Category Archives: psychiatry

Addictive Thinking

by Katharine C. Otto, M.D.
January, 2002

Loosely defined, addiction is any attachment that compromises free will.  Addictive compulsions become problematic when they take precedence over more important life concerns, in defiance of reason and good judgment.

Everyone can identify with some measure of addictive thinking. Understanding your own compulsions – whether eating, exercising, working, television, sex, lifestyle, or even a prevailing mood, like anger, sadness, or guilt – helps to appreciate that the difference between addicts and non-addicts is merely a matter of degree.

With addiction you feel powerless, victimized, or lacking in free will. Thus, the first of the 12 steps of Alcoholics Anonymous states, “We admitted we were powerless over alcohol – that our lives had become unmanageable.” The key words here are “powerless” and “unmanageable,” because the substance could just as easily be tobacco or food.

When your compulsion becomes your priority, affecting more important areas of your life, such as health, relationships, work, or society at large, you become diagnosable. At this point every choice you make is colored by your addiction. For this reason, addiction treatment and AA emphasize making recovery a priority – a concept hard to grasp by many addicts, who fight this step because it is so powerful. Making recovery a priority and “walking the walk” on a day-to-day basis requires conscious choice and confers over time confidence in your ability to change your life. This subtle change in thinking from “power over” to “power to” reflects a shift from the role of victim to that of a responsible, self-directed individual.

Recovery is a growth process, requiring time to mature.  Building a healthy sense of self within the context of the environment takes patience.   We live in an addictive society, and enablers abound. Our systems foster and perpetuate dependency. Mainstream assumptions that the answers are “out there” lead us to doubt our own inner wisdom, yet relying too heavily on external authority eventually results in disappointment, victimization, and power struggles. Power struggles with either internalized or external authority eventually must be balanced by a cooperative spirit.

Relapse is part of the disease of addiction. Addictive thinking includes a rigidly held set of rules, whether consciously acknowledged or not. When these perfectionistic – and frequently unrealistic – rules are violated, the addict will often give in to his underlying sense of powerlessness and intensify his self-destructive activity, becoming a victim once again. Here, the power struggle is within himself, but the whole self loses in the see-saw struggle between “absolute control” and “out of control.”

In the past, addiction treatment took a punitive approach to relapse, but the winds are shifting. The addict who relapses already feels like a failure, and the punitive approach reinforces his negative self-image. At this point he is likely to run from treatment, if he is not reassured about the relapsing nature of addiction and the importance of keeping the relapse short.

Addictive thinking presupposes boundary confusion, a lack of definition of where you end and the next person begins. This inability to establish and maintain appropriate boundaries contributes to the escapism of addiction, and this leads to physical and/or emotional isolation. The “higher power” of Alcoholics Anonymous can just as easily refer to society as it does to a god, because the group is stronger than the individual. It helps set boundaries when the addict is unwilling or unable to do so. It’s also good for supporting the recovering addict in his strengths. For this reason, addiction treatment relies heavily on group process.

Everyone is susceptible to negative attachments, to situations and circumstances that lead to unwise choices. Addictive belief systems perpetuate those attachments, employing such tactics as victimization, power struggles, perfectionism, impatience, and deception. As the recovering addict walks the walk, he learns through everyday experience how to avoid those pitfalls and live a more fulfilling life.

 

The Power of Life

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May 28, 2017—The following thoughts give an overview of my reasons for skepticism about Western, allopathic medicine and the paradigm it represents.  I claim the overriding belief in external agents for healing or symptomatic relief ignores the basic dignity of the individuals in question and the “vitality” that keeps us going.

The body is a marvelous homeostatic instrument, for which health is the natural state.  This understanding pervades Oriental medicine, which is based on the concept of “qi” (“chi”) or life force.

I’m an amateur student of Oriental medicine so can only describe it in general, simplified terms.  Essentially, it holds that there is a continuum between spiritual, mental, emotional, and physical levels.  Problems begin as spiritual.  If not resolved at that level, the problems become increasingly “dense” until they show up in the physical body.

In Chinese medicine, the idea of qi underlies and informs the entire system.  This sets Oriental medicine at odds with the Western, mechanistic viewpoint we Occidentals take for granted.  With the advent of the industrial age, the “scientific method,” and the requirement for “objectively verifiable” evidence, we’ve come to rely on instrumentation and a cause-and-effect sequence for assessment and treatment of any given condition.  The body is treated as though it’s a machine, with the resident human being largely a passive recipient of the diagnoses and treatments decided by the technician/physicians who administer them.

While the official stance of “science” receives almost religious devotion and some legitimate respect, it is exceedingly limited in what it can do.  “Science,” which relies on measurable “proof” has yet to prove that life exists.  Nor has it located the “mind,” although most believe the “mind” is in the brain.  The scientific method relies on studies that theorize causes, then set up conditions that limit variables to one, to determine whether there’s a significant correlation between cause and effect.

My unorthodox approach to life, health, and medicine stems from a fundamental belief in the power of the life force.  I call it “vitality,” but others may refer to “qi,” “quality of life” or use any number of terms to describe this battery that keeps us going.

Whether individuals survive physical death, and if so, in what capacity, is a question no one can answer, although religions and philosophers of all persuasions have tried.  What is life, anyway?  Is it a candle flame that can be extinguished?  Is it an essence, like “qi” that joins the “qi” of the cosmos, to be re-born in another place and time?

I won’t try to answer these questions but raise them simply to note that a belief in life beyond death strongly influences how I live mine.  Certainly others wrestle with the question, especially as they get older and wonder what lies ahead.

I became a psychiatrist partly to help make philosophy practical, but the profession—and Western medicine as a whole–is going in the opposite direction.

“How so?” a reasonable person may ask.  The most obvious answer is that it devalues the most basic principles that keep us healthy or make us sick.  Western medicine systematically undermines the individual’s faith in his or her own body’s self-correcting mechanisms.  It pits mind against body, which is deemed untrustworthy, a thing to be feared, unreliable.

The intangibles that formerly distinguished psychiatry from other medical specialties, the “quality of life” issues—now take a back seat to “evidence-based medicine” and the vain attempt of psychiatrists to align with the more “scientific” practitioners.

The antidepressant Prozac (fluoxetine) was introduced in 1989, two years before I graduated from medical school.  This began the separation of psychotherapy and other “talk therapy” from “medical management” of emotional problems.  While other antidepressants, anti-psychotics, anti-anxiety agents, and mood stabilizers had been on the market for decades, Prozac began the trend toward a raft of new, patented, drugs that could treat symptoms while ignoring the larger life pattern that led to the problems.  “Talk therapy” was shifted to psychologists and social workers, with the move heavily supported by government and insurance reimbursement criteria.

Since that time, the avalanche of patented drugs, technologies, diagnostic tests, and other interventions has made the “health care industry” one of the most profitable sectors in the United States.  Costs for the individual have skyrocketed, such that few can afford medical help without insurance.  Now, the government has made insurance mandatory.  No one seems to recognize that insurance does not equal health care.  In fact, insurance impedes, rations, and delays health care, and it raises the price for everyone.

Medical care costs twice as much in the US as anywhere else.  Medications are significantly more expensive.  A continuing medical education article I read says medical error is now the third leading cause of death in the US, after cardiovascular events and cancer.

That medicine and psychiatry seem obsessed with finding or creating problems already puts patients at a disadvantage, in a defensive position.  Psychiatrists don’t get reimbursed for “no diagnosis.” They must find or invent a diagnosis, a label, to justify the time they spend.

No wonder Oriental medicine has such appeal for me.  Here, diagnosis is based on patterns of disharmony within the body and mind.  The hands-on approach is individualized and personal.  The patients and the practitioners are partners, with the belief in the treatment’s effectiveness–“the placebo effect” in Western terms—a desirable component.  In short, it respects the dignity of the vital forces that medicine presumes to reinforce.

I hear people say that “health care is a right.”  We also have a right to refuse health care, especially when it’s forced on us by hostile, predatory forces.  We have the right to eat nutritious foods, life a balanced life, and keep stress levels low.  We have the right to maintain our vitality and health they best way we know and to choose who and what to trust for help when we need it.

 

The More Things Change . . .

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Above:  The professional literature in Psychiatry remains funded primarily by pharmaceutical companies.  I get up to eight Psychiatry periodicals every month, all containing about 50% advertising, most of it by Pharma.  This junk enjoys a privileged postage rate, because it is “educational.”

April 12, 2017–Reading old journal entries helps me focus blogs and show the trend of my thinking over time.  In April, 2007, ten years ago this month, I was considering allowing my medical and DEA licenses to expire, because I felt used by a medical system that causes more disease and suffering than it alleviates.  As a psychiatrist, I was under a virtual mandate to prescribe drugs that promised more help than they delivered.  Not only that, but the system itself was so dysfunctional that it put everyone at risk.

ON MEDICINE AND PSYCHIATRY
Wednesday, April 18, 2007 – If I can get out of the business of medicine, I can enjoy the fun of medicine, when it’s done right.

It starts with honesty.  We have created a sado-masochistic society that feeds failure and punishes success.  In today’s climate, the individual doesn’t matter.  “Equality” means bringing everyone down to the lowest common denominator, statistically speaking, to save the “economy” from the individuals who take more than they give.

Our society has rendered them so dysfunctional that they are incapable of doing anything useful and resentful of those who expect them to make an honest living.
What kind of psychiatrist would I be if I didn’t point out the insanity of that?  I believe the individual matters, if only to herself.  I matter enough to stand my ground in the face of society’s power struggles and to comment on the process.

The US psyche is caught up in the emotional two-year-old anal stage of psycho-sexual development, the “terrible twos,” the year of potty training, the age in which life-long issues related to power and power struggles emerge.  The “self” vs. “not-self.”
As we play with the shit we have created, we are evolving, hopefully, toward a greater understanding of what it means to be free.  Demonizing and drugging the individual mind and spirit is society’s game, not mine.  I have evolved beyond the anal stage.  I quit.  Get ahead by slowing down.  Take time to smell the roses before you pave them over.

This patient-churning prescription writing machine throws the government credentials—the medical licenses—into the compost bin.  Thus relieved of the paper shield, I step from in front of the DEA’s guns to show them aiming at my back, to control invisibly every aspect of the prescription game.

They need me more than I need them, but only because they believe in drug laws.  If there were no drug laws, we wouldn’t need the DEA, but doctors would still have jobs.

“Doctor,” a word my absentee bosses don’t know, is derived from the Latin “docere” meaning “to teach.”  A doctor is fundamentally a teacher about health.  That’s what I do – teach people about health, especially mental health.

You know what I tell my patients?

“It really is them,” I say.  “They are the crazy ones.  Don’t put your life on hold waiting for the government.  You’ll grow old and die waiting.  Live it up while you still can.  Dance in the living room.  Turn off the television, for your sanity’s sake.  Shut off the mind and noise pollution so you can hear yourself think, and you’ll get back in touch with your common sense.”

ADHD (ATTENTION DEFICIT HYPERACTIVITY DISORDER)

Tuesday, April 3, 2007 – I enjoyed working with kids and parents yesterday.  I gave practical advice and supported them in their efforts.  A little six-year-old hugged me on the way out.

These aren’t bad kids.  In fact, I think many who are branded with ADHD are brighter and more creative than the rest, with skills and interests that reach beyond the classroom.  A 12-year-old girl who is about to fail sixth grade for the second time daydreams and draws during class.  Likes violin and reading Japanese books in English.

I reassure them school really is boring, and teachers are busy pleasing absentee bosses.  Moms nod vigorously, and the kids stare at me as if they are shocked I would express such heresy.

CME ON ADULT ADHD

Tuesday, April 3, 2007 – I read a Continuing Medical Education article on ADHD (Attention Deficit Hyperactivity Disorder).  Bottom line is there’s nothing new, except the diagnosis of adult ADHD.

Do you think anyone would consider causes pills won’t treat, like multi-sensory fatigue from the environment?  Machine noise from traffic and power tools, airplanes, blowers, coffee grinders, speakers in coffee shops, grocery stores, hardware stores, banks, blaring “I Died and Went to Hell” music and advertising at top volume?  The screeching, attention-starved voices from the halls of hell?  Who can attend to anything with all that noise?

No.

Think they might consider that the same drugs are used by drug addicts and schools to treat the same symptoms, but it’s okay if you have the correct diagnosis?

No.

Think the lack of physical education in the schools, or the fact that kids with too much energy are punished by depriving them of play time might contribute to their hyperactivity?

No.

It’s all in the brain chemistry, you know.  Hit ‘em up with a little Adderall or Ritalin and we’ll let ‘em come back to school.  Never mind that they have been suspended the last X days and are even further behind.  They shouldn’t have acted out.

The other two psychiatrists here, Child & Adolescent psychiatrists, indulge me in my one-to-two minutes of tirade.  Each says separately, unfortunately, the kids who come here need to be on meds.  Doctors have adapted to being prescription writing machines, drones in the endless grind of patient-churning status quo.  They see the hypocrisy, but they learn quickly to keep quiet, to show in behavior the repressed anger generated by power abuses.

Learned helplessness vies with identification with the aggressor, but do you think psychiatrists make the connection between abstract understanding and the evidence in front of them?

No.

Why learn psychiatry if nobody cares?  You could get a computer to write prescriptions faster and more legibly.

The inertia is as cloying as clear gelatin.  Perhaps this is the egg; the yolk, the planet, the albumin the atmosphere, with humans poised at the interface, possibly growing and possibly getting big enough to crack the shell.

 

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If We’re So Smart, Why Aren’t We Sane?

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September 10, 2016

by Kookie the Shrink
an alter ego of katharineotto.wordpress.com
President, Chair, and CEO, Psychiatrists for Sanity
(and so far the only member)

The August, 2016 issue of Psychiatric Times has two good articles related to recent topics in my senior citizens’ discussion group.  One is on gun violence, and the other on physician-assisted suicide.

Gun Violence and Mental Illness

There’s a good interview with forensic psychiatrist Liza H. Gold, MD regarding her book, Gun Violence and Mental Illness.  She claims that most serious mental illness is only weakly associated with violence, and gun violence in particular.  There are 33,000 firearm deaths each year, and two-thirds of them are suicides.  Less than one percent occur in mass shootings.   Firearm violence by individuals with serious mental illness against strangers is one of the rarest forms in the US.  If seriously mentally ill people do become violent, it is usually against family members or in committing suicide.  Those with serious mental illness only commit 3-5% of all types of violence.

When Dr. Gold talks about legislation, she says only felons with a history of gun violence should be denied weapons.  Now, all felons are prevented from buying guns.  Psychiatrists and therapists should ask not only if the patient owns a gun but whether there is a gun in the household.  Better access to mental health care would perhaps prevent suicides (10th leading cause of death in the US and second among adolescents and young adults).  There are 40,000 suicides/year in the US with more than one-half using a gun.  As many as 90% of people who commit suicide have a history or current diagnosis of a psychiatric problem

We are the only nation in the world with this kind of gun violence problem.  Access to mental health treatment would not reduce homicide rates (11,000/year), which are usually interpersonal (domestic, gang wars, etc.)

The most dangerous time for a woman is in trying to leave an abusive relationship.  Temporary restraining orders do not prevent the perpetrator from having a firearm, but permanent ones do.  Gold says the temporary restraining order should also prohibit firearm possession for the perpetrator.

She says we should educate family members to remove firearms from the homes of those in crisis, such as depression, psychosis, substance abuse, dementia, recent trauma–such as loss of job or relationship–or has a recent diagnosis of serious medical illness.

Physician-Assisted Suicide

A commentary, “Physician-Assisted Suicide and the Rise of the Consumer Movement,” by Ronald W. Pies, MD, addresses the current status of so-called “physician-assisted suicide” movement and the ethical implications for psychiatrists.  While others refer to “death with dignity,” he likes to think in terms of “life with dignity,” and implies this is the main goal of psychiatry.

Dr. Pies says PAS is now legal in Oregon, Washington, Vermont and California.  They are considering a law in Canada that would allow for assisted suicide in mentally ill adult minors. He states the broad terms under which euthanasia is used in the Netherlands.

Dr. Pies correlated this with the growing “consumer rights” movement, which has replaced “physician” with “provider,” and “patient” with “consumer.” He hints that insurance companies–guided by numbers and statistics more than good care–are behind this language pollution.  He implies this subtle shift in terminology has dehumanized both parties and has undermined the therapeutic relationship between patient and physician.

My take is medical journals subsist on advertising, primarily from pharmaceutical companies.  Content usually reveals the medical bias toward expensive, patented medications and overtreatment for relatively minor problems.  The August issue of Psychiatric Times shows a heartening trend toward more clinically relevant information.  I commend this issue’s attempt to educate psychiatrists and the public about common sense solutions to common problems.