{"id":59038,"date":"2015-08-12T15:25:20","date_gmt":"2015-08-12T19:25:20","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=59038"},"modified":"2015-08-15T15:34:13","modified_gmt":"2015-08-15T19:34:13","slug":"dont-take-sides","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2015\/08\/12\/dont-take-sides\/","title":{"rendered":"don’t take sides…"},"content":{"rendered":"\n
While it’s not fashionable these days to acknowledge that Sigmund Freud even existed other than as a caricature, a container for the things he got wrong, this is one of those places where I would evoke something he got right – neutrality<\/font>. Actually, his daughter Anna wrote it down in the most frequently quoted form, saying the analyst "takes his stand at a point equidistant from the id, the ego, and the superego." In just plain English that means, "Don’t take sides."<\/sup><\/em><\/div>\n
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Stepping Up to Address Our Nation’s Shame<\/a><\/div>\n
Psychiatric<\/font>News <\/font><\/strong><\/div>\n
by Ren\u00e9e Binder, M.D.<\/div>\n
July 13, 2015<\/div>\n

… In June, I arranged for the Board of Trustees to tour San Quentin in northern California. It was a powerful, moving, and formative experience, and I’m thankful to Dr. Paul Burton, the chief psychiatrist, and to the California Department of Corrections and Rehabilitation for giving us that access. Our visit was important because, if one wants to understand firsthand the toll mental illness is taking on our country, one just needs to peer beyond the bars of our nation’s jails and prisons. It’s also important to have a detailed and nuanced understanding of the situation. Our tour was a no-holds-barred look at San Quentin State Prison. For three hours, we were shown various aspects of prison life…. We specifically saw the psychiatric facilities, which are highly used by the inmates. In many ways they are state of the art. As you’d expect, sharp angles in the halls and cells, down to the door hinges and door handles, were filed smooth to prevent inmates from using them to aid in a suicide attempt. Many cells provided a sanctuary for inmates, nearly always curled up on a plain bed with a blanket covering them head to toe.<\/p>\n

But the rooms that captivated our group were the group therapy rooms. Separate enclosures or “modules” formed a semi-circle for people who are at once both dangerous and needing and deserving of help. We briefly observed one group. Those participating highly praised the care they were getting. One patient’s body language told us when he had enough of our interruption; in a visceral way, it was clear he valued his treatment. <\/p>\n

The four psychiatrists with whom we interacted were obviously compassionate and concerned about each of their patients. At each stop, it was abundantly clear that the care provided by the staff psychiatrists was superb and professional. Even if incarceration itself is likely a detriment to many individuals’ mental health, the physician-patient interactions we witnessed gave us hope…<\/p>\n

Jails and prisons have become the front lines of treatment for mental illness. The data indicate that San Quentin is an anomaly in the quality of care that’s available in such a setting. This is likely due to its proximity to a highly desirable metropolitan area and its affiliation with the University of California, San Francisco, Department of Psychiatry. <\/p>\n

According to a 2010 study by the Treatment Advocacy Center and the National Sheriff’s Association, there was one psychiatric bed for every 300 Americans in 1955. By 2005, that rate dropped to one psychiatric bed for every 3,000 Americans. Over time mental illness has been criminalized, and our jails and prisons take up the slack, despite being seriously ill-equipped to do so. Our jails and prisons have turned into warehouses for those with mental illness; the number of people with mental illness in jails is three to six times higher than that of the general public.<\/p>\n

This is why APA and the American Psychiatric Association Foundation have joined forces with the National Association of Counties and the Council of State Governments Justice Center in the “Stepping Up” Initiative. The initiative seeks to reduce the number of people with mental illness in our prisons and jails by promoting the use of mental health courts and diverting minor offenders who have mental illness to treatment resources rather than incarceration…<\/p>\n

We must reduce the use of our jails and prisons as warehouses for Americans with mental illness, partly to help our patients, but also because of what this tragedy says about the kind of nation we are. This is an effort for our patients, for our profession, and for our nation.<\/div>\n<\/blockquote>\n
I personally couldn’t be more pleased that Dr. Binder wants to do something about this very real  problem, but this reporting doesn’t acknowledge the layers of history and controversy that lie embedded in this particular mustard seed – dating all the way back to Philippe Pinel<\/a> and beyond. It frames the problem from one particular vantage point. But as soon as one does that, you hear:<\/div>\n
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… psychiatry’s concern about the imprisonment of the mentally ill is being used by advocates of forced outpatient treatment as a Trojan Horse.  The advocates for forced treatment in outpatient settings [such as the Treatment Advocacy Center] argue that forced drug treatment would prevent the mentally ill from ending up in prison, and thus their legislation, which in fact curbs the civil rights of citizens in profound ways, comes cloaked in the rhetorical garb of “humanism.” If we are going to have an honest societal discussion about the shame of imprisoning the “mentally ill,” then it needs to be completely decoupled from that legislative agenda. Indeed, an argument can be made that the growing imprisonment of the “mentally ill” is yet another example of how our drug-based paradigm of care has failed us. The use of psychiatric medications in our society has exploded over the past 25 years; there is great societal pressure put on people diagnosed with schizophrenia or bipolar disorder to take their medications; and yet we now have this problem of hundreds of thousands of “mentally ill” in prisons and jails…<\/div>\n

<\/p>\n

However, I do agree with Allen Frances on this point: Any effort to remake mental health care in this country needs to include a focus on what can be done to help the multitudes of poor people and disenfranchised people who show up in distressed emotional states in emergency rooms and homeless shelters, and the eventual routing of many such people to jails and prisons.  But, in my opinion, if we want to find a solution, we should focus on providing housing, social support and jobs that help people lead meaningful lives. If we want to reduce the number of people said to be mentally ill and in jail, then we should focus on reducing poverty in this country. Substantially raising the minimum wage would, undoubtedly, be a good first step in addressing this problem… <\/div>\n
A Debate Between Allen Frances and Robert Whitaker<\/a>
Robert Whitaker<\/font><\/strong><\/div>\n<\/blockquote>\n
Sound familiar? Here’s another version from the last time around: <\/div>\n
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For some time now I have maintained that commitment—that is, the detention of persons in mental institutions against their will—is a form of imprisonment; that such deprivation of liberty is contrary to the moral principles embodied in the Declaration of Independence and the Constitution of the United States; and that it is a crass violation of contemporary concepts of fundamental human rights. The practice of "sane" men incarcerating their "insane" fellow men in "mental hospitals" can be compared to that of white men enslaving black men. In short, I consider commitment a crime against humanity. In the first place, the difference between committing the "insane" and imprisoning the "criminal" is the same as that between the rule of man and the rule of law: whereas the "insane" are subjected to the coercive controls of the state because persons more powerful than they have labeled them as "psychotic" "criminals" are subjected to such controls because they have violated legal rules applicable equally to all…<\/div>\n

The fundamental parallel between master and slave on the one hand, and institutional psychiatrist and involuntarily hospitalized patient on the other, lies in this: in each instance, the former member of the pair defines the social role of the latter, and casts him in that role by force…<\/p>\n

In this therapeutic-meliorist<\/a> view of society, the ill form a special class of ”victims” who must, both for their own good and for the interests of the community, be "helped"  — coercively and against their will, if necessary — by the healthy, and especially by physicians who are "scientifically" qualified to be their masters. This perspective developed first and has advanced farthest in psychiatry, where the oppression of "insane patients" by "sane physicians" is by now a social custom hallowed by medical and legal tradition. At present, the medical profession as a whole seems to be emulating this model. In the Therapeutic State toward which we appear to be moving, the principal requirement for the position of Big Brother may be an M.D. degree.<\/div>\n
Involuntary Mental Hospitalization: A Crime against Humanity<\/a>
Thomas Szasz, <\/font><\/strong><\/div>\n<\/blockquote>\n
I want to say "ditto" to my last post. Dr. Binder seems to be a decent person, and I expect her concern for the jailed psychotic people is genuine. But she isn’t talking like she knows what awaits her up ahead. The collective other have decided that the problem isn’t mental illness but something else. She should probably go to the Mad in America site and read a few blogs, then read the British Psychological Society’s report, then think about this era of KOLs we’ve just been though, before proceeding as if good intentions will carry the day. She doesn’t seem to grasp that she’s now representing an organization that many see as the problem rather than part of the solution. <\/div>\n

Right now, there’s an enormous and somewhat understandable back lash to the recent era of psychopharmacological\/neuroscientific goings on, and pressing ahead without addressing all the conflicts in the air is likely to be a lesson in futility. The sentiment expressed above by Robert Whitaker and in the British Psychological Society’s Report suggests that psychotic conditions aren’t, in fact, mental illness at all, but rather some barometer of social ills and imbalances, or even a sign of psychiatrists not listening. <\/p>\n

If Dr. Binder is serious about approaching this problem, she’s going to have to address all of the views. The official mouthpieces in psychiatry right now seem to think that they can just ignore what’s happened in these last 20 or 30 years if they start behaving in more rational ways now. They think that they can avoid acknowledging the sins of the fathers. That is unlikely to help anyone at this point.  All they’re going to hear about is forced drugging, imprisonment, overmedication, "bio-bio-bio," medical models, the DSM-whatever, pharma this and pharma that. <\/p>\n

Dr. Lieberman had a shot at attacking and discounting the critics which was decidedly ill-conceived. Dr. Summergrad was more balanced, but didn’t address or acknowledge the conflicts in the air. Dr. Binder has the opportunity to take a different and more realistic tack, but I’m afraid that the course she’s setting here could use a bit more thought because it raises specters she’s failing to mention. For the moment, it would be a much better idea to look into problems like this one, and get input from as many players as she can find. "We must reduce the use of our jails and prisons as warehouses for Americans with mental illness"<\/font><\/em> is totally correct. But for the moment, she needs to listen to some time honored advice, "Don’t take sides." At least not yet…<\/div>\n","protected":false},"excerpt":{"rendered":"

While it’s not fashionable these days to acknowledge that Sigmund Freud even existed other than as a caricature, a container for the things he got wrong, this is one of those places where I would evoke something he got right – neutrality. Actually, his daughter Anna wrote it down in the most frequently quoted form, […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-59038","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/59038","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=59038"}],"version-history":[{"count":27,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/59038\/revisions"}],"predecessor-version":[{"id":59139,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/59038\/revisions\/59139"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=59038"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=59038"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=59038"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}