Beam Me Up, Doc
By: Joshua Koerner

Scott Miller is the co-founder of the Institute for the Study of Therapeutic Change. Back when he was an intern at a psychiatric hospital he met a man with a delusion: the patient believed himself to be the Terminator. He was living out the second Terminator movie, part of which is set in a locked psychiatric unit. I love the scene in which the unit psychiatrist, dismissive and contemptuous of Sarah Connor’s story about the robots from the future, gets flung across the room by Sarah’s "delusion".

This patient had been leading other patients in repeated escape attempts, and the staff’s efforts at rational discussions, and drugging, failed to calm the situation. By the time Miller first talks to him he’s in the quiet room, stripped to his underwear. The situation can’t get much worse, so the senior staff don’t think this student can do any damage, and Miller, young and not yet indoctrinated in the ways of the psychiatric establishment, tries something new.

First, he talks to the patient as if he were the Terminator. He doesn’t question his "fixed" delusion. Miller then asks him if he is not the Terminator, but really Arnold Schwarzenegger. The patient smiles and asks, "How did you know?" Miller addresses him as if he’s Arnold, telling him he has accomplished so much since coming to America. And then Miller asks if he’d be willing to attempt a role like nothing he’s played before, a difficult stretch. Would he be willing to play a mental patient? Would he be willing to go to groups, take meds and not attempt to escape? The patient responds, "I can do it".

And he did: after weeks of deteriorating, he was released in a matter of days. Miller noted on the radio program This American Life, and also in the book, The Mummy at the Dining Room Table, that: "We have these notions that psychosis is a biological condition, and talking just really isn’t the thing that helps them, they really need the drugs. In fact, very often people are advised you don’t actually engage people in conversations about their delusions; that might perpetuate them. So you want to make sure you are very rational with them, set limits with them, and with some clients that’s going to work. But when you’ve tried that approach and it doesn’t work, you probably need to try something else. And our research actually says that clinicians frequently don’t recognize when a case is failing. That means they persist in doing more of the same thing that hadn’t worked before; either the same class of intervention, or type of intervention. So if a little medication doesn’t work well then we’ll try a little bit more. If a little confrontation doesn’t work to overcome the client’s denial, well then by God we’ll put them in a group where 12 people can confront them simultaneously. It’s interesting to me that, in mental health often times when there’s a problem it’s the clients who end up somehow blamed. "

Evidence-based practice is the buzz phrase of the moment in the mental health field; it means we ought to be doing what works. But the evidence is that we know what works, that we’ve known for decades, and that we aren’t doing it. Instead, the field has been co-opted, and corrupted, by the forces of Big Medicine, and has made pharmaceuticals the answer. That’s not an evidence-based approach, as empirically, there’s little to support the notion that mental illness is the result of a "chemical imbalance", just as there is little evidence that drug therapy is superior to psychotherapy.

What does work? Miller and his colleagues state that "using the client’s theory of change to guide choice of technique and integration of various therapy models" is what works. You can read their evidence in detail at www.talkingcure.com.

I recall a psychiatric student I met on an inpatient unit. This was my second hospitalization, in 1984, but my first at the Big Teaching Hospital. With it’s verdant lawns and tennis courts to match its sterling reputation, I cannot blame my mother for thinking this was the best for her son. How could she have known that the campus culture was one of pseudo-Freudian detachment: that doctors never smiled or, if you passed them in the hallway or shared an elevator, would even acknowledge your existence.

I cannot recall anything of the way the resident looked — I may have spent all of a half hour with this man and never saw him again. He never treated me, we just chatted for a half hour shortly after I’d been admitted. He was probably just doing an intake interview, or perhaps had been sent in to observe me, to see what mania looked like up close. Yet to this day the one thing about him I do remember is his smile, a broad grin of delight that told me he was genuinely interested in what I had to say.

I was trying to explain Bell’s Theorem, which states that entangled pairs of electrons will always have spin states that add up zero, even if they are separated by hundreds of miles. Einstein derided this as "spooky action at a distance", but when it came to quantum mechanics, Einstein was wrong.

The young doctor was fascinated; no one had ever told him that anything could travel faster than light, and here it seemed that there was some superluminal signal passing between the particles. What, he wanted to know, did I think that meant. "It means locality fails!" I exclaimed. The whole idea of local causes is wrong, instead there is an implicate order underlying the universe, despite our perceptions of cause and effect, here and there. Where we perceive chaos and disunity there is instead harmony and oneness, a sure sign that God exists.

I hadn’t learned such arcane physics principles in a classroom. When I was first hospitalized in 1979 it was a crushing blow. I was out in California at the time, gone there to seek my fame and fortune. When I had to return home at age 24 to live with my mommy, depressed, unable to work and labeled a mental case, I felt completely disgraced. Then I started to read about quantum mechanics, and Buddhism, and it gave me some solace, because they both said that everyone’s perception of reality was wrong, and in fundamental ways both agreed with each other.

Now I was back in the hospital, perceiving directly how everything is tied together. It was an amazing, expansive, oceanic feeling: birds and trees and clouds and traffic, they all seemed to mesh together in total synchronicity. And this doctor was really interested in it; he really wanted to hear what I had to say, as though he could learn something from me.

Contrast that with the case conference held in 1986, during my fifth hospitalization. I’d been inpatient six months, and I was dying to get out. They asked if I would participate in a case conference. They didn’t say my discharge depended on it -- they didn’t have to. My discharge date had been moved back once; they could move it again. I said sure, anything you want.

The case conference was held in a large meeting room. I sat up front while a senior staff doctor interviewed me, and there were thirty or so residents arrayed around us. I remember one was falling asleep, and many of the others appeared bored and restless. I had been told the topic would be my discharge plans, what I learned in the hospital, blah, blah, blah, and I was all set to tell them what I thought they wanted to hear.

And then, without warning, the interviewer starts to ask me about my father. My dead father. It was an ambush, and I wanted to say, "Screw you, I’m not answering questions about that." But I was on the spot; if I made a scene they might not let me go.

But the worst aspect of the whole thing was sitting there, and answering horribly invasive questions from a total stranger, feeling like a bug under a microscope, getting all choked up and then looking around the room and seeing these callow young doctors, and they were bored. My anguish bored them. As terrible as I already felt, their utter lack of empathy made it ten times worse.

What did those residents learn that day? That you study the disease and ignore the person. What did I learn? That my feelings weren’t important and that doctors aren’t to be trusted.

Years later I learned on my own what a clinician who knew and followed the evidence could have taught me: that the Tao Te Ching, which says "Close your mouth, block off your senses, blunt your sharpness, untie your knots, soften your glare, settle your dust" is an excellent non-pharmaceutical recovery tool.

It would have been so much better to have taken what I was interested in, science and philosophy, as a basis of a theory of change in which I believed, rather than using one packaged by drug companies, or conceived by Freud (while he was using cocaine).

A footnote: In 1997 the practical application of Bell’s Theorem was proven with the first teleportation of a photon, a unit of light, and then on June 17 2004 the National Institute of Standards and Technology, as well as the Quantum Teleportation Team at Innsbruck, Austria, reported the teleportation of whole atoms, thus opening the door to quantum computing. By using qubits, which have four simultaneous possible states rather than the limited on or off states of bits, the power of computers may one day increase by several orders of magnitude.

That is, unless it’s all a delusion.