“Saving Psychiatry” – Dr. Joe’s Blog

The Case Against Randomized Controlled Trials – An Initial Foray Existential Psychoanalysis: Is It Art, Science or Self Healing Miracle?

The Case Against Randomized Controlled Trials - An Initial Foray Existential Psychoanalysis: Is It Art, Science or Self Healing Miracle?

“… the tyranny of randomized controlled experiments…” (David Brooks, New York Times, October 8, 2018)

“… Science Without Humanity…” is 1 of the 7 deadly sins of Mahatma Gandhi

“Most clinical research is not useful.” (John Ioannides, MD - https://www.youtube.com/watch?v=Uok-7NPFn4k)

“… it is essential that psychoanalysis be situated as an existing practice within the art of science… a controlled randomized comparison study has not been conducted…” (Dr. Aida Alayarian, J.A.S.P.E.R. International, 2018 Vol 2, Issue 1)

When in confusion about good and evil, it is often helpful to turn to Nazi atrocities for clarification. Although the Third Reich did not/has not cornered the market on “bad,” they were expert and like many clever evil doers they sucked in those with an insecure hold on their own morals. They did many heinous “experiments” but the most famous was the Dachau hypothermia experiments. Robert L. Berger, MD examined these experiments (see “Nazi Science – the Dachau Hypothermia Experiments, NEJM, 1990, Vol 322:1435-1440.) The experiments were directed by Sigmund Rascher, a deadbeat Nazi with no experience in scientific research who wanted to impress Himmler. The debate has been: given the unethical malice of the experiments – at least 80 of the 300 “volunteers” died – should the data be used anyway in the hope that they, the data, at least might contribute to scientific knowledge? Allegedly Dr. Rascher wanted to find the best way to re-warm soldiers and pilots who were subjected to cold water i.e. sinking ships, crashed airplanes. In sum (I’d rather not give details of the sickening experiments) Dr. Berger demonstrates the scientific uselessness of these experiments: “…critical shortcomings in scientific content and credibility… without an orderly experimental protocol… with inadequate methods and an erratic execution… riddled with inconsistencies… data falsification and… fabrication… [unsupportable] conclusions… a consistent pattern of dishonesty and deception… all the ingredients of a scientific fraud…”

But, there is a problem here for me. There is the implication that if Rascher had not been a medical nincompoop, had been a serious intellectual, had adhered to coherent scientific protocol, maybe then the data would pass muster, putting aside the obvious ethical lapses – clearly these were not “volunteers” fully informed about risk! My contention is that science without humanity is not only a “sin” but it is useless. As David Cohen and David Jacobs point out, Randomized Controlled Trials (RCT) of antidepressants are “clinically and scientifically irrelevant” (see Cohen & Jacobs (2010). Randomized Controlled Trials of Antidepressants: Clinically and Scientifically Irrelevant, The Institute of Mind and Behavior, Inc., 31:1,2, pp. 1-22; & Jacobs & Cohen (2010). The Make-Believe World of Antidepressant Randomized Controlled Trials — An Afterword to Cohen and Jacobs. The Institute of Mind and Behavior, Inc., 31:1,2, pp. 23-36).

I believe this goes for all RCTs.

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PLACEBO IS A BASTARDIZATION OF SELF HEALING

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Cohen and Jacob's critique, however, focuses on the design of the studies, the capriciousness of the medical diagnostic category model, and the toxicities of drugs. They also make clear that the RCT model tries to “stamp out high placebo rates rather than reveal their clinical implication.” (p 1) Let me say more about this because here is where my bias is most pronounced. The premise of the RCT method is if you completely fool/trick the subjects (e.g., in the antidepressant drug experiments), then the experiment is worthwhile, i.e., the subject does not know if they got the real drug or the sugar pill. Of course there is a relatively easy way to do that. Simply use an active placebo rather than sugar pill. Big Pharma will not do this because efficacy of the drug disappears when using an active placebo. Fooling and tricking the subjects, in my estimation, is not ethical, even if you tell the subjects in advance that they will not be told whether they are getting the real thing. There is some evidence, by the way, that placebos often work even when the subject is told that they are receiving a placebo (personal communication, Irving Kirsch, ISEPP Conference, Toronto, 2018). Evidently some people find the ritual of taking a pill beneficial.

So what exactly does a placebo activate? I would say self-healing or better yet, inter-self healing. My position then is that using placebo with its implication of trickery is unethical. Placebo is a bastardization, I believe, of the biological mystery of self-healing. I have often opined that my patients get better in the waiting room. The decision to take on their suffering in and of itself has healing power: the will to live, a hope that past traumas can be tamed, that honest dialogue with an expert all promote healing, self-acceptance and self-care, social integration, building self resiliency. I recently attended a Harvard course on Psychiatry and Neuroscience with more that a dozen psychiatrist and neurologists wedded to the medical model. It was not my cup of tea. They did not attempt to define either consciousness or will, for example, and repeatedly made associations of brain connection with behavior and mood. Cogently one presenter said, “In the brain everything is connected to everything,” indeed! But one truth that we all shared was that a principle “side effect” of antidepressants was “apathy.” So if you maintain an existential philosophy, as I do, this is the killing power of drug treatment. Without the will we don’t heal. The higher power is not the drug or the analyst or a god but rather the biological miracle of self-healing promoted by inter-self dialogue. Some call it psychoanalysis.

“I Want To Die” – Take 2

"I Want To Die” - Take 2


In my previous commentary concerning suicide (see July 21, 2017) I made the point that even though suicidal thinking is quite common, actual suicidal death is not; it’s only 1.5% of all deaths in the U.S. (2015 statistics). One “expert” (I’ve forgotten who it was) claimed it was 250 thinkers of suicide to 1 doer. It’s even greater than that when one realizes that suicidal thoughts are often camouflaged. “I’m sick and tired…,” “I hate my life,” “Life sucks!” But WOW does suicide make headlines, particularly when the rich and famous do it: of late, Anthony Bourdain, the world-traveling chef/social commentator, and Kate Spade, the billionaire handbag entrepreneur. Both hung themselves. Why so much interest? Well, perhaps it’s as in the old Broadway song from Camelot “What do the simple folk do?” Well, “They sit around and wonder what Royal folk would do!”

No, there is more to it.

We are shocked, I think, because: (1) we project on those who seem to have everything (fame, fortune, beauty, brilliance) great happiness, and (2) we (the public) tend to see suicide as a consequence of mental illness. Thus, “We didn’t know that _____ was mentally ill!” There is a dearth of existential thinking in our culture. Our fascination with suicide has really more to do, I think, with our perplexity about life. WHO AM I? WHAT AM I DOING HERE? Facing meaninglessness and/or chronic pain is or can be tortuous.

99.9% of the time suicide is a very private affair. The suicide takes place alone in a hotel room, behind the shed, the privacy of one’s own room, or home when everyone has gone out. The other 0.1% is a grand performance usually to make some profound statement. I recall with horror watching on TV the Buddhist monks in Vietnam self-immolate to protest the goddamned WAR! More recently, a gentle person, environmentalist, David Buckel, on April 14, 2017, imitated the Buddhist monks this time in Prospect Park Brooklyn: “My early death by fossil fuel reflects what we are doing to ourselves,” he wrote in his final email. Perhaps as therapists we must always be looking for the underlying message, whether it be a socially redeeming commentary or a “Fuck YOU to all who hurt me!!”

Steve Pinker in his new book Enlightenment Now: The Case for Reason, Science, Humanism and Progress ( 2018, Viking Press) takes on the issue of happiness (see chapter 18) and examines the suicide rates of three countries for which there is the best historical data (US, Switzerland, England). There are various peaks and troughs these last 150 years with all three countries showing the highest rates during the Great Depression (Switzerland ~25.6/100,000; US ~17/100,000; England ~20/100,000). He has no explanation for the current bump in the US suicide rate from about 10 in 1960 to about 11 in 2000 to about 13 currently. Nor does he find evidence of an increase in depression. We really can’t use the disability numbers because there are economic incentives to declare oneself depressed. The current psychiatric profession helps this along by being quick to diagnose this “brain disease.” Nor is there evidence of any increase in serious mental illness or for that matter of loneliness. And although he feels Americans“should” (page 284) be happier given how “amazing our world has become” he also acknowledges that the increase in anxiety is not pathological. In fact, “anxiety has always been a perquisite of adulthood.”

So, my worried friends, family, colleagues: welcome to maturity.

My Country ‘Tis of Hate

My Country 'Tis of Hate


Coincidence. I read with horror the NY Times exposé by Ron Nixon and Michael D. Shear, “Over 700 Children Taken from Parents at Border” (April 20, 2018) within a few hours of starting to read D. H. Dilbeck ‘s biography “Frederick Douglas, America’s Prophet” (2018 Chapel Hill Press). “The mere whim of a master could separate forever a child from his family,” (p. 13) Douglas is quoted from his autobiography “My Bondage My Freedom.” Six-year-old Frederick was the beloved of his grandmother guardian, also a slave. She was ordered by her master, however, to give him up, and simply disappear from his life. "…granmammy gone! granmammy gone!" “Frederick franticly searched the kitchen. When he realized his grandmother had left, he collapsed in a fit of inconsolable tears. He sobbed himself to sleep that night.” This was the first of many “traumatic terror(s)” inflicted by slavery on Frederick.

We ISEPP members call ourselves a society concerned about “ethical practices” in the mental health field. We are expert in our understanding of the vicissitudes of Attachment and Separation. So, as experts, even putting aside moral and ethical principles, we understand the damage that America’s terrible immigration policies can inflict.


ISEPP members, should we not speak out?


It seems the administration fears that some immigrants commit fraud by using minors, not their own, to bolster their case for admission when seeking asylum from political violence. Alright. I understand desperate people will lie to survive. But our system of justice is based on due process, and as Ben Franklin once said, ”Better that a hundred guilty Persons should escape than one innocent Person should suffer.” This issue, I think, is related to those who criticize psychiatry’s power to commit a person deemed dangerous even if he has committed no crime. I am making a connection here. I am positing that what many members of ISEPP hate about psychiatry is not a psychiatry problem but rather an insidious social/cultural stain directly in contradiction of our avowed ideal that “all men are created equal.” The Eugenics movement of the late 19th century was essentially a continuation of a slave economy justified by the notion that Africans are inferior creatures. An illustration: In 1851 a physician, Samuel A. Cartwright of Louisiana in his book “Diseases and Peculiarities of the Negro Race,” proposed a disease entity, drapetomania, a running away mania, a particular disease entity of Negroes who ran away from their servitude.” The cure was “whipping the devil out of them.” (see Wikipedia, Drapetomania) Of course God is the source, according to Cartwright, of the righteousness of slavery, the white race domination of the black. Please note when our President demeans migrants fleeing for their lives, referring to them as murderers and rapists, he puts us all back into the scientism of the mid-19th century thus justifying their mistreatment.

ISEPP members. Should we not speak out against this madness?

Five Depressed Women, Depressed?

Five Depressed Women, Depressed?


What is depression? A state of being, a feeling, a diagnosis, an affliction, a disease? I find no easy answer to this question despite the fact that I am a so-called expert. As one learns more and more about a subject, any subject, one realizes how little one knows. For over 40 years I have been treating depression in my office. I’m not even sure “treating” is the right word. Maybe “sitting with” or “confronting” or “exploring” or “observing” or “struggling with” would be better terms. Clearly “curing” depression is a foolish notion. Everyone gets depressed in some way. Do we cure being human? So, allow me to explicate the mystery with some very recent on-going cases. Yeah, I know, “case”, such a medical term. Forgive.

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Do we treat people or do we treat diagnoses? I think the former!

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Woman #1: “J.” I saw J. with her husband several decades ago, a childless couple with difficulties not at all unusual: miscommunications, sexual complaints, nothing eccentric or peculiar. When they moved north with hopes of early retirement, they presented me with a lovely clock which I still have in my office, the clock that determines when “time’s up.” J. contacted me last year. Her husband had died of lung cancer 6 years earlier and now she was confined, because of a chronic neurological disease, to a wheel chair. She was forlorn. I encouraged her to get into therapy. I also told her I thought of her every day (an exaggeration) because of the clock. “You’ve made my day,” she exclaimed, really more of a whisper. She is unable to speak loudly because of her neurological condition. Six months later, she again contacted me, “There are no good therapists in the state of ___.” She asked me (begged me?) to have phone sessions with her. I agreed: a hard of hearing psychiatrist and a whispering patient. I did hear one statement clearly, “I’m lonely, so sad, all memories.”

Woman #2: “A.” I started seeing A. shortly after she got married. I initially treated her in combined individual/group therapy and then only in a weekly 2-hour group therapy session. She was a star in the group, beloved of the other members because of her skill in ridiculing the group leader (me), shining a bright light on my every shortfall, inconsistency, and therapeutic blunder. This fireball began falling apart – not a good idiom – a year ago as she approached her perimenopausal “change of life” – a rather useful idiom. A. switched from being highly psychologically-minded to being a woman obsessed with vague and, for her, frightening, physical symptoms: dizziness, headache-like fullness, constriction in her throat, loss of appetite, changes in sleep pattern (less sleep), increased sexual desire, tinnitus. She consulted doctor after doctor: acupuncturist, holistic, GYN, ENT, neurologist, internist. She peeked into her chart when the last physician with whom she consulted left the room. It said “Hypochondriac, refuses to take her antidepressant.” I told her I disagreed with the diagnosis. “There is an old-fashioned term,” I said, “It’s called ‘masked depression’ whereby physical symptoms mask the underlying emotional struggle.” “Well, dammit,” she retorted, the old fireball, “You have to help me figure out what is that emotional stuff!” Indeed.

Woman #3: “Y.” Y. came to my office once a couple of years ago. It was a painful experience for her, for me, and for her husband. Barely able to walk even with her walker, she struggled up the 3 steps to my office, cursing and complaining. We never got beyond the waiting room! She had a left-sided (right-brained) stroke 6 years ago; her family complains that this 83-year old woman doesn’t try hard enough to get better. Coming to my office for weekly sessions would be horrible (for patient and therapist). So, after convincing me to reduce my fee (I don’t participate in the Medicare program. see previous blog), I agreed to phone sessions. Every session begins the same, “I’m worse every day, I’m scared, it’s hopeless.” She never misses a session. She always thanks me at the end of a session. By most clinical measurements her case would be considered a therapeutic failure. It’s not. I validate her, I challenge her – “You’re another day closer to death” – I explore her unsatisfying, painful relationship to her long gone mother. I recommended a book, “Tuesdays With Morrie” by Mitch Albom. Morrie is/was (now deceased) an extraordinary character who decided to embrace his terminal illness, Amyotrophic Lateral Sclerosis; Morrie has become Y.’s ego ideal. So Y. makes baby steps toward coming to grips with death and the indignities of extreme disability. She wrestles with her rage and guilt and shame. I receive a check in the mail promptly, 2 days after every session, from her husband. Evidently, he too values the respite from complaint that the session provides.

Woman #4: “H.” Every session begins the same, “I’m possessed by the devil. I’m trapped in my body. I can’t take care of myself. I want to die.” She lives in an extended care facility, refuses to drive, and has not worked (as a dental assistant) for 6 years. She may be a victim of psychopharmacological poisoning. When she first sought help for “depression” from her GP and then a psychiatrist, she was drugged with antidepressants and neuroleptics. She developed a movement disorder, tremors, and shaking throughout her body. To my amazement, after reviewing her medical records, no one, including NIH mavens, considered this an iatrogenic problem. It was after or during a 6-week hospitalization at a prominent Maryland psychiatric hospital, that she decided she was possessed. It took me 9 months to wean her off of her drugs. Was this a dementia? I sent her for neurological and psychoneurological testing. The tester concluded that she had profound deficits in executive functioning, probably could not take care of herself, and had a “structural apraxia.” Brain scan, EEG, and neurological physical exam were all essentially normal. Embarrassed, not knowing the answer to a question that I should be able to answer as the expert, I asked her, “H., do you think your problem is physical or psychological?” “Both,” she answers. Why do I continue to fall for the body/mind split? It’s always both. Sessions with H. are bawdy and rambunctious, often singing silly songs. “Who you gonna call? Ghost Busters!” She’s very nosy, “What are you going to do this weekend,” she asks. “None of your fucking business,” I answer. Gales of laughter! I tell her, “You know what the devil hates?” “No,” she replies, “what?” “He hates it when you laugh.”

Woman #5: “L.” “You’re the first psychiatrist in 35 years who ever talked to us (she and her husband). They [other psychiatrists] would just check off the symptoms and write a prescription.” L. has suffered from panicky depressions since before her marriage, controlled (suppressed is a better term) by drugs. She had been prescribed more than 20 different antidepressants and neuroleptics. Finally, a year earlier, she paid the piper. The drugs stopped working. So, on to ECT X 18 treatments. - BTW, did you know that each ECT treatment costs between $2,000 - $2,500? You can make quite a nice living off of damaging the brain – No benefit. More enlightened members of her extended family found me through ISEPP. Because she lived 200 miles away we needed to set up phone sessions with monthly in-person meetings.

Have the drugs poisoned her? I don’t know. But what I know drugging has done is seduce her and her husband away from self-examination. For help in this case, I have referred to Bert Karon’s classic (I think) paper on treating depression with psychoanalysis without drugs. (“Recurrent Psychotic Depression is Treatable by Psychoanalytic Therapy Without Medication” Ethical Human Psychology and Psychiatry, Vol 7 #1, Spring 2005) This is not really a technical paper but rather an exhortation. Bert projects 2 not usual psychoanalytic qualities: persistence and optimism. These patients are “geniuses” he says in convincing therapists that their “lives are hopeless and therapy is of no value.” (page 46) He forthrightly counters their pessimism, telling them, (paraphrase) “If you cooperate, meet frequently (2 to 4 times a week) you will get better.” Further, he makes it clear that whatever they are feeling, anger, shame, sadness, that these are the result of real happenings in their life, conscious or unconscious, present or past. Bert makes only one mistake: “… patients are more likely to make optimal progress without the use of medication or with temporary medication which is withdrawn as rapidly as the patient can tolerate.” (page 45) On the face of it, this statement is correct. The problem is when someone has been drugged for long periods of time, one is (I am) never sure what is happening. Is the drug making them feel worse or better? Is withdrawal making them feel worse or better? Is a setback in therapy due to a therapeutic blunder or is the therapeutic intervention irrelevant to what the drugging or the withdrawal of the drugging is doing to the patient? To paraphrase Freud, “A toothache takes precedence over neurotic anxiety.”

My imperfect approach to this dilemma is to assure the patient that it is in their long-term interest to be drug free. While they’re moving through this arduous process, they must practice “good mothering” to themselves with regular exercise, meditation, gentle calming herbs, tea, and dietary supplements.

I’m Not a Healer – I Work for Money

I’m Not a Healer - I Work for Money


Recently a pissing match broke out in the last two ISEPP Bulletins between Ronda E. Richardson who does “peer support” and two of our most stalwart ISEPP members, Ph.D. psychologists Drs. Lloyd Ross and Burt Seitler. In a nutshell: Ronda is envious of her former psychologist who charged $200/hour whereas the going rate for peer support is $15/hour. She demonstrates her envy in the usual fashion, by showing contempt for her former therapist who “gives out purchased wisdom from the pages of a textbook.” Oh my! Burt and Lloyd seem to take umbrage at the idea they work for money and defensively bellow they were not money hogs as proven by the fact that at times they worked “pro bono.” They borrow this term from the legal industry where very, very wealthy law firms offer some free legal representation to worthy causes: makes good public relations and assuages conscience.

Ronda seems to equate psychotherapy to a strange kind of paid friendship. She is “bitter” and preoccupied with criminality: “paying the fines for someone else’s crimes indefinitely.” It’s not clear what she means by this. I suspect she has been traumatized and sought professional help for some sort of PTSD. Also, she seems to struggle with keeping a grasp on reality: “Nothing is real anymore,” she says. She makes it clear that her therapy was not helpful, maybe harmful. Evidently she eventually does get better but not with psychotherapy. Rather, she does her recovery by making intimate connections in her “training” and I would add, safely projecting her horror onto her former therapist. I guess Burt and Lloyd did not want to get involved in all this mishegas, thus their milquetoast response.

Allow me some obvious observations. Our organization eschews the medical model so what to do with medical insurance? If there is no such thing as a mental illness disease, why do we pay for mental health “treatments” out of the medical coffers? Some of us (I’m one of them) do not participate in “network” insurance programs including Medicaid and Medicare. The reasons are manifold: a hatred of paperwork; loathing a third party having anything to say about this very confidential undertaking. And certainly, most important, it irks me to have a third party dictate my fees. The fee should be only the purview of the two parties – patient and therapist. I gave up on Medicare, for example, when I treated a wealthy elderly man but had to accept the scaled down fee forced on me by the State.

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Quit therapy when you have something better to do with your time and money.

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Money, the root of all evil. What the Apostle Paul actually said is that the love of money is the root of all evil (1 Timothy 6:10). Paul was making the case, a Greek idea really, that spiritual life takes precedence over material wealth. It is also the Buddhist idea that attachment to anything material leads to suffering. Islam joins in with condemning the obsession with attachment to this life and worldly possessions rather than preparing for the hereafter with Allah, Most Merciful. But in all of these spiritual traditions, money per se is not condemned. It is how we relate to and use it that is of the essence. Jesus, for example, tells multiple parables having to do with money. But the emphasis he makes is on fairness, condemining cheating (including by tax collectors) and corruption, not money itself.

Money was invented 3 – 4,000 years ago. You can find a wonderful discussion of money in Yuval Harari’s Sapiens, a Brief History of Mankind. He tells us:

"Money is based on two universal principles: a. Universal convertibility: with money as an alchemist, you can turn land into loyalty, justice into wealth, and violence into knowledge. b. Universal trust: with money as go-between, any two people can cooperate on any project.” (p.186)

In therapy, the therapist should help the patient develop a mature attitude about money. It is clear to me that Ronda did not, unfortunately, ever get un-tortured about this wonderful invention.

About the title of this blog. At our last ISEPP conference, there was a movie shown, a documentary that scanned multiple parts of the world where there were approaches to madness quite unlike our approach here in the West. Shamans, medicine men, drums, incantations, exorcisms, dancing, gyrations, speaking in tongues. It was clear in these examples that the various “healers” were not in it to make a living. They were not "professionals". There were no credentials, no code of ethics, no confidentiality. These various cultures were engaging in what broadly we might consider the “spiritual,” casting out demons, imposing good spirits, etc. And they were not paid money for their efforts. I am quite uncomfortable when professional psychotherapists market themselves as healers. They are confusing modalities. Psychotherapy is many things, but at its root it is a disciplined exploration of what makes the patient/client tick. It is not other-worldly or supernatural. These are rules. It is not done to the patient but with the patient. And it costs money.

One final idea. I don’t work from a medical disease model. There is no cure if there’s no disease. So I am often asked, ”Well then, when should I terminate therapy?” My answer: “When you have something better to do with your time and money.”

Who are you and what are you doing here?

Who are you and what are you doing here?

So, you want to do the humanitarian thing, to treat people with respect, care, tenderness, empathy, understanding ? Good for you. Good for us. Good for ISEPP. Somehow, though, I think there is more to it than that.

I am an existential psychiatrist; we are a crusty lot. Our favorite subjects are:

Death
Isolation
Meaninglessness
Responsibility

 

You wonder why we need a drink at the end of the day?

“Yes, Mrs. Smith, you have a disease, an illness, a syndrome. We call  this condition  `being human`.” Some would say just “being,” but believe me (take care when someone starts his spiel with “believe me”) being human is special. I love dogs, cats, elephants, and Orca whales, but my best bet is they don’t think about the same things as I think about. OK, there is some overlap. They think about sex (at the appropriate time) and I think about sex any time. I think I am the center of the universe, all revolves around me and those creatures seem to share my self-centeredness. They do what they do to survive. So do I. Still, truly we humans are different. Why do I care about the Rohingya genocide in Burma or anti-women culture in Saudi Arabia? Why do I espouse such liberal taunts as “An injustice anywhere is an injustice everywhere?” Why do I care what is Dark Matter and Dark Energy? Why do I ask “why” so often? To be an existentialist is to take responsibility for my actions and my being even though I had nothing to say about “joining up” to life. Why do I seek meaning when clearly it is out of reach? Why am I capable of loneliness in a crowd? Why do I fear death in the midst of so much life?

Recently I read an interesting idea about cancer, the title of the article, “Why did God create cancer?” (Tedd Koren, Wise Traditions, Fall 2017, p 16, Vol 18, No. 3). The author gives a teleological explanation for cancer. Note: doctors are taught in medical school not to do this...not to think teleologically.  A teleological explanation  attempts to explain the purpose of a phenomenon rather than its cause. Koren’s argument:  malignancies are not the problem but the body’s attempt at a solution to cleansing the body of toxic substances such as pesticides and heavy metals. He cites Devra Davis’ work (“The Secret History of the War on Cancer”, NY, NY. Basic Books, 2001) which explicates the profoundly increased number of malignancies in toxic environments.  Dr. Davis also makes the case, unfortunately, that the so called War on Cancer actually followed the commercial interests of industry rather than the health of the populace. Also, Koren cites studies (Falck, F. Jr. et al. “Pesticides and polychlorinated biphenyl residues in human breast lipids and their relation to breast cancer. Arch Environ Health 1992; 47(2): 143-146. ) showing the heavy concentrations of toxins within cancers themselves. Oncologists miss the boat, he posits, as they focus on killing tumors which are the body’s filtering system. They should be focusing, instead, on detoxifying the person.

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Are biological psychiatrists like oncologist? Kill, kill, kill?
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Back to the original question, “Who am I, the existential psychiatrist, and what am I doing with this endeavor called “psychotherapy?” Perhaps we can think of psychotherapy as a kind of “filtering” system where the therapist in partnership with the patient filters out the toxicities within relationships: Interpersonal and intrapersonal  relations and the person’s relationship to his environment. The existential therapist also focuses on relationship to being itself. And, for good measure, the existential psychoanalyst focuses on relationship to the past.

Continuing with this metaphor: The biological psychiatrist is more like the current purveyors of oncology. The oncologist focuses on killing the tumor with toxic drugs, surgery, and radiation: slash, poison, burn. The biological psychiatrist attempts to kill symptoms with drugs and ECT. What I am positing is this:  The symptoms of mental and interpersonal anguish, depression, anxiety, delusions, hallucinations are the organism’s (the person’s) attempt to deal with, to cope with, to cleans, to filter, toxic-difficult conflict. The therapist is there to encourage and enhance this process, not kill it. We need more than empathy to do that. It also takes courage.

Breggin Fails in Court

Breggin Fails in Court


Remember folks, Peter Breggin is on our (ISEPP’S) side; so, when Peter fails, we fail. Or do we? How did we/he fail this time?


Commonwealth of Massachusetts vs Michelle Carter. Guilty of manslaughter


Michelle was found guilty of encouraging, coaxing, pushing her despondent boyfriend, Conrad Roy, to kill himself. Peter noted that in June of 2014, Michelle was actually encouraging Conrad to get psychological help, not kill himself. In fact she volunteered to go with him to work on her own problem, an eating disorder. She was then started on Celexa by her doc (she had been taking Prozac for years). By July 2014, a month into her new antidepressant treatment, Peter noted she had become -- transformed if you will -- apathetic, prone to bouts of mania, nightmares in which the devil told her to kill herself. In addition, according to the “Psychiatric Times,” September 2017, p. 13, Peter also testified:

[Carter] was enmeshed in a delusional system…really…a delusion where she’s thinking that it’s a good thing to help him die…[She] was unable to form intent because she was so grandiose that what she was doing was not to harm -- even though she was encouraging his suicide, her absolute intent was to help Conrad.

Well, the judge would have none of it. (Michelle chose not to have a jury trial.) When Michelle encouraged him to poison himself with carbon monoxide, there was no indication of an attempt to “help.”

This case bothers me. Although I am in Peter’s corner, railing against toxic substances poisoning the minds of vulnerable kids, I probably would have made the same judgment as Judge Lawrence Moniz. “The drug made me (her, him) do it!” is a slippery slope, particularly if you are of an existential bent as am I. We existentialists believe in personal responsibility. Note: Of all the drugs on the market, the drug causing the most violence is, you guessed it, alcohol. And alcoholic intoxication is not a defense in a court of law. 


So many culprits in this case


Yes, I know alcohol intoxication is quite different from taking a drug prescribed by an “expert.” When we drink alcohol, it is on our own recognizance.

But, isn’t it peculiar that pregnant women are warned that alcohol might be injurious to the health of the fetus but there is no black box warning indicating that alcohol might impair judgment, remove social inhibitions, lead to violent actions towards others or oneself?

What interests me is: WAS MICHELE EVER WARNED that Celexa could impair her moral judgment? How did the prescriber counsel her? Was she told that apathy was a possible effect? Most of all, the question is still open – where does personal responsibility end and professional responsibility begin? It is here that I am sympathetic to Judge Moniz’s decision. He is called upon to pass judgment on the person, not the system. There are so many culprits in this case: the careless prescribing physician; the corrupt pharmaceutical industry; distortions promulgated by the profession of psychiatry; the negligent families of each of these kids; society, with its futile dependence on pseudo-technical solutions to psychologic/spiritual problems. Michelle and Conrad were the end point of myriad influences. Conrad is dead. Michelle will do some jail time. Maybe she’s wiser. Are we?

Let’s clarify something. It is a mistake to think that patients always follow doctor’s orders. There are very persuasive accounts in the literature that the opposite is true, particularly when it comes to antidepressants.

Some examples:

  1. From Sawada, N et al. Persistence and compliance to antidepressant treatment in patients with depression: A chart review. BMC Psychiatry 2009:38. “In this retrospective chart review, 6-month adherence to antidepressants was examined in 367 outpatients with a major depressive disorder (ICD-10)… Only 161 patients (44.3%) [!] continued antidepressant treatment for 6 months.”
  2. From Warden D et al. Identifying risk for attrition during treatment for depression. Psychother Psychosom 2009:78:372-379. “The attrition rates in the first 12 weeks of treatment can be as high as 65% [!] in naturalistic setting (2,3,4) and 36% in clinical trials [5] and as many as 15% of the patients never begin a prescribed antidepressant [6].”
  3. From SansoneR.A. et al. in “Innovations in Clinical Neuroscience,” 2012. P41-46, “…approximately 50% of psychiatric patents and 50% of primary care patients prematurely discontinue antidepressant therapy…”

My sympathy goes out to Michelle and to Conrad’s family. I can’t explain why Michelle did not toss the drug down the drain, not wanting the effects that may have contributed to Conrad’s death. Often one’s desire to escape psychological pain has dire consequences. Is that what happened to Michelle Carter? “Die Conrad, I don’t want to feel your pain any more.”

VA Damage Control: The VA Has Been Infiltrated!

This is an actual letter I mailed recently to help raise money for my veteran patient . Identifying information including the dog’s name, has been changed.


 

 

September 1, 2017

To Whom It May Concern:

Re: Skip Sullivan, Honorably Discharged Veteran
DOB: Too Young

VA’s Failure

Skip was referred to me by Sally H, Visiting Nurse for Veterans, Camp X, the South. He flew here to the Washington, DC area because he was informed by Colonel Sharon Z. founder of HELPFOR VETSUSA that I could help him.

Two deployments to Iraq, the deaths of a dozen comrades by enemy fire and by suicide, two suicide attempts himself, as well as musculoskeletal damage due to an enemy IED. You would think that would all be enough for him to deal with: psychological trauma, moral injury, the gut of war. No! His principle dilemma now is iatrogenic. Skip lost count after 40 different drugs had been prescribed for him over the last 7 years. When he arrived at my office on August 17, 2017, he was on high doses of nine different drugs all of which have had profound adverse reaction impact. Before arriving at the VA for medical care in 2010, his vision was perfect, now impaired. Before arriving at the VA he had normal GI functioning, now impaired. Before arriving at the VA, he had normal sexual functioning, now impaired. Before arriving at the VA, although in psychological turmoil, he had excellent cognitive function and could emotionally feel authentically, now, “I fake feeling. I know I’m supposed to feel but I can’t.” And he nods off in the middle of substantive discussion.

Skip flew 1500 miles from the MidWest because he could find no doctor with the will or the knowhow within the VA system to wean him. Be clear. Although I am an “expert,” I made it clear to Skip the complexity of dozens of psychotropic drugs interacting is BEYOND KNOWABLE. Without any guarantees, Skip and I have entered into a struggle, requiring daily monitoring and extraordinary help from his fellow vets, a different vet showing up each day to bring him along with Charlie, his companion dog, to my office since it would be dangerously foolhardy for him to drive himself.

What’s the big deal? Just stop the drugs! Well, stopping these drugs cold turkey would be inviting mortal danger. The body and all its systems, neurological, gastrointestinal, cardiovascular, adapt to the onslaught of these potent substances with a myriad of potential adverse reactions. Abrupt withdrawal would be like blowing up a dam, psychologically flooding – overwhelming the organism. It must be done slowly. Unfortunately, it is also painful. It takes courage, “I’m willing to put up with the pain if I can just be normal again.”

Why all the drugs? Thousands upon thousands of veterans are going through this. I believe the difficult answer to this question is that the VA has been infiltrated with self-defeating, and what I consider odious ideas about what it means to have suffered the damage of war battle. Pathologizing these returning warriors rather than accepting, hearing, understanding, and supporting their terror-filled experiences drives them further into misery, e.g., as soon as the idea of “suicide” is mentioned almost invariably the VA physician reaches for the prescription pad. And as the veteran experiences the first adverse reaction, the second drug is added, then the third, the fourth, etc. In time there is utter confusion about what is “real” and what is drug-induced. The chance then of finding a remedy becomes less and less.

So I will work with Skip this next year, seeing him frequently, daily when necessary, doing the necessary testing (e.g., he is probably Mg depleted as his GERD caused by one of his many drugs is being treated with yet another drug, a proton pump inhibitor (PPI), which potentially depletes this essential element. Note, he has been on this drug for more than six years while the recommended length of time to use PPIs is about three months!) and, most importantly working psychotherapeutically, existentially, spiritually as he comes to grips with war trauma. Ultimately, his goal is to help other vets. I believe he’ll do it.

Finally, Nurse Sally is paying for his treatment out of her own pocket. I am giving her some discount. This is a travesty! The government agency that has so poorly treated this veteran does not now take the responsibility of paying for the treatment that he had to seek out on his own. As an American, I feel shame and I am disheartened.

Sincerely,

Joseph Tarantolo, MD

Board Certified Psychiatrist

 

 

“I Want To Die”

"I Want To Die"

If you are a psychotherapist, counselor, psychoanalyst, and especially if you are a psychiatrist, you have heard variations of this refrain many times, which has soullessly come to be called "suicidal ideation". “I don’t want to live anymore… I want to kill myself… I wish it were all over…," etc. What to do with these laments?

Before I address the question, a personal note. I am 74 years old and I’ve been depressed many times. I have never had ETC or pharmacological intervention. I worked on the “depressions” the old-fashioned way. Reflection. Talk. Analysis. Struggle. My bias is that I don’t trust colleagues who claim they have never been depressed. Really? Never depressed? I don’t prescribe ECT either. I’ve witnessed only one ECT administered and that was during my training. OK, I got that off my chest.

Back to suicide talk. In Tom Szasz’s last book, Suicide Prohibition: The Shame of Medicine, (see my book review in Ethical Human Psychology and Psychiatry, Vol. 14, #1, 2012, pg. 74) he makes a powerful case that by locking up patients who speak about self harm we not only infringe on their civil liberties, but also drive that speech underground.

Think of it, if someone tells me they are suicidal I am duty bound to call the cops! An exaggeration, but not much of one. Hospitals and doctors are frequently sued by surviving families. “You should have been more attentive, careful, protective. Had you not been derelict my son/daughter/wife, etc., would still be alive.” So hospitals and clinics and counselors always have on their checklist a rating for self-harm. That checklist surely is for legal purposes. Or perhaps it is there for reassurance for the institution.

You would not be surprised, I suspect, that some in conventional psychiatry would promote, then, their various somatic treatments as suicide preventative. Allow me if you will to focus only on ECT. This blog is not going to be a diatribe against ECT. If you are hankering for an “I-hate-ECT" thesis, read Linda Andre’s Doctors of Deception: What They Don’t Want You To Know About Shock Treatment (2009, Rutgers University Press). She claims that ECT “impaired my intellect” (pg. 131) and did irreparable harm to retrieving her early life memories. She rakes the ECT profession over the coals.

If you are in a particularly angry mood you’ll like Andre’s book. She bashes Peter Breggin as well calling him a “costly disaster “(pg. 118). Evidently the Marilyn Rice case way back in 1977, the first case to adjudicate a malpractice suit against an ECT Doc for memory loss, did not go well for the plaintiff. Breggin was Rice’s expert witness. I’ve never discussed the case with Peter. I assume it is no easy task to prove that ECT treatment in one particular case is the cause of the memory loss. Do your own research. I’ll comment later.

Oh, but you may feel kindly about ECT. Then by all means read Edward Shorter’s and David Healy’s Shock Therapy, A History of Electro Convulsive Treatment in Mental Illness (2007, also Rutgers University Press) which they dedicate to a “small band of European emigres [who]… saw the merits in ECT… [they are] heroes in [the] 20th century of psychiatry…” (dedication page)

Shorter is a prominent medical historian and Healy was a presenter at the 2015 ISEPP Conference. Healy is the beloved psychopharmacologist of our organization because of his litigative efforts that helped lead to the black box warning for SSRIs. In his book Let Them Eat Prozac (2004, New York University Press) he takes on the fraudulence in the psychopharmaceutical industry that hid the danger of SSRI therapy. In his book he also shares some of the best work I know of in testing the impact of these drugs on “normals.” On the other hand he is anti-beloved by many in our organization because of his high regard for ECT. Nobody’s perfect. 

In Shock Therapy, Shorter and Healy toss a lot of statistics at us (see page 97) supporting their thesis that ECT prevents suicide. Maybe. “[There is]…no doubt that ECT was effective in the prevention of suicide. This was confirmed in 2005 in a large multi-center study led by Charles Kellner at University of Medicine and Dentistry of New Jersey.” The second of 16 authors this study was Max Fink, the father of American ECT. The authors hold out this study as particularly worthy to their cause. The conclusion of this very ambitious study is that it was “irresponsible" not to prescribe ECT sooner clinically, not as a “last resort” after the failure of chemical treatments. I had to read this study. After all, I don’t want to be “irresponsible.” But first, some statistics.

If you go to the American Foundation for Suicide Prevention website you are quickly smacked with the statistic: “An American dies every 12.3 minutes by suicide.” That is 42,773 in 2016. Wow, a lot of suicide. And, oh, BTW, 90% of them had diagnosable disorders. Thank God for the DSM to clarify difficult issues!

Hold on. Let’s put aside the hysteria. Just how many people did die in 2016? According to the National Center for Health Statistics that would be 2,626,418. That is, one American died every 12 seconds in 2016. I did the math. What did they die of? The usual suspects:

-Heart Disease: 614,348

-Cancer: 591,699

-Stroke: 133,103

-Alzheimer’s 93,541

-Diabetes: 76,488

-Flu and Pneumonia: 55, 227

-Nephritis: 48,116

-Suicide: 42,777

In other words, only 1.5% of those who died in 2016 were those who chose to die sooner rather than later. When talking about death in America, suicide is not common. Yes, of course it is often tragic, like a kid suffering bullying who can’t stand it any more. Tragic does not mean common.

Back to Kellner and Fink’s large multi-center (there were 5 hospital centers throughout the country) work. They “studied “ 444 depressed ECT patients, 131 of whom reported suicidalness according to the Hamilton Depression Scale. Results: after one ECT treatment, 15% dropped their Hamiltonian suicidalness to 0; after 3 ECT treatments 38% dropped their Hamiltonian suicidalness; 61% after 6, and 76.3% after 9 ECT sessions. And 87.3% dropped their Hamiltonian suicidalness after completing the treatment course. Wow, pretty impressive. No? Well I’m not convinced either. Remember the statistic – suicide is really not that common. Thinking about ending an unhappy life is very common. So let’s go to the fine print.

There were 2 patients in the study who died of suicide, 2 white men aged 76 and 80. One had expressed “no suicidal intent” before or after the treatment and the other scored a “1” before and a ‘0’ after the treatment. Thus this study only corroborates that ECT has a dramatic impact on stopping thinking about suicide. It tells us nothing about the actual action.

And this is why I don’t prescribe ECT. It interferes with thinking and remembering. For me it is more a philosophical stance than a medical-statistical position. I value thinking and remembering. Thinking about suicide is so common, so important, but actual suicide is so rare, it is my impression that suicidal thinking and dialogue in therapy is much more about life than it is about death. What I mean is that many unhappy people just don’t have the language to examine their unhappiness. The best they can do is, “I want to die, end it.” The therapeutic relationship helps give voice and create expressive language. Scrutinizing why someone is suicidal is important, ok. But really, we know why people want to die: despair, rage, hopelessness, pain, profound shame, abject loss. That needs to be validated of course. But as important, perhaps more important is what keeps us alive. So for me it is more important to ask, “What stops you? Why haven’t you done it?” And then I begin to hear about their life. That’s where the therapeutic action is.

I’ve had one completed suicide in my practice, that is, one who killed himself while in therapy. He never once talked of ending his life. Not once. I wish he had. If he had, he might still be alive today.

No One Cares About Crazy People

No One Cares About Crazy People.

Actually, that’s not true. Ron Powers, the author of the book with the above title very much cares about “crazy people”. It took him 10 years to write this book, a highly personal, well thought out, historically accurate and depressing book about madness in America. No, not madness in America, better to say the madness about madness in America. So why 10 years? Well, he had 2 sons, only 1 now. His younger son Kevin, who was diagnosed schizophrenic, suicided by hanging 10 years ago. The father has been stewing and grieving and questioning ever since, struggling to understand what happened. What happened not only to Kevin, but what will happen to his older brother, Dean, also diagnosed with schizophrenia, and what has happened to us, the mental health field. The subtitle is telling: The Chaos and Heartbreak of Mental Health in America. I am a psychiatrist so therefore I am part of that heartbroken mental health structure. Oh dear!

Powers does a particularly good job describing the tragedy of de-institutionalization, “a name that carried the lilting harmony of silverware spilling from a clean-up tray” (page 187). Nice metaphor. Indeed, liberals and conservatives were able to come together for once and completely make a botch of it. Liberals loved the idea of getting rid of inhumane state hospitals and conservatives loved the idea of getting rid of expensive state hospitals. Both could then pretend that community clinics would give out the new wonder drugs, some counseling, and madness would be contained. What happened instead was the mad were transferred to jails and out onto the streets. Powers is cognizant of Robert Whitaker’s work (Anatomy of an Epidemic) so he has some familiarity with the serious limitations of drugging madness. He is too impressed, I think, with genetic and neurological research, which he uses to try to deepen his understanding of his kids. I get it. A decent man, a devoted, loving father, how could this happen to my 2 brilliant, artistically talented sons?

“What is schizophrenia?” he asks (page 21). “So little is known abut schizophrenia that neuropsychiatrists and researchers hesitate to offer a definitive theory of causation.” So perhaps you now see the problem. He is thinking “brain” rather than “person". Madness or schizophrenia or whatever label you wish to use, is a person problem, the problem of the person not getting along. Wow, after 40 years of practice, Dr. Joe, is that the best you can come up with? Schizophrenia is not getting along? My mentors would be so disappointed in me.

Harry Stack Sullivan warned his colleagues, his patients, and his students, to beware of the seduction of the sense of individual uniqueness. No crazy person, no sane or normal person, no one has an absolutely unique psychological interpersonal problem. That is why AA, support groups, NAMI, Hearing Voices International, and group therapy, are such effective healing agents. “I am not the ‘Lone Ranger.’ Others are like me. Others like me seem to do OK. I am not alone.” But, there is no cure for being human. And to be human means to be up against never wholly fitting in. In fact, fitting in is an illusion.

We label the young men/women who seem to be seeing the world in some peculiar way, hearing and seeing stuff others can’t see or hear, believing their own set of “alternate facts.” They act out the not-fitting-in whereas the normals (an interesting name for a rock band – THE NORMALS) ‘go along to get along.’ We normals – I have never been labeled schizophrenic , I have been called a bunch of other names on some occasions – suffer more quietly, discretely, keeping it to ourselves: “Thank you so much for the invitation. I will not be able to attend your gathering because of a previous engagement.”

If you haven’t read Freud’s Civilization and Its Discontents, I recommend it. The “death instinct” he postulates is not, I believe, to be taken literally. He is talking about the yearning to rid ourselves of anxiety. Being dead is really the only way to be anxiety free. To be a person, a unique creature, with common struggles must contend with anxiety, that felt experience anticipating disapprobation, rejection, and abandonment. And we do deal with it, sometimes constructively, sometimes foolishly, sometimes with deadening drugs, and sometimes with suicide.

God be with you!