Monday, June 28, 2010

It's the BEHAVIOR, stupid!

According to an official U. S. government (SAMHSA) website, some people believe that the term "behavioral health" is problematic because: a) it misconstrues the disease nature of mental illness and addictions; b) it implies a choice which a person can change by free will; and/or c) it focuses too much on symptomological behaviors that a person cannot control.

These arguments are presented (by the U. S. government!) as legitimate. But the disease nature of mental illness is quite literally mythical; and if people can't change or control their behavior by exercise of will, I guess we don't even have any basis for law....

There is not one single diagnosis of mental disorder, which can be diagnosed by any method, no matter how much money is available, other than observation of behavior. There is not one single mental disorder which is defined in any terms other than behavior. The "disease nature" of these things is purely a metaphor.

When the most up-to-date textbooks discuss mental disorders, they never fail to point out that all the neuro-chemical and brain theories are precisely theories. The dopamine hypothesis of schizophrenia remains hypothetical. The latest and finest serotonin manipulations still don't don't even beat placebos for effectiveness against depression. The largest pharmaceutical researchers are abandoning searches for cures to mental illnesses. Guess what guys, that's because no "disease nature" can be discovered.

So I think anything other than "behavioral health" certainly misconstrues the non-disease nature of mental illness and addiction. The fact that we control behavior with drugs which neurologically disable miscreants does not change this. Nor does the fact that people sometimes willingly damage their own brains with drugs. And no psychiatrist pretends to cure anything.

As far as abilities to change behavior go, here's a story.

A client of mine (I'll call him Bobby) was found not guilty of first degree murder by reason of insanity, diagnosed with schizophrenia, and committed to Elgin Mental Health Center about fifteen years ago. One of the things everybody noticed about him was that he kept saying he was the King of Egypt. Another thing everybody noticed was that he refused to take psychotropic meds.

When I first spoke to Bobby, he was especially concerned - perhaps obsessed - that I needed to see the official government identification, held for him by the director of the institution, which established that he was King of Egypt.

After a couple monthly staffing meetings, I told Bobby that his treatment team was not likely to stop using this King of Egypt thing against him. I was pretty sure they would continue to say it was a symptom of his psychosis and proof that he shouldn't be released.

I suggested he do one of three things, whichever seemed best to him: a) he could prove conclusively that he was in fact the King of Egypt (his official ID had not been effective for that; but maybe the Egyptian ambassador could vouch for him, or maybe there were other documents proving his lineage); b) he could convince his treatment team that believing he was the King of Egypt did not make him any more likely to be violent in the future, and therefore that what they saw as his delusion was harmless; or c) he could lie about it and tell everybody he no longer believed he was King of Egypt.

Bobby chose to lie, pursuant to option c). Within a year or two, people stopped listing the King of Egypt thing as a symptom in his psychiatric chart. He subsequently was twice granted expanded privileges by the criminal court, and will soon petition for conditional release with the full support of the state institution.

I don't know whether he still believes he's King of Egypt or not. Actually, come to think of it, I don't know whether he ever did believe it. Maybe he was lying to begin with. What I do know is that Bobby's behavior, observed by all the experts as symptomatic of schizophrenia, changed one day, because he decided to change it of his own free will. Nothing else happened, there was no effective medical intervention.

So ... "behavioral health" seems appropriate to me, if it has to be any kind of health to begin with.

Wednesday, June 23, 2010

Mad Scientists and Dupes

There is apparently research suggesting that exercise beats psychotropic meds for effectiveness against mental disorders. The studies aren't funded and promoted with Big Pharma billion$, so the regular authorities whom the Illinois legislature and the Illinois Department of Human Services (DHS) use as mental health experts (e.g., Heyrman at University of Chicago) may not be paying much attention to the implications yet. Let me suggest a couple.

Court ordered "treatment" can be much, much cheaper. When we decide somebody is not criminally culpable and shouldn't be punished for their behavior, well, we just don't necessarily have to go all medical about it.

I have a client, "Mr. D", who was found not-guilty-by-reason-of-insanity (NGRI) for burglary. He's been in the Elgin state nuthouse for a year or so, with various conflicting diagnoses of mental disorder which have justified about a dozen different psychotropic meds. It's just complex as all hell. The guy nearly died from drug side effects at least once. He's young - early twenties - and never had any life threatening health problems before he was psychiatrically "treated". His family is upset with the nuthouse doctors, and litigious. His sister's a pharmacist, so she's not easy to control with PR about medicine. DHS clearly wants this patient out as soon as they can talk his judge into a conditional release. All their clinical expertise is devoted to just stabilizing him for a few months, just making him look good enough to get past the court so they can be rid of him before he becomes their disaster.

Dr. C at Elgin, who took over from Dr. H, after this patient returned from an emergency hospital admission for acute renal failure, asked me one day whether I "believe in" any kind of medications at all. The question presumed of course that I don't "believe in" psychotropic meds. I refrained from laughing, and told him I had occasionally been highly impressed by the efficacy of ibuprofen for shingles. I also said I really have no principles against psychotropics as restraint, if someone is immanently threatening violence. There's nothing fraudulent about that, no betrayal or pretense of help.

But I pointed out that trying to fine-tune somebody's brain chemistry to improve his behavior is a ridiculously complex, expensive and unlikely enterprise. Mr. D is a perfect demonstration. Dr. C was very relieved about recent tests showing medication blood levels better than he expected, because such results should look very positive to Mr. D's court when it is asked to grant his conditional release.

In my experience judges don't know the significance of blood levels of meds any better than they know schizophrenia from schizo-affective, and that is not at all. Dr. C and the Elgin nuthouse have this whole ornate operation going which nobody really understands, and which Illinois taxpayers finance only because they automatically believe in all things medical and think there's no other choice.

At the moment I don't recall the exact amount of the budget deficit Illinois is running. But I know the daily expense of involuntary psychiatric confinement is about $400/person/day. That probably means we spend $350 million annually to keep guys like Mr. D in institutions like Elgin.

Now, what do you know! Maybe Mr. D should have been run around a quarter-mile track for an hour or so every day rather than fed neuroleptic poisons. It would have been much, much cheaper, and it might have worked at least as well for the purposes of the court and community safety, not to mention Mr. D's health.

Another implication: forensic psychiatry has been a major rip-off. The state has been wasting our tax money on a mad-science, vaguely perverted fantasy. The current and prevailing tradition in Illinois suggests somebody should go down for that....

Monday, June 21, 2010

Opportunistic Dx

Dr. Peter Breggin writes in today's Huffington Post that psychiatric diagnoses frequently change, often in an effort to justify a particular drug. But it's worse than that. Diagnoses change to justify any kind of treatment, or none at all.

In regular modern medicine, a patient presents himself to a doctor with a complaint about how he feels or something which is happening to his body. The doctor listens to the complaint, does tests, discovers some kind of objective biophysical problem, and after making a diagnosis looks to clinical experience or medical literature for a cure, which the patient is offered.

In psychiatry, someone else brings the patient in (often under duress). The doctor listens to and automatically believes complaints about the patient's behavior. A decision is made regarding what to do to the patient (usually drug him) to disable him from behaving in such a disagreeable fashion. Last of all, a diagnosis is looked up to formally justify the chosen "treatment".

Regular modern medicine: Dx first - then Rx. (Dx --> Rx.) The treatment depends on the diagnosis.

Psychiatry: Rx first - then whatever Dx will justify. (Rx --> Dx.) The diagnosis depends on the treatment.

In state nuthouses, involuntarily committed patients are told in so many words that they either take the meds or they'll never get out. It's illegal to tell them that; but they are all told exactly that nonetheless. If somebody steadfastly refuses meds and cannot be legally forced to take them, sometimes the only solution is to change the diagnosis. But this can be done with surprising alacrity.

Several years ago I had a client named Jim. He had gone from Chester Mental Health Center to Alton Mental Health Center to Choate Mental Health Center, never taking the meds he had been prescribed for the psychosis which all the doctors were apparently certain he "had". His Thiem date (when the system would be constitutionally required to release him) was fast approaching, and as it turned out, nobody wanted to litigate a civil commitment.

One day Jim called me and reported, with amazement, that his psychiatrist had taken him into an office and asked what diagnosis he wanted. I'd previously given Jim a copy of DSM-IV-TR, so I said, well, that's easy, just look in the book and find a diagnosis that wouldn't be treated with psychotropic meds. He went to pages 338-343, and told his psychiatrist that he should be diagnosed with Substance-Induced Psychotic Disorder (code 292.11), in remission.

This was quickly done. The Illinois Department of Human Services put together all the necessary documentation to make it look medical, and soon petitioned the criminal court for Jim's release, which was granted. Now years later, he lives with his elderly mother and gets along just fine.

In this case, the nuthouse needed to release Jim as successfully "treated", and they wanted credit for it. Because of the timing, they had to justify his not taking meds. No problem, they just changed his diagnosis accordingly.

Psychiatry: Rx --> Dx. Simple, but quite the fraud.

Wednesday, June 9, 2010


Today's Chicago Tribune carries a story all about how mentally ill people should be immune from criminal prosecution because their "brain diseases" cause their violent behavior.

As usual, Mark Heyrman, the leading local proponent of this radical jurisprudence, is cited.

The illustrative narrative in this particular piece concerns Adam Rotheimer, a supposed schizophrenic who told a social worker he wanted to get an AK-47 and kill a judge along with all the people helping him. Professor Heyrman and several other authorities are dismayed that the social worker was obliged to report the threat, because the resulting arrest of Rotheimer was such an affront to that Holy of Holies, psychiatric "treatment".

Ira Burnim of the Washington, DC-based Baselon Center said, "If you want people to avoid mental health treatment, the best way to do that is to ensure they're treated like criminals when they get it."

I see it differently than Heyrman and Burnim. People naturally avoid mental health treatment to the extent that it hurts them rather than helps them, which is a very large extent. Refusing "treatment" is criminalized much more than getting it. Without state coercion on their side, most psychiatrists would be unable to make a living by plying their desperate, ugly political trade.

The Trib article, while purporting to present the problem of Adam Rotheimer's mental health, quotes only others. Adam's mother's and sister's views are presented, as though of course, they have only his best interests in mind, and as though of course, their evaluations of all issues can and should be substituted for Adam's own.

I have represented plenty of people in Adam's situation. Lots of my clients have been plenty crazy, committed violent crimes, and/or caused reasonable fear of harm to those around them. I can say, after nine years of work as an attorney exclusively in this special area (with which most of my colleagues want nothing to do), that this "mental illness" explanation/excuse does not open the door to any solution whatsoever. It makes everything worse, except in the occasional circumstance of an immediate necessity for self defense. (I.e., if somebody's attacking and beating up everyone in sight, a shot of Haldol, like a stun gun, is perfectly appropriate.)

Adam Rotheimer was supposedly "voluntarily committed" in March. This is a cynical euphemism. Adam was told that if he didn't sign a certain document, he'd be involuntarily committed by court order. The document was called a "five-day release". This is a fraudulent, although fairly universal characterization. The form is really used to relieve the hospital of its duty to make legal arguments in court for holding a patient against his or her will, so insurance payments can be collected until coverage runs out without a bill for attorney hours.

Adam's "treatment" is portrayed as something which can keep him out of legal trouble. Nonsense. How long has he been in "treatment"? Why is he in legal trouble now? There are plenty of people who believe, based on substantial evidence, that psychotropic medications cause violence instead of preventing it.

Forensic psychiatry is a corrupt, anti-scientific political racket. History will record our modern love affair with medical solutions to obnoxious and violent behavior as much akin to the 300-year European prosecution of witches. Why does everyone believe in these "brain diseases" which have never been evidenced by any objective signs, for which no etiology can be discovered, and which are admittedly voted into and out of existence according to changing cultural whim?

The answer to the initial question in the Trib article is that there is no line between mental illness and bad behavior.

It costs four times as much per day to involuntarily "treat" someone as it does to imprison them. The result is not better. We are deluded.