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. 

Constitutional Amendment 28

   Section 1. [Abolition of Forced Mental Treatment]

   Neither involuntary mental hospitalization, nor coerced mental treatment of any competent person whose refusal of help is clearly expressed for any reason or for no reason, shall be permitted within the United States or any place subject to their jurisdiction; nor shall the presumption of any person's mental competence require medical or scientific proof; nor shall benevolent medical intent or technique be considered for justification of criminal justice or lawful security measures.

   Section 2. [Power to Enforce this Article]

   Congress shall have power to enforce this article by appropriate legislation.

Rescinding psychiatric "diagnoses"

Dr. Lucy Johnstone, British clinical psychologist and author, recently suggested that a psychiatrist who was praised for his recent, honest about-face regarding his entire life's work on "schizophrenia" could be respected even more if only he would rescind the invalid diagnoses he has saddled so many people with over the decades. This is a great idea just waiting for practical implementation.

My first thought is a standardized form, which could be used immediately by anyone, but gradually accepted and made more and more "official" under whatever organizational and legal rules or policies can be successfully lobbied in support.  For example:

RESCINDED DIAGNOSIS

Name of individual:__________________________________________________

Address of individual:________________________________________________

Date of birth:_____________________________ Gender:__________________________________

Name of mental health professional:__________________________________________

Affiliation:_______________________________ License:__________________________________

STATEMENT:

The individual identified above was given a diagnosis of: ____________________________________________________________ on or about___________(date), by (check one): ___Me ___ a mental health professional whom I have identified as: ___________________________________(name), of ___________________________________(institution and/or address).

I hereby declare this diagnosis to be invalid from this date forward, because of the following (check all that apply):

___ the original diagnosis was based only upon symptoms of which this individual no longer complains, or observations which are not apparent or susceptible to any objective validation in present time;

___ the original diagnosis is no longer considered to be any valid disorder by mental health professionals;

___ the original diagnosis is an unscientific and arbitrary characterization which serves no medical or psychological purpose to help the individual or protect society;

___ other (please summarize):

Therefore, pursuant to _______________________________(specify at least one specific rule, statute, case precedent, ethics code or regulation), enacted on _____ (date) by _________________________ (name of authority), I hereby caution all persons, that any future or continuing reference to, or use of, the above invalid diagnosis, if such reference or use could create any disadvantage to the individual identified in this document, may subject you to civil and/or criminal liability for defamation, discrimination or fraud.

(Signed)

(Witnessed/Notarized)

Michael A. Cohen, dumb hack

A recent article in the Boston Globe is just beyond amazing, for its combined arrogance and naïveté.

Dylan Roof, the murderer of nine black parishioners at the Emanuel AME Church in Charleston, SC, is about to be sentenced to death. The journalist is obviously writing from an anti-death-penalty perspective, which is fine with me, I'm neither pro- nor anti-death penalty, in any general way...

But the real point author Michael A. Cohen wants to make is apparently more about mental illness and crime: "(T)here is perhaps no better example of the inherent flaws in the death penalty -- and the problematic way that the criminal justice system deals with mental illness -- than this case." Dylan Roof supposedly has "a broken brain", for which phrase Cohen cites celebrity TV psychologist Dr. Xavier Amador.

Dr. Amador (at least as Cohen quotes him) quite confidently diagnoses Dylan Roof with schizophrenia. Never mind that Amador has never examined Roof. Never mind that Roof apparently experiences no hallucinations, and he demonstrates no disorganized speech and no grossly disorganized or catatonic behavior. The only "delusions" that can be ascribed to Roof are his racist beliefs. Amador says that Roof shows flat affect and is unable to express emotions. But how does he know that, just from the media about the trial?

Even referring to the diagnostic criteria for schizophrenia in DSM-5 as if it were valid and reliable (which is a real stretch or fantasy), we should notice that Dr. Amador's "diagnosis" of Dylan Roof is pure speculation. But Amador is a TV psych. He makes his living largely by entertaining people, maybe not so much by effectively treating them.

Why would a journalist of Mr. Cohen's stature get so serious about repeating the glib psychobabble and speculation? Cohen seems to believe that Amador is saying something substantial, something that can be analyzed for significant implications about society and justice, etc. But it's pretty obvious to anyone who can read, it's all nonsense.

Something about motive here seems inexplicable....

Well... people hate to look at death, don't they? They fear death, they fear insanity, and they fear evil. Whenever they can, they pretend that these things don't exist, or at least that they're far away. Mental illness, schizophrenia and Dr. Xavier Amador are merely social fashion, to help with the pretense.

And I'm sorry, but Michael A. Cohen is a dumb hack when he writes an article like this.

Judges and lawyers appreciate the nature of "mental illness" better than psychiatrists: at least they occasionally admit they have no idea what causes people to be evil or how to cure them.

All of those "great strides (that) have been made in understanding these illnesses within the public health community" enabled no prediction and no protection against Dylan Roof's bullets, and they offer no solution and no reassurance, whatsoever, for the future.

Those "great strides" are trips and stumbles in the dark, by idiots preyed upon by charlatans. There is no scientific knowledge here, only pretense and fear.

Moral Reconation Therapy verses Mental Illness

Over several years, Moral Reconation Therapy ("MRT") has become a big business at Elgin Mental Health Center. Some people (clinicians or patients - the difference is minimal) like it, and some don't. But veteran administrators in Illinois' "forensic mental health system" must be aware that it presents a rather interesting, perhaps a rather dangerous, intellectual problem.

MRT situates the problem of criminal recidivism in dysfunctional behavioral choices and deficient moral reasoning. Psychiatry situates the problem of an NGRI acquittee's dangerousness in mental illness, a disease like any other, in the brain.

The MRT therapist at Elgin is basically telling patients that their problem is they lie, cheat, steal, betray, victimize and blame other people; and the fact that they are where they are (locked up in that fake "hospital") is their own fault entirely. 

At the same time, the psychiatrist is basically telling patients that it's only the mental illness that limits their ability to make behavioral choices or to reason morally; it's not their fault at all, they just need to take drugs to adjust their brains.

I have several clients who have failed or opted out of MRT because they cannot honestly reconcile the demand for acceptance of sole blame with the demand for acceptance of psychiatric doctrine on mental illness. They figure one idea or the other must be bullshit. But it sure is unacceptable to mention this discrepancy! 

The psychiatrists sure will tell the judges that any patient who questions the "illness needing medicine" view lacks insight and therefore remains dangerous. The MRT therapists sure will tell judges that any patient who blames their brain disease is being manipulative and therefore remains dangerous. The bottom line is, you have to lie, in the right way at the right time, or you can't ever get out.

This is the essential, overriding lesson of forensic mental health: You must become a really competent liar, to others, to society, and to yourself.

It's a terribly expensive lesson, in blood, treasure and human dignity.

What state psychiatrists can't think about, or read

Last week I attended a monthly staffing for a client at Elgin Mental Health Center, and I made it a point to bring copies of three recent articles for the psychiatrist in charge (I'll just call her Dr. R).

Dr. R has told her patient (my client) repeatedly that I (being her pro bono attorney for several years) am really bad for her, that she should watch out for me, that members of my church hurt people... just common, ordinary, vague, stupid negative generalizations like that...

But it occurred to me that I should give Dr. R a little more insight into what my influence on her patient really is, if I could. The three articles I brought were pieces I had sent to my client, who is a very bright woman with a law school education.  She's chronically bored with the "treatment" routine that is worse than useless for her, and she appreciates decent reading material.

I told my client that I would bet her, dollars to donuts, that Dr. R would never read the three articles. This seemed to me an easy prediction, partly because I'm not even sure whether Dr. R can really read anything. She's old and I've occasionally wondered whether she's a little way along toward dementia. But even more of a problem for her, the articles very effectively challenge an orthodoxy of psychiatry as "medical help" for mental-illness-as-brain-disease. This psychiatrist simply cannot afford to consider such a challenge. Given her life-long career wholly within a failing paradigm that will be indicted by history as an atrocity, the cognitive dissonance would surely overwhelm her emotionally.

Yesterday Dr. R admitted to my client that as I predicted, she did not read the articles. It's too bad.

The first article of three is "A Veteran's Letter to Congress" by Dave Cope, a former Navy Lieutenant. My client is also a veteran, and she had similar experiences to the author's with harmful effects of SSRI's. The reason Dr. R would never be able to deal with this is that Lt. Cope clearly states the truth: no physiological dysfunction of the brain has ever been found to be characteristic of any mental illness, and psychiatric drugs disrupt normal brain functioning.

Dr. R has spent her life putting people on psychiatric drugs and lying to them about what the drugs really do. She has deceived countless patients into submitting to iatrogenic mental and physical disability. She is a criminal against humanity; her career could be compared to Mengele's. She can't confront that.

The second article is "From neuroleptics to neuroscience and from Pavlov to psychotherapy: more than just 'the emperor's new treatments' for mental illnesses?" by two German psychologists who argue that psychiatric drugs just don't work, the orthodox concept of mental illness and treatment is deeply flawed, and psychiatry has altered the course of depression, anxiety, schizophrenia and ADHD for the worse.

Dr. R is a psychiatrist, perhaps in the habit of summarily dismissing views of mere psychologists (members of a decidedly junior profession from an MD's perspective). But these authors are respected scientists writing in a mainline publication. Again, there's no question that their article could seriously threaten Dr. R's fragile self esteem by tweaking her guilty conscience. No way she would ever read it!

The third article is a discussion by Bruce Levine, Ph.D., about whether psychiatry should most properly be considered fraud or bullshit. It points out that the pillars of the establishment have now invalidated the "chemical imbalance" theory and the DSM. He explains with subtle but tragic humor that most psychiatrists have never been truth seekers, and it hasn't been in their interest to know what is true or false.

This explanation fits Dr. R perfectly. But her problem would be that it's no excuse, it's an indictment. She cannot ever read this one, either. It's terrifying to be assaulted by the truth of one's own evil.

My client hates the forensic mental health system. But I suspect her doctor ultimately suffers, as the perpetrator, even more than her victims.

Failure in Illinois

Several clients at Elgin Mental Health Center are being transferred to other Illinois Department of Human Services facilities. This is necessary because the Illinois Department of Corrections has commandeered Elgin's Dix and Jenks clinical units for "treatment" of convicted felons.

In the reception area at Elgin there is a fancy bronze plaque which attempts to define for the public what is being done with their tax dollars. It insists, more or less, "This is a hospital where many come to find physical, mental and spiritual restoration and true recovery."

I've been in and out of this hospital on a weekly basis for longer than a majority of the employees there have been on the IDHS payroll. I've never met a "patient" at Elgin who does not recognize that despite what the plaque in the lobby says, he or she is really serving time. They may learn to think of themselves as "patients" (although "consumer" and "recipient of services" are probably preferred nomenclature). But they also almost invariably talk about the amount of time they've been given, as though psychiatric commitment were a criminal sentence.

Clinical staff at Elgin frequently stress the crime a patient committed, as well as the judicial process which has effective seniority over their curative endeavors. For these doctors judges decide when their patients may be released, even though these judges explicitly defer to doctors on what should be done with their criminal defendants.

In short, the supposed distinction between criminality and mental illness is problematic and getting more problematic every day, especially when Elgin Mental Health Center is becoming part-Department-of-Human-Services, part-Department-of-Corrections.

Elgin is a venerable, even an historic institution, built at the end of the 19th century with the inspired purpose to treat crazy people more humanely. Its forensic patients today are not considered culpable for any violent crimes they perpetrated -- they couldn't really help it, they weren't really responsible -- because their mental illness made them do it. The modern, rational thing to do is cure the disease-like-any-other mental illness, not punish the innocent, unfortunate, sick person.

Soon there will be a dramatic, literally glaring demonstration that this whole idea is bullshit, as described so ably by Bruce Levine, Ph.D..

Elgin Mental Health Center, the hospital that helps people, will soon sport two newly built gun shacks, guard towers with flood lights, and a ten-foot-high razor-wire fence. It's an easy bet that the general public will not recognize these additions as symbols of a benevolent healing enterprise. Rather, they'll be reminded that all mental patients are probably dangerous and all criminals are probably insane. Criminality and mental illness: same-same.

Society reacts, always has reacted, and always will react, essentially the same way to people we dislike and people we fear. It's just not a medical issue, unless medicine itself is punitive.

Modern psychiatry was a punitive dead end. We should dump it.