Wednesday, May 24, 2017

The APA is corrupt

Dr. Paul Appelbaum, M.D., a psychiatrist from Columbia University and a past President of the APA, was one panelist in the symposium I attended today in San Diego, entitled "The Battle Over Involuntary Psychiatric Care". This was Dr. Appelbaum's seventh presentation during the week of APAAM 2017. Clearly, he is an APA star.

Dr. Appelbaum did not "battle" at all, however. He gave a fairly boring synopsis of the history of involuntary psychiatry, the main point of which was that it was only beginning in very recent times when voluntary hospitalization even became a concept. Historically, everything was involuntary. He believes now that society will not relinquish its dangerousness-only-based justification for forced treatment, despite the fact that there may be better justifications. In particular, he considers that the possibility of successful treatment should be a basis.

In other words, whether or not a person is truly dangerous to themselves or others, it might make sense to force them into "treatment" that will work and actually help them live better. It seems illogical (to Dr. Appelbaum) that a person can meet legal criteria for involuntary hospitalization and yet be allowed to refuse "treatment". These issues should suggest a new look at the laws, which were more or less all created in the 1970's. The doctor's opinions were communicated in a very calm, conservative way that could be interpreted as banal arrogance. No need for any "battle" in any event.

What Dr. Appelbaum fails or refuses to consider is that his own concept of "treatment" (that would be drugs, drugs, drugs, and nothing but drugs) is something that many people do not want and go to enormous trouble to escape from. It is damaging. It causes disability, dehumanization and loss of life. 

This reality is something that Dr. Appelbaum seems to completely deny, or to be completely ignorant of. In fact when one member of the audience brought up the recently less controversial position that long term "maintenance" on antipsychotic drugs is bad for recovery from psychosis, he threw out a citation of the new article by Jeffrey Lieberman saying neuroleptics aren't bad for people at all! That article, of course, was meticulously criticized and decisively refuted by Robert Whitaker in a MadInAmerica  blog. (What a surprise, Dr. Appelbaum didn't mention Whitaker's criticism.)

Drs. Appelbaum, Lieberman and their ilk are exactly what Whitaker refers to as "a case study of institutional corruption". If they are American psychiatry, then American psychiatry has little or no future. 

I asked Dr. Annette Hanson, M.D., about the future of psychiatry. Dr. Hanson is one of the authors of the book, Committed: The Battle Over Involuntary Psychiatric Care, from which the symposium's name was derived. She graciously signed my copy of her book, and got her co-author Dinah Miller, M.D. to do the same.

My question was, "Given a presumed, hypothetical continuation or acceleration of two trends, how do you see the future of psychiatry and the law? The two trends have been repeatedly suggested and evidenced during the week of the APA conference. They are: 1) the substantial loss of faith in a pure medical/brain-pathology model of psychosis; and 2) the loss of public will to force people into treatment for mental illness."

Dr. Hanson liked my question, and we had a short conversation. She practices in the field of correctional (i.e., prison) psychiatry. Her experience has much in common with my own. People have to be "treated" by alert human beings who understand them and care, and take time to predict what they think and what they will do as people. It may take years, patience, much trial and error, many steps back for many steps forward, much negotiation, etc., before a violent criminal said to be "mentally ill" becomes well and civil. This is a teaching project far more than any procedure for medical cure. In short, the psychiatrist must talk the "patient" into changing his attitudes and his behavior.

Obviously this is a far cry from the Appelbaum-Lieberman vision of psychiatric power based on medical technology and access to legal force. Those guys are on their way out.

I also told Dr. Hanson to let her co-author know I am a member of the group she claims she had to "ambush" to get a statement for her book. (See pages 34-36 of Committed.) More conversation, please!

APA Annual Meeting 2017 (San Diego)

Interesting thoughts provoked by a session on outpatient commitment, or "Assisted Outpatient Treatment" yesterday...

When a court requires an individual to be "treated" although he/she truly and competently wishes not to be, are we trying to help that person, or are we controlling risks and adverse influences in the community? Certainly either purpose is legitimate. The two combined may even describe civilization itself rather fully.

But helping people and controlling them are distinct, separate activities. In psychiatry, especially involuntary psychiatry, they are hopelessly confused. And that may even describe the whole problem rather fully.

The session I attended featured seven speakers: Dinah Miller, M.D., from Maryland; Ryan Bell, M.D., J.D. and Kimberly Butler, LCSW-C, from New York; Erin Klekot, M.D., from Ohio; Mustafa Mufti, M.D., from Delaware; Adam Nelson, M.D., from California; Marvin Schwartz, M.D., from North Carolina.

Dr. Miller, the moderator, was the biggest reason that I actually came to this conference. She and co-author Annette Hanson, M.D. recently published a fascinating book, Committed: The Battle Over Involuntary Psychiatric Care (Baltimore: Johnson Hopkins University Press, 2016). They are also running a symposium today based on that book, at APAAM 2017.

Amost all my life, I've been an advocate for the total abolition of psychiatry. Many people interpret that to mean I am opposed to helping people with "mental illness" or opposed to medical treatment or science generally. None of that has ever been true.

My friend Tom Szasz said that psychiatry as we know it would wither away if it only lost its facility to acquire and retain "patients" using the police power of the state. I have long believed this is a compelling argument and a highly reliable prediction. In fact, it has primarily informed my career as a lawyer and my advocacy as an abolitionist.

Now an even more fundamental framework is occurring to me. Is "treatment" help, or control? If so-called "mental health professionals" could be required to honestly confront that distinction with their "patients" many things could improve.

When you have four security guards hold a woman down, struggling and screaming, for a nurse to force a needle into her body and inject a drug that will alter her mind against her will, there is simply no chance that your "patient" will experience it as help. You should not be allowed to call it help, or even to think that you are helping. Your lie will degrade you, and if your "patient" gets any wind of it she will hate you and forever dream of revenge.

On the other hand, precisely the same violence recognized openly and officially as control, while regrettable, may be an inevitable compromise in an imperfect society subject to disagreements and fears. That can be forgiven. It also may not require creation of elaborate bureaucratic machinery to protect falsehoods in the institutions where I practice law. 

Dr. Miller said yesterday that she doubts forced treatment can or should be justified as a public health measure. I absolutely argue the opposite: it must and can only be justified as a public health measure! The public has a right, and will always assert the right, to protect itself. If subduing a violent person (or even a merely obnoxious person) with antipsychotic medication were workable as public protection or community improvement, we would probably be confident in involuntary psychiatry as morally justified control.

But if you are a doctor and you honestly want to help a person in front of you, it will be necessary to find the insight and patience to treat that person only with his or her informed consent.

Dr. Bell, who had more direct experience with outpatient commitment (in New York) than anyone else on the panel, responded to a question I asked, about whether patients might occasionally change the minds of clinicians, even about such fundamental issues as what is wrong with them and what is needed. He told a story of a man he treated for some years. The end point was, yes, a human being's autonomy must be respected or help simply does not occur. 

This seems obvious and fundamental. There should be a rule or a law.