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.

Does Repeated Suicide Assessment Give Salience to Suicidal Behavior?

Insulin shock therapy is given in Lapinlahti H...

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Anecdotally, I avoid situations in which I am assessed for suicidality.  It’s intrusive, distressing, and the assessment isn’t used to provide relief from the distress.  For me, it’s a well known risk:harm without any benefit.

“Generally speaking, there is no history of providing psychiatric treatment in the emergency room setting,” says Elizabeth Wharff, director of the Emergency Psychiatry Service at Children’s Hospital Boston. “Since the late 1990s, we have seen a significant increase in the number of cases where an adolescent comes to our emergency room with suicidality and needs inpatient care, but there are no available psychiatric beds anywhere in the area.”

Given that the highest known demographic risk for suicide is that of previous suicide attempt, a couple of studies seem to lead to the notion that the current standard of practice of repeated and frequent assessment of suicidality without treatment to reduce the underlying distressors may actually be contributing to the development of suicidal behavior.

In the first study, demographics of suicide risk after the first hospitalization for a mental illness was explored.

Patients with any major psychiatric disorder are at significant risk for suicide after their first hospital visit, according to new research.
~snip~
Dr. Caine noted that although rates of suicide were less than what other researchers have estimated in the past, they were still quite substantial.

“I think this study really teaches us that all those prior results were in the right direction, but we’re now seeing much more clearly what the proper magnitude is, and what the burden of suicide is.”

“You can also clearly see that the suicide risk continues to climb over years. Certainly there’s a steep climb in the first year after hospitalization, but it continues to climb. So, this isn’t something you think about just the first day or week or month. This is something you think about for years,” he concluded.

It would be reasonable to think that hospitalized patients would have been frequently assessed for suicidality and behavior without receiving any treatment to reduce distressors other than masking symptoms with psychotropic medications.  The overall hospital experience is so antitherapeutic and noxious that overwhelmingly, patients avoid rehospitalizations. But they may leave with heightened acclimation to suicidality by way of the concept discussed in the following study.

The second study deals with understanding mortality salience:

Why did the approval ratings of President George W. Bush— who was perceived as indecisive before September 11, 2001—soar over 90 percent after the terrorist attacks? Because Americans were acutely aware of their own deaths. That is one lesson from the psychological literature on “mortality salience” reviewed in a new article called “The Politics of Mortal Terror.”
~snip~
The fear people felt after 9/11 was real, but it also made them ripe for psychological manipulation, experts say. “We all know that fear tactics have been used by politicians for years to sway votes,” says Cohen. Now psychological research offers insight into the chillingly named “terror management.”

The authors cite studies showing that awareness of mortality tends to make people feel more positive toward heroic, charismatic figures and more punitive toward wrongdoers.
~snip~
Awareness of danger and death can bias even peaceful people toward war or aggression. Iranian students in a control condition preferred the statement of a person preaching understanding and the value of human life over a jihadist call to suicide bombing. But primed to think about death, they grew more positive toward the bomber. Some even said that they might consider becoming a martyr.

As time goes by and the memory of danger and death grows fainter, however, “morality salience” tends to polarize people politically, leading them to cling to their own beliefs and demonize others who hold opposing beliefs—seeing in them the cause of their own endangerment.

Isn’t that interesting! If thinking about mortality and death can induce salience, that would seem to be generalizable to suicidality outside of martyrdom.

In Joiner’s Interpersonal Theory of Suicide, he speaks to the idea that people get acclimated to the idea of suicide.  Frequent assessments of suicidality delve into all of the mechanics of committing suicide:  does the person have a plan, if so, describe it in detail, how will they access the supplies and resources necessary to carry out the plan, where will they do it, will they leave a note, do they have reasons for not doing it, etc.  Even when people deny any and all of these aspects, bringing them up over and over again (let’s call it externally applied rumination) promotes acclimation to the idea of suicide behavior, if not also reinforcing the suicidality (perceived burdensomness and thwarted belongingness). In other words, the assessments serve as mental rehearsing or practice without any treatment whatsoever outside of direct observation (not a treatment), incarceration/involuntary hospitalization (doesn’t treat anything, and increases distress), and removal of the stated intended means (TSA and box cutters, leading to shoe bombers, then underwear, then turban bombs – a moving target, NOT a treatment for suicidality).

Tonic Immobility

This is congruent with my experience and how I react now to stress:

When a rabbit or other animal is trapped by a predator, it will freeze and assess the situation. It might then flee or attack, what we usually call the “fight or flight response“. If that fails, a last-ditch defence mechanism is to go completely immobile, to play dead.

Researchers in Brazil now say that in times of grave danger, this same automatic last resort is also exhibited by humans and is experienced as a terrifying feeling of being “locked-in”.

Terrifying feeling is exactly right.  It feels as if it will never end and that I’m totally exposed.  A target.

…physiological evidence of “tonic immobility” in humans…. Participants who reported a strong sense of being paralysed, frozen, unable to move or scream, tended to show less body sway, higher heart rate and less heart rate variability.

Even reading about this phenomenon brings the terror regurgitating up to the surface. I also experience it as an overwhelming sense of dread.  It’s an incredibly large factor in low quality of life and suffering.  It seems to be an automatic/autonomic response, and I wish I could minimize it, but so far, no success.

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.

 

Demoralization

This post is essentially an interim reference list. Demoralization is arguably the most important concept in suicidality that you’ve never heard of.

Demoralization and remoralization: a review of these constructs in the healthcare literature Margaret J Connor, Jo Ann Walton

Nursing Inquiry

Nursing Inquiry

Volume 18, Issue 1, pages 2–11, March 2011

The Social Separation Syndrome
Reprinted from Survival International Review Vol. 5, No. 1(29):13-15, 1980.
G. N. Appell
Brandeis University

Engel and his collaborators have been concerned with the related question: Why do people fall ill or die at the time they do? And they have identified a psychological pattern that appears associated with disease

onset that they call the Agiving up–given up complex@. Five characteristics are identified with this complex (Engel 1968): (1) the giving up affects, i.e. helplessness or hopelessness; (2) a depreciated image of the self; (3) a loss of gratification from relationships or roles in life; (4) a disruption of the sense of continuity between past, present, and future; and (5) a reactivation of memories of earlier periods of giving up.

Pubmed search for demoralization

The term demoralization was first used in the psychiatric literature by Jerome Frank in the 1970s (i.e., “the chief problem of all patients who come to psychotherapy is demoralization . . . the effectiveness of all psychotherapeutic schools lies in their ability to restore patient morale”)1(p271) and represented a persistent failure of coping with (internally or externally induced) stress; Frank believed demoralization left one feeling impotent, isolated, and in despair. This conceptualization was congruent with the psychodynamic approach of the Diagnostic and Statistical Manual of Mental Disorders, Second Edition (DSM-II),2 in which all disorders were considered reactions to environmental events. Frank defined the symptoms of anxiety and depression as direct expressions of demoralization.1
However, in 1975, Schildkraut and Klein3 defined demoralization as a state separate from depression. Whereas patients with depression experienced anhedonia, patients with demoralization lost their sense of efficacy. In the 1980s and 1990s, Frank and De Figueiredo further refined the meaning of demoralization.4 The term demoralization remained distinct from depression and was characterized by 2 states: distress and a sense of incompetence that results from an uncertainty about which direction to take. Individuals with depression and those with anhedonia cannot act (even if they know the proper direction to take).
Curr Psychiatry Rep. 2010 Jun;12(3):229-33.

Differentiation between demoralization, grief, and anhedonic depression.

Source

Department of Veterans Affairs, Central Arkansas Veterans Healthcare System, 4300 West 7th Street, 116T/LR, Little Rock, AR 72205-5484, USA. marcus.wellen@va.gov

Abstract

Demoralization is a phenomenon in which a patient reaches a state of subjective incompetence, hopelessness, and helplessness that can lead to that devastating moment in which he or she feels the only recourse left is to give up. This article reviews the medical literature regarding the current understanding, importance, and impact of demoralization. In addition, using the key characteristics of demoralization, this article attempts to compare and contrast demoralization with anhedonia and grief.

 

TO THE EDITOR: Dr. Slavney’s stimulating article, “DiagnosingDemoralization in Consultation Psychiatry,” is a valuable additionto the ongoing debate on demoralization.1 Dr. Slavney statesthat demoralization is a normal response to adversity and thathe disagrees with my proposal to substitute “demoralization”for “severity of psychosocial stressors” as Axis IV in the DSM.Although demoralization may, at times, be understandable, asin the cases described by Dr. Slavney, the view I proposed isthat demoralization is always abnormal. It is because demoralizationis abnormal that it requires treatment (psychotherapy). I proposedthat demoralization be conceptualized as involving two states:distress (which some other authors have called “demoralization,”incorrectly in my opinion) and subjective incompetence. Althougheach of these two states may be normal by itself, their overlapwould constitute demoralization, which is always abnormal. Demoralizationis thus viewed as a boundary phenomenon, that is, a state thatoccurs within the individual and at the boundary with the environment,something akin to inflammation.

World Psychiatry. 2005 June; 4(2): 96–105.
PMCID: PMC1414748
Copyright World Psychiatric Association
DAVID M. CLARKE,1 DAVID W. KISSANE,1 TOM TRAUER,1 and GRAEME C. SMITH1

What Protects?

I’m working a bit sideways and backwards since I haven’t developed a more comprehensive explanation of suicidality prompts.  But there have been several studies in the news which address compensatory mechanisms and adaptation, so the time’s right to get them out there for people to consider.

To experience external physical warmth which approximates human or possibly mammalian warmth is a basic human need. It turns out that when lonely college students were queried on bathing behaviors, those reporting higher degrees of loneliness had significantly different habits.  They bathed/showered more frequently, for longer periods of time and they used warmer water temperatures.  The authors postulate that this is a self-soothing strategy which serves as a rough proxy for human warmth.

The Ohio State University published a study demonstrating an association between particulate pollution and clinical depression.  Given the inflammatory involvement in depression, these finding serve as more fuel for this fire.  It might be worth trying room-based air filters to see if people get any anti-inflammatory effects. More research needs to be done in essential quality of life factors.

The website, Ostracism Aware, has a resource listing which seems to be fairly comprehensive.

What do you find helps to relieve the feelings of isolation, loneliness, not belonging, depression or being a burden? What doesn’t help?  What do other people do that helps?  And what do other people do that makes things worse?

When People Aren’t De-Stressed

There was an extraordinary commenting discussion about suicide as reader responses to a NYTimes column by the physician and writer, Danielle Ofri. In her essay, she laments the death by suicide of a patient and expresses frustration about the seeming non-suicidality of him making the death an unexpected shock.

Two weeks ago, I called one of my patients to reschedule an appointment. A family member answered and told me that my patient had been found dead in his apartment, most likely a suicide. This robust and healthy 54-year-old had screened “negative” for depression at every visit, despite having risk factors: being unemployed, living alone, caring for an ill relative.

Here she makes a clinical error: screening for depression and suicidality are two distinct entities.  Once does not necessarily presage the other. In terms of perceived burdensomeness, thwarted belongingness, isolation, hopelessness, helplessness and worthlessness, this gentleman was existing in a stew of toxic risk factors.

Maslow’s hierarchy of needs is old, but useful, in my view.  This person exhibited unmet basic needs – financial burdens, caregiver burdens, physical burdens, social isolation burdens.  The question becomes, where art thy neighbor?  Who is thy neighbor?

Maslow's Hierarchy of Needs. Resized, renamed,...

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One of the risk factors for suicidality is that physicians increasingly treat rather than care for patients.  Because the care is missing, patients aren’t supported around anything other than medications, surgery and medical procedures.  One thing Dr. Ofri could have addressed is linking the patient to a home health nursing agency or to a social worker who could help him access caregiver support, perhaps home delivered meals and financial and job search supports.

The bottom line is that it appears that no one was this man’s neighbor, or brother, or fellow citizen.

Now to the commentary:

Readers addressed a wide variety of insightful and thoughtful aspects around suicide and suicidality.  The right to end terminal suffering – psych ache – is addressed quite compellingly.