Wednesday, November 11, 2009

What Have You Done To Yourself?

I work with alcoholics and opiate addicts who are in active physical withdrawal from their drugs. Night after night they are brought onto my unit on stretchers, in wheelchairs or on the arms of concerned family and friends. Often these people look and smell aweful, unbathed, unhealthy, and unhappy. My first task, once they get in, is to take their vital signs. I watch them through the corner of my eye, trying to be unobtrusive in their terrible moment, while the blood pressure cuff inflates. I wonder again and again, “What have you done to yourself?”

This is a question all of us need to answer and not to each other first, but to ourselves. Dr. Michael Stein wrote presciently in The Addict: One Patient, One Doctor, One Year of his experiences as a practicing internist. In his practice he treats people with maladies ranging from hypertension to diabetes to opiate addiction.

In his considerations, Dr. Stein put forward the idea that the most significant gains in overall health for people in the twenty first century will not be a result of science and hygiene, as in the previous centuries, but in lifestyle choices. The CDC reports on their website that two thirds of Americans are over weight or obese. It is not just the heroine addicts who resist making necessary lifestyle changes in the face of life endangering consequences.

What does this mean for the current health care debate? Work on the legislation that could change the way Americans access the health care system is under profound scrutiny perhaps as I write this. Our democratically-elected congress is literally pulling together new law that could make it possible for all American families to enjoy the security hundreds of millions of people in other modern democracies have in knowing health care is accessible and affordable to them. Let’s pray fairness reigns out over the bullies of industry this time.

But the possibility of these remarkable changes will not answer my question. Americans deserve excellent health care at affordable prices. However, health cannot be purchased. How we choose to live is the first and most necessary step towards good health. No legislator or doctor can hand that to us. It is something we must choose and then work towards every day.

Friday, November 6, 2009

An Educated Guess: Hasan Knew Difference Between Right and Wrong (He just didn't care)

The details of Maj. Nidal Malik Hasan's life, accused shooter at yesterday's Fort Hood horror, are few and far between. There is, what I feel, an explanatory tone to what details have been given and some of the commentary offered on network and cable TV. Some of this tone concerns me.

The New York Times is reporting from multiple sources Hasan is an American born of immigrant parents from Palestine, a Muslim, army-educated psychiatrist, and, in the latter capacity, second-hand witness to the horrors of war. It was reported he was to be deployed to a combat zone later this month, and that he told a cousin he did not want to go. He was also reported in the NYT as being a vocal critic of the Iraq and Afghanistan wars and was acutely aware of the brutality some soldiers experienced in these wars through his work treating Post Traumatic Stress Disorder, PTSD, a severe and persistent anxiety disorder, in returning soldiers.

The entire episode is a horror beyond my abilities to describe and the surviving victims will be the appropriate tellers of the story. I simply want to point out the emphasis given by some commentators of Hasan's exposure to second-hand trauma through his treatment of soldiers, and the implication this could have been partly to blame for his outrageous behavior, may be misleading.

I would be surprised if hearing the horrors of war from fellow soldiers didn't negatively impact Hasan. But it is the way in which it effected him that singles Hasan out from other mental health professionals, soldiers, and people in general.

In my work, I have had opportunity to do forensic interviewing with mental health professionals and am trained in the field myself. I have seen a therapist so effected by years spent listening to children recount their stories of abuse and neglect that this woman literally cried the entire time I spoke with her. A coworker happened across this therapist's garage sale around the same time and mentioned how the poor woman began crying in a casual conversation. This is an understandable secondary PTSD reaction in a therapist.

I worked on a case through the juvenile court system as a child advocate that became so upsetting to me I literally had an anxiety reaction to the sight of the social worker on the case. She had the same reaction to the sight of me, and we snickered sadly at how upset we must be to have such a reaction.

Some people in the helping profession who are experiencing what is called Compassion Fatigue, or "burnout," may have difficulty with personal relationships, develop compulsions and even commit suicide at least partly as a result of bearing too much witness to the agony of others. The line that connects these varied negative responses is one that did not intersect with Hasan's deeds yesterday. Burned out helpers generally cause harm to themselves. Of course, people closest to them may suffer, as is typical when a loved one is having a difficult time. But for Hasan to take aggressive action against the very people he was trusted to heal is completely out of bounds and has a different rationale entirely, I suspect.

Hasan's behavior points much more toward anti-social personality disorder or perhaps narcissistic personality disorder than it does a severe anxiety disorder. It certainly sounds in the reports that he was scared as hell of being deployed into a combat zone where he could not control the violence. So why would he walk in and do so much violence, likely aware he would be hurt or killed in the process? My guess is that it wasn't violence this man feared, but not being able to decide who does what violence to whom.

In short, he may have simply wanted control. Where this level of need for control exists, I believe, there cannot be empathy, as well. And empathy for the lives of more than forty people should be an easy thing for a psychiatrist to feel no matter how many horror stories he heard or negative comments he may have gotten from ignorant people about his heritage as a Muslim or Arab.

If I am correct, a desire to control so powerful that it entirely supersedes a person's natural ability to empathize with other people may have a lot to do with serious mental health problems and emotional limitations Hasan developed over a lifetime. These mental health problems, notably, a personality disorder, are distinct from other mental health problems in several ways and very importantly here, because someone with anti-social or narcissistic tendencies knows the difference between right and wrong (unlike people suffering from something like a psychotic stress response). They just don't care what they are doing is considered wrong, because they believe they are unique, separate from others, and not rightly subject to the rules the rest of us live by.

The distinction between knowing the difference between right and wrong and not for this surviving gunmen will become very important when he stands trial. It could become that of life from death. I doubt anyone will afford him any more control when it comes to those matters.

Sunday, November 1, 2009

A Threadbare Representational Government

Ms. Scozzafava’s withdrawal from a congressional race in up-state New York apparently under the pressure put upon her campaign by outside support of a puppet candidate, Mr. Hoffman of the "Conservative Party," may be another death rattle for our representational government. However painful to acknowledge, it is not only the Neo Cons who are working towards the end of any legitimacy to our government. Even our faulty news sources have inadvertently brought us word from all corners of corruption this week.

But starting with the Neo Cons, The New York Times reported this morning that, despite local Republican anger over manipulation of their electoral process, the Neo Con movement moved in aggressively against Scozzafava's moderate views on gay marriage and abortion rights. Perhaps directed by their relationship with "God" or perhaps out of pure ambition, mental giants like Sarah Palin and our own Tim Pawlenty, put their support strongly behind Hoffman. Hoffman recently demonstrated in an interview with the local newspaper, Watertown Daily Times, his unequivocal ignorance of issues in a district he does not live in, but which he apparently believes he is the fittest representative. But why should someone need knowledge of a people or an earnest desire to represent their best interests when you have the will of God on your side?

It is clear that having a competent, moderate African American man in the White House with his equally competent and moderate African American wife has literally driven the Conservative movement (and by that I mean the Conservative White Movement) completely off their rocker. They are running on fear with hair sticking straight out and hands flapping over their screaming heads. Truly ridiculous. But the very degraded state of our economy, financial institutions and every system that supports a strong citizenry, including education and health systems, leaves us very vulnerable. Fanatics are given an ear during desperate times. In fact, in the U.S., fanatics have been given an ear in flush times, as well.

Then there was the leak of information about congress people being investigated on potential ethics violations including several Dems last week. I cringe at the potential involvement of such people as Maxine Waters (D-CA) in ethics violations, but fully support an outing of any and all shady dealings. She has been a strong advocate for economic fairness for all citizens. We need to make sure she hasn't been using her position to advocate for her husband's business interests in a federally-bailed out bank. If this is simply an investigation into unfounded accusations, lets hear who those accusations came from. Any under-handed players potentially involved in this "leak" by political competitors to the Dems may be discouraged by the reactions of Dem supporters.

I say, "Lets have it!" The time for truth is nigh. We need to know, just tell us the truth, who exactly is our representational government representing at this point? Is it the small groups of wealthy folks who control the vast majority of wealth and easily manipulate our government to get that wealth out of the grocery and heating budgets of our citizenry when their business ventures collapse? Is it the angry, White, conservative Christians who consider themselves the foot soldiers of Christ as they work to pummel with their negativity and rage the people they consider less human than themselves? Do these groups overlap? Maybe, maybe not. What they have in common is a deep sense of entitlement to legal, cultural and/or economic resources at the expense of others.

My point is this, competent, moderate folks of all kinds need to stay very active right now. This is a vulnerable time for our nation and our people. Voices of reason need to continue putting pressure on our representatives to act in our interests. We want easily afforded health care, strong investment in our infrastructure, and the acknowledgment and support of all families including those that include a same sex couple. All of these are moderate positions that seek only fair and respectful treatment of our people.