Wednesday, December 26, 2012

Misdiagnosis/Murder


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Sigmund Freud lived from 1856 to 1939.  And, as we all know, from the science section of the New York Times and the psychology coverage in Time magazine and the introductory courses in psychology we took at community college, Freud has not only passed away, but he is dead, really, really dead.  He is not merely an iPhone 4s in the era of iPhone 5, he is Alexander Graham Bell, 12 years after Bell Atlantic decided they preferred to go by the name Verizon.  What in heaven’s name, in 2013, is a psychoanalyst?  And if one has been cloned from the DNA in the marrow of a fossil psychoanalyst’s bones, what, exactly, might a psychoanalyst think? 

Read on, if you must, for a word or two (or two thousand) of what a psychoanalyst might think, after years spent listening to the web of relatedness that emerges from patients on the couch, and in this particular essay, the encounters those patients have had with pedophilic and sadistic perversion, and, from this psychiatrist psychoanalyst, years also of listening to the vicissitudes of psychotic experience in persons with schizophrenia. 

I was a psychiatrist before I became a psychoanalyst, and continue to spend half of my week in a community mental health center performing explicitly psychiatric care. The widespread call, at the moment, for better mental health services in the wake of Sandy Hook school shooting of 20 first-graders leaves this psychiatrist psychoanalyst feeling deeply ambivalent, because of its potential to inaccurately identify a certain kind of illness sufferer as the problem.  Surely, the public mental health system in which I work is in need of better resources—the clinics where my agency treats 5000 outpatients lose money in the average month, which is made up only by the slim profit earned in the agency’s other programs that are slightly better remunerated (residential and day programs).  Some months the agency budget overall is in the red and some months it’s in the black.  My CEO bends the ear of the board about how the money-losing clinics are central to the agency’s mission and to the survival of the other, money-making services.  So far, he’s won that battle, but don’t ask him or me to predict our future 5 years out.  An enormous portion of those seeking mental health care in our country can’t access it. So I will be the last person ever to say spending more resources on mental health care would be a wrong turn for America.

But it shouldn’t be characterized as the single solution, or even the primary solution, to the Sandy Hooks in the headlines.  Wayne LaPierre of the NRA, at his recent press appearance, described the type of person who unloads a semi-automatic rifle on his mother and on an elementary school full of children and their teachers, as “so evil, so possessed by voices and driven by demons, that no sane person can ever possibly comprehend them.”

So, stop right there.

The illness with the most frequent presentation of “hearing voices” is schizophrenia, but my patients with chronic or periodic auditory hallucinations are not the individuals most likely to perpetrate our next Sandy Hook.  Many of my patients who hear voices raise their children and work full-time jobs as grocery clerks and medical records department directors.  When schizophrenia is disabling, it is just as likely or more likely that the disabling symptom is dearth of motivation or decline in cognition, which can and frequently do present relatively independent from any hallucinations, and are less responsive to the medications we have available.

Paranoia in schizophrenia is sometimes more dangerous.  It can be well-organized, persistent, and compelling to the individual.  But in schizophrenia, it more often than not remits with one of our current antipsychotic medications, and the majority of my patients with schizophrenia do take their medications, because the presence of such symptoms is distressing to the individual, and they seek relief from such distress.

Yet Christmas Day in the New York Times, psychiatrist Paul Steinberg wrote an op-ed pointing the finger almost exclusively at schizophrenia as the cause of mass killings.

When I hear of a Sandy Hook or an Aurora or a Name-the-next-eruption-of-mayhem in the news, it is not my patients with schizophrenia that come to mind, or that I worry about. 

In the other half of my life, away from the mental health center, I maintain an office where I conduct psychoanalysis and analytic psychotherapy.  And the parallel that comes to mind when I hear about shooters like Adam Lanza is to the pedophiles and sadists I have heard about fairly incessantly since I started out in practice. 

It is not the pedophiles and sadists themselves who come to lie on my couch and sit in the chair in my consulting room, of course.  It is their daughters and sons, sometimes their nieces and nephews, their grandchildren and neighbors’ children.  They are the living victims of perversion just as the children of Sandy Hook’s first grade are the dead victims of perversion, the difference being, in part, that it is a sexualized perversion rather than a violently sadistic one.

But the commonality lies in the type of brain and the type of sickness that makes the rape and murder of children possible. 

Paranoiacs and psychotics of the schizophrenic type, when untreated or when not responding to the medications they are taking, frequently become so chaotic in their behavior or so out of touch with reality that they come to the attention of other members of their families and communities and to the police.  They lack the filter for their thoughts and actions that would keep them out of trouble.  There is still a need in the current field of psychiatry for better drugs, which would help those with active psychosis that is chronic—despite available medications—to attain remission, and there is still a need for outpatient commitment laws, which would help families and psychiatrists compel treatment for certain patients who won’t take drugs that would work.  But neither of these will in fact eliminate the problem we have with mass murderers.

Many a mass murderer is more like the pedophile than he is to the schizophrenic  psychotic.  They both plot, which takes a high degree of intact reality-testing, and they elude detection while plotting, which is central to achieving their goals.

We shake our heads and say “crazy” when we hear of someone shooting a classroom full of first graders, and it stumps the capacities of our imagination to think of how a human being becomes capable of such evil. 

Well, think for a minute about the taboos in your own mind.  The taboos you take for granted being in your neighbor’s minds.  Those injunctions are not doors slammed shut because there’s nothing in the room behind them.  They are doors slammed shut to keep us away from what’s in the room behind them.  And under particular circumstances, when the mix of motivations is right, the mind opens one of those doors and walks into one of those rooms.  And what it finds there is not necessarily a rudimentary sketch.  The human mind that takes a simple desire to stack a taller tower of blocks and a desire to be big like daddy and makes of them, over time, an architect for the Chrysler building, can make from the rudimentary thoughts on the far side of the open door of taboo something equally elaborate.  It can make, for example, the Austrian father who imprisoned his daughter and several of the children born of his incestuous rape of her in a basement dungeon for years.  It can make the father of one of my patients, who deliberately waited until other family members were away from the house and then just as deliberately broke his son’s bones, often with a baseball bat, passing them off later as “accidents” from clumsy falls.  (My patient kept silent, until telling me years later, for fear of lethal blows where these bone-crunching ones had landed.)  And it can make Adam Lanza, who plotted to get a semi-automatic weapon, kill his mother, and in a blaze of self-imagined glory take out a classroom full of six- and seven-year-olds, the adults who got in the way of his reaching that goal, and, for good measure, himself. 

If the perverse potential murderer or child rapist were sufficiently conflicted, he might come into the mental health system for assistance, might commit his energies to subduing his urges rather than discharging them.  But there are an abundance of murderers and pedophiles more invested in their own perverse behavioral goals than they are in any behavioral goals that might be suggested by  a therapist doing their intake, were they to cross the door to a mental health clinic.

I cannot and would not argue that a psychotic person suffering from schizophrenia or bipolar mania never killed anyone—I’ve had any number of them remanded to my care over the years who did just that—or that one will never kill again.  We should commit ourselves to providing the very best resources we can to provide the most effective intervention we can for these serious and tragic illnesses, and the resources to continue the research into more effective treatments, because God knows, we need them.

But we need additionally, to make the technology of mass murder less accessible to the Adam Lanzas already living among us.  And not delude ourselves into thinking we can identify them with a background check.  Lists of identified “mental patients” are not very likely to capture the future mass murderers among us, and will very likely dissuade many of those who could use mental health intervention from seeking it.  The disorganized psychotic patients will end up on the list, and the perverse murder-plotters won’t.

We need to actively intervene in the bullying of our young, who are vulnerable to turning it back on themselves or back at others in an aggrandized retaliatory way—to reduce, if we can, the number of future Adam Lanzas we might help create. 

We need to educate the young about the scope of mental illnesses and make access to mental health care truly available to any who seek it.

And we should talk frankly about sadistic violence and perverse sexuality as possible and very undesirable outcomes of development, if we hope to raise whatever veils cover our understanding of ourselves and cover our understanding of the difficulties in the human condition. 

It may seem odd for a gay man to be urging the country to talk more about perversion, since it took many decades for psychoanalysis to stop telling the world that my kind were, ourselves, perverted.  But perhaps because I had a need to understand how this came to be, in the profession to which I was certain I had a calling, and to figure out how the perverted in my own life experience escaped being labeled as any such thing by anyone who knew them, I took more than an average interest in the subject.  And then the patients came, one after another, struggling to make sense of the perversion they had encountered in the persons in their own lives, and to understand the silence and secrecy surrounding that perversion.  In sum, it has taught me that comprehending the possibility of sadistic and pedophilic perversion matters, that open acknowledgement of these possibilities matters, that silence only magnifies and multiplies vulnerabilities and the numbers of the vulnerable.

Mass murderers, on the whole, orchestrate murder suicides that cannot be understood in terms of conventional psychology.  Some can be understood in terms of paranoid psychosis, but many can best be understood in terms of what lies beyond the doors of taboo, and its attractions for a certain kind of person who is susceptible to imagining that transcendence of vulnerability lies in the embrace of sadistic power—and nowhere else.  If we can acknowledge this sad possibility, perhaps we can guide a potential Adam Lanza or many potential Adam Lanzas toward an alternative path.  But we have to do it as a culture, and not only as individual psychotherapists meeting with patients in our offices.  Because the evolution of an Adam Lanza too often takes place with deep immersion in the ideas and institutions of the culture as a whole and no acquaintance  whatsoever with the possibilities of help through psychotherapy.

Friday, January 27, 2012

Finger on the Pulse

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I resolve periodically to never again read the “comments” section of anything posted on the internet. Too much exposure to the unbridled id of our culture can, after all, make it hard to get up and go to work in the morning.

And then I slip for some reason, and find myself scrolling through the 172 comments on some political post on Facebook. And I resolve all over again to resist that temptation.

There is the well-worn story about six men in a dark room with an elephant, each asked to describe the animal from the part he touches in his hands. Political commentary on the internet, more than anything else in life, makes me wonder what part of the elephant folks are touching. For my part, it’s hard to imagine that the underclass, the aged, and the disabled that I see every day are the same underclass, aged and disabled that generate such contempt from certain vociferous people on the right end of our political spectrum. Because in America, the “freeloaders” so hated by those who would promote not just the survival but in fact the unencumbered freedom of the fittest among us, are mostly just these--the underclass, the aged, and the disabled. From what I read, the moral narrative goes something like “Those people are lazy, short-sighted, or drug-addicted, and I shouldn’t have to pull their weight.”

Yes, there are people in America who are lazy, short-sighted, or drug-addicted, and who leech off a society to which they would better contribute. But where in the dark room does one sit and with what fingers does one feel the elephant in order to think most of the folks along the financial margins are there through a process of their own election? It baffles me. I guess it’s because the thing I have elected in life is treating the mentally ill (and occasionally addicted) poor that my sense of proportion is so different. I am shoulder-to-shoulder every day with exactly this part of our citizenry, and after twenty years I harbor no hatred of them nor of the system that tries to provide for their care. And when they are the object of contempt, I not only take a contrary view, but I’m truly confused. Just as Ronald Reagan’s “welfare queen” was an apocryphal anecdote told over and over until I guess he actually believed it himself, it seems to me that this “culture of freeloading” so many are fed up with is more myth than reality. Yes, our Social Security and Medicare systems are a demographic time bomb in need of reform if they are going to survive. But a plague of miscreants? I am too intimately acquainted with the true causes of disability to easily buy any story that the majority of folks in our social safety net are just too willfully lazy or self-destructive to get themselves out.

Here’s the reality I know: One of my patients with schizophrenia, I’ll call him William, told me yesterday that he’d had a really good Christmas. About a year ago he got out of the state mental hospital on conditional release after several months’ detention, after getting arrested for some illegal behavior while in a grossly psychotic state of mind. What brought on this episode? Maybe he had stopped his meds, or maybe not. Any number of individuals with schizophrenia have a major break despite taking their meds, and despite the efforts of their doctors to catch the first signs of the episode in time to ward it off. When he improved again and came to live in a residential program, he tried for months to contact his girlfriend of 15 years, who is also someone with chronic mental illness who lives most of the time in one supervised housing program or another. When he first tried to locate her, after falling out of contact for a year, he found that she had moved, and no one at her residential program could tell him where. Finally, Christmas came, and he tried calling her mother’s house on Christmas Eve. Ordinarily, her mother doesn’t answer the phone if it’s from a number she doesn’t recognize, but on Christmas Eve his girlfriend was there visiting and picked up the phone. Since he’s found his girlfriend again, he’s been taking three buses every Saturday to the other side of the county so he can meet her at a McDonald’s for lunch.

Certainly, William is by any standard a person who lives on the margins of our society, and depends on Social Security and expensive psychiatric interventions to keep hide and hair together. But largely, his lot in life is not one he chose. One percent of every population in every culture on the planet will develop schizophrenia, so truly, there but for the grace of God go you, my friend, or your children, or your children’s children. And somehow, I think William’s commitment to his girlfriend, although they live without the benefit of marriage (since marriage would bring them an immediate decrease in benefits), is a bit more tried and true than the commitment Newt Gingrich has demonstrated to any of his three wives.

William’s story is not just a heart-warming anecdote I pull out, as antidote to the apocryphal Reagan story about his “welfare queen.” William is typical of the disabled folks I treat. Just like he’s typical, more or less, of the patients I see who have less profound mental illness, but still don’t work because of another condition, like their severe obstructive lung disease or arthritic knees or advanced age or frequent dialysis. Our agency runs a vocational program for anyone who’s willing and able-bodied and financially eligible, and I have seen dozens of markedly impaired individuals make their way gradually off disability and into the job market, with sufficient time, assistance, coaching, and encouragement. And enough of my attention, which, as it turns out, is costly. Rehabilitation of the mentally ill is expensive.

It seems as though there ought to be some lesson to be taken from the fact that I, who walk daily with the folks who are carried in our social safety net, do not harbor the contempt for them that one finds on the airwaves of talk radio and in the comment sections of online media. I pay taxes, too. And trust me, it’s not a matter of a knowing wink between me and the folks who enable me to keep my cushy gig sucking the teat of government largess. There’s got to be an easier bureaucratic job than the one I have battling schizophrenia with funding through Medicare and Medicaid. Schizophrenia is mostly the shits, and navigating Medicare and Medicaid is an exquisite torture for any soul.

I do not consider myself a Christian, but I definitely read once that the King shall answer and say to them, “Truly I say to you, inasmuch as you have done it to one of the least of these my brothers, you have done it to me.” Seems a little at odds with the narrative that the least among us are the worst among us, but then I guess I just don’t really get Christianity. At least not right-of-center Christianity.

So there you have it-—my part of the elephant. The lesson I take from the life I’ve seen is that it is important to speak out against the caricature that the poor and disabled are shiftless, and that caring for them is an erosion of moral justice. If your part of the elephant is truly different, I'm all ears. But Reagan’s “welfare queen” was always just a mythical creature, and I, for my part, will both model and advocate for charity and compassion in place of meanness and self-concern, for William, and for all of the Williams I know (which number in the thousands) probably until my last day on Earth. (After which, from what I hear, I’m off to burn in hell. But there's always that "what have you done to the least of these, my brothers" card...)