R. L. Cima, Ph.D.

- Hippocrates, On the Nature of Man, circa 5^th century BC

Part 1 - A Balancing Act

21^st Century schools of medicine teach their graduates human behavior – what I do in my own body in the next moment of my life – is understood by microscopically studying invented and invisible anatomical brain centers, each center equipped with miraculous behavioral functions.  Students of psychiatry are instructed that undesirable behavior (psychiatry’s “symptoms”) is caused by a chemical imbalance effecting the brain centers.  Treatment, then, is to prescribe laboratory chemicals to balance natural body chemicals that are, somehow, out of balance.  Worth noting, the Psychiatric Medical Model Theory (PMMT) offers no definition, or explanation, of “balance.”

Practitioners of the PMMT believe you and I are victims of our excessive or insufficient chemicals – usually serotonin or dopamine – as well as our faulty “connectors” that negatively impact the brain centers where all behavior is neatly stored. Thus, psychiatric patients learn undesirable and life altering behaviors are caused by a deficiency, or derangement, or disease, or disorder, or disability, or disturbance, or dysfunction (the 7 D’s of the PMMT).  Patients inadvertently suffer the consequences of these brain flaws. “It’s not you,” the doctor confidently instructs the patient, “it’s your disorder that’s causing you to experience the undesirable behavior.”  Hence the title:  The Zombie Theory.  

Humankind has witnessed miraculous progress in medical science during the past 100 years.  Thanks to new discoveries, medicines and procedures, we have benefitted greatly when it comes to our physical well-being.  Especially true in modern countries, we live longer, our quality of life is better, our physical maladies better treated.  Our flesh, blood and bones have never been in better hands.  However, when it comes to human conduct, medicine has failed miserably throughout human history, up to and including today, without exception.

Medicine as Art¹

Twenty-five hundred years ago, the Hippocratic School of Medicine began to understand medicine as an art form, and healers as practicing artists. Disease was no longer divine wrath, nor was healing a gift from God.  Over time, heavenly punishments and gifts were replaced with cause and effect, providing the underpinnings for the burgeoning artform to become a rational science in the physical world.  Along the way, medical ethics and standards of care were crafted, both keystones of the ancient Greeks that continue to guide modern day medicine.  Most important, three primary conditions were identified and interconnected:  the disease, the patient and the healer. 

Healers were trained in the Seven Natural Factors in this holistic system of medicine: The Four Elements, The Four Humors, The Four Temperaments, The Four Faculties,The Vital Principles, The Organs and Parts and The Forces.  The underlying theory was simple.  When there is balance and harmony within the Seven Natural Factors, there is health. When they are not in balance, there is dysfunction and disease.  When any one of the Seven Natural Factors ceases to function, there is death.  Balance then, as it is now, was the pursuit.

For the first time detailed experiments were conceived and conducted, data was collected, results were assessed and treatments were formalized.  Six healing pathways emerged, from mild to severely invasive.  The first treatment of choice?  Diet, considered the most gentle and safest path to restore balance.  Second in this formal progression of treatment paths focused on altering the patient’s lifestyle and hygiene habits that were causing the imbalance of body humors (fluids).  Only when the first two treatments were found to be ineffective did the healer select the third treatment path:  medicine.  Chemical concoctions with inherent healing powers were dispensed in the form of supplements, potions, tonics and herbs.  These first three paths were self-administered, under the guidance of a healer.  

Paths four, five and six were administered by the healer.  The first of these, physiotherapy, included heat treatments to induce sweating, massages with medicated oils, and a variety of muscle, bone and other body manipulations designed to release trapped toxins.  Physiotherapy was often a preparative stage for detoxification, the fifth path of treatment.  Common purification methods included emetics (to induce vomiting), enemas, diuretics and, frequently, bloodletting.  Only when the first five paths fail does the healer turn to surgery, the last treatment path.  Surgery was seen as the most invasive and, except for immediate trauma and other emergencies, the last resort for the trained healer.

Also historic, diseases were systematically classified according to similarities and differences as the disciplines of etiology and pathology began to emerge.  The goal was to ensure the healers diagnosis and choice of treatment was based on fact-based information.  As momentous, individualized treatment was a core value.  “It's more important,” professed Hippocrates in one of his famous aphorisms,“to know what kind of person has a disease than what kind of disease a person has.”  Healers were trained to understand individual patients as living in a dynamic relationship with their environment.  This new art form treated the patient, not just the disease.

What About Madness?

For epochs before this new medicine ancient civilizations viewed madness as punishment from an angry God for divine trespasses.  The healers of 10,000 years ago treated their patients with music, prayer, charms, spells and other incantations.  This new school of medicine professed madness to be the result of natural occurrences in the brain, centered around the four essential humors.  To treat madness, patients would routinely be bled from the forehead, or from a large vein in the arm or leg or rectum to draw corrupted humors away from the brain in order to bring the body back to balance. 

Thus, Greek medicine began with two interrelated principles.  The first is to provide the body its natural beneficial cravings:  a wholesome diet, healthy habits, adequate exercise, and sufficient rest and sleep.  The second is to cleanse the body of wastes and pathogenic matter inside and out, creating a healthy body balance.  Though form and fashion may be different, modern medicine embraces these same principles. Unfortunately, as you will see, so does modern psychiatry.

Primum Non Nocere – “First, do no harm"²

The Hippocratic Oath is the first expression of medical ethics in human history and it remains a rite of passage for medical graduates around the globe.  This oath reminds the healer to be aware of the possible harm that can occur from any kind of intervention.  “Practice two things in your dealings with disease,” reiterated Thomas Inman, a 19^thcentury Liverpool surgeon, “either help or do not harm the patient.”  Nonetheless, history has many examples of this oath being violated, and much harm done. 

Here’s the longest lasting. 

Bloodletting

For more than two millennia the treatment of choice for healers around the world was bloodletting, mainly because of its versatility.  In addition to madness, this medical technique was prescribed for acne, asthma, cancer, cholera, coma, convulsions, diabetes, epilepsy, gangrene, gout, herpes, indigestion, jaundice, leprosy, ophthalmia, plague, pneumonia, scurvy, smallpox, stroke, tetanus, tuberculosis and a hundred more – including heartsickness, and heartbreak.   

The Talmud was cited by healers to proclaim the most beneficial days and times of the month to use this procedure.  Christian healers gave guidance to their followers by declaring the specific Saints' Days favorable for this medical technique.  Islamic healers too heralded bloodletting, particularly for fevers.  During medieval times bleeding charts were common, designating specific bleeding sites on the body.  The vein in the right hand, for example, was bled for liver problems, the vein in the left hand for spleen problems.  “Do-it-yourself" instructions were created and distributed worldwide. 

Bloodletting was in its heyday during the Middle Ages, prescribed by healers as both a curative and preventative medical procedure.  The actual procedure was often done by a trained barber-surgeon, the red and white barber pole symbols of blood and bandages.  There were a variety of techniques too.  A phlebotomy occurred when blood was drawn from the larger external veins, an arteriotomy from arteries usually from the temple.  Some healers used a scarificator, a specially crafted tool cast in a brass case that enclosed a spring-loaded mechanism with blades of steel.  Leeches were commonly used too.

Bloodletting theory – the science of how it “works” – was based on two ideas; (1) blood did not circulate and would "stagnate" in the extremities; (2) removal was done to attain humoral balance to fight off illness and to restore health.  The more severe the disease, the more blood that needed to be drained, fevers requiring the largest amount of drainage.  Importantly, six hundred years later Galen, a philosopher-physician from the Roman Empire, revitalized, reinvented and “rebooted” Hippocratic humoralism as a meticulously detailed, rational, technique-focused medical theory that retained its popularity in cultures around the world for another seventeen centuries.

The End of Bloodletting    

The 19^thcentury was revolutionary for medical science.  During the first half a British chemist discovered the anesthetic properties of nitrous oxide, a French doctor invented the stethoscope, and a British obstetrician performed the first successful blood transfusion.  In the fourth decade an American surgeon used ether for the first time, and a Hungarian doctor discovered disinfecting the hands of medics, midwives and nurses drastically reduced the incidence of death from childbed fever that was killing nearly a third of infected mothers.

The second half of the century was equally impressive.  A British surgeon introduced phenol to clean wounds and to sterilize surgical instruments.  Louis Pasteur published the Germ Theory of Disease in 1970 and within 12 years his labs produced vaccines for chicken cholera, anthrax and rabies.  The first Nobel Prize in Medicine was awarded to Emil von Behring, a German physiologist, for creating vaccines for diphtheria and tetanus.  X-rays were discovered by German physicist Wilhelm Conrad earning him the Nobel Prize in Physics.  Finally, in 1897, a German pharmaceutical company, Bayer AG, created a new wonder-drug:  aspirin.  Within two years aspirin was a global phenomenon.

The successes of this maturing art of medicine spelled the end to the ancient and barbarous practice of bloodletting.  Centuries old theories as well as healer and patient testimonials could not stand up to the new and emerging regimen found in science.  By the end of the 19^thcentury Bloodletting was nearly extinguished worldwide (though not completely!). 

In its place a new awakening was unfolding:  modern medical science. 

NEXT TIME:  Part 2:  The Era of Medical “Experimentalism”

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Life is short; and the art long.

 - Hippocrates

Bruce Pardy, Professor of Law, Queen's University

In the United States and Canada, universities and colleges routinely provide extra time on exams and assignments for students with cognitive and mental health difficulties such as anxiety, depression, obsessive compulsive disorder, learning disabilities, and attention deficit and hyperactivity disorder. In my article published in the Education and Law Journal (“Head Starts and Extra Time: Academic Accommodation on Post-secondary Exams and Assignments for Cognitive and Mental Disabilities" (2016), 25 Education and Law Journal, 191, available free at https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2828420), I argue that such accommodation is inappropriate. In this piece for the ISEPP Bulletin, I excerpt from and summarize the argument made in that article: granting extra time to some students is unfair to other students in the class and is contrary to the principles of human rights and disability law.

Exams are competitions. In a college or university course, students are in pursuit of high grades. For them, the objective of the course is not merely the education that it offers but the credentials that it provides. A student’s course grade depends in large measure upon how his performance compares to the others in the class. The competition for grades is real and the outcome can carry significant consequences. The competitive nature of assessment is especially acute where the professor is subject to a mandatory grade curve.

To “discriminate” means to distinguish or tell apart. Discrimination is not illegal. Rather, it is an essential tool for functioning in the world. People discriminate constantly. They choose to be friends with some people and not others. Employers hire better qualified candidates rather than those less qualified. In popular parlance, the word “discrimination” has come to be associated with treating people in a way that is illegal, but any instance of discrimination that is not specifically prohibited in legislation is allowed. Even when committed on grounds prohibited in legislation, discrimination will not amount to a violation of a right if the requirement that results in the discrimination is reasonable and bona fide. A requirement will not be bona fide unless, in the case of disability, the needs created by the disability cannot be accommodated without undue hardship. Undue hardship is a function of cost, inconvenience, and compromise of other important considerations such as health and safety. Extra time on exams is unjust and creates undue hardship because it skews the competition to the detriment of other students in the class.

The bona fides of any competition are the skills and abilities that the competition tests. The raison d’être of a race is speed: Whose legs can carry them across the finish line fastest? Races discriminate: they distinguish between people based on their speed. Discrimination is the purpose of the race. Since races discriminate against all people based on speed, they also discriminate against people with disabilities that affect speed, but not in a way that offends the law. The discrimination is not illegal or inappropriate. No accommodation need be made.

If a runner with a limp was accommodated with a 20-metre head start, the consequences would be perverse. A 20-metre head start in the 100 metre dash means that she is not really in the race at all. Her finish is not a genuine result. Perhaps she crosses the line first. Perhaps her lead erodes and two runners pass her ten metres from the tape. Perhaps she is overtaken by all but two others. It does not matter; any finish is meaningless. She did not place in the 100 metre race because she did not run it. She is not the fastest in the field, the third fastest, or the third-slowest. Her result is not comparable to the other runners. She ran, but she did not run the race. The record of her finish is a fiction.

In any competition, the legal objective of accommodation is to enable participation: to allow all to compete under the same conditions relevant to the skill that the contest is about. A deaf runner wants to run the race, which is a contest of speed, not hearing. Therefore hearing is a not a bona fide criterion for the race and accommodation is legitimate. The deaf runner can see a green light flash as effectively as the other runners can hear the start gun, so a flashing light to start the race in addition to the gun is an appropriate accommodation. Of course, she must start the race the same distance from the finish as everybody else. Accommodations that enable disabled athletes to participate in the competition make sense, but accommodations that require modification to the rules of play or create advantages over other competitors do not. Disabled runners should be accommodated to the point of undue hardship so that they can run in the race, but no accommodation should be provided to compensate for lack of speed, which would be to impose an undue hardship on the rest of the field. 

When a professor awards an A to the best exam and a B to the one in the middle of the pack, she discriminates between exams. By extension, she discriminates between students on the basis of their cognitive skills and mental abilities. That discrimination is not prohibited. Indeed, as in a race, discrimination is one of the purposes of the exam– to identify and distinguish different levels of academic achievement. Like races, which discriminate against people with disabilities that affect how fast they can run, exams discriminate against people with disabilities that affect how well they can think, learn, analyze, communicate, plan, prepare, focus and perform under pressure. That discrimination is not illegal or inappropriate. No accommodation need be made.

The purpose of exams and assignments is not merely to test knowledge but analytical ability, critical thinking, logic, pattern recognition, spatial reasoning, memory, creativity, organization, speed, focus, concentration, resilience, preparation, and intestinal fortitude. The assessment may test the ability to read and comprehend written language or abstract or mathematical information; to write concisely, efficiently and clearly; to reason and calculate with insight and accuracy; and to concentrate and apply mental skills and faculties to the task at hand. Stress, anxiety, the pressure of performing well in a limited period of time, the difficulties in overcoming procrastination and distraction, the job of completing assignments by their due dates and being prepared for exams by the exam date are important features of university and college education and assessment. These skills and challenges are not collateral to post-secondary education but are central to it. There is no pure core of knowledge unrelated to these other skills and attributes. If students are unable to use and express that knowledge, then they have not been able to use the skills and perform the tasks that the exam seeks to call upon. A student who can exhibit proficiency only when sources of stress are eliminated is like an athlete who can perform at his best only in practice rather than in the big game. Accommodating the student makes no more sense than accommodating the athlete.

The real purpose of claims for extra time is to increase prospects for success, which is not legitimate. Sometimes advocates for students with mental disabilities claim that extra time levels the playing field. This claim is false. Extra time does not level the field but tilts it. Given enough time, many students in the class could put together an exam deserving an A – if they had actually written it within the normal time for the exam. Because they took extra time, it is not an A paper. Claiming the right to extra time and then insisting that what you produce is an A paper is really no different from claiming that you can win the run 100 metre dash as long as you only have to run 80 metres. In neither case is it true that the accomplishment is superior to others who had a more demanding task to perform.

The purpose of accommodation is to enable participation, not to enhance success. Students with mental disabilities are able to participate without accommodation. If they have the same amount of time as everybody else, they are already participating. They simply expect not to do as well as they would with more time. Extra time skews the competition, is unfair to other students, and is inconsistent with the principles of human rights and disability law. Universities and colleges should not provide extra time as an accommodation for cognitive and mental disabilities.

David Katz, the Jacksonville shooter, is the latest in a long line of scapegoats for an apparent epidemic of violence. Just this past Sunday he opened fire at a e-sports tournament, wounding 10 and killing three, including himself. Katz' motives are still under investigation, but people are already implicating the bogeyman of mental illness. See CNN's reporting today - Jacksonville shooter had a history of mental illness and police visits to family home.

According to the report, Katz was prescribed "a number of psychiatric medications," including antidepressants and antipsychotics. He also was said to have seen "a succession of psychiatrists." These statements imply that Katz' a mysterious alien entity residing with him, called "mental illness," was the culprit. There is even current quibbling over what the "correct" diagnosis was.

A more reasonable explanation would be that Katz had been struggling with several real personal dilemmas, he wasn't infected with a nonsensical illness of the mind. Just one example is that he had to witness his parents' vicious divorce and custody battle over him. Instead of following the suggestion of his father for peer-based support group assistance during middle school, there was the default turn toward psychiatric treatment, as if there was something in him to truly treat via medical means.

If the treatment went as it typically does, this would have meant increasing focus on him as the problem, rather than his circumstances. Being subjected to a "succession of psychiatrists" means that one superficial attempt after another didn't work, so he was shuffled to the next psychiatrist in line. He likely felt the increasing sense of being misunderstood and persecute by those medical attempts to sedate him.

This is just the last in a long and continuing line of horrific episodes. It will continue. It will continue because the authorities are not looking at the causes of these events. They are trying to find a scapegoat. Three hundred years ago that scapegoat would have been witchcraft or demons. Now, it is the internal infection of "mental illness."

To make matters worse, the alleged treatment for that infection is typically to coerce the person into compliance. In other words, it is to get them to stop complaining about the problems (euphemistically called "symptoms reduction"). And the icing on the cake is that psychiatric drugging into a state of agitation clearly increases the chances of impulsive outbursts of violence. See ISEPP's White Paper on the link between psychiatric drugs and violence.

Chuck Ruby, Ph.D.

"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.