After reading Logocentric’s “Notes on the Frontier” and its dealings with the issue of homelessness, shedding light, as it did, on the relationship between homelessness and the expectations society puts upon its members, in how it defines normalcy, I recalled this paper, a fictional doctor’s article from a novel my alter ego Ken Vallario is working on.  As with all great discussions I have decided not to solve the problems in Logocentric’s post, but to pose even more questions.

Akbar Lightning

The Question of Sanity and the Anti-Placebo

By Dr. Thadius J. Freeman III

June 15th, 2004

I would like to think that the following essay is one written by a man who, approaching retirement, is seeking to unload some long held grudges against the field within which he has spent the majority of his life’s energy.  But sadly, this is not the case.  It is a mere accident of fate that brings me, at this age, to address a convergence of social and institutional trends that threaten the integrity of psychiatry as a science and practice.  For most of its long history I believe psychiatrists and researches have exercised within the realm of good intention, prudence and relative consciousness of aims.  However, due to some of the ideas I will address shortly I am unsure if we can say the same thing at present.

This is not an article of science.  What follows is a meditation on our practice and procedures.  It is meant as a provocation that I hope will stir within our field a more revolutionary spirit.  It is my sincere belief that such a revolution is not only necessary but imminent.  But, like all good works of psychology, this one starts with a case study.  It is the promise of our field that by studying an individual one may derive insights about the whole.  Like a man after studying a great work of art for many years who suddenly sees it in a radically new way, my great paradigmatic shift took place after seeing a young man that was not unlike many young men I had seen before.  For the purposes of this paper we will call him Justin.

Justin came into the hospital 2 weeks prior to the writing of this article after attempting to end his life.  Although my work as a director consists mostly of administration, fundraising, and the organization of clinical trials I have always insisted on seeing a few patients a week.  I was not going to perform Justin’s treatment.  I was merely giving him the initial evaluation after which I would corral him into one of a dozen test trials that his symptoms could justify.  This was, after all, the business of post-modern psychiatry and I believed in good data.

So here’s the data:  Justin was a 26 year old man who was born and raised in New York City, brought up by his single mother.  His home life was relatively stable albeit isolated.  He was a shy child who did well in school but failed in adolescence to succeed in social life.  He went to college with the help of loans earning a degree in fashion.  He gained friends in college, a small group of creative types that participated in higher than average drug and alcohol use.  After college he floated from job to job and he exhibits some difficulty with authority.  At present he works as a shipping clerk in a downtown gift company.

The night of his suicide attempt he was at home alone watching his favorite TV show.  He reports having smoked some Marijuana but said his mood was good.  While watching a commercial break the news report came on and aired footage of a man being beheaded in the Middle East by a group of men in black hoods.  Initially, he said, the footage had no affect on him but as the commercials continued he could not stop thinking about the image.  He began intense rumination on what he had seen.  He reported that the juxtaposition of soda commercials and ‘silly’ food advertisements caused him sudden physical pain.  Within a few minutes of seeing the news footage he was on the floor having the first panic attack of his life.  After a few minutes he regained control of himself but he was frightened and quickly spiraled into a deep and manic depression.  He reported lifelong untreated episodes of depression.  In an attempt to get to sleep he started drinking alcohol.  His sudden sensitivity to sound caused him to turn the television off and as he sat on the couch drinking his mind cycled through the short video of the beheading.  Justin had never before experienced suicidal urges but on this night he could not deal with the crushing weight of emotions rushing through his mind.  He grabbed his roommate’s bottle of sleeping pills and swallowed them down with alcohol after which he passed out.  His roommate came home shortly afterward, called 911 and he was brought into the hospital, had his stomach pumped and is now in treatment for post-traumatic stress and depressive disorder.

After evaluating Justin I tried to return to the usual paperwork that required my attention but like him I could not stop my own rumination on his case.  I had seen many like him, especially in the last 10 years, men and women who, after experiencing stark contrasts of life, death, passion and apathy, seem to collapse psychologically, but due to the nature of psychiatric classification their experience was able to be broken down into simple parts that could be mended and then put back together again.  We had become a field attached to the treatment of symptoms.  Often times, it was believed that the crisis experience was a ‘blessing in disguise’ as it revealed long-tolerated minor disorders that had escaped attention, and so the therapist came in with optimism and efficacy and presented another stark contrast, presenting positive affect and affirmation in response to their existential despair and terror.  However, we had long seen that panic attacks and depression, after the first episode, were more likely to reoccur than not.  Relapse was a common ‘issue.’  This had me thinking if we as a hospital were doing anything more for the patient than allowing them to rest before pushing them back out the door into the same world where they felt the initial threat, so that they coped, the way humans do, until the world surpassed their threshold.

This was a common and open question in our field and so bringing it up felt like little more than the usual self-critical humility that every scientist needs to move forward earnestly seeking something more firm for the sake of the clients.  But with Justin I could not escape the following question:  “What is the appropriate coping mechanism for witnessing a beheading?”  This question kept me up that night and I am a psychiatrist who prides himself on leaving his work in the building.  When I got to work the next day I felt like a man who upon noticing a thread sticking out from his sweater could not help but tug on it.  I began tugging and slowly the whole world began to unravel.  Now, as I begin to describe the journey of thought I fully expect this critique to be taken as something symptomatic, to have my investigation pathologized, but the truth is that I went on this journey with an enthusiasm of a scientist without socially prescribed rules of propriety.  I felt like Newton, Pythagoras or Einstein chewing on the nature of my work, I felt like a child again, curious and engaged.  I stopped feeling like an administrator.  In fact, this is one of the most exciting aspects of what happened to me.  I was able to ask myself if these early scientists like Madame Curie or Copernicus or Jung, I wondered if what they envisioned for the future of science was a bureaucracy, a data flow into which patients flung themselves, guaranteed to never see the same doctor twice, bouncing into a variety of experiments whose aim was not to cure them of their ills, rather it was to use them to gather data for the development of more profitable approaches to the creation of a larger data flow.  These ‘patients’ had no idea what to expect from this beaurocracy.  They expected the scientists to either lie to them, to tell them the truth, to trick them perhaps, to give them a ‘real’ medicine, or to give them a placebo.  They became more frightened of the machine than the real world they were struggling with.  In fact, the placebo affect might be understood as an intolerance to the insanity of treatment, and a natural animal instinct to flee the institution that might be worse than the jungle of the real world.  This is what I call the ‘Anti-Placebo’, an affect whereby in our efforts to thwart the dangers of the placebo, the affect of health, we have created its antithesis, an aura of mistrust out of which we find it impossible to build enthusiasm with our patients or ourselves.  Relapse can be understood as an indication of the anti-placebo, what the religious would call a lack of faith in our practice, a lack of confidence, a learned hopelessness.

It has been shown with rats that if you ring a bell and produce an electric shock that initially the rat will respond to the bell with fear and elevated stress levels but if, after repeated shocks, there is nothing the rat can do to change the production of electric shocks the rat will begin to stop showing signs of stress and fear and his/her affect will become more depressed.  This has been called learned hopelessness.  If when a human being lives in the world he/she is subjected to daily shocks and after various creative responses he/she finds no effective way to lessen the threat we see a breakdown of psychic integrity.  Then, if that human being comes to us, the psychiatrists, for treatment and we, because of an unspoken fracturing of our method, present an anti-placebo, a confused and hectic response to their disorder, in other words, we present disorder to their disorder, they receive a shock in response to a shock and the hopelessness gets learned, for good.  Relapse becomes a game of spiritual pong whereby a human being bounces back and forth between two machines that seek to derive financial stability through the treatment or exploitation of this human being.

What?  How do you explain such pessimism coming from a man who has spent his whole life committed to this practice?

It is true that most of my professional years have been invested in support of the psychological tradition but two ideas will suffice to explain this sudden sounding of alarm.  One, I will argue that the convergence of a few very powerful social trends make our time profoundly unique and two, that one of these forces of change and culpability is to be found in psychiatry itself, as a result of what I call institutional aging.  Before I discuss the unique aspects of today’s culture that contribute to our crisis I want to define this institutional aging and defend my argument that we as psychologists are standing at a great crossroads.

When a field of research or system of thought is born, whether we are talking about Psychiatry or Religion, whether we are speaking about America or the Democratic Party, when these groups of men and women who share like curiosities or passions converge and create a movement that movement begins to exist in the substance of Time and because of this, from the time of its genesis it begins to age.  This is a quality of institutions that has received very little attention, but just as the Christian Church is not the same today as it was in 1400 A.D., the Jewish people do not have an identical tradition to those of 2000 B.C., the form of Democracy is different in America than it was in 1830, so too the institution of Psychiatric Medicine and Practice is a far different creature, simply as a result of time and the change that marks its passing.

The practice of Sigmund Freud represents a radical shift in our perception of the concept of sanity.  What had been an unchanging constant for the bulk of human history sanity was given a relative character as Freud’s work suggested that in the presentation of an insane person there was a structure that could be utilized for the collaborative manipulation of one’s perception of reality.  He postulated that there was a bedrock of sanity, a kind of substrate, that came to be known as the subconscious that could be accessed to rejuvenate the psychic state of his patients.  Sanity became an object of fascination and its study and the practice that seeks to restore it for humans who suffer is now known as Psychiatry.

What we are as psychiatrists, it is argued here, are philosophers of sanity.  We are invested in the question of ‘What is sanity?’ and how does one maintain it, how does one lose it, and often forgotten, how does sanity relate to the social order.

As we have aged we have evolved from a highly suspect form of inquiry, ridiculed and derided as a kind of mystical impiety, into a greatly respected scientific tradition.  Slowly because of the undeniable efficacy of these approaches society grew to uphold the legitimacy of our craft.  From its radical roots psychiatry aligned itself with science and began to do what many such movements have done, it sought to verify what it intuited.  In other words, psychiatry entered its adolescence, wishing to disassociate from its own individualism in order to receive the financial blessings that would allow for the curious hunger of its growing membership.  This alignment turned psychiatry from a focus on practitioners and their philosophies into a social project.  This transformation, one may suggest, represents perhaps less the drive toward knowledge than it does the growth of a public demand.  It is this dynamic that is central to the whole arc of my present argument.  What came first, the psychiatric practice or the market pressure of an intense growth of insanity?  As we all age we ask ourselves what roles luck, fate, choice and biology play in the development of our lives.  In the same way as a practice, we psychiatrists should ask ourselves how our growth is related to things such as the industrial revolution, the development of nuclear weapons, the rise in surveillance technology, the internet, the decline of family values, etc.  This is what is meant by institutional aging.  Just as it is normal in adolescence for a human being to exhibit signs of omnipotence and defiant individualism institutions should be aware of the same tendencies in its own rise away from dependence, as it comes into self-sufficiency, it must be mindful of the tendency to over-estimate itself.

One question that might help donate to a healthy, and scientifically valuable, sense of psychiatric humility is:  What if psychiatry owes its growth and rise not to its efficacy but to society’s decline?  This is the question that Justin is responsible for, this is the question that is at the heart of this essay.

What is the role of psychiatrist in a world that is crazy?

For most of my time as a practitioner there were niches in the social structure that allowed the kind of healthy diversity within which my patients could be re-entered and thrive.  With a little guidance and treatment they could find outlets for the frustrated drives that found themselves at dead ends in their social endeavors.  But over the last 10 or more years I have watched these niches close up, as information technologies and the destruction of community structures have made it next to impossible to transplant my patients back into the world.  And so I am forced to take what, in the past, would have been a hopeful case and turn it into a maintenance case for the simple reason that there is no world within which this patient can thrive.  This brings me to another unspoken truth in our field, one that is encapsulated in the term ‘nature vs. nurture.’  There are 2 kinds of patients, that after years of experience, I can describe.  There are those with a healthy mind but an unhealthy psyche, that in spite of being born with a relative high ability to cope were damaged by years of mistreatment, neglect or abuse and there are those who in the years of development were subjected to internal abuses that caused biological damage that made healthy brain function an impossibility.  These two groups of patients almost demand a radical split in the institution of psychology.  And most of us who work with patients on a daily basis, on an intuitive level, can recognize the difference.  However, we are tied so fatally to the rigid demands of scientific verification that it will take us an infinite amount of money and time to verify what it is we already know.  And so to the first group of patients, those who have the biological facility for sanity we are forced to see the birth of dysfunction in their experience and for the second group who have lost biological capacity for self-realization we are also forced to conclude that their hopeless cases are, in the majority, due to preventable causes.  I imply here that the rate of drug and alcohol use, and a vast variety of chemical uses during pregnancy are responsible for a massive increase in these conditions.  The industrial revolution made such a state possible further validating the alignment of modern psychiatry with modern industrialism.

For those patients whose are not biologically scarred but struggle with a damaged psyche we are forced to look at the environment within which kids psyches mature.  The rising demand for labor has created empty family homes, forcing children to seek all their social needs in the institution of public schooling where they are subjected to intense competition with their peers.  The isolation and anti-community practices create an estrangement that I argue here is deeply to blame for the troubling rise in depression, suicide, mood disorders and schizophrenia.

And so when Justin came into my office and he told me about what he had witnessed, how he had seen a man have his head removed by a group of other men, before watching a happy ad for some ice-cold coca cola, when this was presented to him by his society, I wondered how a human being could sanely process such input.

And so here is my conclusion in the form of some questions.  I challenge my colleagues to answer these questions, regardless of the cost:

What is the role of psychologist if he has concluded that society is insane?

Is sanity equivalent to social conformity?

Is sanity an attribute that can be ascribed to a group?

If so, are we as psychologists responsible for the diagnosis?

If so, are we as psychologists qualified to treat a group?

When I evaluated Justin I concluded that he was a very capable young man who had coped with many challenges and that his attainment of 26 years on this earth was an admirable achievement.  Justin represents to me a new type of case that we as psychologists will begin seeing in greater numbers in the years to come.  These cases will not by symptomatic of any individual disorders.  Rather, their symptoms will be varied but will all represent a social disorder.  And we as psychologists will have to grapple with the ethical dilemma that this poses to us.  Justin could not process his experience that evening because the world was still invested in a delusion that the great majority of humanity was sane and that a small number were insane.  This denial reinforces the larger social insanity that has not yet been adequately diagnosed.  It is due to this lack of identification that Justin found it impossible to cope with his fears and his inability to maintain meaning.

To close the argument on institutional aging, and how that relates to a declining social sanity index I argue here that our adolescence is over.  Just as every young man or woman, who in their peak of health and vigor, feeling overly confident about their powers and abilities, eventually meets challenges that are larger than their strengths, thus learning about their limitations, and are then forced to make choices about how to use their finite capacities, so too are we as a field approaching a moment of maturation.  The opportunities for rehabilitation are shrinking and the primary care of young human beings is getting worse, and we must ask ourselves whether or not we are doing a good job of serving sanity, if we have even stopped long enough to make decisions about what sanity is.  Are we saving the day or are we dumping water over the side of a sinking ship?

Conclusion

Like all social critics, I have painted a grim picture.  But like all responsible social critics I have decided not to rest content in this, but rather I present a few crucial variables that represent a prudent direction for change.  My insight in this matter came to me as a result of my meditating, in the light of my argument, on why it is that patients return so often to psychiatric care, why it is that recidivism is both a damning and affirming fact of our field.

How worrisome could this ‘Anti-Placebo’ be if patients came back repeatedly for more of it.  My answer came as I connected what I knew about sleep studies to my experiences as a doctor.  Researchers have found that 85 percent of patients at the time of admittance show signs of chronic sleep deprivation.  It has become a standard part of our treatment to find the causes of sleep stress and to encourage the patient to work on getting better sleep, and it works.  However, we find time and again that disorders compete for a patient’s limited reserves, and often sleep is the first victim, which leads to an acceleration of all the other symptoms.  We find that sleep is dramatically improved in psychiatric care, as the pressures of the world have been removed, the so-called ‘triggers’ of a patient’s environment.  When I thought about what pressures exist within psychiatric care I thought about my own experiences as a researcher.  When working with patients in a research setting I can normally expect them to be pleasant and obedient for about 3 to 4 hours, more toward the latter if I spread the testing out with periods of rest, but anytime after this, after about 4 hours of concentration I learned that I would struggle with crankiness and resistance.  Patients wished to return to their resting areas, after all, as the implication seems obvious by now, that was their reason for being there.  They were in hospital for rest, a reprieve from a world that demanded at the very least 8 hours of fixed concentration and/or labor from them.  I thought about the rapid rise in the attention deficit type diagnoses, and how that related to a rise in medicinal stopgaps for such ‘disorders’ and how that related to a society of increasing labor demands.  Once looking at this series of relationships I could not help but be convinced that the whole field of psychiatry was already working within a highly politicized bias, that they could hardly claim in good conscious the kind of moral detachment that science demands.  And since psychiatry has already broken this taboo by affixing itself to governing labor I am merely asking my colleagues to question that bias, and more specifically to realign it more toward the benefit of our patients.

It seemed necessary to consider the mental model I had for childhood before the industrial revolution.  I found it difficult to imagine that children in any other time would be asked by the age of five to exercise fixed concentration on abstract subject matter for 8 hours a day.  I am not suggesting we return to the state of nature, but I think we must be aware of our limitations, and at least show a respect for the demands of nature and childhood.  Just as we have over-taxed our planet of its resources I am arguing here that we are out-mining, out-stressing, over-working our children from the moment of potty training until they arrive at my desk.  And furthermore, I believe that our field is complicit in this.

Although this seems to be a further description of the problem I argue that it is actually a simple illustration of a profound solution to many of our mental illnesses and social disorders.  We must stop.  We must stop working, allowing ourselves the rights of mental patients to be obedient to society only to the point of one’s natural resistance, not pushing ourselves out of a dysfunctional insanity.  And especially we must stop doing this to children, only in this way will we ensure any hope of a more deeply sane society in the future, a world of adults that were given the time to play and explore the way our species must, if we wish for healthy and flexible brain development.  These are no more politicized prescriptions than those proposed by the pharmaceutical companies, and I suggest that they are much cheaper, serving the interest of economy, if that is the type of thing that is important to you.  It is our relationship with money that has corrupted the purity of our science, and we as psychiatrists must reawaken a passion for individual results.

However, any enthusiasm for individual results will bring us into radical confrontation with these social dynamics.  This is what will propel those of us brave enough to embark on such a journey to see psychiatry over the last 100 years as not so much a science but an alchemy, a fractured set of motivations that were more theoretical than practical.  Just as alchemy abandoned the philosopher’s stone in favor of scientific principles, so too we as psychiatrists must abandon our vague processes, and face the question that we have taken for granted since Freud.  What is sanity?

Such questions will most certainly create a schism in our field, not an off-shoot, not a tangential area of research, but a radical and permanent schism whereby the researcher will grant him/herself the freedom, the absolute liberty to engage with a patient and disregard the larger institution, not because they do not believe in science, but just the opposite, because they acknowledge the corruption of a field that has no ethical center.  Put simply, if a psychologist were to put as much effort in the alleviation of the ‘Anti-Placebo’ as they did the placebo affect, in a very short period of time they would revolutionize their relationship with their patients, and their world.  They would be forced to connect to their patients, to develop trust, and that would force them to question whether or not they trusted themselves, and this would of course force them to look at their society, etc.

When Justin, 26 year old man from New York City, sat on his couch and had a panic attack, after witnessing fellow human beings chop off the head of another one of his fellow human beings, sandwiched between soda-pop commercials and sit-coms, he expressed a remarkable measure of health and when he did this he awakened me to consciousness, and I hope those who read this will not seek to pathologize Justin but rather to see him as a victim of a crime, our crime.