Monthly Archives: January 2015

Lancet Psychiatry: "Do we need to talk?"

Yes, we need to talk. And the links I have collected here point to a theme I would like to talk about: 

PEOPLE ARE NOT LAB RATS
LAB RATS ARE NOT NATURAL RATS IN NATURAL ENVIRONMENTS
EVIDENCE-BASED PSYCH : HUMAN LIVES = RATRUNNING : ECOLOGY



There will be more comments later, for now I’m just quoting the conclusion:

Some people benefit from drugs; some from psychotherapy; some from simple lifestyle changes (including cat ownership); and some from all three. Mental health professionals must work together and learn from one another to give patients timely, appropriate, and honest advice regarding the best options for them. 

And inserting a relevant question: 
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pp: 75-157

http://journals.lww.com/jonmd/pages/currenttoc.aspx

Defining and Refining Self-Harm: A Historical Perspective on Nonsuicidal Self-Injury

Angelotta, Cara
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What Do Psychiatric Patients Believe Regarding Where Control Over Their Illness Lies?: Validation of the Multidimensional Health Locus of Control Scale in Psychiatric Outpatient…

De las Cuevas, Carlos; Peñate, Wenceslao; Betancort, Moisés; More
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Emotion Recognition Impairment in Traumatic Brain Injury Compared With Schizophrenia Spectrum: Similar Deficits With Different Origins

Mancuso, Mauro; Magnani, Nadia; Cantagallo, Anna; More
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Attachment in Romantic Relationships and Somatization

Neumann, Eva; Sattel, Heribert; Gündel, Harald; More
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Nonverbal Communication of Patients With Borderline Personality Disorder During Clinical Interviews: A Double-Blind Placebo-Controlled Study Using Intranasal Oxytocin

Brüne, Martin; Kolb, Meike; Ebert, Andreas; More
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Processing of Facial and Nonsocial Information Is Differentially Associated With Severity of Symptoms in Patients With Multiepisode Schizophrenia

Barkhof, Emile; de Sonneville, Leo M.J.; Meijer, Carin J.; More
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Psychiatrists’ and Primary Care Physicians’ Beliefs About Overtreatment of Depression and Anxiety

Lawrence, Ryan E.; Rasinski, Kenneth A.; Yoon, John D.; More
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A Quantitative Review of Cognitive Functioning in Homeless Adults

Depp, Colin A.; Vella, Lea; Orff, Henry J.; More
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Extended Family and Friendship Support Networks Are Both Protective and Risk Factors for Major Depressive Disorder and Depressive Symptoms Among African-Americans and Black…

Taylor, Robert Joseph; Chae, David H.; Lincoln, Karen D.; More
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Intensive Multidisciplinary Treatment of Severe Somatoform Disorder: A Prospective Evaluation

Houtveen, Jan H.; van Broeckhuysen-Kloth, Saskia; Lintmeijer, Lotte L.; More
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WHEN I HANG FROM AN OUTCROP

Wikimedia commons *
by bruised and bloody fingertips

there are certain actual needs I have.
Even when the cliff is not of stone.


I need eyes that see the abyss.
Eyes that see me, where I hang.
I need strong arms that hold a rope.
Even when the arms are not of flesh and bone.

I need a friendly presence
while deathfear cramps itself out.

I need safe silence when I have no words.
When words are there, I might need:

“What happened?”

I need a clear brain that reality tests with me:

Did I stumble?
Was I pushed?
What do others own?
What do I own?

I need someone who gives me time and space
to find what I can learn from my past.
When the time is right.

My time.

Someone who knows that it is my abyss.
These are my fingers.
This is my past.
Someone with guts to stay beside me
and does not try to show the way.

Can you give me what I need when I hang over an abyss?
If you can’t, more than anything else,
I need sentences that begin with “I”:

I won’t


I am afraid

I do not see you
I cannot help you
I don’t know what’s going on 
I do not understand what you are talking about
I am afraid of doing something wrong
I am fed up with talking about this
I cannot bear to go where you are now
I don’t want to know.
I can’t …
I won’t …
       I …
    I …
I …

When you say it like that
you own your reactions.
You don’t give them to me.

Rude, you say?
Subjective, you say?
Have a look at this:

Patients with your diagnosis …
You really need …
You are delusional
You are paranoid
You lack insight
There’s nothing you can do about it
Don’t worry about it
Your problem is …
You have to realize that you are ill
You can become whatever you want to be
You are overreacting
You …
You …
You are so aggressive and unpleasant
You have talked so much about this
Why did they do it?
Why did you do it?

You need to understand and forgive
You need to love
You need …
You need …
You need …



Don’t think about it

Don’t feel guilty
Don’t let problems stop you
Don’t be so negative
No limits to what you can do! 
Realize your limits!
Learn to live with your problems!

Put them behind you!

GET OVER IT!





Is this polite?
Objective?





Postscript: Have I been “psychotic”? I don’t know. 24 years ago there were months when I was hallucinating, hearing voices, suicidal and very confused, and I managed to hide these symptoms from my family and the health services.  


I had an inner image of  hanging on to a teetering “me” when people in my surroundings were trying to push me into a void. And this “me” was validated and strengthened by memories of people I had known and loved as a child, so I was actually hanging on to them, to what it felt like to be with them, what safety and trust and acceptance felt like. 


And I knew how my mother acted and what she did before she lost touch with reality, so I knew not to go into her world of polarization, of insisting that everyone else was crazy. 


And I finally managed to communicate with my inner critic, who knew that I was wrong, and that the world would be a better place when I was dead. That story is in “Psychiatry or liberation?“, but you need to scroll down a bit. That broke the spell. 

* “Preikestolenjuni2009” by Kjwathne – Own work. Licensed under CC BY 3.0 via Wikimedia Commons. 

BORDERLINE LINKS

I apologize. I posted a draft by mistake yesterday. So, to fill this space, I give you some links.


I decided a long time ago to flaunt my borderline diagnosis as a banner of autonomy. That liberated me from the shame and humiliation that is a harmful side-effect of borderlining. Rebecca J Lester describes this in Lessons from the borderline: Anthropology, psychiatry, and the risks of being human:

Clinicians generally detest working with borderline patients.1 These clients can present as unpredictable, needy, hostile, overly dramatic, and emotionally draining. As McGlashan (1993: 241) observes: ‘Officially, ‘borderline’ is a diagnostic label. Unofficially, in clinical parlance, it is synonymous with ‘anathema.’’ Gabbard (1997: 26) elaborates: ‘A significant number of professionals within the industry regard borderline patients with contempt.’ And as one psychiatrist told anthropologist Tanya Lurhmann (2000: 113), you look for the ‘meat grinder’ sensation: if you are talking to a patient and it feels like your internal organs are being turned into hamburger meat, she’s probably borderline.


Link to: People with a borderline personality disorder diagnosis describe discriminatory experiences

The experiences described by some participants regarding making complaints provide food for thought; the idea that making complaints is typical behaviour for someone with a BPD diagnosis seems to be a powerfully silencing one, positioning the client as someone whose complaints are trivial and/or pathological. The idea of BPD diagnosed clients as prone to making complaints probably also has ties to this client group being seen as difficult and angry, and being responsible for ‘splitting’ staff (Gallop 1985).

In my frame, the symptoms that get labelled Borderline Personality Disorder are symptoms of societal harm, loss, trauma and border violations. The meat grinder sensation is discomfort at getting a glimpse into an invisible war zone that the professional does not want to know about, and the diagnosis of “Borderline Personality Disorder” is generated by a professional Somebody Else’s Problem field and upheld by little homunculi that are jumping up and down in professionals’ heads.

In a strange double bind, psychiatry is clear about there being no need to be ashamed of having been sexually used, hit or gaslighted – and then treats the symptoms of having been used, hit or gaslighted as shameful and contemptible personality defects.


Borderline personality disorder: Abandon the label, find the Person
by Steven Coles

Linking to “Is Anakin Skywalker suffering from borderline personality disorder?” This might seem like a reasonable question to a psychiatrist:

Anakin Skywalker, one of the main characters in the “Star Wars” films, meets the criteria for borderline personality disorder (BPD). This finding is interesting for it may partly explain the commercial success of these movies among adolescents and be useful in educating the general public and medical students about BPD symptoms.

We are three generations of Star Wars fans in my family, and my children and grandchildren have often started discussions about this universe. Looking at how the character’s lives shape their actions and their options has led to useful explorations of free will, ethics, responsibility and values in the world we live in, far, far away from the mental illness frame of psychiatry.

A huge problem with the limited psychiatric illness model is that it gives up on people with “personality disorders”. I’ll be following this program with interest:

“Some psychopaths can be treated”
David Bernstein, Sacha Ruland




THE BORDERLINE PSYCHOTIC PATIENT: THE IMPORTANCE OF DIAGNOSIS IN MEDICAL AND SURGICAL PRACTICE*

MILTON H. MILLER, M.D.
Ann Intern Med. 1957;46(4):736-743. doi:10.7326/0003-4819-46-4-736


Psychoanalytic Dialogues: The International Journal of Relational Perspectives

Volume 7, Issue 6, 1997

Translator disclaimer




http://www.psy-ed.com/wpblog/mental-disorders/borderline-personality-disorder/ 

http://www.practiceofmadness.com/2010/02/borderline-personality-disorder-and-the-control-of-subversive-women/
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"Nature" on P values

From my layperson’s POV, mental help evidence based on P values is information, not TRUTH. And this article explains how and why:

Scientific method: Statistical errors

P values, the ‘gold standard’ of statistical validity, are not as reliable as many scientists assume.



QUOTE: 

P values have always had critics. In their almost nine decades of existence, they have been likened to mosquitoes (annoying and impossible to swat away), the emperor’s new clothes (fraught with obvious problems that everyone ignores) and the tool of a “sterile intellectual rake” who ravishes science but leaves it with no progeny3. One researcher suggested rechristening the methodology “statistical hypothesis inference testing”3, presumably for the acronym it would yield.

The irony is that when UK statistician Ronald Fisher introduced the P value in the 1920s, he did not mean it to be a definitive test. He intended it simply as an informal way to judge whether evidence was significant in the old-fashioned sense: worthy of a second look. The idea was to run an experiment, then see if the results were consistent with what random chance might produce. Researchers would first set up a ‘null hypothesis’ that they wanted to disprove, such as there being no correlation or no difference between two groups. Next, they would play the devil’s advocate and, assuming that this null hypothesis was in fact true, calculate the chances of getting results at least as extreme as what was actually observed. This probability was the P value. The smaller it was, suggested Fisher, the greater the likelihood that the straw-man null hypothesis was false. 

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Reframing the psychological and psychiatric models.

Edited for clarity





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I do realize that professionals have positive associations to the terms “psychological model” and “medical model”.   

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But I suggest substituting them with four terms:

Two are related to actions:

  • Medical mental help
  • Non-medical tools and processes. 
And these really are complementary. Informed and careful use of drugs can be helpful additions to other kinds of help. 

Two are descriptions of cognitive frames:

  • Frame of mental illness
  • Frame of trauma and societal harm
And they are not complementary. But there might be a third frame, where outside factors can cause mental illness. And other frames that I haven’t thought of. Suggestions?

Terms like this, however many, could make “choice” a clear and present alternative for people who need help.

Valuing and empowering choice is just as important for psychology as it is for psychiatry.

When it is natural for people to see their symptoms in a frame of mental illness, trying to force them to look at “what happened to you” is an act of unwitting mental violence.

Insisting that depression, psychosis, PTSD, BPD and so on are mental illnesses when people need to see their symptoms in a frame of what has happened and is happening to them is also unwitting mental violence.

As I see it, coerced medication and coerced CBT or DBT are equally harmful, and both types of coercion are frighteningly common in so-called “mental health care”.

And I do realize how difficult, maybe even impossible, it can be for people in the mental help professions to assimilate information that they may be harming more people than they help.

But there comes a time when information of harm is so ubiquitous and easily accessible that the word “unwitting” loses its relevance. And maybe that time is now?

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YOU CAN’T MAKE ME FLY

Translated from my Norwegian blog, 
where it was a response to an article on user engagement
called “How can I make you fly”



YOU CAN’T MAKE ME FLY

You research makeflying with genuine user engagement.

But have you thought about what you do when you makefly?

You staple onto people mass produced wings, onesizefitsall, with a willpowerdriven rubber band engine. Strong enough to flutter them out of your sight.

Some are OK with that, and that’s OK.

Others lie broken on the ground some distance away – do you see them? Do you hear them, when they say that the wings did not fit? That the rubber band broke?

When you evidencebasedresearch makeflying, what do you look for? Do you only see what you do, what other makeflyers do? Do you only hear the people who were helped?

Do you seek out everyone you madefly, and do you listen, with your mind and your guts, to what they have to say? Setting aside your rating scales and check boxes for later?

Do you seek out the ones who were helped, after six months, one year, two years, ten years, to check the elasticity of their willpower rubber band?


YOU CAN’T MAKE ME FLY

You can’t make me anything, and from me you do not get user engagement. I don’t use. I don’t engage. I steer. I have chosen to live as an autonomous entity.


YOU CAN’T MAKE ME FLY

I have no need for makeflying. I need to fly. Can you give me what I need?

I need help from people who can fly, fly with their own wings, wings that they were born with. People who can show me that it is possible, people who know how it is done.

If you make evidencebased, mass produced, willpowerdriven onesizewings, I need you to get out of my way. Do not dismiss my wings because they are not evidencebased, do not clip my wings because you know that they are abnormal, do not set snares to prove that my wings do not work. And above all … do not expect user engagement. 


I do not use. 
I steer. 
I do not engage. 
I am and do.


YOU CAN SUPPORT MY TRUST IN THE WINGS I WAS BORN WITH

I need to trust my ability to fly, I need to trust my wings, I need to know that I am able to own my life and steer it myself.

I need people to be with me in finding out what harmed my wings, be with me in finding out what I can do to fix them, and I need to own the repair work, also when I cannot do it alone.

I need room to test my wings, I need to let them grow in a safe and peaceful place. I need pride, admiration and acknowledgement when I flap my wings, test them. 


I NEED AIR UNDER MY WINGS

And most of all I need you to show
that you know
that air is not something you can give me.

Air just is.

WHEN DOES "EVIDENCE-BASED" BECOME CARGO CULT SCIENCE?

I’ve been asking myself “what is science”? “How can I separate real science from misleading evidence-based research? This 40-year old essay by Richard Feynman has some good pointers. 

He describes certain educational and psychological studies as cargo cult science.  And asks: “Do they work?”


Cargo Cult Science

Richard Feynman

From a Caltech commencement address given in 1974 
Also in Surely You’re Joking, Mr. Feynman!

So I found things that even more people believe, such as that we have some knowledge of how to educate. There are big schools of reading methods and mathematics methods, and so forth, but if you notice, you’ll see the reading scores keep going down–or hardly going up–in spite of the fact that we continually use these same people to improve the methods. There’s a witch doctor remedy that doesn’t work. It ought to be looked into; how do they know that their method should work? Another example is how to treat criminals. We obviously have made no progress–lots of theory, but no progress–in decreasing the amount of crime by the method that we use to handle criminals.

Yet these things are said to be scientific. We study them. And I think ordinary people with commonsense ideas are intimidated by this pseudoscience. A teacher who has some good idea of how to teach her children to read is forced by the school system to do it some other way–or is even fooled by the school system into thinking that her method is not necessarily a good one. Or a parent of bad boys, after disciplining them in one way or another, feels guilty for the rest of her life because she didn’t do “the right thing,” according to the experts.

So we really ought to look into theories that don’t work, and science that isn’t science.

I think the educational and psychological studies I mentioned are examples of what I would like to call cargo cult science.



Integrity! Yes! And honesty! And leaning over backwards! That is certainly convincing:

There is one feature I notice that is generally missing in cargo cult science. … It’s a kind of scientific integrity, a principle of scientific thought that corresponds to a kind of utter honesty — a kind of leaning over backwards. For example, if you’re doing an experiment, you should report everything that you think might make it invalid — not only what you think is right about it; other causes that could possibly explain your results; and things you thought of that you’ve eliminated by some other experiment, and how they worked — to make sure the other fellow can tell they have been eliminated.

Details that could throw doubt on your interpretation must be given, if you know them. You must do the best you can — if you know anything at all wrong, or possibly wrong — to explain it. If you make a theory, for example, and advertise it, or put it out, then you must also put down all the facts that disagree with it, as well as those that agree with it. There is also a more subtle problem. When you have put a lot of ideas together to make an elaborate theory, you want to make sure, when explaining what it fits, that those things it fits are not just the things that gave you the idea for the theory; but that the finished theory makes something else come out right, in addition.

In summary, the idea is to try to give all of the information to help others to judge the value of your contribution; not just the information that leads to judgement in one particular direction or another.

Emphasis mine.


Scientists who show that they do not fool themselves, and do not to fool the layperson are convincing: 

But this long history of learning how to not fool ourselves–of having utter scientific integrity–is, I’m sorry to say, something that we haven’t specifically included in any particular course that I know of. We just hope you’ve caught on by osmosis.

The first principle is that you must not fool yourself–and you are the easiest person to fool. So you have to be very careful about that. After you’ve not fooled yourself, it’s easy not to fool other scientists. You just have to be honest in a conventional way after that.

I would like to add something that’s not essential to the science, but something I kind of believe, which is that you should not fool the layman when you’re talking as a scientist. (…) I’m talking about a specific, extra type of integrity that is not lying, but bending over backwards to show how you’re maybe wrong, that you ought to have when acting as a scientist. And this is our responsibility as scientists, certainly to other scientists, and I think to laymen.

Feynman also writes about the importance of putting sand in lab rat cages … I’ll let you find that in the link. And he ends with a wish that I send out to all researchers: 

So I have just one wish for you–the good luck to be somewhere where you are free to maintain the kind of integrity I have described, and where you do not feel forced by a need to maintain your position in the organization, or financial support, or so on, to lose your integrity. May you have that freedom.