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GUEST POST: Psychiatry and its Tragedy, by Nelson Borelli, M.D. 12/19/2012

Posted by ALT in Guest Post, Philosophy/Spirituality.
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I am honored to present another guest post from reform-minded (former) psychiatrist Dr. Nelson Borelli.  His website and manifesto are well worth reading, and the thoughts he puts forth here about moral agency and psychiatry come at a very important moment in the national dialogue about these topics.


By Nelson Borelli, M.D.

ALT_mentalities kindly invited me to write a critique on the practice of psychiatry.  I accepted it with reluctance for several reasons.

First: There is not much original thought I can add to the matter after the monumental contribution of many others, Thomas S. Szasz and Karl Menninger in particular.
Second:  Psychiatry,— and I will use that word to include psychiatry and other enterprises such as clinical psychology, social work and all “therapies,” and most respective practitioners — are faith-based organizations, not open to rational thinking and dialogue, let alone change.
Third: History seems to show that critiques to psychiatry are perceived as callous attacks to “science”, to psychiatry practitioners, and to the “mentally ill.” This is usually followed by the hardening of the faith and more closing of the thinking.

Yet I’ll try; the youthful vitality of ALT_mentalities inspires me.

Saving the Underdog

Psychiatry’s tragic course began in the sixteenth century when the political rulers lined up for execution of a woman because she was a “witch.” But a well-connected doctor saved her life by showing she was a sick woman, not a witch. The doctor was Johann Weyer. His deed was certainly good but the reason was bad. That saving-the-underdog became a tragedy of unlimited proportions. After half millennia the tragedy is still with us and it is growing.
The “witches’ law” was wrong then; many social intolerance laws are wrong now. Bad laws should be confronted morally, politically, because that is what they are. They are manmade laws.

Confronting them by “biological-disease” means results in tragedy. The heroic “biological”, medical shortcut is bad. It has built-in badness because it results in bad consequences for the hero (psychiatry) while the moral problems remain unresolved.

Visitors from another planet would be sympathetic to us in learning about our seemingly unsolvable moral problems: When does life begin in the unborn child? Is it permissible to unplug life-supporting equipment from the terminally ill? If so when? Is abortion permissible and if so when and in what circumstances? Should we abolish the death penalty in the USA? Do children have rights? If so what rights, at what age? Do we go for gun control or the Second Amendment? What are the boundaries between Personal and State rights? Et cetera.

Contemporary psychiatry is suffering the bad consequences of the heroic acts of “saving-the-underdog.” Psychiatry is discredited. Self paying patients are fewer and fewer. Third-party payers refuse to pay for “services.” The only thing that keeps the psychiatric industry alive is the state-sponsored/enforced “mental illness/mental treatment” dictum. Nor has the psychiatric industry’s “stigma” cry been working well either.

It is an unnecessary, self- inflicted tragedy, to put it mildly, (for the profit factor cannot be ignored). Psychiatry could be of help to the many folks who suffer from emotional problems. Psychiatry could have room in medicine as a (soft) branch of it. Although the causes and pathology of emotional problems remain obscure, they could continue to be investigated by scientists interested in the field. Emotional problems could be dealt with by professionals who are patient enough to deal (humbly) with diagnoses’ uncertainties by using trial-and-error techniques.

There are already some significant scientific contributions on the relationship between bodily physiology and the perception of emotional reactions. Psychoanalysis and related disciplines have also contributed to the understanding of human emotional conditions. Even the dreadful, drug-pushing, disease-manufacturing pharmaceutical industry has made some contributions. However limited the knowledge of psychiatry at present, there is room within medicine and related disciplines for a respectable Psychiatry specialty.

But that would require present day psychiatry to drop the “mental-illness” ideology.

Psychiatry & Moral Agency

At the core of the “mental illness” ideology is the notion that a person can lose moral agency, this is that the person is no longer able to know what he/she likes or dislikes, or is not able to form and execute (“correct”) personal opinions due to a “biological ill condition.” That is that the person has become “mentally ill.”

That is wrong.

The fact is that humans’ opinions cannot be (biologically) ill. This is a travesty with terrible consequences such as the deprivation of civil rights to citizens who have not committed any crimes.

A court of law may order involuntary psychiatric treatment, known as “Civil Commitment” for a “mentally ill” person. Although the large majority of the “mentally ill” persons are not subjected to involuntary treatment, all “mental Illness” diagnoses suggest possible Civil Commitment, that is, deprivation of personhood.

The fact is that psychiatry is not able to predict criminal behavior on a given person. No legally responsible psychiatrist would publicly state to what percentage of probability a person would act criminally because there is no publication of any scientifically conducted study that objectively demonstrates such a prediction.

Human opinions can be wrong, or right, with respect to a prevailing social code of ethics. A quick look at the history of humans’ opinions shows that even very “important” opinions, come and go. Examples: The learned ones used to sure the Earth was flat. Now the learned ones differ as to whether humans were created or evolved. These are human opinions; they may be errors. But they are not forms of “insanity” or “mental illnesses.” Incidentally, the utterance “sick opinion/belief” is only a pejorative metaphor, an unfortunate metaphor because it is often used literally.

Unfortunately (or fortunately) we humans were born without a God-given “user’s- book.”  If we were we might be angels of God like Adam and Eve were before they CHOSE to eat the apple.

Ever since, we are born with the ability to choose. We are born to be on our own stewardship.

One may or may not choose to use the Biblical story, but the fact is that each one of us is ultimately responsible for the management of our lives. We have to manage our lives by the use of science or inspiration and hope for the best. No guarantee of success.

Be aware of false “saviors” such as psychiatry that offer you the “the brain-made-you-do-it” way out as a means of angelic tranquility. If you go for it you become a robot; a Mental Patient Green Card carrier, with entitlements but deprived of personal moral agency.

Personal Moral Agency

Personal moral agency means that one is born with the ability to know, choose and act in accordance to what one thinks is right. Just in case: What you think is right may not be what others think is right.

Psychiatry did not get a “users’ book” from God either. Psychiatrists’ opinions on persons’ life management can be wrong, very wrong! Psychiatrist Egas Moniz won the 1949 Nobel Prize on the “benefits” of lobotomy on “psychotic patients.”

How to manage your life? Simple: Each of us gets information, input, from the world around us and from our own bodies. It’s up to each of us to look, examine, re-examine the information, look for more information and consult with others as needed. Then we reason. Then we act, execute. The more we work on the information, particularly information-that-I-do-not-want-to-know, and do the reasoning, the greater the chance that we would be pleased with our acts or execution at a later date. Of course there is no guarantee that we would be pleased with our acts at a later day. We humans are not perfect, period.

The more one practices on information gathering and reasoning, the greater the chances to be content with our acts at a future date. Unfortunately, just too often people choose to delegate to others the information gathering and reasoning. In so doing, they dull their minds; this is the ability-to-mind. Minding is an inborn ability. However, the quality of minding depends on how much we practice it.

The tragedy of psychiatry will eventually end in the same way other tragedies ended: the death of the hero. In this case, the “mental illness” heroic attempt to “solve” humans’ moral problems.

Good, serious psychiatry is badly needed. But even more needed is for us to get in touch with, to honor and respect our precious minds and humanness.

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1. jacqueline Roig, PsyD - 12/19/2012

Congratulations and thanks, both, to Dr. Borelli. His comments encapsulate the nature of the beast and the changes so badly needed. I wonder at people like him, Thomas Szasz, and myself, among others, having such a difficult time getting the gist of this message to be integrated into mainstream thinking. Then again, mainstream thinking usually leads to my head-shaking in this realm, because the clearest and simplest messages seem to be the ones that get the most detractors. Instead, people generally prefer staying in the soup with little thought to consequences of it. It is preferred, by professionals and public alike, to apply a convenient label, e.g. Lanza automatically becomes named mentally ill after his disgusting and intentional act of cowardice – (no one labels the good acts as mental illness but rather as heroics). Who determines what is good and bad is fluid, subjective and up for grabs depending on the current culture. Paying attention to moral agency, making choices and intentionality is necessary to get the blindfolds off and stop pretending that we humans are victims of our head demons.
Dr. Borelli’s comments give an excellent primer – a shortcut – to the concepts of minding and moral agency. I hope they reach far!

2. R2DTew - 12/20/2012

Borelli puts his finger on something essential when he discusses psychiatry from the perspective of moral agency. However, it is not so clear just what constitutes moral agency nor, more importantly, when an individual achieves moral agency. Borelli’s comments asking when a child has rights, and what rights, reveal the ambiguities that immediately arise when someone talks about moral agency. What exactly is moral agency? Is it a black-and-white thing? And I don’t mean to refer to racial issues here, although perhaps relevantly, they do bring to mind another facet of the “moral agency problem”. So the dilemma confronted by psychiatry and all of its relatives is not much advanced by asserting that we are each born with moral agency. That is not much different from saying that we each are born alive.

Of course if one gives ground on the absolute of moral agency, then the entire defense of individual choice suffers. It seems to me that this framing of Dr. Borelli’s perspective echoes how people thought of one another long ago. Much of how we think of ourselves and each other today includes those old ideas, not always to our advantage. Today’s view of the person is more nuanced than times past, don’t you think? And if you do not, how then has this aspect of our humanness not manage to develop when so much else has?

There’s no question that psychiatry, and to a great extent medicine in general, has changed because of the forces of business and societal need. And it is not difficult to argue that many of those changes have stripped the humanity from psychiatry (and medicine). Certainly the issue of moral agency arises when an individual offends the expectations of the people around him/her. And people respond differently to the burdens of moral agency. How else to understand the allure of intoxicants?

While he did not state it, Dr. Borelli implies that each person comes into the world with the same moral agency, and I use his definition here: the capacity to know what he/she likes or dislikes and to form and execute (“correct”) personal opinions (“one is born with the ability to know, choose and act in accordance to what one thinks is right.”). If there was no he supposes we all have some sort of homunculus within us that is fully empowered and only needs to learn the local rules in order to fit in or transcend the immediate environment. Modern science, including psychiatry, is far more developmental in its framing of this topic. How much of what we do as infants, even as young children, is reflex? Can we meaningfully say that a young child, a very young child, has intention? This seems like more than a rhetorical puzzle.

Does Dr. Borelli accept the idea of intelligence quotient, or the fact that how a person perceives can be affected by how their body operates? Yes, I understand this introduces the painful and distressing corollary is that we are in part (at least) shaped by our makeup. Certainly we humans have struggled for ages to measure our worth against some external standard, and in the process of doing so, have harmed others and our own progeny because of our ignorance and intolerance. Perhaps that suffering makes it difficult still to consider, let alone accept, the idea that who we are, what we are, to say nothing of how we think, what we think, and feel… that we are shaped, even though a moment’s glance in the mirror reveals so many ways that we are unique. Perhaps too we fool ourselves into thinking that we are not shaped because we are unique. But if we accept the idea that we are shaped, arguably in the same way that a tree is shaped by the place in which it grows, then the question arises whether moral agency is shape-able. (Or if not ‘moral agency’, then whether the actions of a moral agent are shapeable.)

Of course traditional analytic psychiatry rests on the premise that a guided (or not) confrontation with self will shape the individual and that transformation is hoped to advance or mature the moral agency of the individual. Now some might argue — Dr. Borelli included — that such work does not actually change the moral agency of the individual; it only refines its activity. But this distinction, if you want to call it that, highlights the ambiguity between who (or what) we are and what we do. This is

Dr. Borelli would like us to think that a person’s opinions — my opinions — cannot be biologically ill. But of course that is wrong in so many ways that I’m a little surprised he would assert it. Perhaps his point is more subtle than this, but I know I can have a few drinks (of alcohol) and begin to express opinions that I will be very reluctant to acknowledge tomorrow. Now you might say that those are not my opinions but are only those of some intoxicated doppelgänger who was briefly running my body. Or you might say that those opinions were my (fickle) opinions because I deliberately chose to change my thinking with intoxicants. But either way the point is made that what seems to be my opinions can be pretty bizarre under the right circumstances. And since there certainly are more than a few situations in which a person can suffer some sort of altered state, and not intentionally but simply because there’s some physiological process inducing that state, then it becomes relevant that moral agency as manifested by opinions and actions is vulnerable to how the organism functions physiologically.

Now I realize this sort of logic opens the door to all of the difficulties that confront someone who’s way of thinking and behaving clashes with society. And nothing makes the problem more compelling than this: how we think about ourselves may not allow us to recognize that how we are thinking contains a flaw, or a blind spot, or some twist of logic or belief. This is everyone’s dilemma and we all solve it the same way: we accept what we know now as true and real until such time as we have an experience that contradicts that assumption.

Today the world is filled with flawed rationalizations about self and existence. Not only do individuals struggle against the assertions of flaws in their thinking, but entire cultures are today engaged in these arguments. And certainly some individuals struggle within themselves as they try to find their voice and clarity about who they are, what they are, and the larger existence. Further, not all people are articulate to the same degree or in the same way about this existential issue. Still, the point can be made — and this may be Dr. Borelli’s central assertion — that our current ways of confronting this ‘situation of life’ might be better executed if we diminished our culture-wide, perhaps humanity-wide, affinity for comparison and hierarchy (as pathology and other win-loss perspectives) and instead adopted a more generous — developmental? — way to regard this aspect of “individuation” so that people whose orientation to this task is unique (is this not all of us?) are given tools to further their task.

Of course, the arch of history and of individual lives might be seen as having exactly this agenda.

Anonymous - 12/21/2012

R2DTew said:-

“Dr. Borelli would like us to think that a person’s opinions — my opinions — cannot be biologically ill. But of course that is wrong in so many ways that I’m a little surprised he would assert it.”

You shouldn’t be surprised at all. And Dr. Borelli is not wrong. An opinion can’t be literally “ill”. Only a body can. And if when the world can’t prove the body is ill, it should shut up about bodies. Simple. And if the world won’t shut up about bodies, at the very least it should admit it is engaging in nothing but wild speculation and theorizing.

The alcohol analogy was flawed, because even if you are drunk, you are still you, if it your opinion that you’d like to disavow your drunk opinions you have no choice but to use words like “yours” and “my” opinion when even minding this analogy. Even if you altered your state for a while, those memories of that night, with those disinhibited opinions, which came from within you, opinions aren’t an ingredient in the molecular makeup of ethanol, these memories are still part of your life’s timeline and part of you, and you existed in the world on that night, the ID in your pocket had your face on it, and that driver’s license in your wallet can be taken away if you drive home.

Plus, if you perpetrate a risky DUI, you are still held responsible. And if you punch someone in the head in a bar fight, you are still held accountable. MAYBE the judge will have SOME modicum of mercy on you and see it as slightly mitigating if the day before you got drunk, your child was gunned down in Sandy Hook, for example.

What Szaszian thought has always said is, people are people, and it should be people in the dock, not quack speculation about alleged unproveable, unfalsifiable “brain disease”. Maybe the judge takes mercy, maybe the jury comes to see the context of the person’s life story up to the crime, but there should be no hard and fast “psychiatry brain disease insanity defense”, because it is a fraud, and will remain a fraud, until this pathetic profession discovers a damn thing.

There are more levels on which the alcohol analogy are flawed, and this nothing new, simplistic analysis of the problem of the mind and its extremes has often yielded simple minded “intoxication” analogies and experiments, comparing various illicit drugs to “madness” etc… it doesn’t hold water. If you’re drunk, you could say your decision making was impaired, but that is really just a value/moral judgement, a normative statement about what your opinion ought to be, but your ability to operate machinery was also impaired. Whereas, the mythological “brain diseased” mass murderer, is able to operate deadly machinery with the precision of a Navy SEAL.

A body can be impaired, yes, but we have no reason, and parsimony would suggest it would be stupid, to blame the body when every single thing is working just fine, we can’t prove anything is wrong with it, but merely on the periphery a person has some complex problematic behavior, thought or feeling, “problematic” as in from a moral/political/normative standpoint.

Every demonstrable brain disease in real medicine has a predictable course, leading to global systemic problems in all areas of functioning eventually. The same can simply not be said for the millions of people accused of being brain diseased by psychiatry, who are not soiling the bed, gradually losing their motor skills, and exhibiting more simple behaviors by the year, shrinking into complete disability, etc etc which is seen with something like Dementia or PD or Fatal Familial Insomnia, brain cancer, or whatever.

When Borelli says moral agent, he means the person being seen as a human agent, come what may, when all that is happening is some of their thoughts, feelings and behaviors are problematic.

We should view as a moral agent a person even if they are a troubled person with immense problems completely at odds with getting along reasonably in a society that doesn’t share a single one of his allegedly “ill” beliefs or opinions perhaps, but not necessarily permanently, and there is always hope for that person to get better and better at minding and mastering their life and returning or coming to more of an agreement with the beliefs, feelings and minding of those around them, so as to get along in this life.

Regardless of whether one believes their God is acting through their hands, and promising them virgins in heaven, they are the author of their actions, being “impaired” by a belief or an opinion or a feeling one may come to regret doesn’t negate responsibility. The terrorist picked up the box cutter and started slashing throats, he can’t prove it was his God’s will, and psychiatry can’t prove it was his “brain disease’s” will.

For some reason, a lot of people seem to think it is the most “inhumane” and “uncompassionate” thing ever! to actually listen to someone like the Arizona shooter, and give him a quick, speedy trial as guaranteed under the constitution, just because some of what he might have had to say in court might have been “embarrassing” or “incoherent” or “strange”, so we do the “compassionate” thing and drug him like an animal for months, until he can sit silent and drooling in court and watch “his” court case proceed through the glazed eyes of a psychiatrized zombie. And it is considered “compassionate” to deny people equal treatment under the law and instead to deny them the right to be treated like any other criminal, to be punished, banished, and to while away their life in a prison cell with books and cell mates and letters, and time to reflect on their actions and try and reform and master themselves a little better even.

No, it’s considered “compassionate” to force people into indefinite cruel and unusual punishment, with no hope, where they become psychiatry’s dehumanized flesh bag filled with drugs and drool.

All on the basis of what? a pathetic pseudoscience?

An extreme, unconscionable. human action, just because it seems so alien to everybody, is considered a “self evident” proof of “brain disease”.

Until society starts viewing humans as human, and not “diseased brains’ we will not improve anything.

Adam Lanza smashed up his computer hard drive before he carefully draped himself in the garments of war, bulletproof body armor, and multiple weapons, with plenty of rounds. He chose his target decidedly, and hit it at the time of day where he could do maximum damage in carrying out his ghoulish personal military operation, a declaration of war on a society he hated, on a world he hated, culminating in the extermination of the person he hated and saw no hope for most in the world, when he turned the gun on his own head.

Adam Lanza’s actions say a lot, they say premeditation, planning, conscious agency in executing his plan, and covering the tracks of his planning.

The ten million words that have been written in the press all talk about his allegedly diseased brain. But the only thing we know about Adam Lanza’s brain is that there is a bullet in it, and pieces of it were all over the floor next to his corpse.

We are so busy talking about school shooters, we can’t even hear their actions speak. Because they are not human to us, nobody who dares exhibit the extremes of human nature, or human behavior, is ALLOWED to be seen as human.

It is nothing but a glib prejudice, this “brain disease’ religion. Don’t expect this religion to die anytime soon. It was created for a reason. Mankind felt the need for a new, graduation from simplistic God blaming, to simplistic nature blaming.

When somebody does something wrong, we ask what is wrong with their biology. How utterly ridiculous a worldview is this? WHY stick your head in the particle physics clouds, in the physical sciences, when they don’t have any answers about how to live?

Great works of architecture are not designed by materials engineers. We don’t ask particle physicists to solve the problem of “what is better, Coke or Pepsi?”.

The art of living a life is a river carved deep in the human stone of history, philosophy and tradition and culture over thousands of years. We shouldn’t be looking to quacks who slice apart the dead entrails of people arbitrarily labeled labeled “schizophrenic” to tell us what behavior is “out of order” and “in order”. These worthless quacks would be still telling us all gay people are “out of order” if hadn’t have been for political pressure.

Instead of piping the deadly, self-perpetuating, toxic myth into the head of every teenager out there that they “can get” the “brain disease that makes you shoot up a school”…. we should be doing our best to give these kids guidance on what a life well lived is, what good decisions made every day are, what good habits are, not playing shoot em up computer games 6 hours a night, not fetishizing death and killing and nihilism, etc.

Only when we come to accept that brains, like citizens, should be presumed nondiseased until proven diseased, and that PEOPLE with healthy working brains that can send the signals to take the car keys, open the car door, drive a stick shift, drive it to the school, get out the gun, walk into the school, you know the rest…. DO DO EXTREME THINGS, and that all complex human behaviors, are the actions of human agents, will we ever progress.

Thought experiment:

A person labeled a “psycho killer”, “brain diseased”, “psychotic”, is in the middle of a killing spree, machine gun firing, bodies hitting the floor, and at that moment, magically, everyone on Earth except for him drops dead of the plague, instantly, except him…

He’s got no humans left to kill, they are ALL dead. So he starts shooting the birds and deer in the field next to the school he was shooting up, he’s now no longer a “psycho killer”, he’s a hunter.

And nobody is left alive to label him.

Psychiatry is all about outnumbering the person and defining him or her as the one who has something “wrong with them”, outvoting them.

We don’t like what he’s doing, so we label what he’s doing a “symptom of a disease”. It’s just a bullshit fairy story, and around the world, people are reading it to their kids before bed, when they give them their “ADHD” pills.

3. S. Randolph Kretchmar - 12/23/2012

Dr. Borelli, thank you for helping to keep the flame of liberty burning despite the persistent ill wind of psychiatric coercion.

4. jacqueline Roig, PsyD - 12/27/2012

Anonymous – too bad you didn’t take credit with your name, as you had a lot of good to add to Dr. Borelli’s comments. To anyone who does not see your point, your statement would be seen as a wacko manifesto. To those who knew Szasz, who hear Borelli, and who think rather than hysterically react, you are more honest and just than our judicial and certainly psychiatric systems. Psychiatric coercion is alive and well despite the most basic denial of human liberties. Coke v. Pepsi is marketing, and so is ADHD, bipolar, etc etc. Both elicit dollars spent, both wish to earn the generic equivalent of a brand name as culturally dominant. (Kleenex rather than tissue; brain diseased rather than moral agent.)
The social commentary that prevails surrounding psychiatry is in the same house as “guns don’t kill; people kill” – the latter widely accepted as the moral agent employing the tool. In the case of the “mentally ill” who perform abhorrent acts, it is never the moral agent; it is the disease of the brain that drives the bus…
I hope the voices here who question and aim to shed light can be spread outward to appeal to the sheep culture we have become.

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