Aug 27, 2012

Chaos of the Needle Man

My friend and mentor Dr. Sung S. Kim died two years ago this month at age 80. I helped Dr. Kim with his website and with a couple of publications. He was a great acupuncture doctor, and a genuine character. In his youth, he managed to serve on both sides of the Korean War (he always was hush-hush about this).  He completed medical school, moved to America, became a heart surgeon, then an acupuncturist after he and his wife visited China in the early 1970s. Dr. Kim’s passions were day-trading, left-wing politics, golf, and writing. He approached all of these from a mixed Buddhist-Taoist perspective. He loved his wife, but was annoyed by her little dog. He bought gadget after gadget that he never really learned to operate.

Dr. Kim wanted everyone to know how acupuncture worked. He tried to explain Eastern medicine in a way that was compatible with a Western medical perspective. Over the years I learned quite a bit about acupuncture, but the first important lesson he taught me was about the power-and-control strategies of experts. In ancient times, Chinese court acupuncturists described what they did in extremely complicated terms in order to build up their status as experts, and retain their jobs with the Emperor. Meanwhile, throughout the countryside, traveling doctors practiced a much simpler style of acupuncture. People could pay a lot of money to see the Emperor’s acupuncturist or instead, as Dr. Kim phrased it, visit the “needle man under bridge,” and get acupuncture on the cheap, without the fancy ritual. Both styles of acupuncture worked. The fancy explanations and mystifying rituals were extraneous. They made no difference. Everyone got better.

Dr. Kim’s method of acupuncture was radically simplified. He focused on a couple dozen, not hundreds, of acupuncture points. Other acupuncturists used many more needles, and inevitably placed some needles exactly where Dr. Kim did. These points are located in ganglia (bunches of neurons) connected with the parasympathetic nervous system (the set of nerves that control the body’s involuntary functions). Slight effects from the needles induce an adjustment process in the whole body. This changes the production and processing of neurotransmitters and hormones, which delivers the intended result. 

As Dr. Kim explained it, acupuncture’s needles are a direct physical intervention into a complex system. Healing emerges from the complexity of the many feedback loops and processes of the body’s systems. The ancient Chinese authors used Taoist concepts to explain all this. Dr. Kim’s insight was that Taoism is the same as modern systems theory. Both involve tuning in to chaos and complexity. Taoism is modern chaos theory, quantum physics without the troublesome math. 

I have been coming to realize how systems theory and chaos theory might offer solutions to the problems of mental illness. The human brain’s extreme complexity is a given. We also know that our mental distress connects with our whole bodies. On top of that, we must deal with our families and other social structures, and cope with physical conditions that are mostly beyond our control. We clearly need some tool that helps us grapple with the complexity of all of this. 

A systems approach begins with identifying the relevant system. We must think big enough to encompass all the relevant factors. We must include our brains, our bodies, our emotions, our talents, our genetics, our families, our culture, our faiths, our neighborhoods, our governments, our schools, our prisons, our economies and more. Focusing too narrowly creates issues elsewhere. We need to be constantly aware, and tune in as best we can to signals from the whole thing.

The “whole thing” is certainly not a closed system. Closed systems use up whatever fuel they have and stop. People are open systems. We take in fuel, and expel waste, while our body’s processes, if working optimally, keep us going at a state that is close to equilibrium. (Equilibrium is a false goal. Once you reach equilibrium, you’re dead.) The farther from equilibrium a system gets, the more chaotic. 

Yet even chaos has patterns. We can develop a sense of perspective, try various things, and see the changes that emerge. With a little nudging in the right places, we might even make some progress with the whole thing.

Aug 25, 2012

My recovery will not be audited.

The more I read about SAMHSA’s recovery platform, the more I’m convinced it’s not for me. 

A recent SAMHSA “recovery to practice” publication has a great title: Why Adding 'Recovery' to a Treatment Plan Does Not Make It a 'Recovery Plan' -- but a disappointing premise.

The art of recovery planning involves being able to imagine and articulate the steps a person can take in the next 3 to 6 months, along with the interventions other people can provide to enable and support those steps, to improve his or her life and move it in the direction of his or her longer term aspirations. The fact that a person has a condition we call schizophrenia may not change over that 3- to 6-month period, but lots else in the person's life can. This is one of the many reasons funders, auditors, and accrediting bodies prefer to see person-centered care plans in medical records, as these plans clearly articulate what objectives the practitioners are seeking to achieve through their provision of services and supports. To meet auditing criteria, these objectives need not only to be measurable, but they also are expected to change over the period relevant to the care plan (for example, 3 or 6 months).

What’s the deal? I never expected funders to audit me!

My recovery is my business, not theirs. The task of health practitioners – mental health included – is to deliver care that facilitates the process of my life. My goal might be to have a nice house, a girlfriend, a good marriage, successful children, a meaningful job that pays the bills, a chance to express myself, or whatever –but does SAMHSA really expect to audit that? Will an influx of accountable service providers make people’s bosses, teachers and relatives less awful?

If SAMHSA truly sees recovery as an intimate, subjective process of personal transformation, it needs to stop treating people’s lives as objects to manipulate.

Aug 6, 2012

Your hate group, and all our safety

It's hard to witness yet another mass violence incident, so much suffering among innocent people at their community's place of worship.

Unfortunately, this is the US, where we enjoy so many blessings, yet violent microcultures flourish. I'm not surprised to see Wade Page, the latest domestic terrorist, emerge from one of them. Hate talk and hate music offered him a ready-made violent mental model that he used to blow up with.

As I have written before, when people erupt in mass violence, they often pick up a deadly identity or mission from whatever cultural influences they have access to. Observers will blame that culture, but we seldom note how many other people in that culture live out their lives peaceably. We mostly have law-abiding hate groups around here. The guy who explodes is usually a lone gunman, sometimes a guy with a gullible friend who gets in deeper than he planned.

It is relatively easy to identify the role Page was playing, but what's hidden right now is what factors triggered him to violence. Did someone take his job? Kick sand in his face? Serve him a bad meal? Was there some other desperate humiliating circumstance? I saw one news report rumor about a recent break up with a girlfriend. It's too soon to say exactly what happened.

Page certainly knew about the recent Colorado theater shootings. Unfortunately, mass violence is somewhat contagious. Incidents enable people. Each attack chips away a psychological barrier, a cultural taboo that prevents the next horror. It's similar to the mechanism that operates with reports about suicide.

Here's another question that interests me. Was he just another troubled, depressed, anxious guy who ran out of rationality while isolated? Did any of his hate-music band mates see he was falling apart, offer him a hand, keep him company, tell him things would turn out okay?

Did his buddies in his hate group let everybody down?

Aug 5, 2012

In the world of mental illness, nostalgia is a bad thing

Anyone who comes across policy rhetoric proposing that we reinvest in large psychiatric institutions should pick up a copy of Judi Chamberlin’s book On Our Own: Patient-Controlled Alternatives to the Mental Health System. Published in 1978, the book is dedicated

To my sisters and brothers in the mental patients’ liberation movement and to all those who have suffered at the hands of institutional psychiatry for the past three hundred years.

You have to admire this book. It represents an authentic, hard-fought point of view that resonates today. The book is part memoir, part political analysis of mental illness on the eve of deinstitutionalization, plus a tour of mid-1970’s community programs. It embodies the passion of a person who’s been hurt, who has seen others suffer, and who hungers for reform.

For too long, mental patients have been faceless, voiceless people. We have been thought of, at worst, as subhuman monsters, or, at best, as pathetic cripples, who might be able to hold down meager jobs and eke out meager existences, given constant professional support.

The book also serves as a meditation on the dynamics of coercion, torture and humiliation disguised as medical care. This is a political document for a population oppressed throughout history. It is Viktor Frankl’s Man’s Search for Meaning, fine-tuned for people who have been identified as crazy, mad, infantilized, incapable of caring for themselves.

Putting people in detention facilities called mental hospitals is considered humane. Improving mental hospitals then becomes a matter of providing more treatment. It doesn’t matter if the patients call it torture.

And lest we forget, torture it was, perpetuated by an industry that worked in obscurity and operated according to rules it created for itself. In the mid-1970s even E. Fuller Torrey questioned what was going on. Chamberlin quotes Torrey.

The very term [mental disease] itself is nonsensical, a semantic mistake. The two words cannot go together except metaphorically; you can no more have a mental “disease” than you can have a purple idea or a wise space.

Literally anything could be treated as a psychiatric symptom. Once that happened, people in asylums might do anything to you. Chamberlin relates the experiences of Leonard Frank, a psychiatric patient in the mid-1960s. Frank was involuntarily committed by his parents when they discovered he lost his job and started living off his savings. He had become interested in Orthodox Judaism – plus he grew a beard, studied the Bible and started following the dietary laws.  These were all interpreted as mental illness symptoms. Years later, Frank published the medical records of his psychiatric hospitalization in an ex-patient’s newsletter he founded. Chamberlin notes

The records show that the only “symptoms” the psychiatrists were able to find, “symptoms” that they used to justify administering to him against his will fifty insulin shock and thirty-five electric shock treatments were his vegetarianism, his beard, and his denial that he was mentally ill. … The record indicates that whenever Leonard was given a mental-status examination, he answered all the factual questions correctly; he was, in psychiatric terminology, “well-oriented.” …It was considered progress that “he asked for a bowl of clam chowder soup and took some bread and used butter on it.” His “delusions” – that he should be a vegetarian, wear a beard, and observe his religion – were enough for a court order of commitment, requested by the doctors on the grounds that he was “dangerous to himself and others under these circumstances.” What danger? Whose delusions?

Chamberlin notes that institutional psychiatry was designed to dehumanize.  Mental hospitals were “total institutions” that controlled every aspect of an inmate’s life. Institutions not only controlled the type of treatment to which a person was subjected, but the coercive rules of the “therapeutic milieu” controlled nearly every other detail about an inmate’s life. This included when and where the person ate or slept, what the person wore, when to use the bathroom, and whether the toilet in the bathroom was in full public view. Chamberlin points out how the effects of institutionalization reinforced pathology, piling on justification for further treatment.

A natural consequence of being subjected to such a regimen is a feeling of depersonalization. Feelings of depersonalization are frequently considered primary symptoms of mental illness. To complete the circle, psychiatrists usually attribute their patients’ feelings of depersonalization to their internal state and not to conditions within mental institutions. The whole experience of mental hospitalization promotes weakness and dependency. Not only are the lives of patients controlled, but patients are constantly told that such control is for their own good, which they are unable to see because of their mental illness. Patients become unable to trust their own judgment, become indecisive, overly submissive to authority, frightened of the outside world.

This emphasis on dependency reinforced the tremendous power gulf within institutions.

Patients are seen as sick, untrustworthy, and needing constant supervision. Staff members are seen as competent, knowledgeable, natural leaders. These stereotypes are believed by large numbers of patients and staff members. Communication is difficult across this gulf. Staff members don’t believe what patients tell them. Patients don’t believe what other patients say. Patients begin to question their own perception of situations, including their very accurate perceptions that they are looked down on and spied on by the staff.

Chamberlin experienced mid-1960s psychiatry first-hand, spending five months as a patient in six mental hospitals, an experience that left her traumatized.

I had never thought of myself as a particularly strong person, but after hospitalization, I was convinced of my own worthlessness. I had been told that I could not exist outside an institution. I was terrified that people would find out that I was an ex-patient and look down on me as much as I looked down on myself…It was years before I allowed myself to feel anger at a system that had locked me up, denied me warm and meaningful contact with other human beings, drugged me, and so thoroughly confused me that I thought of this treatment as helpful.

On Our Own aimed to create an alternative future, with changed commitment laws, and increased constitutional guarantees for patients. Chamberlin sought to “end the demeaning and harmful psychiatric system and replace it with true asylums, places to which people can retreat to deal with the pain of their existence.” She favored patient-controlled alternatives that emphasized people helping one another, where the gulf between “patient” and “staff” disappeared; but she also recognized the existence of difficult problems,  particularly funding issues and opposition from professionals.  

In the ensuing 35 years, parts of Chamberlin’s vision have been realized. For one thing, the psychiatric hospital system has been pretty much wiped out, which is, on balance, a good thing. The institutional psychiatry of the past was certainly not optimal. I think that the people who compare numbers of lost mental hospital beds to numbers of contemporary jail mental health beds are operating from a misplaced sense of nostalgia and wishful thinking. Confinement, coercion and misery were as nasty then as now, and neither type of institution really works. There are good reasons why so many horror movies are set in mental institutions – and good reasons why today’s hospitals are designed for brief stays and small populations.

Psychiatric jurisprudence has certainly improved. Fewer people are subject to coercive treatment just because their parents are worried. It may be harder for parents to get courts to act, but still, even in the old days parents did not really want their children harmed, which is what the system unfortunately offered. Parents then as now simply want their children to be safe and well. Of course we still have much work to do with respect to court-connected remedies and mandatory care. Many more people are losing their lives to suicide and violence than need to. Stopping suicide and violence is the bottom line for me, but these are always hard cases.

We are, of course, still working on the alternative institutions that Chamberlin envisioned. Chamberlin’s book is a key piece in designing a future where the experience of mental illness comes out right.  

Aug 2, 2012

Campus security failures in two mass killings

In two 2012 mass murder incidents, college security forces were alerted to a student’s potential dangerousness, but failed to act to stop mass violence.  

In June, psychiatrist Lynne Fenton reported Colorado theater shooter James Holmes to the University of Colorado’s behavioral evaluation and threat assessment team.  And in February, twelve days before John F. Shick opened fire inside Pittsburgh’s Western Psychiatric Institute and Clinic, a California gastroenterologist who received a letter from him with bizarre, rambling writing urged University of Pittsburgh Medical School administrator to make haste and investigate the situation thoroughly.

Neither threat was reported to police in the community, even though both shooters lived off campus. Both threats remained bottled up inside of college security systems.

How much of a threat does it take for a college official to pick up a phone and dial 911?


Denver case news report

Pittsburgh shooter case