Does anyone think that was a decent shot of journalism? Then damn your eyes. Oh I can imagine an earlier me who would come away from that complete piece of shit grateful for the exposure and yay for recognition! But that column pissed off a lot of people in a number of ways I can relate to, beginning with its placement. I ask you, does this social stigma make my butt look too big? Because Gabrielle Glaser’s ‘Mad Pride’ Fights a Stigma is in the Fashion & Style Section, it must be tres chic, don’tchaknow, the fight against prejudice and discrimination, just one more set of kooks aboard the pop cult bandwagon with their self-important, trendy and disposable cause. Sigh.

First she pokes a stick at some prominent crazies in the blogosphere - Liz Spikol, Scatter at The Icarus Project, Mindfreedom’s David Oaks- then puts it all in perspective by quoting reigning tower of babel Fuller Torrey, as if he was just some random psychiatrist chiming in with all we need to know about Mad Pride (nudge nudge, wink wink). Bloody Christ on a catshit cupcake, if this quack has any place in a story about MAD PRIDE he should be correctly rendered as its ideological opponent, his views presented as subordinate to those of the subjects, rather than, you know, the authority on their movement.

Sara, commenting at furious seasons puts it well:

I think the article has all sorts of insidious undercurrents myself. Like I don’t think the author is really glorifying Liz or even Saks — in fact I think she’s almost denigrating them, especially Liz. I mean she sure is harping on the way Liz likes to revel in some of the more off putting aspects of her treatment — incontinence from ECT and drooling from meds — please — is this being respectful to Liz — are these the things that we remember about Liz when we read her blog? Ach — no. I wonder if Liz is angry about this. I think I would be. And David Oaks — well to me she’s kind of making fun of how he is controlling his purported madness as if it’s naive. She quotes Torrey because he’s of the school that thinks “mad pride” is bloody dangerous and maybe Gabrielle Glaser does too.

The psychologist John Grohol at Psych Central:

She also apparently believes that mental disorders can only be treated by drugs (which is mentioned a few times in the article; psychotherapy is mentioned zero times) …Really now? Having regular exercise, a good diet, and engaging in self-help support groups is “outside the mainstream thinking of psychiatrists” when it comes to maintaining good mental health and wellness? How does she know that? Did she survey them?

Of course not — this is the writer’s opinion creeping into the writing, and getting it 100% wrong. Most mental health professionals recognize the importance of maintaining a good diet, exercising, and self-help support groups in helping a person in their recovery efforts. None of these ideas are outside of the mainstream thinking

But I can think of no greater crime in a cultural study than ignoring its historical context. Mad Pride was founded by the tragic-comic powerhouse campaigner Pete Shaughnessy, who was linked to the English punk rock/DIY scene, the roots of which can be seen in the confessional poetry made famous by Sexton, Bukowski and Lowell. Mad Pride was about passion, policy and performance. There is history here. The writer should know it.

Let us pause to make an argument for history, for knowing where we are, how we got here, and how to move forward. I swear we could reduce the infighting by half if we’d do this kind of homework. It’s that lack of context driving the comments I’ve seen by some stakeholders who say they don’t “get” Mad Pride, that it’s bizarre to glorify what can be truly destructive and debilitating severe and persistent blahblahblah, which leads to the counter retort that hey man, mad pride makes me feel good about myself, yes, I know, but Mad Pride isn’t as much about how we’re feeling as what we’re doing, out there.

I realize the glib and stylish do invoke the term as a way to be groovy and I have nothing to offer them but a pox on their houses. How does “Glad To Be Mad” even begin to make sense? If I admonish a toothless schizophrenic living in a dumpster to take pride in her mad self what would that make me if not clueless and cruel? And yet, that is what some people are taking away from this discussion; that Mad Pride is a misguided attempt in building self-esteem. That it encourages navel-gazing in people who think too much. I believe Mad Pride was originally more ambitious than simple therapeutics, broader than the internal and solitary landscape. I think the focus was taken pointedly off the internal and made external, from the self to the group, uniting the twin and rival disciplines of psychology and sociology, which is revolutionary in itself, by pioneers who recognized that doing mental illness takes both disciplines.

So, Mad Pride as a frame. Who needs a frame? Wiki says “A frame defines the packaging of an element of rhetoric in such a way as to encourage certain interpretations and to discourage others. When done by political or social organizations, it is likely to advance their causes or views.” The point of framing is preparation for action, the groundwork in getting an agenda on the table. Vaughan shows how in his Mindhacks review:

Mad Pride is often rather clumsily related to ‘antipsychiatry’ but they are are often at the forefront of campaigns when essential services are threatened.

In London, the campaign against the shutting of the Maudsley Hospital psychiatric emergency clinic was spearheaded by several ‘mad pride’ organisations - who had a mischievous and witty banner at one demo saying “We must be mad! We want the emergency clinic kept open!”.

For the sake of pragmatism I endorse the actions taken in the name of Mad Pride, but that’s where I draw my own line. I juggle too many social identities (feminist, existentialist, liberal, punk) to over-identify with any of them, but I can think of nothing I want to define me less than the state of mental illness. And frankly, that’s where the message falls apart, when it’s patterned on the discourse of the civil rights movement. It’s one thing to make common cause with similar social justice groups (and the case can be made that we win the Oppression Olympics™ handsdown), but the identity politics in mental illness veers toward nonsense. In civil rights terms, Identity is not just about what I am, but what you’re not and can never be. You don’t understand what it is to be black/female/queer/outside the dominant white male patriarchy. I am the authority on what it means to be so situated, and it’s your boot on my neck that makes me your moral superior.

Except madness is not fixed and immutable, not even in the same person, much less categorically, as in some people have it and some others don’t. All humans have what it takes, anyone who denies their spark of madness this second remains eligible, if you have a mind you can lose your mind, there’s nothing to it really. We’re not exceptional. The language of diversity doesn’t fit. Crazies are not cast out of society because we are different from the rest, but because we are so similar.

Setting ourselves apart from a belief that we are the chosen few who are “mentally interesting” feeds a false dichotomy and endorses the fiction that we’re Other when crazy is more likely roiling under the surface of everyone you meet.

Setting ourselves apart as the world’s ruling victim class entails a preening sanctimony impossible to stomach.

But setting ourselves apart from an intent to get shit done makes practical sense, and for me that’s where it stops.

Inclusion by most out-groups is a demand for society to include them. I think our paradigm calls for the mad to include society. Mad Pride has this sensibility. Good god this post is over 1600 words and I am still muddling through what was said much better by the aching Anne Sexton:

For John, Who Begs Me Not to Enquire Further

Not that it was beautiful,
but that, in the end, there was
a certain sense of order there;
something worth learning
in that narrow diary of my mind,
in the commonplaces of the asylum
where the cracked mirror
or my own selfish death
outstared me.
And if I tried
to give you something else,
something outside of myself,
you would not know
that the worst of anyone
can be, finally,
an accident of hope.
I tapped my own head;
it was a glass, an inverted bowl.
It is a small thing
to rage in your own bowl.
At first it was private.
Then it was more than myself;
it was you, or your house
or your kitchen.
And if you turn away
because there is no lesson here
I will hold my awkward bowl,
with all its cracked stars shining
like a complicated lie,
and fasten a new skin around it
as if I were dressing an orange
or a strange sun.
Not that it was beautiful,
but that I found some order there.
There ought to be something special
for someone
in this kind of hope.
This is something I would never find
in a lovelier place, my dear,
although your fear is anyone’s fear,
like an invisible veil between us all…
and sometimes in private,
my kitchen, your kitchen,
my face, your face.

Our officials do nothing while a flood of ink spills about the known atrocities taking place in Texas MHMR residential facilities. From my initial link three weeks ago on 800 disciplinary actions taken against Texas state schools, to the latest coverage of “choke holds, headlocks, torture, rape and death” in psych hospitals, perhaps our governor would like to revise his blithe summation that “the state is doing its job.” Meanwhile, accounts from the reality-based community beg to differ:

United Press International: Abuse Common in Texas Mental Hospitals.

Psych Central: Texas Mental Hospitals: A Haven for Abuse.

Furious Seasons: Article Exposes Injuries, Death at Texas Psych Hospital.

New York Times: Firings at Mental Hospitals Over Abuse.

Reason: One Flew Over the Lone Star State.

Rad Geek (must read): Texas Psychoprisons.

The Trouble With Spikol: Happy happy joy joy…uh…maybe not.

Houston Press: Mental Anguish at Texas West Oaks Hospital.

Reeves Law Blog: TX Psychiatric Patients Suffer Abuse, Neglect.

Hymes: Acceptance and Expectation of Abuse and Neglect in State Hospitals Are a Large Part of the Problem.

Texas Observer: Systemic Neglect.

Dallas News: Reports Show Systemic Abuse at Texas’ Psychiatric Hospitals.

Systemic is the operative word, systemic tells us the apple is rotten to the core, overall, built in, affecting an entire system, making it untenable in its totality. Documented systemic abuse, requiring swift and decisive action and impossible to ignore. You would think so. Who among us could ignore these published findings but the paid parasites who earn their professional cred by providing oversight of the system in question? The entities that are charged with getting hysterical over these facts will of course ignore them, and because that’s not surprising makes it no less unbearable. If you have any doubt that’s just what they’re doing, scour a few websites, and wait for the blackout:

Department of Aging and Disability Services.

Texas Department of State Health Services.

Governor’s Task Force on Mental Health Transformation. (pdf of May 6th agenda).

Texas Health and Human Services: May 12th “Stakeholder” hearing agenda.

Every front-page News brief at all 40 Community Psychiatric Centers, example: Austin-Travis County Mental Health Mental Retardation Center.

Blackout, zip, zero, nada, not a word of acknowledgment from the mental health overlords charged with public accountability. Pretend it’s not happening, maybe the public won’t notice. 135 news articles. What’s that if not delusional? A complete break with consensual reality, there is a place to put people like that.

Shit. I haven’t been able to look at this, til talking on the phone with Poodie tonight who said the story isn’t getting proper coverage. So I went looking for the truth at Shakesville, who hits it out of the park from the git:

THIS story should be reported with purpose. If it is not to be consumed as a pithy bit of titillation over one’s morning tea, it should be blunt, and it should be contextualized. No whitewashing, framed within a larger cultural narrative about the mistreatment of women and/or incidents of incest/child abuse in Austria. And then every. single. time. there is another story of this nature, the frame should be repeated. And repeated. And repeated. And repeated.

Until we can’t ignore its prevalence any longer. Until we can’t treat sexual abuse and torture as so much faff to be dismissed once we’ve had the obligatory “What a world!” grouse to salve our barely piqued consciences.

SEE ALSO:

“I am not a monster…I could have killed all of them — then nothing would have happened. No one would have ever known about it.”

The latest..

.

The Verdict:

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Over the last 4 years I’ve heard the term Evidence-Based Medicine™ invoked 20 times a day at the Capitol and named it gobbledygook from day one. Evidence-Based Medicine™ refers to interventions based on established criteria in the medical literature, involving steaming piles of horseshit from the academic domain that just happen to call for the most expensive procedures. But not til 2 weeks ago did I hear the first professional talk it down, in a committee on domestic violence, where “stop the bleeding” has become “drug the victim” since we live in an era that has medicalized what any reasonably empathic person should recognize as predictable aftermath. Meetings where victimization is the theme — battery, rape, child sodomy — this is domestic violence, while invited testimony is dominated by medical professionals. Fucking obscene.

After some six hours listening to her peers wank glowingly of Evidence-Based Medicine™ the representative from Texas Network of Abuse Prevention Services warned the senate to be wary of EBM terminology, said it is not a black and white seal of approval, that evidence-based appraisals are contested in the academy, due largely to bias in research, conflict of interest and the inherent difficulty of quantitative data-collection in human service research experiments. Evidence based services cost more, she said, agencies that make these investments need to know what an evidence based product is and how it is so denoted, and make sure that it is evidence based in substance and not in name only.

Speaking truth to power is always unexpected from that quarter, I’d say it’s a fluke but for what hit my inbox this week:

Why Evidence-Based Medicine Cannot Be Applied to Psychiatry

Co-written by Robert Levine, MD, associate professor of clinical psychiatry at New York University School of Medicine and Max Fink, MD, professor emeritus of psychiatry and neurology at Stony Brook NY, founding editor of The Journal of ECT and author of Electroshock: Restoring the Mind. Worthy opinion by the likes of dirty rotten scoundrels bears some looking into, and it goes without saying they’re going to get smacked down by their colleagues for publishing this in Psychiatric Times. Oh yes, it’s hard going, but anyone interested in EBM, this is the shit. (Sorry no linky, subscription only):

Evidence-based medicine (EBM) is rapidly becoming the norm. It is taught in medical schools and is encouraged by both government agencies and insurance plan providers. Yet, there is little proof that this model can be adapted to fit psychiatry.

EBM supposedly allows the clinician to offer the most effective treatment for each patient.^1,2 This goal is laudable, but the model is not appropriate for psychiatry because precise and stable diagnostic criteria are lacking in our specialty. Treatment outcomes in psychiatry are not defined by remission or cure. Instead, fractional reductions in the number and severity of symptoms are accepted, as measured by rating scale scores. Evidence-based psychiatry (EBP) is an untested hypothesis; for this theory to be either useful or valid, 3 basic assumptions must be examined.

• Is the diagnostic system valid?
• Are the data from clinical trials assessing efficacy and safety sound?
• Are the conclusions in a form that can be applied in clinical practice?

Definitions
The paradigms that define EBM (and EBP) are based on data in published clinical studies. Each study is assessed according to the methods used to collect the data and a value placed (by the reviewer) on its quality. EBM uses 3 types of evidence³:

• Grade A: Randomized clinical trials, homogeneous populations, placebo-controlled.
• Grade B: Randomized clinical trials, heterogeneous populations, not placebo-controlled.
• Grade C: Observational studies, case collections, open clinical trials.

The strength of the evidence decreases from Grade A to Grade C, with more weight given to Grade A than to Grade C studies.

The diagnostic system
The DSM represents diagnostic groupings developed through discussion and consultation. These groupings are not based on experimental evidence. The manner in which the DSM creates diagnoses assumes that psychiatric illnesses can be divided into separate categories and that each illness is unique. The process is circular. It begins by assuming that discrete categories exist and produces a document that divides psychiatric illness into discrete categories.

The illnesses in the DSM are delineated by phenotypic features, with a contribution from the patient’s recall of the course of the illness. The separation of classes based on these criteria is, by its nature, imprecise. Although these criteria are intended to separate clinical entities, their descriptions are overlapping. The judgments introduced by the clinician’s need to decide which of several conditions best meets the diagnostic criteria are subjective, putting the system in doubt. It is not surprising that overlaps are common.

Major psychiatric disorders overlap
The committee-driven DSM classification divides psychiatric diseases into discrete entities based on cross-sectional symptoms and signs. These disorders exist as syndromes and not as specific illnesses. Psychosis, for example, may result from drug toxicity, neurological illness, trauma, or as a feature of delusional depression and isolated delusional states. The genetic predispositions for schizophrenia and affective illness overlap.^4,5 Kendall⁶ has demonstrated that most patients have characteristics of both groups and that our diagnostic concepts are based on the extremes of what is better visualized as a continuum.

EBP relies on categories that call for specified algorithms for treatment.⁷ However, in clinical practice the emphasis is not on treating syndromes or diseases but on applying empirically derived prescriptions for symptoms and symptom complexes. Psychiatry lacks antischizophrenia, antidepression, or antianxiety disorder medications. What exist are medications that symptomatically treat psychosis, depressed mood, and anxiety. The severity and associations of the symptoms vary greatly depending on genetic traits, environmental influences, and duration. The genetic traits are particularly subtle; the substitution of a single nucleic acid markedly alters symptoms.^8-10 Variations in genetic polymorphism influence phenotypic presentations of illnesses over a spectrum of clinical syndromes. It is difficult to reconcile these observations with the current diagnostic system’s separation of these conditions into distinct categories and subcategories.

Several conditions exhibit such high rates of comorbidity that one must be skeptical of the idea that we are dealing with discrete entities. The overlap between attention-deficit disorder (ADD), oppositional defiant disorder, and conduct disorder is an example.^11-13 Separating these syndromes into distinct entities obscures the possibility that they may be expressions of a single genotype. This is also the case with obsessive-compulsive disorder (OCD), generalized anxiety disorder, panic disorder, and major depressive disorder, in which patients may display symptoms of each condition, with the dominant symptom changing with time and circumstance.^14-17

This relationship frequently causes problems when the nosological diagnosis obscures the possibility of a common biological substrate. A common example of this occurs in patients with OCD in whom manic symptoms develop when they are taking antidepressants.¹⁸

If a nosological approach were reliable, we would expect greater homogeneity in treatment response. That is, if depressive mood disorders were a single entity, we would expect that a single treatment agent would be effective in all or almost all patients who receive this diagnosis. Such uniformity of diagnosis and treatment response is expected, for example, in bacterial infections and in diabetes. However, this is not the case in psychiatric disorders. Lacking effective predictors or tests, the clinician searches for clues for treatment selection in personal and family history or engages in multiple drug trials, augmentation strategies, and polypharmacy.

Syndromes that are separated by DSM criteria as single entities often respond to the same pharmacological therapies. OCD, panic disorder, generalized anxiety disorder, and depressive disorder respond to SSRI agents. Schizophrenia, bipolar disorder, toxic psychosis, and major depressive disorder with psychosis respond to atypical antipsychotic agents. Are we to assume that the treatment agents have very broad effects, and that they are effective for different disorders? Or should we assume that the different disorders have a common biological underpinning that responds to the singular effects of specific medications? Either assumption casts doubt on the present diagnostic schema.

Similarly, diagnostic categories are added or deleted in each iteration of the classification based on fashion and political correctness. Examples include the rejection of homosexuality, unipolar mania, and melancholia, and the addition of caffeine and nicotine addiction. When fashion, rather than scientific evidence, dictates diagnoses, the entire system should be questioned.

DSM categories
The DSM categorizes illnesses into discrete entities, using 5 axes to assign severity and plausible cause. Axis I is a description of the presumed clinical disorder. Many conditions share comorbidities of 70% to 90% (eg, ADD, oppositional defiant disorder, conduct disorder, and antisocial personality disorder), thus blurring diagnostic boundaries. Conditions change from one form to another depending on when the patient is seen (eg, OCD, generalized anxiety disorder, panic disorder, atypical affective disorder).

Because physicians are limited to a few tests to define a disorder (serology for syphilis, blood glucose for diabetes, and neuroimaging for dementias come to mind), the diagnosis takes on the hallmarks of a Rorschach projective test, based on the judgment and experience of the observer.

Conversely, when psychiatrists use a system based on a checklist of symptoms, disorders that are etiologically related are viewed as different. Tucker¹⁹ gives the example of Huntington disease, a condition in which the cause is well defined but the expressions of the illness meet the criteria for dementia, psychosis, depression, and antisocial personality disorder.

Data validity
EBM places heavy emphasis on the results of large, multi-site, double-blind studies. This being the case, it is important to know where and how these studies are conducted.

For the most part, studies are commissioned by industry consultants and are conducted either at institutions that do clinical trials for profit or at academic institutions where such studies are considered of low merit and the actual data collection is done by nurses, social workers, or narrowly trained raters with no clinical experience. Participants are often enrolled from databases of patients who have participated in previous studies or who are “borrowed” from clinics. It is not uncommon for patients to participate in multiple studies. Participants become “professional” research patients who take part in several studies to collect the stipend. These populations are not representative of the patients in clinical psychiatric practices.

Assuming the best of circumstances–that is, the participants represent a cross-section of patients with a defined psychiatric illness–the validity of double-blind, placebo-controlled evidence must still be assessed. Ideally, neither the patient nor the investigator should be able to distinguish the active substance from placebo; however, numerous experiments show that the “blind” condition is easily broken.

In studies of antidepressants, physicians correctly distinguished the active drug in 73% to 89% of cases, and patients correctly distinguished the treatments 64% to 75% of the time. In crossover studies, physicians successfully identified the active drug 100% of the time and patients were correct 93% of the time.²⁰

The failure to report negative findings is most egregious in assessing efficacy. In addition to the reluctance of editors of journals to publish negative findings, industry project managers “seal” negative results and neither file the data with the FDA nor allow the investigators to report the results.²¹ For every study of a psychotropic drug that reports positive results, there are often 4 to 8 unpublished studies that fail to show superiority to placebo.²² This “file-drawer phenomenon” explains, in part, why drug company-supported research is 4 times as likely to produce a positive response as studies from other sources.²³ If the results of the studies that did not show positive results were reported, it is conceivable that they would alter the conclusions of the meta-analysis.⁷

Newer agents that may be patented are preferentially studied, diluting evidence that supports the effectiveness of older treatments and encouraging the wider use of newer and more expensive treatments.²⁴

Dosage problem
Clinical trials underestimate the effective dose of medications; they may also overestimate, but this is unusual. The “evidence” is then used by insurance companies and government agencies to accept or reject claims for payment for the higher doses often needed in clinical practice, depriving patients of adequate treatment. The Table illustrates the differences between the originally suggested doses of atypical antipsychotics and what are now accepted as the actual clinical doses.²⁵

Application to clinical practice
It takes considerable time for a clinical observation to be validated by a large-scale study.^2,26 In practice, a medication is first approved for marketing as an effective treatment for one entity and then clinical observations reveal that it has other uses. If we assume that it will generally take up to 4 years for a clinical trial to be designed and executed, EBM will always be several years behind clinical practice. If the standard of clinical practice is limited to evidence-based studies, practitioners will be reluctant to attempt novel treatments or to vary dosing regimens. The evaluation process reduces innovation.

EBM is favored by insurance companies and national health services.^27,28 This method is, by its very nature, conservative, and it promotes the use of lower doses of medication and discourages polypharmacy. Such restrictions and standards reduce costs, but they also reduce effective treatments. The problem is compounded when we consider that EBM criteria are commonly offered as the basis for malpractice litigation.

Conclusion
Critics of present practices call for narrow diagnostic criteria in patient selection, better monitoring of the patients selected for studies, longer periods of study, and better criteria for outcome. Some relatively simple measures that would be helpful are monitoring the participants by their social security numbers (to minimize the use of “professional patients”), tracking placebo response percentages, and ensuring better reporting of adverse events. The common practice of competitive enrollment, which encourages research sites to enroll as many patients as possible, should be discouraged because it magnifies the contributions made by specific research installations and skews results even further.

EBP is a system that is based on unreliable data. Its unreliability results from an imprecise and poorly founded diagnostic system, inaccurate data collection, and obfuscation of experience by the pharmaceutical industry and compliant academic leaders. Whatever the reasons, the drive to adopt EBP as a standard of practice is best discouraged.

References
1. Sackett DL, Rosenberg WM, Gray JA, et al. Evidence-based medicine: what it is and what it isn’t. BMJ. 1996;312:71-72.
2. Sackett DL, Strauss SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. New York: Churchill Livingstone; 2000.
3. Gray GE. The philosophy and methods of evidence-based medicine: an introduction for psychiatrists. Dir Psychiatry. 2002;22:165-173.
4. Maier W, Lichtermann D, Minges J, et al. Continuity and discontinuity of affective disorders and schizophrenia. Results of a controlled family study. Arch Gen Psychiatry. 1993;50:871-883.
5. Rende R, Hodgins S, Palmour R, et al. Familial overlap between bipolar disorder and psychotic symptoms in a Canadian cohort.Can J Psychiatry. 2004;50:189-194.
6. Kendall RE. The major functional psyches: are they independent entities or part of a continuum? In: A Kerr, H McClellan, eds. Concepts of Mental Disorder. London: Gaskell; 1991:1-16.
7. Williams DD, Garner J. The case against “the evidence”: a different perspective on evidence-based medicine. Br J Psychiatry. 2002;180:8-12.
8. Weinberger DR, Egan MF, Bertolino A, et al. Prefrontal neurons and the genetics of schizophrenia. Biol Psychiatry. 2001;50:825-844.
9. Goldberg TE, Egan MF, Gschidle T, et al. Executive subprocesses in working memory: relationship to catechol-O-methyltransferase Val158Met genotype and schizophrenia. Arch Gen Psychiatry. 2003;60:889-896.
10. Numakawa T, Yagasaki Y, Ishimoto T, et al. Evidence of novel neuronal functions of dysbindin, a susceptibility gene for schizophrenia. Hum Mol Genet (England). 2004;13:2699-2708.
11. Burt SA, Krueger RF, McGue M, Iacono W. Parent-child conflict and the comorbidity among childhood externalizing disorders. Arch Gen Psychiatry.2003; 60:505-513.
12. Maughan B, Rowe R, Messer J, et al. Conduct disorder and oppositional defiant disorder in a national sample: developmental epidemiology. J Child Psychol Psychiatry. 2004;45:609-621.
13. Thapar A, Harrington R, McGuffin P. Examining the comorbidity of ADHD-related behaviours and conduct problems using a twin study design. Br J Psychiatry. 2001;179:224-229.
14. Cassano GB, Pini S, Saettoni M, Dell’Osso L. Multiple anxiety disorder comorbidity in patients with mood spectrum disorders with psychotic features. Am J Psychiatry. 1999;156:474-476.
15. Katerndahl DA, Realini JP. Comorbid psychiatric disorders in subjects with panic attacks. J Nerv Ment Dis. 1997;185:669-674.
16. Richter MA, Summerfeldt LJ, Antony MM, Swinson RP. Obsessive-compulsive spectrum conditions in obsessive-compulsive disorder and other anxiety disorders. Depress Anxiety. 2003;18:118-127.
17. Sanderson WC, DiNardo PA, Rapee RM, et al. Syndrome comorbidity in patients diagnosed with a DSM-III-R anxiety disorder. J Abnorm Psychol. 1990; 99:308-312.
18. Rihmer Z, Barsi J, Belso N, et al. Antidepressant induced hypomania in obsessive-compulsive disorder. Int Clin Psychopharmacol. 1996;11:203-205.
19. Tucker GJ. Limitations of the DSM-IV as a diagnostic tool. Dir Psychiatry. 2000;20:127-135.
20. Shapiro AK, Shapiro E. The Powerful Placebo. Baltimore: Johns Hopkins University Press; 1997:190-201.
21. Vedamtan S. Drugmakers prefer silence on test data. Washington Post. July 6, 2004:A01. Available at: http://www.washingtonpost.com/wpdyn/articles/A29576-2004Jul5.html. Accessed September 21, 2007.
22. Sussman N. Misuse of evidence: an open secret. Prim Psychiatry. 2003;10:14.
23. Lexchin J, Bero LA, Djulbegovic B, Clark O. Pharmaceutical industry sponsorship and research outcome and quality: systematic review. BMJ. 2003; 326:1167-1170.
24. Bauer MS. How solid is the evidence for the efficacy of mood stabilizers in bipolar disorder? Dir Psychiatry. 2005;25:165-181.
25. Weinberger D, Stahl SM. Genes, Circuits, and Pharmacology: Clinical Connections in Schizophrenia. Archived satellite presentation. Carlsbad, Calif. NeuroScience Education Institute; July 2004.
26. Egger M, Smith GD, O’Rourke K. Rationale, potentials, and promise of systematic reviews. In: Egger M, Smith GD, Altman DG, eds. Systematic Reviews in Health Care: Meta-Analysis in Context. London: BMJ Books; 2001:3-19.
27. Baker M, Kleijnen J. The drive towards evidence-based health care. In: Rowland N, Gross S, eds. Evidence-Based Counseling and Psychological Therapies: Research and Applications. Philadelphia: Routledge; 2000:3013-3029.
28. Reynolds S. The anatomy of evidence-based practice: principles and methods. In: Trinder L, Reynolds S, eds. Evidence Based Practice: A Critical Appraisal. Malden, Mass: Blackwell Science; 2000.

Sitting here thinking about the ways I’m fucked up, if I will stay in the house day after day like this til my real life starts when I lose 20 pounds, meanwhile Nick Lowe is playing at Antone’s THIS NIGHT, the beat poet Anne Waldman is giving a lecture at the Humanities Center THIS NIGHT, life passing me by because I’m too fat to partake of what the attractive people get. I know better. That only makes it worse. I’m fighting internally with the patriarchy, Mom, the social imperatives of other women who will judge me by the same standards, and I’m fighting against the entire fat pride blogosphere, which I refuse to read, because number one, I’m not THAT fat, no one is, and number two, I don’t want to be modified, intellectually, emotionally, physically in any way by anyone no matter how well-meaning. People are so glib about how change comes about. I know everything you’re going to teach me, we always do. Staying this way has to hurt more than the effort to change, the reward for staying the same has to turn into a punishment, it has to look like welcome relief, that’s what creates change. You can’t do it for someone else, not by kindness or threats. You’re gonna change or I’m agonna leave. Yeah, that’s original. When it comes to behavioral modification you can wait or make things worse. People would rather be directive, it makes them feel powerful and purposeful, but more than that, it’s hard to wait and watch someone self-destruct no matter how sacred it is to do no more than witness with complete conscious awareness of what is going to happen. Better to intervene, and right their your world. Who is the teacher, who is the student? Sit down and shut up. People who’ve been really in it are the only ones who know what it requires to get out. Me, I am nowhere near the mess I could be, better luck tomorrow.

I was rummaging around in an old file and found this scribble that I must have used to believe, whatever it means, still speaks to me, in the moment at least~

I am not gullible doesn’t mean I am not ideal-starved. I don’t idealize doesn’t mean it’s the default or something easy.

Nothing against people who are striving to be happy. I’m not a striver, don’t want to get in the way of my genuine experience, whatever it is. I experience everything I experience and without striving for something other, which would make me an ordinary self-alienated phony. Ordinary, no one wants to Be. Just be.

On what grounds? No one is free from correction. You need re-education, something to make you acceptable.

No, my experience is always appropriate, interesting and informative. Even this. Anemic. Fatuous. Hackneyed. Bumper sticker mentality.

Autonomy, differentiation as healthy and desirable, yes. Difference without resentment or loss of affection the ideal state that eludes us most of the time. I am not going to merge with people who need me to confirm them, their politics, their sloganeering, two can play at that. Be.

Would you tell Hitler to be himself?

Do you know the difference between being and doing?

I can’t believe I got sucked into a thread with a child abuse denier but it looks like I stepped in it. Sally caught the stink of evil for what it was off the bat in Why are so many kids mentally ill? while I was doing my “multi-perspective, tease out the complexities” liberal tolerant fence-sitting claptrap like a lamb jumping for the knife. The post brought out the “You’ll have to pry this troublesome child’s pharmaceuticals from my cold, dead hands” grandstanding by a mother who’s first post was an incoherent mess of spelling and grammatical errors; who’s style became remarkably more intelligent and articulate as she was challenged step by step, until she revealed that oh my stars and garters she happens to work in an official capacity with impaired children. It’s all very creepy and gotcha, the way this mindfuck game is played: present yourself initially as an inferior adversary, then gradually demonstrate your ability to think and speak like educated people, make jaws drop by alluding to some vague expertise of your own in these matters and you win, flounce away, savoring your devastating impact. I remember as a DV counselor encountering this type, it was the child rapists who above all felt entitled to be seen as good people, superior to their judges, and would call the child abuse hotline and attempt to paint a picture of reality that the counselor would validate as acceptable parenting, but the more you tease out those complexities the more the truly horrifying picture emerges. It’s very manipulative, almost seductive, and deliberately bewildering, once you realize what you’re dealing with the world drops out from beneath your feet. You will physically age for every call you get like that. Not to say I know what this woman’s deal is, but given she devotes 400 words to disputing the prevalence of child abuse and follows that with a disingenuous handling of the question of environment in assessing what makes a child run riot I’ve got the old chills up my spine today. I think she is amused by her own deft avoidance of the issue of environmental impact on behavior, as if that can only mean we are talking about this:

flawed plan, thank you for caring about my child’s environment. It’s been an interesting adventure, often to the surprising benefit of everyone, to make the environment more comfortable for him.

We were lucky to find a gifted OT who could help give us insight into the kind of activities that were calming to him, and those that helped to strengthen and organize his activity level and concentration, and raise his level of physical balance and bodily awareness. Brava!

Fail. “Environment” is code for what is going on in that house and I’m sure she knows it.

So I dropped by the more enlightened comforts of Pandagon, and see they’re trying to figure out how to make a DV victim testify against her abuser, since it is a frustration for law enforcement (to say nothing of the Cause) that so often women who have been abused recant their testimony and the beater goes free. A helpful commenter gained traction with this idea:

One could argue that beaten and brainwashed women are in mental health crisis, and should be treated the same way as anybody who is considered a danger to themselves.

In other words, they could be committed for a short time to receive the mental health services they require to fully restore their agency.

Fail fail, headdesk, emergency, smelling salts, seriously, Amanda says there are no right answers; I think there are, but that’s not it. After leaving my own typically inscrutable, hysterical 500 word comment I turn from that thread to todays paper and find
AP Exclusive: More than 800 employees have been suspended or fired for abusing mentally and developmentally disabled patients since fiscal year 2004, state officials said Tuesday.

Abuse, where? Mental health facilities! Which means? Governor Goodhair:

The state is doing its job.

I have no words.

I’m not a special interest voter. I believe single-issue voters who refuse to vote for a progressive based on one policy are responsible for keeping the left in splinters and the status quo dominant. Single-issue voting also suggests over-investment in a single cause, which makes me question the voter’s overall judgment and dedication to the common good. But at base we’re all single-interest babies to some extent, and during election cycles it’s something I try to monitor and question to keep from queering my perspective, so to speak. So, while I don’t care only about mental health policy, I care enough to be frustrated by the moratorium on discussing my issue with force and meaning. Yes it’s scary and there’s a lot we don’t know about mental illness, but the same can be said for the war and we’re talking about that.

I caught some of yesterday’s Congressional hearings, and it appears Obama was the smartest person in the room. But 2 minutes into her testimony it was Hillary Clinton who said this:

The cost to our men and women in uniform is growing. Last week the New York Times noted the stress on the mental health of our returning soldiers and marines from multiple and extended deployments. Among combat troops sent to Iraq for the third and fourth time, more than one in four show signs of anxiety, depression, or acute stress. … The Administration and supporters of the Administration’s policy often talk about the cost of leaving Iraq yet ignore the greater cost of continuing the same failed policy.

Word. What she means by “anxiety, depression and acute stress” can be seen up close and personal here.

While we’re on it, might as well compare and contrast a couple mental health policy statements the candidates gave to NAMI dearest last winter. You may recall NAMI sent the candidates a 24 item questionnaire based on their pro-drug, anti-choice medical model propaganda. Thin gruel, but the only documented clue we have as to where the candidates stand on mental illness. Little wonder that McCain, who is in the news this week for calling his wife a “cunt” wouldn’t go within an inch of responding to NAMI’s questions about mental health, and the Democrat’s responses are party-line, which is good, but we need sharper discourse and real vetting, especially with regard to Obama’s focus on preventive policy, which rings the nanny bells that so many of us have had it up to here with. But then he goes and hints he will appoint our kind to his executive branch:

I also believe that the federal government should be a model employer of workers with disabilities or mental illness…. To assure that the federal government holds itself to high anti-discrimination standards, I will increase funding to the Equal Employment Opportunity Commission and assure that the person I appoint to chair the Equal Employment Opportunity Commission is committed to enforcing anti-discrimination laws that protect federal employees through a strong Office of Federal Operations. Perhaps most important, I will provide leadership to my appointees throughout the executive branch so that they, employers in the private sector, and workers with disabilities across the country will understand the importance of this issue.

I also find his strong-worded responses to issues of discrimination, seclusion and restraint encouraging but hard to believe so long as he remains subservient to the biopsychiatry framework. On the other hand, Clinton, responding to the question of parity, takes the opportunity to link pharma with the very idea that things aren’t all that hunky dory: (my bold)

All patients should have access to effective treatments recommended by their prescribing physician without the fear that government-sponsored or private insurance will deny these life-saving medicines. That said, we do need to have a better understanding of the best pharmaceutical treatment options for all patients, which is why I have proposed establishing an independent public-private Best Practices Institute. A public-private partnership, this institute would develop and guide research priorities so that doctors, nurses, and other health professionals know what drugs, devices, surgeries, and treatments work best.

Not exactly fighting words, but a hella more than the Rethuglicans have brought to the table, which by my count is nothing.

Friday I learned something serious in a CPS hearing about the leading CSA (child sexual abuse) prevention program known as Good Touch/Bad Touch. I was grateful when this program came out 25 years ago, thought it would have helped me if it was around when I was growing up, I’ve used the teaching tools myself with kids, in accordance with the general rule: you think you’re helping but you’re making things worse. You’d think we’d take the law of unintended consequences seriously, review and revise these trendy pet programs to make sure they’re not doing more harm than good. But this was news to me, makes intuitive sense, and I hope our legislators were listening to the witness who described GOOD TOUCH/BAD TOUCH as

one model that is valuable for teaching children that sexual abuse is terrible, but exposure to GT/BT creates shame in victims who are being sexually abused, which compounds their isolation and despair. The example of GOOD TOUCH/BAD TOUCH is but one indication of the need for support and follow-through to effectively intervene with victimized children who are exposed to it and similar educational programs.

Imagine the cruelty; a room of 20 kids being taught they can say NO! IT’S MY BODY, HANDS OFF! when we know five of those kids are going to go home and get raped in the mouth by their caregiver. That’s what the one-in-four statistic means. Is it stupidity or denial? More review please, less self-congratulatory and feel-good window dressing. What we need are CSA projects that don’t depend on the child to self-protect.

Better yet, let me explain them. Ask yourself, why do “activists” “fighting” for the “civil rights” of people with psychiatric labels denounce mental health parity legislation? What do you call the denial of care for an anorectic if not discrimination? I don’t think people who post against mental health parity should get to sidle up next to Martin Luther King. People who are motivated to dismantle the mental health system may have learned to present themselves as “civil rights advocates” in order to get a hearing. These people must support mental health parity as a civil rights issue, and anyone who speaks against it is not honestly working to end discrimination. At best, their gears aren’t meshing, at worst, they will be with us forever.