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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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.

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:

Sidetrackings

Update:  I found this Berenice Abbott photo of  a NY railroad in the Met’s online collection, so you get an added treat.  If you aren’t familiar with Abbott’s work, consider this an invitation to “meet” her.

Today’s press release:  obesity accounts for 21% total US healthcare spending.

The Cornell study reports that an incurs medical costs that are $2,741 higher (in 2005 dollars) than if they were not obese. Nationwide, that translates into $190.2 billion per year, or 20.6 percent of national health expenditures. The study appeared in the January issue of the (31:1). Previous estimates had pegged the cost of obesity at $85.7 billion, or 9.1 percent of national health expenditures.

“Historically we’ve been underestimating the benefit of preventing and reducing obesity,” said lead author John Cawley, professor of policy analysis and management in the College of and professor of economics. “Obesity raises the risk of cancer, stroke, heart attack and diabetes. For any type of surgery, there are complications with anesthesia, with healing [for the obese].”

HT Dr. Grumpy

What does that have to do with addressing suicidality causes?

Many of the distressors associated with psychache have to do with social connectedness.  Social connectedness is intregral in the immediate environment. What comprises a healthy, socially conducive environment?

Natural green spaces: parks, trails, gardens and safe places to experience them.

That means sidewalks, bike trails, cleared paths.

Adequate lighting, places to rest, benches, beaches, tables.

Access to fresh, potable water.

Access to places that provide fresh, whole foods – grocers, restaurants, farmstands, foodtrucks, delivery services – at affordable prices.

Access to educational and entertainment media suitable for all ages, cultures and customs – that would be the public library via walking, bike and public transportation.

Access to clean, fresh air – via public health regulations, and state and federal regulations on pollutants.

See where this is leading?

Back to the pump handle  – public health measures provide the biggest bang for the healthcare buck.  It’s all about making a healthy environment – one which promotes natural interaction by people in a healthful and pleasing environment – the default mode.

If Lillian Wald were here today, she would be doing the very same things she did almost 100 years ago in New York City.

People who are obese are, for them most part, uncomfortable. But they are responding to  a culture of immersion in faulty food cues. Their suffering is largely preventable, and public health is the way to go.  Regulate food producers, marketers and manufacturers. Remove advertising for manufactured food products from TV and print sources.  Invest in public transportation, pedestrian and bicycling infrastructure and services.  Regulate clean air, water and substances pollution.

In the US, it is incredibly difficult to find public places and spaces which encourage natural civil discourse. Culture is built around commerce, and indeed, today, politicians refer to Americans as consumers and not fellow citizens. People speak of “going to the mall, hanging out in bars, and going shopping” much more than any other activity where they would naturally come into contact with others.  There are very few venues in which people can casually meet and interact with others.  Almost all communal gatherings in the US are passive – attending movies, concerts and other events require no interaction or active participation. People remain isolated and alone even among large crowds.

It’s not rocket science – it’s basic humane infrastructure and service.

Unemployment and Suicide

The BBC posted an article “linking” a significant increase in European suicides to a concomitant rise in unemployment.

The financial crisis “almost certainly” led to an increase in suicides across Europe, health experts say.

The analysis by US and UK researchers found a rise in suicides was recorded among working age people from 2007 to 2009 in nine of the 10 nations studied.

The increases varied between 5% and 17% for under 65s after a period of falling suicide rates, The Lancet reported.

Researchers said investment in welfare systems was the key to keeping rates down.

Beyond the distress unemployment creates via loss of work role, loss of dignity, loss in family roles, social class loss, etc., the underlying stress is that of fearing the loss of survival.  No income equals no food, no shelter, no clothing, no fresh water, no safety.  In agricultural societies, people could literally eke out an existence from the land and create shelters from the landscape.  Not so in industrial societies where homelessness has literally been criminalized and legislated into invisibleness.  There is literally nowhere to escape to.Researchers have demonstrated that when people feel trapped and intolerably distressed, their risk for suicide heightens. Where does one go when there is nowhere to go?

Addressing unemployment and living wage accessibility for all is a key upstream issue.  Employment and living wage conditions should correlate with lower suicide rates in working age individuals.