A Phenomenological View of Madness and Medicine

I got to thinking. In my essay “The Reality Is In Our Heads,” I espoused a phenomenological view of the world in which human meanings cannot be located in the physical world. Yet, human experience requires the notion of a mind that is biologically mediated by a material brain.

Huh? Let me translate that. I believe that all experience is biophysically mediated according to natural laws (mediated by a material brain). Our minds, our beings are part of the natural world and operate according to physical laws.

Yet, I thought it absurd to think that our meanings, selves, beings, our human experience could be reduced to bouncing molecular billiard balls any more than what makes a great painting great can be deeply appreciated by a chemical analysis of the pigments that make up the painting. Utterly absurd. Our minds and hearts cannot be found in the analysis of the cellular, biochemical activity of our nervous systems.

So, I got to wondering how we can understand the effects of the neuroleptics on human beings if we don’t do the mirror image opposite of those who attempt to understand madness with neuro-physiological explanations and conclude that “antipsychotic medication” is the proper response.

What if we don’t do what the honest researchers who — in response to this erroneous but highly profitable, destructive misunderstanding — rather than deny the devastation wrought by neuroleptics, try to explain the deterioration of the souls of the medicated by invoking things like “destruction of basal ganglia” or “the medication caused increase in D2 receptors.”

Despite the fact that the neurophysiological explanations of psychotropic damage to the central nervous system appear to be closely tied to and consistent with the actual evidence, what if we didn’t join in the reductionist worldview of the neurophysiologist and stayed instead on the phenomenological plane? What if we tried to understand the internal experience of the medicated individual in order to answer the question, “Why do people medicated with the so-called antipsychotics lose their minds?” In addition to the understanding of drug-induced brain damage, would our phenomenological view add to our understanding of why outcomes are so poor with the use of neuroleptics?

The Socio-Political Context

Spanish lady come to me, she lays on me this rose.
It rainbow spirals round and round,
It trembles and explodes.
It left a smoking crater of my mind,
I like to blow away.
But the heat came round and busted me
For smilin’ on a cloudy day.
(from “The Faster We Go, The Rounder We Get” by the Grateful Dead)

If we are going to understand the phenomenological experience of being deemed crazy, which is then followed by medication and the deterioration of the self — a deterioration of the self which appears to me to begin well before there is any significant, lasting neurological damage from the drugs — we have to take into account the socio-political context, the interpersonal politics of the situation. Who are the players and what are they experiencing and responding to?

So to begin, let’s look at what those who are medicated have in common. As difficult as it is to avoid stereotyping, labeling, and thus diminishing the appreciation of the individuals involved, if we are to develop a larger understanding of the interpersonal politics involving psychiatric treatment, we have to keep in mind that, as varied and vastly different as they are, people who get medicated do tend to have some things in common.

First of all, prior to recommending and pushing neuroleptic medication, someone has to come to the judgment that the medication target is talking or acting in ways that don’t make sense. Whether the target is suicidally depressed and voices despondent beliefs that others consider psychotic, or the target appears to others to be manically grandiose, or caught up in fantastic persecutory paranoia, or is seen by others as merely talking incomprehensibly … it doesn’t matter. To receive “antipsychotics,” something about a person’s actions or beliefs must suggest a way of experiencing the world that others find to be contradictory to (or disconnected from) what the others believe is reality. Being perceived by others in this manner is one of the two things that most of those who receive long term “antipsychotic medication” have in common. In addition, medication targets tend to have another feature in common.

That is, when they talk or act in ways that don’t make sense to many of the people around them, they do it in a manner that others find disturbing. The importance of the socio-political context becomes obvious when considering this factor. What is disturbing in certain social settings can be the norm in another and praiseworthy in yet another.

Danger to Self or Others: The Justification for Drastic Intervention

One way the medication target may disturb others is by posing a real danger to themselves or others. When they do this — and, of course, there is still a good deal of politics involved in assessing when danger is both real and substantial — there is a universal experience of an obligation to act to protect the target or to protect others who are threatened.

In addition to the politics involved in assessing the level of acceptable risk/danger required to justify various interventions, there is another factor that complicates the socio-political context. That is, the natural tendency to experience strangeness as a valid indicator of increased danger.

This gets us into some difficult considerations. Consider: To some degree, our inability to understand the motivation behind another’s behavior is a valid predictor of increased danger when that individual is compared with people whose understandable motivation reassures us that they are not dangerous. This is true by definition; it is tautological if our understanding of motivation enables us to predict another’s behavior with any accuracy; and what other selective pressure, other than predicting behavior, could have led to the evolution of the ability to read another’s motivation?

To understand why unpredictable folks do, in fact, pose some increased risk simply by dint of being unpredictable, first assume that we have used a valid method to assess the risk posed by people, i.e., that our ability to understand another’s motivation helps us to make somewhat accurate predictions of their behavior. Based on our assessment, we can place folks in Group S who are safer than the average person and put folks in Group D who are more dangerous than average. While our assessment method will be imperfect and we will place some dangerous folks in Group S and vice versa, because we used a valid method to make our dangerousness evaluations — and to be valid, methods need only increase our average accuracy — by definition, a random member of Group S is, on average, less dangerous than a random member of Group D.

Group ?, however, is composed of folks for whom our assessment method — understanding the person’s motives and predicting future behavior based on our understanding — doesn’t work. It doesn’t work for members of Group ? because we can’t understand their motivation and thus cannot use our understanding to make a prediction.

There are then three possibilities:

– The members of Group ? are, on average, less dangerous than the average person, like the members of Group S.

– The members of Group ? are, on average, more dangerous than the average person, like the members of Group D.

– The members of Group ? are no more or less dangerous than the average person.

Psychosis and Dangerousness

It is my understanding that we have empirical data that indicates that members of Group ? — i.e., people whose motivations are unintelligible to others and who are often labeled “psychotic” — are somewhat more likely to commit acts of violence than the average person in the general population. One well known researcher who had long championed the notion that serious mental illness was not associated with increased violence felt forced by the data to change his opinion:

“The data that have recently become available, fairly read, suggest the one conclusion I did not want to reach: Whether the measure is the prevalence of violence among the disordered or the prevalence of disorder among the violent, whether the sample is people who are selected for treatment as inmates or patients in institutions or people randomly chosen from the open community, and no matter how many social and demographic factors are statistically taken into account, there appears to be a relationship between mental disorder and violent behavior.” (1)

The increase in risk, however, may be largely caused by the increase in substance abuse comorbidity. That is, rather than cause violence, psychosis may be correlated with another factor (drug abuse) that could be a true causal factor leading to increased violence. All we know is that folks suffering from psychosis appear to be more likely to become involved with substance abuse and substance abuse is associated with increased violence; those suffering from psychosis and substance abuse are not much more likely to be violent than those involved with substance abuse without psychosis. (2)

Be that as it may, while we know that the political context surrounding such findings may be biased and we may be wrong, it certainly seems reasonable to conclude that it is unlikely that the average member of Group ? is less dangerous than the average person in the general population.

So by dint of these facts, it is simply a truism that there is some reason to assume that members of Group S (i.e., folks whose motives we understand and our understanding leads us to expect them to be safer than a random, average person) are, on average, less dangerous than members of Group ? (folks whose motives we don’t understand and are frequently labeled psychotic).

Thus, we have a natural tendency to be wary of strangeness, of behavior we don’t understand. However, while there may be a slight increase in dangerousness associated with psychosis that can’t be accounted for by the correlation with drug abuse, our ability to use our apprehension to assess risk accurately in a specific case is profoundly limited.

Accuracy of Expert Predictions

So we face a major problem. Though strangeness thus does indicate a somewhat greater risk of dangerousness when compared to people whom we understand and expect to behave safely, the human ability to use information about strangeness — as opposed to using historical and recent information about past and recent dangerous behavior, strange or not — to assess the increase in risk with a good degree of accuracy is, based on all the empirical evidence, virtually nonexistent.

The inability to make accurate predictions about future dangerousness in the vast majority of cases is a well-established, empirical fact; this inability exists even (or especially) in most of those cases in which some “expert” willingly (and confidently) testifies that the risk can be accurately assessed and is high. Predictions of dangerousness are wrong more often than they are right. Other than those obvious cases of high risk — in which, by the way, lay people are equal to or more accurate diagnosticians/predictors than the experts (3) — psychologists and psychiatrists can’t predict their way out of a paper bag. And this has long been acknowledged by their respective professional associations.

The “Report of the Task Force on the Role of Psychology in the Criminal Justice System” published in the American Psychological Association’s primary organizational journal (American Psychologist, 1978), stated:

“The validity of psychological predictions of violent behavior, at least in sentencing and release situations we are considering, is extremely poor, so poor that one could oppose their use on the strictly empirical grounds that psychologists are not professionally competent to make such judgments.”

In an amicus brief filed by the American Psychiatric Association in a case before the Supreme Court, the APA concluded that “psychiatric predictions of long-term future dangerousness are wrong in two out of every three cases.”(4) And these longstanding beliefs about predicting violence and danger have been reaffirmed more recently by these professional organizations. (5)

The Conflation of Strangeness and Dangerousness

Furthermore, I know from my experience that the two factors — behavior that appears odd to others and danger — are often conflated.

For example, a couple of months ago, I testified in the case of Henry, a man imprisoned against his will. The hospital had petitioned against him asking the courts to allow them to forcefully medicate him. Henry comes from a troubled family. While everybody’s family is troubled, his stood out by at least three uncommon facts. His mother committed suicide a year ago. Second, his father, with whom he lives, threatened the hospital staff with bodily harm should they “turn my son into a vegetable!” When his father arrived for his next daily visit to see Henry, he was arrested and a restraining order was obtained barring him from the hospital (which also barred him from attending and testifying in the commitment hearing at the hospital that was to determine whether or not his son would be released or forcefully medicated).

And the third uncommon fact about Henry’s family was that they are devout, evangelical Mennonite Christians. Henry carried a Bible with him in the hospital and frequently read out loud. While being a devout Christian is not particularly rare, being an evangelical Christian who reads out loud from his Bible — and I should note, Henry also heard God talking to him and would occasionally proclaim the heard words to others — was considered odd in the culture of the hospital staff as well as in the larger culture on the streets of Northeastern America.

So because he heard voices no one else heard or believed could be real, he was deemed “crazy” and we had the first of the two factors that are usually necessary for someone to be put on medication. His belief that God was speaking aloud to him was deemed to be inconsistent with reality as experienced by others, especially by the hospital doctor. The hospital doc testified that this made Henry a danger to himself because he might provoke others into attacking him (which I admitted was a small risk, but not one that was likely to lead to serious harm). Once judged “crazy,” it was almost reflexive for the hosdoc to say he couldn’t fend for himself and therefore was a danger to himself.

Yet the fact was that the hospital’s own records documented that this 35-year-old man had lived like this for ten years — with hospitalizations every now and then (nine short admissions) — without coming to or causing anyone serious harm. This fact alone completely belied the hosdoc’s prediction of imminent danger. Henry had never been suicidal or assaultive or even threatening, even though during his current imprisonment in the “hospital” — where they were trying to force him to accept medication — he did jump up on a table and grab a staff member’s necklace as he was preaching God’s word in response to the staff trying to forcefully medicate another patient.

Furthermore, this disturbing — and now we had the second of two factors that are usually necessary for someone to be put on medication (6) — but not particularly dangerous behavior had occurred in response to an assault on another human being in a rather extreme situation of isolation, incarceration, and the threat of forced medication. And even then, he was “talked down.” Where was the serious danger in this case?

So I do understand the risk of conflating talking and acting in ways that others think is out of synch with reality and danger. Still, if we believe — even if we are wrong — that a person’s behavior is likely to lead to imminent harm to a human being, we are morally called upon to act. If we don’t act, we would be no better than the 38 witnesses who stood by when Kitty Genovese was raped and stabbed to death over a one hour period. (7)

Though intervention in dangerous situations may be called for at times, accurate assessment of the risk and how we respond to real danger clearly matter. They matter a lot. Holding down human beings and forcing toxic chemicals into their bodies is an awful act that requires great justification. And while we know that — given the frequency with which this occurs and the corrupt science upon which such interventions are based — there is rarely, if ever, any real justification for such acts, let me leave this moral horror and return to the phenomenology of psychosis, medication, and the death of the self.

Remember, there are two things that the medicated tend to have in common: (1) they talk or act in a manner that those around them find strange, and (2) those around them are disturbed by the talk and/or actions that they find strange. I just discussed how a subset of disturbing behavior may justify an intervention when there is real danger (though there was nothing said to suggest that forced medication is the proper intervention). And I noted how easy it is to see danger when what is really present is a feeling of strangeness.

The Involuntary Voluntary Decision to Take Neuroleptics

In the majority of cases of long term medication, the situation is even fuzzier than the politics of danger from violence. In most cases, the drugs are taken somewhat “voluntarily,” though the existence of any voluntary decision is confounded by the almost universal lack of any real informed consent. More often, medication is taken pseudo-voluntarily as a result of a pressured sales pitch, e.g., after continuous, verbal harangues following abduction and/or a “voluntary admission” to a compulsory, medication training camp (i.e., a mental hospital) run by scientifically trained medical doctors, all of which, gives the verbal coercion much of its power. (8) Henry had presented himself at the hospital seeking medication after some of those disturbed by his behavior suggested he do so. At the emergency room, he was persuaded to voluntarily admit himself. Two days later he changed his mind and signed a “three-day paper” that gave him the right to have a commitment hearing in court within three business days. BTW, the judge’s decision was not made, until after 40 days of incarceration had passed after he submitted his “three-day paper.”

[The hearing was continued because we ran out of time (which is unusual in that most such hearings are pro forma) and the judge ordered that the restraining order be lifted to allow Henry’s father to come to the hospital to testify. In the continued hearing, the father’s testimony was chaotic and disturbing. Henry insisted on testifying and his pressured speech appears to have convinced the judge that some form of treatment was necessary. Unfortunately, when the judge asked me what available treatment I would recommend as an alternative to forced drugging, I had to suggest that letting Henry find his own troubled way through the world might be the best “treatment” available. I had failed to overturn the judge’s long held belief that psychiatric treatment with antipsychotics was a valid, well researched, proven form of medical treatment. And so, feeling that something was needed and believing that neuroleptics were generally helpful, the judge sided with the hospital.]

So while the voluntary nature of such treatment may be illusory, once compliance is obtained, there need be no further attempt to prove the existence of a clear, present, and imminent danger when promoting the long term use of dangerous drugs. Treatment can then continue to be focused exclusively on “medication compliance.” It, and nothing else of substance, was on every page of Henry’s hospital, treatment record.

What then is the justification for pushing toxins? (And nobody dares deny that these drugs have toxic “side” effects.) The justification is based on the belief — based as we now know on pseudoscience — that the toxins are helpful medicines overall, albeit medicines with problematic side effects. Once you possess such a belief, it becomes almost obligatory to promote the use of these medicines for anyone whose behavior is either dangerous or disturbing; and if the person’s strange behavior makes others feel he is dangerous, then it is not hard to promote forcing these medications upon a person.

Medicinal Treatment of the Underlying Problem Versus Quieting Tonics for Management

Understanding the impact of disturbing behavior on the politics and experience of medication is crucial. The fact is that, though a person may be advised ad nauseam to take medication, someone who is passive, relatively quiet and who doesn’t pose any real or apparent danger is, with some exceptions, unlikely to be physically forced to take medication. It is the disturbance — whether because their behavior poses a real or imagined danger or because the behavior is simply experienced as disturbing, offensive, intrusive, off-putting, or annoying — that leads others to try to force toxic chemicals on strangers.

And while the neuroleptics do rapidly reduce disturbing behavior over the short run, we don’t need to have any understanding of the biochemistry of how these drugs work anymore than we need to understand the biomechanics of electrical shock to be able to use a stun gun. Instead, let’s consider the phenomenological, experiential aspects of these drugs.

“I have tried the antipsychotics … chlorpromazine. They’re terrible! … In the early days of chlorpromazine, they were trying to figure out what it did to your alcohol tolerance. … I was a medical student who needed money … I was pretreated [at home] for a day with chlorpromazine, which meant I spent the day on the couch; I couldn’t move, I couldn’t move. Then I would get myself into the lab and they would feed me Johnny Walker scotch. … I finally decided the thing I needed to do was to get my girlfriend to sign up for the experiment, too. So the two of us would get drunk and then they’d give us money to go out to dinner. So, we had a great time, except we had to get rid of the Thorazine as quick as we could get it out of our system. [How would you describe the Thorazine effect before you started drinking the alcohol?] I felt like somebody had injected concrete into my muscles. I couldn’t move for the 24 hours before the experiment.” (Loren Mosher) (9)

Now remember that the targets of these toxins are those who appear strange and disturbing to others. With relatively passive, quiet people — who are not acting in a clearly dangerous manner — it is harder to justify forced medication even if such people believe (and occasionally and quietly say) the oddest things. So, it is those who act loudly enough to disturb others who tend to get the drugs.

Now consider the phenomenological experience: not being able to move, with concrete in one’s muscles. These drugs are phenomenologically toxic like alcohol. When I drink, it becomes harder and harder to think clearly. When people drink, reaction times go up and accidents occur. In small doses large enough to provide a clear psychological impact, alcohol begins to impair the ability to think and perform. In larger doses, the toxic quality of its impact becomes clear as behavior becomes increasingly dangerous. In large enough doses, it causes unconsciousness and eventually shuts down body chemistry causing death.

Phenomenologically, those who have experienced antipsychotics describe similar effects, without the low dose, pleasurable high. Of course, the lack of a pleasurable high is precisely why these drugs can be used in a treatment regimen that can be differentiated from drug addiction; they interfere with functioning — different from but somewhat like alcohol in producing a stuporous response in sufficient doses — without causing a pleasurable high. In fact, they are quite unpleasant.

You see, without the high, it is decidedly unpleasant to have your mind clouded. It is quite unpleasant not to be able to think clearly. It is terrible not to be able to find the will to get off the couch. It is disturbingly unpleasant to walk around struggling to hold on to your sense of yourself in a fuzzily perceived world while feeling like your brain has become enveloped in a thick, gelatinous, numbing, atmospheric gauze.

The “Therapeutic Effect” of Neuroleptics

So, how can we understand the “therapeutic” effect, i.e., the rapid symptom reduction that the neuroleptics produce?

“What was I complaining/screaming about? Something was terribly wrong. Yes, I remember. But I just don’t feel like standing up and protesting and letting others know that something is terribly wrong, I … I, what was I complaining/screaming about? Something was terribly wrong. Oh yeah, I do remember. At least, I think I remember. Yes, I do. But it’s just so hard to get up and let others know that something … what was it? … is terribly wrong, I … Yes, of course, I remember. But … I … dammit! I know something is terribly wrong, but it is so difficult to even maintain concentration on … ”

When you have to work so hard just to keep your mind focused enough to remember who and where you are and what you’re thinking and feeling, at a sufficient dose of medication, at a sufficient level of toxic dysfunction, the ability to think and act is impaired enough to make you … confused, lost, unclear. And when you are confused and feel like all life’s urgency has been flushed out of your being, it is simply much harder to act and speak up enough to be clearly seen and heard. This is the “curative” effect. More accurately, it is the tonic effect: When you have to struggle so arduously just to hold on to your thoughts, it is difficult to talk and act in a way that disturbs others. When just getting to the point that you can keep in mind something important that you feel you must say is so wearisome, you can’t really be sure you need to do anything about it. Besides, it’s just too hard.

Tonics Can be Useful

Bob Whitaker was the first person I heard call the neuroleptics “tonics” in suggesting a possible, limited, rational use for these chemicals. In the Scandinavian treatment programs that see these tonics as toxic and try to avoid their use, a small number (less than 15%) of people do appear to benefit from their use. In this small percentage of cases, when other approaches have failed and the situation has remained too problematic to make alternative arrangements, the neuroleptic tonics may be useful.

They are, however, not medications that address the causes of an illness; they are like the process that Intel used to produce cheap Celeron processors out of more capable Pentium chips. Intel made Pentiums and then crippled them by intentionally destroying some of their circuitry so they could be marketed separately in low end computers and thus maintain a separate market for higher priced Pentium based systems. Rather than cure, neuroleptics can be used to impair functioning, turning down the capability to Celeron or below, i.e., until the disturbing behavior is minimized.

Now when used as part of a minimalist, tonic treatment regimen — as in the Scandinavian programs — in some cases, this may actually be beneficial. I remember going down to Bridgewater State Hospital for the Criminally Insane where George, a friend of a friend I met in the survivor’s movement, was imprisoned. He had beliefs that were strange. Something about being a direct descendant of John Harvard and thus belonging to an important family. And George felt he had to talk to the Harvard students about something he and his family knew about Harvard, something the wayward university was now hiding; his behavior was disturbing. In any case, he was arrested for trespassing and the second time he was sent to Bridgewater where they forced some Zyprexa into him.

By the time his friend and I got down there to see if there was something I could do to help him obtain his release, George was no longer psychotic. Well, actually he still believed everything he believed when he was considered psychotic. But he was unable to muster the burning clarity of thought that made it feel imperative to act, to speak up. And in his struggle to maintain his sense of himself in such an ugly environment, he had already decided that the path of least resistance could lead to his freedom in the smallest amount of time; i.e., stay out of trouble, act like you agree with the doctors, and take the medication, at least until he could get out. That is, the interference in mentation produced by the neuroleptic tonic — that did make him appear less agitated — actually helped him come up with an alternative response and to act more rationally, i.e., in a manner that was likely to end further incarceration. Unable to feel the full urgency of acting on his idiosyncratic beliefs, he was not continuously involved in a disturbing struggle with his surround; he was then able to step back long enough to think through an alternative, more rational course of action.

So by the hosdocs’ definition he was no longer psychotic. George still believed all the things he believed before. But now he was able to keep his beliefs to himself. As did the researchers in the Rosenhan experiment, he realized that he would only be able to obtain his release by agreeing with his jailers that he was sick and needed their medication.

And I had to admit that, even though the drug didn’t change or alter his beliefs, it did help George to be able to calm down rapidly and conform to societal expectations in a way that caused everyone less trouble. When he did that — even though he was only pretending and taking the medication in order to be released — he seemed like the epitome of rationality. His thinking appeared lucid and intelligible. I had to ask him about the “delusions” that caused so much trouble. Aware that we could be trusted not to inform the staff about their continued existence, he told us they had not abated at all. He just knew he should keep them to himself. Keeping information from your jailers that would be used to keep you incarcerated in a horrific place was truly more rational and “healthy.”

Here’s the problem even with this apparently effective, short term, tonic “treatment.” While in some cases tonic treatment may enable people to be less disturbing to others and thus able to function with relative freedom outside of an institutional setting, there is something terribly diminishing — not by brain damage or long term side effects; those horrors will come later — by not being able to feel oneself clearly, not being able to have a vivid sense of being.

It is confusing. Mindfuddling. In such a confused, fuddled state when everyone is telling you you need to take your meds, many people do so. After all, what do you know; you’re all befuddled anyway.

I said who am I
To blow against the wind.
I know what I know.
I’ll sing what I said.
We come and we go;
That’s a thing that I keep
In the back of my head. (Paul Simon)

But now you also have to take your meds to help you get rid of the new sense that something is terribly wrong. Now you have a new problem of feeling like there is something missing from your being. In some way, you are not quite real, not fully alive; maybe you feel like you are being poisoned. But with more meds, even that awful feeling can be obliterated or at least dulled into deeper confusion.

Unfortunately, you are now on a deadly treadmill. The faster you go the rounder you get. The one thing you know/feel for sure is that there is something wrong with you. You can hardly think straight.

Maybe they’re right; maybe you should take your meds.

Later, your inability to think clearly will become permanent and the researchers will be able to find evidence of neurological damage. But right now, you’re already disappearing. 

 

Citations:

(1) Monahan J. Mental disorder and violent behavior. American Psychologist 1992;47:511–521.

(2) Fazel S, Gulati G, Linsell L, Geddes JR, Grann M (2009) Schizophrenia and Violence: Systematic Review and Meta-Analysis. PLoS Med 6(8): e1000120. doi:10.1371/journal.pmed.1000120

(3) Goldberg, L. (1959). The effectiveness of clinician’s judgment: Diagnosis of organic brain damage from the Bender Gestalt test. Journal of Consulting Psychology, 23, 25-33.
Monahan, J. (1981). Predicting violent behavior: An assessment of clinical techniques. Beverly Hills, CA: Sage.
Menzies, R. J., Webster, C. D., & Sepejak, D. S. (1985). Hitting the forensic sound barrier: Predictions of dangerousness in a pre-trial clinic. In C. D.
Webster, M. H. Ben-Aron, & S. J. Hucker (Eds.), Dangerousness: Probability and prediction, psychiatric and public policy (pp. 115—143). New York: Cambridge University Press.
Faust, D., & Ziskin, J. (1988). The expert witness in psychology and psychiatry. Science, 241, 31-35.
Dawes, R. M., Faust, D., & Meehl, P. E. (1989). Clinical versus actuarial judgment. Science, 243, 1668-1674.
Mossman, D. (1994). Assessing predictions of violence: Being accurate about accuracy. Journal of Consulting and Clinical Psychology, 62, 783—792.
Menzies, R., Webster, C. D., McMain, S., Staley, S., & Scaglione, R. (1994). The dimensions of dangerousness revisited: Assessing forensic predictions about violence. Law and Human Behavior, 18 (1), 1-28.
Rice, M. E., & Harris, G. T. (1995). Violent recidivism: Assessing predictive validity. Journal of Consulting and Clinical Psychology, 63, 737-748.

(4) Amicus Brief for the American Psychiatric Association at 13, Barefoot v. Estelle, 463 U.S. (1983) (No. 82-6080).

(5) Zonana, H., Abel, G., Bradford, J., Hoge, S. K., & Metzner, J. (1998). APA Task Force Report On Sexually Dangerous Offenders. American Psychiatric Association.
DeBruin, D. W., Stevens, T. N., & Gilfoyle, N. F. P. (2005). Brief of Amicus Curiae American Psychological Association in support of defendant-appellant (in Case No. 04-50393, U.S. Court of Appeals for the Fifth Circuit, U.S.A. v. Sherman Lamont Fields).

(6) Though Henry was hospitalized a month earlier after he engaged in an unpleasant interaction with a man who wouldn’t let Henry use his cellphone when Henry was penniless and unable to call home to get help, there was no real danger in that interaction. The more dangerous appearing behavior during the current hospitalization was clearly a response to an ugly human interaction. Given the antagonistic, forceful nature of psychiatric intervention in psychotic conditions, the small increase in violence (beyond that which would be predicted by the comorbidity of psychosis and drug abuse) attributable to psychotic conditions might well be a natural reaction to feeling threatened as a response to actual threats and assaults on one’s liberty and well being. And after a first hospitalization, this state of heightened anxiety exists outside of hospital settings as there is always a threat that people could call the authorities who may try to hospitalize you. Everyone, every interaction becomes fraught with heightened danger.

(7) The fact that further investigation revealed that the number was less than 38 and that the actual witnesses in that case did take action or only witnessed too little of the altercation to know that a serious assault was occurring only makes matters worse, for that means we would be worse than the actual witnesses of the Genovese murder. We would be no better than the Mythical 38 who people were horrified to believe stood by as a woman got raped and stabbed to death.

(8) These doctors and/or their orderlies — the men in white coats — often wear the superfluous uniform of a medical doctor, even though the white coat was an affectation even for medical doctors. It became commonplace in the early 20th Century as medical doctors sought to differentiate themselves from a large variety of quacks offering a wide array of treatments. In a clever, guild, marketing move, medical doctors donned what had become the uniform of science, i.e., the lab coats often worn by laboratory researchers. The germ theory of disease — that came from the work of laboratory scientists — and the notion that cleanliness would reduce infections and deaths in hospitals (especially following surgery) had just recently become widely accepted; there appeared to be special value in a scientific approach to medical treatment. So doctors, in marketing their brand of treatment, adopted the costume of science after changing the color (beige) to white to indicate more purity and sterility.
Ironically, recent studies (e.g., Microbial flora on doctors’ white coats. Wong D, Nye K, Hollis P. BMJ. 1991 Dec 21-28; 303(6817):1602-4.) have found that “White coats are a potential source of cross infection, especially in surgical areas.” This led to a debate in 2009 by the American Medical Association about whether to ban such costumes from hospitals. Interestingly, the AMA was not ready to abandon their costume and the matter was referred to a committee for further study. Psychiatric patients, however, will be relieved to know that the authors of the article concluded
“There is little microbiological reason for … excluding the wearing of white coats in non-clinical areas.” (ibid)
Note that they didn’t address the political danger of undue, unwarranted influence from the use of misleading costumery.

(9) Loren Mosher, M.D. was the first Chief of the Center for Studies of Schizophrenia at the National Institute of Mental Health, 1969-1980. He founded the prestigious research journal, Schizophrenia Bulletin and for twelve years was its Editor-in-Chief. He led the Soteria Project that demonstrated much better long term outcomes when treating first break psychosis without medication. These quotations are from a videotaped interview I conducted with Loren and Bob Whitaker in 2004.

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Daniel Kriegman, a psychologist and writer, was one of the founders of the Psychoanalytic Couple and Family Institute of New England and was a faculty member at the Massachusetts Institute for Psychoanalysis. He was Chief Psychologist and the Director of Supervision and Training at the Massachusetts Treatment Center for Sexually Dangerous Offenders, as well as the Clinical Director for the maximum-security, intensive-treatment unit for adolescents in Boston. Kriegman is co-author (with Malcolm Slavin) of The Adaptive Design of the Human Psyche: Psychoanalysis, Evolutionary Biology, and the Therapeutic Process, a book that created the psychoanalytic paradigm known as evolutionary psychoanalysis, and co-editor (with Judith Guss Teicholz) of Trauma, Repetition, & Affect Regulation: The Work of Paul Russell. He has published over 30 scholarly articles and book chapters on topics related to the evolutionary understanding of human behavior and the theory and practice of psychoanalytic approaches to psychotherapy. He has a full-time private practice providing psychoanalytic treatment to individuals, couples, and families in Newton, Massachusetts, and provides expert witness testimony in cases involving the prediction of dangerousness.

Also by Dan Kriegman:
The Reality is in Our Heads