Inkwell: Authors and Artists

    
Gary, are you still seeing therapy clients?  If so -- and without
revealing any confidences -- what is one of the most important things
you've learned from your clients in the last couple of years?
  

    <scribbled by gower Mon 1 Dec 08 15:19>
  

    
(As someone who's never had therapy or even shown much interest in it,
I'd sign up as a client of Gary's in a heartbeat based on what I've
read here! Just ordered the book, and can't wait to read it.)
  

    <scribbled by tnf Mon 1 Dec 08 15:37>
  

    

I've never been a client of Gary's, but we've been friends for several years
and I have found his counsel to be of great value.  And the jams in his Band
Shack have been quite memorable, too.
  

    
Well, the funny thing is that for at least ten years, I've been pretty
ambivalent about being a therapist. Some of the reasons for this are
somewhere in the book, although mostly buried. They have to do with the
fact that there's a kind of bad faith at the heart of my profession. 

The Noble Lie is about the misuse of authority, about the way that
scientists, especially doctors, claim objective knowledge of matters
about which they don't--and most likely can't--possess it. It's not an
accident that many of the cases I write about are in the field of
psychiatry. That's where it's easiest to make pronouncements about
human nature, and where they have the most impact. 

Now you can do all you want to undermine your own authority with your
patients. YOu can, for instance, give patients the option of not
getting a diagnosis (which means not using their insurance and probably
paying me less than full freight) or of choosing it from the DSM
options that seem most applicable. You can also challenge them when
they seem to be taking what you say at face value, as if you were in
possession of some truth beyond question. YOu can try to weave the
whole question of authority into the therapy, reconstruct the way that
theme has developed in their life stories. But no matter how
transparent you are, no matter how self-effacing or  self-disclosing or
collaborative, on the bottom line they are paying you to know
something that they don't know.

Which I do. I have lots of experience helping people to form a
coherent narrative about their lives. I think this is useful because so
much of what has gone wrong is often the result of an incomplete
story, one that can't encompass some important events or aspects of
events that have actually occurred. But there is absolutely nothing
scientific about this, and to the extent that medicine gains its
authority by being scientific, there's nothing medical about it. It's
effective, in its own way, but it's not effective like an antibiotic or
surgery. 

So my involvement in the medical-industrial complex bothers me. My
book is a way of lobbing a little grenade into the factory, which makes
me feel better, but not nearly as better as it would if I just weren't
in it in the first place. THere was a time when you could practice
therapy outside the medical field, right when I began, but changes in
licensing laws have made this impossible. 

Of course, it's too much to expect in a world as broken as this one
that you can live without bad faith, at least not without the kind of
moral anorexia I had when I lived in the woods without the mod cons. So
I've settled in, and really I can;t complain too much. I get paid a
lot more than I would if I had most jobs, and mostly I get paid to tell
the truth as I see it. 
  

    
But I've been telling myself I'm getting out for so long that it's
become a habit. When I got a book contract last year, with an advance
big enough to keep me going for awhile, I finally had my opportunity.
My new corporate masters didn't want me to quit--they thought it would
be better for their book sales if I was a practicing therapist when the
book comes out in 2010(it's about depression)--but they couldn't
really stop me. It was the last chapter of the Kaczynksi caper--the
whole idea behind trying to get a writing career by attaching myself to
his coattails was to get out of the therapy racket.

But I didn't quit. I cut back, from about twenty hours a week to about
fifteen, which means I work two afternoons a week and one full day.
But I'm still doing it. Because, and this gets to STeve's question
about what I've learned from my clients, I need this work. I'm really
dependent on the intimacy that it brings me. NOt that I don;'t have
that in my personal life, but the fact that I can spend fifteen hours a
week doing nothing but trying to clear out the obstacles to intimacy
with a whole variety of people, some of whom are easier to love than
others, and all of whom have vastly different stories--this is
something that has become really important to me, and without my
knowing it. It snuck up on me, and I;ve learned it only as the work has
become more and more voluntary. 
  

    

Do you tell your patients what diagnosis you are reporting to the
insurance company?  If it weren't for the insurance companies, would you 
even be as concerned with diagnosing as you are with simply helping your 
patients, or is the diagnosis integral to the help you can provide?
  

    

You slipped!
  

    
If it weren't for the insurance companies, I would rarely, if ever,
think about diagnoses. They have a limited usefulness, providing a
shorthand way of talking with others in the field, but that's about it.
And yes I always tell people what their diagnosis is, and I further
explain that this becomes part of their permanent medical record, which
may be of interest if they ever apply for life insurance, a job
requiring a security clearance, or high political office.
  

    
Speaking of which....

1 in 5 young Americans has personality disorder
Fewer than 25 percent of college-age suffers get treatment, study finds
        

updated 2:10 p.m. PT, Mon., Dec. 1, 2008

CHICAGO - Almost one in five young American adults has a personality 
disorder that interferes with everyday life, and even more abuse alcohol 
or drugs, researchers reported Monday in the most extensive study of its 
kind.

The disorders include problems such as obsessive or compulsive tendencies 
and anti-social behavior that can sometimes lead to violence. The study 
also found that fewer than 25 percent of college-aged Americans with 
mental problems get treatment.

One expert said personality disorders may be overdiagnosed. But others 
said the results were not surprising since previous, less rigorous 
evidence has suggested mental problems are common on college campuses and 
elsewhere.

Experts praised the study's scope -- face-to-face interviews about 
numerous disorders with more than 5,000 young people ages 19 to 25 -- and 
said it spotlights a problem college administrators need to address.

Study co-author Dr. Mark Olfson of Columbia University and New York State 
Psychiatric Institute called the widespread lack of treatment particularly 
worrisome. He said it should alert not only "students and parents, but 
also deans and people who run college mental health services about the 
need to extend access to treatment."

Particularly vulnerable
Counting substance abuse, the study found that nearly half of young people 
surveyed have some sort of psychiatric condition, including students and 
non-students.

Personality disorders were the second most common problem behind drug or 
alcohol abuse as a single category. The disorders include obsessive, 
anti-social and paranoid behaviors that are not mere quirks but actually 
interfere with ordinary functioning.

[...]


http://www.msnbc.msn.com/id/28002991/
  

    
Kids these days. Why, when I was in college, at least 75% of us were
mentally ill.
  

    
And the ones who weren't were stoned or drunk all the time.
  

    
Gary, I was wondering what you think of ADHD.  I can't tell you how many
young people I've met in the past 10 years or so who tell me they were
medicated for ADHD from a very young age on.  At times, it seems like
*every* bright, energetic, subversive kid I meet has been put in that
category and medicated accordingly, starting at about age 12.  Knowing
what we now know about neuroplasticity, it wouldn't surprise me if this
situation emerged as an Infamous Medical Horror Story someday, a national
scandal.  But I don't want to be Monday-morning quarterbacking some other 
family's difficult situation;  what do you think is going on with ADHD?
  

    
But seriously, this is a great example of how the diagnosis craze
interacts with other forces in the culture--in this case the fear-based
parenting that has parents  (not to mention teachers and deans) and
ultimately the children themselves constantly monitoring for signs of
"illness," so that the terms of inner life increasingly become the
terms of pathology and othner shrink-friendly deficit.

Here's Francine Prose on this subject, in her novel Blue Angel. The
protagonist's wife is a nurse in a student health center. There's a kid
in the infirmary retching with the stomach flu. She's talking to her
husband. 

"Stomach flu," says Sherrie. "Nasty. Not half so bad as it sounds.
Ted, can you imagine? Kids come in here to puke. When we were their
age, we knew enough to crawl off and dig ourselves a hole and throw up
in private. No one went to student health unless we were overdsoing on
LSD and seeing green snakes crawl up our legs."

Of course, those kids come from homes, and in those homes, there is
great fear that the children will have ADHD, depression,
Asperger's--which are exactly the labels they will end up with if they
venture into a doctor's or a psychologist's office. Sometimes, I would
say the minority of times, the diagnosis is actually effective in some
way. But most of the time, it's just a massive and unconscious
collusion between doctor, parent, school, and drug company to attribute
trouble to the brain. 

Personality disorders, by the way, are a much discredited diagnostic
category. Insurance companies won't pay to treat them. They're the last
holdover of Freudian psychology in the DSM, and they don't really fit
in. I wouldn't be surprised to see the whole thing go away in the
DSM-V. Of course, no one knows what will come out in the DSM-V because
the American Psychiatric Association has cut off all communication with
the outside world on the subject, making a secrecy oath a condition of
serving on any of the committees that will write the book. Even the
psychiatrists won't know till they see it. 
  

    
I asked the editors of the DSM-V a couple of very basic questions in 
email as a science journalist -- not even about particular entries! --
and never got a reply.
  

    
AS for ADHD, I think that there are probably a relatively few kids out
there who are constitutionally incapable of sitting still and paying
the kind of attention to boring shit that you have to pay attention to
in school. It's probably a dimensional thing rather than a categorical
thing, a spectrum along which all of us are arrayed by temperament and
experience. This is probably true of most psychiatric illnesses. Common
sense lies in keeping as many people as possible out of the diagnostic
category, erring on the side of normalcy, but economics dictates an
entirely different approach. 

You can actually see this happen in Major Depressive Disorder, where
the decision wa made, by a DSM committee, to fold all the old
categories, like neurotic depression, into this one serious illness.
Between the drug companies and the insurance industry, it was not very
hard to sell the APA membership on this approach.

But I digress. ADHD is another illness whose existence is validated by
a drug-induced syllogism. Prozac makes you feel better, prozac is an
antidepressant, therefore you must have been depressed all along. With
ADHD, it's even more obvious. I discovered this firsthand about nine
months ago. 

That's when the doctors finally convinced Susan and me that we should
try some drugs on Joel, our ten-year-old son, who has some severe
learning disabilities, but is very bright and not terribly hyperactive.
That's a measure of how fucked up things get when you are in the maw
of the medical-industrial complex, suffering and worried and desperate:
that I, of all people, should have been convinced that I was doing my
child a disservice by not seeing that he had a disease that needed
treatment. 

So I got him a prescription for Adderall, which is amphetamine salts.
Our family doc is a totally reasonable guy, for a doctor, and he
prescribed the 10mg controlled release (long-acting) version. On the
first day we gave it to Joel, I took it. It was absolutely shocking. My
mind was focused on my work like a magnet on metal. It was painful to
disengage. I sat at my desk for hours and hours. I was not in the least
bit hungry or interested in playing the piano or fooling around with
the chickens or any of my usual distractions. I didn't crave my midday
nap. I wrote like crazy, doubled my daily output. I've taken a lot of
drugs, but while this one wasn't mind-expanding, it was still, in its
own way, amazing.

The only thing that distracted me that day was the fact that my son,
who weighs about half what I do, and who has zero experience with
psychotropics, was at that very moment, taking the same drug AT THE
SAME DOSE. When he came home, his pupils were LSD-wide. He was a little
hyper, but mostly focused. Of course, neither of us could get to sleep
that night. 

We eventually got some 5-mg, short-acting tabs and tried them for a
few more days. But the more I thought about it, the more I turned
against the idea. And not only because I wanted the amphetamines for
myself. But for exactly the reason Steve mentioned--the one about the
possibility of some eventual neurological disaster. It is nearly
impossible to believe that a drug that could do what it does can be
safe for a developing brain. It's probably not even safe for an adult
brain at the normal dose, and it's certainly not safe at high doses.
Amphetamines are used in the lab all the time to induce brain damage.
And we know what happens to people after long term, high-dose use. No
way I'm going to subject my kid to that, any more than I'm going to
turn him on to pot or let him sniff glue.

But I have no doubt that the drug would work, i.e., that it would help
him focus. This idea, handed down from the fifties, that kids with
ADHD have a "paradoxical reaction," to amphetamine and other stimulants
like Ritalin, that indeed this response is what confirms that they
were sick in the first place, is totally bogus. They're calmer because
they're focused, not focused because they're calmer. That's what the
drug does. That's why we pay it the big bucks.

There may well be kids for whom a cost-benefit calculation comes down
on the side of the stimulants. But the costs are probably way
underrated--these are addictive, neurotoxic drugs, not to mention the
hazards of telling a kid he's got a mental illness--and the benefits
are contingent on the very bizarre social order we have wrought, and in
particular on the nearly inhuman way we try to educate our young. 
  

    
>I asked the editors of the DSM-V a couple of very basic questions >in
email as a science journalist -- not even about particular >entries!
--and never got a reply.

Yes. It's a total embargo. Secrecy as befits a fascist regime. The
fact that they survived the homosexuality debacle is some kind of
miracle--and the guy, by the way, who brokered the deletion deal ended
up as the architect of the DSM-III, the one that changed
psychiatry--and it made them arrogant. 

The good news is that eventually what will happen is that
psychotherapy will get spun off from an increasingly bankrupt (morally
and scientifically) neuro-psychiatry, and we therapists will be left
alone to do the work we always wanted to do in the first place. For a
lot less money, I should add, but still...
  

    
Gary, can you offer a pointer to some reading on the results of
amphetamine use on the brain? I know someone who was tipped over into
bipolar disorder by a Ritalin overdose followed by a tricyclic; I'd be
interested in understanding more about the actual science of the brain
damage. 
  

    
First Grade, Second Grade, Third Grade...Twelfth Grade

Our Nationally institutionalized Twelve-Step Program where we turn our
children over to a higher power.  Except in this program, certain
numbing drugs (for ADHD) are cool.

A bit ironic, sociologically speaking.



Good stuff here, Gary! 
  

    
Yeah, they ought to just name it Adderall Deficit Disorder and be done
with it.
  

    
>Gary, can you offer a pointer to some reading on the results of
>amphetamine use on the brain? I know someone who was tipped over
>into bipolar disorder by a Ritalin overdose followed by a >tricyclic;
I'd beinterested in understanding more about the actual >science of the
brain damage. 

You and everyone else would be interested in the answer to that
question. Unless we're talking about frank brain damage--lesions that
can be seen, that have functional consequences, amnd that don't
reverse, it's very hard to say anything about this, at least in human
brains. And even then that stuff shows up mostly in autopsy. Brain
imaging, like fMRI and SPECT, is pretty crude stuff--just a way to see
blood flow, which in turn indicates brain activity. 

But Ritalin (which is not an amphetamine, but a different type of
stimulant) can certainly kick off a manic episode. Sometimes that's how
kids have their first manic episode. More to the point, sometimes
that's how kids end up with a bipolar diagnosis, espcially since
Bipolar II--in which you don't have to have a full-fledged mania or
depression to qualify, just relatively intense moods--was invented.
(Another drug-wags-the-disease story, this time about the new
antipsychotic.) The kid gets the Ritalin, gets impulsive, does
something way stupid--for instance, comes to school dressed as a penis
for Halloween, as one of Susan's students did recently--and when
confronted freaks out further, and the next thing you know they've
graduated from Ritalin to Depakote, from ADHD to Bipolar, and
psychiatry has a customer for life. 

AS for what to read, you could do worse than Peter Breggin's book
about ADHD. It's very polemical, but full of interesting info, and many
resources in the bibiliography. Talking Back To Ritalin is the name, a
companion to TAlking Back to Prozac.
  

    
Amazing stuff, Gary, and that story about your son was really poignant.
  

    
Today's instant disease:

Radiologists uncover, label new teen affliction
By Deborah L. Shelton

Researchers evaluating a new technique for locating and removing objects 
accidentally embedded in the body say they may have uncovered a new form 
of self-mutilating behavior in which teenagers intentionally insert 
objects into their flesh.

Personnel at Nationwide Children's Hospital in Columbus, Ohio, report 
extracting 52 foreign objects that 10 teenage girls deliberately embedded 
in their arms, hands, feet, ankles and necks over the last three years, 
including needles, staples, wood, stone, glass, pencil lead and a crayon.

One patient had inserted 11 objects, including an unfolded metal paper 
clip more than 6 inches long.

The study, presented Wednesday at the annual meeting of the Radiological 
Society of North America in Chicago, is the first to report on this type 
of self-inflicted injury among teenagers, the researchers said. They call 
the behavior "self-embedding disorder."

[...]


More: 
http://www.chicagotribune.com/features/lifestyle/health/chi-embedding-disorder
- 
03-dec03,0,7552924.story
  

    
>  I have lots of experience helping people to form a
 coherent narrative about their lives. I think this is useful because so
 much of what has gone wrong is often the result of an incomplete
 story, one that can't encompass some important events or aspects of
 events that have actually occurred. But there is absolutely nothing
 scientific about this, and to the extent that medicine gains its
 authority by being scientific, there's nothing medical about it. It's
 effective, in its own way, but it's not effective like an antibiotic or
 surgery. 


I think you're defining the words "medical" and "scientific" too narrowly.  
Uncovering and/or weaving a coherent narrative has been at the heart of
the healing process for thousands of years.  In fact, it's only with the
rise of big pharma, computerized testing, and the other tools of 20th
century medicine that the exchange of stories between healer and patient
takes a back seat to the _techne_, and not always to the benefit of the
patient.  If placebo is the most widely effective drug known to humankind,
the active ingredient is skillful narrative.  You may be selling that
potent healing mechanism short.