Monday, August 8, 2022

Comments by Alice Maher, MD

Showing 15 of 15 comments.

  • Thanks again to everyone who responded. I’ve heard about the Parachute program but I don’t know anyone who has been involved with it. Does anyone reading this have any first-hand experience? I’d love to have that contact info if it’s operative and effective.

    I got the idea of creating a “hospital at home” from Jessica Arenella, President of ISPS-US. When our patients are in an extreme state, we make sure they’re safe at home, see or call them once or several times a day, help them and their families understand what’s happening, and offer meds and/or healing techniques of various kinds. It works very well, especially for people who have had mixed or bad experiences with hospitals in the past.

    I trained during the five minute period when psychodynamic understanding and medication were integrated and done by the same practitioners. Meds were used only for the most severe cases. Most people were treated with analytic understanding and family therapy. That model had problems of its own – the problem of blame. If you had a psychotic break, it was because you had a flawed ego and/or suffered at the hands of schizophrenogenic parents. When the medical model arrived, people felt liberated from blame. Whew, it’s just an illness! Problems in communication arose because our thinking and behavior was idiosyncratic and hard to understand, but it wasn’t necessary to begin from a position of self/other accusation. Believe it or not, that was liberating at the time. At the same time, Prozac arrived on the scene and the fantasy emerged that common ordinary unhappiness could be treated with a drug. That was a shared societal delusion, but it was pretty exciting at the time.

    I’m not sure what I’m trying to say… Maybe just offering some historical context for the serious problems we face today. I witnessed a change in tide once long ago, and I’m convinced that it will change again soon.

  • Again, my apologies for not addressing every point. I appreciate them and will continue to think about all of them. The problem is merely one of time.

    I’ve been asked why I don’t spend more energy lobbying against coercive treatment. It’s also been suggested that my statement about our toxic society was defensive against recognition of the evils of my own profession. This post addresses those questions.

    I don’t know where the rest of you live, but New York City is a horrid place to regress. Everyone here moves so fast that the idea of stopping, creating a safe environment, really listening and responding appropriately and effectively to what another person is saying, doesn’t exist. As soon as a person enters some kind of extreme state, they lose their jobs, their families have to get to work or they’ll lose theirs, their kids are in danger or others believe that they are, and people respond to them in all sorts of problematic ways. Psychiatrists are no longer trained to listen. They diagnose “thought disorder” and walk away, leaving the person totally alone, relating to no one other than the people who populate their inner world. This makes everything worse.

    Question: If forced hospitalization is wrong, but there’s no one around to offer support, safety, human connection and genuine listening, and the person is potentially dangerous to self or other, what would you do?

    This is a genuine question, NOT a commercial for forced hospitalization. I’m very opposed to that. But if I’m going to fight against it, I need to offer my field, and society, a worthy alternative. I’d appreciate your thoughts about this problem. (I’m also curious if it’s better in other parts of the country or the world.)

  • Thanks, Jens, for your openness and willingness to talk to me. You remind me of a woman I saw some years ago. She had been hospitalized for “paranoid schizophrenia” in the pre-medication era, and was treated in 5x/week psychoanalysis with a marvelous analyst. She came to talk to me not for herself, but to help her think about the best way to deal with her son who was developing similar symptoms. This woman was blind, in her 80s, and traveled alone on the bus from another state. How was she able to do that? Because that accepting, meaningful treatment by a man who cared enough to get to know her and help her know herself transformed her persecutory voices into loving, embracing ones. She negotiated the NYC transit system because her voices told her that she was smart, beautiful, loving, capable of doing anything she wanted to do. I thought it was the most beautiful story I ever heard.

    If our world – not just the world of psychiatry, but The World – were less toxic, this could be true for most, if not all of us.

    You guys should continue to come on strong, and I’ll try my best to soften around the edges. Maybe our perspectives will come together someday, in better times.

  • Hi Kathy, Sera, Ron, Alex and others (sorry again for skimming),

    Sera, I’d love to see your film (after I finish Alex’s). How can I get hold of it?

    I stand firm in my belief that the medical model is severely flawed, dangerous and hurtful to many. But I stand equally firm in my belief that it is lifesaving for some and helpful for others. A smaller subgroup of people want meds and don’t need them or shouldn’t take them, and another subgroup could potentially benefit but adamantly refuse. Side effects and withdrawal effects are awful.

    After 40 years in the profession (private practice), I like to think that I can differentiate these situation much if not most of the time, to the best of my ability. I don’t work in a hospital and I haven’t forced hospitalization on anyone since I was a resident. People come to my office because they choose to ask for my help, and I offer what I can with honesty and integrity. Most of what I do is long-term psychodynamic psychotherapy, with adjunctive medication used very judiciously.

    This is just in the realm of a thought experiment, but I could imagine doing something like this down the road…. Would any of you be willing to be filmed in dialogue with people from the other side of the medical spectrum – people who take medication and are grateful for it, side effects and all – with a filmmaker acceptable to all? That might be fascinating.

    I fear that if your message is that all psychiatry is destructive, period, your will remain more marginalized than you ought to be. I could be wrong.

    I’m sorry if my film didn’t show that element. Perhaps it should have, but our focus was on stigma, not the strengths and weaknesses of the mental health profession. We believe that it’s important to come together before prejudice against people who think, feel, and behave outside socially accepted norms can be better accepted, understood, and integrated into society. Given society’s fears (especially with the rash of shootings), I think coming on too strong might scare them off. I could easily be wrong.

  • Like Sera, I want to thank all of you for responding to me. I sometimes felt attacked by you, and I know many of you felt offended by me. I don’t think either was intended. Feelings aren’t facts.

    I understand that many, many people have been terribly hurt by experiences with the psychiatric profession, and I DO want to do something to change that. Many of you are saying that that horrid problem needs to be confronted in direct and powerful ways, and you’re put off by my model of “softening.” I get that, but I’m not going to change my perspective because it’s the best that I can do. If I came on too strong I’d just be ostracized, and I don’t believe that all psychiatry is hurtful and dangerous. I think it is for many, but not all, and for some it’s lifesaving. My work emerges from within that paradox. I understand that that feels wrong to a lot of the people in this group. The fact that the film is shown in classrooms allows for discussion that – you may not believe this – moves away from the medical model – the model that is often presented as the only true perspective to young people today. If I wanted to show some of your more powerful and one-sided films, they’d never be granted a screening because they would be considered too extreme.

    In the future, if you could tolerate me, I could imagine collaborating with some of you to make a film about the survivor movement, a film that would come on much stronger in opposition to the medical model than this one does; a film that could be offered screenings in places that you can’t reach right now.

    If you want to hear larger segments of the interviews, many of them are on our website, http://www.thehotstoveproject.org. I apologize to Ron for the bad quality of his interview. That wasn’t done by Sheryll. It was a skype interview filmed at a university, at the same time as Elyn Saks. (As I said, we filmed with virtually no budget, and they were too far away.) Elyn’s visuals didn’t come through at all, which is why she’s just a photograph.

    I also apologize for not responding to all of your questions. Like Sera, that’s simply a question of time. I come home every night to dozens of posts, all of which are detailed, challenging, and thoughtful. Unfortunately I have to pick and choose, only because there are not enough hours in the day to do justice to all of them.

    I hope we can continue this dialogue, slowly, over time. Thanks again for listening and responding. I particularly appreciate the opportunity to share more of myself with those of you who have reached out to me personally.

  • Hi all,

    It’s 10:30 and I just got home and skimmed your comments. Here’s my emotional response. I apologize for not having the time to respond thoughtfully to every idea and every question.

    When I used the analogy of political parties, I meant to imply that perspectives exist here that are very different from each other. VERY different. When that happens, challenges to specific ideas and specific plans of action almost never work, because the underlying paradigms are too different.

    I believe that, but I also believe in the power of dialogue – not rabbit holes or tolerating aggressive attacks, but genuine dialogue across divides. I believe that that must, by necessity, take a very long time, because it involves a process of softening edges over time, not submitting and admitting guilt or sending retaliatory weapons across massive divides.

    If you will have me, I’d like to share more about who I am, what I believe, what I do, and how this film came to be. I’d like to humanize myself, even though yes, you’re right, I’m a successful, well off, Caucasian psychiatrist. Maybe I don’t belong here, or maybe the fact that I feel like I don’t represents a kind of reverse prejudice on “your” part.

    The kind of “softening” I think is necessary is a process that can only happen over time. I’m willing to post on this thread once or twice a week, and/or invite some of you to friend me on Facebook where I post challenging thought experiments every day. I’d like to continue to relate to you from my personal center, and invite you to do the same. If you prefer that I engage in detailed responses to your detailed questions and challenges, I won’t do that, because I think it won’t work and may lead to more defensive/aggressive reactions that will suck time and energy from all of us.

  • Sera, here is my response to your questions:

    1) Areas where people come from non-medicalized places? I don’t have time to watch it again, but to my recollection the ISPS people, Alex, Tom, and the other young people. You heard Lieberman as speaking strongly, but to my ears just the fact that he, Elyn Saks and Alice Flaherty said that they believe the medical model was a way of pointing out the fact that another perspective exists! If we didn’t want to convey the other side – that some people don’t believe the medical model – we wouldn’t have had them state that they believe it. BTW, Oliver Saks – speaking of famous people – didn’t speak to the medical model. He liked the word “mad” and referred to people coming from a different center.

    2) Why could we not tweak the narration? Do you know how complicated it was to get John Turturro to a studio to film it? He was comfortable with the words he was asked to speak, and we couldn’t ask him to do it again.

    3) About people of color. Yes, that’s a flaw, but honestly we didn’t know any. The focus group were students from Lois’ college, and the professionals were, are, all white. Looking back I know it’s a problem, but in retrospect I’m not sure I would have been comfortable combing the world for a person from a minority group, just for the sake of having one. That feels just as discriminating as not having one. I think it’s a problem in the field, not just our film.

    4) Please see my response to Frank about my political perspective – the need for left and right sides to focus on a shared horizon. To me, that shared horizon is our children and people who are suffering. I think if medical and anti-medical people could respect the landscape that the other side sees rather than fight against it, we could come together in ways that would be more helpful to them. Honestly, it’s also a way for me to focus the two sides of myself.

    5) I think that exhorting society to stop using words like “crazy” is a first step in the direction you want to go. It wasn’t the goal of the film to look at issues like forced restraint and drugging, or the Murphy Bill. That would have taken it too far afield. It’s something I see on the horizon, but adding that element to this film didn’t feel like a place we wanted to go. Maybe at some point we will.

    6) I’m sorry if the film hurts you, but I don’t intend to stop screening it. Others respond positively, and it opens eyes and invites dialogue in classrooms. Interestingly, your side often rises to the surface. It allows students to question the medical model, which is typically the only one that they’re taught. It may be hurtful to you, but I don’t believe it will hurt your cause. When I say that, please try to think of me as a person who comes from a different political party. One of us believes in higher/lower taxes, gun control and climate change or not, etc. We’re not going to change those beliefs, but we can respect the fact that we believe something different and keep fighting for what we believe to be true. Hurt may happen (or not), but it’s not intended by either of us.

    I know there is much left unsaid, but I have other things to do to prepare for a long (ICD-10 infused – ugh!!!) week. Thanks for the dialogue. I do appreciate it. I hope we can continue it, slowly, over time.

  • Frank (and others), you ask “Is the film not an example of that (big pharma) corruption?” It’s hard for me to say that my film is part of something corrupt, except that I don’t think so. Same with your reference to the idea that the film “lumps all mental patients together in one big blob.” No, it does not. The people in the film are as different as night and day. Maybe that wasn’t made clear enough and should have been. It seemed obvious to us. With regard to looking at the coercive and damaging nature of mental health treatment, that’s not what we were trying to do it this film. We could go there, but it would be a different film.

    Perhaps it would help to look at the problem this way. The one line that I myself speak in the film addresses the problem as one of difference, and of the need for hard work that society doesn’t want to do. “A democrat and a republican in a room together would have the same dynamic.”

    That’s how I feel when I read and respond to these posts. It feels as if I and many if not most members of MAI belong to different political parties, with different platforms addressing the problem of prejudice and integration. “Your” platform believes that the medical model needs to be addressed and fought head-on, while mine believes that people who believe in different models need to come together first. Maybe if we just accept those beliefs as simple differences, we can stop pathologizing one another.

    I’d like to tell all of you about my other projects. One is an emotional literacy curriculum, http://www.emotionalimprint.org, and the other is the overarching not-for-profit organization, http://www.changingourconsciousness.org. I also have a very intense dialogue page on Facebook, and a separate public page, the Depth Perception Party.

    My model is that left and right eyes and left and right sides of the body, working together with one side dominant and leading, allows us to move forward with stability and focus on a shared horizon with depth, clarity and focus. If one eye wears blinders to the landscape that the other eye sees, the person will see nothing and go nowhere.

    I think that’s true of our “body politic” as well – not just in the mental health arena, but all of them.

    I could be wrong, but that’s the very well intentioned place that I come from. What I see in the film is right and left perspectives alternating. I hear that that didn’t come through for many of you.

  • Wow, lots of powerful responses, and not enough time to give them the thought they deserve. For now, I’d like to respond to Sera. Sera, you say that you would like to hear a doctor speak like this: “So, we don’t truly know what is happening or why you are experiencing x. What my training suggests is that your experiences are consistent with a diagnosis of x, and the most commonly used treatments when someone has a diagnosis of x is y. However, I have to be honest that there are no real tests for x which is a diagnosis (like all other diagnoses of this sort) that was created as a best attempt to explain a particular experience and bill for associated treatments. Sometimes, people who get this diagnosis find these other ways of thinking about it to be a better fit, and here some of the approaches associated with those models. In truth, even if we go down the medical model path and I prescribe medications to you, I can’t claim to know how they work, and here’s some of the reactions I hear from people – both good and bad…’ And for those for whom it doesn’t work – regardless of what way of thinking about their experiences they find most helpful – here are some of the alternatives they’ve tried that some have found helpful.”

    Sera, that’s almost exactly the language I use when I offer medication to people that I see in my office. Does it help to know that??

    I apologize if I seem to be responding to comments that you didn’t specifically make. Sometimes I respond to you as an individual (whom I don’t know, and email is fraught with ambiguity), and other times I respond to “you” – a composite of several posts by different people who seem to be against the medical model in very intense and powerful ways.

    I’ll go back and respond to your questions in another post.

  • Thanks, Jens. Communicating in this faceless, affect-free medium is really hard. I appreciate your efforts very much.

    AA, yes, I work very hard to use a minimal amount of medication and help the person wean from it as soon as possible, as much as possible. I see a lot of teachers in my practice. They don’t have time to wait to see if time and tools and support and insight will help. If they behave in ways that are even a little bit outside expected norms, they will be accused of “corporal punishment,” lose their jobs and their insurance, and/or be outed as being “crazy” and “sick.” A little bit of medication can allow them to function effectively while they work to understand and tolerate their affects and perceptions. I completely agree about people getting substandard care when records are shared. My personal compromise is to keep handwritten records as far away as possible from the eyes of others. I think change needs to be slow right now, but there will be a tipping point when it will happen quickly.

  • Jens, as much as you say that you’re criticizing the system and not me, your responses make me feel criticized as an individual as well as a representative of that system. I could well be wrong about many things and I like to think that I’m open to hearing that, but I don’t know how to respond when you exhort me to stop my “projective identification.” I’m very sincere about what I say and what I believe to be true; it’s not a “tactic.” I do think it’s possible to coax the medical profession to think differently. Many of us feel highly compromised by the increasing medicalization of our profession. We may misunderstand a lot, but we truly do want things to change and want to help facilitate those changes. All I’m saying is that if you push us away, you could be doing yourselves a disservice. Or maybe not; I dunno.

  • Thanks, Alex, very much. I responded to your email and I’m looking forward to seeing your film and remaining in dialogue.

    Jens, you say, “the very notion that there are bridges to build would only serve as a feeding line for the oppressing machinery.” OK, you don’t like the film. That’s fine; you don’t have to like it. But right now I’m speaking not as a filmmaker, but as a human being – a psychiatrist who feels like one of those “oppressors” that you seem to lump together, criticize and dismiss. I trained in psychoanalysis 40 years ago, when our pharmacology class was optional, and I watched my profession change into something I no longer recognize. Now with the new billing and coding system, complete lack of privacy, and need to diagnose a disease in order to get paid, I’m horrified. A seismic change needs to happen, and it needs to happen now. I want to be on the forefront of that change process.

    But change has to happen slowly, and in the right way. If the rest of you are going to react by lumping me together with your “oppressors” simply because I have an MD after my name and I sometimes prescribe drugs that I believe to be helpful, then you’re shooting yourselves in the foot and increasing stigma against your own community. Because I bridge the divide, I can help, maybe a lot, because people on my side of that divide may be more likely to listen to one of their own. When we show the film in classrooms, we have an opportunity to share other points of view besides the medical model, which is the only one the students come to know. The only way we can get a foot in the door of those classrooms is because the medical model is an integral part of that presentation and that dialogue.

  • I think it’s impossible to catalyze large scale social change around the problem of difference unless the position of people who have benefited from medications are offered respect and empathy. I believe that meds will become less necessary and will be used much less frequently once we have a world that invites “different” people to live in it without marginalization and oppression. Until then, some people will suffer less with the judicious use of medications. I don’t want to make a film that attacks that model head on, because I don’t think attacking people on the other side of a divide will be as effective as a position that gets people talking across that divide. That was our intent in the film
    .

  • Hi Sera,

    I hear you that you found the film offensive. I feel really bad about that, but I think you wanted it to be a different film. We may not have effectively communicated all that we intended, but your assessment of our intent is different from what our intent actually was.

    When I used the word “triggered” – which I understand was offensive and poorly chosen – I meant that I think you overreacted to the medical people and gave less weight to the equally important non-medical representatives. Or maybe we emphasized that side too much. We may have. It’s hard for me to know, but if we did, it was definitely NOT what we intended to do.

    I agree with you that it’s up to people “in the system” to define such things. We’re working on filming, in much greater depth, four people with different lived experience, ranging from a young man who defines himself as having schizophrenia and takes large doses of medications to an older woman who regained her life and her voice when she stopped them. Yes, at least one of those people will be a member of a minority group. That’s a flaw with the first film, to be sure. We didn’t know any, and we didn’t think to actively seek them out.

    I AM invested in dialogue, and I do appreciate your questions. Here are my preliminary responses:

    1) As I said, I think we tried hard not to do that. We may have failed in that attempt, or you may be overreacting to the (more famous) medical people in the film. The truth is probably somewhere in between.

    2) The narration by Turturro was written by Anne Harrington, Chair of the Dept of the History of Science at Harvard. She studies the problem of stigma from a historical perspective, and wrote it from that point of view. We filmed that narration early in the process and we couldn’t tweak it at the end when we might have wanted to. But they would have been subtle changes. I don’t agree with you that that narration comes from a strictly medical model. Anne isn’t like that, and neither are we. I’m a psychiatrist, but I’m desperately trying to emerge from society’s demand that I be a “medical doctor” and diagnose from that place, especially if I want to get paid. That’s why I did the film in the first place. I’m not only not trying to advertise the medical model, I’m trying to do the opposite.

    3) As I said, that’s a flaw.

    4) There is no civil rights movement yet, because “we” are too conflicted among ourselves to come together and create one that works. People who think, feel and behave outside socially accepted norms need to be integrated into society with value, meaning, and creative contributions. But as long as the medical people and the non-medical people remain antagonistic, that movement won’t happen. It reminds me of the conflict among the gay community when I was young. Half of them wanted to come out and own their place in the world, and the other half wanted to stay in the closet because life seemed easier that way. It was the AIDS epidemic that brought them together. Once they did, seismic changes happened. I’m hoping for an analogous process to occur in the mental health community. I think you want the same thing, but I don’t think you’ll be able to do it without befriending and empathizing with people who have a different perspective on their own mental disorders; people who value their medications and believe that it works for them.

    5) I think we touched on it (a lot!) in the segment about the way society still comfortably uses words like “crazy” and “psycho.” I see those words as representing that force of oppression, similar to the way “nigger” and “faggot” were comfortably used, oppressively, in years past.

    6) I didn’t think of that at the time we made the movie, but I hear you and I will.

    7) I’d be grateful for some links. I hope I’m taking your feedback to heart, and I hope you’re hearing me as well. I’ll be glad to continue this discussion if others would like me to.

  • Hi Sera and everyone,

    First of all, I’m grateful for your reactions, powerful and negative as they are. You ask about the meaning of the film. What’s happening right here, right now, IS the dynamic that Lois and I hoped to catalyze. We ARE “hot stoves” to one another right now (ouch!), and the fact that we’re talking across that divide is a very good thing.

    Why? Because as much as we might want a civil rights movement to catalyze integration of people who think, feel or behave outside socially accepted norms, THAT WILL NOT HAPPEN unless and until people immersed in the issues are able to talk across OUR OWN MASSIVE DIVIDES. For every person and practitioner who believes that the medical model is toxic, there is another person and practitioner who experiences it as lifesaving, or maybe just helpful. If people in the mental health field are going to join separate organizations and fight for vastly different solutions, people who need help, social acceptance and empathic imagination, will continue to suffer.

    When the film was first shown at ISPS, the discussion went on for 2 HOURS, until we were asked to leave at… was it 11 PM? Yes, the film itself is clumsily filmed and edited. Neither of us ever made a film before and we did it for almost no money, with a young and inexperienced (though highly creative) filmmaker. But given that the “hot stove” dynamic was exactly what we were hoping to catalyze, it was gratifying to feel the energy in that heated conversation. We have shown it in multiple arenas since then, and the conversations are always excellent. It’s a very short film, meant to be shown and discussed in classrooms. (It also received honorable mention at the SAMHSA Voice Awards.)

    I understand that the number of “white coat” people might have been triggering to many of you, but please realize that we tried hard to show all points of view. What specific people said was less important than the meta-level communication. As we clearly state, PERSPECTIVES DIFFERED DRAMATICALLY. We tried to show one point of view followed immediately by another. For example, as I recall, Joanne Greenberg’s line came right after Jeffrey Lieberman’s. He said he believed in the brain disorder model, and she is then shown saying, “It’s in the brain. Yes, it’s in the brain. You haven’t said anything!!! Yes, it’s in the brain. Now get rid of it!” I think that’s exactly what she meant to say, and it’s exactly what WE meant to say.

    The movements were also presented as different, often clashing perspectives. We state that clearly in the title screens. Patrick Kennedy, Glenn Close, David Oaks, Mad Pride and others represented those vastly different points of view. Our point is that we need to talk, bridge those “hot stove” divides, and eventually come together, before a new civil rights movement that addresses prejudice against people with mental disorders and differences can emerge and be effective on a large scale.

    I could go on, but I think I’ll stop here. I’m looking forward to your responses. If you want to see the film, it’s 22 minutes long and it can be found on http://www.thehotstoveproject.org website.

    Alice