don't care what the scilons say, psychiatry now a sick joke

[compared2what?]

.

Right. So.

What, exactly, prompts you to say that commonly prescribed psychotropic medications are likely and/or known possibly to be useless or even harmful?

That wasn't really my question, in spirit. Rather, it was:

What, exactly, prompts you to say that commonly prescribed psychotropic medications are likely and/or known possibly to be useless or even harmful?

As opposed, let's say, to overprescribed and often of limited therapeutic utility that's further compromised in many cases by a wide range of empirically non-harmful but practically unbearable side effects?

Or, let's say, so inherently inimical to a respect for the integrity of the individual that should be sacrosanct to all human beings and doubly so to doctors that they should only be used with extreme caution, care and attention as a treatment of last resort for all cases in which life, limb and safety are not at risk?

Because, frankly, while I myself wouldn't be satisfied with making any of those statements and then just calling it a day, leaving 99 percent of the problems as they really exist on the ground completely unaddressed, the two alternates that I proposed have what is (to me) an enormous, huge and immeasurable advantage over the first. And it's this:

They formulate the problem in terms that emphasize the needs and experience of the patient. Which are, imo, not just the central consideration, but the one that has primacy over all others.

Anyway. I'll be getting back to that in a few. I more or less just wanted to put it within easy reach first.

[compared2what?]

But first, some throat clearing. I mean, from me not you.

Leaving aside all the drugs that have come and gone as wonder cures for this or that in decades long past -- barbituates, amphetamines, valium, even Heroic Heroin -- let's just deal with some of the still-titanic brandname cures of today.

I actually think all four of those drugs have their uses**. In fact, out of the legal three, I'd say that only barbiturates have so many ways of leading to, well, death that it prohibits prescribing them for anything but clearly proscribed and absolutely unavoidable medical purposes.
__________

**FWIW:

Valium -- Habit-forming, and therefore obviously should not be prescribed without regard to that consideration. But still. It's got some miinor recreational and anxiolotic values, though you could probably do better on both scores.

Amphetamines -- Addictive, and therefore obviously should not be prescribed without regard to that consideration. But still. They're massively fabulous recreational drugs on an occasional basis, and I would deal with their pros and cons as an ADHD treatment in a separate post if I thought anyone would hear it as anything other than an endorsement of child torture. When in truth I'm not very enthusiastic about any of this stuff, at best. But it does have its specific pros and cons. And I can't really help that. It's just how it is.

Heroin -- I wish that I was born a thousand years ago. I wish that I'd sailed the darkened seas on a great big clipper ship, going from this land here to that in a sailor's suit and cap away from the big city where a man can not be free of all of the evils of this town, and of himself and those around.

Also, it's a really fun recreational drug, though very addictive and potentially lethal. As well as an excellent pain-killer that should be used as one in some medical circumstances but isn't, due to nothing but social bias.
___________________

That's it for the throat-clearing, I believe.
___________________

Edited for punctuation and ragging and signature attachment.

[compared2what?]

http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050045

Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration

[Excellent study, with which I have no quarrels at all, stating, basically, that antidepressants alleviate Major Depression in patients for whom it's really an acute or chronic condition but don't do all that much for anybody else, linked above, but cut for length -- c2w.)

c2w?, you may say this is the evil of Pharm, and that you've condemned Pharm in no uncertain terms, which you have. But don't tell me you can cleanly separate the psychiatric profession from Pharm, just because they're downstream writers of scrips. Most of them are the soldiers enforcing the regime, so to speak.

Well. I don't actually think that I have said that this is the evil of Pharm, period, end of reductive sentence. But I guess that if I had to put it very, very simply, I'd say that the evil of Pharm and other big corporate lobbying interests, including but not limited to the HMOs, are overwhelmingly the primary major contributing factor to the problem, with widespread public ignorance and misinformation running a very distant second. That's kind of unsatisfactory, because there's a pretty substantial political dimension, too. But you can't have everything. So oh well.

But be that as it may.

The reason that I wouldn't and haven't told you that you can cleanly separate the use and abuse of psychotropics from their prescription by psychiatrists is that you can't. However, I can and will tell you that neither can you cleanly merge them into a seamless and undifferentiated whole, afaik. Because, afaik, there's not really any data or evidence that attests to "most of them" being "soldiers enforcing the regime."

Or at least not if what you mean by that is that the overprescription of antidepressants is mostly done by psychiatrists who are mostly doing it strictly to make a profit and without the slightest regard for the welfare of their patients. But to be honest, I'm proceeding under the assumption that it is more because I can't really imagine what else you could mean than because I'm certain that you do mean that. So please clarify, if clarification is called for. Okay?

In the meantime:

First of all. I do fully grant that it's possible that you're correct. Because -- also afaik -- there's not really any data or evidence that definitively exculpates psychiatrists from that charge. And certainly none that exculpates them from (far more likely, imo, based on indirect evidence) a more modestly stated version of it.

However, second of all: I'm sorry but that still does leave my fundamental question -- ie, why demonize psychiatrists to the exclusion of, effectively, all other considerations? -- substantially unaddressed. So honey, tell me, please, why do you?

Because while it may not be totally decisive, there is definitely more than enough extant evidence to suggest that keeping a relentlessly harsh spotlight trained exclusively on psychiatry might very well inadvertently and indirectly be making things worse and not better.

This evidence, for example...

Use of antidepressants by general practitioners and psychiatrists in Australia.

McManus P, Mant A, Mitchell P, Britt H, Dudley J.

Department of Health and Ageing, Canberra, Australian Capital Territory 2605, Australia. peter.mcmanus@health.gov.au
Abstract

OBJECTIVE: To examine the antidepressant prescribing patterns of psychiatrists and general practitioners (GPs) in Australia, focusing specifically on: the prescribed daily dose, the relative proportions (from subsidized dispensing data) of prescriptions written, and how these proportions change over time for a newly listed antidepressant drug (using paroxetine as an example).

METHOD: Retrospective analyses of subsidized claims data (comprising nearly 90% of the community supply of antidepressants) and prescriber surveys.

RESULTS: General practitioners prescribe 86% of subsidized antidepressants in Australia. Almost three-quarters of the antidepressant prescriptions prescribed in primary care management are also initiated by a GP. Psychiatrists prescribed higher doses than general practitioners for all the antidepressants examined. For paroxetine, a higher than average proportion of scripts were written by psychiatrists when the drug was initially available and it only reached the GP/psychiatrist split seen with an established drug in the same therapeutic class (fluoxetine) four years after marketing. The most prominent type of depression that GPs believed they were treating was 'chronic mild depression', which contrasts with the subsidized indication for all newer antidepressant classes of 'major depressive disorders'.

CONCLUSIONS: General practitioners are the major providers of treatment for depression in Australia. When writing prescriptions for tricyclic antidepressants GPs use doses lower than those recommended for major depression, however, most management in primary care is not for conditions regarded by the GP as major depression. A significant number of prescriptions for the newer antidepressants may not accord with the Pharmaceutical Benefits Scheme (PBS) restrictions for use.

....suggests that most antidepressant prescriptions -- and virtually all antidepressants prescrbed to the population identified by the study you cite as not at all in need of antidepressants, which won't help them -- is done by GPs and not by psychiatrists. And that's fully in line with most studies, although there are some that state their conclusions in rather less forthright terms. For example, MEPS chose to report its finding of a 70.7 percent non-psychiatric-prescribing-physician/29.3 percent psychiatric-specialty-prescribing physician split for antidepressants in the United States like so:

Which certainly isn't as likely to needlessly increase the overall amount of suspicion and hostility toward psychiatrists felt by the general public as unilaterally condemning them for all ills on the basis of no data at all is. But, you know. Affordability and access trends being what they are, it doesn't exactly seem calculated to help either.

In any event. My question is still the question I asked in spirit when I asked:

What, exactly, prompts you to say that commonly prescribed psychotropic medications are likely and/or known possibly to be useless or even harmful?

As opposed, let's say, to overprescribed and often of limited therapeutic utility that's further compromised in many cases by a wide range of empirically non-harmful but practically unbearable side effects?

Or, let's say, so inherently inimical to a respect for the integrity of the individual that should be sacrosanct to all human beings and doubly so to doctors that they should only be used with extreme caution, care and attention as a treatment of last resort for all cases in which life, limb and safety are not at risk?

IOW -- Why frame it that way? On what grounds do you formulate the problem as being primarily a simple matter of useless or even harmful drug prescription by (implicitly or explicitly) psychiatrists?

I mean, where'd you get that idea? If I may be so bold to ask?

More shortly, I think. I'm doing this piecemeal.
_______________________-

edited to put my initials after the italicized study recap.

AND ALSO TO EMPHASIZE FOR THOSE WHO DIDN'T READ IT ALL THAT WHAT I'M SAYING IS THAT ALL AVAILABLE DATA SUGGESTS THAT:

(A) THE OVERPRESCRIPTION OF PSYCHOTROPICS IS LARGELY ATTRIBUTABLE TO THE IGNORANCE AND IRRESPONSIBILITY OF GENERAL PRACTITIONERS OR THEIR CLOSE EQUIVALENTS AND NOT TO THE GREED AND INHUMANITY OF PSYCHIATRISTS; AND

(B) IF PSYCHOTROPICS WERE INDEED ONLY PRESCRIBED BY PSYCHIATRISTS -- WHOSE SPECIALTY STRONGLY PREDISPOSES THEM TO READ THE LITERATURE ABOUT FOR WHOM SUCH MEDICATIONS ARE AND ARE NOT LIKELY TO BE HELPFUL -- THEY MIGHT NOT BE SO VERY FUCKING OVERPRESCRIBED.

In light of which I ask whether it really makes all that much sense for people who feel strongly about the overprescription of psychotropic medications continually to curse and blame and, I'd submit, basically demonize psychiatrists in connection with it.

In short.

[vanlose kid]

The Rosenhan experiment does not do anything to rebut the mountains and mountains of data of every conceivable kind attesting to the reality and the frequency of real, painful and sometimes fatal psychiatric disorders. It says nothing about them whatsoever, in fact. It does say something about the slipshod and horrifying clinical practices of psych wards. though.

Quit thinking about yourselves, please. For one stone fucking second. There are people out there who need your help and attention and commiseration for what THEY are experiencing and not for what YOU are experiencing.

That's it. I've got nothing else to say.

hey c2w?, sorry for butting in here. bear with me okay?

i can see that quote within the quote above was meant as a general admonition and an expression of embattled had-enough-ness, so i won't take it as directed at me. the reason i looked it up is because i'd never heard of it and it was relevant to what JR was saying. so i posted it.

re you and JR. so far, in this thread i've been agreeing with you re your points concerning Levin etc. they're relevant and valid and as usual you're learning me plenty. thing is though, i also agree with Jack. a further thing is i don't see your points (both of youse) as being mutually exclusive. nor do i think, in the final analysis, that you and Jack do either.

re scilons and the CoS. i admit to being a bit sceptical re your evaluation of the power of CoS and psychiatry. then again, i conflated psychiatry and PhrMA. looking back i think you're probably right, again. -- i did go and check it out though and found this:

The Church of Scientology claims 3.5 million members in the United States,[15] though an independent survey has found the number of people in the United States would state their religion as 'Scientology' is close to 55,000.[16] By comparison, the American Psychiatric Association and the American Psychological Association, which are composed of psychiatrists and psychologists, have 38,000 and 148,000 members respectively.[17][18]

http://en.wikipedia.org/wiki/Scientology_and_psychiatry

so, i also think Jack is right to say that psychiatry should grow itself some balls. and i thought that already when i read the OP, viz:

He could have accepted less money and could have provided time to patients even when insurers did not pay, but, he said, “I want to retire with the lifestyle that my wife and I have been living for the last 40 years.”

“Nobody wants to go backwards, moneywise, in their career,” he said. “Would you?”

Dr. Levin would not reveal his income. In 2009, the median annual compensation for psychiatrists was about $191,000, according to surveys by a medical trade group. To maintain their incomes, physicians often respond to fee cuts by increasing the volume of services they provide, but psychiatrists rarely earn enough to compensate for their additional training. Most would have been better off financially choosing other medical specialties.

Dr. Louisa Lance, a former colleague of Dr. Levin’s, practices the old style of psychiatry from an office next to her house, 14 miles from Dr. Levin’s office. She sees new patients for 90 minutes and schedules follow-up appointments for 45 minutes. Everyone gets talk therapy. Cutting ties with insurers was frightening since it meant relying solely on word-of-mouth, rather than referrals within insurers’ networks, Dr. Lance said, but she cannot imagine seeing patients for just 15 minutes. She charges $200 for most appointments and treats fewer patients in a week than Dr. Levin treats in a day.

viewtopic.php?p=387730#p387730

that says Levin made a choice. it doesn't say, in my reading, that he was forced, nor that he was powerless.

something else i've gotten out of reading your posts is that it made me curious as to why CoS use so much effort targeting the practitioners and none targeting PhrMa. if you have anything to say on that front i'd love to hear it.

anyway, hope you can forgive me for posting on the Rosenhan experiment, because as you youself say: " It does say something about the slipshod and horrifying clinical practices of psych wards."

i just think it's more than just slipshod. though.

:handshake?

*

edit: typos, formatting.

*

[compared2what?]

.


The drugs they proceed to expose as useless to tens of millions of people who are taking them (except possibly in a minority of severe cases) are in the SSRI class and better known by their brandnames as big stars of the last two decades: Prozac, Effexor, Serzone and the really addictive Paxil. That one I've seen fuck up someone personally by being highly addictive and causing ironically melancholy "side" effects. Sorry, my anecdotes count if they line up with the data. And sometimes in the absence of sufficient data -- EDIT: i.e., assuming absence of sufficient data for or aganst an idea -- if I see a valid argument for thinking an anecdotal gathering is representative or strongly indicative of something, I won't shy away from it, assuming the proper caveats are given and I remain open-minded to new data. Note also that the story isn't about me getting fucked up as a result of false faith in a useless medicine, or due to a careless diagnosis, but someone else, someone who counts too, and the person really did have a terrible time.

Among other things the authors of the above find that the studies wherein these heavily-pimped Pharm Stars don't beat the placebo tend not to be published, thus distorting the overall view of given treatments! What a shock. ON EDIT: Failure to publish when results are inconclusive, boring or nothing new (and therefore boost no careers and make it look like "money was wasted"), or when results are not in line with what a private funder hoped for, is one of the best-known ways (within and without the science community) that scientific findings are distorted and the scientific community allows itself to be used for corrupt ends due to the mechanisms of funding science research in capitalist, corporate-authoritarian, society in which all are trained to prioritize individual "success." That's not a critique or rejection of "science," as some seem to think when you talk about the corrosive effects of money on research in the real world, it's a critique of capitalist, corporate-authoritarian society that trains the smart and capable to prioritize their individual success above all, and leads to a corruption, a failure by institutions or practitioners to meet their own high standards of science.


Also, given how this argument has gone, I already feel like I again need to please note: I'm answering the question, "what prompts you to say that commonly prescribed psychotropic medications are likely and/or known possibly to be useless or even harmful?"

I am NOT saying and would never say that there aren't good drugs for given severe conditions that help people who would otherwise suffer. I am not saying that anyone should feel shame for taking drugs they hope will improve their lives, or for finding that this is actually the case. (Never!)

I am saying that the placebo-equivalent SSRIs whose mythos is debunked in the Kirsch study (except that placebos are not known to make anyone sluggish or kill their sex drive or change the color of their piss) are a grave disservice to the tens of millions of non-severe cases who get them and who are, in fact, harmed by false hope and by being given the false impression that they are receiving treatment (and possibly even more so in cases when serious conditions are mis-diagnosed as some vague general Non-Disease Du Jour).

I agree with all of what you say here, near enough as makes no difference.

Next we have the famous St. John's Wort trial.
http://nccam.nih.gov/research/results/stjohnswort/

I knew someone who worked on this project as a research assistant for years. Basically, NIH decided to do away with the myth of St. John's Wort as a treatment for depression. Which they did.

But in this unusually large trial, besides a placebo group and a St. John's Wort group, they included an additional "control group" that was given Zoloft. And surprise, surprise, the placebo was better than Zoloft. That was the real lede, but the press stories buried it and headlined the failure of St. John's Wort, as though that was even news. (St. John's Wort is more likely to be like c2w?'s example of a case where a treatment is ineffective but not harmful, given that it's being sold by quacks on the side, and not appearing to have the force of research science behind it like the Pharma products.)

Wait, what? St. John's Wort is an effective antidepressant. The only legitimate concerns with it that I know of are the usual ones that attach to stuff that's sold under the lax (ie -- non-existent) regulatory standards that the FDA uses for the pills and whatnot it classifies as "food" rather than "drugs" -- ie, unreliable dosage information relative to pill content, highly exploitable by scammers, etcetera.

I should say that my understanding is not au courant on this one, because I haven't really kept up with the SJW news. I guess that I more or less assumed that it was still viewed as the same old uncontroversial known quantity that it was when it first came on the scene. At which point (WARNING: anecdotal) many psychiatrists appeared to have all at once read the same study, then started recommending it to patients for whom the Prozac bubble hadn't done much good.

But fwiw, to the best of my non-extensive understanding, apart from the less exacting regulation, it has at least as much and probably more going for it as any other SSRI (which is apparently, though not certainly what it is) when it comes to the treatment of, basically, chronic or episodic dysthymia-ish-type depression.

I mean, obviously, I don't think it's ideal or problem-free for anyone who feels like it to just up and start fucking around with his or her serotonin levels on a long-term basis as a means of treating a medical condition, absent some kind of consultation, research or oversight with someone of a qualified and caring professional nature.

For pretty much the same reasons that I don't think it's ideal for a psychiatrist who only sees patients for fifteen minutes every few months to do the same thing. Whether he's handing out St. John's Wort or a prescription SSRI. The risks are not enormous. But there are some. And they need to be heeded.

Check out this weasel sentence from Scientific American, in a lower paragraph of an article titled, "Study Finds St. John's Wort Ineffective Against Depression":

But because Zoloft was also not significantly different than a placebo on the primary measure of the study, the results were far from straightforward.

http://www.scientificamerican.com/artic ... johns-wort

The whole story is packed and hidden in that "also." Far from straighforward, my ass! If you're going to headline the study as finding no effect favoring St. John's Wort over the placebo, then you've got to also say it found no effect for Zoloft, because that's equally true and probably more important.

This kind of avoidance in language is evidence of a social orthodoxy at work.

I agree.

And the orthodoxy is supported by funding streams that are literally dozens, if not hundreds of times greater than anything available to Scientology, as well you know. (EDIT: Perhaps hundreds is a wild exaggeration, but shall we compare the economic size and social reach of GlaxoPfizerSmithBayerScheringLillyKline and their teams of experts who bear the label of psychiatrists to the economic size and social reach of Scientology and its explicit or disguised spokespersons?

Let's not and say we did. I'm not all that interested in the Scientology angle, really. It's a real concern, but not my main concern. Allow me to say for the one-zillionth time, as an act of penitence for ever having been stupid enough to bring it up at all in any context in such a discussion.

What's the ratio of commercials selling supposed anti-depression meds plugged by persons with qualifications as psychiatrists, to those selling Dianetics?)

Thus phrased, I don't know. But I suppose that it's probably somewhere around....Maybe, 200 or 300 to one?

Or scratch that. I'm going with: Less than a thousand to one, but more than a hundred to one.

Yes, that is my final answer.

Back in a few.

[American Dream]

Here is an excerpt of an interview between Bruce Levine and Robert Whitaker that is relevant to some of the themes in this thread. The whole article is interesting, and well worth checking out.

Levine: Big Pharma and their partners in establishment psychiatry would like the general public to believe that the only critics of psychiatry are Scientologists. In reality, most scientists who are critics of psychiatry are also critics of the pseudoscience of Scientology. It is my experience that serious critics of psychiatry are not anti-drug zealots. For example, I know that you have talked with “psychiatric survivors” -- ex-patients who want to reform mental health treatment. David Oaks, one of the leading activists in the psychiatric survivor movement, often repeats that some members of his MindFreedom organization continue to take their psychiatric drugs while many choose not to, and what MindFreedom and other psychiatric survivors are fighting for is truly informed choice and a wider range of treatment options. Do you think that David Oaks’s fight is the right one?

Whitaker: Big Pharma and their partners in establishment psychiatry have smartly used Scientology to defuse criticism of their medications. I honestly believe that if Scientology weren't around, then our society could have a much more rational discussion about our drug-based paradigm of care. As for the position taken by MindFreedom and other psychiatric survivors, I basically do think that is the right one to take, with two caveats. In order to make a “truly informed choice,” a person needs to know the long-term effects of a treatment. It’s not enough for people to be fully informed about the immediate “side effects” of a drug. People need to be presented with information about whether such treatment has been shown to better the long-term course of the disorder, or worsen it. They need to be told about long-term physical and cognitive problems that often arise with every day use of psychiatric drugs. So providing people with a “truly informed choice” is a tall order.

My second caveat is this: As a society, we expect the medical community to develop the best possible form of care. We do not expect a medical community to offer a therapy that regularly leads to a bad end. And so, if we were to draw up a blueprint for reforming the current paradigm of care, it would be nice if the psychiatric community would try to develop therapeutic approaches that involved using psychiatric medications in a selective, cautious way that best promoted good long-term outcomes. In other words, I think psychiatry does have a responsibility to develop a true evidence-based model for using its drugs, a model that incorporates the long-term outcomes data. In the solution section of Anatomy of an Epidemic, I write of how doctors and psychologists in northern Finland use antipsychotics in a selective, cautious manner when treating first-episode psychotic patients, and their long-term outcomes are, by far, the best in the Western World. So if you believe in evidence-based medicine, then American psychiatry should look to the Finnish program as a model for reform. Doctors have a responsibility to lead, but I think that you see in David Oaks’ position a belief that establishment psychiatry in America cannot be trusted to provide such leadership. He’s right to believe that, of course, and that's what is so tragic about modern American psychiatry.

More at: http://www.counterpunch.org/levine04282010.html

[compared2what?]

Quit thinking about yourselves, please. For one stone fucking second. There are people out there who need your help and attention and commiseration for what THEY are experiencing and not for what YOU are experiencing.

hey c2w?, sorry for butting in here. bear with me okay?

Okay.

i can see that quote within the quote above was meant as a general admonition and an expression of embattled had-enough-ness, so i won't take it as directed at me. the reason i looked it up is because i'd never heard of it and it was relevant to what JR was saying. so i posted it.

I assumed. And you're right not to take it as directed at you. It wasn't directed at you or, really, at anyone. It was an expression of frustration addressed to the world at large, self included. In any event, I could never yell or speak harshly to you. Your avatar is just too disarmingly dashing and sexy to permit it.

re you and JR. so far, in this thread i've been agreeing with you re your points concerning Levin etc. they're relevant and valid and as usual you're learning me plenty. thing is though, i also agree with Jack. a further thing is i don't see your points (both of youse) as being mutually exclusive. nor do i think, in the final analysis, that you and Jack do either.

re scilons and the CoS. i admit to being a bit sceptical re your evaluation of the power of CoS and psychiatry. then again, i conflated psychiatry and PhrMA. looking back i think you're probably right, again. -- i did go and check it out though and found this:

The Church of Scientology claims 3.5 million members in the United States,[15] though an independent survey has found the number of people in the United States would state their religion as 'Scientology' is close to 55,000.[16] By comparison, the American Psychiatric Association and the American Psychological Association, which are composed of psychiatrists and psychologists, have 38,000 and 148,000 members respectively.[17][18]

http://en.wikipedia.org/wiki/Scientology_and_psychiatry

Do you mind if I address this later or possibly never? It's not really key to anything I have to say.

Seriously. May I address that very briefly when I'm done with the stuff that's more on-topic? Thanks in advance for your patience.

so, i also think Jack is right to say that psychiatry should grow itself some balls. and i thought that already when i read the OP, viz:

He could have accepted less money and could have provided time to patients even when insurers did not pay, but, he said, “I want to retire with the lifestyle that my wife and I have been living for the last 40 years.”

“Nobody wants to go backwards, moneywise, in their career,” he said. “Would you?”

Dr. Levin would not reveal his income. In 2009, the median annual compensation for psychiatrists was about $191,000, according to surveys by a medical trade group. To maintain their incomes, physicians often respond to fee cuts by increasing the volume of services they provide, but psychiatrists rarely earn enough to compensate for their additional training. Most would have been better off financially choosing other medical specialties.

Dr. Louisa Lance, a former colleague of Dr. Levin’s, practices the old style of psychiatry from an office next to her house, 14 miles from Dr. Levin’s office. She sees new patients for 90 minutes and schedules follow-up appointments for 45 minutes. Everyone gets talk therapy. Cutting ties with insurers was frightening since it meant relying solely on word-of-mouth, rather than referrals within insurers’ networks, Dr. Lance said, but she cannot imagine seeing patients for just 15 minutes. She charges $200 for most appointments and treats fewer patients in a week than Dr. Levin treats in a day.

http://www.rigorousintuition.ca/board2/ ... 30#p387730

that says Levin made a choice. it doesn't say, in my reading, that he was forced, nor that he was powerless.

I agree. I believe that I addressed the issue of "power" and "powerlessness"...um, compared to what, so to speak, in an earlier post. But just to recap:

Obviously, he is fully empowered to make choices and decisions about his own life, as well as fully repsonsible for his own actions and their consequences.

Equally obviously, it's almost certain that one consequence of his decision to make a mighty fine upper middle class living by prescribing meds to patients he only sees for fifteen minutes every now and again has been a statistically insignificant net decrease in the number of patients who are receiving any kind of non-prescription-meds-based psychiatric treatment.

It's also arguable, though less certain, that another consequence of the same decision has been a statistically insignificant net increase in the number of patients seeking psychiatric care who get it, in whole or in part, in the form of prescription medication.

Psychiatrists are, overall, less likely to overprescribe or wrongly prescribe psychoactive medications than MDs with a non-psychiatric specialty are. However, it's possible -- if indeterminable -- that yet a third consequence of his decision is a statistically insignificant net increase in the number of patients who are either not helped or, loosely speaking, harmed by prescription psychophamaceuticals.

I grant that if Dr. Levin were multiplied many times -- ie, if many, most or all psychiatrists did what he's doing -- those numbers would become statistically significant.

And I further grant that statistics don't diminish the tragedy of the putative lone person who comes to harm by taking presciption psychopharmaceuticals by one whit, jot or tittle.

That all being settled to, I believe, a point of general all-around consensus for the purposes of this thread, personally, I next turn my attention to the task of identifying, if possible, who principally has and/or had the power -- as in "causative force" rather than as in "personal agency" -- to reduce the number of professional options realistically available to Dr. Levin and (presumably) the many multiples of him (let's call them "potential and actual psychiatrists") for whom income is or would be, as it is for so many, a determining factor when it comes to career choice by vastly diminishing the percentage who can and/or could make what-let's-call "a doctor's salary" by establishing a talk-therapy-based private practice.

Because, I don't know, that just strikes me as kind of a useful thing to determine for future practical purposes, just in case cursing the darkness doesn't work out and I need to resort to Plan B. Kind of like having candles, batteries, bottled water and canned goods in the house in the event of an electrical outage. Just to push that "power" motif into the realm of simile.

So. "Do psychiatrists constitute that power?" I ask myself.

And echo answers, "No, you idiot. Why would psychiatrists reduce their own realistically available options for making a doctor's salary via the practice of psychiatry?"

"Oh, okay," I whimper, cringing -- as fucking usual -- at the absolutely unrelenting and infinitely nasty, unforgiving and harshly judgmental tones in which rhetorical embodiments of something or other always[i/] and [i]invariably seem to fucking address me. "How about....the health insurance lobby in conjunction with Big Pharma?"

That's about as far as I got before running into an obstacle, though. I think it may have been some Scientology shit or something like that, but I've really been trying just to forget the whole thing and move on, to be honest with you. So I'm not, like, fully a hundred percent positive.

I do hope the above clarified my position on the power question, however.
___________________


___________________

something else i've gotten out of reading your posts is that it made me curious as to why CoS use so much effort targeting the practitioners and none targeting PhrMa. if you have anything to say on that front i'd love to hear it.

Yikes. Okay. When done w/topic, I'll see what I can do.

anyway, hope you can forgive me for posting on the Rosenhan experiment, because as you youself say: " It does say something about the slipshod and horrifying clinical practices of psych wards."

Don't be ridiculous. You know perfectly well that there is nothing to forgive. Please forgive me for just coopting your post into the run of, strictly speaking, utterly unrelated responses I happened then to be on.

i just think it's more than just slipshod. though.

Yeah, me too. That's why I also said "horrifying."

Though I also think it's more than slipshod and horrifying, as it happens. But you know. There are those who think I'm overly verbose.

[compared2what?]

Here is an excerpt of an interview between Bruce Levine and Robert Whitaker that is relevant to some of the themes in this thread. The whole article is interesting, and well worth checking out.

Would that be Robert Whitaker, son of longtime Scientologist/Osteopath/CCHR-Board-of-Advisors-Member Julian Whitaker, by any chance?

Or another Robert Whitaker, with whom I'm unfamiliar?

Because if the former, his word should, perhaps, be taken advisedly. And it might cast a little bit of a pall on Bruce Levine's judgment that he didn't, too, really. If you think about it for a moment.

Your call, though. Of course.

[compared2what?]

.

Kiddie Prozac Docs Took Millions From Drug Makers
By Brandon Keim June 9, 2008
http://www.wired.com/wiredscience/2008/ ... -antidepr/

Three prominent advocates of antidepressant use by children received millions of dollars from antidepressant manufacturers, casting into question the integrity of their already-controversial research.

The New York Times reported Saturday that Harvard University psychiatrists Joseph Biederman and Timothy Wilens received $1.6 million each from drug companies between 2000 and 2007. Thomas Spencer, another Harvard psychiatrist, received $1 million.

The payments were uncovered by Congressional investigators searching for conflict-of-interest violations. Federal law requires researchers who receive National Institutes of Health funding to report annual outside earnings above $10,000 to their universities. Biederman, Wilens and Spencer all took NIH money, but never reported the full extent of their drug company income.

That the researchers’ results were influenced by the payments isn’t clear, but the situation is ugly. Biederman has a very high profile; as the Times describes, he

is one of the most influential researchers in child psychiatry and is widely admired for focusing the field’s attention on its most troubled young patients. Although many of his studies are small and often financed by drug makers, his work helped to fuel a controversial 40-fold increase from 1994 to 2003 in the diagnosis of pediatric bipolar disorder … and a rapid rise in the use of antipsychotic medicines in children.

SNIP

Do you really want to distract from Biederman by bringing up some completely unrelated abuse by Scientology?

No. I do not. I condemn Biederman absolutely. As, I imagine, do most people, including most psychiatrists. If you have a reason to think otherwise, please state it. If you do not, I ask you:

Do you really want to condemn all psychiatrists for Biederman's crimes? And if, so, why? He is not at all typical of your basic, average practicing clinician. He's a very, as it were, powerful man. And power corrupts.

Further, his corruption was exposed, in part, because he was a part of the system and therefore not completely free to get away with behaviors and actions that the system -- including the system of medical ethics and the system of government oversight, shot through with flaws though they may be -- keeps an occasional eye out for and condemns upon discovery. There is also such a thing as malpractice litigation, and malpractitioners do expose themselves to liability.

In short, Biederman represents a problem, known to be endemic to some extent among the relatively small group of psychiatrists who take Big Cash from Big Pharma, a practice that the general population of clinical psychiatrists knows of and abhors. In part because it might expose them to legal liabilities through no witting fault of their own. There are checks. And there are balances.

Also, let me take that one again.

Do you really want to distract from Biederman by bringing up some completely unrelated abuse by Scientology?

No. I do not. Nor have I. You are attributing a case to me that I have never, ever made by suggesting that I do.

Another one was exposed a few months later: Charles B. Nemeroff.

http://www.nytimes.com/2008/10/04/health/policy/04drug.html?_r=1&em

October 4, 2008

Top Psychiatrist Didn’t Report Drug Makers’ Pay

By GARDINER HARRIS

One of the nation’s most influential psychiatrists earned more than $2.8 million in consulting arrangements with drug makers from 2000 to 2007, failed to report at least $1.2 million of that income to his university and violated federal research rules, according to documents provided to Congressional investigators.

The psychiatrist, Dr. Charles B. Nemeroff of Emory University, is the most prominent figure to date in a series of disclosures that is shaking the world of academic medicine and seems likely to force broad changes in the relationships between doctors and drug makers.

In one telling example, Dr. Nemeroff signed a letter dated July 15, 2004, promising Emory administrators that he would earn less than $10,000 a year from GlaxoSmithKline to comply with federal rules. But on that day, he was at the Four Seasons Resort in Jackson Hole, Wyo., earning $3,000 of what would become $170,000 in income that year from that company — 17 times the figure he had agreed on.

The Congressional inquiry, led by Senator Charles E. Grassley, Republican of Iowa, is systematically asking some of the nation’s leading researchers to provide their conflict-of-interest disclosures, and Mr. Grassley is comparing those documents with records of actual payments from drug companies. The records often conflict, sometimes starkly.

“After questioning about 20 doctors and research institutions, it looks like problems with transparency are everywhere,” Mr. Grassley said. “The current system for tracking financial relationships isn’t working.”

SNIP

So what are you going to tell me?

I'll get to it.

Is Grassley working for Scientology? Obviously he might be, and if he is I know you guys will tell me.

As far as I know, Grassley's story is that he used to have a super-far-(IIRC, Christian)-right Chief of Staff who was said to be the key to what often otherwise might have appeared to be his boss's various quixotic pursuits. (Prosperity churches, bad charities of various kinds, etcetera.) I don't recall the guy's name at the moment, but you could look it up. He was there until, IIRC, maybe two or so years ago. As I believe I've already said, the Way-Far-Right is also a significant player in the anti-Meds wars. And that's why there are Scientology fronts sitting cheek-by-jowl with The Eagle Forum on the Council for National Policy membership lists. (Note. I have no idea what that site I just linked to is, but afaik, that list info is good.) In case you've ever wondered about that.

As you know -- or maybe not, but I assume that you do -- in general, any loss of public enthusiasm or public confidence wrt social welfare and maintenance (ie, education, health care, social security) favors the far right. And as you most certainly know, the far right has been investing a tremendous amount of money and energy on cracking open a veritable array of Overton windows fronting on that territory for several decades, during which the country has slid ineluctably far-right-ward. They're not picky about whom they do business with, either. As you also know.

But wanna know something else? That was pretty much just gossip for gossip's sake. Returning to the questions at hand:

I don't in fact know if the way-far-right thing does actually account for Grassley's hearings. Nor do I particularly care. Because (a) I don't fucking care whether Scientology is in the picture or out of it, at the end of the day; and (b) for entirely unrelated reasons, I'm very heavily disinclined not to fucking trust the ultimate agenda behind anything that Chuck Grassley, (R -- Insanity) does or says. He's got a very long track record of being politically reprehensible.

Needless to say, that doesn't make Nemeroff or Biederman any less vile on their own terms. I just wish they were being persecuted by the non-existent left, whose turf should (theoretically) comprehend safeguarding the public weal from corrupt and greedy men.

Does that change what the financial records tell us about Nemeroff and his relationship to GSK?

Oops. Jumped the gun on that one. No. And also: See above.

Back soon.

[compared2what?]

Okay, summing up so far:

We're seeing corruption from corporate Pharm. They hide studies that show their drugs being ineffective, or harmful. They pay off willing big-name psychiatrist experts to push their drugs to the public, and these experts abuse their status and authority specifically as "psychiatrists," which I maintain is a strong, confidence-inspiring label to most people when considering matters of their brain chemistry, more so than "star of Mission Impossible."

It also turns out the most prescribed -- and the most profitable, not coincidentally -- class of psychotropic drugs in the last 20 years is junk for the vast majority of those who have received it.

That's all very, very true. What then shall we do?

Shall we, for example, conclude that SSRIs are, as Peter Breggin has written, unpredictable drugs that drive people to murder and tractors to cows?

I'd say that case has not been met.

You?
________________

Shall we, for another example, conclude that all psychiatric medicine -- prescription-drug-based and non-prescription-drug-based alike or, if you prefer, just prescription-drug-based -- has been so thoroughly and pervasively corrupted by Pharma's cooptation of the Biedermans and Nemeroffs of this world that the entire enterprise is tainted and corrupt?

I'd say that we cannot answer that question based on the evidence before us, and that it behooves us all to make an independent effort to search out the defense's case before voting to convict on the basis of a prosecution that should strike us, simply on the level of common sense, as fundamentally an argument for guilt by association with fewer than a dozen instances of extremely egregious acts and behaviors, none of which are solely attributable to psychiatry and psychiatrists and some of which aren't even principally attributable to them.

Because we'd just be falling for an appeal to emotion, otherwise.

You?
________________

Shall we, for yet still a third example, discount the documentable and very prominent presence of figures and entities of dubious and/or extremely reactionary tendencies (such as that crypto-fascist group that Mercola belongs to, the name of which isn't springing to my mind right now, sorry) at the forefront of the fight against mainstream medicine and prescription medications of all kinds for all ailments, as if the reasons for their investment in the cause were entirely without implications?

I'd say definitely not. Because you really can't be too alert for signs of what fascism might be wrapped in when it comes to America, in my view. Although I'd also say that you can't go too far overboard on that one, since it's not really probative by itself. You should just be generally alert and receptive. That's all.

You?
________________

Shall we, as citizens of, whom and by our system of governance is,examine the entire question in a political context, and as one that's subject to a political solutions, such as -- let's say -- crowd-sourced popular identification of dirty money in affairs that touch on our welfare, or potentially dangerous agents of influence with a founder whose declared policy it was that lying, cheating and committing crimes of any or all kinds somewhere in the mix, or....Hell, I don't know, something and/or anything that was a little more praxis-friendly than the wholesale condemnation of an entire branch of medicine based on very partial and very inflammatory evidence that -- for who knows what reason, really? -- somehow always ended up directing the greater part of our attention away from the sickest and neediest among us by stoking our easily stoked resentments of real and/or perceived power?

Yes. I think we should do that. It's a lot of work, and it's not always pretty. But I know of no better way.

You?

[compared2what?]

And FINALLY:

Shall we discount, minimize, or dismiss the harm -- whether permanent or transitory, actual or potential, and major or minor -- done to vulnerable people like ourselved by, depending on how you define your terms, psychiatry, psychiatrists, and psychotropic medications?

I'd say, no. Absolutely fucking not. But neither should we go rushing like, as it were, madmen in the opposite direction. Especially if, chance being a fine thing, we had some reason to believe that there were people who did not wish us well out there seeking to maximize our justified outrage at living and dealing daily with a system that asks us to be grateful that some of what it offers us in the guise of help doesn't actually kill us.

You?

And that's an open-ended question/invitation addressed to all. Please read it as: What's your understanding of the subject and on what do you base your confidence in it?

Also, sorry Vanlose, but there's something else claiming my time and energy right now. But seriously, do a little search-engine work. The answers to your questions are not obscure ones, really. Although you might have to take a more expansive view of wherein the identity and power of an organization really lies, at the end of the day. Or not. As you prefer.
_____________

Okay. I'm really, really done now.

So if anyone ever comes up with any of those cites, mea culpa in advance. And otherwise, so long.

[vanlose kid]

^^ ok, i will. thanks though.

out.

*

[American Dream]

Here is another excerpt from the interview quoted above:

Levine: So mental illness disability rates have doubled since 1987 and increased six-fold since 1955. And at the same time, psychiatric drug use greatly increased in the 1950s and 1960s, then skyrocketed after 1988 when Prozac hit the market, so now antidepressant and antipsychotic drugs alone gross more than $25 billion annually in the U.S. But as you know, correlation isn’t causation. What makes you feel that the increase in psychiatric drug use is a big part of the reason for the increase in mental illness?

Whitaker: The rise in the disability rate due to mental illness is simply the starting point for the book. The disability numbers don’t prove anything, but, given that this astonishing increase has occurred in lockstep with our society’s increased use of psychiatric medications, the numbers do raise an obvious question. Could our drug-based paradigm of care, for some unforeseen reason, be fueling the increase in disability rates? And in order to investigate that question, you need to look at two things. First, do psychiatric medications alter the long-term course of mental disorders for the better, or for the worse? Do they increase the likelihood that a person will be able to function well over the long-term, or do they increase the likelihood that a person will end up on disability? Second, is it possible that a person with a mild disorder may have a bad reaction to an initial drug, and that puts the person onto a path that can lead to long-term disability. For instance, a person with a mild bout of depression may have a manic reaction to an antidepressant, and then is diagnosed with bipolar disorder and put on a cocktail of medications. Does that happen with any frequency? Could that be an iatrogenic [physician-caused illness] pathway that is helping to fuel the increase in the disability rates?

So that’s the starting point for the book. What I then did was look at what the scientific literature -- a literature that now extends over 50 years -- has to say about those questions. And the literature is remarkably consistent in the story it tells. Although psychiatric medications may be effective over the short term, they increase the likelihood that a person will become chronically ill over the long term. I was startled to see this picture emerge over and over again as I traced the long-term outcomes literature for schizophrenia, anxiety, depression, and bipolar illness. In addition, the scientific literature shows that many patients treated for a milder problem will worsen in response to a drug-- say have a manic episode after taking an antidepressant -- and that can lead to a new and more severe diagnosis like bipolar disorder. That is a well-documented iatrogenic pathway that is helping to fuel the increase in the disability numbers.

Now there may be various cultural factors contributing to the increase in the number of disabled mentally ill in our society. But the outcomes literature -- and this really is a tragic story -- clearly shows that our drug-based paradigm of care is a primary cause.

More at: http://www.counterpunch.org/levine04282010.html

[compared2what?]

Here is another excerpt from the interview quoted above:

Levine: So mental illness disability rates have doubled since 1987 ...[snip] What makes you feel that the increase in psychiatric drug use is a big part of the reason for the increase in mental illness?

Whitaker: The rise in the disability rate due to mental illness is simply the starting point for the book. The disability numbers don’t prove anything, but, given that this astonishing increase has occurred in lockstep with our society’s increased use of psychiatric medications, the numbers do raise an obvious question. Could our drug-based paradigm of care, for some unforeseen reason, be fueling the increase in disability rates?

Interesting hypothesis. Hmm. How to test it?

And in order to investigate that question, you need to look at two things. First, do psychiatric medications alter the long-term course of mental disorders for the better, or for the worse? Do they increase the likelihood that a person will be able to function well over the long-term, or do they increase the likelihood that a person will end up on disability? Second, is it possible that a person with a mild disorder may have a bad reaction to an initial drug, and that puts the person onto a path that can lead to long-term disability. For instance, a person with a mild bout of depression may have a manic reaction to an antidepressant, and then is diagnosed with bipolar disorder and put on a cocktail of medications. Does that happen with any frequency? Could that be an iatrogenic [physician-caused illness] pathway that is helping to fuel the increase in the disability rates?

Okay. I don't see how that gets you past that causation/correlation thing, though. Hey! Say, Robert Whitaker. Where'd you get those disability figures?

In Anatomy of an Epidemic, I traced the number of adults under government care due to mental illness from 1955 to today. In 1955, there were 355,000 adults in state and county mental hospitals with a psychiatric diagnosis, a disability rate of 1 in every 468 Americans. Over the next 30 years, the United States sought to empty its state hospitals and care for the “disabled” mentally ill in the community, with people so disabled receiving a SSI or SSDI payment from the federal government. In 1987, there were 1.25 million adults receiving an SSI or SSDI payment due to a mental illness, or 1 in every 184 Americans. In 2007, there were 3.97 million adults on SSI or SSDI due to mental illness, or 1 in every 76 Americans.

Now, in Anatomy (page 7), I noted that comparing the hospitalized mentally ill to those on SSI and SSDI may be “an apples to oranges comparison.” But the SSI and SSDI numbers from 1987 to 2007, I observed, is an “apples to apples” comparison. And this is very focused data: It tells of the number of adults, 18 to 65, who received a federal disability payment because they were “disabled” by a psychiatric illness during those years. And this number tripled between 1987 and 2007.

(REFER).

I see. Apples to apples, you say. Was there maybe anything affecting the rates of apple growth between 1987 and 2007 that you noticed while you were getting those stats from the Social Security Administration?

Now there may be various cultural factors contributing to the increase in the number of disabled mentally ill in our society. But the outcomes literature -- and this really is a tragic story -- clearly shows that our drug-based paradigm of care is a primary cause.

Oh. Well, I suppose I'll take that as a "No."

Funny, though. Because I swear that I thought you were going to acknowledge that, among other things, new SSDI awards for all conditions -- mental and physical -- had doubled between 1987 and 2007. Look. Here's a hard-to-miss graph from the SSA website:



Awkward.

Because whatever way you slice it, that really just inevitably cuts the number of recipients that you can reasonably attribute to something as discrete as a rise in psychoactive medication prescriptions (represented by a number that you garnered from multiple data sets that don't even have comparable sample populations or sample sizes or uniform methodologies vis-a-vis one another, let alone vis-a-vis the SSA stats) by way, way too much simply to ignore.

Tell you what, though. I think you should add a third question:

Did new beneficiaries of SSDI go from just over 400,000 to just under 800,000 during that time period?

The answer to that one's "Yes," btw. And here's a fourth:

Do the legislative and policy literature -- and those actually really are a tragic story, usually -- also clearly show that our drug-based paradigm of care is a primary cause?

Don't worry. I'll answer that for you. The answer is:

No. Not at all. What's more, you can't really spend more than twenty seconds remembering your President Reagan and the bills you had to pay (or even yesterday) without tripping and falling straight into what almost certainly adds up to a full explanation for the entire rise in mental disability beneficiaries between 1987 and 2007 that has nothing at all to do with our drug-based paradigm. [ON EDIT: (Per se.)] But....Hm. I seem to have lost your attention somehow. Oh, well. Since you're obviously not interested, I'll keep it short and just stick to the highlights.

1982 - 1984: The Reagan administration, concentrating heavily on people receiving benefits for mental disabilities cut 500,000 recipients from the rolls leading to an enormous political-and-media-outrage clusterfuck. (NOTE: Many of the axed mentally disabled returned by 1985, I don't know about the rest.)

1984: Congress passed the Social Security Disability Reform Act of 1984, aka "legislation which vastly liberalized the criteria for awarding benefits to applicants with mental disabilities." Consequently, much as one would expect, the rate of approval in that category has been climbing ever since. Also, although it was somewhat less intended, another upshot of that bill was that the review process in that category for continuing eligibility virtually ground to a halt. As a result of which, most people who get the benefit stay on it for life.

1981-ish - 1988 and ever since: The Reagan administration cut the fuck out of federal subsidies to state and local social welfare and education programs, which has had numerous, dreadful long-term consequences, most of which people don't perceive as such. And why? Because more and more bright sparks like yourself, Robert Whitaker, are coming around every corner offering emotionally appealing explanations for them with every passing year.

But I digress. One specific longterm consequence that seems highly likely to bear on the trend that you're attributing to psychotropics was -- that's right -- the closing of state mental institutions, coupled with a decline in already barely-there community and local resources. As a result of which states ended up tossing a large number of their unemployed mentally disabled residents into the SSI/SSDI pool, basically because -- due to an administrative quirk whereby the award of social security disability benefits (though federal) is processed on a state level by state employees -- they could. So they did.

1990: Passage of the Americans with Disabilities Act, and concomitant further cultural acceptance of the okay-ness of being (among other things) mentally disabled, plus, of course, greater equality under law between people with mental disabilities and people with physical disabilities. Which the SSA and many other federal agencies actually totally ignore when they feel like it, truth be told, but never mind that, because within the narrow parameters that concern us here, it had a generally expansive effect on entitlements for the mentally disabled.

1996: Congress passed the Welfare Reform Act without taking into account that there were a very significant number of welfare recipients for whom TANF just didn't cut it, due to their inability to make the transition to work because they were mentally disabled.

1990-ish - The Present: You know how they're always saying that the precipitous decline in the number of Americans with health insurance has huge, hidden costs? They're not just saying that.
_____________

There's more. Quite a bit more, in fact. But I guess I'll let it go there.

Because, frankly, just that first graph from SSA.gov all by itself establishes beyond question that you, Robert Whitaker, have such a gigantic and blatantly biased approach to your subject that you're apparently willing to present the statistical figures about pretty much any damn thing on earth exclusively as evidence that psychiatrists are using our drug-based paradigm to make us sick and crazy. And without even making a token gesture in the direction of looking for confounding factors, too.

So I don't really see how any honest critical thinker (sorry, Bruce E. Levine!) could possibly maintain that your work was credible, trustworthy or even, properly speaking, work.

Really, it's kind of a sad comment on the state of critical thinking in the public sphere that as far as I can see, you only got one review pointing out (rather mildly) that you were offering a hypothesis as if it was proof, and evidently none by anyone whose memory of widely covered landmark political events in America even extends as far back as yesterday, let alone 1984.

Isn't it?

Because it's not like there aren't forces abroad in the land today who are about 10,000 times more determined to demolish the SSA than old Ronald W. Reagan ever was. Which sorta makes me wonder what your game really is. To be honest. I mean, those SSDI numbers don't come with a whole lot of frills. And even on their own terms, they're not naturally reflective of trends in the general population, due to their very nature. So it does seem like something of an idiosyncratic choice, especially once you have to admit that because of policy considerations, they're not really apples to apples. I would have gone for some numbers from the census bureau, myself. They still wouldn't prove anything, but they do provide a lot of room for improvisation.

Not that it matters a whole hell of a lot what your agenda is, or even if you have one that's unstated, ftm. Because it's just not nice to bamboozle well-meaning people, including yourself, no matter why you do it. They could get hurt.

[barracuda]