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.

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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-

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…)

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

 

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.