Multiple Personalities and Responsibility

Multiple Personalities, now known as Dissociative Identity Disorder (DID), is the single most controversial diagnosis in the diagnostic manual.  Most would agree with that statement I think.

One of the most bizarre aspects of this diagnosis and its promoters is the wish to have their cake and eat it too.  Let me give you a few examples of what I am talking about.  These are composite examples that have been slightly altered, not pertaining to any individual patient, but the comments attributed to therapists essentially express comments I have heard at one point or another.

Patient A signed a legal contract and later wanted to back out.  Patient A's therapist states, without any sign of misgiving or embarrassment: "People just don't understand that [Patient A]'s part [alternate personality] signed the contract and [Patient A] can't be held responsible."  Why is this having and eating cake simultaneously?  Well, let me explain.  Both the patient and the therapist believe and strongly advocate for Patient A's right to live and act in the community as a fully fledged adult citizen, and yet, they both want the world hold Patient A free of all agreements and obligations that Patient A has selectively decided some other personality inhabiting her body is responsible for.  This sort of undermines the basic social contract doesn't it?  Either Patient A is mentally competent to make agreements and sign contracts and be held responsible for her obligations, or if she really cannot competently sign contracts and be held responsible due to her psychiatric condition she should not be allowed to and her her therapist needs to be working to develop a legal guardian who can actually make binding decisions on behalf of Patient A who is apparently not competent to do so on her own.

Patient B is granted Social Security Disability for a psychiatric condition.  His primary diagnosis is DID.  He then enters university and goes through to complete a graduate program.  Throughout, he continues to receive monthly disability payments intended for individuals who are too disabled to work.  Both he and his therapist maintain that Patient B is both entitled to disability and able to legitimately complete a graduate program in the field of economics because his parts switch only when he is at the school and he can temporarily maintain his "host personality."  When returning home or out in the community he "switches" to different personalities and is therefore disabled.  After receiving his degree in economics, he continues to receive monthly disability payments and his therapist continues to be paid by Medicaid.  Patient B is both disabled and yet he is not.  It seems to me an ethical and competent therapist would be working with Patient B to utilize his graduate degree in a productive manner to his own personal and financial benefit.  Instead, the therapist continues to promote the idea that in spite of earning a graduate degree Patient B is too disabled to work and must continue in therapy indefinitely.  It may be no coincidence that if Patient B earns wage income, he will ultimately lose both Social Security Disability and Medicaid and the therapist's cash cow with dry up.

Patient C commits a felony crime of posing as a property owner (which she is not), collecting deposits and rents from multiple prospective renters and then flees the scene.  She spends the money on a car, clothing and a purebred Pomeranian dog for herself.  When tracked down by detectives and arrested, Patient C, her therapist and her defense lawyer all maintain that Patient C cannot be held responsible for the crime.  None of them dispute that her physical body was present at the time of the crime and in fact committed the crime, but they claim her body was inhabited by a personality who believed it was the property owner, therefore person/body of Patient C (the only legal and biological entity in this case) cannot be held responsible.  The "host personality" of Patient C cannot be held responsible because she was dissociated and was not aware of what occurred and had no control over it.  Furthermore, the "property owner" personality cannot be held responsible either because he/she/it really believed it was a property owner and did not realize it was committing a crime.  What does the therapist and defense attorney request?  That Patient C be freed and allowed to continue the same therapy (that failed to prevent her criminal behavior in the first place) because this is what Patient C "needs."

DID patients, therapists and promoters seem to have a problem with responsibility.  Basically they can disavow responsibility for anything with negative consequences for the patient/client/consumer but otherwise expect the world to treat the DID patient as a completely competent and responsible citizen.  Does that sound just a little too convenient?  Most jurors find it pretty fishy, that's why it almost never succeeds as a legal defense, but that doesn't stop people from trying.

Here are some interesting facts about DID and crime.  A small study published in 1989 (Putnum, Diagnosis and treatment of multiple personality disorder) found that 35% of female DID patients reported committing crimes including 7% of which were homicides and 47% of men with DID reported committing crimes of which 19% had committed homicide.

In the end, you can't have your cake and eat it too.

Why Does Norway Want Breivik to Be Insane?

Anders Breivik bombed downtown Oslo and went about methodically murdering 77 people and injuring many more.  In his recent trial that came to a close last month he calmly described how he did it and discussed with detached curiosity the victims' various reactions or lack of reactions to his attacks.  Throughout, he taunted family members, survivors and the world with what can only be described as a psychopathic sneer.

A sneer, micro or macro, is the universal expression of contempt

Is he insane?  This was the central question the recent trial revolved around.  Prosecutors want him to be insane, even though they now admit their doubt on the subject.  Prosecutor, Svein Holden, is quoted by the BBC as stating, "We are not convinced or certain that Breivik is insane but we are in doubt."  And yet, they continue to argue he should not be imprisoned but should instead be committed to a psychiatric institution.

Here, insane is more or less defined as psychotic.  Is he psychotic (insane) or psychopathic (sane but very very bad)?  That is the question.  Technically the defense is on a fool's mission to explain his actions as justified, but that is beyond absurd.  One wonders if the defense attorneys have undergone cognitive deficiency testing themselves--if not, perhaps they should.  While there is little if any evidence of actual psychosis there is a strong desire to place Breivik in that category, or maybe more to the point, to place him outside the categories of normal or sane.

Other than the fact that Norway has one of the most lenient and forgiving criminal justice systems on the planet, I know too little of that place and culture to fully understand their reasoning.  I can only surmise it gives some comfort to hold a belief that a man capable of doing what Breivik did cannot be normal or sane.  In a lay sense, what Breivik did makes him, by definition, insane.  This creates a safe psychological boundary between him and us.

It is an understandable sentiment, I'm sure.  But what does it say about a criminal justice system where prosecutors are not motivated by truth but by the outcome that makes them the most comfortable?

Can a man like Breivik be helped by psychiatric care?  If he were in fact psychotic, there are drugs that may (or may not) help.  Add some cognitive-behavioral whatnot and sometimes we see improvement, even dramatic improvement at times.  Conversely, if he is a straight up psychopath (as is likely the case), there is very little help possible if we want to be honest about it.

The Norwegian prosecutors fail to recognize the collateral impact of their strategy is to add more fear and stigma to the actual insane, the 1% or so of the world's population with a form of psychosis at some point in their lives.  Granted there have been plenty of psychotic shooters and killers over the years, and we may very well have experienced another one in Colorado just this month, but the vast majority of people with psychotic experiences, 1% of the world's population, are as non-violent as anyone else.  Some psychotic individuals can be dangerous, but lets not pin everything too horrific to comprehend on them just to make us feel a little more removed from the human potential for evil.

Crime, stupidity and responsibility among mental health professionals

I in no way want to promote the Church of Scientology nor am I in the fan club of Dr. Thomas Szasz.

I don’t have much to say about Scientology other than the fact that it gets pretty annoying to be accused of being a Scientologist simply because I question the validity of a diagnostic category like Attention Deficit Disorder and maybe I’ve suggested that giving amphetamines to young children might not be the best solution to this non-disease.

On the other hand, I could say a lot about Szasz who is something like the father of the anti-psychiatry movement.  I certainly think that he has done a lot of good by questioning the assumptions and practices in the mental health field going all the way back to the 1950’s.  Unfortunately, his discourse and that of his anti-psychiatry disciples is just as ideological and lacking in factuality as the worst drivel coming out of NAMI and from pharmaceutical marketers and the APA for that matter.  But, we’ll save that discussion for a later post.

Today, I just wanted to share about their Psychiatric Crimes Database, a rogues' gallery of badly behaved mental health professionals.  It makes for a, maybe not exactly fun, but perhaps amusing at times and otherwise disturbing read.  It is part of a website presented to the world by the Citizens’ Commission on Human Rights (CCHR).  CCHR is a joint effort by Szasz and the Scientologists dating back to 1969.  Its mission is to ”investigate and expose psychiatric violations of human rights and to clean up the field of mental healing.”

They claim to have aided in increasing prosecutions of mental health professionals of all kinds and to have promoted improved ethical and legal standards in the industry.  As to the later of these claims, I cannot vouch for the activities of CCHR itself, but I can say from my experience in mental health that the consistent pressure from the psychiatric survivor and anti-psychiatry movements, which have at least symbolic if not real leadership and impetus from Szasz, have had an actual and positive impact in the industry by increasing awareness and respect for things like informed consent and patient/client choice.  Yet, that being said, I do have to question what they seem to want to imply about themselves and the industry with their database.

Carrie Denbow, social worker, had her license suspended, according to the CCHR site, due to accusations she had sexual relations with a minor client in a motel room with two other students while drinking and smoking marijuana.  The client was an adolescent to whom she was providing counseling.  It is further alleged that Ms. Denbow took the client to her office three or four times a week where she performed oral sex followed by intercourse.  It is also alleged she broke confidence by seeking relationship advice from her minor client's peers.  Ms. Denbow was let go from her job in 2009.

The Psychiatirc Crimes Database is, very simply, a list of prosecutions and licensing censures against mental health professionals.  It appears to be updated quite frequently; there are eleven items in the database for January of 2011.  If CCHR had a role in any of these investigations, it is not evident and seems unlikely.  It appears to simply be a list of items gathered from the news and public records.  Items span a gambit of crimes and ethical violations.  Just in the last couple of months we see everything from a psychologist having his license placed on probation due to DUI to a psychiatrist charged with attempted murder for stabbing a patient twice in the chest with a sword.

My non-scientific cursory look at the database leads me to the conclusion that the most common category is the big no-no of sexual relationships between providers and clients, in some cases with minor clients.  This appears to be followed by billing and documentational faults leading to charges of fraud.  A third category is providing excessive prescriptions of controlled substances, sometimes for a payoff, sometimes without medical examination (as in being handed out in a public park in one case).  Otherwise, items are a miscellany of misdemeanors, violations and serious crimes.

The website explains its purpose:

The following database is being presented as a public interest service to law enforcement agencies, health care fraud investigators, immigration offices, international police agencies, medical and psychological licensing boards, and the general public.

And claims to impact larger issues:

Many psychiatrists have an intimate knowledge of criminality-one which has nothing to do with the professions involvement in the expert witness field.

• Between $20 billion and $40 billion is defrauded by the American psychiatric industry in any given year.

• At least 10% of psychiatrists admit to sexually abusing their patients: In America, that's at least 4,500 rapes and, internationally, more than 15,000 rapes.

• Psychiatrists, psychologists and psychotherapists have the dubious distinction of having laws specifically designed to curtail their tendency to commit sex crimes against those in their charge.

• A 1992 study of Medicaid and Medicare insurance fraud in the U.S. showed psychiatry to have the worst track record of all medical disciplines.

They don’t indicate how they came up with the specific numbers (e.g., 10% of psychiatrists admit to sexually abusing patients), but it is also true that both Szasz and the Scientologists share an overall denouncement of the very concept of mental illness and this database has to be seen as part of their larger pogrom against all things psychiatric.

Psychiatrist Douglas Rank who, according to CCHR, was charged with stabbing a woman in the chest twice with a sword in front of his office.  The wounds were life-threatening, but she survived after hospitalization.   She was apparently both his patient and in a "personal relationship" with him.  Rank was sentenced to 15 years after plea bargaining down from attempted murder to first-degree assault.  He had previously been investigated for over medicating and having sex with a patient.

Speaking to that implied intent, I have to feel that simply listing every kind of crime and stupid behavior of individual mental health providers cannot be taken as a condemnation of the industry as a whole.  There is plenty of room to criticize the mental health field and all of its tenuous assumptions and cherished beliefs, but, in my opinion, the fact that a particular California psychologist had his license placed on a probationary status, for instance, according to the CCHR site, because he was found awakening from unconsciousness in a department store after hours with a pocket full of methamphetamine, has no real bearing on the field of mental health other than the fact that it is peopled by human beings who are capable of addictions, errors, criminality and stupidity as humans are in any profession.  

Furthermore, the fact that professionals are censured, placed on probation, suspended and prosecuted, if anything, indicates that the industry does in fact have good safeguards and oversight by which to protect consumers and the public.

Yet, the database does have an impact on the reader, and if you haven’t yet, I suggest every one take a look at it who has an interest in mental health whether as a provider, consumer, family member or interested bystander.  If nothing else, it serves as a reminder that it is always a good idea to be cautious and do a little research before accepting a particular professional as the mechanic of your mind, so to speak.

Psychiatric Crimes Database

Borderline Personality Disorder, Crime, and Responsibility

On the topic of mental disorders and responsibility—of late, I’ve been hearing several therapists repeat a couple things that bother me:

1) Borderline Personality Disorder is just as serious as Schizophrenia and sufferers of BPD should be given just as much clinical attention and services.

I have to say, no, BPD is not the same as schizophrenia and should not in fact be treated the in the same manner.  Should medical professionals be told they need to treat sunburn the same way they treat cancer?  I think not.  Furthermore, I don’t know why we treat so many people whose primary presenting problem is BPD in the public mental health system intended for people with severe disabilities.  The bulk of the empirical research seems to show that BPD is best treated in the community with an established and effective therapy such as Dialectical Behavioral Therapy or similar.  Placing people with BPD in residential facilities for the severely disabled will only be detrimental for both the client and everyone else who lives or works at the facility.

2)  People with BPD who behave manipulatively should not be blamed or expected to change because their behavior is avolitional.

I will agree that “blaming” the client is in no way helpful, nor will expecting someone with BPD to instantly change result in anything but frustration.  However, it is simply false to say that someone with BPD has no ability to modulate mood or behavior.  No human behavior short of reflexes or seizures are avolitional.  Making false statements of this kind, even in apparent defense of people with serious disorders, only serves to increase the divide in understanding.  It also takes away from the agency and empowerment of the client that we are trying to help.  Someone with BPD is not helpless to change.  Change can happen with trust and support as long as there is a real desire in the person to make a change.  Setting clear but respectful limits helps too, because we all know that, like it or not, life has limits.  It is not at all helpful to give the BPD patient the message that anything they do is okay just because they have a diagnosis.  Such a message can be devastatingly harmful.

It might help to illustrate this issue.  Take a look at this excerpt from a recent news article (well, it's news-ish, I guess, it's from The Sun):

A WOMAN has been jailed for cruelly imprisoning three young children in a disgusting room without clothes, food or water.

Jan. 25, 2011.  Sick Daniella Henderson left the youngsters in the squalid conditions and their ordeal only ended when the kids were seen hanging out of a window desperate for help.

When police arrived at the house they found the bedroom they had been left in all day stank of urine, had no beds or furniture and had a bucket as a toilet.

The grandfather of one of the children today slammed sick Henderson's 15-month jail term as too lenient. . . .

Penny Moreland, defending, said: "Most people will find this shocking and distressing. This has not borne out of pure malice or badness.

"She was deteriorating mentally and has a borderline personality disorder [sic]."

The defense attorney here is presenting what a certain ilk of therapists are trying to put out there, that someone with BPD cannot be held responsible for their behavior. I would say, yes, it is distressing.  The defense states that the behavior was not malice or badness and seems to imply that the behavior cannot be malice or badness as long as the behavior is “explained” by a mental health disorder, in this case BPD.  It seems to be an underlying tacit assumption that the categories of malicious behavior and symptomatic behavior are mutually exclusive. At the risk of blaming people with BPD for their own behaviors, I have to question the validity of this assumed dichotomy.  Is it possible that someone’s behavior might be driven by BPD and that person is acting with malice?

Yet another opinion on mental illness, violence, and responsibility

I am hesitant to add to the din about mental illness and violence in the wake of Jared Loughner, but I’d like to make a few small points on the topic.

First of all, I have to say, I find it a little creepy that someone describing himself as a forensic psychologist, would so quickly put up a full website, complete with domain name, dedicated to this suddenly infamous young man: loughner.info

It feels a little exploitative, but probably not anymore than traditional journalism I suppose. The posts seem thoughtful and informative in any case.

But, to the real point, the consensus seems to be that our Mr. Loughner was coming down with a nasty case of schizophrenia. As more details come out, the more this seems likely. I wouldn’t dispute it, but I'm not going to diagnose him via media reports, either.  Still, I think it's fair to acknowledge there is a mental health component and this ties into larger social concerns about mental illness, danger and responsibility. 

The next questions are, (1) what then is the personal/moral responsibility of a person with mental illness in regard to their behaviors, and (2) are people with schizophrenia dangerous?

As to the first, well, maybe it’s a question for the philosophers, but that won’t stop the lawyers and pundits from opining. I won’t bother to answer such an expansive question myself, but I do want to make note of the fact there is a very large population of people with schizophrenia who suffer from paranoid delusions who chose not to act out violently toward others. This interesting fact touches on both of the above mentioned questions, I think. From my own experience, I’ve known quite a few individuals who believed very strongly that they were being persecuted by specific others in some way and in some cases the belief systems included threats to their lives. Very often this involves poison but there can be any number of creative delusory devices.

So why is it that people who believe they are being poisoned, attacked and persecuted, are so often non-violent even in the face of an overwhelming belief that their own life is being threatened?

This is something like a key question and the answer(s) touch on both personal responsibility and risk assessment. But, this question tends to get overshadowed in the immediate aftermath of a spectacular psychiatric failure as we saw recently in Tucson and not so long ago at Virginia Tech.

The somewhat simplistic explanation is that most people who suffer from schizophrenia have an intact moral capacity and it is only a small subset of people with schizophrenia who also fit an anti-social profile in which there is a lack of compassion or concern for others. I do think this is true in a general sense even if the categories of schizophrenia and anti-social personality suffer from fuzzy boundaries and arbitrariness.

The other important clinical factor is severity of delusions (along with other symptoms). For someone with schizophrenia, delusions seem to follow a sort of hydraulic principle. That is, as the severity of symptoms fluctuate, there is a shift in the psychic pressure of the delusional system (metaphorically speaking). As an episode increases in severity, the delusions shift in two ways, (1) strength of belief, and (2) amount of mental time and energy given over to ruminating on the delusions. With increasing severity there is an intensifying obsessional quality in the person and an increasingly aggressive reaction to reality checks or questioning of the delusory beliefs. Severity comes into play with violence and responsibility because the greater the severity of the symptoms, the harder it is for the individual to ignore the direction of delusory thought and the harder it is for the person to receive any form of feedback or external redirection.

There can be a number of ameliorating factors however. One factor, in some cases, is life experience. After going through a number of episodes, some individuals learn from very difficult experiences (homelessness, hospitalization, loss of family support, etc.) that their beliefs can be problematic and with time this can aid an individual in developing coping and self-management skills. The reverse is also true, that a young person who is first developing schizophrenia does not have the benefit of those life experiences and the first emergence of delusory beliefs can have a seductive, intoxicating quality and are very difficult to challenge from the outside.

Aside from clinical analysis, I think it is very important to know that people with schizophrenia are individuals. I do not mean this as a slogan, but in a very real way. As overwhelming as the effects of schizophrenia may appear to be on the personality, it does not in fact do away with it. People living with psychosis and schizophrenia continue to hold and express values and morals and a full range of human motivations both good and bad, just like the rest of us. More so than any other label in mental health, the term “schizophrenia” too often overshadows the person.

These kind of catastrophic events, as in Tucson, tend to trigger the latent fears in the public and inevitably lead to calls for greater controls on the mentally ill and stronger commitment laws to allow the mental health system to more easily intervene with involuntarily measures. All this puts the focus on the illness while de-emphasizing personal volition. In this round, by and large, I think the media response has been a little better informed than after Virginia Tech and mostly I see calls for increased mental health services, which is a safe and reasonable position to take, although, I think people need to be better informed about the limits of what mental health services can do. Simply throwing more money at the problem is not necessarily going to help, and there is a good chance the resources will be diverted to other people and other agendas.

Even where a wide array of mental health services are available, the people who need them most often have no interest in them (while there are plenty of other people who don't really need all that care but are willing to accept social security checks and get all kinds of counseling--but that's a whole different story). There really is no way to force therapy and treatment on someone who absolutely doesn't want it, not unless they can be placed under civil commitment, and that is determined by presentation of immediate and believable danger to self or others. Assessing danger has elements of best and customary practice, but in the end it is educated guesswork based on past history, stated intentions and a range of known risk factors. How do you know their history? Well, unless you get past clinical data, it comes down to what the client is able or willing to tell you. For someone who doesn't have an established history, assessing danger is quite tricky and there is a certain amount of intuition and personal judgment involved. There simply are no guarantees or simple solutions.