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.

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National Distress Is A National Disgrace

I remember the Tuesday in September.  The morning was crisp, clear and with eye-watering bluest of blue skies.  I had already finished morning barn chores and was in the house having coffee, checking the net and listening to the tee vee.  For the next three hours, I watched the sky overhead where normally the aircraft were in their final landing pattern turnaround to the local metropolis’ airport gradually clear of all thing winged and rotored.  The silence and stillness was ominous and dreadful, even though the sounds of nature could finally be heard as intended.

The US on that day, could have moved forward by examining the hows and whys of terrorism.  It could have held steady on the solid bedrock of tolerance and inclusion, dignity and respect for all.  It could have made conditions permanently inhospitable to terrorism by not condoning and allowing bigotry, bullying and alienation.

But instead, the US was led by the nose in exactly the opposite direction by Dick Cheney, ostensibly the president in deed if not in title, George W Bush who never had a single edifying thought, but instead sought retaliation, retribution and revenge for deeds real and imagined, the Cabinet of fundamentalist Christians and lobbyist-tainted hangers-on – power and control mongers all, a Supreme Court which is firmly Corporatist and devoid of human decency, a media which is commercially bought and paid for to produce “what the viewer wants” – meaning what the viewer watches/reads that leads to advertising revenue, and a willfully ignorant citizenry which indeed paid attention to all of the above and neglected to apply critical thinking and adequate skepticism to the calls for war, violence, national paranoia, suspicion and a (permanent) suspension of the rights guaranteed in the Constitution.

Instead of building a welcoming and open society, we have let it go to wrack and ruin.  Instead of educating thinking productive citizens, we have trained a nation of gullible test takers.  Instead of building on the classical virtues, we have a nation of individuals that don’t know the first thing about voluntary cooperation, collaboration and compassion for the greater good and for our fellow humans.

We could have spent our dollars on research, new technologies, renewable energy, professional growth and development, infrastructure renewal and development and transportation growth.  We could have invested in our citizenry with healthcare, education, healthy-based communities and in the liberal and fine arts.

Instead, we have funded wars, terrorism, global arms, an enormous, off the books contracted spy industry, state-sponsored violence and government disruptions.  We have criminalized mental illness.  We have made prisons the largest growth industry in the US. We have made over one third of Americans too poor to afford necessary health care.  We have turned out a generation of Americans who are ill prepared to be engaged and informed citizens and who do not have the ability to be successful in a trade or profession.  We have neglected everything from the air we breathe to the food we eat, the water we drink to the ground in which our crops are grown.

We have gone from a two party political system to a one party, corporatocracy.  There isn’t any point in voting, as there is no one to vote FOR as a legitimate representative of the constituency.

We are constantly surveilled via cameras, data bases and undisclosed programs and organizations.  We are extolled to “see something, say something”.  Everyone has been made into an out group. We are prompted every day in many ways to be “alert, be aware” and be suspicious of everyone and everything around us.

On this day of reflection, I mourn for the lives lost on September 11, 2001, as well as for all of the lives lost in Iraq, Afghanistan, & Pakistan by both military and civilians.  I mourn for those affected by any act of terrorism.  I mourn for alienated people who react to ostracism with extremism.  I mostly mourn for the loss of the Republic.  Franklin said that it would last only “if you can keep it”.  But none of us did, and it’s gone.

What’s in its place is a worn out shell filled with a people made very weak and seemingly still without a will and the means to try to take it back.

This is a demoralized people, and more and more of its inhabitants are becoming hopeless about it because of their seeming helplessness and the betrayal by those who promised, hope, change, transparency and equality.

And as more citizens are deemed to be burdensome by politicians (failure to extend unemployment, criminalization of homelessness, retrenchment of Medicaid and SCHIP, the general promotion of ostracism), will the national collective perception of thwarted belongingness propel civil unrest or violence?

I bring this up because as the two fundamental conditions for people to choose to act on suicidal ideation, on a large scale, I wonder what actions people might take when these conditions become intolerable to bear. Kip Williams discusses the final phase of ostracism when coping has failed to produce re-inclusion and affiliation as resignation (ostensibly to one’s fate as permanently ostracized – ed).

This is when people who have been ostracized are less helpful and more aggressive to others in general,” he said. “It also increases anger and sadness, and long-term ostracism can result in alienation, depression, helplessness and feelings of unworthiness.”

Williams is trying to better understand how ostracized individuals may be attracted to extreme groups and what might be the reactions of ostracized groups.

“These groups provide members with a sense of belonging, self-worth and control, but they can fuel narrowness, radicalism and intolerance, and perhaps a propensity toward hostility and violence toward others,” he said. “When a person feels ostracized they feel out of control, and aggressive behavior is one way to restore that control. When these individuals come together in a group there can be negative consequences.”

Emotions and Social Behavior

Well, so much for keeping up with blogging.  An unexpected health insult, weeks of bedrest and sequelae of fatigue and brain fog haven’t done me any favors. But whatever, here’s a bit of catch up, even if presented through a dense fog….

Kipling Williams is one of the few researchers who is investigating ostracism.  I want to read his major opus, Ostracism: The Power of Silence, but will have to wait until I can do so in library residence, as it doesn’t circulate. (If you have a copy to lend or re-sell at a bargain, I’d be thrilled.)  The library has it catalogued under social isolation, and in a collection titled emotions and social behavior.

The latter label struck a chord, for what is suicidality but distress signaling (the emotion) which if unaddressed, leads to suicidal attempts (the social behavior)?

So when I start thinking more clearly again, I’ll try to put together some sort of framework for addressing the distress signaling:

  • alienation
  • burdensomeness (perceived)
  • demoralization
  • despair
  • grief (situational)
  • guilt
  • helplessness
  • hopelessness
  • ostracism (externally applied isolation)
  • pessimism
  • powerlessness
  • realism
  • self identity loss – externally removed (loss/denial of social roles)
  • self loathing
  • shame
  • social isolation (as opposed to voluntary avoidance and isolating behavior)
  • thwarted belongingness
  • worthlessness (perceived and externally applied)

To date, no one has studied people who have made suicide attempts or completed suicides to evaluate what behaviors they used to try to adapt to the distressors, what train of events (thoughts, feelings and behaviors) they experienced when the distress wasn’t adequately relieved, and what directly led to the suicidal ideation, the suicidal attempt, and the completed suicides. But at certainly needs must be done in order to treat suicidality upstream – preferably before the suicidality is entertained and certainly before it is acted upon.