Monday, December 5, 2022

Comments by George cLoony

Showing 19 of 19 comments.

  • Pies and Aftab are trying to discredit their perceived opponents by manufacturing associations with “anti” or conspiracy groups and to scare and mislead the parts of the political spectrum that more generally are concerned with social and science issues. It’s in one long, incoherent diatribe – those Qanon antivaxx Trump maga scientologist flat earther evilbads! Pay no heed! They just need their meds. It’s a just a slurry of words and names.

    The irony that they are themselves anti-science, paranoid, hyper-conservative, Trumpian psychos will be lost on them and much of their audience.

    It’s similar to how it’s been with “anti-psychiatry”. What even is that? Szasz himself, the biggest evilbad of them all in Pies mind, was a psychiatrist (ahem, excuse me, he was, according to these psychos, a “self-hating” psychiatrist), whatever significance that holds, and never claimed the “anti” label defensive institutionalists applied to him and others they saw as just out to get them. So is Moncrief, and her team, and a rigorous researcher at that, not just a superficial clinician or paper pusher.

    This garbage needs to be assertively called out, the whole history and dynamic. It’s deliberate undermining of discourse and indefensible, but it’s also obviously very effective. That’s part of the problem I have with pieces like this. It doesn’t really do anything to combat false narratives to observers and can even play into them a little bit by seeming to just complain about the system. Science and details and history are lost on most people who just see the odd bit of sophistry from one source or another, and sees a tv ad for drugs to restore chemical imbalances in the mentally ill and a NAMI pamphlet in the mail. For them, they see purported authority structures telling them to pay no heed to the “antis” in a world filled with nonsense, and so they’re dismissive. Until they learn the hard way, anyway. It also has to be said there are some confused people who latch into these issues and may provide ammunition to deflect discourse. But people like Moncrief are real psychiatrists – or what legitimate clinicians should look like – and that has to be made clear. Being perceived to be shouting at the street corner hasn’t worked.

  • There have been bigger “nightmare” years before; nothing ever changes, and judging by the discourse in many popular publications (NPR, for example, had a guest on to say in vague terms, essentially, “pay no mind, nothing to see here”), this year’s developments have been brushed aside successfully.

    It’s not even like there’s been anything new. While someone who isn’t superficial or disingenuous will take Moncrief and team’s review, or the other commentary, as more concerning to the bigger picture, institutionalists – the hysterical and paranoid defenders – will continue to assure all is well and everything that says otherwise is the product of the evilbad. Aftab’s attempt to paint legitimate psychiatrists and recipients etc. as right wing is as amusing as it is ironic, but I’m sure it’s effective, especially now. There is rightfully outrage over anti-vaxxers and and a backlash against anything that can be asserted to be “alt” or anti-establishment or whatever. I’ve noticed that subtle shift in the dynamic. But even that isn’t new – the term “anti-psychiatry” wasn’t one claimed, but one imposed (on legitimate psychiatrists…) in order to appeal to authority and fear. It’s why, for example, no one but “defenders” like Pies and Torrey constantly screech and misdirect about Scientology, because establishing association is useful to deflect and discredit. Institutional psychiatry and its relatives – from phrenology to lobotomy to the present – has always been hyperconservative and superficial and hysterical and speculative and grandiose. Sounds like Trump, probably because peddling bullshit often works the same basic way.

    I think there needs to be more proactive, assertive setting-things straight, real talk about all this. Institutional rhetorical actors might not have much insight into the domain, but they absolutely know what they’re doing on their blogs and phone calls. Wild hysterics – especially stuff that goes uncorrected – is effective. Torrey has been very effective in getting legislation passed and funding secured. Even SAMSHA has commented in reviews about his opportunistic tactics (see Kevin’s law, for example). “mentalillnesspolicy.org” is a well-SEOed result that gets copy-pasted – obviously without even basic vetting – into articles and even laws and facility policy and care standards. We need to stop pretending like these clowns will ever act in good faith.

    I think we also need to start culling some of the nonsense that gets thrown around though, that can get used as ammunition. The same goes for attitude. For any observer – or for professionals for that matter – seeing yet another “everything mainstream is bs” posting somewhere isn’t going to elicit anything other than a yawn. There is such a thing as legitimate psychiatry and institutional defenders are anti-science, dishonest and backwards and dangerous. I’m tired of this weird combination of tepid and outraged shouting into the wind, as if whining for hoping for enough people in positions of power to just figure it out and act differently. Maybe that will happen, but I don’t think it’s realistic. I want to see more straight talk and demands for accountability and showing what the parameters of legitimate psychiatric practice look like and how to provide social justice.

  • I spoke to Elizabeth a couple of times about a case a few years ago. It was plain as day that she’s wonderful person who is struggling against systemic injustice, a kind that she, like many of her peers, would have presumed unreal, until she discovered reality the hard way. It’s that disconnect that is really insidious about all these things. It’s so obscure and absurd in the degree and scale of the problems, that it’s almost as if the absurdity itself is a problem, that it’s hard to get it taken seriously. Frankly, I think this is probably a dynamic present even within our systems, where people simply are in very deep and don’t want to entertain the notion that we’ve been digging a hole in the wrong direction for a long time…

    The insular groups of people she struggles against have little insight into and little other than contempt for those that suffer under them. And there is a parallel for everyone else, from judges to other lawyers to families and other staff themselves, in that they have very little understanding of the law – its history or letter – and a great deal of contempt for the entire process. To institutional clinicians, rights, laws, medical validity, science, health and the rest are essentially immoral, anti-them constructions. People want to assume that, behind the veil of mysticism, there is competence, well-intent, and adherence to principle and law with due diligence conducted. In reality, it’s an abusive, exploitative farce. She needs help though, mostly in trying to build a legal network both within and outside of Wisconsin. Whittaker can talk about class action suits that are unlikely to succeed in the present environment all he wants, but his commentary on the necessity of legal levers is on point. It’s clear nothing is going to change until people are held accountable, and that means first recognizing the problems that Elizabeth is struggling against. In order to hold a treating clinician or evaluator accountable, the wrongs and violations of law – against the recipient – first have to be taken seriously.

  • I don’t think it’s appropriate to just let the “more sophisticated understanding” claim stand, as if deference is warranted.

    For science (and medicine) to be science, you have to be scientific. Sophistry from the likes of Pies, who recently repeated this nonsense, is anti-science. It’s not even Feynman’s “cargo cult medicine”, since it’s assertively contemptuous of scientific rigor and prudence. In science, you check your work, you question everything, and you never stop. You don’t try to stop others from questioning your sense of authority and entitlement. If there is understanding, prove it.

    And the dog-whistles to try to malign real scientists, recipients, and advocates as “right wing” or extremists or disingenuous has no lack of irony. For individuals who write how “they” need to be coerced into line in exactly those sorts of places – think tanks like the Manhattan Institute – and who have jumped at every opportunity to reduce the rights and health of “them” and deny their own behavior while claiming perpetual victimhood and throwing out conspiracy theories and on and on, there apparently is no such thing as integrity. Or is it insight? Or both. There’s an awful lot of Trumpism, but it isn’t coming from “them”. Maybe we should start seriously calling out “mentalillnesspolicy” (.org), the pretend institute from Jaffe and Torrey, and highlighting both its content and its impact, and the antics to promote policy aims. Kevin’s Law? Maybe we should start talking about what went into that (and who helped pay).

    Anyway, I’m actually less patient also with discussions about the limitations the practice has to understand distress. I’m more concerned with what actual clinicians do, and with policies put in place that are based on bogus anti-science sophistry. There is no caring and investigate and balanced approach in any state institution. Talk to clinicians, and they don’t even talk about chemical imbalances, except as excuses to recipients (when there is any explanation) and courts (and the fact that these assertions are continually made further undermines any claim that psychiatrists at large have not made these claims or have a better understanding of anything); they simply assert, in line with expectation, that all recipients are essentially subhuman and must comply (with drugs) and validate what is done to them. It’s automatic. Mischaracterization of a person and their behavior is a matter of course to fit a rote and convenient narrative on diagnostic nosology and treatment. Recovery is heretical and denied. Harm imposed is denied or blamed on the victim, or the condition, which is synonymous with the victim. Insight is automatically lacking as convenient, and may either never be gained or is defined not as insight, but as compliance and validation. What “chemical imbalances” has always been, and will continue to be, is a vague, hand-wavy excuse to rationalize convenient narratives in diagnosis, policy, compliance etc. as well as why treatment is “you take drug and say thank you”. In the face of courts and insurance claims and other business, something simple and measurable is needed, and following the civil rights movement, a response to arbitrary confinement and the bad press about surgeries had to give existing structures an “out”. Que “chemical lobotomizers”. It’s not like the history isn’t history. Now, “You thingy, you take drug, always, no matter what”. This is not sophisticated, and it’s not effective, and it’s dishonest and exploitative and abusive.

    We have some pretty brazen nonsense out there. The culture pervading psychiatric practice is as empty as it is paranoid, dishonest, and violent, and the responses to the study are par for the course.

  • We lived and worked in Michigan alongside its “mental health” system for quite a while. While nice to see, this doesn’t even begin to cover the breadth of dysfunction and abuse in that state. It’s worse than anything I’ve seen elsewhere at the scale of a whole state.

    It’s not just the system’s structure. While wrestling with myopic or ignorant or abusive psychiatrists is a problem almost everywhere, the culture that pervades the relatively small psychiatric community in Michigan is a dumpster fire of ignorance, extremism, and abuse. Paranoid of anything perceived as threatening to their own nonsense, you can’t even get CEUs on anything that isn’t trite or rooted in empty dehumanization and violence. Much as someone like Pies’ might try to claim otherwise, Michigan – and the University of Michigan’s department, interestingly – are a poster child for chemical imbalance tropes, not something you might expect given its reputation. I’ve wondered if part of that is its ties to Michigan’s Center for Forensic Psychiatry, nearby. You want horror, look no further. The “NGRI Committee” there has been the subject of complaints and sued (and lost, in various respects) repeatedly for arbitrary commitments, violence, failing or refusing to conduct evaluations or move people through or find placements, blatant manufacturing of basis for commitment as a matter of course, abusive practices, failing or refusing to investigate complaints, perjury, interfering with *other* institutions and programs to guarantee perpetual commitment, and on and on and on. It’s been held in contempt of court as an institution multiple times, for years straight, but nothing seems to matter. Many of the state’s practitioners have connections to the center, and more still are connected to a few also-notorious facilities (Forest View and Pine Rest and Hawthorne) that have been described even by other state psychiatrists as indefensible, in-it-for-the-money, abusive farces, with one expressing concern to the state’s MPAS (now Disability Rights Michigan) about one facility – Forest View – essentially being an assembly line of arbitrary diagnoses and “treatments” and essentially incapable of not hurting people, let alone helping them. That hasn’t seem to have deterred a new multi-million dollar expansion in Grand Rapids. Walk in to court, and the prevailing attitude seems to be to not even pretend to conduct due diligence. People complain how these things tend to be rubber-stamped? How about listening to a judge say they *should* be. The state’s politicians seem unconcerned as well, unsurprisingly. Michigan is one of the states that E Fuller Torrey leaned hard into in order to get one of the worst constructions of his AOT programs I’ve seen in place (“Kevin’s Law”). Even SAMHSA commented on his antics. It’s totally out of control at every level.

    The state’s board, also, is insular and extremely hostile and essentially sees their mission as protecting practitioners and policies. Picture a state run by Torreys and sycophants and you’ll get a pretty good idea for what Michigan is like.

    That the “recipient rights” offices are superficial is nothing new. Frankly I’m surprised to see any reporting on it, though the DFP is a pretty stellar group of journalists on the whole so no surprise it’s them. I’ve had tangential work with RR offices at the state’s facilities and I’ll confirm it’s a farce. They’re basically there to protect the facilities and push meaningless paperwork. We had one investigator actually compile a (still pretty restrained) report for one patient at a state hospital and the vitriolic backlash that came with it was mind-blowing to watch, even as someone a bit jaded. Conversely, despite indisputable conclusions of misconduct, nothing changed. No one was fired, no policies addressed. Nothing. There is no accountability at all.

  • This captures quite a bit of my thinking on it all, and is well written. As has been the case before, I wish some version of it were posted in the NYT, not just a MIA or similar.

    I hold the same pessimism about Whitaker’s proposal for legal action, off-hand as it may have actually been. But I also think it’s necessary for any change.

    I had a discussion with a psychiatrist recently w.r.t. a person he wanted to commit and drug. The circumstances – the person had been held for a long period of time following a complicated incident, and had never displayed a hint of psychiatric distress, but you wouldn’t make clear sense of that from the medical records – aren’t too important, except that this person was cogent and, although traumatized, very much not ill. The bottom line was the institution had applied a diagnosis and had a process that compelled commitment and all the rest, and the evaluator would say, as he put it, “whatever” to achieve that end. This guy looks at me upon the slightest hint of a perception of questioning or resistance, and snarls (literally snarls) “You have court cases!?”, going on to say without waiting for a response, essentially, that unless he would be held liable for the consequences of commitment and treatment and the content of his evaluation etc., he would always do as he is doing here, partly out of fear of liability if he doesn’t given “common practice” and partly (probably moreso) because it was just par for the course. This man had never not recommended commitment in this setting in his career and made little secret of it, and that wasn’t changing. The report to the judge, which was rubber-stamped without question, was as superficial as it was riddled with blatant misinformation and derogatory. No hearing; judge wouldn’t allow it and kept delaying without providing a reason. Eventually, the poor guy gave up, although with some clever maneuvering he ending up avoiding more drugs and did great when he got out, all things considered, although the time lost and legal and medical stain, and the trauma of it all, clearly is a heavy burden.

    The bottom line is that a legal hammer is probably the only thing that could set psychiatry back toward the straight and narrow. I don’t think some pedantry – and it is, or would be portrayed as, a kind of pedantry – about chemical imbalances and etiological confusion is sufficient. I know Whitaker doesn’t put forth such a reductionist argument, but it could be a lot better and it’s something I’ve noticed before here, and I’m not alone in that. The infamous Rondald Pies published another rant on his blog (ahem – excuse me, the Psychiatric Times) asserting that “they” can’t be taken seriously (following Moncrief’s study) because obviously psychiatrists (but certainly not Moncrief and her colleagues, or anyone else inconvenient) never said it was just solely only exclusively about this one “chemical”, (and that even if they did it doesn’t matter) and Psychiatrists, as opposed to psychiatrists and the rest of “them”, have an unassailable and dignified sophisticated understanding that he can never seem to actually show… But that b.s. will likely work wonders in court. Courts won’t want to insert their judgement on “medical matters”, and so will defer to what authoritative figures tell them and to what is institutionally convenient and has been done previously. It is very much a concrete part of legal doctrine that, essentially, questioning institutional entitlement, upending things in any way, is something to be avoided. If at present the APA has come to a narrative position that supports court actions previously (commitment and “treatment” following incidents etc.), however vague or inaccurate or disingenuous or whatever, courts have previously just said “what they said works for us, no begone so we don’t have to consider anything” and will likely continue to do so.

    I think what needs to be done is that we need to stop beating around the bush so as to not too greatly injure people like Pies, out of fear (and also, it has to be said, shoo away some nonsense that pops up from time to time among the community, like religious interpretations of distress etc.) What needs to be made abundantly clear is that people like Pies and Aftab and Torrey are dishonest, ignorant, self-serving quacks, the drug industry is grubby (that should be less difficult), that real people are suffering terribly because of them, and that real science and real psychiatry do not fit in with “Psychiatry” and psychiatric practice and that deflections and attempts to obfuscate are yet another facet of institutional misconduct, and to demand change. In court, instead of beating one’s head against the wall, assert risk of irreparable harm, not arguments about etiology, and fraud: liability. Maybe then I won’t have to suffer conversations like the one I had with the asshole above.

  • I see a lot of discussions like this (not in the Psychiatric Times of course, but so it goes), but I don’t see much on the sources of data. Abusing statistics, dishonest presentation, misguided notions etc. But…

    I read a family member’s “records”, something I had never done in the years of tortured nonsense we were all put through. It proclaimed not only a grossly superficial and contorted – at times outright fabricated, because who’s ensuring accountability anyway – narrative on the person, history, diagnosis etc., but also fabulous success in all things imposed and claimed. Uh, I was there — no.

    So I see years later as we start to look into things this psychiatrist who was involved at first had been paid to give a talk promoting his success with a drug that he had pushed on us. I wonder, then, if his bs and our hurt is a falsely exploited data point in some “research” somewhere. Of course he might have just been informally spouting nonsense, but the point is I wonder: How does one obtain their data?

    Someone can write a critique on the significance of a 2 point difference on some 52-point scale… But who filled in the data? I’m sure it wasn’t the recipient in most cases. And of course, who even came up with the scale in the first place? The validity problem with diagnosis and with treatment has an inseparable analogue in methodology and integirty in data.

  • In many jurisdictions a person who has ever been committed or involuntarily treated in any capacity is legally barred from licensure, working in clinical settings (or anywhere that could reasonably result in them facing a recipient) or both. It would be very hard to commit to becoming a psychiatrist, if one would want anything to do with practice or if you could even get a program to admit you, when after all the extra obstacles such a person would face they would find themselves formally shut out anyway.

    We had someone here not long ago complete a nursing program after being hospitalized with the outpatient staff (one of Torrey’s, AOT programs) were referring to her as a “well would you look at that” kind of thing to other recipients, until everyone realized she was unemployable. It was actually a little funny because there were several “peer” persons employed by the state to act as counselors to other state recipients, but those persons had been technically prohibited from their positions as well, just having not undergone the same background checks as clinical hires. They were filtered, however, so that only those who validated the AOT programs were able to participate – there was generally a lot of hostility in the air in state facilities about those employees.

  • To be fair, it’s messy and isn’t necessarily the point, in fact/ It might be the point of whether to conduct an intervention or which one and so on, but attempting to evaluate something asserted to be biomedical doesn’t necessarily have to take into account success.

    If it really was like insulin and diabetes, with valid measures and everything else, then focusing on them wouldn’t be the big picture, but it would have a place.

    The problem, of course, is that it isn’t insulin or diabetes and the measures aren’t valid. So the crux of the problem is that it’s contrived and less than meaningless.

  • Aftab was an author huh?

    Anyway, it seems there is never the kind of diligent effort into these things that goes into what professional groups like Pew or Gallup put out. Were there different versions of the questions, in different orders and how does that affect responses? Did people understand what AOTs even are, what they entail, or who advocates for them or anything else? The very important qualifier “violent assault” is left without question – AOT laws, like Kevin’s law in Michigan or others, don’t make that distinction. Rather, they are intentionally architected to include vague “need for treatment” criteria, no violence required. Nor is “serious mental illness” defined anywhere. Would providing specificity or varying the inclusion of qualifiers that don’t resemble reality change the responses? I wonder…

  • Seriously. As much as I generally want to say “you do you” and respect “personal truths” or the possibility that someone is ‘objectively’ deriving benefit… What percentage of people say booze or pot has are an objective biomedical treatment in some form? There may be some ways to contrive an argument, moreso for pot, but then there always is. Same goes for LSD or psybicilin, which have gotten a lot of attention lately.

    And still, more power to you. But in terms of a biomedical narrative, if all these things have a place or are interchangeable, the biomedical justification falls apart. It’s difficult to say, “you have a biomedical need for this” based on an assumed etiology in turn rooted in a narrative on efficacy (which is scientifically bogus, but…), but be unable to juxtapose that narrative with analogous but incompatible ones for totally unrelated psychoactive substances as well as psychotherapies, other modalities, or indeed nothing.

  • Short of “confrontation” by legal means – which is a difficult mess in many ways – the only practical way forward is for people like Aftab to bluntly embrace what he is so afraid of and hostile toward. People like Moncriefe or Whitaker will do what they do as best they can see to do it, but doing so alone pigeonholes them in a sense and puts them at odds with prominent voices doubling down on the status quo narrative and practice. When you have a reality that prompts scientists and reporters etc. to do their part and raise a dilemma, the next step is for more “authority” figures who have traditionally been seen as “not with ‘them'” to come out and just say to colleagues who may be lashing out, “no, stop, we have a serious and fundamental problem that we have been in denial over and it has to change and there has to be accountability for there to ever be hope of legitimacy for any of us”.

    Unfortunately, despite a comment off-hand here or there about soul searching, it seems he has chosen to do the opposite. He might not be quite as bad as Ronald Pies, for example, but frankly, same difference. The details and content of these diatribes changes but what doesn’t change is a need to control and distort the discourse. He, like Pies, doesn’t focus on facts or harms or ethics or policy failures, but on how he is entitled to serve as the arbiter for what counts as valid “criticism” and what does not, and how in doing so he reasserts legitimacy by being open to review (his own) whole denying wrongdoing. It seems it really is hard for many people to get over themselves and do right when they are not forced to do so.

    As Whitaker says, that’s where the lever of the law can step in to level the field. But it’s an extremely tall order. The legal system we have, perhaps moreso than psychiatry (well, that’s another topic) abhors the notion of systemic fault and correction and has adopted a loose scheme in this domain that defers to voices like Aftab’s by virtue of their position and defense of the status quo.

    I was recently speaking to a psychiatrist about forcing a patient of his, who I was concerned about, into commitment and drugs despite a lack of illness and good understanding of the facts and an informed choice to not take drugs “just because”. It was a classic situation – the prospective recipient was mentally ill presently despite no evidence (and it has to be said, a clear and developed explanation for how everything had come about and then changed and what challenges remain and a commitment to flexible and responsible follow-up and self-management) of ongoing dysfunction and more than that, was “bad” and a host of other things for having the audacity to “question” him, the doctor, or not blindly validate what was asserted (it also has to be said – this person was unreasonably respectful, while the staff were… not reciprocal, yet still the projecting discomfort and consternation ontp the person being evaluated were evidence of that evaluee’s rudeness or still more vague problems) or for wanting to protect himself and his legal record and life. No, he was a subhuman thing, a sick, and a “bad” for not going along with it all and knowing his stuff and actually taking the situation seriously. Anyway, when it comes to the “need for treatment”, there is never-ending evasiveness. Somehow, they write their patient “will not consider treatment” (despite fighting them to even be allowed to be in therapy, on his own, which they seemed to view as undermining their process) because he won’t just “take his medicine”, which is prescribed for reasons that cannot be elucidated or justified beyond their inherent necessity following any history of a diagnosis. “Are you saying there is a chemical imbalance, or that there is some other reason his judgement should be discounted or different treatm–” interjecting with a scowl, “sir ‘these people’ need to take their medicine. You are not a psychiatrist and it is not your place to question me”. In his testimony to a court, he made vague statements or just blatantly lied (he also previously stated that he would “just say things”) – without question from the judge – in order to procure an order that the recipient comply with all treatments and orders from the facility. Despite what the law says on paper and what these talking heads claim, no vetting, no review, no evidence-based anything, no listening, no consideration of concerns or desires or even logical coherence for that matter. Nothing. Just “these people”, whatever that’s supposed to mean beyond the medico-legal circumstances that prompted the evaluation in the first place or a history, somehow somewhere, of a label, need to be processed, and that means having a DSM label – any label, really (he didn’t even know what the past diagnosis was or why) – and taking “their medicine” (and really any medicine in a category, and however more are tacked on) and validating what is done to them. Rubber stamp. Rinse, repeat. It’s a farce.

    So these “arguments” in the media, journals, on Twitter, whatever… it’s not even discussing reality. That psychiatrist isn’t thinking about research he’s never read or legal rights or ethics quandaries he doesn’t care about. He waddled his way through the hoops and is a doctor now and his parents are very proud, and he was invited to a function last month, and he as a nice car (apparently), and thinking or caring or having integrity is not how he gets through his day. His job is rote bullshitting and paperwork at a facility that does things as it always has and expects compliance and validation. Everything else is fluff. He doesn’t care if there are or aren’t chemical imbalances or anything else and he doesn’t have “a more sophisticated understanding” of anything. He just wants to get on with his day without being “questioned” or thinking about it. That is psychiatry in practice. And I think focusing on whether or not “low serotonin” was pushed or some other thing is a trap for those who speak of soul searching or reform. If that were the problem – simple but legitimate misguided science capable of reflection and correction – we wouldn’t be here. If there is admission of misleading advertisements, nothing really changes. Some other nonsense that is a drop-in replacement will follow (or already has). The problem is that the whole thing is rotten on the ground.

  • 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.