“Most senior US military officers now believe the war on Iraq has turned into a disaster on an unprecedented scale“, says Sidney Blumenthal.

The Left Coaster believes that Gallup greatly oversamples the Republican component of its poll participants, because of an unwavering assumption that a greater percentage of those turning out to vote will be Republicans than Democrats.

And Jimmy Breslin tells you you might as well make up the poll results yourself for all they are worth, making much of the fact that those will cellular phones instead of landlines are never polled by current methodologies, which means younger voters are disproportionately ignored. (NewsDay)

Pointed to by a reader in the comments, this site amplifies on Breslin’s point, mentioning VoIP customers who get to choose their area codes (although I suspect this a vanishingly small proportion of the electorate).

Is the commenting system broken, or is nothing I’m logging worth commenting upon? There haven’t been any comments here in days. Or is no one even visiting? Did everyone get out of the habit of reading FmH when I took several weeks off from making entries here this summer?

Let’s try something. Instead of you just answering the above questions in your comments to this post, why not make this an open discussion thread? Enter a comment about anything on your mind that you would like to discuss with other FmH readers, such as they might be…

FmH readers know I am a fan of fellow traveller and Wired contributing editor Steve Silberman’s writing. This new piece is, he wrote me, “the first look inside a new Pentagon-sponsored training program for soldiers headed to Iraq and elsewhere that immerses them in highly realistic virtual environments designed by Hollywood special effects artists.” Silberman’s article on this unholy alliance is all about the romance of the advanced technology being used and the cost savings to the Pentagon, which won’t have to waste so much ammunition in live fire exercises anymore. What I would have liked to see, and what is virtually absent from the piece, is something about the moral compunctions I imagine some of the Hollywood or computer-geek types might have about contributing to the war machine. Or are my expectations about a generation behind? Steve?

It is amazing, one would have thought that after the national outrage about the Florida ballot shenanigans of 2000, the state’s Division of Elections would have to tread lightly in 2004. But, no fans of subtlety, getting away with it in 2000 seems to have emboldened them to even more clumsy manipulations this time around. We have already heard about the mysterious visits uniformed officers have been paying to elderly African American voters suggesting some ill-defined investigation of their right to vote, in an obvious attempt to scare them away from the polls. Now, despite a court order against putting Nader on the Florida ballot, the Republican chief of the Division of Elections is using Hurricane Ivan as a pretext to do so anyway. If the hurricane interfered, the ballots could not be prepared in time if she waited for a Wednesday hearing on the court injunction, she ruled, so Nader’s name should appear just in case he wins the right to be there. If he doesn’t belong on the ballot, any Nader votes would just have to be discarded. (The American Prospect) See also this (BBC).

This weblogger known as Reinman, who has been writing a weblog for only 17 posts and one month, posted a review of FmH because, apparently finding my site at random, he was pleasantly surprised by the soft drink post below. This 20-year old Minnesota student and football fan whose tastes run to Fiddler on the Roof, Lawrence of Arabia, The Catcher in the Rye and The King James Bible, is kind enough to say that my anti-Bush sentiment (from his vast experience perusing the weblog universe, he puzzles about whether all bloggers are of that persuasion) doesn’t get in the way of his enjoyment of ‘some of the stuff on the site’.

He seems to be looking for ‘humorous references to pop. culture’ which (sound of headscratching) he seems to find best characterize the material at FmH. Funny, I didn’t think I was being all that funny all that often. However, he concludes in the last analysis that there isn’t much reason, other than the soft drink map, to come here, because “if… you’re craving… a classic blog with some humorous stuff”, he thinks he does it better. More power to him.

Tragically, he announces that his series on “blogging the bloggers” is to end with FmH, the fifth he reviews. He makes the curious comment that he is “not planning any prequels”, which allows him to come out with a witticism about how

I think I get it. Come to think of it, this post may qualify as a ‘humorous reference to pop. culture’. I wouldn’t know how else to categorize it, so maybe Reinman is onto something.

The US and its coalition attempted to use the violations of UN resolutions to legitimize the invasion. Now, as Annan finally breaks his ‘tactful silence’ and delegitimizes the war, coalition representatives continue to try to have it both ways, both insisting the war conforms to the UN charter and saying the UN is a useless agency obstructed by differences of opinion within its ranks. (Guardian.UK)

The art and the importance of doing the least possible in the workplace:

1 You are a modern day slave. There is no scope for personal fulfilment. You work for your pay-check at the end of the month, full stop.

2 It’s pointless to try to change the system. Opposing it simply makes it stronger.

3 What you do is pointless. You can be replaced from one day to the next by any cretin sitting next to you. So work as little as possible and spend time (not too much, if you can help it) cultivating your personal network so that you’re untouchable when the next restructuring comes around.

4 You’re not judged on merit, but on whether you look and sound the part. Speak lots of leaden jargon: people will suspect you have an inside track

5 Never accept a position of responsibility for any reason. You’ll only have to work harder for what amounts to peanuts.

6 Make a beeline for the most useless positions, (research, strategy and business development), where it is impossible to assess your ‘contribution to the wealth of the firm’. Avoid ‘on the ground’ operational roles like the plague.

7 Once you’ve found one of these plum jobs, never move. It is only the most exposed who get fired.

8 Learn to identify kindred spirits who, like you, believe the system is absurd through discreet signs (quirks in clothing, peculiar jokes, warm smiles).

9 Be nice to people on short-term contracts. They are the only people who do any real work.

10 Tell yourself that the absurd ideology underpinning this corporate bullshit cannot last for ever. It will go the same way as the dialectical materialism of the communist system. The problem is knowning when…

 

Radical Protest and the Underground Press in the “Sixties”: An Exhibition (University of Connecticut Libraries)

A reader’s guide to Kitty Kelley’s The Family: “Want the best (if somewhat dubious) dish from The Family, Kitty Kelley’s new treatise on the Bush clan? Follow Slate‘s reading guide straight to the good parts.” As others have noted, unfortunately there is nothing here that will bring down the Bush misadministration or even change the minds of those who are going to vote for him…

“By deciding to invade Iraq, the Bush Administration decided not to do many other things: not to reconstruct Afghanistan, not to deal with the threats posed by North Korea and Iran, and not to wage an effective war on terror. An inventory of opportunities lost.” — James Fallow (The Atlantic)

• Snyder on his relationship with Jack Kerouac
  

  “Jack was, in a sense, a twentieth-century American Lithographer. And that’s why maybe those novels will stand up, because they will be one of the best statements of the myth of the twentieth century. just as Ginsberg represents one clear archetypal aspect of twentieth century America, I think Jack saw me, in a funny way, as being another archetypal twentieth-century American of the West, of the anarchist, libertarian, IWW tradition, of a tradition of working outdoors and fitting in already with his fascination with the hobo, railroad bum, working man. I was another dimension on that.”

• “Four Changes” 1970
  

  “We are the first human beings in history to have all of humanity’s culture and previous experience available to our study — the first members of a civilized society since the early Neolithic to wish to look clearly into the eyes of the wild and see our selfhood, our family, there. We have these advantages to set off the obvious disadvantages of being as screwed up as we are — which gives us a fair chance to penetrate into some of the riddles of ourselves and the universe.”

• The Dhrma Eye of d.a.levy
  

  “d.a.levy – Darryl Levy – I try out his names, reaching to know the man; his poems, his polemics. I feel brother to Levy not only as poet but as fellow-worker in the Buddha-fields. Levy had a remarkable karma: he saw who he was, where he was, what his field of activity was, and what his tools were to be.”

“Is it too late to frame this election game of 2004 as a choice: Empire or Republic?“

Since sundown last night, it has been year 5765 of the Jewish calendar. In Jewish tradition, that means 5765 years since the creation of the universe. Maybe this is inaccurate, but it emphasizes what order of magnitude we should place on each of our years anyway. It has always made sense to me to celebrate two new year’s days each year, one when the cyclical dimming of the days turns to the promise of renewal of the natural world at the winter solstice; and the other more aligned with the cycle of human activity, when the fallow time of late summer transitions into the renewed activity of the autumn, whether we are talking about the annual cycle of agricultural activity, of the school year or the world of commerce and the fiscal year.

The two types of new year’s celebrations also have a somewhat different emphasis. It has always seemed to me that the ritual of the Pagan New Year we celebrate in the winter, attuning oneself to the natural order of things, stands to invoke good fortune for the year to come. The Jewish New Year is more about setting oneself straight with manmade standards of right living, opening as it does the ten days of awe culminating in the Day of Atonement.

It is said that the life unexamined is the life unlived. This is a time to use in reflection on the year just past, in order to live the next fully. How much time was wasted? Were your days filled with life or dull routine? Was love expressed or left unsaid? Was there real companionship with those around you or a growing apart and a taking for granted? Were the kind deeds done or postponed? the gibes unleashed or the tongue held? Have you worked for peace and social justice as much as you could have? Did you acquire only things, or insights and knowledge as well? Have you freely asked for and granted forgiveness ? Did you deceive others? yourself?

Finding oneself wanting, as I do, in some or all of these regards helps in considering the uses to which one will put the year to come. What I do with my next year is important, because I will pay for it with a year of my life, and I hope I do not regret the price.

So, to all my readers Jewish and otherwise, a happy new year. I pray for assistance being kind to my fellow creatures and working for peace. I ask your forgiveness if I have wronged any of you reading this, and I absolve anyone of you who has wronged or offended me.

US commercial truck maker touts ‘extreme’ passenger truck. Modelled after comercial haulage trucks and dump trucks, the International CXT will be the world’s biggest pick-up truck when it goes on sale later this year. 600-1000 of these babies are expected to be manufactured the first year, for the likes of tradesman and builders. But, at $95-100,000 apiece, aren’t we likely to see most of them snapped up by rappers and movie stars instead? Just when you thought SUVs were losing their appeal and it was safe to get back on the highway…

I join those in applauding this as an important first step toward full disclosure in clinical drug research. Anyone who is an intelligent consumer of medical research studies has no confidence in the body of literature. Biases in favor of publishing positive findings arise both from the simple fact that a positive finding is more ‘sexy’ to report and from the increasingly, and depressingly, consistent reliance for research funding on precisely those pharmaceutical companies with a stake in the outcome. Publishing preponderantly positive findings skews medical practice toward newer and newer (and more and more expensive) medications, of course. Several sorts of studies tend never to make it to the light of day. There are those which say that a particular treatment did not show benefits significantly different than placebo. Other studies show that a new medication is no better than the old standard reference medication against which it is being compared. And a third sort of study will show that adverse effects emerged, or a medication was not tolerated well enough, often enough that patients would not stick with it to derive therapeutic gains. When these studies are not published, the adverse reactions they describe, of obvious importance for a physician to know, are from that point potentially dead and buried forever.

The impact of this reform on the evidentiary basis for medical practice will depend on whether it is adopted far more widely than by just a handful of, admittedly influential, journals. (I see none of the preeminent journals in which psychiatric medication findings are published on the list, for one thing.) Of course, since the proportion of physicians who keep up with their field of practice by actually reading the refereed journals is so small and continues to decline, the pharmaceutical representatives’ ‘detail’ visits and the drug-company-sponsored dinner talks and junkets from which many physicians learn about new medications will be free to continue to spin the merits of their latest and greatest breakthrough drug with no pretense of being fair and balanced. Even among those consumers of the medical literature, we will have to face the inherent cognitive bias toward remembering and being influenced by positive findings as well.

Critics of the reform plan are asking for government regulations requiring this sort of registration database for clinical trials, rather than a voluntary system initiated by a fragment of the medical publications. A more profound step would be to get the pharmaceutical industry out of the role of funding the preponderance of drug studies and returning to the old system of government-funded research. Or perhaps pharmaceutical companies should pool their research funds and endow a foundation to give out grants rather than each doing it individually. It is hard to see what incentive the industry would have to do so and forego both the PR value of their research funding and the potential influence over the findings unless, again, there is some government mandate. This impetus for reform may well be the silver lining in the midst of the cloud of the furor about SSRIs and suicidality among adolescents and children, about which FmH readers doubtless know my position.

So you cannot make much headway convincing your swing-voter friend not to vote for Bush on the basis of Iraq alone? Here is the rest of the scorecard for the worst president of the postwar epoch.

…and neglects causal research. ”Since I am a psychiatrist, I have for a long time been intrigued by the extraordinary use of psychiatric causal explanations for illnesses that not only go with predominantly somatic symptoms, but also lack any basic similarity to known mental disorders.” — Per Dalen (The Art Bin)

Wikipedia’s Wikiquote project has compiled this list of what you thought were famous quotations… but aren’t.

Somebody has to monitor America’s favorite drug dealer.

This US map uses color to depict the most popular term used in every county of the US — ‘pop’, ‘coke’, ‘soda’ or something else. The gross regional differences are pretty clear but what grabs my attention are the anomalies. Why are there single counties in the middle of Nebraska, North Dakota, Colorado and Idaho, for example, where ‘soda’ predominates in the midst of ‘pop’? And what is going on in the large, circumscribed regions of Nevada, northern Minnesota and New Mexico where some other term predominates, as well as scattered counties in North Carolina and Texas? Anyone from any of those regions reading? How do you refer to soft drinks there?? (via Incoming Signals)

Kevin Murphy advises: “Aside from the Philippines, Nigeria, and Poland, the world wants John Kerry by a landslide. Undecided voters out there, you know how you can ‘Ask the Audience’ on Who Wants to Be a Millionaire when you’re stumped? Consider it like that.” (ghost in the machine)

Our Forests at Risk: For lovers of wilderness, this is an emergency.

Get involved; bowing to public pressure, the administration has just extended the comment period through November 15. Check out what is at stake and send your own message directly to the relevant decision makers today.

Boing boing pointed to this New Scientist article showing measurable changes in brain function under hypnosis. It is described as significant because it shows that hypnosis is not just a parlor trick performed by stage magicians. But it has long been recognized that it is a truly altered state of consciousness, so it should surprise no one that it produces frank alterations in brain function. Readers of FmH will know that I am enamored of and tend to link to functional MRI studies that show which brain regions are active during particular cognitive tasks. For me, the accumulating evidence of localization of a given cognitive function is much more important than what I consider the trivial finding that brain function is altered when you perform the task. Yeah, so?

I haven’t read the research paper but the New Scientist article doesn’t describe the experimental design in enough detail to help me understand hypnosis any better. It does not even describe the nature of the cognitive taks that was used, called the Stroop test. Here is a link to a description of the Stroop, which essentiallly involves being given a list of color names printed in colored ink. A given word is printed in a color different from the color it names; for instance the word “blue” may be printed in orange. The test is a measure of a person’s ability to operate under conditions of cognitive interference, in that you must name the colors of the words successive cards without reading the words. It is not as easy as you think. In the current fMRI study, subjects performed the Stroop test first unhypnotized, and then again hypnotized; the performance of ‘suggestible’ (easily hypnotized) subjects was compared with those who were less susceptible to hypnosis. The susceptible group showed greater activation in the anterior cingulate gyrus and the left prefrontal cortex when performing the task under hypnosis. The New Scientist article does a further disservice of making some pat pronouncements about what these two implicated brain regions ‘do’. In fact, just as the cognitive changes in hypnosis are quite abit more complicated than you think, so too are the information-processing roles of these brain regions.

Graphic artists putting their art where their mouth is; “15 designers and artists using their time and talent to help bring about change.” (via Booknotes)

This is what Rafe Colburn has to say about the Bush National Guard issue. As usual, I think it is plain-speaking truth:

I would add that the Democrats could make hay if they pointed out that Kerry was staying above the fray and refraining from mudslinging in the way Bush has been doing with the Swift Boat issue. There’s an old neurolinguistic programming strategem called ‘talking in quotes’, in which you can both get your criticism across and yet maintain plausible deniability. Kerry should be saying, “Notice I’m not saying ‘Bush shirked his military duty and they’re concealing and lying about it’ the way he is talking about my war record in Vietnam. My campaign is about the issues, his is about diversion from his record.” See how that works? The criticism is ‘in quotes’ but Kerry’s not saying it.

Besides, although it appears to be counterintuitive, Kerry would do better taking a page from Karl Rove’s play book by attacking Bush’s perceived strengths rather than his recognized weaknesses. It is a simple issue to grasp; if someone hasn’t already gotten, or doesn’t care, that Bush was a shirker during Vietnam, there’s little chance of changing their mind at this stage and, as Coburn points out, it matters little. But taking the country down the drain during the past three and a half years in office is a different matter.

When Medicine Turns Evil: “No association or guild was more complicit in the rise of Nazism and the desecrations committed by its leaders and followers than the profession of medicine.” — Sherwin Nuland (The New Republic via walker)

Putting the faces of the fallen before the public:

“Coming just days after the 1,000th U.S. soldier died in the war in Iraq, the display was organized by Army veteran Nicholas Cohen, who said merely listing deaths in the newspapers each day did not capture the human cost of the war.” (Yahoo! News)

FAQ about this vision-inducing plant which is a member of the sage family.

Q. What is a Salvia divinorum experience like?

A. It is almost certainly not like what you expect. Even if you have considerable experience with other psychoactive drugs, you will find that salvia is significantly different from what you may have encountered before. Salvia is unique, and it is best understood on its own terms, and not by analogy with other substances. Salvia is not a recreational drug, rather, it is best used by those wishing to explore deep meditative states, spiritual realms, mysticism, the nature of consciousness and reality, or the possibilities of shamanistic healing. Experiences vary with the individual, set, and setting as well as with dose and route of administration. It produces a short-lived inebriation that is very different from that of alcohol. However, like alcohol it interferes with the ability to drive, produces incoordination (ataxia), and may produce slurred speech.

The inebriation, at low doses, can facilitate aesthetic and sensual appreciation. However, the experience is not marijuana-like, and salvia is not a marijuana substitute. At somewhat higher doses, visionary trances occur.

This ‘divine inebriant’ has a long history of sacred use in shamanic highland Mexican indigenous cluture. Pharmacologically, the active ingredient of Salvia, salvinorin, appears to be difficult to categorize and unlike other psychoactive compounds. One psychonaut has called the plant a ‘phantasticant’. Salvia is relatively easy to grow and entirely legal. Other members of the mint-like sage family also reputedly have psychoactive properties, although none as robust as those of Salvia. Interestingly, culinary sage itself containes thujone, the compound which is central to the vision-inducing properties of absinthe (derived from wormwood). Although, during the 60’s and 70’s, there was a folklore about getting ‘high’ by smoking sage leaves, they are probably better left for use as a spice, as thujone is thought to cause brain damage (although that may be just a typical scurrilous piece of anti-drug anti-visionary lore).

Welcome to MusicBrainz, “a community music metadatabase that attempts to create a comprehensive music information site. You can use the MusicBrainz data either by browsing this web site, or you can access the data from a client program — for example, a CD player program can use MusicBrainz to identify CDs and provide information about the CD, about the artist or about related information. You can also use the MusicBrainz Tagger to automatically identify and clean up the metadata tags in your MP3 collections….

Many MP3 lovers have a huge collection of MP3 files but often have a hard time finding the music to which they want to listen. The MusicBrainz solution for this is the MusicBrainz Tagger, a Windows application that uses acoustic fingerprints (TRMs) to semiautomatically identify tracks in your music collection and then write clean and accurate metadata to your music files.” [There is also a Mac version.]

Welcome to MusicBrainz, “a community music metadatabase that attempts to create a comprehensive music information site. You can use the MusicBrainz data either by browsing this web site, or you can access the data from a client program — for example, a CD player program can use MusicBrainz to identify CDs and provide information about the CD, about the artist or about related information. You can also use the MusicBrainz Tagger to automatically identify and clean up the metadata tags in your MP3 collections….

Many MP3 lovers have a huge collection of MP3 files but often have a hard time finding the music to which they want to listen. The MusicBrainz solution for this is the MusicBrainz Tagger, a Windows application that uses acoustic fingerprints (TRMs) to semiautomatically identify tracks in your music collection and then write clean and accurate metadata to your music files.” [There is also a Mac version.]

My family and I will be travelling until Labor Day; you should not expect any new posts on FmH until I am back home. Enjoy the last week of summer!

This is something I’ve been curious about and don’t really know where to ask. I like to update my music collection with the little thumbnails of the album art that iTunes displays in the lower left corner. I notice that the songs to which I have added art are updated on my iPod the next time I synchronize. Could there possibly be a hidden mode on the iPod that would display (lo-res) images of the album art, given that the data is there, or do I have to wait for the next-generation machine? Any iPod aficionados out there who might know?

“When Mr. Bush accepted the party’s nomination in Philadelphia in 2000, he stepped up to a typical battleship-style stage, with multiple video screens and a sweep of stairs leading up to a lectern. But the Bush campaign team has had four years to think about their next convention, and from the beginning it signaled a desire to do something different.” (New York Times via abby)

“Want to learn how to create and sustain psychosis on a national scale? Look carefully at the public statements made by the Department of Homeland Security.” — Bruce Schneier (Minneapolis Star-Tribune op-ed)

Taking a closer look at the War Medals of George W. Bush [thanks, carol]

Are these signs of erratic desperation or part of a calculated campaign strategy, as things go from bad to worse for Bush? At this point, it is difficult ot say for which candidate, Kerry or Bush, the Swift Boat Veterans furor has done more damage, as the illegal coordination and overlap with the Bush campaign becomes more and more evident. Most likely, this announcement on Bush’s part was part of a deal Bush and McCain made to ensure McCain continues to campaign for Bush. McCain has also called for Kerry to pull the ads, to which I referred last week, in which McCain is shown taking a speechless Bush to task for smearing McCain’s war record during the 2000 primary campaign.

But (on the erratic side?) Bush also let slip an admission that he had miscalculated post-invasion conditions in Iraq (and then quickly clammed up and stonewalled additional questions attempting to get him to amplify on his admission; it would have been nice to be a fly on the wall in the interview and see the beady-eyed panic-stricken look on his face at that point). Yet this is juxtaposed with the following:

Fascinating, useful summary of of readers’ accounts of their professions’ clever little occupational secrets (The Morning News) [via boing boing]

And speaking of the tricks of the trade, Republican conduct during this campaign reminds us that, even within a profession, there are gradations. Here’s a dissection of the Bush family skullduggery tradition. (CBS News). And UC Berkeley’s George Lakoff, linguist extraordinaire whose consulting work is so much in demand by progressive groups in this election season that he had to shelve his research plans for his recent sabbatical, explains why the Republicans are so much better at dominating the terms of debate (and obscuring the fact that they are in control) than the Democrats. Watch for his commentary on the Republican Convention, and his forthcoming book, Don’t Think of an Elephant: Know Your Values and Frame the Debate. Lakoff advises, among other things, that progressive opponents of the current dysadministration avoid the term “War on Terror”. [My reasoning is similar in making sure that all my references to it are ironic and sarcastic in tone. Readers of FmH will recognize that, whenever I have used the term, I turn it into a product brand name “WoT®”.] For another take on the issue of word choice in political spin, see this New York Times piece. If you are writing about current political struggles, sharpen your discourse; it matters! If you are reading my discourse, refine it for me by offering criticisms and corrections whenever I become undisciplined. Let us wake up; this is one of the more important fronts on which the battle for hearts and minds is being fought.

Thanks to walker for suggesting this reflection by the curmudgeonly Dr. Dalrymple on ‘a moral confusion typical of our age’. A recent Lancet editorial considered the controversy over whether alcoholic liver failure ought to disqualify one for a liver transplant, given the predominant opinion that the condition is self-inflicted. The Lancet authors cite evidence that alcoholism is not the patient’s fault, since “clear genetic and environmental influences exist.” Yet Dalrymple points out that the data the Lancet reviews shows that, after liver transplantation, former alcoholics have vastly increased rates of abstinence compared to those who have undergone ‘conventional treatment’ for their alcohol abuse. His conclusion is that alcoholics with sufficient motivation can control their drinking, that despite influences one has the freedom to resist; Dalrymple considers these equivalent to confirmation of the ‘self-inflicted’ terminology.

If the evidence is clear that motivation can affect abstinence, Dalrymple wonders why the medical profession has gone to such lengths to ‘acquit those suffering from alcoholic cirrhosis of the self-infliction charge.’ He finds the answer in the ‘crude sentimentality of our modern moral sensibility’, in which only victims are worthy of sympathy. Since there are so many alcoholics, it would be cruel to be so unsympathetic, so we perforce pretend that they are all victims of circumstances beyond their control. Dalrymple would rather we take a more spiritual (he does not use the term, but what he really means is more Christian) viewpoint in which one forgives and does not withhold sympathy from someone even who has harmed themself.

Without saying so, Dalrymple has taken on one of the core issues I see in modern medicine — what threshold must a maladaptive lifestyle choice cross to be worthy of being called a disease? However, his moral triumphalism relies on setting up and then overthrowing a straw man. Very few physicians take the black and white view he accuses them of having — that alcoholism must be a matter of either free will or determinism. The more nuanced understanding, that genetic and environmental influences create a likelihood and a vulnerability that makes abstinence more difficult than it would be for the next person, but not impossible, is actually the most common. Dalrymple is back in the ’50’s or ’60’s, when debates about nature vs. nurture raged, at least in psychiatry. These have long since been resolved in the minds of all but the most naive thinkers in the field. And Dalrymple forgets that the helpful emotion for a physician is not sympathy — either for the ‘fallen man’ (and, Dr. Dalrymple, what about alcoholic women?) or the ‘victim’ — but empathy for the complexities of the struggle. True, where free will plays a part, we are in a different realm of medicine than that which treats, for example, juvenile onset diabetes or rheumatoid arthritis, which no one in their right mind would accuse the patient of having caused. (Notice, I did not use the more paradigmatic examples of cancer and heart disease, about which legitimate controversies over lifestyle contributions and ‘self-infliction’ exist.) But embracing the more difficult empathic stance places the physician right with the patient in the midst of the struggle over their motivation and ‘willpower’, rather than at Dalrymple’s morally superior distance. While he may be willing to be sympathetic, to bestow forgiveness, to facilitate salvation, on sufferers, his attitude just as easily leaves itself open to heaping moral opprobrium on them. Although it sounds sophisticated, it is really not very different from that which I hear from the families of my psychiatric patients who in their lack of understanding inject an element of moral failing into their loved ones’ mental illnesses all the time — that the sufferer is ‘just not trying hard enough’, needs ‘nothing more than a swift kick in the pants to get going’, is deliberately prolonging their invalidism, is ‘indulging themself’, ‘everybody gets a little down once in awhile but most of us don’t let it get to us like you do’. It is true that, as a physician educating and counseling such a family, I want to say something like, “(S)he can’t help it, it’s a disease, (s)he needs your sympathy,” but we don’t say it because we believe that only guiltless victims of impersonal forces deserve sympathy; it is in large measure public stigmatization the physician is attempting to counter here. Dr. Dalrymple, I fear, misunderstands, despite the fact that moralists always want to paint themselves as more understanding and sympathetic, and their opponents’ ability for sympathy impaired by their faulty understanding.

Of course, I am talking from the perspective of a psychiatrist, one of whose core skills is examining and clarifying countertransference feelings, one’s own hidden assumptions about and attitudes toward our patients, so these are not the powerful behind-the-scene players they otherwise would be. Most physicians and other healthcare workers outside the mental health end of the field have probably never heard of countertransference, not to mention explored their own.Still, I think, most physicians have a more complicated view of their patients’ moral agency than Dalrymple assumes. What, I wonder, would Dalrymple make of the views of humanity of such physician-writers as Sherwin Nuland, Jerome Groopman, Oliver Sacks or indeed William Carlos Williams?

The unsophistication of Dalrymple’s viewpoint becomes clearer if one examines the most successful technique for helping alcoholics become and remain abstinent, the AA model. What is AA’s position on the role of ‘willpower’ in sobriety? On the surface of it, it seems that AA is dead set against it. The first, dogmatic, step in the AA program is acknowledging that one is helpless against alcoholism and cannot help oneself. Of course, AA doesn’t work for everyone, because of the difficulties some have with its remedy for such powerlessness — to ask for help from the group, and from a ‘Higher Power’. But, for those whose interpersonal capacities and spiritual inclinations allow, those steps are the foundations of success. And it seems to me that they are an embrace of paradox the significance of which is lost on Dalrymple. By acknowledging powerlessness, the alcoholic bolsters their willpower and motivation to exert control for recovery. By invalidating the effectiveness of willpower, one gains power. The embrace of such paradox is clear in the AA credo per the ‘serenity prayer’, in which one yearns for both “the serenity to accept the things I cannot change (and the) courage to change the things I can” (as well as “the wisdom to know the difference”). Perhaps the theory of alcoholism and recovery that elucidates it best is psychiatrist Gregory Bateson’s ‘cybernetic’ model (in Steps to an Ecology of Mind), describing the ways in which willpower and powerlessness are not dichotomous, in conflict in one mind, but that they are rather coexistent and interdependent, at different levels of abstraction of the self.

I will not be ‘blogging for dollars’, in case you wondered…

Guess he feels ‘Mission Accomplished’ (Yahoo! News)

This historical quote was not written by an observer of the 2004 Republican campaign, but it may as well have been:

“All this was inspired by the principle – which is quite true in itself – that in the big lie there is always a certain force of credibility; because the broad masses of a nation are always more easily corrupted in the deeper strata of their emotional nature than consciously or voluntarily; and thus in the primitive simplicity of their minds they more readily fall victims to the big lie than the small lie, since they themselves often tell small lies in little matters but would be ashamed to resort to large-scale falsehoods. It would never come into their heads to fabricate colossal untruths, and they would not believe that others could have the impudence to distort the truth so infamously. Even though the facts which prove this to be so may be brought clearly to their minds, they will still doubt and waver and will continue to think that there may be some other explanation. For the grossly impudent lie always leaves traces behind it, even after it has been nailed down, a fact which is known to all expert liars in this world and to all who conspire together in the art of lying. These people know only too well how to use falsehood for the basest purposes.” [via kos via unfutz]

Click on the link above to see the author identified, or post your guess here as a comment (no cheating).

“Reruns on demand: We can get there legally or illegally.” (MIT Technology Review)

Bush contradicts his own “Roadmap to Peace” by reversing himself on the West Bank settlements, in an attempt to help embattled Israeli prime minister Sharon get his Gaza withdrawal plan past the recalcitrant right wing of his own party. Palestinians have feared all along that the Gaza plan is a cover for reinforcing the Israeli presence on the West Bank.

This April, 2003 report of a blue ribbon federal panel of mental health professionals has recently attracted attention because it is interpreted as proposing an alarming plan to screen the mental health of every American, beginning in the schools. The Bush administration is using the ‘New Freedom’ rubric to refer to a hodge podge of initiatives directed toward people with disabilities; this report maps out the mental health component of the effort. The fact that, as a politically savvy mental health professional, I had never heard of this commission, this report or this initiative may be an indication of how little impact it will have on real mental health practice, but I reviewed the report at the urging of several FmH readers and other webloggers who wanted a professional’s perspective.

Some critics view the screening mandate as a giveaway to the pharmaceutical industry, and place it in the context of the Republicans’ efforts, to paraphrase Bill Moyers, to “privatize public services in order to enrich the corporate interests that fund campaigns and provide golden parachutes to pliable politicians. If unchecked, the result of these machinations will be the dismantling of every last brick of the social contract…. I think this is a deliberate, intentional destruction of the United States of America.” Further alarm is raised by the report’s embrace of “evidence-based” practices and treatment by standardized algorithms exemplified by the Texas Medical Algorithm Project (TMAP). This has been a monumental attempt to reduce medicine to a cookbook approach — if conditions A, B, and C exist, you try treatment X, (which is usually a medication) then if it doesn’t work you go to Y, etc. Treatment guidelines in the algorithms are “evidence-based”, the hot buzzword in clinical medicine (including psychiatry), which is meant to refer to practices proven by research data rather than based on intuition. (I probably don’t need to remind you that most research into treatment outcomes of medications is funded by the pharmaceutical companies that have a vested interest in the findings.) Critics of the TMAP claim that it is driven by a “political/pharmaceutical alliance” for the sole purpose of making newer, expensive, profitable drugs the mainstays of treatment for various disorders. Furthermore, critics claim, Texas officials have reportedly received financial perks from the pharmaceutical industry to influence their adoption of the algorithms. (Let me caution that a critique based on the assumption that drug companies’ contributions are meant to ensure that their drug gets recommended are naive and easily refuted. The pharmaceutical industry usually wields its influence more subtly; by dispensing its largesse to create a warm and fuzzy feeling in the researchers, clinicians and regulators who are worth influencing, rather than as direct bribes.)

Let’s start with the TMAP angle. My reservations about the funding of pharmacological research apart, I have always found algorithm-based medical practice fundamentally flawed. The whole process of identifying what class of patients a given individual falls into, and then treating that individual in a rote manner, seems to ignore crucial aspects of each patient’s uniqueness and the health professional’s need for sensitivity, skill, yes, artistry in applying medical knowledge to the case at hand. This is especially true in the psychiatric field. Thus, the foremost danger of algorithm-based treatment is not that it is a giveaway to Big Pharma. The newer, more expensive medications are used not because they are mandated by algorithms but, simply, because they represent signficant medical advances in efficacy and tolerability. Those of us who scoff at algorithms do not use less of the expensive new medications. The obscenity is not that a government interested in industry giveaways is trying to mandate more expensive drugs as better; it is that it is doing nothing to make better drugs less expensive. Even without algorithms, the pharmaceutical industry already has a captive audience of sick consumers in desperate need on whom it can foist its price-fixing. One of the greatest flaws in the commission report, to my reading, is that the penetration of the drug manufacturers into medical practice is not addressed at all despite an awful lot of highfalutin’ language about making mental health care ‘consumer-driven’ and ‘recovery-based.” In this case, with all due respects to Bill Moyers, it does not appear so much to be a potential windfall for the industry but rather protecting it from a firestorm of criticism that is the Bush administration’s major favor to its friends. It is worth noting, however, the pharmaceutical industry was not overtly represented on the panel, whose members are a large and varied cross-section of the mental health professions, from community mental health practitioners to academics and administrators.

Apart from the algorithmic and “evidence-based” agenda and the screening proposals, the other goals the commission articulates for improving mental health care include reducing stigmatization and enhancing the rights of the mentally ill, achieving parity with physical health care, promoting a national strategy for suicide prevention, promoting comprehensive individual care plans, improving access to mental health services in underserved areas and making mental health care culturally sensitive, improving child psychiatric services and school-based mental health care, improved recognition of the co-occurrence of substance use and mental disorders, shaping research priorities to address clinically useful questions, “develop(ing) the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care”, and improving the integration of modern electronic technologies in the delivery of mental health care. In medical school, we are taught to generate a comprehensive ‘problem list’ for each patient we follow. If the patient were the American mental health care system, I am struck by how closely this list gibes with my own problem list. The question is whether there is an action-based agenda to back up the goals, and whether we will put our money where our mouth is.

I have seen too many treatment plans for patients based on comprehensive problem lists in which the plan for problem A is little more than “treat problem A.” In a similar vein, the commission’s verbiage on achieving these goals for the improvement of ailing American mental health care is diffuse and vague. The list includes: educating the public about mental illness to reduce stigmatization; enhancing affordability, access and choice; emphasizing the interconnection of physical and mental health and the coordination of the care of both; a recovery-based model; better alignment of federal mental health policy across agencies, to coordinate health care with the other human needs of mentally ill consumers; community-baase alternatives to institutions; making supported housing and supported employment opportunities more available; improving mental health care in the penal system; meeting specific rural and minority mental health needs; addressing the shortage of personnel in the mental health fields. Yawn. For a specific example of the mind-numbing vagueness that passes for a plan, here are the report’s suggestions for improving acute mental health care (my main interest as an inpatient psychiatrist treating patients with major mental illness during acute crises): “synthesizing the …knowledge base, reviewing the many outstanding model programs…, developing new knowledge as necessary, assessing existing capacities and shortages, and proposing workable solutions.” I know we are supposed to like generics in mental health care, but I thought they were talking about generic drugs, not verbiage!

I usually find “recovery-based” language worrisome, since much mental health care should not be oriented toward an unrealistic goal of curing the patient’s psychiatric illness but helping them stabilize acute symptoms and adapt to what is often a lifelong chronic condition. The commission report counterbalances this with enough attention to mental illness as a lifelong disability and the expectation that consumers will have to negotiate the systems of providing their human needs as mentally ill clients. There is little, however, about the sort of community-based psychosocial rehab, vocational training and social club models that are incredibly useful and humane; nor about the powerful assertive community treatment model to keep our sickest clients in the communities and out of the hospitals. I collaborate enthusiastically with ACT teams around some of the most desperately ill patients I see recurrently in my hospital practice, but they should be providing services to at least three times as many patients as they are able to do.

So, at last, turning to the controversial screening proposals, early identification of and intervention with both at-risk and precociously symptomatic patients, yes, through school- and population-based screening programs, is another area with proven potential to slow or halt the progression to chronicity, and it is another area which is woefully neglected in current mental health practice. The rationale for a school-based focus is at least partially because it is a nonstigmatizing setting a fragile child is already accustomed to, in comparison to hospitals and doctors’ offices. If cases are identified earlier in life and treatment needs, including psychopharmaceutical approaches, are addressed sooner, suffering can be alleviated. Furthermore, the proportion of a child’s social and cognitive demands that occur in the school setting is, of course, enormous, so school-based treatment is community treatment. Screening is no handout to the pharmaceutical industrly unless — and this is a big unless — nothing is done to rectify the current problems with pediatric overdiagnosis, overtreatment and inadequate followup.

By my reasoning, an effective early intervention program would actually alleviate some of these problems. Here’s how it goes. Readers of FmH know that I think the expansion of medication use has been driven not only by the rapacious pharmaceutical industry but by market pressures within psychiatry itself. As MDs have priced themselves out of the market and have been replaced progressively by cheaper non-MD professionals in the delivery of mental health services, the psychiatric profession has been forced to expand the range of conditions it defines as medication-responsive, since psychiatrists are (almost) the only ones who can prescribe. This has ushered in the era of “cosmetic psychopharmacology”, which is fist-in-glove with the dumbing down of psychiatric training to the point that newly-qualified psychiatrists neither see the value of nor have the inclination or skills to do psychotherapy, i.e. communicate effectively, get to know their patients, create a relationship with a patient whose suffering often makes them difficult to reach, and to use that relationship as a healing instrument. If a coherent process exists to match the expansion of the mental health workforce with the expansion of identified treatment needs, my hope is that the market pressure to prescribe needlessly for more trivial conditions will atrophy. It is not likely someone not in the business of delivering mental health services understands how critical the shortage of providers to address pediatric mental health needs is. Children wait days in ERs for a bed in a psychiatric hospital after demonstrating the urgent need; they wait weeks or months to access outpatient services. If screening reprioritizes the focus of care to the truly, urgently sick, and is accompanied by an expansion in manpower, I am all for it. On the other hand, I’m not a health care economist, just a doctor. (When he comes to town, a world-renowned health care economist from Stanford who is a family friend picks my brain on the view from the trenches; I’m going to have to turn the tables the next time I see him — whichshould be next week — and pump him for his reactions to the commission report from a health policy perspective.)

On the other hand, if a national screening agenda is not matched by a dramatic increase in mental health personnel at both the primary care and the referral levels, I am afraid such a program would be carried out through some totally inadequate standardized testing program akin to the standardized educational testing that has become the sole, braindead, standard for ‘leaving no child behind’ educationally. While a robust, individualized and sensitive screening process with adequate personnel and funding could provide early detection and treatment if it focused on at-risk children, those with behavioral problems, and those referred by concerned classroom teachers, the literature shows that standardized, survey-based measures of mental health of entire populations have proven of dubious value when used for epidemiological research purposes, are of no value in targeting clinical interventions, and are too unwieldy to carry out. Again, as in the educational sphere, I can see federal funds for mental health care being tied to state compliance in administering the screening protocols. And, again, as with No Child Left Behind, an unscrupulous Bush or Bush-like administration could comandeer mental health data for other purposes such as military conscription classification. (How would you like to be told that you cannot have a psychiatric deferment from the coming draft, despite the insistence of a sympathetic psychiatrist such as myself that you are mentally unfit to serve, because your childhood psychometric scores ‘proved’ you were across-the-board well-adjusted?)

In short, the report is a puff piece that is not likely to turn into implementable policy. To the extent that it is, I think the concerns about “Bush wanting to be your shrink” are kneejerk alarmism. Although there are a range of issues about which to be concerned in the report, they are not the ones upon which the critics have so far focused. And while, in one alarmist’s turn of phrase, “your first great freedom, the power to control your own thoughts, … (and) your secondary freedom of being able to control the approval for your own medical treatments” are indeed important frontiers of modern freedom, the New Freedom Commission on Mental Health does not represent the immediate threat to them it is made out to be. The greatest problems of the ‘reform’ of the mental health care system proposed by this commission, as I see it, are that it does not address the sellout of psychiatric care to the pharmaceutical industry and the increasing tendencies to conduct treatment in a rote, braindead manner. Even if you had the improved access to mental health services you deserve under this system, you would still end up being treated by someone with little training in or tendency toward creative independent thinking; inadequate familiarity with the range of available (both new and time-honored) treatment options and the possibilities of an individualized and original approach to your problems; and little immunity to having prescribing practices bought and sold by corporate influences. In other words, the problem with the new initiative is not that it will create massive intolerable changes in your care and infringe on your civil rights, as the naive critics propose; rather, it is that it will not change anything. Besides, Ashcroft will not be in charge of the mental health screening, and Bush and his intiiative will be out of office in January in any case, right?

Let the flamewars begin…

This April, 2003 report of a blue ribbon federal panel of mental health professionals has recently attracted attention because it is interpreted as proposing an alarming plan to screen the mental health of every American, beginning in the schools. The Bush administration is using the ‘New Freedom’ rubric to refer to a hodge podge of initiatives directed toward people with disabilities; this report maps out the mental health component of the effort. The fact that, as a politically savvy mental health professional, I had never heard of this commission, this report or this initiative may be an indication of how little impact it will have on real mental health practice, but I reviewed the report at the urging of several FmH readers and other webloggers who wanted a professional’s perspective.

Some critics view the screening mandate as a giveaway to the pharmaceutical industry, and place it in the context of the Republicans’ efforts, to paraphrase Bill Moyers, to “privatize public services in order to enrich the corporate interests that fund campaigns and provide golden parachutes to pliable politicians. If unchecked, the result of these machinations will be the dismantling of every last brick of the social contract…. I think this is a deliberate, intentional destruction of the United States of America.” Further alarm is raised by the report’s embrace of “evidence-based” practices and treatment by standardized algorithms exemplified by the Texas Medical Algorithm Project (TMAP). This has been a monumental attempt to reduce medicine to a cookbook approach — if conditions A, B, and C exist, you try treatment X, (which is usually a medication) then if it doesn’t work you go to Y, etc. Treatment guidelines in the algorithms are “evidence-based”, the hot buzzword in clinical medicine (including psychiatry), which is meant to refer to practices proven by research data rather than based on intuition. (I probably don’t need to remind you that most research into treatment outcomes of medications is funded by the pharmaceutical companies that have a vested interest in the findings.) Critics of the TMAP claim that it is driven by a “political/pharmaceutical alliance” for the sole purpose of making newer, expensive, profitable drugs the mainstays of treatment for various disorders. Furthermore, critics claim, Texas officials have reportedly received financial perks from the pharmaceutical industry to influence their adoption of the algorithms. (Let me caution that a critique based on the assumption that drug companies’ contributions are meant to ensure that their drug gets recommended are naive and easily refuted. The pharmaceutical industry usually wields its influence more subtly; by dispensing its largesse to create a warm and fuzzy feeling in the researchers, clinicians and regulators who are worth influencing, rather than as direct bribes.)

Let’s start with the TMAP angle. My reservations about the funding of pharmacological research apart, I have always found algorithm-based medical practice fundamentally flawed. The whole process of identifying what class of patients a given individual falls into, and then treating that individual in a rote manner, seems to ignore crucial aspects of each patient’s uniqueness and the health professional’s need for sensitivity, skill, yes, artistry in applying medical knowledge to the case at hand. This is especially true in the psychiatric field. Thus, the foremost danger of algorithm-based treatment is not that it is a giveaway to Big Pharma. The newer, more expensive medications are used not because they are mandated by algorithms but, simply, because they represent signficant medical advances in efficacy and tolerability. Those of us who scoff at algorithms do not use less of the expensive new medications. The obscenity is not that a government interested in industry giveaways is trying to mandate more expensive drugs as better; it is that it is doing nothing to make better drugs less expensive. Even without algorithms, the pharmaceutical industry already has a captive audience of sick consumers in desperate need on whom it can foist its price-fixing. One of the greatest flaws in the commission report, to my reading, is that the penetration of the drug manufacturers into medical practice is not addressed at all despite an awful lot of highfalutin’ language about making mental health care ‘consumer-driven’ and ‘recovery-based.” In this case, with all due respects to Bill Moyers, it does not appear so much to be a potential windfall for the industry but rather protecting it from a firestorm of criticism that is the Bush administration’s major favor to its friends. It is worth noting, however, the pharmaceutical industry was not overtly represented on the panel, whose members are a large and varied cross-section of the mental health professions, from community mental health practitioners to academics and administrators.

Apart from the algorithmic and “evidence-based” agenda and the screening proposals, the other goals the commission articulates for improving mental health care include reducing stigmatization and enhancing the rights of the mentally ill, achieving parity with physical health care, promoting a national strategy for suicide prevention, promoting comprehensive individual care plans, improving access to mental health services in underserved areas and making mental health care culturally sensitive, improving child psychiatric services and school-based mental health care, improved recognition of the co-occurrence of substance use and mental disorders, shaping research priorities to address clinically useful questions, “develop(ing) the knowledge base in four understudied areas: mental health disparities, long-term effects of medications, trauma, and acute care”, and improving the integration of modern electronic technologies in the delivery of mental health care. In medical school, we are taught to generate a comprehensive ‘problem list’ for each patient we follow. If the patient were the American mental health care system, I am struck by how closely this list gibes with my own problem list. The question is whether there is an action-based agenda to back up the goals, and whether we will put our money where our mouth is.

I have seen too many treatment plans for patients based on comprehensive problem lists in which the plan for problem A is little more than “treat problem A.” In a similar vein, the commission’s verbiage on achieving these goals for the improvement of ailing American mental health care is diffuse and vague. The list includes: educating the public about mental illness to reduce stigmatization; enhancing affordability, access and choice; emphasizing the interconnection of physical and mental health and the coordination of the care of both; a recovery-based model; better alignment of federal mental health policy across agencies, to coordinate health care with the other human needs of mentally ill consumers; community-baase alternatives to institutions; making supported housing and supported employment opportunities more available; improving mental health care in the penal system; meeting specific rural and minority mental health needs; addressing the shortage of personnel in the mental health fields. Yawn. For a specific example of the mind-numbing vagueness that passes for a plan, here are the report’s suggestions for improving acute mental health care (my main interest as an inpatient psychiatrist treating patients with major mental illness during acute crises): “synthesizing the …knowledge base, reviewing the many outstanding model programs…, developing new knowledge as necessary, assessing existing capacities and shortages, and proposing workable solutions.” I know we are supposed to like generics in mental health care, but I thought they were talking about generic drugs, not verbiage!

I usually find “recovery-based” language worrisome, since much mental health care should not be oriented toward an unrealistic goal of curing the patient’s psychiatric illness but helping them stabilize acute symptoms and adapt to what is often a lifelong chronic condition. The commission report counterbalances this with enough attention to mental illness as a lifelong disability and the expectation that consumers will have to negotiate the systems of providing their human needs as mentally ill clients. There is little, however, about the sort of community-based psychosocial rehab, vocational training and social club models that are incredibly useful and humane; nor about the powerful assertive community treatment model to keep our sickest clients in the communities and out of the hospitals. I collaborate enthusiastically with ACT teams around some of the most desperately ill patients I see recurrently in my hospital practice, but they should be providing services to at least three times as many patients as they are able to do.

So, at last, turning to the controversial screening proposals, early identification of and intervention with both at-risk and precociously symptomatic patients, yes, through school- and population-based screening programs, is another area with proven potential to slow or halt the progression to chronicity, and it is another area which is woefully neglected in current mental health practice. The rationale for a school-based focus is at least partially because it is a nonstigmatizing setting a fragile child is already accustomed to, in comparison to hospitals and doctors’ offices. If cases are identified earlier in life and treatment needs, including psychopharmaceutical approaches, are addressed sooner, suffering can be alleviated. Furthermore, the proportion of a child’s social and cognitive demands that occur in the school setting is, of course, enormous, so school-based treatment is community treatment. Screening is no handout to the pharmaceutical industrly unless — and this is a big unless — nothing is done to rectify the current problems with pediatric overdiagnosis, overtreatment and inadequate followup.

By my reasoning, an effective early intervention program would actually alleviate some of these problems. Here’s how it goes. Readers of FmH know that I think the expansion of medication use has been driven not only by the rapacious pharmaceutical industry but by market pressures within psychiatry itself. As MDs have priced themselves out of the market and have been replaced progressively by cheaper non-MD professionals in the delivery of mental health services, the psychiatric profession has been forced to expand the range of conditions it defines as medication-responsive, since psychiatrists are (almost) the only ones who can prescribe. This has ushered in the era of “cosmetic psychopharmacology”, which is fist-in-glove with the dumbing down of psychiatric training to the point that newly-qualified psychiatrists neither see the value of nor have the inclination or skills to do psychotherapy, i.e. communicate effectively, get to know their patients, create a relationship with a patient whose suffering often makes them difficult to reach, and to use that relationship as a healing instrument. If a coherent process exists to match the expansion of the mental health workforce with the expansion of identified treatment needs, my hope is that the market pressure to prescribe needlessly for more trivial conditions will atrophy. It is not likely someone not in the business of delivering mental health services understands how critical the shortage of providers to address pediatric mental health needs is. Children wait days in ERs for a bed in a psychiatric hospital after demonstrating the urgent need; they wait weeks or months to access outpatient services. If screening reprioritizes the focus of care to the truly, urgently sick, and is accompanied by an expansion in manpower, I am all for it. On the other hand, I’m not a health care economist, just a doctor. (When he comes to town, a world-renowned health care economist from Stanford who is a family friend picks my brain on the view from the trenches; I’m going to have to turn the tables the next time I see him — whichshould be next week — and pump him for his reactions to the commission report from a health policy perspective.)

On the other hand, if a national screening agenda is not matched by a dramatic increase in mental health personnel at both the primary care and the referral levels, I am afraid such a program would be carried out through some totally inadequate standardized testing program akin to the standardized educational testing that has become the sole, braindead, standard for ‘leaving no child behind’ educationally. While a robust, individualized and sensitive screening process with adequate personnel and funding could provide early detection and treatment if it focused on at-risk children, those with behavioral problems, and those referred by concerned classroom teachers, the literature shows that standardized, survey-based measures of mental health of entire populations have proven of dubious value when used for epidemiological research purposes, are of no value in targeting clinical interventions, and are too unwieldy to carry out. Again, as in the educational sphere, I can see federal funds for mental health care being tied to state compliance in administering the screening protocols. And, again, as with No Child Left Behind, an unscrupulous Bush or Bush-like administration could comandeer mental health data for other purposes such as military conscription classification. (How would you like to be told that you cannot have a psychiatric deferment from the coming draft, despite the insistence of a sympathetic psychiatrist such as myself that you are mentally unfit to serve, because your childhood psychometric scores ‘proved’ you were across-the-board well-adjusted?)

In short, the report is a puff piece that is not likely to turn into implementable policy. To the extent that it is, I think the concerns about “Bush wanting to be your shrink” are kneejerk alarmism. Although there are a range of issues about which to be concerned in the report, they are not the ones upon which the critics have so far focused. And while, in one alarmist’s turn of phrase, “your first great freedom, the power to control your own thoughts, … (and) your secondary freedom of being able to control the approval for your own medical treatments” are indeed important frontiers of modern freedom, the New Freedom Commission on Mental Health does not represent the immediate threat to them it is made out to be. The greatest problems of the ‘reform’ of the mental health care system proposed by this commission, as I see it, are that it does not address the sellout of psychiatric care to the pharmaceutical industry and the increasing tendencies to conduct treatment in a rote, braindead manner. Even if you had the improved access to mental health services you deserve under this system, you would still end up being treated by someone with little training in or tendency toward creative independent thinking; inadequate familiarity with the range of available (both new and time-honored) treatment options and the possibilities of an individualized and original approach to your problems; and little immunity to having prescribing practices bought and sold by corporate influences. In other words, the problem with the new initiative is not that it will create massive intolerable changes in your care and infringe on your civil rights, as the naive critics propose; rather, it is that it will not change anything. Besides, Ashcroft will not be in charge of the mental health screening, and Bush and his intiiative will be out of office in January in any case, right?

Let the flamewars begin…

Rafe Colburn comments on the slime machine:

Colburn is despondent today, thinking that the Swift Boat Veterans will torpedo Kerry’s chances to win the presidency all on their own.

But Josh Marshall thinks Kerry is getting fighting mad, discussing a new Kerry campaign ad which uses 2000 footage of John McCain castigating candidate Bush’s attempt to besmirch his war record, finishing with a shot of Bush’s speechless trapped face that cannot fail to convince us what a shameless coward he was, and is. It strikes me that this is as much Kerry’s response to McCain’s re-embrace of the President, about which I wrote below, as to Bush’s smear attack.

And Ed Fitzgerald holds a hand out for people trying to find a way to kick the self-deceived-Republican-vote habit:

Fitzgerald is building on this wonderful plain speakin’ from Matt Yglesias:

Reduced to its essence, Yglesias is trying to hammer home a single concept, on which I repeatedly harp here — that, as he puts it, “intelligence matters more than character.” FmH readers will know that I have been pretty despondent about the voters’ receptivity to this notion.

But, hey, Bush and his slimy ilk just sink further and further into their sleazy morass, as made clear by this pair of columns from Bob Herbert and Paul Krugman on their latest Florida dirty trick. Maybe even the voters who still believe they need to vote for righteousness regardless of brains will have their eyes opened if this sort of thing continues.

PS: Do voters who like South Park have a sense of humor?

“A top government scientist who concluded last year that most antidepressants are too dangerous for children because of a suicide risk wrote in a memo this week that a new study confirms his findings.” (New York TimesThe ) The senior FDA epidemiologist drew his conclusion from a study of 22 studies, but his findings were reportedly suppressed by his bosses at the FDA. A newer study using different data analyzed by a different methodology parallels his conclusions. Should antidepressant prescribing to children be banned? Certainly, the credible evidence that they are more likely to commit suicide when administered antidepressants is worrisome. Children have less ability than adults to understand and contain the bodily agitation, the feeling “like you’re crawling out of your skin” (in the words of numerous patients), that some antidepressants can cause, so they are far more likely to get into trouble with these medications. And I feel that, like most psychotropics, they are far overprescribed by the pharmacological evangelists most of my profession have become, uncritically. However, I would be concerned if the rare truly, desperately, lethally depressed child were deprived of the possibility of a properly used powerful therapeutic agent. In other branches of medicine, doctors use very dangerous medications when the potential benefit outweighs the risk, and they are capable of using them carefully. Police the profession, not its armamentarium! And get the damn pharmaceutical industry and its single-minded devotion to its profit, which mediates for prescribing to more and more patients more and more uncritically, out of the central role it has in healthcare!

Actually, the FDA does not have the power to ban thei drugs’ use. As the equivalent agency in the UK has done, they can recommend restrictions in a medication’s use, but any licensed physician is able to prescribe a legal drug for any indication, including so-called ‘off-label’ uses, they deem necessary. Making antidepressant use off-label for children would have several consequences. First, one would hope doctors would become far more cautious, since an adverse outcome arising from an off-label use presents far more liability to the physician. Second, risk management in off-label prescribing requires far more stringent informed consent to the patient (or the patient’s parents or guardians). A thorough explanation of regulatory concerns about these drugs’ use would make many a parent too skittish to consent. Finally, prescription coverage by third-party payors for off-label uses may be denied or may require prior approval, effectively placing the drugs out of financial reach of many patients.

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An effective Democratic response to this would be to paint McCain’s newfound compliance as the selfserving attempt that it is to reestablish his party loyalty iin order to position himself for a 2008 presidential run.

One of my readers alluded to this study in a comment on another post on medical ethics, but it certainly deserves to be put out front. The medical profession has always considered such breaches as failures of individual ethical responsibility, and taken individual disciplinary action. This is consistent with the official whitewash of the Abu Ghraib scandal, where I predict (and have predicted) that official ‘soulsearching’ will ignore systemic permissiveness and facilitation of abuse in the military command structure and Pentagon/administration culture, blaming only the ‘morally depraved’ perpetrators. The evidence of medical and psychiatric participation in the abuses calls for an examination of broader issues of the corruption of inherent medical standards when used to support an immoral war machine.

Juan Cole wonders. His thinking is that Muslim Americans are an important voting bloc in the Midwest, including several important swing states. Adding to Muslim (and Christian Arab?) voters’ dismay at the defilement of the holy city are the domestic trampling on civil rights of Arab Americans, the poor economy and the ripple effect of rising oil prices because of the continuing Iraqi unrest. Much of the Arab American support Bush got on 2000, Cole says, was based on fears that a Gore-Lieberman administration would be heavily pro-Israel.

“He can find another way to advertise himself.” (Sports Illustrated) Another team member (whose cousin and several friends were killed by US military action in Fallujah) said that, if he were not playing soccer, he would “for sure” be fighting with the resistance to the US occupation.

This LA Times report says the embarrassed CIA Iraq Survey Group charged with finding WMD in Iraq will release a final report next month that shifts gears into speculating on what Iraq’s arsenal might have looked like by 2008 if the US had not invaded. The report is being assailed as a departure from the mandate of the group, as designed to obscure the fact that WMD were never found, as confusing the distinction between evidence and fanciful speculation, and as clearly politically motivated. It seems to me that David Kay (former director of the survey group)’s main problem was in resigning too soon. Of course, the dysadministration would try to repair the damage by putting in place a successor without his integrity who would be willing to have the group’s agenda hijacked in this manner. With the deceptions about WMD at the core of the growing outrage about the war and the change in dysadministration justification of the invasion from asserting Iraq had WMD to asserting it had intentions of and capability for weapons production, shouldn’t opponents have had their sights on what the Iraq Survey Group was doing for, oh, the past year or so? It was only last month that Congressional leaders were taken aback to learn of this plan in briefings from a representative of the weapons survey team who acknowledged (before moving on to another assignment and refusing to comment further) that its mandate indeed was “the search for and elimination of weapons of mass destruction.” While an outraged Representative’s request for assurances from John McLaughlin, interim director of the CIA, that the group’s report confine itself to what the search efforts in Iraq had actually yielded has gone unanswered, a CIA spokesperson dismissed charges that the shift in the group’s focus is politically motivated as [perhaps the most common phrase on the lips of government officials these days? &m-dash; FmH] “nonsense.”

Ostracizing the people who were right on Iraq.:

Cannabis extract shrinks brain tumours (New Scientist)

Pollen-blocking cream cuts hayfever (New Scientist)

Novelist Tibor Fischer reflects on what he learned in reading 126 novels as a Booker Prize judge:

Review of The End of Faith: Religion, Terror, and the Future of Reason by Sam Harris:

What can the history of psychosurgery tell us about medicine today? An interview with Elliot Valenstein, author of Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness (Basic Books, 1986).

“STAY FREE!: What brought on the backlash? How did that come about?

VALENSTEIN: Well, there were some scientists who argued that, since we now know a lot more about the brain, psychosurgery should be revisited. This was at a time when there was a lot of public concern about violence in the streets. Two doctors, Frank Ervin and Vernon Mark, had published a book called Violence and the Brain, which argued that brain abnormalities can cause violence. Word got out that the Department of Justice, which maintains federal prisons and special prisons for violent inmates, had some exchanges with the authors. There was a lot of suspicion that the Department of Justice was going to perform massive psychosurgical procedures on violent prisoners as a means of social control. So it became a big issue in some circles. I was at some neuroscience meetings that discussed the biology of aggression, and people came in and broke up the meeting and demanded time on the program.

STAY FREE!: Was there any truth to the rumors that lobotomy was being performed in prisons? “

(Stay Free!)

This devastating piece by The Nation‘s Tom Englehardt dissects the failures of current Iraq reporting, now that we are familiar with the NY Times‘ and Washington Post‘s mea culpas for their pre-war coverage. Englehardt catalogues the aspects of the war discussions of which are missing in action in the major media:

• Al-Sadr’s fighters are called ‘cowardly’ for taking refuge in a holy shrine, but the real cowardice lies in the increasing resort of the US military to devastating air power
• “…If you don’t grasp that, from the beginning, the Pentagon was planning a major string of “enduring camps” in Iraq, then you really can’t grasp why the Bush administration had no exit strategy from that country — because, of course, it had no plans to depart”.
• When Baghdad fell without a struggle, those who had worried that US forces would be bogged down in street-to-street urban guerrilla warfare were dismissed and the subject forgotten. Now, in a range of Iraqi cities from the north to the south, the US and British forces’ worst nightmare is largely coming to pass, only nobody takes note of the fact that we told you so.
• After the handover of power to the Allawi government at the end of June, the US plan to get the American strategists of the occupation behind the lines in the Green Zone to become invisible has largely worked. The combination of coverage of Iraqi government statements and the US military policy of emphasizing that they are doing Allawi’s bidding whenever questioned (e.g. on the run-up to the Najaf offensive) go unquestioned, but it is “obvious to any sane observer that the Americans are still in charge and that American strategic decisions are largely being implemented by Americans, not Iraqis”
• While the Imam Ali Shrine is routinely referred to as “holy” in all coverage of the current fighting in Najaf, American ignorance about Islam and Shi’ism has not been countered with sufficient background about how centrally holy it is to that faith and why the American threat to the mosque is so unnerving and enraging to Muslim and other observers around the world. “It matters that we, who simply read about this, can’t even begin to put ourselves in the shoes of Iraqis experiencing it — although this should at least give us insight into why American policy makers and military men, no less ignorant than the rest of us, can make such staggering tactical blunders.”
• The administration’s characterization of the elements of the Iraqi uprising against the occupation as outlaws, terrorists, ex-Ba’athists and foreign elements (and, I might add, the rhetorical tactic of contrasting them with ‘Iraqis’ and ‘the Iraqi people’) goes largely unquestioned. In fact, it is the US that is more in the role of the Saddam-era ‘Ba’athist’ counter-revolutionary crushing of popular resistance to its rule. In a similar vein, al-Sadr is perennially labelled a ‘rogue cleric’ and his forces always referred to as a ‘renegade militia’, Allawi’s puppet regime in Baghdad inevitably gets described as a ‘fledgling government’.

Note the emphasis on language. The cruelest confirmation of the Whorfian hypothesis is in political reporting — what you call something imposes subtle but firm constraints on how you think about it. (Serendipitously related: this New Scientist article). Englehardt concludes (in the should-go-without-saying category), “How the naming of embattled reality is brokered in our newsrooms and how it changes is a fascinating subject, though one you’re unlikely ever to find discussed in the press itself.”

The first part of Englehardt’s piece, from last week, is also quite worth reading if you missed it:

This is written by a professor of law and an ‘advisor to the MIT Security Studies Program’, whatever that is. The only problem is, they sound like they did not consult a psychiatrist or neuroscientist before going off halfcocked. The lie-detecting functions of brain imaging techniques which they describe are quite fanciful, whether the Pentagon is funding research into their interrogation applications or not. And the SSRI antidepressants do not do anything to ‘reduce…the urge to deceive’ as they assert! Far from it; they probably improve a subject’s resistance to fear-based interrogation techniques and give the subject a higher pain threshold. Moreover, if they could do what the authors assert they do, the ethical dilemma would be much like that around ‘kinder gentler’ ways of executing condemned prisoners which require physicians to violate their Hippocratic oath against “first doing no harm”. The techniques the authors allude to would, in my opinion, undermine American values no less than the torture and abuse American interrogators currently use. Finally, there is nothing to indicate that the jingoistic thug types who conduct debriefings of the demonized adversaries we come up against, when faced with a spectrum of choices of techniques, would choose the less abusive, less invasive ones for any reason. After all, new interrogation methodologies do not supplant old ones….

At staged “Ask President Bush” events, audience members have to pledge their allegiance to his reelection to gain admission. Bush has forgotten who’s sovereign in America. — Sidney Blumenthal (Salon)

Programs that may behave differently in Windows XP Service Pack 2: Many who use WinXP can be forgiven for the temptation to apply Service Pack 2, especially if they are reading any of the media paeans to how indispensible it is. The Washington Post technology pundit went so far as to proclaim that any computer manufacturer who doesn’t upgrade the Windows installs they provide with new machines to SP2 isn’t fit to market PCs. What SP2 is supposed to do is largely to close interconnectivity security holes (it turns on the Microsoft firewall by default… duh!) and (finally! they decry) add popup-blocking to Internet Explorer. However, before you decide to apply SP2, read the list of programs which may ‘behave differently’ (read: ‘stop working’?) afterwards. While there are alot of games on the list, such heavyhitters as Symantec and McAfee products, Nero Burning ROM, the ZoneAlarm woftware firewall, Adobe Pagemaker, and many of Microsoft’s own Office components can also be found there. So I don’t think I’ll be applying the upgrade after all, especially since I already use effective ways of protecting myself in the manner Microsoft boasts of doing with SP2 — the aforementioned ZoneAlarm (plus a hardware firewall) , both server- and client-based spam blocking, and the built-in pop-up blocking in the Mozilla and Firebird browsers. No matter how improved Internet Explorer is, why bother?

And the reports that will emerge of what Microsoft has inevitably ‘broken’ in implementing this ‘fix’ are probably just beginning. [Yes, yes, I know, this whole discussion is really irrelevant, since the real issue is that Microsoft’s OS is such an imperfect creature overall, and those of you out there using Linux or OS-X are sitting there smirking smugly…]

Agre goes on to elucidate the deceptions at the core of conservatism, which become increasingly desperate and at times subtle in a society predisposed toward egalitarianism. I particularly like his take on the ‘mockery of conscience.’ Agre’s laundry list of how to defeat conservatism deserves to be studied by anyone with any interest (read it in full; he elaborates convincingly on every point):

• Rebut conservative arguments
• Benchmark the Wall Street Journal
• Build a better pundit
• Say something new
• Teach logic
• Conservatism is the problem
• Critically analyze leftover conservative theories
• Ditch Marx
• Talk American
• Stop surrendering powerful words
• Tipper Gore is right
• Assess the sixties
• Teach nonviolence
• Tell the taxpayers what they are getting for their money
• Make government work better for small business
• Clone George Soros
• Build the Democratic Party

Apparently, security screeners on the Staten Island Ferry are trying to confiscate ‘inappropriate’ books as security threats. As did the writer, perhaps you ought to put the ACLU’s phone numbers in your phone book and carry a printout of relevant parts of the Bill of Rights…and pray things are different after Inauguration Day. But at least for those of you in the New York area, expect the ridiculousness, outrage and offense quotient to rise at least until after the Republican convention.

Glad I’m a fountain pen devotee. (The Economist)

‘Gene banking and cloning of exceptional pets’; they claim their first two cloned cats were born in June, 2004, and predict dog cloning will be available next year. Before you ask, yes, I and my family are fervent lovers of dogs and cats and always have any number of each around, but I join adam, who sent me this link, in thinking this is an extraordinary waste of resources.