Beacon Broadside

Moral Injury: The Crucial Missing Piece in Understanding Soldier Suicides

Rita Nakashima Brock is Founding Co-Director of the Soul Repair Center at Brite Divinity School. She was a professor for twenty years, directed the Fellowship Program at the Radcliffe Institute for Advanced Study, Harvard University, a prominent advanced research institute, and from 2001-2002, was a Fellow at the Harvard Divinity School Center for Values in Public Life. This piece was co-authored by Col. Herman Keizer, Jr. (ret.), Co-Director of the Soul Repair Center, who served for 34 years as a military chaplain, and Dr. Gabriella Lettini, co-author with Brock of Soul Repair: Recovering from Moral Injury After War.

This piece originally appeared at Huffington Post.

The crisis of military suicides, averaging one a day, has captured national attention. The July 23 cover story in Time magazine summarizes much of this coverage. Unfortunately, it is misleading.

The article presents the suicides of two officers—a helicopter pilot who served in Iraq and a medical doctor who did not serve in Iraq or Afghanistan. This example skews the article in two ways. First, in focusing on officers, it selects a group that tends to see less direct combat than the enlisted men who both do more direct fighting and commit suicide at higher rates than officers. Second, in contrasting the two officers' deaths, it suggests that suicide rates are the same for those who serve and those who do not serve in combat. However, the medical doctor first was an enlisted soldier who worked on a bomb squad and served in Bosnia. He was also in Oklahoma City just after the federal building was attacked—years before he decided to become a doctor. It's likely he saw war conditions during his earlier service. We need to remember that the U.S. has sent its forces into violent conflicts every year since World War II, except one, so Iraq and Afghanistan are not the only ways a soldier may have experienced combat.

The most serious blind spot in the reporting on military suicides is an absence of discussions about the moral impact of military training and its implementation in combat. Soldiers are trained to kill, which is regarded as criminal behavior in civilian life, and they are trained to be lethal without even thinking about it, a method of training called reflexive fire training.

We suggest that moral injury is likely one of the most important factors in military suicide rates.

Moral injury is not PTSD. The latter is a dysfunction of brain areas that suppress fear and integrate feeling with coherent memory; symptoms include flashbacks, nightmares, dissociative episodes and hyper-vigilance. PTSD is an immediate injury of trauma.

Related posts on Beacon Broadside:

An Epidemic in the US Military

Casualties on the Home Front

Rita Nakashima Brock on the Obama Legacy at Occupy Oakland

Moral injury has a slow burn quality that often takes time to sink in. To be morally injured requires a healthy brain that can experience empathy, create a coherent memory narrative, understand moral reasoning and evaluate behavior. Moral injury is a negative self-judgment based on having transgressed core moral beliefs and values or on feeling betrayed by authorities. It is reflected in the destruction of a moral identity and loss of meaning. Its symptoms include shame, survivor guilt, depression, despair, addiction, distrust, anger, a need to make amends and the loss of a desire to live.

While the Army has long provided protective training for soldiers sent to war, this is clearly now inadequate. Battles with insurgencies make violence against civilians commonplace and acceptable in ways that violate international standards for the conduct of war and the moral code of conduct for soldiers. For example, "Sniper Wonderland," a military drill chant says:

See the little girl with the puppy;
Lock and load a hollow pointed round...
Take the shot and maybe if you're lucky;
You'll watch their lifeless bodies hit the ground....

The most recent Army attempt to prepare troops for battle appears to have failed miserably. Its "Comprehensive Soldier Fitness" (CSF) program, begun in 2009 with a $125 million investment and lauded in a New York Times Magazine article in March 2012, has been widely criticized. It bypasses the difficult ethical questions that many healthy human beings ask about war, and its spiritual fitness component has no moral content. It suggests that a soldier's commitment to a higher purpose—mission first—makes for resiliency. But most people capable of such a commitment also have empathy for others and deep moral values.

The Army's "spiritual fitness" encourages soldiers to see events in a neutral light, rather than labeling them as good or bad, and to create a nightly list of positive things that happened that day. The lack of awareness is startling regarding what it might mean to ask someone to think of killing a child, losing a close friend or torturing detainees as neutral or positive.

Proving a direct cause-effect relationship between such training and suicides is difficult, of course. However, there are certain moral reactions to war and the experience of combat training that indicate a violation of moral conscience in war can have devastating inner consequences in soldiers. A larger proportion of soldiers and veterans who serve in combat seek the counseling help of a chaplain over the help of a clinician. This choice has two likely reasons. First, speaking to a chaplain does not create a negative psychological record in a military career. Second, psychological training does not require knowledge of theological issues, moral discussions of good and evil, or religious meaning. In fact, when soldiers raise moral questions about conscience in therapy, they are often referred to clergy.

The reporting on military and veteran suicides mostly fails to explore the role of moral injury. When a suicide occurs years after a soldier returns from war, combat experience is often disregarded as a primary cause of the suicide. Yet, as Karl Marlantes, a Vietnam veteran, reports in "What It Is Like to Go to War," he was fine for a decade, and then, he crashed. Often, such delays are used to deny VA services or are regarded as a family problem, rather than as a consequence of service in combat.

The alarming rates of reported suicides are squishy statistics and do not reflect the true numbers of soldiers who take their own lives. Many combat veterans tell stories of comrades who shot themselves, but who were reported as "non-combat" or "accidental" casualties. Soldiers who deliberately place themselves in harm's way in hopes of dying are reported as casualties, not suicides. Since many life-insurance policies will not pay benefits to families if suicide is the cause of death, the need to disguise suicide may mean some apparently accidental deaths were, in actuality, planned. We will never know the true suicide numbers, but we do know moral injury causes intense inner anguish.

Moral injury is not a clinical condition that can be medicated or cured by psychology. It requires the reconstruction of a moral identity and meaning system with the support of a caring, nonjudgmental community that can provide a way for veterans to learn to forgive themselves. But any community that wants to offer such support must have the moral courage to examine its own responsibility for war. With such a small percentage of Americans (1 percent) serving in the military, and the escalating unpopularity of the wars in Iraq and Afghanistan, too few people or communities remember the initial popularity of the wars or care about the cost to the men and women we send to fight on our behalf.

We care, and we believe our whole society bears responsibility for addressing moral injury. Whether or not we supported the wars, they do not end when soldiers come home. Instead, they continue in the souls of those who fought and in their families and communities when they return to civilian life. That is why we believe one right response of moral conscience to military and veteran suicides is to study and address moral injury as a hidden wound of war.

 

An Epidemic in the U.S. Military

Imagine a military health issue that affects almost every woman who enlists. Imagine that this same problem affects a smaller proportion, but a large number, of men. This problem seriously impacts a soldier's ability to serve, often causes mental and physical health issues, and can even lead to suicide.

And imagine that those who face this issue are likely to find themselves further traumatized by any attempt to address the problem. According to Invisible No More, since 2006 more than 95,000 service members have been sexually assaulted in the military. While most victims do not report their crimes, the few that have the courage to come forward are often ostracized, further harassed, and sometimes even punished more harshly than their perpetrators. They can see their dreams of serving their country in the military shattered, their careers derailed by something for which they are not to blame. 

On July 6th at the Coolidge Corner Theatre, I saw The Invisible War, a film that investigates the epidemic of rape in the U. S. military. This wasn't a topic that was news to me: I am old enough to remember the Tailhook scandal and the assaults at Aberdeen Proving Ground. And in 2009, Beacon published Helen Benedict's book The Lonely Soldier: The Private War of Women Serving in Iraq, which tells the story of five women soldiers who bravely served in Iraq but were faced with a culture of misogyny, homophobia, and sexual violence so pervasive, as one female soldier put it, "I ended up waging my own war against an enemy dressed in the same uniform as mine." 

The Invisible War filmmakers (director Kirby Dick and producers Amy Ziering and Tanner King Barklow) credited Benedict's writing as an inspiration, and she is one of many experts who appears in the film. Since the book was first published, Benedict has appeared before Congress to testify about military sexual assault. She has also written a novel, Sand Queen (Soho Press), and a play, The Lonely Soldier Monologues, inspired by her research.

I've followed Benedict's work since the book was published, and through it I've had an education in the lives of women in the military. I've learned about organizations such as the Service Women's Action Network and Protect Our Defenders, and about the work being done by Massachusetts Representative Niki Tsongas (who introduced the movie when I saw it at the Coolidge) and others in Congress to investigate the problem of military sexual assault and encourage positive changes in military culture. The men and women who have come forward to share their stories--with Benedict, with the filmmakers, before Congress--to call them brave is an understatement. They speak for countless others who suffer in silence. 

After seeing the film, I interviewed Helen Benedict via email. —Jessica Bennett, Blog Editor, Beacon Broadside

---

The women profiled in the film and in your book were different and their stories were each unique, but the similarities are striking: harassment, assault, retaliation, threats, and a lack of accountability. The Lonely Soldier focuses on women from one war, in one branch of the military, but it seems that this is a problem that has been persistent in all branches of service, and one that manifests itself both stateside and overseas. How pervasive is sexual assault and harassment in the military and how does it affect soldiers—both women and men?

The latest Department of Defense figures are showing that 20 percent of military women are sexually assaulted while serving, while for men, the number is one percent. Because men outnumber women in the military, this means that many more men than women are assaulted, but proportionally the vast number of victims are women. Other studies I cite in my book show an even higher rate – 33 percent of women sexually assaulted – and a 90 percent rate of sexual harassment. These numbers are of epidemic proportions and affect women on home bases and at war.

Watch Helen Benedict on C-SPAN's BookTV discussing The Lonely Soldier

The stories of abuse in the movie and in your book are harrowing, but it seems that a good deal of the damage inflicted upon victims comes from the way they were treated by the military after they are assaulted. How does military leadership fail assault and harassment victims?

The military is a blame-the-victim culture, thus many victims are met with skepticism, disbelief or outright blame when they report an assault. They are often treated as liars trying to get attention or bring down the career of a man, or blamed for drinking, flirting or otherwise “inviting” the assault. (No one invites a brutal attack, ever.) Furthermore, even for those cases that are taken seriously and prosecuted, the conviction and punishment rates are shockingly low--much lower than they are in civilian courts. This sends the message that assailants will be protected by the military, whereas their victims will be vilified.

The most recent scandal--which has received surprisingly little media attention--involves twelve instructors and at least 31 female trainees at Lackland Air Force Base. One instructor, Staff Sgt. Peter Vega-Maldonado, was allowed to plead guilty to "having sex with a female trainee" and received 90 days confinement before he acknowledged being involved with a total of ten trainees. The most serious charges, which will be addressed in a court-martial trial beginning this week, are leveled against Staff Sgt. Luis Walker. The leadership at Lackland has taken great pains to stress the personal responsibility of the perpetrators for their crimes, emphasizing that the great majority of instructors are ethical in their treatment of trainees. While this is certainly the case, does this PR tactic sound familiar?

Well, in all fairness, most men in the military are not sexual predators. Many too many are, but not most, so in a way the military is justified in saying most of their leaders behave correctly. We should be careful not to paint all military men as rapists, for this is terribly unfair to the majority who would never behave like that and are as appalled by it as women are. Sexual predators are repeat offenders, so one man can cause an egregious amount of harm.

That said, the military must take more responsibility for this huge problem in its ranks and its culture. It has been denying and covering up the problem for decade after decade, thus perpetuating and even supporting what is essentially a rape culture. No organization in the U.S. gives individuals as much power as the military does: with that power must come ethical behavior and anyone who abuses the power should meet with the proper justice.

Sexual "predators" or repeat sexual offenders like Jerry Sandusky at Penn State, Catholic Priests accused of abusing parishioners, and military serial abusers thrive in an environment where they have power imbalances and institutional secrecy on their side. Predators also feel empowered by "getting away with it," something that happens in an overwhelming number of sexual assault cases in the military. What does the military do to screen out or identify sexual predators?

As far as I understand, the military does almost nothing to screen out or identify sexual predators. Under President Bush, many criminal records were waived for recruits because the military was too short-staffed to run two wars. No one with a criminal record, especially one that entails abuse of women, should be allowed to serve.

At the moment, one in four veterans in prison is there for a sexual assault. Furthermore, if a sexual predator is expelled from the military, the civilian community to which he returns is not informed of his record.

In a postscript at the end of the Invisible War, the filmmakers note that Defense Secretary Leon Panetta took steps this past April to assist victims, clarify sexual assault policies, and elevate investigations of assault beyond the local unit commanders. When I saw the film, Representative Niki Tsongas of Massachusetts spoke to the audience about how she has worked in Congress to affect positive change in the military. The military has promised change before—do you think that we are finally moving in the right direction?

I do. We need to take sexual assault cases out of the chain of command and military justice system because it is too closed a system to be fair to victims. For example, some 25 percent of victims must report their assault to the very man who assaulted them; whereas 33 or so percent must report to someone who knows the assailant. This results in a system in which friends and those in command can close ranks and protect one another, shutting out all justice for the victim.

Read Helen Benedict on Invisible War at Word and Film.

Watch the Trailer for The Invisible War

Dosed: The Medication Generation Grows Up

“The author’s clear rending of the tough questions surrounding this knotty topic should make it required reading for anyone touched by this issue.” Kirkus Reviews

Over the last two decades, we have seen a dramatic spike in young people taking psychiatric medication. As new drugs have come on the market and diagnoses have proliferated, prescriptions have increased many times over. The issue has sparked heated debates, with most arguments breaking down into predictable pro-med advocacy or anti-med jeremiads. Yet, we've heard little from the "medicated kids" themselves.

In Dosed, Kaitlin Bell Barnett, who began taking antidepressants as a teenager, takes a nuanced look at the issue as she weaves together stories from members of this "medication generation," exploring how drugs informed their experiences at home, in school, and with the mental health professions.

For many, taking meds has proved more complicated than merely popping a pill. The questions we all ask growing up-"Who am I?" and "What can I achieve?"-take on extra layers of complexity for kids who spend their formative years on medication. As Barnett shows, parents' fears that "labeling" kids will hurt their self-esteem means that many young children don't understand why they take pills at all, or what the drugs are supposed to accomplish. Teens must try to figure out whether intense emotions and risk-taking behaviors fall within the spectrum of normal adolescent angst, or whether they represent new symptoms or drug side effects. Young adults negotiate schoolwork, relationships, and the workplace, while struggling to find the right medication, dealing with breakdowns and relapses, and trying to decide whether they still need pharmaceutical treatment at all. And for some young people, what seemed like a quick fix turns into a saga of different diagnoses, symptoms, and a changing cocktail of medications.

The results of what one psychopharmacologist describes as a "giant, uncontrolled experiment" are just starting to trickle in. Barnett shows that a lack of ready answers and guidance has often proven extremely difficult for these young people as they transition from childhood to adolescence and now to adulthood. With its in-depth accounts of individual experiences combined with sociological and scientific context, Dosed provides a much-needed road map for patients, friends, parents, and those in the helping professions trying to navigate the complicated terrain of growing up on meds.

Buy from Beacon Press | Independent Bookstore | Amazon | Barnes and Noble | Powells

Buy the ebook Kindle | Nook | Google eBookstore | Kobo | Apple iBookstore

Read an excerpt of Dosed at Salon.

Kaitlin Bell Barnett is a journalist and blogger based in Brooklyn. She also blogs about the experiences of young people taking psychiatric drugs at PsychCentral.

Her work has appeared in the New York Observer, Parents, the Huffington Post, Berkshire Living, Gastronomica, Prevention, InTheFray, Hungry, the Brooklyn Rail, and the Boston Globe, among other publications.

Kaitlin grew up in Williamstown, Massachusetts, and attended Columbia Journalism School and Dartmouth College, where she served as executive editor of the independent daily student newspaper. From 2005 to 2007, she worked as a reporter at the Monitor, a daily newspaper in McAllen, Texas, on the Mexico border. There, she covered city government, politics, schools, crime and general assignments.

'Xanax' Nation? My Anti-Anxiety Meds Give Me Enough to Worry About

Kaitlin Bell Barnett is the author of Dosed: The Medication Generation Grows Up. She is a freelance writer whose articles have appeared in numerous national and regional outlets, including the Boston Globe, New York Observer, Parents, and Prevention. This piece originally appeared at Huffington Post. 

Journalists love declaring that psychiatric medications symbolize some slice of the zeitgeist. So I can't say I was entirely surprised when I opened my mailbox the other day and saw New York magazine's cover article proclaiming that "If the 90s were the decade of Prozac, all hollow-eyed and depressed, then this is the era of Xanax, all jumpy and edgy and short of breath."

Translation: Depression is out, anxiety is in, antidepressants are passé (Statistics showing continued robust usage be damned), and anti-anxiety benzodiazepines, around since the 60s, are trendy again, the perfect no-commitment chill pills for a nation of "panicked strivers" contending with a new age of anxiety but without time or inclination to commit to actually changing their lives or going to therapy.

How convenient, I thought. My psychiatric problems -- and corresponding psychopharmaceuticals -- match up with the trends! First I was depressed and angsty and got Prozac, then I got anxious and got benzos! Of course, I happen to be getting depressed again lately, but one can't be completely on-trend all the time.

In fact, if you didn't know me better, you might well mistake me for one of the "functionally anxious" types who dominate journalist Lisa Miller's New York story, rather than the sort of person she quickly shuffles off into another category altogether -- the people with an actual, you know, anxiety disorder.

The people without anxiety disorders who do populate the New York piece are the sort most of us love to hate, but also can't resist reading about in these sorts of articles: Manhattanite professionals who in the Annie Hall era would have been called "neurotic" but who now like to describe themselves as "super stressed," like it's a badge of honor.

According to the article, they're turning more often these days to drugs like Xanax or Ativan when anxiety from their legitimately high-pressure lives gets to be too much. Prescriptions of these drugs, collectively referred to as benzodiazepines, are up 17 percent since 2006. The article does not mention that prescriptions for other psychiatric medications have increased, too -- antidepressant use in adults grew nearly 30 percent between 2001 and 2010 at Medco, one of the nation's largest pharmacy systems, and atypical antipsychotic usage grew a staggering 350 percent. Writing the New York article with a different thesis in mind, one could contend that we're all demoralized over the stalled economic recovery and turning to antidepressants -- or that we're frustrated and adding antipsychotics to our antidepressant regimens to give them a boost.

But back to benzos and anxiety.

The article makes it sound as though it's terribly easy to distinguish between the ordinary, high-functioning people who turn to benzos every so often when the stress of their lives overwhelms them and the people with diagnosed anxiety disorders. In fact, it can be quite complicated -- and that's why psychiatrists are fighting so bitterly over the definitions of the various disorders to be included in the DSM-5, the profession's diagnostic manual, which is under revision and due out in May 2013.

Doctors are curiously absent from the New York piece, though they are, of course, the ones responsible for actually doling out the prescriptions for benzos and all other drugs. They are quite rightly very concerned about how to determine which anxiety is pathological and overwhelming and warrants such a drug, and which kind might be better dealt with through other means.

This is a subject that has been troubling the medical profession for decades, In the 70s and 80s, benzodiazepine misuse became enough of a public health problem to prompt doctors to cut down on prescribing -- and publish a lot of anguished articles on the subject in medical journals. Some of the increase in use the New York article discusses may even reflect a return in doctor's attitudes to more comfort prescribing the drugs after years of shying away from them. (Recent articles in trade publications have made a case for their judicious use.)

All this difficulty distinguishing the casual users from the truly stricken lies in the nature of the conditions for which benzos are typically prescribed. Although sometimes given in high doses as sedatives to seriously agitated patients in psychiatric hospital settings, they are more commonly given to people whose anxiety is self-described and not necessarily readily observable to the doctor. This is true even when we are talking about anxiety of the sort that impairs people's day-to-day functioning, as opposed to the kind Miller focuses on in her New York article, which we might call the "just as easily dispatched with a glass of wine variety."

Anxiety is a funny thing, because although it seems the most all-consuming and obvious thing in the world when you are experiencing it, in fact it's actually quite difficult to detect. When I've been at my most anxious, I suspect that I've struck my psychiatrists and therapists as, at most, a bit agitated. Perhaps they've noticed some circles under my eyes, or that I look a little thin. Conceivably, I would talk a little faster than usual, or my eyes would dart around the room. But they have told me that, frankly, I don't seem all that different. I put on a good façade of normality.

In contrast, here is what I do experience: When I arrive at the psychiatrist for a "med check," I won't have slept a solid eight hours in weeks. I will have awoken early every morning with a jolt, my heart racing at some threat I can't place. It will continue that way all day until I go to bed. My stomach will churn and the room will spin and I'll be unable to eat. My thoughts will race from one unarticulated worry to another. I will feel desperate for companionship yet unable to listen or focus on conversation. I will feel constantly on the verge of tears. But I would have to tell my doctor all of this. She is not likely to go offering me a benzodiazepine prescription on the basis of some dark circles and a little hurried speech.

Once procured, such a prescription usually works magic, however. During the three periods of sustained anxiety I've suffered, I have taken a small dose of Klonopin, a long-lasting benzo, every few hours, as a way of keeping a steady level in my system. I've also taken it many other times when I've felt my anxiety flare on isolated occasions.

Despite the drug's effectiveness -- or perhaps because of it -- I never feel good about taking it. When my anxiety is pervasive, I need to constantly watch for a resurgence of panic. This makes me feel dependent, like a drug addict eyeing the clock for my next hit. When my anxiety returns in isolated episodes, I wonder if I'm simply the equivalent of the functionally anxious people in the New York article -- someone who happens to have a Klonopin prescription but who really doesn't need to be taking it and could just as well go to a yoga class. I tend to feel guilty about it until I get the telltale early morning waking -- and then I start to worry that I'm entering another terrible extended anxious phase.

The other reason articles like the one in New York make me cringe is that benzos, being controlled substances, already carry the taint of misuse, and talk of overworked PR execs popping pills to deal with anxiety over a work presentation or helicopter moms doing so to handle separation anxiety from their preschoolers is likely to make doctors, already cagey about prescribing, even more so.

Even for those of us with an anxiety disorder diagnosis and a history of benzo prescriptions, there's already an awkward dance involved in procuring a refill. Since benzos are controlled substances, doctors can't call in prescriptions (and may not have emergency appointments available go hand over the precious slip of paper). Anxiety, however, has a tendency to spiral -- and quickly. Many people find it useful, therefore, to have a bottle around in case of an emergency. But that means requesting a refill when you are not, technically, quaking under the covers in a fetal position.

Some doctors are sensitive enough to realize this, but, wanting to avoid tolerance and misuse, the responsible ones generally don't go around offering up refills out of the blue. For many people, especially young people in their 20s and 30s, who happen to be the group most likely to abuse psychotherapeutic prescription drugs according to federal government statistics, this makes asking for refills a delicate and awkward affair. I'm sure that my requests, for example, are accompanied by far too much justifying. One young woman I interviewed for my book on the topic of growing up on psychiatric medication suffered from debilitating anxiety and was so terrified of being judged an addict (She had a family history of alcohol abuse) that she refused to ask for benzo refills at all. This, even though it was patently obvious from the most casual encounter with her that some benzos would have done her good.

After my last psychiatrist's appointment, during which my doctor upped the dosage of my antidepressant to deal with a creeping recurrence of my depression, she ended the appointment by asking what I was doing for the rest of the day. I told her I was working on a column responding to the apparent news that benzodiazepines were the hot new drugs. She rolled her eyes as though this were the height of ridiculousness. "Benzodiazepines are the hot new drugs? Since when?" She did not ask if I would like a refill on my Klonopin.

High Stakes: The Rising Cost of America's Gambling Addiction

"The suicides and murder-suicides, the property crime, the child neglect -- we often assume these are tied to problem gambling ... but we rarely tie the disparate pieces together into the obvious whole." Review of High Stakes in the Las Vegas Sun, July 5, 2011

America is becoming hooked on gambling. From the millions of dens and dorm rooms lit by online poker games to the neighborhoods transformed by new casinos and slot machine parlors, legalized gambling has become an integral part of our lives.

With a singular blend of investigative journalism and poignant narratives of gambling addiction, award-winning journalist Sam Skolnik provides an in-depth exploration of the consequences of this national phenomenon. The result is High Stakes, an unflinching look at the explosive growth of legalized gambling in our country, the concurrent rise of addicted gamblers, and what it all means.

Thirty-five years ago, casinos were legal in just one state, Nevada. Today, legalized gambling has morphed into a $92 billion industry established in all but two states. As elected officials are urging voters to expand gambling's reach, the industry's supporters and their equally impassioned detractors are squaring off in prolonged state-by-state battles. Millions of Americans are being asked to decide: Are the benefits worth the costs?

Industry officials and their political allies assert that gambling is an effective way to raise revenue and create jobs. But these rewards come at a steep price. Fast-rising numbers of addicted gamblers are causing higher indebtedness and bankruptcy rates, as well as increased divorces, suicides, and gambling-related crime. Skolnik shows how the gambling industry is targeting Asian Americans-and why this population, more than any other ethnic group, is likely to develop gambling problems. He also illustrates how gambling has helped turn Las Vegas into America's most dysfunctional community, and how the upsurge of poker and Internet gambling has created a new generation of gambling junkies.

In High Stakes, we meet politicians eager to promote legalized gambling as an economic cure-all, scientists wrestling with the meaning of gambling addiction, and ensnared players so caught up in the chase that they've lost their livelihoods and their minds. Throughout it all, Skolnik-an avid poker player-never loses sight of the human side of these struggles.

Book Trailer for High Stakes on YouTube

Read an excerpt if High Stakes here or on Scribd

Big Think Interview with Jonathan Metzl

Jonathan Metzl discusses schizophrenia, the DSM (The Diagnostic and Statistical Manual of Mental Disorders), and how the disease moved from being thought of as a ailment of housewives to a diagnosis of violent behavior among African-American men.

If the video doesn't embed in your reader, check it out here: http://bigthink.com/ideas/18711

Jonathan M. Metzl: In Medical Records, a Story of the Racialization of Schizophrenia

Today's post is an excerpt from The Protest Psychosis: How Schizophrenia Became a Black Disease by Jonathan M. Metzl. Metzl is associate professor of psychiatry and women's studies and director of the Culture, Health, and Medicine Program at the University of Michigan. A 2008 Guggenheim Fellowship recipient, Metzl has written extensively for medical, psychiatry, and popular publications. His books include Prozac on the Couch and Difference and Identity in Medicine. 

Reading the medical charts of the patients of Ionia State Hospital for the Criminally Insane, I felt a mixture of responsibility and deep sadness. For better and largely for worse, the Ionia charts documented the lives of the marginalized and the forgotten in novel-like detail, and in ways that made the medical records of today seem impersonal and flat. This was because the charts recorded people in two conflicting ways: in their roles as patients and convicts, as defined by interactions with the state hospital complex and the courts, and in their roles as sons, daughters, fathers, husbands, wives, or loners, as defined by letters, cards, and other texts. The charts also documented in minute detail the tragedy of what it meant to be warehoused in a state asylum at midcentury -- and in particular, in an asylum where short sentences devolved into lifelong incarceration. A number of charts contained yearly notes from patients to their doctors voicing such sentiments as "Doc, I really think I am cured," or "Dear Doctor, I believe I am ready to go home," or "You have no right to keep me here after my sentence is over." These letters stacked thirty deep in some charts, signifying years of pleading and longing and anger, together with thirty years' of responses from clinicians urging, "You are almost there" or "Perhaps next year." Invariably, the last note in each stack was a death certificate from the Ionia coroner.

I visited the archive regularly over the next four years. With the help of my research assistant, I analyzed and catalogued hospital administrative records and the charts of nearly six hundred randomly selected patients admitted to the hospital between the late 1920s and the early 1970s, under the agreement that I significantly alter all personal identifying information about patients, as I have done in the case descriptions that appear in this book. Names, dates, and places have been changed, and vignettes represent condensed and extrapolated aggregates drawn from the rich case materials. All doctor-patient dialogue and text in quotation marks is reproduced verbatim. I also visited Ionia on numerous occasions and conducted a series of oral histories with surviving members of the hospital staff, though, perhaps tellingly, I located no surviving patients despite numerous attempts.

What stories boxes tell. Ionia was its own planet, walled off, orbiting, a place where real people worked and lived and died. Then came a series of public scandals, the advent of psychopharmaceuticals, and changes in legal systems and penal codes. Decreased public funding followed, along with encroachment by regional forensic centers. Finally, the transformation. The boxes were but light-years of this implosion, vapor trails, found poems, measurable heat. Disembodied voices that told silent stories of what it meant to be incarcerated, or neglected, or entrenched, or immured.

Link Roundup: Sri Lanka, Schizophrenia, The Abortion Wars

The Sri Lankan election is tomorrow, and the Toronto Star spoke with Adele Barker about the tensions and bitterness of the contest.

African-American men are diagnosed with schizophrenia at rates four to five times more than other groups. The Root talked with Jonathan Metzl about this issue and his new book, The Protest Psychosis.

Sophia Raday is now blogging at Military.com, contributing posts about her politically-mixed marriage.

Carole Joffe discusses the Abortion Wars with Salon.com.

The authors of Hollowing Out the Middle look at an Endangered Species: the American Heartland.

CNN Newsroom featured a live interview with Sonia Sanchez on Sunday. The five minute interview focused on the Smithsonian's Freedom's Sisters traveling exhibit, which features Sonia Sanchez and nineteen other 19th and 20th century African-American female activists. The video is embedded here, but if it doesn't appear, you can follow this link.

David Chura: Mentally Ill Inmates in a Crazy Prison System

Today's post is from David Chura, author of I Don't Wish Nobody to Have a Life Like Mine: Tales of Kids in Adult Lockup. Chura has worked with at-risk teenagers for forty years. His writing has appeared in the New York Times and multiple literary journals and anthologies, and he is a frequent lecturer and advisor on incarcerated youth.

In March 2007, the nonprofit Disability Law Center sued the state of Massachusetts over its treatment of hundreds of mentally ill inmates. Prisoners with emotional problems who are unruly in some way are kept in 23 hour solitary confinement, which, according to a November 10 Boston Globe article, has "led to self-mutilations, swallowing of razor blades, and numerous suicides."    

In response to these grave concerns the Patrick administration, in an out-of-court negotiation, proposed building special treatment units for mentally disturbed inmates. Now, that proposal is off the table; citing the budget crisis, those units will not be built. So it's back to court in an effort to force the state to give its incarcerated citizens their constitutional protection against "cruel and unusual punishment."

Massachusetts isn't alone in facing the problem of caring for mentally ill inmates. Every state has had to confront this growing trend which started in the 1960s and accelerated in the 1980s, when the system of large state psychiatric hospitals was shut down even though, as Oliver Sacks states in his bittersweet eulogy to these former mental hospitals ("The Lost Virtues of the Asylum" New York Review of Books, 9-24-2009), it was obvious that these closings created "as many problems as they solved." Communities weren't prepared, and still aren't prepared, to absorb and meet the needs of what he calls "sidewalk psychotics."

With these closings, along with the current "tough on crime" policies, it shouldn't surprise anyone, then, that these same people-- alone, unsupported, often self-medicated with drugs and alcohol-- increasingly end up behind bars, despite the fact that jails aren't set up to help people deal with emotional problems, problems that confuse their judgments and impel them to destructive actions

No doubt these are hard choices in hard economic times for any state. Yet, once again, as municipalities struggle to come up with innovative ways to deal with the money crunch, the one formula that never gets recalibrated is that the people with the greatest need and the least resources take the biggest hit. 

Loneliness Doesn't Have to Get You Down on Valentine's Day

Today's post is from Jacqueline Olds, MD, co-author with Richard S. Schwartz, MD, of The Lonely American: Drifting Apart in the Twenty-first Century. Drs. Olds and Schwartz are both psychoanalysts and Associate Clinical Professors of Psychiatry at Harvard Medical School. They have written two other books, Overcoming Loneliness in Everyday Life and Marriage in Motion. Drs. Olds and Schwartz will discuss The Lonely American at the Cambridge Forum, Wednesday, February 11th at 7:30pm. Details here.

Here it is Valentine's Day again... and many of us are thinking, "Oh dear, I'm alone again. How I hate this celebration of couples!" There are in fact a lot of us who live alone (approximately 25% of households are single-person households according to the latest census), and the General Social Survey from 2004 revealed that many of us have no really close confidants. So how are we to cope with such a "holiday" when there seems to be so little to celebrate?

Well, much of the research done on health and social connection does not specify that to achieve longevity, you have to have a Valentine, but it does imply that you have to be socially connected to some small groups in such a way that you schmooze regularly with them. And, even though we don't know for sure whether it lengthens lives, many psychologists stress the benefits of having a couple of people with whom you "can truly be yourself" without worrying about the impression you're making. So one of the worst things you can do if you don't happen to have a Valentine is huddle at home feeling too ashamed to go out and let everyone know that there's no special someone in your life.

Home for the Holidays?

Today's post is from Jacqueline Olds, MD, and Richard S. Schwartz, MD, authors of The Lonely American: Drifting Apart in the Twenty-first Century. Drs. Olds and Schwartz are both psychoanalysts and Associate Clinical Professors of Psychiatry at Harvard Medical School. Dr. Olds teaches child psychiatry and Dr. Schwartz teaches adult psychiatry at the McLean and Massachusetts General Hospitals. Married to each other and with two grown children, they each maintain a private practice in Cambridge, MA. They have written two other books, Overcoming Loneliness in Everyday Life and Marriage in Motion.

On the front page of the Boston Globe, just beneath the story on surging unemployment, is another headline. "Guess who's not coming to dinner? Amid slump, holiday travel plans stall." The economic crisis threatens to disrupt one of the few moments when we, as Americans, regularly remember that electronic connections can't replace a family meal. Thanksgiving has been the time to emerge from our wired (and wireless) solitude to move real bodies through physical space, over clogged highways and through packed airports to be at the table with our families for the holiday. But even before the economic crisis, it was already tempting not to go.

These days, we can do so much from home – our work, our shopping, our socializing, our game-playing. It's not only convenient; it's also high status. It shows that we have access to all the latest technologies of connection. It shows we are freer than neighbors who are still tied to commutes and schedules. Busyness itself has become high status, an upwardly mobile contest to see who can keep more balls in the air. With so much to do, who has time to run to the store? Or to pack up for the holidays?

Sarah Palin: No Friend to Children and Adults with Disabilities

Today's post is from Jane Bernstein, the author of five books, most recently Rachel in the World, a memoir of raising her developmentally disabled daughter. Her essay "Rachel at Work: Enclosed, a Mother's Report" was included in I Love You to Pieces: Creative Writers on Raising a Child With Special Needs, edited by Suzanne Kamata. Bernstein is a professor of English and creative writing at Carnegie Mellon University and lives in Pittsburgh, PA.

As the mother of a young adult with mental retardation, nothing should make me happier than a candidate for vice president vowing that my daughter would at last have a "friend and advocate in the White House." Instead, I find myself more concerned than ever about the fate of children and adults with disabilities.

As most of us know by now, Sarah Palin's fifth child has Down Syndrome. When Palin learned through genetic testing that her unborn baby would likely "face special challenges," she confessed that she "initially felt sad" but now that he was four months old felt "truly blessed."

Of course she loves her infant son. He's an adorable little boy. It's hard to find parents who don't love their newborns –- even when we learn that our babies have disabilities. While for most of us, the grief we feel after hearing that our babies are less than perfect doesn't abate as quickly as it did for Palin, it hardly matters, because when our tears dry, as eventually they do, what's left is love and commitment.

Michael Phelps Just Said “No” to ADHD Drugs

Today's post is from Chris Mercogliano, author of In Defense of Childhood: Protecting Kids' Inner Wildness. He has been a teacher at the Albany Free School since 1973 and co-director since 1985. His writing has appeared in numerous publications, and he is also the author of Making It Up As We Go Along, and Teaching the Restless: One School's Remarkable No-Ritalin Approach to Helping Children Learn and Succeed.

Michael Phelps didn't need drugs to 'fly into Olympic history. And at the tender age of 11 he decided he didn't need them to negotiate his way through school.

Growing up in what by several accounts was an authoritarian household—his father was a state trooper and in an interview in the New York Times his mother describes herself as "stern"—Michael was diagnosed ADHD at age 9. His parents' on- again, off-again relationship had finally ended in divorce two years earlier, and his teachers had been complaining since kindergarten that he was restless, talkative, and easily distracted in class. These, of course, are all classic "symptoms" of a supposedly genetic neurochemical imbalance in the brain, and so a pediatrician suggested to Michael's mom that she put him on Ritalin.

According to Mrs. Phelps, Ritalin marginally improved her son's school performance and dulled him into peacefully doing the minimum on his nightly homework assignments. But he felt stigmatized by having to go to the nurse's office at lunchtime to swallow a pill every day, and after two years Michael pleaded to be taken off the drug. "I don't want to do this anymore, Mom. My buddies don't do it. I can do this on my own." Fortunately for Michael, his mother believed in him deeply and so she listened.

Stop Trying to “Fix” Trans People

Today's post is from Matt Kailey, the author of Just Add Hormones: An Insider's Guide the Transsexual Experience (Beacon Press, 2005), the editor of Focus on the Fabulous: Colorado GLBT Voices (Johnson Books, 2007), and the managing editor of Out Front Colorado, Colorado's oldest and largest GLBT publication.

Trans people aren't broken. We aren't looking to be "fixed," and we have no need of a repairman. We have spent decades trying to convince the Western world of this, and forgive us if some in our ranks were starting to feel a little optimistic about our progress – until, maybe, now.

Just when we thought that an end to the tinkering around with our brains might be in sight – at least for those who are very far sighted – along comes a repairman in the form of Dr. Kenneth Zucker, a non-transman who, like so many before him, thinks he knows what's better for us than we do. Dr. Zucker thinks he can "fix" us – whether we want him to or not.

Now Dr. Zucker might be merely an annoying interruption in our otherwise peaceful day – some scam artist who knocks on our door and tells us that our roof or our driveway or our air conditioning is in disrepair and that he can fix it for cheap – and we could easily tell him that we have our own service, thank you very much, and close the door in his face. Unfortunately, in this case, there's one small catch – Dr. Kenneth Zucker has been appointed by the American Psychiatric Association to serve as the chair for the Sexual and Gender Identities Disorder task force that reviews the new version of the DSM – the Diagnostic and Statistical Manual that is used by psychiatrists, psychologists, and therapists to diagnose mental illness. And, in this regard, Dr. Zucker is no mere annoyance knocking on our door. He is a very dangerous man – and not just to trans people.

The Psychological Trauma of War

by Margot Adler

It's not something you read in a newspaper or hear on an ordinary news show; it's only on the comedy shows like Real Time with Bill Maher where you hear it whispered: the idea that John McCain has PTSD, and that it would be scary to have his finger on the button. Whether or not this is the same kind of slur we hear from those who say Barak Obama was schooled in a madrassa, it seems perfectly reasonable to wonder if anyone who spent five years in a tiger cage might have some remnants of PTSD - even decades later.

So when I heard it on Bill Maher the other night, it reminded me that we are living in a society where thousands of young men and women, our very future, are returning home every day scarred from battles in Iraq and Afghanistan. Some of those scars are painfully visible; many others are not. Few people are really looking deeply at what this means for families and relationships, even what it means for our daily lives as Americans. Only one person that I know of in the mainstream media has delved deeply and movingly into this issue. For more than a year, in a series of searing pieces, Daniel Zwerdling at NPR has chronicled the plight of military personnel to get the mental health care they need. In many cases, veterans with PTSD have been kicked out of the military for bad behavior and are unable to access mental health services.

Ten years ago, I wrote a book called Heretic's Heart about my own life during the 1960's. Several chapters of that book were letters between me, as a twenty-year-old University of California - Berkeley student and activist, and Marc Anderson, a soldier fighting in Vietnam whom I met through the mail after he wrote a letter to the campus newspaper that could only be described as a cry from the abyss.

Media, Technology and Bullying: New Partners in Nastiness

by Mara Sapon-Shevin

When I was in middle-school, the way the “popular kids” tormented those of us who weren’t so lucky, was through something called “Slam Books.” A popular kid (it was usually a girl) would start a notebook with individual pages headed with the names of unpopular students. The book would be passed around to the other “popular” kids and they would take turns making nasty entries under the unpopular students’ names. Under Beth’s name, for example, they would write, “Ugly,” “Bad complexion,” “Stupid,” and “Slutty.”

There would be lots of snickering and giggling as the notebook was passed (not that unobstrusively) between the popular kids who were writing the nasty comments. Slam books were the source of public humiliation, and they made the lives of some of us miserable. It was never clear whether or not teachers were aware of what was going on, but I don’t remember any intervention at the time.

Now, however, we have entered the era of high technology, and the ways in which students torment one another are far more sophisticated. Cyberbullying is a growing and distressing phenomenon that has recently received extensive media attention.

Drug-Free School Zone

By Chris Mercogliano

I am in absolute agreement with Bruce E. Levine: it isn’t ODD at all that our society has stepped up its efforts to pathologize young people with biopsychiatric labels like Attention Deficit Disorder (ADD) and Oppositional Defiance Disorder (ODD), when they either cannot or will not march in step with the majority culture, and then dose them with the corresponding biopsychiatric drugs.

As Levine reminds us with his deft bit of historical research, America has a long tradition of marginalizing anyone who deviates from established norms—which currently are narrowing at an alarming rate. Or as French philosopher Michel Foucault pointed out in Discipline and Punish, the control of its citizens has always been a primary aim of the state, and what we are witnessing in modern times is the evolution of increasingly subtle ways in which to do so. Today, instead of relying on brute force as was the case in the days of pharaohs and emperors, social institutions like schools, the military, and the mass media subliminally enforce a conformity so pervasive that overt forms of control are no longer necessary. All who resist and refuse to take their places in the social and economic machine, according to Foucault in Madness and Civilization, are labeled with some form of abnormality, and then, as I argue in my book, Teaching the Restless, about the ongoing ADHD hoax, they are medicated with powerful psychotropic drugs that extend society’s control all the way down to the biochemical level.

This business of labeling and drugging kids who won’t sit still, can’t keep up, or don’t fit in became a deep concern of mine in my role as a teacher at the Free School, a noncoercive, democratic, inner-city school for sixty-five students ages two through fourteen in Albany, NY. In the early 1990s there was a sudden spike in the number of students who came to us having been labeled in their previous schools, and so, curious as to why, I embarked on an exhaustive review of the already considerable ADHD literature.

An Overextended Prison Health System Loses its Mercurial Advocate

by Sasha Abramsky

In the years after World War II, California’s prisons were seen as being some of the most progressive correctional institutions in America. They were generally well funded, and the officials in charge of the system had a real interest in utilizing new rehabilitation tools within their facilities. In the late 1960s and 1970s, a wave of prison riots and rebellions put the skids on reform-based strategies. By the 1980s, when the first waves of the nationwide tough-on-crime, tough-on-criminals movement washed ashore, conditions in the prisons were deteriorating fast.

As the courts sent evermore prisoners into the prison system, even the massive prison-building spree California embarked on couldn’t keep up with the numbers. The prisons got more and more crowded, gyms were converted into dorms, access to medical, mental health, drug treatment, education, and job training services and programs declined. By the 1990s, the state prison system was being rocked by a series of scandals – guards beating inmates, seriously mentally ill inmates being placed in solitary, prisoners dying because they were denied adequate medical care.

A couple years back, the federal courts got so frustrated with the Department of Corrections and Rehabilitation’s inability to deliver basic healthcare to the state’s 170,000 inmates that they hired an independent receiver to push through change. The receiver, Bob Sillen, used his office to force prisons to invest more in basic items, such as specialized vans to take sick prisoners to hospitals; and he also promoted more systemic changes – higher pay for prison doctors and nurses, the investment of tens of millions of dollars in on-site medical facilities.

Losing Sleep

by Kelly Bulkeley

Last night the students in my "Psychology of Dreaming" course at John F. Kennedy University turned in their first assignment of the quarter: a personal sleep history from childhood to the present. I like to begin my dream classes with a focus on sleep because it's a great way to jar people into taking a fresh look at the nocturnal dimension of their lives. Most people have never reflected on their sleep patterns or thought about sleep in relation to their life's development and growth over time. When they're encouraged to do so, the results are often startling. As soon as I opened the discussion in class last night, one of the students quickly raised her hand. I called on her, and with no further ado she declared:

"I'm 45 years old, and I just realized I've been sleep deprived for the last 40 years!"

Several other students followed with their own tales of sleepless woe, just like I've found every time I give this assignment in a class and just like I found in the research for American Dreamers. The conclusion is hard to avoid: We are becoming a chronically sleep-deprived nation. Problems with sleep afflict a surprisingly large number of people in contemporary American society, and we don’t really know how widespread these problems are or how they impact people’s long term health and well-being.

Monday Link Roundup: Interfaith Heroes, Praise for Our World, Womb Outsourcing, and Vet Suicides

Read the Spirit, an ambitious and thoughtful site devoted to issues of spirituality and religion, is devoting a portion of their impressive energies to a month of Interfaith Heroes. Featured so far, brief, illuminating essays on the lives of such disparate voices for tolerance as Moses Maimonides, Jaluddin Muhammed Akbar, and Roger Williams.

(Incidentally, we also owe a word of thanks to Read the Spirit for their link to us and a very flattering mention for Beacon Press generally and the blog specifically.)

In other good reviews of work from Beacon, the L.A. Times ran a thoughtful and moving piece by Susan Salter Reynolds about Our World, a book that collects Molly Malone Cook's photographs with accompanying text by her life partner, the poet Mary Oliver.

The photographs Oliver has chosen reflect Cook's intuitive relationship with her subjects (even inanimate objects). The little girl on the stoop in New York City looks directly at the photographer, as does a kindly Robert Motherwell and a fierce, almost intimidating Walker Evans. Even though most of the photographs are dominated by a central person or object, there is a lot to look at in the margins, all part of the story. The stance of her subjects -- reading a book, looking through a telescope -- is always distinctive, creating the mood of the entire composition. The two photos of Oliver could have been taken only by someone who knew the subject well.

Marketplace ran a story over the holiday break that many, including Judith Warner on the New York Times opinion blogs, found troubling. The story highlighted the practice of "womb outsourcing," an increasingly popular surrogacy option involving hopeful parents from wealthy countries paying what amounts to "bargain rates" (when compared with the high cost of surrogacy in the U.S.) for surrogates in India. Amy Tiemann at MojoMom condemned the practice – "Is this what colonialism looks like in the 21st century?" – and invited Barbara Katz Rothman, author of Weaving a Family: Untangling Race and Adoption, to comment as well:

We women of the wealthy world profit from the exploitation of poor women, men and children with almost every shirt we put on our backs, almost every bite of food we take. We exploit people in poverty and never have to think about it. And now we can profit in our motherhood -- but unlike the shirt and the food, this time the product is going to grow up and demand an explanation. (Read more here)

And, to return to a topic  we discussed during Veterans Day Week last November, Penny Coleman, author of Flashback: Posttraumatic Stress Disorder, Suicide, and the Lessons of War, has been writing about the issue of veteran suicides regularly at Alternet. Her latest post is an account of her experience testifying before Congress alongside Mike and Kim Bowman, who lost their son to suicide after he returned from Iraq. In the piece she quotes Rep. Cliff Stearns of Florida, who displayed a stunning lack of tact and understanding of the issue when he passed the buck to the Bowman family for their son's death:

"The building up of the self-esteem is the key," he said, "and the parents somehow have to convince him or her that everything is going to be all right, we're going to work through it. And in this case it didn't happen, and so, tragic and sad."

It is precisely because of this tendency to blame the victims that the work that Coleman and the Bowmans do is so important. The hearing ultimately resulted in a dressing down of the head of mental health at the VA by the chair of the Veterans Affairs Committee, Bob Filner, along with the appeal that the VA start listening to the stories of families who have lost loved ones to suicide. Excuses and passing the buck are not going to save any lives.