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.

Advertisements

Chasing Tails

Thomas Joiner’s interpersonal theory of suicide is one I refer to often here.  However, even he doesn’t move upstream to look at distress causality.  Exhibit the last:

J Psychiatr Res. 2012 Apr 2. [Epub ahead of print]

Behaviorally-indexed distress tolerance and suicidality.

Source

Military Suicide Research Consortium, United States.

Abstract

Research indicates that distress tolerance exhibits a complicated relationship with risk factors for suicidal behavior. Specifically, low self-reported distress tolerance has been linked to perceived burdensomeness and thwarted belongingness. Contrastingly, high self-reported distress tolerance has been linked to the acquired capability for suicide. Given the frequently discrepant findings between self-report and behavioral indices of distress tolerance, we sought to expand upon prior findings by testing these relationships utilizing a behavioral measure of distress tolerance. Additionally, in an effort to further clarify the role of distress tolerance relative to painful and/or provocative experiences in the acquired capability, we examined whether distress tolerance serves as a moderator. Results revealed no significant associations between distress tolerance and burdensomeness or belongingness; however, distress tolerance was positively associated with the acquired capability. Furthermore, the interaction of distress tolerance and painful and/or provocative experiences significantly predicted the acquired capability, with the strength of the association increasing at higher levels of distress tolerance. Results highlight the potential importance of perceived versus actual ability to tolerate distress with respect to suicidal desire. In contrast, the results reflect the importance of actual persistence in the acquired capability.

“The only one.”

English: Consequences of whistleblowing, from ...

Update:  NPR just published a compelling story about Mr. Boisjoly, and it includes two audio interviews- one about his whistleblowing and one with his perspective after the fact. Listening to NPR’s Howard Berkes talking With Roger Boisjoly In 1987 is incredibly heartbreaking.

I am ashamed that I have not always intervened to stand with those who stand alone.  Now I am a liability to others.  A pariah is not a help, but just more weight dragging the person farther down the rabbit hole.

Read the NYTimes’ activist obituary, if there is such a thing, and feel just a bit of what this man experienced.

Six months before the space shuttle Challenger exploded over Florida on Jan. 28, 1986, Roger Boisjoly wrote a portentous   memo. He warned that if the weather was too cold, seals connecting sections of the shuttle’s huge rocket boosters could fail. “The result could be a catastrophe of the highest order, loss of human life,” he wrote.

Mr. Boisjoly’s memo was soon made public. He became widely known as a whistle-blower in a federal investigation of the disaster. And though he was hailed for his action by many, he was also made to suffer for it.

Mr. Boisjoly … died in Nephi, Utah, near Provo, on Jan. 6. He was 73. His death was reported only locally at the time. He lived in southwest Utah, in St. George. His wife, Roberta, said he recently learned he had cancer in his colon, kidneys and liver.

But before then he had paid the stiff price often exacted of whistle-blowers. Thiokol cut him off from space work, and he was shunned by colleagues and managers. A former friend warned him, “If you wreck this company, I’m going to put my kids on your doorstep,” Mr. Boisjoly told The Los Angeles Times in 1987.

He had headaches, double-vision and depression, he said. He yelled at his dog and his daughters and skipped church to avoid people. He filed two suits against Thiokol; both were dismissed.

He later said he was sustained by a single gesture of support. Sally Ride, the first American woman in space, hugged him after his appearance before the commission.

“She was the only one,” he said in a whisper to a Newsday reporter in 1988. “The only one.”

His obituary lists family.  I hope they brought him solace and comfort.  Families mostly don’t survive intact. He was only 73.

The sole study (small, Australian) that looked at the health effects of whistle blowing listed 17 of 35 people admitting to suicidality.  The suicide rate couldn’t be ascertained because the study was done in questionnaire format and only used a single sampling. But adverse significant health effects were 100%.

100%

I know – you don’t believe me because you are a GOOD person, and you live in a society with safety nets for this type of thing. But here’s the gist of it:

OBJECTIVE–To examine the response of organizations to “whistleblowing” and the effects on individual whistleblowers. DESIGN–Questionnaire survey of whistleblowers who contacted Whistleblowers Australia after its publicity campaign. SETTING–Australia. SUBJECTS–25 men and 10 women from various occupations who had exposed corruption or danger to the public, or both, from a few months to over 20 years before. RESULTS–All subjects in this non-random sample had suffered adverse consequences. For 29 victimization had started immediately after their first, internal, complaint. Only 17 approached the media. Victimization at work was extensive: dismissal (eight subjects), demotion (10), and resignation or early retirement because of ill health related to victimization (10) were common. Only 10 had a full time job. Long term relationships broke up in seven cases, and 60 of the 77 children of 30 subjects were adversely affected. Twenty nine subjects had a mean of 5.3 stress related symptoms initially, with a mean of 3.6 still present. Fifteen were prescribed long term treatment with drugs which they had not been prescribed before. Seventeen had considered suicide. Income had been reduced by three quarters or more for 14 subjects. Total financial loss was estimated in hundreds of thousands of Australian dollars in 17. Whistleblowers received little or no help from statutory authorities and only a modest amount from workmates. In most cases the corruption and malpractice continued unchanged. CONCLUSION–Although whistleblowing is important in protecting society, the typical organisational response causes severe and longlasting health, financial, and personal problems for whistleblowers and their families. (emphasis throughout is mine)

I know how difficult it is to stand alone and support a person who has been ostracized.  There is real risk to do that.  So like other whistle-blowers, I don’t ask, and I never expect it. Moreover, people will not TOUCH whistle-blowers.  Whistle-blowers are literally toxic. That is why Mr. Boisjoly was so profoundly TOUCHED by Dr. Ride’s gesture.

But, hot damn, Sally Ride stood there and HUGGED him.  In public. If that isn’t a meeting of heroes, I don’t know what is. Funny thing is that she retired from NASA later that year, and in 2002, she was appointed to the Space Shuttle Columbia Accident Investigation Board. Accidents still happened.  Same old boring story – multiple Swiss cheese systems failures because the people advocating for time out and caution were over-ridden by those who gun always for the shareholders’ (lobbyists/politicians and their corporate overlord shareholders) bottom lines.  Sacrifices always have to be made by those who will never come into contact with the bottom feeders liners.

Professor Liam Donaldson, the chief medical officer for England’s National Health System, wrote,

We should “applaud heroes, and hope they are among us, but to base our hope of remedy in ordinary systems on the existence of extraordinary courage is insufficient.”

I’ve pretty much scoured the literature, and no one addresses whistle-blowing, ostracism and suicide.  No one addresses the life ruination, the total and complete losses, and the resultant world goes on while leaving the whistle-blower (and surviving family, if any) in literal limbo.

And really, it’s the perfect crime.  Because it’s like Holmes’ dog that didn’t bark.  No one notices the absence of whistle-blowers.  No one sees them missing in group photos, nor misses their names in employee recognition events, nor has any notion at all about their well-being. Much better than Jimmy Hoffa’s demise with that pesky media and all keeping his name alive and the issues addressed.

Whistle-blowers are disappeared much more cleanly and completely than any CIA black site prison. The torture leaves no mark.

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.

Predictions

Honestly.  In the conflation department, I keep reading comments about how much a need there is to have a reliable tool to predict suicides.  Well, that ain’t happenin’ until there is effective, available and safe treatment which reduces distressors.  Otherwise, all of the rewards and incentives are lined up squarely against anyone admitting suicidality, let alone seeking incarceration quaintly and deceptively referred to as containment and hospitalization, applied emotional trauma, humiliation and intrusiveness which is all the “standard of care” does in the US, at least, when someone admits to suicidality.

I have been explicitly instructed by three psychiatrists on how to dodge a suicidality assessment in order for us to play charades:  me, so that I escape imprisonment and them to escape legal risk and actually intervening to alleviate my distress.  So why in the world would I seek out any “help” at all when it is clear that there is none to be had?  Sheer lunacy, (irony alert).

And so, the world goes on without me. Silence punctuated by external noise. Unending hell. No reason to get up, go anywhere, do anything. There is no intervention for ostracism.  Untouchable, literally untouchable. Enduring social death until physical death.  Hurry up, already.

For those who have friends and family, a recent large scale study examined some of the factors involved in them not intervening or providing help when people close to them are suicidal:

As the suicidal process unfolds, significant others are required to make a series of complex decisions about what is happening and what, if anything, they should do about it. They must collect and weigh evidence from a range of sources, correctly decipher and assess the significance of both signs and countersigns, identify the appropriate actions to take, and then summon the courage to take them. Risks are involved at every stage; cherished relationships are at stake. Significant others must weigh the danger of doing nothing against the perceived dangers of saying or doing “the wrong thing.”

Experts agree that a clear and unambiguous warning message is a prerequisite for effective disaster planning and crisis management.29 Our data suggest that, in a suicidal crisis, members of the family and social network may not always receive a clear and unambiguous warning message. This may be because the person fails to give out a clear enough distress signal or because distress signals are given but significant others cannot decode them correctly at the time  Equally, they may not be able to bring themselves to accept that anything is seriously wrong or that suicide is a possibility. Writing in another context, about clinical identification of child abuse, one author comments: “[It] is a difficult intellectual and emotional exercise. . . The biggest barrier to diagnosis is the existence of emotional blocks in the minds of professionals.”30 The emotional blocks that can operate in clinical practice are magnified many times in close personal relationships, where every word or action may be emotionally charged and gauging the right response is critical. Our findings suggest that those very relationships, generally believed to be a protective factor for suicide,31 32 may sometimes heighten risk by acting as barriers to both awareness and intervention.

….critical errors in judgment often result from the so-called “normalcy bias,” defined as the tendency of people who have never experienced a catastrophe to disregard ominous signs and behave as if nothing is wrong. The strong desire for everything to be normal inclines people to believe that it is, even in the face of evidence to the contrary.33 Our findings suggest that this same principle may operate at the private level, particularly in the context of family life. The cycles of avoidance model, proposed by Biddle et al to account for non-help seeking for mental distress, provides an alternative framework that also fits our data well.   Our data show that lay people may go to considerable lengths to avoid pathologising the distress of those close to them; their thresholds are repeatedly pushed back by powerful emotions, especially fear of the consequences (for themselves, as well as for the distressed person) of acknowledgment and intervention.

Yale Open Philosophy Course: The Suicide Lectures

Detail of The Death of Socrates. A disciple is...

Image via Wikipedia

The course is entitled, The Philosophy of Death, taught by Professor Shelly Kagan at Yale University in 2009. Each lecture is just under an hour.  The written transcript and reading references are available on the individual lecture pages.  The course link above will take you to the introductory lecture and all of the lecture links.

Course Index

Philosophy of Death
The Nature of Persons: Dualism vs. Physicalism
Arguments for the Existence of the Soul, Part I
Introduction to Plato‘s Phaedo; Arguments for the Existence of the Soul, Part II
Arguments for the Existence of the Soul, Part III
Arguments for the Existence of the Soul, Part IV; Plato, Part I
Plato, Part II: Arguments for the Immortality of the Soul
Plato, Part III: Arguments for the Immortality of the Soul (cont.)
Plato, Part IV: Arguments for the Immortality of the Soul (cont.)
Personal Identity, Part I: Identity Across Space and Time and the Soul Theory
Personal Identity, Part II: The Body Theory and the Personality Theory
Personal Identity, Part III: Objections to the Personality Theory
Personal identity, Part IV; What matters?
What Matters (cont.); The Nature of Death, Part I
The Nature of Death (cont.); Believing You Will Die
Dying Alone; The Badness of Death, Part I
The Badness of Death, Part II: The Deprivation Account
The Badness of Death, Part III; Immortality, Part I
Immortality Part II; The Value of Life, Part I
The Value of Life, Part II; Other Bad Aspects of Death, Part I
Other Bad Aspects of Death, Part II
Fear of Death
How to Live Given the Certainty of Death
Suicide, Part I: The Rationality of Suicide
Suicide, Part II: Deciding Under Uncertainty
Suicide, Part III: The Morality of Suicide and Course Conclusion

There are three suicide lectures.  Part I and transcript, Part II and transcript and Part III and transcript may be viewed at the links.  From the latter part of the Morality of Suicide lecture:

So, the utilitarian position is in the middle. It doesn’t say suicide’s never acceptable, doesn’t say suicide is always acceptable. It says, perhaps unsurprisingly, it’s sometimes acceptable; it depends on the facts. It depends on the results. It depends on comparing the results of this action, killing yourself, to the alternatives open to you. We have to ask, is your life worse than nothing? Is there some medical procedure available to you that would cure you? If there is, and even if your life is worse than nothing, that still doesn’t make it the best choice in terms of the consequences. Getting medical help is a preferable choice in terms of the consequences.

We can even think of cases where your life is worse than nothing, you’d be better off dead, and there is no medical alternative of a cure available to you, but for all that, it still isn’t morally legitimate to kill yourself in terms of the utilitarian outlook. Because, as always, we have to think about the consequences for others. And there may be others who’d be so adversely affected by your death that the harm to them outweighs the cost to you of keeping yourself alive. Suppose, for example, that you’re the single parent of young children. You’ve got a kind of moral obligation to look after them. If you were to die, they’d really have it horribly. It’s conceivable then, in cases like that, the suffering of your children, were you to kill yourself, would outweigh the suffering that you’d have to undergo were you to keep yourself alive for the sake of your children. So, it all depends on the facts.

Still, if we accept the utilitarian position, we do end up with a moderate conclusion. In certain circumstances suicide will be morally justified — roughly speaking, in those cases where you’re better off dead and the effects on others aren’t so great as to outweigh that. Those will be the paradigm cases in which suicide makes sense or is legitimate, morally speaking, from the utilitarian perspective.

Watch it on Academic Earth