Lincoln South at Packard again

Social worker Shelby Daniels stated at about 10:15 AM in a treatment plan review on May 15, 2024, that her patient, Ethan, was said by CP staff to be "overly fixated on working out." This is a negative characterization which could arguably imply (and in this case was probably meant to imply) some mental illness or personality disorder, or even a potential danger to the therapeutic milieu or the community.

The first problem with such (laughable) "professional mental health expertise" is that CP staff means any one of several people, and we don't know who. The second problem is that we don't know how fixated is overly fixated. The third problem is that we don't know what fixated even means. Thus, if such a casual, probably speculative comment by an unknown person ends up in a medical chart as a pretended "clinical observation" reported as if under oath, it becomes very poor, unreliable, prejudicial, and possibly perjured "evidence" indeed! 

The forensic mental health system thereby discredits itself and endangers the reputations of those medical and legal professionals who work in it, supposedly to help patients and serve justice. It also (needless to say!) pisses off the patient and his lawyers.

But this is exactly what staff at all of Illinois' state-operated psychiatric facilities do, day-in and day-out: they rumor-monger and natter about people they don't like, and pretend they know something about mental health which makes them worth their salaries. They are ignorant, mean people who sponge off the taxpayers and deliver no value whatsoever to society. They are my enemies, and I must do my best to love them.

In this case. Ethan told me that Shelby let it slip when he queried who said he was overly fixated on working out, that the comment was in some email. Shelby probably just wanted to disavow having spoken to any real individual. Ethan then came back and asked who sent the email. Shelby said she didn't know, she didn't remember who sent it, it was just a big, long email which incidentally included that comment among lots of other stuff.

Hmmm. That is plausible. But it certainly raises more questions!

Will Shelby Daniels, or the person who sent the email, or some IDHS information technology manager or custodian, delete that email at some point in time? Shouldn't it be preserved as evidence? After all, the report, or the opinion or whatever it was, came up in a monthly treatment plan review for a patient, apparently as relevant clinical information. If evidence is destroyed or tampered with, that could become a serious due process issue.

Or alternatively, if this "Ethan is overly fixated..." is just an unimportant bit in a mass of information that's part of routine traffic, why did Shelby mention it prominently at the start of a monthly review?

My guess is that the "treatment" team just doesn't like Ethan, and they instinctively feel like they have to discredit him. I don't think he takes meds (that would certainly prejudice Dr. Cash against him!), and he's very recalcitrant about sucking up, admiring or even respecting the plantation overseers. He just doesn't want to be a slave.

This is a wonderful situation to watch, top-drawer entertainment! These oh-so-superior people (Cash, Daniels, et al.) will founder, perhaps dramatically, on the rock of somebody (Ethan or any other high-functioning and reasonably honest NGRI patient) who patiently and intelligently refuses to bow down and tell the lies they want him to tell.

I will help Ethan get out of Packard; but the longer he's there, the more it might benefit my own prospects... to "burn Atlanta and march to the sea." War is hell, right?

Psychiatria delenda est!

APAAM 2024: an incriminating moment

At 10:30 AM, Sunday, May 5, 2024, at the American Psychiatric Association's Annual Meeting in New York City, a session was held which was entitled, "Responding to Reports of Sexual Violence on Psychiatric Inpatient Units."

It should have been entitled, "Responding to Reports of Sexual Violence on Psychiatric Inpatient Units, as long as No Staff are Suspected Perpetrators." (Sorry for my bitter sarcasm here, but this was the most discouraging moment of the whole APA weekend in New York!)

Four clinicians were presenters: Benjamin Brody, M.D., of Weill Cornell Medical College; Victoria Wilkins, Ph.D., also of Weill Cornell; Elizabeth Ford, M.D., of Columbia; and Kati N. Lake, Ph.D.  About 40-50 people attended, most of whom were mental health professionals who work on in-patient psychiatric units.

Dr. Brody was very fidgety and nervous. He was a little hard for me to hear, although I was actually sitting in the first row. He spewed loads of statistics. (That seems to be a sort of automatic response to the whole world by these people, as though numbers and raw, unevaluated data in sufficient mass can protect them.) The important point Brody made early on was that some kind of investigation must be conducted into every patient allegation of sexual abuse, even if the patient says they were raped by Santa Claus. 

He didn't say what kind of investigation, and I had no opportunity to ask whether it should be... thorough or a sham, honest or part of some cynical political cover-up.

There was in fact a carefully suppressed undertone throughout this session of minimizing, or even dehumanizing, patients. Of course they will say they were raped by Santa Claus, right? They're crazy after all, they don't have real points of view. I didn't like some of the things people laughed at.

Dr. Brody was followed by Kati Lake. Her contribution was all about trauma-informed care. Being subjected to sexual violence in a psychiatric institution sure does cause trauma! In fact, Dr. Lake made the quotable statement, "The hallmark of sexual violence is betrayal of trust." She also repeatedly suggested that mental health professionals ought to ask patients a different question than what they have been trained to ask: they should not ask, "What's wrong with you?" but instead, "What has happened to you?"

At some point Victoria Wilkens mentioned that patients know everything that's happening on a clinical unit. This was a point of agreement for Dr. Brody. He replied (nervously fidgeting), "Yes, they certainly know what's happening better than staff: that is 1000% correct!"

Almost all of this hour-and-a-half session was about how to deal with patient-on-patient sexual violence. E.g., the perpetrator has to be treated, too; but there are legal, even criminal implications, and that complexity along with the trauma factor (which extends beyond individuals to the whole milieu) must be competently managed.

Only Dr. Ford ever mentioned the elephant in the room, and she did so very briefly, with a mere passing comment: "Sexual violence can also be perpetrated by visitors, or even (implying... as unlikely as it may seem, or as rare as we all may know it to be...) by staff.

I stood up immediately when they called for questions or feedback from the audience, and thanked Dr. Ford for acknowledging, if only barely, the reality that my entire legal practice is all about. Sexual abuse of involuntary mental patients by staff is absolutely endemic in state operated psychiatric inpatient facilities. I asked the panel why this reality was so severely, desperately, avoided in the session.

Dr. Brody fidgeted a bit more. He offered what was to my mind a comment, not an answer: There are other ways to deal with that, like strict rules about boundaries and the ability to fire or even prosecute staff who violate the rules. "We don't owe staff any treatment, we only owe that to patients."

I responded that if indeed patients know what's going on on a clinical unit better than staff, and if indeed the hallmark of sexual violence is betrayal of trust, then surely the whole therapeutic milieu that's necessary for any mental health treatment to occur at all will be utterly ruined by the kinds of situations that I am suing people for in Illinois. I described the claims we have filed, e.g., for a young black man who was seduced by his middle-aged white female social worker into a three-year sexual affair that took place entirely on the inpatient clinical unit. I mentioned that the social worker did eventually get fired and go to prison for that; but the patient still attempted suicide three times within a few months after he was released, and he will never again trust anyone who offers to "treat" him.

There was some back-and-forth, but nobody in the audience was willing to comment or engage. This was obviously not their preferred subject of discussion. I can't say for sure whether that was because it just wasn't very relevant to their experience, or whether it was all too relevant. I sure suspect the latter.

Afterwards, I had a collegial conversation with a Dr. Kayla Isaacs, M.D., who spoke about a patient she recalled, obviously delusional, who complained virtually every day that she'd been raped the previous night in her psychiatric hospital room. (What to do, what to do?)

I also asked Dr. Lake if she was familiar with Lucy Johnstone, the psychologist from England, who as far as I know invented the idea that patients should be asked what happened to them instead of what is wrong with them. She didn't know of Lucy, but Dr. Wilkens piped up to say that she was familiar with her.

As I walked out of that room, I got the funny feeling that these people might be talking about me, and they might have been suspicious of me. 

They sure as hell should have been!

APA 2024: "Comfortable with spirituality"

The subject of psychedelic assisted therapy may not be the main or only hot topic at the 2024 annual meeting of the American Psychiatric Association in New York City. Maybe this whole scene of psychs-and-Shrooms/psychs-and-LSD/psychs-and-Ecstasy/psychs-and-Special K, is just my own peculiar fetish. 

But man! Stephen Ross, M.D. sure did draw a crowd on Saturday!

Dr. Ross ran a featured session at 10:30 AM entitled, "The Leading Edge of Psilocybin Therapeutics: Psychiatric & Existential Distress in Advanced Cancer, Alcohol Use Disorder, and Major Depression." The room was filled to capacity with about 300 people. 

Dr. Ross started with a summary of the history of psychedelics which was fully in tune with the way "Psychedelic Renaissance" people usually present the story. He commented as a preface that he loves history, and said the history of psychedelics "...is a very important part of our field (in psychiatry), which has been sort of erased." He went over the traditional use of psychedelic drugs for millennia by indigenous peoples, Albert Hoffman's 1943 bicycle ride, the 60's, Timothy Leary, and Nixon's war on drugs. He seemed to have a pretty good command of the Twentieth Century narrative.

At several points Ross reminded his audience that these drugs have occasionally been used in very unethical ways, like by the CIA, and by Charlie Manson. (He never mentioned any unethical use by psychiatrists, of course; psychiatrists from NYU/Belleview/NIMH are the good guys!) The audience could have detected a hint that Ross thinks those bad old, unethical things could happen again, because the current enthusiasm, the Renaissance, "is almost moving too quickly now. There are real risks, and there's way too much hype." Drug companies want to hop on board this enthusiasm, with shorter-acting versions of shrooms and acid that could just be prescribed, and wouldn't need any therapists.

Dr. Ross categorically asserted, "We must have a therapy model." In other words, Big Pharma's wet dream of gazillions in profits from just selling these drugs to a mass market is impossible. Doctors are never going to tell patients to just trip. Ross seemed a little too casually dismissive of such scenarios, though like, oh of course everyone there in the room would agree with him, because he's the top expert and they were professionals always dedicated to following his opinion and obeying his every advice.

He did seem very confident in reeling off details from a large number of studies, and more raw data than anyone could remember or evaluate. There were occasional gem-quality, if disjointed, comments, e.g., "Psilocybin is really about the search for a good death;" and a slide which detailed the "Psychological Safety Profile" of Psilocybin which included "acute psychological distress, fear, panic, psychosis, acute dangerous behavior, suicidality, violence, persisting adverse psychological sequelae, hallucinogen persisting perceptual disorder (HPPD), and hallucinogen misuse/abuse;" or for treating alcohol use disorder, "Religiomania is the best cure for for dipsomania;" and "MDD is the most problematic brain based illness" but "data suggest that the mystical experience really matters in treatment."

One of my favorite APA guys is Paul Appelbaum, M.D., from Columbia University. He and Jeffrey "freak-of-nature" Lieberman (also an erstwhile Columbia professor) were back-to-back APA Presidents, in the days when they could imagine that psychiatrists would soon be the powerful captains of mental health treatment teams, with the closest access to brain science enabling high status and huge money. Now Dr. Appelbaum is in the thrall of psychedelics, because everything else psychiatry has done failed. He gave his talk from 1:30 to 3:00 PM Sunday, about "Challenges in the Use of Psychedelic Compounds for Psychiatric Treatment."

Psychedelics are "compounds" (rather than "drugs" or "medicines") for Dr. Appelbaum, and I failed to wonder why, until hours after his session. Now I think maybe it's a more neutral term (not to mention more technical/chemical), which wouldn't tip his hand about whether he approves or disapproves of this trend in his profession. His opening question for an audience of at least 500 people was, "What accounts for the rapidly growing interest in psychedelics?"

Appelbaum had two considerably younger co-presenters, both of whom were perhaps far more into psychedelics than he wanted the audience to believe he was. These were Dr. Natalie Gukasyan, M.D., of Columbia, and Dr. Amy McGuire, Ph.D., of Baylor College of Medicine. Dr. Gukasyan mumbled a lot, so she was hard to understand although she mentioned a couple scary downsides: anyone who is on lithium is at high risk for seizures with psychedelics; and boundary violations (sexual or financial abuse) are a very important problem, because people taking psychedelics are so suggestible.

Nevertheless, Dr. Gukasyan was certainly there to testify about the upside of psychedelics. She's too young to believe the truth, that psychiatry has simply failed and it has no hope.

Dr. McGuire was an interesting case, too. She has actually run a psychedelic retreat herself. Her specific points were that due to the expense of doing psychedelic assisted therapy "correctly" (with a substantial therapy component, hours of counseling before and even more hours of counseling after tripping), there will be enormous incentive for unregulated use of the drugs, and for an increasing number of retreats that cannot be closely supervised. They will be branded/marketed as "alternative health" and "religious" retreats, and only rarely as actual medical care.

All three presenters in this standing-room-only session emphasized the dire importance for mental health professionals to get themselves educated in the issues involved, because the demand for psychedelic drugs and psychedelic assisted treatment is already huge, and increasing rapidly beyond their control. Although Appelbaum and his cohorts were admittedly shell-shocked by the magnitude of this development, they seemed to have no sense of any solution to an obvious looming danger, other than just their continued presumption that "science" as they have always understood it is the necessary, and the only possible, answer. 

Paul Appelbaum gave the final portion of the presentation. He expanded on the difficulties of informed consent in psychedelic therapy. For example, how can a patient be "informed" by a therapist, about possible experiences and phenomena that are really ineffable? How can a therapist explain or warn about things (like "oceanic boundlessness," or "dissolution of ego," or apparent communications with "higher powers and spiritual entities") which are simply not understood at all?

Advanced planning for interventions when therapy gets difficult is also very hard. A patient might say before a psychedelic session that he or she does not want to be touched by the therapist, but then want such reassurance desperately if they are terrified by experiences on the drug. Once a psychedelic session has begun, it is very difficult to stop.

Many people who want psychedelic therapy have unrealistic expectations of benefits. The media often contribute to this problem. 

Appelbaum's basic position seemed to be, "We know little or nothing about psychedelics, we cannot predict what they will do to any person or to society. But we sure are going to use them anyway."

Stephen Ross said, "I have become comfortable with spirituality."

For him and for psychiatry, that is surrender.