10.2174/1573400054065541

Williams, Kipling D (2001). Ostracism: The Power of Silence 2001 Other: 1572306890

Why, oh why

Annalaw, this one’s for you:

First – here’s the email I tried to send to you, but which aol rejected:
Thanks for allowing me to contact you off the blog.  And again, many thanks for your comments, insight and support.  They have meant a great deal to me!
I’m sorry that I didn’t turn out to be who you’d hoped, but I’m grateful that you stuck around, anyway.  It sounds as if you have a pretty rough row to hoe, too, and I hope you find some competent and compassionate people to help you do that.
I don’t know if my blog content or my comments on other WordPress blogs were flagged, but WordPress has censored me on all of its sites.  The reason you didn’t see me commenting is that they all disappeared into the ether.  I didn’t realize what was happening for awhile.
The only blog I still comment on is 1 boring old man. (update – read below for a revised view) He was kind enough to fish my comments out of spam and somehow keep them viewable.  I’ve also corresponded with Dr. Nardo via email a few times.  He has been polite, but he’s has also been clear that he is not interested in my perspective on things.  He did not visit the blog again after leaving an initial comment there. He doesn’t acknowledge my comments on his blog, either.
I also comment on a few pieces at the NY Times under aek, but lately, those have been censored, too.  Prior to the current blogs, I used to blog every day (links to the rehomed content are included in the most recent 1boringoldman comment), mostly on professional nursing issues and health policy.  Got me a group of cyberstalkers (nurses, physicians and even an EMT), and then homelessness and a fall into the psych system intervened. I had tried to use blogging to build writing skills, network and possibly find freelance writing jobs.  Failed on all counts.
Because my sleep is so poor and chronic pain is worsening, I have a lot of days where I cannot think clearly and so do not write or respond.  I apologize for these silences, but it’s physically impossible. And on other days, I’m so pathetically incompetent that I can’t think of a single thing to write…
At any rate, that’s why I would prefer not to continue to shuttle comments on the blog.  I’ll leave everything intact, though, and I still occasionally add to the reading list.
Best-
Annie (my name – the email addy is a Columbia alumni one)
Yesterday, shortly after I commented on Mickey Nardo’s 1 boringoldman blog, this arrived in my email:

Dr. Spitzer apologizes to patients for a mistake. Dr. Frances ends with “and of course most important to our patients” and I’m making a plea for scientific integrity. Do you really think this blog deserves your comments based on that last sentence – which is directed to the DSM-5 Task Force asking them to set a strong example for the profession? Something we surely need.  Do you actually think this blog has “patients consistently absent”? Is this blog as example of a “predatory bankster” mentality?

I published it. And I’m responding privately because I don’t fight in comments. But I just wanted to say that I think you ought to think before you ink. You told me once before that was a problem. You were right. I’d appreciate your keeping your comments on this blog limited to things about this blog or its topics rather than seeing it as a billboard.

For the record, I do care about “our morale, our reputation, and our future.” Yours too…

Mickey Nardo

I was shocked. And I responded in kind, sad to say:

Dear Dr. Nardo:

Without actions that underlie them, the examples you cite are empty words. Where is harm mitigation?  Harm prevention?
I apologize for writing in a way that conflated my opinion of the state of extant organized psychiatry with your personal views and those expressed in your blog.  That was not my intent.
In a previous comment, I searched out links to several posts I had written several years previously about some fundamental issues in professional nursing that appear to have some degree of applicability to organized psychiatry.  I gave a great deal of thought to writing that. I now understand why you did not acknowledge it.
My morale, reputation, future?  Surely you jest.
It is your blog; I don’t quibble with your right to moderate comments.
I appreciate you sharing your dislike for me so that I won’t subject myself to it again, and you and your readers won’t be further tainted.
However, after thinking on this, he did me a favor.  He himself tore the curtain away from the great and (self-portrayed) compassionate Oz/psychoanalytic academic wannabe psychiatrist.
It’s not for nuthin’ that he hasn’t acknowledged your or altostrata’s comments since they both mentioned me.  He’ll just let people think I’m the one choosing silence.  He’s all wise, all knowing, all cult leader all the time.

I have a huge problem with trust. He knew that, and he still did this. In a nutshell (punny), that’s my meta issue with psychiatry. It’s dishonest at its core.

And it’s why there is no professional engagement here or anywhere else I post where mental health practitioners appear. And so, I’m done with blogging about issues which will never be addressed in any extant venue.

Housekeeping: I took the blog private, and you are the sole invitee. I’m happy to swap off to email if we can figure out how to make that work – and of course, it works for you.

Best-

That’s all, folks

I’ve scoured the interwebs and continue to come up empty.  Suffice to say that the US is a predatory, brutal place with a societal culture that promotes predation.  As someone who was committed to patient advocacy, and yet failing miserably when I needed and sought help, I don’t want to lead others on a wild goose chase predicated on false hope and foolish optimism.  Those lead to betrayal, failure and more suffering.

That, in all of this medical mecca town, not a single psychiatrist, psychologist, psychiatric social worker or academic program offers any effective care and treatment to reduce unbearable psychological distress, nor is interested in doing so, speaks for itself.

That no one is interested on this blog or any other in discussing approaches or treatment alternatives sends a clear message.

Only I can find a place on the interwebs where no one else resides and Google turns up no results. WordPress putting all of my blog posts and comments on other WP blogs into spam was also a large factor in stopping.

In how many ways can one be ostracized?  I’ve lost count.  But I also just don’t give a damn anymore. They’ve got me where they want me – disappeared so as not to ugly up the place.

For the all one person (annalaw, that would be you) who read and commented, I am very grateful and appreciative.  I wish you the best in your quest for minimally acceptable care.

The reading list will remain in its messy, disorganized place.

And I will remain in this living hell until I can get myself euthanized and catch up to the social death.

Dogs that do not bark: ostracism, psychache and suicidality

The Way Out, or Suicidal Ideation: George Grie...

The Way Out, or Suicidal Ideation: George Grie, 2007. (Photo credit: Wikipedia)

1 boring old man referenced this historical and alarming analysis on the evolution of melancholia to major depressive disorder.  Science?  Evidence?  Fuggediboudit.

MDD, the most influential diagnosis of the past 30 years, emerged from intraprofessional pressures and the ability of research-oriented psychiatrists to gain dominance within the profession. Most importantly, psychiatry needed a credible classificatory scheme to maintain its legitimacy in both the broader medical profession and the culture at large. As prominent depression specialist Gerald Klerman (1984:539) succinctly summarized: “The decision of the APA first to develop DSM-III and then to promulgate its use represents a significant reaffirmation on the part of American psychiatry to its medical identity and to its commitment to scientific medicine.” Medical legitimacy required easily measurable and reliable diagnoses. The diagnostic criteria grounded in the Feighner measure that emerged in the DSM-III to resolve the many unsettled diagnostic controversies—and that have remained mostly unchanged until the present—did produce a far more reliable system of measurement than the amorphous criteria they replaced. Yet, this particular diagnostic system was not tested against the many alternative classifications that were available during the 1970s that might have been as good or even superior to the Feighner criteria. Instead, their adoption resulted from the shared commitment to a view of psychiatric diagnoses and the path that the psychiatric profession should follow among the research-oriented psychiatrists who controlled the development of the DSM-III classifications.

The developers of the MDD diagnosis did not foresee the profound consequences it would have. They inadvertently developed criteria that encompassed what had previously been viewed as a number of distinct types of depressive conditions. Endogenous, exogenous, and neurotic forms of depression could all meet the expansive criteria of the MDD diagnosis. Moreover, because it could incorporate short-lived responses to stressful conditions, MDD was the most suitable label for many of the heterogeneous and diffuse complaints that many primary medical care patients present. Likewise, depression became the most prevalent form of mental illness measured in epidemiological studies because so many community members suffer from common symptoms such as sadness, sleep and appetite difficulties, and fatigue that need only last for a two-week period to be considered disordered (Kessler et al. 2005). The sweeping qualities of the diagnosis also made it the most attractive target for the vastly popular SSRI medications that came on the market a few years after the publication of the DSM-III. Primarily through pharmaceutical advertisements, ubiquitous messages associated the most common forms of distress with major depression. This condition became psychiatry’s most marketable diagnosis, driving mental health treatment, research, and policy. Ultimately, the Age of Depression that has engulfed the United States and much of the Western world since 1980 resulted from relatively esoteric changes in diagnostic criteria.

It’s all about c.v. building by a chief resident of a backwater psychiatry program.

Then there’s this – relational ostracism – an unwanted enforced state of thwarted belonging.  It can take many forms, and its effects are severe, persistent and devastating.

The impact of stranger-ostracism is strong and painful,and has been shown to lead to aversive psychological responses (i.e., a threat to four primary human needs—belonging, control, self-esteem, and meaningful existence; see Williams, 2001), and a rangeof detrimental behavioral responses such as social susceptibility (e.g., Maner, et al., Carter-Sowell & Williams, 2007), inappropriate mate choice (e.g., Winten et al., 2006), risk-taking behavior (e.g. Daleet al., 2006), and anti-social behavior (e.g., Warburton, Williams, & Cairns, 2006).Despite the prevalence of ostracism in interpersonal relationships, ostracism research to date has not systematically investigated relational ostracism (i.e., the silent treatment, or ostracism carried out by one partner on another).

What’s missing in both of the above?  Their relationship to suicidality and psychache.

There is such a dearth of literature about ostracism – and virtually none about clinical intervention, treatment and support for people who are targets – that it isn’t surprising to find it absent.

But Kipling Williams, Thomas Joiner and C Fred Alford’s work can form a pillar by which to build a clinical and research model to aggressively address unbearable psychache, develop strategies (which may include public health and social justice policy and programming) to minimize and remove ostracism in all of its ugly forms, and to reformulate how suicidality is assessed and addressed.

The highest priority items for me would be to deep six “suicide assessment” in favor of distressors as described by Joiner’s three domains of perceived burdensomeness, thwarted belongingness and the capacity/rehearsal to tolerate self-inflicted death.

The second is to couple all assessment with immediate and adequate distress reduction which does not entail threats of or actual involuntary confinement, intrusive observation, forced medication, any type of restraint or anything other than active multi-sensory comfort, safety and mutually deemed appropriate and acceptable interventions, resources and supports.

One more thing that is never addressed in relation to psychache:  the extraordinary amount of physical and psychological energy toll it takes.  The relational ostracism study illustrates that for many, being a target is permanent as long as the “source” is present.

When one is powerless to escape ostracism, has no ability to affect a preferred future, and is effectively trapped, suicide becomes more salient as an alternative to put a permanent ending on an intolerable condition.

Here I discovered a study about people with severe/terminal illnesses who wish to hasten death – WTHD. Of course it doesn’t include people with psychiatric diagnoses (those people are nuts, donchaknow), but it fits right in with Joiner’s theory:

WTHD as a way of ending suffering

Among participants in the studies included, the WTHD also emerged as a way out, and in some cases [45][69] as the only way of ending their physical and psychological suffering. Death was not considered as an aim in itself, but rather as an escape. Indeed, the idea of putting an end to their life brought a sense of relief to some patients.

In the study by Schroepfer [71] the WTHD was regarded as a way out or as a means of relieving loneliness, fear, dependence, a lack of hope and the feeling that life was no longer enjoyable. The study by Nissim et al.[69] suggested that in the face of oppression and despair, death could be seen as the only alternative, with the WTHD being the essence of a plan to relieve suffering. Similarly, Lavery et al. [45] reported that the WTHD was seen by participants as a means of limiting disintegration and loss of self.

In five of the studies reviewed [14][46][69][70][71] the participants also described the WTHD as a way of reducing the suffering being caused to family and carers. Coyle and Sculco [14] interpret this as a gesture of altruism, since the WTHD is motivated by a desire to relieve the family of the burden of care and of witnessing their relative’s progressive deterioration. However, although the WTHD was driven by such a motive in some patients [71], in others (or simultaneously in the former patients) the desire to cause no more pain to their relatives led them to precisely the opposite conclusion, i.e. they repressed the WTHD. As such, their wish to protect their family took precedence over their own wish to hasten death [71].

And so we circle around to Alford’s “knowledge as disaster” concepts. See the About page for a listing.

Until the key elements of this circl(ing the drain) are interrupted permanently and predictably, suicidality will go on unabated, unaddressed and just as vicious.

The strangest part?  Psychiatry, with all of its disorders, doesn’t ever mention suicidality, psychache, thwarted belongingness, perceived burdensomeness and rehearsed capacity for self-inflicted death.

But suicide is on the Diagnosis and Statistical Manual of Mental Disorders (DSM5) radar – and of course, its proposed listing as suicide behavior disorder is nonsensical and is made up à la the Mad Hatter.

Poverty of Thought

Steve Balt wrote a post about some of his take-away thoughts from the American Psychiatric Association conference.

Commenters responded with thoughtful, illuminating insights about the gestalt of extant American psychiatry.  I was gratified to read that David Healy‘s Pharmageddon book is being cited as important.  He emphasized understanding the history of how capitalistic forces have emerged as the predominant force in shaping psychiatry and in shaping policies and practices which directly affect patient treatment (I refuse to use the word, care, relative to psychiatry and mental illness treatment, because it has specific meaning in the helping professions, and it is absent here.) and patient outcomes.

Steve’s post and your response, along with Emily Deans’ highlights a type of “poverty of thought” rampant in organized psychiatry. One cannot successfully treat people without the people. The old adage, “the surgery was successful but the patient died,” is apt for this field, too.

From assessment – how do you know you’re asking the right, germane, and appropriate questions? (glaring example: asking patients about suicide plans instead of about intolerable psychache and unbearable distressors. The first results in patients’ loss of civil rights and incarceration/observation, etc., the second SHOULD result in an urgent/emergent treatment intervention to lower the levels of immediate distress and to devise a treatment plan to reduce/eliminate the causative distressors. But that would mean knowing the patient, his living conditions and intervening where social justice is required. Ew. Messy. Takes longer than writing a prescription.)

To patient relationships – currently based on legal coercion, deception, and adverserial threat

To treatment – psychotropic medication, invasive surgery, inducing seizures and electrical stimulation, plus a dollop of who-knows-what talk therapy

To outcome goals – treatment adherence (do patients name their goals of being that of treatment adherence? /derisive snorting) which are unrelated to patients’ perceptions and functions in quality of life

Everything. Everything is oriented toward the psychiatrist. These are psychiatrists‘ interests at work. Patients are simply objects upon which to act, and are the means toward psychiatrists’ rewards: professional reimbursement, the source of research funds, the means to publication, and fodder for career recognition and success.

It’s Alice down the rabbit hole or through the looking glass.

It’s wrong.

But that it’s making more psychiatrists increasingly uneasy and uncomfortable is a good thing.  Eventually, that uneasiness will increase until it becomes an unbearable, distressing force, and action will become inevitable, if not impulsive. (Yes, I’m making a sarcastic swipe at extant suicide risk assessment, but I’m not going to advocate for incarcerating the poor psychiatric victims – in this case, the psychiatrists.  Maybe a little cognitive behavioral therapy so that they can recognize their distorted thoughts, and a round of ECT to jolt them out of their depression about their situation…)

Intentional Complications

Empty suit

Because THAT helps to explain this:  the fundamental devolution of the practice of medicine, psychiatry and nursing with the concomitant declining health and welfare of the citizenry in the US.

Truth?  Whose truth?

Branding?

Market share?

Global leadership?

Cui bono?

Harvard.

Controlling healthcare costs

Despite trying to engage in distractions and diversions during every waking moment and engaging in supposedly cognitive and memory stimulating reading (I can’t concentrate, can’t comprehend and can’t retain much info, so consider everything I write with a healthy dose of skepticism), I am increasingly experiencing noticeable memory lapses and episodes of confusion.  The memory lapses are annoying and disheartening.  The confusion is frightening.  Because no one was interested in learning about those problems and instantly dismissed them as “due to the depression”, I am left to my own devices to manage them. Enter Google.  There are self-assessment tools which purport to distinguish between dementia and depression in memory loss.  I tried them out and came away with a 100% alignment with depression.  However, these tools, and the physician feedback I received, conflated correlation with causation.  The real answer is that no one knows. After a winter of experiencing much more back and joint pain, the inability to self-plan and perform even a basic yoga practice, and a months long stretch of not leaving the bed except for bodily functions needs, I find myself so fatigued, dull, and slow that forcing myself to stay alert, attentive and mobile is a monumental task.  And really, since I do not have any obligations to work, socialize or contribute in any way, no one cares or is affected, which brings me a perverse sense of relief of not failing anyone.  When all of society yanks those away and sends you off to a life of dying and social death, this apparently is the benefit. (For all of you psychiatrists who found your “EBM” on that most medically scientific principle of false hope and optimism serving as a default component of “insight”, this is it for optimism and flexible thinking.  Insight I’ve got in spades.) I have struggled to attend scheduled volunteer activities.  But I think I am bringing a poor benefit/risk ratio to the organization.  I can’t perform much of the physical work, and sometimes I can’t remember the very simple instructions to carry it out. The people I’ve met are seriously smart, wise, witty, knowledgeable and committed to the goals and work.  The leaders lead well (coming from me, that’s the equivalent of the Nobel Peace Prize).  Two of these people are dealing with immediate end of life issues, and I try to be a reliable and comforting presence.  That, at least, I can offer and carry out. So back to self management.  I started looking around again for resources and strategies to try.  Because I root around in PubMed, am located in a city where a vast amount of clinical research is occurring, and have a sense of what I need in the way of outcomes, I called the HMO and asked to speak with the mental health case manager.  The marketing and sales people weren’t happy with that.  The person I spoke with was sullen and only after repeated requests and my refusal to give her clinical info was I transferred.  And I got the same woman who when I first called to find a psychologist with expertise in both PTSD/trauma and depression gave me four names where either the person was no longer in the plan or was outside my ability to travel. When I called to report this and ask for appropriate options, she became belligerant and defensive, and so I ended the call since I had already been through the provider list and discovered that there weren’t any at all who met the above criteria. This time, I asked her if she knew of any research or clinicians who dealt with ketamine for severe depression, or with rapid responses to severe depression.  She started in on the spiel that it wouldn’t be paid – it was experimental.  After a few minutes of this abuse – no referrals, no answer,  I told her I’d had enough and hung up. Ten minutes later the police were at my door.  Luckily, my computer screen was on and open to the complaint and disenrollment line, the coffee pot was full, and no weapons were    in sight (that last one is a joke).  The sergeant grilled me about what I had said that “would make her call”.  I explained about inquiring about the ketamine research.  I offered him the phone number to call the woman.  He couldn’t get past the telephony.  I had to sign a form declining emergency transport to the ED. The officers declined coffee, inquired as to the rent I pay for this attic dump, rolled their eyes at the response, and then changed the conversation to “we have to do our jobs.” I replied that experiencing public humiliation (lovely lights, multiple police cars and ambulance in the drive and street) and terror (nothing like having 5 uniformed and armed men on your doorstep banging on the door and demanding to be let in.  NOW.) was obviously what the HMO’s objective was, and they agreed. Which is just the latest experience which illustrates why I still have no health support, no trusting relationship with anyone, and no hope of finding same. What I ended up doing was perusing the research studies for chronic pain and finding several that are non-pharmacologic and low risk to enroll in. I was assigned to the treatment arm of two, and two more are simply looking at different biomarkers and immune responses.  I’m an easy stick, so I’m happy to donate a little serum to that cause.  However, one study requires a combo PET/MRI along with an arterial lineinsertion.  Having been on the managing end of those before as a critical care nurse, I think receiving one (they are uncomfortable at best) is a dose of my own former medicine. I wasn’t permitted to disenroll from the HMO.  The abusive case manager is still a “valued employee”, and I effectively have no health insurance, because there I will not provide any information to, use any provider affiliated with, or voluntarily use any aspect of that HMO’s products and services.  They really have the keeping costs controlled portion covered.  Abuse, terrify and threaten enrollees, collect their premiums and watch the profit margin soar. And the research compensation (for “subject “expenses”) will pay for dental and vision exams.  At least those don’t come with threats of imprisonment and assault and battery. (Optimism and hope, psychiatrists.)

Substitutions

I follow food and nutrition science to some extent.  This caught my attention:

It’s been a profitable venture for the drug companies, as well as for the professors and their universities. Agriculture schools increasingly depend on the industry for research grants, a sizable portion of which cover overhead and administrative costs. And many professors now add to their personal bank accounts by working for the companies as consultants and speakers. More than two-thirds of animal scientists reported in a 2005 survey that they had received money from industry in the previous five years.

Yet unlike a growing number of medical schools around the country, where administrators have recently tightened rules to better police their faculty’s ties to pharmaceutical companies, the schools of agriculture have largely rejected critics’ concerns about industry cash. Administrators have set few limits on how much corporate money agricultural professors can accept. Faculty work with industry is governed by confidentiality rules that veil it from public view.

In certain ways, the close relationship between animal scientists and pharmaceutical companies has never served the public well. Few animal scientists have been interested in looking at what harm the livestock drugs may be causing to the cattle, the environment, or the people eating the meat. They’ve left most of that work to scientists outside of agriculture, consumer groups, and others who take interest.

But with the introduction of Zilmax, the situation may have reached a tipping point. Critics say some academic animal scientists have become so closely tied to the drug companies that they may be working more in the companies’ interests than in those of farmers and ranchers—the very groups that land-grant universities were created to serve.

Substitute patient for beef cattle and psychiatrist/primary care physician for animal scientist and voila! Patients growing enormous and iatrogenically ill and diseased on second generation antipsychotics, and their physicians so entangled with pharma and medical device industries that they fail to serve patients’ interests.

The Chronicle of Higher Education isn’t usually where I find in depth whistle-blower investigative reporting.  Read the entire article.  It will (or should) make your hair stand on end.

Ethics and malfeasance, anyone?

Social contract. In pieces.

Letters to Children and Other Juveniles

A little while ago, I dropped in at one of the many libraries in the area that sell books and ephemera.  A nondescript thin unmarked cover demanded closer inspection. In muted gold script, the title emerged, Letters to Children by Beatrix Potter, Harvard University Press.

Inside were several otherwise unpublished tales embedded in very kind and respectful letters to children that Potter had written.  Like another favorite author, Madeleine L’Engle, she was careful to get out of her own way and write of salience and thought-provoking ethics which all ages could enjoy and take away the gifts of essence.

It occurred to me that the ever louder and defensive whining tales of woe coming from self-proclaimed “good” psychiatrists might benefit from a session or two with Potter’s and L’Engle’s stories.

Here are some of the take aways for them:

1. Who is the subject of the tale?  Patients (others) or self (psychiatry and psychiatrists)

2. Who is the hero? See #1

3. Who and what constitutes the villain?  Patients, insurers, third party reimbursers, employers (hospitals, institutions, jails, prisons, lawyers, universities, patients), laws, regulations, society, colleagues, non-psychiatrists health professionals

4. What needs to happen for the hero to triumph? Patient compliance, better financial renumeration, more professional power, greater professional autonomy, more prestige (all this assumes psychiatry is the hero)?  Or in the case of patient as hero, recovery, respect, successful societal integration, independence, personal autonomy, belonging, self-efficacy, prestige, greater financial renumeration?

5. What are the dangers interfering with hero triumph? What are the resources the hero brings to bear on the dangers?

OK, so with that in mind, have fun re-reading your childhood favorites.  And take a gander at two recent posts penned by psychiatrists who define themselves as “good guys”, but do not specify exactly what that means for readers. The Steve twins – Drs. Moffic and Balt, have a go and try to engage with commenters who self identify primarily as people who had experiences as psychiatric patients and family of psychiatric patients. Refer to the list above and see if you can’t help them out in their obvious confusion and self-contradictions.

Hint: psychiatry’s subject is supposed to be patient well-being and health derived from a respectful and trust-based relationship with patients

 

Riffing off A Powerful Message

A week’s worth of (medicated) sleep, and my noggin can at least process a few thoughts, here and there. 1 boring old man published an important post titled, A Powerful Message.  He chronicled the increasing clamor of psychiatry to use a neural circuitry model as evidence of psychopathologic causality and therefore an avenue for research and treatment.  I had noticed this, too, with increasing alarm and a sense of deja vu. I yammered a bit in a comment:

As a long time critical care nurse and educator, I witnessed an enormous transition in thinking about the care and treatment of myocardial infarctions (heart attacks). Care and treatment initially and historically was focused on complete bed rest and inactivity – up to and including only allowing room temperature food and drink lest cold irritate the vagus nerve. As the plumbing and electrical circuitry interface with the muscle stimulation and perfusion became more well known, treatments became more aggressive – getting patients up and moving right away, reperfusing coronary arteries and stenting them, ablating lesions, etc. Then the focus spotlighted statin use for prevention, concomitant with pharma DTC advertising and KOLs. Only recently has any of this been questioned, and lo and behold, stenting and preventive statin use may not do anything at all in terms of disease prevention.

Not for nuthin’ has clinical depression been found to coexist and correlate with heightened morbidity and mortality with of heart disease.

Patient stays in critical care units for heart attacks (MIs) went from 7-10 days to 1-2. Of course, patient education, diet teaching, stress management, socioeconomic assessment went out the window. In other words, self management and quality of life factors were ignored and abandoned. Patients are sent home with prescriptions, stents, pacemakers, automatic internal defibrillators and all manner of coronary hardware, and sometimes followup appointments. They are not linked to case managers, community resources and psychosocial supports.

The forces of capitalism, free markets and decreasing corporate regulation have converged to erode worker protections, environmental protections, food safety, community development (corporations receiving tax breaks, outsourcing jobs to other countries and pulling up stakes, leaving communities dying on the vine), and overall, contributing to the deterioration of social life and community throughout the US.  Vicious and poisonous politics have contaminated the well of civil discourse.

Whither health and well-being?

Here, my collegiate roots show.  Case Western Reserve University’s Frances Payne Bolton School of Nursing and the Department of Nursing Education, Teachers College, Columbia University, both were founded on the critically important work of nurses who established, grew, and nurtured public health and psychiatric nursing theory and practice.  My education was based on the principles and practices of Lillian Wald, Hildegard Peplau, Virginia Henderson, Isabel Hampton Robb (yes, the Robbs of Johns Hopkins and later, Lakeside Hospital of Case Western Reserve – this hospital was noted by Flexner in his famous Report on Medical Education, for serving as an exemplar), and Mary Adams, pioneer in gerontologic nursing and later a Dean at her home state, South Dakota’s State University School of Nursing.  These names will mean nothing to almost all members of the public, physicians, and sorry to say, nurses.

But I hope you’ll click on the links because their work has critical importance and influence on the individual, family and community health and well-being of Americans today. What you will see is their universal concern with the immediate and larger social and community environments which affect health and well-being of the targeted patient populations.

Physicians, nurses and indeed, all members of the (licensed, ergo, regulated) helping professions have an obligation to address, influence and lead policy and programming which are congruent with and supportive of a healthy environment and social life.  Those include wages which allow adults to work a single job and provide for safe shelter, clean water and air, nutritious fresh whole foods, reliable transportation, access to education and natural recreational facilities and adequate protective clothing for themselves and dependents.  It means assuring clean air and potable water.  It means assuring access for all to basic communicable disease prevention: vaccines, safe food, zoonoses prevention.  It means worker protections which promote tolerable physical and psychological stress levels.  It means protections for whistleblowers – rewarding workers for upholding ethical business, research and professional ethics.  It means promoting civil discourse and discouraging ostracism – whether that be racism, bullying, intimidation or any other type of behavior which is exclusionary.

Embracing the classical virtues and publicly upholding the inherent worth of every person will lead more to health and well-being than any pill, potion, invasive treatment or state of the art assessment tool.

The bottom line:  Each and every member of a helping profession by the social contract is an agent for social change.  Without that, patient treatment is devoid of care. And treatment will only palliate and blunt symptoms, rather than address disease and distress causality. Futile, impotent and, ultimately, destructive. Like this, perhaps:

Chasing Tails

Thomas Joiner’s interpersonal theory of suicide is one I refer to often here.  However, even he doesn’t move upstream to look at distress causality.  Exhibit the last:

J Psychiatr Res. 2012 Apr 2. [Epub ahead of print]

Behaviorally-indexed distress tolerance and suicidality.

Source

Military Suicide Research Consortium, United States.

Abstract

Research indicates that distress tolerance exhibits a complicated relationship with risk factors for suicidal behavior. Specifically, low self-reported distress tolerance has been linked to perceived burdensomeness and thwarted belongingness. Contrastingly, high self-reported distress tolerance has been linked to the acquired capability for suicide. Given the frequently discrepant findings between self-report and behavioral indices of distress tolerance, we sought to expand upon prior findings by testing these relationships utilizing a behavioral measure of distress tolerance. Additionally, in an effort to further clarify the role of distress tolerance relative to painful and/or provocative experiences in the acquired capability, we examined whether distress tolerance serves as a moderator. Results revealed no significant associations between distress tolerance and burdensomeness or belongingness; however, distress tolerance was positively associated with the acquired capability. Furthermore, the interaction of distress tolerance and painful and/or provocative experiences significantly predicted the acquired capability, with the strength of the association increasing at higher levels of distress tolerance. Results highlight the potential importance of perceived versus actual ability to tolerate distress with respect to suicidal desire. In contrast, the results reflect the importance of actual persistence in the acquired capability.

Sidetrackings

Update:  I found this Berenice Abbott photo of  a NY railroad in the Met’s online collection, so you get an added treat.  If you aren’t familiar with Abbott’s work, consider this an invitation to “meet” her.

Today’s press release:  obesity accounts for 21% total US healthcare spending.

The Cornell study reports that an incurs medical costs that are $2,741 higher (in 2005 dollars) than if they were not obese. Nationwide, that translates into $190.2 billion per year, or 20.6 percent of national health expenditures. The study appeared in the January issue of the (31:1). Previous estimates had pegged the cost of obesity at $85.7 billion, or 9.1 percent of national health expenditures.

“Historically we’ve been underestimating the benefit of preventing and reducing obesity,” said lead author John Cawley, professor of policy analysis and management in the College of and professor of economics. “Obesity raises the risk of cancer, stroke, heart attack and diabetes. For any type of surgery, there are complications with anesthesia, with healing [for the obese].”

HT Dr. Grumpy

What does that have to do with addressing suicidality causes?

Many of the distressors associated with psychache have to do with social connectedness.  Social connectedness is intregral in the immediate environment. What comprises a healthy, socially conducive environment?

Natural green spaces: parks, trails, gardens and safe places to experience them.

That means sidewalks, bike trails, cleared paths.

Adequate lighting, places to rest, benches, beaches, tables.

Access to fresh, potable water.

Access to places that provide fresh, whole foods – grocers, restaurants, farmstands, foodtrucks, delivery services – at affordable prices.

Access to educational and entertainment media suitable for all ages, cultures and customs – that would be the public library via walking, bike and public transportation.

Access to clean, fresh air – via public health regulations, and state and federal regulations on pollutants.

See where this is leading?

Back to the pump handle  – public health measures provide the biggest bang for the healthcare buck.  It’s all about making a healthy environment – one which promotes natural interaction by people in a healthful and pleasing environment – the default mode.

If Lillian Wald were here today, she would be doing the very same things she did almost 100 years ago in New York City.

People who are obese are, for them most part, uncomfortable. But they are responding to  a culture of immersion in faulty food cues. Their suffering is largely preventable, and public health is the way to go.  Regulate food producers, marketers and manufacturers. Remove advertising for manufactured food products from TV and print sources.  Invest in public transportation, pedestrian and bicycling infrastructure and services.  Regulate clean air, water and substances pollution.

In the US, it is incredibly difficult to find public places and spaces which encourage natural civil discourse. Culture is built around commerce, and indeed, today, politicians refer to Americans as consumers and not fellow citizens. People speak of “going to the mall, hanging out in bars, and going shopping” much more than any other activity where they would naturally come into contact with others.  There are very few venues in which people can casually meet and interact with others.  Almost all communal gatherings in the US are passive – attending movies, concerts and other events require no interaction or active participation. People remain isolated and alone even among large crowds.

It’s not rocket science – it’s basic humane infrastructure and service.

Cui bono?

I haven’t blogged about meta psychiatry much.  If you are following the unfolding DSM debacle, you may well see the demise of extant US psychiatry (take it away, 1 boring old man). As I responded to Steve Balt’s weasel words excuse-filled post, I believe that psychiatry has broken the social contract. UPDATE: Steve deleted my response and apparently banned me from commenting. In a perverse way, I’m pleased because it validates what I am writing here.)  It deserves to have limits placed on it via licensure restrictions and practice proscriptions. It should be demoted to technician helper status, and it should no longer be viewed as having the right to call itself a medical specialty.  Indeed, psychiatrists should be mandated to practice as physician’s assistants – under the direct supervision and accountability by a physician.

US psychiatry is having a Flexner Report (pdf, but well worth the hassle) moment, and here’s hoping that a modern day Flexner – or committee – will appear, free of conflicts of interest (snort), and raring to delve into every psychiatry department of every medical school, academic medical center and private and public psychiatric facility.

The key question here is who benefits?  In the case of the licensed helping professions, the underlying ethic historically has been that the patient’s interests are first and foremost, and that the helping relationship is one of beneficence.

Well, let’s see:

Are there clear standards of practice and care in psychiatry?

Beyond that of assessment of “symptoms” and socially defined unacceptable and undesirable behaviors (dangerousness, aggression, agitation), and establishing a therapeutic alliance, no there are not.  You will not find any Cochrane meta analyses of psychiatric care demonstrating efficacy, patient cure or higher quality of life, effective palliation or patient satisfaction. There are no medical diagnoses which fall under psychiatry.  Bunches of symptoms labelled arbitrarily with “disorder”, but no biologically-based pathophysiology.  That falls under neurology, or as manifestations of symptoms of endocrine, cardiac and infectious diseases.

What are the drivers of psychiatry?

Sources of reimbursement demand patient diagnoses, even if there is no “disorder” present.  The absence of a pathologic diagnosis means that the psychiatrist will not be paid by a third party.  Ergo, the patient becomes the means to the psychiatrist’s ends. Stigma?  What the hell do they care? Well, actually, distress from stigma is a source of their business.

Practice and professional autonomy.  No one can tell the psychiatrist how to practice.  Indeed, the literature is filled with admonitions for psychiatrists to use their “informed intuition” and “professional judgment.”  There is no difference between this and the practice of quackery.  None.  It’s based on nothing scientific, reproducible and ethical.  Moreover, in using intentionally flowery and obscure terms such as psychoeducation and psychopharmacology, psychiatrists try to make patient education and medication prescription something mysterious, specialized and requiring advanced knowledge and practice. That is deceptive, inaccurate and serves only the psychiatrist’s interests in perpetuating a sham specialty.

How does extant US psychiatry practice benefit patients?

It doesn’t. Patients present seeking help for distressing symptoms – feelings, emotions, perceptions, thinking and behavior which interferes with their perceived quality of life. Alternatively, they present involuntarily when law enforcement becomes involved.

The therapeutic alliance is a dishonest relationship which is presented as one of equals, partnering to address distressing symptoms.  In reality, it is a sham cover for the psychiatrist to retain control and power and to coerce the patient into compliance with the psychiatrist’s ordered treatment.  Many, if not most, medications used by psychiatrists cause iatrogenic harm – up to and including death.  Patients are not routinely warned about these, and so cannot and do not make informed decisions about taking them.  The adverse effects of them are the most common reasons that patients stop taking them, which is entirely their right.

Psychiatric hospital facilities are prisons.  There is no therapeutic benefit to patients.  The routines used in them are designed to maintain power and control over patients by staff, to facilitate custodial functions (eating, hygiene, activity), and to intrusively observe patients/inmates.  Most deny inmates access to fresh air, direct sunlight and nature.  Diets are non-nutritive. Patients are denied visitors, their dignity, and their civil rights.

Most of all, the psychiatrist/patient relationship is judgmental, dehumanizing and designed to keep the patient under the psychiatrist’s “care” on a chronic basis.  The emphasis is on continuity, not cure.

Everything about this is unethical, unprofessional and wrong.

Why write about it here?

People who suffer with suicidality need a place of absolute safety to discuss their feelings of unbearable distress.  They need to be able to speak with someone who is knowledgeable about the distressors and their causes, tolerates having someone else share this distress, and has the capability and professional experience to support and coach them to lower their level of distress to the point that they can then address alleviating the underlying causes.

Patients need to be equal partners in the relationship, and their needs, wants, desires and functional goals should be paramount within the constraints of civil society. (Psychiatry is alone in hosting a forensic subspecialty and working for law enforcement agencies [prisons and jails] as well as serving as for-profit expert witnesses in court trials.)  There should never be a threat of law enforcement involvement as a condition of care.  There should be no threat of involuntary incarceration – forget about calling it hospitalization – it’s no such thing.

In the Reading List, I’ve included some programs and interventions which do this.  But to date, I’ve not found a single licensed provider of any sort who has the above skill set and practices by the stated objectives. And while support groups can be helpful in long term coping and adaptation, I think that acutely distressed people deserve to have competent, capable and non-coercive, humane care.

That care is decidedly not to be found within extant US psychiatry.

Putrid Positivity

Another inconvenient truth about the edict to think positive thoughts as a panacea – thinking is fluid.  Forced positive thinking leads to negative thoughts, and it’s just added mental work for naught.

The bottom line is that positive thinking doesn’t work because, other than for solving math problems, thinking doesn’t work. Or said another way: if not for thought—you’d never be stuck. So why intentionally fill your head with more of what sticks (thoughts), and thwart your own level of performance and contentment?

Therefore, the next time you are tempted to reach for an affirmation, remember: you’re reaching for an illusion, for fool’s gold. You can’t think yourself into peace of mind, competitiveness, resilience, or love. For true positivity—you’ll  never, ever, have to work that hard.

“The only one.”

English: Consequences of whistleblowing, from ...

Update:  NPR just published a compelling story about Mr. Boisjoly, and it includes two audio interviews- one about his whistleblowing and one with his perspective after the fact. Listening to NPR’s Howard Berkes talking With Roger Boisjoly In 1987 is incredibly heartbreaking.

I am ashamed that I have not always intervened to stand with those who stand alone.  Now I am a liability to others.  A pariah is not a help, but just more weight dragging the person farther down the rabbit hole.

Read the NYTimes’ activist obituary, if there is such a thing, and feel just a bit of what this man experienced.

Six months before the space shuttle Challenger exploded over Florida on Jan. 28, 1986, Roger Boisjoly wrote a portentous   memo. He warned that if the weather was too cold, seals connecting sections of the shuttle’s huge rocket boosters could fail. “The result could be a catastrophe of the highest order, loss of human life,” he wrote.

Mr. Boisjoly’s memo was soon made public. He became widely known as a whistle-blower in a federal investigation of the disaster. And though he was hailed for his action by many, he was also made to suffer for it.

Mr. Boisjoly … died in Nephi, Utah, near Provo, on Jan. 6. He was 73. His death was reported only locally at the time. He lived in southwest Utah, in St. George. His wife, Roberta, said he recently learned he had cancer in his colon, kidneys and liver.

But before then he had paid the stiff price often exacted of whistle-blowers. Thiokol cut him off from space work, and he was shunned by colleagues and managers. A former friend warned him, “If you wreck this company, I’m going to put my kids on your doorstep,” Mr. Boisjoly told The Los Angeles Times in 1987.

He had headaches, double-vision and depression, he said. He yelled at his dog and his daughters and skipped church to avoid people. He filed two suits against Thiokol; both were dismissed.

He later said he was sustained by a single gesture of support. Sally Ride, the first American woman in space, hugged him after his appearance before the commission.

“She was the only one,” he said in a whisper to a Newsday reporter in 1988. “The only one.”

His obituary lists family.  I hope they brought him solace and comfort.  Families mostly don’t survive intact. He was only 73.

The sole study (small, Australian) that looked at the health effects of whistle blowing listed 17 of 35 people admitting to suicidality.  The suicide rate couldn’t be ascertained because the study was done in questionnaire format and only used a single sampling. But adverse significant health effects were 100%.

100%

I know – you don’t believe me because you are a GOOD person, and you live in a society with safety nets for this type of thing. But here’s the gist of it:

OBJECTIVE–To examine the response of organizations to “whistleblowing” and the effects on individual whistleblowers. DESIGN–Questionnaire survey of whistleblowers who contacted Whistleblowers Australia after its publicity campaign. SETTING–Australia. SUBJECTS–25 men and 10 women from various occupations who had exposed corruption or danger to the public, or both, from a few months to over 20 years before. RESULTS–All subjects in this non-random sample had suffered adverse consequences. For 29 victimization had started immediately after their first, internal, complaint. Only 17 approached the media. Victimization at work was extensive: dismissal (eight subjects), demotion (10), and resignation or early retirement because of ill health related to victimization (10) were common. Only 10 had a full time job. Long term relationships broke up in seven cases, and 60 of the 77 children of 30 subjects were adversely affected. Twenty nine subjects had a mean of 5.3 stress related symptoms initially, with a mean of 3.6 still present. Fifteen were prescribed long term treatment with drugs which they had not been prescribed before. Seventeen had considered suicide. Income had been reduced by three quarters or more for 14 subjects. Total financial loss was estimated in hundreds of thousands of Australian dollars in 17. Whistleblowers received little or no help from statutory authorities and only a modest amount from workmates. In most cases the corruption and malpractice continued unchanged. CONCLUSION–Although whistleblowing is important in protecting society, the typical organisational response causes severe and longlasting health, financial, and personal problems for whistleblowers and their families. (emphasis throughout is mine)

I know how difficult it is to stand alone and support a person who has been ostracized.  There is real risk to do that.  So like other whistle-blowers, I don’t ask, and I never expect it. Moreover, people will not TOUCH whistle-blowers.  Whistle-blowers are literally toxic. That is why Mr. Boisjoly was so profoundly TOUCHED by Dr. Ride’s gesture.

But, hot damn, Sally Ride stood there and HUGGED him.  In public. If that isn’t a meeting of heroes, I don’t know what is. Funny thing is that she retired from NASA later that year, and in 2002, she was appointed to the Space Shuttle Columbia Accident Investigation Board. Accidents still happened.  Same old boring story – multiple Swiss cheese systems failures because the people advocating for time out and caution were over-ridden by those who gun always for the shareholders’ (lobbyists/politicians and their corporate overlord shareholders) bottom lines.  Sacrifices always have to be made by those who will never come into contact with the bottom feeders liners.

Professor Liam Donaldson, the chief medical officer for England’s National Health System, wrote,

We should “applaud heroes, and hope they are among us, but to base our hope of remedy in ordinary systems on the existence of extraordinary courage is insufficient.”

I’ve pretty much scoured the literature, and no one addresses whistle-blowing, ostracism and suicide.  No one addresses the life ruination, the total and complete losses, and the resultant world goes on while leaving the whistle-blower (and surviving family, if any) in literal limbo.

And really, it’s the perfect crime.  Because it’s like Holmes’ dog that didn’t bark.  No one notices the absence of whistle-blowers.  No one sees them missing in group photos, nor misses their names in employee recognition events, nor has any notion at all about their well-being. Much better than Jimmy Hoffa’s demise with that pesky media and all keeping his name alive and the issues addressed.

Whistle-blowers are disappeared much more cleanly and completely than any CIA black site prison. The torture leaves no mark.