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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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.)

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.