Behind Bars Without Help: The Mental Health Controversy in Michigan

Posted at NAMI blog Thursday, August 25, 2011 Reposted at darkestcloset.bloggerspot.com

By Ron Honberg, NAMI Director of Policy and Legal AffairsThe new head of Michigan's Department of Corrections recently made national news when he expressed concerns about the extent to which his department's resources are used to provide mental health to inmates.
On August 21, it was reported in the Detroit News that Dan Heyns, director of Michigan's Department of Corrections wanted to work with sheriffs, prosecutors and local officials to ensure that fewer people living with mental illnesses come to prison.

"I've got institutions that are just packed with people who are very, very seriously mentally ill", Heyns said. "These aren't stress cases. I can't exactly provide a therapeutic environment."

Jails and prisons are the worst possible environments for people struggling with the symptoms of severe mental illnesses. Prisons are ill-equipped to provide effective psychiatric treatment. Inmates with the most severe mental illnesses are too often isolated in administrative segregation, special housing units, super-max prisons and other forms of solitary confinement. The long term isolation of individuals experiencing delusions, hallucinations or other severe psychiatric symptoms has been characterized as being akin to torture.

Sadly, the problems highlighted by Director Heyns are not unique to Michigan. A recent study revealed that about 17.1 of male inmates and 34.3 percent of female inmates in local jails throughout the country live with a serious mental illness such as schizophrenia, bipolar disorder or PTSD. When compared to figures for the general population this is roughly a 470 percent increase in prevalence for both men and women.

So what can be done to achieve Director Heyns vision that fewer individuals living with mental illnesses come to prison to begin with?

Some would respond that we need to take a close look at our nation's treatment laws. Until the 1960s, people living with serious mental illnesses were virtually devoid of civil rights protections and were frequently institutionalized for long periods of time with no due process or right to appeal. Fortunately, these egregious civil rights abuses are a thing of the past.

There are many who believe that the laws have gone too far in the other direction, asserting that requiring proof of immediate or imminent danger to self or others means that certain people will not get help when they need it the most. Not everyone agrees. Many argue equally strenuously that the laws should remain as they are, citing continuing abuses and civil rights violations in hospitals, adult care homes, and other settings as evidence that we need to maintain strict, narrow civil commitment standards.

Irrespective of how you feel about these complex issues, the overall lack of mental health services and supports across the country is beyond dispute. Even during the best of economic times, the availability of good mental health services has been limited in the US, particularly for those who rely on the public mental health system for their care. In 2006 and 2009, before the full impact of the economic crisis, NAMI gave the nation's mental health system a grade of "D" in its Grading the States 2006 and 2009 reports.

Unfortunately, the economic recession has only made these problems worse. In March, 2011, NAMI released a report entitled State Mental Health Cuts: A National Crisis. This report revealed cuts to non-Medicaid state mental health spending of nearly $1.6 billion dollars between 2009 and 2011, with even deeper cuts projected for 2012. These cuts have led to the erosion of vital inpatient and community services for tens of thousands of youth and adults living with the most serious mental illnesses. Hospital beds have been eliminated and in many parts of the country, there are virtually no community services available either.
Not surprisingly, these cuts have added to already considerable burdens faced by law enforcement and correction centers. In Nevada, Judge Jackie Glass, who runs the Clark County (Las Vegas) Mental Health Court implored legislators not to impose further cuts on mental health services. She testified that "you will see … people [who lose mental health services] ending up in prisons, jails, emergency rooms, homeless…"
In Sacramento County, California, U.S. District Court Judge John A. Mendez went further, blocking the county from cutting mental health services as a way to balance the budget. He stated that the county's budget cutting plan would cause "catastrophic harm" and violate the Americans with Disabilities Act (ADA).
The U.S. is clearly at a pivotal moment in its history. Solutions to the budget crisis are not easy. However, one thing is clear: Indiscriminate cuts to mental health budgets will not save money, but cost more in the long run. Cuts of the magnitude that have occurred will continue to perpetuate the national disgrace of incarcerating people for the "crime" of having a serious mental illness. We should pay heed to Director Heyns, Judge Glass, Judge Mendez and others on the front lines responding to people in crisis. A civilized, advanced nation must do better for its most vulnerable citizens.

Book Review: "A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness" by Nassir Ghaemi, M.D.

The Penguin Press (2011), $27.95 (hardcover)

By Bob Carolla, NAMI Director of Media Relations

One of the best books to document and discuss in detail the link between mental illness—specifically depression—and great leadership is Lincoln's Melancholy by Joshua Wolf Shenk. Dr. Ghaemi, the director of the Mood Disorders Program at Tufts University, now takes the discussion of mental illness and leaders further by including bipolar disorder and expanding the scope to several other historical and contemporary leaders, including Civil War general William Sherman, Winston Churchill and Ted Turner. Also included are Mahatma Gandhi and Martin Luther King, whose names are new to "famous people" lists that provide inspiration to many people who live with mental illness.

The book makes the case that four elements are essential to leadership in times of crisis: realism, empathy, creativity and resilience. Living with depression can enhance the first two traits and mania can enrich the third. Both can help instill resiliency. At the same time, some conditions such as psychosis can prove disastrous.

Leadership can be exercised for good or evil— independent from mental illness. In other words, free will and moral values remain part of the equation. The book includes a chilling discussion of Adolf Hitler, who presided as the leader of Germany during World War II and the Holocaust; Ghaemi makes a case that Hitler lived with untreated bipolar disorder which gave him charisma, resilience and political creativity in his rise to power. On the other hand, by the time the war began, he was being treated with barbiturates and amphetamines (including meth) for insomnia and fatigue, a combination that only worsened his mental illness. Essentially, his mind spun out of control—possibly into some form of psychosis. In that respect, impairment of his leadership abilities because of heavy drug use was a stroke of good fortune for civilization. “In his final two years, Hitler probably never experienced a day of normal mood,” Ghaemi writes. “His world was collapsing; his mind already had.”

The book also includes discussion of other leaders such as John F. Kennedy, Richard Nixon and George W. Bush, arguing that “homoclite” leaders who “want to be liked” can be dangerous in times of crisis. “Normal” mental health may actually be a drawback. This section, as well a chapter on stigma and politics, are not the books strongest but they raise issues that are worth thinking about carefully. Would our country ever elect a president who acknowledges living with bipolar disorder—and perhaps even campaigns on it as a qualification suited for the times? In some cases, personal experience with mental illness may be a strength, providing vision and a foundation for brilliant leadership, but the stigma surrounding mental illness still prevents a completely open discussion.

Posted at NAMI Advocate. NAMI Bookshelf August 2011. http://www.nami.org/ADVTemplate.cfm?Section=20111&Template=/ContentManagement/ContentDisplay.cfm&ContentID=126353

Reposted at darkestcloset.blogspot.com

New HIV Incidence Estimates Confirm Increased Impact among Latino Gay Males

WASHINGTON, DC
 About NLAAN: The National Latino AIDS Action Network (NLAAN) was developed as a response to the HIV/AIDS crisis within Latino/Hispanic communities and is a participatory, collaborative and diverse network of community-based organizations, national organizations, state and local health departments, researchers and concerned individuals that identifies and prioritizes the key needs of Latinos regarding HIV/AIDS prevention, research and care and treatment. For more information on NLAAN, please visit us at www.latinoaidsagenda.org or www.facebook.com/NLAAN.
"These estimates underscore the historic challenge that Latino communities, particularly Latino gay men, have experienced in terms of the development of HIV prevention and testing efforts that are culturally and linguistically relevant," stated Francisco Ruiz, Senior Manager at the National Alliance of State and Territorial AIDS Directors and co-chair of NLAAN. "These new HIV estimates point to the depth of the HIV crisis among Latino gay men and the consequences associated with paltry efforts to prevent HIV transmission and combat multi-faceted forms of stigma," he added.

As health departments and community-based organizations continue to experience drastic cuts in funding, we must carefully weigh the results of slashing prevention budgets. "The nation is at a turning point in the history of the HIV/AIDS epidemic," noted Oscar Raul Lopez, CEO/Lead Trainer of Connected Heath Solutions and co-chair of NLAAN. "We need to examine existing funding streams to ensure the development and support of effective behavioral, structural, and biomedical interventions for Latino gay men, including strategies that employ the use of technology like the Internet," he stated.

The issue of immigration is a significant challenge faced by some Latino gay men. "As the disparity worsens with little relief promised to the newly immigrated Latinos under the Affordable Care Act, new measures to insure that the undocumented and new residents within the 5-year window have access to prevention, outreach, testing and treatment are imperative," according to Dr. Britt Rios-Ellis, Director at the NCLR/CSULB Center for Latino Community Health and co-chair of NLAAN. She further explained, "This is particularly true given the fact that many immigrant Latino males often report facing particular challenges in accessing healthcare, including isolation from traditional social support systems, discrimination and a strong apprehension toward law enforcement."

In light of the new HIV incidence estimates released today, NLAAN calls upon community-based organizations, health departments, federal agencies, policymakers, faith-based institutions, media outlets and other community entities to recommit to the goals outlined in the National HIV/AIDS Strategy. Only together can we effectively tackle this public health crisis.
– Today the Centers for Disease Control and Prevention (CDC) released new HIV incidence estimates in the Public Library of Science Medicine (PLoS) which indicate that the overall number of new HIV infections has remained fairly steady from 2006–2009. However, the National Latino AIDS Action Network (NLAAN) is alarmed by the new estimates which identify Latino gay men as moving from the fourth to third most impacted population.

National Asian American Pacific Islander Mental Health Association

The National Asian American Pacific Islander Mental Health Association (NAAPIMHA) is proud to announce the formation of the National Asian American Pacific Islander Empowerment Network (NAAPIEN), developed with funding from SAMHSA. NAAPIEN is a peer advocacy group that develops leadership among those who have personally experienced the challenges of serious mental health issues. Members have led personal journeys of recovery, which broadens their insight into improving wellness services. They are current and future leaders who will play a critical role in ensuring those with mental health problems receive the quality of care they deserve.

For more information, please visit http://naapimha.org.

By Helping a Girl Testify at a Rape Trial, a Dog Ignites a Legal Debate

posted at http://www.nytimes.com/2011/08/09/nyregion/dog-helps-rape-victim-15-testify.html?pagewanted=all reposted at darkestcloset.blogspot.com

  WILLIAM GLABERSON Published: August 8, 2011 – New York Times

 POUGHKEEPSIE, N.Y. — Rosie, the first judicially approved courtroom dog in New York, was in the witness box here nuzzling a 15-year-old girl who was testifying that her father had raped and impregnated her. Rosie sat by the teenager’s feet. At particularly bad moments, she leaned in.

When the trial ended in June with the father’s conviction, the teenager “was most grateful to Rosie above all,” said David A. Crenshaw, a psychologist who works with the teenager.

“She just kept hugging Rosie,” he continued.

Now an appeal planned by the defense lawyers is placing Rosie at the heart of a legal debate that will test whether there will be more Rosies in courtrooms in New York and, possibly, other states.

Rosie is a golden retriever therapy dog who specializes in comforting people when they are under stress. Both prosecutors and defense lawyers have described her as adorable, though she has been known to slobber.

Prosecutors here noted that she is also in the vanguard of a growing trial trend: in Arizona, Hawaii, Idaho, Indiana and some other states in the last few years, courts have allowed such trained dogs to offer children and other vulnerable witnesses nuzzling solace in front of juries.

The new role for dogs as testimony enablers can, however, raise thorny legal questions. Defense lawyers argue that the dogs may unfairly sway jurors with their cuteness and the natural empathy they attract, whether a witness is telling the truth or not, and some prosecutors insist that the courtroom dogs can be a crucial comfort to those enduring the ordeal of testifying, especially children.

The new witness-stand role for dogs in several states began in 2003, when the prosecution won permission for a dog named Jeeter with a beige button nose to help in a sexual assault case in Seattle. “Sometimes the dog means the difference between a conviction and an acquittal,” said Ellen O’Neill-Stephens, a prosecutor there who has become a campaigner for the dog-in-court cause.

Service dogs have long been permitted in courts. But in a ruling in June that allowed Rosie to accompany the teenage rape victim to the trial here, a

Dutchess County Court

judge, Stephen L. Greller, said the teenager was traumatized and the defendant, Victor Tohom, appeared threatening. Although he said there was no precedent in the state, Judge Greller ruled that Rosie was similar to the teddy bear that a New York appeals court said in 1994 could accompany a child witness.

At least once when the teenager hesitated in Judge Greller’s courtroom, the dog rose and seemed to push the girl gently with her nose. Tohom was convicted and sentenced to 25 years to life.

His lawyers, David S. Martin and Steven W. Levine of the public defender’s office, have raised a series of objections that they say seems likely to land the case in New York’s highest court. They argue that as a therapy dog, Rosie responds to people under stress by comforting them, whether the stress comes from confronting a guilty defendant or lying under oath.

But they say jurors are likely to conclude that the dog is helping victims expose the truth. “Every time she stroked the dog,” Martin said in an interview, “it sent an unconscious message to the jury that she was under stress because she was telling the truth.”

“There was no way for me to cross-examine the dog,” Martin added.

In written arguments, the defense lawyers claimed it was “prosecutorial misconduct” for the Dutchess County assistant district attorney handling the rape case, Kristine Hawlk, to arrange for Rosie to be taken into the courtroom. Cute as the dog was, the defense said, Rosie’s presence “infected the trial with such unfairness” that it constituted a violation of their client’s constitutional rights.

Hawlk declined to discuss Rosie. In written arguments, she said that all Rosie did was help a victim suffering from serious emotional distress, and she called the defense claims “frivolous accusations.”

The defense lawyers acknowledged the risk of appearing antidog. Rosie, they wrote, “is a lovely creature and by all standards a ‘good dog,’ ” and, they added, the defendant “wishes her only the best.”

As the lawyers prepare their appeal, Rosie has been busy. She spent much of her time in recent weeks with two girls, ages 5 and 11, who were getting ready to testify against the man accused of murder in the stabbing of their mother.

The Dutchess prosecutor in that case, Matthew A. Weishaupt, argued that Rosie and dogs like her did not affect the substance of the testimony about horrifying crimes. “These dogs ease the stress and ease the trauma so a child can take the stand,” Weishaupt said in an interview.

In the end, Rosie was not needed in the second case: the defendant, Gabriel Lopez-Perez, who had a history of domestic violence, interrupted his trial last week to plead guilty to killing the girls’ mother, his girlfriend, in the Wappingers Falls rooming house where they lived.

But Rosie’s promised appearance next to the children might well have played a role. “It became obvious,” said Mr. Lopez-Perez’s lawyer, Andres Aranda, “that the children were going to be testifying, and he decided to avoid that.”

The defense’s appeal of Rosie’s first courtroom outing, in the rape case, is likely to establish legal principles on the issues of dogs in the witness box. “It is an important case, and appeals courts will consider it an important case,” James A. Cohen, a professor of criminal law at Fordham University School of Law, said.

When New York appeals courts study the question, they are likely to look at the experience of courtroom dogs around the country, including in Washington. In Seattle, a developmentally disabled 57-year-old man, Douglas K. Lare, recently recalled how a Labrador retriever named Ellie, who has made more than 50 court appearances, helped him testify against a man charged with a scheme to steal from him.

Ellie gave him courage when he was afraid, Lare said in an interview: “It was like I had no other friends in the courthouse except Ellie,” he said.

For 11-year-old Rosie, said her owners, Dale and Lu Picard, the courtroom work is a career change after years working with emotionally troubled children at a residential center in Brewster. The Picards’ organization, Educated Canines Assisting With Disabilities, or ECAD, places service dogs after training them to perform tasks like turning lights on and off and opening doors.

Rosie, named for the civil rights pioneer Rosa Parks, was originally taught to follow 80 commands, including taking off a person’s socks without biting any toes. But she has a special talent with traumatized children, said Crenshaw, the psychologist who has worked with all three of Rosie’s witnesses and many other troubled children.

“When they start talking about difficult things,” Crenshaw said, “Rosie picks up on that and goes over and nudges them. I’ve seen it with my own eyes.”

Ethical Concerns in Assertiveness Community Treatment

Author Daniel Farrell is cited in an article featured on the Homelesssness Website and newsletter, in a discussion of ethical concerns about Assertiveness Community Treatment (ACT)

http://homeless.samhsa.gov/Resource/View.aspx?id=52119
Reposted at darkestcloset.bloggerspot

Description: Some critics call Assertive Community Treatment (ACT) a fundamentally coercive model of care because of the level of control that case managers have over their clients’ lives. This article explores some of the resulting ethical concerns of using the ACT model. This article is the third in a series of three articles about ACT.

Embedded in Assertive Community Treatment (ACT) is the element of, well, assertion on the part of service providers. This has led some critics to call ACT a fundamentally coercive model of care. And indeed, many ACT providers find the balance between social control and client independence a very difficult one to strike.

Social Control versus Client Independence

Traditionally, mental health treatment has focused on acting in the best interest of the client. ACT, however, has been accused of being more concerned with benefits to systems instead of individuals. ACT’s community-based approach has its roots in inpatient psychiatric care. Because of this, the idea of patient independence or freedom has been very limited from its earliest beginnings.

These roots can be seen in various forms of social control that are still present in ACT. For instance, ACT staff has the power to force clients into hospitalization, or to remove them from a homeless shelter or drop-in center. They may also demand that clients change their behavior, forcing them to take medication or abstain from alcohol, for instance. If clients do not comply, they may face loss of personal freedom.

ACT staff may also control many other aspects of clients’ lives. They may manage flow of money for clients, their access to doctors and pharmacies, decisions about treatments, and contact with their social networks. The ongoing ethical challenge for ACT staff is to strike a balance. They need to empower clients without neglecting them, care for them without controlling them too much, and give them as much independence as possible even while intervening in their lives.

ACT: A Coercive Model?

It is easy to see how some would perceive coercion to be woven into all aspects of ACT. And it is true that this can happen in many ways. However, some ACT clients are at the extreme end of psychosis. They may suffer a great deal because of their untreated symptoms. Moreover, their experiences may render them unable to understand their illness and their right to humane treatment. In such cases, compassionate coercion may be what allows ACT staff to fulfill their client’s right to this treatment.

It may be helpful to think of coercion on a continuum. At one end is friendly persuasion, in the middle is control of resources, and at the other end of the spectrum is the use of force in treatment. The level of involvement from the case worker depends on many factors, most especially the severity of the case.

What do the critics think?

There are many different players involved in Assertive Community Treatment. Of course, the main players are the clients themselves and their teams of providers, but there is also a diverse community of people who are interested in treatment outcomes.

ACT clients are largely lower-income, rely on public assistance, and have historically had minimal input into their own treatment to begin with. Critics of ACT say treatment that is forced upon individuals is inherently coercive (especially individuals with limited options, as described above). They see this as especially true because a person enrolled in ACT cannot end these services.

Criticism of ACT goes beyond the question of coercion, though. Some doubt the positive outcomes for ACT clients. They argue that the results seen with ACT are not actually all that different from standard treatment, and concerns about the design of studies comparing the two have also been raised.

In addition, critics say that the greatest benefit of ACT (reduced hospitalizations for clients) is not a result of the intervention itself. They see this as simply a part of the design of the model, and administrative distinctions which seek to move clients away from hospitals in general.

What do clients think?

In some ways, it is not surprising that clients themselves did not have a voice in the debate surrounding ACT until decades after the model was developed. But in the mid-1990s, the academic community did start asking clients about their experiences with the program.

Some studies looked at the most important factors in client satisfaction. They found that for clients, these included having consistent contact with staff, supportive services, a positive helping alliance, and a sense of trust and caring by ACT staff. Other studies found that clients enrolled in ACT were happy with housing assistance and the help they received in adjusting to their communities.

The feedback wasn’t all positive, though. One study found that even though clients were satisfied with many aspects of care, they were not happy with medication and treatment issues. Clients in another study said they disliked what they saw as “program intrusiveness.” They felt that the program was too confining and echoed earlier sentiments that there was too much of a focus on medication compliance.

In the end, the question of coercion in ACT may be largely a matter of opinion. But what is less subjective is the issue of balance, as service providers are pulled between control over and independence for their clients.

Read the first two articles in the series: All About Assertive Community Treatment (ACT),  Assertive Community Treatment (ACT) for People Experiencing Homelessness

 

 

"An Anatomy of Addiction": Sigmund Freud, cokehead How a "wonder drug" shaped the birth of psychoanalysis and modern surgery

Sunday, Jul 17, 2011 19:01 ET  Reposted at darkestcloset.blogspot.com     By Laura Miller

Published at WIkipedia/Salon

Nicholas Meyer's bestselling 1974 novel, "The Seven Percent Solution," isn't mentioned once in "An Anatomy of Addiction: Sigmund Freud, William Halsted and the Miracle Drug Cocaine" by Howard Markel, but any of Markel's readers who have also read Meyer's highly entertaining Sherlock Holmes pastiche will think of it often all the same. The novel "reveals" that Holmes' "Great Hiatus" (the three years between his false death at Reichenbach Falls and his reappearance in "The Adventure of the Empty House") was actually a period of recovery from cocaine addiction after his treatment by the great Viennese therapist Sigmund Freud. The founder of psychoanalysis brought exceptional insight to bear in providing this cure; he once abused cocaine himself.

Markel's provocative book is a dual addiction biography of Freud and his contemporary, William Halsted, arguably the greatest surgeon of his time, a founding professor at Johns Hopkins Hospital and deviser of at least a half-dozen revolutionary surgical techniques and procedures still employed today, such as the use of rubber gloves. Both were unquestionably great men, but they also wrestled with dangerous drug habits that imperiled their work. Both sought to conceal or downplay their drug use and, as a result, information on that use and how, if at all, they managed to stop it is pretty sparse on the ground. If Meyer's novel is the story of a doctor investigating the psyche of a great detective, then "An Anatomy of Addiction" is the work of a doctor -- Markel is an M.D. and director for the Center of the History of Medicine at the University of Michigan -- who plays detective to understand the secret lives of two medical giants.

Halsted and Freud never met, and came from very different backgrounds, but they were both ambitious and energetic young doctors in the 1880s, when cocaine was being celebrated as a new wonder drug whose full potential had yet to be explored. In Austria, Freud wrote a prominent paper touting the newly isolated alkaloid as a treatment for morphine and opium addiction. He tested it on a close friend who had become hooked on the morphine he used to manage a chronic injury.

What Freud missed, and what became the drug's chief medical use for the next decade or so, was cocaine's value as a local anesthetic. Halsted, an indefatigable and daring young surgeon (he successfully removed his own mother's gall bladder on the family's kitchen table at 2 a.m., with his untrained father and siblings attending), was as eager to explore its possibilities as he was to adopt the new antiseptic protocols advocated by Joseph Lister. Like many doctors of the time, including Freud, he tested the drug's properties on himself, his colleagues and his students. "In a matter of weeks," Markel writes, "Halsted and his immediate circle transformed from an elite cadre of doctors into active cocaine abusers."

Halsted shot up; Freud snorted. Halsted was rich and well connected; Freud was close to broke and struggling to make a name for himself in a profession afflicted by expanding pockets of anti-Semitism. Freud by all accounts figured out how to give up the drug, while Halsted, Markel believes, would go on occasional binges throughout the rest of his distinguished life. At least twice, Halsted resorted to staying at a Rhode Island sanitarium to get clean. He also used morphine, probably daily. Behavior that many of his students and colleagues shrugged off as eccentricity -- lateness, incommunicado periods, a refusal to look people in the eyes (and thereby reveal his dilated pupils) -- were read by a handful of astute observers as signs that the drug use he'd supposedly abandoned before arriving at Hopkins was still going on.

Freud, on the other hand, seems to have entirely stopped using cocaine by the turn of the century. For the rest of his days he strove to downplay the effect it had on his life and work. Markel will have none of this, arguing that cocaine played a major role in Freud's friendship with Wilhelm Fliess, a general practitioner who espoused the crackpot theory that many physical and emotional problems could be cured by intensive surgery to the nose (with liberal applications of cocaine). Freud recommended one of his own patients to Fliess, who proceeded to disfigure and nearly kill the young woman in a case of flagrant malpractice. Freud made excuses for him.

The Fliess affair seems less a case of cocaine-induced incompetence than an example of Freud's propensity for stubbornly idealizing a particular friend to the point of delusion. Similarly, it took him far too long to admit he had understated the dangers of cocaine, even after he'd witnessed its eventual, disastrous effect on his morphine-addicted friend. All discussions of Freud are further complicated by the fact that the brilliance of his ideas and his writings was not mirrored in his therapeutic success rate. He was a major thinker, but an indifferent doctor. Far better to be his student than his patient.

For the most part, however, "An Anatomy of Addiction" is persuasive and engrossing. Markel is especially good at capturing the hierarchical, ultra-competitive, pressurized world of 19th-century medicine, with its revered masters and mentors presiding over students and young doctors desperately striving to make an impression and a reputation. Perceptively, he traces the birth of psychoanalysis to Freud's use of himself as an experimental subject in documenting the effects of cocaine. For the first time, Freud "incorporates his own feelings, sensations and experiences into his scientific observations."

Freud was always at his best when contemplating the subject of his own psyche. (His weaknesses, furthermore, often spring from a tendency to overgeneralize from it.) If his cocaine experiments nudged him in that direction, then perhaps we do owe some of the most influential ideas of the last century to the influence of Bolivian Marching Powder. More's the pity, then, that pride or fear or something else kept Freud from recounting how he kicked the habit.

An Anatomy of Addiction

by Howard Markel

 

Laura Miller is a senior writer for Salon. She is the author of "The Magician's Book: A Skeptic's Adventures in Narnia" and has a Web site, magiciansbook.com. More: Laura Miller