by Peter ParryJournal of Clinical Medicine. 2014 3:334-347.
Pediatric bipolar disorder is a diagnosis that arose in the mid 1990s in the USA and has mostly remained confined to that nation. In this article a young American man (under a pseudonym) describes his experience of having the diagnosis throughout his adolescent years. His story was conveyed via correspondence and a meeting with the author, an Australian child psychiatrist. The young American’s story reveals several issues that afflict contemporary psychiatry, particularly in the USA, where social and economic factors have contributed to the rise of a dominant biomedical paradigm—or “biologism”. This focus on the “bio” to the relative exclusion of the “psychosocial” in both diagnosis and treatment can have serious consequences as this young man’s story attests. The author explores aspects of his tale to analyze how the pediatric bipolar disorder “epidemic” arose and became emblematic of a dominant biologism. This narrative points to the need, depending on the service and country, to return to or retain/improve a balanced biopsychosocial perspective in child and adolescent mental health. Child psychiatry needs to advocate for health systems that support deeper listening to our patients. Then we can explore with them the full range of contextual factors that contribute to symptoms of individual and family distress.
While it’s refreshing to read a case study, the topic is anything but pleasant. Peter Parry, an Australian Child Psychiatrist, met an young American on-line who had spent his adolescence being treated for Childhood Bipolar Disorder. Later, on a visit to the US, Dr. Parry met and interviewed the young man in person. I’ll not even attempt to summarize what the former patient has to say. It’s on-line and he says it quite well for himself. Likewise for Dr. Parry whose commentary is a particularly clear outline of the damage that can be done when treatment is driven by ideology – in this case the biological mania that swept through psychiatry with the Bipolar Child diagnosis, part if a larger wave of what he calls "biologism." The child lost his adolescence in a medication fog. It’s an important developmental period for all of us, but particularly for a gay man coming into his identity. And Dr. Parry appropriately points out that this epidemic was Made in America.
This is one of those articles that keeps on giving. Back in my underlining days, I would’ve painted the whole thing yellow with my highlighter, but there’s one part that I thought was particularly important in the sea of importants:
3.5 Projective Identification and “Munchausen’s by Proxy”It is traditional wisdom in child psychiatry that parents often project unresolved issues onto their offspring. The children may identify and act out accordingly. Some extreme versions of this can lead to “Munchausen’s syndrome by proxy”, where a parent , through having an ill child, vicariously gains desired attention from respected medical experts for unmet and disavowed dependency needs. It appears that once Adam left the home his mother produced spurious medical symptoms and diagnoses for herself, in other words her own likely case of Munchausen’s disorder.
An early critique of PBD noted that not only could parents have a psychological investment in the PBD diagnosis, but so too could a range of others including the pharmaceutical industry, academic child psychiatry, schools and cons umer advocacy groups. The authors speculated whether PBD may be a “variant on Munchausen’s syndrome”.
This is not to say that there need be any negligence or mal-intent at all. Factors operate at systemic and subconscious levels. Adam’s mother, his doctors and others no doubt acted with Adam’s best interests in mind. A dominant paradigm is hard to see when you’re living and working within it.
Again, it’s refreshing to hear someone talking about Projective Identification, something I consider one of the most powerful forces on the planet. Projection proper is easy. You walk into a room with a stranger and the first thing he says is, "I know that you and my mother have been plotting …" You immediately know that you are the placeholder for his fear. The case may be hard, but at least you’re not struggling wondering if he’s right, as you’ve met neither he nor his mother before. Projective Identification is much more difficult. The patient, whom you know [and knows you], comes for a session late in the day and says, "You’re tired. Listening to patients all day. You don’t want to hear my troubles." And she’s right, at least sort of. You are tired. It is the end of the day. Is the patient making an observation about you that’s true? or projectively identifying an internal sense of unimportance, or perhaps a rage at not being listened to, or something else? The point is that both is the probable answer – that’s the Identification part. The Projection lands on something that is at least partially true.
“Munchausen’s by Proxy” is one of the most difficult of things because all of the forces are unconscious, subjective, and as likely to effect the treaters as the treated. The case of Rebecca Riley should remain emblazened on all of our minds to remind us of the tragic possibilities. While it’s not Parry’s central point, it is an important point. Was the Bipolar Child epidemic largely an example of this phenomena? In the post about Rebecca, I quoted a piece from a deposition of Dr. Biederman:
"But the patients that come to me, and the families in tears and despair with these type of problems, I in good faith cannot tell them, ‘Come back in ten years until we have all the data in hand.’ I still need to use medicines that I am assuming that if they work in adults, with appropriate care and supervision, may also work in children."
Peter’s comments here are dead center:
This is not to say that there need be any negligence or mal-intent at all. Factors operate at systemic and subconscious levels. Adam’s mother, his doctors and others no doubt acted with Adam’s best interests in mind. A dominant paradigm is hard to see when you’re living and working within it.
[I would change hard to sometimes impossible]. And he’s also offering a hint at the correct solution, get an outside opinion [or two or three]. People who are otherwise rational and sane do crazy things when under the spell of Projective Identification. An outside person can often see it clearly. When it’s happening to you, it’s hard to see, but one of the hints is that you’re about to do something out of the ordinary [and rationalizing it]. Dr. Biederman’s comment is something that felt compassionate to him, I expect. But it’s still a crazy, unmedical assumption that, as we all know, mushroomed into an epidemic that became an affliction in its own right to people like Adam. And speaking of Projective Identification and spells, the recent reminders about SRA [satanic ritualized abuse] epidemic is another example, in my opinion [see un·retraction watch…]. The power of Projective Identification underlies my only rule for living:
Never accept an invitation to go crazy…
“Never accept an invitation to go crazy…”
I do not understand; that is, in what concrete context have you been invited to craziness & either accepted (once perhaps) or refused (every time thereafter). What were the consequences.
As stated, it too general &/or abstract for me to grasp. I would like to know more.
I am intrigued.
Sláinte
While now an older piece The Medicated Child from PBS may be of interest.
Steve Lucas
As a nanny for an attachment disordered child, her father and I had been under suspicion of something akin to “Munchausen by Proxy”. Fortunately, we had conversations with adoptive and foster parents, and a school counselor with ten years of experience working with attachment disordered children in state institutions and we got solid advice for dealing with the child. We were also open-minded enough to accept that what worked was often counterintituitive and that if something didn’t work, it didn’t work — try something else. We also both did everything we could to control our own affect and did that quite well, though, admittedly, the necessity of doing so was motivating.
I could tell when she was being manipulative and when she was truly regressed. We have a recording of her crying in tantrum when she was seven years old. Anyone who listened to it would be sure that she was a keening infant. e used basket holds to keep her from tearing up the house. In one tantrum, she bent the square brass connecting rod in a door knob. She was formidable/ She as also near incapable of feeling trust. The stricter we became, the more controlled the environment, the more relaxed and pleasant she became. The difference was real and consequential enough that protests from adults who did not know her or us about us being “too strict” rolled right off our backs.
I’ve found that there is often a knee-jerk response by child specialists of blaming the parents for not being “consistent enough,” as if any child would invariably do Aa if their parent invariably did A. It’s an inadvertent objectification of children. As a child, I understood why the parent asking, “Why doesn’t he listen to me?” wasn’t being listened to and so have always made a point of saying what I mean and meaning what I say to children. And saying it once. There is a lot of bad parenting that results in what should be predictable problems and bad behavior which can be corrected with parenting advice and tutoring.
We knew well enough, with our radishchild, to know that as soon as “the honeymoon” wore off that the adults who thought that they could handle her so much better than we did would find out differently. So we could just smile whenever we heard something like, “Oh. I had a boy like that last year, and by the end of the year he was fine.” At the end of the year, that teacher was literally pulling her hair while she told us, “She’s the most difficult child I ever met! I’ve never met any child like her!! I tried everything!!!” She tried everything but what we told her worked on the day we met her. We knew the teacher was giving her dishonestly rosy conduct reports to “raise her self-esteem” and that it wasn’t working; but she kept doing it. Bless her heart.
What produced this attachment disordered child was her attachment disordered mother, who began bringing the girl to her father when she was a baby because she couldn’t get her to stop crying. That’s what’s called “a clue”. I have to wonder, if one or both of Rebecca Riley’s parents were sociopaths or drug addicts or alcoholics who might as well have been sociopaths, who just wanted the girl to shut up. The fact that they found a psychiatrist who would give them what they wanted is not, I think, evidence of Munchausen, but a failure on the part of the pediactric psychiatrist to recognize the needs of a baby. That’s a pretty basic human failure— not being able to give a two year old the comfort they need— not being able or willing to set aside one’s own non-essential concerns on the behalf of a helpless baby. How on earth did that psychiatrist get away with what she did? The jury certainly found it a miscarriage of justice that she was not on trial. How does a pediatric psychiatrist diagnose a two year old with mental illness? Then treat it with drugs? For two years? While that child was supposed to be taken care of and developing through empathetic care? Without putting the parents under the microscope?
Whether she was blinded by “science” or her own ambitions, it’s not really being called into question in any meaningful way, is it? No parent should be able to complain about their child and have their child diagnosed with mental illness based on their testimony alone.
Agree with getting a second opinion or two or three. Its important to seek out people or articles who have a different orientation or way of thinking. It helps us see what is in our own blindspots.
Logic can be the art of going wrong with confidence.
I think I ended my psychoanalytic training just around the time we got to projective identification. Or perhaps my failure to grasp this was one more push to my falling off the couch. This description is one of the more cogent I have read. But it reminded me of my discomfort with psychodynamic language – do we really need to buy into the notion of dynamic unconscious to describe this? Sometimes people pick up on things about us or perhaps they think things about us that are correct by chance.
The Finns talk a lot about dropping the clinical gaze. They make a big point of accepting and tolerating the uncertainty that is inherent to this field of ours – large with unknowns.
I loved the article but I was least comfortable with the talk of Munchausen’s, by proxy or otherwise. It raises a speculation to a diagnosis. It labels a person and it risks turning conjecture into fact. It is a slippery slope that risks alienating families rather than trying to understand them.
The Munchausen’s by proxy, in this case, allowed the physician to be the victim of conniving parents, and released her from responsibility. Of course physicians can be fooled, but in this case there is no excuse. Dr. Dr. Kifuji had diagnosed the girl with bipolar disorder and ADHD when she was two. The parents were scamming social security disability, all their children were on psyche drugs and so were they. The drugs that Rebecca Riley was prescribed alone were likely responsible for damage to her heart and lungs that contributed to her death.
She was supposed to examine the parents and their interaction with their daughter, but often saw the parents while Rebecca was knocked out from the drugs. Anyone can be fooled by sociopaths and other sorts of scammers, but shouldn’t psychiatrists be on the lookout for this? Before any diagnosis was considered, the parents should have been studied and tested in the hospital and at home. From the sound of it, one unscheduled home visit would have resulted in these two parents losing custody of their children. The girl may have been attachment disordered or just unsocialized to the degree that she would have been difficult for anyone to handle; but being diagnosed with mental illness and drugged before trying all other intervention is just wrong.
Or, perhaps Rebecca really was bipolar and ADHDisordered. It’s not out of the realm of possibility, but that doesn’t change the fact that she was being woefully neglected and abused. A pediatric psychiatrist should be well versed in the effects of neglect/abuse and be able to make a distinction between what is going on with a child aside from what parents report. When me and my charge’s father went through the hoops before and after her diagnosis with RAD, we were thoroughly questioned. We don’t know if it was because we weren’t a conventional “family,” but we did notice that her mother didn’t get away with the manipulative behavior she got away with with teachers, neighbors, and the seedy people she hung out with. On that account, I was quite impressed. Had the Riley’s been subject to similar scrutiny and were required to explain their parenting habits in detail and to demonstrate them, then it probably would have turned out differently. Though it’s important for people in the ‘system’ of SSDI not to be discriminated against and treated like criminals, it’s also important to treat parent’s problems with their disabled children with some reasonable scrutiny and to treat it as a family problem that may require modification of the parents’ behavior before locating a problem to be in the toddler. I’m thinking that this is obvious— exceedingly obvious. What agency does a two year old child have?
It’s most unfortunate that the children they lost to foster parents are statistically more likely to be drugged than other children, but the tables do appear to be turning on that account and every bit of progress is of consequence to many persons.
What it takes to raise an attached and socialized child is often taken for granted, even to the degree that we tend to give ourselves credit for qualities that we have developed from good enough empathetic parenting in our first three years. I’m happy to see that the ACA includes home visits by nurses for new parents and I think it will solve a whole lot of problems before they start.
Wiley-
There is a fundamental question. Is there EVER a reason to give any child the kind of drugs in the doses prescribed in the article with multiple drugs prescribed simultaneously?
I wouldn’t rule it out entirely, Sandra; but if every other intervention is not ruled out first, I can only consider it to be malpractice and a form of institutional violence that is too readily accepted in the world of experimercials, direct to consumer advertising, industry funded studies, and a technocratic approach to medicine that is devoid of the wisdom of the humanities and recognition of most social realities.
I see bio-psychiatry as it is to be a symptom of larger social ills that are made worse by its own fickle history which includes toxic masculinity and unearned certitude, a diminution of women, and the pathologizing of defense mechanisms that is akin to victim blaming. The impact of being labeled as a genetically defective person who suffers because of some endogenous disorder cannot be dismissed as incidental regarding the feelings of helplessness and surrender that that entails. Even having a psychotic episode is not as damning, and it can make it possible to take oneself in hand, so to speak, and put oneself back together with realizations about one’s self and history that might otherwise have been impossible to pinpoint with ordinary thought or rumination.
Psychiatry is right about many things, but seems to have forgotten that somewhere around DSM-4. I’ve no doubt that most people who have become psychiatrists have done so with good intentions and a genuine desire to solve some of the most recalcitrant and elusive conditions known to humankind. But, aside from the necessary corrections in progress, people in the field need to be educated about structural violence and other sociological forces that deform people psychically, making them sick in the process, or sicker in the case of bio-bio-bio drug therapy and the dismissal of human experience and human relations as causative factors in mental distress.
I do believe that psychiatrists in training need to undertake rigorous self-examination of themselves, their biases, and their blind spots before even attempting to figure out what someone else’s problem is.
There’s a lot of information about Rebecca Riley’s family situation and how she was diagnosed. It seems that sedating the children was convenient for the parents and enabled them to collect additional government money. The diagnosis procedure was cursory. Rebecca was grossly overmedicated. That’s my take, anyway.
http://en.wikipedia.org/wiki/Projective_identification
“Is there EVER a reason to give any child the kind of drugs in the doses prescribed in the article with multiple drugs prescribed simultaneously?”
I think the answer is a loud “No,”
“Psychiatry is right about many things, but seems to have forgotten that somewhere around DSM-4.”
That’s a perceptive piece of timing. I think it came before then, but you’re in the right ball park. The DSM-III revolution had some positive and desirable outcomes, I think. But the wheels came off when the “pipeline” began to pour out the drugs, the PHARMA money began to flow into academia, and Managed Care decided to define psychiatrists as medicine men.
There was something else that’s difficult to talk about. The perspective you discuss was unfortunately the “baby” in the “bathwater” that got thrown out in the reaction to the hegemony of the psychoanalysts at the top of psychiatry. I sort of understand most of that, but we “psycho-social” types spent our time as the pariahs for a very long time. That wasn’t universal, but it sure happened enough to extinguish any counterfoil to what followed. I wasn’t around before, but I suspect that the psychosocial world was as impervious to change as we now see the bio world. I’m not sure I see the solution clearly. From my side, there’s one thing I’m sure of and that’s where I direct my efforts. It has been a long hard road for people on both sides of this fence.
Sandra,
No disagreement about “slippery slopes.” My concern about “Munchausen’s, by proxy” and “Munchausen’s” is that both terms are used as if it’s a uniform category, a kind of person. It’s neither. But I get Peter’s point. By Biederman’s comment, he responded to the “tears and dispair” of the parents, but came up with a diagnostic category for their children that spread like wildfire among other people who were seeing other parents in “tears and dispair.” It became a nightmare.
Projective Identification can, as you say, be used as an indictment. It’s not an indictment, it’s a description of an automatic mental mechanism that can become a dominant force in the life trajectory of some people, and there’s no helping them without taking it on, a painful enterprise not engaged lightly. I’m not trying to sell it on the street corner, but if you’re engaged in trying to help people with personality disorders where it’s prominent – it’s essential info.
Thanks, Mickey. I am going to a seminar with Bertram Karon this week-end. I am deep into his writings right now. So psychoanalytic thought is more on my mind than usual. That is way, way off topic, though. Just sharing.
Dr. Steingard,
As the young man Dr. Parry is writing about, I am compelled to defend the aptness of his use of the terms Munchausen Syndrome (MS) and Munchausen Syndrome by proxy (MSBP) to describe both my case and the role this controversial diagnosis plays in the context of child psychiatry and its role within our social context here in the US.
Firstly, I want to state that independently and long before Healy ever used these terms in the context of child bipolar disorder I came to this conclusion about my mother by myself. When I later talked with Dr. Parry through e-mail and in person, I’m sure my conviction about this was congruent with the Healy article he references.
MS and MSBP are indeed heavy, poorly understood labels ( not unlike many diagnoses in psychiatry) and I myself am skeptical about their use and misuse, but as loose concepts they best capture what happened in my situation, on both a literal and factual basis. I know the MSBP diagnosis has been in the press lately and sensational, baseless speculation ( especially critical of the doctors) has occurred on a grand scale, mainly I think because of the strong anti-government political currents in our country at this time, but these diagnoses are important and capture something that I think is hard to explain in any terms less than those of the unconscious.
In my specific case, my mother delighted in telling others how sick I was and would in fact tell others that I had some serious diagnosis that I maybe was only being investigated for (med side-effects). In the psychiatrists office she would greatly exaggerate or even make up symptoms. Even as a youngster it was very clear to me that my mother was motivated to see my behavior through this particular lens and constantly rebuffed my attempts to defend it or provide explanations that didn’t center on the biology-> disease-> symptom-> medicine paradigm. It was perverse and frankly ruined my adolescence. To call this MSBP is in fact quite fitting ( although I am not aware of any cases reported of this in a psychiatric setting). Sadly, this phenomenon is ignored and understudied much to the detriment of children everywhere, in my opinion probably because it is such an uncomfortable, perverse and scary topic to investigate (unconcious moitvation anyone?).
If you asked my mom today which I have, she would not be able to “see” this or admit to it, although in retrospect it was quite clear to me, my brothers and my extended family.
Personally a lot of the anger toward my mother has been replaced as I get older by compassion, that although she was a good mother and quite functional in many respects, that she could be so “characterologically challenged” for lack of a better term, that this is how she would meet her needs for intimacy and self-worth. Additionally, I think Dr. Parry was both prudent and correct in stating that at the same time my mother’s “intentions” were the best, as were my treaters. Additionally my mother has sought out numerous medical diagnoses for herself (serious ones), which I have confirmed she does not have and basically uses this as a coping mechanism. Again how is this explained other than through unconscious motivation?
Granted, most parents of children diagnosed with child bipolar illness whether or not they are emotionally attuned and psychologically minded (all good things for the child) do not have this extreme kind of character pathology to help grease the wheels so to speak. This brings to mind for me two families followed as Dr. Lucas mentions, in the PBS series The Medicated Child, where one family, the well-off couple in Colorado? with a son, who were attuned to their child’s needs and were sufficiently skeptical to question prescriptions and independently assess their impact on him, vs. the younger single? mother with a bunch of kids whose son got his klonopin? upped so he would be better in the morning going to school.
One family is doing a better job, but both are probably doing the best they can. Both are well-intentioned. Where this issue of MSBP may come in on a broader social/community level is; Which parent is more motivated to accept this “biological diagnosis”? My concern is that, for parents who are overwhelmed and poorly equipped to handle the rigors of childcare let alone of multiple children, turning around and saying “wow, i could be doing better for these kids, but my situation sucks and im doing the best I can, so maybe my child doesn’t have a disorder” may be uncomfortable or impossible. In many ways it is much more comfortable to accept this diagnosis, lest anyone’s parenting capabilities and self-worth be cast in a poor light. In this way as a metaphor, the idea of MSBP is useful, I absolutely do not believe Dr. Parry is advocating diagnosing every parents who lacks insight into the meaning of their child’s behavior be diagnosed with MSBP.
And psychiatry as an institution, and as we all know, has gone from extremes on the issue of parent’s roles in the genesis of psychopathology, but currently is at the extreme where parents have basically little or no role in this process. In this way there is a confluence of interests between a parents need for this diagnosis to explain their child’s behavior and psychiatry’s unwillingness to accept the role of parents/environment in child psychopathology. But the problem here is that with a growing literature on the neuroscience of attachment it is just as “unbiological” to claim this stance on the role of parenting. Psychiatry in my opinion, is unmotivated to accept let alone investigate, other explanations for child bipolar behavior because to do so would undermine the fields biological /medical identity to mention nothing of academic prestige, funding, and pharmaceutical influence and support.
My point is that in my situation, the use of the terms MSBP and MS were in fact accurate in a literal sense. On a societal/ community level, the idea of child bipolar as MSBP is also a useful metaphor, I think. For anyone whose encountered, lived with someone who displays illness seeking behavior it is very hard to explain such things in any logical way without resorting to notions of unconscious motivations, which by the way, as I understand it, is increasingly being understood as a characteristic of human cognition with a neuroscientific basis.
(I wrote this very quickly I apologize for any errors)
Btw Dr. Steingard, I relish reading your articles at MIA, and think you’re and awesome person and am extremely thankful for your work!
Very nice examination of the complexity of the Munchausen label, JL.
Two of my mother’s sisters were confabulators. After returning to the states, and catching up with one of my aunts and cousins, my aunt told me that one of my brothers had gone blind. I was devastated until I found out that he had merely gotten a new prescription for his glasses for the stigmatism he had always had.
Another aunt would talk about her husband having lung cancer a lot. One day my cousin and I were thinking about that when it occurred to us that our uncle had had lung cancer for an awfully long time, longer than most people survived it. So we called our aunt. After we asked her how she and her family were doing, she began talking about our uncle’s lung cancer with no prompting at all. In the background, we heard him yelling, “GOD DAMN IT! STOP TELLING PEOPLE I HAVE LUNG CANCER!!”
We were quite relieved that he didn’t really have lung cancer, and we laughed a lot about the exchange. Had she been talking about one of her children, it would not have been funny. He was a hydraulic engineer who worked for Pantex, so maybe her lung cancer thingy was a legitimate fear. Or maybe it was a death wish for her husband; but it was likely just a coping mechanism she and her sister used to manage their own fears. Their childhood experiences at the hands of their parents is nearly unspeakable, and none of us are as aware of what drives us as we think we are, which can be beneficial and prevent us from spiraling into endless speculation. There is no homonculus. Deal with it.
I was just reading some of the open source articles that I think Joseph Arpaia linked to on another thread
http://www.mentalhealthacademy.com.au/author_details.php?authorid=6562
Pediatric bipolar diagnoses going up 4000% in nine years is an indicator in itself that something was running amok. Though I was aware that the diagnosis was changed in the DSM-5 to Disruptive Mood Dysregulation Disorder, I had no idea that follow-up studies had demonstrated that people diagnosed with PBD were no more likely to develop bipolar disorder as an adult than the general population. You’d think that that would be news— very good news, in fact. Pediatric bipolar disorder isn’t spreading like a wildfire in July. Hurrah!
The exclusion of attachment and trauma in favor of biological reductionism as the primary root of mental dysfunction has long seemed wrong-headed to me; but in the case of pediatric bipolar, long held and uncontroversial facts from the behavioral sciences seem to have been abandoned as well. It’s gobsmacking. Toddlers in tantrum is a prime subject for behavioral modification through empathy, feedback, reward, and the modeling of appropriate behavior. A two year old, in many ways, has the intellect of a puppy. A statistic I like to quote that upsets some people, but nevertheless has the sting of truth is that young children and dogs find it worth their while to push limits if parents and owners respectively give in one out of fourteen(?) or so times—I don’t remember the precise number anymore, it was definitely in the teens. Although tantrum is a natural response to frustration, and a natural part of being two years old, it is also a behavior which can be discouraged, while better behavior can be encouraged. I suppose that a lot of parents don’t understand that, which is why I think that human development should be a part of public education from pre-school to high school. It tells us a lot about ourselves, others, and relatedness. Anyone who doesn’t have the time, energy, patience, and competence to properly train a puppy should be encouraged not to have children any time soon if they can avoid it.
And now for the point I originally I wanted to make—
Healy and LeNoury (2007) considered that as industry and others gain from the diagnosis, PBD can even be likened to a case of Munchausen’s by proxy.
I agree. The fact that it is iatrogenic doesn’t change that. Pediatric bipolar appears to be about as real as the effects of “Satanic Ritual Abuse,” dissociation, and multiple personalities. Perhaps it should be noted that there is no DSM classification for the false belief induced by misguided clinicians that one has been Satanically ritually abused by kindergarden teachers.
Mickey, you might be interested in this book— Of Two Minds: An Anthropologist Looks at American Psychiatry
It’s a very earnest and respectful look at the cultures of psychoanalysts and biological psychiatry. After spending time with top psychoanalysts, she asked one of them how many people he believed that he had helped in a remarkable way. He thought about it a moment, then said, “three”. There’s a serious drawback, right there.
I like Peter I. Parry’s term “biobabble”. Next to “psychobabble” it encapsulates the worst of each and something they have in common. I’m liking Sandra’s idea of interdisciplinary teams to replace the current model and have no doubt that useful, if not necessary, concepts and practices from each approach can be used to benefit people in mental distress or crisis. In the end, however, I think what will work best is the quality of the relationships between the helpers and those in need of help.
http://www.amazon.com/Two-Minds-Anthropologist-American-Psychiatry-ebook/dp/B004JHYRWM/ref=sr_1_1?ie=UTF8&qid=1397063092&sr=8-1&keywords=of+two+minds+an+anthropologist+looks+at+american+psychiatry
JL
Thanks so much for your comments. We rarely get this kind of live feedback from actual patients like this. .I hope it will be widely read as accurate recognition can prevent a lot of unnecessary suffering and confusion.
JL,
First of all thank you for your words. Thank you for your comments; I can say that I already think you are pretty awesome! The contribution from you and Dr. Parry is extremely important and I am trying to get every psychiatrist I know to read it.
Let me try to clarify. You are correct that my sensitivity to the term is due to a particular case that has garnered much attention recently.
I have also been recently immersed in reading the work of Bertram Karon, a pioneer in the psychoanalytic treatment of people who have psychosis. So some of this is just a personal thing that I could explain if we ever meet. But it has to do with my history of psychoanalysis and my attempts to pick out form it what I find useful and what I don’t. I deeply respect Mickey and Dr. Karon. I am just not sure about the theory. But I also think they both have something to teach me and I am trying to work that out. Mickey is gracious enough to tolerate my questions and – I hope respectful – challenges.
I am also thinking about how we can be of better help to families like yours. For I do not dispute your account. I see something like this in adults. People go from doctor to doctor accumulating medications and procedures. It can be very difficult to find a way to say to someone, “I get that you are in pain but giving you a new label or drug is not likely to be of benefit.”
I also just worry that MHBP can be used to label people when we have no answers. Many years ago, I did a fellowship in Behavioral Neurology. I was the psychiatrist who would consult to the neurology service. Typically people would come in and get a work up. When their tests did not reveal anything conclusive, the neurologists would conclude the problem was “psych”.
But thank you for your comments her and in the article! They are very much appreciated.
It’s Doctor Perry that I want to thank for those open-source papers on pediatric bipolar disorder. One can never be too sober.
Karon sounds interesting, Sandra. Might his perspective have the same problem that biological psychiatry has with reifying a category that doesn’t actually exist as a discrete condition? I have no doubt that an uncle of mine suffered “chronic terror.” When not psychotic and not on drugs he could be sweet as a baby bird and very easy to talk with— he was a sensitive and empathetic person. He was also the only member of his family who spoke the truth about his father. I’m thinking that that was his role among his siblings— projective identification, yada yada. My mother’s role was to acknowledge their grueling poverty.
But then I think about “Will”— he was known as being schizophrenic. He was able to live in a student housing co-op in which 100 + people traipsed in and out all day. Sometimes he would sit in front of a mirror in the entrance hallway amusing himself by making sloth like movements and making faces at himself. I and my housemates had seen many people stopped in their tracks by the first sight of him. Some would look at us questioningly. We would smile and shrug our shoulders, which was all the assurance they needed to not worry about him. They could go around him by taking a short detour through the living room, and it appeared that many of them did so more as to not interrupt him than out of aversion. He wasn’t a threat and wasn’t treated like one. We were a democratically operated household, if he were a problem, he wouldn’t be there. Whether or not he was on medication wasn’t an issue for us. I cannot imagine that happening now with the alleged stigma reduction of bio-psychiatry. He was able to associate freely, come and go as he pleased, and was treated kindly.
But, he started to isolate himself, stopped eating and bathing, and started to spend most of his time chain smoking on a dirty mattress on the floor of his room. We weren’t bothered that he used kitchen matches, and struck them on the wall by his bed to light his cigarettes; it was the fact that he had narrowed his existence to a very small space and an economy of energy that was severe.
The prospect of him burning to death and torching the house was a real concern to his roommate, but because anyone else who smoked and drank could have posed the same threat, I focused on his incompetence. No one was in such a relationship with him that they were committed to or had any idea what to do to about his wretched condition. He had gotten gaunt and very unhealthy looking. He could have been suffering from any number of physical illnesses. I told my housemates that I was going to call his parents because I felt that it was irresponsible to let him dissipate like that. Several reacted by crying, “Noooo— his parents made him that way!”
I talked to his mother and recognized Will’s good nature and gentleness in her. She was concerned, but not reactionary or dramatic. We talked for about an hour. I simply cannot imagine her having made him psychotic. The father? I don’t know, but I find it hard to believe that everyone who fits the description of schizophrenia is in a state of “chronic terror” from abuse. The possibility that some suffer from what can be described as schizophrenia due to an in vitro virus, for instance, might explain why some people prone to psychosis do not come from abusive or neglectful homes. Though I’m sure a lot of homes that do not appear to be overtly abusive or neglectful are perfectly capable of making a child act and feel crazy.
I think the movement to dispense with psychiatric labels may be on to something that could clear up a lot of confusion by not starting from a position that is too loaded with alterity to be a useful lens with which to relate to another human being in real-time. However, regardless of labels and schools of thought, psychotic episodes are very real and powerful. Not talking about them is bizarre, especially in the context of a professional psychiatric relationship.
Wiley,
You bring up an interesting point. I also do not think there is “one” explanation for all psychosis. I am troubled by that notion no matter its origins. You describe well how the impulse to intervene on another’s behalf is not in every instance an over reaction.