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.

Won’t You Come In and Set A Spell?

I’d like to invite one and all who think about dying, wanting to die, plan your own death, attempt(ed) to die, study these thoughts, beliefs and behaviors or care for or about those who do, to help me in my exploration of alleviating distressors “upstream” from suicidality.

It occurred to me that survivors of suicide are usually described as family and friends of those who died by self inflicted death.  But what about those of us who remained alive after our attempts?  I haven’t found a term for that. Isn’t that interesting?

And what about those of us who find no relief in having remained alive after suicidality?  Or who don’t find relief from suicidality?

Perhaps there is belongingness and worthiness to be found in helping those who are navigating – mostly alone – these very rocky shoals.  Maybe bringing your wisdom, experience and perceptions in how to regain thwarted belongingness and regaining a real and abiding sense of purpose and meaning to someone who is suffering will help you to acquire the same attributes.

I was thinking about the study out today that demonstrates a deep and broad lack of trust by people with depression of their physicians. Then I thought about the known problem of medical students’ reluctance to seek help for mental illness.  I think there may be a lot of overlap in these two studies in the following areas:

There is fear of the negative consequences of reporting symptoms of mental illness – stigma, loss of career, loss of income, loss of health insurance, loss of healthcare (after a psych diagnosis, the quality of healthcare goes down significantly and dramatically as symptoms are chalked up to psychosomaticism and preventive healthcare doesn’t include aggressive care for psychotropic medication adverse effects),loss of personal relationships, loss of home, loss of social standing, loss of social roles, loss of self worth.  There is also the fear of coercion in accepting treatment.  And there is fear of undesirable effects of treatment.

But in admitting suicidality, there is a real danger of losing one’s civil rights, of being detained, incarcerated and treated against one’s will, of being publicly humiliated and shamed, and worst, of being intrusively assessed and evaluated with no care which alleviates intolerable distress.  Every single time I tried to bring up suicidality and how to deal with it, the treater instantly launched into the “dangerousness” assessment.  I eventually learned to clam up immediately and not to bring up suicidality again.

Is it any wonder that we scratch our heads and can’t figure out why people attempt suicide then?  It’s really because no one wants to know the lived experience – the phenomena – of suicidality.

The psychological autopsies are largely stupid, in my view.  There are living, breathing, distressed people who are more than willing to explain if only someone was there to be open enough (and not terrified) to listen and to help work through the distress.

I think that “someone” is those of us who experience suicidality. We may be our own best resource.

So if this speaks to you, consider yourself welcome.  Bring your best – critical thought, analysis, resources, references, support – and help to build ways to lower distress, prevent it in the first place, and find some relief for yourself.

 

Suicide

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Suicide remains an unmentionable in the US.  People who act upon suicidality are forcibly restrained, imprisoned (involuntarily confined), intensely and intrusively observed, and are subjected to treatment and conditions which make the already unbearable even moreso.

I aim to move upstream and address the conditions which lead toward unbearable distress, what Thomas Joiner has termed thwarted belongingness and perceived burdensomeness, and overwhelming despair.

I want to explore what people find helpful, how they are comforted and reassured, and what stops suicidality from developing to the point that the distress is incompatible with life – a phrase that is used in pathophysiology to describe a condition in which a living organism can no longer survive. I also want to go further and discover what prevents suicidality from occurring in the first place.

To that end, this blog is a safe venue in which to discuss the taboos, the precipitants, and all of the hidden and concealed facets around suicidality.  No one will track or monitor visitor identities.  There will not be online interventions responding to statements about intending to end one’s life. Your autonomy over your own life is respected.  To that end, comments that threaten harm as a manipulating device will not be published.

The overarching purpose is to address ways to relieve and to prevent feelings of intolerable distress.  People who would like to author around these topics are welcome and may drop me an email to discuss.