voices…

Posted on Monday 26 August 2013

When I came to psychiatry, I was not drawn by the major disorders like Schizophrenia or Manic Depressive Illness. My experience with madness was like most, spotty from encounters in life – a Manic who wandered into a clothing store where I worked, a medical school classmate who had a psychotic break in our first year, things like that. My interest was in the walking wounded, in part because I’d realized that realm was not so personally distant after all. But those first years of residency were spent primarily among the ranks of the very ill. And the realities of those acute wards in the VA, the state facility, and our charity  hospital were as disconnected from the uplifting deinstitutionalization and scientific pharmacotherapy rhetoric of our lectures as you could imagine. It was a time like now when in the public dialog, psychiatry was described as the problem, but that was hardly the point on those wards where wheelchairs were as frequently flying missiles as conveyances. It was an unfamiliar terrain where my first patient had drowned two of her children under God’s direction [something I've personally not seen since]. But in those days, I understood early why psychiatrists had been called Alienists.

I’ve wondered over the years, why I never looked back to my first career as an Internist embedded in the comfort of hard science. It felt like I’d moved to a new country, and I hadn’t come for as visit but to stay. I mostly remember night call, when a steady stream of patients were reluctantly brought in because they weren’t handling the world and were making that extremely clear, but rarely seemed to to be glad to be in the emergency room either. So many stories. Once, I made the mistake of sitting by the door interviewing a very agitated and psychotic young man, inadvertently blocking the exit. I found myself held aloft against the wall looking at a cocked fist. I said, "You’re scaring the hell out of me." He said, "You’re not afraid of me!" I hastened assure him that I was very serious about my fear [and I was]. He stopped and said, "You got a straight jacket?" I said, "We don’t have those anymore, but I have some officers who can take us to a safe place." And he walked with me to the locked ward where we talked calmly. So many stories on the way to learning about fear, mine and other’s.

But that’s not the story I started out to tell. I developed something of a hobby on those nights. We saw a lot of patients who were "on the road" traveling on some journey with no clear destination. I began mapping their travels. I remember one guy who had been moving in enlarging circles from his parents’ home in Baltimore. I sketched his forrays on a desk-blotter map as he recounted his travels. I made up a name – Schizophrenia Migrans – the wandering Schizophrenic, and there were many. I speculated that they were looking for a place that "felt right" and I think I was right about that. I spent those early years doing what I do in an unfamiliar place – I read and read. I came to see what we call Schizophrenia as a way of living, hardly alien, just different with different rules, and I considered making it a life work. But as most of us know too well, we were headed for a time of medicalization and that wasn’t where my own wanderings were headed. So after those years, I drifted into the equally fascinating world of neurosis, a word now villified [unless you live there]. But those early years are still emblazoned on my memory and come up frequently.

So to my story. One night, I was lying on the bed in the on-call room. It was off a hallway that lead to the Emergency Room desk. I recall that I was reading a book by Allen Wheelis, a psychoanalyst/writer who had had his own brushes with psychosis and wrote about it eloquently. Earlier, I had admitted a young man to our "overnight" unit in the ER itself. He was such a case of Schizophrenia Migrans who had been picked up on the highway confused and psychotic. On arrival, he’d said, "I need some meds" and told me which one. The "voices" had become ominous. As I was reading later, I became aware of a presence and turned to see him standing in the room near the door. He said something like, "I was wondering. You seem like a nice guy, and I was wondering if you wanted to hear my voices." I don’t recall what I said, but it wasn’t "yes." He said, "I understand. But, you know, when you’re on the road, they can be great comfort – like company, except sometimes they really turn on you." And he went back to bed.

That said, this morning I read Allen Frances’ post, Psychiatry and Recovery: Finding Common Ground And Joining Forces, about a TED talk video. The comments focus on Dr. Frances and his discussion, pro and con about disease models, medications, and the like – arguments we’re all familiar with. I have another hobby – one about dilemmas. I can argue either side with equal facility, sure I will leave no lasting legacy on either side of that coin. Instead, I thought of my stories as an introduction. Here’s the fascinating video:

  1.  
    Karen Nolan
    August 26, 2013 | 12:44 PM
     

    Thank you for sharing this. Those of us who are trained to identify “symptoms” tend naturally to assume that our goal is to eliminate them. What’s the old saying – if all you have is a hammer everything looks like a nail?

  2.  
    Steve Lucas
    August 26, 2013 | 3:31 PM
     

    Some of us just wish we had a hammer so we could better understand some very puzzling motivations.

    Steve Lucas

  3.  
    CannotSay2013
    August 26, 2013 | 8:15 PM
     

    Allen Frances is a profoundly misguided individual and so are those who think along his lines.

    On one side he recognizes that,

    “Schizophrenia is most certainly not a unitary disease. Its symptom presentation is very variable and there will likely be hundreds of different underlying causes. Indeed, the term ‘Schizophrenia’ is confusing, stigmatizing, and has probably outlived is usefulness.”

    You’d say, WOW, he admits that? Before giving you time to get excited, he goes on to say,

    “But the concept of schizophrenia still remains necessary and is no myth, as claimed by Thomas Szasz and his followers.”

    Even though, in a recent post he, for the first time since I have been reading his columns, went on to say,

    http://www.psychologytoday.com/blog/saving-normal/201308/two-flew-over-the-cuckoos-nest

    “At the time I loved my work on that terribly flawed unit and thought I was helping people and learning a lot. It was only later when I had gathered much greater experience in the wider world of psychiatry and life that I realized I was also hurting people and learning a lot of the wrong things.”

    So here is a man who,

    - Is aware that DSM labels are constructs that are not backed by biology

    - That many, if not all, of those constructs might be caused by people’s reactions to personal circumstances that have nothing to do with “medical issues”

    - Is aware that imposing the notion that schizophrenia as a “medical problem” has resulted in he himself harming individual people (beyond his role of chairman of the DSM-IV taskfoce).

    Still, he considers the current paradigm of psychiatry worthy and deserving of improvement because “done well” helps a lot of people. Nevermind that the cumulative data says otherwise (from the CDC numbers on the increase in suicide rates to the different studies that speak of bad secondary effects experienced by people taking psychiatric drugs).

    In a way, it doesn’t come as a surprise that those who believe in pseudo science, as Allen Frances does, are not persuaded when the data contradicts their pseudo science. They would not be practicing pseudo science if they believed in science in the first place!

  4.  
    a-non
    August 26, 2013 | 8:17 PM
     

    The complexity of the hammer itself is not understood in the larger context of things-whats this thing doing in unison?
    https://en.wikipedia.org/wiki/File:Hydraulic-Powdered_Trip_Hammers.jpg

  5.  
    Tom
    August 26, 2013 | 9:30 PM
     

    Longden’s presentation is powerful, uplifting, and moving. It gives hope to a lot of people suffering with psychotic symptoms. She seems to have been blessed with a keen intellect, and her “disorder” or “illness” never over-powered her “observing ego” or capacity to reflect and reason in a reality-based manner about her “symptoms” or experiences. Her discussion of her battles (and understandings, dialogues and compromises) with her voices led me to think about Martin Harrow’s work indicating that a subset of those individuals we label as “schizophrenic” are able to do well in the long term without the aid of medication. Harrow interpreted his results to mean that some “schizophrenics” have enhanced premorbid capacities and adaptive assets that allow them to to function well and essentially overcome their “illnesses.” Others, of course, say his results indicate that medications are harmful in the long run as far as recovery is concerned. I don’t pretend, and psychiatry certainly doesn’t have, the answer to this riddle.

  6.  
    wiley
    August 27, 2013 | 12:07 AM
     

    “Mental distress” is a useful and honest term.

  7.  
    Richard Noll
    August 27, 2013 | 9:09 AM
     

    I could not help but engage in a time travel fantasy when i watched this clip of Eleanor Longden’s compelling testament. I imagined taking this video back to 1990 America and showing it to a large conference of mental health professionals in Chicago that I attended that was organized by Dr. Bennett Braun, a psychiatrist who was also deeply involved as a member of the DSM working group for the dissociative disorders.

    In the historical moment of 1990 her diagnosis would have been clear: multiple personality disorder. It’s all there: the history of childhood trauma and sexual abuse, the autonomous voices who seemed to have their own agendas (good and bad for her), the diagnosis of schizophrenia (which the experts at the time said was often a misdiagnosis hiding the “true” diagnosis), and so on.

    Perhaps her treatment would have been different as well: her therapists may have encouraged her, perhaps under hypnosis, to recover hidden memories of abuse, including, perhaps, recovered memories of her abuse conducted by family members who belonged to satanic cults. I suspect that the fact she seemed to be in the UK and not in the US may have protected her from the cultural scripts of that era. If she had been in the US, and had been affluent enough to be admitted to one of those dissociative disorders/MPD treatment units that were set up at Rush-Presbyterian hospital in Chicago or the Institute of the Pennsylvania Hospital in Philadelphia, she may have not only been encouraged to recover memories of satanic ritual abuse but also acknowledge her voices as “alters” or “personalities” with names and histories.

    I attended a presentation on Dr. Braun on MPD and satanic ritual abuse at that conference in which he displayed crayon drawings of his MPD patients. I remember one that looked like something a 3 yr-old might make: multicolored scratches on a piece of paper, but with a heavy emphasis on the use of a red crayon. Dr. Braun’s eyes lit up when he showed this. “See the satanism!” he cried out, jumping out of his seat with an almost sexual excitement. “See it!” Around me, eyes widened, mouths opened in awe, and heads nodded. The audience bought it. they were, after all, in the presence of a man at the top of the psychiatric profession. I still remember this incident as one of the most insane things I had ever encountered in my professional life, and that says a lot considering the years I spent working on inpatient units.

    Another DSM working group member, psychiatrist Richard Kluft, published an editorial in 1989 in the journal he edited –Dissociation — in which he urged clinicians to not rush to judgment about the factual basis of patient reports of recovered memories of satanic ritual abuse. He cautioned them not to be “good Germans” who ignored a possible “hidden Holocaust” that might be going on. With the top experts in this area of psychiatry making such statements, far too many mental health and law enforcement professionals followed this advice.

    But Ms. Longden’s testament is of our time, not that time. She hears voices and works with them, not alternate personalities. She does not hint at a family history of Black Masses where babies are ritually sacrificed by grandma and grandpa dressed in red robes. Our cultural narratives are different in 2013, and so are the frames for the stories we tell ourselves about our struggles.

    In his many books historian Edward Shorter vividly illustrates how cultural scripts and patient narratives are historically framed. The philosopher Ian Hacking has written extensively about MPD, Asperger’s, etc., and has suggested ways in which we all begin to think, feel and behave in accordance with the social assumptions of the diagnosis we are given and in some instances (such as with Asperger’s), social identity groups are formed by those who see themsleves in new ways because of a shared diagnosis and then advocate for its continuance.

    Just some thoughts, and a little time travel fantasy, about a dark time in American psychiatric history (which, although well-documented by journalists and others, has largely been untouched by historians of psychiatry). After DSM-III appeared in 1980, psychodynamic clinicians were squeezed by the new diagnostic scheme, and the Dissociative Disorders group served, for a time, as the last island of refuge of clinical relevance for many, but unfortunately the serious consideration of claims of ritual abuse at the hands of satanic cults damaged the otherwise valuable therapeutic approaches to trauma-induced conditions for quite a few years after that.

  8.  
    Nick Stuart
    August 27, 2013 | 12:44 PM
     

    ‘Allen Frances is a profoundly misguided individual and so are those who think along his lines.’

    True.

    “But the concept of schizophrenia still remains necessary and is no myth, as claimed by Thomas Szasz and his followers.”

    I am totally astounded at how psychiatry continually misrepresents the work of Szasz (or else does not have the intellectual capacity to understand his position.) Of course Szasz did not say conditions that are called ‘mental illness’ do not exist, only that there is no biological or scientific evidence to prove that ‘bad’ behaviour is a pathalogical disease. (Which is the current position today). He of course used the word ‘myth’ in its true academic meaning as per Gilbert Ryle.

    “A myth is, of course, not a fairy story. It is the presentation of facts belonging in one category in the idioms appropriate to another. To explode a myth is accordingly not to deny the facts but to re-allocate them”

    Being ‘sick’ in the mind is a metaphor that has become literalised. A joke may be called ‘sick’ but we do not send the comedians to their doctor. For over 50 years psychiatry has failed to engage Szasz’s arguments but current views, Insel et al, are now Szaszian!

  9.  
    August 27, 2013 | 3:35 PM
     

    As Richard Noll points out, psychiatry seems to be susceptible to fads. For speculation of why this is so, see The Last Psychiatrist’s exegesis of House of Games http://thelastpsychiatrist.com/2013/05/dove.html , where the focus of a con is a psychiatrist, who is all too willing to be recruited.

  10.  
    a-non
    August 27, 2013 | 8:47 PM
     

    “After DSM-III appeared in 1980, psychodynamic clinicians were squeezed by the new diagnostic scheme, and the Dissociative Disorders group served, for a time, as the last island of refuge of clinical relevance for many, but unfortunately the serious consideration of claims of ritual abuse at the hands of satanic cults damaged the otherwise valuable therapeutic approaches to trauma-induced conditions for quite a few years after that.” -Richard Noll

    A fad diagnosis might also $erve a$ an important venue in Community Mental Health:
    “Nonprofit Faith Based Grants”
    http://us-government-grants.net/nonprofit-faith-based-grants/

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