Peers of the Mental Health Realm

The last decade has seen a flood of peer counselors in the public mental health system in the U.S., the basic idea modeled, if loosely, on the the practice of recovered addicts becoming counselors in the alcohol and other drug (AOD) treatment field.  In mental health it has the added gain of making public mental health treatment a more humane and understanding place.  Psychiatric survivor activists have long called for this move.  If services are provided by counselors who have themselves experienced mental health problems and have been on the receiving end of services, then services will inevitably be rendered in a more sensitive and user-friendly manner.

These things are true as intended, but I feel the need to point out there is also a dark tangled mass of contradictions, uncertainty, and politics that inhabit the practice of peer counseling like a hidden cyst threatening to break open and poison the entire initiative.  As always, I find myself the voice of doom and gloom in the fantasy land of Mental Health where fake positivism, false prophets, and general quackery goes hand in hand with unicorns, pixies, and evidence base practices.

Peer counselors come to the public mental health field like faerie-activists waving their magic "recovery" wands.  They go to the dark places of mental health--think Shutter Island, Sucker Punch, One Who Flew Over the Cuckoo's Nest, and hundred other examples--and these peers turn the dark places into sunlit gardens of recovery with doors broken open to let the sunlight in and to let the inmates out to discover they were never mentally ill to begin with--it was all a lie made up by psychiatry and Big Pharma.

The only thing is, it’s just another lie really.  Let me give you a smattering.

1. Peers do not necessarily have special insight into the experience of individual mental health system users.

Mental health peers are self defined.  It has to be so for simple legal reasons.  A prospective employer is not permitted to ask about an applicant’s disability.  It is contingent upon the applicant to decide if she or he is or is not a mental health peer.

In the AOD field, addiction disorders are a straightforward set of behavioral categories that are bound by a single phenomenon: addiction.  Straightforward, relative to mental health anyway.  By contrast, mental health disorders cover so vast an array of human behavior patterns so as to be absurd.  What does it mean to be a mental health peer?  Does someone who experienced adult attention deficit have some kind of special insight into what it’s like to experience schizophrenia?  Or vice versa?  If that seems like a stretch, it’s because it is.

Imagine, if you will, a world in which medical peers--people who have experienced medical problems and have received medical treatment in their lifetimes--replace nurses in your doctor’s clinic.  Will a medical peer who has experienced medical treatment for eczema have some special understanding, gleaned from experience, into the medical needs of a patient with necrotizing fasciitis?  Sound preposterous?  Why then is the idea of mental health peers any less preposterous?

2. In mental health, recovery is a word without meaning.

One of the basic rationalizations for peer counselors is that a peer is a living example of recovery, a person with a mental health condition who has persevered, and met their therapeutic goals, and now can work productively as a peer counselor.

It stands to reason.  This rationale works very well in AOD services where peer counselors are the norm.  In that field, peer counselors have beat their addiction--they are in recovery--and they can help other addicts on the path to recovery through the wisdom of their experience.

Okay, that’s all well and good.  But.  In the AOD field, recovery is black and white.  You are either using, or you aren’t.  Recovery is tested and assured by urinalysis.

If you think mental health has a standard of recovery, you are mistaken.  Recovery, like the peer identity itself, is entirely self defined.  Anyone, and I mean anyone, can walk through the door and proclaim they are a peer and they are in recovery.  There is no testing and such claims are accepted at face value, at least at time of hire.  This literally true.

Sadly, I have seen peer counselors (and therapists and psychiatrists for that matter) with untreated axis II disorders do great harm.

3. The sudden, poorly thought-out growth in peer services is driven by feel-good politics.

This true statement does not discount the possibility of benefit from having peers working in the system, but, it does tell us something about the process that led to the current situation and can illuminate how preventable problems were allowed to fester.  The peer counselor initiative may have a grassroots origin in the consumer/survivor movement, but it came to fruition because of state legislatures and state level department heads made the decision that peer delivered services is a good thing and made it so through law and regulation that, if not mandates, at least incentivises the practice in many states.

System changes driven at the state level are seldom well considered.

4.  And it is powered by cost cutting.

Medicaid reimbursement for services delivered by a peer counselor is considerably less than reimbursement for services provided by bachelors and masters level clinicians.  This impacts state budgets.

Need I say more?

The Folly of DID

Not that I've been there myself, but I understand if you travel through England you might come across some of these apparent medieval towers or castles in various states of ruin.

Except that they aren't medieval and they aren't ruins.  They were built to look like ruins.  Many of them were constructed in the 18th and 19th centuries by persons with excess wealth and imagination.  A little bit of deception for someone's amusement.  They refer to them with the term folly.

That brings us to Dissociative Identity Disorder, AKA multiple personalities . . .

I just came across this good review of the DID controversy by Dr. August Piper:

The Persistence of Folly: A Critical Examination of Dissociative Identity Disorder. Part I. The Excesses of an Improbable Concept

Here is an excerpt:

With the recent appearance of several critical articles and books, the concepts of dissociative amnesia and dissociative identity disorder (DID) have suffered some significant wounds (1–5). Between 1993 and 1998, the principal dissociative disorders organization lost nearly one-half of its members (1). In 1998, Dissociation, the journal of the dissociative disorders field, ceased publication. A paper published in 2000 examined the weaknesses in the dissociative amnesia construct (6). Various dissociative disorder units in Canada and the US (for example, in Manitoba, Illinois, Pennsylvania, and Texas) have been closed down. US appellate courts have repeatedly refused to accept dissociative amnesia as a valid entity (6), and several ardent defenders of dissociative disorders faced criminal sanctions, malpractice lawsuits, and other serious legal difficulties.

Nevertheless, despite the significant harm these concepts have wrought in North America, some Canadian and US practitioners continue to support, and practise according to, dissociative disorder concepts (7–9). Further, these North American countries export the concepts. In India, for example, the cinema has influenced the production of dissociative signs (10), and 4 recent papers demonstrate a recurring interest in spreading awareness of DID to other countries (11–14).

and on it goes.

Like the follies built by the idle rich of the romantic period, DID is not simply wrong, it is a fantasy people want to believe and proliferate.

Mental Illness and Danger: The Data

Yet again, Neuroskeptic delivers well vetted empirical data on topic and, as if, on cue.  In this case a massive study in Australia exploring the statistical links between crime and mental illness.

Mental Illness and Crime, Yet Again

Mental Health or Gun Control?

[accidentally deleted this post, so I'm reposting]

Public discourse, political, media, whatever, likes to frame things in dichotomies, false or otherwise.  No wonder that in the wake of yet another tragedy we seem to hear we have a choice with two options.  Limit access to military style weaponry or provide more mental health services.

I don't like forced choice questions.  Usually makes me feel like I'm being railroaded.  Usually is the case too.

Just a few thoughts on the mental health side of the equation.  People on both, or all, sides of the political spectrum are generally supportive of increased mental health services when something like this happens, but few people are aware of what that means or the issues involved.

Here is just an outline of a few things people should be aware of.

• Not every mental health problem can be resolved by talk therapy (an understatement)
• Not every mental health problem can be resolved by medication (another understatement)
• Except under very legally circumscribed circumstances, we, as a society, cannot make people visit and talk to a therapist.
• Even where we can legally compel someone to see a therapist, we can't compel individuals to care or to want to change or to benefit from therapy they don't want.
• Likewise, we cannot compel most people to take medications even if we think they are very not sane.
• When we can compel someone to take medications, it may not actually help much, and may have severe repercussions for the individual (side effects up to and including death, psychological and physical trauma from restraints and forced injections).
• Civil commitment laws (or interpretation of them) have drifted toward the individual liberty side of the equation.  This is in no small degree a result of historical abuses in the mental health system.  It likely also reflects shifts in the overall sociopolitical zeitgeist.
• We generally cannot civilly commit, and thus compel treatment and seclusion, unless someone has already engaged violently or they have made credible threats.  There are times when individuals with mental health problems plan violent actions and choose not to broadcast their intentions to mental health professionals.  In these cases it is very hard to predict and even where we have concerns there is often very little we can do.

This continues to be the state of the field when it comes to extreme mental states and available interventions

It saddens me deeply every time I talk to some parent who has come to me believing I will be able to intervene with their adult son or daughter with a psychiatric disability and I see the relentless disappointment on their faces as I explain to them the limitations of what we can do to intervene with an adult who does not want help.

Just so everyone knows.  Increasing availability of mental health support may be a good thing and it may help, but it will never be a complete solution to protect us and our children from rampages and violence.

addendum -- Oregon is now looking at increasing civil commitment from six months to two years after a Eugene police officer was gunned down by a woman in a psychotic and paranoid mental state.  I happen to think this is the wrong approach.  Lengthening commitment would have made no difference to the death of the officer.  The real rub is what it takes to place a hold and then commit someone.  If the legislators want to make a difference, they will need to look at that issue instead.

A Buffet of Childhood Diagnoses

I just want to promote this very good post on Neuroskeptic on the North American epidemic of diagnosing young children with the adult disorder of Bipolar and the American Psychiatric Association's attempt to fight this problem by writing yet another childhood disorder into the DSM-V.

Psychiatrists: Does Fire Put Out Fire?

What is it about North America that we want to believe all our children are mentally sick?

Dissociation, DID, Culture, and Empirical Evidence

Dissociation is some kind of human phenomenon that crosses time and place in the human experience.  Most forms of dissociation occur in the context of religious ecstasy.  There are many many examples.  Umbanda in Brazil.  Indigenous Taiwanese healers.  Balinese ritual trance (people have been know to go into spontaneous trance states even working in factories in Indonesia).  Pentecostal direct experiences with the Holy Spirit.  Speaking in tongues.

The list goes on.  But, we find that dissociation manifests differently in different cultural contexts.

Dissociation itself is not what is in question, but Dissociative Identity Disorder (DID), previously known as multiple personalities, is.

In North American culture, dissociation generally manifests, if not in a tent revival, than in the context of hypnosis or with the patients of certain therapists with proclivities for the promotion of DID.

Does DID occur universally or is it a product of the North American culture of psychopathology?  We already know that mental health disorders can be a product of cultural place and time.  Hysteria in Victorian Europe and America is one well known example.  Neurasthenia in China is another example that has been written on extensively.

Is DID another disorder that is not universal but tied to the Zeitgeist of a particular place an time?  Right now the field of mental health is in an intellectual tug of war on the topic.  We have the historical record that gives us some insight.  The concept of multiple personalities appeared early on in the development of the field of psychology, but it was an extremely rare diagnosis up to a certain point.  That point was the publication of "Sybil" in 1973 and the subsequent film adaptation.  This was the story of Shirley Mason, AKA Sybil Dorsett, who claimed to have multiple personalities, (and later said she made the whole thing up to please her therapist, and then changed her mind again).  After the popularization of multiple personalities by "Sybil" it became a mainstream diagnosis and has benefited from several waves of popularity since.

Sally Field acting

Shirley in youth

"Sybil" acting?

Dr. Richard J. McNally, et al., has now provided us with an empirical window on the topic.  He crafted a controlled study to test a fundamental basis of the DID construct, the amnesic barrier.  The amnesic barrier being the concept that as a DID identified individual transitions from personality to personality, the one personality has no direct memory of the other personality or personalities.

These researchers used a concealed information task that consisted of flashed words on a screen in which subjects were instructed to push "yes" or "no" based on whether or not the word was on a list.  What DID identified subjects did not know is that some of the words flashed on the screen were taken from surveys conducted with at least two of each of their personalities.  The words were specific to the personalities, such as the name of a friend or a favorite food, for instance.

The crux of the study was on a microsecond lag in pressing the button related to words autobiographical to the personality.  This occurred as expected.  Unfortunately for the construct of DID, the same delay occurred for words related to alternate personalities (not currently present/aware personalities), showing that knowledge crosses alternate personalities, undermining if not disproving the amnesic barrier.  It also implies, if not deception, at least an attempt on the part of the subjects to conform to the cultural model of DID.

McNally concludes that "Cultures provide envelopes for people to express suffering or psychological pain and DID is one such cultural trope. . . . I don't think much would be lost if the diagnosis were eliminated from the Diagnostic and Statistical Manual."

Source:  "A story that doesn't hold up" in the Harvard Gazette

Original paper is on PloS ONE here

DID in defense of crime: the case of William Bergen Greene and his therapist

William Bergen Greene was a troubled man who started with a troubled childhood.  He apparently suffered severe abuse as an early child until he was made a ward of the state at age eight.  He suffered further abuse in foster homes and institutions.  At age 17 he escaped from his institution and started his adult life of chronic criminality.  He was so frequently convicted of sexual offences that he spent the vast majority of his adult life in prison.  He remains incarcerated today in Washington State.

He became a prison sex offender patient after a 1988 conviction.  His prison sex offender therapist, known to the public only by the initials M.S. (because she later became another victim of Mr. Greene's many sex offenses), was the first to diagnose him with Dissociative Identity Disorder (DID) otherwise known as multiple personalities.

Her course of therapy started with hypnosis.  With this extremely questionable (if not negligent) technique she proceeded to draw out (or co-develop) some 24 personalities in her patient, not the least of whom were "Auto," a non-human robot personality, and "Smokey" the dragon.  Yes, a dragon personality.

Another therapist at the prison disagreed with M.S.'s diagnosis.  Instead he diagnosed Greene with Malingering.  Incidentally, malingering is listed and described in the psychiatric diagnostic manual and is designated with code V65.2.  V-codes generally indicate a diagnostically important factor or condition that is not itself a disorder.  Malingering, of course, is not a disorder that is treatable under Medicaid but is described as "the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives."  Typically, external incentives have to do with financial gain, or avoidance of responsibilities or consequences.  In this case, Greene was already convicted and incarcerated.  The dissenting therapist warned that Greene's malingering was motivated by his life-long pursuit of sexual victims.  He warned that Greene was setting his therapist, M.S., up for a future assault.  The dissenting therapist's assessment proved to be prophetic, but sadly failed to influence M.S.  Not only did she continue her work treating Greene's purported DID, she seemed to become increasingly close to her patient.

Greene was released from prison in 1992.  Within days of his release, M.S. quit her job at the prison and took Greene on as a private patient.

Was it coincidence that she quit immediately after his release?  I can't say, but it is suggestive of a therapist who was severely enmeshed with her patient.

She met him for therapy on a routine of bi-weekly sessions, but if so, they must have been extremely long sessions, because by the end, when he finally assaulted her in 1994, she had racked up over 2000 hours of therapy with this single patient.  By comparison, standard out-patient therapy is generally in the range of 12 to 54 hours of therapy per year.  Yet more evidence of enmeshment if not outright obsession on the part of the therapist.

M.S. received a phone call from a distressed Greene on April 29, 1994.  She knew he was under stress from several things and she was worried he might be suicidal, so she went to meet him at his apartment.  He was talking very slowly with a childlike voice.  He kept referring to himself as "we."  I will add here, the "royal we" is a common trait or affectation among DID patients and it seems unlikely it was the first time he used it in M.S.'s presence but later, in court, she would use it as one of the evidences of his personality fragmentation at the time of the crime.

At some point, as M.S. tried to console the oddly behaving Greene, alone with him in his apartment, she figured out that he was on cocaine.  In a moment of good judgment, she chose to leave.  Unfortunately for her, he barred her way out.  They struggled and M.S. fell.  He ripped off her shirt and bra and touched her, ignoring her protestations and clear statements for him to stop.  He took her to the bathroom and held her there for two hours.  He continued to molest her there, taking breaks only to shoot up a drug, presumably cocaine.  Throughout this incident, Greene's behaviors were later described by M.S. as childlike with frequent but brief bouts of crying. Near the end he removed his own pants and touched himself but failed to achieve a result and soon after said she could go, but when she tried, he changed him mind, tackling her and left her bound and gagged as he removed himself from the scene in M.S.'s car.

Once Greene had fled, M.S. was able to remove her bonds and escaped to a hospital across the street where she called the police.  Greene was soon apprehended and charged with kidnapping and indecent liberties.

Greene plead not guilty by reason of insanity, but in his first trial, Judge Thorpe ruled that DID could not be used in an insanity defense due to lack scientific consensus on the existence of the disorder.  The defense attorney, David Koch, was not permitted to even mention DID.  Greene himself assisted his defense attorney, telling his attorney that one of his alter personalities was trained in law.  Without DID as a defense, the case rested solely on whether or not Greene had committed the deeds.  He was quickly found guilty on both counts.

In 1998, Greene and Koch appealed to the Washington Court of Appeals.  Appeals continued back and forth up to the U.S. Ninth Circuit Court and, in the end, he was granted a retrial.

A pre-trial hearing was held to determine if DID could be used as an insanity defense.  The defense team brought in expert Dr. Robert B. Olsen who testified that DID was generally accepted in the field but conceded after interviewing Greene, he could not say who Greene really was much less determine his sanity due to the number of alter personalities.  The prosecution brought in their own expert, Gregg J. Gabliardi who failed to challenge DID, stating that he agreed it was generally accepted.  His only contribution to the prosecution was to testify that it would be impossible to determine the sanity of each separate personality or determine which personality was responsible for which of the actions Greene had taken.

This was clearly a low point in the field of psychiatry when two psychiatrists under oath fail to mention any controversy related to this diagnosis.  One wonders if Olsen or Gabliardi had in fact believed they could determine guilt and responsibility of one specific personality out of 15, what the criminal justice system would be expected to do with that information?  How do you incarcerate one personality out of many?

With the given experts, it is not surprising in the retrial the defense was allowed to use DID as an insanity defense to claim that Greene was not legally responsible for his actions.  He had two new public defenders in the second trial, Teresa Conlan and Marybeth Dingledy.  The second trial took place over five days in September 2003 in Snohomish County courthouse.

In one of the strangest twists in the history of DID being used to avoid truth and consequences, Greene's victim, his former therapist, the now 53-year-old M.S. demanded to testify in his defense.  In the retrial she was permitted to do so.  She claimed that only she could explain the impact of his terrible disorder, DID, on Greene and its role in causing his behavior on the night of his attack on her.  M.S. testified before the court that it was not Greene himself who had attacked her but actually three of his alter personalities:  Sam; Tyrone, a three or four year old; and Auto, a robot.  She explained to the jury it was not Greene, but Auto the robot who grabbed her and held her down.  It was not Greene who molested her for two hours, but Tyrone the child.  The personality Sam appeared for only a moment and tried to save her, but was quickly taken over by the other two personalities.  M.S. testified her belief that the chronic sex offender Greene was not responsible for the attack because he was not present during the attack and had no awareness of it until he was informed of it later when he was in police custody.

In an odd about face, the expert witness, Dr. Olsen, who had originally testified for the defense, switched sides and testified for the prosecution in the actual trial itself.  He now said he believed Greene was malingering.  In the trial, the prosecution also brought in a new expert witness, psychologist Richard Packard who testified that Greene did not have DID at all.  Packard diagnosed the chronic sex offender with antisocial (AKA psychopathic) personality disorder and a sexual paraphilia disorder.  Packard further stated his doubt about the veracity of DID as a legitimate disorder.  Packard firmly believed that Greene had simply been faking DID from the beginning.  Greene's cellmate, a certain Eric Fleischmann, testified that he too attempted to fake DID with Greene's coaching but had failed.

Defense witness, Dr. Marlene Streinberg, then vice president of the International Society for the Study of Dissociation, testified that DID was real and that Greene fit the profile.  In spite of Dr. Streinberg's rather weak assertions and in spite of the frantic testimony of an enmeshed and obsessed therapist, Greene lost his second trial and was again found guilty on both counts.  The jury deliberated for five hours and were done in time to go home for dinner.  Greene was sentenced to life as a three-strike felon

Now in prison, Greene has since been charged with the 1979 rape and murder of a 25 year old woman by the name of Sylvia Durante in Seattle.  Greene's DNA from his sperm was found on Ms. Durante's body.  He was convicted of her murder in 2005.

Not everybody is a believer in DID.  No matter how self important and self righteous the tone of its promoters like Streinberg, jurors, and most people with any level of critical thought or common sense, remain unconvinced.  Juror, Jim Camp, from Greene's retrial, stated the jury "just didn't believe it."

Sources:

Sullivan, Jennifer; Insanity defense fails for attacker; The Seattle Times; Nov. 21 2003; as viewed on web 8/2012. 

Fersch, Ellsworth; Thinking About the Insanity Defense: Answers to Frequently Asked Questions; iUniverse, Lincoln, NE: 2005