“Saving Psychiatry” – Dr. Joe’s Blog

Baying at the Moon: ISEPP’s Struggle with Psychiatry’s Perfidy

Baying at the Moon: ISEPP’s Struggle with Psychiatry’s Perfidy

Baying at the Moon: ISEPP's Struggle with Psychiatry's Perfidy


Joe Tarantolo, M.D., Psychiatrist


See my letter below I sent to the ISEPP Board after our Philly conference in 2012 (edited for easier reading)


Reflections By the Chair, ISEPP Conference, Philly, 2012

To the Board of Directors:

THE “GREAT” ORGANIZATION SYNDROME

First, let me remind you, I am privileged to be your Chair. Also, you give me comfort when I fear I am isolated with this non-Bio model.

IDEAS: response to the conference, MindFreedom, Karon’s PSPP talk and our Board discussion of “Where do we go from here?”

We are not a great organization; we are ,however, worthy.

In 2009, as we went through our wrenching breakup with Peter Breggin, I wrote him a personal letter about which I’m told by reliable sources, he hated. I warned him of what I call the “Great Man” syndrome. It affects most men, and increasingly, more and more women. It’s rooted in early life experience, around the age of seven after reading our 1st Superman comic ( Batman, Cap Marvel, Wonder Woman, etc.) and we secretly identify with their great powers, powers we lust after for the rest of our lives. It is driven, of course, by a deep sense of shame-ridden inadequacy. It plagues us because no matter our accomplishments, they never measure up, we never meet the Superman measure.

This dynamic affects organizations as well, oh yes whole nations too, US exceptionalism!? I note a despair when we decry our puny membership numbers and not-at-all-enough conference attendance. The problem with this syndrome is, not only does it generate sadness, despair and a lack of celebration at small successes, it also is out of touch with reality.

The reality is, and here I must cross over the aisle to my Republican friends, we are only 1 of a 1000 points of light that have begun to shed light on the terrible murderous nature of much of psychiatric practice. (Note that Grace Jackson needed 100’s of research papers, 1000’s perhaps, to make her excellent power point presentation. She did none of the research herself. She is just a small part of the big picture.) If you don’t like that metaphor, how about our being a splash-piece of a giant wave. We don’t have to be grand leaders in this march (a 3rd metaphor), we are just one of many worthy groups not only trying to accomplish something but also trying to discover something.

Bert pointed out in his talk that the Nazis killed off virtually all of their schizophrenics between 1940 and 1945. After the great WW2 conflagration, guess what, the incidence of schizophrenia in Germany was the same as before the Eugenics cleansing. (BTW, the Eugenic movement originated here in the US in the late 19th century and was then exported to Europe.) Bert was using this little epidemiological tidbit to demonstrate how absurd is the notion that schizophrenia is a genetic disease. What he didn’t address though, is given they got rid of all the schizophrenics, regardless of the etiology, why was there still that 1% of the population that is nuts?

This is how I explain it: not only is schizophrenia not a disease and not a neurological problem, but rather that that process of craziness, eccentric painful thinking, has survival value for the culture at large. We create schizophrenia because we need it. There is a fine line, perhaps no line, between delusional thinking and creativity. I suspect we need to have 1% thinking about the world in absurd and disturbing ways to counter a tendency towards uniformity, sterility, and inhibited problem solving. While I’m at it, we need 5% of the population to be gay with a smattering  of transgender because our sexuality is so important for the survival of the species, it must constantly be tested, however discomforting.

I recommend : 

1-We stay small, and like it.

2-We limit our conference to 300 participants: (“REGISTER  SOON., LIMTED NUMBER OF OPENINGS”  (300 is roughly the size of my church and  the school where my 2 daughters went to between Pre-K and 8th. They both went on to ivy league schools by the way)

3-Consider limiting membership to 400-500 paying members, with a waiting list of course. Donations will be accepted by non members.

The $5 million Vision Fund which Al is starting shall be used to connect the dots (oh god, another metaphor) to bring together a confederation of points of light to illuminate a New Mainstream of mental health. I suspect this new mainstream will spill over into political, spiritual, and the general medical scheme.

It is hard for me to define this Stream. It has something to do with Freedom and Placere (to serve) and healing and learning. Bert was cute in this area: “Wouldn’t it be horrible to go 24 hours without learning something?” However excellent was Kirsch’s presentation, he did not emphasize the biological & spiritual reality that ALL ORGANISMS TEND TOWARDS  HEALING THEMSELVES. We are all on a course of healing & learning. When you listen to master therapists such as Karon what you invariably hear is not their know-it-alls. You hear about their ignorance. They become the student; the patient becomes the teacher.

Best to all of you,

Start cracking about next year’s conference,

Sincerely,

JT, Chair

Hypochondriasis in the age of COVID-19

Hypochondriasis in the age of COVID-19

Hypochondriasis in the age of COVID-19


Joe Tarantolo, M.D., Psychiatrist


A cough, a sneeze, feel a chill, an uncomfortable response to pollen : "Oh dear, I got it, I’m going to die on a respirator. All alone, that damn virus got me." This all happens in a moment and passes just as quickly. But in that moment there is a basic truth which every psychotherapist explores. What is the nature of our experience and from whence does it come?

I was asked recently on the ISEPP Listserve (from which I usually keep my distance), "What do you do in psychotherapy that warrants payment from the patient? " A perfectly reasonable question, why did it irritate me so much?

A digression that I hope will help answer the inquiry: Several years ago Tomi Gomory (one of the "3 amigos" of Kirk, Cohen and Gomory, authors of Mad Science, Psychiatric Coercion, Diagnosis, and Drugs) in a presentation at an ISEPP conference proclaimed that psychotherapy was nothing more than an educational process. The ignorant-patient-client is educated by the knowlegable-teacher-psychoanalyst. Hold that for a bit.

A prominent complaint of many ISEPP members is that they loathe the medical model. A brief definition: the person, the prospective patient perceives that there is something wrong (i.e., he has a symptom). He consults with a physician and presents his symptom. The physician explores the history of the symptom, does a physical examination, makes a diagnosis, and prescribes: a drug, ECT, exercise, dietary and life style modification, etc., or in the world of "mental illness" psychotherapy, psychoanalysis, cognitive behavioral therapy, family therapy, group therapy—you get the idea.

The Listserve crowd just doesn’t like this medical model. And the DSM language and jargon used by practitioners can create despair about earning a living using such a model. I understand this despair and indeed partake of it periodically myself, the despair that is. My better angels, however, allow me to avoid the traditional trap of the medical (educational) model. Remember, psychoanalysis is based on the medical model. So follow me:

Routinely, I tell this new person in my office (or on the phone or video in this era of "social distancing" to "flatten the curve" of the corona menace): "You are troubled, yes, you are struggling and in pain but you do not have a disease." I may offer an interpersonal "diagnosis" at this point such as "You are in grief" or "You have problems with intimacy" or "You are furious at your father with murderous rage that paralyzes you because you also love him." I then tell them I am interested in their struggle or not. If not I refer them on to get help else where, a lawyer or neurologist or financial advisor, or a psychopharmacologist if they are believers in better-living-through-chemistry, and I believe I could work with them. We might need another session or two to make up our minds. The next is crucial, and it is counter to the usual "educational" model.


Psychotherapy: Who is teaching Whom?


I tell the patient THEY ARE THE TEACHER and I am the student. For example, "I’m a woman,  what do you know about women?" One might ask. I reply, "Exactly! You will have to teach me, what the hell does a man know about being a woman!" And it is up to them to educate me by addressing the question, "Who are you and what are you doing here?" Unfortunately many take this question so literally they miss the existential point so some explanation might be needed.

A "technical" example of the implication of this approach: When a patient tells me a dream for the first time, I give a little speech, "I don’t think it proper to tell another person what their dream means, to interpret their dream." In fact I think it disrespectful. However, I will tell them what their dream means to me if I had that dream. I adopt the dream. "If that had been my dream last night, that desolate landscape would be a reflection of how I wish to get rid of all the troubling people in my life because I feel so inadequate in having to please all of them." "No Doc, that’s not what it means to me, I’ve been freaked out how all the streets are empty because of this fucking virus." Okay.

Harry Stack Sullivan coined the term "participant observation" as  the function of the psychotherapist. The therapist is the participating-expert-student of the patient- teacher. The "psychotherapy" takes place within that relationship.

Back to the stressful COVID19 pandemic times. There is now massive hypochondriasis. The hypochondriac is forever frightened that he is sick. Actually he knows there is something wrong and obsesses in his effort to interpret his symptoms and sensations. In the case of the pandemic, however, it is not just "I am sick." But rather "We are sick, our leaders are sick, our physicians are sick. Our society is sick. The world is sick, etc." Whereas the individual misinterprets some felt sensation, e.g., a cough, and obsesses about it, the pandemic unleashes pervasive misgivings about the meaning(s) of life and our relationship to the universe.

My true feeling at this time is depression. Depression for me means I am working on something deep within me. Who am I and who are we? How do I survive? Why do I survive? Randomness? Determined? Must I make up the meaning or must I discover it? Both?

The “Sorry” State of American Health Practice

The “Sorry” State of American Health Practice

The “Sorry” State of American Health Practice


Joe Tarantolo, M.D., Psychiatrist


"Sorry, this medical practice does not take Medicare." "Sorry, I don't take Medicaid." "Sorry, I am not in your insurance network." "Sorry, your insurance does not cover this procedure." "Sorry, your insurance does not pay for this medication." How often do Americans hear these laments! The American medical "insurance" industry is fraught. I put “insurance” in quotation marks BECAUSE  AMERICAN INSURANCE IS NOT REALLY INSURANCE. Let me explain.

If you own an automobile, you are required to have automobile insurance. This insurance does not pay for gas, oil, new brakes, and other usual maintenance. You pay out of pocket for these. And you shop around ( if you are the thrifty type) to get the best price for these products and services. Insurance pays up if you have an accident or if your auto is stolen or vandalized. The same applies with homeowner insurance. It does not pay for maintenance. It pays up for fire or floods or if the wind blows your roof off or if you are robbed or vandalized. What we have come to call medical “insurance” is actually a way to pay for any medical attention. It is an elaborate bill paying scheme.

An example:  A couple years ago I had an inguinal hernia operation. A year later I needed a second repair on the opposite side. Same surgical problem, different side, and different surgeon. Both went pretty much as they should, the second with a bit more post surgical discomfort, nothing dangerous, in the hospital a few extra hours. I was interested in why I was a bit sicker post 2nd operation so I did some inquiries. It seems the 2nd anesthesiologist gave me more drugs.  Maybe that was why I needed a few more hours to recoup. Okay, each anesthesiologist has his own way to do the procedure. Interesting, but no significant complaints on my part. The shocker was in my research I discovered that the first operation cost about $8,000, and the 2nd operation cost about $16,000. When discussing what procedure to use for the 2nd hernia ( the surgeon was well versed in both), it didn’t occur to me to ask the price. I/we chose the 2nd procedure because it gave some quite small advantage to avoid relapse, i.e. failure of the repair. And the surgeon liked the 2nd procedure a bit more. The point I’m making here is: I NEVER ASKED HOW MUCH THE PROCEDURE(S) COST! (Note: There is a "Hernia Clinic" in California that offers hernia repairs for under $4,000)

I’m a capitalist. I’m also a progressive democrat. So I believe both in competition in the market place and I also understand that regulations are necessary given human insecurity and greed. I also understand the concept of universal responsibility for the poor, the hungry, the lame, the homeless, and children. So I see “universal health care” not as a political right (health care is not mentioned in the Bill of Rights) but a moral responsibility.  Oh, I have existential and  libertarian leanings as well, i.e. I believe in personal responsibility. How does a capitalist, a social democrat, a humanist, an existentialist come up with a plan for universal access to medical care. The answer: SUBSIDIZED PERSONAL HEALTH ACCOUNTS.

The US spends roughly $10,000 per person per year for medical care, twice the amount of other 1st world countries. Even so we get poorer outcomes as indicated by significantly decreased longevity and increased infant mortality. What Richard Nixon taught us (besides never to record personal criminal conversations) is that price fixing does not work. At least it does not work in the USA. His Executive order #11615 placing a nation-wide price freeze was a gross failure. “Ranchers stopped shipping their cattle to the market, farmers drowned their chickens, and consumers emptied the shelves of supermarkets.”  (Daniel Yergin and Joseph Stanislaw explain in The Commanding Heights: The Battle for the World Economy, 1973).  

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We need 329,000,000-payor medical coverage, not single-payor

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Medicare, Medicaid, and most insurance plans dictate both to the doctors and the patients not only what procedures and treatments are allowed but also how much they will pay. And oh yes, let's not forget the “co-pays”. There are even terrible plans that pay nothing until you spend $2,000-3,000. How many of you are told, “No, we will not pay for services with that doctor. He is not in your network!” And, you are not rewarded for being thrifty. Dr. X in your plan may charge $1,000 for a test whereas you might be charged $500 by Dr. Y. But Dr. Y is not in your plan. And there is no incentive to challenge or negotiate with your doctor. “Do I really need that expensive MRI?" "Can’t we wait a few weeks and see if  X clears?” And we never ask “How much does it cost?” No, we only want to know if our insurance plan pays for it.

Personal health accounts would require each of us to contribute to our own account. Those who can’t afford the contribution would be subsidized by public funds. Those whose Labor Union or corporation supplies coverage would place that money into each private health plan. So no one would lose the coverage that they like. But, it would give individuals more control of their coverage. And, this is important, each of us would have more responsibility. “How much is that going to cost, Doc? Hmmm, maybe I can get that cheaper!” Those who value their health and rarely use the medical system could be rewarded: A yearly refund out of their private health account!

One last important issue. There would have to be medical insurance for catastrophic events. Middle class incomes would be able to afford medical “maintenance” out of their health account. Very few would be able to afford hundreds of thousands dollars for a protracted hospitalization. That would require insurance.

In future blogs I will spell out how our horribly dysfunctional insurance system has a particularly injurious impact on the "mentally ill."

Reaching Out

Reaching Out

Reaching Out


Joe Tarantolo, M.D., Psychiatrist


Reaching out to the other fringe groups in conflict with conventional medicine. (Yes, ISEPP is at the margins, not with the conventional.)

Wise Traditions is the quarterly journal of the Weston A. Price Foundation, an organization that is dedicated to restoring “nutrient dense” food to our  20th-21st century high fructose corn syrup processed food addicted diets. High fat, unpasteurized milk, grass fed beef, wild salmon, fermented vegetables, anti fluoridation, anti vaccination---you get the picture.

Sally Fallon, an old friend whose cook book is my frequent guide in the kitchen , called me recently to ask me to present a talk this fall at their conference in Dallas. Their yearly conference attracts over a thousand folk (has ISEPP ever had a thousand attendees?). I hadn’t spoken to Sally in several years but she remembered a comment I had made about the dangers of antidepressants, viz., they induce “not caring.” She asked me to present  a talk. I accepted. The title of my talk: NOT BY BREAD ALONE DOTH MAN LIVE, EVEN IF IT’S SOURDOUGH: A CRITIQUE OF ANTIDEPRESSANTS AND THE MEDICAL MODEL IN PSYCHIATRY.”

My observations of those I see and read and with whom I interact in the alternative world, the herbalists, the naturopaths, the nutritionists is that they tend to make a mistake similar to the conventional model. But because they are not burdened by the prescription pad and the legal torments of forced treatments, they do less harm. But, they too make the mind/body split and tend to characterize “mental illness” as a “brain disease.” In fact “brain health” is a big seller in the alternative world. I am not dumping criticisms on brain herbs. I love them: Bacopa, Gingko, Rosemary, Kava, not to mention the plethora of herbs called adaptogens such as Reishi mushrooms  and Ashwaganda (one of my favorites, a potent Indian herb very useful in the prevention and treatment of cancer). But what I will tell the Wise Traditions crowd is that no amount of the best high Vitamin A and E cod liver oil will cure a bad marriage. High dose vitamin therapy will not cure schizophrenia. Actually, the high dose vitamin crowd doesn’t do too badly with schizophrenia. If you read the Canadian guru, Dr. Carl Pfeiffer, who claims an 80% cure rate of schizophrenia, what you see is he takes the schizophrenic off of neuroleptics and gets rid of those who don’t cooperate, i.e., they are not included in his statistics. Yes, taking people off of neuroleptics will improve their chances of getting better. I suspect it has little to do with the vitamins.

A healthy body does not determine psychological health. The person dying with a terminal illness can be psychologically and spiritually healthy: facing mortality with courage, leaving behind old complaints and petty slights. I was thinking about “The Longest Day”; yesterday was the 75th anniversary of D-Day. I’m told that General Eisehower could not sleep the whole week before the Normandy invasion. I am sure he did not go to a psychiatrist and complain about insomnia. Ike was psychologically healthy, preoccupied about the thousands of boys he was sending on an uncertain task to certain death. He was healthy. Hitler took a sedative, he was sick!

Mental health is not about being happy. Evil sadists are often happy and they are mentally sick. Mother Teresa who cared for the dying struggled with despair. She was mentally/spiritually healthy. Mental health includes the ability to hold conflict, i.e., to suffer. The psychotic, the manic, the obsessed, the somatically preoccupied, the sadist, the pathologic narcissist, all take flight from suffering. Drugging and ECT aid in this escape caper. They do not promote mental and spiritual health. That’s the second time I used the term “spiritual.” What’s up with spiritual? The terminology about health is fungible. The pre-enlightenment idea of health was being at peace with God/Yahweh/Allah. We post-enlightenment religious types are not satisfied with that too easy of a position. The capacity to doubt and question and struggle with meaninglessness must be part of the picture. There is no easy path.

PTSD, The Grand Scapegoat

PTSD, The Grand Scapegoat

PTSD, The Grand Scapegoat


Joe Tarantolo, M.D., Psychiatrist


The diagnosis of PTSD was created in response to pressure from Vietnam veterans who wanted to be sure of their right to receive medical and financial benefits as befitting any man (the military was minimally integrated at that time) who fought in an unpopular and hateful war. We must be clear about this to be able to take PTSD out of the sphere of medical diagnoses and place it where it belongs: a social, political, and moral position in a country ambivalent about its warriors.

If PTSD is not an illness, a medical condition, if we are clear about that, we can then be able to ask pertinent questions about the function and purpose of this pseudo-illness. What purpose does this diagnosis serve? Whereas initially, post-Vietnam, the diagnosis allowed an outlet for the country’s guilt for over 50,000 American deaths and a million Vietnamese deaths for an ill-begotten war which ultimately detracted from our world status and security, we are once again faced with harrowing questions about our national character:

(1) Are we a peace-loving or warmongering nation?

(2) Are we freedom-loving? Do we love freedom more than security?

(3) Are we committed to a noble view of the “warrior class” or is our deeper value more darkly cynical?

In answering these questions certain truths should be addressed:

(1) A large chunk of our volunteer military, perhaps a majority, seek out the military for a secure job, not out of patriotic love of country or the honor and courage associated with military service. This is particularly true in difficult economic times. We now have a type of military socialism – not quite what Eisenhower warned about a “military-industrial complex” but close – where very large numbers of the populace directly rely on the war machine to earn a living.

(2) Our freedom has been lessened, not enhanced, by the misnomer “war on terror:” restrictions on movement, unauthorized government intervention wiretaps, restrictions on habeas corpus and more. This is important given that the rationale for the war machine is to “protect our freedom,” literally die for our freedom. To understand pseudo-diagnoses one has to address Orwellian misspeak.

(3) With the perfecting of drone attacks, killing increasingly comes from afar. Killing from afar runs contrary to every cultural notion of a noble warrior class. This idea got significant play under the Clinton administration with the sending of bombers but no foot soldiers to make war on Serbia. There were actually some national/international voices calling us cowards. “Why don’t you fight like a man?!”

My thesis is that the function of the PTSD pseudo-diagnosis is that it gives voice as scapegoat to disowned parts of our national laments. We might think of PTSD as scapegoat – those with the diagnosis hold the revulsion that we can’t express more directly because of political and cultural constraint.

The PTSDer gets an enormous amount of pseudo-sympathy directed at him. The complexity is that he is also held in contempt, drugged as if he is unable to bear his memories, pathetic, requiring medical attention in lieu of compassionate understanding.

He, the PTSDer, must hold both our shame and our guilt, our guilt in that we have become the primary international killers and our shame in that we kill out of fear rather than noble cause.

A true “treatment” of PTSD needs a national voice that will not be spoken. We are not allowed to “apologize for American values” nor criticize our rationale for war. Recall, a decorated veteran (J. Kerry) of the Vietnam War, running for President, was called a liar and coward because he headed a band of vets who condemned the war. On the other side of that coin we were not allowed to criticize another nominee (J. McCain) for his bombing of innocent Viet Nam civilians.

We are now faced with an overwhelming number of veterans demanding disability benefits. I suspect much of this “disability” is the inability to speak out against the “war on terror.” Rage has become pathos, spousal abuse, suicide, homicide, drunkenness, and wounded brains. As Stan White (father of 2 vets lost because of the war on terror and who has championed better treatment of veterans) says, “Anger doesn’t accomplish anything.” Indeed.

Treatment Principles: ( The term “treatment “ is problematic but for now we are stuck with it.)

(1) Best in a group where multiple points of view are aired.

(2) Group leader quickly establishes that he does not think they have a disease.

(3) Minimal emphasis on symptoms such as insomnia, anxiety, depression, etc.

(4) The object of the intervention is clarity of thought, not in “ feeling better”.

(5) Therapist must be able to hold a whole spectrum of points of view, “ God bless America” “ God damn America”.

(6) The position of the therapist/facilitator is we are dealing with a moral, political, spiritual, existential problem, not a brain disease.

(7) Encouragement to “Speak-Up” about what you think about country, war, the “enemy”, government, leaders, particularly the negative views. In the negative views one will find the anger and ultimately the deeper sadness about themselves as “failed” warriors and failed peacemakers.

(8) The object, ultimately is to transform the military scapegoat (alias PTSD) into a role model for honest debate about who & what we are as a nation & a people.

(9) The group, as they reflect & debate will discover they are a microcosm of their country/culture debate, a debate poorly articulated. As they experience the conflict within the group, they will begin to see the conflict within each individual.

(10) Bad dreams & flashbacks are respected as the mechanism whereby we dare not forget. We must all hold the various horrors together.

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

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

Joe Tarantolo, M.D., Psychiatrist


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

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

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

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

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

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

I believe this goes for all RCTs.

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PLACEBO IS A BASTARDIZATION OF SELF HEALING

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

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

“I Want To Die” – Take 2

“I Want To Die” – Take 2

"I Want To Die” - Take 2


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

No, there is more to it.

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

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

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

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

My Country ‘Tis of Hate

My Country ‘Tis of Hate

My Country 'Tis of Hate


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

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


ISEPP members, should we not speak out?


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

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

Five Depressed Women, Depressed?

Five Depressed Women, Depressed?

Five Depressed Women, Depressed?


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

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

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

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

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

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

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

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

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

I’m Not a Healer – I Work for Money

I’m Not a Healer – I Work for Money

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.”