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Robin Williams Melancholy Suicide--Hopelessness, helplessness, and Defeat

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There's something in his soul
O'er which his melancholy sits on brood,
And I do doubt the hatch and the disclose
Will be some danger--which for to prevent,
I have in quick determination""..
It shall be so. Madness in great ones must not unwatched go.
--Hamlet Act III, Scene 1

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According to Radar Online Robin Williams is looking "grim and focused." Grim? Yes. Focused? No. His visage is one of entrapment, despair, and dread.
In F. Scott Fitzgerald's The Great Gatsby, Nick Carraway observes that "the loneliest moment in someone's life is when they are watching their whole world fall apart, and all they can do is stare blankly" This is not focus but melancholia--hopelessness, helplessness, and defeat.
In 1896 Émile Durkheim described "melancholy suicide" as being "connected with a general state of extreme depression and exaggerated sadness, causing the patient no longer to realize sanely the bonds which connect him with people and things about him. Pleasures no longer attract." Williams' face is weighted with melancholy. Not focus.

Heightened perceptions of defeat and entrapment are known to be powerful predictors of suicide. According to the Cry of Pain" model people are particularly prone to suicide when life experiences are interpreted as signaling defeat, defined as a sense of a "failed struggle." Unable to find some sort of resolution to a defeating situation, a sense of entrapment proliferates and the perception of no way out provides the central impetus for ending ones life.

As in all suicidal tragedies, the role of addiction and mental illness has been posited as the cause. Although depression and substance abuse are the two biggest risk factors for suicide, neither explain completion of the act--the descent from ideation and planning to finality and oblivion. Saying suicide is caused by depression and drugs is not unlike the claim that marijuana is a "gateway drug" to the use of heroin. It may be a pre-conditional requirement. But it is not the cause. It is a non sequitur. And just as the majority of marijuana users never develop the inclination to stick a needle of opiates in their arms, the majority of depressed individuals or substance abusers do not kill themselves. One does not lead to the other.

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And as we have seen in the reports of bullied teenagers who have died by suicide, it is all too often the bullies themselves who are quickest to pronounce this conclusion. Attributing suicide to mental illness and substance abuse deflects culpability. It negates the need for further inquiry. It creates an absence of the need to change. The rationalization diffuses both individual and collective blame. It scatters responsibility and guilt. It is both an individual and community defense mechanism. Shaming, humiliating, and degrading a person incessantly over long periods of time because of their race, body type, sexual preference, or whatever perceived eccentricity and non-conformity threatened the community herd was irrelevant. It played no role. It was drink, drugs, or depression--the unspoken understanding is they would have done it anyway. And no one stops to ponder that said depression or desire to alter ones mental state just might be a symptom of the humiliation and shame they themselves created. And it works. The bullies are never held accountable. But it is nevertheless they who figuratively loaded the gun, placed it in the victims mouth, and pulled the trigger.

The link link between bullying and suicide is well known, especially when combined with entrapment and the feeling there is no way out. "They would have done it anyway." No, they would not have and a modicum of perceived support or concern from another human being may have prevented it.

Dr. Drew was seemed omnipresent in discussing Williams suicide. "The death of Robin Williams has led me to this plea -- let's loudly and seriously address something that's still hidden, stigmatized and even ignored in this country: Mental illness," Pinsky writes on his blog. I don't see the logic here in how this is a product of Williams suicide. He was open, unashamed, and forthright about his prior addictions and depression. He was not hiding it.

The more important issue that I see needs pleading, is that mental illness beproperly, accurately, and thoughtfully diagnosed and treated.

Depression, as with any mental illness, needs to be diagnosed, monitored, and treated by educated, trained, and experienced experts in depression. Not self-proclaimed experts. Pinsky's specialty is "addiction medicine" and he is "board certified" by the American Board of Addiction Medicine (ABAM).

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The American Society of Addiction Medicine can trace its roots to the 1954 founding of the New York City Medical Society on Alcoholism (NYCMSA) by Ruth Fox, M.D. Fox, whose husband died from alcoholism. This group promoted the concept of alcoholism as a chronic relapsing disease requiring lifelong spiritual recovery through the 12-steps of AA. And the primary goal of the ASAM is and always has been the acceptance of 12-step doctrine, lifelong abstinence, and spiritual recovery as the one and only treatment for addiction.

This philosophy and guiding doctrine stems from the "impaired physician movement", a group that, according to British sociologist G.V. Stimson: " is characterized by a number of evangelical recovered alcoholic and addict physicians, whose recovery has been accompanied by an involvement in medical society and treatment programs. Their ability to make authoritative pronouncements on physician impairment is based on their own claim to insider's knowledge." This group grew in numbers, organized, and became the ASAM.

The ABMS recognizes 24 medical specialties and subspecialties. Addiction Medicine is not one of them. The only ABMS recognized subspecialty is Addiction Psychiatry and it requires a four-year psychiatric-residency program followed by a 1-year Fellowship focusing on addiction in an accredited program.

In contrast, ABAM certification requires only a medical degree, a valid license to practice medicine, and completion of residency training in ANY specialty.

Hazelden, the facility where Williams was admitted in July is an ASAM facility. And the Medical Director, Marvin Seppala is a Like-Minded Doc. Unlike most ASAM physicians, however, Seppala is a psychiatrist. But he is a psychiatrist brought up in the folds of ASAM ideology. He was, in fact, the first adolescent graduate of Hazelden in the 1970s when he completed the program at the age of 19.

Pinsky, predictably goes on to state that "Williams had a brain disease, " He posits it against demons or devils as if it is either/or. This concrete splitting of complex subjects into two separate entities to claim only one correct is just one of many simplistic and misleading "false dichotomies" used by the ASAM. Of course addiction is a brain disease. But in reality the definition is unhelpful unless we are living in the Victorian era. It's like saying Gonorrhea is a genital disease not venereal. In reality it involves a number of factors including psychosocial and medical.

Addiction is multifactorial and diverse. Simplifying it into binary options does little to advance understanding. And it too involves a variety of issues including the situational, the psychosocial, the genetic and the biochemical. Like every other medical issue there are a number of factors to be taken into consideration. And imposing the 12-steps to salvation on all-comers is not only illogical, but anti-science, and downright improper. It can also be deadly. Especially when the the person it is imposed on is not a full-blown addict but a substance abuser or dabbler, or someone who has simply had a "lapse."

The ASAM uses "brain disease" as a tool to contrast it against a "moral failing" as if there are only two black and white choices in substance use disorder. But substance use, abuse, and addiction comes in every color. And those colors in turn come in different saturations, hues, and shades. It is complex and not amenable to binary equations.

The chronic brain disease model is just one of many simplified and false dichotomies used by the ASAM. Others include "Recovery" or "relapse," treatment" or "discipline," and admitting a problem or "denial." The only true dichotomy in this paradigm is you are either "with us" or "against us."

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http://www.disruptedphysician.com

M.D, Harvard Medical School, Massachusetts General Hospital (1997-2013) Geriatric Medicine, Internal Medicine


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