Yes indeed there is hope and indeed there are many people here who can attest to recovering without meds after polypharmacy treatment. Great to hear that you were able to successfully wean off.
I have worked with a number of people who are deeply challenged when tapering and feel understandably extremely angry at being trapped by having to take meds to avoid relapse into worsening mental health due to iatrogenic nervous system disregulation.
It would be so much easier to not go down that road at all if at all possible, especially in light of this meta study which repeats the idea that long term recovery and prognosis is likely worse on meds than off.
Yes Stephen. Agreed that it is the elephant in the room. Ground zero for this is the hospital setting where “first break” folks invariably go. They then will almost always be prescribed neuroleptics, often at high doses and often multiple drugs.
That is where this has to change and where true “evidenced based practice” needs to occur. And that means full information that includes the meta study Whitaker referenced.
Until then, a whole new generation of young folks will be ushered down the same path that can be very challenging to walk away from.
I recently helped somebody get out of a court commitment. They were going through an extreme state and were then prescribed a combination of high dose haldol cogent in. Klonopin and Prozac. This was a young underweight person who then had horrible reactions and felt a million times worse. There was no discussion. No communication with family members and no listening to the needs of the patient.
We were able to get this person out quickly enough and the person stopped all meds and quickly recovered.
We need a sea change in our approach to crisis states.
Bob thank you so much for your work. Though many in the field have argued against your views, it will be much much harder to ignore this study. I am also very interested to see how Torrey, Jaffe and Lieberman respond to this.
On a deeper note, in my work as a private practice therapist with young people going through a “first break”, I often work with people who are choosing not to take medications. I support that decision in large part because of the longitudinal studies that show worse prognosis. But I am often very much alone in my field and I really hope that this view becomes mainstream soon.
It is much much harder when I work with people who have started down the road of long term neuroleptic usage. If they are looking at trying to reduce or come off meds, it can become much more challenging, especially if there is large dose polypharmacy- as you well know.
My hope is that this information is disseminated to anyone who is going through a “first break” so that they can have adequate informed consent before deciding to embark on taking neuroleptics long term.
David thanks of your piece. I think it is pivotal that we have more and more conversations between different groups, including with people with whom we very much disagree. I think of Bob Whitaker speaking at NAMI or Will Hall speaking to the APA. These are pivotal moments where we are witnessing a sea change. Whether you want to call it reform or attrition, dialogues like these are the first steps in changing the entire system as we know it. Perhaps some would like to have abolition in one fell swoop but even many abolitionists support an attrition model.
Thank you David for all the hard work you have been doing all these years.
In my mind this is huge news and is validating Open Dialogue and the work of Whitaker and others in raising these questions. This seems like the final blow for the “high dose polypharmacy neuroleptic/throw away the key you have a permanent disease” model of care. I want to see this translated into on the ground care as soon as possible.
Just recently I worked with a client who had been committed and had to strenuously advocate for her meds to be dropped significantly…and they did do that- down to a very low dose- but that took a lot of effort and willingness to fight and stand up to the doctors at that hospital. Most people don’t have advocates doing that for them and it should be required practice to not prescribe high poly pharmacy doses anymore.
I’m very happy this article is strongly highlighted in the NYT.
I wrote a comment on Ronald Pies thread that somehow came out as being from Kermit-perhaps because it car right after Kermit’s link. Here is my comment referencing your article…
“For those of you who want a shorthand reading of that article…Whitaker outlines the numerous places the APA has promoted the “chemical imbalance theory.”
Here are some quotes:
“However, letās now continue with the laying down of cards. The āLetās Talk About Factsā brochures that the APA published in 2005 were part of an ongoing pr campaign titled “Healthy Minds, Healthy Lives,” and that same year the APA also published a brochure for the public titled, Letās Talk Facts About Depression. This brochure, in a section titled “How is Depression Treated,” informed the public that: āAntidepressants may be prescribed to correct imbalances in the levels of chemicals in the brain.ā
There is more. That same year, 2005, the APA put out a press release celebrating the fact that, based on a survey it had conducted, ā75 percent of consumers believe that mental illnesses are usually caused by a chemical imbalance in the brain.ā The survey results, said APA President Steven Sharfstein, was evidence of āgood news for [public] understanding of mental health.ā Indeed, the APA stated in its press release that a psychiatrist was āa specialist specifically trained to diagnose and treat chemical imbalances.ā
There is more in there but it really belies what you are saying here Dr. Pies- that the APA had a cursory “crush” on the chemical imbalance theory. In the last few decades the APA has helped promulgate this theory until it has become common parlance amongst the lay public.
Though you may suggest that psychiatrists more strongly believe in a biopsychosocial model, the proof is in the pudding. 20 percent of Americans are now on some form of psychiatric drug. Ten percent of Americans take an antidepressant. That is an enormous rise in the last few decades. Though there may be a discussion of environmental social factors, the answer is generally the same- take medication. And often the reasoning has been that a person has a “chemical imbalance”.
I’m afraid your article does not properly express the intertwining relationship psychiatry has had with the chemical imbalance theory.”
And then this is his response. It is baffling and nonsensical as he seems to somehow try to pretend that the APA didn’t say what they said…
“One additional point that critics tend to confuse: The statement in one APA publication–“Antidepressants may be prescribed to correct imbalances in the levels of chemicals in the brain.ā –does not entail an endorsement of the claim, “Depression is caused by a chemical imbalance.” There are many drugs that are prescribed because they address some component of a pathophysiological process that may or may not be–by itself–the “cause” of the illness or disease. For example, if we say, “Statin drugs may be prescribed in order to correct an imbalance between “good” and “bad” cholesterol”–we are not necessarily claiming that the patient’s lipid disorder is caused by this imbalance. The “cause” may lie in a combination of the person’s genetic make-up; fatty diet, excess synthesis of low-density lipoproteins, etc. Thus, I stand by my point: The APA did not endorse the claim that depression is “caused by” a chemical imbalance, or, indeed, that any mental illness is so caused. And of course, most knowledgeable psychiatrists never did either! Q.E.D.
One of the concerns I have with just using a probiotic supplement is that they tend to carry only a few different strains of beneficial bacteria but there are upwards of a thousand different types of bacteria. When we are adding just a few strains as a supplement we ignore hundreds of others.
As an herbalist I support using fermented foods and bitter herbs that generally promote good intestinal flora without specifically focusing on similar probiotic strains. It’s also important to note what Madmom said…which is that psychiatric drugs impact gut health adversely, (as well as antibiotics) so we engender worse intestinal and mental health with prolonged chronic use.
The use of fermented foods and bitter herbs (chicory, dandelion, burdock, angelica, dock) are time honored ways of improving digestive health which in turn improves emotional wellbeing.
Interesting thoughts. With marijuana there has been increasing research as to its efficacy for a lot of complaints…mainly done abroad in places like Israel. And Sandra you’re right that there are many active ingredients and potencies that make it more complex to offer as medicine.
But really up until the 1950s and the psychiatric revolution we were primarily using plants as medicine. Part of the magic of plant medicine is that there are a variety of constituents that often work synergistically and in ways that are hard to reduce to single constituent effects.
In many ways we wildly changed course when we decided to use single chemicals as ways of chronically managing complex emotional states. It is like eating only one food for years when we are hungry.
Herbs are not so easily reduced to randomized control studies as their constituents are variable and the method of administration and dosage affect the outcome. But certainly some have already been shown to be effective…such as St. Johns Wort for mild to moderate depression. Offering an herb such as this instead of embarking on a risky course of antidepressants is already a common practice in places like Germany.
Outside of acute situations, my hope is that we begin to review traditional and indigenous ways of approaching “mental illness” that seemed to have served us far better than the modern drug model, and often involved the use of plants with their complex and varied constituents.
Hey yes Monica…the strains that I have seen be very effective for certain people have been high CBD varietals…either smoked or used a edibles. However even high CHD strains have affected many of my clients poorly. Even though high cannabidiol varietals seems to be much more effective for calming pain, for insomnia, severe restlessness and extreme states, I am continuing to see many folks with already taxed nervous systems react poorly to these strains.
As an herbalist I think of marijuana as one very strong tool amongst many tools. Some people do well with it but others do better with milder anxiolytic herbs as well as a variety of tonic and adaptogenic herbs. And as you know so well, I have found diet to be paramount in assisting people to recover.
I think when exploring helping people through extreme states we should be looking at a whole panoply of plant medicines…and that should very much include marijuana as one option. Several people I work with use pot as their primary tool for reducing the potential for mania. That should be legal and easily accessible for anyone.
This is an important discussion and as therapist and herbalist who often works with people in extreme states marijuana has had a mixed record. I have seen pot increase susceptibility to severe distress and for a smaller group pot has been an effective tool for decreasing anxiety, reducing manic symptoms and extreme states.
Though dosage and the specific strains play a key role, one of the main factors in the decision to use pot has been personal neuro chemistry. Most of my clients are extremely sensitive due to their constitution and due to iatrogenic damage from psych drugs. Pot only increases their sensitivity, anxiety and potential to dissociate and experience confusion. I would say this is for about 80 percent of the people I work with. For a smaller percentage pot is a life saver and extremely useful.
Great piece Jeremy. My father is an anthropologist who was colleagues with Arthur Kleinman in the 70’s. He did his field work in NorthEast Thailand and amongst many things, he wrote about their approach to working with grief, sorrow and extreme forms of distress. One woman had lost her son and spent many years deeply sad. Her process of healing involved talking to the village monks and deepening her Buddhist practice. Healing took place in a culturally specific way without western therapy or meds.
I am reminded of a recent Guardian article that talked about how western therapists were parachuted into Rwanda to help…only to find out that Rwandans were horrified by the idea of sitting in a “dingy room” rehashing the horrible atrocities that occurred and much preferred the idea of drumming and being out in the sun wth community to help heal those wounds.
I think of this a lot when I hear the term “evidence based medicine” and I wonder if a Quichua Indian who has lost his home and been displaced by an oil company really needs antidepressants and cognitive behavioral therapy for his “major depression.” Bu imposing our western models of mental health on other cultures we reenact the same imperialism and “cultural cleansing” that has taken place for hundreds of years. Perhaps it’s time to honor culture bound notions of emotional illness and wellbeing without imposing our value system.
Thanks so much for this piece Joanna. I have helped a number of people who have chosen to get off lithium after an initial diagnosis of bipolar. And I entirely agree that the long term health implications far outweigh the potential for reducing “episodes.”
I think we need to move towards examining how to help people work through manic states without reliance on any long term pharmacological agent. There can definitely be place for the short term use of psych drugs- especially benzos- in the case of strong episodes of mania/psychosis.
At the same time, there is a strong move by alternative mental health practitioners to examine non-pharmacological tools – including managing environment, diet, herbal medicine, acupuncture, etc that I have seen in my practice as effective in helping people- even in strong heightened complex manic states.
Most all of the relapses I have seen into mania have been due to people stopping meds- usually due to their horrendous side effects. I believe that the mania that occurs afterwards is almost always iatrogenic in nature- due to the withdrawal.
We would not look at a heroin addict who is withdrawing and experiencing horrendous hallucinations, severe anxiety, panic and insomnia as having a mental illness. Why do we call someone experiencing withdrawal off of lithium “mental illness?”
yes…stigma comes because the modern DSM psychiatric language implies permanence, disease and the need for medical drug based intervention.
Consider it this way. your child is bright, quick, interests in many things, sometimes can’t focus and is deeply curious….or your child has ADHD.
From perjorative language, stigma springs.
I think this again is an issue of language and terminology. Language using labels like ADHD and bipolar, even if there is a basis in biological temperament, is inherently stigmatizing and I plies a medical condition needing medical treatment…namely meds.
While in traditional societies, the language of temperaments and constitutions was not perjorative.
For example, In Indian medicine, someone born with a Vata temperament might be excitable and restless and prone to anxiety, but also sharp minded, clever and bright. Diet and lifestyle is geared to making sure this type does not fall into imbalance.
Traditional medicine cross culturally takes into account these temperamental differences, and also acknowledges the potential for falling out of balance and distress. But traditional systems of healing from throughout the world emphasize nourishment, not drug intervention.
The language of modern DSM labels implies disease, permanence and drug intervention. DSM language is about 70 years old. The language of traditional medicines are thousands of years old.
We have been led astray.
Interestingly, the Meyers-Briggs system (ENTJ here) came from Jung, who borrowed from the ancient Greek system of constitutional assessment and healing (choleric, sanguine, phlegmatic, melancholic). Like you said, The Meyers Briggs system points out sensitivities but also points our strengths and capabilities.
At core the whole battle is over language. The language of health and distress created by our ancestors has been marginalized in place of a language that is reductionist and based in pathology instead of potential strengths.
The main issue I have with labeling is that by and large the terms are social constructs that are simply ways for insurance companies to reimburse providers and for drug companies to niche market drugs. Psychiatry and Big Pharma learned the strong advantages of labeling long ago.
And yes there are realms where labeling can be important. You start out with autism…which is a permanent condition…and then morph to anxiety disorders and bipolar, which are far more murky. While the first one can be helpful and not necessarily tied to Big Pharma/psychiatry, the next ones are.
The language that we use is deeply important. In older times, traditional societies might point to constitutional differences- choleric or sanguine in Greek medicine, pitta, vata, kapha in Indian medicine. But these labels would point to tendencies that could be modified by diet and lifestyle. These were not disease labels, but ways of describing personality and health characteristics as ways to guide healing when someone fell out of balance.
Today we have created a panoply of labs that imply disease and permanence. While autism may fit as a permanent label, labels like ADHD, bipolar II, borderline and histrionic personality disorder often appear to be no more than shorthand for the marketing and prescribing of drugs.
Labels also tend to pigeon hole vast swaths of people into one size fits all categories, while human complexity is far greater. I have never met two people labeled with schizophrenia alike, but they tend to all be treated the same way- neuroleptics. Again, traditional systems of seeing imbalance describe a wide variety of emotional suffering but tend to imply that the condition need not be permanent and that tailored healing approaches for unique people are key.
So yes I get that some folks feel happy to have a label, as a way of externalizing experience, reducing shame, etc. But the language of labeling has morphed from traditional holistic conceptions to reductionistic, medical jargon tied to drug regimens. Deeply problematic.
Very interesting article. I’m wondering if anyone here has experience of working with people using the herb kratom to try and detox off opiates. There have been quite a lot of stories of people using this herb to help them through both methadone and heroin detox. I have worked with a few people who have found it effective. It is also addictive in its own right but appears much easier to discontinue than prescription opiates.
What’s strange is the idea that there is this distinct differentiation between Axis I (mood disorders) and axis II (personality disorders). The belief has been that axis I disorders such as depression, bipolar and schizophrenia can be “treated” while disorders such as narcissism, borderline tendencies and sociopathy are inherent, ego-syntonic and cannot be treated. So it used to be that folks with axis II disorders were not given drugs- because they can’t treat underlying personality traits.
But now pretty much everyone is given axis I diagnoses- because you can bill insurance for them. So everyone labelled with a personality disorder also has a co-occurring mood disorder (as Sandra said). That way everyone gets paid. And that means people who are “borderline” and have experienced abuse, and trauma- are not only accused of having this awful borderline personality disorder but they are also pushed to take psych drugs to manage the severe emotional distress associated with trauma.
Good news that psychiatry is ceding ground on the language of distress, even if they aren’t acknowledging the real issues (validity, reliability).
I think the real issue is less whether counselors, psychologists and others stop using psychiatric language, its when insurance companies stop giving all the money to psychiatry.
One of the worst aspects of Obamacare is the focus on increased “treatment” for the low income and impoverished “mentally ill”. Anyone who has low income insurance essentially only has access to a doctor, diagnoses and meds. High co-pays and deductibles act as a firewall to getting any other type of holistic care.
Essentially, insurance companies are approving prescribing seroquel and prozac for poverty. This is where the real battle is- changing how insurance companies operate and shifting money away from drugs and “treatment” to modalities that are far more effective at addressing societal based problems.
What is the alternative?
Well that is a very large question. But I would suggest that seeing that ECT is the *only* solution at that point is deeply myopic.
When the only solution renders a portion of those they treat with grave brain damage, one must really wonder about the “cure.”
Psychiatry has not really ever looked at “alternatives”, have they? They are pretty much stuck on drugs and electroshock.
I think it would be wonderful if they actually, truly explored alternatives. Imagine if they looked at nutrition, socio-economic factors, peer supports, acupuncture, and yes…greater access to individual counseling (which insurance companies makes impossible via co-pays and deductibles for low income earners.)
But really there aren’t too many insurance supported “alternatives” because psychiatry takes all the air out of the room. The money all goes to…meds…or ECT.
And perhaps we should ask a deeper question. If someone is deeply suicidal due to depression because “they have tried everything else”, meaning gone through taking reams of SSRIs, mood stabilizers, antipsychotics and TCAs, perhaps…perhaps…the suicidal depression is happening in large part…
due to the iatrogenic effects of the meds themselves?
Consider that possibility the next time you see some one who is considering ECT.
How can you have fully informed consent for someone who is deeply desperate and depressed? If you offered almost anything they are likely to say yes…even while telling them all the risks…because they are looking for anything at that point.
But the larger point is that while some may feel relief, this barbaric procedure leaves some with severe memory loss, cognitive decline, deepening depression, anxiety and suicidality.
Is that really a treatment that should be promoted?
Yes- I agree that a lot of folks are doing this on their own with groups of supportive peers who really understand the work… without true support from the medical establishment… and they are figuring out much safer ways to do this.
As to colleagues who understand this stuff?
Sadly very few. Tapering is a complex and very unique process and though a general caveat of going slow is helpful, each person must find their own way in terms of when to hold, when to taper, how quickly, what supportive techniques work best, etc. It really is a unique process.
Most therapists I know have very little understanding of this. Or they may have a general understanding and want to put that in the hands of a doctor- as it is “outside their purview” or “practicing medicine”, etc.
Here in Portland, there are a few good therapists, NDs and NPs who do understand this- but even with them it can be complicated.
It can easily become complex when family members don’t understand the length of time tapering can take, or feel that the iatrogenic injury is made up and couldn’t be that bad. This leads to strong family dynamics tension which causes further deepening issues.
Tapering and iatrogenic injury don’t just affect the individual- they affect the whole family and the extended network of friends and allies the person is in contact with. These are complicated problems that are easily brushed off in the medical system.
Anyways- again I thank you for this very important work Laura. I’m spreading the news in my circles…
Interesting. Has there been lawsuits by people who feel they have received poor advice from support groups? Or lawsuits against groups saying they are practicing medicine without a license?
Whats crazy is…if your doctor says you shouldn’t go off the meds…but you want to and need additionaly supports…where can you go? The only main places for this type of work has been online support groups of people who actually have gone through this process. (And a few good NPs, Docs and NDs).
And yes I get that there could be erroneous or conflicting advice which indeed makes it a bit like the Wild West- but this is because the medical community has not acknowleged the dangers and suffering in discontinuation- or created effective protocols for people who are tapering.
Wow- amazing! Thank you so much for the hard work in putting this together.
Sometimes when I am wearing my herbalist hat, I am blown away by how the FDA and the media tries to scare the jeewilikers out of anyone taking an herb but ignore information that shows obvious deleterious health effects.
Kava- the Polynesian herb used for hundreds of years with rare damaging side effects- “Dangerous! Ban it! Herbs are scary. Who knows what could happen?”
Recently invented pharmaceutical that ends up causing grave harm to many….”Well its for the greater good”, or “Oops sorry…but have you tried our new product?”
In my private practice I work with a number of people who have been labeled as having a “first break” and who have been trying anything to avoid labels and neuroleptics. As you well know psychosis is complicated with many different etiologies and trying to create sanctuary for folks going through unusual experiences can be very challenging. It feels increasingly important that these individuals be given a chance to process their experience without drugs, even if that means ongoing, or recurring “episodes.” And the reason is very much along the lines of what Harrow and Wunderink have discovered. If you give a person a chance, there is a place for integration and recovery. Long term with the neuroleptics, the chance goes down.
You said that many folks dismiss these findings because they use the argument that these people were likely not very sick to begin with. But that begs the question- how do they know who will recover and who won’t? And seeing that long term use definitely worsens prognosis, isn’t it far better to attempt non-drug interventions?
I think the big challenge is creating that support and sanctuary for those experiencing psychosis- and it is far easier to sedate a person than to support them through that process. Creating the template for support is far more expensive and complex. But if we viewed an episode like drug rehab, then there would be centers where people could go, often for a month or more, paid for by insurance, that would support reintegration without drug intervention.
Yes I think it can be deeply challenging for people to avoid medications for psychological distress in this society. Insurance willingly pays for it. Doctors recommend it and it promises an easy solution. Therapy tends to have large copays and deductibles that act as a firewall for most low and moderate income people.
But underlying that, there is a general desire to simply feel better, or at least- not be tortured by the…depression, anxiety, panic, mean voices, fill in the blank. In some ways psych drugs fill that role- they sedate and stimulate in a measurable way and change biochemistry. Instead of wading through the miasma of complex narratives, previous trauma and current stressors, psych drugs promise immediate (or very quick) relief of pain. Evidence based too!
I sometimes think therapists who tend to critically appraise psychiatry underestimate this desire to simply “feel better”, to feel more pleasure and relaxation, to reduce the horrible symptoms please.
If one thinks in simple forms of pleasure and pain, people see psych drugs as increasing pleasure and reducing pain. However, over time, it is often clear that they often cause more pain- in the form of deteriorating health, reduced cognitive function, metabolic issues, apathy, and lowered libido. Essentially, like most drugs- the beginning is great and down the road can often be bad.
As a therapist and an herbalist, I am often struck by people’s desires to…simply feel better…to feel physically, somatically, cellularly better. Folks in distress truly do feel ill…mentally, emotionally and physically. We would do well to honor that physical feeling of illness and address it. Yes there is importance in honoring pain, exploring the root of issues, developing insight- but there is also importance in alleviating suffering- offering tools and techniques to reduce the pain, to offer alternatives to medications which promise immediate pain relief, immediate tranquility.
Very interesting Emma and thank you so much for your research and words. I work with many young people in private practice who are deemed “psychotic” who I think are deeply sensitive souls, often having experienced trauma. I think of “psychosis” as a form of emergence and a deep process of unfoldment. At times people go through experiences that are so overwhelming that they need a safe place, a sanctuary- to work through these complex states. It sounds like Spiritist hospitals an example of this type of sanctuary.
I also work in a psychiatric hospital setting very part time as a therapist and we use a variety of “unusual” tools such as drumming, aromatherapy, chanting, singing, dancing and movement in different group settings. What you wrote about spiritist hospitals sounds deeply healing and hopefully we can truly create sanctuaries such as you describe.
I think its key to bring up the issue of money and its generally what I think of as the achilles heal of psychiatry. Hospitals are shuttering hospital beds at an astounding rate for just the reason you have outlined. They can make far more money doing medical procedures than for managing complex emotional problems through psychiatric consultations and temporary housing, aka psych units.
In Portland this last week, all the main hospitals went on “divert” because they were overloaded with people coming to the hospital for a mental health crisis and looking for a bed. For those that don’t know, going on divert means having so many patients in the ER that there is not enough room for them and they have to be diverted to other hospitals if possible. For many mental health patients, this also means “boarding”, staying for days in a small room waiting for a bed.
Going on “divert” is extraordinarily expensive for hospitals and they try to avoid it like the plague. Even though my hospital was losing quite a bit of money in their psychiatric units, they chose to keep them open because it was still more cost effective than often going on divert.
This has led Portland to creating a new hospital that will be devoted to psych admissions (sometime in late 2016.) The new Unity hospital will replace most all the hospital beds in the city. In many ways it is likely that they will try to turnstile patients out the door as quickly as possible because it is simply too expensive to manage emotional crisis using a medical model.
I think this is the number one argument to make with people who don’t care about mental health, issues with medications, coercion, etc. Creating non-medical alternatives is….cheaper.
The problem is that there once one has gone down the road of taking meds for long periods of time, there is no way to avoid working with the medical model- meaning someone who has gone off their meds, or is experiencing instability with their psych drugs, has to see a doctor in order to adjust them, or restart them and taper down if possible. Essentially, those in crisis are forced to use the excessively expensive medical model of crisis because of their need for medication assistance. Its a snake eating its tail.
Thanks for your article Peter and Anne, and the links to other critiques and comments, some of which I had not read and were fascinating. Really this feels like a watershed moment where psychologists and therapists, at least in Europe, are finally saying no more. No more to reductionist ways of perceiving psychosis that elicit labels and prescriptions far too readily. This is a very positive statement that posits that we must perceive extreme states as complex and highly individuated narratives that are often rooted in trauma.
My quibble is this, and it looks like it has already been somewhat addressed. I come from the perspective as a therapist but I see this statement as having the implicit suggestion that many of these folks would be far better served working with a therapist, and esepcially one steeped in CBT.
I see you address this by saying that in fact many people would be helped by a wide variety of support…friends, family and community. But the suggestion is still there to visit a therapist…”later.”
In the wider world, many people experiencing profound distress go to traditional healers, herbalists, spiritual ministers, etc. The thought of sitting down in an office for 50 minutes to talk about problems, esepcially by a practitioner using a particular “evidence based” treatment style, does not fit global pan-cultural needs. I think its key to note that there have been an enormous number of ways of approaching “psychosis” that do not fit into the mold of therapy or psychiatry.
I applaud this statement heartily for expanding our understanding of extreme states as quite common and certainly not requiring medicalization and patholigization…but I worry that it is not expansive enough to be open to the complex unique worldviews and systems of healing found throughout the world.
In any event, thanks so much for your hard work. I am very interested to see how the ongoing debate unfolds.
Hey Lovelife, that is indeed an awful and sadly all too common story. A seemingly innocuous prescription of an antidepressant turns into a merry go round of SSRIs, mood stabilzers, benzos and antipsychotics with a bevy of ever increasingly severe psychiatric labels. It is wonderful that your family is on board with creating a safe space to taper off the mood stabilizers. As a therapist I am often confronted by people who want to taper off but their family is not on board and that makes it far more challenging. The only suggestion I would have is to go slow. Some docs want to taper folks off far too quickly and there is much evidence that a slow taper is the best bet. I also would suggest trying to optimize your diet with lots of whole foods and reduce stimulants such as caffeine and sugar as they can make the taper much harder. Even though you are tapering off mood stabilizers, http://www.survivingantidepressants.org is a good resource and support forum for tapering. Good thoughts sent your way…
The new focus on orthorexia has been fascinating to me. I get that deeply unhealthy eating patterns, whether it’s junk or “health” food can cause severe mental and emotional concerns.
At the same time, I am surprised there is a desire to label people who eat “too healthy” as having a mental disorder. Should we label a diabetic who continues to eat junk food with a disorder? Should we label people who eat a lot of fast food with a disorder?
Where does it stop? And is it simply a convenient way to market yet another drug for yet another “mental illness”?
Like you said in the article, we’ve already done this in the 60s…uppers for weight control, downers for anxiety, often caused by the “pep pills.”
How does a Big Pharma 11week study equate to “science” and evidence based practice?
I have just been working with someone and helping her as she tapered off of vyvanse for binge eating. She had taken part in one of these studies to determine its “effectiveness”. It certainly helped curb her appetite and to lose weight. I asked her what she was eating and she said she snacked here and there. She described feeling very anxious a lot of the time and had difficulty in sleeping.
When I explained that vyvanse is essentially a form of amphetamine and that it is likely to have long term repercussions as well as these side effects she tapered off.
I’m wondering why I had to be the one to tell her. I guess I should no longer be shocked that doctors are now willing to prescribe speed for weight loss and appetite control.
I think it’s interesting to note that there is a new disorder that some are bandying about called orthorexia…essentially focusing on eating “healthy food” to the point of malnutrition. Perhaps they will have a drug for this too?
I recently worked with someone who i helped get off vyvanse for binge eating. She said it was making her feel way too wired and anxious but she said she had lost a lot of weight and it curbed her appetite (big surprise). I gently explained that it was essentially a form of speed and she was quite surprised. Once she stopped it she gained aslo the weight back…which I suppose is one of the big disincentives to ever stop it. She says she feels way better, way more grounded now.
How is this possibly legal? I’m surprised they don’t prescribe it for obesity…or would it be…extra overly large syndrome? No need to diet and exercise…just take this scientifically proven pill…
The whole idea that an amphetamine…sorry… adderall….is effective and benign medicine for people who suffer from ADHD but is a dangerous illicit drug for everyone else is just a fanciful mythology.
Speed makes *anyone* concentrate harder, work more efficiently, get things done, stay more clear and focused….in the beginning.
Excederin take the time to really read the testimonials. Go through them one by one- especially the long term users. There are some positive ones- but by far you will see a list of woes…a litany of misery and heartbreak.
Frankly I don’t care if they find a biological marker, gene codes and brain imaging scans that absolutely tells you you have “ADHD.” That just doesn’t translate into- and therefore you should take amphetamines the rest of your life. Craziness.
Look at the types of things Steve recommends. There are plenty of ways of helping kids that does not involve drugging them with speed. They don’t get to say…no thanks.
Well if you look at the testimonials…it seems like a large share of people have experienced very poor effects. I would suggest looking at the long term users of both ritalin and adderall (similar testimonials). At that point…”if the price is too great”, they can’t just “stop.” These testimonials describe the harrowing suffering inherent in withdrawing and then the severe post-withdrawal issues.
If you don’t like corrective lenses, you can, indeed, just stop. For those who have been taking them a long time…”just stopping” sounds ludicrous.
Here’s someone who rated adder all a 5 out of 5…
“This is a life long decision with a high potential for negative outcomes. I think you should allow yourself or your children to be the way they are, and find social, mental, physical outlets and ways to be accomplished and successful without the drug. Also research what it does to your dopamine stores in your brain. Coming off of it after years of use can lead to a pretty lack luster view of life. That being said… time for another dose. Sigh.”
Another “positive” testimonial…
“I’ve become reckless. And it’s addictive as all get out. There are many days I find myself taking twice my dose. If I run out early, I count down the days to my refill, finding myself incapacitated otherwise. But – I’m a junior at a prestigious college and I have straight As. My teachers rave about my work ethic and my dedication. It’s boosted my sex drive significantly, as has my confidence. I juggle a full school schedule with several internships, side projects, a boyfriend, etc. My focus is often streamlined and my the work produced is high caliber. Ultimately – it’s a double sided sword. Has it helped me? Enormously. Am I a different person than when I started taking it? Unquestionably, almost unrecognizably transformed. So seriously weight the consequences before you start. Because no matter how strong you think you are, the drug will suck you in. Some days, it’s beyond worth it. Some days i’m in hell.”
Please don’t preach pollyanna…or ease in stopping. These people will tell you your wrong.
No problem Steve.
This has been my “go-to site” for anyone interested in starting a course of psych drugs (of any kind). There are plenty of pro-drug reports so it is not one sided. But the reports of adverse effects are common and overwhelmingly tragic.
It is important for people to know they are rolling the dice when they start psych drugs. This site is about as clear as day on those risks.
To me, stimulants like adderall/ritalin, are a lot like their counterpart benzodiazapenes such as valium/xanax/klonopin.
At first they seem miraculous. They indeed “work” in the short term providing immense short term benefits. But like speed and downers, they start to catch up to you. They start to not work. You can’t stop them without horrendous withdrawal effects and they lead to complicated emotional and health problems down the road.
Like downers and speed, both benzos and stimulants are sold illegally on the street for a reason- they get you high. But for some reason we’ve created an entire field of medicine that supports them as being effective and evidence based.
“Are they manifesting the indications theyāve been drugged in the traditional sense?”
Yes. Please see testimonials…
A diagnosis of ADHD almost always leads to a prescription of stimulants…
“Insomnia, flushing of face, anxiety, sweaty at random times, back pain, teeth grinding, depression, Loss of social interaction I only took this drug because I felt pressured from how my grades were and my parents when I was a freshman in high-school, my grades went from d/f’s to B’s and A’s feeling like I was on-top of the world(especially after the first couple of months).. now a senior I feel like I’m really depended on it, this drug has messed my life up in every way possible. Yes I got those grades, but is it really worth it to now have anxiety, depression, dependents on adderal, secluding myself from society?… ”
“Adderall seemed to work for me at first. But it’s facade quickly faded to reveal a chain-smoking, binge drinker. I became socially withdrawn, lost my job, & lost my passion for life. Adderall has caused me to lose the best years of my life. I hate this drug with my whole heart. Never ever take adder all.”
“weight loss, lack of appetite, rapid heart-rate, failing vision, bruxism and resulting tooth fracture, gum recession, personality changes, seasonal depression, anti-social behavior, bipolar & borderline personality disorder tendencies, hair loss, decreased libido, insomnia, poor short term memory, headache, hyper-focusing on unnecessary tasks, dry mouth, increased thirst, rapid decline in BMR (basil metabolic rate), cold hands and feet, abnormally low body temperature, overall detachment from the natural ‘cadence’ or rhythm of life.”
Why are we giving these drugs to our children?
Hmmmm. its key to examine testimonials of people who have been taking stimulants- especially for prolonged periods of time….
Lots and lots and lots of adverse reactions. Even the people who rated the drugs high (4 and 5) describe lots of adverse reactions.
Take a close look at what many kids are going through when taking speed…Here’s a few testimonials of people who have been taking adder all for a long time…
“Very OCD, depression, loss of sex drive, impulsiveness, any symptom you can think of I had while taking this medicine. I have serious heart problems, social anxiety, rice developed an eating disorder, lost every friend I’ve ever had from isolating. I don’t feel like a human being anymore, nor do I remember how to live a normal life. I permanently feel bugs crawling on me and have destroyed my skin from the length if time on this drug. I am a pretty girl but adderall has ruined my appearance more then you can imagine. It’s great at first, your on top of the world but it doesn’t last and it is NOT worth what I’ve been though with health problems the past year linked directly to adderall. ”
“I can tell through years of taking it that my brain goes fuzzy when I don’t. Even now when I’m on it I seem to have trouble with my memory. When I mix it with alcohol (horrific mix) I only need a drink or two before I blackout. I fear telling people when I do because I don’t want to know what I said or did. Lately, I have been having bad insomnia. I’ve taken this for years and didn’t have this problem until recently. I’m trying to get my life together, doing things I don’t want to do, which this pill is good for, but I’m starting to think the physical side effects and long term damage aren’t worth it. So then what? Fuck off my life until I give in and start taking it again? I’ve seen this medication do wonders, I’ve seen it wreck lives. I don’t really know where I fall in this spectrum, but I know this stuff is nasty… super bad for me, but I depend on it now. I truly wish I had never taken this stuff. Parents or people considering taking this drug, seriously reconsider….”
“It’s tricky, because Adderall has done some wonders for me, but not without it’s heavy price. Most significantly: I am much, much more antisocial when I take Adderall. I used to be a hard partier, going out four nights a week. Now I go out once a month. I’ve lost touch with many friends. I get irritable or uncomfortable around people. I get very paranoid. I have a hellish sleep schedule. I was always lean, but I’ve lost about 20 lbs. I have to force myself to eat.”
Randy I don’t know if I would classify you as Pro-medication…but how about “pro-selective use without bias from pharmaceutical companies and a hell of a lot less than what we have been doing medication? “. That might not fit on a bumper sticker though.
I think there a re a number of people who are fine with a model of using psych drugs much more cautiously as long as people are informed of their long term complications and are not given false information such as Meds are necessary for “mental illness” just as insulin is necessary for diabetes.
There are people who take meds intermittently, or only during a crisis, or at a low dose.
I think the main ire I have is against the excessive over prescription of the drugs, the corruption in the industry, massive unnecessary polypharmacy, irresponsible use of drugs for youth and the elderly, and on and on. But I am not against the idea of using psych drugs so I would agree with you. I don’t think I would characterize that as “pro-meds” though. :).
Very interesting article Randy and thanks for the info. The dollar amount used to “influence” doctors is mindboggling.
I though this piece of your article was also interesting…
“Nevertheless, the end of patent means fewer free samples, fewer visits from pharmaceutical reps, fewer paid lunches, fewer āopinion leadersā making the rounds showing the companiesā own slides, fewer conference symposia lavishly funded by patent owners, and less general noise distorting the environment. Medical decision-making is likely to be based at least somewhat more on science than on enthusiasm and hoopla.”
I guess my question would be…what science? The biased big Pharma studies fill many of the medical journals and alternative interpretations of the effectiveness (or non-effectiveness) of antidepressants is likely to be downplayed even after the “patent cliff.”
I would like to think that the medical profession would reexamine the merits of these drugs using more unbiased non-industry studies and “science’ but I fear I have become fairly cynical.
Timothy, I think this really comes down to the interpretation of these studies (and several others). Sadly, I think most of the psychiatric profession dismisses these longitudinal studies in the same way you do.
Essentially, these studies wedded with personal experiences of long term suffering by survivors due to iatrogenic illness from meds form the key component of this national debate over the merits of psychiatry.
Dismissing them out of hand simply doesn’t jibe with the experience of tens of thousands who have been damaged by medications.
Though I agree we should augment the discussion by discussing other issues (social injustice, poverty, etc), I don’t personally want to see it watered down too much. The key issues of medications affects too many people to be dismissed so easily.
Really interesting piece Timothy – thanks for the in depth analysis.
I also think there are intersecting issues that have led to rising disability rates. You mentioned socio-economic issues such as poverty, racial injustice as well as issues such as the tacit “built in disincentives to exploring and pursuing meaningful work for people on disability.
I would add one more factor to this kaleidocope of reasons for increasing disability levels and that is the profound change in the global food system since the advent of the Green Revolution in the 60’s. I believe that the vast increase in the consumption of the processed form of just a few crops (wheat, soy, corn) and the subsequent massive rise in rates of obesity, metabolic disorders, diabetes and “mental illnesses” also contribute to the great rise in disability rates.
At the same time, I think the issue of medications is a key part of this discussion. Whitaker has pointed to studies done by the WHO as well as longitudinal studies by Harrow et al and studies done by Wunderink et al that all show worsening prognosis and disability for chronic use of neuroleptics.
Though these studies may not show that neuroleptics are the definitive reason for rising disability rates, they definitely are implicated as a strong part of the equation.
I would agree with you however that there are certainly other factors that play into this complex issue.
Thanks for your detailed thoughts.
First off I just want to say thanks Scott for looking at alternatives for helping people that do not immediately involve psychiatry. That is a much needed and welcome step and your program sounds innovative.
However, I echo the concerns for creating alternatives that are cheap, accessible, “low-tech” and that also allow for people that have “safety issues.” I recently was talking to a woman who was describing the place she would have loved to find when she was deep in crisis and suicidal.
The place would be in nature, quiet and low stim with people cooking nourishing meals. There would be activities available such as yoga, meditation, therapy, but for some people it would simply be a place to rest, talk to peers and eat healthy food without having to think of their problems medically. But it would differ from a retreat center in that the staff would understand that people were coming because they are in crisis and are looking for support/love. Ultimately, it would be paid by state or private insurance and available as much as hospitalization is available.
I support any and all endeavors to create alternatives and I heartily support your approach Scott- we need more people not just thinking and talking- but doing and creating…Thanks for being part of that effort!
Thanks so much for your piece Dick. It reminds me more than ever the need to make sure people don’t get started on strong neuroleptics because the road becomes much more challenging if you’ve been taking them for long periods. As a therapist I have been working with several young people who were diagnosed “First break” and then given whopping doses of mood stabilizers and antipsychotics. Each one has been told that taking meds for their “illness” is just like taking insulin for diabetes.
With the help of holistic minded NPs and naturopaths, they have weaned off these neuroleptics as quickly as possible and a team of us support that process. The problem comes that some people are not on board…family members, friends, and it can create a split because it defies psychiatric “advice”.
As you write…the evidence is clear. Chronic use of drugs like Zyprexa rearrange neurochemistry to make one increasingly sensitive with a heightened potential for disability and “relapse” into psychosis.
The shamanic piece is very interesting as well as I believe we have completely discounted traditional techniques of healing that have long been a part of indigenous cultures throughout the world. There is a pressing need to explore these deeper fountains of wisdom. Thanks for your words.
Oliver’s piece was amazing and Chuck you are right…those were “non responses.”
Though Oliver addressed the corruption inherent in direct advertising (“Ask your doctor!”), scripted lectures from Pharma for “thought leader” doctors, the amazing over prescription of meds (70 percent on at least one med), he did not address the poor outcomes of many of these drugs and especially the deleterious effects of long term use of psychiatric drugs.
The movement here to address the ills of psychiatry easily bleeds into a wide critique of modern medicine in toto.
Lovely to see Oliver’s piece get so much play though.
This was a study that caught the attention of a lot of people I know who aren’t particularly interested in issues related to psychiatry…mainly because of many articles highlighting Benadryl/dementia. Perhaps it will help people to further delve into the complications of long term use of anticholinergics.
But I was not aware of that site that you link to that shows the breakdown in anticholinergic properties of most psych drugs. In the category that shows strong anticholinergics effects (scoring a 3), that is quite a list that includes most of the “1st generation” antipsychotics but also the very commonly prescribed seroquel and Zyprexa.
Sadly, I assume this won’t have a great effect on prescribing patterns, but I wonder why. Will the APA try to dismiss these findings? Simply ignore them?
Great piece Joanna. I often look to askapatient.com when I want to see a more comprehensive, longitudinal and subjective experience of drugs and their effects. I really would like anyone who wants to start a drug to go there first. It is an amazing compendium of stories and voices of lived experience.
One of the singularly frustrating things I hear in the mental health world is the term evidence based treatment. It implies that a course of psychiatric drug therapy is a scientifically effective modality. Yes there may be partial alleviation of symptoms (perhaps), but at what cost? What side effects? What long term health consequences? What long term effects to metabolic and organic functioning?
In any event- Lived experience- It trumps all RCTs in my book. Here’s seroquel…1349 ratings…
Great comments from all here and I just want to continue on with what madmom says. Imagine a campaign where the expenses for “helping” someone is tallied up. Put a monetary figure on each person in terms of hospitalizations, psych drugs, health complication medicine and surgeries, disability checks, etc…
Call these folks the million dollar man or million dollar woman. Then describe how that money could be spent…as you just did Madmom. Then simply ask…is this how you want your taxpayer money spent?
I agree- well said Corinna.
I think the assertion that there may or may not be high presynaptic dopamine production in the brain for folks labeled with schizophrenia, or going through psychosis- is not the main issue.
The main issue is the idea that antipsychotics somehow “correct” this.
Even if what they posit is correct: there are higher levels of dopamine- neuroleptics in no way “correct” this. Certainly they are dopamine agonists, but they work at such a global level as to damage organic and metabolic pathways when taken chronically.
An antipsychotic “corrects” dopamine levels as much as a shotgun kills a mosquito on a wall.
Thanks for the piece Sandra. I agree that there should be a” safe place for people to stay while they work through their crisis.” The complexity arises when we talk about the varieties of crisis.
Here in Portland, the various hospitals have found themselves increasingly squeezed and are losing large amounts of money in their acute settings. This is largely due to the fact that acute hospitalization tends to involve people who have limited or state insurance. This leads to poor reimbursement while funding the payroll for all the doctors and nurses is exorbitant.
For this reason, the largest hospitals are pooling their moneys to centralize and create one large inpatient facility in Portland with its own psychiatric ER. This is mainly a cost savings measure but points to the inherent problem with crisis mental health care. Generally, the medical system is far too expensive to “manage” crisis. Its just not a model that has made fiscal sense.
We are in desperate need of alternatives that are not only cheaper, but far more humane. One of the main problems I see is that most anyone in crisis is funneled into one monolithic system. Those who are high, drunk and acting bizarre and agitated, someone with dementia who is violent, someone who has stopped taking strong neuroleptics, people experiencing “first-break” episodes- all get funneled into this one system and tend to receive very similar care- psychiatric drugs and often a short stay of a few days before being sent out for services (generally lacking) in the community.
We need systems where we funnel a number of these folks to systems of care that do not prioritize med management. This is especially important for “first break” folks. In my perfect world there would be “asylums” designed to allow crisis to run its course without medical intervention. But my second best choice (and likely more realistic) is to promote a non-interventionist model for first-break in a hospital setting where people are not immediately started on strong doses of neuroleptics, or at least offered a choice for selective use.
In this way we may not create a group of folks who require long term med management. Once this happens, folks often cycle in and out of hospitals due to intermittent and understandable “non-compliance.” Then it becomes much harder to create non-medical alternatives for crisis. I believe we have to really start at the beginning when people first start taking strong meds and try to avoid that as much as possible. Once an individual has been taking psych drugs for a while, it is deeply challenging to offer alternatives that don’t in some way involve psychiatric intervention, even if it means to help taper someone safely as you have been talking about. And when someone is agitated and has been cycling on and off meds, soteria and respite models are not effective. We have to go the root and start from the beginning and address how this epidemic has happened. Trying to fix it midstream is deeply challenging.
Fascinating piece and one that gets to the heart of our cultural assumptions about “mental illness.” I had not seen the statistic of 90 % cross cultural belief in possession before but it rings true. Though we disregard it as an absolute relic of pre-scientific superstition I think it is key to understand that metaphysical explanations of extreme states are extremely common outside of the Western psychiatric model.
I once witnessed an orthodox Russian exorcism of a woman who was diagnosed with schizophrenia. The process of a community coming together to offer healing to someone in distress was beautiful…but also complicated. many would not only dismiss this experience, they would consider it dangerous and contrary to what she really “needs”…namely psychiatric drug treatment.
We have heard many stories of people foregoing medical treatment for spiritual healing coming under extreme scrutiny for abuse and negligence of family members. This is somewhat understandable in life and death medical matters.,.but seems grossly unfair to those going through emotional distress…as many of the Pharma drugs have severe well understood problems. Which is worse? An exorcism or a lifetime course of neuroleptics?
When I lived in Ecuador for a while I worked with some of the indigenous “shamans”, aka ayahuasceros, and they held a deeply complex syncretic animist and catholic cosmology. They often thought illness patterns developed due to black magic…brujeria. They envisioned sorcerers sending evil invisible “darts” to hurt others and the ayahuascero could remove that dart through ritual and communion with plant and animal spirits.
I also saw ayahuasceros describe remarkably prescient visions that could only be thought of as telepathic. Something deeply mysterious and incomprehensible was going on, which often mirrors the experience of those in deep crisis. I think we should deeply explore these frameworks, and should certainly honor cross cultural traditions outside of the standardized modern Western psychiatric model. Thanks for your words.
I’m not really sure you have looked at that site and those reports I mentioned at askapatient.com….heres the link again…
These aren’t just a few people- there are hundreds of reports in here of serious and adverse effects. Not just a few, or even a small sampling- a significant percentage of folks report very poor reactions. What do you think about some of these reports?
How about something cheaper that gets straight to the point. AskaPatient.com. Take a look at the testimonials of people who have been taking the drugs themselves. Since this post is on seroquel, lets take a look at the 1346 ratings it has been given… http://www.askapatient.com/viewrating.asp?drug=20639&name=SEROQUEL
There are certainly a number of folks that extol its benefit- but literally hundreds and hundreds of folks that describe horrendous reactions to this drug. How many people are told that this is the type of experience that could very well happen for them…here is a sample…
“All Delusions, hallucinations, sleep, dry mouth, weight gain, overactive libido, mood swings Over confidence all side effects. I am 100 days free of this dangerous drug”
“This medication did not really help me at all with my problems and it very possibly may have completely killed my reproductive function. I am currently waiting to find out if my body will ever recover, it has caused me to gain weight, develop breasts, varying levels of sexual dysfunction, it has damaged my blood sugar levels, and I may have completely lost the ability to procreate. There are over 10,000 law suits filed against AstraZeneca for things like this and I may be another soon, I implore you to research the rare and serious side effects before taking this in my experience worthless and dangerous pill.”
“Just a bad over prescribed bad drug Went cold turkey, it cost me my life, it destroyed friendships, prescribed to shut me up, this drug is used as a catch all for any ailment, I would not recommend this for anyone, I’m working through insomnia and angst for not researching this drug, nothing will ever have me take this drug again, did not dose down did not tell my doctor, just left it along.”
“Within days of taking this drug I developed Spasmodic Torticollis. Was in severe pain and still recovering the damage of what this drug did to me.”
These are not just a small sampling. Reviews like these are extremely common there. Your thoughts?
Hey Rossa- I think Castaneda really made it tough on himself by presenting his experience as a first hand narrative. If he had just explained things as a deeply imbedded anthropologist he wouldn’t have caused himself so many problems.
But…I think there is quite a bit of value in those books- and he very much popularized the idea of examining experience from a non-ordinary, non-linear perspective. This influenced a lot of folks who have been interested in seeing our experience outside of reductionistic ways of examining life.
This can be really important for people going through extreme states because the process is often very non-ordinary/non-linear. So- not trying to trash. But I am acknowledging what many other people will say when discussing Castaneda and his works. On an academic level, he lost his good standing. But his willingness to deeply explore and describe these complex experiences deserve admiration, and certainly they have helped many people understand their own process better.
Yes- I am afraid Bipolar waking up is right. Casteneda has been dismissed as fiction, though he borrows from a lot of anthropological literature and first hand accounts. This is one of the problems when talking about this sort of thing. It can be easily dismissed. That’s too bad, because there is tremendous wisdom inherent in these ancient practices.
It talks about my personal experience going through “madness”, my experience of possession and healing. One of things I wrote fits here as well…
“When I look back at that experience now I wonder a few things. On a certain level, I could see the whole experience as imagined, a part of the process of psychosis, a grand delusion. And from a scientific and logical perspective that seems rationally true. But from a different perspective, I see how the descent into darkness and then coming through a horrific and torturous experience through the help of a healer and plant medicine is a story that is as old as time. We are walking in a world where treating madness through the use of double blind study proven antipsychotic neuroleptics is the main accepted form of treating “mental illness.”
What is challenging is how easily these conversations can drift into feeling “new Agey”, assembling indigenous cultural perspectives into a modern formulated “shamanism”- created almost entirely for white and privileged people. This is a fair critique- but I would also suggest that by dismissing these ancient traditions, we have exchanged them for a rationalistic, scientific and reductionist way of working with madness that is deeply flawed and often far more dangerous.
One of the most interesting things that have been happening lately is a very strong interest in exploring healing with Ayahuasca, a South American hallucinogen. This medicine has been used entirely in unique tribalistic contexts but numerous Westerners are exploring and finding great healing through ritual work with ayahuasca. There has been quite a bit of talk on CNN (just google) about returning veterans feeling completely zombified by psych drugs for treating their PTSD, and a number of them have traveled south to take part in ayahuasca ceremonies that they describe as being tremendously transformative.
I think we need to be careful, but open, to these wider possibilities for healing.
Hey Alex, I think by scientific rationality, I’m mainly talking about the gold standard of double blind studies. Frankly, I think the idea of something needing to be proved by a double blind study is often ridiculous. How do you use a placebo for the warmth of the sun, the kindness of a stranger, warm home cooked food, a cup of warm linden tea- all things that have obvious merit for improving wellbeing.
Shamanic techniques are fairly impossible to verify as something repeatable and verifiable s effective under the classic double blind scientific paradigm.
But I would say…bah. There is a long history of using these techniques in many settings with good anecdotal support. But there are many complexities in bringing that wisdom forth. One of the main problems is cultural imperialism, appropriating another culture’s healing forms. A second problem is that some of these forms just don’t translate to many modern people. They often involve culturally unique cosmologies, spirits, deities, etc.
But…I still think its something we should deeply explore as shamanic/spiritual techniques of working with people in deep distress is a time honored tradition and one that I have personally seen as effective.
Very interesting post Natalie.
I think we tend to get lost in our cultural assumptions about mental distress and its etiology. Most are influenced by psychiatry and the DSM and others are influenced by psychological thinking. But we tend to relegate non-western approaches to being superstitious, magical and non-scientific.
This is strange because most of the world does integrate a lot of these tools for helping people in crisis that are often effective and merit deeper examination. I think its important to separate out traditional systems of healing people such as Traditional Chinese Medicine, Ayurveda and Unani-Tibb from more tribalistic and religious practices. The former have developed countless tools for helping people in crisis such as acupuncture, qi gong, herbalism, yoga, massage and dietary advice. Though these are lumped in with “New Ageism”, they are simply traditional tools that have thousands of years of historical, anecdotal and empirical efficacy.
Shamanic, spiritual and religious tools are more complicated because they do rely on a willingness to forego scientific rationality. As you mentioned, concepts like possession, out of body experiences, shamanic healing, ritual and ceremony are common to many indigenous cultures throughout the world. Deriding these tools for being superstitious and magical is somewhat amusing when we offer an alternative (psychiatry) that has led to an epidemic of worsening mental health.
I think the challenge is that these tools don’t easily translate well into cultures based in scientific rationality and modernity. But they do hold an important place for many indigenous and religious groups throughout the world. Even if one were to consider them metaphorical, they help allow for a community to embrace and help in the healing process for someone who is in deep distress. These techniques are ways for the community to come together and offer hope and care for someone who is experiencing extreme distress. Frankly I’d like to see a whole lot more of that than a drug based approach to distress.
Interesting- I have always wondered about the thinking of psychiatrists for prescribing multiple meds in such large doses. I will give an example of someone from a while back who was receiving 800 mg of seroquel, 2 mg twice a day of xanax, and 120 mg of celexa. This is for someone diagnosed with depression- no psychosis. She says the seroquel was for sleep.
I have always wondered how doctors simply pick and choose meds- subjective preference, research, etc?…and what leads them to high dose polypharmacy. Is there literature that supports it?
Sandra interesting about effectiveness range being around 3.5 mg. I regularly see people in the community and in my practice who are prescribed at least 20 mg of haloperidol a day and a few times as much as 40 mg. The effect is very noticeable with muscle rigidity, akathisia, anhedonia, tics, etc. Horrible. I have almost never seen someone prescribed less than 5 a day, and it is often paired with other antipsychotics.
so yes, conservative dosing and much less poly pharmacy would go a long way to mitigating extra pyramidal side effects. That would be wonderful to see.
Ya Hermes,
I know that risperdal is now available generic and that was one of the first (the first?) atypical to be marketed….so that is indeed cheaper. I know that the cousin to Risperdal…the Invega shot…is pretty pricey. Add it all together…hospitalization, expensive drugs, regular med checks, etc….leads to busted mental health budgets.
Drug based “therapy” is stealing money out of the hands of community services.
ya Duane…some of these drugs are indeed very expensive…Abilify I think is the most but so is Geodon and other newer “atypicals.”. Big Pharma has made a fortune marketing these drugs as wonder meds that are far more safe and effective than older antipsychotics such as Haldol and Thorazine. But of course we are now learning about severe metabolic problems, weight gain, diabetes, heart disease, etc, associated with the newer drugs.
So some say the answer is to return to those cheaper older neuroleptics that were horrifically damaging. Like you say Duane, hopefully the sheer cost of drugging enormous swaths of population will force the hands of those who manage State Budgets to rethink this approach to mental health.
If longitudinal studies showing poor outcomes and long term health effects doesn’t change the debate, perhaps financial budgetary burdens will convince people to make significant changes to reduce drug based treatment strategies.
Excellent analysis Bob and thanks much for the in depth examination of these issues. I have long felt that the sheer expense of the medical/disease model of “mental illness” is the Achilles heel that will eventually cause it to have to radically change. The cost of not only employing high priced doctors and nurses in acute and outpatient settings, but also paying for very expensive pharmaceutical drugs, is becoming untenable in many counties and states.
You mention the cost/effectiveness of antipsychotics. There seems to be a push towards using the older “typicals” such as Haldol and Prolixin, not only because they are much cheaper than most atypicals, but because some research is saying they are just as “effective.” Of course this ignores the severe extra pyramidal side effects and potential for long term neurological disorders of the older antipsychotics. So will we trade more expensive drugs such as seroquel and zyprexa with their known metabolic side effects, for older antipsychotics that cause Parkinson like symptoms?
How about what we do what you suggest…shift monies to much more effective and cheaper ways of helping people… Community and peer supports with increased available housing?
Thanks for your words Bob.
On a deeper note, I think the key issue to resolve is why we have shifted towards 20 percent of people (in America) taking psychiatric drugs. A back of the napkin estimate would mean that 60 million folks are taking drugs for emotional distress. They are not generally getting these drugs from psychiatrists. They are mainly getting them from their GP. I don’t think many of them are interested in whether they meet a DSM-V diagnosis. They want relief from symptoms, and doctors, the AMA, the APA and pharmaceutical companies are saying that drug based therapy is an evidence based and generally safe way to manage distress.
If we want to get to the heart of the matter, the question becomes less about psychiatry and more about the role of drug based amelioration of emotional suffering in modern society. There are many culprits, and that includes us as a society that wants a quick fix to complex emotional pain. If we want to unwind this “epidemic”, we have to not only point fingers at the medical establishment and Big pharmacy, we have to choose as a society to employ healthier methods for working with our distress. We have to not only choose a slower, healthier path, we have to acknowledge the role of systemic racism, classism, poverty, food politics, industrial agriculture and quick-fix thinking at the root of our suffering.
These are complex problems not easily solved by
Thanks to Bob and Allen for debating these deeply important issues. I want to address Allen’s piece first.
I applaud Allen for directing a lot of his critique at “Big Pharma” and their advertising and marketing efforts. Yes I agree that this is absolutely important to address and reform. However, Big Pharma would not have the power to influence without the help of the APA and the DSM. Without the DSM, Big Pharma marketing would not be able to wrap itself in the cloak of scientific legitimacy. Truly the two are wedded and Big Pharma would lose much of its power to influence if the DSM was seen as lacking scientific underpinnings.
As tothe role of medication. Again I applaud Allen for recognizing that overmediction is deeply problematic. However he differs in that he would reserve medication for those that are acutely psychotic. Strangely I would agree but not for the reasons Allen may say. Sadly once a person has become habituated to antipsychotics I would guess the leading cause of psychosis is due to med changes and abrupt tapers. Because of this the humane thing to do is to suggest returning to taking psychiatric drugs as a way of curtailing florid psychosis. This does not imply that a person is essentially “mentally Ill” or needs meds for some chemical imbalance…but simply needs a safer and slower taper off very potent drugs. I would also reserve the use of drugs for short term care as we are already seeing that long term use are leading to worsening prognosis and health. I think it is key that Allen acknowledges this.
On the third point I think Allen is addressing a really important point. We have shifted from having around a half millions psychiatric hospitabeds in the 50s to having around 50000. Hospitals are generally turn mills to get people in distress back out the door. Prisons have taken up the role of long term “care” which is abysmal and torturous. Both options are awful and we need to revamp better possibilities for those in distress via humane non medical respite, housing first, community outreach, and non medical wellness programs designed to offer healthy non-drug options for helping those in distress. What I cant abide is Allens support for outpatient treatment. He must know that these drugs cause worsening prognosis and physical health. Why support their use as any form of “care”? I would hope Allen would become a leading critic in disavowing this practice understanding what he knows from longitudinal studies done by Harrow and others.
Anyways, though I disagree with you on a number of matters I appreciate you taking the time to debate and discuss these issues.
Wonderful work Sandra…and work that I wish was replicated by many psychiatrists. and I love the idea of fully monitoring weight, and also adding other concerns such as blood pressure, blood glucose levels, metabolic panels, etc. This should be standard practice for any doctor putting a patient on an antipsychotic. The tapering process is often complex, with lots of stops and starts, reinstatement, cold turkey experiments, complexities of poly pharmacy tapering, med changes, etc…very hard to track exactly, and I really applaud your efforts.
Bob this is wonderful news…and a very smart way to change the standard of practice for prescribers as well as forward the conversation about long term implications of psyhciatric drugs.
Eventually I think mainstream media, APA and those taking these meds will have to catch up to the implications of the Harrow and Wunderink studies (as well as other studies on other classes of psych drugs) and this is another way to press the issue.
Thank you to all who are taking part in this.
Thanks Emmeline…you’re welcome to expunge my comments now that they are gone…thanks…
Sounds like a great program Bonnie and Julia. Thanks for talking about this. At the farmers market I helped start, we initiated a program to give matching dollars for folks with food stamps for purchasing locally grown fruits/veggies. Examining food politics and poverty is really key to this discussion.
Oh…you asked about prisons. I think far greater attention should be placed on prisons as well as hospitals. The stat I quoted above says there are 350,000 people with mental illness in prisons and about 35,000 in hospitals. MIA needs to shine a serious spotlight on the immense crimes being committed in the penal system.
We need to create centers for people to experience psychosis without the threat of mandated treatment.
Hey Noel. Thanks for your thoughts.
I think we are all in agreement that
I think you raise some key points and I see you are in agreement with Ruchard and others when you say…
” I completely agree with everybody who has brought up the issue of breaking the law; if a person breaks the law, then they should learn to deal with the consequences. Not doing so, and creating some alternative ātreatmentā avenue because somebody is āsickā is probably the biggest impediment to getting past #1 the association of violence with āmental illnessā and #2 the learned helplessness of those who have been so misfortunate to end up in the system.”
I just want to ask how you would look at things given this example. A man is in his home going through some delusions that his parents are aliens and they need to be killed. He actively starts hitting and attacking them. Police would likely be called…but where should he go? Does he deserve to be tried in front of a court and put in prison for this episode?
How about if someone is on the street with command hallucinations telling him to break into a house and find a Bible? What should happen if they do that? Prison for breaking and entering?
My hope is that we can create centers where people can go that do not require psych drugs and the person can work through their episode without having to be criminalized for psychosis. But right now we are left with really poor options.
Many of these folks end up in hospitals because we have not created an alternative non-medical infrastructure. They come and so do people who have a history of being predatory and assaultive. At rare times I have had to protect vulnerable people in that setting from people who have a criminal background. If you call the rare instance of defending vulnerable people “abusive” I wonder how you would approach helping and defending them? I have already said cops won’t put down their guns to come in…so how do you work with those situations?
Ugh…these threads get so mixed up…here is where I was hoping that comment would land…
Whoopsā¦I should have said police are not allowed in any other Portland hospital units. I have seen them in the ED escorting a patient here.
But reallyā¦you say if I am not part of the solution, I am part of the problem.
If the solution means cops in hospitals, I donāt want to be part of the solution.
Whoops…I should have said police are not allowed in any other Portland hospital units. I have seen them in the ED escorting a patient here.
But really…you say if I am not part of the solution, I am part of the problem.
If the solution means cops in hospitals, I don’t want to be part of the solution.
Hey Richard…back for a brief mo before off to the hills to dig up some Oregon grape roots…
Per your questions…
1″What world are you living in? Police are involved ALL the time in matters of āforceā and violence in psychiatric hospitals. Donāt police frequently āescortā aggressive people (in psychological distress) into locked psych wards on a regular basis?”
No. Police are not allowed on our units because they carry guns. They are not allowed in any other portland hospital either. At my hospital, they have been asked to remove the guns and all other tazers and weapons and they laugh at the suggestion.
It’s the main reason I could never support police being allowed in a hospital setting.
2 “And when (or if) a psychiatrist or nurse is struck or assaulted by a patient on a psych ward are you telling me that you donāt believe the police are called and that person is prosecuted?”
Police are almost never called because these cases are never prosecuted. The reason is they are deemed “mentally ill” and not responsible for their crime as a legal matter. That could be a thread of its own.
AA, thanks for your comments.
Richard,
I’m still not sure you understand my position on “force”.
I am against the use of force in the form of the courts and doctors mandating treatment. By the way, this issue…not the issue of whether to use force in extremely dangerous situations…is the key sticking point in the public arena. Kendra’s law and AOT are the principle methods of using force and should be fought vociferously. We have a legion of opponents to our side on that view. NAMI, Torrey, Murphy, etc.
I am against the use of coercive force for offering people psychiatric drugs without fully informing people of their perils. Advertising, doctors lectures, misleading information, 5 minute doctor appointments are all subtle but pervasive forms of “force” that we need to oppose. Again, there are a legion of opponents to this view from the AMA, APA to Big Pharma.
But you have zeroed in on a very narrow use of the force…and magnify it to imply that I support all force. This couldn’t be farther from the truth. I am fundamentally against the “wrongful use of force”. Any survivor story here strikes me as a blatant abuse of power. I am against any blatant abuse of power.
But you take it a step farther Richard. You demand that force never be used….no matter the circumstance. Or that matters of violence be handed over to the police. I just have to fundamentally disagree.
Like AA said, police intervention has gotten a lot of people killed. I will fight you or any others who try to suggest that hospitals should now have police involvement in matters of violence.
Instead. we need humane workers in hospital settings and in the community who understand how to use deescalation skills and will do everything humanly possible to avoid force.
And yes, there are cases where people step over the line and start inflicting damage on others. That is unacceptable and force is obviously merited. By abdicating force, one would endorse the traumatization of vulnerable people. So of course there should be force in those situations. How could you argue otherwise? But it should be used extremely rare and abuse of power should be fought vociferously.
In any event, I’m busy today….gonna do some work, enjoy the family and brief windows of sun so I won’t be back to reply. But I hope you and Jonah, and all else here have a good day. Take care,
Jon
gardenlisa,
That’s a hard path to walk. And it’s esepcially hard if you don’t have a lot of support. So much of the time folks are isolated in these situations. That’s wonderful that he was able to wean off the anti-depressants and anxiety meds and that he was seeing a naturopath. Zyprexa, and all the antipsychotics can just be horrible to quit.
Sometimes the family member will take a lot of the anger/pain/confusion out on the parents and the rest of the family. Is there any way to bring someone in outside of the family to encourage him to start doing healthy things…clean, shower, eat?
You asked about recovery…at some point his neurochemistry will adjust to being completely off zyprexa and that process is really helped by nutritious food, rest, good sleep. As an herbalist and someone who works with people withdrawing off psych drugs, I second Fred’s ideas of offering good supplements too but it sounds like it’s hard to interact on this level.
Sometimes people experience prolonged discomfort, neurological disorganization and extreme states for quite a while after withdrawal. Recovery can look uneven. Having family members and friends around who are supportive and offer unconditional love and care is vital. It sounds like you are playing that main role and it can really burn people out…it’s really helpful to do a lot of self care so you can help him.
Anyways, hope you and your son find a way through to a better place…
Man….really challenging. One thing is that I would hope you are getting some support for yourself because that is really hard stuff you are going through.
I was saying before, I try to steer people away from hospitalization as much as humanly possible…but if he is truly talking about death wishes against the family that is scary stuff. I know people who are fundamentally opposed to psychiatry who have brought family members into a hospital setting because of the fear of violence. It’s a very hard decision to make.
Whoops…hopefully this will find the right place…
Richard,
I am trying not to twist your words. Here they areā¦
āNigel, I am very worried about your situation. Because we donāt yet have safe alternative programs for people in your situation if you donāt calm down now and continue to act aggressive or violent, we will be forced to call the police. This will be our only available option.ā
Forced to call the police is another term forā¦using force. And itās somethng I see folks here repeatedly trying to wriggle out of. Though you say you donāt support force everā¦is just not true. You support allowing the police to use force in these rare extreme conditions.
That is not abolition of force.
Richard,
I am trying not to twist your words. Here they are…
āNigel, I am very worried about your situation. Because we donāt yet have safe alternative programs for people in your situation if you donāt calm down now and continue to act aggressive or violent, we will be forced to call the police. This will be our only available option.ā
Forced to call the police is another term for…using force. And it’s somethng I see folks here repeatedly trying to wriggle out of. Though you say you don’t support force ever…is just not true. You support allowing the police to use force in these rare extreme conditions.
That is not abolition of force.
By the way, I completely disagree with the author’s (Sederer) prescription for more draconian treatment laws. We need to eliminate a doctors ability to prescribe and force any drug cocktail possible…absurd…
Hey Jonah,
For you, and anyone else who is interested…this is a good write up of the national statutes that were codified back in the 70s.
“It may seem odd that a person can be involuntarily admitted, or ācommitted,ā to a hospital and then refuse treatment. But the right to refuse treatment is also fundamental to the legal requirements for psychiatric treatment.
Someone who enters a hospital voluntarily and shows no imminent risk of danger to self or others may express the right to refuse treatment by stating he or she wants to leave the hospital. But a person admitted involuntarily, due to danger to self or others, cannot leave, at least not right away. However, despite having the authority to keep the patient in the hospital, the professional staff cannot treat the person against his or her will, except by court order.
The concept of a right to refuse treatment was built on basic rights to privacy, equal protection under the law, and due process. In other words, involuntarily hospitalized patients still have a right to decide what happens to their bodies.”
Now again, I honk horrible abuses take place where folks are “treated” against their will, or a flimsy excuse will be made to give a shot. Many folks can attest to brutal experiences in a hospital setting.
What I aslo want to warn someone against, anyone who thinks about hospitalization…is that “right to refuse” will go away if the person goes to a court hearing and the judge decides to commit them. That means anyone going into a hospital is gambling that they will not be committed and then treated against their will.
Civil Commitments have gone down rapidly in the last few decades and are now mainly reserved for folks who are deemed “psychotic” and a danger to self or others. But anyone entering a hospital should think hard about that possibility of commitment and it’s one of the main reasons I try to steer most folks away from hospitalization if at all possible.
Again- really really hard real world problem there gardenlisa…with no easy answers. One of the things I hear right off the bat is that he went cold turkey off psych meds- which can really cause severe complications and disorganization for anyone…but especially for those prone to extreme states. Even if it was 3 months ago- that may still be causing ramifications. However, I would not be as concerned with CT causing permanent harm. 7 years of drugging can indeed train the brain to be habituated to those drugs- and then when someone quickly cold turkeys off them…it can cause a hell of a lot of problems.
There really is no easy solution. The main problem with hospitalization is the very distinct possibility that he will not just be held-but then taken to civil court and be committed. At that point doctors can choose what drugs and at what dosage they want to prescribe psych drugs. He also faces the possibility of transfer to a State Hospital setting and indefinitely being caught up in the system.
At the same time, in a hospital setting he may decide to take a psych drug voluntarily and then hopefully stabilize and be released- and this time with the goal of tapering slowly and carefully off the drug.
The best option- like you say- would be a place where he could recover without facing the possibility of being forced to take psych drugs.
Hard stuff…I hope your son will improve and recover in time.
Whoops- my comment at 2:56 is in response to Richard’s comment down there at 12:56.
I just can’t support the idea that we should criminalize everyone who is aggressive/violent and psychotic. I take exception to the idea that
“people like this assailant almost always have prior histories of violence.”
Hope this comment makes it to the end of the thread line here :).
I think we need to be very clear that there are a lot of different types of aggressive and violent behavior and there is no clear line saying that anyone who is aggressive/violent should be dealt with by the justice system. You call that “enabling.”
I have worked with countless people who act extremely aggressively in the throes of psychosis. But once the psychosis has passed they are no longer violent or aggressive.
I also have worked with people who are predatory and violent by nature.
I think its key that we separate out these two separate populations. In the first case, I think it is highly troubling to turn over every aggressive and psychotic person over to the justice system. The humane thing to do is to give them space until the psychosis passes. If you call that enabling…so be it.
Really tough questions hearsbirds. I think a few things have to be examined with that incident. Why were hospital staff negligent in allowing an obviously violent person in a shared room with a vulnerable person? Why did they not look in on this vulnerable person regularly? There is obviously a lot of negligence going on with that hospital and there should be justice in that case.
The questions I have would be- what state of mind was that violent person in? Were they going through psychosis or paranoid delusions that led to this attack? Or was the assailant simply predatory and predominantly lucid and clear in thought when she attacked?
If its the second case, I have no problem with handing that person over to the justice system. In the first case, that’s a lot harder. Violent people who are “mentally ill” tend to go to forensics wings of state mental hospitals. They then get “treated” which generally means being forced to take loads of neuroleptics. Would the assailant fair better in a prison setting? Doubtful…but both are awful places to end up.
What should have happened is that a potentially violent person should have been somewhat isolated from vulnerable people and been monitored very closely. My hope is that if the violent impulses were related to psychosis, that those impulses would fade as an episode of psychosis passed. But if those violent impulses were related to underlying aggressive and predatory traits, my hope is that person would be transferred out of a hospital setting as soon as possible.
The problem comes that people who both aggressive and psychotic- often get court committed and end up in State hospitals. As other people mentioned, this is a horrible type of vague “sentence” with no fixed end. Forced treatment with neuroleptics is the norm. So many would say prison may be better for those who are likely to be committed. But as I described in the link above, prisons are overwhelmingly brutal to “mentally ill” inmates.
My hope would be that we pass laws to end the right of doctors to force treatment. In that case, someone may be detained for violent and psychotic behavior, but not required to take meds.
These questions you bring up are complex and very challenging to answer. In my heart, I don’t believe we should treat every aggressive and psychotic person as a criminal. However, in this case, and with the severity of the crime, the assailant needs to be isolated from vulnerable people for a long time.
In reply to Jonah at 6:46…
“Each time I was āhospitalizedā against my will, it would come ultimately as the result of my being falsely accused of being a danger to myself. And, each time, Iād be forcibly drugged. Never was I committed by a judge.
Jonathan consistently fails to acknowledge that this happens.
Perhaps, in Jonathanās āhospitalā setting, people who are viewed as āsuicidalā are treated with the relative degree of respect that heās describing, but why does he generalize?”
What you are describing is against the law Jonah. From Wikipedia…
“Involuntary treatment (also referred to by proponents as assisted treatment and by critics as forced drugging) refers to medical treatment undertaken without a person’s consent. In almost all circumstances, involuntary treatment refers to psychiatric treatment administered despite an individual’s objections. These are typically individuals who have been diagnosed with a mental illness and are deemed by a court to be a danger to themselves or others.”
To be “treated” against your will without having been seen by a judge is a violation of 1975 law. And that law does not go far enough. No one should ever be involuntarily treated….period.
But the reality of your experience, and many many others, show that many hospitals have been routinely abusive and it looks like in your case they flouted that law.
I also have to check in with this statement here Steve…
“But even so, the same thinking applies: even if you decide it is OK to detain a person for self protection, it should not take away their right to consent or refuse medical treatment, in particular, the drug-based pseudo-ātreatmentsā that are usually enforced on every detained person in the psych ward.”
People who are suicidal are generally never “forced” to take a drug based “treatment.” You can only be forced if you have been committed by a judge and it is very rare for a suicidal and non-psychotic person to be committed.
However, suicidal folks are coerced by doctors into taking psychiatric drugs without full informed consent and without presenting alternatives- something that is seriously wrong.
Hey Richard- I wanted to reply to these words here…
“Here is the best I can offer in a very difficult dilemma for anyone working inside the system.They (the distressed person) should be told ahead of time what will happen if they are violent or threatening violence. They should be pulled away from harming some one else. They should be offered support, consolation and compassion. If they are so aroused that they cannot calm themselves (with this kind of support) then they should be offered short term use of sedative drugs (such as Benzos).
If none of this support or offer of drugs works then they should be told that if they cannot control themselves the police will be called to intervene. They should never be forcibly drugged or contained in a psych ward against their will; the short and long term harm FAR exceeds other alternatives.”
This is the real meat of the matter. I totally agree with the first part, and I think you’re right that just creating a space to vent, rage, receive support and just listening can be really powerful. I once was in the ED when an enraged 350 pound man came out into the hallway screaming and demanding to fight me. He had scars from bullet wounds and knife fights and looked totally scary. I told him I didn’t want to fight because he’d crush me. I told him I was scared of him but I’d be open to hearing what he was going through. After a while he stopped screaming, calmed down and told me about his life, which was incredibly hard and sad and painful. That was all that was needed in that moment.
The part where we disagree is the police part. There have been times when police wanted to come in and talk with a patient with a criminal history and we said that they could not enter with weapons of any kind. They refused. I just can’t support the use of police tools for dealing with really precarious and potentially violent situations.
You ask about me making a stance against forced drugging and forced hospitalization? Lets start with the first. I absolutely oppose forced drug “treatment.” But you are talking about forced drugging in violent situations. I will say, as I have said before, I will only support the use of it in the rarest of circumstances when all other measures fail and other individuals are threatened with trauma. I don’t think supporting police involvement means you don’t support force.
As to forced hospitalization?
In general I agree with Steve here that…
“Iāll say as I have before that there is no reason that detention of a person for acts or threats of violence has to be coupled with enforced treatment.”
Right. People are only forced into mandated drug “treatment” after they have been committed. This should be abolished. No one should be forced to take regularly scheduled potent neuroleptics.
I don’t think that has to mean a hospital but I would far prefer a non-prison setting for deescalation of someone who presents as psychotic and aggressive.
By the way, you asked a few other questions in there Richard and I’ll try to get back to you later on those. Thanks,
Jon
Hey Richard…ok thanks for your reply.
So yes…everyone has a right to defend themselves. We’re in agreement there. I think what might make this more clear is describing in real terms how to work with people who are violent.
Many people here, we’re abused. Force was used against them needlessly and horrifically. I will never support that. But you also say that force should Never be used. I just don’t get that. Let’s talk specifics.
If someone who is labeled “mentally ill” is attacking a vulnerable person, would you intervene…and how?
You mainly suggest that police and the prison system should manage all violence, even if it emanates from someone who is psychotic, confused and delusional. I just will have to disagree. I don’t see hospitals as a panacea where nothing bad happens. hospitals are deeply problematic and I see that from an inside perspective. But I will agree with Allen Frances that the level of brutality committed against the “mentally ill” is overwhelmingly horrific. The use of extended periods in solitary confinement is routinely used as a way to “manage” the ” mentally ill.” They are regularly beaten by guards and tortured by other inmates.
I think this comes down to my fundamental question. If you oppose force, why do you support police and the prison system for working with the “mentally ill”?
Thanks Richard for your piece. As I have been the prime person involved in this ongoing debate for the past year, I’ll try to respond. At the same time, I know a number of us have gone round and round on this issue and at some point it may just be better to refer to previous discussions.
First off, I want to look at the term reformist…which you argue against. When I say I am reformist, that doesn’t mean I don’t think some aspects of psychiatry should be abolished.
I also support the abolition of ECT, even voluntary. While some people say they have been helped by it, the level of suffering that it has caused should require this procedure to be shelved…permanently.
But the term anti-psychiatry, or abolitionist…is far too general and global for me. It implies a complete cessation of all aspects of psychiatry, which not only seems impossible, it doesn’t even seem desirable. There will always be people who seek out psychiatric drugs, even if it is in the tapering process. I don’t believe that should be abolished.
What I do believe is that there should be far more available information about the perils of psychiatric drugs available to the consumer. There should be curbs on advertising, paying doctors to promote psych drugs. There should be impartial longitudinal studies of drugs that are not run by pharmaceutical companies. There should be a curb on prescribing psych drugs just as there have been curbs on opiates due to the potential for damage.
Finally, I think instead of funding NIMH “silver bullet” genetic research, I think our tax payer monies would be far more wisely spent on increased services for the poor, homeless and disenfranchised through “Housing First”, respite centers, holistic alternatives, changing agriculture subsidies to promote fruits and vegetables, etc.
Ok- so lets get to the meat of the matter- where we disagree…
Force.
You say that you don’t support any force…whatsoever. Not even in rare or extreme cases.
I really just can’t agree that that is a reasonable view. I think you are mainly talking about hospital situations but lets look at how violence or how the threat of violence is handled in society today.
Generally, people who are acting in an uncompromisingly threatening and violent way are managed by police through the use of tasers, nightsticks, beanbag guns and handguns. There are police trained in how to work with people labeled “mentally ill” who are able to help deescalate folks without the use of force but often these types of incidences end in the use of one of the types of “tools” I just mentioned.
If a person is deemed criminal, they end up in the prison system. Right now more than 350,000 people with “mental illness” are in the prison system. There are about 35,000 in state hospitals. We have shifted from hospitalizing the “mentally ill to jailing them. In the prison system, any sort of violence or threat of violence is met with brute and overwhelming force. For a brief overview of how these folks are treated…here is an article…
At Rikers, 40 % of the 11,000 inmates are deemed “mentally ill.” Besides beatings and frequent injuries to “threatening inmates”, isolation is one of the main ways of using “force” to manage “illness.” Long term isolation is known to make people go increasingly “mad.”
When working with the “mentally ill” population, overwhelming force by police, and in the prison system…is commonplace, and often brutal.
OK- so lets shift to the hospital system. I think its key to first talk about how the hospital system has changed over the past few decades. 50 years ago there were over a half million hospital beds. Now there are about 50,000 while population has doubled. The long term hospital model has been dramatically reduced in favor of the prison system for managing “mental illness.”
Richard, as you have written, you don’t support force at any level in these settings (and I assume other settings). But we are challenged by a fundamental question- how do we work with someone who is actively trying to harm another vulnerable person. My first take on this is, all people working with this population need to learn skills to work with highly agitated folks without responding with force. Deescalation skills are essential, such as building rapport, listening, offering comfort measures, food, TV, a radio, a phone, a place to be angry and vent, to even throw things and tear up a room without intervention.
The problem comes when a person does not deescalate and becomes increasingly intent on hurting others. Often the act of putting hands on and moving the person to a quieter area to calm down helps. But occasionally, rarely, it doesn’t. Even this level of force is controversial. Putting hands on someone who has been traumatized, especially sexually, can be increasingly traumatizing. Keeping a person in a physical hold or mechanical restraints can be deeply traumatizing to some. Isolating a person for a period of time in a state of extreme agitation is also traumatizing. Giving a forced shot of a sedative is traumatizing. There is no good answer at this point.
But the alternative is to allow that person to inflict damage…to severely traumatize another person. And that is where I draw the line…and where I am willing to defend the use of mechanical restraints or a forced injection.
What I will not support, is making this a legal matter- turning this over to police and their tools, or to the prison system and its ways of managing force. There is no easy answers in the face of these rare circumstances. My goal is to make this type of encounter extremely rare. And in the hospital where I work in- it is rare.
But I acknowledge in other hospitals, it is likely not rare and far more draconian. One of the best ways I have seen for reducing the use of force in hospitals is by requiring hospitals to document every incidence and then publicizing the results in the media. Hospitals that use force commonly will be pointed out and should be severely criticized and humiliated into changing their policies.
So…Richard…I understand your desire to support an all or nothing abolition of force mindframe. I do support the abolition of mandated “treatment”. I don’t think we will come to agreement on the issue of how to work with violent individuals but I do want to acknowledge that we are largely in agreement on most all other issues. Thanks for your words.
Wow- I just want to say- thank you for sharing those words. Sometimes spiritual practices can unearth a lot of deep and traumatic inner work. I think this is especially the case with sitting meditation. That act of simply sitting and observing can allow the rawest and deepest unconscious terrain to open up which can be truly frightening and hard to manage. I have known people who have had profound psychotic/spiritual experiences from spending prolonged periods in meditation. It can indeed dissolve gates of perception so that a lot of extra hidden information comes in.
I tend to steer people towards more gentle movement based practice (yoga/tai chi) if there is a propensity towards extreme states as that can often help mediate and ground that rippling “hurricane” energy that can suddenly surface.
I really loved this last paragraph of yours…so poetic…
“I donāt run anymore, I stumble. But I stumble because she is with me now, that broken part of myself. We are tethered together by love and fate, like two sisters in a sack race. My life is very different, but I will never leave her side again. I dropped straight into hell to get her back and I will never walk until she can walk with me. I will never begin to run until she can keep up.”
Har har!
But seriously…how hard is it to understand that psych drugs won’t cure homelessness, poverty and the stress and perils of modernity? How bout we spend our hard earned tax dollars on “housing first” and respite centers that serve nutritious meals with staff that can provide support and care?
Even if we found a magic marker for a “mental illness”, how would that ever translate into the need to take a drug that has long term health consequences and poor longitudinal outcomes?
Hey first off- Sandra- thanks for your counting work in this area.
I read the Insel piece…I think its great that there are leaders in the field who are really acknowledging some of the deep problems with psychiatry and are willing to “atone” for some of the failures. My only problem is that Insel seems to really believe in the “magic bullet” method of helping people win distress. By that I mean that he really wants to direct NIMH into deeper reductionist pathways to find “markers” and underlying genetic etiology for illness patterns…and therefore create a scientific way of matching treatment with illness patterns.
This seems remarkably short sighted and diving further into the rabbit hole of trying to develop a more “scientific” diagnostic framework. For someone who wants to atone for the failures of psychiatric “paternalism” and hubris, this seems like continuing down the same road of trying to reduce and medicalize complex psychological states.
Anyways- thank you for continuing to share your journey.
Sometimes you gotta cook…and sometimes you gotta chill…
Whoops meant to say ashtanga, not Ayengar in that first sentence.
Yes there is a lot of controversy Chris. When yoga first came to the West, there were only a few main teachers and styles (Iyengar, Desikachar’s viniyoga, Ayengar). As yoga has become incredibly popular, many different styles have bloomed, and many have become focused on the physical portion of yoga and eschewing the Hindu yogic philosophy. Power yoga and Bikhram come to mind. Most Americans don’t want to study Sanskrit, mantra, deeper levels of pranayama (breathwork), vegetarian diet, and are simply looking for a good workout and stretch.
I honestly don’t think there’s anything too wrong with that though there are issues of yoga being commodified, watered down, and removed from its spiritual roots. At the same time, the practice itself can be very rejuvenating for anyone, without a need for delving into intricacies. I think we can get caught up in who is doing a “truer” form of yoga.
Credentialization is also an issue. Some folks call themselves a yoga teacher after a few weekend trainings. Others gain a certificate after long study that doesn’t just examine the physical (Hathaway) part of yoga but delve into the deeper wisdom of yoga. My one friend who became a teacher was required to read the Bhagavad Gita.
I do think it is important to have a strong understanding of the ethics of teaching/practicing yoga( yamas and niyamas), Patanjali’s eight fold path, basic yoga philosophy, as well as a strong understanding of body mechanics, the asanas, etc.
Yes indeed there is hope and indeed there are many people here who can attest to recovering without meds after polypharmacy treatment. Great to hear that you were able to successfully wean off.
I have worked with a number of people who are deeply challenged when tapering and feel understandably extremely angry at being trapped by having to take meds to avoid relapse into worsening mental health due to iatrogenic nervous system disregulation.
It would be so much easier to not go down that road at all if at all possible, especially in light of this meta study which repeats the idea that long term recovery and prognosis is likely worse on meds than off.
Yes Stephen. Agreed that it is the elephant in the room. Ground zero for this is the hospital setting where “first break” folks invariably go. They then will almost always be prescribed neuroleptics, often at high doses and often multiple drugs.
That is where this has to change and where true “evidenced based practice” needs to occur. And that means full information that includes the meta study Whitaker referenced.
Until then, a whole new generation of young folks will be ushered down the same path that can be very challenging to walk away from.
I recently helped somebody get out of a court commitment. They were going through an extreme state and were then prescribed a combination of high dose haldol cogent in. Klonopin and Prozac. This was a young underweight person who then had horrible reactions and felt a million times worse. There was no discussion. No communication with family members and no listening to the needs of the patient.
We were able to get this person out quickly enough and the person stopped all meds and quickly recovered.
We need a sea change in our approach to crisis states.
Bob thank you so much for your work. Though many in the field have argued against your views, it will be much much harder to ignore this study. I am also very interested to see how Torrey, Jaffe and Lieberman respond to this.
On a deeper note, in my work as a private practice therapist with young people going through a “first break”, I often work with people who are choosing not to take medications. I support that decision in large part because of the longitudinal studies that show worse prognosis. But I am often very much alone in my field and I really hope that this view becomes mainstream soon.
It is much much harder when I work with people who have started down the road of long term neuroleptic usage. If they are looking at trying to reduce or come off meds, it can become much more challenging, especially if there is large dose polypharmacy- as you well know.
My hope is that this information is disseminated to anyone who is going through a “first break” so that they can have adequate informed consent before deciding to embark on taking neuroleptics long term.
David thanks of your piece. I think it is pivotal that we have more and more conversations between different groups, including with people with whom we very much disagree. I think of Bob Whitaker speaking at NAMI or Will Hall speaking to the APA. These are pivotal moments where we are witnessing a sea change. Whether you want to call it reform or attrition, dialogues like these are the first steps in changing the entire system as we know it. Perhaps some would like to have abolition in one fell swoop but even many abolitionists support an attrition model.
Thank you David for all the hard work you have been doing all these years.
In my mind this is huge news and is validating Open Dialogue and the work of Whitaker and others in raising these questions. This seems like the final blow for the “high dose polypharmacy neuroleptic/throw away the key you have a permanent disease” model of care. I want to see this translated into on the ground care as soon as possible.
Just recently I worked with a client who had been committed and had to strenuously advocate for her meds to be dropped significantly…and they did do that- down to a very low dose- but that took a lot of effort and willingness to fight and stand up to the doctors at that hospital. Most people don’t have advocates doing that for them and it should be required practice to not prescribe high poly pharmacy doses anymore.
I’m very happy this article is strongly highlighted in the NYT.
I wrote a comment on Ronald Pies thread that somehow came out as being from Kermit-perhaps because it car right after Kermit’s link. Here is my comment referencing your article…
“For those of you who want a shorthand reading of that article…Whitaker outlines the numerous places the APA has promoted the “chemical imbalance theory.”
Here are some quotes:
“However, letās now continue with the laying down of cards. The āLetās Talk About Factsā brochures that the APA published in 2005 were part of an ongoing pr campaign titled “Healthy Minds, Healthy Lives,” and that same year the APA also published a brochure for the public titled, Letās Talk Facts About Depression. This brochure, in a section titled “How is Depression Treated,” informed the public that: āAntidepressants may be prescribed to correct imbalances in the levels of chemicals in the brain.ā
There is more. That same year, 2005, the APA put out a press release celebrating the fact that, based on a survey it had conducted, ā75 percent of consumers believe that mental illnesses are usually caused by a chemical imbalance in the brain.ā The survey results, said APA President Steven Sharfstein, was evidence of āgood news for [public] understanding of mental health.ā Indeed, the APA stated in its press release that a psychiatrist was āa specialist specifically trained to diagnose and treat chemical imbalances.ā
There is more in there but it really belies what you are saying here Dr. Pies- that the APA had a cursory “crush” on the chemical imbalance theory. In the last few decades the APA has helped promulgate this theory until it has become common parlance amongst the lay public.
Though you may suggest that psychiatrists more strongly believe in a biopsychosocial model, the proof is in the pudding. 20 percent of Americans are now on some form of psychiatric drug. Ten percent of Americans take an antidepressant. That is an enormous rise in the last few decades. Though there may be a discussion of environmental social factors, the answer is generally the same- take medication. And often the reasoning has been that a person has a “chemical imbalance”.
I’m afraid your article does not properly express the intertwining relationship psychiatry has had with the chemical imbalance theory.”
And then this is his response. It is baffling and nonsensical as he seems to somehow try to pretend that the APA didn’t say what they said…
“One additional point that critics tend to confuse: The statement in one APA publication–“Antidepressants may be prescribed to correct imbalances in the levels of chemicals in the brain.ā –does not entail an endorsement of the claim, “Depression is caused by a chemical imbalance.” There are many drugs that are prescribed because they address some component of a pathophysiological process that may or may not be–by itself–the “cause” of the illness or disease. For example, if we say, “Statin drugs may be prescribed in order to correct an imbalance between “good” and “bad” cholesterol”–we are not necessarily claiming that the patient’s lipid disorder is caused by this imbalance. The “cause” may lie in a combination of the person’s genetic make-up; fatty diet, excess synthesis of low-density lipoproteins, etc. Thus, I stand by my point: The APA did not endorse the claim that depression is “caused by” a chemical imbalance, or, indeed, that any mental illness is so caused. And of course, most knowledgeable psychiatrists never did either! Q.E.D.
Ronald Pies MD
– See more at: http://www.psychiatrictimes.com/blogs/couch-crisis/serotonin-how-psychiatry-got-over-its-high-school-crush?GUID=1333E4FC-A3C0-42D9-9672-036BAE50FEB9&rememberme=1&ts=19092015#sthash.c1osfOf4.dpuf
One of the concerns I have with just using a probiotic supplement is that they tend to carry only a few different strains of beneficial bacteria but there are upwards of a thousand different types of bacteria. When we are adding just a few strains as a supplement we ignore hundreds of others.
As an herbalist I support using fermented foods and bitter herbs that generally promote good intestinal flora without specifically focusing on similar probiotic strains. It’s also important to note what Madmom said…which is that psychiatric drugs impact gut health adversely, (as well as antibiotics) so we engender worse intestinal and mental health with prolonged chronic use.
The use of fermented foods and bitter herbs (chicory, dandelion, burdock, angelica, dock) are time honored ways of improving digestive health which in turn improves emotional wellbeing.
Interesting thoughts. With marijuana there has been increasing research as to its efficacy for a lot of complaints…mainly done abroad in places like Israel. And Sandra you’re right that there are many active ingredients and potencies that make it more complex to offer as medicine.
But really up until the 1950s and the psychiatric revolution we were primarily using plants as medicine. Part of the magic of plant medicine is that there are a variety of constituents that often work synergistically and in ways that are hard to reduce to single constituent effects.
In many ways we wildly changed course when we decided to use single chemicals as ways of chronically managing complex emotional states. It is like eating only one food for years when we are hungry.
Herbs are not so easily reduced to randomized control studies as their constituents are variable and the method of administration and dosage affect the outcome. But certainly some have already been shown to be effective…such as St. Johns Wort for mild to moderate depression. Offering an herb such as this instead of embarking on a risky course of antidepressants is already a common practice in places like Germany.
Outside of acute situations, my hope is that we begin to review traditional and indigenous ways of approaching “mental illness” that seemed to have served us far better than the modern drug model, and often involved the use of plants with their complex and varied constituents.
Hey yes Monica…the strains that I have seen be very effective for certain people have been high CBD varietals…either smoked or used a edibles. However even high CHD strains have affected many of my clients poorly. Even though high cannabidiol varietals seems to be much more effective for calming pain, for insomnia, severe restlessness and extreme states, I am continuing to see many folks with already taxed nervous systems react poorly to these strains.
As an herbalist I think of marijuana as one very strong tool amongst many tools. Some people do well with it but others do better with milder anxiolytic herbs as well as a variety of tonic and adaptogenic herbs. And as you know so well, I have found diet to be paramount in assisting people to recover.
I think when exploring helping people through extreme states we should be looking at a whole panoply of plant medicines…and that should very much include marijuana as one option. Several people I work with use pot as their primary tool for reducing the potential for mania. That should be legal and easily accessible for anyone.
This is an important discussion and as therapist and herbalist who often works with people in extreme states marijuana has had a mixed record. I have seen pot increase susceptibility to severe distress and for a smaller group pot has been an effective tool for decreasing anxiety, reducing manic symptoms and extreme states.
Though dosage and the specific strains play a key role, one of the main factors in the decision to use pot has been personal neuro chemistry. Most of my clients are extremely sensitive due to their constitution and due to iatrogenic damage from psych drugs. Pot only increases their sensitivity, anxiety and potential to dissociate and experience confusion. I would say this is for about 80 percent of the people I work with. For a smaller percentage pot is a life saver and extremely useful.
Great piece Jeremy. My father is an anthropologist who was colleagues with Arthur Kleinman in the 70’s. He did his field work in NorthEast Thailand and amongst many things, he wrote about their approach to working with grief, sorrow and extreme forms of distress. One woman had lost her son and spent many years deeply sad. Her process of healing involved talking to the village monks and deepening her Buddhist practice. Healing took place in a culturally specific way without western therapy or meds.
I am reminded of a recent Guardian article that talked about how western therapists were parachuted into Rwanda to help…only to find out that Rwandans were horrified by the idea of sitting in a “dingy room” rehashing the horrible atrocities that occurred and much preferred the idea of drumming and being out in the sun wth community to help heal those wounds.
I think of this a lot when I hear the term “evidence based medicine” and I wonder if a Quichua Indian who has lost his home and been displaced by an oil company really needs antidepressants and cognitive behavioral therapy for his “major depression.” Bu imposing our western models of mental health on other cultures we reenact the same imperialism and “cultural cleansing” that has taken place for hundreds of years. Perhaps it’s time to honor culture bound notions of emotional illness and wellbeing without imposing our value system.
Thanks so much for this piece Joanna. I have helped a number of people who have chosen to get off lithium after an initial diagnosis of bipolar. And I entirely agree that the long term health implications far outweigh the potential for reducing “episodes.”
I think we need to move towards examining how to help people work through manic states without reliance on any long term pharmacological agent. There can definitely be place for the short term use of psych drugs- especially benzos- in the case of strong episodes of mania/psychosis.
At the same time, there is a strong move by alternative mental health practitioners to examine non-pharmacological tools – including managing environment, diet, herbal medicine, acupuncture, etc that I have seen in my practice as effective in helping people- even in strong heightened complex manic states.
Most all of the relapses I have seen into mania have been due to people stopping meds- usually due to their horrendous side effects. I believe that the mania that occurs afterwards is almost always iatrogenic in nature- due to the withdrawal.
We would not look at a heroin addict who is withdrawing and experiencing horrendous hallucinations, severe anxiety, panic and insomnia as having a mental illness. Why do we call someone experiencing withdrawal off of lithium “mental illness?”
yes…stigma comes because the modern DSM psychiatric language implies permanence, disease and the need for medical drug based intervention.
Consider it this way. your child is bright, quick, interests in many things, sometimes can’t focus and is deeply curious….or your child has ADHD.
From perjorative language, stigma springs.
I think this again is an issue of language and terminology. Language using labels like ADHD and bipolar, even if there is a basis in biological temperament, is inherently stigmatizing and I plies a medical condition needing medical treatment…namely meds.
While in traditional societies, the language of temperaments and constitutions was not perjorative.
For example, In Indian medicine, someone born with a Vata temperament might be excitable and restless and prone to anxiety, but also sharp minded, clever and bright. Diet and lifestyle is geared to making sure this type does not fall into imbalance.
Traditional medicine cross culturally takes into account these temperamental differences, and also acknowledges the potential for falling out of balance and distress. But traditional systems of healing from throughout the world emphasize nourishment, not drug intervention.
The language of modern DSM labels implies disease, permanence and drug intervention. DSM language is about 70 years old. The language of traditional medicines are thousands of years old.
We have been led astray.
Interestingly, the Meyers-Briggs system (ENTJ here) came from Jung, who borrowed from the ancient Greek system of constitutional assessment and healing (choleric, sanguine, phlegmatic, melancholic). Like you said, The Meyers Briggs system points out sensitivities but also points our strengths and capabilities.
At core the whole battle is over language. The language of health and distress created by our ancestors has been marginalized in place of a language that is reductionist and based in pathology instead of potential strengths.
The main issue I have with labeling is that by and large the terms are social constructs that are simply ways for insurance companies to reimburse providers and for drug companies to niche market drugs. Psychiatry and Big Pharma learned the strong advantages of labeling long ago.
And yes there are realms where labeling can be important. You start out with autism…which is a permanent condition…and then morph to anxiety disorders and bipolar, which are far more murky. While the first one can be helpful and not necessarily tied to Big Pharma/psychiatry, the next ones are.
The language that we use is deeply important. In older times, traditional societies might point to constitutional differences- choleric or sanguine in Greek medicine, pitta, vata, kapha in Indian medicine. But these labels would point to tendencies that could be modified by diet and lifestyle. These were not disease labels, but ways of describing personality and health characteristics as ways to guide healing when someone fell out of balance.
Today we have created a panoply of labs that imply disease and permanence. While autism may fit as a permanent label, labels like ADHD, bipolar II, borderline and histrionic personality disorder often appear to be no more than shorthand for the marketing and prescribing of drugs.
Labels also tend to pigeon hole vast swaths of people into one size fits all categories, while human complexity is far greater. I have never met two people labeled with schizophrenia alike, but they tend to all be treated the same way- neuroleptics. Again, traditional systems of seeing imbalance describe a wide variety of emotional suffering but tend to imply that the condition need not be permanent and that tailored healing approaches for unique people are key.
So yes I get that some folks feel happy to have a label, as a way of externalizing experience, reducing shame, etc. But the language of labeling has morphed from traditional holistic conceptions to reductionistic, medical jargon tied to drug regimens. Deeply problematic.
Very interesting article. I’m wondering if anyone here has experience of working with people using the herb kratom to try and detox off opiates. There have been quite a lot of stories of people using this herb to help them through both methadone and heroin detox. I have worked with a few people who have found it effective. It is also addictive in its own right but appears much easier to discontinue than prescription opiates.
What’s strange is the idea that there is this distinct differentiation between Axis I (mood disorders) and axis II (personality disorders). The belief has been that axis I disorders such as depression, bipolar and schizophrenia can be “treated” while disorders such as narcissism, borderline tendencies and sociopathy are inherent, ego-syntonic and cannot be treated. So it used to be that folks with axis II disorders were not given drugs- because they can’t treat underlying personality traits.
But now pretty much everyone is given axis I diagnoses- because you can bill insurance for them. So everyone labelled with a personality disorder also has a co-occurring mood disorder (as Sandra said). That way everyone gets paid. And that means people who are “borderline” and have experienced abuse, and trauma- are not only accused of having this awful borderline personality disorder but they are also pushed to take psych drugs to manage the severe emotional distress associated with trauma.
Good news that psychiatry is ceding ground on the language of distress, even if they aren’t acknowledging the real issues (validity, reliability).
I think the real issue is less whether counselors, psychologists and others stop using psychiatric language, its when insurance companies stop giving all the money to psychiatry.
One of the worst aspects of Obamacare is the focus on increased “treatment” for the low income and impoverished “mentally ill”. Anyone who has low income insurance essentially only has access to a doctor, diagnoses and meds. High co-pays and deductibles act as a firewall to getting any other type of holistic care.
Essentially, insurance companies are approving prescribing seroquel and prozac for poverty. This is where the real battle is- changing how insurance companies operate and shifting money away from drugs and “treatment” to modalities that are far more effective at addressing societal based problems.
What is the alternative?
Well that is a very large question. But I would suggest that seeing that ECT is the *only* solution at that point is deeply myopic.
When the only solution renders a portion of those they treat with grave brain damage, one must really wonder about the “cure.”
Psychiatry has not really ever looked at “alternatives”, have they? They are pretty much stuck on drugs and electroshock.
I think it would be wonderful if they actually, truly explored alternatives. Imagine if they looked at nutrition, socio-economic factors, peer supports, acupuncture, and yes…greater access to individual counseling (which insurance companies makes impossible via co-pays and deductibles for low income earners.)
But really there aren’t too many insurance supported “alternatives” because psychiatry takes all the air out of the room. The money all goes to…meds…or ECT.
And perhaps we should ask a deeper question. If someone is deeply suicidal due to depression because “they have tried everything else”, meaning gone through taking reams of SSRIs, mood stabilizers, antipsychotics and TCAs, perhaps…perhaps…the suicidal depression is happening in large part…
due to the iatrogenic effects of the meds themselves?
Consider that possibility the next time you see some one who is considering ECT.
How can you have fully informed consent for someone who is deeply desperate and depressed? If you offered almost anything they are likely to say yes…even while telling them all the risks…because they are looking for anything at that point.
But the larger point is that while some may feel relief, this barbaric procedure leaves some with severe memory loss, cognitive decline, deepening depression, anxiety and suicidality.
Is that really a treatment that should be promoted?
Yes- I agree that a lot of folks are doing this on their own with groups of supportive peers who really understand the work… without true support from the medical establishment… and they are figuring out much safer ways to do this.
As to colleagues who understand this stuff?
Sadly very few. Tapering is a complex and very unique process and though a general caveat of going slow is helpful, each person must find their own way in terms of when to hold, when to taper, how quickly, what supportive techniques work best, etc. It really is a unique process.
Most therapists I know have very little understanding of this. Or they may have a general understanding and want to put that in the hands of a doctor- as it is “outside their purview” or “practicing medicine”, etc.
Here in Portland, there are a few good therapists, NDs and NPs who do understand this- but even with them it can be complicated.
It can easily become complex when family members don’t understand the length of time tapering can take, or feel that the iatrogenic injury is made up and couldn’t be that bad. This leads to strong family dynamics tension which causes further deepening issues.
Tapering and iatrogenic injury don’t just affect the individual- they affect the whole family and the extended network of friends and allies the person is in contact with. These are complicated problems that are easily brushed off in the medical system.
Anyways- again I thank you for this very important work Laura. I’m spreading the news in my circles…
Interesting. Has there been lawsuits by people who feel they have received poor advice from support groups? Or lawsuits against groups saying they are practicing medicine without a license?
Whats crazy is…if your doctor says you shouldn’t go off the meds…but you want to and need additionaly supports…where can you go? The only main places for this type of work has been online support groups of people who actually have gone through this process. (And a few good NPs, Docs and NDs).
And yes I get that there could be erroneous or conflicting advice which indeed makes it a bit like the Wild West- but this is because the medical community has not acknowleged the dangers and suffering in discontinuation- or created effective protocols for people who are tapering.
Wow- amazing! Thank you so much for the hard work in putting this together.
Sometimes when I am wearing my herbalist hat, I am blown away by how the FDA and the media tries to scare the jeewilikers out of anyone taking an herb but ignore information that shows obvious deleterious health effects.
Kava- the Polynesian herb used for hundreds of years with rare damaging side effects- “Dangerous! Ban it! Herbs are scary. Who knows what could happen?”
Recently invented pharmaceutical that ends up causing grave harm to many….”Well its for the greater good”, or “Oops sorry…but have you tried our new product?”
In my private practice I work with a number of people who have been labeled as having a “first break” and who have been trying anything to avoid labels and neuroleptics. As you well know psychosis is complicated with many different etiologies and trying to create sanctuary for folks going through unusual experiences can be very challenging. It feels increasingly important that these individuals be given a chance to process their experience without drugs, even if that means ongoing, or recurring “episodes.” And the reason is very much along the lines of what Harrow and Wunderink have discovered. If you give a person a chance, there is a place for integration and recovery. Long term with the neuroleptics, the chance goes down.
You said that many folks dismiss these findings because they use the argument that these people were likely not very sick to begin with. But that begs the question- how do they know who will recover and who won’t? And seeing that long term use definitely worsens prognosis, isn’t it far better to attempt non-drug interventions?
I think the big challenge is creating that support and sanctuary for those experiencing psychosis- and it is far easier to sedate a person than to support them through that process. Creating the template for support is far more expensive and complex. But if we viewed an episode like drug rehab, then there would be centers where people could go, often for a month or more, paid for by insurance, that would support reintegration without drug intervention.
Yes I think it can be deeply challenging for people to avoid medications for psychological distress in this society. Insurance willingly pays for it. Doctors recommend it and it promises an easy solution. Therapy tends to have large copays and deductibles that act as a firewall for most low and moderate income people.
But underlying that, there is a general desire to simply feel better, or at least- not be tortured by the…depression, anxiety, panic, mean voices, fill in the blank. In some ways psych drugs fill that role- they sedate and stimulate in a measurable way and change biochemistry. Instead of wading through the miasma of complex narratives, previous trauma and current stressors, psych drugs promise immediate (or very quick) relief of pain. Evidence based too!
I sometimes think therapists who tend to critically appraise psychiatry underestimate this desire to simply “feel better”, to feel more pleasure and relaxation, to reduce the horrible symptoms please.
If one thinks in simple forms of pleasure and pain, people see psych drugs as increasing pleasure and reducing pain. However, over time, it is often clear that they often cause more pain- in the form of deteriorating health, reduced cognitive function, metabolic issues, apathy, and lowered libido. Essentially, like most drugs- the beginning is great and down the road can often be bad.
As a therapist and an herbalist, I am often struck by people’s desires to…simply feel better…to feel physically, somatically, cellularly better. Folks in distress truly do feel ill…mentally, emotionally and physically. We would do well to honor that physical feeling of illness and address it. Yes there is importance in honoring pain, exploring the root of issues, developing insight- but there is also importance in alleviating suffering- offering tools and techniques to reduce the pain, to offer alternatives to medications which promise immediate pain relief, immediate tranquility.
Very interesting Emma and thank you so much for your research and words. I work with many young people in private practice who are deemed “psychotic” who I think are deeply sensitive souls, often having experienced trauma. I think of “psychosis” as a form of emergence and a deep process of unfoldment. At times people go through experiences that are so overwhelming that they need a safe place, a sanctuary- to work through these complex states. It sounds like Spiritist hospitals an example of this type of sanctuary.
I also work in a psychiatric hospital setting very part time as a therapist and we use a variety of “unusual” tools such as drumming, aromatherapy, chanting, singing, dancing and movement in different group settings. What you wrote about spiritist hospitals sounds deeply healing and hopefully we can truly create sanctuaries such as you describe.
I think its key to bring up the issue of money and its generally what I think of as the achilles heal of psychiatry. Hospitals are shuttering hospital beds at an astounding rate for just the reason you have outlined. They can make far more money doing medical procedures than for managing complex emotional problems through psychiatric consultations and temporary housing, aka psych units.
In Portland this last week, all the main hospitals went on “divert” because they were overloaded with people coming to the hospital for a mental health crisis and looking for a bed. For those that don’t know, going on divert means having so many patients in the ER that there is not enough room for them and they have to be diverted to other hospitals if possible. For many mental health patients, this also means “boarding”, staying for days in a small room waiting for a bed.
Going on “divert” is extraordinarily expensive for hospitals and they try to avoid it like the plague. Even though my hospital was losing quite a bit of money in their psychiatric units, they chose to keep them open because it was still more cost effective than often going on divert.
This has led Portland to creating a new hospital that will be devoted to psych admissions (sometime in late 2016.) The new Unity hospital will replace most all the hospital beds in the city. In many ways it is likely that they will try to turnstile patients out the door as quickly as possible because it is simply too expensive to manage emotional crisis using a medical model.
I think this is the number one argument to make with people who don’t care about mental health, issues with medications, coercion, etc. Creating non-medical alternatives is….cheaper.
The problem is that there once one has gone down the road of taking meds for long periods of time, there is no way to avoid working with the medical model- meaning someone who has gone off their meds, or is experiencing instability with their psych drugs, has to see a doctor in order to adjust them, or restart them and taper down if possible. Essentially, those in crisis are forced to use the excessively expensive medical model of crisis because of their need for medication assistance. Its a snake eating its tail.
Thanks for your article Peter and Anne, and the links to other critiques and comments, some of which I had not read and were fascinating. Really this feels like a watershed moment where psychologists and therapists, at least in Europe, are finally saying no more. No more to reductionist ways of perceiving psychosis that elicit labels and prescriptions far too readily. This is a very positive statement that posits that we must perceive extreme states as complex and highly individuated narratives that are often rooted in trauma.
My quibble is this, and it looks like it has already been somewhat addressed. I come from the perspective as a therapist but I see this statement as having the implicit suggestion that many of these folks would be far better served working with a therapist, and esepcially one steeped in CBT.
I see you address this by saying that in fact many people would be helped by a wide variety of support…friends, family and community. But the suggestion is still there to visit a therapist…”later.”
In the wider world, many people experiencing profound distress go to traditional healers, herbalists, spiritual ministers, etc. The thought of sitting down in an office for 50 minutes to talk about problems, esepcially by a practitioner using a particular “evidence based” treatment style, does not fit global pan-cultural needs. I think its key to note that there have been an enormous number of ways of approaching “psychosis” that do not fit into the mold of therapy or psychiatry.
I applaud this statement heartily for expanding our understanding of extreme states as quite common and certainly not requiring medicalization and patholigization…but I worry that it is not expansive enough to be open to the complex unique worldviews and systems of healing found throughout the world.
In any event, thanks so much for your hard work. I am very interested to see how the ongoing debate unfolds.
Hey Lovelife, that is indeed an awful and sadly all too common story. A seemingly innocuous prescription of an antidepressant turns into a merry go round of SSRIs, mood stabilzers, benzos and antipsychotics with a bevy of ever increasingly severe psychiatric labels. It is wonderful that your family is on board with creating a safe space to taper off the mood stabilizers. As a therapist I am often confronted by people who want to taper off but their family is not on board and that makes it far more challenging. The only suggestion I would have is to go slow. Some docs want to taper folks off far too quickly and there is much evidence that a slow taper is the best bet. I also would suggest trying to optimize your diet with lots of whole foods and reduce stimulants such as caffeine and sugar as they can make the taper much harder. Even though you are tapering off mood stabilizers, http://www.survivingantidepressants.org is a good resource and support forum for tapering. Good thoughts sent your way…
The new focus on orthorexia has been fascinating to me. I get that deeply unhealthy eating patterns, whether it’s junk or “health” food can cause severe mental and emotional concerns.
At the same time, I am surprised there is a desire to label people who eat “too healthy” as having a mental disorder. Should we label a diabetic who continues to eat junk food with a disorder? Should we label people who eat a lot of fast food with a disorder?
Where does it stop? And is it simply a convenient way to market yet another drug for yet another “mental illness”?
Like you said in the article, we’ve already done this in the 60s…uppers for weight control, downers for anxiety, often caused by the “pep pills.”
How does a Big Pharma 11week study equate to “science” and evidence based practice?
I have just been working with someone and helping her as she tapered off of vyvanse for binge eating. She had taken part in one of these studies to determine its “effectiveness”. It certainly helped curb her appetite and to lose weight. I asked her what she was eating and she said she snacked here and there. She described feeling very anxious a lot of the time and had difficulty in sleeping.
When I explained that vyvanse is essentially a form of amphetamine and that it is likely to have long term repercussions as well as these side effects she tapered off.
I’m wondering why I had to be the one to tell her. I guess I should no longer be shocked that doctors are now willing to prescribe speed for weight loss and appetite control.
I think it’s interesting to note that there is a new disorder that some are bandying about called orthorexia…essentially focusing on eating “healthy food” to the point of malnutrition. Perhaps they will have a drug for this too?
I recently worked with someone who i helped get off vyvanse for binge eating. She said it was making her feel way too wired and anxious but she said she had lost a lot of weight and it curbed her appetite (big surprise). I gently explained that it was essentially a form of speed and she was quite surprised. Once she stopped it she gained aslo the weight back…which I suppose is one of the big disincentives to ever stop it. She says she feels way better, way more grounded now.
How is this possibly legal? I’m surprised they don’t prescribe it for obesity…or would it be…extra overly large syndrome? No need to diet and exercise…just take this scientifically proven pill…
The whole idea that an amphetamine…sorry… adderall….is effective and benign medicine for people who suffer from ADHD but is a dangerous illicit drug for everyone else is just a fanciful mythology.
Speed makes *anyone* concentrate harder, work more efficiently, get things done, stay more clear and focused….in the beginning.
Excederin take the time to really read the testimonials. Go through them one by one- especially the long term users. There are some positive ones- but by far you will see a list of woes…a litany of misery and heartbreak.
Frankly I don’t care if they find a biological marker, gene codes and brain imaging scans that absolutely tells you you have “ADHD.” That just doesn’t translate into- and therefore you should take amphetamines the rest of your life. Craziness.
Look at the types of things Steve recommends. There are plenty of ways of helping kids that does not involve drugging them with speed. They don’t get to say…no thanks.
Well if you look at the testimonials…it seems like a large share of people have experienced very poor effects. I would suggest looking at the long term users of both ritalin and adderall (similar testimonials). At that point…”if the price is too great”, they can’t just “stop.” These testimonials describe the harrowing suffering inherent in withdrawing and then the severe post-withdrawal issues.
If you don’t like corrective lenses, you can, indeed, just stop. For those who have been taking them a long time…”just stopping” sounds ludicrous.
Here’s someone who rated adder all a 5 out of 5…
“This is a life long decision with a high potential for negative outcomes. I think you should allow yourself or your children to be the way they are, and find social, mental, physical outlets and ways to be accomplished and successful without the drug. Also research what it does to your dopamine stores in your brain. Coming off of it after years of use can lead to a pretty lack luster view of life. That being said… time for another dose. Sigh.”
Another “positive” testimonial…
“I’ve become reckless. And it’s addictive as all get out. There are many days I find myself taking twice my dose. If I run out early, I count down the days to my refill, finding myself incapacitated otherwise. But – I’m a junior at a prestigious college and I have straight As. My teachers rave about my work ethic and my dedication. It’s boosted my sex drive significantly, as has my confidence. I juggle a full school schedule with several internships, side projects, a boyfriend, etc. My focus is often streamlined and my the work produced is high caliber. Ultimately – it’s a double sided sword. Has it helped me? Enormously. Am I a different person than when I started taking it? Unquestionably, almost unrecognizably transformed. So seriously weight the consequences before you start. Because no matter how strong you think you are, the drug will suck you in. Some days, it’s beyond worth it. Some days i’m in hell.”
Please don’t preach pollyanna…or ease in stopping. These people will tell you your wrong.
No problem Steve.
This has been my “go-to site” for anyone interested in starting a course of psych drugs (of any kind). There are plenty of pro-drug reports so it is not one sided. But the reports of adverse effects are common and overwhelmingly tragic.
It is important for people to know they are rolling the dice when they start psych drugs. This site is about as clear as day on those risks.
To me, stimulants like adderall/ritalin, are a lot like their counterpart benzodiazapenes such as valium/xanax/klonopin.
At first they seem miraculous. They indeed “work” in the short term providing immense short term benefits. But like speed and downers, they start to catch up to you. They start to not work. You can’t stop them without horrendous withdrawal effects and they lead to complicated emotional and health problems down the road.
Like downers and speed, both benzos and stimulants are sold illegally on the street for a reason- they get you high. But for some reason we’ve created an entire field of medicine that supports them as being effective and evidence based.
“Are they manifesting the indications theyāve been drugged in the traditional sense?”
Yes. Please see testimonials…
A diagnosis of ADHD almost always leads to a prescription of stimulants…
More testimonial fro askapatient.com….http://www.askapatient.com/viewrating.asp?drug=11522&name=ADDERALL+10
“Insomnia, flushing of face, anxiety, sweaty at random times, back pain, teeth grinding, depression, Loss of social interaction I only took this drug because I felt pressured from how my grades were and my parents when I was a freshman in high-school, my grades went from d/f’s to B’s and A’s feeling like I was on-top of the world(especially after the first couple of months).. now a senior I feel like I’m really depended on it, this drug has messed my life up in every way possible. Yes I got those grades, but is it really worth it to now have anxiety, depression, dependents on adderal, secluding myself from society?… ”
“Adderall seemed to work for me at first. But it’s facade quickly faded to reveal a chain-smoking, binge drinker. I became socially withdrawn, lost my job, & lost my passion for life. Adderall has caused me to lose the best years of my life. I hate this drug with my whole heart. Never ever take adder all.”
“weight loss, lack of appetite, rapid heart-rate, failing vision, bruxism and resulting tooth fracture, gum recession, personality changes, seasonal depression, anti-social behavior, bipolar & borderline personality disorder tendencies, hair loss, decreased libido, insomnia, poor short term memory, headache, hyper-focusing on unnecessary tasks, dry mouth, increased thirst, rapid decline in BMR (basil metabolic rate), cold hands and feet, abnormally low body temperature, overall detachment from the natural ‘cadence’ or rhythm of life.”
Why are we giving these drugs to our children?
Hmmmm. its key to examine testimonials of people who have been taking stimulants- especially for prolonged periods of time….
Lots and lots and lots of adverse reactions. Even the people who rated the drugs high (4 and 5) describe lots of adverse reactions.
http://www.askapatient.com/viewrating.asp?drug=11522&name=ADDERALL+10
Take a close look at what many kids are going through when taking speed…Here’s a few testimonials of people who have been taking adder all for a long time…
“Very OCD, depression, loss of sex drive, impulsiveness, any symptom you can think of I had while taking this medicine. I have serious heart problems, social anxiety, rice developed an eating disorder, lost every friend I’ve ever had from isolating. I don’t feel like a human being anymore, nor do I remember how to live a normal life. I permanently feel bugs crawling on me and have destroyed my skin from the length if time on this drug. I am a pretty girl but adderall has ruined my appearance more then you can imagine. It’s great at first, your on top of the world but it doesn’t last and it is NOT worth what I’ve been though with health problems the past year linked directly to adderall. ”
“I can tell through years of taking it that my brain goes fuzzy when I don’t. Even now when I’m on it I seem to have trouble with my memory. When I mix it with alcohol (horrific mix) I only need a drink or two before I blackout. I fear telling people when I do because I don’t want to know what I said or did. Lately, I have been having bad insomnia. I’ve taken this for years and didn’t have this problem until recently. I’m trying to get my life together, doing things I don’t want to do, which this pill is good for, but I’m starting to think the physical side effects and long term damage aren’t worth it. So then what? Fuck off my life until I give in and start taking it again? I’ve seen this medication do wonders, I’ve seen it wreck lives. I don’t really know where I fall in this spectrum, but I know this stuff is nasty… super bad for me, but I depend on it now. I truly wish I had never taken this stuff. Parents or people considering taking this drug, seriously reconsider….”
“It’s tricky, because Adderall has done some wonders for me, but not without it’s heavy price. Most significantly: I am much, much more antisocial when I take Adderall. I used to be a hard partier, going out four nights a week. Now I go out once a month. I’ve lost touch with many friends. I get irritable or uncomfortable around people. I get very paranoid. I have a hellish sleep schedule. I was always lean, but I’ve lost about 20 lbs. I have to force myself to eat.”
Randy I don’t know if I would classify you as Pro-medication…but how about “pro-selective use without bias from pharmaceutical companies and a hell of a lot less than what we have been doing medication? “. That might not fit on a bumper sticker though.
I think there a re a number of people who are fine with a model of using psych drugs much more cautiously as long as people are informed of their long term complications and are not given false information such as Meds are necessary for “mental illness” just as insulin is necessary for diabetes.
There are people who take meds intermittently, or only during a crisis, or at a low dose.
I think the main ire I have is against the excessive over prescription of the drugs, the corruption in the industry, massive unnecessary polypharmacy, irresponsible use of drugs for youth and the elderly, and on and on. But I am not against the idea of using psych drugs so I would agree with you. I don’t think I would characterize that as “pro-meds” though. :).
Very interesting article Randy and thanks for the info. The dollar amount used to “influence” doctors is mindboggling.
I though this piece of your article was also interesting…
“Nevertheless, the end of patent means fewer free samples, fewer visits from pharmaceutical reps, fewer paid lunches, fewer āopinion leadersā making the rounds showing the companiesā own slides, fewer conference symposia lavishly funded by patent owners, and less general noise distorting the environment. Medical decision-making is likely to be based at least somewhat more on science than on enthusiasm and hoopla.”
I guess my question would be…what science? The biased big Pharma studies fill many of the medical journals and alternative interpretations of the effectiveness (or non-effectiveness) of antidepressants is likely to be downplayed even after the “patent cliff.”
I would like to think that the medical profession would reexamine the merits of these drugs using more unbiased non-industry studies and “science’ but I fear I have become fairly cynical.
Timothy, I think this really comes down to the interpretation of these studies (and several others). Sadly, I think most of the psychiatric profession dismisses these longitudinal studies in the same way you do.
Essentially, these studies wedded with personal experiences of long term suffering by survivors due to iatrogenic illness from meds form the key component of this national debate over the merits of psychiatry.
Dismissing them out of hand simply doesn’t jibe with the experience of tens of thousands who have been damaged by medications.
Though I agree we should augment the discussion by discussing other issues (social injustice, poverty, etc), I don’t personally want to see it watered down too much. The key issues of medications affects too many people to be dismissed so easily.
Really interesting piece Timothy – thanks for the in depth analysis.
I also think there are intersecting issues that have led to rising disability rates. You mentioned socio-economic issues such as poverty, racial injustice as well as issues such as the tacit “built in disincentives to exploring and pursuing meaningful work for people on disability.
I would add one more factor to this kaleidocope of reasons for increasing disability levels and that is the profound change in the global food system since the advent of the Green Revolution in the 60’s. I believe that the vast increase in the consumption of the processed form of just a few crops (wheat, soy, corn) and the subsequent massive rise in rates of obesity, metabolic disorders, diabetes and “mental illnesses” also contribute to the great rise in disability rates.
At the same time, I think the issue of medications is a key part of this discussion. Whitaker has pointed to studies done by the WHO as well as longitudinal studies by Harrow et al and studies done by Wunderink et al that all show worsening prognosis and disability for chronic use of neuroleptics.
Though these studies may not show that neuroleptics are the definitive reason for rising disability rates, they definitely are implicated as a strong part of the equation.
I would agree with you however that there are certainly other factors that play into this complex issue.
Thanks for your detailed thoughts.
First off I just want to say thanks Scott for looking at alternatives for helping people that do not immediately involve psychiatry. That is a much needed and welcome step and your program sounds innovative.
However, I echo the concerns for creating alternatives that are cheap, accessible, “low-tech” and that also allow for people that have “safety issues.” I recently was talking to a woman who was describing the place she would have loved to find when she was deep in crisis and suicidal.
The place would be in nature, quiet and low stim with people cooking nourishing meals. There would be activities available such as yoga, meditation, therapy, but for some people it would simply be a place to rest, talk to peers and eat healthy food without having to think of their problems medically. But it would differ from a retreat center in that the staff would understand that people were coming because they are in crisis and are looking for support/love. Ultimately, it would be paid by state or private insurance and available as much as hospitalization is available.
I support any and all endeavors to create alternatives and I heartily support your approach Scott- we need more people not just thinking and talking- but doing and creating…Thanks for being part of that effort!
Thanks so much for your piece Dick. It reminds me more than ever the need to make sure people don’t get started on strong neuroleptics because the road becomes much more challenging if you’ve been taking them for long periods. As a therapist I have been working with several young people who were diagnosed “First break” and then given whopping doses of mood stabilizers and antipsychotics. Each one has been told that taking meds for their “illness” is just like taking insulin for diabetes.
With the help of holistic minded NPs and naturopaths, they have weaned off these neuroleptics as quickly as possible and a team of us support that process. The problem comes that some people are not on board…family members, friends, and it can create a split because it defies psychiatric “advice”.
As you write…the evidence is clear. Chronic use of drugs like Zyprexa rearrange neurochemistry to make one increasingly sensitive with a heightened potential for disability and “relapse” into psychosis.
The shamanic piece is very interesting as well as I believe we have completely discounted traditional techniques of healing that have long been a part of indigenous cultures throughout the world. There is a pressing need to explore these deeper fountains of wisdom. Thanks for your words.
Oliver’s piece was amazing and Chuck you are right…those were “non responses.”
Though Oliver addressed the corruption inherent in direct advertising (“Ask your doctor!”), scripted lectures from Pharma for “thought leader” doctors, the amazing over prescription of meds (70 percent on at least one med), he did not address the poor outcomes of many of these drugs and especially the deleterious effects of long term use of psychiatric drugs.
The movement here to address the ills of psychiatry easily bleeds into a wide critique of modern medicine in toto.
Lovely to see Oliver’s piece get so much play though.
This was a study that caught the attention of a lot of people I know who aren’t particularly interested in issues related to psychiatry…mainly because of many articles highlighting Benadryl/dementia. Perhaps it will help people to further delve into the complications of long term use of anticholinergics.
But I was not aware of that site that you link to that shows the breakdown in anticholinergic properties of most psych drugs. In the category that shows strong anticholinergics effects (scoring a 3), that is quite a list that includes most of the “1st generation” antipsychotics but also the very commonly prescribed seroquel and Zyprexa.
Sadly, I assume this won’t have a great effect on prescribing patterns, but I wonder why. Will the APA try to dismiss these findings? Simply ignore them?
Great piece Joanna. I often look to askapatient.com when I want to see a more comprehensive, longitudinal and subjective experience of drugs and their effects. I really would like anyone who wants to start a drug to go there first. It is an amazing compendium of stories and voices of lived experience.
One of the singularly frustrating things I hear in the mental health world is the term evidence based treatment. It implies that a course of psychiatric drug therapy is a scientifically effective modality. Yes there may be partial alleviation of symptoms (perhaps), but at what cost? What side effects? What long term health consequences? What long term effects to metabolic and organic functioning?
In any event- Lived experience- It trumps all RCTs in my book. Here’s seroquel…1349 ratings…
http://www.askapatient.com/viewrating.asp?drug=20639&name=SEROQUEL
And here’s Paxil…943 ratings…
http://www.askapatient.com/viewrating.asp?drug=20031&name=PAXIL
Great comments from all here and I just want to continue on with what madmom says. Imagine a campaign where the expenses for “helping” someone is tallied up. Put a monetary figure on each person in terms of hospitalizations, psych drugs, health complication medicine and surgeries, disability checks, etc…
Call these folks the million dollar man or million dollar woman. Then describe how that money could be spent…as you just did Madmom. Then simply ask…is this how you want your taxpayer money spent?
I agree- well said Corinna.
I think the assertion that there may or may not be high presynaptic dopamine production in the brain for folks labeled with schizophrenia, or going through psychosis- is not the main issue.
The main issue is the idea that antipsychotics somehow “correct” this.
Even if what they posit is correct: there are higher levels of dopamine- neuroleptics in no way “correct” this. Certainly they are dopamine agonists, but they work at such a global level as to damage organic and metabolic pathways when taken chronically.
An antipsychotic “corrects” dopamine levels as much as a shotgun kills a mosquito on a wall.
Thanks for the piece Sandra. I agree that there should be a” safe place for people to stay while they work through their crisis.” The complexity arises when we talk about the varieties of crisis.
Here in Portland, the various hospitals have found themselves increasingly squeezed and are losing large amounts of money in their acute settings. This is largely due to the fact that acute hospitalization tends to involve people who have limited or state insurance. This leads to poor reimbursement while funding the payroll for all the doctors and nurses is exorbitant.
For this reason, the largest hospitals are pooling their moneys to centralize and create one large inpatient facility in Portland with its own psychiatric ER. This is mainly a cost savings measure but points to the inherent problem with crisis mental health care. Generally, the medical system is far too expensive to “manage” crisis. Its just not a model that has made fiscal sense.
We are in desperate need of alternatives that are not only cheaper, but far more humane. One of the main problems I see is that most anyone in crisis is funneled into one monolithic system. Those who are high, drunk and acting bizarre and agitated, someone with dementia who is violent, someone who has stopped taking strong neuroleptics, people experiencing “first-break” episodes- all get funneled into this one system and tend to receive very similar care- psychiatric drugs and often a short stay of a few days before being sent out for services (generally lacking) in the community.
We need systems where we funnel a number of these folks to systems of care that do not prioritize med management. This is especially important for “first break” folks. In my perfect world there would be “asylums” designed to allow crisis to run its course without medical intervention. But my second best choice (and likely more realistic) is to promote a non-interventionist model for first-break in a hospital setting where people are not immediately started on strong doses of neuroleptics, or at least offered a choice for selective use.
In this way we may not create a group of folks who require long term med management. Once this happens, folks often cycle in and out of hospitals due to intermittent and understandable “non-compliance.” Then it becomes much harder to create non-medical alternatives for crisis. I believe we have to really start at the beginning when people first start taking strong meds and try to avoid that as much as possible. Once an individual has been taking psych drugs for a while, it is deeply challenging to offer alternatives that don’t in some way involve psychiatric intervention, even if it means to help taper someone safely as you have been talking about. And when someone is agitated and has been cycling on and off meds, soteria and respite models are not effective. We have to go the root and start from the beginning and address how this epidemic has happened. Trying to fix it midstream is deeply challenging.
Fascinating piece and one that gets to the heart of our cultural assumptions about “mental illness.” I had not seen the statistic of 90 % cross cultural belief in possession before but it rings true. Though we disregard it as an absolute relic of pre-scientific superstition I think it is key to understand that metaphysical explanations of extreme states are extremely common outside of the Western psychiatric model.
I once witnessed an orthodox Russian exorcism of a woman who was diagnosed with schizophrenia. The process of a community coming together to offer healing to someone in distress was beautiful…but also complicated. many would not only dismiss this experience, they would consider it dangerous and contrary to what she really “needs”…namely psychiatric drug treatment.
We have heard many stories of people foregoing medical treatment for spiritual healing coming under extreme scrutiny for abuse and negligence of family members. This is somewhat understandable in life and death medical matters.,.but seems grossly unfair to those going through emotional distress…as many of the Pharma drugs have severe well understood problems. Which is worse? An exorcism or a lifetime course of neuroleptics?
When I lived in Ecuador for a while I worked with some of the indigenous “shamans”, aka ayahuasceros, and they held a deeply complex syncretic animist and catholic cosmology. They often thought illness patterns developed due to black magic…brujeria. They envisioned sorcerers sending evil invisible “darts” to hurt others and the ayahuascero could remove that dart through ritual and communion with plant and animal spirits.
I also saw ayahuasceros describe remarkably prescient visions that could only be thought of as telepathic. Something deeply mysterious and incomprehensible was going on, which often mirrors the experience of those in deep crisis. I think we should deeply explore these frameworks, and should certainly honor cross cultural traditions outside of the standardized modern Western psychiatric model. Thanks for your words.
I’m not really sure you have looked at that site and those reports I mentioned at askapatient.com….heres the link again…
http://www.askapatient.com/viewrating.asp?drug=20639&name=SEROQUEL
These aren’t just a few people- there are hundreds of reports in here of serious and adverse effects. Not just a few, or even a small sampling- a significant percentage of folks report very poor reactions. What do you think about some of these reports?
How about something cheaper that gets straight to the point. AskaPatient.com. Take a look at the testimonials of people who have been taking the drugs themselves. Since this post is on seroquel, lets take a look at the 1346 ratings it has been given… http://www.askapatient.com/viewrating.asp?drug=20639&name=SEROQUEL
There are certainly a number of folks that extol its benefit- but literally hundreds and hundreds of folks that describe horrendous reactions to this drug. How many people are told that this is the type of experience that could very well happen for them…here is a sample…
“All Delusions, hallucinations, sleep, dry mouth, weight gain, overactive libido, mood swings Over confidence all side effects. I am 100 days free of this dangerous drug”
“This medication did not really help me at all with my problems and it very possibly may have completely killed my reproductive function. I am currently waiting to find out if my body will ever recover, it has caused me to gain weight, develop breasts, varying levels of sexual dysfunction, it has damaged my blood sugar levels, and I may have completely lost the ability to procreate. There are over 10,000 law suits filed against AstraZeneca for things like this and I may be another soon, I implore you to research the rare and serious side effects before taking this in my experience worthless and dangerous pill.”
“Just a bad over prescribed bad drug Went cold turkey, it cost me my life, it destroyed friendships, prescribed to shut me up, this drug is used as a catch all for any ailment, I would not recommend this for anyone, I’m working through insomnia and angst for not researching this drug, nothing will ever have me take this drug again, did not dose down did not tell my doctor, just left it along.”
“Within days of taking this drug I developed Spasmodic Torticollis. Was in severe pain and still recovering the damage of what this drug did to me.”
These are not just a small sampling. Reviews like these are extremely common there. Your thoughts?
Hey Rossa- I think Castaneda really made it tough on himself by presenting his experience as a first hand narrative. If he had just explained things as a deeply imbedded anthropologist he wouldn’t have caused himself so many problems.
But…I think there is quite a bit of value in those books- and he very much popularized the idea of examining experience from a non-ordinary, non-linear perspective. This influenced a lot of folks who have been interested in seeing our experience outside of reductionistic ways of examining life.
This can be really important for people going through extreme states because the process is often very non-ordinary/non-linear. So- not trying to trash. But I am acknowledging what many other people will say when discussing Castaneda and his works. On an academic level, he lost his good standing. But his willingness to deeply explore and describe these complex experiences deserve admiration, and certainly they have helped many people understand their own process better.
Yes- I am afraid Bipolar waking up is right. Casteneda has been dismissed as fiction, though he borrows from a lot of anthropological literature and first hand accounts. This is one of the problems when talking about this sort of thing. It can be easily dismissed. That’s too bad, because there is tremendous wisdom inherent in these ancient practices.
Hey Rossa- Yes I wrote a piece that was up on Monica’s site- Beyond Meds and can be found at my site here- http://www.hearthsidehealing.com/madness-possession-and-transformation-a-personal-narrative-of-healing/.
It talks about my personal experience going through “madness”, my experience of possession and healing. One of things I wrote fits here as well…
“When I look back at that experience now I wonder a few things. On a certain level, I could see the whole experience as imagined, a part of the process of psychosis, a grand delusion. And from a scientific and logical perspective that seems rationally true. But from a different perspective, I see how the descent into darkness and then coming through a horrific and torturous experience through the help of a healer and plant medicine is a story that is as old as time. We are walking in a world where treating madness through the use of double blind study proven antipsychotic neuroleptics is the main accepted form of treating “mental illness.”
What is challenging is how easily these conversations can drift into feeling “new Agey”, assembling indigenous cultural perspectives into a modern formulated “shamanism”- created almost entirely for white and privileged people. This is a fair critique- but I would also suggest that by dismissing these ancient traditions, we have exchanged them for a rationalistic, scientific and reductionist way of working with madness that is deeply flawed and often far more dangerous.
One of the most interesting things that have been happening lately is a very strong interest in exploring healing with Ayahuasca, a South American hallucinogen. This medicine has been used entirely in unique tribalistic contexts but numerous Westerners are exploring and finding great healing through ritual work with ayahuasca. There has been quite a bit of talk on CNN (just google) about returning veterans feeling completely zombified by psych drugs for treating their PTSD, and a number of them have traveled south to take part in ayahuasca ceremonies that they describe as being tremendously transformative.
I think we need to be careful, but open, to these wider possibilities for healing.
Hey Alex, I think by scientific rationality, I’m mainly talking about the gold standard of double blind studies. Frankly, I think the idea of something needing to be proved by a double blind study is often ridiculous. How do you use a placebo for the warmth of the sun, the kindness of a stranger, warm home cooked food, a cup of warm linden tea- all things that have obvious merit for improving wellbeing.
Shamanic techniques are fairly impossible to verify as something repeatable and verifiable s effective under the classic double blind scientific paradigm.
But I would say…bah. There is a long history of using these techniques in many settings with good anecdotal support. But there are many complexities in bringing that wisdom forth. One of the main problems is cultural imperialism, appropriating another culture’s healing forms. A second problem is that some of these forms just don’t translate to many modern people. They often involve culturally unique cosmologies, spirits, deities, etc.
But…I still think its something we should deeply explore as shamanic/spiritual techniques of working with people in deep distress is a time honored tradition and one that I have personally seen as effective.
Very interesting post Natalie.
I think we tend to get lost in our cultural assumptions about mental distress and its etiology. Most are influenced by psychiatry and the DSM and others are influenced by psychological thinking. But we tend to relegate non-western approaches to being superstitious, magical and non-scientific.
This is strange because most of the world does integrate a lot of these tools for helping people in crisis that are often effective and merit deeper examination. I think its important to separate out traditional systems of healing people such as Traditional Chinese Medicine, Ayurveda and Unani-Tibb from more tribalistic and religious practices. The former have developed countless tools for helping people in crisis such as acupuncture, qi gong, herbalism, yoga, massage and dietary advice. Though these are lumped in with “New Ageism”, they are simply traditional tools that have thousands of years of historical, anecdotal and empirical efficacy.
Shamanic, spiritual and religious tools are more complicated because they do rely on a willingness to forego scientific rationality. As you mentioned, concepts like possession, out of body experiences, shamanic healing, ritual and ceremony are common to many indigenous cultures throughout the world. Deriding these tools for being superstitious and magical is somewhat amusing when we offer an alternative (psychiatry) that has led to an epidemic of worsening mental health.
I think the challenge is that these tools don’t easily translate well into cultures based in scientific rationality and modernity. But they do hold an important place for many indigenous and religious groups throughout the world. Even if one were to consider them metaphorical, they help allow for a community to embrace and help in the healing process for someone who is in deep distress. These techniques are ways for the community to come together and offer hope and care for someone who is experiencing extreme distress. Frankly I’d like to see a whole lot more of that than a drug based approach to distress.
Interesting- I have always wondered about the thinking of psychiatrists for prescribing multiple meds in such large doses. I will give an example of someone from a while back who was receiving 800 mg of seroquel, 2 mg twice a day of xanax, and 120 mg of celexa. This is for someone diagnosed with depression- no psychosis. She says the seroquel was for sleep.
I have always wondered how doctors simply pick and choose meds- subjective preference, research, etc?…and what leads them to high dose polypharmacy. Is there literature that supports it?
Sandra interesting about effectiveness range being around 3.5 mg. I regularly see people in the community and in my practice who are prescribed at least 20 mg of haloperidol a day and a few times as much as 40 mg. The effect is very noticeable with muscle rigidity, akathisia, anhedonia, tics, etc. Horrible. I have almost never seen someone prescribed less than 5 a day, and it is often paired with other antipsychotics.
so yes, conservative dosing and much less poly pharmacy would go a long way to mitigating extra pyramidal side effects. That would be wonderful to see.
Ya Hermes,
I know that risperdal is now available generic and that was one of the first (the first?) atypical to be marketed….so that is indeed cheaper. I know that the cousin to Risperdal…the Invega shot…is pretty pricey. Add it all together…hospitalization, expensive drugs, regular med checks, etc….leads to busted mental health budgets.
Drug based “therapy” is stealing money out of the hands of community services.
ya Duane…some of these drugs are indeed very expensive…Abilify I think is the most but so is Geodon and other newer “atypicals.”. Big Pharma has made a fortune marketing these drugs as wonder meds that are far more safe and effective than older antipsychotics such as Haldol and Thorazine. But of course we are now learning about severe metabolic problems, weight gain, diabetes, heart disease, etc, associated with the newer drugs.
So some say the answer is to return to those cheaper older neuroleptics that were horrifically damaging. Like you say Duane, hopefully the sheer cost of drugging enormous swaths of population will force the hands of those who manage State Budgets to rethink this approach to mental health.
If longitudinal studies showing poor outcomes and long term health effects doesn’t change the debate, perhaps financial budgetary burdens will convince people to make significant changes to reduce drug based treatment strategies.
Excellent analysis Bob and thanks much for the in depth examination of these issues. I have long felt that the sheer expense of the medical/disease model of “mental illness” is the Achilles heel that will eventually cause it to have to radically change. The cost of not only employing high priced doctors and nurses in acute and outpatient settings, but also paying for very expensive pharmaceutical drugs, is becoming untenable in many counties and states.
You mention the cost/effectiveness of antipsychotics. There seems to be a push towards using the older “typicals” such as Haldol and Prolixin, not only because they are much cheaper than most atypicals, but because some research is saying they are just as “effective.” Of course this ignores the severe extra pyramidal side effects and potential for long term neurological disorders of the older antipsychotics. So will we trade more expensive drugs such as seroquel and zyprexa with their known metabolic side effects, for older antipsychotics that cause Parkinson like symptoms?
How about what we do what you suggest…shift monies to much more effective and cheaper ways of helping people… Community and peer supports with increased available housing?
Thanks for your words Bob.
On a deeper note, I think the key issue to resolve is why we have shifted towards 20 percent of people (in America) taking psychiatric drugs. A back of the napkin estimate would mean that 60 million folks are taking drugs for emotional distress. They are not generally getting these drugs from psychiatrists. They are mainly getting them from their GP. I don’t think many of them are interested in whether they meet a DSM-V diagnosis. They want relief from symptoms, and doctors, the AMA, the APA and pharmaceutical companies are saying that drug based therapy is an evidence based and generally safe way to manage distress.
If we want to get to the heart of the matter, the question becomes less about psychiatry and more about the role of drug based amelioration of emotional suffering in modern society. There are many culprits, and that includes us as a society that wants a quick fix to complex emotional pain. If we want to unwind this “epidemic”, we have to not only point fingers at the medical establishment and Big pharmacy, we have to choose as a society to employ healthier methods for working with our distress. We have to not only choose a slower, healthier path, we have to acknowledge the role of systemic racism, classism, poverty, food politics, industrial agriculture and quick-fix thinking at the root of our suffering.
These are complex problems not easily solved by
Thanks to Bob and Allen for debating these deeply important issues. I want to address Allen’s piece first.
I applaud Allen for directing a lot of his critique at “Big Pharma” and their advertising and marketing efforts. Yes I agree that this is absolutely important to address and reform. However, Big Pharma would not have the power to influence without the help of the APA and the DSM. Without the DSM, Big Pharma marketing would not be able to wrap itself in the cloak of scientific legitimacy. Truly the two are wedded and Big Pharma would lose much of its power to influence if the DSM was seen as lacking scientific underpinnings.
As tothe role of medication. Again I applaud Allen for recognizing that overmediction is deeply problematic. However he differs in that he would reserve medication for those that are acutely psychotic. Strangely I would agree but not for the reasons Allen may say. Sadly once a person has become habituated to antipsychotics I would guess the leading cause of psychosis is due to med changes and abrupt tapers. Because of this the humane thing to do is to suggest returning to taking psychiatric drugs as a way of curtailing florid psychosis. This does not imply that a person is essentially “mentally Ill” or needs meds for some chemical imbalance…but simply needs a safer and slower taper off very potent drugs. I would also reserve the use of drugs for short term care as we are already seeing that long term use are leading to worsening prognosis and health. I think it is key that Allen acknowledges this.
On the third point I think Allen is addressing a really important point. We have shifted from having around a half millions psychiatric hospitabeds in the 50s to having around 50000. Hospitals are generally turn mills to get people in distress back out the door. Prisons have taken up the role of long term “care” which is abysmal and torturous. Both options are awful and we need to revamp better possibilities for those in distress via humane non medical respite, housing first, community outreach, and non medical wellness programs designed to offer healthy non-drug options for helping those in distress. What I cant abide is Allens support for outpatient treatment. He must know that these drugs cause worsening prognosis and physical health. Why support their use as any form of “care”? I would hope Allen would become a leading critic in disavowing this practice understanding what he knows from longitudinal studies done by Harrow and others.
Anyways, though I disagree with you on a number of matters I appreciate you taking the time to debate and discuss these issues.
Wonderful work Sandra…and work that I wish was replicated by many psychiatrists. and I love the idea of fully monitoring weight, and also adding other concerns such as blood pressure, blood glucose levels, metabolic panels, etc. This should be standard practice for any doctor putting a patient on an antipsychotic. The tapering process is often complex, with lots of stops and starts, reinstatement, cold turkey experiments, complexities of poly pharmacy tapering, med changes, etc…very hard to track exactly, and I really applaud your efforts.
Bob this is wonderful news…and a very smart way to change the standard of practice for prescribers as well as forward the conversation about long term implications of psyhciatric drugs.
Eventually I think mainstream media, APA and those taking these meds will have to catch up to the implications of the Harrow and Wunderink studies (as well as other studies on other classes of psych drugs) and this is another way to press the issue.
Thank you to all who are taking part in this.
Thanks Emmeline…you’re welcome to expunge my comments now that they are gone…thanks…
Sounds like a great program Bonnie and Julia. Thanks for talking about this. At the farmers market I helped start, we initiated a program to give matching dollars for folks with food stamps for purchasing locally grown fruits/veggies. Examining food politics and poverty is really key to this discussion.
Oh…you asked about prisons. I think far greater attention should be placed on prisons as well as hospitals. The stat I quoted above says there are 350,000 people with mental illness in prisons and about 35,000 in hospitals. MIA needs to shine a serious spotlight on the immense crimes being committed in the penal system.
We need to create centers for people to experience psychosis without the threat of mandated treatment.
Hey Noel. Thanks for your thoughts.
I think we are all in agreement that
I think you raise some key points and I see you are in agreement with Ruchard and others when you say…
” I completely agree with everybody who has brought up the issue of breaking the law; if a person breaks the law, then they should learn to deal with the consequences. Not doing so, and creating some alternative ātreatmentā avenue because somebody is āsickā is probably the biggest impediment to getting past #1 the association of violence with āmental illnessā and #2 the learned helplessness of those who have been so misfortunate to end up in the system.”
I just want to ask how you would look at things given this example. A man is in his home going through some delusions that his parents are aliens and they need to be killed. He actively starts hitting and attacking them. Police would likely be called…but where should he go? Does he deserve to be tried in front of a court and put in prison for this episode?
How about if someone is on the street with command hallucinations telling him to break into a house and find a Bible? What should happen if they do that? Prison for breaking and entering?
My hope is that we can create centers where people can go that do not require psych drugs and the person can work through their episode without having to be criminalized for psychosis. But right now we are left with really poor options.
Many of these folks end up in hospitals because we have not created an alternative non-medical infrastructure. They come and so do people who have a history of being predatory and assaultive. At rare times I have had to protect vulnerable people in that setting from people who have a criminal background. If you call the rare instance of defending vulnerable people “abusive” I wonder how you would approach helping and defending them? I have already said cops won’t put down their guns to come in…so how do you work with those situations?
Ugh…these threads get so mixed up…here is where I was hoping that comment would land…
Whoopsā¦I should have said police are not allowed in any other Portland hospital units. I have seen them in the ED escorting a patient here.
But reallyā¦you say if I am not part of the solution, I am part of the problem.
If the solution means cops in hospitals, I donāt want to be part of the solution.
Whoops…I should have said police are not allowed in any other Portland hospital units. I have seen them in the ED escorting a patient here.
But really…you say if I am not part of the solution, I am part of the problem.
If the solution means cops in hospitals, I don’t want to be part of the solution.
Hey Richard…back for a brief mo before off to the hills to dig up some Oregon grape roots…
Per your questions…
1″What world are you living in? Police are involved ALL the time in matters of āforceā and violence in psychiatric hospitals. Donāt police frequently āescortā aggressive people (in psychological distress) into locked psych wards on a regular basis?”
No. Police are not allowed on our units because they carry guns. They are not allowed in any other portland hospital either. At my hospital, they have been asked to remove the guns and all other tazers and weapons and they laugh at the suggestion.
It’s the main reason I could never support police being allowed in a hospital setting.
2 “And when (or if) a psychiatrist or nurse is struck or assaulted by a patient on a psych ward are you telling me that you donāt believe the police are called and that person is prosecuted?”
Police are almost never called because these cases are never prosecuted. The reason is they are deemed “mentally ill” and not responsible for their crime as a legal matter. That could be a thread of its own.
AA, thanks for your comments.
Richard,
I’m still not sure you understand my position on “force”.
I am against the use of force in the form of the courts and doctors mandating treatment. By the way, this issue…not the issue of whether to use force in extremely dangerous situations…is the key sticking point in the public arena. Kendra’s law and AOT are the principle methods of using force and should be fought vociferously. We have a legion of opponents to our side on that view. NAMI, Torrey, Murphy, etc.
I am against the use of coercive force for offering people psychiatric drugs without fully informing people of their perils. Advertising, doctors lectures, misleading information, 5 minute doctor appointments are all subtle but pervasive forms of “force” that we need to oppose. Again, there are a legion of opponents to this view from the AMA, APA to Big Pharma.
But you have zeroed in on a very narrow use of the force…and magnify it to imply that I support all force. This couldn’t be farther from the truth. I am fundamentally against the “wrongful use of force”. Any survivor story here strikes me as a blatant abuse of power. I am against any blatant abuse of power.
But you take it a step farther Richard. You demand that force never be used….no matter the circumstance. Or that matters of violence be handed over to the police. I just have to fundamentally disagree.
Like AA said, police intervention has gotten a lot of people killed. I will fight you or any others who try to suggest that hospitals should now have police involvement in matters of violence.
Instead. we need humane workers in hospital settings and in the community who understand how to use deescalation skills and will do everything humanly possible to avoid force.
And yes, there are cases where people step over the line and start inflicting damage on others. That is unacceptable and force is obviously merited. By abdicating force, one would endorse the traumatization of vulnerable people. So of course there should be force in those situations. How could you argue otherwise? But it should be used extremely rare and abuse of power should be fought vociferously.
In any event, I’m busy today….gonna do some work, enjoy the family and brief windows of sun so I won’t be back to reply. But I hope you and Jonah, and all else here have a good day. Take care,
Jon
gardenlisa,
That’s a hard path to walk. And it’s esepcially hard if you don’t have a lot of support. So much of the time folks are isolated in these situations. That’s wonderful that he was able to wean off the anti-depressants and anxiety meds and that he was seeing a naturopath. Zyprexa, and all the antipsychotics can just be horrible to quit.
Sometimes the family member will take a lot of the anger/pain/confusion out on the parents and the rest of the family. Is there any way to bring someone in outside of the family to encourage him to start doing healthy things…clean, shower, eat?
You asked about recovery…at some point his neurochemistry will adjust to being completely off zyprexa and that process is really helped by nutritious food, rest, good sleep. As an herbalist and someone who works with people withdrawing off psych drugs, I second Fred’s ideas of offering good supplements too but it sounds like it’s hard to interact on this level.
Sometimes people experience prolonged discomfort, neurological disorganization and extreme states for quite a while after withdrawal. Recovery can look uneven. Having family members and friends around who are supportive and offer unconditional love and care is vital. It sounds like you are playing that main role and it can really burn people out…it’s really helpful to do a lot of self care so you can help him.
Anyways, hope you and your son find a way through to a better place…
Man….really challenging. One thing is that I would hope you are getting some support for yourself because that is really hard stuff you are going through.
I was saying before, I try to steer people away from hospitalization as much as humanly possible…but if he is truly talking about death wishes against the family that is scary stuff. I know people who are fundamentally opposed to psychiatry who have brought family members into a hospital setting because of the fear of violence. It’s a very hard decision to make.
Whoops…hopefully this will find the right place…
Richard,
I am trying not to twist your words. Here they areā¦
āNigel, I am very worried about your situation. Because we donāt yet have safe alternative programs for people in your situation if you donāt calm down now and continue to act aggressive or violent, we will be forced to call the police. This will be our only available option.ā
Forced to call the police is another term forā¦using force. And itās somethng I see folks here repeatedly trying to wriggle out of. Though you say you donāt support force everā¦is just not true. You support allowing the police to use force in these rare extreme conditions.
That is not abolition of force.
Richard,
I am trying not to twist your words. Here they are…
āNigel, I am very worried about your situation. Because we donāt yet have safe alternative programs for people in your situation if you donāt calm down now and continue to act aggressive or violent, we will be forced to call the police. This will be our only available option.ā
Forced to call the police is another term for…using force. And it’s somethng I see folks here repeatedly trying to wriggle out of. Though you say you don’t support force ever…is just not true. You support allowing the police to use force in these rare extreme conditions.
That is not abolition of force.
By the way, I completely disagree with the author’s (Sederer) prescription for more draconian treatment laws. We need to eliminate a doctors ability to prescribe and force any drug cocktail possible…absurd…
Hey Jonah,
For you, and anyone else who is interested…this is a good write up of the national statutes that were codified back in the 70s.
http://careforyourmind.org/the-right-to-treatment-and-the-right-to-refuse-treatment/
Here’s a key piece of the article:
“It may seem odd that a person can be involuntarily admitted, or ācommitted,ā to a hospital and then refuse treatment. But the right to refuse treatment is also fundamental to the legal requirements for psychiatric treatment.
Someone who enters a hospital voluntarily and shows no imminent risk of danger to self or others may express the right to refuse treatment by stating he or she wants to leave the hospital. But a person admitted involuntarily, due to danger to self or others, cannot leave, at least not right away. However, despite having the authority to keep the patient in the hospital, the professional staff cannot treat the person against his or her will, except by court order.
The concept of a right to refuse treatment was built on basic rights to privacy, equal protection under the law, and due process. In other words, involuntarily hospitalized patients still have a right to decide what happens to their bodies.”
Now again, I honk horrible abuses take place where folks are “treated” against their will, or a flimsy excuse will be made to give a shot. Many folks can attest to brutal experiences in a hospital setting.
What I aslo want to warn someone against, anyone who thinks about hospitalization…is that “right to refuse” will go away if the person goes to a court hearing and the judge decides to commit them. That means anyone going into a hospital is gambling that they will not be committed and then treated against their will.
Civil Commitments have gone down rapidly in the last few decades and are now mainly reserved for folks who are deemed “psychotic” and a danger to self or others. But anyone entering a hospital should think hard about that possibility of commitment and it’s one of the main reasons I try to steer most folks away from hospitalization if at all possible.
Again- really really hard real world problem there gardenlisa…with no easy answers. One of the things I hear right off the bat is that he went cold turkey off psych meds- which can really cause severe complications and disorganization for anyone…but especially for those prone to extreme states. Even if it was 3 months ago- that may still be causing ramifications. However, I would not be as concerned with CT causing permanent harm. 7 years of drugging can indeed train the brain to be habituated to those drugs- and then when someone quickly cold turkeys off them…it can cause a hell of a lot of problems.
There really is no easy solution. The main problem with hospitalization is the very distinct possibility that he will not just be held-but then taken to civil court and be committed. At that point doctors can choose what drugs and at what dosage they want to prescribe psych drugs. He also faces the possibility of transfer to a State Hospital setting and indefinitely being caught up in the system.
At the same time, in a hospital setting he may decide to take a psych drug voluntarily and then hopefully stabilize and be released- and this time with the goal of tapering slowly and carefully off the drug.
The best option- like you say- would be a place where he could recover without facing the possibility of being forced to take psych drugs.
Hard stuff…I hope your son will improve and recover in time.
Whoops- my comment at 2:56 is in response to Richard’s comment down there at 12:56.
I just can’t support the idea that we should criminalize everyone who is aggressive/violent and psychotic. I take exception to the idea that
“people like this assailant almost always have prior histories of violence.”
Hope this comment makes it to the end of the thread line here :).
I think we need to be very clear that there are a lot of different types of aggressive and violent behavior and there is no clear line saying that anyone who is aggressive/violent should be dealt with by the justice system. You call that “enabling.”
I have worked with countless people who act extremely aggressively in the throes of psychosis. But once the psychosis has passed they are no longer violent or aggressive.
I also have worked with people who are predatory and violent by nature.
I think its key that we separate out these two separate populations. In the first case, I think it is highly troubling to turn over every aggressive and psychotic person over to the justice system. The humane thing to do is to give them space until the psychosis passes. If you call that enabling…so be it.
Really tough questions hearsbirds. I think a few things have to be examined with that incident. Why were hospital staff negligent in allowing an obviously violent person in a shared room with a vulnerable person? Why did they not look in on this vulnerable person regularly? There is obviously a lot of negligence going on with that hospital and there should be justice in that case.
The questions I have would be- what state of mind was that violent person in? Were they going through psychosis or paranoid delusions that led to this attack? Or was the assailant simply predatory and predominantly lucid and clear in thought when she attacked?
If its the second case, I have no problem with handing that person over to the justice system. In the first case, that’s a lot harder. Violent people who are “mentally ill” tend to go to forensics wings of state mental hospitals. They then get “treated” which generally means being forced to take loads of neuroleptics. Would the assailant fair better in a prison setting? Doubtful…but both are awful places to end up.
What should have happened is that a potentially violent person should have been somewhat isolated from vulnerable people and been monitored very closely. My hope is that if the violent impulses were related to psychosis, that those impulses would fade as an episode of psychosis passed. But if those violent impulses were related to underlying aggressive and predatory traits, my hope is that person would be transferred out of a hospital setting as soon as possible.
The problem comes that people who both aggressive and psychotic- often get court committed and end up in State hospitals. As other people mentioned, this is a horrible type of vague “sentence” with no fixed end. Forced treatment with neuroleptics is the norm. So many would say prison may be better for those who are likely to be committed. But as I described in the link above, prisons are overwhelmingly brutal to “mentally ill” inmates.
My hope would be that we pass laws to end the right of doctors to force treatment. In that case, someone may be detained for violent and psychotic behavior, but not required to take meds.
These questions you bring up are complex and very challenging to answer. In my heart, I don’t believe we should treat every aggressive and psychotic person as a criminal. However, in this case, and with the severity of the crime, the assailant needs to be isolated from vulnerable people for a long time.
In reply to Jonah at 6:46…
“Each time I was āhospitalizedā against my will, it would come ultimately as the result of my being falsely accused of being a danger to myself. And, each time, Iād be forcibly drugged. Never was I committed by a judge.
Jonathan consistently fails to acknowledge that this happens.
Perhaps, in Jonathanās āhospitalā setting, people who are viewed as āsuicidalā are treated with the relative degree of respect that heās describing, but why does he generalize?”
What you are describing is against the law Jonah. From Wikipedia…
“Involuntary treatment (also referred to by proponents as assisted treatment and by critics as forced drugging) refers to medical treatment undertaken without a person’s consent. In almost all circumstances, involuntary treatment refers to psychiatric treatment administered despite an individual’s objections. These are typically individuals who have been diagnosed with a mental illness and are deemed by a court to be a danger to themselves or others.”
To be “treated” against your will without having been seen by a judge is a violation of 1975 law. And that law does not go far enough. No one should ever be involuntarily treated….period.
But the reality of your experience, and many many others, show that many hospitals have been routinely abusive and it looks like in your case they flouted that law.
I also have to check in with this statement here Steve…
“But even so, the same thinking applies: even if you decide it is OK to detain a person for self protection, it should not take away their right to consent or refuse medical treatment, in particular, the drug-based pseudo-ātreatmentsā that are usually enforced on every detained person in the psych ward.”
People who are suicidal are generally never “forced” to take a drug based “treatment.” You can only be forced if you have been committed by a judge and it is very rare for a suicidal and non-psychotic person to be committed.
However, suicidal folks are coerced by doctors into taking psychiatric drugs without full informed consent and without presenting alternatives- something that is seriously wrong.
Hey Richard- I wanted to reply to these words here…
“Here is the best I can offer in a very difficult dilemma for anyone working inside the system.They (the distressed person) should be told ahead of time what will happen if they are violent or threatening violence. They should be pulled away from harming some one else. They should be offered support, consolation and compassion. If they are so aroused that they cannot calm themselves (with this kind of support) then they should be offered short term use of sedative drugs (such as Benzos).
If none of this support or offer of drugs works then they should be told that if they cannot control themselves the police will be called to intervene. They should never be forcibly drugged or contained in a psych ward against their will; the short and long term harm FAR exceeds other alternatives.”
This is the real meat of the matter. I totally agree with the first part, and I think you’re right that just creating a space to vent, rage, receive support and just listening can be really powerful. I once was in the ED when an enraged 350 pound man came out into the hallway screaming and demanding to fight me. He had scars from bullet wounds and knife fights and looked totally scary. I told him I didn’t want to fight because he’d crush me. I told him I was scared of him but I’d be open to hearing what he was going through. After a while he stopped screaming, calmed down and told me about his life, which was incredibly hard and sad and painful. That was all that was needed in that moment.
The part where we disagree is the police part. There have been times when police wanted to come in and talk with a patient with a criminal history and we said that they could not enter with weapons of any kind. They refused. I just can’t support the use of police tools for dealing with really precarious and potentially violent situations.
You ask about me making a stance against forced drugging and forced hospitalization? Lets start with the first. I absolutely oppose forced drug “treatment.” But you are talking about forced drugging in violent situations. I will say, as I have said before, I will only support the use of it in the rarest of circumstances when all other measures fail and other individuals are threatened with trauma. I don’t think supporting police involvement means you don’t support force.
As to forced hospitalization?
In general I agree with Steve here that…
“Iāll say as I have before that there is no reason that detention of a person for acts or threats of violence has to be coupled with enforced treatment.”
Right. People are only forced into mandated drug “treatment” after they have been committed. This should be abolished. No one should be forced to take regularly scheduled potent neuroleptics.
I don’t think that has to mean a hospital but I would far prefer a non-prison setting for deescalation of someone who presents as psychotic and aggressive.
By the way, you asked a few other questions in there Richard and I’ll try to get back to you later on those. Thanks,
Jon
Hey Richard…ok thanks for your reply.
So yes…everyone has a right to defend themselves. We’re in agreement there. I think what might make this more clear is describing in real terms how to work with people who are violent.
Many people here, we’re abused. Force was used against them needlessly and horrifically. I will never support that. But you also say that force should Never be used. I just don’t get that. Let’s talk specifics.
If someone who is labeled “mentally ill” is attacking a vulnerable person, would you intervene…and how?
You mainly suggest that police and the prison system should manage all violence, even if it emanates from someone who is psychotic, confused and delusional. I just will have to disagree. I don’t see hospitals as a panacea where nothing bad happens. hospitals are deeply problematic and I see that from an inside perspective. But I will agree with Allen Frances that the level of brutality committed against the “mentally ill” is overwhelmingly horrific. The use of extended periods in solitary confinement is routinely used as a way to “manage” the ” mentally ill.” They are regularly beaten by guards and tortured by other inmates.
I think this comes down to my fundamental question. If you oppose force, why do you support police and the prison system for working with the “mentally ill”?
Thanks Richard for your piece. As I have been the prime person involved in this ongoing debate for the past year, I’ll try to respond. At the same time, I know a number of us have gone round and round on this issue and at some point it may just be better to refer to previous discussions.
First off, I want to look at the term reformist…which you argue against. When I say I am reformist, that doesn’t mean I don’t think some aspects of psychiatry should be abolished.
I believe that there should be a complete abolition of mandated treatment with any psychiatric drug. That is an untenable position and I wrote about that in this article here… http://www.madinamerica.com/2013/12/homelessness-hospitalization-compliance/
I also support the abolition of ECT, even voluntary. While some people say they have been helped by it, the level of suffering that it has caused should require this procedure to be shelved…permanently.
But the term anti-psychiatry, or abolitionist…is far too general and global for me. It implies a complete cessation of all aspects of psychiatry, which not only seems impossible, it doesn’t even seem desirable. There will always be people who seek out psychiatric drugs, even if it is in the tapering process. I don’t believe that should be abolished.
What I do believe is that there should be far more available information about the perils of psychiatric drugs available to the consumer. There should be curbs on advertising, paying doctors to promote psych drugs. There should be impartial longitudinal studies of drugs that are not run by pharmaceutical companies. There should be a curb on prescribing psych drugs just as there have been curbs on opiates due to the potential for damage.
Finally, I think instead of funding NIMH “silver bullet” genetic research, I think our tax payer monies would be far more wisely spent on increased services for the poor, homeless and disenfranchised through “Housing First”, respite centers, holistic alternatives, changing agriculture subsidies to promote fruits and vegetables, etc.
Ok- so lets get to the meat of the matter- where we disagree…
Force.
You say that you don’t support any force…whatsoever. Not even in rare or extreme cases.
I really just can’t agree that that is a reasonable view. I think you are mainly talking about hospital situations but lets look at how violence or how the threat of violence is handled in society today.
Generally, people who are acting in an uncompromisingly threatening and violent way are managed by police through the use of tasers, nightsticks, beanbag guns and handguns. There are police trained in how to work with people labeled “mentally ill” who are able to help deescalate folks without the use of force but often these types of incidences end in the use of one of the types of “tools” I just mentioned.
If a person is deemed criminal, they end up in the prison system. Right now more than 350,000 people with “mental illness” are in the prison system. There are about 35,000 in state hospitals. We have shifted from hospitalizing the “mentally ill to jailing them. In the prison system, any sort of violence or threat of violence is met with brute and overwhelming force. For a brief overview of how these folks are treated…here is an article…
http://www.nytimes.com/2014/07/14/nyregion/rikers-study-finds-prisoners-injured-by-employees.html?_r=0
At Rikers, 40 % of the 11,000 inmates are deemed “mentally ill.” Besides beatings and frequent injuries to “threatening inmates”, isolation is one of the main ways of using “force” to manage “illness.” Long term isolation is known to make people go increasingly “mad.”
When working with the “mentally ill” population, overwhelming force by police, and in the prison system…is commonplace, and often brutal.
OK- so lets shift to the hospital system. I think its key to first talk about how the hospital system has changed over the past few decades. 50 years ago there were over a half million hospital beds. Now there are about 50,000 while population has doubled. The long term hospital model has been dramatically reduced in favor of the prison system for managing “mental illness.”
Richard, as you have written, you don’t support force at any level in these settings (and I assume other settings). But we are challenged by a fundamental question- how do we work with someone who is actively trying to harm another vulnerable person. My first take on this is, all people working with this population need to learn skills to work with highly agitated folks without responding with force. Deescalation skills are essential, such as building rapport, listening, offering comfort measures, food, TV, a radio, a phone, a place to be angry and vent, to even throw things and tear up a room without intervention.
The problem comes when a person does not deescalate and becomes increasingly intent on hurting others. Often the act of putting hands on and moving the person to a quieter area to calm down helps. But occasionally, rarely, it doesn’t. Even this level of force is controversial. Putting hands on someone who has been traumatized, especially sexually, can be increasingly traumatizing. Keeping a person in a physical hold or mechanical restraints can be deeply traumatizing to some. Isolating a person for a period of time in a state of extreme agitation is also traumatizing. Giving a forced shot of a sedative is traumatizing. There is no good answer at this point.
But the alternative is to allow that person to inflict damage…to severely traumatize another person. And that is where I draw the line…and where I am willing to defend the use of mechanical restraints or a forced injection.
What I will not support, is making this a legal matter- turning this over to police and their tools, or to the prison system and its ways of managing force. There is no easy answers in the face of these rare circumstances. My goal is to make this type of encounter extremely rare. And in the hospital where I work in- it is rare.
But I acknowledge in other hospitals, it is likely not rare and far more draconian. One of the best ways I have seen for reducing the use of force in hospitals is by requiring hospitals to document every incidence and then publicizing the results in the media. Hospitals that use force commonly will be pointed out and should be severely criticized and humiliated into changing their policies.
So…Richard…I understand your desire to support an all or nothing abolition of force mindframe. I do support the abolition of mandated “treatment”. I don’t think we will come to agreement on the issue of how to work with violent individuals but I do want to acknowledge that we are largely in agreement on most all other issues. Thanks for your words.
Wow- I just want to say- thank you for sharing those words. Sometimes spiritual practices can unearth a lot of deep and traumatic inner work. I think this is especially the case with sitting meditation. That act of simply sitting and observing can allow the rawest and deepest unconscious terrain to open up which can be truly frightening and hard to manage. I have known people who have had profound psychotic/spiritual experiences from spending prolonged periods in meditation. It can indeed dissolve gates of perception so that a lot of extra hidden information comes in.
I tend to steer people towards more gentle movement based practice (yoga/tai chi) if there is a propensity towards extreme states as that can often help mediate and ground that rippling “hurricane” energy that can suddenly surface.
I really loved this last paragraph of yours…so poetic…
“I donāt run anymore, I stumble. But I stumble because she is with me now, that broken part of myself. We are tethered together by love and fate, like two sisters in a sack race. My life is very different, but I will never leave her side again. I dropped straight into hell to get her back and I will never walk until she can walk with me. I will never begin to run until she can keep up.”
Har har!
But seriously…how hard is it to understand that psych drugs won’t cure homelessness, poverty and the stress and perils of modernity? How bout we spend our hard earned tax dollars on “housing first” and respite centers that serve nutritious meals with staff that can provide support and care?
Even if we found a magic marker for a “mental illness”, how would that ever translate into the need to take a drug that has long term health consequences and poor longitudinal outcomes?
Hey first off- Sandra- thanks for your counting work in this area.
I read the Insel piece…I think its great that there are leaders in the field who are really acknowledging some of the deep problems with psychiatry and are willing to “atone” for some of the failures. My only problem is that Insel seems to really believe in the “magic bullet” method of helping people win distress. By that I mean that he really wants to direct NIMH into deeper reductionist pathways to find “markers” and underlying genetic etiology for illness patterns…and therefore create a scientific way of matching treatment with illness patterns.
This seems remarkably short sighted and diving further into the rabbit hole of trying to develop a more “scientific” diagnostic framework. For someone who wants to atone for the failures of psychiatric “paternalism” and hubris, this seems like continuing down the same road of trying to reduce and medicalize complex psychological states.
Anyways- thank you for continuing to share your journey.
Sometimes you gotta cook…and sometimes you gotta chill…
Whoops meant to say ashtanga, not Ayengar in that first sentence.
Yes there is a lot of controversy Chris. When yoga first came to the West, there were only a few main teachers and styles (Iyengar, Desikachar’s viniyoga, Ayengar). As yoga has become incredibly popular, many different styles have bloomed, and many have become focused on the physical portion of yoga and eschewing the Hindu yogic philosophy. Power yoga and Bikhram come to mind. Most Americans don’t want to study Sanskrit, mantra, deeper levels of pranayama (breathwork), vegetarian diet, and are simply looking for a good workout and stretch.
I honestly don’t think there’s anything too wrong with that though there are issues of yoga being commodified, watered down, and removed from its spiritual roots. At the same time, the practice itself can be very rejuvenating for anyone, without a need for delving into intricacies. I think we can get caught up in who is doing a “truer” form of yoga.
Credentialization is also an issue. Some folks call themselves a yoga teacher after a few weekend trainings. Others gain a certificate after long study that doesn’t just examine the physical (Hathaway) part of yoga but delve into the deeper wisdom of yoga. My one friend who became a teacher was required to read the Bhagavad Gita.
I do think it is important to have a strong understanding of the ethics of teaching/practicing yoga( yamas and niyamas), Patanjali’s eight fold path, basic yoga philosophy, as well as a strong understanding of body mechanics, the asanas, etc.
Anyways, interesting to look into.