October 2013 Archives

  My line of thought on this started with a compelling analysis of the origin and maintenance of the Tea Party. Definitely worth reading at http://t.co/4AQ1AZkled

  Connecting the economic and political dots proves how much the Tea Party is the brainchild of the ultra-billionaire Koch brothers. This so-called 'grass roots' movement is really made of artificial Astroturf. It has been created by, and is meant to serve, the interests of some of the richest people on ear.

  I have always wondered why the Koch brothers bother? Were I blessed with their tens of billions, I certainly wouldn't spend my very limited time on earth energetically devising ways to make myself even richer and the middle and poorer classes even poorer.

  It is not as if the super rich are hurting. There has been a massive transfer of wealth in the US during the past 40 years. Three economic and political forces have driven a growing and gaping inequality.

  First, technology gains and globalization have greatly favored capital over labor. The stock market has exploded while wages have stagnated. And corporate CEO's who used to earn 25 times as much an average worker, now cash in grandly at over 200 times. 

  Second, the relative tax burdens for rich people and big corporations have been cut drastically, putting more of the burden on the middle class.

  Third, public services are being pruned and privatised. The rich can afford and prefer to have private everything- private health care, private schools, private security guards, private planes, private pension plans, and on and on. The Tea Party (ie Koch) agenda is to help them avoid responsibility for paying for public services needed by everyone else- even though, in all other developed countries, these are deemed as absolutely essential, a matter of simple fairness, and a guarantor of social harmony.

  The US already has one of the most unequal wealth distributions in history. The top 1% of the population already owns almost half the wealth, while the bottom 80% owns only 7%. The Tea Party agenda reveals that the top 1% is still not satisfied and wants to increase even further its lion-size share.

  Which brings us back to our original question. Why don't the Koch brothers (and their like minded, super rich brethren) just kick back and enjoy what they already have, rather than energetically gaming Washington and state capitals to ensure they will have even more. How many billions are enough?

  Apparently the sky is the limit. It is not hard to see why- the evolutionary race has always been won by the greedy and greed is deeply engraved in our DNA. The relentless pursuit of supplies and offspring was a winning combination because supplies were usually scarce and offspring were the ticket to evolutionary success.

  So greed goes back to the earliest life forms and has influenced their evolution into us. Greed is an important contributor to the human condition and affects most things we feel, do, and think. Greed has its uses, but carries within it the seeds of its own destruction. I experience this myself in acute form every single time I confront an open refrigerator.

  All the world's religions have warned against the risks of greed:

  "A greedy man brings trouble to his family, but he who hates bribes will live." Old Testament

  "Be on your guard against all kinds of greed; for one's life does not consist in the abundance of possessions." Luke, New Testament

   "There are three gates to self-destructive hell: lust, anger, and greed." Bhagavad Gita

   "In his love for the world, the greedy is like the silkworm: the more it wraps in its cocoon, the less chance it has of escaping from it, until it dies of grief." Imam Muhammad al-Baqir

  "Greed is an imperfection that defiles the mind." Gautama Buddha

  Ancient Rome declined and fell partly because of greedy practices that created economic inequalities very much mirroring ours today. A sample from worried Roman commentators

  "Poverty wants much; but avarice, everything." Publilius Syrus"

   "The covetous man is always in want."  Horace

   "For greed all nature is too little." Seneca

  My two favorite modern greed quotes are:

  "There is a sufficiency in the world for man's need but not for man's greed."

Mahatma Gandhi

  "Greed is a bottomless pit which exhausts the person in an endless effort to satisfy the need without ever reaching satisfaction."

Erich Fromm

  And here are some statements by the greedy that nicely reveal the nature of their greed. Wallis Simpson said 'you can't be too rich or too thin'. When multi-billionaire septuagenarian Carl Icahn was asked what motivated him to keep raiding corporations, he said that money was the only way to 'keep score'. When asked what he really wanted, Johnny Rocco in Key Largo says 'More'. And Gordon Gecco in Wall Street proudly proclaims that 'greed is good'.

  Well, only up to a point. The evolution of  species and the fate of human civilisations both reveal the same repetitive and depressing pattern. Species and civilisations typically die out just after they are puffed up by greed. The population grows beyond the carrying capacity of the environment- and then it abruptly crashes.

  And to mix my metaphors- societies come apart at the seams when the slicing of a shrinking pie results in excessive inequalities that rend the social fabric.

  The lessons are clear and tragic- greed wins in the short run, but dooms us in the long.

  Can rational thinking and fair minded public policy possibly curb self destructive greed?

  Hard to predict. You would come to very different conclusions depending on how you choose your test cases. For example, the Koch brothers' political positions are diametrically opposed to the social safety net and relative economic equality established by of the Scandinavian countries.

  But there is a small glimmer of hope across time in this cross country comparison. After all, currently fair minded Scandinavians are just 1000 years removed from being greedy, marauding Vikings. Perhaps we will wise up before it is too late to save our country's social harmony and to preserve our planet's environment. Perhaps we won't.

     Pinel, the father of modern psychiatry, is famous for liberating his patients from their chains. But he did a whole lot more. Pinel spent long hours listening attentively to each patient's life story so that he could correlate their life experiences with the onset and course of symptoms.

  Pinel got to know his patients well enough to like them as people. When given the choice of joining Napoleon as personal physician or staying on at the hospital, Pinel picked his psychiatric patients over his emperor.

  Pinel's closest collaborator and teacher was a former patient who became chief administrator. Together they developed a diagnostic classification and a treatment approach that combined cognitive, social skills, and humanistic methods.

  When I started my training in psychiatry 45 years ago, the prevailing model for understanding mental disorders was broadly bio/psycho/social- in the grand tradition of Pinel. When psychiatry is practised well, it integrates insights from all the different ways of understanding human nature.

 But, along the way, an unfortunate reductionism has limited the scope of much of psychiatric practice. The psychological and the social viewpoints survive, but only in truncated form. For many practitioners and training programs the biological leg of the tripod  has been unduly emphasized at the expense of a fully rounded picture of the patient.

  Many interacting contributions promote a biological reductionism that reduces the richness and effectiveness of psychiatry. The brilliant findings of basic neuroscience blind people to the fact that so far these have had absolutely no impact on day to day clinical practice. Big Pharma sells the misleading idea that mental ills are all due to chemical imbalance and always require pill solutions.  Psychological factors and social context are difficult to evaluate in the too brief visits approved by insurance reimbursement. And training programs often overemphasize DSM checklist diagnosis at the expense of more broadly based and fully realised evaluations.

   See my recent blogs for a wonderful   conversation with Eleanor Longden. Eleanor was a victim both of incapacitating psychiatric symptoms and of harmful psychiatric treatment. She was able to find her way back to a remarkably productive life partly through the application of her own inner resources, but also with the help of the Hearing Voices Network and her psychiatrist Pat Bracken.

  Aside from being a terrific clinician, Pat has a strong interest in the role of meaning, relationship, and values in psychiatric care. He is a founder of the Critical Psychiatry Network.

I asked him where psychiatry should be headed. This is Pat's response:
   "A technological approach to mental health problems currently dominates in most of the Western world. This paradigm is associated with a particular way of framing and responding to states of distress and dislocation. See http://bjp.rcpsych.org/content/201/6/430.abstract"

 "By technological, I mean an approach to experiences (eg low mood, hearing voices, suicidality, self harm, fearfulness, and elation) that sees them primarily as problems that need to be fixed by some sort of professional intervention. Non-technical, non-specific, aspects of mental health care have been pushed to the margins. The technical approach does not totally ignore questions of relationships, values, and meanings- but it does see them as only as secondary concerns."

 "The technical paradigm dominates in our publications, research agendas, teaching,
and service priorities- and it is generally accepted that technical knowledge should trump all other ways of framing and thinking about mental health issues."

  "The balance of evidence does not support this idea that mental health problems are best grasped through a technical idiom or that good mental health work can be characterised as a series of discrete interventions. This is not to say that medical knowledge and expertise are not relevant (even vital) in the field of mental health. However, the problems we grapple with cry out for a more nuanced form of medical understanding and practice."

 "The mind is not simply another organ of the body. It is impossible to understand mental illness without understanding the experiences, meanings, relationships, and values of the person and his social context. A purely medical approach that works well in the field of cardiology or respiratory medicine is incomplete for psychiatry. It is our task to develop a medical discourse that takes a broader view."

  "A post-technological psychiatry would not replace all the theories and treatments we use today, but would develop a primary discourse that is hermeneutic and ethical in nature and from which choices would be made about what research should be prioritised, what training our professionals should have, and what sort of services we should develop."

 "Such a discourse can not be developed by professionals on their own and clearly requires conversations and negotiation with the growing service-user/consumer movement  (individuals who are 'experts by experience')."

 "I believe that the Hearing Voices Network offers a very good example of how such collaborations can yield significant positives results for patients and professionals alike."

  Thanks so much, Pat. I think we should  expand your critique of technological reductionism beyond psychiatry and apply it to all of medicine.

  Sad to say, most doctors ignore Hippocrates' precious advice from 2500 years ago: "It is more important to know the patient who has the disease than the disease the patient has."

  Knowing the whole patient has taken a back seat to knowing the patient's lab values. Most doctors barely talk to (or even look at or touch) their patients in the brief and cold contacts that now pass for a medical visit. They are too busy focusing on the computer screen and ordering an endless battery of often unnecessary and sometimes very harmful tests.

  The result of any purely technological medicine is bad medicine- one that loses the patient in the profusion of procedures and treatments.

  Seeing one movie will illustrate this folly much better than reading a thousand of my blogs. I heartily recommend that everyone view Paddy Chayefsky's 'The Hospital' - the most brilliant and biting and hauntingly funny depiction of all the medical wrongs that can occur when a patient loses his identity in the maze of simple minded technical virtuosity.

  Psychiatry is still by far the most human and humane of the medical specialities. But it too has been handicapped by the privileging of its still inadequate science base over its enduring foundation in the art of human relationships.

  It will be likely be many decades before neuroscience has any dramatic impact on psychiatric practice. The breathtaking complexities of brain functioning will continue to defy quick and easy answers.

  Meanwhile, we have patients who need help and we have the tools to help them. Some of these tools are technical and specific (meds; CBT); but even these work best only in the context of a rich therapeutic relationship that is based on all that makes us human.

  Pat has pointed the way back toward a full bodied, big hearted, mindful, and patient based psychiatry- the kind Pinel taught us to practice and that Pat himself embodies.

When Is It Justified To Force Treatment On Someone?

  Some would shout a resounding, impassioned, all inclusive, Never! No psychiatric coercion, not ever, not even under the most seemingly urgent of circumstances.

I once put the question to its supreme test- thirty five years ago while having dinner with Tom Szasz. Tom was the probably the greatest defender of patient rights since Pinel (the father of modern psychiatry who, two centuries ago, started the profession off on the right foot by releasing the mentally ill from their chains). 

  Tom's landmark book 'The Myth of Mental Illness', written one half century ago, contained a crusading bill of rights for psychiatric patients. He argued passionately for the dignity and freedom of choice of mentally ill inmates who were then often warehoused for life in hospitals that were aptly compared to snake pits.

  Tom's childhood experiences under the repressive, fascist government in Hungary had shaped him into a radical libertarian and staunch defender of the categorical imperative to protect at all costs the right of the mentally ill to make their own decisions- even if they made bad ones.

  Well maybe 'not at all costs'. I posed to Tom a hypothetical in which his son was having a transient psychotic episode, was hearing voices commanding that he kill himself, felt compelled to act on this, and refused treatment. As a father, would you stand by your libertarian principles or protect your son from himself, even if this required coercion. Tom smiled ruefully and said: 'I am a father first and protector of human rights second."

  I recall this episode now for two reasons. First, I am in the midst of a wonderful exchange with Eleanor Longden trying to find common ground between psychiatry and those who have rightfully questioned some of its current practices.

  Second, the recent mass murder in Washington DC was likely triggered by voices and delusions in someone who had not received adequate treatment. Elsewhere I have explained why gun control can't possibly work if restricted to the mentally ill. But the question here is whether forced treatment would be justified in someone having such clearly dangerous psychotic experiences.

  Tom Szasz was much honoured during the fiftieth anniversary of the publication of his book and then died recently at the age of 91. I think I know how he would answer the question, but can't be sure. He remained strongly libertarian to the end, but always had more common sense than his most fervid followers.

  In Tom's stead, Eleanor Longden is well situated to take on the haunting question of how best to balance individual liberty and dignity on one side; with individual and public safety on the other. She is a prominent defender of patients' rights and was herself the victim of harms done by coercive psychiatric treatment.

  In our last joint blog Eleanor wrote: "What we [the Hearing Voices Movement] emphasize is something often missing in mainstream mental health: choice. We believe that people are experts in their own experience; that meaning should not be coercively imposed by outsiders."

  I asked Eleanor to tackle the difficult problem posed by the hypothetical case I presented to Tom and the real one presented by the Washington DC mass murderer. Would her support of the ideal of patient freedom be flexible enough to deal with pressing practical exigency.?

  She wrote: "Mental health services have not demonstrated reliable, consistent rationales for predicting or pre-empting violent behaviour, and as such the Hearing Voices Movement has been critical of blanket strategies that attempt to justify chronic, politicized forms of coercion."

  "Nevertheless, we recognise that emergency treatment is necessary on occasions and, if managed well, can be a means of healing, positive outcomes for both distressed individuals and their communities. The likelihood of this increases exponentially if involuntary treatment is done in a 'harm-minimization' way that respects the dignity, needs, and safety of the person concerned, where the use of physical force is kept to a minimum, and when it is implemented as a last resort when more collaborative strategies have failed."

  "Otherwise, an already distressed person can be left feeling even more traumatized and disenfranchised, less motivated to engage with support, and less likely to disclose troubling experiences- all factors which elevate future risk."

  "What we also advocate is being very proactive from the outset in trying to de-escalate crisis situations before they happen - for example, supporting the person to reclaim power dynamics with destructive voices, seeking ways to manage overwhelming emotion, and promoting a sense of choice and autonomy."

  "Positive risk-taking is a necessary part of recovery- in fact it's what distinguishes active recovery from passive maintenance models - and to do this successfully requires active partnership between the client, mental health/social service professionals, friends and family members and, as activist and former nurse Karen Taylor says, 'practicing from a place of freedom rather than fear.'"

  Thanks again, Eleanor. Involuntary treatment is perhaps the most contentious source of dispute between psychiatry and its critics (especially former patients who were forced into treatments that were harmful to them).

  In our previous blog, Eleanor Longden and I succeeded in finding surprising common ground on most of the issues that might seem to separate psychiatry and recovery. In this blog, we come to similar agreement on this, perhaps the most difficult question of all.

  Where bright lines are difficult to draw, common sense and good will must prevail. Granted that allowing the necessity of any coercion is a slippery slope, but never applying psychiatric coercion even under extreme circumstances can both be dangerous in the short run and result in much worse coercion in the longer run.

  As Eleanor points out, psychiatrists cannot predict violence with any precision, but some situations are explosive enough for anyone to identify as an obvious call to action. Someone has to stand in for a patient who has become clearly dangerous to himself or others. Not to intervene when catastrophe is so tangible would be irresponsible on the part of the professional and would ignore what the patient would want done if he were not impaired by the psychotic symptoms.

  The majority of patients who do well come to recognise the necessity of the intervention and are thankful for the protection it afforded. Advance directives are a useful way to handle the risk of future recurrence.

  Those who fare poorly are much less forgiving. Their outrage is always understandable and also is completely justified if the coercive treatment was unnecessary and/or second rate. But there are some situations that are so obviously dangerous that coercion is necessary, even if the outcome can't possibly always be satisfactory.

  And the type of coercion that is most harmful for the mentally ill has changed dramatically since Tom began his career. Fifty years ago, the dread was long term involuntary commitment to psychiatric hospital. Now the risk is prison, usually for nuisance crimes that were completely avoidable were there adequate community treatment, support, and housing.

  The numbers tell the tale- a million psychiatric beds have been closed; a million prison beds for psychiatric patients have been opened. We have experienced a dreadfully coercive trans-institutionalization, not the hoped for reduction of coercion that was the goal of deinstitutionalization.

   Coercive psychiatric treatment is now relatively rare; prison coercion all too common. Getting into a psychiatric hospital is extremely difficult and stays are usually about a week. Being jailed is easy and sentences are long. Patients should not be prisoners. We all need to advocate for the end of this barbarity.

  Eleanor and I come to these issues from opposite experiences, but converge closely in our understanding and conclusions. For both of us, ideology is much less important than common sense solutions. The mentally ill have many unmet needs and suffer from great and undeserved coercion. Those of us concerned about their welfare must unify our efforts and stop the silly bickering that solves nothing and helps no one.

 This could be one of my most important blogs. It is an attempt to find common ground between psychiatry and the Hearing Voices Movement (HVM) - a growing international grassroots effort to help people find meaning in their troubling experiences.


The dialogue began when Eleanor Longden gave a wonderful TED Talk (The Voices in my Head) viewed nearly a million times since its release last month.
 The editors at Huffington Post then asked me to comment on her talk Psychiatry and Recovery: Finding Common Ground and Joining Forces.



I was enormously impressed by Ms Longden and have always looked favorably on the HVM, but did express the concern that some viewers who really need psychiatric medicine might misinterpret her talk as an invitation to stop taking it.
  There has since been a productive back and forth on the relationship between psychiatry and recovery. See the Open Letter to me from members and supporters of Intervoice, the organizational body of the HVM and my response.
  Along the way, Eleanor and I began an enjoyable email correspondence that made clear to both of us how like-minded we are. Here are her thoughts and my summary of our agreements:



Ms Longden: "As Allen says, there is considerable overlap in our perspectives, and Intervoice respects and supports his work in highlighting the dangers of over-diagnosis and over-medication."


"Many Intervoice members receive support from mental health services, and we have always encouraged respectful partnerships and alliance with mental health professionals of all disciplines (for example the co-founder of the HVM, and the current Chair of Intervoice, are both psychiatrists).   And I personally discovered the HVM via an extremely creative, empathic psychiatrist whose patient I was at the time."



"Intervoice likewise recognizes that many people find medication helpful and advocates for informed choice following honest, open discussions between patients and prescribers about the benefits and limitations of psychiatric drugs."



"Essentially, we support people to find solutions that are meaningful and useful for them, and our emphasis is on propagating choice and good information."



"Clearly, people have been helped as well as harmed by mental health treatment, and while we critique and question the practice of some psychiatrists, we have never located ourselves as an 'anti-psychiatry' movement."



"Intervoice does, however, object to reductionistic biomedical mindsets; especially in our approach to voice-hearing. While we acknowledge that hearing voices can cause extreme distress, we consider it a meaningful experience that can be explored and understood (an opportunity for learning and psychological growth, even if the lessons are painful and difficult) rather than just a pathological symptom devoid of context."



"We emphasise research that locates voice-hearing (and other classic indications of psychosis) as the result of life conflicts and difficulties. Correspondingly, we question the dominance of therapeutic practices derived solely from biomedical models."



"What I endured so disastrously was the application of a reductionistic biomedical model that is practised in numerous hospitals in the Western world. Voice-hearing was seen as a meaningless symptom of disease - leading to coercive, over-zealous prescription practices, the privileging of biology over psychosocial circumstances, and the overstating of medication's effectiveness whilst minimizing both its limitations, and the hazards of long-term use."


"Intervoice's approach is not a therapeutic model. At its heart, it is about solidarity and social justice. It emphasizes the right of individuals to hold their own beliefs about their experiences and recognizes that, whatever their cause, these are personally meaningful. We believe in the possibility for positive coping, whole-life recovery, and learning to listen to voices without torment and distress. No one is 'too ill' to benefit."


"We use diverse strategies to promote change, including self-help groups, recovery and coping models, psychosocial formulation, social/political activism, narrative approaches, and sharing hopeful, positive information."


"Just like traditional psychiatric models, Intervoice's approach does not suit or appeal to everyone. We see that every recovery story is unique, and never advocate for restrictive, 'one size fits all' policies."


"What we emphasize is something often missing in mainstream mental health:
choice. We believe that people are experts in their own experience; that meaning should not be coercively imposed by outsiders. Those who are distressed by what's happening to them should be treated as active partners in seeking solutions."


"For example, people who come to voice-hearing self-help groups endorse a broad range of explanatory frameworks for the voices they hear. We support people to make sense of what's happening to them, listen to their stories, explore what their beliefs mean to them, and offer support and input in working towards healing and recovery; but no one is told their beliefs are 'wrong,' and no one is turned away."


"Too often, these choices are withheld in traditional services. A final, crucial aim of Intervoice is supporting people to have positive identities as voice-hearers."


"In mental health there are groups perceived as great medical organizations, or great therapy organizations, or organizations excelling in research. To me, Intervoice and the HVM it represents, is a great humanitarian organization, reaching out across the world."


" I first encountered it as a traumatized, demoralized patient, and through it discovered aspirations that transcended notions of 'cure': to envisage and enact a society that understands and respects voice-hearing, which supports the needs of those who hear voices, that values and protects their citizenship, and which promotes a liberating space to feel pride, dignity, empowerment, and a voice that can be heard."


Thanks, Eleanor. We are in complete agreement on all the following points:

• 
 We both believe there is no one size fits all way to understand and deal with hearing voices.

• We both agree that medication prescribed appropriately and collaboratively can be necessary and helpful for some people; and when prescribed inappropriately can be excessive and harmful for others.

• We both agree that voices (just like dreams) are meaningful experiences that are informative about both internal psychological conflicts and external life stresses - and are not just a pathological symptom devoid of context.

• We both believe in the value of individual resilience and fortitude in listening to, learning about, and coping with voices.

• We both believe in hope, courage, and that no one is 'too ill to benefit.'

• We both believe that treatment relationships should be collaborative
partnerships.

• We both believe in the important role Intervoice has played in supporting those who are struggling with voices.

• We both believe that psychiatry done poorly follows a narrow biomedical reductionism, while psychiatry done well benefits from an inclusive and humanitarian model that integrates biological, psychological, and social factors.

• We both believe in active advocacy for those who are badly under-served, unsupported, and stigmatized in so many parts of the world.


Thanks, Eleanor. This exchange has been a great pleasure and I hope contributes in some small way to greater interaction and synergy among all of us who are trying to do our part to relieve emotional and mental suffering.