Posts Tagged ‘Psychiatry’

Gun laws and psychiatric surveillance

January 19, 2013

If you live in New York state and go to see a therapist about anger management problems, there is a possibility you may lose your deer rifle and go into a police data base of potentially dangerous people.

New York’s new gun-control law requires therapists and social workers to report to county mental health directors whether they believe a patient is dangerous.  That information will go into a state data base, which would be used to confiscate gun owners’ weapons.

mental_health-220x120I would not go to a therapist if I did not think I could trust him or her to keep what I confided in confidence.  I would not trust a therapist if I thought the therapist was going to report what I said to the police.  The unintended consequence of such a law is that people most in need of therapy will not seek it.

Human beings have free will.  That means human behavior is unpredictable.  But New York state law puts the burden of predicting human behavior on therapists, but does not allow them to use their own judgment as to what to do.  A therapist has options if a patient seems dangerously violent—to increase the patient’s medications, to notify people who may be at-risk, to start proceedings to have the patient committed to a mental institution and, yes, to notify the police if that seems necessary.

Simply by the law of averages, someday somebody who is in therapy is going to commit a violent crime with a gun.  No therapist wants to be in the position of not having notified the authorities in advance that the person is dangerous.  The incentive will be to notify the authorities even if there is only a slight possibility of danger.

A conservative friend of mine pointed out that the same incentive applies to prosecutors and judges, and is nothing new.  But prosecutors and judges have to justify their decisions by actual evidence.  Therapists make a subjective judgment and don’t have to prove they’re right.

Even if there were an accurate predictive science of psychology, as in the movie and Philip K. Dick short story “Minority Report”, there still would be a problem in denying you of your legal rights not because of what you had done, but because of what someone thinks you might do.  There are people in prison who have served their sentences, but who are not released because some psychiatrist thinks the person will be a recidivist.

The basic principle of liberty under law, as affirmed in England’s Magna Carta of 1215, the English Bill of Rights of 1688 and the U.S. Constitution in Article One, Section 9, is that the government can punish you only if you have broken a law and that you have a right to know the specific law you are accused of breaking.  Another principle of liberty under law is presumption of innocence.  The prosecution has to prove you have broken the law.

When we look at the old Soviet Union, and how psychiatry was abused to punish political dissidents who had broken no law, we ought to be wary of making therapists agents of the police.

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Click on NY Gun Law May Discourage Mental Health Therapy for Those Who Need It for a report by CBS News.

An abused minority: the mentally ill

February 6, 2012

I recently read Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness by science journalist Robert Whitaker, which described the abuse of psychiatric drugs by the psychiatric profession and the pharmaceutical industry in the last decades of the 20th century.

That book was so well-documented, so well-written and so shocking that I went back to read Whitaker’s 2003 book,  Mad in America: Bad Science, Bad Medicine and the Enduring Mistreatment of the Mentally Ill.   In this book, Whitaker showed that the abuse of the mentally ill has a long history.

He told how the insane in the 18th and 19th centuries were routinely “spun” until they grew so weak and dizzy they couldn’t move, how they were subjected to removal of teeth, ovaries and intestines, and how they were submerged in water or chilled to the point of hypothermia.  Some were exhibited in madhouses as subhuman freaks.  None of these supposed treatments were of any benefit to the patient.  They merely made mentally ill people more passive and less troublesome.

The exception was “moral treatment” originated by Quakers in York, England.  This consisted of good food, regular exercise, an orderly routine and kind treatment.  Most of the mentally ill who received moral treatment recovered, and the Quakers treated those who did not as brothers and sisters who were worthy of kindness and help.  Philadelphia Quakers adopted the same system with good success.

Ironically this was undermined by the humanitarian reformer Dorothea Dix.  She campaigned for state governments to set up mental institutions along Quaker lines.  They did, but the underfunded state mental institutions over time became warehouses in which the mentally ill, the mentally retarded, the senile elderly, alcoholics and syphilitics were thrown in together without much treatment for any of them.

Moral treatment was not considered scientific; eugenics was, and it shaped psychiatry during the 20th century, Whitaker said.  I had know generally what eugenics was and why it was bad, but I had not known how widespread and enduring it was.  The mentally ill were classified among those who were unfit to reproduce.  From there, as Whitaker said, it is a short step to defining them, as the Nazis tried to do, as unfit to live.

Since being mentally ill defined you as being at the nadir of human existence, then anything that could be done to remove the mental illness was, by definition, justified.  Mental patients were subjected to lobotomies, insulin shock and electroshock, whose “cure” consisted in making them passive and obedient.

The next wave of reform of mental institutions came from Quaker and Mennonite conscientious objectors who did alternative service during World War Two in mental institutions.  Appalled at the conditions they found, they sought something better.  This led initially to improvement of conditions in mental institutions, but in the long run to the widespread use of psychiatric drugs as a substitute for institutional care.

Starting in the 1950s, patients were subjected to new drugs which, like shock therapies and lobotomies, worked by damaging the brain.  As the harmful side effects of each generation of drugs came to be known, the pharmaceutical industry kept coming out with new drugs which, in many cases, deepened the patients’ suffering, created addictions and impaired hope of recovery.

I wouldn’t say, and I don’t think that Whitaker would say, that psychiatric drugs should never be used.  Like most Americans, I know people who need medications in order to be able to function.  What I would say, and I think Whitaker would say, is that mental illnesses such as schizophrenia are poorly understood, and psychiatrists should exercise humility in presuming to prescribe.  Psychiatric drugs are less like insulin for diabetics than they are like mastectomies, hysterectomies, radical prostate surgery or brain surgery, a drastic intervention to be made only when there is no alternative.

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Shyness: How Normal Behavior Became a Sickness

April 12, 2010

I recently read a disturbing book, Shyness: How Normal Behavior Became Sickness, by Christopher Lane, about the selling of mental illness in order to sell therapy and therapeutic drugs.

Lane tells how attributes once considered within the normal range of human diversity came to be defined as mental illness, and how a therapeutic and drug industry sprang up around those definitions.  It is disturbing as an example of perverse market incentives undermine professional standards and scientific objectivity.

The book begins with an account of the academic politics behind the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), which came out in 1980. The purpose of the original DSM, which came out in 1952, was to provide standard and evidence-based definitions of mental illnesses, to diminish the subjective element in psychiatry and to enable therapists to speak a common language.  In DMS-III, as a result of neuropsychiatrists outmaneuvering psychoanalysts, there was a great expansion of the number and scope of defined mental illnesses.

Among these was “social anxiety disorder,” which, according to some estimates, affects one in five Americans. This proved a great boon to the anti-depressant and anti-anxiety drug industry; according to Lane, nearly 200 million prescriptions for such drugs are filled every year. This is due to the drug industry’s massive and successful advertising and public relations campaign, to sell people on the idea they were sick and needed treatment.

DSM-IV came out in 1994 with an expanded list of mental illnesses, and a DSM-V is due out in 2015.

The American advertising industry has a long history of selling problems – dandruff, hair loss, “Mr. Coffee Nerves,” “BO: what your best friends won’t tell you” – in order to sell products. The most disturbing thing about this disturbing book is the advertisements selling people on need to drug themselves.

It is a bad idea, as Lane says, to encourage people to become dependent on drugs to cope with bad feelings. The use of psychopharmacological drugs is a step up from altering human behavior by means of brain surgery or electroshock “therapy,” but it, too, alters the brain in unforeseeable ways. By providing a chemical solution to emotional problems, you reduce the ability of people to cope with or live with problems. By chemically eliminating negative emotions, you blunt the ability to feel emotion at all. By biochemically altering the function of the brain, a delicate organ whose workings are imperfectly understood,  you may make irreversible changes whose effects you don’t know.

There are too many vested interests in the present system to expect change anytime soon.  DSMs are used as the basis for determining Medicare, Medicaid and other insurance reimbursement. To change the definitions to make them more narrow would be to cut off many thousands, maybe even millions, for needed therapy.  The therapeutic profession will not willingly a curtailment of the number of clients, nor will the drug industry willingly accept a curtailment of a lucrative market.

But many people really do suffer from “social anxiety disorder” and really do need medications.  “Social anxiety disorder” may include normal shyness, but I have met people who are unable to function in society at all without their medications. And I have had the misfortune to have to cope over an extended period with someone who needed to be on medications, but refused to take them.

So the question is not how to get rid of psychopharmocological drugs, but where you draw the line on using them.  And I, like most people outside the psychiatric profession, lack the expert knowledge to say where that line should be drawn.  I am grateful for Christopher Lane for calling attention to this situation, but I don’t know what to do about it. I am reduced to the pious hope that the psychiatric profession itself will push back against perverse market forces and reassert professional and scientific standards.