Friday, December 28, 2012

Laura's Law

In case you missed it the PBS News Hour had an interesting piece on court ordered outpatient treatment. California has a new law allowing for court ordered outpatient psychiatric treatment for psychiatric patients thought to be dangerous. The law, which is named for a young woman who was killed by a paranoid patient, hasn't been funded. The state, in its wisdom, is leaving this to localities. So far only one county has done so. The piece gives various people an opportunity to speak for and against the law, but doesn't say anything about those few states that have such a law. From my limited experience working in a state that allows for court ordered outpatient treatment I would say that it is neither as helpful nor as harmful as as the two sides quoted in this story suggest. It would be interesting to know whether there is data on how such laws work.

Wednesday, December 26, 2012

A Dark Day for Psychiatry

An article in the Guardian reports that in the first case of its kind in France, Danièle Canarelli, a 58 year old psychiatrist was sentenced to one year's suspended sentence for failing to recognize the grave danger posed by a patient she had been treating for four years.

The union for French state psychiatrists, which backed Canarelli during the trial, said that the landmark verdict was worrying and risked scapegoating the profession over a complex case.

I thought the case raised interesting questions about when or whether negligence should ever be considered as a criminal offense. Beyond that the case highlights psychiatry's sometimes conflicting  responsibilities-- caring for patients and protecting society from the actions of some of those patients.

A more detailed report of the case in Le Monde gives something of the flavor of the case. Here is my attempt at a  summary.

At the opening of the trial the President of the Court, aware of the controversial nature of the trial, spoke directly to the psychiatrists who had come to protest in support for their colleague. "We can understand the legitimate emotion of a profession," he said, "but we are not judging psychiatry or psychiatrists. For us it is a question of knowing if, in a concrete situation, serious misconduct has been committed." Referring to an article in the penal code under which 'unintentional offenses' may be charged, he added that, "There can be no impunity, society does not accept it."

This case began after charges against a murderer were dismissed because he was declared irresponsible as a result of psychiatric troubles. The victim's son opened a civil case against the doctor during which the judged referred the case for criminal prosecution because of a breach of duties of caution and safety. In France such prosecution is allowed if an indirect link between misconduct and damage exposes others to particularly serious risk that "could not be ignored."

In making this ruling the judge relied on the testimony of a psychiatric expert. Over a period of years, the expert pointed out, the murderer had been back and forth between prison and a psychiatric hospital for assault with a knife, arson and attempted murder. During this time he was repeatedly diagnosed as suffering suffering from schizophrenia 'with established dangerousness.'

While other doctors came to this conclusion, Dr. Canarelli did not make this diagnosis, regularly voided his involuntary status in the hospital and granted him furloughs. When asked by the judge why she had done this she replied, "You cannot keep someone involuntarily forever." When the judge asked how else one could treat someone who was unwilling to be treated, the doctor answered, "I was in a trusting relationship with him. He came to all of his appointments, which is rare, and there were no behavioral incidents during his hospitalization."

When confronted with her repeated disagreements with other doctors about this patient's diagnosis, she responded that , "He was a patient who was more complicated than others. I was faced with a conundrum. I was convinced that he had a psychotic condition, but I was puzzled [embarrassée] by the absence of symptoms."

The case against the doctor was strengthened when she was questioned about the patient's exit from her clinic three weeks prior to the murder. At that time, the patient's sister warned the doctor that her brother was making death threats. In addition he failed an appointment with the doctor because of a wound received during an altercation. At Dr. Canarelli's request the patient was sent to her office after treatment of his wound. However, he refused her offer of hospitalization and abruptly left her office. She said that she was alone with a nurse and felt she couldn't detain him, but she didn't  call for help. She waited three hours to call the police.

In response to this testimony the judge commented that the doctor's failure to call the police for three hours meant that the patient was "in the city, while you told us that he was sick and could do harm." This comment sparked indignation among the psychiatrists in the courtroom. "Judges should do internships in psychiatric hospitals," one audience member commented to another.

The prosecutor argued successfully that "there is a moment when social defense must come before the patient."

On December 18 Dr. Canarelli was sentenced to one year's suspended sentence for manslaughter [homicide involontaire]. The court concluded that 'shortcomings identified in monitoring the patient' were 'at the origin' of the behavior leading to the murder. These shortcomings, court concluded, constituted serious misconduct and warranted the criminal liability of the psychiatrist. Recalling the multiple incidents that should have alerted the doctor to the patient's dangerousness, the judge said that Dr. Canelli's attitude "bordered on blindness."

Above all, the judge noted, this doctor had time to see her patient evolve. The judge was careful avoid including all errors made by doctors in his judgement noting that, "contrary to other doctors …who must act and react in emergencies, she was able to register clinical observations over time."

The president of the Union syndical de la psychiatrie responded to the court proceedings by answering several questions. Here are two questions and answers.

1. Why do you support Dr. Canarelli?
"What bothers us in this process, is the impression that we must find a scapegoat. We consider unacceptable and will make this the main responsible psychiatrist, because here this was a complex situation where the responsibility of the physician is practically zero. What exactly is she being criticized for. … failing to ensure public safety, as if  that was her role and not that of the police. In spite of her reporting his flight, he was not arrested. We are not police officers. Between the patient and the psychiatrist, everything must be based on trust and therapeutic care, not security.
2. What impact would the conviction of Dr. Canarelli have?
This would surely lead to there being a sword of Damocles over every practitioner. This pressure transform psychiatrists into guardians of public order. The risk that  patients would then remain confined to the hospital longer -while you reducing the number of beds ! Fortunately, this kind of case is rare, because the police normally intervene in reported cases, and, it is always useful to remember, because psychiatric patients are not more dangerous than the rest of the population. .

Tuesday, December 18, 2012

I am Adam Lanza's mother

My daughter sent me this article following the Newtown masacre. What struck me was the mother's view that the choices for her son were between prison and shuttered hospitals. I had thought that the twentieth century had created comprehensive community programs  for difficult cases such as hers. Reading her impassioned plea I felt that I had returned to the nineteenth century.  Are community programs also shuttered in her area or is access to them so difficult that it amounts to the same thing.  It does seem to me that the question of access to such programs should be an important part of the 'conversation' that we are having in the wake of this most recent tragedy. Certainly in the area where I practiced psychiatry, funding for comprehensive public  programs are being cut. Such programs are necessary because the incentives in the private sector do not favor providing adequate treatment for difficult people such this woman's son.

Friday, August 24, 2012

More on Breivik

The Washington Post reports that a Norwegian court sentenced Anders Behring Breivik to prison on Friday, denying prosecutors the insanity ruling they hoped would show that his massacre of 77 people was the work of a madman, not part of an anti-Muslim crusade. In a reversal of my expectations the prosecution continued to argue that he was insane while the defense argued that he was an anti-Muslim terrorist. Importantly Breivik wanted to be considered a terrorist. As I said in my earlier post this seems significant in showing that insanity is two edged in that it can be used both as an exculpating defense and a delegitimizing accusation. 
I recently learned David Mark Chapman,  who was convicted for murdering John Lennon in 1980 also refused an opportunity to plead insanity and insisted on pleading guilty.

Saturday, June 23, 2012

Prosecutors in Norway Seek Hospital for Gunman

The New York Times has reported that in a remarkable turn of events prosecutors in Norway asked that  Anders Behring Breivik   be committed to a hospital rather than sent to prison. What seemed particularly significant was their reasoning: “In our opinion, they said, it is worse that a psychotic person is sentenced to preventative detention than a nonpsychotic person is sentenced to compulsory mental health care.” The following day the Times reported that Breivik's defense lawyers were arguing that he was of sound mind when he committed the crimes. Understanding why these arguments are the reverse from what I would ordinarily expect is certainly a puzzle. Later I learned that Members of the defense team evoked Mr. Breivik’s human rights in their conclusion that he should be held accountable for his crimes. Mr. Breivik has said that the killings were committed in self-defense to combat what he has called the “Islamic colonization” of Europe. He has argued that an insanity judgment would detract from his cause. "The defendant has a radical political project, said Geir Lippestad, onf of his lawyers. "To make his acts something pathological and sick deprives him of his right to take responsibility for his own actions."I am curious about other cases where the defense and prosecution have made similar arguments. 

Tuesday, June 05, 2012


The Archives of General Psychiatry has published another of James Harris' wonderful discussions of art and psychiatry. This month Harris discusses the American painter Benjamin West's (1738-1820) painting of Erasistratus Discovering the Cause of Antichochus' Disease. He uses the painting as an opportunity to provide brief, incisive  discussion of Lovesickness. I have had a longstanding interest in lovesickness. As Stanley Jackson pointed out many years ago Lovesickness provided one of the earliest circumstances where doctors diagnosed and treated pathogenic secrets as the cause of illness.   Thanks to Harris for expanding my appreciation of this interesting disorder. 

Thursday, May 31, 2012

How I Became a Historian of Psychiatry: Gerald Grob

Gerald Grob, one of the great historians of psychiatry, has submitted his statement to the blog h-madness' series on "How I Became a Historian of Psychiatry." Having read much of Grob's work many years ago and been much impressed by his intelligence and good judgment, I was quite moved by this piece. I pass it along for those who don't regularly read h-madness.

Friday, May 18, 2012

Spitzer Apologizes

Psychiatry seems endlessly political. Having read Ronald Bayer's excellent chronicle of the story of homosexuality being read out of psychiatry's Diagnostic and Statistical Manual I was puzzled when I read the New York Times headline " Leading Psychiatrist apologizes for Study Supporting Gay 'Cure'." I was completely unfamiliar with the story it relates of Robert Spitzer's sponsoring and publishing a study on treating homosexuality in 2001.  The author of the article, Benedict Cary, suggests that it was Spitzer's anti-establishment impulses manifesting themselves again that led him to conduct the study. I found myself wondering if the study didn't express some  reservations that Spitzer still had about his advocacy for the de-medicalization of homosexuality. At the end of the article Spitzer, clearly thinking about his legacy in the history of psychiatry says of his apology: " You know, it's the only regret I have; the only professional one, … And I  think, in the history of psychiatry, I don't know that I've ever seen a scientist write a letter saying that the data were all there but were totally misinterpreted. Who admitted that and who apologized to his readers."  He might have added that it would be hard to find a psychiatrist turning 180 degrees from one politically controversial position to another -- not to mention in the wrong direction.

Wednesday, May 16, 2012

Diagnosing the DSM

Allen Frances' May 11, 2012 op-ed piece in the New York Times "Diagnosing the DSM" is a wonderful piece of common sense. He argues that we don't need to insist that psychiatrists are in cahoots with drug companies to see that conflicts of interests render the American Psychiatric Association incapable of developing a diagnostic manual that does not overreach and medicalize much of everyday life. His suggestion that some presumably neutral arbiter such as the National Institutes of Health should take on this task is worth discussion.
As it happens I was just rereading a wonderful essay by Peter Sedgwick in his 1982 book Psychopolitics, titled "Illness--Mental and Otherwise." While it is aimed at the anti-psychiatry theorists of the day, its central point is that all diagnosis, whether of mental or of physical disorders, involves value judgments. The great success of the DSM as well as its scientific pretentions make it clear that we must take Sedgwick's arguments seriously if we are going to have an honest debate over the reasonable limits of psychiatric diagnosis.

Tuesday, May 01, 2012

More on straitjackets

       In a  2006 post I wrote that the camisole de force was invented at the Bicêtre in 1790.  I recently realized that my source got that wrong. Most sources cite the same inventor, but give the date as 1770. In addition it seems that the strait waistcoat was in use at least by that date and probably much earlier. In 1772 David MacBride gives a detailed description of construction of the strait waistcoat, implying that it was well known in Britain by that time.
       By 1784, and perhaps as early as 1777, the very influential Scottish physician William Cullen in his First Lines of the Practice of Physick was praising the waistcoat not only as a means of restraint, but also as a remedy and even suggesting a physiological rationale for its benefit. This passage is so striking that it is worth quoting at length.

     "Restraining the anger and violence of madmen is always necessary for preventing their hurting themselves or others: but this restraint is also to be considered as a remedy. Angry passions are always rendered more violent by the indulgence of the impetuous motions they produce; and even in madmen, the feeling of restraint will sometimes prevent the efforts which their passion would otherwise occasion. Restraint, therefore, is useful, and ought to be complete; but it should be executed in the easiest manner possible for the patient, and the strait waistcoat answers every purpose better than any other that has been yet thought of. The restraining madmen by force of other men as occasioning a constant struggle and violent agitation is often hurtful. although there may be no symptoms of any preternatural fulness or increased impetus of blood in the vessels of the brain, a horizontal posture always increases the fulness and tension of these vessels, and may thereby increase the excitement of the brain."
      Philippe Pinel may have learned about the strait waist coat from Cullen when he translated this passage in 1785, incidentally using the term chemisette serrèe, suggesting that he was not yet familiar with the commonly used term camisole de force. In his Treatise on Insanity in 1800, Pinel argued that his use of the camisole de force was evidence that he subscribe to the same philanthropic principles as those of the York Retreat:
       We are doubtless without the advantages of Dr. [Thomas] Fowler's establishment in Scotland [actually the Retreat in York] with its expansive grounds and fine accommodations. But I can attest after two years of diligent observation that the same principles of philanthropy prevail in the management of the insane at Bicêtre. The attendants, under no pretext whatever, ever raise a hand, even in reprisal. Strait jackets [Gilets de force] and seclusion, for short periods, are the only punishments inflicted. When kind treatment or the imposing trappings of repression fail, a clever ploy sometimes produces unexpected cures [TAM. 1800, 65-6].

Defending Psychoanalysis in France

The dispute in France over the role of psychoanalysis in treating autism brought a defense of analysis in the Nouvelle Observateur [NO] from Elisabeth Roudinesco [ER] and Alain Badiou [AB].  I found one section of their comments of particular interest, not because it related to the issue of autism, but rather because it offered a social psychological interpretation of the plight of psychoanalysis. Here is my effort at a translation:
[ER]The dissatisfaction [of the relatives of autistic children] does not come from nowhere. However, all the critiques are not acceptable. For example, we are witnessing a new phenomenon: patients want to decide their treatments and consider in particular that their symptoms belong to their identity. [she uses the term boufées délirantes. I would paraphrase the CNRTL dictionary definition of this term as a sudden, short lived mental disturbance manifesting itself through hallucinations, sensory illusions and accompanied by mental confusion.] They do not see why they should be numbed by medication on the pretext that they hear voices. In which case one must listen to them. But we are going towards the patient as master of his destiny, and this is not desirable. Here again, psychoanalysts bear part of the responsibility, because by enclosing themselves in chapels they lose their authority. At bottom what has been lost in psychoanalytic societies is the position of master to the benefit of that of little chiefs [petit chefs].
[NO] What do you mean by “master?”
[ER] The position of master permits the transference: the psychoanalyst is “supposed to know” what the analysand is going to discover. Without that, trying to discover the origin of the suffering is almost impossible.
[NO] Is it really necessary to go through the restoration of the master?
[AB] The master is what helps the individual become a subject. Because if one admits that the subject emerges in the tension between the individual and universality, then it is evident that there is a need for mediation to advance on this road. And therefore the need for an authority. The crisis of the master is the logical consequence of the crisis of the subject, and psychoanalysis is no escape  from it. It is necessary to restore the position  of the master, but it is not true that one can do without it, even and especially from the perspective of emancipation.
[ER] When the master disappears, he is replaced by the chief, authoritarianism, and that ends always, sooner or later, in fascism- history has, alas, proved this.

I found this part of the interview interesting because it suggests that for psychoanalysis to be successful as an individual therapy and as a therapeutic institution the analyst must be accepted as a ‘master,. that is as one who is ‘supposed to know.’  While the priestly role of the doctor is an important part of many, if not most, areas of medicine, these remarks indicate that for psychoanalysis this role is the critical ingredient. Indeed, they seem to say that without the analyst being able to assume the role of master the process cannot occur. In a patriarchal society, such as the one Freud lived in, the doctor as a ‘master’ could be assumed. What the authors seem to be suggesting is that the challenge to psychoanalysis posed by such people as the relatives of ‘autistes’ is part of a larger challenge to patriarchal norms that may be occurring in France somewhat later that it did in the United States. This raises the question of what  role of the challenge to patriarchal norms in the United States has played in the decline in the fortunes of psychoanalysis.

Saturday, April 28, 2012

The Wall

Although the controversy over Sophie Robert's documentary film "The Wall: Psychoanalysis put to the test for autism" has been going on for a while, I first learned about this week when I ran into an article in the Nouvelle Observateur titled "Faut-il brûler la psychanalyse ?" in which Elisabeth Roudinesco and Alain Badiou defend psychoanalysis. Frustrated with reading this I learned that in January 2012 The New York Times published an article "A French Film Takes Issue with the Psychoanalytic Approach to Autism," which reviews the controversy quite clearly. However, clicking on the link to the Youtube version of the film in the article, I found that it had been removed from Youtube. This act of censorship  got me interested in finding a way to view the film. Indeed several sites no longer had the film available. I did find one site where the film is available. As a document in the history of psychiatry, it is well worth viewing. It reminded me of the controversies over psychoanalytic theories of Tourette Syndrome that Howard Kushner describes so well in his book A Cursing Brain? Histories of Tourette Syndrome.

Sunday, April 22, 2012

Rabbi's Little Helper

Psychiatry has long been accused of being an agent of social control. It appears that a new chapter to this story is being written in Israel.  A few weeks ago Haaretz published  "Rabbi's Little Helper," which related stories of people being taken to psychiatrists by their rabbis for medication, presumably in the hopes that their behavior will better conform to community standards. Today Haaretz published a follow-up titled  "Psychiatric drugs become talk of the ultra-Orthodox community.

Tuesday, January 10, 2012

Biology vs. Psychology in the 1920s

     Some years ago, while rummaging around in a room full of psychiatric hospital records from the 1920s, I ran across the verbatim typescript of a memorable case conference. During this period two perspectives on understanding patients were actively competing. Psychoanalytic ideas were still relatively new and attempting to explain all sorts of phenomena that had previously been explained biologically. At the same time new biological treatments were infusing biologically oriented psychiatrists with new confidence. At this hospital the ambitious medical director had recruited a number of young clinicians from each of these perspectives. The case presented on that day was a middle aged man who had been treated with mercury some ten years earlier for symptoms of general paresis of the insane. Now he was admitted to the hospital for symptoms of depression with some suspicion that his general paresis had returned. In the days before penicillin, general paresis, which is a form of tertiary syphilis was a common frightening cause of madness and death. Its early psychiatric manifestations were quite variable, though most often they were mood related--mania and depression. While severe dementia eventually dominated the clinical picture, symptoms of dementia were, in the early stages, often subtle and easy to miss.
      Why was this man depressed? The medical director posed this question to his young new staff somewhat in the manner of a professor presenting a question to a class. A lively discussion broke out. The  biologically oriented psychiatrists noted that  mood symptoms were common in such cases of general paresis. The psychoanalytically oriented psychiatrists argued that the sexual nature of the disorder ws producing guilt and that was leading to the symptoms of depression. The discussion went on for some time without resolution since the two perspectives were incommensurable. Eventually the medical director asked that they simply review the facts of the case.  After some further discussion, he pointed out that ten years earlier the patient had thought himself cured of syphilis and free from the possibility of general paresis. Now, perhaps, the patient was able to subtle signs of dementia in himself and understood what was in store for himself. "Isn't that," the medical director concluded, "reason enough to be depressed."
       Reading that case many years ago, I thought about how ideological arguments have the power to distract psychiatrists from what is staring them in the face. Over the years that I have practiced psychiatry, i have often had occasion to recall the lesson of that case conference.