08/31/15

Getting Set to Cope with Cravings

© Boris Ryaposov | 123rf.com

© Boris Ryaposov | 123rf.com

On his blog, Terence Gorski described a three-stage model for addicts and alcoholics to manage cravings without them leading back to active drug or alcohol use. The first stage of set-up behaviors was discussed in a previous article, “Ready to Cope with Cravings.” This article will review the next two stages, trigger events (The Set Stage) and the craving cycle (The Go Stage).

The Set Stage

There are four main triggers that can activate immediate, powerful cravings during the Set stage, according to Gorski. Thinking triggers arise out of the mind-set or pattern of thought that follows the person into early recovery. Abstinence doesn’t magically make them disappear. Feeling triggers often come from sensory cues—seeing, hearing, touching tasting or smelling something that reminds the person of their drug of choice. “It also results from experiencing feelings or emotions that were normally medicated by use.” Behavioral triggers stem from behaviors and rituals that were previously associated with drug use. Situational triggers include relationships or circumstances that used to be associated with using.

There can be some overlap between set-ups and triggers. What distinguishes them in the discussion by Gorski seems to be the ability of a trigger to activate the immediate experience of a craving cycle.

Euphoric recall or fantasy that continues unchecked could become a thought or feeling trigger. Listening attentively as someone describes his or her own struggles with past addictive behavior or current struggles with set-ups or cravings can lead to a thought trigger. Seeing movies that portray drug use can initiate a strong craving. Intravenous drug users can be triggered when their blood is drawn. Alcoholics can be triggered by hearing someone snap open a soda can.

Certain situations, rituals or behaviors that become associated with using can become behavioral or situational triggers. Think here about the principles of classical Pavlovian conditioning. One person I knew couldn’t listen to a certain CD, because he has regularly listened to it when he was high. Another individual discovered that sitting and thinking in a particular chair in their home was a trigger, because that was where she had sat when she drank. Another person avoided the cleaning supply isle in supermarkets because they had used chore boy scrubbers to make their crack pipes.

The often-repeated mantra to avoid People, Places and Things associated with addiction will include all the above categories of set-ups and triggers. But the nuance of addictive experience means that not every physical, psychological or social set-up is equally dangerous to all addicts and alcoholics. Not all thinking, feeling, behavioral or situational events will immediately trigger a craving cycle with all alcoholics and addicts. Not all People, Places and Things put addicts and alcoholics equally at risk of cravings or relapse. The failure to acknowledge this will potentially awfulize recovery (one of the psychological set-ups).

Using Gorski’s stages of set-ups and triggers, I’d suggest that any person, place or thing associated with addiction should be considered to be a set-up. Careful examination, discussion and analysis of these set-ups will determine whether they have a greater or lesser potential to become a trigger and activate a craving cycle for the individual. The earlier a person is in recovery, or the more stressful or unstable the life of a person with longer-term recovery is, the more careful they should be to avoid set-ups. The more stable the person’s life and recovery is, the greater nuance they can have in their exposure to set-ups. Any set-up that carries the potential to become a trigger for the individual should be avoided. The diversity of experiences when using, even among individuals with the same drug of choice, means that not every physical, psychological or social set-up is equally dangerous to all addicts and alcoholics.

The Go Stage

The third stage of craving is the actual craving cycle. Here the obsessive thoughts to use triggers a compulsive desire to get high, with physical cravings for the drug and then actual drug seeking behavior occurs.

When an obsession becomes activated, the person experiences a loss-of-control with their thinking. “Intrusive thoughts invade their mind and they can’t turn them off.” The obsession will quickly become a compulsion. Despite knowing it would be dangerous to use drugs, in a compulsion the person has an overwhelming urge to get high. This obsession and compulsion leads to full-blown physical craving, which can be quite powerful. The person may have a rapid heart beat, shortness of breath, perspiration; even an actual sense of tasting smelling, or feeling the drug they are craving.

Attempting to manage the cycle of obsession, compulsion and craving, the person begins active drug-seeking behavior. They might return to their old hangouts; call up old drug using friends. In other words, return to people, places and things associated with addiction. This exposure to more triggers intensifies the craving cycle. Ultimately, the person becomes overwhelmed with this cycle of obsession-compulsion-craving and they return to active drug use.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s blog, where he graciously shares much of what he has learned, researched and written over the years. This is the second of a three-part series on coping with cravings. The other two articles are “Ready to Cope with Cravings” and “Preventing and Stopping Cravings.” You can access additional articles stemming from Terence Gorski’s material under the Gorski link on Faith Seeking Understanding.

08/28/15

What’s Your Treasure?

© Iryna Denysova | 123rf.com

© Iryna Denysova | 123rf.com

There is a great scene in The Hobbit: The Battle of the Five Armies where Thorin Oakenshield realizes that the golden treasure of Smaug had captured his heart. He forgot the simple truth of Matthew 6:19-24, that whatever he treasured controlled his heart; and whatever controlled his heart would control his behavior. “A treasure such as this cannot be counted in lives lost. It is worth all the blood we can spend.” He finally realized that he’d been blinded by his greed for Smaug’s earthly treasure and had turned against everything he valued. “You sit here in these vast halls with a crown upon your head, and yet you are lesser now than you have ever been.” Tossing aside his crown, which was a symbol of what ruled his heart, he joined in the battle against the Orcs, helping to turn a defeat into victory.

Do not lay up for yourselves treasures on earth, where moth and rust destroy and where thieves break in and steal, but lay up for yourselves treasures in heaven, where neither moth nor rust destroys and where thieves do not break in and steal. For where your treasure is, there your heart will be also. “The eye is the lamp of the body. So, if your eye is healthy, your whole body will be full of light, but if your eye is bad, your whole body will be full of darkness. If then the light in you is darkness, how great is the darkness! “No one can serve two masters, for either he will hate the one and love the other, or he will be devoted to the one and despise the other. You cannot serve God and money. (Matthew 6:19-24)

Both within The Hobbit and the Matthew passage, the metaphor of treasure is used to illustrate the consequences of allowing earthly treasure to rule our heart. Jesus cautioned his listeners to not hoard (lay up) treasures on earth. Rather they should strive to do the things that result in (lay up) treasures in heaven. Hoarding earthly treasure will not protect it from being corrupted and consumed. Investing in heavenly treasure provides a storehouse of wealth beyond the reach of earthly corruption. Paul Tripp, in Instruments in the Redeemer’s Hands, said:

There are only two kinds of treasures, earthly and heavenly, and whatever treasures we choose will become our rulers. They exercise control over us, for if something is your treasure, you will live to gain, maintain and enjoy it. Sadly, we often fail to see this in ourselves, though we can see it in others. One of the most tragic things that could happen to a human being is to invest his life in pursuit of the wrong treasure.

There is a parallel here between the “heart” in verse 21, and the “eyes” of verses 22 and 23. In his commentary on Matthew, Craig Blomberg commented that just as the heart represents the center of our psychic life, the eyes enable us to see the world around us. “Good and bad eyes probably parallel a good and bad heart and thus refer, respectively, to storing up treasures in heaven versus storing them up on earth.” So if that which should lead to good (the light in you) actually causes evil (darkness), “the person is truly perverse.”

So there is an association here to the blindness and heart issues discussed in Luke 6:39-45 and Ezekiel 14:1-11 (See “Diagnosing Spiritual Heart Problems” and “Spiritual Heart Problems” respectively). There cannot be a bad tree that bears good fruit or a good tree that bears bad fruit. The idol in our heart has a stumbling block that will trip us up, even as we come to seek the Lord. “The things we set our hearts on never remain under our control. Instead, they capture, control, and enslave us.”

There are only two options open.  Each person must choose between the competing treasures of heaven and earth, God and money. Using the institution of slavery to illustrate his point, Jesus stated that service to God was antithetical to hoarding earthly treasure. In other words, there is a binary relationship between God and wealth. If you are ruled by one, you will be devoted to it and love it. You will also hate and despise the other. “You cannot serve both God and money.”

Although the immediate context of the passage addresses material wealth, the lessons learned here apply to all other areas of our lives. Earthly treasure will not last, while heavenly treasure will. Whatever you treasure controls your heart. You can’t serve God and anything else at the same time. And whatever controls your heart, controls your behavior.

08/26/15

The Elephant in the Room

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© tiero | 123rf.com

In 2006, Joanna Moncrieff asked why it was so difficult to stop psychiatric drug treatment? Received wisdom had answered that the difficulty arises from the underlying illness manifesting itself as the therapeutic effects of the medication becomes weaker. This presumes that the medications have disease-specific actions; that there is a disease-centered model of psychotropic drug action. But what if it had nothing to do with the original problem? Moncrieff suggested that problems experienced after psychiatric drug withdrawal were often related to the withdrawal process rather than the underlying condition. “If this is the case, then the recurrent nature of psychiatric disorders may be partially attributable to the iatrogenic effects of psychiatric drugs.”

She reviewed several case study examples to illustrate this concern and then indicated there were two possible mechanisms for withdrawal related disorders from this evidence. First, there were pharmacodynamic adaptations that took place. Long-term use of drugs that suppresses particular neurotransmitters (like serotonin in SSRIs) seems to cause an increase in number or a supersensitivity of the relevant receptors. When the receptors are no longer influenced by the drug, there is an over-activation of the neurotransmitter system—a rebound effect.

This may result in the characteristic discontinuation syndromes, may cause rapid onset psychosis and may act a source of  ‘‘pharmacodynamic stress,’’ which increases vulnerability to relapse.

A psychological reaction to the medication withdrawal, either by others or the patient, can also trigger symptoms or increase the patient’s vulnerability to relapse. Moncrieff said: “In my experience, psychological reactions by patients, staff and carers are important determinants of the success or failure of drug discontinuation, a proposition that is open to empirical testing.”

Moncrieff seems to be suggesting two things here. First, the importance of recognizing that post withdrawal symptoms will occur when a drug is tapered or stopped. Second, the importance of a system of support to the person seeking to successfully taper or stop their medications. Both of these factors are well known to anyone attempting to establish and maintain abstinence from addictive substances.

Along with David Cohen, Jonna Moncrieff suggested that we rethink our models of psychotropic drug action in their 2005 article. They noted the predominant “disease-centered model” of drug action that presumed psychiatric medications worked by acting on a specific disease process. In contrast, they suggested a “drug-centered model” that focused on the physiological, behavioral and subjective effects of the drug. Here, the therapeutic value of a drug stemmed from the usefulness of its effects in clinical situations. There is no presumption that it corrects some biological abnormality.

Moncrieff has also presented the differences between the disease-centered and the drug-centered models of drug action in her book, The Myth of the Chemical Cure. Moncrieff and Cohen used the distinction in a 2006 article, “Do Antidepressants Cure or Create Abnormal Brain States?” Applying the disease-centered model to antidepressants, they said:

Modelled on paradigmatic situations in general medicine—such as the use of insulin in diabetes, antibiotics in infectious disease, chemotherapy in cancer—the disease-centred model suggests that antidepressants help restore normal functioning by acting on the neuropathology of depression or of depressive symptoms.

Instead they proposed the drug-centered model was a better explanation for the observed drug effects in psychiatric conditions. “Instead of relieving a hypothetical biochemical abnormality, drugs themselves cause abnormal states, which may coincidentally relieve psychiatric symptoms.” After completing their analysis, they suggested that the term “antidepressant” should be abandoned, as the drugs were not treating a specific disease state.

Our analysis indicates that there are no specific antidepressant drugs, that most of the short-term effects of antidepressants are shared by many other drugs, and that long-term drug treatment with antidepressants or any other drugs has not been shown to lead to long-term elevation of mood.

This then brings us to “the elephant in the room”: a frank discussion on “The Psychoactive Effects of Psychiatric Medication” by Moncrieff, Cohen and Porter. They said when viewing the influence of psychiatric medications through the disease-centered model of action, their psychoactive effects have been obscured. “Despite six decades of intensive research in neuropharmacology … there is a lack of evidence that psychiatric drugs have a disease-specific action independent of their demonstrable psychoactive effects.” Approaching psychotropics as drugs that produce immediate and delayed psychoactive effects, with tolerance and dependence suggests that a radical change of thinking is needed.

Lessons from the use and misuse of other psychoactive substances can help to enlighten us about the broad range of behavioral effects that different psychiatric medications are likely to exert, and how these effects might interact with the psychological, behavioral, and other problems we call mental disorders.

Individuals who are prescribed psychiatric medications in this manner should be treated as consumers, “rather than passive recipients of diagnosis-driven prescribing.” The subjective experience of the individual would guide the use of psychiatric medications in a “collaborative dialogue” with the prescriber—rather than changes in symptoms or clusters of symptoms. “Only when we appreciate the nature of psychiatric drugs as psychoactive substances can we start to accumulate the knowledge necessary to enable prescribers and consumers to use these drugs safely and effectively.”

I heartily agree that we need to promote a drug-centered model of psychiatric drug action. However, additional changes will need to be made. Otherwise, the consumer-driven marketing model—“Ask your doctor if “X” is right for you”—will continue largely unchanged. Direct to the consumer advertising by Pharma will have to stop. Changes in how pharmaceuticals are approved though the FDA will have to occur. Better methodologies need to be developed for the approval process.

Transparency in pharmaceutical research needs to become the norm. Closer scrutiny into the potential harm and negative side effects has to occur, including long-term negative side effects. The psychoactive effect of drugs and its potential as negative side effect in all pharmacological products has to be weighed equally with the potential therapeutic benefit.

08/24/15

Fake Heroin and Homemade Opioids

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© zerbor | 123rf.com

Okay, now there is a “fake” heroin on the market. What’s going on in the drug trade? There seems to be wanna-be “Walter White” biochemists trying to tweak opioid molecules for a bigger-and-better high. On July 17, 2015, the DEA issued a final order to temporarily schedule acetyl fentanyl into Schedule 1. This was said to be “necessary to avoid an imminent hazard to the public safety.” Before the action by the DEA, the drug was illicit, but still technically legal as long as it had a label that read “Not for human consumption.”

Paul Gaia, writing for The Fix, said acetyl fentanyl was first identified in 2013. A small amount can produce a euphoria like heroin or oxycodone. Because of the similar euphoria, acetyl fentanyl can be sold as heroin or mixed with heroin or oxycodone to produce a stronger high. Regularly buyers are unaware of the mixture or the added danger it brings. Acetyl fentanyl is said to be 5 to 15 times more potent than heroin. It has resulted in a series of ER visits and at least 39 overdose deaths.

Reporting for Vice News, Tessa Stuart said a Montreal supplier of acetyl fentanyl was busted with three kilograms. “Given that a typical dose of acetyl fentanyl is in the microgram range, a three-kilogram quantity could potentially produce millions of dosage units.” Because of its strength, it requires a larger dose of naloxone, perhaps double, to counteract overdoses. Its greater potency also means the difference between a recreational dose and a lethal dose of acetyl fentanyl is much smaller, leading to the increase in overdoses among individuals who are unaware they are not shooting pure heroin.

An editorial published in 2014, “The Potential Threat of Acetyl Fentanyl,” said that because it is an analogue of fentanyl, before the DEA action, drug distribution networks faced less severe legal penalties from cutting or replacing drugs like heroin or oxycodone with acetyl fentanyl. This legal grey area meant that as long as it was unregulated, there was a clear motivation for distribution networks to replace or mix heroin with it. Pressed into a pill form, acetyl fentanyl can be peddled as oxycodone. The author recommended the elimination of the loophole for products containing an analogue of a controlled substance when it is labeled “not for human consumption.”

Analogues regulated in this way present a challenge for law enforcement and prosecutors because products that are clearly intended for recreational use sidestep regulations of their marketed purpose is something else.

Fentanyl-laced heroin is not new. The CDC warned in a “Morbidity and Mortality Weekly Report” that 10 overdose deaths in Rhode Island in March-May of 2013 were from acetyl fentanyl. On June 27, 2013, the State of Pennsylvania Department of Drug and Alcohol Programs published a bulletin, “News for Immediate Release,” which noted that there were at least 50 confirmed fatalities and five non-fatal overdoses that year from fentanyl or acetyl fentanyl. The “Theraflu” overdose epidemic in the Pittsburgh area in January of 2014 seems to have been acetyl fentanyl-laced heroin.

Fentanyl-related deaths are also going global. Both The Fix and Vice News reported a 25% rise in overdose deaths attributed to fentanyl in British Columbia (BC) over the past three years. A Vice reference to a pill form known as “fake oxy” suggests that what is being sold is acetyl fentanyl. A survey by the BC Center for Disease Control found that 29% of drug users in the province had fentanyl in their system.

And the problem isn’t limited to BC, with a growing number of similar deaths happening across the country. In 2014, fentanyl was a factor in the deaths of 120 people in Alberta, and there have been 50 such deaths already this year. In Ontario, the drug is killing twice as many people as heroin. Across North American, fentanyl is rapidly becoming a drug of choice for many users.

Reporting for The Fix, Paul Gaia said that fentanyl has been a problem in countries such as Russia, the Ukraine and Sweden. Manufacturing labs have been seized in Mexico, Germany, Japan and China. A gas used in the 2002 assault on a Moscow theatre was based on fentanyl. A report from the European Monitoring Centre for Drugs and Drug Addiction, “Fentanyl in Europe” indicated there were an estimated 650 deaths in Estonia due to fentanyl between 2005 and 2011. Almost all the cases were IV drug users of illicitly produced fentanyl.

Not only is there fake heroin, there is the potential to produce a variety of different opiates from yeast. Lexi Pandell, reported for Wired how Stanford researchers have developed a method for replicating the poppy’s opiate-producing chemical pathways by genetically modifying yeast. John Duber, a bioengineer at UC Berkley said that you would need a background in synthetic biology and genetics to produce the right kind of yeast, so it’s not an imminent threat. “But if a strain made for licit purposes got out, then all that would be required is knowledge of brewing beer to ferment it into morphine.” Here is a link to the abstract of their article published in Science.

Dueber said that at this point, “the illicit danger is concrete.” But he also thinks the potential benefits are immense. He suggested that scientists and policymakers start now to consider the possibilities before the science gets ahead of the regulations—like what happened with acetyl fentanyl. Kenneth Oye, an MIT professor, suggested that developers could make yeast less appealing for illegal use by generating yeast strains that produce less-addictive drugs. Or they could make finicky strains that are hard to maintain outside of a lab. Oye also said regulators could require the yeast DNA be “watermarked,” so it could be traced back to specific labs.

In a May 2015 commentary published in Nature, Oye also said:

The synthetic-biology community, in tandem with regulators, needs to be proactive in evaluating the costs and benefits of such dual-use technologies. Here we lay out the priorities for discussions that are crucial to public health and safety, and to the progress of synthetic biology more broadly. These include restricting engineered yeast strains to licensed facilities and authorized researchers and technicians; reducing the attractiveness of engineered yeast strains in the illicit marketplace; and implementing a regulatory approach that is flexible and responsive to changes in understanding and capabilities.

Oye downplayed the high received from hydrocordone in a New York Times article, rightly earning the wrath of the addiction blogger, Guinevere, at Guinevere Gets Sober. She said she’d like to send him some of the mail she’s received over the years by individuals who have spent tens of thousands of dollars buying Vicodin (hydrocodone) through the internet and on the street. “I’d like to see Stanford, MIT, and other schools spend the money on researching effective treatment standards and educating medical students about how to recognize and treat this illness.”

Fake heroin is spreading globally. Hydrocordone and other opiates can be manufactured from yeast. And the FDA is getting ready to approve an antidepressant containing buprenorphine (See “The Coming Depression Apocalypse”). And then there are the heroin and prescription pain killer problems. What does the future hold for opioid addiction?

08/21/15

Diagnosing Spiritual Heart Problems

© madelaide | stockfresh.com

© madelaide | stockfresh.com

While classically known in biblical passages like Luke 6:39, the “blind leading the blind” metaphor is also found outside of Scripture. In Horace, it exists as “the blind leader of the blind.” It is also found in the Katha Upanishad, an important Hindu religious text: “Abiding in the midst of ignorance, thinking themselves wise and learned, fools go aimlessly hither and thither, like blind led by the blind.”

In Luke 6:39, Jesus asks two rhetorical questions: “Can a blind man lead a blind man? Will they not both fall into a pit?” The answer to the first rhetorical question is obviously “No.” The second question directs attention to the consequences of the blind leading the blind: will they not both fall into a pit? Yes, they will.

Then Jesus declares that a disciple is not above his teacher. When he is fully trained he will be like his teacher. There is a dual meaning to the Greek word translated as “lead” in verse 43. It can refer to guiding someone in reaching a destination or to guide someone in acquiring knowledge. So the two seemingly unconnected statements in verses 39 and 40 are joined to say: Just as a physically blind man cannot lead a person to a destination he cannot see, a blind leader cannot impart knowledge he does not have to a disciple.

In order to reinforce this teaching, Jesus moved on to the hyperbolic contrast of the log and the speck in verses 41 and 42. So how can you help someone remove a “speck” from his eye, when you have a “log” in your own? The presence of the log in you eye blinds you and prevents you from effectively helping another person remove the speck from their eye. As Robert Stein said in his commentary, “Luke understood the parable as referring to the danger of being blind to one’s own faults and at the same time judging others. If a disciple has not learned enough to see his or her own faults and yet judges others, how can such a person truly teach or correct others?”

Now, to drive home what he is saying, Jesus makes another metaphorical comparison, saying that people are like trees. “For no good tree bears bad fruit, nor again does a bad tree bear good fruit.” The conjunction “for” connects the next three verses, Luke 6:43 to 45, with the previous verses, 39 to 42. Paul Tripp said In Instruments in the Redeemer’s Hands that within these verses, Jesus is answering the age-old question of human motivation—why we do the things we do. Just as there is an organic relationship between the roots of a tree and its fruit, there is a connection between a person’s heart and their behavior—what they do and say.

For no good tree bears bad fruit, nor again does a bad tree bear good fruit, for each tree is known by its own fruit. For figs are not gathered from thornbushes, nor are grapes picked from a bramble bush. The good person out of the good treasure of his heart produces good, and the evil person out of his evil treasure produces evil, for out of the abundance of the heart his mouth speaks (Luke 6:43-45).

The roots of the tree correspond to the heart, while its fruit equals our behavior. “We speak and act the way we do because of what is in our hearts.” And if our heart is the source of our sinful behavior, then lasting personal change must always occurs through the heart. Paul Tripp illustrated this principle with a parable of his own.

He has an apple tree in his back yard that year in and year out produces dry, wrinkled, brown, pulpy apples. After several seasons, his wife suggests that they should cut down the tree if they can’t get good fruit from it. Paul gets an idea of what to do. He returns home with branch cutters, a heavy-duty staple gun, a ladder, and two bushels of apples. He then cuts off all the pulpy, wrinkled, brown apples and staples the shiny red apples to every branch of the tree. “From a distance, our tree looks like it is full of a beautiful harvest. . . . For a while, it may seem like the real thing, but it will prove temporary and cosmetic.”

If a tree produces bad apples year after year, there is something drastically wrong with its system, down to its very roots. I won’t solve the problem by stapling new apples onto the branches. They will also rot because they are not attached to a life-giving root system. And next spring, I will get the same problem again. I will not see a new crop of healthy apples because my solution has not gone to the heart of the problem. If the tree’s roots remain unchanged, it will never produce good apples.

Luke doesn’t say here what makes a heart “good.” But Stein in his commentary pointed back to passages like Luke 3:7-9, which calls people to repent and bear good fruit. Just before the passage discussed here, Jesus described what this “good fruit” might look like: love your enemies; bless those who curse you; give to everyone in need. “Be merciful, even as your Father is merciful” (Luke 6:27-36).

From this illustration of how a tree and its fruit represents the connection between our hearts and what we do and say, Paul Tripp drew three principles:

  • There is an undeniable root and fruit connection between our heart and our behavior. People and situations do not determine our behavior; they provide the occasion where our behavior reveals our hearts.
  • Lasting change always takes place through the pathway of the heart. Fruit change is the results of root change. Any agenda for change must focus on the thoughts and desires of the heart.
  • The heart is the target in personal growth and counseling.

Tied now to the Ezekiel 14:1-11 passage discussed in “Spiritual Heart Problems,” we have a greater understanding of the blinding, distorting action of the stumbling block and the heart idol. The elders who came to Ezekiel were truly blind to the idols in their own hearts. And they would not have been able to understand anything the Lord said to them through Ezekiel as long as the “log” of their sin was lodged in their hearts.

A new heart (Ezekiel 36:25-26) was needed. There must be a radical change at the root level. A good tree bears good fruit. A bad tree, ruled by its heart idols, its gillûlîm, will produce bad fruit. You’ll know what is going on in your heart or that of another person by the fruit of their behavior. How can you tell whether or not it is stapled fruit? Watch the tree. Stapled fruit doesn’t last. It gets brown, pulpy and wrinkled and then falls off the tree.

08/19/15

A Censored Story of Psychiatry, Part 2

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© alexskopje | 123rf.com

I was taken aback by Lieberman’s tone in describing Rosenhan as scornfully observing that no staff raised an issue of the apparent sanity of the pseudopatients in his famous study: “Being Sane in Insane Places.” Lieberman then said Rosenhan “saw another opportunity to inflict damage on psychiatry’s crumbling credibility.” Actually, a research and teaching hospital had been vocally saying that they doubted that such an error could occur in their hospital. So Rosenhan approached them and proposed that over a three month time period (not a year, as Lieberman claimed in what he indicated was a direct quote), “one or more pseudopatients would attempt to be admitted into the psychiatric hospital.” Here is what Lieberman wrote concerning what Rosenhan did:

He approached a large prestigious teaching hospital that had been especially vocal in contesting Rosenhan’s finding with a new challenge: “Over the coming year, I will send in another round of imposters to your hospital. You try to detect them, knowing full well that they will be coming, and at the end of the year we will see how many you catch.”

Rosenhan reported that the hospital staff members rated each patient on the likelihood of being a pseudopatient. Judgments were obtained on 193 patients admitted for psychiatric treatment. All staff members that had contact with the patients were asked to make judgments. Forty-one admissions were judged with high confidence to be pseudopatients. “Twenty-three were considered suspect by at least one psychiatrist. Nineteen were suspected by one psychiatrist and one other staff member.” Rosenhan then said: “Actually, no genuine pseudopatient (at least from my group) presented himself during this period.” Rosenhan encapsulated the question raised by his study in the provocative opening sentence of his article: “If sanity and insanity exist, how shall we know them?”

Psychiatry was at a crucial time of its history in 1973. Rosenhan’s article was published in January of 1973. Lieberman reported that the Board of Trustees for the American Psychiatric Association (APA) called an emergency conference in February of 1973 “to consider how to address the crisis and counter the rampant criticism.” He said that the Board realized that the best way to counter the “tidal wave of reproof” was to produce a fundamental change in how mental illness was “conceptualized and diagnosed.” They authorized the creation of a third edition of the Diagnostic and Statistical Manual, the DSM.

The APA eventually appointed Robert Spitzer to chair the revision process of the DSM-III, which was a radical change in how psychiatric diagnosis was done and how mental illness was conceptualized. As Robert Whitaker and Lisa Cosgrove reported in Psychiatry Under the Influence, the DSM-III was an instant success. “In the first six months following its publication, the APA sold more copies of its new manual than it had previously sold of its two prior DSM editions combined.” The DSM was adopted by insurance companies, the courts, governmental agencies, colleges and universities. It structured discussion in psychology textbooks. It was required to do research in the U.S. and eventually abroad as well. “DSM III became psychiatry’s new ‘Bible’ throughout much of the world.” Lieberman claimed:

The DSM-III turned psychiatry away from the task of curing social ills and refocused it on the medical treatment of severe mental illnesses. Spitzer’s diagnostic criteria could be used with impressive reliability by any psychiatrist from Wichita to Walla Walla.

What’s missing from this triumphal rhetoric is the battle waged by Spitzer against Rosenhan’s study and its implications as he and others worked to revise psychiatric diagnosis—and its reliability problems. In the 1980 issue of the Journal of the American Academy of Child [& Adolescent] Psychiatry, Michael Rutter and David Shaffer, both academic psychiatrists, were critical of the published reports of reliability studies done of the DSM-III field trials. Referring to two 1979 published reports by Spitzer, they commented that while the studies were useful, “as pieces of research they leave much to be desired.”

Both reports concern the reliability study which involved clinicians “from Maine to Hawaii.” Unfortunately this impression of spread is largely spurious in that the reliability concerned agreements only between close colleagues (each clinician chose his own partner in the study). . . . Of course, we are acutely aware of the difficulties involved in such field studies and it may well be that this was the best that could be done within the time and resources available. However, the findings do little to provide a scientific basis for DSM-III.

Note how Rutter and Shaffer’s comments about: “clinicians from Maine to Hawaii” applies equally to Lieberman’s rhetoric on: “any psychiatrist from Wichita to Walla Walla.” Both Psychiatry Under the Influence and The Selling of DSM have more comprehensive critiques of the claimed success in conquering reliability and validity problems with psychiatric diagnosis. But Lieberman’s “uncensored history” of psychiatry in Shrinks is completely silent on this well documented dispute. Ironically, in the same issue of the Journal of the American Academy of Child Psychiatry, Spitzer and Cantwell described how the DSM-III was “considerably more inclusive and more comprehensive,” than its predecessor, the DSM-II.

In a disclaimer paragraph on the page before the Shrinks Table of Contents, Lieberman said that bucking the convention in academics of using ellipses or brackets in quotations, he avoided them. “So as to not interrupt the narrative flow of the story.” But he assured us that he made sure that any extra or missing words did not change the original meaning of the speaker or the writer. So he did not use an author-date reference system that included endnotes with references and page numbers for the quotes he cited. But he did say the sources of the quotes are all listed in the Sources and Additional Reading section. And if you wanted to see the original versions of the quotations, they were available at: www.jeffreyliebermanmd.com. When I checked the website at the end of July 2015, they were not available for download or viewing on any page.

As I think I’ve demonstrated, Dr. Lieberman made some very specific claims about David Rosenhan’s professional background and expertise that were false. His presentation of the famous Rosenhan study appeared to be distinctly biased and inaccurate in places. He presented as a quote of David Rosenhan something that he did not say in “Being Sane in Insane Places.” Was it a quote from another source, perhaps someone else claiming the quoted material as what Rosenhan said? We don’t know and cannot know because Lieberman didn’t use conventional citations in presenting his storyline for Shrinks. He was tellingly silent on issues such as questions about the reliability of DSM-III diagnoses from the time of its publication.

Because of these and other problems with his version of psychiatric history, I did not find that Shrinks was “the uncensored story of how we [psychiatry] overcame our dubious past.” If anything, its dubiousness seems to be continuing into the present. But you won’t hear about those issues in Shrinks.

If you are interested in alternative views of psychiatric history, ones with endnotes and footnotes, I suggest you read Mad in America or Anatomy of an Epidemic by Robert Whitaker; Psychiatry Under the Influence, by Robert Whitaker and Lisa Cosgrove; or The Mad Among Us by Gerald Grob. Chapter two of Psychiatry Under the Influence, “Psychiatry Adopts a Disease Model,” gives a significantly more nuanced survey of psychiatric diagnostic history than Shrinks. Whitaker and Cosgrove’s use of the idea of guild interests of psychiatry was very helpful to me in putting Shrinks into perspective.

Be forewarned that Whitaker is not one of Lieberman’s favorite people. In a radio interview promoting his new book Shrinks, Dr Lieberman said that Whitaker was a “menace to society because he’s basically fomenting misinformation and misunderstanding about mental illness and the nature of treatment.” Here is a link to where this was reported on Whitaker’s website, Mad in America. There is also a link there to the original radio interview. Look around at the other material on the site, including further responses by Whitaker and others on Dr. Lieberman’s remarks.

08/17/15

Ready to Cope with Cravings

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© Boris Ryaposov | 123rf.com

Terence Gorski described a three-stage model for addicts and alcoholics to manage cravings without them leading back to active drug or alcohol use. The first stage was what he called Set-Up Behaviors—“ways of thinking, managing feelings, and behaving that increase the risk of relapse.” The second stage was Trigger Events—“events that activate the physiological brain responses associated with craving.” The third stage was the Craving Cycle—“a series of self-reinforcing thoughts and behaviors that continue to activate and intensify the craving response.” For ease of remembrance, we will refer to the first stage as “Ready,” the second stage as “Set,” and the third stage as “Go.”

Within the Ready stage, Gorski described physical, psychological and social set-ups that can lower the individual’s resistance to craving. At the Set stage, he said there were four primary kinds of triggers that could immediately activate a craving: Thoughts, Feelings, Behaviors and Situations. The Go stage, what Gorski called the Craving Cycle, was obsession, compulsion, physical craving and drug-seeking behavior.

There is often a progression from Ready, to Set, to Go—but not always. For example, euphoric recall is one of the psychological set-ups within the Ready stage, but these memories can be powerful enough to immediately activate a craving cycle (the Go stage). Here the memory is a “thought trigger” in the Set stage, one that immediately triggers a craving. Conversely, sometimes there can be set-ups—say socializing with drug-using friends—that don’t trigger thoughts, feelings, behaviors or situations that lead to a craving cycle. But such “misses” can give a person a false sense of security about future opportunities within this kind of set-up. The next time, you may not be so lucky.

The Ready Stage

Physical Set-Ups

Gorski said there are five common physical set-ups for cravings. The first is Brain Dysfunction from Drug Use. “Mind altering drugs [including alcohol] damage the brain” when they are misused or abused.  I would add that all drugs with mind-altering properties should be included here. The obvious drug classes are the benzodiazepines and opioids. However, I’d also include the antidepressants and the antipsychotics.

Current antidepressant medications typically modify levels of serotonin (or sometimes norepinephrine) in the brain. Antipsychotics generally work by blocking a dopamine receptor referred to as the D2 receptor. This receptor has been suggested in research to be related to compulsive eating and cocaine abuse. Carleton Erickson, in The Science of Addiction, indicated there were fifteen separate receptor subtypes of serotonin involved in chemical dependence, and five separate dopamine receptor subtypes. Neurontin (gabapentin) effects levels of the neurotransmitter GABA, which is influenced by benzodiazepines. GABA dysregulation also plays a part in alcohol dependence. My point is not that all addicts should taper off of their psychotropic medication. But in learning to manage and cope with cravings, they should consider the potential influence of their medications.

The second physical set-up is poor diet. Simply put, “Recovering addicts are often nutritional disaster areas because they live on junk food and don’t know what a healthy meal is.” Gorski adds that many individuals have coexisting eating disorders.

A third physical set-up for cravings is the excessive use of caffeine and nicotine. Gorski noted how both caffeine and nicotine, which are low-grade stimulants, could increase the likelihood of having a craving.

The fourth physical set-up is a lack of exercise. “Regular aerobic exercise is a protective factor against craving.” It can reduce the intensity of cravings.

A fifth physical set-up is poor stress management. Stress management activities such as meditation, relaxation exercises, regular periods of rest, relaxation and sleep are all helpful ways to manage stress. When people do not manage stress appropriately in recovery, they set themselves up for cravings during the times of stress that often occur in early recovery.

Psychological Set-ups

Euphoric recall occurs when an addict “romances” past times of drug use. They remember and magnify the pleasurable experiences of past use, while blocking out the painful and unpleasant memories. Spontaneous recollection of past “fun” times is common. To avoid euphoric recall leading to a craving cycle, “play the whole tape.” Don’t stop at the fun times, intentionally add where the pain and unpleasantness of past use fits into the story.

Awfulizing abstinence is another set-up. Here the addict attends to all the negatives and perceived losses about getting sober, while blocking out thoughts of the benefits. This leads to a mistaken belief that “being sober is not nearly as good as using the drug.”

In magical thinking, the addict sees drug use as the solution to their problems. Gorski said this was a combination of euphoric recall (Remember how good using was) and “awfulizing” sobriety (how awful it is that I can’t use). I’d suggest that an individual is also in magical thinking when their using history has demonstrated a clear inability to control drug or alcohol use, but they continue to harbor thoughts that when XYZ happens, they could try social or controlled using again.

This will lead to empowering the compulsion. The person exaggerates the power of the compulsion by telling themselves there is no way they can resist the craving; they can’t stand not having the drug. I’ve seen a subtype of this psychological set-up where the person will convince themselves they wouldn’t be able to resist the compulsion to use again if “X” disaster or crisis happened to them.

Gorski sees the psychological set-ups listed above as leading to the fifth and final one of denial and evasion. Here the addict rejects or denies that their actions could be setting themselves up to have a craving. They may deny that they need the help of a recovery program or treatment. “This denial does not go away simply because they are not using the drug.” Because denial is largely an unconscious process, many addicts believe they are doing the best they can; that they are making the right decision for their life and recovery when, in fact, they aren’t.

The stress of the instability and unmanageable circumstances that often occur in early recovery could lead to this as well. Awfulizing the obligations of early recovery or their lives, such as time away from work and family for treatment or meetings, possibly changing jobs or colleges, fear of financial consequences from not working, etc., can lead to this set-up.

Social Set-Ups

Socializing with drug using friends can be a stumbling block for addicts. Trying to negotiate abstinence without losing the ability to go around certain people who they used to drink and drug with is a major problem for some people. A potential loss of the relationship seems unthinkable at the time. Even when the active user voices support of the individual’s desire to establish and maintain abstinence, the contact may not be a good idea. For one thing, knowing the person is high, or has drugs close by can be a trigger for craving.

One of the reasons that an addict, particularly in early recovery, is drawn to socialize with their using friends is the desire to be with other people who understand them—how they think and what they struggle with. This is why social isolation is so dangerous for someone in recovery. This also points to a couple of the benefits to active participation in AA or NA—these are places where the person can share their fears, doubts and struggles without fear of rejection. And they can form new friendships with people who can relate to how they think and feel.

When open and honest self-disclosure is replaced by superficial communication, the person in recovery gets into trouble. They neutralize another benefit of active participation in self-help groups—the ability to get feedback and reality checks from others who understand how they think and feel about an issue. The lack of honest, heart-felt communication with other people who understand addiction is another social set-up.

If the above lack of honest sharing with others continues, it can lead to isolation from other people in recovery. This can happen through decreased meeting attendance and/or avoiding sober social situations with other recovering addicts. Another contributing factor here is if conflict of some sort occurs and becomes a justification for why the person avoids a particular meeting, or why honest sharing of what they are struggling with is not talked about. Unresolved conflict is another social set-up.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, Terry Gorski’s blog, where he graciously shares much of what he has learned, researched and written over the years. This is the first of a three part series on coping with cravings. The other two articles are “Getting Set to Cope with Cravings” and “Preventing and Stopping Cravings.” You can access additional articles stemming from Terence Gorski’s material under the Gorski link on Faith Seeking Understanding.

08/14/15

The Imprints of His Glory

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© szefei | stockfresh.com

“I have never met the man I could despair of after discerning what lies in me apart from the grace of God.” (My Utmost for His Highest, June 17th)

Before venturing onto the main highway of the Romans Road of Recovery, we should start our journey by looking at chapter one of Romans and what it says about general revelation, the certainty of God and how it can be applied to addiction. Since belief in Jesus Christ is optional for Twelve Step spirituality, there will be a divergence between the Romans Road and the path of recovery. Yet for an extended part of their journey, Christians along the Romans Road and sojourners along the path of recovery travel in the same direction. The theological explanation for how this is possible is found in Romans 1:20: “For his invisible attributes, namely, his eternal power and divine nature, have been clearly perceived, ever since the creation of the world, in the things that have been made. So they are without excuse.” God has made it possible for all people to have some general knowledge of who He is and what He requires of us to live life—including how to live a sober life.

Romans 1:20 sets this ‘general revelation’ of God within an oxymoron: the invisible attributes of God are clearly perceived in the created order. Commenting on this verse, John Murray said: “God has left the imprints of his glory upon his handiwork.” No one who truly looks at the created order around them can deny the reality of God. The A.A. Big Book, Alcoholics Anonymous, seems to echo this thought: “He was as much a fact as we were. We found the Great Reality deep down within us.” It is in this sense, and this sense only that the path of recovery embodied in the Twelve Steps and the fellowship of self-help groups exists. From a biblical perspective, it is the path to a life aligned with the general revelation of God in the created universe. It provides the way out of the active enslavement for all human beings to drugs and alcohol.

“The Way Out” was originally proposed as the title for the first edition of the Big Book. A search of the Library of Congress showed 25 previously published books titled “The Way Out,” so Alcoholics Anonymous was chosen instead.

Discovering your place in the natural order is a common theme in many non-Christian philosophies and religions. And this idea exists within the recovery literature. Bill Wilson wrote in the “We Agnostics” chapter of the Big Book: “As soon as we admitted the possible existence of a Creative Intelligence, a Spirit of the Universe, underlying the totality of things, we began to be possessed of a new sense of power and direction.” Within Came to Believe, a collection of the diversity of opinions on God as we understood Him, “I believe that the A.A. program is simply the will of God being put to practical, everyday use.” And from the AA Grapevine, the international journal of Alcoholics Anonymous, “I like to think that putting myself in harmony with what seems to be the spirit of the universe is in actuality ‘turning my will and my life over to the care of God as I understand Him.’”

The Introduction to the “Blue Book” of Narcotics Anonymous, a fellowship for drug addicts adapted from Alcoholics Anonymous, states that: “We believe that as a fellowship, we have been guided by a Greater Consciousness, and are grateful for the direction that has enabled us to build upon a proven program of recovery.” In dedicating their book, the writers of the Blue Book said:

God grant us knowledge that we may write according to Your Divine precepts. Instill in us a sense of Your purpose. Make us servants of Your will and grant us a bond of selflessness, that this may truly be your work, not ours–in order that no addict, anywhere need die from the horrors of addiction.

As humans we straddle the border between health and sickness, good and evil, happiness and sadness. We are always trying to gain harmony in life; to preserve beauty and to find order again after balance has been disturbed. All these beliefs have similarities to Stoic philosophy, which was popular during the time when Paul wrote the book of Romans.

Stoicism was founded in the third century BC and remained popular though 529 AD. More than just a philosophical system, it was a way of life. The theologian Paul Tillich said it was “the only real alternative to Christianity in the Western world.” Stoic philosophers said that happiness did not come from the accrual of goods or success, but from virtue. Echoing Twelve Step recovery, they emphasized self-control as the path out of destructive emotions. This self-control was established and maintained through meditation, training, and self-vigilance.

David Davidson said that in meditation the Stoics would visualize their futures. They would imagine the worst possible outcomes as present sufferings—not as distant, unlikely events. “They sought to realize that even the worst misfortunes can be survived and are not worth fearing.” In their training they practiced various physical disciplines from sexual abstinence and vigorous exercise to the avoidance of tempting foods. Their self-vigilance meant they monitored their thoughts and emotions, “seeking to avoid lust, greed, and ambition in favor of reason.” This contemplation, discipline and vigilance have similarities to both Twelve Step recovery and Christian thought.

Stoics applied the imagery of head and body to God and the universe respectively. The universe was the body, and God’s logos or reason was the mind or head that directed it. Stoic ‘salvation’ was then to seek to align your will with the inherent Reason or Logos of the universe. A person was happy when he did not want things to be other than the way they were. He was to strive to know the system of nature and then cultivate an acceptance of it. He was to search for and discover his place within the natural order; and then consciously seek out the things in life that suited his place in that order. It was best to see this life of service as the ‘natural’ life, a life aligned with the logos of the universe.

Although a Christian prayer a written by Reinhold Neibhur, The Serenity Prayer seems to capture this Stoic alignment with logos of the universe. Not surprisingly, the Serenity Prayer holds a special place in A.A. history and Twelve Step Recovery.

The correspondence noted here between Christianity, Stocism and Twelve Step recovery is a product of the general revelation spoken of in Romans 1:20. “God has left the imprints of his glory upon his handiwork.” Part of that handiwork lies within the system of meditation, self-vigilance and training embodied in the Twelve Steps as a way out of the thralldom of active addiction.

For Christians, there is a biblical concern in how we understand general revelation. The theologian G. C. Berkouwer cautioned that while Romans 1 was “good material” for the confession of general revelation, we must be careful of how we apply it. The knowledge of general revelation should never be isolated from the prevailing theme of Romans 1—the wrath of God. Berkouwer said: “The history of theology parades before us numerous attempts to isolate it from the context.” Perhaps the greatest objection of some Christians with Twelve Step recovery lies at this point. If by applying the general revelation of the Twelve Steps, an individual is able to stop the unmanageability in his or her life because of drug or alcohol abuse, they may be aligned with the Logos of the universe in a broad sense, but they will not have reckoned with the wrath of God for their unmanageable, ungodly behavior. They may be sober, but they are not saved from the just spiritual consequences of their unrighteousness.

If you’re interested, more articles from this series can be found under the link for “The Romans Road of Recovery.” “A Common Spiritual Path” (01) and “The Romans Road of Recovery” (02) will introduce this series of articles. If you began by reading one that came from the middle or the end of the series, try reading them before reading others. Follow the numerical listing of the articles (i.e., 01, 02, etc.), if you want to read them in the order they were originally intended. This article is “03,” the third one. Enjoy.

08/12/15

A Censored Story of Psychiatry, Part 1

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© alexskopje | 123rf.com

Doctor Jeffrey Lieberman, the Chair of Psychiatry at the Columbia University College of Physicians and Surgeons and a former president of the American Psychiatric Association (APA), recently wrote a book, Shrinks. It purports to tell the true story of how psychiatry grew from a pseudoscience into “a science-driven profession that saves lives.” But for me, it reads more like a piece of APA propaganda. What follows is an illustration of why I believe Shrinks is not a credible historical account of the history of psychiatry.

In his Introduction, Dr. Lieberman wrote: “As I write this, psychiatry is finally taking its rightful place in the medical community after a long sojourn in the scientific wilderness.” He added that psychiatry has earned much of its “pervasive stigma.”

There’s good reason that so many people will do everything they can to avoid seeing a psychiatrist. I believe that the only way psychiatrists can demonstrate just how far we have hoisted ourselves from the murk is to first own up to our long history of missteps and share the uncensored story of how we overcame our dubious past.

He said that modern psychiatrist now possesses the tools (medications?) to lead anyone “out of a maze of mental chaos into a place of clarity, care and recovery.” He said he is fortunate to be living through the time in history when psychiatry matured from “a psychoanalytic cult of shrinks into a scientific medicine of the brain.” But in concluding his book, he said he was under no illusion that “the specters of psychiatry’s past have vanished,” or that psychiatry has “freed itself from suspicion and scorn.” Notice the implication that any current suspicion or scorn of psychiatry is illegitimate, as its missteps are in the past.

Lieberman is aware that others disagree with his sense how psychiatry has become “a scientific medicine of the brain.” Again in his Introduction, he said: “The profession to which I have dedicated my life remains the most distrusted, feared, and denigrated of all medical specialties.” He then quoted from some of the rude and abusive emails he’s received. His comment was that such skeptics don’t look to psychiatry to help solve mental health problems. Rather, they see psychiatry itself as a mental health problem. While not explicitly using the term at this point, Lieberman does seem to be referring to what he calls the “antipsychiatry” movement.

This is a term that has been applied to individuals critical of some aspect psychiatry, or even psychiatry as an institution, since the 1960s. And Lieberman touched on and dismissed many of the historically big names tied to “antipsychiatry”: Thomas Szasz, R.D. Laing, and David Rosenhan. Here, I want to look at Lieberman’s portrayal of Rosenhan and give you an alternate perspective to his to illustrate why I see Shrinks as APA propaganda.

In an aside, Lieberman seems to have neglected to mention Dr. E. F. Torrey’s 1974 contribution to the antipsychiatry movement, The Death of Psychiatry. Torrey maintained that most of the so-called mentally ill are suffering from problems in social adaptation, not from diseases of the mind. He would later become affiliated with The Stanley Medical Research Institute (SMRI), where he is now an Associate Director. SMRI has spent over $550 million researching “brain diseases” like schizophrenia and bipolar disorder since it began in 1989. It seems Torrey changed his tune. Perhaps that’s why his antipsychiatry work wasn’t mentioned. Lieberman also cited Torrey as providing anecdotal evidence (no references or footnotes) that both Laing and Szasz eventually believed that schizophrenia was a brain disease, but would not sat so publically.

In chapter three of Shrinks, Lieberman described the impact of the classic 1973 study done by David Rosenhan, “Being Sane in Insane Places.” Another copy of the article is available here on a link from Harvard University. Lieberman gave an inaccurate and unfair gloss of Rosenhan as “a little-known Stanford-trained lawyer who had recently obtained a psychology degree but lacked any clinical experience.” As a matter of fact, David Rosenhan had a BA in mathematics from Yeshiva College (1951), an MA in economics (1953) and a PhD in psychology (1958), from Columbia University—the same academic institution to which Lieberman would become affiliated in his own professional career.

In addition, Rosenhan was a psychologist for the Counseling Center at the Stevens Institute of technology from 1954 to 1956; a lecturer at Hunter College and the director of research in the Department of Psychiatry at City Hospital at Elmhurst from 1958 to 1960. He was an assistant professor for the Departments of Psychology and Sociology at Haverford College from 1960 to 1962; a lecturer for the Department of Psychology and Psychiatry at the University of Pennsylvania from 1961 to 1964; a lecturer for the Department of Psychology at Princeton University from 1964 to 1968; a professor in the Department of Psychology and Education at Swarthmore College from 1968 to 1970; and a visiting professor in the Department of Psychology at Stanford University from 1970-1971. He was a professor of law and psychiatry at Stanford from 1971. The above biographical information on David Rosenhan was taken from a February 16, 2012 article from the Stanford Law School News announcing his death at 82 years old.

This information was readily available to anyone interested enough in David Rosenhan to do a simple online search. It certainly doesn’t agree with Lieberman’s dismissal of Rosenhan’s credibility. Here’s what David Rosenhan did in his study. He had eight “pseudopatients” (individuals with no history of serious psychiatric disorders) seek admission to 12 different psychiatric hospitals. They complained of hearing voices say “empty,” “hollow,” and “thump.” They were all admitted to the various hospitals. The eight pseudopatients consisted of a psychology graduate student in his 20s, three psychologists, a pediatrician, a psychiatrist, a painter and a housewife. Rosenhan was one of the three psychologists. Three pseudopatients were women and five were men.

Once admitted to the hospital, they stopped simulating any symptoms of abnormality and waited to see how long it took before they were released. Their length of stay at the hospitals ranged from 7 to 52 days, with an average of 19 days. None of the pseudopatients were indentified as such by hospital staff members. However, it was quite common for the patients to uncover the pseudopatients. Other patients in the hospitals were reported as saying things such as: “You’re not crazy. You’re a journalist, or a professor [referring to the continual notetaking]. You’re checking up on the hospital.” Rosenhan commented: “The fact that the patients often recognized normality when staff did not raises important questions.”

Lieberman said that claim was debatable, “since many nurses did record that the pseudopatients were behaving normally.” Actually, Lieberman’s comment is itself debateable. If nursing staff recognized the pseudopatients as normal, why was the average length of stay 19 days? If nursing staff recorded impressions that particular pseudopatients were behaving normally, it seems their observations were ignored or failed to result in speedy identification and release. Seven of the eight were admitted with diagnoses of schizophrenia and their discharge diagnoses were schizophrenia “in remission.”

What Rosenhan actually said was that the pseudopatients were to secure their own release from the hospital by convincing staff that they were sane. The psychological stressors associated with hospitalization were considerable and as a result, the pseudopatients were motivated to be discharged “almost immediately after being admitted.”

They were, therefore, motivated not only to behave sanely, but to be paragons of cooperation. That their behavior was in no way disruptive is confirmed by nursing reports, which have been obtained on most of the patients. These reports uniformly indicate that the patients were “friendly,” “cooperative,” and “exhibited no abnormal indications.”

Rosenhan’s study and its opening question, “If sanity and insanity exist, how shall we know them?” remains today a powerful question of the legitimacy of psychiatric diagnosis. He noted how most mental health professionals would insist they are sympathetic toward the mentally ill. But it is more likely that “an exquisite ambivalence” characterizes their relationships with psychiatric patients. The mentally ill, said Rosenhan, are society’s current lepers. Negative attitudes are the natural offspring of the labels patients wear.

A psychiatric label has a life and influence of its own. Once the impression has been formed that the patient is schizophrenic, the expectation is that he will continue to be szhizophrenic. When a sufficient amount of time has passed, during which the patient has done nothing bizarre, he is considered to be in remission and available for discharge. But the label endures beyond discharge. . . . Such labels, conferred by mental health professionals, are as influential on the patients as they are on his relatives and friends, and it should not surprise anyone that the diagnosis acts on all of them as a self-fulfilling prophecy.

Psychiatry had a guild interest at the time for revising psychiatric diagnosis. Citing an article by M. Wilson in their book, Psychiatry Under the Influence, Whitaker and Cosgrove noted where APA leaders felt psychiatry was under siege and worried that it could be headed for extinction.

Psychiatry in the 1970s faced a crisis of legitimacy and Rosenhan was one of its opponents who intensified the crisis.  Although the publication of the DSM-III would become an answer to that crisis, Rosenhan’s study threatened to discredit psychiatry before that makeover could be accomplished—to recast psychiatry as “a science-driven profession that saves lives.” The censored history of psychiatry presented by Lieberman attempts to present “an extreme makeover” of a profession that may still be more “pseudo” than science. Whitaker and Cosgrove’s comment seems to hit the mark:

Remaking psychiatric diagnoses could be part of a larger effort by psychiatry to put forth a new image, which metaphorically speaking, would emphasize that psychiatrists were doctors, and that they treat real ‘diseases.’

08/10/15

Marijuana Peek-a-Boo

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© antonprado | stockfresh.com

On Friday, July 10th, the House of Representatives passed H.R. 6, the 21st Century Cures Act (244-183). The bill is now in the Senate for consideration. There had been an amendment proposed that would have rescheduled marijuana and its derivatives under a new 1-R schedule, which would have facilitated research. Marijuana could then have been rescheduled further, after that research was completed and further reclassification was warranted. The National Institute of Health (NIH) and the Drug Enforcement Agency (DEA) were also directed in the amendment to study the benefits and risks of medical marijuana. But the bipartisan amendment was defeated. The irony is that both critics and supporters of legalizing marijuana put forth the failed amendment.

Reporting for the Washington Post, Aaron Davis said that House Republicans have consistently defended their opposition to marijuana laws, saying there is no evidence that such action would do anything “but destroy the brains of the nation’s adolescents.” But the lack of evidence can be traced to Congressional resistance to fund federal agencies to do objective testing on the effects of marijuana. This “Catch 22” led to the support of the amendment by critics and supporters of legalization.

Maryland Representative Andy Harris, a doctor and outspoken critic of legalization over the past two years, co-sponsored the amendment. Before the House Rules Committee sidelined the amendment, he said: “We need science to clearly determine whether marijuana has medicinal benefits and, if so, what is the best way to gain those benefits.”  Harris reportedly doesn’t think that research will find medical benefits, but another Republican, H. Morgan Griffith of Virginia, thinks there are limited circumstances in which marijuana has medical benefits. He said: “This amendment would have answered the question one way or the other. I think it would have shown it is a valuable medical substance, but now we don’t have the evidence.”

The failed effort put advocates for marijuana legislation in the odd position of having to praise Harris, who had become a nemesis of their cause. Michael Collins, the policy manager for the pro-marijuana Drug Policy Alliance, said: “To Mr. Harris’s credit, he thinks there are benefits to researching marijuana, whether you support it or not.” Opponents to legalization of marijuana also see research as a logical step forward. Sue Rusche, head of the National Families in Action, a drug prevention organization, said: “Right now we really don’t know what you’re getting. What we need is research to show us what level of CBD and THC should be given and what’s safe.”

Back in January of 2014, President Obama said it was up to Congress, not his administration, to reschedule marijuana. Steven Nelson, reporting for US News and World Report, said that marijuana advocates said that wasn’t entirely accurate. Representative Earl Blumenauer from Oregon said the law actually permits the current administration to reclassify marijuana. “I don’t dispute that Congress could and should make the change, but it’s also something the administration could do in a matter of days and I hope they will consider it.” Rep. Blumenauer is one of 17 cosponsors of other legislation aimed at reclassifying marijuana, the “Regulate Marijuana Like Alcohol Act.” There has been no action reported on the bill at this point. Govtrack.us said the bill had a 3% chance of getting past committee, and a 1% chance of being enacted. Blumenauer has introduced “The Marijuana Tax Act,” also listed as having a 1% chance of being enacted by Govtrack.us.

Tom Angell, chairman of the group, Marijuana Majority, said it was unfortunate that President Obama “passed the buck” to Congress on marijuana. Dan Riffle, the director of federal policies for the Marijuana Policy Project, said that rescheduling marijuana “is not a ‘job for Congress,’ as the president says.” Riffle said that scheduling decisions are handled by the DEA. In June of 2014, Anna Edney for Bloomberg Business reported that the FDA had been asked by the DEA to review marijuana’s status. This is the third time since 2001. In 2001 and 2006 the FDA recommended that marijuana remain a Schedule 1 Controlled Substance.

Douglas Throckmorton, the Deputy Director for Regulatory Programs at the FDA, acknowledged the FDA was once again conducting an analysis, but could not say when the FDA would complete its analysis or whether it would recommend a change. His testimony before a House subcommittee described the FDA’s role in potentially approving marijuana as a prescription drug.  Dr. Throckmorton affirmed the FDA’s belief that its drug approval process was “the best way to ensure that safe and effective new medicines from marijuana are available as soon as possible for the largest numbers of patients.” He added that it was important to apply these scientific standards to the development and assessment of any alleged therapeutic uses of marijuana.

One of the considerations with establishing the safety and efficacy of a drug is a manufacturer’s ability to demonstrate an ability to consistently manufacture a high-quality drug product. This presents a special challenge with botanically derived drugs like marijuana, including the consistency of lot-to-lot potency. Another consideration is the need to identify a method of consistently providing a specific drug dose. Citing a report from the Institute of Medicine (IOM), Throckmorton noted problems associated with getting consistent dosing from smoked products such as marijuana. The IOM recommended that clinical trials involving marijuana be conducted to find a safe, alternative delivery system.

If there is any future for marijuana as a medicine, it lies in its isolated components, the cannabinoids and their synthetic derivatives. Isolated cannabinoids will provide more reliable effects than crude plant mixtures. Therefore, the purpose of clinical trials of smoked marijuana would not be to develop marijuana as a licensed drug but rather to serve as a first step toward the development of nonsmoked rapid-onset cannabinoid delivery systems.

Throckmorton then cited two drugs approved for human use that contain active ingredients that are present or similar to those in botanical marijuana: Marinol and Cesamet.

These products have undergone FDA’s rigorous approval process and have been determined to be safe and effective for their respective indications, and reflect the views of the IOM that the future of marijuana as a potential medicine lies in classical pharmacological drug development. As a result, patients who need medication can have confidence that any approved drug will be safe and effective for its indicated uses.

So here’s what I’m thinking. When the 21st Century Cures Act is reviewed by the Senate, it needs a provision that will add the changes proposed by the Griffth-Harris-Blumenauer-Farr amendment. This would bring future research into medical marijuana under the authority of the FDA. Effective regulations for the safety and efficacy of medical marijuana can be developed. All states, those who have already approved the use of medical marijuana and those in the future who may approve it, would benefit from the standardization of FDA regulation. The existing problems with medical marijuana (see “Let’s Not Get Ahead of Ourselves”) such as biological and chemical contaminants, accurate labeling, overmedication, and consistent dosing in products could be worked out. The at times outrageous claims for exactly what marijuana DOES medically treat can be examined systematically and scientifically.

But I’m also thinking that isn’t what some legalization advocates want, because it will take time; and the momentum towards recreational marijuana legalization could be lost.  The best path to legalization is to let the political infighting in Congress and federal agencies like the FDA and the DEA continue to neutralize any federal regulation of medical marijuana while marijuana activists continue their state-by-state battle.  If I wanted to develop a strategy for national legalization of marijuana, I’d suggest the following.

The strategy for eventual national legalization of recreational marijuana is to eat the elephant one bite at a time. Keep the battles going state-by-state and keep the federal government out of the fight. Legislatures within the states where medical marijuana is not yet approved should hear about the income and health benefits of legalizing medical marijuana, but not the existing problems where it has been approved. Information on the different kinds of cannabinoids in marijuana and their varying medical benefits—some greater than others—needs to be suppressed. Let them think the medical benefits are all or nothing with marijuana and not contingent upon specific cannabinoids within marijuana. The known health problems from smoking marijuana should be minimized or ridiculed. If I wanted a sound national policy toward medical marijuana, I’d look for the following developments.

The best strategy to slow and perhaps stop the growth of state-by-state legalization of recreational marijuana is to be proactive about the legalization of medical marijuana at the federal level. Quality research that showed the medical benefits of specific cannabinoids, like CBD and THC, the psychoactive cannabinoid in marijuana needs to be done. A more efficient delivery system for medical marijuana than smoking an herbal product of varying potency, with possible biological and chemical contaminants could be developed. The sideshow of existing medical marijuana “treatment” as an excuse to legally medicate (and overmedicate) with THC to get high would stop. Individuals who could benefit from legitimate medicinal marijuana products would get the help they need. And the recreational advocates couldn’t hide behind the medical marijuana movement anymore.