Thursday, November 25, 2021

Worst of Sinners - Part II

I'm going a lot of unexpected places here.  I got too cute in introducing this in the previous post, throwing you off.  I didn't do that for humor and writing-reveal purposes, it was just clumsy.

There is a longstanding joke in medicine that you should prescribe a medication when it is new and still does magic, because after a few years it is less magical and becomes just one more treatment with an array of effects and side effects. What is being described is our impression about its value, of course.  The efficacy of the medicine has not changed.

When the vaccines came out a year ago I was excited, like most other people.  It looked to bring the end in sight more quickly.  It was a new layer of safety for people of my generation and created hope that relatives in nursing homes could soon be visited again. There was an initial flurry of people telling us they were horrible and unsafe, but as I pointed out at the time, most of these fell into two camps: antivaxxers and people selling alternative treatments, who needed for previous reasons for the vaccines to be discredited; and anti-Trump forces who wanted to cast doubt on anything he could take credit for. I was appalled to learn that the rollout and endorsements and been held back even by some for whom science is their profession, solely in order to prevent him from having credit. I focused on pointing these things out. I think I would have justified that by noting that these were the prominent arguments the society was now having, and were thus important for people weigh in on reasonably. Hold that thought.  The fact that I had something else to offer to the discussion did not occur to me.

It half occurred to me. When there were very quick objections that this seemed precipitous and there might be side effects I thought it important to note from my own experience that there are always side effects, and this is to be expected. Not necessarily a problem in itself. But there is a second half to this that I knew but was oblivious to. When there is an expectation of magic, there will be a snap-back, a counter-reaction when it dawns on people that the new treatment is not magic. In their disillusionment, people will not merely complain that the new treatment isn't as good as hoped, they will start trying to find ways to show that it is actually bad.  It is as if we overcompensate for believing too much by believing too little. 

I have seen this happen enough times, including a couple of major changes in psychiatric treatment that were large enough to be among the defining points of the careers of all of us, that it really should have been front-and-center in my thought.  The development of clozapine, for example, really was magic.  Patients who had been psychotic for decades came alert and said "I felt like I was living in this fog and had no way of getting out. Then I woke up could say things again."  Parents would say, weeping, "This is the child we have not seen for twenty years." Eventually we would find that patients who had done moderately well on other medications did extremely well on clozapine. Again, magically well. It is still the gold standard of antipsychotics, decades later. 

We were told about the rare but deadly side effects right from the beginning and exercised extreme caution, unprecedented caution, in initiating the drug in a patient. And yet even that was not enough. It was even a little more dangerous than we thought. We lost patients to the direct effects of the drug.  Few, very few, but there they were, dead. They had at least been alive a few weeks earlier. We almost lost one of my favorite patients of all time, one of the few I considered an actual friend even when he was horribly crazy.* The drug worked with him, magically. Then he developed the one truly deadly side effect and nearly went cold.  We could no longer use it, and he went largely back under the waves of mental illness again, lovely and kind but inaccessible. 

The counter-reaction began. Clozapine isn't magic. Fine. It actually SUCKS. Oh please. It kills people and is the most dangerous psychiatric drug we've ever seen. That is, frankly, a high bar to get over. You have to stop doing this. No. We have to go back to the Goode Olde Dayes when psychiatry was based on lengthy psychoanalysis and gradually working out the id-ego-superego conflicts to get free.  Or maybe to change our whole conception of mental illness...

Okay, I'm getting worked up all over to fight a battle that was won thirty years ago. The counter-reaction was fueled by the clamoring Freud/Jung/Perls/Szasz/Laing/Satir/Jackson tribes clutching at their last straws to preserve their idiot theories. Declaration I want those who come after to remember because it is going to be lost: It was not accidental that the Recovered Memory and Satanic Ritual Abuse psychoses of the providers arose at that time. Because clozapine treated not only the positive symptoms (hallucinations) but negative symptoms (initiation), it destroyed the last shreds of their explanatory power. They were firmly consigned to the Worried Well forever, and they hated it. The long knives were out and the counterrevolution had begun, not in spite of the magic of the medication, but precisely because of it.  Because in the rest of us, we did feel bad that we had said "This is magic," and then it was only really good.

That is the big example, but others have happened and more are coming in. Ketamine is going to be magic, but it is complicated and also damaging and doesn't work on some people it was supposed to.  Ditto deep-brain stimulation, vagus nerve stimulation, low-dose psychedelics, EMDR.  All magic, all destined to go through periods of sudden condemnation and unpopularity.

In the humanities there is such an overarching control of Theory that despite the near-continuous attempts to create counterrevolutions, I don't think any have taken hold. It keeps looking inevitable, but like the arising of Brazil as a world power, is forever threatened but never-happening. 

Thus, while I am not unique in knowing this about the vaccines beforehand, I was unusually well-placed to point out to y'all "This is just about to happen.  The vaccines aren't magic, because they never are, but they are fine. They will underperform according to expectations in some areas, and that will piss people off enough that they will go to the Dark Side and say they are dangerous. They will have downsides, but that is no big deal when one looks at the actual numbers underneath instead of the stories -  many of which are from people who have other agendas if you take a moment to examine.  However, because there was such an incredibly high expectation and positive spin about them, it was inevitable that there would not only be a mild snap-back, but that a positively rabid rejection very soon." But I was paying attention to other things that a million other people could see just fine and express better, and the chance passed. 

So here is my real point, larger than Covid: This happens to all of us all the time, because we too get blown about by the winds of every teaching. We get distracted away from what our unique gift is into things any number of people could do. It's what I complain all the time about the Church doing. My son's church does podcasts, and after spending 18 months discussing gay marriage every other week they have gone on to discussing racism in the church every other week, and then the pandemic, and now who knows what will be next?  What will be the Cause O' The Month? My own denomination, if you go to the central website, does the same thing. It's all what's fashionable now. There's nothing wrong in general about the Church noticing, trying to understand, and addressing such things. The drive to "speak to" the issues of the day from a Christian perspective is fine.

But after complaining about the Church doing that so often, I am a little sheepish to note how easy it is to fall into that myself. Among several good missions of the church there are also some key missions.  Not getting around to those because we are wondering what our vaccination rate is is rather missing the point. Lion's Club can do that. The League of Women Voters can do that. The PTA and Food Bank and Red Cross can do that. Sometimes the great sins look like small sins at first, and their subtlety is their danger.

There will be a new fashion for the church to get distracted into coming along soon.  I don't know what it will be. Conservatives will get their heads jerked around responding to some other fashion. The schools do it every year or two and liberals essentially live for these...and I am likely to fall into another new one myself, if only I knew what it was. As in Matthew 24: But know this, that if the householder had known in what part of the night the thief was coming, he would have watched and would not have let his house be broken into. Therefore you also must be ready; Well, yeah.  If I had known...

The same as me addressing the hypocrisy of scientists or hammering home recent updates about bad reasoning about covid. That's not a sin in itself.  Yet there is something I could have brought that was more valuable. We have both general and specific callings.

*We are not supposed to use that word anymore, and I get it. It is still used behind closed doors but it has a subtler meaning for us. My dear friend has a mental illness. I do not define him as a "crazy" person, that is not his identity. That there is a Person who is separate from the Illness is very clear.  In fact, painfully clear. But when everything is off and medications are absent or inadequate he is sometimes so disorganised, so psychotic, so different from regular humanity that describing him as something separate is not the dehumanising word one would think. It is in fact the opposite, the acknowledgement that the real person is temporarily obscured. Consider it similar to a person with dementia, who inhabits the body of a person you loved and uses his voice and mannerisms, but is not the same.


Grim said...

I have an operating theory that the body is mostly a receiver rather than a producer of consciousness. A body that comes out of tune with the signal, much like an old radio or television that wasn't quite lined up with the frequency, ends up being fuzzy -- eventually losing any capacity to carry the signal at all.

It sounds like these drugs sometimes work to refine the tuning, so that things come clearer for a while. Maybe. Sometimes; and with costs.

james said...

I suspect that by and large your readership, with a few exceptions, were already realists about what to expect from vaccines.

Donna B. said...

I do not understand the connection to the "Recovered Memory and Satanic Ritual Abuse psychoses of the providers" to clozapine.

(The list of things I don't understand is getting longer and longer.)

Assistant Village Idiot said...

The belief that things that family did to you when you were very small explains all your problems now would be my off-the-cuff summary. Even family systems theory smuggled it in as this stuff that needed to be unraveled after years. Those had been under fire for a few years, as the medications stopping hallucinations raised the question of "How do medications/treatments affect your relationship with your mother, Sigmund?" There were excuses about "just covering up" symptoms, or with ECT's "these women feel guilty and this answers their need to be punished." Clozapine took it one step farther by restoring some missing personality pieces.


David Foster said...

Just about all technologies, not only medicines, sometimes show undesirable behavior in ways not expected by their creators. Nobody expected the first passenger jetliner, the Comet, to break apart in midair, but it did.

Michael or Janice said...

It is good to be reminded that newest treatment usually is not magic with no side affects or shortcomings. We are a bit spoiled with vaccinations that are very safe and effective with one or two and done (polio, smallpox).

It is easy to ignore how hard it is to get the dose just right, strong enough that the body develops an immune response, weak enough that no one gets the disease from the shot. After reading this post I spent some time poking around the net, looking for vaccines that were too weak or strong.

First one I found is Hepatitis B, which has a 10% failure rate. A series of 3 or 4 shots and then a test to check for an immune response. I had the series 10 years ago and was one of the people with no immunity.

I had forgotten all about my Hepatitis B shots. So I was alternating between covid shots are worthless, dangerous - and they lower the chance of getting covid and the severity if you do get it.

Yours is one of the few conservative sites that talks about and links to actual covid numbers and statistics instead of innumerate stories that dramatize the inevitable problems. You have helped keep me from buying the worst of anti-covid vax nonsense.

Thank you,

Assistant Village Idiot said...

You are welcome, and I am grateful that anyone is listening. I depend on Bethany at Graph Paper Diaries (sidebar) a great deal, as she is a nerd who actually likes looking this stuff up rather than just doing it in order to keep up. My other rule of thumb is "skin in the game." Who loses their job if they get this horribly wrong, not because of bad luck but because they were an arrogant prick? You can hear people screaming in many places. Who actually has to go in and try to choose among risks for the people they are responsible for? Who actually looks at the consequences of decisions and has to adjust to them?

Even if I say no other useful things, let those be your guide. Talk to people in your area who work ERs and ICUs. What are they seeing? It's not perfect, but it's a helluva good starting place, way better than (ahem) law professors and pissed-off journalists.