“Saving Psychiatry” – Dr. Joe’s Blog

“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!

Mind/Body Argument: Stop It, Just Stop It!

If you are not sick and tired of the question, “Is MADNESS a neurological disease of the brain or is it a mythological disease of the mind?” you should be! I defy you to have a thought without your body or to work your body without a brain. There is no mind/body split. And the countless scholarly papers regaling us with the proofs of how schizophrenia is a disease of the brain and not the mind or that schizophrenia is a disorder of the mind and not the body (remember, the brain is part of the body), well, to my mind they are all for naught.

Some historical perspective: There is a 1924 paper in the American Journal of Psychiatry, authored by the then prominent pathologist, Charles B. Dunlap, M.D., entitled, “Dementia Praecox. Some Preliminary Observations from Carefully Selected Cases, and a Consideration of Certain Sources of Error”. I reviewed this paper because one of my favorite mentors, Harry Stack Sullivan, who died in 1949 when I was 6 years old, referred to it when making the case that schizophrenia is NOT a brain disease.

Read the very first sentence of the paper: “Too many changes have been described in [autopsy] brains of dementia praecox even to be enumerated in this paper” (p. 403). He continues on page 404: “We have considered control brain [autopsy] material, collected from so-called normal persons [italics mine] without psychoses to be absolutely necessary…. No one knows the limitations of what is normal in the brain anyway…. Nissl [a prominent pathologist] who all his life was searching for a normal brain, died without finding one…”!!

Suffice it to say that Dr. Dunlap was not able to find any consistent gross or microscopic (cell counts & cellular pathology - pain staking work) abnormalities in these schizophrenic brains to warrant "an organic [my italics] basis for dementia praecox.” Thus, H.S. Sullivan was satisfied he was not dealing with neurological issues in his schizophrenic patients.

What interested me even more, though, was what was said in the discussion of the paper by other prominent physicians including Dr. William Alanson White, a pioneer of 20th century psychiatry and the director of St. Elizabeth’s Hospital (where I currently supervise residents). By the way, White was also a mentor to H.S. Sullivan.

Anyway, White points out that there was so much wrong with these patients whose brains Dunlap studied, that “… a pathological explanation of the mental disease [need not] be found in the [cerebral] cortex.” There were “defects of organs, thyroid, gonads, and adrenals and the circulatory system…that we would not expect the individual to be able to function efficiently, at least under stress.” Don’t you love that phrase “function efficiently”? In other words Dr White is beginning to suggest what I am more emphatically proclaiming, that schizophrenia, madness, is a “disease” of the PERSON, not the brain and not the mind.

Fast forward 78 years and E. Fuller Torrey in his “Studies of Individuals with Schizophrenia Never Treated with Antipsychotic Medication: A Review”, in Schizophrenia Research, Vol 58, pp. 101-115. Torrey wants to take on Breggin’s and Whitaker’s and others’ arguments that the brain pathology in people diagnosed with schizophrenia is all iatrogenic. He concludes: “…schizophrenia is a brain disease in the same sense that Parkinson’s disease and multiple sclerosis are….”

But wait, two other observations in his paper: “…psychiatrically normal individuals also [may] have structural changes in their brains” (p. 102) and on page 111, “It should be emphasized, however, that there is no single abnormality in brain structure or function that is pathognomonic for schizophrenia.” Torrey is an honorable man, I think. But he too is stuck in an either/or world of mind or body. None of the papers he reviews take up the challenge of examining the whole person, physiologically, psychologically, spiritually, and sociologically.

I say let’s be forgiving though, for indeed that is no simple task. We human creatures are so complex as are our ape relatives and other mammalian creatures. It is the role of the psychiatrist, ideally, to take on this task with each individual he treats. Few of us do that, I fear. The system is just not cut out that way yet. If we are to “save psychiatry” there has to be a change in medicine as a whole not just psychiatry. You might want to read Jim Gordon’s A Manifesto For A New Medicine. He takes on this dilemma. More to come.

Psychiatry, Medicine, and the Commonweal

Let me introduce myself and my blog.

I am a physician, first and foremost. Ironic though, when I first decided to become a doctor, at age 19, it was “psychiatrist” that I told myself was the goal, not simply physician. And throughout my training I oscillated between medicine and psychiatry. Intrigued by psychosomatic medicine yet hounded by my mentors, “Joe, you have to decide! Medicine or psychiatry.” Little did I realize at the time that this quandary, physical OR psychological, would become the hallmark of psychiatry’s split-personality: mental illness, a disease of the brain; no, mental illness a mental/social problem-of-living construct. And the debate has been belabored for millennia. Throughout this blog I will favor the concept that ALL ILLNESS IS PSYCHOSOMATIC/SOMATOPSYCHIC. There is no mind-body split.
In future blogs I will address what motivates one to become a physician but here just a few ethical reminders associated with the Hippocratic Oath:

(1) Primum Non Nocere (First Not To Harm)

(2) Keep confidential what the patient tells you, and

(3) Never promise more than you can deliver

I made #3 up but it is implied in the oath to honesty. Alright, it was not exactly how Hippocrates said it. In fact, the first do-no-harmer was a Frenchman, Auguste Francois Chomel (1788-1858) in his oral teaching to students. Then as now, I think, the debate centered on natural healing vs. radical intervention.

So, I want to SAVE psychiatry. Really? Psychiatry seems to be thriving without my help. Well over 10,000 psychiatrists attend their yearly conference, the American Psychiatric Association. No, I say “save” because I belong to ISEPP, I have contributed to Mad in America, I support Mind Freedom, and other similar organizations. In all of these and others there are folk who would like to disband psychiatry all together.

“No,” I say, if we rid ourselves of Psychiatry: WHO WILL MIND THE MAD HOUSE? WHO WILL MIND THE PHYSICIANS?

I liken this Anti-Psychiatry movement ushered in by the likes of Tom Szasz and Ronald D. Laing to the Anti-War movement of the 60’sand 70’s. But first I must clarify, Szasz would be livid to be placed in the same category as R D Laing. He saw Laing as an irresponsible “trickster” and miscreant. In fact he wrote a book about it:”Antipsychiatry: Quakery Squared” published in 2009. Szasz makes the case that Laing and others abandoned liberty, responsible science, and ethical social commentary. “Anti psychiatry” was merely a catch phrase for Laing and his followers, Szasz believed, in an attempt to appear like authentic critics of the status quo.

But back to the Vietnam war: We who were against the war were told to “Love It (i.e., the USA) or Leave It!” Most of us knew we were patriots but patriotic to the ideas of liberty, justice, and international peace. We knew the war was a horrible mistake, immoral, foolish, and ultimately self defeating. We opposed the war policy, not our country. We paid a heavy cost for that military adventure: 56,000 Americans dead, over a million Vietnamese dead. Laos suffered the worst per capita dead ever in the history of war! As you probably know given the front page publicity, the suicide rate of veterans is 2-4 times the civilian rate. More soldiers have been dying from suicide than in combat. And most of these suicides are Vietnam vets. Yes, 40 years after the fact of that foolish war, the moral, spiritual and psychological ill effects still haunt us. Some commentators believe, and I agree, that the moral injury of our current 14-year (and counting) middle east war(s) will be worse.

In my next blog rendition I will be asking the question “Are you really anti psychiatry?”—IF THIS IS AN EMERGENCY GO TO YOUR LOCAL EMERGENCY WARD. Hmmm.