"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

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?

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.

Genetic Language Smokescreen

Chuck Ruby, Ph.D.

The online magazine Science published a study titled "Shared molecular neuropathology across major psychiatric disorders parallels polygenic overlap," which purports to show genetic underpinnings of several mental disorders. It claims a breakthrough in understanding the genetic causes of these "disorders." 

I’m not a geneticist but my read of this research suggests it is another language smokescreen that obscures a simpler, more humane, and non-disease description of human problems. It is a way to continue on the charade of the myth of mental illness through a verbal sleight of hand trick. The genetic and medical terms used sound impressive (e.g., transcriptomic, phenotypes, pleiotropic) but they are euphemisms that refer to far more common, non-disease matters. Yet because they are used, they give the flavor of real disease.

Just a quick look at the study's abstract demonstrates this deceptive ploy:

"The predisposition to neuropsychiatric disease involves a complex, polygenic, and pleiotropic genetic architecture. However, little is known about how genetic variants impart brain dysfunction or pathology. We used transcriptomic profiling as a quantitative readout of molecular brain-based phenotypes across five major psychiatric disorders—autism, schizophrenia, bipolar disorder, depression, and alcoholism—compared with matched controls. We identified patterns of shared and distinct gene-expression perturbations across these conditions. The degree of sharing of transcriptional dysregulation is related to polygenic (single-nucleotide polymorphism–based) overlap across disorders, suggesting a substantial causal genetic component. This comprehensive systems-level view of the neurobiological architecture of major neuropsychiatric illness demonstrates pathways of molecular convergence and specificity.”

• neuropsychiatric disease, polygenic, pleiotropic,architecture, dysfunction, pathology, transcriptomic, phenotypes, perturbations, dysregulation, polymorphism, and molecular convergence and specificity??

Now doesn't that sound impressive? I'm certain that most people will glaze over about half way through it and stop reading, and instead just accept the claims like this headline:

"Major mental illnesses unexpectedly share brain gene activity, raising hope for better diagnostics and therapies."

I’ve taken the time to wade through the abstract's wording and replace all that nifty medicaleze and substituting more common and humane terms:

"Behaviors have a genetic substrata. However, we don’t know how that substrata causes those behaviors. We examined cellular RNA activity to see how they varied across different types of behaviors. This showed differences and similarities among those behaviors, suggesting they have a genetic substrata.”

All this research says is there are genes being expressed as people experience the problems we call “mental illness” and that genetic expression is shared to some degrees across different types of problems, but also retains a degree of differences across those problems.

Didn’t we already know this?

Further, don't we already know that any human activity or experience is going to be represented by underlying gene expressions? What does that have to do with verifying something as an illness? Ans. Nothing. Looking from the outside, this smokescreen gives the impression of precision science identifying and confirming that mental illnesses are about genetic anomalies. But on the inside, once the smokescreen is blown away, it is merely pointing out that gene activity is going on during any human behavior.

Ignoring the Real World of Depression

Chuck Ruby, Ph.D.

The Observer published a January 7th article by Johann Hari entitled, "Is Everything You Think You Know About Depression Wrong?" In it he questions the prevailing views about depression being caused by a chemical imbalance, among other things, such as the grief exception in the DSM5. One day later, Dean Burnett, identified as a "doctor of neuroscience," critiqued Hari in one called, "Is Everything Johann Hari Knows About Depression Is Wrong?" Dr. Burnett's piece addresses Hari's claims by, first, denigrating him, and then by basically claiming the bulk of what Hari said was either not true or that it is common knowledge and, thus, inconsequential. But there are some huge problems with Dr. Burnett's critique.

Whereas considering one's reputation is important in assessing an author's credibility, still the validity of the material is an independent matter. Disreputable people can claim valid facts. Ad hominem attacks are never helpful. Ending the opening section after having denigrated Hari with a comment to imply something like, "Let's see what he has to say anyway" ("...assume Hari has written this article with 100% good intentions and practices.") Dr. Burnett doesn't negate the preemptive negative effect of questioning his credibility.

Dr. Burnett avoids, as do most advocates of the medical model of human suffering, the big question: Is depression (and all other so-called "mental illnesses) a brain illness as supported by scientific evidence? Demonstrating biological underpinnings of depression obfuscates the issue. All things human are accompanied by biological underpinnings without being considered illness. Take for example hair color, height, temperament, athleticism, and cognitive ability. All these things are possible because of their biological underpinnings. But none are considered illnesses. It is only when we can scientifically demonstrate some lesion, malfunction, or defect in that biology that leads us to a conclusion of illness. For instance, we can demonstrate dangerous blood glucose levels with diabetes; detect damage to bones in a broken leg; and observe the ravenous onslaught of cancer. There is no such thing happening to the biology that underlies depression (or any other mental illness). Given this lack of evidence, medical treatment is not appropriate, and potentially dangerous.

And please don't counter with the worn-out "but things like chronic fatigue syndrome and restless leg syndrome don't have evidence of pathology either." First, you're right. But I question whether these "syndromes" are actually physiological illness, since they can be explained by other means. But second, this lack-of-evidence problem doesn't apply to a whole grouping of disease entities in real medicine. The so-called mental illnesses are all this way. Imagine if all pulmonary diseases were created without any evidence!

The chemical imbalance theory of mental illness does not need to be "challenged." One cannot challenge a theory that has no supporting evidence, other than to point out it has no supporting evidence. Science doesn't work by proving negatives; i.e., that there is no chemical imbalance. Those who assert the hypothesis are obligated to provide the evidence, and they haven't. There has never been any evidence presented that demonstrates a chemical imbalance (or any other bodily malfunction) causes depression or that depression is an illness. Keep in mind the term "imbalance": an imbalance vs. a balance must be demonstrated. Not just neurochemical changes that occur when a person is depressed. Neurochemical changes occur for every human experience and activity. And this empty theory has been going on since the 1950's when the drug industry and psychiatry stumbled upon chemical "cures." The convenience of this coincidence cannot be ignored.

Despite pointing out that Wikipedia outlines "several factors widely considered to be important" in depression, physicians, psychiatrists, and drug companies (at least as of last night when I watched the Abilify commercial) still encourage people to think it is a chemical imbalance. People don't go to Wikipedia for depression; they go to their doctor. Those of us in the business know first hand that those doctors tell people they have a chemical imbalance, sometimes for life, and sidestep "bio-psycho-social" factors as mostly irrelevant (actually, and not surprisingly, they do give some attention to the "bio-" part).

They also do not explain how drugs work, what they do, what they don't do, and the harmful effects of taking them, especially in combination with other drugs and over a long period of time. In my 20 years of doing this work I have never heard of even one example of such an explanation.

All this despite what NHS, NIMH, NAMI, CDC, or any other organizations may display on their websites and despite what faculty and students talk about in universities. The truth is that where the rubber meets the road it is explained as a chemical imbalance and pills are pushed, and the psycho-social part is just portrayed as an afterthought. The widespread belief in this chemical imbalance by the lay public attests to what they are being told.

While it is clear Hari's exaggerated use of depression being diagnosed one minute after the loss of a baby was intended for effect, any currently practicing psychotherapist, psychologist, psychiatrist, or physician knows full well that it doesn't take weeks of complaints before a person is diagnosed with depression. That can happen within minutes of walking into a doc's office for the first time and complaining about the so-called symptoms of depression. We who actually do this work on a daily basis hear about examples from the victims themselves. And the typical response by the doc is a prescription for antidepressants, or worse yet, benzodiazepines. "Oh, and yes, it would be a good idea to talk to someone."

It is not about what Dr. Burnett knows that is important. It is about what happens to that "average person” he talks about when they seek out help in real life. And what happens to them is a shame. That is why what he knows and what they know is wildly different, as he points out.

And, finally, people do not get depression in their brain. Depression is a meaningful dilemma that resides in experience. It is not a medical matter, nor a matter to be drugged, anymore than a rough day should be drugged with a stiff drink. But then, we don't consider stiff drinks as medicine and we don't think of bartenders as doctors.

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.”

Bipolar Disorder - Missing the Point!

by Al Galves, Ph.D.

A recent study on bipolar disorder published at the International Journal of Epidemiology has problems. The biggest problem is it is not asking the most important question: How is bipolar disorder related to the desire and ability of people to live the lives they want to live? Bipolar disorder is a state of being characterized by certain subjective feelings and certain behaviors. If we assume that human beings are organisms which want to live their lives in enjoyable, satisfying ways, what does this state of being have to do with their ability or inability to do that?

The study is being done with apparent ignorance of the fact that human beings are meaning-making, desiring organisms who want to live their lives in certain ways and who, if they are unable to do so, are going to experience the states of being associated with all of the mental illness diagnoses. The study is missing its proper context. It is hanging in a kind of limbo. In the absence of a proper context, it is unlikely to be very useful to human beings.

I’m making an assumption here. I need to explicate it. I am assuming that human beings want to live enjoyable, satisfying lives. I’m also assuming that, in order to live satisfying and enjoyable lives, the great majority of human beings will have to be able to love the way in which they want to love and work (express themselves) in the way in which they want to express themselves. In the words of the positive psychologists, they will have to use the best part of themselves in the interest of something larger than themselves, have positive relationships with others and experience competence, achievement and mastery.

What evidence is there for these assumptions? What do human beings want in their lives? What are the roots of happiness? What are the ingredients of human well-being? What are the components of health? What are some of the factors with which health is associated?

I don’t have the answers to these questions. But I think these are the questions that need to be asked.

How does this relate to this study? This study is gathering information about people who have been diagnosed with bipolar disorder. It is comparing that information with similar information on persons who are not diagnosed with bipolar disorder or who have not been diagnosed with any psychiatric disorder. It is gathering information on the neurocognitive functioning of these people, their temperaments and personalities, their motivated behaviors, their life stories, their patterns of sleep and circadian rhythms and the outcomes and courses of their lives. It is also gathering information on biological factors – genetic components, the nature of the disease and nutrition.

But this data is being gathered in the absence of a useful context or an attempt to make meaningful sense of it. The authors say the etiology of bipolar disorder is unknown. But they don’t offer any hypotheses about what that etiology might be. And they don’t seem interested in exploring that question. It used to be that one of the psychologist’s jobs was to come up with a formulation of the case. What is going on with this person? This person is engaging in some bizarre, troubling and somewhat impairing behavior. What is the meaning of it? In what way may it be somehow functional? What can this tell us about what this person wants, how are they going about getting it and how they are reacting to the results they are achieving. These researchers aren’t asking these questions.

They also don’t seem open to the possibility that mania or depression might be somewhat functional for a person, might help a person have a useful experience or a desired experience, albeit bizarre and even impairing in some way. They are assuming that these states of beings are diseases and nothing more.

So the researchers find that there is a history of childhood trauma among the people diagnosed with bipolar disorder. They have suffered significantly more childhood trauma than the control group. But they don’t seem interested in wondering about how a history of childhood trauma would be related to the experiences and behaviors associated with bipolar disorder. Why might it be that people who have experienced childhood trauma would be subject to alternating mania and depression? How might we understand this in the context of people wanting to live satisfying and enjoyable lives? They also find that this history of childhood trauma is associated with a detrimental effect on inhibitory control and attention accuracy. This seems to fit with mania, to be somewhat of an explanation of the connection between what happened to this person as a child and being subject to manic episodes. But they don’t connect these dots.

I, for example, hypothesize that the manic episode is an attempt by an individual who has had a lot of pressure to be great and hugely successful but who is unable to do so, to experience the illusion of being great and successful. In other words it is an attempt to fake success and greatness or to have a faux experience of success and greatness.

The connections between childhood trauma and mania makes sense in this context. People who experience trauma in early life will likely have trouble managing their emotions and will have various kinds of trouble in interpersonal relationships. They will also suffer from cognitive deficits. The development of the brain in the first year of life is contingent on good attunement between mother and infant. We can assume that a child who is traumatized probably did not benefit from such attunement. So this child will suffer some cognitive and emotional deficits. Those deficits will make it difficult for him to be as successful in life as he might want to be. If a tremendous about of pressure is put on him to be successful, great, exalted, he might want to experience that kind of success and greatness. But the only way he will be able to do that is to go through a manic episode in which he can have the illusion of such greatness and success.

The researchers are not open to this connection between the states of being of mania and depression and the desire of people to live the kinds of lives they want to live and the inability to do that. Therefore, their efforts are unlikely to help human beings live the kinds of lives they want to live. Their considerations are too decontextualized from life, too divorced from what matters to human beings to be of much use.

Joanne Cacciatore's Care Farm

Take a look at the Yahoo Lifestyle article showcasing Joanne Cacciatore's Care Farm in Sedona, Arizona. Joanne's brainchild is a unique application of this model to helping people who are in the throes of bereavement. She helps people reconnect to the earth, animals, nature, and themselves while allowing the painful process of mourning to happen as it naturally does. This stands in stark contrast to the conventional and absurd method of trying to make the pain go away. Congrats Joanne!

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:

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.

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.

Spooky Language!

Chuck Ruby, Ph.D.

In 2001 the late irreverent comedian George Carlin used the phrase "spooky language" to describe the wording of the 10 commandments. I do not cite Carlin in order to debase religious beliefs as he did. I think spirituality and religion can be of immense comfort and contribute to a sense of meaningful well-being for some people. I mention Carlin's comedic use of the phrase only in order to apply it to a recent study by Schmitz and colleagues entitled, "Hippocampal GABA enables inhibitory control over unwanted thoughts". This study claims that brain activity is the key to understanding a person's intrusive thoughts. But the authors of this study use spooky language in order to obfuscate and mislead about what would otherwise be a more simple, yet still difficult, non-disease matter.

This study is peppered with the same spooky language as others reported throughout academic journals and the media that make the ontological mistake of conflating human experiences with the neurochemical happenings going on during those experiences, and of using this language in a way that implies those brain happenings are pathological, while no evidence is ever presented to support that assertion.

The mental health industry is replete with this mistake because it is an inevitable result of the medical model - assuming troublesome experiences are symptoms of brain dysfunction without evidence of such. If this assumption were true, it would make sense to pay attention to brain chemistry and functioning when those experiences occur.

For instance, when a person has a brain tumor in just the right place, she might experience the world differently and act differently than without the tumor. In this situation, neurologists are helpful medical specialists who can address this problem and possibly alter brain chemistry or surgically remove the tumor in order to fix the problem.

This is similar to how a mechanic would identify a faulty car part and repair or replace it. But absent an identifiable broken brain part, this model is inappropriate when dealing with individual experiences of intrusive thoughts. People are not cars and, as far as we know, cars do not have meaningful experiences they can complain about.

Consider just a few examples of spooky language in the Schmitz study and a more simple, straightforward (non-spooky) translation in parentheses:

"Intrusive memories, hallucinations, ruminations, and persistent worries lie at the core of conditions such as post-traumatic stress disorder, schizophrenia, major depression, and anxiety." (When people complain of persistent and intrusive thoughts we say they have a disease.)

"These debilitating symptoms are widely believed to reflect, in part, the diminished engagement of the lateral prefrontal cortex to stop unwanted mental processes, a process known as inhibitory control." (When people are experiencing intrusive thoughts, we notice a part of the brain becomes less active.)

"In individuals with schizophrenia, the severity of positive symptoms, such as hallucination, increases with hippocampal hyperactivity, as indexed from abnormally elevated resting blood oxygen-level-dependent (BOLD) activity, or increased regional cerebral blood flow, blood volume, or blood glucose metabolic rate." (When the severity of intrusive thoughts increases, we notice another part of the brain becomes more active.)

"Consistent with this view, animal models of schizophrenia show that disrupting GABAergic inhibition in the hippocampus by transgenic or pharmacological manipulations reliably reproduces hippocampal hyperactivity and volume loss, along with behavioral phenomena paralleling symptoms present in this disorder." (When we disrupt the natural workings of the brain it causes problems for the owner of the brain.)

"Together, these findings suggest that a deficit of GABAergic inhibition local to the hippocampus contributes to problems controlling a spectrum of intrusive memories and thoughts, although the pathogenesis of this deficit and its specific manifestations across disorders may vary." (When people experience intrusive thoughts, an area of the brain becomes more active, but we really aren't clear on this.)

"We hypothesized that GABAergic inhibition in the hippocampus forms a critical link in a fronto-hippocampal inhibitory control pathway that suppresses unwanted thoughts." (We think two areas of the brain change in activity level when people experience intrusive thoughts.)

I could go on and on. The point is that spooky language is often used in studies like this in order to mislead the reader into thinking something that isn't true; that being, scientific medical precision about a brain disease. Despite all the medical-sounding words and phrases, there is not one bit of real evidence ever presented that intrusive thoughts have anything to do with real brain health or illness. And, by the way, if such evidence were presented, this wouldn't be a matter for psychiatry. It would be a neurological problem to be addressed by neurologists and other real medical specialists.

All this study shows is that when people are having experiences (intrusive thoughts), their brains are working. The fundamental mistake is in conflating individual experiences with the workings of the brain during those experiences, and claiming that brain activity is therefore pathological.

Perhaps an analogy would help. What if we noticed that when people are lifting weights their level of muscular contraction and innervation simultaneously react in a particular way. Would we then conclude that lifting weights is a disease? Of course not. And we wouldn't say things like, "In individuals with weight lifting disorder, the severity of positive symptoms, such as muscular contraction, increases with motor and sensory cortex hyperactivity, as indexed from abnormally elevated resting blood oxygen-level-dependent (BOLD) activity, or increased regional cerebral blood flow, blood volume, or blood glucose metabolic rate." That would be preposterous.

Muscle contraction and changes in the sensory/motor cortex is not evidence of disease and it is not the same as the human experience of lifting weights. Likewise, hippocampal and prefrontal cortex activity is not evidence of disease and it is not the same as the meaningful human experience of intrusive thoughts.

That is another matter completely.