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.

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.)

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:

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.

Fuggeddiboudit

Cut up rat

Image via Wikipedia

Previously I noted that disparate studies suggest that incessantly assessing suicide risk without providing distressor relief may actually kindle – make worse – suicidality.  Over the recent past this has been my experience. The chief source of “treatment” such as it is, is by serving as a lab rat in studies.  I have been subjected to incredibly intrusive and distressing assessments on a very frequent basis.  I haven’t responded to any of the treatments and have instead had side effects including a liver injury from one – where the CRO (for profit contracted research organization) and IRB disappeared into the ether and left me to my own devices.

Last week I served as a subject that I thought wouldn’t involve distress or harm because I needed $$ to pay for treatment I received as a result of the liver injury.  Well, the assessment was awful to the extent that I called a crisis hotline – was treated to a rude and dismissive response and then the crisis provoker hung up on me. “Just read a book,” she commanded.  And,
“I’ve never been suicidal,” she crowed.

I lost time after that – a few days at least.  Apparently I threw the phone away, which makes sense.  No one calls me, and it isn’t needed since no one responds to calls for help, either.  One cost reduced.

I’m withdrawing from the other studies.  I can’t tolerate the distress.

I used to blog to try to stay current in health policy and clinical practice, but I’m too far gone to do that or to care.

So I’m signing off at this juncture with a link to what looked to be a thoughtful and fairly comprehensive report about the state of suicidality “treatment” in the US with some Western countries’ best practices thrown in.

And a plea to offer a humane death for those of us ostracized by you.  There’s a difference in wanting to hurt oneself and desiring a peaceful death. I failed at finding a means to the latter, and am forced to resort to the former.  That is cruel and unusual punishment for being deemed a worthless freak.

TNTC

TNTC in the healthcare trade refers to too numerous to count, often referring to types of cells on a slide.

I’ve been reading all sorts of studies and reports and have managed to keep TNTC tabs open.  I’m not able to concentrate well enough to put them into much of an interesting and pertinent context, so here they are, more or less in list form.  Perhaps another day the noggin will be more willing to oblige in the coherence and cogitation departments….

Kaiser Health News (an excellent resource) reports on states cutting mental health budgets concurrent with need and use increases.

Despite the sketchy, COI (conflict of interest) riddled authors, this is an interesting review.

This review summarizes the phenomenon of adult hippocampal neurogenesis, the initial and continued evidence leading to the development of the neurogenesis hypothesis of depression, and the recent studies that have disputed and/or qualified those findings, to conclude that it can be affected by stress and antidepressants under certain conditions, but that these effects do not appear in all cases of psychological stress, depression, and antidepressant treatment.

This study refers to people who committed suicide as “depressed suicides”.  Ahem, authors, suicide is a verb and not a noun to be used to pathologize a person as an act. I included it because it found credible evidence of neuroinflammation in people who were diagnosed prior to their deaths with severe depression. (I’ve been eating an anti-inflammatory diet which has provided some health benefits, but to date, has not mitigated depression or PTSD.  However, my labs are golden.  Whoopee.)

These results provide the first evidence of altered cortical astrocytic morphology in mood disorders. The presence of hypertrophic astrocytes in BA24 white matter is consistent with reports suggesting white matter alterations in depression, and provides further support to the neuroinflammatory theory of depression.

Shotgun ’em. This study looked at the outcomes of people who were prescribed antipsychotic medications for anxiety. Except for the adverse effects, not much good happened. Lesson: don’t let this happen to you.

Lithium has a reputation for lowering the suicide rate. When it was stacked up next to valproate, not so much.

Despite the high frequency of suicide events during the study, this randomized controlled trial detected no difference between lithium and valproate in time to suicide attempt or suicide event in a sample of suicide attempters with bipolar disorder.

Australian national youth suicide prevention strategy didn’t affect the suicide rate – just like every other prevention strategy globally.

Yet another suicide rating scale – this time it’s the Columbia-Suicide Severity Rating Scale C-SSRS. It’s apparently reliable for suicidality but not for actual attempts. Kindling effect, people. Keep asking questions which demand extensive detailed thought about planning, the method, the needed resources and the desire, and hey – look at this bright shiny object – the biggest risk factor for suicide is prior attempts. Practice and rehearsal (mental as well as physical) makes perfect. Still conflating assessment with treatment with iatrogenically lethal result.

I’m stopping here, although there are many, many more links to go.