Wednesday, August 17, 2022

Comments by George cLoony

Showing 5 of 5 comments.

  • Something I never see mentioned is selection bias in these sorts of things. Who gets interviewed? People in programs, participating in an acceptable way, referred. What do they say? Certainly nothing that invites potential consequences.

    In ostensibly anonymous interviews in literature, it always seems to be the case that many respond that they learn, essentially, to “smile and nod”, else risk the ire of their treaters, more drugs, being labeled low insight, loss of rights etc. Others regurgitate what clinicians tell them, perhaps having internalized it. Many report that drugs do some very contrived thing on prompting for the thing, like sedation “helping with sleep”, but not more than that. Superficial or nonexistent exploration to their thinking and emotions or experiences or circumstances. It’s worse still in institutions, where it is literally part of the process: The only way out is to validate (or else). I’ve seen it. I participated in it, prompting a relative to voice agreement to a psychiatrist nodding her head up and down as she asked a question that we all knew was wrong.

    Canned conclusions indeed. The whole thing is canned.

  • Even these sorts of reviews are misguided and superficial.

    No matter what “clinical scale” is used – a down-stream perception, not anything objective – there is little meaningful insight that can be gleaned from this sort of evaluation. And of course, we have worked backwards an in circles, asserting etiologies for a vague disease entity based on (flawed) evaluations and then asserting their validity and necessity from the presumed etiology. (Oh right, it’s not “chemical imbalances” anymore, but other chemical imbalance stand-ins like “it’s all inflammation” or “it’s more than one chemical!”.) At the end of the day, the thing being targeted is mental state and perception and any attempt to deny that is delusion and misdirection. It doesn’t matter if there is or is not some day a discovery of a biological factor; there are always biological factors, depending on how silly we want to be, like having enough oxygen to be alive. If someone does not want chemical interference with their mind, their consciousness, then that has to be respected. And if they are fed misinformation or coerced into compliance with a treatment or narrative, then there is certainly no consent. It’s just violence. Period. All this business about clinical scales or “chemicals” and the rest of it is distracting from the crux of the issue.

    It’s invalid to say “here we (think) we observe a behavior or feeling, and so we say it is a disease defined as such” while also saying “if the thing of concern is explained by other means or is otherwise gone, the disease must remain (and be of the form we have asserted) because it is necessary to justify what we do”.

    There are many reasons a given clinical scale or individual or clinician might report one way or another for these reviews. Some of them can be controlled for and others cannot and still others will remain unknown. It’s especially difficult with this sort of thing because a person who is expecting a medical fix may see any psychological effect – which they would not see with a sugar pill or no pill – as “working”. It’s more difficult to have a simple placebo experiment. Broad meta reviews are worse still, since they will examine data that includes people “smiling and nodding” in order to be seen as compliant (probably more so for other diagnoses more likely to involve involuntary commitment) or clinicians “just saying what they’re doing is good and works” – I’ve seen that many times. I’ve heard psychiatrists blatantly say they’ll “just say things” in records or in court to get a desired order or “cover my rear”. And then we have iatrogenic effects, either from the drugs or from the confusion, confinement, loss of rights, and other general treatment and circumstances. Objectivity from an observer’s perspective is extremely difficult and just about always biased toward presumed or convenient or desired narratives. I’ve never seen any study or review pay more than lip service – if any consideration at all – to these problems.

    I’m not even saying no one should ever use these substances. But no one should ever have them imposed for any reason, especially not disingenuous excuses based on bogus science. But the problem for psychiatrists is two-fold: First, that means they have to admit things are more complicated and they don’t have the expertise to navigate their jobs without relying on the above; Second, they may be relegated to a seldom-employed therapeutic role, rather than the center of all things, harming job prospects. Overhanging everything is the prospect of damage to reputations or even liability for past actions. Most people don’t want to attack the foundations and institutions they are a part of and their own legitimacy. It’s Ironic because that defensiveness is what makes them illegitimate. There is probably a role for real psychiatrists and proper psychiatry, people like Joan Moncrieff, but instead those genuine figures are demonized.

  • Unable – and unwilling – to tell the difference between ‘sane’ and ‘insane’, or between help and harm, or support and blame. The narrative is vaguely and superficially built not on facts, but on what someone else said or thought or claimed, or on another unvetted narrative in a medical or court record, or a misinterpretation of one of those things that happened somewhere along the way, or nothing at all except status as “one of them”, however that came to be. Disease is defined and demonstrated in part or in whole by refutation or ‘refusal’; progress is defined as validation of what is said and done. But there is no end, not because ‘recovery’ isn’t possible, but because it is not compatible with the narrative and the model and with the notion that anyone within or any part of the system could be flawed in any way, because to consider the possibility has dangerous implications, personally and professionally, even legally.

    The system isn’t ‘imperfect’; it’s assertively contemptuous of reality and of people. It’s dishonest and upheld by fragile, myopic sycophancy. Because it’s fragile, it’s hostile and defensive. So these stories develop along similar lines even when the details and circumstances would otherwise be wildly different. It’s always the same at the end of the day.

  • Sera, you need to submit a version of this article to the New York Times, and they need to publish it. Please, please try to do this.

    I noticed this vitriol in a NYT piece a couple of years ago about arbitrary, never-ending commitment (even for someone who is demonstrably not ill) in forensic situations. There were then all the same tropes as referenced here, with extra emphasis on “I don’t care lock ’em up” due to the context. (Although the focus on perhaps one of the least sympathetic cases I’ve ever seen instead of the reams of relatively inconsequential stuff was also noteworthy to me, almost as if it were designed to get clicks and elicit outrage…)

    The comments are prototypical of how these things play out. Publishing a response to them wouldn’t be some sort of retort. The comments – ignorance, dismissive, fear, anger, the ironic but still frustrating attempt to compare pleas for evidence and ethics based treatment and policy to antivaxxers/anti-science nonsense (I’m surprised I had to scroll as far as I did to find proclamations of conspiracy and connection to Scientology) and the rest of it – are exactly the problem, and so breaking them down, in the same public impossible-to-ignore forum is, would be exactly the thing to do, and hard hitting to boot. Perhaps the real conversation starts with why we can’t seem to have the conversation.

    On another note, one thing I do think is lacking here and even in general in places like MiA is that there are other people, other diagnoses, than just schizophrenia (and depression) that suffer the same abuses and are treated in the same way, but that look very, very different. There are also many people that aren’t trying to live with something, as the Hearing Voices Network focuses on, but trying to escape unwarranted treatment or regain lost rights/dignity, that have no symptoms at all but do have a label, and are not allowed, no matter what they do, to be recovered. There are people with substance use histories that are treated in the same way (and in a different way in psychiatric facilities as compared to dedicated substance use facilities) and there are people who have maladaptive coping, trauma, compulsive and all sorts of disordered behaviors, but who do not hear voices and so on, but are treated in the same way. And there are people with problems that go unaddressed because of the myopic lens through which they are viewed while conforming to the Model. Someone who was diagnosed as OCD for example is usually never allowed to recover; a lot of non-research literature reports it as impossible, despite it clearly being untrue and contrary to what little research there is for many. Even for PTSD – which is universally acknowledged as recoverable in principle – I’ve seen many clinicians tell recipients their PTSD needs medication and demand to know if the recipient understand that their PTSD “has a biological basis/is a chemical imbalance”, as if physically incapable of thinking about what they’re saying (or at least caring). It may be proportionally less common for people with other sorts of labels to be institutionalized or violated to to the same degree as someone with a schizophrenia diagnosis, but it still happens frequently. As you say, it’s not about the truth or mental health at all, but about narratives and Models and other circumstances. Once in the system, they are treated the same way, dismissed in the same way, and face the same helplessness. But the stories can both be different and I think may resonate differently.

    The personal stories of those who for whatever reason received a psychiatric label, recovered and are not permitted to have that reality acknowledged are especially troubling to me (and probably also to people like Jaffe and Torrey, which may be why they froth at the mouth to insist no such thing really exists). But they are endless. And when being diagnosed, treated, and when receiving a prognosis – that they must take their medicine, validate their treatment, acknowledge their badness/dangerousness/cluelessness, or else – they are blamed for having real insight and goals that that do not align with a narrative wholly detached from reality. And of course all are kept silent. I think it would be more approachable to have this sort of conversation about someone struggling with the system and stigma but who is not as “alien”, hearing voices or hallucinating etc. or someone who is not trying to get others to see past stigma but to just get others to see the reality of their mental status and condition not at all being what is asserted or presumed about them, that “everyone knows that these people are/do/need to be X’d” is catastrophically wrong.