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.

What’s therapeutic about that?

The environment about where people are assessed and treated when experiencing a crisis of distress is critical.  Two bloggers recently addressed how much of a difference in help and harm leading to very different outcomes the physical treatment environment made here and here.

A recent post on the Bipolar Advantage blog discusses how to better help people during mental health crises, and proposes that “much of the hostility that [people who are part of the anti-psychiatry movement] have comes from bad experiences when in crisis.” I would absolutely agree.

When John had to enter the hospital a second time two weeks after his first, week-long stay, it was a real struggle to convince him to go because his first experience in the hospital had been such a negative one. I, on the other hand, have only gratitude for the people who helped me during my hospital stay.

It seems to me that mental hospitals could learn a lot about how to handle mental crises from the way general hospitals handle physical emergencies.

Many of the examples included actions by physicians and nurses that escalated and increasingly distressed patients already critically distressed.  In a comment on the Bipolar Advantage post, I summarized the desires of commenters in designing a helpful environment:

  Essential needs:

Dignity protected
Respectful
Family/significant supporters’ unrestricted presence
Advocate present
Comforting
Reassuring
Coaching
Partnering
Truthful and transparent information
Autonomy preserved
Planning for post-crisis self-management
Safe medication administration (right drug, right dose, right route,  right time, affordable, accessible, acceptable)
Tools for successful disease management and healthy living provided

Environment:

Medically therapeutic
Eliminate law enforcement/incarceration/containment aspects
Clear written rules – same as hotel room/gym/spa rules of conduct –         NOT  punitive/control/power-based

Health:

Healthful foods served appealingly: open kitchen
Privacy for rest and sleep
Ability to get sun, green space/nature and fresh air as desired
Meeting rooms and lounges for care, socialization, quiet activities (meditation/exercise/reading/contemplation) and care planning
Clean, attractive and non-odiferous patient care areas

That doesn’t look like to much to ask. In fact, it looks like the run of the mill hospital quality standards for every other service except psychiatry.