Thursday, September 26, 2013

Political opportunities and Thomas Insel’s response to the Wunderink study

In the past, when responding to various public statements from psychiatry’s leading figures and their cheerleaders in the media, I’ve tended to focus on the spin – the obfuscation and misleading assertions they’ve used to negate the impact of the significant admissions they’ve found themselves compelled to make. This has especially been the case with Thomas Insel, both because he’s an absolute master of spin (really – it’s quite impressive) and because as he’s the head of a government agency his utterances have – or potentially have – important consequences.

So when I read Insel’s post about the Wunderink study, this was my immediate focus and how I planned to write about it – “more spin from Insel.” But Robert Whitaker’s response to Nancy Andreasen’s comments and Bruce Levine’s post about the Insel article have led me to change course a bit. I think they get it (mostly) right. We need to cover the spin, but approaching these statements from the perspective of political opportunities is equally important.

Previously, I quoted from Whitaker’s comment in the thread at the Mad in America post about Andreasen* in which he emphasized the significance of her reaffirmation that neuroleptic drugs lead to brain shrinkage. That comment came in response to some others suggesting that Mad in America was selectively focusing on the grudging admission and naively ignoring all of the bogus claims under which it's buried. As one commenter wrote:
I’m starting to think that MIA has a hear-what-you-want to hear mentality when interpreting these articles.

The summary on MIA:
Oh no, the drugs cause brain damage. We’ve more than verified it; should we stop using them?

What the article actually says;
Schizphrenia causes brain damage. The longer the relapse/psychosis the more the damage. It’s a problem that patients and family members interpret the article she published years ago as reasons to quit taking the drugs. The drugs emptied the aslyums and even though they have side effects, “they have fewer side effects than some of the other medications we use.”

Same old, same old.
It’s true that the article is for the most part the “same old, same old.” And Insel's piece is full of similarly infuriating distortions and misinformation. Insel describes “schizophrenia” as a mental disease/disorder, when he knows it’s an invalid construct. He refers to neuroleptic drugs as “medicines” and to their use as “treatment.” The following paragraphs give some flavor of the spin:
It appears that what we currently call “schizophrenia” may comprise disorders with quite different trajectories. For some people, remaining on medication long-term might impede a full return to wellness. For others, discontinuing medication can be disastrous.

We realize that for too many people, today’s treatments are not good enough. New, better treatments are essential if we are to improve outcomes for all – that is the promise of research. But in the meantime, we need to be thoughtful about the treatments we have. Clearly, some individuals need to be on medication continually to avoid relapse. At the same time, we need to ask whether in the long-term, some individuals with a history of psychosis may do better off medication. This is a tough call, where known risks need to be balanced against potential benefits. As the RAISE project has emphasized, shared decision-making between patients, families, and providers is essential for long-term management of psychotic disorders.
He asserts that some presumably significant number of people “[c]learly…need to be on medication continually to avoid relapse” and that for them “discontinuing medication can be disastrous” when these are not conclusions reasonably drawn from the data. He presents the very question answered in the studies he’s discussing – “whether in the long-term, some [or all – SC] individuals with a history of psychosis may do better off medication” - as one yet to be asked. He assumes there needs to be long-term “management” of these (now plural, note) alleged disorders. He talks about shared decision-making, when the reality for people on the receiving end of these diagnoses is often anything but participatory or consensual….

But, like Whitaker’s response to the Andreasen reaffirmation, Bruce Levine’s new article at MIA, “Amazing Victory for Mental Health Activists: NIMH Director Accepts Ideas Once Seen as Radical,” emphasizes what’s new and significant about Insel’s remarks. Focusing on the same paragraphs I just quoted, Levine concludes:
It is an amazing victory for mental health treatment reform activists and Robert Whitaker. On August 28, 2013, National Institute of Mental Health (NIMH) director, Thomas Insel, announced that psychiatry’s standard treatment for people diagnosed with schizophrenia and other psychoses needs to change.

After examining two long-term studies on schizophrenia and psychoses, Insel has come to what was previously considered a radical conclusion: in the long-term, some individuals with a history of psychosis do better off medication.

Insel finally recognizes what mental health treatment reform activists and investigative reporter Robert Whitaker have been talking about for years—the research shows that American psychiatry’s standard treatment protocol has hurt many people who could have been helped by a more selective and limited use of drugs, and a more diverse approach such as the one utilized in Finland, which has produced the best long-term outcomes in the developed world.**
Despite what the last paragraph suggests, Levine notes below that Insel “omits a proven alternative,” referring to the Open Dialogue approach in Finland, while choosing to focus on the RAISE project.*** But Insel's and Andreasen’s admissions about the drug research and its potential meanings, as Whitaker and Levine suggest, aren’t negligible.

These sorts of public statements are similar to others witnessed in recent days and months: Obama’s acknowledgment last year of a change of heart concerning same-sex marriage, for example, or the Pope’s recent remarks, or the IMF’s admission of its inaccurate and self-serving (pseudo)scientific assumptions and apology to the Greek people, or, indeed, the announcements we saw from Insel and from David Kupfer in May. There are a few different ways of approaching these statements, and they’re by no means mutually exclusive.

First, we can focus on what the statements say – positive and negative - about the people making them. After reading Whitaker’s clarification, some people thought Andreasen should be “applauded” for her public acknowledgment of the drugs’ effects. Others continued to deem it “too little, too late” and to point to the grudging and misleading nature of her statements. These discussions are valid and useful. I don’t think anyone should be telling people, especially those who’ve been harmed by a person’s or an organization’s past actions, that they should congratulate those making such statements; encouraging people to forget about a person’s or an organization’s other harmful actions because of them; prodding people to start regarding these individuals or organizations as allies; or suggesting that they put aside their anger in the name of “moving on.” I believe that discussion, with all of its anger and bitterness and other emotions, should happen, but we shouldn’t stop there.

Second, we can try to analyze what these pronouncements might mean beyond the words - in terms of policy shifts or institutional changes. As one of the commenters at Levine’s post says:
I am afraid that, like Warmac, I am skeptical. Thomas Insel has been Director of NIMH for 11 years, and the evidence was there for most of that time. I do agree that the reason he has “discovered” the clear findings now is thanks to the unrelenting evidence provided by activists and the reaction to Anatomy of an Epidemic. That book was so well constructed it was impossible to ignore.

However, what he has conceded is that some people do better over the long run if they do not take neuroleptics as a permanent solution. One worries that his concession will keep us off guard, and it may be years before we notice that nothing has changed in NMHI beliefs about prescribing to first episode people, nothing new has been added in terms of options available, and worst of al nothing has changed in who gets research grants and the type of research done. Research in the area of serious “mental health” issues has been blatantly slanted to the pharma agenda or decades. It is a crime how much has been spent while a huge body of solid, ground-breaking research just did not happen.
This is also a valuable approach. Trying to gauge whether a statement like Insel’s might portend a significant change of course for his and allied institutions requires knowledge of the history of the institution and of the individual.**** It requires skepticism - avoiding overly optimistic assessments and unwarranted pessimism, especially when they could lead to a diminution rather than a reinforcement of activism.

Third, we can consider these admissions or announcements of changed ideas in terms of political opportunities: what do they mean in terms of changed possibilities for the movement? Or better, since opportunities can be missed, how can we use them in pushing for further change? As the commenter I just quoted concludes about the Insel article: “So, yes this is an important breakthrough, forced on an unreceptive audience. But, this is no time to let up the pressure to ensure that the implications of the knowledge are reflected in NIMH future actions and recommendations.”

I think this idea is what’s behind Whitaker’s and Levine’s responses at MIA, and it’s a useful approach. It encompasses the first two approaches, because understanding how best to make use of political opportunities***** means understanding the character and trajectory of the people and institutions you’re dealing with. But it also changes the calculus. Taking advantage of political openings like the ones provided by these announcements means potentially pushing forward personal and institutional changes of course that wouldn’t otherwise happen or would otherwise take much longer. Thus, it counters a negative tendency of the first two approaches used alone - to fall into a fatalistic mode of seeing transformation solely or primarily as the result of elite choices and actions.

This combined approach provides chances to examine (and celebrate, and give credit for) what the movements have been doing to bring about these successes, and to think about how best to adjust the movements to the somewhat changed landscape and exploit the new openings. How are these statements and the institutional shifts they might indicate useful in legal cases, at the UN, in writing, in dealing with the media, in protest actions, in pushing for policy changes,…?

*I have to quote the last comment in that thread, just because I love it:
Yes “we” should stop using psychiatric drugs. Psychiatry is suffering from “Münchausen syndrome by proxy” when it prescribes or forces psychiatric drugs into their patients .

Definition of MSbP or MBP “a caregiver deliberately exaggerates, fabricates, and/or induces physical, psychological, behavioral, and/or mental health problems in those who are in their care.”
**It's worth noting that outcomes in the "developed world" are not generally better than in other places; in fact, they're decidedly worse.

***“The Recovery After Initial Schizophrenia Episode (RAISE) project combines low-dose medication with family psycho-education, supported education/employment, individual resilience training, and other interventions to focus on more than just the psychotic symptoms.4 Combining current treatments, as done in RAISE, looks like a promising approach.”

****This can involve understanding the internal dynamics in the organization, awareness of groups that might be pushing for change (and against it) in the organization, and so on.

*****I do recognize that I'm stretching the concept of political opportunities pretty far beyond its meaning and use in the sociological literature, but it's the same basic idea and this isn't a journal article so I really don't care. :)

Monday, September 23, 2013

Pope condemns global capitalism

As reported by Al Jazeera:
...He discarded his prepared speech after listening to Francesco Mattana, a 45-year-old married father of three who lost his job with an alternative energy company four years ago.

Mattana, his voice trembling, told the pope that unemployment "oppresses you and wears you out to the depths of your soul."

The crowd of about 20,000 people in a square near the city port chanted what Francis called a prayer for "work, work, work." They cheered each time he spoke of the rights of workers and the personal devastation caused by joblessness.

The pope, who later celebrated Mass for some 300,000 people outside the city's cathedral, told them: "We don't want this globalized economic system which does us so much harm. Men and women have to be at the center (of an economic system) as God wants, not money."

Sunday, September 22, 2013

Pavlos Fissas

Pavlos Fissas was an antifascist activist and rapper in Greece. He was stabbed to death a few nights ago by a supporter of the neo-Nazi Golden Dawn. Here are two articles about Fissas and his murder:

• Joshua Stephens, “Anti-fascist Struggle and Race in the Face of Golden Dawn: A Greek Anarchist Responds”

• Leonidas Oikonomakis, “For Pavlos: The Antifa Rapper Killed by Golden Dawn”

The person Stephens interviews emphasizes that his murder shouldn’t be seen as special:
...[A] politician from Syriza was on TV today saying that Pavlos represents the first casualty of Golden Dawn. And he said that straight-faced, with no shame, as though the immigrants who’ve been murdered don’t count; as though Pavlos is somehow more of a person. And that sentiment is fairly widespread. I think a lot of people will be “shocked” today, as though this most recent event is some sort of a revelation.

Like a white body is somehow more jarring to the collective conscience.

Exactly. Why weren’t people equally shocked when Golden Dawn murdered a Pakistani [Shehzad Luqman] biking home from work? The only response came from anarchists and leftists. But maybe now people will finally listen. Maybe it’ll be like when Alexis Grigoropoulos was murdered in 2008. Police kill people all the time; that uprising happened because Alexis was someone people felt connected to.

And you think Pavlos’s visibility as a musician might provoke that same response?

Possibly. I don’t want to diminish anyone’s anger. I just find this “shock” a little repulsive, I think. A musician? A white male? It’s easier for people to identify with him than with nameless immigrants, but they’ve been killed by fascists, killed in detention centers, killed in police offices, and not seen such a broad response as Pavlos's murder has.
I don’t want to minimize the earlier victims of GD violence by talking about Fissas’ murder. Nor do I mean to reduce him to an abstract political symbol when I quote this portion of his friend’s tribute:
…[T]he rise of fascism in Greece is a direct result of the austerity policies that have driven the people here into extreme levels of poverty, marginalization and insecurity, providing fertile ground for the neo-Nazis of Golden Dawn who promise them national glory in place for economic security.

The neoliberal austerity policies that have brought Greece to this condition are being imposed by the Troika of foreign lenders: the ECB, the IMF, and the EU, and implemented by the servile government of this country.

Both the Troika and the Greek government have chosen to turn a blind eye to the murderous actions of Golden Dawn. They know about it — it’s not that they don’t. But as long as the austerity measures are voted through Parliament and the debt is repaid, the Troika is happy. At the same time, Antonis Samaras’ ruling right-wing party views Golden Dawn supporters as “their own people”, and even the Prime Minister himself regularly adopts Golden Dawn’s hate speech, especially when it comes to matters of immigration….
It seems that his tragic death might be the beginning of the end for the Golden Dawn. I hope it is, but that doesn’t make the loss of this unique human being any less tragic.

(An English translation would be much appreciated.)

The Alaskan Collie Fluffyterrier

I was delighted to read this story last month about Costa Rica’s plan to close its zoos. Since I was lazy posting about it and then Mano Singham scooped me :), I decided to wait* for an occasion to include it with some related news.

That occasion has already arrived, with this charming story about a Costa Rican dog shelter:


*In the meantime, I also came across a response to one of Singham’s questions:
I do not like zoos or circuses for many reasons but one is the way that animals are kept in captivity. At least with some of the better public zoos where the animals are given lots of room and are treated well, some sort of case can be made for their existence, that they increase awareness in the public of the need to preserve wildlife and their habitats. I do not know though if a causal relationship has been established between visiting zoos and increased support for wildlife .
I mentioned Lori Marino in a recent post, and while getting a link to some more information about her work I noticed a link to her critique of a study about the educational and conservation value of zoos and aquaria. (There’s a link to the full text on the page at the red “This is to announce a new publication in Society & Animals.”)What I love about it is that she rigorously picks apart the methodology of this research exactly as she did the methods of woo/PR studies about “Dolphin-Assisted Therapy.” These critical pieces would be useful for teaching about research methods in the social sciences.

(Of course, even if zoos did serve an educational/conservation purpose, this wouldn’t necessarily be sufficient justification for treating other animals in this way. Nor would it necessarily mean that better alternatives don’t exist.)

Saturday, September 21, 2013

Social justice and animal liberation: a few resources

There seems to be some confusion in the secular social-justice community concerning the relationship between feminism and animal liberation, and what feminist vegans and animal liberation advocates are really arguing, so I’d like to offer a few recommendations.

My first recommendation is simply that people acknowledge the possibility that they might be ignorant about the reality of the oppression and exploitation of other animals and about the animal liberation movement. It seems many people are, admirably, willing to admit that they have a lot to learn from the experiences and perspectives of other oppressed humans and their liberation movements. This same humility doesn’t seem to characterize the responses to attempts to inform about other animals and the animal liberation movement.

More specific recommendations (these are of course a tiny sample):

Generally, and not specific to the social justice connection, I recommend Jonathan Safran Foer’s Eating Animals

For people with a genuine interest in understanding how animal liberation fits with, and really is essential to, feminism and all social justice movements, I recommend:

• John Sanbonmatsu, ed., Critical Theory and Animal Liberation

• Carol Adams, The Sexual Politics of Meat: A Feminist-vegetarian Critical Theory

• David A. Nibert, Animal Oppression and Human Violence: Domesecration, Capitalism and Global Conflict

• and the blog Vegan Feminist Agitator

None of these sources is perfect. As with my recommendations for critical and political-humanist-liberation psychology, I’m not suggesting that people read them uncritically. Only fairly. Hell, just read them.

The NLG has an Animal Rights Activism Committee!

I was thrilled to learn recently that the National Lawyers Guild now has an Animal Rights Activism Committee, working both directly for other animals and in support of human animal rights activists:
The Animal Rights Activism Committee works to end oppression and exploitation of non-human animals. The committee engages Guild members to advocate for changes in the law to recognize the rights of non-human animals, and to provide legal support and resources to animal rights activists. It works in coalition with other groups to fight--in the courts and in the streets--to liberate non-human animals.
And they’ve been active! This is wonderful news, and another sign of the growing moral and legal recognition of the rights of other animals.

Se equivocaron estos empresarios


I wrote last week about my firm belief that the movements for social justice in Latin America have turned the tide, and that even where the Right appears to be holding strong or advancing, their gains will be short-lived. This doesn’t mean that they’ll give up. In fact, as they come to realize their power is eroding and feel threatened, they’ll fight even harder to preserve their illegitimate privilege.

Berta Cáceres, leader of COPINH, the Consejo Cívico de Organizaciones Populares e Indígenas de Honduras (Civic Council of Popular and Indigenous Organizations of Honduras), has been ordered to prison for her role in mobilizations against the Agua Zarca hydroelectric project.

"Me mantengo con la frente en alto y con toda dignidad: les digo que se equivocaron estos empresarios al pensar que el pueblo Lenca frenara su lucha histórica en defensa de los bienes comunes,” Cáceres told Radio Globo.

Friday, September 20, 2013

The World Before Her

Nirmukta posted last month about a documentary to be aired on PBS, The World Before Her, so I set the recording.

I recommend it, actually.* When we talk about people being victimized by or victims of unequal and oppressive systems, some listeners appear to hear "victim" as a sort of total identity that renders someone incapable of willful action. But what we're generally talking about is how people's paths are shaped and their options constrained in ways suited to others' purposes rather than their own needs and fulfillment. Within these limiting systems, they still make choices and pursue goals. They have agency, but this makes them no less victims.

Anyway, you can watch it free online at PBS (I think only if you're in the US, though) through October 16. It appears you can also watch it on iTunes, on YouTube, and probably elsewhere as well. After you do, check out this update on what the people involved have been doing since.

*I added the "actually" in tribute to the people in the film, who seem inordinately fond of the word. :)

The highest transgression

It is absurd to speak of humane treatment of animals when it comes to their handling, management, food, and shelter if you deny them the most basic right—to live out their lives—and condone or are complicit in their slaughter. Clearly, the killing of the animal is the most severe transgression, greater than any mistreatment that allows the victim to live. And because of that, our greatest concern should not necessarily be the treatment of the animal, though this is obviously very important; rather, the greatest consideration should be that the animal be allowed to live.
Read the whole thing.

Thursday, September 19, 2013

“…so we decided to go ahead and publish it.”

Mad in America recently highlighted Nancy Andreasen’s public acknowledgment that “anti-psychotic” drugs lead to the loss of brain tissue. The posts at PsychCentral and Science Daily to which MIA links are infuriatingly bad, but the story of Andreasen’s reluctant admission is important to publicize for reasons social and scientific.

I remember reading years ago in various places about this research that showed an association between schizophrenia and the loss of brain tissue. The articles painted a picture of schizophrenia as a degenerative disease that ate away at the brain, with psychotic symptoms being the first indications of trouble, but celebrated the fact that medication could address the symptoms and arrest this progression. This seemed like a clear justification for maintaining people on medications which would treat the disease and thus stop the deterioration. I would also have seen this research as evidence of the biological basis of mental illness, had I even suspected at the time that this biological basis wasn’t well established. I didn’t have those suspicions, so I was horrified to learn a few years ago – first from Anatomy of an Epidemic, I believe – that not only has no biological basis for “schizophrenia” been found, but the drugs themselves cause brain shrinkage.

This is shocking. It appears that what's happened is that the damaging effects of the drugs have been claimed for, and used as evidence of the existence of, the disease of schizophrenia, a claim which has then been used to promote the use of the very drugs that cause the damage! As the articles MIA links to show, they will continue with this spin: the demonstrated effects of the drugs are sidelined while the emphasis is on the alleged effects of the disease. But as Whitaker explains in a comment at the MIA post:
As for the evidence that there is shrinkage associated with the “disease,” meaning that people so diagnosed have smaller brain volumes, JOnathan Leo and Joann Moncrieff did a very good job of investigating this literature, and what you find is that most of the studies that claim to be of drug naive patients (and thus report smaller brain volumes), are not in fact of drug naive patients, but in patients who have been exposed to the drugs for a brief time. IN the three studies where patients trully were drug naive, they did not show significant brain shrinkage comparable to controls.

Now, it may be that trauma and other environmental factors that may lead to psychosis and the other “symptoms” that lead to a schizophrenia diagnosis are associated with brain shrinkage. I don’t know. But the real news here, for the field, is that Andreasen is, within the article, acknowledging that the drugs shrink the brain. [my emphasis]
I think Whitaker is right about the pertinent issues here. MIA chose to highlight the interview, despite Andreasen’s continuing claims about schizophrenia causing brain tissue loss and their uncritical acceptance by the writer, because the admission about the drugs is an important one:
In her last publication [here], the one referred to here, she so completely obscured the fact that she had previoiusly found declining brain volumes associated with drug usage, that many readers of that article started discounting that association, saying Andreasen had back away from it. I hear this all the time now when I speak–oh, Andreasen no longer believes that to be so. So, from that context, that is the news here, that she acknowledges (again) the drugs do cause this shrinkage.
Back in 2011 when Andreasen published about the relationship between drugs and tissue loss, Whitaker recognized the significance of these findings and published an article in Psychology Today – “Andreasen Drops a Bombshell: Antipsychotics Shrink the Brain.” In it, he wrote:
In this February report, Andreasen does not tie the drug-related brain shrinkage to an increase in negative symptoms, functional impairment, and cognitive decline. But in earlier articles, she did just that. And it is that larger context that makes this February report such a bombshell: When pieced together, this is a story of drug treatment that, over the long-term, causes long-term harm.

The other reason this is such a bombshell is that antipsychotics are widely prescribed now to children, often to control their "behavior," and to adults with bipolar diagnoses. They are being used to treat "non-psychotic" conditions. The risk-benefit analysis for those patients will be dramatically changed by the findings of this study.

One hopes that the study will be widely publicized in the media, and it will stir a vigorous discussion. Here are a few of the questions that I believe need to be asked:

• Does long-term use of antipsychotics for people diagnosed with psychotic disorders need to be rethought?

• Is there reason to prescribe these drugs to people with non-psychotic disorders?

• Should the prescribing of these drugs to children and youth, whose brains are still developing, be halted (or, in essence, banned?)

• Many adults diagnosed with psychiatric disorders are mandated by court orders to take antipsychotics. Should society have the right to require such treatment, given that the drugs shrink brain volumes and this shrinkage is associated with cognitive decline?
While Andreasen and her coauthors spun the article, they did include a recognition of at least some of the issues to which the findings would, and should, give rise. As noted in the article itself (the full text is available here):
Understanding the long-term effects of antipsychotics on the brain has wider clinical ramifications beyond treatment of patients with schizophrenia. Given the sharp rise in antipsychotic utilization,27 especially among pediatric and geriatric populations,27- 30 examining the possibility of antipsychotic-associated brain tissue loss has important implications for assessing the risk-benefit ratio in a large number of psychiatric patients.
But the bombshell failed to explode, as was probably predictable. The questions posed by Whitaker haven’t been seriously considered. The article wasn’t that widely publicized, no vigorous discussion was stirred, and the prescribing and forcible administration of these drugs doesn’t seem to have been affected. As Whitaker describes, Andreasen, for her part, has subsequently played down these findings, leading others both to do the same and to believe that she’s backed off from them.

But this interview shows that this isn’t the case - Andreasen refers to the association as a “solid finding.” The interview also reveals the depth of the desire in the psychiatric community for this not to be so. Whitaker continues in his comment, “You can see too in this article how she didn’t want to acknowledge this, or even really publish it. That is news here too.” It certainly is! From the interview:
“This was a very upsetting finding,” Andreasen said.

“We spent a couple of years analyzing the data more or less hoping we had made a mistake. But in the end, it was a solid finding that wasn’t going to go away, so we decided to go ahead and publish it.

“The impact is painful because psychiatrists, patients and family members don’t know how to interpret this finding. ‘Should we stop using antipsychotic medication? Should we be using less?’”
Their research suggested that drugs that are very widely prescribed and also forcibly or coercively administered, including to children, have serious harmful effects. This is of major, urgent importance for public health and human rights. Of course, it’s advisable to reexamine your work for errors and weaknesses before submitting your findings for publication. But the long delay of two years in this case appears to have been motivated more by a dislike of the results than by an abundance of caution. In fact, they seem more disturbed by the prospect of a decline in the use of the drugs than by the harm being caused to the millions of unsuspecting people taking them.

And apparently, even though the research was publicly funded, the decision to publish or not was at the discretion of the researchers. Despite this being a serious public health and human rights concern, they could, it seems, have chosen not only to delay publication and to downplay the results, as they did, but not to publish them at all. Andreasen’s and another author’s financial connections to a pharmaceutical company are listed in the paper. Given the history of pharmaceutical companies with regard to psychiatric drug research, I have to imagine that if the work had been privately funded it would have been buried entirely.

Andreasen’s behavior looks even more ethically problematic if we consider the context. “Antipsychotic” drugs are among the most used, including involuntarily, and the most profitable. They’re being prescribed in increasing numbers to people with a variety of psychiatric diagnoses, and their use in children has skyrocketed in the past few years. There are investigations underway across the US into the use of these drugs in children, and particularly children in the Medicaid and foster care system. As a recent WSJ article describes:
In 2008, the most recent year for which complete data are available, Medicaid, the government health program for the poor, spent $3.6 billion on antipsychotic medications, up from $1.65 billion in 1999, according to Mathematica Policy Research, a Washington firm that crunches Medicaid data for HHS. The growth came even as pharmacy benefits for millions of Medicaid recipients shifted to Medicare in 2006.

…Medicaid spends more on antipsychotics than on any other class of drugs. Abilify, made by Otsuka Pharmaceutical Co., appears on lists of the top 10 drugs paid for by Medicaid in various states.

…The number of people under age 20 receiving Medicaid-funded prescriptions for antipsychotic drugs tripled between 1999 and 2008, according to an analysis by Mathematica.

…Government Medicaid data indicate that some of the prescriptions are being written for very young children. An analysis by Mathematica found that in 2008, 19,045 children age 5 and under were prescribed antipsychotics through Medicaid, 3% of recipients under 20, up from 7,759 in 1999, according to James Verdier, a senior fellow at the organization.

Data from the inspector general's five-state probe indicate that 482 children 3 and under were prescribed antipsychotics during the period in question, including 107 children 2 and under. Six were under a year old, including one listed as a month old. The records don't indicate the diagnoses involved.* [my emphasis]
The nonconsensual use of these drugs, particularly in vulnerable populations, is increasingly recognized as a human rights violation and the movement to stop it is growing.

So, the disease these drugs are supposed to treat hasn’t been shown even to exist. The scientific invalidity of “schizophrenia” has been publicly acknowledged by the top figures in psychiatry. The history of the use of the drugs shows convincingly the shift from a drug model to the disease model that has been used to market these drugs as treatments for mental disease and how it was driven by politics and profits rather than scientific evidence. There is now very good evidence that the drugs are not only ineffective in any sort of longer term, but actually lead to worse outcomes, while knowledge of the social roots of these experiences continues to advance and psychosocial interventions have proven successful. The drugs appear to cause the “increase in negative symptoms, functional impairment, and cognitive decline” Whitaker referred to in 2011 (and there’s no real reason to expect that they wouldn’t, given how they act in the brain). There’s good evidence that they lead to the loss of brain tissue, with all that this entails, as well as a host of other significant physical harms, as described in this report to the UN Human Rights Committee and in the books by Whitaker and Moncrieff.

And still they continue to promote these drugs. The pharmaceutical corporations and the psychiatric profession have not shown in this context any commitment to science-based practice, public health or well being, or human rights. It’s well past time for, at the very least, the ban Whitaker suggests on the use of these dangerous drugs in children and an end to their involuntary use in adults.

* The use of these drugs to control and “discipline” children is often not even hidden:
Dr. Fernando Siles, a pediatric psychiatrist in the Dallas area who treats many poor foster children, says he sometimes prescribes such medications to treat serious behavior problems. "A child that continues to be aggressive will be kicked out from his foster home," he says. "The antipsychotic is to stabilize the behavior of the child, to keep him from being moved and moved again."

Good art: Mishka Henner and Front404

Some art I that think deserves wider exposure (I won’t reproduce the still images here, but just follow the links).

First, Mishka Henner’s aerial photographs of feedlots:

Precious Commodities from Mishka Henner on Vimeo.

Second, Front404. They came to my attention a few months ago for their Orwell birthday celebration. Their plantmines are also wonderful.
When you trigger one of these plantmines they shoot a cloud of flower confetti at you. The flower confetti contains flower seeds, to create a permanent happy and colourful spot in the place of the plantmine explosion. The explosion of flower confetti also serves as an instant party to celebrate that you live in a country where you don’t have to worry about stepping on a real landmine.

Plantmines @ Kleurenblind Festival Utrecht 2012 from FRONT404 on Vimeo.

Animals and landmines...

Wednesday, September 18, 2013


I haven’t done a Honduras update for a while, thinking it better to point people to the best sources of regular information on developments there. But reading some recent articles online inspired me to collect some of the news and compile it into a short update. Mark Weisbrot’s recent Al Jazeera op ed is heartening. Around the anniversary of the coup that overthrew the democratically elected government of Salvador Allende in Chile and put in its place the murderous regime of Augusto Pinochet, it’s important to be aware not only of the continuing efforts to obtain some modicum of justice and accountability for the victims of the coup and dictatorship but also of the positive democratic changes that have been sweeping through Latin America. Weisbrot argues that “Forty years on, much of Allende’s dream has come true”:
President Richard Nixon was clear, at least in private conversations, about why he wanted the coup that destroyed one the hemisphere’s longest-running democracies, from his point of view:

"The main concern in Chile is that [President Salvador Allende] can consolidate himself, and the picture projected to the world will be his success ... If we let the potential leaders in South America think they can move like Chile and have it both ways, we will be in trouble."

The ironic thing, and one that the world can now celebrate 40 years on, is that Nixon later turned out to be right about his "domino theory" of Latin America. When the US tried but failed to overthrow the democratically elected government of Venezuela in 2002, it ended up losing control over most of the region, especially South America. Allende died in the coup, but his dream lived on and much of it has been fulfilled….
The struggle continues, but the changes have been enormous. Weisbrot cites Honduras as one of the “weaker countries” where democratizing efforts have suffered setbacks, referring to the 2009 coup and the conditions since. But, as Suyapa Portillo Villeda points out, Honduras appears again to be “on the brink of change”:
…[T]his year’s election [voting will be on November 24th] has nine candidates running for president, including one woman, Xiomara Castro de Zelaya. Castro is the candidate of the new party LIBRE (Freedom and Refoundation) and has a great potential to win. Change comes in that the biggest contender for the president is a woman and from a new party, breaking the 100 year old bipartisan ring of rule (between the Liberal Party and Nationalist Party) that has ensnared Honduras for most of the 20th century and nearly strangled i[t]s democratic potential. The opportunity to destroy bipartisanship and to choose a new option for a new era is a change in itself. A woman president at the same time would also break with the old, as women have historically occupied low places in the Honduran political system. Lastly, and perhaps more importantly, the new party proposes a new set of social and economic policies that look to the future with a progressive and modern agenda, bringing Honduras current with the modern world. The new agenda marks the beginning of democratization and progress that has only just begun.
Honduras Culture and Politics has been following the campaigns, and, while the media – local and international – haven’t exactly been kind to Xiomara Castro, she’s leading in the polls.

All of this suggests how fragile and fleeting are the victories of the Right in Latin America, despite the brazenness and brutality with which they’re “won.” They can still destroy and intimidate and bribe and terrorize, but the political landscape has transformed and they face increasing difficulty holding on to their political gains. Force won’t work, and neither will propaganda. The movements for democracy and social justice in the region are too strong and dynamic.

Blackfish: Love, oppression, and science

I’ve made no secret of my thoughts about SeaWorld and other marine parks, and was happy a couple of months ago to learn of a new documentary, Blackfish, about the experiences of orcas and human trainers and their interactions at SeaWorld. I saw it recently, and was impressed. Via Ecorazzi, a few clips:

The movie is kind of a chronicle of a death foretold, focusing on the history of encounters between human workers and orcas at SeaWorld to help the audience better comprehend the fatal attack on trainer Dawn Brancheau by the orca Tilikum at SeaWorld Orlando in 2010.

It’s the focus on this one whale and on the experiences of the human workers, many of whom worked closely with Tilikum, that gives the film much of its power. The movie shows the workers' initial enthusiasm and increasing disillusionment as they came to appreciate the whales’ reality. Their stories are relatable: countless young people who love animals and the ocean visit these theme parks and dream of becoming “trainers.” (Many imagine that the position requires a high level of education about the animals rather than, as it turns out, attractiveness, athleticism, and performance abilities.)

The former trainers interviewed are thoughtful and compassionate to a one, impossible to dismiss as disgruntled former employees. They went into the work with an image of themselves, an image encouraged by SeaWorld, as “partners” with and caretakers of the orcas. As they came to recognize the real physical and psychological condition of the orcas and their own role in perpetuating the animals’ oppression and distress, intense embarrassment and guilt set in. This is really a tale of scientific awakening, even though it doesn’t superficially look to be about science. It’s a story of their growing recognition that their understanding of reality had been limited and highly distorted by the situation.

This failure to understand was direct. As one of the former “trainers” describes, she had believed when she worked at SeaWorld that she was knowledgeable about orcas, but over time came to realize that she actually knew very little about them. The workers came to recognize the partiality and inaccuracy of the information about the whales (such as about their typical life span in the wild vs. in captivity) that they were being fed by the company and then passing on to the public.1

But the nature of the relationship between humans – all humans - and orcas at SeaWorld interferes with understanding in much more fundamental ways. That former trainer’s comment about the false sense of knowledge reminded me of Erich Fromm’s discussion of the nature of love, which I’ve argued is inseparable from an understanding of science.

As I’ve discussed, Fromm argued that love was characterized by care (“the active concern for the life and the growth of that which we love”), responsibility (“my response to the needs, expressed and unexpressed, of another human being”), respect (“the ability to see a person as he is”), and knowledge. Fromm emphasizes the incompatibility of love with relations of domination and exploitation. These relations, which encourage narcissistic distortions, aren’t conducive to respect or to the development of objective knowledge about others. He argues for the importance of combating narcissism in forming knowledge: “I must try to see the difference between my picture of a person and his behavior, as it is narcissistically distorted, and the person’s reality as it exists regardless of my interests, needs and fears.” (111-12)

Fromm expands on this argument in Beyond the Chains of Illusion: My Encounter with Marx and Freud

in which he makes a case for the essential “connection between ‘thought’ and ‘concern’,” the “interrelation between concern and knowledge.” He contends that, in the human sciences at least, the advance of knowledge depends on caring for, being engaged with and sympathetic to, those we’re studying. He explains:
Both psychology and sociology have as their object man. I can get to know a great deal about man by observing him like any other object. I – the observer – stand against my ‘ob-ject’ (‘ob-ject’ and ‘objection’ have the same root; in German, Gegenstand=‘counterstand’) to observe it, describe it, measure it, weigh it – yet I do not understand that which is alive if it remains an ‘object’. I understand man only in the situation of being related to him, when he ceases to be a split-off object and becomes part of me or, to be still more correct, when he becomes ‘me’, yet remains also ‘not-me’. If I remain a distant observer I see only manifest behavior, and if this is all I want to know, I can be satisfied with being an observer. But in this position the whole of the other person, his full reality, escapes me.
The sort of concern needed for science requires a recognition of shared experience:
I need to be myself in order to see the other. How could I understand his fear, his sadness, his aloneness, his hope. His love – unless I felt my own fear, sadness, aloneness, hope, or love? If I cannot mobilize my own human experience, mobilize it and engage myself with my fellow man, I might come to know a great deal about him, but I shall never know him.
The most promising approach to knowledge of human beings is the most caring - concerned, “therapeutically oriented knowledge” inspired by questions like “how can man be free, how can he be fully human [sic], how can he become what he could be?” Fromm offers the paradigmatic example of medicine: “How many medical discoveries,” he asks, “would have been made without the wish to heal?”

He insists on the importance of this active concern to fruitful discovery. “[R]andom and uninterested observation,” in contrast, “rarely leads to significant knowledge.” Countering the common argument that an active interest and concern interfere with objectivity, he contends that “[t]his interest, far from being opposed to knowledge, is its very condition, provided it is blended with reason, that is, with the capacity to see things as they are, ‘to let them be’.”2

So, in Fromm’s view, not only is objective knowledge an essential element of love, but the reverse is true. In fact, the two are inseparable. The foundation of good science is not cold detachment but an approach guided by care, concern, responsibility, and a therapeutic intent. Rather than a futile attempt to transcend or achieve distance from the objects of study, Fromm advises cultivating respect: attempting to overcome the narcissistic inclination to view others through the lens of our perceived interests in order to see them (and by extension ourselves) as they/we really are. Although Fromm is talking about relations among humans and the human sciences, his insights can be, and need to be, expanded to include our relationships with and attempts to understand other animals as well.

Considered from this perspective, the various ways in which relations and systems of oppression obstruct the advance of science become more apparent. Everything in these systems militates against the respect and active concern necessary to objectivity and the formation of real knowledge. Theme parks like SeaWorld are a good example. Billed as sites where humans can encounter and learn about orcas, in fact they’re a microcosm of the system of domination and exploitation in which they operate. This makes them useful in illustrating the sorts of epistemic distortions that all such systems necessarily produce.

Our role in orcas' exploitation, for example, encourages a sort of active indifference to rather than an active interest in their experience. It leads people to block out consideration of the orcas’ real subjective experiences and psychological states. This includes a reluctance to investigate their psychological-emotional capacities, both those we share and those we might not.3 It also encourages apathy toward their interests and needs, both species-specific and individual.

We don’t want to look behind the stage set, or learn the truth about how the whales came to be performing in the parks. In fact, we shrink from recognizing the artificiality of the orcas’ treatment in the parks and its stark contrast with their lives in the wild. This motivated inattention shades into active denial. We’re inclined to believe the stories told by the corporation about the whales’ experiences and motivations, and even to embellish them with our own details. We eagerly accept assertions of the orcas’ stimulus-response simplicity and cognitive limitations. Just as the effects of poverty on human children are often taken as evidence of their genetic limitations, the effects of the orcas’ conditions of deprivation and their responses to these conditions are viewed as evidence of their relatively simple animal brains.

The position in which these parks situate humans in relation to the orcas - as accessories to their oppression and exploitation - leads to the muting of empathy. Rather than marshalling our own emotional experience to try to appreciate theirs, we actively deny that orcas have emotional capacities that conflict with the role they’ve been forced into. We convince ourselves that they enjoy the performances and their lives at the park.4 At least, we’re easily led to believe, they don’t mind their situation; in some sense, maybe they’ve even chosen it. We’re motivated to regard anything short of open distress or rebellion as cheerful acquiescence and cooperation.

When we encounter evidence of physical harm, we’re inclined to look away and to accept the explanations offered – the photos and videos don’t show what they purport to show, the injuries are superficial, orcas harming other orcas are engaging in natural behaviors, and so on. When we’re confronted with evidence of distress, we tend to deprive it of meaning or reframe it in ways that make it more palatable. We display a similar willful cluelessness toward acts of rebellion or resistance, including displays of aggression toward or attacks on humans. We tend to accept the explanations offered: these incidents were due to human mistakes, the whales were playing and didn’t understand what they were doing,…

The system leads to a similar distortion of our self-image, in which our role in the orcas’ oppression and exploitation is hidden or disguised as beneficial. While adopting more or less unconsciously the corporate perspective, which sees the orcas as objects valued for their usefulness, we like to see ourselves as part of a system of protection and caretaking centered in the parks. Rather than appreciating the epistemic and psychological distortions caused by our role in the system of oppression and exploitation, we actually believe we’re being enriched and educated while contributing to the well-being of orcas.

The marine park experience is very distant from Fromm’s therapeutic approach, which would try to understand the whales in terms of their real needs and capacities and promote conditions in which these are fulfilled. In fact, the system feeds narcissism and objectification, which are contrary to scientific understanding. As the film argues, if our understanding of the orcas’ reality weren’t thwarted by our position in a system of oppression and exploitation, we would have predicted the violence we’ve seen.

The awakening of the SeaWorld workers is instructive. In a sense, they were pulled toward both extremes, the system-serving and the scientific. On the one hand, their position in the system and their need to go on with their work and feel good about what they were doing virtually required the epistemic contortions described above – willful ignorance, denial, system-serving interpretation, accepting comforting myths, and so on. Despite their years of working closely with the orcas, the oppressive system in which they worked required bad faith. By way of contrast, scientists like Ingrid Visser and Lori Marino, also interviewed for the film, work in conditions that facilitate knowledge rather than systemically distorting and obstructing understanding.

On the other hand, the trainers’ proximity to the whales combined with the genuine love for the animals enabled them to see behind the veil – to witness firsthand the real conditions of the orcas' lives and their distress. Even though most seem to have had limited knowledge at the time of the orcas’ lives in the wild and their real capacities and abilities, the beliefs they were encouraged to hold due to their role in the system became increasingly difficult to sustain in the face of the evidence. They moved in several stages away from the systemic perspective and toward Fromm’s respectful, therapeutic orientation: from seeing themselves as the whales’ “partners” in a beneficent system, to understanding their role as that of the orcas’ protectors within and in some sense from the system, to realizing that the system itself is rotten and advocating for its end. Their descriptions of moments in this transformation are poignant: one interviewee describes being ridiculed by other workers for expressing her own pain at witnessing the suffering of orcas being separated from their families, while another explains how he remained at his job for a while to protect “Tilly.” More thoughts from a former trainer interviewed for the film:

The trainers’ experiences illustrate how easy it is to distort our understanding when we’re in oppressive and unequal systems that require a distorted understanding. But they also point the way forward. Examining how these theme parks interfere with the formation of knowledge of reality – of other animals and of ourselves - provides an opportunity to look critically at how our positions within systems of oppression and exploitation, including our seemingly innocent roles as tourists and visitors, work against not just the wellbeing of those most oppressed by those systems (and of the oppressors as well) but against understanding, against knowledge, and to find ways to move in a new direction.

1 The film shows a current employee being asked a question about how long the orcas generally live in the wild and giving the canned, incorrect corporate response. In an earlier post, I discussed Susan G. Davis’ work describing the problems with SeaWorld’s so-called educational programs, including the downplaying of evolution in order to cater to creationists.

2 As the quotation that opens one of my recent posts describes, this orientation is the foundation of the critical theory of the Frankfurt School, to which Fromm was (uneasily) linked, and really of all critical social science.

3 Some of the experts interviewed for the film discuss orcas’ lifelong close family relationships and speculate that these patterns might have led to emotions and emotional bonds that we don’t experience. It’s hard for humans, accustomed as we are to seeing other animals as precursors to or lesser, incomplete versions of ourselves, to even conceive of other animals having cognitive or emotional capacities that we don’t. The systems of oppression in which we typically meet make it even less likely that this recognition will emerge.

4 We fail even to consider that the orcas might be performing emotional labor, encouraged, as we are when faced with human emotional labor, to take expressions of emotion at face value.

Saturday, September 14, 2013

Inequality today

(US and Europe edition)

It’s grown to historic proportions. Here are a few items:

Democracy Now! interviews Robert Reich about inequality in the US and his new film, Inequality for All, out September 27:

Here’s a video from last year with some good graphics illustrating specifically wealth inequality in the US (I don’t agree with their take, but it’s well made and informative):

And here’s a new report from Oxfam, “A Cautionary Tale: The true cost of austerity and inequality in Europe,” which argues that “If left unchecked, austerity policies could put between 15 and 25 million more Europeans at risk of poverty by 2025.”

One major issue I have with the report summary is with this section:
The only people benefiting from austerity are the richest 10% of Europeans who alone have seen their wealth rise. Greece, Ireland, Italy, Portugal, Spain and the UK – countries that are most aggressively pursuing austerity measures - will soon rank amongst the most unequal in the world if their leaders don’t change course. For example, the gap between rich and poor in the UK and Spain could become the same as in South Sudan or Paraguay,” added Alonso.

Three years on, leading proponents of austerity such as the International Monetary Fund and many respected economists are starting to recognise that these measures have not only failed to achieve their objective to shrink government debt and budget deficits, but have also increased inequality and stunted economic growth.
I realize that people working as consultants and organizations hoping to maintain decent relations and open communication with the IMF in the hopes of influencing its direction feel the need to be politic when discussing its actions. But please, stop with these absurdly naïve representations of the knowledge and motives of the people behind austerity plans. Refer to their stated objectives if you must, but don’t encourage people to believe those are genuine.

The IMF has been imposing these sorts of austerity measures for decades around the world. They know better than anyone what the outcomes are going to be in terms of equality, human well being, and politics as well as deficit reduction and economic growth. Even the most blinkered ideologue amongst them – and they seem to have a never-ending supply – can’t deny this obvious reality. It’s impossible that they’re only now “starting to recognise” these results. Impossible.

Their history of continued insistence on these policies, despite decades of data showing their “failure” to achieve their alleged objectives, demonstrates clearly that those aren’t in fact their objectives. They wouldn’t have continued for decades to pursue policies that weren’t successful in some important way. The “leading proponents of austerity” know whose interests they serve, and it’s not the people of the countries where these plans are being imposed.

There’s no reason to expect austerity plans to have consequences any different than they’re having in Europe. As the authors of the report themselves note, there was no reason to expect it going in. It’s irrational to think that the austerity czars didn’t know that. Social movements can’t afford to be diverted by these gullible narratives. They can’t afford to waste time on efforts to educate the people imposing austerity measures. They can’t afford to become complacent, thinking that surely now the IMF is recognizing its “failure” and will have to change course.

Wednesday, September 11, 2013

Ham on the lam

Last month, I happened to catch a segment of Today in which Jenna Wolfe and the other hosts laughed it up over some video of policemen in China trying to capture several pigs who were trying to get away after the truck they were in overturned on a highway. They seemed to find the video and Wolfe’s “this little piggy” remarks highly entertaining. I haven’t been able to find the Today segment online, but I did find this ITN report

and another post about it that captures the same tone.
Ham went on the lam in China when a truck carrying piglets overturned on a motorway.

Hilarious cellphone footage shows traffic cops struggling to contain the stampeding hogs as they desperately made a break for freedom.
The pigs are clearly terrified. The one the video shows being pulled from under the truck is literally screaming in fear and pain. They’re being captured to eventually be killed. And the response the policemen, the reporters, and the people commenting on the story think is most appropriate is laughter.

Thanks, Johns Hopkins!

Sometimes, briefly, I forget about the university branch of the corporate-government-university complex.

Then a read a story like this one about a dean at Johns Hopkins telling cryptography professor Matthew Green to take down a blog post about NSA spying. It has a happy ending: dean realizes he was misinformed (he couldn't be expected to investigate before issuing the order), he apologizes and proclaims his commitment to academic freedom, and the site is up.

Who called Green's post to the attention of the dean? It appears it wasn't the NSA, but someone from the Applied Physics Laboratory at Johns Hopkins. The APL,
which employs about 5,000 people, does many projects with the NSA.

According to the lab’s website, “APL staff working with NSA are engaged in strategic planning, development of enterprise and program architectures, conducting quantitative analysis to support engineering decisions, development of engineering processes, and formulation of the governance structures for the work in the new Technology Directorate (TD).”

The website also notes that the lab “completed a strategic study that analyzed NSA’s global information technology infrastructure to determine the top locations for the large-scale data centers.”
Good to know. Is this 1950?

9/11: The fight for justice in Chile…and the US

Today is the 40th anniversary of the US-backed coup that overthrew the elected government of Salvador Allende in Chile and installed the brutal dictatorship of Augusto Pinochet. The commemorations, it seems, are as much about the present as they are about the past, which is as it should be.

Democracy Now! has been focusing on the efforts to get justice for the families of journalist Charles Horman (I’ve written about this case before)

and singer Victor Jara

They link to Peter Kornbluh’s article in The Nation about the role of the US government – primarily Nixon and Kissinger – in the coup. Kornbluh is also interviewed about recently declassified documents providing further evidence of their complicity.

These struggles for justice rely on the US public to develop a willingness to listen and to criticize our nation’s past and present.

(Unfortunately, the Vatican isn’t discussed.

Neither is Friedrich von Hayek.)

Tuesday, September 10, 2013

Leaving Capri

So what do I want to do with all of my brightly colored photos capturing the lush beauty of the Amalfi coast? Remove a lot of the color, of course.

I’m working on some that I took on the boat returning from Capri. I’d hoped to go to Pompeii but didn’t make it this trip, which has been a sort of blessing in disguise since it's been pushing me to think of different ways of talking about time and history and memory and so on. My first effort:

I’m not entirely sure about it (too…gimmicky, maybe?). But I like the direction, and I’m having a ball with hue desaturation in GIMP.

Day Is Done

Doesn't actually reflect my mood at the moment, but I've been going for a lot of long walks and I'm at MNO in the Top Rated list on my iPod. And it's beautiful.

(This one has more songs. I like the accompanying video.)

Blue in Green

In vegan food news…

It’s Vegan MoFo, the vegan month of food, so I’m going to gather some food news items that have come my way recently and add a note of my own.

First, two fast food chains are introducing vegan options. Chipotle is going to expand nationally its sofritas, which has been a hit on the West coast. (It’s not actually their first vegan menu item: their burritos with black beans and guacamole are also vegan.) TCBY will be (or already is – I haven’t yet been in to check) offering Silk Chocolate Almond flavor, made with Silk almond milk.

In other restaurant news, eight new vegan restaurants across the US. For those in the New York City area, Gothamist’s nine best vegan dishes in NYC.

Also, “Groundbreaking, Game Changing Vegan Cheese Is Here”! (I haven’t ordered the cook book yet, though I’m quite excited about it, because I think that for many of the cheeses I’ll need a better blender than I have. I can’t remotely afford a Vitamix, but perhaps a Ninja Pro…?)

Finally, ZUCCHINI. For the past few weeks I’ve been perfecting my zucchini risotto. Zucchini was never one of my favorites, but I had a delicious pasta mista (I have to admit, mixing pastas goes against my grain :)) with zucchini in Italy which changed my mind. Of course, I can’t recreate the al fresco dining by the Mediterranean, but I’m thrilled to have discovered another vegetable to love.

Wunderink and The Bitterest Pills*

A study on the longer-term effects of “antipsychotics” by the awesomely named Lex Wunderink was published back in July that deserves some attention. Since Robert Whitaker and Joanna Moncrieff at Mad in America have summarized its findings and talked about its context and implications, I’ll just link to their posts.

• Robert Whitaker, “Harrow + Wunderink + Open Dialogue = An Evidence-based Mandate for A New Standard of Care”

• Joanna Moncrieff, “Long-Term Antipsychotics: Making Sense of the Evidence in the Light of the Dutch Follow-Up Study”

I will say that Whitaker is being extraordinarily generous with psychiatry, though, when he writes:
In my opinion, this represents a defining moment for the profession. If it changes its protocols for prescribing antipsychotics, in the manner set forth in the JAMA Psychiatry editorial, then “hats off” to the profession. It will have responded to evidence that didn’t show up in shorter withdrawal studies, and changed its ways in response to new evidence, even though that will surely be a difficult thing to do. This would be a beautiful—and inspiring—change to watch.

But, if psychiatry doesn’t amend its protocols, and if psychiatry doesn’t sponsor new research to best reach these goals, then—and I know no other way to say this—then I think psychiatry will have to be seen, by mainstream society, as a failed medical discipline. Psychiatry will no longer be able to claim that its practices are evidence-based and driven by a desire to achieve the best possible outcomes for its patients. Instead, the lack of change will be evidence that its prescribing practices are, in fact, driven by an ideology, which is to maintain a societal belief that antipsychotics are a necessary long-term treatment for psychotic disorders, and that it is more important for the profession to maintain that belief than it is to help those it treats to have the best chance possible to achieve a good functional outcome, which is the outcome that counts.
He acknowledges that his “realistic self expects the latter,” but, really, it’s far too late for a scientific or ethical hats off for psychiatry. It’s far too late for any of their actions in this regard to be seen as beautiful or inspiring, far too late for them to demonstrate that their practices are evidence-based. The fact that this is being discussed as a gold-standard RCT studying the effects of drugs on the “symptoms,” “relapse,” and “remission” of a disease that hasn’t even been shown to exist is an indication of just how far out at sea they are.

In related news, as mentioned in her post, Joanna Moncrieff has a new book coming out: The Bitterest Pills: The Troubling Story of Antipsychotic Drugs.

Antipsychotic (neuroleptic) drugs have become some of the biggest blockbusters of the early 21st century, increasingly prescribed not just to people with 'schizophrenia' or other severe forms of mental disturbance but for a range of more common psychological complaints. This book challenges the accepted account that portrays antipsychotics as specific treatments that target an underlying brain disease and explores early views that suggested, in contrast, that antipsychotics achieve their effects by inducing a state of neurological suppression. Professional enthusiasm for antipsychotics eclipsed this understanding, exaggerated the benefits of antipsychotics and minimized or ignored evidence of their toxic effects. The pharmaceutical industry has been involved in expanding the use of antipsychotics into territory where it is likely that their dangers far outweigh their advantages.
I don’t understand why even this new one isn’t available for Kindle, but it looks good.

*Sounds like a scary fairy tale about biopsychiatry.

Sunday, September 8, 2013

Mad Science 2: Adjustment vs. Political-Humanist-Liberation Psychology

“Critical theory…sets out from a single intuition about the world – that the predominant values, institutions, representational schemata, and so forth of the prevailing social order are a distortion of the real, unjustly constituted in such a way as to prevent the world from becoming something other than it ‘is’; that is, from becoming what it ought to be…. [T]he critical theorist sets out…from a prior standpoint of normative sociological critique and existential refusal…. Confronted with a totality rooted in unfreedom, the critical theorist seeks to generate forms of knowledge and practice that are themselves ‘real’ – which is to say, adequate to the task of comprehending, and changing, the totality of existing social fact. The goal of critical praxis, therefore, is to liberate humanity and nature too from the brutalizing logics of power that prevent us from realizing our capacities and essence as free, creative beings.” – John Sanbonmatsu, Critical Theory and Animal Liberation, KL 157

“[M]ental disorders or problems pertain not only to the individual but also to the individual’s relationships with others. But if this is the case, then mental health should also be understood as a problem of social relationships – between people and between groups – which will provoke crises, depending on the case, within an individual or a family, inside an institution, or in a whole society.

It is important to emphasize that we are not trying to simplify a problem as complex as mental health by denying its personal roots or, in trying to avoid individual reductionism, replacing it with social reductionism…. But we want to emphasize how enlightening it is to change the lens and see mental health or illness not from the inside out but from the outside in; not as the result of an individual’s internal functioning but as the manifestation, in a person or group, of the humanizing or alienating character of a framework of historical relationships… From this perspective,…it may be that a psychological disorder is an abnormal reaction to a normal situation, but it may also happen to be a normal reaction to an abnormal situation.” - Ignacio Martín-Baró, Writings for a Liberation Psychology, pp. 110-111*
In this post, I continue to discuss the book Mad Science, but the post isn’t so much about the book specifically as using a critical evaluation of the authors’ proposals for an alternative psychiatric vision to illuminate the contrast between “adjustment” psychiatry/psychology and what I’ve come to call the Political-Humanist-Liberation or PHL approach to mental health (I admit, I like that it sounds like “full,” suggesting its comprehensiveness).1 Important PHL proponents have included Erich Fromm and Ignacio Martín-Baró, the liberation psychologist and priest murdered by a US-trained death squad in El Salvador in 1989. But its spirit isn’t found only in explicitly PHL writings, but in the work of people in the other social sciences, in history, in philosophy, and in literature.


So, as I talked about in my previous post, Mad Science is a worthwhile addition to the growing literature on psychiatry. It doesn’t break much new ground (aside, perhaps, from the extended discussion of the history and “evidence-based” evaluation of Assertive Community Treatment), but it contributes to the literature a focus on the specifically scientific failings and effects of biopsychiatry.

In my view, that’s sufficient for any individual book or article. I don’t believe that any of the authors of these critical works are obliged to provide either solutions to the problems they describe or alternative understandings of or approaches to “madness.” We don’t ask this of everyone debunking every form of pseudoscience, even when these relate to relieving suffering, and biopsychiatry is currently so powerful and harmful that revealing its failings and damaging effects is itself a valuable and needed service. Further, the obligatory attempts to provide alternative answers or proposed solutions frequently lead to a lot of tacked-on, half-baked ideas about how to “fix” things, often in lists in concluding chapters, that are at best naïve and at worst counterproductive and can detract from the power of the preceding critical analysis (see, e.g., Goldacre’s Bad Pharma and Harriet Washington’s Deadly Monopolies).

This doesn’t mean that we as a society don’t have to develop alternative understandings and approaches to “madness,” though. We do, and urgently, so I understand the impulse to include them in otherwise primarily critical books. The reign of biopsychiatry is coming to an end – it’s inevitable. As I’ve discussed, there are religious and other superstitious alternatives lining up to take its place. There are self-help charlatans eager to profit from people’s alienation. There are those with a rightwing political agenda all too pleased to attribute psychological distress and disruptive behavior to personal moral failings and weakness and to retain the coercive and eugenics aspects of biopsychiatry while abandoning any therapeutic impulse.

Talking about alternatives is also important to debunking itself. Debunking can happen and needs to happen even in those cases in which real solutions to real problems aren’t, or aren’t yet, available. We can and should, for example, work to debunk claims about the effectiveness of various alternative treatments in curing aggressive cancers even when there are no known effective cures. (This isn’t to say that a focus on cures alone is best; in many cases, contributing environmental causes should also be a focus.) It’s fine and good to debunk false and harmful explanations and treatments even when valid and useful ones aren’t known or available; and we can indicate the directions from which useful answers and responses are most likely to come, providing a general framework for investigation and action.

But it’s frequent that debunkers of biopsychiatry run into a wall of accusations that they’re necessarily denying the reality of psychic distress itself or claiming that distressed people are at fault for their suffering.2 The frequency of these accusations and their success at diverting people’s attention from the invalidity and harms of biopsychiatry is largely the result of the successful marketing of biopsychiatry and psychiatric drugs. Part of their marketing message has been that alternative – nonmedical or nonbiological - understandings of psychic distress are inherently moralizing or stigmatizing and that the only way to validate suffering as real and to remove its stigma is to treat it as a disease or disorder. These claims – like the core claims of biopsychiatry itself - are demonstrably false, and even if the debunkers were suggesting what they’re accused of suggesting, their failure to provide correct or adequate alternative understandings wouldn’t strengthen the case for biopsychiatry, either as a scientific field or as a political institution, in the slightest. But they make debunking biopsychiatry more difficult.

The success of these accusations is also to some extent the fault of the critics of biopsychiatry themselves. This isn’t to say that these critics are denying the reality of psychological distress and suffering. In my reading of this literature, I can think of vanishingly few if any cases of that sort of denial. Given how many of these critics are practicing psychiatrists or psychologists or victims of psychiatry themselves, it would be surprising if such denial were a prominent feature of the debunking literature. No, the weakness lies in their proposed alternative explanations and approaches, in the responses to the implicit or explicit questions, “Well, what do you think causes this suffering or these experiences or behaviors? What do you think is the best way to address them?”

The basic problem I’ve found with this critical genre is both scientific and political: it lacks an overarching social scientific and social justice vision and commitment. This can lead to a hodgepodge of proposed alternatives and to the acceptance of various bogus and irrational arguments, insufficient and in some cases potentially quite harmful. This is an issue at Mad in America.3 Worse, it can lead to responses that reflect and perpetuate an oppressive status quo.

Unfortunately, this is the case with the alternative vision put forward in Mad Science. First, the authors depoliticize and dehistoricize psychological suffering, abstracting it from real-world social structures and processes. Their “alternative vision of madness”4
recurs throughout history. It accepts of course the mental and behavioral consequences of well-defined diseases such as pellagra, neurosyphilis, Alzheimer’s dementia, or alcohol poisoning resulting in delirium tremens. It portrays madness not as a medical issue (disease/illness) or a phenomenon of nature as much as a human locus for a wide variety of existential struggles and deviant human actions. That conception requires a willingness to see the vast majority of mad persons, those whose behavior has not been scientifically linked to pathological processes, as poorly, sometimes very poorly, prepared actors (or sometimes evil actors) in a complex world, who try their best to deal with problems in living, sometimes very grave ones. (KL 7543)
Their model of madness and psychological distress describes these in terms of perennial, transhistorical “existential struggles,” conceiving of “traumas, fears, dilemmas, conflicts, and misbehaviors” as “inevitable parts of the human comedy” (KL 7974). They recognize that “human travail and anguish have many sources – poverty, bad parenting, troubled childhoods, and the common stresses of life” (KL 4867), but delink these from concrete social structures and historical processes.

In fact, Kirk et al. appear to endorse a sort of Social Darwinist notion that “existence is a struggle” in which the stronger succeed or just cope better than others. In this sense, the forms of distress and behavior that are deemed problematic are seen, in very capitalist terms, as evidence of poor individual coping:
In the old normal, one recognized that existence is a struggle, an effort to be engaged with the world. Everyone’s life had its ups and downs; people had strengths and weaknesses; and all experienced times of loss, disorientation and restoration, failure and resilience. Some dealt better than others with these challenges. This was viewed as part of the textured variation and diversity of human life. (KL 7974)
As this quotation suggests, just as they depoliticize social problems by reducing them to a vague existential condition, they abstract away from the social situatedness of individual experiences by suggesting that all humans face similar challenges.

Further, they seem largely to fail to recognize the definitions of psychological problems themselves as socially determined or used to label and control those who challenge the system. In discussing the various definitions of “mental illness,” for example, they leave unchallenged the common diagnostic criterion of (non-)“functioning” and how this coincides with capitalism's demands for work and submission to the logic of the system.5 They use terms like “deviant” and “misbehaviors” uncritically, appearing to accept our culture’s (and by extension any other culture’s) definitions of those terms while draining deviancy and rebellion and their labeling of political content.

The authors seem oddly eager to reassure the reader that their alternative vision “does not dismiss…personal responsibility” (KL 8013).6 For instance, they suggest at a few points that the public has been an enthusiastic partner in the selling of biopsychiatry and its drugs. People have wanted to believe in this model, they argue, not just because “the medical explanation of human travails provides comfort, solace, and hope,” but because “[i]t suggests that personal distress, inadequacy, and failure are really due to internal neurological defects that once fixed will eradicate these failings, much as antibiotics cure bacterial infections. It promises that people will not be held responsible for their failings” (KL 7948).

In other words, according to the authors a key reason people have embraced biopsychiatry is that it allows them to reframe their “personal…inadequacy and failure” as sickness and therefore not their fault or responsibility. The language of poor coping, of “failings” and “failure,” is used repeatedly, with the authors I believe at one point characterizing people experiencing psychological distress as having “failed at the game of life” (a remark I can’t find now – damn you, Windows 8 Kindle app!).

The conservatism of this vision is also evident in the role they envision for mental health professionals. Kirk et al. recognize, importantly, the destructive consequences of the fact that poor people often have to agree to a diagnosis of a mental disorder and to psychiatric drugs in order to have access to needed aid and services. In this context, it seems for a moment that they’re going to connect large-scale structural problems to people’s experiences and their psychological problems:
The problem is this: people who need assistance are labeled as mentally ill in order to receive income supports, health care, and social services. Why do so many people need assistance? The economy is stalled or spiraling down, fewer unskilled [sic] jobs are available and unemployment has increased, inflation-adjusted wages for the average middle-class family have not increased in two generations, record numbers of families have lost their homes, and services from nonprofits and local and state governments have been sharply cut in the Great Recession. Millions of adults and children, normally living in relatively precarious circumstances, are now under enormous social stress. This stress does not result from the increasing incidence of brain defects, but from economic and policy defects. (KL 7921)
This passage appears to reflect an understanding of the social sources of psychological troubles, as described, for example, in The Body Economic. Immediately, though, economic and policy problems are pushed aside as the authors respond from within their narrow vision. What’s needed to help these millions of struggling and suffering people, they argue, aren’t better policies but the “compassionate assistance” (KL 8013) of mental health professionals: “These people need opportunities and assistance, and social workers and mental health clinicians would like to help them with some of their problems so that they might seize opportunities or bear discomfort more constructively until circumstances improve” (KL 7921).

So what were previously recognized as economic and political issues are to a large extent reframed in terms of personal shortcomings. “Their” problem is that they have to learn to “bear discomfort more constructively” [!] and to be ready to avail themselves of the great opportunities that exist or will arise. Their problems are no longer pictured as the outcome of “enormous social stress” but as individual deficiencies and poor coping skills they can individually, with the aid of professionals, overcome. The problem isn’t with the system, but with individuals.

The role of mental health workers in this and other adjustment approaches is to help people deal with their nonspecific “problems in living” within the system. Mental health professionals should offer a compassionate ear and be the teachers of “life skills.” The authors, with a background in social work, see this as a positive and hopeful vision: “[P]eople can overcome adversity and improve their circumstances. This view accepts human pain and struggle as inevitable but within the abilities of people, perhaps with assistance, to overcome” (KL 4867). Mad or distressed people might need some help in learning to cope and compete in the game of life, but ultimately they're expected to pull themselves up by their own psychological bootstraps.

This vision – which instead of treating people’s psychological struggles and disturbances as meaningful responses to social conditions dismisses them as a lack of resilience in the face of the unavoidable difficulties of living – takes a similar approach to thinking about the sources of change in psychiatry. The authors devote considerable attention to leading figures within psychiatry like Allen Frances who’ve broken ranks, criticized some aspects of the model, or acknowledged problems in psychiatry. It’s often very effective to point out that even those socialized within and who’ve benefit from the system can be among the most effective forces for change. But they take a generally elitist view of historical change. They appear to expect – and want – change to follow the enlightenment of a rich and powerful man who makes it his mission to tell the truth about the model. (They actually suggest this as a hopeful scenario.) With their focus on elite insider-defectors and billionaire saviors, the authors largely ignore the critical voices of the psych rights movement and how their activism has been driving much of the work of critical psychiatry. These activists’ understanding of the personal and political meaning of their experiences is of little interest and appears to play no role in the formation of the authors’ vision.7

The authors of Mad Science claim that part of the allure of biopsychiatry has been that it sees psychological troubles as symptoms involuntary physical ailments and “not – as in former times – as signs of immorality, failure, or personal weakness” (KL 4867). But all they have to offer when push comes to shove is a rehash of those archaic notions, a model presenting distress and disturbing behaviors as reflecting immorality, failure, and personal weakness – the inability to cope with the stresses and demands of “normal events in the struggles of living.” In terms of understanding the causes and nature of psychological distress, this approach actually shares many of the weakest aspects of biopsychiatry.

Given a choice between these two sad, narrow alternatives – brain disease or personal inadequacy – it’s easy to see why many people might lean toward the former. But the fundamental problem with this vision isn’t that it’s an unappealing alternative to a pseudoscientific biopsychiatry, but that it’s wrong. It’s also ideological - of little utility outside of maintaining an oppressive status quo. In fact, while the authors of Mad Science present their vision as the classically humanistic, it’s really a selection of some of the worst elements of conservative-libertarian ideology. Theirs is a form of adjustment psychiatry, in a different universe from the political, humanist, liberation psychiatry-psychology of Erich Fromm or Ignacio Martín-Baró.

It’s interesting that the authors consider theirs a “broader” vision, more informed by philosophy, history, and the social sciences. Their
alternative view is that the array of misbehaviors, mistaken and disturbing feelings experienced by those now labeled with brain disorders are better viewed as normal human experiences in all their varieties, as described by scholars in sociology, psychology, anthropology, history, philosophy, and other disciplines that study the human condition, than by neuroscience. (KL 8000)
But as the phrase “normal human experiences in all their varieties” suggests, theirs isn’t a model that considers or seeks to understand the differences amongst the varieties, their causes or effects, but one that dissolves them all in the featureless category of “the human condition.” Their abstract and ahistorical vision is completely unlike historical and sociological understandings, which focus on the specific nature of systems, cultures, and social experiences and their positive and negative effects on the human psychological experience.

An inability or refusal to appreciate that societies can be psychologically pathogenic8 in general, with extremely damaging effects for oppressed people, leads the advocates of this model to locate the sources of psychological problems in individuals and to see the ideal of mental health as the successful adjustment of individuals to the system. As Fromm argued, the refusal to look critically at society leaves the proponents of adjustment psychiatry with two options: either a total cultural relativism in which mental health means successful adjustment to one’s position in whatever society one happens to live, or the patriotic assumption that, even if other societies have been and are currently unhealthy, the psychiatrist’s own society is the best of all possible worlds for all of its members. In practice, adjustment psychiatry’s advocates, including the authors of Mad Science, aren’t enthusiastic about making explicit the assumptions that underlie their model; but this silence on the subject with its implicit presumption of societal health serves the status quo and the interests of the powerful.

PHL models, in contrast, make no such assumptions, as described in the quotations that open this post. Rather than starting from the belief that a given society is conducive to mental health, the advocates of liberationist psychology begin with a focus on human needs and potentials. Societies are critically analyzed in terms of how they impede or facilitate the realization of these needs and potentials. In the words of Martín-Baró, “[O]ur subjective aspirations, both as groups and as individuals, must be oriented toward the satisfaction of our true needs…” (Writings, p. 121).

In PHL psychiatry, societies are criticized for their structures of oppression, which work against human (and nonhuman) fulfillment and create psychological problems. This essentially reverses the adjustment equation – instead of beginning with existing society and viewing mental health in terms of successful adaptation to it, PHL models begin with human well-being and judge societies on how well they contribute to or block its fulfillment. (My point isn’t that every one of us is entirely correct about what constitutes well-being or the best means of realizing human thriving, but that these are the normative and scientific point of departure for any real PHL psychology.)

Liberationists recognize that societies can and do have features (capitalist consumerism, for example) that work against general psychological well being and development. They seek to analyze how societies characterized by inequality, oppression, superstition, exploitation, violence, and trauma, with their associated racism, sexism, imperialism, homophobia, transphobia, ableism, militarism, and speciesism, can be pathological or pathogenic. Martín-Baró describes El Salvador’s repressive system in the 1980s, for example, as “the ‘normal abnormality’ that dehumanizes the weak and the powerful, the oppressor and the oppressed, soldier and victim, dominator and dominated alike” (Writings, p. 135). All of these structures have a negative impact on everyone in the society, including, importantly, those who appear to benefit from the system and who vigorously defend it.9

But they also appreciate that in societies characterized by inequality, oppression, and exploitation, people’s experiences and struggles are systemically, institutionally shaped. These visions are informed by feminist, antiracist, and anticolonialist work describing these structures and their effects.10 They can draw from a huge amount of research on the psychological effects of childhood abuse, of torture, of war, of sexual assault, of social and political marginalization, of prejudice and discrimination, of economic insecurity, of unemployment, of poverty, of indebtedness, of chronic illness, of harassment, of government violence,... And they recognize that these are structural problems that affect everyone negatively but affect people differently based on their social location. So, while the Mad Science authors argue that “there is no convincing scientific evidence concerning what causes people to feel or act in ways that are uncomfortable to themselves or bothersome to others” (KL 4304), PHL psychologists can point to very strong evidence of social sources of psychological distress.

Appreciating the social causes of psychological troubles naturally moves the focus away from individual-level explanations, both those locating these problems in biology and those pointing to personal character or inadequacies, and toward a psychosocial understanding. From this viewpoint, psychological suffering and madness are seen as symptoms not of individual but of societal malfunctions. C. Wright Mills’ classic statement about the sociological imagination applies here:
When, in a city of 100,000, only one is unemployed, that is his personal trouble, and for its relief we properly look to the character of the individual, his skills and his immediate opportunities. But when in a nation of 50 million employees, 15 million people are unemployed, that is an issue, and we may not hope to find its solution within the range of opportunities open to any one individual. The very structure of opportunities has collapsed. Both the correct statement of the problem and the range of possible solutions require us to consider the economic and political institutions of the society, and not merely the personal situation and character of a scatter of individuals.” (“The Promise,” in The Sociological Imagination)
These experiences and actions aren’t seen as evidence of personal weakness but as responses to, and possibly rebellion against, bad forms of human social organization.

Of course, in keeping with this expanded sociological understanding, PHL psychology also questions the definitions of deviance or misbehavior put forth by the powerful – their very conception of what constitutes a psychological problem. The history of psychiatry and psychology, and of politics more generally, is replete with the pathologization and marginalization of experiences and actions that challenged the social order. Rejecting sanctioned gender roles, being gay or transsexual or leftwing – these have all been labeled deviant, pathological, problematic experiences and actions. As noted above, in a capitalistic system, a “failure” or refusal to “function” – to work and to consume in the prescribed fashion – is viewed as a criterion for diagnosis. (Our current system, in which psychiatry functions as an ally of pharmaceutical corporations, adds new and terrible facets. The incentive to sell drugs encourages the creation of ever more alleged psychological problems. And as someone commented here a while back, political power and economic profit join hands.)

Furthermore, in connection with recognizing the political character of what’s defined as deviant and pathological, a PHL psychology is attuned to what’s defined as healthy and well-adjusted.

At the extreme end of the spectrum, in fascist and Stalinist systems, behaviors that we (mostly) now recognize as depraved were considered mentally healthy and normal. In my society, many elements of rape culture, militarism, consumerism and environmental destruction, and the killing of some other animals for sport or for food are normal, and certainly not seen as psychological abnormalities warranting therapeutic intervention.11

Clearly this is a sociological perspective, drawing on the wealth of findings by feminist and other scholars who’ve studied the psychological effects of living in conditions of inequality, oppression, fear, insecurity, violence, and trauma. But that doesn’t mean PHL psychology’s proponents cease to be interested in helping individual people. Many of the great PHL psychiatrists and psychologists have worked in clinical practice, andor written books containing advice and suggestions for troubled people. But this work isn’t individualizing. It doesn’t view or treat human psychological problems as wholly rooted in the individual psyche. The goal of PHL psychology is to help people recognize the sources of their troubles, including in the society they live in, and to thrive psychologically.

Adjustment psychology begins from the implicit premise that, well, even if society isn’t perfect, fighting for social change is outside the professional purview of the mental health worker. PHL psychology begins with a different understanding: since no individual can thrive while adapting to or trying futilely to transcend a systematically oppressive and unequal society, since oppressive social orders are psychologically harmful to everyone in them, including the oppressors, its project is inherently, unavoidably about changing the system – about fighting for and working together to create a society that will not only cease to systematically cause psychological harm but will foster psychological well being and true fulfillment.12 As Martín-Baró writes,
If the foundation for a people’s mental health lies in the existence of humanizing relationships, of collective ties within which and through which the personal humanity of each individual is acknowledged and in which no one’s reality is denied, then the building of a new society, or at least a better and more just society, is not only an economic and political problem; it is also essentially a mental health problem. (Writings, p. 120)
As Martín-Baró explains in the quotation at the beginning of this post, this doesn’t mean that individual troubles can all easily or directly be related back, much less reduced, to large-scale structural causes. The “brutalizing logics of power” show their effects in troubled minds, but the relationship between oppressive systems and psychological experiences and troubles is of course highly complex.

This vision, which puts psychology and psychiatry in the service of efforts to end oppression, recommends a very different professional role for the psychologist or psychiatrist. For one thing, those working in this approach look critically at the role of psychiatrists, psychologists, social workers, and researchers themselves in ideologically supporting and enforcing systems of oppression. They pay attention to the history of psychiatric theory and diagnosis – to how the cultural definitions of madness and of mental health have tracked and continue to track the interests of power and been used to control and discredit rebellion or messages of discontent.

In this context, they (self-)critically analyze whether the depoliticized model of “curing” itself serves the perpetuation of an unjust status quo. As Martín-Baró suggests in reference to addressing the trauma suffered by child victims of the civil war in El Salvador, psychologists should think about
what [they] accomplish while they are at work, particularly in situations like civil war. The curative work of the psychologist is necessary, but if psychology’s work is limited to curing, it can become simply a palliative that contributes to prolonging a situation which generates and multiplies the very ills it strives to remedy. Hence, we cannot limit ourselves to the question of what treatment is most effective for children who have suffered the traumas inherent in war; we cannot limit ourselves to discussing post-traumatic stress. Our analysis has to extend itself to the roots of those traumas, and therefore to the war itself as a social psychopathogenic situation. (Writings, p. 122)13
Equally important, PHL is attuned to the history and continuation of abusive practices. It rejects paternalistic, authoritarian, and coercive relations in psychiatric and psychological work just as in the broader society, recognizing that these aren’t conducive to the psychic health and growth of any party. Their ideal relationship with struggling and troubled people is one of respect and compassion, with prospects for mutual learning and growth, one which doesn’t fetishize any particular method. It’s one in which psychologists and psychiatrists listen to people in distress and take their experiences and the meanings they give them seriously rather than focusing on trying to “fix” people.

This is far from the easiest route. It’s not like people can be diagnosed with Capitalism Syndrome or Acute Patriarchy Disorder and given a pill or a few therapy sessions. There are financial and practical barriers to working in this way. But it’s the only form of mental health work that responds to the real problems in society, that offers these fields the possibility of contributing to genuine mental health – an ambitious vision of mental health that understands it not just as the absence of suffering but as true human fulfillment and thriving.

So, to summarize the differences between adjustment (of both the biopsychiatric and Mad Science varieties) and political-humanist-liberation visions:14

• Adjustment approaches begin by accepting the(ir) social order generally as natural and good, either explicitly or implicitly. They understand mental health as the successful adjustment to this social order. PHL approaches begin with real human needs, and understand mental health as the positive fulfillment of these needs. They compare, criticize, and challenge societies based on whether and how they promote or impede the realization of genuine human (and other animal) needs.

• Adjustment approaches individualize mental health: they understand mental health as an individual matter, particularly seeing psychological “disorders” as resulting from individual flaws or malfunctions. Psychological troubles are individual troubles. PHL approaches come from an explicitly political psychosocial perspective: they seek to understand mental health in terms of relationships amongst individuals and groups and sociohistorical structures and processes.

• Adjustment approaches abstract from individual and local contexts and experiences, ignoring systematic patterns of oppression and the resulting experiential differences for people in different categories and positions. PHL approaches focus on these structures and examine the resulting differences in experience.

• Adjustment approaches accept the dominant categories of abnormality and maladjustment and their negative valuation (as well as those of normality and well-adjusted behavior and their positive valuation). PHL approaches attribute no inherent value to these categories, and are alert to the role of this practice of categorizing experiences and behaviors in the perpetuation of oppressive social orders.

• Adjustment approaches ignore or deny that psychological-psychiatric theory and practice are political. PHL approaches recognize and confront this reality.

• Adjustment approaches envision the role of the mental health workers in individual terms: helping troubled or nonfunctioning individuals adjust, cope, and function by the standards of their society. PHL approaches view the role of mental health workers as working toward the realization of human thriving, which entails recognizing oppression and working for nonoppressive and liberating social relations.

• Adjustment approaches accept authoritarian and paternalistic relations in mental health work. PHL approaches view mental health work in terms of broader structures of oppression, inequality, and exploitation. They look to understand the ways their institutional or individual practices serve oppressive social relations, and work toward developing practices that help to ease suffering while contributing to a better society; this involves relationships of respect and mutual learning with people in distress.

*These two quotations are from Critical Theory and Animal Liberation

And Writings for a Liberation Psychology

All subsequent quotations from Marín-Baró are from the same edition.

1 While I recognize the institutional differences that exist today between psychiatry and other mental health fields, and among the nonpsychiatric fields themselves, I’m going to use “psychiatry,” “psychology,” “mental health work,” and the like interchangeably here. There’s no reason not to in this context: the proponents of both models can be found across fields.

2 I add “necessarily” to recognize that some debunkers are making these or similar suggestions, though most that I’ve seen aren’t. This is similar to the situation faced by atheist activists and others attempting to debunk the claims of powerful people and organizations. The attempt is made to make the discussion about the sort of people the debunkers allegedly are – heartless, callous, self-promoting, utopian,… - rather than about the strength of their arguments or the claims they’re debunking. It can be a very effective tactic.

3 I’ve seen wooish perspectives and claims of several varieties from the contributors to Mad in America. I understand and even accept the approach they’ve taken: they clearly want the site to be a welcoming space for a variety of perspectives, where diverse understandings can be aired, considered, respectfully debated, and sometimes rejected. I’m actually OK with that, and so far I think the desire to provide a space for the marginalized voices – especially for the victims of psychiatry – has been fruitful. (Even the Vatican conference I was concerned about received an honest and critical evaluation from some of the participants.) However, there need to be more perspectives that are knowledgeable about and engaged with the PHL tradition with its scientific and political commitments.

4 Throughout, the authors present theirs as “the” alternative, as though others haven’t existed.

5 They almost take note of it at one point, in a discussion of Assertive Community Treatment in which they describe how people might have their refusal to work at some no doubt boring and repetitive job coded as “apathy” rather than an assertion of their will. But then they don’t investigate or remark further on how central paid labor is to the psychiatric vision of mental health and how pushing people to work is considered a part of psychiatric treatment.

6 This emphasis leads me to wonder who their expected audience is. Their vision appears to show the influence of the libertarian Thomas Szasz, and it seems they expect the reader to share those libertarian biases.

7 It is to their credit and important that the authors do address psychiatric coercion. Unfortunately, they ignore the voices of the psych/human rights movement on this subject.

8 I’m of course using the term metaphorically.

9 This is an important point to which I’ll return in my next post on the subject.

10 It shows how successful psychiatric propaganda-marketing has been that so many people are familiar with and often refer to this literature but then don’t use it in their thinking through of psychiatric assumptions and claims.

11 This position doesn’t assume that all behavior labeled problematic is wrongly so or that all behavior viewed as consistent with mental health is wrongly so. Nor does it, as I’ve pointed out in the past, reflexively celebrate what’s considered deviant or problematic in the prevailing social view. The point is that PHL psychology doesn’t uncritically accept a society’s dominant definitions of healthy/normal vs. deviant/problematic. It appreciates that in societies characterized by various axes of oppression, the categories of psychology, like those in any other realm of culture, will tend to justify and perpetuate the system and the status quo. As discussed above, the normative starting point for PHL is real needs for well being, freedom, and fulfillment rather than the needs of the system people happen to be born into. In this view, socially defined categories of normal and abnormal don’t have any necessary normative meaning – an experience or action that’s normal, statistically or culturally, in any given society doesn’t have any claim to being psychologically positive on that basis.

12 While a PHL approach rejects the medical model of psychiatry as scientifically unfounded and harmful, it has much in common with social medicine.

13 It’s interesting that by this time – the mid-1980s – the concept of “post-traumatic stress” itself had already become so fully depoliticized that Martín-Baró could use it in his contrast of a narrowly curative approach to trauma with his own conception of “psychosocial trauma.”

14 The contrast is somewhat overstated, to be sure, but I think it captures the essential differences.