Unawareness Versus Denial

Grim's recent post Blindness put me in mind of things I wrote years ago.  This was the first post in what eventually became the series "May We Believe Our Thoughts." I don't think I'm going to reprise much of that, but I thought I would put this in anyway, partly because of the comments there.

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Because of the neurological research coming out over the last decade or two three, psychiatry is increasingly making a distinction between denial and unawareness. Some of the research is being done up at Dartmouth MS by folks I admire and used to work with, so I keep up with this more than other areas.

Everything has been in the "denial" category since Freud, or before: the idea that mentally ill people really do know, at some level, what reality is, but hide it from themselves. Therapy was a way of developing insight, and having the courage to accept the unpleasant.

Unawareness, in contrast, is the idea that certain brain dysfunctions make the owners of those brains unable to see their illness, no more than a blind person can see, or even more exactly, than a color-blind person can distinguish colors. Like an amputee who feels a phantom limb, or like Oliver Sacks, losing the sense of ownership of a limb after injury, they cannot perceive their illness, regardless of the evidence submitted. Dr. Flashman gave the example of the patients who believed he had implanted chips in their brain, shown their chipless MRI's. The responses were varied - my sort of chip doesn't show up...that's not my MRI...you doctored the photo... but none were able to muster even a 0.1% acceptance of the no-chip idea. Not even in theory. Not even as a "what if" scenario.

We are moving lack of insight from the "denial" pile into the "unawareness" pile, for psychotic disorders certainly, but even for mood disorders when they are untreated. How far will this go? Will it turn out that no depressed people ever respond to any offered advice or insight, but only to the intervention of attention, of exercise, of medication, of practicing agency? Lincoln's comment that people are about as happy as they make up their minds to be might turn out to be completely untrue, and useful only for the reminding the folks outside the depression that nothing, absolutely nothing they advise is going to have the slightest effect.

I am increasingly convinced of this for many illnesses, and it makes me feel shame at the conversations I have had over the years with patients, attributing (usually, but not always, unconsciously) their lack of insight to some stubbornness or cowardice on their part - a refusal to engage reality rather than a biological inability to perceive it. It's not just a waste of time. It's thirty-plus years of unnecessary cruelty.

If you absorb this, you will see that it makes things both better and worse. If the patient is not going to be convinced, whether you explain for two seconds or two hours, why bother to give any explanation at all? Or if you listening to her for two hours will make no more difference than listening for two seconds, why listen at all? Isn't it just a waste of time and ultimately cruel, pretending to a patient that her opinion makes the slightest difference when if fact it doesn't? So let's just ignore everything she says until we get a guardian then, and hold her down and give her medicine and be done with it. Why any charade?

I don't think it takes much imagination to see that as a chilling scenario, and an enormously bad precedent to set.

But is badgering a deaf person because they can't hear any better? Because even if the mental health practitioner is speaking in the kindest tones, is really rooting for the patient to "get it," and has the best intentions, if we really think that underneath it all they are denying reality, that some trick or intervention on our part will help them turn the corner and begin to see, then badgering is what we are actually doing.

It gets worse. It may apply to a high percentage of all beliefs, not only to mental illness.

Update: Roper's comment reminds me that I have at least a half-dozen professionals reading here, so I should provide some links. Xavier Amador looks like he'd be pop psych, but he is not. His books cover a fair bit of the brain research. (as of 2011)

Laura Flashman

Thomas McAllister

Sex Offender Registry

I had cause to be examining NH's sex-offender registry in detail today, looking at photos and someone who may be using an alias.  Not that my actions contribute in the slightest to the patient's treatment or the well-being of the citizens of NH, but because I'm going to look evil if someone slipped through, once someone wondered allowed whether X was an RSO.  She is and is quite open about it.  She had sex with a 13 y/o when she was 27 and bore his child.  She did two years and has been on parole ever since.  She didn't show up on the registry, because the registry is inaccurate, as it often is.  And apparently much more inaccurate in other states.

I have never mentioned it before, but I am deeply opposed to these registries.  I know a few of the people on New Hampshire's, maybe a dozen or so.

I know lots of folks more dangerous, including sexually dangerous, who are not on that list.  And I know for certain that there are folks on the list who are at most marginally more dangerous than the average person-on-the-street.  We put up these registries to express our anger, and how much we CARE ABOUT OUR CHILDREN rather than to increase our safety in any way.

There is no evidence that these measures have increased our community safety even 1%.

There is plenty of evidence that people on the registries have been harassed, lost jobs, and even been murdered. (A bunch in Maine.  The murderer, from Canada, had a list of NH offenders to go ofter next.)

Paragraph 4 and Paragraph 5:  That's not a fair trade.

No one has to tell me that there are perpetrators who reoffend hundreds of times, and bear constant scrutiny.  Yup, and I know three of 'em.  None of 'em is on NH's registry.  There is a subset of offenders, usually male, usually targeting 10-12 y/o boys (the age at which they themselves were molested) - though there are exceptions, who have literally hundreds of victims, and all interventions to date have been only partially effective - who are ongoing flat-out dangerous and should never be unsupervised.  But even the most experienced clinicians have a poor record of identifying who those will be, except after long and sad perpetration.  There is no one in the country who can identify which 20 year-old offenders will continue to reoffend and which won't.  On the whole, sex offenders have the second-lowest rate of recidivism, after murderers.

We pass these laws to beat our chests.  They are therefore worse than doing nothing at all.  Anytime we feed that beast in our own souls, the idea that we have slain seven with one blow when we have only killed flies, we endanger our children more, not less.

There are perpetrators who continue to lie to themselves and excuse their behavior - don't I know it.  But our rage at their lack of remorse is not the issue - public safety is the only issue.  I know penitents who are still dangerous, and impenitents who are not.  I see little correlation, if any.  Opportunity, substance abuse, accountability - those are the only issues.  Humiliation and punishment are irrelevant.

BTW, note on substance abuse:  I would give a convicted sex offender a lifetime subscription to his ten favorite fetish sites before I would give him a beer.

Memory

There must have been a day long ago when I said "Mummy, I want one of those jobs where people scream at you and condescend to you and call you names and accuse you of things you didn't do." But it was so long ago that I can't recall the exact time.

I can't remember my mother's exact words, but I know her character, so I am sure she said something like "Are you sure that's what you want? Because it sounds all very fine to say you want to help people, but those jobs are harder than they look on television." And she was absolutely right, of course.

I rejoice that none of my sons have gone into human services - though Ben's job trends toward that somewhat. Kyle makes noises about social work at times, which I discourage. I have always said those words with humor, so as not to drag down the general conversation and become a pariah. But I absolutely mean it. Mamas, don't let your babies grow up to be social workers.

אמר הבלים הקוהלת הכל הבל׃ הבל׃ Ecclesiastes 12:8

Presentation

My team presented at Schwartz Center Rounds today. We discussed compassionate care of the homeless. The format is that an individual case is presented, and the general issues of compassionate care that the patient presents are discussed. We presented a young man who came to the hospital suicidal, identifying the fact that his girlfriend kicked him out and he was homeless as one of the things that "made" him suicidal. There were plenty of reasons to dislike the fellow. He doesn't seem particularly depressed, and in fact was cheery and social with the other patients, especially the younger, vulnerable females who he attempted to cuddle up with. He was rude, threatening, and insulting to staff, while reminding them that they had to be polite to him because he's a patient. He is trained as a welder but has not worked since 2003, collecting disability for depression, though not being treated for depression all that much. He drinks too much, but resists efforts to get him into any sort of treatment or lifestyle that would address this. I could go on, but you get the idea.

The unit staff had a great deal of trouble remaining objective, of course, as they w4ere the ones in the thick of it. But even those of us with more distance seethed, not so much for the sneering and insulting attitude, but the interfering with others' treatment.

Yet we are also trained to recognise that things are not always as they appear on the surface, and to be alert for what our own feelings tell us about the patient and the world he likely inhabits. The idea of countertransference is never supposed to be far from our thoughts. As one of the psychiatrists mentioned in the discussion "When I start blaming everything on the patient, it's time to take a vacation. Or get out of this field." Very true.

He did very little to find himself any housing, despite my supplying him with lists and offering to pay the first month's rent. The nurses became increasingly rude in demanding that I find him a place and get him out. They kept making suggestions of what I should be doing, rather obvious suggestions which I had long since tried. They wanted him gone because they didn't like him, and the fact that he was homeless because everyone else didn't like him - well, they didn't want to hear that.

They were quite happy to send him out without shelter, but I am not allowed to do that. Or rather, it happens all the time because the patient is discharged, but I am regarded as having failed because they don't have housing. It's unpleasant, and it still bothers me after all these years to work with people who regard me as a failure. But that's what the job is.

I batted cleanup in the Schwartz presentation, and highlighted the enormous conflict we feel in not wanting to blame the patient for things that they have little control over, but also want them to have natural consequences for their actions, as that is often the last teacher when all others have failed. I talked about volition, and recent research, and some of the issues we have discussed in my May We Believe Our Thoughts series.

I was nearly brilliant. I suspected it, but it was confirmed by those who came up to discuss for the rest of the day. Many comments were simply the polite affirmations of nice people, very nice to hear but not to be taken too seriously, but others were complimentary in a deeper way, referencing exact quotes, which they had even copied down. That sort of thing.

Here's the problem, which I am reminded is the great discouragement of all preachers and teachers who look for insight: everyone seemed to hear the part they already agreed with, while being completely unaffected by consideration of the competing value. Those who felt that irritating patients were being pampered altogether too much by the hospital, and we had to recognise the limits of compassion and take a firm hand yada yada yada... thought I expressed very clearly the need to move these people on and take the consequences of their behavior, and glad that administration had heard me say it so bluntly. Others felt enormously vindicated that I had spoken out about how much countertransference was allowed in current hospital culture and how wrong that was, and our need for...well, whatever. Something that will fix bad staff attitudes.

And a third group felt gratified that I had highlighted the recent research on volition and how indeterminate agency and self-control can be. They wanted references.

All that in eight minutes of presentation, plus about three thirty-second answers to questions. I was brilliant, I tell you. So why do I weep?



I posted the song because of the "Still a man hears..." line, but it's appropriate for the later verse as well:

After changes, we are more or less the same.

Ridiculous Quote

The nursing administrators in my building must have been to some conference or class which instructed them to put some inspiring quote on their regular email, because they all popped up at once about six months ago. I don't know if it is supposed to be a general strategy, or specific to nurses, to illustrate what a literary and philosophical bunch they are. Most quotes are banal, harmless. Today the following was appended to the bottom of the education and training coordinator's email:

You don't stop laughing because you grow old, you grow old because you stop laughing.
Michael Pritchard

Michael Pritchard, then, is an ass. This is precisely the sort of blithe optimism which masquerades as encouragement but is in fact a sharp departure from reality, which causes much mischief. People who laugh easily like to say things like this, implying that they have made themselves into superior beings with the steady application of folk wisdom.

Ah, yes, it's all just a matter of hazzin' the right attitude.

Incest and DNA

My son in Nome, referencing another grim situation that has come across his screen, said that the joke about the villages is that a virgin is defined as a girl who can run faster than her father. “The Villages” means almost entirely Native populations, Yupik and Inuit. I had heard the sad joke about other places many times – first, I think, about the peninsula counties of Maryland in the 18th C, though the reference was to being able to run faster than one’s uncle. The accusation has been made about Appalachian areas as long as I can remember (though those often took the form of cousin-marriage jokes), and I am starting to hear that incest is distressingly common in some African groups recently coming to America. There were towns and village sections of NH that were rumored to be incest-ridden – being familiar with the dark side of social histories in this state over the last 35 years, I can confirm that some of the rumors, at least, are true. (I have no sense there is any ethnic difference, BTW.) I had only heard of brother-sister incest in professional settings, never in news stories or general discussion, but that is being acknowledged recently. We have long known that step-relatives are far more risk to children than blood relatives, and the data are bearing this out.

We have lived in a swirl of rumor with little data all these years, and the excesses of recovered or implanted memory have added to the confusion. We have speculated whether certain cultures are more prone to incest, but our knowledge has been so limited that this has been irresponsible. I have suspicions on that score, but disbelieve them myself. We have identified some common themes that seem to be holding up – that older siblings are more likely to perpetrate on brothers and sisters when no father is present; that father-daughter incest is more common when the mother is unavailable, depressed, or loses to her daughter in some competition for power in the family; we have wondered whether particular dislocations of culture, such as expulsion or refugee status, create an increase because of the thoroughness of family breakdown, though that is only theory.

That drug and especially alcohol abuse co-occur is one of the strands of information we actually do know with confidence at present.

We are about to start knowing the answers to these questions. And some among us are going to be harmed by it and fight to insist it isn’t true. If whites of certain groups or subcultures show up badly, expect an increasing in them pointing out terrible things that black or Hispanic people do – unless of course there are subgroups of blacks or hispanics exposed under the same light. This will be knowledge we don’t want to have, but we will have it. I don’t know whether we’ll be able to disguise the truths on this one.

One note on how cultures that are either prone to such breakdowns or have such breakdown thrust upon them have been able to survive darwinian selection, given that more children with disabilities would seem to decrease group survival: think of it as natural selection in high gear, if tribes leave the weak behind. There will be little or no greater chance of exceptionally good genes for survival, but the bad genes will be expressed rather than being carried in secret, and weak lines culled. Rather chilling, even if one is considering our ancestors of 100,000 years ago. We may all have benefited from it.

Institutional Memory

Grumbling about work...

The central narrative of my 30+ year employment at the hospital was being asked to work with the staff that no one else would, often put in those exact terms, culminating in being supervised by an insane person 1991-99. Then, the liberation from this in 1999-2006, when I worked with the most wonderful people and everything I touched turned to gold. As central as those are, they are virtually unknown outside a circle of about a half dozen people at work, and perhaps a dozen of my friends and family.

This was brought home forcefully over the last month in three work conversations. The previous supervisor, and what a strange, almost dangerous person she was, came up in conversation in matters unrelated to me. I mentioned that she had been my supervisor for eight years and received amazed, shocked looks. But she's diagnosable. Dr. (redacted) made a detailed, non-humorous case for it when she covered on our unit, and gave us instructions how we were to deal with it. The other stunned comment was similar.

Yes, yes I know this. I said this for years, trying to get people to listen. But it's over now, and it ended well, actually. You didn't know? You worked the next unit over and no one ever mentioned it? Huh.

Similarly, the buoyant days of doing two jobs at once for the sheer joy of being appreciated and feeling competent had also slipped the minds of some I was sure would remember. Vague nods. Well shucks, then. I was kind of thinking I was holding the department aloft, covering for the impossible person, then covering two jobs. Those powerful people who assured me this was all being observed at a high level, and something would be done about it...well, I long ago figured out that no one was going to take any risks and do anything about it. But I guess I had still harbored the fantasy that someone had noticed those decades.

So I asked the head of my department whether any of this information had ever come to her in passing over her three years here. Nope. She was quite fascinated, actually. She spoke with at least one other long-time member of the department about it after. I don't know that it changes anything. Just another up-short reminder: it is not merely that people see things differently and remember things differently - it is that most things aren't remembered at all. On the plus side, that may mean two major screwups of mine from those years, topics that I still wince at whenever someone wanders near them, may also have vanished.

Human nature being what it is, that's less likely, actually. But we are less noticed than we think.

Ah, if only Stalin knew.

Dictation

We have one medical transcriptionist whose mistakes are becoming legendary. Anyone can make occasional spelling or grammar errors (she's got plenty of those, too), and what is dictated into the phone may not always be completely clear. But the following come from only two documents total over the last month - the only two she has done for my coworker and me. They all stem from a lack of vocabulary and general knowledge.

He is uncertain who his sir name comes from...

He is at panes to point out how dangerous the people he hangs with are...

He stresses that he worships satin...

She then studied at the University of Rock Chester...

When she entered primate school...

Other than the Alzheimer's Disease and the depression, she knows of no gastrotrophic illness in the family.

Peer Support

I'm very big on peer support networks, even if it is the current bandwagon.

Where Have The Good Women Gone?

Among the links at Instapundit discussing Kay S Hymowitz's book Manning Up; How The Women's Movement Has Turned Men Into Boys and her WSJ article this weekend "Where Have All The Good Men Gone?" was one to The Art of Manliness site, a personal favorite of mine. An excellent short take on the topic.

The topic of boys becoming men, and whether particular individuals are on schedule, has occupied much of my thought these past 30+ years, especially the last 10 (and the next 5, I'll bet), and I have shared the worrying concern that the grim statistics reveal. Yet might I mention that because of the boys and their friends, I have also had a fair bit of exposure to young women, and their behavior is uh, not uniformly encouraging either. Apparently it is impolite to mention this.

Also, any reading of history suggests that young men and young women have always presented much the same difficulty. There is a narrative, much beloved of sentimentalists and conservatives - I'm not implying any particular correlation there; it might be negative - that in the Good Old Days young people knew that life was hard and grew up quickly, taking responsibility for repairing the pigs or darning the buckboard or whatever, so that papa and mama would be able to work 30 hours a day at the vegetable mines and make some money.

This is certainly true in comparison to the present day, for if there is anything we know about history, it is that people mostly starved, were exploited, and died young. Working hard was not a matter of good character, but mere survival. But most of the stories today of folks remembering their own childhood and the stories of their parent's are subject to selective bias. People who became successful enough to write for a national audience, remembering themselves and their circle, portray a society of industrious, responsible young people - not like you slacking whippersnappers today, dammit.

But the historical record is also full of bastardy and abandonment, murder, robbery - all those things mentioned in the folk songs, actually.

Well, I do social histories on people as part of my job and have been doing so for thirty years. A psychiatric facility is very much a restricted sample of another sort, but not so much as you'd think. There have been 18,000 separate individuals admitted to our facility over that time, and we get a fair bit of information about their families as well. So perhaps 5% of the population have something of themselves in our records - which is part of why confidentiality is such a big deal to us. That 5% is certainly slanted toward those homes your mother wouldn't let you visit, which had forgotten until I just reminded you, but we also know a fair bit about the dark underside of some of the prominent attorneys, physicians, college professors, business owners, and other respectable people. And I don't just mean that they happened to have a child or a spouse who hit a bad patch in the genetic lottery and have some sad condition. The full display of incest, violence, addiction, and criminality of even the elite runs through our histories.

From those data bases, let me assure you that youthful irresponsibility, in more than a Disney sense of stealing muskmelons or putting glue on Miss McDonald's chair, is not confined to the present age. Nor is it confined to young men. Women may have some different pathologies - perhaps, sadly, complementary pathologies - but they can be just as damaging.


I sometimes point out that the most economical explanation of societal change since the 1950's is that teenagers had discretionary income for the first time in history. Most pathologies could be at least theoretically explained by that - even the sexual ones. And we note that the few individuals in history who also had discretionary income as teenagers acted just about as irresponsibly as anyone we've got now. When I consider the lives of my grandfathers, I doubt I could endure it. Yet clearly, I could have. There is nothing they had genetically that I don't have. The need brings such responsibilities forth.

Which suggests the lack of need suppresses them as less necessary, but they are there if the need arises.

Rolfing In The Rain Forest

We received an invitation for training at my hospital. Here is the bio of one of the presenters (name redacted).

(She) is an Advanced level Instructor of Somatic Experiencing® for the S.E. Trauma Institute and a founding member of the A.B.T (Brazilian Trauma Association). She has been a Rolfer since 1984 and teaches Rolfing® and Rolf Movement® for the Rolf Institute and is also a founding member of the Brazilian Rolfing Association. Lael holds a 5th degree black belt in Ki-Aikido and is a teacher of both Ki-Aikido and Shin Shin Toitsu Do—Mind and Body Coordination, certified by the Ki Society International in Tokyo Japan. (She) teaches in the US, Brazil, Japan and Europe . She is currently studying Anthroposophic Art Therapy and together with (he) operates an integrative healing center in the Brazilian rainforest.

Quite a collection of cliches there, innit? rainforest, anthroposophic art, integrative healing, Oriental martial/philosophic arts, rolfing. Welcome to the edges of my field.

Easy to mock. Fish. Barrel. But before you sneer, two things: not this specifically, but something like this, is actually a very promising area of trauma studies. This, EMDR, and a dozen less well-known therapies have their rituals and gimmicks to set them apart from each other, and they are fairly unanimous that dreaded western medicine misses the point. But this idea of treating trauma by changing how the brain stores it, and changing what associations the brain has with traumatic events through physical, mechanical processes rather than talk therapies, may actually prove out. I am no judge as to which of these ideas is the most likely path to tread. Perhaps none. But however strange it seems, it's not turning out to be crazy. How the brain stores trauma and the emotional associations that cripple may indeed be key.

Second thing: however much I kick liberals, here is where they are best. They want to help. They want to relieve suffering. They may be open to new ideas to the point of preferring them to old ones for no reason, but they will risk a great deal in order to help. They will endure ridicule gladly for that chance. There is an entire important discussion about what the possible abuses are if we discover how to manipulate minds at such a level. But even if these people are ushering in those abuses through fuzziness, or inattention, or trusting the wrong leaders to supervise the regulation of this, they mean you no harm, and should not be seen as such.

These are not the droids you are looking for.

Revisiting The Cost

As the mental health debate - by which I mean the "why are we letting obviously crazy people run loose so they can shoot people in Tucson" hand-wringing comments, with no credible solutions offered - heats up, I direct readers to my recent post The Cost.

Here's the bottom line of the discussion: If I had met and interviewed Jared Loughner the day before the shooting, he would not have made the top hundred, maybe not the top thousand, of most-dangerous-sounding-people I have met. So all these calls for "better" mental health services for all these troubled people running around leads immediately to the two central questions, How many of those people - those false positives who are walking the streets of NH and haven't hurt anyone - do you want locked up or forcibly treated, even though they haven't done anything dangerous, just sounded dangerous? And Are you willing to pay for that? The upper number for the first question could run to a million people. The cost would be at least ten times, and more likely a hundred times more than we are paying now.

That's the reality. People blathering about the issue who don't recognise the scope of the problem, how many people we are talking about and how different the rights of a society are when you do that, really shouldn't be talking.

We have chosen our level of safety. It's not an accident, it's a reflection of a hundred cultural values.

Underground DSM Addition

My entries from my Underground DSM are based on a specific setting which I have been in for decades: a patient coming in to meet with the entire treatment team (4-7 people) for a diagnostic or treatment planning meeting in an involuntary state hospital setting. I've done a few thousand of these (though some patients are repeats), so while the methodology isn't rigorous, the N is large. The diagnostic tricks may not generalise outside that setting. Except, I'll bet they do.

Psychiatrist: Can you tell me something about what brought you to the hospital?

Patient: I wrote it down last night and want to read it to you. It's three pages long.

Diagnosis: Borderline Personality Disorder. (Though Narcissistic might be a go.)

" - not much, anyway"

There is a general myth in circulation in Christian circles that if we ever started acting like we should, the world would be amazed at our example and many would be converted. I suspect this is because nonbelievers make the accusation frequently, that they cannot take Christianity seriously because of oh, it varies from person to person, but all those wars of religion, y'know, conveniently overlooking all actual history, in the service of a narrative about all those evil religious people. It can become fairly sophisticated, this inability to take in the relevant data because so much of it contradicts the favored premise. There are certainly plenty of popular writers and even actual historians who subscribe to it.

Where was I? Yes, wars of religion, and of course, Christians saying stupid things - there's a first-class proof for you; or not standing up for justice - defined variously, with negative points awarded for standing up against you for justice. There are other excuses, but you get the idea. If Christians would just stop all that, then well heck, I guess people wouldn't have any more objections and would gladly walk the sawdust trail.

But I think Christians embrace the idea for reasons of their own, also hoping it's true. It's certainly the idea behind all those stirring speeches on the scripture "If my people, who are called according to My Name..." If we just all prayed more, and repented as a people, and refrained from unrighteousness, everything would turn around. Folks want it to be true, and scramble around in the scriptures for proof that it is. For America. In the 21st C. The religious left has its own political version, less well-known but just as pernicious, but I'm not picking on them especially this time.

Not only politics. The idea may be even more pervasive when it comes to evangelism. If we would all, individually and collectively, (block that metaphor), be a City on a Hill, the heathen would bow down. If only. Contemporary Christian musicians seem particularly susceptible to this.

''The greatest single cause of atheism in the world today is Christians who acknowledge Jesus with their lips then walk out the door and deny him by their lifestyle. That is what an unbelieving world simply find unbelievable.'' (''What If I Stumble'' by dcTalk)

comes to mind. I think that's rubbish. You can probably find some atheists who say that, but my experience is they put forth other reasons. If they reference Christian behavior at all, it is usually in the collective or national sense, as above. Come to think of it, though, shooting doctors who perform abortions - and heck, we all do that. That's been the Advent focus at our church for years - does come up from time to time.

My favorite example is my patient John, a charming bipolar man I knew thirty years ago. John had been a permanently baked 60's hippie who had become a Jesus Freak in the 70's. Big lifestyle conflict here, but John had a plan. He was going to go hang out with Bob Marley and convert him. But in a subtle way, not by preaching, by being constantly cheerful and upbeat. When I knew John in the early 80's he was discouraged - he had hung around Marley five years, but Bob had died a Rastafarian anyway.

But John had been ready. He had the script ready if ever called on. One day Bob Marley was going to turn to him and say "John, you're different from the rest of us. You don't smoke ganja - not much, anyway - but you are always happy." And John would say "Bob, that's because I have the Lord Jesus Christ." And then Bob would know.

I still think of John whenever I hear those sermons.

Post 2700 - Disabilities Rights Center

Every state has one - a nonprofit dedicated to protecting the rights of people with various disabilities. This is New Hampshire's. You'd think that for a civil libertarian type such as myself, they would have a good reputation with me. I grudgingly have a mildly positive view of them in general. They do very good work badgering, cajoling, advising, threatening, or suing other agencies on behalf of people with other types of disabilities to receive more services.

But in mental health, they reverse field. They badger, cajole, advise, threaten, and sue mental health agencies to provide fewer services. That's not how they would describe it, but that is the practical effect. Mental health services are seen as an intrusion and burden that should not be placed on people who don't want them. And I will not be dissuaded from the belief that such is exactly their opinion of mental health services, however much they deny it. I have observed them and interacted with them for decades. Ultimately, they think that people really don't need these services, and that the evil MH system goes around trying to force ourselves on people who could just as well be left alone.

I get the civil liberties part. I get the concept that people have the right of self-determination, and the state does not have the right to interfere with a person unless the state can show a necessity for doing so. But that principle fails to take into account that lack of insight is one of the symptoms of several major mental illnesses. Depressed or anxious people seek services. They want relief, and are sometimes only too willing to try treatments that are more risky than they would otherwise entertain. The personality disorders are mixed, sometimes demanding services, sometimes evading them, and often both: help-seeking and help-rejecting at the same time. But those with schizophrenia and other psychotic disorders, or those with affective disorders on the manic side, often think that they're doing just fine, and it is everyone else who doesn't get it. Lack of insight is a symptom, and there are detectable brain-reasons why this is so.

I testified at a very complicated hearing on one patient today and cleaned up the legal confusion on another who was discharged back to jail yesterday. In both cases, the procedures put in place to protect them from receiving treatment because they think they don't need it, have resulted in both patients having miserable, isolated lives, rejected by friends and family and frequently in trouble with the law, because we are not allowed to give them the treatment they need. And the DRC is dead-center in this. Our current policies are based around the idea that someone's artsy and eccentric wife is going to get locked up for years because the fascist overbearing System is going to squeeze all the life out of her by giving her mind-numbing chemicals and make her into a zombie, depriving the world of the next great advance in sculpture. Or something. And to effect this protection for women in Birkenstocks, as if they are in constant danger of being silenced, we willingly sacrifice the lives of hundreds of intelligent, decent people, putting them on the altar of pretended dignity and slicing their throats.

They are stuck at the college bull-session "What is reality?" stage of philosophical understanding, selectively quoting Thomas Szasz. (I dare them to take his whole philosophy seriously.) They would not for half a second entertain the idea that brain injury or paraplegia were merely alternate ways of experiencing reality, but they willingly grant that to schizophrenics, who by definition misunderstand reality.

Okay, I'm done now. Rant over. Tomorrow I go back to explaining NH's RSA 135:C to people who believe that the vent over the cat litter box has made the air in their house dangerous and caused silica to clog up their veins, and that's why they drew a gun on their daughter who didn't believe them and wanted them to go to the hospital; or that the government has implanted a chip in their brain that makes them hear voices.

Coping Strategy

Work has taken on a surreal quality of inefficiency lately - I will not publicly explain why - but a new coping strategy occurred to me over the 4-day weekend, and it worked pretty well today.

I've decided I'm in a sitcom or a reality show. This is all being taped, and they're going to be broadcasting my reactions nationwide. So I don't want to be an ass. I want to appear witty, efficient, good-hearted, wise.

The Cost

A small NH town has a dump man named Ed. Now, I know Ed, because he was for many years a resident of the state psychiatric hospital, where I have worked for over 30 years. Ed originally came from this town, and when the hospital was trying to place him years ago, the social worker decided to move away from the usual plan of finding an SRO or a little apartment in town, setting him up with the local mental health center, and gradually teaching him to live in the world he had left in the early 60's. She contacted the town selectman - that's a singular - and asked if anyone might have a place for someone that came from there but they had probably forgotten.

Forgotten young Ed? How old would he be now? Of course we remember Ed. He was in my sister's class at school. His father used to have a little shop in town. Ed needs a place? Let me get back to you. Let's see what we can do. I will point out that no one from the town had ever visited Ed or sent him a card in 25 years, but that's NH. They didn't want to embarrass him by having people see him in the state hospital, probably.

The selectman got back to her a few days later. There was a woman glad to have Ed in, and the town had even arranged a job for him, as the assistant dump guy. A few years later the regular dump guy retired, and Ed became the dump guy. He's still delusional - tells the townspeople all kinds of crazy stories - but it doesn't interfere with his work much. A local PCP follows his meds - no psychiatrist or interfering human services people to clutter up the joint.

In the same town there's a retired guy with a truck. For $1 a bag, he'll pick up your trash Tuesday or Thursday and bring it to the dump. Leave the dollar attached to each bag. If you can't get out, he'll come into your house by prearrangement and take the trash out himself. He probably should have some sort of license and meet some state or federal standards that folks suspect exist but no one wants to look into it. So the sweet old guy makes another $200/week, and everyone's happy.

It is the ideal solution everyone is thinking about in the back of their minds when they are setting policy. This is the way life should be. This is how communities should act. It is the thought behind Tolkien's anarcho-monarchism, the idea behind the libertarians's love of small, naturalised, spontaneous solutions, the force behind all the liberal programs to teach job skills, develop natural networks of support, and have self-determination.

Wouldn't it be nice if.

It's 90% fantasy.

Y'see, Ed's not violent, and he shows up to work everyday. He stays on his medication, he's not addicted to drugs, and because years back he belonged to some independent Baptist sect, he's never had a drop of alcohol. But more than all that, it's only one guy. What's the town going to do if they have another Ed, or three, even if he's one of the easier ones to figure out. And then next sweet old retired guy with a truck has to figure out some other scheme as well. When you think of it, there are already retired people in town who don't have the health to pick up bags - but they didn't come into the story.

How would you replicate this solution in Boston? Hell, how would you replicate it in Concord? There are many, many more people out there, all of them with added difficulties - some of their own making, but many not. Making a life for all of them is an expensive proposition. In fact, it is furiously more expensive than any of you imagine. To do this right, to provide the services that people need to have a life, is well beyond our ability to fund. Well beyond. We might hope for technological solutions to bail us out over time: medications with fewer side effects, or gene manipulation to pull some of the developmental and psychiatric problems out of the equation. Better methods of incentive and persuasion to keep people in the treatment they need. New communication technologies that allow people to work without having their oddness and lack of social or employment skills show.

But for now, we have these people, and they are real people, and they are just difficult and expensive.

Conservatives and liberals have their separate ways of screwing this up. Small-government types entertain the fantasy that a lot of this would work itself out if people were more self-reliant - if individuals and families stepped up and made these natural solutions happen. They have a point, of course. I am very reluctant to apply for disability benefits for young people, knowing that this dooms them to a rather meager, helpless life in many cases. A lot of people could indeed smarten up and fly right if they had to. The risk of that is, some people can't, even with significant family support, or can't quite, and pushing them out into the world is merely kicking them when they are down. And let me assure you, you don't know which one's are which.

Liberals feel your pain, and in their kind-heartedness think we could do what is necessary if we would just try harder. They also have no idea how extensive the problems are. But you can see how they sense it at a distance, because a lot of them move into parts of the human-services bureaucracy where they are no longer providing services. They set up information clearinghouses, in order to connect people to services that already exist. They go into advocacy, trying to get this miserly, uncaring society to see how much we need to increase our support and grow new programs. They believe that if we all just pull together, dammit, we could make this pretty good. And so human service bureaucracies, and non-profits supported by government money, become about 50% people not doing anything that actually provides services. They go to meetings a lot.

They move into these positions to avoid despair. And it keeps the fantasy alive that if we would just be a good society like oh, all of Europe, they think, that this is manageable. Yes we can.

No we can't. Sooner or later liberals are going to have to face the despair, and deal with it emotionally. Their emotion drives their politics, and their hatred of people who won't do what they just know is important is a hatred of that despair. A hatred of reality. There is the hope that the pain of others will go away, and we can be free of it. Say, rather, that everyone picks their place along the line of pain, and endures from there. We're pretty good at that, actually.

No one wants this reality. In a fallen world, this will always be here. But facing the despair, and deciding what is my part in this, is a task of adulthood. There will be no comity until everyone faces a little more of the truth.

And hey, this is just mental health, developmental delays, autism, and substance abuse. I haven't even touched on physical problems, crime, or a dozen other things I know little about.

The Cost - Part II

The Cost was partly intended to set up a second post. If you haven’t read that one, do so now. I will reverse the order on the site in few days, so that it will read top to bottom, rather than internet style of latest first. I would appreciate it if anyone linking to the posts put them in that order.

The answer “We can’t fix this in our current world. The best one can do is adjust to the bad feelings as best you can” is unsatisfying. Not the old can-do American spirit, is it? Surely if we all tried just a bit harder we could make it somewhat better, right? Things do change. Things do get fixed, albeit slowly at times. What should we do? We tend to regard going into the “helping professions” (a strange phrase) the most natural choice. Might that not keep our despair at bay, feeling that we were doing all we could to relieving suffering?

A friend asked a few years ago what career one should consider if one wanted to improve the world. He asked it in the context of what we all might do differently if we were starting over. I went the Norman Borlaug route. I would be a food engineer. Plants, fish, quail, algae – something. That might seem to work only for specially gifted people, but such efforts usually have a considerable supporting cast. If you want purpose and meaning to your days here, you could do worse than saving a billion people from starvation.

There are similar avenues in mental health. Genetic manipulation to eliminate some conditions altogether seems in reach, and treatment techniques for those who already have an illness are always improving. You can relieve a lot of suffering that way. There may be unforeseen downsides and damages, but that’s true of direct care as well. That’s the risk you take with anything in life. There’s a nobility to the attempt, and the hope of great benefit, right?

Okay, you want to be the Jonas Salk of schizophrenia research, and eliminate the disease altogether, devoting your life to it. Let’s add in a twist here. Let’s say you’re not doing it for compassionate reasons at all. You just want to be famous and important, or playing around with genes and the brain is just fascinating to you, and you care little for your fellow man. The other people who have to work with you, in fact, will gladly attest to the fact that you are a rotten selfish person who doesn’t play well with others. Problem? What’s the moral calculus here?

I have intentionally left the God part out of this. I may do a part 3 exploring exactly that, but for now I’m just sticking to the vague Law of General Beneficence. In practical morality, selfish Salk is the same as selfless Salk, right? That’s a slightly uncomfortable idea, but hardly a new one in theory. We ignore it in everyday life, though. However much we assent to the principle, we want professional helpers to sound like they care. We have had social workers in my department who were very good at listening, looking sorrowful, and showing empathy, but screwed up things like getting necessary followup appointments, getting the benefit applications right, and keeping up the nuts and bolts. We have had social workers just the opposite. Which do you think gets the grateful letters and assurances that they have changed people’s lives? Right. The people who make you feel like they care are more highly regarded than those who actually help you. This is more pronounced for doctors, I believe. It is certainly true for politicians. Actually fixing something counts for much less than giving people the impression that you care deeply about the same things they do.

The friend who asked me what I thought I would do had decided that if he had to do over he would build a business that created lots of jobs. It’s hard to argue with that one, either. The mill owner was a stock villain – but it was thousands of jobs for those communities, wasn’t it? When you have a job, creating jobs doesn’t seem to be much of boon to society. Once you don’t have a job, or someone close to you can’t get one, the importance of jobs sinks in. When people think of noble professions that help the downtrodden, they don’t think of mill owners, they think of jobs like mine. I certainly did when I started out, with secret contempt for anyone who wasn’t down in the trenches with us. I don’t think that anymore.

So you want to relieve human suffering. How are you going to do it? I’m not trying to prove any point here, I’m just asking the imagination question. In the context of The Cost, where suffering will always haunt us throughout our short lives, what do we do, and encourage others to do?

For the humorous side, there’s always PJ O’Rourke’s commencement address.

The Cost - Part III

Again, read the first two before this one. I will be reversing the order on this as well.

Years ago I attnded a retreat weekend, part of which was concerned with knowing the will of God. The speaker claimed there were three signs to look for in discerning His will. The call of God is persistent. That is, it will not be a one-off ambiguous statement, like a pagan oracle or a divination. Those who seek, find. Second, it is usally a call downward in the eyes of the world. Not because God is always interested in making our situation more humble, but in making us more humble, which usually entails going against worldly ambitions.

I forget what the third sign was. Sorry. There's an outside chance Michael will remember. Mike?

It’s the first that I want to attend to anyway. The call of God is persistent. My 70’s Jesus-freak culture tended more to the constant anxiety or wondering whether God had called us to something we had missed. It goes with a soulwinner theolgy somewhat. If you miss your chance, people die that night and go to hell, brother. There would be “a really anointed speaker” somewhere, but you had something else planned. If it was something secular, of course, the opinion around the table would be that got was calling you to go hear that speaker, while the movie or changing your oil was a temptation of the devil. But even that simple division would soon fall apart, because as a Jesus freak your other activities were often spiritual as well. Go to the speaker or work on your testimony? Speaker, testimony? Speaker, testimony? What does God want me to dooooo? I don’t know, I don’t know.

I bring up the extreme to illustrate my point about The Cost. What are we to do with ourselves? Where should we go?

I have found that the will of God comes and finds me much of the time. There is value to prayerful seeking, but often, the next possible act of generosity, the next learning experience, the next project…comes and sits on your porch, waiting for you to come home.