Antidepressants and Suicide Redux

On my post of July 19, Do Antidepressants Cause Suicide, I listed several reasons why antidepressants might increase suicidal ideation in some adult patients.  (I was not talking about children or adolescents since clinical trials in those populations have taken place only rarely). 

Now comes a huge study of adults and antidepressants out of Germany (Stubner, S et. al, "Suicidality as Rare Adverse Event of Antidepressant Medication," Journal of Clinical Psychiatry 71:10, p.1293).  The dataset from the European drug surveillance program was reviewed for patients on inpatient psychiatric units.  142,090 of these patients had taken antidpressants.

Of this ginormous sample, only 33 incidents of suicidality were documented.  12 of these consisted of suicidal ideas only, 18 were actual suicide attempts, and 3 people successfully completed the act.  14 of the 33 cases seemed to be probably, and 19 definitely, related to the medication.  Consistent with my earlier blog post, fully 23 of these 33 of these cases were associated with restlessness.  This is most probably a side effect of antidepressants, and it is one which is completely and very easily treatable.

The authors concluded that antidepressants rarely trigger suicidality, although even this conclusion is hard to be sure of since the attempters were not assessesed at all for psychological, social, or environmental events which might have contributed to their suidality.

Even assuming that a drug was the only cause of the suicide attempts, just 10 patients in this large sample made attempts that were seemingly unrelated to a common and treatable side effect.  10 out of 142,090.  This was in hospitalized patients, who in general tend to be have more serious symptoms and have far more suicidal ideation than comparable outpatients.

The risk therefore is .007 percent in this population.  And that's a maybe.  That is roughly one third of the minimum estimate of the risk of death from having liposuction for cosmetic surgery.

How to Disarm a Borderline, Part III: Overall Philosophy

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6) and Part II (October 29).

In this post I will discuss the general philosophy about approaching anyone who is trying to distance you (also see my post, Distancing: Early Warning [apologies to the rock group Rush] , from July 6), particularly if that person is very good at it like an individual with BPD is. In future posts, I will begin to run down specific countermeasures to the usual strategies in the BPD bag of tricks used to distance and/or invalidate you.

An observation held in common by many psychotherapy treatment paradigms for BPD is that respectful treatment of the patient by therapists in the face of the patient’s chaotic behavior patterns often seems to induce the patient to behave less chaotically with the therapist, although not with anyone else. It is particularly important for a therapist to respects differing values while not changing his or her own.

To disarm someone with BPD, you should look to find something that is wise, correct, or of value in the emotions, thinking, and behavior of the BPD person. You should never assume that the BPD’s problems stem primarily from crazy thinking, faulty interpretations, distortions of reality, or maladaptive assumptions. You should assume that individuals with BPD have unhappy lives and therefore, despite all evidence and appearances to the contrary, they really want down deep to act better.

Persons with BPD often have a high level of interpersonal skills, as evidenced by their ability to manipulate others. You should try to keep their considerable strengths in mind as you interact with them.

You should aim to validate the BPD’s reality and try to make sense of their behavior within their current interpersonal environment. See my post Validating Invalidation from Sept. 23 to get a better idea of the importance of being willing to validate someone when that someone is practically inviting you to invalidate him or her.

The troublesome behaviors of the BPD must be looked at not as a problem with the BPD but as imminently reasonable and understandable responses that derive from a problem for the BPD. You should not view the BPD as psychotic, malevolent, immature, or unintelligent but as someone who is struggling with a highly dysfunctional social network.

Remember, you yourself are very likely to be an important part of that dysfunctional social network, so please do not act like you think that you are superior to the BPD in any way. If you do, you are inviting the BPD to knock you off of the pedestal that you put yourself on, and you will not know what hit you.

Never treat the BPD as if he or she is fragile or incapable of being reasonable, particularly when tension occurs in your relationship. Ultimately, no subject should be thought of as too sensitive to discuss. While you should be sensitive to such issues such as incest or family violence, you should try to talk about them when they arise calmly and reasonably even in the face of the BPD’s anxiety or acting out (This ain’t easy, and it is where a therapist for you would be useful if not indispensable).

If you do not agree with what a BPD says, calmly say you disagree without making an issue of who is right and who is wrong. If you feel that something you have said or done is being misinterpreted or being taken out of context, kindly explain what you had meant to say or do without trying to convince the BPD that they got you wrong the first time. Therapist par excellence Lorna Smith Benjamin employs what she calls the Caribbean Solution, named for the behavior of a hotel clerk confronted by an irate guest. You remain calm and friendly but continually reiterate your own opinion about a disputed interaction.

Lorna Smith Benjamin

Be scrupulously honest. If you actually have done something wrong, do not deny or minimize it, but do not go into a big mea culpa either. (The best way to come clean if you were physically or sexually abusive to the BPD when he or she was a child is another matter and will be discussed in a future post). On the other hand, I have seen individuals admit to things they had not done in order to pacify someone with BPD. Not a smart move.

You will have to be comfortable with your own limitations concerning what you can or cannot do for the BPD. Be respectful of your own needs. Never rush in to “take care” of the BPD in an infantilizing manner even when the need to do so seems to hit you across the face.

You cannot be afraid of the BPD’s anger, neediness, or anxiety; and you must be completely unwilling to attack him or her in the face of provocation. Once again, this is where a therapist for you might be necessary.

In summary, be relentlessly respectful of BPD’s suffering, abilities, and values. Be humble without disrespecting yourself or your own well being. Be honest. Communicate an expectation that the BPD will be able to behave in a reasonable and cooperative manner, and play to the BPD’s strengths. And keep it up, or ye olde variable intermittent reinforcement schedule will rear its ugly head.

Diagnonsense: an editorial

I published an op-ed piece in the Memphis newspaper, the Commercial Appeal, on Sunday, November 21, 2010.  It was also picked up by the Associated Press newswire.  You can read it at:

http://m.commercialappeal.com/news/2010/nov/21/my-thoughts-its-never-too-late-to-tackle-issues/

or at:

http://m.apnews.com/ap/db_15980/contentdetail.htm?contentguid=cPLIA3og

Changing the Rules of A Game That Will Not End

You can check out any time you like

But you can never leave

    -----The Eagles

Why is it so damn difficult for family members to stop engaging in repetitive behavior that is clearly driving them all nuts?  Back in baby boom lore, we used to refer to a big question like that as the $64,000 question, in reference to a TV quiz show.  But hey, there's been inflation, so now if we want to refer to a TV game show question, we have to call it the million dollar question.

One reason it is so hard to change was described way back in 1967 by Watzlawick, Beavin, and Jackson in a book called Pragmatics of Human Communication. It was the first book to look at the linguistics of family dysfunction.  That subject later became the main theme of a book that I wrote called Deciphering Motivation in Psychotherapy.  One of the most interesting and curious concepts introduced in the Watzlawick book was called the game without end.  The book describes what happens when someone in a family steps out of a role that they had, up to that point, always been playing in their family system, and tries to get everyone else to change the rules by which the whole family operates. 

What often happens is that no one else in the family is certain that said individual really wants the change he or she is requesting, because he or she had compulsively played the role all the time up to that point.  Leopards do not change their spots, after all.  They all suspect that the request is, in reality, just another maneuver in the same old game that had been going on up to that point. Therefore, no one else takes the request seriously.  This happens even when everyone else covertly would actually be happy with the changes.

The example Watzlawick et. al. used to illustrate what they were talking about was cute, but I did not quite understand exactly what it would mean for a real family.  They imagined a family where the rule was that everything anyone said really meant the exact opposite of what it seemed to mean.  How would anyone in this family go about trying to change this rule? 

If someone said, "Let's change the rule," this would naturally be taken by everyone else to mean its opposite, "Let's not change the rule." Therefore, the rule would stay the same.

Aha, you say.  Why couldn't the person requesting the rule change just say, "Let's not change that rule."  By the original rules of the game, this statement should be interpreted as a request to change the rule.  Not so fast! Remember, everything said under the old rules is supposed to mean the opposite of what it seems to mean.  The request not to change the rule would in fact seem to be a request to change it.  Therefore, under the old rule, it would be interpreted to mean the opposite of that, namely, "Let's not change the rule."

No matter what anyone said about the rules, it could therefore be interpreted to mean a request to go on playing the game with the original rules.  Every move to change the rules of the game could be interpreted as a strategic move to make them continue.

Clever, but what family would ever operate by such a bizarre rule?  It took me a while to truly understand the game without end, but let me see if I can explain it to readers. To understand it, let me describe some actual rules under which real families do operate, and how they can be devilishly difficult to change.  

I will start with a very typical example that you might just recognize.  Let's say a middle aged couple had always operated under traditional gender rules and roles, so that the man had always been the breadwinner and the woman had always taken care of the house and the kids.  After the kids leave, one of them, say the wife, decides that she is really bored being just a housewife and decides to get a job.  Her husband is actually really happy that he no longer has to be the only one responsible for making money, since that had been a real burden for him, even though he had guarded the breadwinner role rather jealously.

The wife tells the husband that, since they are now both working, she wants him to start to help with the laundry, the dishes, and maybe the housework.  He says he agrees, since it's only fair.

We know what typically happens next.  He never starts doing the housework that he promised to do unless she specifically asks him to each and every time.  Never shows any initiative.  She finally gets frustrated having to constantly nag him about the housework, gives up, and angrilly starts to again do the housework all by herself.   The husband is a typical male chauvinist pig, right?

Wrong.  What happened when he first started doing, say,  the dishes?  What happened was that she kept telling him he was not doing it right!  He was putting them in the wrong cupboard, he was missing a spot or two, he was using the wrong detergent, whatever.  The husband starts to think that maybe she really wants to continue to be in charge of the kitchen, like she always has been, and does not really want him there in spite of her request.

He will not tell her of this belief, because he knows she will get angry with him and deny it.  Unbeknownst to him, she is secretly feeling vaguely guilty about making him do the housework, because she was raised in her own family of origin to believe that doing so was the woman's job, and she is guilty of derilection of duty.  She will not admit this to her husband, because she really does want him to help with the housework, despite her overall ambivalence about it.

From her perspective, he keeps doing a poor job in order to get her to take over the tasks again because of his own selfish wish to avoid housework, not because he might think she really wants to keep doing it herself.  After all, she thinks, he actually does know what soap to use, where they keep the dishes, and that he is doing a poor job.  He just acts like he does not.  In actual fact he does indeed act that way - but only because he thinks she's just looking for an excuse to nitpick so she can take over.  When she does nitpick, that convinces him even more that the real reason she nitpicks is because she wants to remain in charge of the house.  Still with me?

This situation is all the more complicated because all these events, mixed signals, thinking about the motives of the other person in the relationship, etc. go on simultaneously.  They do not follow sequentially one after the other.  Understanding this aspect of human interaction was one of the most difficult problems I faced when I created my treatment paradigm, which I call Unified Therapy.  We are all used to thinking sequentially rather than seeing everything as simultaneous.  Systems theorists call this linear thinking.  A leads to B which leads to C, etc.

Systems theorists, on the other hand, see what's going on as a feedback loop - like a vicious circle - but that is not accurate either. The events in the feedback loop are thought of by systems people as sequential even as each even feeds back to the next.  A leads to B which leads to A1 which leads to B1, etc. The mutual (two-way) and simultaneous nature of human interactions is better accounted for by something called dialectical thinking, which I will not go into here.

But why do the people in this situation follow the "new" rules in such a half-assed, irritating manner, when they know doing so will almost certainly elicit criticism by the partner?  They do so because they already think they know what the other person really wants, so they are just providing him or her with an excuse to do what he or she seems to want to do anyway.  They allow the other person to blame them for what is actually a shared problem.  So very thoughtful.

Here are some more examples of the game without end from Deciphering:

1. A wife had been encouraging her husband to be more honest about his true feelings. Consequently, he began to express himself, but in a loud, abrasive, and embarrassing fashion - and in front of her boss.   (Not in the book: he's thinking about the girls he knew in high school.  Which type of guy got to go out with the most popular girls - the sensitive, touchy-feely guys or the macho football players?  Does she really want him to act like the former?)

2. A mother finally got her twenty-five-year-old son to get out of the house and find a job; he opted for a low-paying job at a fast food
when he had been offered a high-paying apprenticeship.

3. The same mother got the boy to fill out his own tax return; he then claimed himself as a dependent so she could not claim him, even though she was still supporting him.

4. A husband had been encouraging his wife to pursue her long-repressed desire to have a career. When she finally got a job, she chose one in which she had to work a different shift than he did. As a result, the couple never had any time to spend together. When he complained, she told him that he never really did want her to be more than a housewife.

5. A young couple encouraged the wife's mother to learn to drive after the death of the wife's father so mom could be more independent.  The mother indeed learned to drive.  However, she would never drive to visit the couple because, she said, they lived too far away. However, the mother would regularly drive a similar distance in another direction.  (She secretly believed that the only reason the couple wanted her to drive was so they could use her as a baby sitter).

There is relatively simple way for game players to end the game without end, but I will save that for a later post.

None Dare Call it Acting Out

Recent headline (November 11, 2010) in the Memphis Commercial Appeal newpaper:  "Survey: 1 in 10 U.S. children has ADHD."  One in ten.  Imagine that!  "Biological" psychiatrists believe that ADHD is a genetic and/or neurodevelopmental disorder.  I can't think of any other such disorder that effects 10% of the entire population.

The survey was performed by the U.S. Goverment.  According to the newspaper article, this represents a "sizable increase from a few years earlier that might be explained by growing awareness and better screening."  Specifically, the number represents an increase of 22% from 2003 to 2007.  The actual numbers of affected kids would be 5.4 million children - an increase of about one million in that period of time. Two thirds of the children were on medication.

Of course, the study seemed to just assume that the diagnoses were all valid.  Surely there are more parents aware of ADHD than ever before, so the "increased awareness" part of the story is undoubtedly true. 

The statistics for the "incidence" of childhood bipolar disorder (also called pediatric bipolar) are even more striking.  Prescriptions for powerful psychiatric drugs to young children for this disorder quintupled in less than four years.  The graph below shows the amazing increase in private office visits for bipolar disorder in children under twenty. 

Source: Pharmed Out

Of course, real bipolar disorder often first manifests in sufferer's late teens, and rarely occurs in children - as reflected in the number of office visits shown in '94-95, before pediatric bipolar diagnosis became a fad.  For decades, the incidence of bipolar disorder was pegged at about 1%, but now suddenly it is almost 5%.  This figure includes many who are diagnosed as "bipolar II" or "bipolar NOS" (see my post of July 24, 2010, Counting Symptoms that Don't Count for a discussion of how the designation NOS has been misused in defining bipolar disorder).

The dramatic increase in diagnosis of both ADHD and pediatric bipolar (without any change in the gene pool) is more strong evidence for the main thesis of my book, How Dysfunctional Families Spur Mental Disorders.  An upspoken and unholy alliance between pharmaceutical companies, biological psychiatrists, and overwhelmed and guilty parents has led to the disappearance in many mental health circles of the use of the term acting out in children in favor of a brain disease model for out-of-control children. 

As defined by Psychcentral.com, acting out is performing an extreme behavior in order to express thoughts or feelings the person feels incapable of otherwise expressing. Instead of saying, “I’m angry with you,” a person who acts out may instead throw a book at the person, or punch a hole through a wall. When a person acts out, it can act as a pressure release, and often helps the individual feel calmer and peaceful once again. For instance, a child’s temper tantrum is a form of acting out when he or she doesn’t get his or her way with a parent. Self-injury may also be a form of acting-out, expressing in physical pain what one cannot stand to feel emotionally.

Heaven forbid we should look at the problematic parenting trends described in detail by parenting columnist John Rosemond or the staggering incidence of child abuse and neglect in creating acting out.  How much more comforting for parents to think they bear no responsibility for how their children turn out.

Nothing Other than Stupid (NOS): Is Being a Rapist a Mental Disorder?

This post relates to two seemingly unrelated topics that were subjects of previous posts.  First, in my post of July 24, 2010, Counting Symptoms that Don't Count, I mentioned the improper use of the "NOS" category of psychiatric disorders in the DSM, psychiatry's diagnostic manual.  NOS stand for not otherwise specified.   This designation is used for patients who just barely miss DSM criteria for a particular disorder, like someone having manic symptoms for six rather than the required seven days, but who are suffering distress and/or dysfunction from their symptoms similar to that from the real thing.  It is not supposed to be used for people who just sorta kinda somewhat resemble people with the disorder on some dimension or other.

Second, in my post of November 3, 2010, Psychiatry Bashing, I kvetched about how pressure from the public is one of the major factors that has led to the misuse of psychiatric drugs and diagnoses by psychiatrists.

Now, one of the things the public is often somewhat hysterical about, and justifiably so, is the release of violent sexual offenders such as serial rapists after they have served their prison sentences.  However, as pointed out by Allen Frances in an article in the September 2010 issue of Psychiatric Times, the length of prison sentences for these felons is partially a product of the public's own misguided pressure on politicians. 

In their zeal to deal with judges who were perceived as "soft on crime," large segments of the public demanded fixed sentences for various crimes, rather than allowing the judge any discretion in the matter.  This actually led in some cases to sentences for those who were termed Sexually Violent Predators (SVPs) that were much shorter than they would have been had judges been allowed to use discretionary sentencing. (This problem has lately been correcting itself, but those sentenced under the old guidelines still have to be released).

What to do?  Well, according to Dr. Frances, twenty states and the federal government have passed laws allowing continued incarceration of SVP's, often for life, in psychiatric settings.  This is, in effect, preventive detention, which is generally considered a violation of due process and unconstitutional in legal circles.  Nonetheless, the Supreme Court has ruled that SVP statutes are constitutional on three different occasions.  In order for SVP's to be subject to preventive detention, however, the court ruled that their dangerousness must be the result of a "mental disorder."  Trouble is, they refused to exactly define what qualifies as a "mental disorder."

This has led to extreme pressure on forensic psychiatrists to invent specious diagnoses in order to protect the public from serial rapists and other SVP's.  One way to do that is through the use of the "NOS" category.  The DSM lists several sexual perversions (paraphilias), such as exhibitionism or fetishism, as mental disorders.  The  definition of a paraphila is recurrent, intense sexually arousing fantasies, sexual urges, or behaviors generally involving nonhuman objects, the suffering or humiliation of oneself or one's partner, or  children or other nonconsenting persons.

By the general definition of a paraphilia, it would seem that a serial rapist would qualify, since rape involves non-consenting persons as well as the suffering and humiliation of the victim.  However, rape is not listed in the DSM as a mental disorder.  Most people correctly think of it merely as a crime.  So under pressure forensic psychiatrists came up with paraphilia NOS, nonconsent. This seems to me to be just a made up diagnosis used to deny criminals due process.  It sure is not in the DSM.  (Then again, why is having a foot fetish a mental disorder?  That is in there).

Psychiatry bashers would undoubtedly have the opinion that forensic psychiatrists are, once again, acting like Nazis.  This opinion does not take into account at least two essential considerations: forensic psychiatrists are under tremendous pressure from all sides to protect the public from SVP's (and who would want to be responsible for unleashing one?), and for a variety of reasons the public is loathe to make rape (or even pedophilia, for that matter), a crime punishable by life imprisonment.

If you were forced into a choice between setting a SVP loose on women everywhere, or making up a diagnosis, what would you do?  Readers?

50 Excellent Therapists Who Blog

Here's a website with an excellent list of blogs by psychotherapists:

http://www.nursingschools.net/blog/2010/11/50-excellent-therapists-who-blog/

I'd like to thank Nursingschools.net for including mine.

Psychiatry Bashing

Anyone who follows this blog or who has read my new book is well aware that I am highly critical of many of my colleagues in the mental health professions. Drugs are prescribed inappropriately and dangerously, diagnoses are made cavalierly and without considering all the evidence, relationship problems and family dysfunction are ignored, and some therapists think that an unresoved Oedipus Complex is the final common pathway for all mental and behavioral problems, or that food pellets and electric shocks are more important than relationships in shaping human behavior.

Furthermore, I have written about how many so-called psychiatric "experts" are in bed with the pharmaceutical companies and how managed care insurance has done its best to devalue all psychiatric treatments.

My own brother-in-law stated, after he read my book, that on the basis of what I had written he would be reluctant to consult any mental health provider.

Nonetheless, I know that there are a lot of ethical and competent psychopharmacologists and psychotherapists doing fine work out there.  They have just become a bit harder to find.  In my book I tell the reader what to look for when they first visit a new clinician.

Folks, there is more than enough blame to go around for the current troublesome trends in the mental health field.  Another party also worthy of blame is the American public.  In fact, none of the horrible practices in mental health could have taken root without the American public's enthusiastic support and participation.

Consider the following: a lot of people these days seem to be looking for a quick cure for everything. For all the anti-drug hysteria in this country, people want to be medicated for everything. Do the hard work of therapy on your relationships? It's too much work!

Distracted at home or at work?  Taken an Adderal.  Doctors will hand them out like water.

As one psychiatry blogger, FunPsych, pointed out, "...many Americans, if given a choice between exercising for an hour a week versus taking a weight-loss pill, would choose the pill...Furthermore, Americans are already overworked and feel pressured to work even more. At least half the patients that I've seen that I want to do therapy with just don't have time for it."  Or so they say. 

Kids out of control? Do most parents want to look at their own parenting practices to see if they are contributing to their children's behavior problems? Some may write to get free advice from the Supernanny and get on TV, but I've already placed several posts about the answer to this question.  Rampant child abuse and neglect?  Nothing but implanted memories and false accusations, according to many.

A psychiatrist who wants to do the right thing can go bankrupt.  If a resident fresh out of training is looking for a job, he or she will find this situation as described by another psychiatry blogger, Pacificpsych: 

"Show me one [psychiatry] job in the entire US ... that entails psychiatrists doing therapy. The entire system consists of psychiatrists being forced to medicate, as well as them being controlled by insurance, UR people, nurse admin, non nurse admin...Show me the clinics or hospitals where you can get a job doing anything else but medicating patients." 

Rehabilitation for schizophrenic patients instead of just meds?  The public will not pay for it, and therefore it has become nearly non-existant in the public sector, and almost as rare privately.

Mental health is the first thing that is cut when state finances get tight?   Why?  I'll tell you why.  Because the mentally ill do not vote, and most of the public does not give a sh*t.  Because many politicians seem to think the mentally ill are all slackers, agreeing with the rabid antipsychiatry zealots (more on them shortly) that all mental illness is a myth. (How ironic that Ronald Reagan suffered from a mental illness - Alzheimer's disease - for the last part of his life).

And then we have the antipsychiatry lot who seem to be incapable of making any distinctions at all. All psychiatric drugs damage people and do nothing else, according to these people.

Apparently they believe there is some vast worldwide conspiracy to ignore the supposed horrific dangers of, say, antidepressants (which have been in use since the 1950's), and that the FDA as well as legitimate FDA watchdog groups like Public Citizen (not to be confused with Scientology's Citizens Commission on Human Rights) have somehow completely missed the millions and millions of patients around the world who have been destroyed by these widely-used and popular drugs.

But we know the FDA is completely in the hip pocket of the pharmaceutical companies.  (Of course, the FDA put a "black box" label on antidepressants on the basis of rather minimal evidence warning of potential suicidal ideation caused in teens and children.  How did that ever happen?)

I received a few comments on one of my blog posts by one reader that I decided not to post. I'd like to share some of them here: 

"Psychiatry is an evil profession, and you know it...Psychiatry has changed very little since 1938, when it was the training ground for the SS - exterminating up to 100,000 German citizens who were deemed "mentally ill" with 'special treatment'...Is psychiatry an evil profession? Absolutely...

I looked [at your blog]. What I found was the writing of a guy who wants to be different from his peers, but isn't. You have very little respect for people who suffer. One minute, describing how their condition is related to past trauma, the next minute ridiculing their behavior. You wrote the book on personality disorders, it appears. Yet your own personality is about as twisted as any person I've ever read...You seem to be a very miserable person, an abusive person...Your arrogance leaves me nauseated...You are an abuser, and YOU KNOW IT !!!!!!!!!!!!!!!!!!!!!!!!!!!!!"

Let's see. If I use a little snarky humor or exaggeration in a blog in order to make a point and to entertain readers (guilty as charged!), then of course I surely must consistently and abusively ridicule my own patients. I suppose I should never see any black humor in my patients' horrible predicaments; if I had any empathy at all I would be depressed along with them. (That's what patients really need: a doctor who is as depressed as they are).

This guy says I am a knowing participant in an evil profession. Psychiatrists like me who have committed people who are a danger to themselves or others are no better than the Nazi psychiatrists who helped exterminate the mentally ill during WWII.  Yes, I know all about Ernst Rudin and the eugenics movement - you will find an interesting discussion of it in Chapter One of my new book.   I guess that makes me a Nazi. There will undoubtedly be a picture of me with a Hitler mustache on some placard someday.

He accuses me of all these horrible things and yet he tells me I am abusive? That's rich! Pot, meet kettle.

Are patients who are terrified by persecutory delusions and hallucinations and who are found running nude on the freeway by the police better off in jail, where many of them in fact are now, or on Skid Row, than in a hospital? 

Pacificpsych also said, "...even psychiatrists who are completely opposed to the current system have no power to change it. They are trapped, unless they are in private practice and doing well there. YOU, yes YOU need to help us. Go to the administrator of the clinic, call the health insurance/medicare/medicaid administrator, call your senator and congressman. Demand that you get proper treatment. That means spending as much time with your psychiatrist as you and your psychiatrist feel is necessary..."